Deposition Testimony, Centers of Excellence and Confirmation Bias ... Like Forrest, Jenni and Bill ?

“I did not have sexual relations with that woman …”

            President Bill Clinton, January 26, 1998

That statement was the catalyst resulting in the United States House of Representatives issuing articles of impeachment against then President Bill Clinton on the grounds of obstruction of justice and perjury. After a 21 day trial in the United States Senate, the Senate acquitted him of all charges. But, the ramifications of the alleged perjury were not over.

President Clinton was also a defendant in a lawsuit filed by Paula Jones. In that case, United States District Court Judge Susan Webber Wright determined that President Clinton had given misleading testimony regarding his sexual relationship with Monica Lewinsky, held him in civil contempt of court and fined him $90,000.00. In 2001, the State Bar of Arkansas suspended his law license for 5 years and later, the United States Supreme Court suspended his law license.

Perjury. Sworn deposition testimony. Over 90% of all cases get settled or dismissed prior to trial. As such, sworn deposition testimony is vital to a case and can either “make or break” a party’s lawsuit. Therefore, emphasis is placed on accurate testimony, honesty and a person’s integrity when they are being deposed. The ramifications of anything less can result in catastrophic results.

Centers of Excellence

This past week, our friends at the Residential Eating Disorder Consortium (“Consortium”) issued its “Standards of Excellence Project” [“STEP”] consisting of the following: “Centers of Excellence” White Paper; its “Marketing Best Practices” guidelines; its “Code of Ethics,” and “Standards of Excellence of Medical Care for People with Eating Disorders” guidelines.

As a person who has criticized and published information regarding substantial issues within the Consortium, when problems are recognized and addressed by the Consortium, they should rightly be commended for attempting to update its standards. These published guidelines will certainly generate debate and conversation on what is a very broken industry. There are some obvious flaws beyond the scope of this article but which will be addressed in future publications with the hope that constructive criticism will also result in improvement and refinement of the standards.

The Consortium attempts to define the term “Center of Excellence” as part of this STEP and as such, we need to contextually address the term. In the past three months, the term “Center of Excellence” has been used three times pertaining to significant events impacting the eating disorder industry. 

First, on September 6, 2018, the noted doctors, Angela S. Guarda, Stephen Wonderlich, Walter Kaye and Evelyn Attia published a paper entitled, “A Path to Defining Excellence in Intensive Treatment for Eating Disorders.” The doctors recommended establishing Centers of Excellence (COEs). The doctors stated that, “… the concept of COE has been applied by business corporations, government entities, and health care systems to work aimed at establishing quality metrics and promoting consumer trust in the commodity the COE develops. In health care, a COE may be defined as “a program within a healthcare institution which is assembled to supply an exceptionally high concentration of expertise and related resources centered on a particular area of medicine, delivering associated care in a comprehensive, interdisciplinary fashion to afford the best patient outcomes possible” (Elrod & Fortenberry,2017).”

Then, on October 22, 2018, Anthem Health, the largest for-profit managed health care company in the Blue Cross and Blue Shield Association, designated Denver’s Acute Center for Eating Disorders a national “Center of Excellence.” The manner in which Anthem considers and then designates certain centers for this award is apparently a closely guarded secret rivaling the Colonel’s secret recipe.

Now, the Consortium has brought to fruition its “Center of Excellence” designation. So which designation best suits and assists those who are suffering from this disease? And ultimately, isn’t that the quintessential challenge that must be paramount in our thinking? One can only hope that “Center of Excellence” doesn’t become this year’s version of “Evidence Based Treatment,” wherein that phrase can mean whatever the user believes or wants it to mean.

Without objective, scientifically based parameters and standards upon which the eating disorder industry can rely and families who are suffering and dying as a result of this disease can depend, we will continue to be subjected to overinflated claims and puffery and “Confirmation Bias” will continue to dominate the thinking and treatment parameters in the eating disorder industry.

Confirmation Bias

Confirmation Bias, also called confirmatory bias was identified by the ancient Greeks over two thousand years ago and is prevalent in the mental health and eating disorder industries today. Confirmation Bias is generally defined as the tendency to search for, interpret, favor, and recall information in a way that confirms one's preexisting beliefs or hypotheses. It is a type of cognitive bias and a systematic error of inductive reasoning. People display this bias when they gather or remember information selectively, or when they interpret it in a biased manner.

Left unchecked, Confirmation Bias can lead therapists to embrace ineffective and improper treatment processes which ultimately hurt the patient instead of helping them. The ground-breaking documentary, “Going Sane,” produced by Lisa Blair Sabey clearly illustrates this point.

Going Sane prominently features Dr. Cynthia Bulik and includes insights from Dr. Walter Kaye both of whom speak to Confirmation Bias and the eating disorder industry. Further, according to William Pelham, PhD, “Most therapists do not use evidence based practices.” The documentary discloses that a recent study indicates that most therapists place far greater value on colleague endorsements, their own personalities, opinions and observations over peer-reviewed studies. This study indicated that the former elements were more influential in selecting treatment than relying upon peer reviewed studies.

The documentary then disclosed the results of a study conducted by Emory & Henry College in conjunction with Brigham Young University. This study definitively showed a large gap between therapist predicted outcomes versus actual treatment results. The Emory/BYU study showed that therapists predicted their therapy resulted in 91% positive improvement and only a very small percentage attributed to no change or deterioration in conditions. The reality was much different. This study indicated that in actuality, only 42% resulted in positive change, 50% had no change and 8% deteriorated.

91% versus 42%. A dramatic difference. A difference which should be fully explored, investigated, exposed and studied. A difference that all families and people suffering from this disease should know about. Numbers that if accurate should be brought into the light of day and questions should be asked of those exploiting those who suffer from this disease.

But … how could we possibly expose that treatment centers are relying upon Confirmation Bias and ignoring the very existence of peer-reviewed studies? For example, if only we could find definitive proof that a large residential treatment center is relying exclusively upon Confirmation Bias to the exclusion of peer-reviewed studies. That should understandably send shock waves through the industry and make centers question the manner in which they design their own treatment policies and procedures.

But … how? Maybe, if a Chief Executive Officer and Medical Director of a large residential treatment center disclosed, while under oath while he was being deposed, that that treatment center utilized Confirmation Bias and not only discounted the importance, but the very existence of peer review studies would be dispositive proof of the existence and gross utilization of Confirmation Bias. If only …

August 27, 2015 Deposition Testimony

On August 27, 2015, the Chief Executive Officer of a large residential treatment center gave a deposition in a case then pending in the United States District Court for the Southern District of New York. He had been retained as an expert witness to testify on behalf of the plaintiff in that case to opine whether the defendant had been at fault for precipitating and/or exacerbating an eating disorder. During his testimony, the following exchanges took place:

Q: And as far as you know, the odds you assign to the various degree of recovery have never been subject to the scientific method:

A: Correct.

Q: Would it be fair to say that these odds are just kind of more of the general gestalt, as you referred to it previously this morning?

A: Thirty-five years of experience in the field.

Q: But, it’s really – ultimately, it’s your best guesstimate in the form of assigning probabilities?

A: Yes.

Q. And do you recall having written, on one or more occasion, that it's important for patients and families to know that clinicians and scientists in the eating disorders' field are equally frustrated with the lack of empirical data on effectiveness of residential treatment of anorexia nervosa and bulimia nervosa?

A. It sounds like something I would say. [emphasis added]

Q. That is something you've said. And no reason to believe that you haven't said that?

A. Absolutely not.

Q: And would that frustration that clinicians and scientists and obviously families of persons afflicted with eating disorders, in fact, make it difficult, if not impossible, to prognosticate as to any individual's likelihood of recovery?

A: Again, there's scientific method and there's papers which you've established don't exist, and then there's one's clinical experience working in the field of eating disorders and those who get hospitalized or come into residential treatment and those -- you know, so this is my best guess at what J. Doe is looking forward to.

Q. Do clinical psychiatrists sometimes rely on their professional judgment based upon experience in treating other patients?

A. Yes. As a matter of fact, you know, there's a paucity of evidence-based medicine in the world of eating disorders. So as an eating disorders expert, you're relying on clinical experience more than the literature and the data. [emphasis added]

Q. And explain why there's a paucity of information in some instances with respect to, as Mr. Carton said, double blind trials and things like that?

A. Well, I mean, one explanation is most double blind trials are done by pharmaceutical companies who have deep pockets. There's not a lot of people doing clinical trials with a large enough patient population. So, you

know, I'm not aware of a whole lot of good data.”

Wait… So, this doctor, and Chief Executive Officer, testified while under oath and subject to the penalties of perjury that there is a lack of empirical data on the effectiveness of residential treatment. He also testified that since there is allegedly a paucity of evidence-based medicine in the world of eating disorders, one must utilize Confirmation Bias.

Again, “there is a paucity of evidence-based medicine in the world of eating disorders.”

It is undetermined why this doctor failed to reference the Royal Australian and New Zealand College of Psychiatrists’ (RANZCP) guidelines, published in 2014, which revised their latest set of protocols to state that adults with anorexia, including Severe and Enduring Anorexia Nervosa (“SE-AN”) should be treated in the least restrictive environment possible. This doctor failed to reference that research supporting these updated guidelines include studies on SE-AN individuals that have emerged from pilot programs in Australia, New Zealand, British Columbia, Sweden and Canada. 

It is also curious why this doctor did not mention the existence of “The Clinical Practice Recommendations for Residential and Inpatient Eating Disorder Programs” which was performed between 2004 and 2011 headlined by the Academy for Eating Disorders. This White Paper was issued in 2012. This White Paper mentions collaborating with the National Eating Disorder Association (NEDA) in 2004 and later with the International Association of Eating Disorder Professionals (IAEDP).

So, who was this doctor/Chief Executive Officer who admitted that Confirmation Bias is widely utilized while ignoring the existence of authoritative research papers on the topic? He is the Chief Executive Officer of the private equity owned residential treatment center which advertises on its direct-to-consumer website, an alleged satisfaction rate of 99% without fear of adverse repercussion. He is the same person who testified under the penalties of perjury that there is “a paucity of “evidence-based medicine in the world of eating disorders.”  He is the same person who testified that there is a “…lack of empirical data on the effectiveness of residential treatment of anorexia nervosa and bulimia nervosa.”

According to this doctor, Confirmation Bias is very real, it is being widely utilized by the treatment center over whom he is the Chief Executive Officer and that there is no empirical proof on the effectiveness of residential treatment rendered by the treatment center he oversees or any other treatment center.

So, who is this doctor?

Dr. Ken Weiner, the former owner and now Chief Executive Officer of The Eating Recovery Center.

So, you have testimony under oath that there is no empirical proof that your treatment program is effective, that you use Confirmation Bias and then you represent to those suffering and dying from this disease that 99% of your patients are satisfied. 

What could possibly be inaccurate or wrong with that?