CLINICAL PRACTICE GUIDELINES for the BC EATING DISORDERS CONTINUUM OF SERVICES SEPTEMBER 1, 2012 < ONLY REVERSE OUT OF PHC BLUE, BLACK AND PHC OCHRE Ministry of Health (Project Leader) Gerrit van der Leer, MSW, Director, Mental Health and Addictions Authors Josie Geller, PhD, R. Psych, Director of Research, Eating Disorders Program, Providence Health Care. Associate Professor, Department of Psychiatry, University of British Columbia. Shawna Goodrich, MSW, Former Clinical Director, Eating Disorders Program, Providence Health Care Kathy Chan, MA, Graduate Student, University of Ottawa Sarah Cockell, PhD, R. Psych, Psychologist, Heart Centre, Providence Health Care Suja Srikameswaran, PhD., R. Psych, Professional Practice Leader, Psychology, Providence Health Care, Outpatient Psychologist, Eating Disorders Program, SPH, Clinical Associate Professor, Department of Psychiatry, University of British Columbia Provincial Advisory Committee Connie Coniglio, EdD, Clinical Director, Provincial Specialized Eating Disorder Program for Children and Adolescents, BC Children’s Hospital. Pei Yoong Lam, MD, FRACP, Assistant Clinical professor, Division of Adolescent Medicine, Department of Pediatrics, University of BC. Provincial Specialized Eating Disorders Program for Children and Adolescents, BC Children’s Hospital. Kim Williams, RD, Dietician, Eating Disorders Program, Providence Health Care Randy Murray, Practice Lead, Mental Health and Substance Use, Interior Health Shelagh Bouttell, MSc RD, Nutrition Therapist, Fraser South Eating Disorder Program, Fraser Health Authority Anne Merrit-Hiley, MSW, RSW, Program Coordinator, Fraser South Eating Disorders Program, Fraser Health Authority Miranda Pearson, RPN MA, Coordinator, Vista Residential Facility,Vancouver Coastal Health Authority Cliff Duncalf, MD, FRCPC, Psychiatrist, Vancouver Island Health Authority, Victoria, BC. Julie Dhaliwal, BA CYC (cert), Manager, Youth Regional Services and Eating Disorders Mental Health and Addiction Services, Northern Health Sandi DeWolf, MA, Team leader, Eating Disorder Clinic, Early Psychosis Intervention and Youth Mental Health & Addictions Outpatient Services, Northern Health, Prince George Eating Disorders Clinic Rachael Johnson, MC, Eating Disorder Clinician, Child & Youth Mental Health Catherine Carr, Med, RCC, CEC, Child and Youth Mental Health Policy, Mental Health Consultant Eva Hemmerich, MD, CCFP, Primary Care Physician, Courtney, BC Provincial Expert Consultants Dr. Jane McKay (Internist, specialist in adult tertiary care) Dr. Lori Taylor (Registered Psychologist, specialist in adult tertiary care) Dr. Bertrand Wicholas (Psychiatrist, specialist in adolescent tertiary care) International Experts: Ivan Eisler, PhD Joint Head of CAMHS Eating Disorders Service Professor of Family Psychology and Family Therapy Joint Head of the Trust’s, Child and Adolescent Eating Disorder Service Professor of Family Psychology and Family Therapy at the Institute of Psychiatry, Kings College London. Bryan Lask, MD Prof of Child and Adolescent Psychiatry, University of London Academic Director, Ellen Mede Eating Disorders Service, London Research Director, Regional Eating Disorders Service, Oslo, Norway President, Eating Disorders Research Society Daniel LeGrange, PhD Professor of Psychiatry & Behavioral Neuroscience, University of Chicago Marion Olmsted, PhD Director, Eating Disorder Program, Toronto General Hospital, University Health Network Professor in Psychiatry, University of Toronto Stephen Touyz, PhD Professor of Clinical Psychology and Honorary Professor in the Discipline of Psychiatry, University of Sydney Co-Director, Beumont Centre for Eating Disorders Walter Vandereycken, MD, PhD Professor of Psychiatry at the Catholic University Leuven Clinical Director of the Eating Disorders Unit of the Alexian Brothers Psychiatric Hospital in Tienen, Belgium This report is available on the British Columbia Ministry of Health – Mental Health and substance use website: http://www.healthservices.gov.bc.ca i TABLE OF CONTENTS TABLE OF CONTENTS ACRONYMS ..................................................................................................................................... 1 BACKGROUND ................................................................................................................................. 3 QUALIFYING STATEMENT............................................................................................................... 4 EXECUTIVE SUMMARY ................................................................................................................... 5 Key Principles .............................................................................................................................6 OVERVIEW OF THE GUIDELINES .................................................................................................... 9 Scope ..........................................................................................................................................9 Methodology ...............................................................................................................................9 Limitations ................................................................................................................................10 Layout of Guidelines .................................................................................................................10 PART 1: GENERAL OVERVIEW ......................................................................................................11 Barriers to Engagement ............................................................................................................11 The Significance of the Therapeutic Alliance .............................................................................12 Engagement and Readiness Across the Continuum ...................................................................12 Clinician Stance ........................................................................................................................13 Therapeutic Boundaries / Treatment Non-Negotiables ..............................................................14 Collaborative Care, Teamwork and Role Clarity .......................................................................15 Family and Caregivers ...............................................................................................................16 ii MINISTRY OF HEALTH SERVICES TABLE OF CONTENTS PART 2: TREATMENT PLANNING ACROSS THE CONTINUUM OF CARE .................................... 17 The Short Treatment Allocation Tool for Eating Disorders (STATED) ......................................17 PART 3: ASSESSMENT ................................................................................................................. 21 Diagnostic Criteria ....................................................................................................................21 Clinical Interview ......................................................................................................................24 Nutritional Interview ...............................................................................................................34 Readiness and Motivation for Change .......................................................................................36 PART 4: PRIMARY CARE ............................................................................................................... 37 Identification & Screening ........................................................................................................37 Barriers and Solutions to Effective Screening ............................................................................39 Ethical Issues .............................................................................................................................55 Self-Help ...................................................................................................................................55 PART 5: LOW INTENSITY OUTPATIENT TREAtment – ENGAGEMENT OR RECOVERY FOCUS (STATED SECTION A) .................................................................................................................... 56 Rationale for this Level of Care ................................................................................................56 Patient Profile ...........................................................................................................................56 Determining Type of Outpatient Treatment .............................................................................58 Description and Guidelines: Engagement and Preparation Focus ..............................................59 Description and Guidelines: Recovery Focus .............................................................................64 Patients in Transition .................................................................................................................76 CLINICAL PRACTICE GUIDELINES FOR THE BC EATING DISORDERS CONTINUUM OF SERVICES iii TABLE OF CONTENTS PART 6: RECOVERY-FOCUSED INTENSIVE (DAY, RESIDENTIAL, INPATIENT) TREATMENT (STATED SECTION B) .................................................................................................................... 77 Rationale for this Level of Care .................................................................................................77 Patient Profile ............................................................................................................................77