Since Monday, this article has been floating around the interwebz causing much buzz in the eating disorder world. It’s hardly news to most of us; similar articles have been popping up for the past year or so. Since the early 2000s, the number of residential treatment centers devoted to treating eating disorders has increased from 22 to more than 75. These days it’s pretty easy for those affected to find a specialized center within reasonable travel distance. Actually getting into these places is much trickier, however, as insurance companies are far less likely to offer coverage for residential treatment versus more traditional inpatient or hospital-based treatment. If you’re wondering what the difference is between a “residential” and an “inpatient” center, the answer is, it varies greatly. Inpatient facilities are generally shorter-term programs aimed at medical and psychiatric stabilization, whereas residential centers cater to longer-term treatment and usually incorporate more therapy and “real-world” practice. Or so they say. I have found that sometimes the distinction between inpatient and residential is quite subtle– either in “residential” centers that offer little more than your typical inpatient unit or in “inpatient” units that operate more like longer term residential centers.
Why is this even important? Well, because over the years inpatient programs have gotten a pretty bad name, whereas residential centers are often hailed as the mecca of recovery. “If only I could afford to go to [insert name of popular residential center], then I could finally get better.” Or (yes, this really happens), “Please donate to my GoFundMe account to help me go to [insert name of most expensive residential center]. My doctors told me I need to go here and only here in order to get better.”
I am where I am today because of the changes I decided to make after living with a serious eating disorder for most of my life. I spent much of my youth and young adulthood bouncing in and out of various hospitals, inpatient units, and residential centers trying to get better. Nothing seemed to help. I was no better off after leaving the fancy residential center my parents paid out of pocket for than I was leaving the hospital where I received free treatment in exchange for my participation in research. Talking to other long-time sufferers like me, I find this is often the case. We have long histories of admissions that are now hardly distinguishable from each other, despite how different they seemed at the time. A lot of us do end up getting “better” (not necessarily “recovered”) but we cannot attribute our success to any one program.
I consider my turning point to be around the time of my last inpatient admission three and a half years ago, although it would be false to say that I got better as a result of going there, it was merely the setting for many personal changes I initiated during that time. This place was far from the picture-perfect center you see in the shiny facility brochures (or these days, the websites). There was no equine therapy, lush green landscapes, or private bedrooms with views of the beach. This was a makeshift wing of a psychiatric hospital surrounded by barbed wire fencing. We had to walk outside to get to the middle school style “cafeteria” and then take our food back to the smelly hospital gym to eat (yes, they thought it would be cool to have a bunch of exercise-restricted ED patients eat in a gym). This was no Monte Nido, but it was what my insurance covered at the time. And believe it or not, I had a better experience at this barbed-wire joint than I had at many of the much nicer cushy facilities I stayed at over the years. It was here that I first started to believe I could have a life that consisted of more than my eating disorder.
Let’s compare this to what I consider to be the least helpful (and in many ways, harmful) place I went back in 2006. I’m talking about Mirasol, that beautiful house in Tucson, AZ that should never have been licensed to treat eating disorders. Here are just a few of the atrocities I encountered while there:
No, I wasn’t being held there against my will and I could have left well before I did. Hindsight is 20/20 though and at the time I wanted so badly to believe this stuff could help me. The facility came highly recommended from my outpatient therapist who thought I needed something different from your run-of-the-mill hospital ED unit that hadn’t helped me in the past. She helped get me a 50% “scholarship” but my parents still put down a pretty penny to send me there. And for what? I can’t say I benefitted at all from that place. I mean, I learned what a javelina is and how to make organic peanut butter balls but that’s about it.
People often complain about insurance and how it’s so hard to get coverage for residential treatment. Well, I wonder why? Maybe because the insurance companies see how most of these places do not bring about lasting change, and instead breed revolving door patients. Don’t get me wrong, I’ve had my own battles with insurance and have seen some very sick people denied treatment they desperately needed. The problem I have is when people think these expensive residential centers in particular are the answer, as opposed to the less fancy inpatient hospital-based programs insurance companies are more likely to cover.
When I first moved to Los Angeles I had a therapist try to convince me that in order to get better I absolutely had to go to Monte Nido (for those not aware, Monte Nido is a residential facility in Malibu that runs about $1,500/day and does not take most insurance). This therapist used to work at Monte Nido and claimed it was the very very best in eating disorder treatment, and even though I had been to 9 different places already (many of which also claimed to be the “very very best”), Monte Nido would be different. Well, seeing as I was a poor unemployed grad student living off of student loans with state health insurance, that wasn’t happening. And you know what? I’m glad it didn’t happen. Even though I struggled pretty damn hard over the next couple years I doubt I would have been any better off had I gone there. Also, that place always strikes me as mildly cult-like and I value my independence.
Just for fun, I took a look at the “Trusted Outcomes” page of the Monte Nido website. This is where they try to tell you how awesome all their former clients are doing. Most residential centers present something like this, and to be honest, Monte Nido’s is far from the worst I’ve seen (in terms of flawed research methods). That said, it’s still pretty bad. A few things that popped out right away:
There is some good news– In July, The Joint Commission will implement a set of minimum requirements needed for accreditation of residential centers for eating disorders. These requirements include new standards for assessment, treatment planning, family involvement, transitions of care, and outcome measures. This is definitely a step in the right direction.
However, it is still my personal opinion that residential treatment is rarely the answer. I think treatment should always be administered in the least restrictive setting. Inpatient facilities or hospital admissions should be reserved for when there is significant medical or psychiatric instability and/or when behaviors are so rampant they interfere with normal functioning. I can think of several occasions when this kind of treatment definitely benefitted me, either because it legit “saved my life” or because it helped bring my disorder under enough control so I could work on my real issues outside the hospital. This is helpful. These kind of admissions should absolutely be covered. But, 5 month stays at beachside houses where you pay upwards of $1,500/day to draw pretty pictures and do watered down yoga? Maybe not.
There seems to be a widespread generalization that everyone in this country is overweight, lazy, and in need of a drastic body and nutrition makeover. I, like so many others, bought into the Fitbit craze last year and purchased a shiny new purple Fitbit Charge HR (which I no longer use because it quickly made me fear for my sanity, but that’s a blog for another day). One of the first things I noticed when I set up my account was that it just assumed anyone who bought a Fitbit was looking to lose weight. I was immediately asked about my weight loss goals. Just for kicks I decided to put in a ridiculously low “goal weight” (a weight even I’ll admit I probably wouldn’t survive long at) and I got the following message, “Good luck achieving your goals! In order to reach ___ lbs in two months, please sustain a _____ calorie deficit, or adjust to a _____ calorie deficit to reach your goal in just one month!” Welp, that was awkward! My new Fitbit just wished me well on my path to probable death! Obviously it was just a stock message, and obviously I was not serious when putting in my “goal.” I just wanted to test my suspicions. I can now easily distinguish the messages that are meant for me and those that are not, but what about that 9, 10, or 11 year-old who grew up being scolded for every “bad” food she ever laid eyes on?
I realize the population of people who may internalize these messages and react by self-destructing is very small compared to those people who either (a) don’t give a damn or who (b) may actually benefit from them. I’m not suggesting we ignore the nation’s obesity problem all for the sake of not upsetting a small subset of people. I am suggesting we go about the problem in a different way, although I’m not sure what that is yet. Maybe we could start by not asking 5 year-olds to draw sad faces on pictures of ice cream cones?