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Jul 20, 2023

Eating disorder patients say punitive, threatening methods at Denver treatment center left them with new trauma

June 6, 2023

June 6, 2023

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by Meg Wingerter, Seth Klamann

Lizzy Earhart didn't know much about Eating Recovery Center when she agreed to get treatment there in October 2020. She'd already received treatment for anorexia at another treatment provider in Denver, but she'd relapsed immediately after. But Eating Recovery Center was big, well-known. It seemed her best option.

But the months she spent there reinforced her illness, the 21-year-old said, and the punitive environment left her with new trauma.

If she didn't comply with treatment, she wouldn't be allowed outside the facility. Patients were lined up each morning to be weighed wearing nothing but ill-fitting mesh or paper gowns. When Earhart expressed concerns about her treatment plans, her psychiatrist told her she was out of options and that her concerns were "just the eating disorder talking."

"I wouldn't go outside for a week, two weeks at a time. It just made my anxiety and other issues a lot worse," Earhart said. "And they would threaten you with an NG (nasogastric) tube, a feeding tube, if you were struggling without medical grounds to do so. They would threaten it as a fear tactic."

The experience reshaped Earhart's fundamental perception of treatment.

"It definitely shifted my focus from wanting to get better so I can live my life to, 'I want to get better so I can get out of here, so I don't get the (feeding) tube, so I can go outside,'" she said.

Amid a nationwide explosion of eating disorder diagnoses, seven former patients and three former staff members staff described to The Denver Post a punitive and traumatic environment at the Denver-based Eating Recovery Center, one of the largest treatment providers in the country.

The former patients cast the organization's methods as rigid and said they often layered new trauma upon pre-existing issues. Feeding tubes and room-based care—in which patients can't leave their rooms except to use the bathroom—were used as threats to ensure compliance, patients said. Their partially nude bodies could be routinely exposed to one another during daily weigh-ins. Some said they still had nightmares about their experiences.

Dr. Anne Marie O'Melia, chief medical officer and chief clinical officer at Eating Recovery Center, said she couldn't discuss any specific patient's experience because of confidentiality rules. But she defended the facility's methods as at times uncomfortable but critical to treating patients afflicted with a life-threatening disease, and she said the criticism from patients showed that the facility needed to better communicate with its clients.

But a brain in the grips of an eating disorder will try to hold onto it, O'Melia and other providers said, and that can fuel patient pushback against treatment. Three patients who spoke to The Post also described positive experiences at Eating Recovery Center.

The criticism highlights the tension that exists between treating a severe illness and respecting patients' dignity and personal autonomy. The complaints have drawn the attention of Colorado lawmakers, who considered a bill this year to more tightly regulate the facilities. Sen. Lisa Cutter, a Jefferson County Democrat who co-sponsored that bill, described some treatment practices as "barbaric."

Effective treatment is critical, experts say. Long stigmatized and stereotyped, the diseases are among the deadliest mental illnesses, and their prevalence doubled nationwide in both teen girls and boys from March 2020 to March 2022. Treatment is often unavailable, and stigma and stereotypes have hampered eating disorder diagnoses and treatment, particularly for people who aren't young, thin, white and female.

Colorado serves as a national hub for eating disorder treatment, with multiple facilities in the Denver area attracting patients from across the country. Eating Recovery Center is one of the largest providers, with 101 beds in Colorado, including 36 licensed to care for patients who are there involuntarily. The organization also has programs in 10 other states, according to its website.

O'Melia said the facilities are overseen by the state and the Joint Commission, which both have strict rules about patients' rights. The Joint Commission is a private group that accredits medical facilities.

"I want to reiterate that eating disorders can be life-threatening," she said in a statement. "Involuntary treatment is used only as a last resort; we do not want to step in if the patient is able to manage their own safety and symptoms with less support. We intervene only when a patient's life is threatened by their eating disorder."

Treatment can be lucrative. According to an analysis by IBISWorld, the eating disorder treatment industry is $4 billion annual market. The number of residential treatment programs has more than tripled since 2011, according to a 2021 analysis published in the American Academy of Pediatrics, which also encouraged families to "exercise caution when selecting a residential treatment program."

Many providers are for-profit. Eating Recovery Center, for instance, was purchased by a private-equity firm in 2017 for $580 million, according to Behavioral Health Business. Four years after that, it was sold again—to two more equity firms—for $1.4 billion.

Former staff members told The Post that the care the center provided caused its own harm, but that patients were sometimes sick enough that they had no good options. Providers need to quickly address patients' physical health and weight, which can mean taking steps that feel excessively restrictive or even punitive, providers and experts said. Patients who are severely underweight need to be physically stabilized, they said, and will go to extreme lengths to continue the behaviors that come with the disease.

"For some folks (for whom) a higher level of care is really needed, there are aspects of treatment that are extremely uncomfortable," said Emily Hemendinger, a social worker who works with eating disorder patients at the University of Colorado's Anschutz Medical Campus.

Several former patients told The Post that they were aware of the severity of their illness and understood the need for serious intervention. But those practices were often traumatic to patients in a delicate mental and physical state, they said, and can reinforce pre-existing trauma and prompt patients to avoid treatment. One person said they attempted suicide rather than go to treatment because of the horror stories they'd heard.

"These things are important, but the way that you approach them makes them longer lasting because you can restore weight for somebody and they'll leave and relapse immediately because of how you treated them in the process," Earhart said. "So how much help is it actually going to be if it's the punitive kind and outweighs the medical help?"

Another former patient, who was treated at Eating Recovery Center's Lowry location for two months in the summer of 2016, told a similar story, saying the experience was more traumatic than in two other places where she was treated for an eating disorder. There was a strict time limit to finish meals, and if someone didn't eat everything on their plate, they had five minutes to down a Boost supplement drink to avoid the possibility of a feeding tube, she said.

"It was really scary, to be honest," said the former patient, who spoke about her medical treatment on condition of anonymity to protect her privacy.

The former patient, who was 15 at the time, said that those who had too many tube feedings were put in isolation in their rooms. One girl who was there at the same time was isolated for about two months, she said.

The use of supplement drinks isn't uncommon in treatment, said Jean Doak, a professor at the University of North Carolina and the clinical director of the school's Center of Excellence for Eating Disorders.

"If someone has lost a significant amount of weight and their (heart monitoring) is unstable and labs are unstable and heart rate is acutely low, the 100% priority will be medical stabilization," she said. "That is just the way it is. That becomes the No. 1 focus because of how acutely, medically unstable somebody is."

Eating disorders are complex psychiatric illnesses that manifest physically and have been saddled with stigma, which complicates their diagnosis and treatment. They include anorexia, typified by an extreme limitation or avoidance of eating, and bulimia, which often involves binge eating followed by behaviors like vomiting or over-exercise.

Suicide is more prevalent among people with eating disorders, which, coupled with the physical effects of the diseases, make them particularly deadly. People with the disorders often identify strongly with them, experts said, making them defensive of the behaviors and more difficult to treat.

Doak and other experts said treatment needs to be individualized to patients' specific needs and experiences, particularly given the prevalence of trauma and other mental health diagnoses. Former patients said they often felt like Eating Recovery Center offered a one-size-fits-all approach that focused on physical, rather than mental, restoration.

Hemendinger, the CU social worker, said treatment providers often are caught between treating a devastating disease and the realities of the American health care system.

"Because insurance often pushes back and cuts people's treatment stays and doesn't fund full treatment stays, some of these treatment centers can turn more into just focusing on symptom reduction, and they're not individualizing care as much," she said.

Eric Dorsa, an eating disorder advocate, said they frequently were hospitalized as a teenager for refeeding because none of the eating disorder programs in their home state of Texas took teens who were assigned male at birth. They said they also objected to tube feeding and had to be physically restrained at age 12 so they couldn't pull the tube out.

But in retrospect, there was no other choice, Dorsa said. Their organs were shutting down, and the disorder had such a tight grip that it was impossible to make the decision to eat, they said. Dorsa has been in recovery for more than a decade after treatment at a facility that Eating Recovery Center later purchased in San Antonio, Texas.

"The only intervention I credit to saving my life was a feeding tube," they said. "While I understand that it sounds incredibly extreme, so is the reality of an eating disorder."

Erin Beal, of Philadelphia, said she traveled to Denver for treatment at Eating Recovery Center in the spring of 2022. At the time, she was sick enough that she needed a wheelchair and spent the first three weeks in a medical observation unit, though she said she only saw a doctor twice in that time. Most symptoms were dismissed as anxiety-driven, she said.

Beal, 20, said she was given a feeding tube after she didn't eat enough at her first meal and snack time. Because she wasn't considered compliant, she couldn't call home for emotional support after getting the tube, she said.

"They tell family members to not believe anything we say," she said. "We're still humans, and that's not how I was treated."

A therapist who worked at Eating Recovery Center in Denver until 2022 said that some patients need tube feeding to stabilize them medically, but tubes were also used as a threat if patients weren't willing to finish their meals or to drink supplements quickly enough.

"It was very much, 'You don't have a choice,'" said the therapist, who spoke on the condition of anonymity because he feared professional repercussions.

A female therapist, who also left a job at Eating Recovery Center in 2022, said she still feels uncomfortable with the way some patients were treated. They were seriously ill and needed to be fed, but it's traumatic for a teenager to be held down by five adults while a tube is inserted in their nose, she said. She spoke to The Post on condition of anonymity because her current employer didn't authorize her to speak publicly.

The female therapist said she wasn't sure whether Eating Recovery Center patients were threatened with tube feeding, but said she did feel room-based isolation was "weaponized." At the same time, she continued, it's understandable why it was an appealing solution because some patients did become more compliant to avoid being isolated again.

"When I look back at it," she said, "it makes me sick."

O'Melia, the chief medical and clinical officer for Eating Recovery Center, said feeding tubes are a last resort for involuntary patients and that state and regulatory oversight ensure they're used appropriately.

Former patients described a rigid system, run by understaffed providers. Treatment had five levels, each with increasing freedoms as patients showed fewer eating disorder behaviors, Beal said. On level 1, patients couldn't leave their rooms, except to use the bathroom, she said, while people on level 2 were allowed to eat in the dining room and make 15-minute phone calls.

To stay on level 5, where they could use their phones and had more freedom, patients had to eat every bite offered, Beal said. Staff didn't like to order additional food if someone dropped part of their meal, so patients would eat the things they dropped to avoid being knocked down a level, she said.

"There were a lot of patients who had to eat things off the floor," Beal said.

Staff monitored phone calls, and one hung up the phone when the patient who was 15 at the time tried to tell her mother she didn't like it there, the patient said. (Her mother assumed the patient had gotten annoyed and hung up herself.) She later learned her therapist told her parents she was "faking" that she was getting better just so she could leave and that her decision to be vegetarian was part of the eating disorder.

The bathrooms were locked overnight, and patients had to wait for someone to take them, Beal said. She threw up accidentally on the floor when she couldn't get into the bathroom, and a staff member who thought she'd vomited intentionally yelled at the janitor for cleaning it up instead of making her do it herself, Beal said, adding the same thing happened to another patient while she was there. Another former patient, Alexa Cohen, said she vomited as an anxiety response and would often be berated for it.

Despite the extensive rules and surveillance, patients were able to leave or harm themselves. Cohen said she passed out in a hallway on her second day in the facility and was left there for 90 minutes. The First Avenue location had eight incidents of patients leaving without permission between July 2019 and February 2020, according to inspection documents filed with the Colorado Department of Public Health and Environment.

The Spruce Street location was cited by the state in May 2018 for not regularly checking on a patient who had talked about killing himself. A similar incident happened about two months later. The facility was dinged in July 2020 after three patients used broken pens and pencils to harm themselves.

A Denver 13-year-old who was treated for anorexia in early 2022 said they could get away easily because the staff was trying to watch 29 other patients. The teen, who is nonbinary, made multiple suicide attempts, but said the staff refused to take them to the hospital when they felt suicidal again. Staff told the patient to just sit by the medication window where they could be watched, the patient said. The Post interviewed the teen with their parents present and isn't identifying them because they are a minor.

Sometimes, the patient peeled off their skin while on "sit protocol," where they were required to sit down and do nothing because they hadn't complied with directions. A friend stopped breathing following a suicide attempt at the facility, though she was revived, they said.

"They treated us like we were eating disorders instead of kids," they said. "Residential is supposed to be a place of healing, not a place to hurt you."

Former patients and staff members said employees were frequently overworked and would burn out quickly. The female therapist who left in 2022 said it wasn't unusual to have only two people overseeing 18 patients. Sometimes, patients cut themselves or made themselves throw up while staff were busy with others, she said.

"The staffing ratios were dangerous to both the staff and the kids," she said.

The 13-year-old patient said they begged to come home, but the staff told their parents not to trust them. Patients weren't allowed to hug each other, they said, so people whose parents lived in another state sometimes went months without physical contact.

"They did a lot of breaking trust," they said.

Patients' experiences were not universally negative.

Dylan Orrange, who came to Denver from Orlando, Florida, in March 2022, said their team was "kind and understanding." Orrange felt like they'd won the lottery with their providers, though they said the broader institution often treated patients like prisoners and that "punishment-based treatment" was common.

Shay Ayres, a transgender woman from Highlands Ranch, said the staff was "super compassionate," took time to ask about her emotional state when she wasn't eating and was comfortable when she expressed her feminine nature.

Ayres said she understands why people report negative experiences, but much of that is a reflection of the disease. In treatment, they take away coping mechanisms that numb emotions, leaving people feeling raw and more likely to misinterpret innocuous behavior, she said.

"The first couple of weeks are hellish," she said. "When the treatment team draws a hard line with the disorder, you have a strong reaction."

To be successful in the long term, treatment needs to address what function the eating disorder is serving in a person's life while teaching healthier ways of dealing with the underlying mental health concern or trauma, said Hemendinger, the CU social worker. Binge eating can numb someone's emotions for a while, and restricting food can be a way of asserting control or a consequence of perfectionism, she said. Obsessing about food can also be a subconscious way to avoid thinking about past traumas.

"Our bodies are easy targets," she said. "They provide that false sense of something we can change."

Patients need to understand that they're going to feel worse before they feel better, because they're losing a coping mechanism, Hemendinger said. It can help if they focus on what the disorder was taking from them, since people's relationships and other aspects of their lives tend to wither as the disorder takes over, she said.

"Eating disorder treatment is a very difficult thing to go through," she said. "It's like you've been trying to hold a beach ball underwater and you finally let it go, and it pops up."

The male former therapist said the group therapy sessions couldn't delve into the trauma many patients have, for fear of leaving them worse off if they were discharged before fully processing what happened to them.

Ultimately, people with eating disorders and their families have to balance the damage that the disease is doing to their health with the possibility of additional trauma from inpatient treatment, said Serena Nangia, marketing and communications manager at Project Heal, a nonprofit advocating for people with eating disorders. For some people, it may still make sense, while others might be able to recover with treatment in a less-restrictive setting, she said.

"Even if treatment is going to be harmful… it's possibly going to be less harmful than going it alone or continuing in their eating disorders," she said.

Several patients said they continued to struggle after leaving Eating Recovery Center. But their experiences there made future treatment more daunting.

The 13-year-old patient from Denver started eating while in a partial hospitalization program to avoid being sent back to residential treatment, but they began purging not long afterward. Their father said the family didn't receive much therapy or support to help their child after they returned home, and it wasn't long before the family was back in the emergency room.

"It was obvious the wheels were going to come off, and they were going to come off fast," the patient's father said. "We got this very sick kid, who was re-fed but who was ready to fall off the wagon."

The teen was admitted to Children's Hospital Colorado for refeeding again and then received outpatient treatment. They self-harmed while sitting with nothing to do during tube feedings, but they still said the experience was less traumatic than what they'd experienced at Eating Recovery Center because they could go outside and their parents could visit. They still use a feeding tube and are seeing a therapist to work through their mental health needs.

Despite lawmakers' concern about eating disorder treatment, they stripped tighter regulations from a bill passed earlier this year, citing budgetary concerns. Advocates criticized that move and said lawmakers were allowing problematic care to continue. After the bill was signed into law Tuesday, Cutter, the lawmaker who co-sponsored the measure, said she was interested in returning to the issue next year.

Earhart, the former patient who said she wanted to get better so she could leave, said her time at Eating Recovery Center was traumatizing. She was sexually assaulted while away from the center's campus in the spring 2022 and was told by staff not to talk about it with other patients. When she did anyway, she was discharged. She believes the concerns she'd expressed about her treatment influenced that decision, too.

A year later, Earhart still struggles with the effects of her time in treatment. She would have panic attacks in her room at night because she hadn't been allowed outside, she said. She still gets panicky and has to walk outside to prove she's not trapped.

Earhart's still struggling with her health, too: She's recently had seizures because her blood sugar dropped too low, she said. To stabilize her, her doctors floated a return to a high-level eating disorder treatment provider. She refused.

"I have mornings where I probably shouldn't have woken up (because) my blood sugar had dropped critically low," Earhart said. "And I was like, this is still better than going back. In the past, ERC has been so much more unhelpful that I would rather deal with maybe not waking up in the morning at my own house than being there for that."

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