REDC was formed in 2011 partly as a result of the publicity surrounding my lawsuit, Harlick v. Blue Shield. Critics of the ruling focused on the lack of evidence supporting residential treatment’s efficacy, as well as the variation in licensing and standards; a group of centers came together to try and start addressing the weaknesses in the current model of care, and that group became REDC, Lampert said.
Currently twenty eating disorder programs are members of REDC. You can see which ones by visiting REDC’s Web site here. While “twenty” sounds small, according to Lampert, REDC members represent more than 45 different centers – which she says is the majority of the residential eating disorder programs. With no firm figures on the specific number of residential treatment centers in the U.S., however, it’s difficult to nail down such figures.
“We decided instead of competing with each other, we should work together to improve treatment,” Lampert said, about REDC’s genesis. “We wanted to be able to address those critiques and provide the back-up data to refute them…[by] delivering programs that were meeting the same set of national standards, and by starting to do collaborative, outcome research studies.”
Lampert disputed the notion that placing profit over quality-of-care accounts for why many adults end up cycling in and out of residential treatment centers for years.
“I think it’s because eating disorders are complicated illnesses that generally take a fair amount of treatment visits” to obtain recovery, she said. “There is also the insurance piece – when clients are forced out early they don’t receive complete treatment.”
The CARF standards REDC helped develop require programs offer treatment modalities supported by evidence, and recommend, for example, incorporating SSCM and modified CBT for adult clients.
The standards also require care be delivered by clinicians with expertise in eating disorders and specialist training, and require that even lower-level staff receive at least six hours of continuing education training in eating disorders per year. Centers must also pay greater attention to clients’ unique needs and history, as well as age, socio-economic circumstances, career goals and quality of life. The guidelines also call for more cooperative, collaborative treatment plans.
CARF’s general, behavioral health standards – which programs who obtain the ED accreditation also have to follow – require organizations track client performance post-treatment, and report that data to relevant stakeholders.
It remains to be seen whether other residential treatment centers follow the lead of programs like Castlewood, the Emily Program and the Center for Balanced Living by adopting the specialized, ED accreditation, and therefore committing to delivering empirically supported treatment, as well as providing higher levels of transparency and accountability.
But when I learned more about CARF’s accreditation process, I had to wonder – does accreditation really ensure quality control? While the initial obtaining of it requires an external, on-site review – in CARF’s case, the review is conducted by a group of expert practitioners – external reviews occur just once every three years following that (the same goes for JCAHO). Apart from the three-year site visits, CARF relies entirely on periodic, self reports completed by facility administrators to measure whether a program is in compliance with standards. Client input – whether current or former – as to whether centers are living up to quality standards is never part of the review process.
If you look at Castlewood Treatment Center’s Web site, you will see that they still utilize a type of therapy called “Internal Family Systems.” This treatment – as well as lacking no evidence-base whatsoever, and whose use with individuals battling eating disorders has been criticized by many leading experts – was at the center of a highly-publicized lawsuit which eventually led to the resignation of former founders, Mark Schwartz and Lori Galperin. The lawsuit involved former clients who accused Schwartz and other Castlewood therapists of using IFS to implant false memories of sexual and ritualistic abuse in them, among other things.
How can accreditation be a safeguard, if a facility which has the CARF seal of approval – whose criteria explicitly includes the use of empirically-supported therapies – is still prominently employing a widely discredited modality?
The required, post-discharge, outcome tracking is also left up to centers to conform with on a “good faith” basis. Centers are not required to report the data to CARF (or anybody else), nor provide proof that they’re even collecting the data. Programs are simply required to show that they have a plan to track client outcomes. While CARF provides recommendations as to which kind of outcome measures best demonstrate treatment efficacy, it is left to centers to decide what measures, and for how long, the programs will track client status.
But again, even if centers design a good plan – whether they actually follow through with this outcome tracking is not monitored by CARF or anybody else.
I asked Brad Contento, a CARF communications officer, whether heavy reliance on center self-reports, combined with minimal, external reviews, is sufficient to ensure private treatment centers are providing care that is in accordance with best practices and the remainder of CARF’s accrediting criteria.
Contento seemed to think CARF’s reporting requirements were rigorous enough to guarantee quality control. He said accreditation is an “ongoing” process, and that facilities are “expected” [my emphasis] to conform every year to CARF’s standards manual, as well as submit an Annual Conformance to Quality Report, among other things.
“CARF also maintains ongoing contact with accredited organizations to consult on how to maintain conformance in between surveys,” Contento said. “In addition, we maintain internal studies as to the benefits reported by organizations themselves [my emphasis]. Accountability to persons served, greater focus on needs and goals of persons served, and improved quality of service delivery are some of the top reported benefits seen after implementation of accreditation.”
But Contento also emphasized that CARF, like any accreditation agency, is not a regulatory or licensing body; the ultimate responsibility of center conformance with quality treatment guidelines lies with the state wherein a program resides, he said.
“Our standards are designed more as an overarching framework for quality that can accommodate multiple approaches to treatment, as long as they are accepted practices,” Contento said. “Generally, CARF standards would not get into the level of mandating or excluding specific treatments… CARF is not a licensure or regulatory agency, so we do not prescribe specific treatment methods.”
When you put this last statement in the context of the overall regulatory situation, it pretty much epitomizes the multiple gaps which exist in the system. Because, as stated earlier, most state licensing standards for eating disorder programs are minimal, lack specificity, and involve little oversight. Moreover, in some states, once a center attains accreditation from a national body, the state defers oversight to that agency, through a process called “deemed status.”