Evaluating Residential Treatment Programs

The number of residential treatment programs designed for persons with eating disorders is growing, but such centers vary widely and are still largely unregulated, according to the results of a recent study (Int J Eat Disord 2006; 39:434). These programs offer an alternative to inpatient care, particularly when managed-care companies limit coverage and individuals become responsible for their own care.

A survey of program directors

To evaluate current residential treatment centers, Maria J. Frisch, David B. Herzog, MD, and Debra Franko, PhD surveyed program directors at 22 residential eating disorders treatment programs across the United States. The programs were selected based on availability of residential treatment services, treatment for persons with anorexia nervosa or bulimia nervosa, and location within the U.S.

The authors used e-mail to gather information about each treatment programs including treatment theories, methods, licenses, extra services, completed outcome and in-process outcome studies, education levels of staff members and types of staff in the organization. The online questionnaire included open-ended questions about length of stay, demographic characteristics, growth rates, treatment methods, and research involvement.

Results

Thirteen of the 22 residential treatment programs completed the survey. Information about 6 of the programs was obtained through a combination of publicly available information and telephone verification. Three refused to participate. Thus, the study results included information from 18 of the 22 programs contacted (82%).

The authors noted a surprising inconsistency in licensure. Most programs held a general state license, although few if any states required licenses specific to the treatment of eating disorders. The type of licenses reported included communal living licenses to foster care licenses. About 28% of programs had received Joint Commission of Healthcare Organization accreditation.

Females had greater access to residential treatment for eating disorders than did males. All programs accepted females for treatment, whereas only 22.2% of programs accepted males.

Length of stay and costs

The average length of stay in residential treatment, a mean of 83 days, was more than three times that of a recently reported study of inpatient length of stay for treatment of eating disorders; however, treatment length was highly individualized. The average cost per day in U.S. dollars was $956 (range $550-$1,500). Therefore, according to the authors, an average length of stay in residential treatment costs approximately $79,348.

Treatment

Most of the residential treatment centers used an eclectic, integrative approach to treatment. Therapeutic orientation and techniques varied widely. Eighty-nine percent of programs reported using cognitive-behavioral therapy (CBT) as the primary method of treatment. Only 16.7% of programs reported using interpersonal therapy and 33.3% reported using dialectical behavioral therapy.

The authors gathered information on types of therapy by quantifying weekly resident schedules for each program. They categorized therapies as: traditional group, nontraditional group, and individual therapy. Clients received an average of 5.9 hours of nontraditional therapy for every 10 hours of traditional group therapy. Clients also received an average of 1.8 hours of individual therapy for every 10 hours of traditional group therapies. The most common nontraditional therapies were arts-based (334 minutes per patient per week), recreational-experiential (175 minutes per patient per week) and yoga/meditation (122 minutes per patients per week).

Slightly more than half (55.6%) of all programs reported 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 at all to the question. More than a third of the programs reported having at least one doctoral-level staff member specifically engaged in research. Those programs that did not conduct research reported lack of time, staff and financial resources as the main reasons.

Lack of regulations, standard measures of efficacy

The authors found that the number of residential programs has more than tripled over the past 10 years; between 2000 and 2004 alone, the number of residential programs expanded by 44.4%. Most residential treatment centers are found in the Southwest. According to the authors, even though residential treatment programs are becoming increasingly available, they are still highly varied and largely unregulated. Effectiveness measures are currently underutilized and, in many programs, nonexistent. Although daily program costs range from $550 to $1500, there are no published data about effectiveness or quality, aside from the varying accounts of treatment success found in promotional brochures. Many operate with licenses not related to treatment of eating disorders, including licenses for group homes, foster care, or no license at all.

Compared to the average $2,000 a day cost for inpatient care, residential treatment care may be a very cost-effective option for short and longer-term care. One area that surprised the authors was that no programs offered services exclusively for males.

Little information on treatment outcome

Finally, even though a higher proportion of residential treatment programs had conducted current and past outcome research, the authors found that few studies have been published concerning treatment outcomes for individuals with eating disorders. There are several possible reasons for this: Health organizations may conduct internal quality assurance research, but not submit their data to peer-reviewed publications, and may not be motivated to do so. Some consider their data to be proprietary information. Also, outcome research originally produced for internal management purposes or for reporting to insurance companies may not meet the standards of peer-reviewed publication. The authors found that one-third of all programs evaluating treatment effectiveness relied only on client-initiated post-treatment telephone calls as a measure of the effectiveness of treatment.

The authors recommend that residential treatment facilities conduct empirically sound studies to measure the effectiveness of their treatment approaches. Given the length and cost of residential treatment, information about effectiveness of treatment is crucial.