468 CHAPTER 10
Psychiatric hospitalization can improve eating symptoms and help to change
distorted thoughts about food, weight, and body. But, in many cases, these positive
changes are not enduring. Twelve months after discharge from a psychiatric hospi-
talization, 30–50% of patients relapse (Pike, 1998). Consider that in 1 year, Marya
Hornbacher was hospitalized three times. Why is there such a high relapse rate?
There are various explanations. One is that some patients are reluctant to change
their behaviors, and they accept the intensive treatment for health reasons or because
of pressure from family members––but once out of the hospital, they are not willing
to continue the changes they began. For example, each time Hornbacher was released
from the hospital, she reverted to her old eating behaviors. Some researchers have
examined the amount of weight gained during hospitalization for anorexia. Patients
who gain more weight during their hospitalizations are likely to fare better 1 year
later. This fi nding could mean that patients who are more motivated to improve will
gain more weight while in the hospital; alternatively, it could mean that a higher level
of weight gain in and of itself starts an upward spiral of recovery (Lund et al., 2009).
A second reason for the high relapse rate after psychiatric hospitalization is that
some patients do not receive appropriate outpatient care after they leave the hospital.
This lack of care makes it more difficult for them to learn how to sustain their
changed eating, weight, and views about their bodies when they are not in a super-
vised therapeutic environment.
A third reason for the high relapse rate focuses on economic pressures from
insurance companies, which have cut the approved length of hospital stays for
people with eating disorders (and for those with psychological disorders in gen-
eral). Psychiatric hospitalizations have become increasingly short, which reduces
the amount of change that can realistically be accomplished during a stay. For
instance, one study found that the average stay of a patient who is hospitalized for
an eating disorder fell dramatically from 149.5 days in 1984 to 23.7 days in 1998
(Wiseman et al., 2001), and this decreased average length of stay may continue
(Calderon et al., 2007). Psychiatric hospitalization no longer provides long-term
treatment that yields enduring changes in eating habits and in thoughts and feelings
about food and weight; instead, hospitalization now responds to symptom-related
problems by stabilizing people when their medical or eating disorder symptoms ap-
proach a danger point (Wiseman et al., 2001). The “dose” of inpatient treatment is
shorter, and so it is not surprising that the “response” is shorter-lasting and relapse
is likely to occur. Marya Hornbacher described her experience:
In the last week of February, my vital [medical] signs stabilized and my [health]
insurance pulled out. I was discharged on grounds of noncompliance and insuffi cient
[insurance] coverage. Eating disorders are regarded, by the insurance companies, as
temporary and cured once the heart speeds up a bit. I was returned to my parents’
house, batty and sicker than when I’d gone in. The tiny bit of weight I’d gained in the
hospital scared me, and once discharged, I just stopped eating altogether.
(1998, p. 182)Prevention Programs
Many mental health clinicians and researchers seek to prevent eating disorders, par-
ticularly for those individuals most at risk (Coughlin & Kalodner, 2006; Shaw et al.,
2009; Stice & Hoffman, 2004): namely, those people who have some symptoms of an
eating disorder but do not meet all the diagnostic criteria. Prevention programs often
seek to challenge maladaptive beliefs about appearance and food and to decrease over-
eating, fasting, and avoidance of some types of foods. Prevention programs may take
place as a single session or multiple sessions, may take the form of presentations or
workshops, or may even be provided via the Internet (Zabinski et al., 2001, 2004).
At least under some circumstances, such programs can be helpful. Meta-analyses
have found that certain aspects of prevention programs (such as multiple sessions
rather than a single session) were associated with less disordered eating in partici-
pants, compared to those in a control group (Stice & Shaw, 2004; Stice, Shaw, &
Marti, 2006). Unfortunately, not all studies and reviews fi nd prevention programs
to be effective (Pratt & Woolfenden, 2002).