To Refer or Not to Refer? When to Seek Higher Levels of Care During the Holidays – Jeana Cost

<p>Individuals struggling with eating disorders can present as unmotivated, resistant and willful when confronted with the recommendation to enter a higher level of eating disorder care (partial hospitalization and above).&nbsp;This ambivalence may be heightened during the holiday season. Here&#39;s why.</p>



Individuals struggling with eating disorders can present as unmotivated, resistant and willful when confronted with the recommendation to enter a higher level of eating disorder care (partial hospitalization and above).

This ambivalence may be heightened during the holiday season as patients face common seasonal triggers, including:


  • Having more unstructured time away from work and school
  • Spending more time with family and friends
  • Attending many food-centric gatherings

While understandable, a patient's resistance to enter treatment simply delays their admission to a treatment program. It also delays the structure and support that this patient so desperately needs in order to both 1) interrupt eating disorder behaviors and 2) restore and maintain medical/psychiatric stability. 

At ERC, we believe that outpatient treatment professionals can be powerful champions for encouraging individuals to seek effective treatment at any time of the year — including the holidays. 

We encourage treatment providers to consider taking the following three steps with their high-risk patients as the holiday season approaches:

1. Consider assessment 

Build in a window with enough time for assessment before you take your own time off — to determine whether clients can make it through the holidays without the regular support to which they are accustomed. Often, providers will return from vacation to find their patients have deteriorated; patients often try to attempt to manage the perfect storm of holiday triggers — even with lower accountability and less support. 

"This should not deter outpatient providers from taking time away from their practice; time off is essential to preventing clinician burnout when working with high-risk and complex eating disorder patients. Prior to vacation, however, a thorough evaluation of patients’ likelihood of maintaining treatment gains and stability is essential, especially during this triggering time of year.” - Jeana Cost, LPC, CEDS

Consult APA guidelines and level of care criteria. These tools provide objective criteria that can help outpatient providers recognize the small signs of deterioration that signal a need for additional support and containment.

2. Know how to respond to what-if's

We recommend that you listen compassionately to your patient's motivation and logic for wanting to “stick it out” in an outpatient setting during the holidays. But, before sessions, prepare compelling responses for patients that are struggling.

These are some of the more common reasons we hear from patients; you may want to prepare responses for these and others:

  • “I’ve been in outpatient treatment so long; what are a few more weeks?”
  • “If I wait to enter treatment until after Thanksgiving, I might as well wait until the New Year.”
  • “I need to finish out the semester to avoid academic penalties.”
  • “I already have plans over the holiday break/vacation.”
  • “Time with friends and family will help me.”

Have effective, supportive responses ready to go in advance. Messaging should communicate why postponing treatment may further jeopardize the patient’s mental and physical status.

“Well-meaning providers can tend to side with patients wanting to remain at a lower level of care during the holiday season because it's true that it is less disruptive and disappointing. Also, many patients have been in outpatient treatment for so long that ‘What’s a few more weeks?’ seems like a reasonable argument to not advance to a higher level of care. The reality is that the holiday season is a particularly triggering time of year that makes maintaining treatment gains and avoiding relapse more challenging for patients. Be understanding and validate patients’ ideas about treatment while remaining confident and firm in a treatment recommendation.” - Jeana Cost

3. Let your patients and families know what to expect

You can help your patients and their families navigate practical concerns for delaying admission to a higher level of care during the holidays. Beyond disrupting holiday plans and traditions, treatment costs and insurance coverage are often viewed as significant barriers to treatment — and, in reality, they certainly can be. Costs and insurance coverage are important—and often stressful — aspects of any conversation about entering treatment at a higher level of care — not just during the holidays but year-round.

In many cases, admitting to a higher level of care and using available benefits before the end of the year can be a cost effective strategy as policy deductibles renew in January.

Should your patients have questions about insurance benefits and treatment costs, our Business Office staff are available to help patients and families demystify behavioral health benefits and navigate seamless transitions into treatment.

For additional support, our Clinical Assessment team is available to provide consultation and insight when developing a holiday treatment recommendation. 

Call us at (877) 711-1690 to speak to our team and to get more information. You can also email us at

Jeana Cost, LPC, CEDS is VP, Patient Engagement at Eating Recovery Center and has been with the center since 2010.

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