Introduction
Nikki Fata is a registered dietitian and virtual private practice owner. She has spent the past 8 years working in the field of eating disorders with 5 of those years working in higher levels of care in eating disorder treatment. Nikki began her work experience at PHP and IOP levels of care, transitioned to RES and PHP levels of care, then transitioned to virtual IOP prior to starting her private practice and working in an outpatient setting.
What role does an RD have in the Intensive Outpatient Program (IOP) setting for eating disorders and how does it differ from other levels of care?
I would describe IOP as the balance between intensive support and individual freedom which allows clients to begin to thrive in their own lives and environments with decreased presence or without the presence of their eating disorder. This means that the role of the dietitian in this setting involves providing support to clients in balancing the demands of day-to-day life like relationships with family and friends, work commitments and schedules, meal planning, and grocery shopping, all while being in their own environment which often brings triggers, activating factors, and barriers that do not exist in a higher level of care.
In a level of care like PHP, RES, and inpatient, there is much more containment and less bombardment with activities of daily life which allows the client to focus solely on themself and their recovery. IOP brings the integration of treatment and daily life and conversations shift toward the sustainability of their thoughts and behaviors.
Give a description of an IOP level case.
In an ideal world a client would admit to an appropriate level of care based on their ED severity, medical and physical stability, mental stability, and motivation and willingness to change. This doesn’t often occur as smoothly as desired and things like client willingness, personal commitments or schedules, and insurance coverage often end up playing a major role in the admitting level of care.
This means that the type of client you may work with at an IOP level of care is extremely variable. Sometimes a client will present as a step down from a higher level of care like RES or PHP, is weight restored and medically stable, motivated for recovery, knows helpful coping skills to manage unhelpful emotions or thoughts, and ready to begin integrating treatment with their daily life. Other times a client will present in IOP when in reality they need a RES level of care, however, due to family and work schedule, IOP is all the client is willing to participate in. This makes it a bit more difficult to manage but not impossible. Boundaries, direct communication and compassion are necessary in this scenario.
Describe a typical day working in IOP.
A day in the life of an IOP dietitian depends on if you are scheduled to run IOP groups. Typically an IOP dietitian will be assigned a combination of group and non-group days. A typical group day involved a 3 hour time commitment which consisted of a skills or educational group, a meal support group, and a cooking group. Outside of group hours, I spent my time responding to emails from clients and other providers both within the treatment team and collaborating with outpatient providers, participating in continuing education and other training opportunities, creating content for skills/educational groups and brainstorming the cooking group recipe of the week, attending consultation or supervision meetings with the team and direct manager, and scheduling and meeting individually with assigned clients. Generally, my work day was ~8 hours but I was not required to clock in and out and report direct hours. I could work days, evenings or weekends and schedule clients when it worked best for my schedule. Because of the flexibility and independence in schedule, I found work-life balance to be great and stress was manageable. I found that the most stressful situations came with working with a client who was admitted to IOP and not appropriate for that level of care due to medical acuity or severity of ED behaviors. This then required increased communication and collaboration with the treatment team and strong boundaries. Beyond that, being invested in someone’s treatment can be difficult to manage. You want to see your client succeed and achieve their goals and it can be difficult when the eating disorder gets in the way of that. Learning to separate from your work allows for a sustainable work-life balance.
What are appointments like and how does an RD measure progress in IOP?
Individual client sessions are always approached collaboratively and begin with an assessment of how the client is managing nourishing themself. This involves discussions about completion of meal plan, assessment of adequacy of meal plan in meeting body’s needs, progress toward weight restoration or weight stabilization goals, reduction of ED behaviors, management of distressing physical sensations and ability to cope with negative or unhelpful thoughts, fact checking nutrition myths and food fears, and problem solving/planning tasks associated with eating such as grocery shopping and meal preparation/cooking. Dietitians measure progress in IOP by looking at a combination of all of these things and above all involves assessment by the client themself to determine where they succeed and struggle, to establish what support might be needed to continue to make positive changes toward their goals.
What type of person would be a good fit for this role?
Boundaries, direct communication and compassion are some of the characteristics needed to be a successful IOP dietitian. In addition, openness, use of humor, and willingness to connect and show aspects of your true personality are invaluable in this work. Clients need to feel comfortable talking about the ins and outs of their ED thoughts and behaviors and in order to create an environment that allows them to feel comfortable, they want to know that you are someone they can lean on as a professional support. Finally, time management and organization skills are beneficial in order to be as efficient as possible in this role.
How does working virtual IOP differ from in-person IOP?
Overall there is not much difference between in-person and virtual IOP. It comes down to what feels most important to you. If you feel confident working independently and have the experience working with eating disorder clients, virtual might be a good fit, but if you are a less-experienced dietitian, in-person IOP allows for greater opportunities to collaborate and learn from other providers who specialize in eating disorders. Virtual IOP provides the flexibility and freedom that may be desired after working with the ED population for some time, and personally, I found virtual IOP incredibly rewarding because I could continue working in a treatment center setting with a team of providers, but I had enough space and freedom to set my schedule in a way that worked for me. I also felt more than comfortable holding boundaries, running educational and cooking groups so the virtual environment felt like a nice new challenge and a way to mix up my work. Finally, virtual IOP allows you to work with clients who may not be able to access treatment otherwise related to their physical location or work schedule and family life. I found this rewarding on a different level. Regardless, working as an IOP dietitian allows you to be part of a larger team supporting ED clients at a lower acuity level and you get to see clients begin to live their lives with less involvement from their eating disorders. Win, win, win!
What advice would you give to students who want to work in IOP?
My advice to anyone considering working as a dietitian in an IOP setting is to ensure you feel confident and comfortable with nutritional counseling and in client sessions using motivational interviewing, have a good hold on your own relationship with food, feel able to manage questions from clients or activating conversations, and are equipped to hold strong boundaries. No one is perfect and some of these skills take time to hone. Set yourself up for success by taking on board opportunities to learn and grow. Whether that be from a direct supervisor, through work-sponsored training, continuing education, podcasts, books, etc, willingness to learn more is key in the field of eating disorders! Do not be afraid to say you don’t know or admit that you made a mistake. It’s important to keep client reactions and feelings in check. Be aware of bias that presents as a human and approach clinical situations using your best judgment. Recognize when you need to “drop the rope” and meet the client where they are at instead of trying to “cure” the client or set goals for the client. Most importantly, listen. Listen to your client, to the other members of the treatment team, to the client’s family and friends, to your supervisor. It can be difficult when you think you “know what to do” but remember that the client knows best. Listening and truly hearing your client will take you further than you think.
