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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

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.


Stay tuned for the rest of the series: Sign up to receive an email when a new article in the series is posted, by using the subscription form at the bottom of this page.

If you find this series, or any other writing here helpful, please also consider donating to keep this site alive, by clicking on the “Donate” icon below. Donations are critical to my continued ability to write about mental health issues in a way that dismantles myths and stigma; improves treatment; sheds light on the truth behind the misinformation spread by the media as well as some advocates and professionals; help reduce inequities and oppression; and help provide those of us labelled “mentally ill” with a true Voice in society.

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:

[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:

[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.:, and Guideline Watch (August 2012):

[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.


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  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 (or

    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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