The state of Missouri, for example, stopped overseeing Castlewood Treatment Center’s standards compliance once it obtained its Joint Commission and CARF accreditations, James said. JHACO and CARF are now responsible for ensuring Castlewood is living up to acceptable practice standards.
So let me spell this out: We have organizations like REDC or the AED offering accreditation as a solution to the disparity in licensing standards across states. But when you dig into accrediting bodies’ conformance criteria, you find the bodies’ assessment of whether a center is meeting standards to be mostly-based on inherently unreliable self-reports. And then, when you ask the accrediting bodies about the questionable reliability of such compliance measurement, the bodies say, “Well um, you know, please remember, we are not a regulatory agency.”
Which basically amounts to a regulatory, feedback loop in which no consumer has any assurance standards are being followed. Checks and balances are virtually non-existent.
I had already searched the academic literature for studies investigating whether accreditation impacts quality-of-care at eating disorder programs – there are none. So, given that, I asked Contento if he knew of any other studies as to whether accreditation impacts, similar forms of mental health care. He pointed me toward a few studies, and I did some additional literature searches myself. Most of the studies that have been conducted, however, are on facilities such as nursing homes and assisted living facilities. The study with the most similarity to for-profit, eating disorder treatment was an impact study conducted during 1998 – 2002, by the U.S. Department of Health and Human Services, which looked at whether accrediting opioid treatment programs through JCAHO or CARF improved the quality and effectiveness of these programs. The study evaluated 175 programs in 15 states. Like women with severe, long-term anorexia, the client demographic was also trending toward older individuals with more complex social and medical needs. Evaluators also noted the increasing role for-profit programs were playing in opioid treatment.
While the study unfortunately relied heavily on staff reports of accreditation impact, it nonetheless provided some helpful information. Overall, it affirmed that utilizing an accreditation-based regulatory model improved overall care and oversight[x]. Accredited programs, as compared to non-accredited ones, offered a greater array of comprehensive services, and 74 percent of program directors said accreditation improved their monitoring of patient outcomes. Seventy percent of administrators said accreditation improved programs’ quality assurance procedures. Shortcomings noted were a lack of patient input into care design and quality, and a need for better-specifying the protocols used to carry out routine yet critical functions – something which I also think CARF’s ED accreditation standards could use (CARF provided me a copy of the standards).
In another study – a 2007 evaluation of outpatient, substance abuse programs that looked at statistics from the National Survey of Substance Abuse Treatment Services database – positive results from accreditation were also found[xi]. Substance abuse programs in states where accreditation was mandatory had significantly more wrap-around and continuing care services than programs in states which only required licensure to operate. The enhanced serves were associated with better, long-term client outcomes.
While these substance abuse studies provide tentative indication that CARF’s (and JCAHO’s forthcoming), specialized accreditation could ensure better quality control at treatment programs which obtain it, it’s still clearly too early to tell what the impact will be. Some changes Castlewood has implemented since adopting the CARF accreditation do seem to be in line with what is now considered best practices for adults – for example, according to James, Castlewood has shifted its residential treatment protocol to keeping clients at that level of care for as little time as possible, and then transferring them to the center’s day or intensive outpatient programs.
“It’s becoming clear that these long, long lengths-of-stay, in residential treatment, are not appropriate… What works is keeping people connected to their lives,” James said.
CARF’s eating disorder-specific standards, James added, “help ensure we are keeping up with all the latest research” so that such empirically-supported models are followed.
So while I hope that specialized accreditation will improve treatment quality and accountability within the for-profit, eating disorder treatment industry, I remain worried nonetheless – particularly considering the gaps discussed above. There also remains the fact that only six programs currently have the ED accreditation, and that we may have to way until July 2016 until more attempt to get one.
The substance abuse studies on accreditation – while positive – do not necessarily translate to eating disorder treatment, either. While the illnesses certainly have some commonalities, eating disorder and substance abuse treatment are two different animals.
The only reliable way to know whether residential – or any level of private, for-profit, eating disorder care – is actuality helping clients, is by conducting post-discharge outcome studies such as the one recently completed by the Emily Program. That’s why we will turn to examining the striking dearth of outcome research in the field of eating disorder treatment in “Part 3” of this series. While I am well aware of the costliness and complexity of this form of research, the time for excuses is over. Women’s lives are at stake. Demanding that the private treatment industry start implementing this essential check on an unregulated system is urgent; until such reform occurs, we won’t be able to even begin to answer what type or level of treatment can truly help people battling the most lethal mental illness in existence today.
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Forthcoming articles in this series include:
- Part 3: An Essential, Failed Check on the System: The Dearth of Client Outcome Tracking by For-Profit, Eating Disorder Centers; How it Contrasts with the Transparency Provided by Hospital/University-Based Programs as well as Treatment Centers Outside the U.S.; And Efforts Being Made by a Small Coalition of Quality-Committed, Residential Centers to Remedy This
- Part 4 What’s So Wrong With Standard Treatment Practices Used With Adult Clients in Most U.S. Programs Today, and a Deeper Look at the Novel Approaches Being Piloted in Other Countries That are Showing Better Results
- Part 5 Inside Those Doors – My Story and Other Women’s; What Really Goes on Inside a Residential, Eating Disorder Treatment Center – Prepare to be Shocked
- Part 6 Why Do Some Women Go on to Develop Chronic Eating Disorders, and Many Others Don’t? Quick Answer: It’s Different for Everyone, But Research Indicates Some Common, Underlying Issues and Conditions
- More Importantly – Is it Time to Do Away with Eating Disorder Labels Altogether? The Labels Take Away from the Unique Conglomeration of Underlying Causation for Every Client, Placing Treatment Focus on Superficial, Behavioral Manifestations Instead of the Inextricably Complicated, Personal Etiology Which Can Only be Dissected Individual by Individual
- Part 7 Proposed Solutions: The Types of Systemic Change Research and Personal Experience Suggest Needs to Occur, to Help Improve Recovery Rates – and Save the Lives – of Women With Long Term Eating Disorders
[i] Hay, P. (2013). “New Evidence and Approaches in the Psychological Treatment of Severe and Enduring Anorexia Nervosa,” a paper presented at the 2013 European Forum Alpbach Conference: http://www.netzwerk-essstoerungen.at/download/k13_presentations/teachingday/Hay2_ED13.pdf
[ii] “Fighting the stigma: Rising awareness of eating disorders will boost demand for clinics,” IBISWorld Industry Report 0D5999, Eating Disorder Clinics in the US, August 2013.
[iii] “Congressman press HHS to investigate Universal Health Services behavioral facilities,” by Lisa Schencker, Modern Healthcare, June 23 2015: http://www.modernhealthcare.com/article/20150623/NEWS/150629958/congressmen-press-hhs-to-investigate-universal-health-services
[iv] “Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders,” by Hay, P., Maddden, S., Newton, R et al in the Australian & New Zealand Journal of Psychiatry, Oct. 2014.
[v] American Psychiatric Association (2006). Practice Guideline for the Treatment of patients with eating disorders, Third Ed.: http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/eatingdisorders.pdf, and Guideline Watch (August 2012): http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/eatingdisorders-watch.pdf
[vi] Dold M, Aigner M, Klabunde M, Treasure J, Kasper S. (2015). Second-Generation Antipsychotic Drugs in Anorexia Nervosa: A Meta-Analysis of Randomized Controlled Trials. Psychotherapy and Psychosomatics Journal, 84(2), 110-6.
[vii] Center for Substance Abuse Treatment, Opioid Treatment Program Accreditation Impact Study. Web publication. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 2004.
[viia] Programs with CARF’s ED accreditation include The Emily Program, Castlewood Treatment Center, Fairhaven Treatment Center, Canopy Cove, the Houston Eating Disorders Center, and the Center for Balanced Living.
[viii] “Update from The Joint Commission Regarding Eating Disorder Treatment Program Standards,” by Keesha Amezcua and Felicia Kolodner, in the AED Forum Newsletter:
[ix] See above (AED Forum Newsletter).
[x] See endnote vii.
[xi] Chriqui, J., Terry-McElrath, Y., McBride, D., Eidson, S., VanderWaal, C. (2007). Does State Certification or Licensure Influence Outpatient Substance Abuse Treatment Program Practices? Journal of Behavioral Health Services & Research, 34(3), 309-328.