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Buyer Beware – Behind the Smoke-And-Mirrors: How Residential Treatment Is Being Sold as “First-Line” Treatment For Severe Eating Disorders Despite Research Backing; The Problematic Variation In State Licensing Standards and Oversight Across States; and Whether Accreditation is Really a Remedy to the Lack of Quality Control

Our numbers are small, so maybe that’s one reason we’re so easy to silence. The lifetime prevalence of anorexia, in the general population, is 1 percent of women, and of that 1 percent, about 40 percent will recover within five years, and an additional 40 percent will achieve partial recovery. So while, as I will continue to demonstrate below, adult women with long-term anorexia are often being routinely subjected to forced treatment which decreases rather than increases our chances of recovery and at times rises, I believe, to the level of abuse and malpractice –we are tiny in number and stature, and thus hard to hear among the clamor of apparently more-pressing issues in mental health policy today.

And the most extreme of us look ghastly on top of it – only further reinforcing the incorrect perception that we’re literally out of our minds, one of the many widespread misconceptions about adult women battling severe and enduring anorexia (SE-AN)* which proliferate today. (Many women with severe, long-term anorexia are also not severely emaciated, per DSM standards, but struggle significantly nonetheless).

This article in my series will continue my attempt to shed awareness about how the eating disorder (ED) field’s continued institutionalization of women battling long-term eating disorders – particularly anorexia – is hurting more than helping, by taking a closer look at the lack of data supporting residential treatment’s efficacy, the wide disparity in licensing standards and enforcement nationwide, and the issues surrounding accreditation.

In an era of health care reform where more efficient spending of health care dollars, outcome-oriented accountability, is being stressed, it seems that examining what is looking more and more like a flagrantly wasteful use of insurance companies’ as well as families’ money is long over-due.

Particularly when you consider that, globally, we are spending more on inpatient treatment for individuals with SE-AN than we are for schizophrenia[i].

As noted in “Part 1” of this series, eating disorder treatment is a an estimated $3 billion industry, according to the most recent IBISWorld market report[ii]. Due to growing demand, industry revenue is expected to annually increase at – a minimum – a robust rate of 5 percent. The profit potential of the ED treatment industry is so ripe that nearly the entire market has been bought up by behavioral healthcare networks or investment firms. Acadia Healthcare, one of the largest behavioral healthcare conglomerates in the nation (following its purchase of CRC Health Group last year), owns many of the nation’s most prominent ED centers, including Timberline Knolls (Illinois), Sierra Tucson (Arizona), McCallum Place (St. Louis and Austin, TX), Montecatini (Carlsbad, CA) and Center for Hope of the Sierras (Reno).

The industry buy-out can work for good or bad, said Deanna James, director of marketing for Castlewood Treatment Center. While the influx of money can help improve programs, conglomerate ownership has the potential to hurt centers when industry giants purchase too much at once and impose standardized, cookie-cutter approaches on programs for efficiency and economics’ sake.

“It’s very hush-hush – treatment centers don’t want to be [publicly] branded as being owned by these conglomerates,” James said. “I do think it definitely plays a role in the quality of care.”

Castlewood – as well as the Eating Recovery Center in Denver – was itself bought up by a smaller, private equity firm, Trinity Hunt Partners, a few years ago. James said Trinity has not forced Castlewood to cut corners or compromise the center’s flexibility in the range of tailored treatment it offers clients, nor the center’s commitment to using empirically-supported practices. She believes the center has only benefited from its ownership.

[Disclosure: Castlewood Treatment Center is one of the many programs I’ve attended; I was a client there before it was bought by Trinity Hunt Partners, and before Castlewood obtained the quality-control accreditations which will be discussed below].

United Health Services, another huge behavioral healthcare network whose ED centers include River Oaks Hospital (New Orleans) and the Center for Change (Utah), is currently being investigated by the federal department of Health and Human Services for allegations of fraud and neglect that have endangered the welfare of patients. The investigation was spurred by a series of articles by two major newspapers, finding negligence, “cutting corners,” staffing failures and patient deaths across Arbour Health System facilities in Massachusetts, and violence and sexual assault, among other things, at some other, Midwest[iii]. United Health Services’ corporate office has also been under investigation for fraudulent Medicare and Medicaid billing.

But Jillian Lampert, a leader in the field and chief strategy officer of the Emily Program, whose levels of care include the Anna Westin House, hasn’t seen investment firm buy-out impact the quality of eating disorder treatment.

“I know that it’s a concern, but I think those [entities] are investing because they see some eating disorder programs as providing really high quality of care,” said Lampert, whose center remains privately owned and has not been purchased by any such company.

It’s impossible to know what, if any, impact this industry trend has actually had, because for-profit ED programs are, for the most part, not tracking clients’ long-term outcomes – leaving consumers with no impartial measuring stick by which to judge whether a program is effectively treating clients or not. The Emily Program is an exception, being the only private program I know, of to date, to have completed a 2 ½ year outcome study – including a control group – that will be published in the coming months. That study, and the state of outcome research in general, will be discussed in depth in “Part 3” of this series.

Despite the paucity of such research, however, insurance coverage of residential treatment continues to expand. National awareness campaigns by eating disorder “advocacy” groups – some of whose primary funding base is the for-profit, treatment industry – are constant, and insurance parity legislation, as a result, on the rise. Recently, the state of Missouri expanded insurance coverage for all levels of treatment, including residential, despite its unproven efficacy. If the federal government passes the recently-introduced Anna Westin Act this year, insurance providers in every state will be required to cover all residential, eating disorder treatment centers, regardless of the quality or efficacy of the treatment that center provides – a huge boon to the industry. While expanded coverage of eating disorder treatment is certainly a positive, it is essential consumers demand this legislative mandate come with strings attached: greater transparency and oversight of programs which now operate with minimal regulation and virtually no accountability. That the federal government allocate more of its medical research funds toward eating disorders, to help enable program outcome studies, is essential, too.

*The “SE-AN” diagnosis is generally used for individuals who’ve battled anorexia for seven or more years, have experienced multiple treatment failures, and have poor quality of life, among other variables.

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7 comments

  1. Hi Jeanene, Your articles are amazing. We need to link up somehow. Please contact me. I am linking to this article and recommending your site to others.

    I also know that “help” for anyone who can’t pay an outrageous fortune doesn’t exist out there, and that “no treatment” or to escape what is forced upon us is for most of us, the best option of all. I am not the only one who “got better” by realizing that all the lies taught to me over the three decades I spent in “therapy” were completely false, and their drugs were useless to me and poisoning my body. My aim now is to get my family back, to repair the lies that were told to them, and to warn others not to fall into the trap I fell into. My blog is at http://juliemadblogger.wordpress.com (or http://www.juliemadblogger.com).

    Julie Greene

  2. Melanie says:

    Wow! You are so spot on about the needs of treatment for older women! I’m 48, have been in multiple treatment centers, inpatient and out, for the over the last sixteen years. You’d think I’d be in a much better place after having had this much “help”. What I am dealing with now is the shame and humiliation of not being “willing” or “compliant” enough to beat SA. I’m at the lowest BMI I’ve ever been at, the most depressed/anxious and feel I’ll never get better. The most recent attempt at residential was a year ago. Due to my low weight I was forced to sit in a wheel chair every waking moment without any concern how this would affect my severe chronic spine condition (would have been much happier being stuck in a bed tube fed). I complied like a good little girl and the result was the worst pain I’ve had in years finally crawling out of the chair just to lie on the floor bawling and praying for relief. This happened on a weekend which meant there were no specialists at the center. A 20 year old tech admonished me to get back into my chair or I would be in trouble. That’s when I said, “ENOUGH”! so checked myself out never going back. I got an apology from the center but the damage was done. I spent the next month trying to recover from the immense pain and damage of being in that flimsy wheelchair. My doctor was aghast at what happened. And by the way, I was expected to wait for a tech every time I needed to get my meds, eat, go to the bathroom, group, outings, etc…They were way understaffed so I just sat in a hallway most of the day waiting for anyone to help me. The crazy thing is they knew about my concern for individualized care but once they got me in there I received none. I’ll end by empathizing with you and the forced medication issue. At one center I was on enough gabapentin and Serequel to sedate an elephant. I was a walking zombie. When my family came to visit they said it was like I had a lobotomy. The center stated that if I refused to take the meds as directed my insurance company wouldn’t pay my bill and I’d be responsible for the charges. Ugh. Let’s keep this conversation going. THANK YOU FROM THE BOTTOM OF MY HEART FOR WHAT YOU’RE DOING!!!!

  3. Kate G says:

    I have experienced the horrors of a residential treatment center and also the benefits of one. I have gone to two programs and they were as different as night and day. I left the first program much worse than when I entered and relapsed within three months when I then entered my second program. This program was different. They were kind, nurturing, effective and knowledgable. I spent about six months there and that time “jump-started” me into recovery. I left in a very solid place and have now managed to remain treatment center free for about four years. I do credit this to the intense work that happened at that center. They took a whole person approach as well as an individualized patient approach and I (and many other women) responded well to it.

    I won’t say they cured me but I will say that they made it possible for me to begin living in the world again. I’m not in any way, shape or form functioning as a normal person of my age but I am stable enough with my ED that I can be treatment center free and remain physically stable. I struggle more with my co-morbids than I do my ED.

    I agree that residential centers need more oversight and outcome studies but I do think there are more good ones out there than you are implying in your article. And perhaps they shouldn’t be the first line of care but in an area like my own where the next level of care offered up from 1 hour OP sessions is an IOP four hours away there isn’t many other options to receive more intensive help. Perhaps a good answer would be to offer more day programs and the like but I can’t see that happening in my area of the country.

    I do think many of the quality residential programs often aren’t covered by insurance and so many people are limited in their options and end up in places that do have poor success rates and very poor programs. I do believe you when you say that you believe a different approach should be taken for SE-AN. However, for more typical and early manifestations of the disease I do think quality RTCs can be very valuable.

    I look forward to reading the rest of the series but I do hope you fairly portray RTCs when you write the section of experiences inside the centers. Not everyone has the horrible experiences you had. Some like me had good experience and I hope you portray a fair representation.

  4. Krista says:

    As someone who, for many years, was what most would call a “revolving door treatment kid” I have seen the best and worst treatment has to offer. I can say now, with complete confidence, that after a 15 year battle with anorexia, I am recoverED. Not “in recovery” like most facilities tell you that you will always be, but recovered. I have been kicked out of centers, called a chronic case, a hopeless case, and I am now recovered. Have you looked into the Monte Nido programs? I seriously owe them my life. They are the only program have I have been to that fights the eating disorder, not the client. It is the most well rounded program I have ever been to and the founder is one of the most amazing, humble women I have ever met. I worked with therapists, RDs, trainers, etc. who were recovered. I never once felt like it was just some talking head who really had absolutely no idea what I was going through. When they said they understood, it was the first time I was in treatment that that phrase didn’t make me absolutely irate because I knew they actually did understand. They fed my soul as well as my body and made me realize that I had the ability to live the life I wanted to.

    My first treatment experience was Remuda Ranch and where I thought I had failed, it was a case of the facility failing me. It was before insurance would even consider covering eating disorder treatment- they wanted my parents money. They wanted to strip me down and make me feel like I needed them and couldn’t continue to do any of the things I loved if I “really wanted to get better.” I’ve also been to my fair share of inpatient facilities- only one of which I would ever recommend to anyone. Anyway- your article was an interesting read and one with plenty of merit. I’m just saying, I did find the right place, and they weren’t after my money and genuinely wanted me to succeed. I’m still in contact with the majority of the staff i worked with and visit the house any time I’m in California. There is an up side out there- it’s a matter of knowing the questions to ask and what to look for.

  5. Melinda says:

    I would be so interested in your continuing this series. It’s given me a lot to think about. I work in the mental health system in authorization, and find it so interested to see that there is such little evidence based practice for eating disorders, and also find the comparison to SUD services interesting- long term residential isn’t proven to be effective treatment, so my agency generally prefers community based treatment. However, I feel conflicted–I went to a residential program when I was 18, and thankfully have been in recovery ever since. I had tried lower levels of care prior to that and was in a perpetual cycle of brief stabilization and relapse. From the authorization perspective I can completely understand why insurance doesn’t want to pay, and think it’s horrible that there is such little accountability for providers, which results in poor patient care. It’s so sad to think that so many of these for profit companies are earning billions, while the patients are chronically ill with a poor quality of life, or even death. But I also do feel personally thankful to a residential facility that aided me in getting my life back…All that to say, I hope you keep writing. It is prompting a lot of good thought, and hopefully change.

    • Melinda says:

      To clarify-my own treatment was eating disorder treatment, not SUD, which is why I feel so conflicted. I can see why you write what you do, and how the system has failed, but have also maybe by a stroke of luck been fortunate to benefit from it, and was fortunate to have received compassionate care/not have a traumatizing experience, although I now see that isn’t always the norm. Thanks for sharing your research and perspective on this difficult topic.

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