So Your Therapist Recommended HLOC…

…And you’re sure as heck not going.

Hey there! Emily and Erin here. We’re both therapists on the Bloom team specializing in eating disorders (EDs), disordered eating, and coexisting mental health issues. We have a lot of experience navigating ED treatment with our clients and thought writing about some of the considerations we have might be helpful to some folx who have recently been recommended a higher level of care (HLOC).

Let Yourself Be Heard

First of all, recall your first reaction (or maybe even your present feelings) after hearing from your therapist that HLOC might offer better care and support for your ED.

I can’t go to a facility!

I’m fine. I’m not sick enough.

What’s the point…

Only really thin white women get that kind of treatment.

I have school/work/family/that big trip… I don’t want to miss out.

Let these statements land with you for a moment. What is your emotional reaction? Your physical reaction? Your thoughts? Notice any tension or resistance that is present and practice allowing that to be here while taking a soft, smooth breath.

Maybe there’s a part of you showing up that is scared, angry, or resistant. It’s important to allow that part to be heard and to bring curiosity toward why your therapist might be recommending more support.

Your ED Might Be Mad

While bringing curiosity, what would it be like to externalize your ED (i.e., conceive as a separate yet interrelated entity of yourself) right now? If you haven’t explored this with your therapist, this can look like writing down some thoughts (or saying them out loud) that you are having about HLOC. How might your ED be impacting your automatic thoughts? Some things to consider…

EDs like their own rules.
- “If I go to a facility, I won’t be able to eat the way I want to.”
EDs try to minimize and can embolden a condition called Anosognosia.
- “My therapist is totally blowing this out of proportion. I am not sick enough. “
EDs get stuck in comparisons.
- “I won’t have anything in common with the other clients in HLOC because most of them are young, thin, white women.”
EDs can act as the “excuse maker”— there’s always a reason not to go to treatment.
- “I am really looking forward to Halloween this year. If I go to treatment, I’ll miss out on dressing up with my friends.”
EDs are not often logical.
- “Maybe I’ll deal with this after soccer season. It’s not a big deal that I passed out after practice. It just happened once.”
EDs like to negotiate.
- “I know I said I don't want to do group therapy, but I promise I’ll consider doing something differently if I don’t have to go to HLOC.”

What if Your ED is Right? (And what if the truth is more than that?)

The thing is, it can be really hard to identify when your ED is present. Some of the thoughts you have about HLOC might actually be true! We want to acknowledge that stigma around EDs has perpetuated unfortunate truths, while also encouraging you to get the care that you deserve. You are worth it and we will fight for your right for supportive care.

Your therapist did not make the decision to recommend HLOC lightly. In fact, your therapist (or someone on your treatment team) likely identified that some harm is being caused to your body, mind, relationships, or another area of your life for which more support is needed.

Here are some of the things going on in your therapist’s awareness:

“All eating disorders (EDs) are serious mental illnesses with significant, life-threatening medical and psychiatric morbidity and mortality, regardless of an individual’s weight.” (AED guidelines)

ALL organ systems and the skeletal system are impacted by EDs. Most complications can be reversed with early intervention.

Recommended lab tests/vitals can still have normal results despite the presence of an ED and the need for HLOC. (See Dr. Jennifer Guadiani’s book Sick Enough for more on why and how our bodies do this.)

Psychological impacts can include anxiety, irritability, obsessive thinking about food, apathy, low libido, and neurological deficits (like poor concentration).

EDs cause disconnection in relationships and disruptions in daily life. Have you ever skipped out on an outing with friends/family that included food due to feelings of shame, anxiety, or guilt? Have you felt so rigid in your routine that you could only think about exercise or counting calories while on a fun trip?

Outpatient treatment can be considered unethical and/or unsafe if an ED is causing harm to your body, mind, relationships, or other areas of your life. More structure in care might be needed to help reverse or stop the impacts of harm.

We Can Explore This With You

Putting this in all caps because it’s very important: YOU ARE NOT ALONE IN THIS.

There are other folx who have gone through this HLOC recommendation process, and emotions like anxiety and fear are very often a part of this process. Your therapist can help explore different levels of care for the best fit, work through barriers to accessing treatment, and most importantly, validate and support you in your thoughts, feelings, and emotions after getting a recommendation for HLOC. Your therapist can also help to create a plan and have specific referrals for you to look into.

For example, if finances are a barrier, Project HEAL may be a good resource for you. And, in exploring HLOC treatment center options, here are some common referrals that come from Bloom therapists: