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NEDA TOOLKIT for Parents c) Lack of motivation in treatment i. Discuss external influences on the patient’s motivation (i.e. stress within family) and emphasize the need for ongoing support during this difficult time. Also emphasize the triggering effects of these external influences and the likelihood of relapse if patient is stepped down too soon. ii. Highlight anything patient has said or done which would indicate patient wants recovery iii. Change something (medications, structure, schedule, therapeutic approach, anything that could spark a change) d) Inconsistent attendance i. If absences were planned or for legitimate reasons, the explanation should be enough. However, it always helps to discuss the reasons in clinical terms related to the patient’s recovery. (Ex:  The patient’s schedule was modified to allow her to work a few shifts per week. This was discussed with the treatment team and will alleviate some of the financial burdens that have distracted her from focusing 100% on recovery. She has worked with her dietary team to plan meals and structure outside of treatment). ii. If absences were not planned or were not for legitimate reasons, discuss the next steps the treatment team plans to take in order to encourage attendance. It is important to convey that the treatment team takes absences very seriously. It is also important to emphasize the patient’s need for extra support during this time. It does not hurt to speculate about the costs of terminating treatment while the patient is struggling. iii. Frame it as “struggling with the ED” and discuss interventions moving forward 4. Absence of Behaviors (i.e., patient is doing too well in treatment and may be appropriate for a step-down) a) Continued weight restoration is imperative for a successful recovery. Stepping down now would slow or stop restoration altogether. (This argument is especially effective with patients who have previously failed at restoring weight on an outpatient or IOP basis.) b) The patient has been using the program very effectively and is learning healthy coping skills. The patient is challenging herself with new skills and will benefit from additional time to practice these skills in a structured environment. c) The patient will have several meals off within the next week. The patient must complete several successful meals off before we can determine that a step-down would be appropriate. If the patient struggles with the meals off, he or she will benefit from the continued structure of program in order to identify and address the issues that arise. d) Emphasize the emotional/MH issues that contribute directly to the ED and the patient’s need for continued structure and support while beginning to address these issues. 5. No medical complications a) Emphasize the medical issues that the patient will likely develop if the behaviors continue. Serious, internal, long-term damage is not always apparent right away. b) Dig for more information from the patient and/or medical providers. Patients often minimize or deny medical issues out of embarrassment and may be more forthcoming once they understand the benefits of disclosing the information. c) Check the medical necessity criteria. Sometimes this is cited as a reason for denial even if it is not a criterion. In that case you have a pretty simple rebuttal. Page  | 51