Tips and conversations about Higher Level of Care (HLOC)
Imagine being asked to go to a place alone, without friends or family, comforts, or familiarities. Now, imagine this place might have the capabilities to take your identity away, to transform the way you survive, to show you a ‘better’ way of living, yet this way of living is something that is unfamiliar, and terrifying.
The first tip that I can give any dietitian (or clinician) is to appreciate the emotional roadblocks that individuals experience when HLOC is on the table.
I would say (anecdotally) that north of 90% of those who I have ever referred to HLOC are terrified of going. Usually people are extremely worried about
‘not being sick enough’, or
‘what if the level of care doesn’t help me to get better?’, or
‘what if I fail?’, or
‘what if I succeed?’, or
‘what if I don’t fit in?’.
Also, worries like, ‘is Shawna just trying to get rid of me?’, ‘I don’t want to leave my family’.
These are all real and understandable worries that need careful attention and tending to with a dedicated treatment team. Our jobs as dietitians is to validate these worries, provide reassurance, support and patience. Including frequent discussions with the team therapist and medical provider, to ensure you are all on the same page.
This may sound like,
“I can imagine that the mere idea of attending residential sends your brain into a tornado of worries. I can tell these worries are stopping you from receiving the care that you need and absolutely deserve. I am hearing that you are scared of missing your family and not being sick enough for the program. These are real and understandable worries, and of course it makes your eating disorder loud and angry. I am so sorry this is happening, and I want to assure you that I’m not going to give up, even while your eating disorder is loud and bossy.”
The second step is to appreciate that HLOC is not there to eradicate the eating disorder, to transform the person into a fully recovered individual.
Rather, it is there to build capacity for the taste of operating with a nourished brain and body, or maybe building trust that recovery is possible. Communicating this to individuals and families is so important to help set expectations.
This may sound like,
“I’m hearing that you are so worried that HLOC will take your eating disorder away. You have relied on this way of coping, and it has allowed you to survive many obstacles. As we know, this eating disorder has taken away so many valuable things in your life that have brought you joy and comfort. We all want you to have these beautiful things back in your life, as while you are terrified of going, the inpatient stay will help you to build that capacity so you have room for more of these things that bring you joy.”
While we all wish these kinds of conversations will somehow flip that emotional switch and allow the space for individuals to just say, “yes, let’s do this”, I’m afraid this isn’t usually the case. Usually what we see are many sessions spent validating, reflecting, supporting and caring, and perhaps taking the lead on submitting the application for HLOC, even if the person is hesitant.
It feels terrible for many clinicians to feel as though we are ‘forcing’ someone to attend HLOC. Yet, when we appreciate the nature of the eating disorder, which ultimately resists treatment, we can replace the word ‘force’ with the word ‘support’.
Bringing up HLOC is never a threat, or an ultimatum, yet a way of cheerleading individuals to take these brave steps to build the capacity towards a life that feels good.
What are your thoughts? Leave your comments below: