What does an RD do in a PHP setting?
The primary role of the RD in the PHP setting is to monitor a patient’s meal plan, and support the patient in their efforts to combine recovery with their real life. Most patients who are in PHP are there as a “step-down” plan from a Residential Treatment Center. The PHP dietitian’s role in this case is to be the support for nutrition challenges that arise when the client is inside and outside of treatment. A typical session may include meal planning for meals outside of program, identifying barriers to having adequate meals/snacks outside of program, and more. The main difference between PHP and inpatient/ residential care is that in the PHP setting, the patient goes home. So, the RD in the PHP role is to be collecting evidence for eating behaviors inside and outside of program. A PHP dietitian, on the other hand, has more access to evidence of eating behaviors on program than one would have outside of program. There are many more opportunities for support in the PHP level care than there are in the outpatient level of care.
Give a description of a PHP level case
Medical: Possible osteopenia/osteoporosis from restriction, possible amenorrhea
Physical symptoms: can be anywhere from 80/85%-100% of IBW. Typically, a client has experienced some level of weight restoration prior to entering PHP but this is not always the case.
Psychological symptoms: we see a lot of cooccurring diagnosis including but not limited to Obsessive Compulsive Disorder, Anxiety, Depression, various personality disorders, and more.
Severity of ED: This varies greatly. A lot of folks who may benefit from a HLOC such as residential will enter PHP on what’s called a “lower level of care agreement”. This means that the team believes they need more support than PHP, but they are willing to do PHP on a “trial run”. Because of this, the severity of the eating disorder at admission varies. However, in theory, someone in PHP should be able to be in a place where they can, for the most part, avoid engaging in behaviors outside of program. As far as %EBW (Expected Body Weight) goes, I would say we see clients at about 85-95% of their EBW.
Motivation to change: I think PHP an be really motivating for many because it’s typically an exciting time where clients have opportunity to engage with the “Real world” after RTC. Sometimes being back home with families can be motivating for folks, and being around other recovery-oriented individuals in PHP can help as well.
Barriers to change: I think the same things that can feel motivating can also be barriers. Being home with family can be exciting and motivating, and can be challenging when family members say well-intended (or not) diet-culture comments for example. This is the type of stuff we deal with a lot in PHP. How do you manage triggers from the outside world without reverting to your eating disorder.
Describe a typical day at your job
As a PHP dietitian, I would typically start my day by reviewing the meal and snack notes to see if my clients completed their meals in program. I would also check weights, any recent labs, etc. A big part of my job is also communicating with the therapists to see if there is anything that happened in or out of session they think I should know about. I would then have session with my clients and check in about meal plan completion outside of program, and typically talk about some goals we can set for the upcoming week (goals can include meal challenges, completing certain meals/snacks, having dinner out with a friend, bringing a hard food to program, etc.). I then spend time charting (least favorite part of my day lol). I may keep outpatient providers updated after this. On certain days, I may run nutrition group, or sit for lunch as a support person for the clients where I would eat with them.
How does an RD measure progress in PHP?
Lab values, and psychiatric stability – especially as it relates to the severity of the eating disorder thoughts and urges – are progress markers. However, I would say the biggest measures for an RD in PHP would be weight and meal plan completion. The goal is – for the most part – to complete 100% of the meal plan in and out of program. If a client/patient I able to do so for a significant amount of time, the team may want them to step down to IOP to see how they do with less support. On the other hand, if a client is unable to complete and/or gain weight at an appropriate level (typically 2-5#/week), there may be conversations about stepping up to RTC.
Describe your work-life balance
Work life balance is complicated because its hard not to take the emotional weight of this work home with you. The work is heavy and complex and it travels home a lot. Some of these clients need a lot of attention and support and it sometimes takes away from your ability to get things done in a timely manner. The art of boundaries is so key here, I’m still really working on it honestly. It’s a stressful job for that reason – there are big decisions happening in regards to people’s lives (careers, education, health, etc.) on a daily basis, and that feels big and heavy. Its so important to build in lightness throughout the day and self-care. I would say I probably average at about 8.5hours a day – sometimes its more sometimes its less. I do not work on the weekends.
What are the best and most rewarding aspects that are unique to the PHP level of care?
Seeing people grow their world outside their eating disorder. I love when a client is really doing the work and towards the end of their PHP stay they’re almost bored of the eating disorder. They just don’t really care about the thoughts anymore and they find them uninteresting and annoying. I just find this so rewarding and exciting for them – it opens up so much space in their brain to have fun, engage with loved ones, focus on school or work or hobbies. That’s fun and I’d say pretty unique to PHP since they’re going home and actually doing the fun things.
What are the biggest challenges you face in the PHP environment and what advice would you give to a new RD or intern stepping into this setting?
The biggest challenge is that a lot of clients come in that should be in residential but they’re maybe afraid to go. Its challenging because it typically leaves the RD vulnerable to doing more work than the client is capable of doing in the PHP level of care. My biggest piece of advice is to upfront with the client about the team’s expectations so there isn’t confusion if the discussion about stepping up has to happen. And you really can’t work harder than the client. Its so easy to want to because we care about them, but it rarely works… They have to want it.
What classes or experiences helped you the most?
MNT! I rely a lot on my basic nutrition knowledge when educating people. Other than that, it’s just been so helpful to learn about eating disorders and other co-occurring disorders from the therapists I’ve worked with. The best part of treatment center work is the interdisciplinary team. Everyone has such amazing ideas I pull from every day.
What soft and interpersonal skills do you rely on the most in this setting?
Empathy and listening skills. A lot of this work is managing emotional and physical discomfort that can’t necessarily be “Fixed” but has to be felt. Feeling emotional and physical discomfort is hard work and scary and sometimes the clients just want to be heard or know they’re being supported.
What type of personality is this role perfect for?
I honestly think there is room for a lot of different personalities. I’m a sociable, talkative person which makes it easy to connect with people but sometimes challenging when holding boundaries. Anyone who has a passion for helping people normalize food and feel good in their bodies can fit in this space.
How many years of experience should an RD have before working at the PHP level?
It might be challenging to enter as an entry level dietitian without any supervision at this level of care. The treatment is so nuanced and eating disorder work is so specific. However, in a lot of PHP settings, there are multiple dietitians, which I think can make it the perfect setting for an entry-level dietitian who wants to work in this field. I actually recently transferred to a residential site where I’m the only dietitian which I think would be really difficult without my 2 years of experience. I would tell any students who want to work in this level of care (and this field in general), to reach out to treatment centers and inquire about Recovery Coach positions. The dietitians work so closely with the Recovery Coaches, and the Recovery Coaches know the ins and outs of treatment to be successful at their role.
How do you see the PHP level of care evolving?
I think PHP level of care is becoming a first-stop for more people, especially for those who don’t have access to residential level benefits. I think the PHP level of care is so beneficial because it helps with the transition to the “real world”. It really allows people to rely on the support of treatment while gaining independence before jumping right back into the world. I would hate to see the PHP level of care be abolished.
Do you have any
I kind of said this above but get a part-time job at a treatment center if you can. There’s really no better way to learn than to do. I also love the book Nutrition Counseling in the Treatment of Eating Disorders by Marcia Herrin and Maria Larkin. SickEnough by Jennifer Gaudiani is also a great read. Understanding the medical complications of eating disorders is paramount at this level of care.
