Shards of Glass and Jacob Marley

On Sunday, December 9, 2019, I attended church services at Highland Park United Methodist Church in Dallas, Texas. The sanctuary was awash with vibrant, red poinsettias. Long strands of garland interspersed with large red ribbons were draped over the choir loft and majestic, organ pipes. The world-class choir was elevated to an even greater level by a soprano soloist whose angelic version of “O’ Holy Night” brought many to tears.

The lead pastor is Reverend Paul Rasmussen. Reverend Paul is not one of these television evangelist type ministers screaming fire and brimstone, urging one and all to, “LET THE DEVIL COME OUT! REACH DEEP IN YOUR POCKET FOR THE LOOOORD!!” No instead, Reverend Paul’s sermons are impassioned, they weave in every day life experiences with biblical references and one can readily sense that his message is not just coming from his head … but his heart and soul as well.

On this day, he held up a plastic baggy filled with a broken light bulb. He noted that at one point, we all have dropped a light bulb and watched it break into many pieces. We then routinely get a broom and dustpan, sweep the broken shards of glass away, grab another bulb and go about our day. After all, how can we be expected to fix a shattered light bulb? It is broken beyond repair. In any event, most people wouldn’t even know where or how to begin to repair it. Do you start with the base? What about the wiring? Do you assemble the larger pieces of glass first? Even trying to come up with a plan to repair this fragile, broken item is daunting. It is much easier to simply replace it.

Reverend Paul then poignantly described to some extent, we humans are all broken light bulbs  We all have flaws. But, God doesn't simply discard us because we are fractured. As a Loving Father, God has the recipe for salvation and it is up to us to find that journey of healing.

And at that point, the analogy and message became quite clear. I read on a number of Facebook groups, on other internet groups, through social media and through speaking with doctors, counselors and professionals in the eating disorder industry, of the fear, the hopelessness, the grief, the anger, the frustration and the helplessness felt and expressed by parents whose beloved children are afflicted with this damnable, insidious disease. They see their child, their very heart, slowly wasting away, self-harming, acting out, abusing drugs or alcohol speeding what they fear will ultimately result in the death of the most precious thing they hold dear. They are shaken to their very core. Their light, their love, their hope for the future lay at their feet, unworkable shards of glass, fractured to a point beyond measure or repair. They also know that this is a light bulb that they cannot merely sweep up, discard into the trash bin and then replace. And yet, many don’t even know where to begin to try to repair this fragile, broken life. Fear and despair cloud their vision and falsely point to a path that leads to even greater catastrophe. Where does one begin?

Parents, I so wish I could give to you as a Holiday Present, a copyrighted repair manual complete with blueprints for a successful reconstruction of a human life being torn apart by this disease. Alas, I cannot. In fact, in some ways, I feel like the mythical character Jacob Marley. We know Marley as Ebenezer Scrooge’s deceased business partner, now a chained and tormented ghost, doomed to wander the earth forever as punishment for his greed and selfishness when he was alive. Marley roams restlessly, witnessing the hardships others suffer and lamenting that he has forever lost his chance to help them. But then, in an ironic twist of fate, Marley arranges for the three spirits to visit Scrooge and gives his friend an opportunity for redemption, which Marley tells him was "... a chance and hope of my procuring." Until I breathe my last, my reality is that it is too late for me. But, it is not too late for you.

Moms … Dads … parents, I urge you to simply start with a beginning, any type of beginning. It doesn’t matter if it is the base, the electrical wires or the shards of glass that you address. But, address it you surely must. I can suggest that perhaps a starting point may be found by steeling up your courage, staring at yourself in a mirror and then, look within yourself. Right now, you may be overwrought with fear, despair and yes, perhaps anger. If those emotions dictate your every waking thought, if they dictate your decisions, there is very little doubt that the path upon which your journey will take you will be filled with mistakes, negativity, false hope and dead ends.

We also know that the manner in which we deal with fear and despair is as individual as the person experiencing it. So, where is a starting point? Perhaps for many, a starting point could be … educate yourself! Read vociferously. Actively join and participate in parent support groups. Start support groups in your community if you are able. Read academic research papers and studies. When you speak with treatment professionals, ask as many questions as you deem necessary. Arm yourself with knowledge. “Ipsa scientia postesta est.” [Knowledge itself is power.] That way, when you confront doctors, counselors, insurance claims representatives you will know much more than they believe they know and you can argue with more authority for more effective treatment protocols. You will be able to cite independent studies. You will empower yourself. As you learn, as your strength grows you may learn to take those negative emotions of fear and despair, and instead of them defining you in a negative manner, you use them to motivate you, to inspire you. Do not ignore those emotions. They are currently present in your life. However, the only place that fear can exist is in our thoughts of the future. It is a product of our imagination, causing us to fear things that do not at present and may not ever exist. And isn’t that near insanity?

Moms … Dads … You can save your beloved child. You will find your voice. And maybe along the way, you may find, or you may rediscover your very soul.

Therapist - Client Sexual Relationships ... The Problem is Real.

For Brutus, as you know, was Caesar's angel
Judge, O you gods, how dearly Caesar loved him!
This was the most unkindest cut of all;
For when the noble Caesar saw him stab,
Ingratitude, more strong than traitors' arms,
Quite vanquish'd him: then burst his mighty heart;

William Shakespeare, “Julius Caesar, Act III, Scene 2”

Of the many hurdles, obstacles and life-threatening issues confronting persons suffering from severe eating disorders, being mentally, emotionally or sexually exploited by the very person from whom they seek help, guidance and sometimes even salvation truly is “the most unkindest cut of all.” It would be easy to dismiss reported incidents of therapists taking advantage of their patients as isolated and rare. Persons may argue that proven instances are so rare that they do not constitute a grave issue worth consideration and as such, we would be seeking to find a solution to a problem that does not really exist. You maintain these false beliefs at your peril.

Studies on Prevalence and Addressing the Issue

In 1991, Kenneth Pope published the definitive research study on “Prior Therapist – Patient Sexual Involvement Among Patients Seen by Psychologists[1].” The findings of this study were shocking. The study found, “A national survey of 1,320 psychologists found that half the respondents reported assessing or treating at least one patient who had been sexually intimate with a prior therapist; a total of 958 sexual intimacy cases were reported. Most cases involved female patients; most involved intimacies prior to termination; and most involved harm to the patient. Harm occurred in at least 80% of the instances in which the therapists engaged in sex with a patient after termination. Respondents reported that in only about 4% of the 1,000 cases in which the issue of sexual intimacies arose, the allegations were false.”

Other significant findings discovered and published by Pope include the following:

“1. It is crucial to note that the sole national study using the same instrument during the same time period with the three major mental health professionals found no significant difference among the rates at which psychiatrists, psychologists, and social workers acknowledged engaging in sex with their patients (Borys & Pope, 1989). 

2. Female patients were more likely to experience harm if the intimacy was initiated before termination (95%) than after (80%), while male patients were not more likely to experience harm from intimacies initiated before termination (80%) than after (86%).”

With regard to implementing processes to lessen the likelihood of this sexual exploitation, Pope and his team also submitted some very damning hypothesis and data. To this end, Pope’s study stated:

We need to reexamine the opportunities for preventing sexual exploitation of patients. To some extent this may involve increased understanding of the tendency of most therapists to experience sexual attraction to patients (Pope, Keith-Spiegel & Tabachnick, 1986; Pope, Sonne, & Holroyd, 1993) and the phenomenon of engaging in sexual fantasies about patients (Pope et al., 1986; Pope, Tabachnick & Keith-Spiegel, 1987). It may also involve increased understanding of the sexualization of our teaching relationships and the ways in which training programs provide education and modeling regarding sexual issues (Glaser & Thorpe, 1986; Pope, Levenson & Schover, 1979; Robinson & Reid, 1985; Tabachnick, Keith-Spiegel & Pope, 1991). What seems likely, however, is that creating, implementing, and evaluating comprehensive and effective prevention efforts will not come easily for us as clinicians. As much as we may talk about the concept, it is hard to argue with Sarason's (1985) conclusion: "The fact is that in practice, and the ways clinicians are prepared for practice, the preventive stance is conspicuous by its absence" (p. 63). And yet as psychologists, we have a rich and growing legacy of theory, research, and experience in attempting to bring about the kind of sustained, systematic changes that might be part of an effective prevention program (e.g., Bronfenbrenner, 1974; Cowen, 1977; Kelly & Hess, 1987; Sarason, 1972, 1988; Trickett, 1990). As we consider the feasibility and desirability of various preventive strategies, it is important that we also consider carefully their ethical implications (Bond & Albee, 1990; Trickett & Levin, 1990).

Based in part upon Pope’s study, the American Psychological Association enacted a number of ethical codes addressing this sexual exploitation. These guidelines include the following:

3.02 Sexual Harassment. Sexual harassment is unwanted/offensive sexual solicitation, physical advances, or conduct that is sexual in nature, which may be deemed abusive to another party. Psychologists avoid sexually harassing those with whom they work.

3.04 Avoiding Harm. Psychologists take reasonable steps to avoid/minimize harming their clients, students, supervisees, research participants, and others.

3.05 Multiple Relationships. A multiple relationship occurs when a psychologist is in both a professional and additional role with another person, with a person associated with the person with whom the psychologist has a professional relationship, or when he/she promises to enter into another relationship in the future with any of these persons. If such a dual relationship impairs objectivity and/or competence, or could potentially risk exploitation or harm to those who are served, the actions are deemed unethical.

3.08 Exploitative Relationships. Psychologists do not exploit persons over whom they have power/authority.

7.07 Sexual Relationships with Students and Supervisees. Psychologists do not engage in sexual relationships with those over whom they have evaluative authority.

10.01 Informed Consent to Therapy. This is pertinent to the nature of therapy, so that clients have realistic expectations; the therapeutic relationship is a professional one, which should be made explicit to clients at the outset.

10.05 Sexual Intimacies with Current Therapy Clients/Patients. Psychologists must not engage in sexual intimacies with current therapy clients.

10.06 Sexual Intimacies with Relatives or Significant Others of Current Therapy Clients/Patients. Psychologists must not engage in sexual intimacies with relatives or significant others of current therapy clients.

10.07 Therapy with Former Sexual Partners. Psychologists must not conduct therapy with former sexual partners.

10.08 Sexual Intimacies with Former Therapy Clients/Patients. Psychologists must not engage in sexual intimacies with former therapy clients for at least two years after cessation or termination of therapy. After this interval, psychologists can potentially, albeit infrequently, become exempted from this principle if they demonstrate that no client exploitation occurred in the following areas: the amount of time that has passed since therapy terminated; the nature, duration, and intensity of the therapy; the circumstances of termination; the client’s/patient’s personal history; the client’s/patient’s current mental status; the likelihood of adverse impact on the client/patient; and any statements or actions made by the therapist during the course of therapy suggesting or inviting the possibility of a post-termination sexual or romantic relationship with the client/patient (American Psychological Association, 2002 American Psychological Association. (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060–1073. Adrian, C. (1996). Therapist sexual feelings in hypnotherapy: Managing therapeutic boundaries in hypnotic work. International Journal of Clinical and Experimental Hypnosis, 44, 7–19. , 2010 American Psychological Association. (2010). 2010 amendments to the 2002 ethical principles of psychologists and code of conduct. American Psychologist,65, 493.[Crossref], [PubMed], , [Google Scholar]).

In 2016, the statistics and harmful ramifications were reiterated in an article authored by Michael R. Capawana, PhD, who has privileges at Massachusetts General Hospital and published in the Journal of Cogent Psychology, Volume 3, Issue 1 (2016). In his article, “Intimate Attractions and Sexual Misconduct in the Therapeutic Relationship: Implications for Socially Just Practice[2],” Dr. Capawana stated:

Sexual contact between therapists and clients is unethical due to the power imbalance that permeates all aspects of the relationship, and because research has demonstrated that this form of sexual contact has ramifications for clients in the form of psychological damage (Sommers-Flanagan & Sommers-Flanagan, 2004 Sommers-Flanagan, J., & Sommers-Flanagan, R. (2004). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques. Hoboken, NJ: Wiley. [Google Scholar]). Pope (2001Pope, K. (2001). Sex between therapists and clients. In J. Worell (Ed.), Encyclopedia of women and gender: Sex similarities and differences and the impact of society on gender (Vol. 2, pp. 955–962). Waltham, MA: Academic Press. [Google Scholar]) documented the most common reactions that are frequently associated with therapist–client sex, articulating them as comparable to outcomes of incest or rape. These reactions are: ambivalence; cognitive dysfunction; emotional lability; emptiness and isolation; impaired ability to trust; guilt; increased suicidal risk; role reversal and boundary confusion; sexual confusion; and suppressed anger (Pope, 2001Pope, K. (2001). Sex between therapists and clients. In J. Worell (Ed.), Encyclopedia of women and gender: Sex similarities and differences and the impact of society on gender (Vol. 2, pp. 955–962). Waltham, MA: Academic Press. [Google Scholar]). A majority of clients surveyed reported sex with therapists as damaging; even those who found it pleasurable at first, eventually viewed it as exploitative (Koocher & Keith-Spiegel, 2008 Koocher, G. P., & Keith-Spiegel, P. (2008). Ethics in psychology and the mental health professions (3rd ed.). New York, NY: Oxford University Press. [Google Scholar]).

Real Life Examples and Impact

We previously set forth the issues regarding Nicole P. Siegfried who has been with Castlewood/Alsana from April 2013 to present. In January 2018, Castlewood/Alsana named Ms. Siegfried as its Chief Clinical Officer. We disclosed that Castlewood offered employment to Ms. Siegfried while she was still on professional probation and under practice supervision for having an inappropriate sexual relationship with a patient. Five months after she was placed on professional probation, she began her employment with Castlewood and her misdeeds went largely undisclosed and unknown. And yet, that horse is at the glue factory and there is no reason to continue to beat it.

However most recently, on August 21, 2018, Michael Jacksa, a counselor at Timberline Knolls was arrested and charged with assaulting a 29 year old patient at Timberline Knolls during two counseling sessions between May and June of 2018. Jacksa was accused by patients of digitally penetrating their vaginas and buttocks, putting his hands beneath their clothing, fondling their breasts and forcing them to give him oral sex. During his first bond hearing on Aug. 21, Jacksa reportedly admitted to police that he "probably went too far."

This “probably went too far” conduct manifested itself by him being indicted for his reprehensible conduct directed toward a second victim. According to the new charges, between Dec. 1, 2017 and Jan. 10, 2018, Jacksa was treating an out-of-state woman for eating disorders, anxiety and past sexual abuse. The patient alleges that Jacksa sexually assaulted her during four therapy sessions at Timberline Knolls. The prosecutor said the second woman came forward after seeing media reports.

According to the prosecutor, at least six other former patients of Jacksa's from across the country have contacted the Lemont Police Department, stating that Jacksa allegedly engaged in "inappropriate sexual behavior" during their respective therapy sessions.

And therein lies the greater issue. More often than not, these instances are not isolated events, restricted to one person. More often than not, we are dealing with predators who repeatedly prey on the weak and the vulnerable. More often than not, these attacks are not about sex … they are about power, taking advantage of the weak and exploiting those most vulnerable knowing that they are less likely to get reported.

Unlike Castlewood, Timberline Knolls took immediate steps addressing the matter. They discharged Jacksa, stated that they performed a thorough background search on not only him, but on all employees and stated that they are cooperating with authorities. But, even this is not enough.

Address the Problem

As the many studies show, therapist – patient sexual involvement is not rare. And when it does happen, the damage and injury to the patient is very real, substantive and can be debilitating. It is long past time for the eating disorder industry to step to the plate and aggressively address this issue … before you are forced to do so by one of my brethren of the bar who represents one of the many victims.

First, this problem is tailor-made to be addressed by those programs in the Residential Eating Disorder Consortium. (“Consortium”). Last month, the Consortium published their new Standards of Excellence Project. (“STEP”). As part of this STEP project, they included the REDC Code of Ethics. A review of this Code of Ethics indicates with regard to this very real issue of therapist – patient sexual exploitation, the Consortium did not address this problem. This oversight must be rectified immediately.

Any attorney with any sense and experience would advise the Consortium to appoint a blue ribbon panel to address this problem; to come up with new standards and investigative techniques to increase the likelihood of finding predators who apply for and are offered jobs. Improve your interviewing standards and administer testing designed to increase the likelihood of discovering characteristics exhibited by predators who take advantage of our loved ones.

This issue is real. Our children are being exploited and harmed. The statistics and studies indicate that the problem is prevalent. It exists today. Improve your standards and pledge to employ only the best. Clean up your houses … or the court system will.

We entrust the most precious thing we hold dear … the very lives of our loved ones to the Consortium and other entities. And yet, the Consortium and these other entities are not “entitled” to that gift. It is a gift that must be earned each and every day. The duty is absolute and non-delegable. But, if the Consortium, its members or any other entity in the eating disorder industry fails at this task through neglect, avarice or sloth? 

The Bard, penned the line, “This was the most unkindest cut of all.” And yet, he also wrote, “Prick us do we not bleed? Tickle us do we not laugh? Poison us, do we not die? Wrong us, shall we not revenge.”

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[1] https://kspope.com/sexiss/sex2.php#copy

[2] https://www.tandfonline.com/doi/full/10.1080/23311908.2016.1194176

The Mental Health Doomsday Clock ... And Midnight Approaches.

“It's no use talking about the 'Doomsday Clock' when it has already chimed. But, alas, the chimes fell on deaf ears.”

Anthony T. Hincks,  Author

The symbolic Doomsday Clock represents the likelihood of a human-made global disaster. Maintained since 1947 by the members of the Bulletin of the Atomic Scientists’ Science and Security Board, it originally was an analogy for the threat of global nuclear war. But, since 2007 it has also included climate change and new developments in life sciences and technology that could cause permanent harm to humanity.

The clock represents the hypothetical global catastrophe as "midnight" and the Bulletin's opinion on how close the world is to a global catastrophe as a number of minutes until midnight. Its original setting in 1947 was seven minutes to midnight. It has been set backward and forward 23 times since then, the smallest-ever number of minutes to midnight being two (in 1953 and 2018) and the largest seventeen (in 1991).

The Doomsday Clock scenario is tailor-made for the mental health field and specifically, the eating disorder industry. This is particularly true for the following reasons:

(1). Private equity firms have taken over residential treatment centers due to the passage of the Mental Health Parity Act and the Affordable Care Act.

(2). There is a lack of government oversight and no legislative guidelines in place to monitor or regulate the industry.

(3). A prominent doctor in the eating disorder industry testified while under oath that there is a lack of empirical data on the effectiveness of residential treatment.

(4). Despite the enactment of the Mental Health Parity Act, recent studies indicate insurance providers are more closely evaluating and denying extended treatment at residential programs.

(5). A high and escalating debt/equity ratio indicating perceived growth is in actuality, merely refinanced debt structure combined with a lack of tangible assets make future transactions problematic if not doubtful and bankruptcy more likely.

(6). Loans and debt payments exceeding in some instances over one hundred million dollars are coming due and must be restructured or paid and if not, will result in bankruptcy at the very least.

When taking these issues into account, one can surmise that the delicate house of cards upon which the residential treatment industry has been built is teetering and we are approaching Midnight on the Mental Health Doomsday Clock.

And now, the first card has fallen.

Private Equity investment led to … Bankruptcy 

In 2018, HCR ManorCare, the second largest nursing home chain in the United States, filed for bankruptcy. In 2007, the Carlyle Group, one of the wealthiest private-equity firms in the world acquired HCR ManorCare.

The Washington Post conducted an investigation into HCR ManorCare and the Carlyle Group and published an extensive article in November 2018. In the article, the Post noted that the deal immediately faced protests from critics who said the aggressive tactics of private-equity firms are ill suited for companies that tend to some of society’s most vulnerable. From the start, Carlyle’s acquisition of HCR ManorCare made the company’s finances more risky because the transaction burdened it with billions in long-term debt.

Carlyle and investors then exacerbated the financial situation by completing a 2011 financial deal that extracted $1.3 billion from the company for investors while saddling HCR ManorCare with what proved to be untenable financial obligations. Under the terms of that deal, HCR ManorCare sold nearly all of the real estate in its nursing home empire and then agreed to pay rent to the new owners. This kind of deal, known as a sale-leaseback, is a common tactic of private-equity firms, and it generated financial benefits for Carlyle and its investors. The rent HCR ManorCare was obliged to pay — to occupy the nursing homes it had once owned — amounted to $472 million annually, according to legal filings. The rent was set to escalate at 3.5 percent a year, and according to the lease, HCR ManorCare also had to pay for property taxes, insurance and upkeep at the homes.

Because of this 2011 transaction, HCR ManorCare’s long-term financial obligations had risen from less than $1 billion to over $5 billion, according to financial statements. The real estate deal yielded enough money to help the company pay down some of that debt. But the deal also meant that HCR ManorCare had to make massive rent payments to its new landlord, and these, according to the company’s accounting, raised the company’s long-term financial obligations to $6 billion.

In addition, Carlyle received annual “advisory fees” from the companies that it purchases — essentially; Carlyle pays itself to manage the companies it owns. The Post disclosed that at HCR ManorCare, those fees averaged about $3 million a year from 2007 to 2015, or about $27 million, according to documents and interviews. That money was also distributed to Carlyle and its investors.

Carlyle also received a “transaction fee,” which is money Carlyle receives when it buys a company, typically 1 percent (1%) of the purchase. The $6.1 billion HCR ManorCare purchase price, yielded Carlyle $61 million, Carlyle officials confirmed. That money was distributed to Carlyle and its investors.

The increasing financial burden and long term debt obligations led to the inevitable deterioration of the services it provided and the health conditions in the nursing homes.

Under the ownership of the Carlyle Group, for the five years preceding the bankruptcy filing, HCR ManorCare exposed its roughly 25,000 patients to increasing health risks, according to inspection records analyzed and reported by The Post. “The number of health-code violations found at the chain each year rose 26 percent between 2013 and 2017, according to a Post review of 230 of the chain’s retirement homes.”

The Post quoted Andrew Porch, a consultant on quality statistics to whom HCR ManorCare referred questions about health-code violations, “Carlyle was a very interesting group to deal with. They’re all bankers and investment people. We had some very tough conversations where they did not know a thing about this business at all.”

The Post interviewed financial experts familiar with HCR ManorCare who stated that it was massive financial obligations that led the company to bankruptcy. The company had been “over-levered” with debt. Chad Vanacore, vice president and research analyst of health-care providers at Stifel, the investment bank stated, “I think it’s fair to say they were over-levered.” Tom DeRosa, chief executive of Welltower, a company that acquired HCR ManorCare’s real estate after the bankruptcy, said in an interview at a real estate conference, “HCR ManorCare was doomed. It was over-levered, and it couldn’t work under the capital structure that had been crafted.”

And after the private equity owners enrichened themselves, HCR ManorCare was left financially devastated, picked apart in its bankruptcy and sold piecemeal while leaving a trail of elderly who suffered and died as a result of the short-sightedness and greed.

Is Acadia Healthcare Next?

We previously reported that Acadia Healthcare Company, Inc. is ripe for financial disaster. We previously reported that in a 7 year time period, Acadia expanded its operations to a total of 584 behavioral health care facilities in the United States, the United Kingdom and Puerto Rico with approximately 17,800 beds. Of those 584 facilities, 256 allegedly treat eating disorders in some fashion. Included amongst these 256 facilities are McCallum Place, based in the State of Missouri and Timberline Knolls, based just outside of Chicago, Illinois.

Acadia is now one of the largest mental health system providers in the United States. And according to Penn Little, the Managing Partner of Bar Nothin’ Capital Management based out of Chicago, Illinois it could be on the verge of financial collapse. Reports and rumors from last month were that Acadia was positioning itself to be sold to Kohlberg, Kravis, Roberts & Company and then taken private. But these talks have stalled as reports of long term debt in the amount of $3.2 billion are come to light. Mr. Little’s research also found that many of the Acadia facilities are woefully understaffed. Further, Mr. Little reiterated that if interest rates climb, Acadia is approaching the point where it will be very difficult for it to pay its debt.

Other issues are conspiring against Acadia. Emily Evans, a health care director at Hedgeye Risk Management stated, “Acadia is also hurt by the fact that health insurance payments for mental health and addiction services are “bad” right now despite federal parity laws.”  

As the sale to KKR looks ever more remote, Acadia stock plummeted 14%. Finally, of the greatest immediate concern to McCallum, Timberline Knolls and other entities owned by Acadia, is that the Chief Executive Officer of Acadia, Joey Jacobs reportedly stated that he might prune ten percent (10%) or more of the lower performing British centers by shutting them down. What that means is that with the stroke of a pen, Mr. Jacobs and his board can shut down treatment centers if they do not generate enough revenue. And the question remains, if that is the inevitable action, how many people will die because they happen to be in a treatment center that does not financially perform to Mr. Jacobs’ satisfaction?

And Finally …

As we stare at the possible financial apocalypse, we must be reminded of the debt we know Eating Recovery Center has incurred: $30 million senior secured revolving credit facility expiring in 2022;  a $190 million senior secured first lien term loan due in 2024, and; a $30 million senior secured delayed draw term loan due in 2024. You may add management/advisory fees being paid to CCMP Capital Advisors and transaction fees to its equation. ERC’s Doomsday Clock has a definite midnight date and the results will be far worse than a glass slipper being lost.

The reality and the horrible ramifications of having private equity own the eating disorder industry, from the halls of the treatment centers to the halls of Congress have arrived. Our children are dying. Our loved ones still suffering are subjected to vood00-based treatment with no roots based in objective, scientific research. Treatment is monetary based. An incompetent practitioner who sexually took advantage of a patient is allowed to continue to practice with no tangible ramifications. Hundreds of people suffering from this insidious disease are kicked out of outpatient treatment on a concocted, bogus excuse while spokespersons for that treatment center try to spin the reality of their reprehensible conduct.

And so parents, it is up to you. Your children’s lives depend on you. You must not back down nor let fear dictate your course. Arm yourself with facts and be bold. Embrace the message of Admiral William McRaven, who in a commencement speech given at the University of Texas said these powerful words, “So, if you want to change the world, start each day with a task completed. Find someone to help you through life. Respect everyone. Know that life is not fair and you will fail often. But if you take some risks, step up when the times are the toughest, face down the bullies, lift up the downtrodden, and never ever give up, if you do these things, the next generation and the generations that follow will live in a world far better than the one we have today. And what started here, will indeed have changed the world for the better.”

Change the world.

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?