Residential Treatment for Eating Disorders

REGULAR ARTICLE Residential Treatment for Eating Disorders Maria J. Frisch, BS 1 David B. Herzog, MD 2 Debra L. Franko, PhD 2,3 ABSTRACT Objective: The current study describes residential treatment for eating disorders in the United States. Method: A national study involving 22 residential eating disorder treatment programs was conducted using a survey to determine treatment program descriptions and trends. Data from 19 respondents, representing 86% of all residential treatment programs in the United States, were examined. Results: Residential treatment options for individuals with anorexia nervosa and bulimia nervosa are becoming increasingly more common. A wide variety of techniques and methods are employed in the treatment of individuals with eating disorders in residential treatment programs. The average length of stay in treatment was 83 days, with an average cost per day of $956 U.S. dollars. Conclusion: The residential treatment of individuals with eating disorders is a growing, variable, and largely unregulated enterprise. Future research is needed to focus on quantifying treatment program effectiveness in the residential treatment of individuals with eating disorders. VC 2006 by Wiley Periodicals, Inc. Keywords: residential treatment; eating disorders; program effectiveness (Int J Eat Disord 2006; 39:434 442) Introduction Accepted 12 April 2005 This project was supported in part by a Matina S. Horner PhD Summer Fellowship at the Harvard Eating Disorders Center, Boston, Massachusetts. *Correspondence to: Maria J. Frisch, Department of Psychiatry, University of Minnesota, Riverside Professional Building, 606 24th Avenue South, Suite 602, Minneapolis, MN 55454. E-mail: fris0039@umn.edu 1 University of Minnesota, Minneapolis, Minnesota 2 Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts 3 Department of Counseling and Applied Educational Psychology, Northeastern University, Boston, Massachusetts Published online 9 March 2006 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/eat.20255 VC 2006 Wiley Periodicals, Inc. Residential treatment for individuals with eating disorders is becoming increasingly more common. However, little research exists in this area. Inpatient and day treatment units no longer are home to long-term or chronic cases, 1,2 but more often serve to stabilize acute clients before a more long-term transition into less restrictive care such as outpatient or individual therapy. In a 15-year retrospective record review of patients treated at an eating disorders program in a large metropolitan area, Wiseman et al. 1 found a decrease in inpatient average length of stay (LOS) from 149.5 days in 1984 to 23.7 days in 1998. In addition to shortened stays, Kaye et al. 3 found that managed care companies often limit coverage for the treatment of eating disorders, leaving individuals responsible for the cost of more intensive rehabilitation after medical stabilization. In response to the changing dynamics of inpatient treatment and the less intensive alternative option of outpatient or individual therapy, many patients and providers have turned to non hospital-based, residential programs for longerterm, intensive treatment. Residential treatment programs often require a significant financial contribution from the patient and usually involve comprehensive therapeutic resources, but data concerning program composition and effectiveness are limited. 4 In fact, we were able to find only two published articles in the area of residential treatment for individuals with eating disorders. The first described a residential summer camp for individuals with eating disorders. 5 The second 6 assessed changes in eating disorder symptom severity within a residential setting utilizing the Eating Disorder Inventory (EDI 7 ) with 47 females with bulimia nervosa (BN) and 52 females with anorexia nervosa (AN). Overall, there was significant symptom improvement on eight subscales of the EDI, leading to the conclusion that residential treatment was effective. However, the lack of a control group necessitates caution in interpreting these results. To the best of our knowledge, no other study has examined residential treatment for individuals with eating disorders. Research describing the current 434 International Journal of Eating Disorders 39:5 434 442 2006 DOI 10.1002/eat

RESIDENTIAL TREATMENT EATING DISORDERS TABLE 1. Complete list of residential eating disorder treatment programs that were contacted to participate in the current study Monte Nido Remuda Ranch Montecatini Renfrew Milestones in Recovery Castlewood Structure House Anna Westin House Rogers Memorial Laurel Hill Inn Oceanaire Fairwinds Shades of Hope McCallum Place Center for Hope of Klarman Center Avalon Hills the Sierras Renaissance Rosewood Ranch Canopy Cove The Victorian Mirasol state of residential treatment for individuals with eating disorders is warranted. The objectives of the current study were to examine the following characteristics within residential treatment programs: demographic characteristics, average LOS and costs, growth rates, treatment methodology and techniques, and research involvement and production. of 35 days to respond. Program directors were initially contacted via e-mail with a letter explaining the study and requesting their participation, along with a copy of the 30-question survey. Programs that did not respond within 7 days received a follow-up telephone call and a hard copy of the survey through U.S. mail, along with an additional letter requesting participation. Those that did not reply received additional follow-up telephone calls requesting participation. Websites and brochures produced by each program also were reviewed as a secondary means of obtaining information that was not reported in the surveys. In addition, we utilized public literature to confirm the selfreported survey answers in an effort to systematically eliminate bias that may have been present in survey responses. Method Participants Program directors at 22 residential eating disorder treatment programs from across the United States (Table 1) participated in the current study. Programs were selected based on the following criteria: (a) they offered residential treatment services, (b) they offered treatment for individuals with AN and/or BN, and (c) they were located in the United States. The 22 selected programs were the only programs that were found to meet these criteria, based on a comprehensive national search of all residential treatment programs for eating disorders. The comprehensive search was conducted by searching the Internet, national eating disorder treatment referral databases, and on-line yellow pages. Programs were not offered any form of compensation for participation in this project. Materials A survey (see Appendix) sent via e-mail was developed to gather information about different treatment programs. Thirty open- and close-ended questions elicited responses in the areas of demographic characteristics, average LOS and costs, growth rates, treatment methodology and techniques, and research involvement and production. Open-ended questions were incorporated when sets of predetermined responses were possibly limiting or biased. The survey was pretested with eight residential treatment programs before distribution for the current study. Procedure Recruitment was conducted using e-mail, telephone, and U.S. mail contact, with all participants given a total Results Program Demographics A total of 22 residential eating disorder treatment programs were contacted. Of these 22, 13 programs (59.1%) completed the survey. Information was obtained about 6 programs (27.3%) through a combination of publicly available information and verification telephone calls. Three programs (13.6%) refused to participate. Of the 13 self-report programs, 1 program was eliminated from the final analysis because it only offered services for the treatment of individuals with binge eating disorder (BED). Thus, information is reported on 18 of the 22 (82%) programs. Of the programs that refused to participate, one program initially agreed to participate, but then declined after reviewing the required survey, stating they did not give out that type of information. The other two programs did not respond to any contact regarding the current study. It was confirmed that these programs were still in operation. The demographic characteristics of the programs are listed in Table 2. All programs offered treatment for both AN and BN. Most programs also offered treatment for eating disorder not otherwise specified (EDNOS; 72.2%) and BED (61.1%). Some programs offered treatment for compulsive exercising (44.4%), whereas only a small portion of programs treated obesity (22.2%). The majority of programs held a general state license, although few, if any, states required licenses specific to the treatment of eating disorders. Types of licenses ranged from communal living licenses to foster care licenses. Approximately 27.8% of programs received Joint Commission International Journal of Eating Disorders 39:5 434 442 2006 DOI 10.1002/eat 435

FRISCH ET AL. TABLE 2. Demographic characteristics of residential programs in 2004 Type of eating disorder treated Anorexia nervosa 18 (100) Bulimia nervosa 18 (100) EDNOS 13 (72.2) Binge eating disorder 11 (61.1) Compulsive exercise 8 (44.4) Obesity 4 (22.2) Gender accepted for treatment Females 18 (100) Males 4 (22.2) Average (SD) Average length of treatment Number of days 83 (44) Average (SD) Average age treated Average age 22 (3.7) Average youngest 14 (2.9) Youngest 8 Average oldest 40 (23) Oldest 65 Average Average cost per day Average cost per day in U.S. dollars 956 (250) (SD) Year founded 1985 1990 3 (16.7) 1991 1995 1 (5.6) 1996 2000 6 (33.3) 2001 2004 8 (44.4) Program operational licenses held General State 17 (94.4) JCAHO 5 (27.8) Types of residential staff employed Nonpsychiatric physicians 16 (100) RD 16 (100) Psychiatrists 15 (93.8) RN 15 (93.8) Administrative 14 (87.5) Doctoral-level therapists 13 (81.3) Master s-level therapists 12 (75.0) MSW 11 (68.8) Interns 11 (68.8) Holistic staff 9 (56.3) Teacher 8 (50.0) Bachelor s-level social worker 6 (37.5) Doctoral-level researcher 6 (37.5) Most commonly employed traditional therapies Individual 18 (100) Group 18 (100) CBT 16 (88.9) Family 15 (83.3) 12-step 9 (50) DBT 6 (33.3) IPT 3 (16.7) Most commonly employed alternative therapies Arts-based 18 (100) Dance 13 (72.2) Yoga 12 (66.7) Music 7 (38.9) Equine 5 (27.8) Spirituality Incorporated into treatment 17 (94.4) Treatment based on a specific religious belief 2 (11.1) Note: EDNOS ¼ eating disorder not otherwise specified; SD ¼ standard deviation; JCAHO ¼ Joint Commission on Accreditation of Health Care Organizations; RD ¼ registered dietitian; RN ¼ registered nurse; MSW ¼ master s-level social worker; CBT ¼ cognitive-behavioral therapy; DBT ¼ dialectical-behavioral therapy; IPT ¼ interpersonal therapy. on Accreditation of Health Care Organizations (JCAHO) accreditation. In this sample, females had greater access to residential treatment for eating disorders than males. Females were accepted for treatment in all (100%) programs, whereas males were accepted in only 22.2% of programs. Proportionally, the average age treated in residential care was 22 years (SD ¼ 3.7), with an average age range of 14 years 40 years. Three programs restricted admissions to adolescents only. Average LOS and Costs The average LOS in residential treatment (M ¼ 83 days, SD ¼ 44) was more than triple that of a recently reported average inpatient LOS 1 for the treatment of eating disorders. However, many programs reported a high variability in LOS among patients, as treatment time was remarkably individualized. The average cost per day in U.S. dollars was $956 (SD ¼ $250, range ¼ $550 $1,500). Therefore, an average LOS in residential treatment costs approximately $79,348. 436 International Journal of Eating Disorders 39:5 434 442 2006 DOI 10.1002/eat

RESIDENTIAL TREATMENT EATING DISORDERS FIGURE 1. Growth in residential treatment programs, 1985 2004. FIGURE 2. Residential treatment program location by state. Growth Rates Residential program growth rates have more than tripled over the past decade. Between 2000 and 2004 alone, the number of residential programs expanded by 44.4%. Figure 1 shows growth of programs since 1985, based on the founding year, or year of incorporation, for each program. Programs are located all across the United States, with a higher proportion residing within the Southwest (Figure 2). Treatment Methodology and Techniques Most programs reported an eclectic, integrative approach to treatment. However, therapeutic orientation and techniques varied widely among treatment programs. Eighty-nine percent of pro- International Journal of Eating Disorders 39:5 434 442 2006 DOI 10.1002/eat 437

FRISCH ET AL. TABLE 3. Types of therapies reported within each group, ranked by frequency Traditional Group Therapies Nontraditional Group Therapies Individual Therapy General Art Individual sessions with 12-step Recreational a doctoral or master s-level Process Meditation counselor, psychologist, Food/feelings Experiential psychiatrist, or physician Spirituality Yoga Psychoeducation Equine Body image Dance Nutrition Music Goal setting Journaling CBT Message Relapse prevention Family Family systems Intimacy/sexuality Trauma Contract DBT Aftercare Note: CBT ¼ cognitive-behavioral therapy; DBT ¼ dialectical-behavioral therapy. grams reported cognitive-behavioral therapy (CBT) as the primary method of treatment. Comparatively, only 16.7% of programs reported using interpersonal therapy (IPT) and 33.3% reported using dialectical-behavioral therapy (DBT). Information on types of therapy employed by each program was gathered by quantifying weekly resident schedules for each program. Therapies were categorized by traditional group, nontraditional group, and individual therapy. Table 3 shows the types of therapies reported for each of the 3 groups, ranked by frequency of weekly occurrence. In comparison to traditional group therapies, nontraditional group therapies (otherwise known as complementary therapies) commonly were employed (Table 4). Clients received an average of 5.9 hr of nontraditional therapy for every 10 hr of traditional group therapy. Comparatively, clients received an average of 1.8 hr of individual therapy for every 10 hr of traditional group therapy (Figure 3). The most common traditional group therapies were general group (503 min per week per patient [p/ wk/pt]), 12-step group (208 min p/wk/pt), and process group (206 min p/wk/pt). The most common nontraditional group therapies were artsbased (334 min p/wk/pt), recreational/experimental (175 min p/wk/pt), and yoga/meditation (122 min p/ wk/pt). Individual therapy included one-on-one sessions with a doctoral or master s-level counselor, psychologist, psychiatrist, or physician. Although it was not clear what proportion of individual therapy was nontraditional, most sessions appeared to employ primarily traditional therapeutic techniques. TABLE 4. Average amount of time spent each week on traditional and nontraditional group therapies, ranked by frequency Minutes per week Therapy per Patient T - General 503 A - Art 262 T - 12-step 208 T - Process 206 A - Recreational 119 T - Food/feelings 85 T - Spirituality 76 A - Meditation 68 T - Psychoeducation 67 A - Experiential 56 A - Yoga 54 T - Body image 50 T - Nutrition 49 A - Equine 42 A - Dance 42 T - Goal setting 32 A - Music 30 A - Journaling 30 T - CBT 29 T - Relapse prevention 26 A - Massage 25 T - Family 22 T - Family systems 19 T - Intimacy/sexuality 18 T - trauma 18 T - Contract 17 T - DBT 13 T - Aftercare 12 Note: T ¼ traditional; A ¼ alternative; CBT ¼ cognitive-behavioral therapy; DBT ¼ dialectical-behavioral therapy. Research Involvement and Production Greater than one half (55.6%) of all programs reported that they were currently conducting treatment outcome studies, 11.1% responded that they were not currently conducting treatment outcome studies, and 33.3% did not respond to this question. Greater than one third (37.5%) of programs reported staffing 1 doctoral-level staff member specifically for research purposes. For the 11.1% of programs not currently conducting research, lack of time, staff, and financial resources were the top reasons given for not engaging in any current research. Of the programs currently conducting treatment outcome studies, 100% reported treatment outcome studies (showing positive changes) 12 months posttreatment. Forty percent of those programs reported completion of studies with outcome data up to 5 years posttreatment. Fifty percent of all residential programs reported conducting treatment outcome research for a minimum of 3 years. One fourth (25%) of all programs reported conducting research from 3 to 5 years. Another one fourth (25%) of all programs reported conducting research for the last 6 10 years. However, all treatment programs combined reported the completion 438 International Journal of Eating Disorders 39:5 434 442 2006 DOI 10.1002/eat

RESIDENTIAL TREATMENT EATING DISORDERS FIGURE 3. of only 11 research studies, with an additional 12 studies in progress. Of the 11 completed treatment outcome studies, we found only 2 that had been published. Many programs did not provide information about how many studies they had completed or currently had in progress. Sixty-nine percent of programs reported plans for future outcome studies, with approximately 56% of programs anticipating completion of new research within the next 6 months. Sixty-one percent of all programs reported using some type of data to evaluate the effectiveness of their treatment program. Of these 61%, 63.6% of programs used self-report surveys to gauge treatment effectiveness, 36.4% used outcome studies, 18.2% used laboratory tests, and 18.2% used program-initiated telephone calls. Some programs used more than one of the previous listed methods. Greater than one third (36.4%) of the programs evaluating treatment effectiveness relied only on clientinitiated posttreatment telephone calls for effectiveness measures. Thirty-nine percent of all programs did not provide information on the measures used to determine treatment effectiveness. Conclusion Group versus individual therapy. The current study provides an important contribution to the field for several reasons. Principally, it is the first study to describe the state of residential treatment for eating disorders within the United States. Further, the trends described provide a useful framework for providers working within intensive eating disorder treatment milieus. Finally, examination of research involvement and practices within the residential setting reveals unique and alternative perspectives on treatment outcome research. Residential treatment options for AN and BN have become increasingly available. The emergence of this popular for-profit mode of treatment necessitates the need for quantification and standardization of quality and effectiveness within this industry. Residential treatment of individuals with eating disorders is a growing, variable, and largely unregulated enterprise. Effectiveness measures are currently unstandardized and, within many programs, nonexistent. Further, daily program costs range from $550 to $1,500 per day, with no published data about effectiveness or quality, aside from the varying accounts of success found within each program s promotional package. Finally, many programs operate with licenses unrelated to eating disorders or residential care. Some programs reported having foster care licenses, some had group home licenses, and at least one program had no license at all. JCAHO-accredited programs are measured against reputable national standards set by health care professionals. However, only 28% of all programs reported JCAHO accreditation. Moreover, although this certification is indeed a reflection of high organizational standards, in the absence of a state license exclusive to residential treatment or to eating disorders, this national certification may not be enough to regulate statebased residential programs. Regulation and standardization of the residential treatment industry are suggested as a topic of future investigation. The average LOS in residential treatment (M ¼ 83 days, SD ¼ 44) costs approximately $79,348. This figure may slightly underreport average costs, as many programs reported billing medical charges, such as physician and prescription fees, separately. However, residential treatment may still be a more cost-effective option than inpatient treatment. Estimating an average cost per day of $2,000 for inpatient hospitalization, 8 the average LOS for an average inpatient stay of 23.7 days 1 costs approximately $47,400, but more often requires immediate stepdown care. Thus, strictly comparing the average cost per day of residential treatment ($956) versus inpatient treatment ($2,000), residential treatment may be a more cost-effective option for shorter and longer-term care. International Journal of Eating Disorders 39:5 434 442 2006 DOI 10.1002/eat 439

FRISCH ET AL. It is widely known that more women than men suffer from AN and/or BN. The incidence rates of AN are highest among females 15 19 years and rates of BN are highest among women 20 24 years. 9 In a sample of 1,960 adolescent girls and boys living in The Netherlands, lifetime prevalence rates (LPR) of clinically significant AN and BN in adolescent girls were reported to average approximately 1.9%. 10 This same study 10 reported that LPR of clinically significant AN and BN in adolescent boys averages about 0.6%. Proportionately, men were only accepted at 22.2% of all residential programs. Although populations of individuals with eating disorders in the United States and The Netherlands may slightly differ in gender-based trends, it is clear that AN and BN are no longer viewed as femalespecific disorders. However, we found no programs that offered services exclusive, or specific, to the needs of males. A high proportion of residential programs reported current, past, and future involvement in treatment outcome research. In fact, some programs employed a doctoral-level researcher on staff. However, few studies have been published in the area of residential treatment outcomes for individuals with eating disorders. The reasons for this discrepancy are unknown. It is possible that programs overreported their involvement in research. Conversely, it is possible that a good deal of outcome research has been conducted within the area of residential treatment but has not been published. It is not uncommon for health organizations to conduct internal quality assurance research, but not to submit these data to peer-reviewed publications. Residential programs may not be motivated to publish their data in research journals. Some programs may consider their outcomes research to be proprietary information. Alternatively, the outcome research produced for internal management purposes or reporting to payers may not meet the standards of peer-reviewed publications. One third of all programs evaluating treatment effectiveness relied only on client-initiated, posttreatment telephone calls as a measure of treatment effectiveness. Although this may meet the requirement of treatment outcome research within some programs, it does not meet the standards of more universal claims of effectiveness. What is clear, however, is that residential treatment offers a unique avenue for treatment outcome studies and we recommend that these facilities begin to conduct empirically sound studies to measure the effectiveness of their treatment approaches. It is important for both patients with eating disorders and their families to appeal that such studies be conducted. Given the length and expense of residential treatment, effectiveness data are crucial. References 1. Wiseman CV, Sunday SR, Harris WA, et al. Changing patterns of hospitalization in eating disorder patients. Int J Eat Disord 2001;30:69. 2. Willer M, Thuras P, Crow S. Implications of the changing utilization of hospitalization for anorexia nervosa. Am J Psychiatry 2005;162:2374. 3. Kaye WH, Kaplan AS, Zucker ML. Treating eating-disorder patients in a managed care environment. Contemporary American issues and Canadian response. Psychiatr Clin North Am 1996;19:793. 4. Kachele H, Kordy H, Richard M. Therapy amount and outcome of inpatient psychodynamic treatment of eating disorders in Germany: data from a multicenter study. Psychother Res 2001;11:239. 5. Tonkin R. Evaluation of a summer camp for adolescents with eating disorders [letter]. J Adolesc Health 1997;20:412. 6. Bean P, Weltzin T. Evolution of symptom severity during residential treatment of females with eating disorders. Eat Weight Disord 2001;6:197. 7. Garner MG, Olmsted MP, Polivy J. Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int J Eat Disord 1983:215. 8. Crow S, Nyman J. Cost-effectiveness of anorexia nervosa treatment. Int J Eat Disord 2004;35:155. 9. Hoek HW, Hoeken DV. Review of the prevalence and incidence of eating disorders. Int J Eat Disord 2003;34:383. 10. Ljelsas E, Bjornstrom C, Gotestam KG. Prevalence of eating disorders in female and male adolescents (14 15 years). Eat Behav 2004;5:13. (See Appendix on next page.) 440 International Journal of Eating Disorders 39:5 434 442 2006 DOI 10.1002/eat

RESIDENTIAL TREATMENT EATING DISORDERS Appendix: Residential Program Survey *** All questions on this survey are in relation to your organization s residential treatment program. 1. Types of eating disorders treated: Anorexia Bulimia EDNOS Obesity Binge eating disorder Exercise disorder Others 2. What is the average length of residential treatment stay for your clients? 3. What is the average age and age range of your clients? 4. Do you accept males for residential treatment? 5. What is the minimum client age that you are able to accept? The maximum? 6. What licenses does your program currently have? 7. What year was your organization founded? 8. What is the all-inclusive cost per week of your program? 9. What types of insurance do you accept? 10. Types of staff in your organization (please check all that apply): Physician (MD) Psychiatrist (MD) Doctoral level therapists RN Master s level clinical therapists Holistic therapy staff RD Master s level licensed social worker Educational/teacher Doctoral level researcher Bachelor s level licensed social worker Interns Administrative Bachelor s/master s level researcher Other 11. Please list all of your location(s): 12. What are your organization s treatment theories (please attach an additional sheet if necessary)? 13. What are your organization s treatment methods (please attach an additional sheet if necessary)? 14. What is your organization s treatment structure (please provide/attach a weekly schedule)? If it is not apparent within your weekly schedule, please list all groups (i.e. family, individual, couples, etc.) and services (i.e. outpatient, partial, etc.) that you offer. 15. What extra services do you offer and/or what makes you unique from other residential eating disorder treatment programs? 16. Do you incorporate spirituality into your program? If yes, how so? Do you support all religions or are you geared towards a specific religion? 17. Do you incorporate any arts-based therapies into your program? Please check all that you offer: Arts-based therapy Dance therapy Music therapy Other International Journal of Eating Disorders 39:5 434 442 2006 DOI 10.1002/eat 441

FRISCH ET AL. 18. On average, what percentage of your residential clients participate in arts-based therapies while in treatment? 19. On average, do your clients participate in arts-based therapies at least: Once p/day Once p/wk. Once p/mo Once in 3/mo Never 20. Why do you offer/incorporate arts-based therapies into your treatment program? 21. What primary and/or secondary methods does your organization use for measuring program effectiveness and/or success of treatment? 22. What methods (short- and long-term) do you use for measuring client recovery? 23. How do you define client recovery? 24. Do you currently conduct outcome studies? Yes No 25. How long has your organization been conducting outcome studies? 6 mo. or less 7 11 mo. 1 2 yrs. 3 5 yrs. 6 10 yrs. 11 þ yrs. N/A 26. What length of time do your outcome studies measure (please check all that apply)? Before residential During residential Less than 1 mo after residential 1-3 mo. after residential 4 6 mo. after residential 7 9 mo. after residential 10-12 mo. after residential 13 17 mo. after residential 2 5 yrs. after residential More than 5 yrs. after residential N/A 27. As of today, how many outcome studies has your organization completed? 28. As of today, how many outcome studies does your organization have in process? 29. What is/are the reason(s) you do not conduct outcome studies (please check all that apply): We do not currently have the staff expertise We do not have the time We are not interested in conducting outcome studies Outcome studies are not effective We do not have the financial resources Other: N/A 29. Does your organization have plans to conduct outcome studies at anytime in the future? Yes No 30. Does your organization have plans to conduct an outcome study or studies within the next 6 months? Yes No 442 International Journal of Eating Disorders 39:5 434 442 2006 DOI 10.1002/eat