Vector art by "Truffelpix," on Shutterstock.

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

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.”

Print this article | Print this page

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.

Leave a Reply

Your email address will not be published. Required fields are marked *