Therapists have boundaries too: A conversation about treatment contracts and ultimatums

What happens when someone with a high acuity eating disorder needs more support than can be provided in outpatient settings, but refuses a higher level of care?

Considering the high mortality rate of eating disorders, this question can quite literally be a matter of life and death.

In a previous episode on harm reduction, we discussed the value of meeting clients where they’re at and how high-risk behaviors can, and sometimes must, be mitigated in outpatient settings, especially for those with treatment trauma.

In this episode, we explore the flip side: the importance of acknowledging when a client’s needs exceed our limitations and, at times, challenging a client to seek higher levels of care, despite their apprehension, in the interest of preserving their safety.

Psychotherapist, Amber Cardemil reflects on how she supports and, when necessary, challenges clients with treatment ambivalence. We discuss the benefits and limitations of treatment contracts which clarify the minimum requirements for maintaining safety in outpatient settings and outline the conditions under which more intensive treatment becomes necessary. Amber also shares the nuanced, individualized nature of decisions as to whether to refer out or continue a therapeutic relationship based on the quality of rapport and individual client’s needs. Beyond the sticky, complicated ethical questions, Amber speaks to what it is to be a human being supporting someone who struggles deeply—what it's like to celebrate their growth, grieve their setbacks, and let go when it's time to move on.

Amber is a Licensed Clinical Social Worker with extensive experience treating eating disorders, food-related concerns, and co-occurring conditions. She is trained across all levels of care—inpatient, residential, PHP, and IOP—and has worked in admissions, assessment, individual, family, and group therapy. She is a certified Health at Every Size® provider and has advanced training in Family-Based Treatment for adolescents with Anorexia Nervosa.

She uses evidence-based treatments tailored to each client, with attention to individual and family dynamics. She empowers families to support recovery and collaborates closely with other providers to ensure effective, multidisciplinary care. In addition to eating disorders, she treats anxiety, depression, and life transitions.

Amber also provides psychoeducation to schools and universities on early detection and prevention of eating disorders, and serves as a Body Project facilitator through NEDA. She is a member of Project HEAL and is committed to equitable treatment access.

Treatment with Amber https://www.collectivehealingtherapy.com/about

Binge eating recovery with Elka https://elkacubacub.com/