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:
- They prided themselves in employing only staff who had recovered from their own eating disorders or addictions. This can be a good thing, when staff are actually recovered and mature enough to handle working with such a close-to-home population. Many staff were not. I still remember walking into my first group and hearing a man describe his most recent (as in, a couple weeks earlier) very graphic suicide attempt. It was almost like a step-by-step how-to guide. I assumed he was a client, but no– clinical director.
- There were a variety of alternative “modalities” we were required to participate in. Some were kind of cool and maybe even helpful (like the biofeedback training for anxiety) but most were a colossal waste of time (e.g., tribal drumming group). Some were downright inappropriate or harmful to some. I tried to get out of the required acupuncture and new-age “polarity” because I hate being touched by weird people, especially while in the process of gaining weight and hating my body tenfold. They told me I was “hiding behind my eating disorder.” No… I just don’t need people rubbing me or sticking needles in my face.
- If you struggled with binge/purging behaviors, they had you keep boxes of your most triggering foods in your bedroom at night (“exposure therapy”). And because they didn’t believe in locking bathrooms, this resulted in the all-too-common awkward group binge/purging sessions. Where was staff? Oh, probably relaxing with Margaritas by the pool (seriously though).
- They took us to the gym several times a week– all of us, even those of us who were significantly underweight and would have been on bed-rest or at least restricted movement at any other place. The intention was to teach us about “moderate/healthy exercise,” which was a noble goal but absolutely not what occurred. Instead, most of us felt pressure to out-do one another and things got ugly fast. I guess that’s what happens when you take a bunch of eating disordered clients to a gym and leave them unattended for 4 hours. Who would have thought?
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:
- The study they cite is 10-20 years old (data collected from 1996 – 2006). While I have never been to Monte Nido myself, I have heard from numerous sources that it has changed dramatically over the past 5-10 years. What started out as a small intimate center with two sites in the LA area has now expanded to include facilities in five states across the country. Clients who have experienced treatment at both the original site and the newer affiliate sites say there are more differences than similarities. Presenting this data as illustrative of the current treatment they offer is misleading.
- Anorexic patients were considered to have “good,” “intermediate” or “poor” outcomes based solely on two indicators– weight and return of menses. If a patient was at a BMI of 18 or higher and was menstruating at discharge/follow-up, she was judged to have a “good outcome.” Having just one or the other was considered “intermediate.” So many problems here:
- A client may have gained weight but held onto or even picked up new symptoms. By these indicators, it would be completely possible for someone to have a “good outcome” while binge/purging multiple times a day, as long as she had a normal BMI and a period when filling out the survey. This client should not be considered a success story; she merely falls into a different diagnostic category.
- Also by these indicators, it would be possible for someone to have an “intermediate outcome” while still drastically underweight and engaging in multiple behaviors on a daily basis, as long as she was getting a period. While not common, it is possible to still menstruate normally while severely underweight, which is why the DSM-5 removed this as a qualifier for anorexia.
- And hello, what about men with eating disorders? Hint: they never menstruate, hehe. (Although irrelevant to this particular study because Monte Nido only admits females)
- They do use some additional outcome measures to assess progress (Eating Disorder Inventory [EDI-2], Beck Depression Inventory [BDI-II], self-reported progress] and while these measures do indicate some significant improvement, it is important to consider who is completing the discharge and follow-up surveys. While there was a 75% completion rate of follow-up surveys, this only included clients who stayed at least 30 days. This weeds out those who dropped out early, most likely due to not finding the program helpful or requiring a higher level of care (e.g., medical hospitalization). Also, with any follow-up survey like this, it is far more common to get participation from those doing well, which does not lend itself to a very representative sample.
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.