2012.02.28 Req. For Judicial Notice

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REQUEST FOR JUDICIAL NOTICE

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John Doe
SC109466@gmail.com
8721 Santa Monica Blvd. no. 503
Los Angeles, CA 90069
Telephone: (424) 249-9363
Plaintiff in pro per

Superior Court of the State of California
County of Los Angeles West District
John Doe,
Plaintiff,
vs.
Carolyn Costin, et al.,
Defendants.
Case no. SC109466
Request for Judicial Notice;
Declaration of John Doe in Support Thereof
Assigned to the Hon. John H. Reid, Dept. WEF
Hearing Date: March 20, 2012
Hearing Time: 8:30 a.m.
Hearing Dept.: WEF, 1725 Main Street, 90401
Plaintiff John Doe hereby requests the Court take judicial notice of certain facts, as follows:
I. AUTHORITY
1. Pursuant to Cal. Evid. Code 453, the Court shall take judicial notice of any matter
specified in Section 452 if a party requests it and (a) Gives each adverse party sufficient notice of the
request, through the pleadings or otherwise, to enable such adverse party to prepare to meet the
request; and (b) furnishes the court with sufficient information to enable it to take judicial notice of the
matter.
2. Cal. Evid. Code 452(g) provides for judicial notice of [f]acts and propositions that are
of such common knowledge within the territorial jurisdiction of the court that they cannot reasonably be
the subject of dispute.
3. The Evidence Code likewise provides for judicial notice of [f]acts and propositions that
are not reasonably subject to dispute and are capable of immediate and accurate determination by resort

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to sources of reasonably indisputable accuracy. Cal. Evid. Code 452(h).
(a) Cal. Evid. Code 454(a)(1) permits the Court to consult or use [a]ny source of
pertinent information, including the advice of persons learned in the subject matter whether or not
furnished by a party.
(b) Judicial notice under Evidence Code section 452, subdivision (h) is intended to
cover facts which are not reasonably subject to dispute and are easily verified. These include, for
example, facts which are widely accepted as established by experts and specialists in the natural,
physical, and social sciences which can be verified by reference to treatises, encyclopedias, almanacs and
the like or by persons learned in the subject matter. Gould v. Maryland Sound Indus., Inc., 31 Cal. App.
4th 1137, 1145 (1995); see also, e.g., People v. Archerd, 3 Cal. 3d 615, 638 (1970) (permitting a judge to
consult reference works for the purposes of determining whether or not to take judicial notice and
determining the tenor of the matter to be noticed).
(c) Judicial notice has also been extended to the fact of news articles discussing
topics provoked by the facts underlying litigation: Seelig v. Infinity Broadcasting Corp. 97 Cal.App.4th
798, 807 n5 (2002) (citing Larson v. State Personnel Bd., 28 Cal.App.4th 265 (1994)).
(d) Judicial notice may also be taken of mortality statistics. See, e.g., Valente v. Sierra
Ry. Co. of California, 151 Cal. 534 (1907); Dickinson v. Southern Pac. Co., 172 Cal. 727 (1916); Froeming
v. Stockton Electric R. Co., 171 Cal. 401 (1916);Gallentine v. Fierro, 110 Cal.App. 345 (1930); Foerster v.
Direito, 75 Cal.App.2d 323 (1946); Temple v. De Mirjian, 51 Cal.App.2d 559 (1942), Ewens v. Newman,
131 Cal.App. 602 (1933).
(e) Computer website printouts may be relied on to establish Evid. Code 452(h)
facts: Ampex Corp. v. Cargle, 128 Cal. App. 4th 1569, 1573 n2 (2005).
(f) A court may take judicial notice of the fact that institutions meeting certain
criteria or definition(s) exist within the State of California: Bowker v. Baker, 73 Cal. App. 2d 653, 665
(1946).
(g) The Court may also take judicial notice of judicial notice of nationwide,
generally accepted standards pertaining to medical care. Matchett v. Superior Court, 40 Cal. App. 3d
623, 627 (1974).

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II. FACTS FOR WHICH JUDICIAL NOTICE IS REQUESTED
A. The Number of Men Affected by Eating Disorders is: (i) Significant; and (ii) Increasing
Defendant Carolyn Costin (Costin) is a person learned in the subject matter ( 3(a), above),
who in her The Eating Disorder Sourcebook reference texts (which are treatises, encyclopedias, almanacs
and the like, 3(b); relevant portions of the 1999 second edition and 2007 third edition of which are
attached hereto as Exhibits A and B, respectively) notes: [R]oughly one million males in the United
States suffer from eating disorders
1
and [a]pproximately 10 percent of eating disordered individuals
coming to the attention of mental health professionals are male. (Id., p. 5.)
The number of affected men appears to be rising: [I]n the last few years reported cases of males
with anorexia nervosa and bulimia nervosa have been steadily increasing. (Ex. A, p. 4.) [T]he
incidence of males with eating disorders is also increasing[.] (Id., p. 10.) [M]ales do suffer from
eating disorders, and the number of these cases is on the rise. (Id., p. 18.)
Similar statistics have been widely reported in California ( 2), generally provided by
organizations and/or individuals specializing in the field of eating disorders ( 3(a)), e.g.:
Anorexia nervosa affects nearly one in 200 Americans in their lives (three-quarters of them
female). (Ex. C, p. 2.)
Contrary to the long-held belief that anorexia and bulimia are female afflictions, the first
national survey on eating disorders has found that one-quarter of adults with the conditions
are men. (Ex. D, p. 1.)
With an estimated 15.9 percent of males and 21.4 percent of females in the UCSB student
population meeting the formal criteria for an eating disorder, according to a 2002 UCSB
survey, the problem is significant . . . While we are all familiar with the horrible effects of
anorexia and bulimia in women, many people are surprised to learn that quite a few men
suffer from eating disorders. (Cat Neushul, Love Your Body Eye on Eating Disorders,
Santa Barbara Independent, Feb. 26, 2011,
http://www.independent.com/news/2011/feb/26/love-your-body/ .)

1
This statistic is highlighted on the back cover of Costins Sourcebook 2e (Ex. A, p. 19).

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Experts say the number of men with eating disorders is on the rise . . . The National
Association of Anorexia Nervosa and Associated Disorders estimates that 1 million men
suffer from eating disorders - 1 in every 8 Americans with such a disorder. (Shaya Tayefe
Mohajer, Silent scourge: 1 million men have eating disorder, Orange County Register, Jan.
12, 2006, http://www.ocregister.com/articles/eating-31815-disorder-grahl.html .)
As many as 10 million females and 1 million males in the U.S. are affected by eating
disorders, including anorexia nervosa, bulimia nervosa and binge eating disorder. (Dr.
Esther Dechant and Beth Mayer, Physician Focus: Eating disorders on the rise, Mt. Shasta
News, Sep. 29, 2011, http://www.mtshastanews.com/mysource/health/x1291382403/
Physician-Focus-Eating-disorders-on-the-rise .)
[E]ating disorders affect 8 million Americans. These numbers have doubled since the 1960s.
Although 90 percent of the afflicted are young women, the numbers are growing for young
children, males (Aly Grisby, MFT, When eating becomes a problem, Ojai Valley News,
Jan. 27, 2006, http://www.ojaivalleynews.com/archives/2006/OVN1-27.pdf .)
About 10 percent of all anorexia nervosa cases involve males Campus Offers New
Anorexia Treatment, The University of California, San Diego Guardian, Mar. 14,
2007, http://www.ucsdguardian.org/home/item/8711-campusoffersnewanorexiatreatment
(UCSD.))
According to the National Institute of Health, approximately 1 to 4 percent of all young
women in the United States will have an eating disorder of some kind during their lives. Men
constitute approximately 5 to 15 percent of people with anorexia or bulimia . . . (Diana
Whitaker, Body image issues affect college experience, The University of California, Los
Angeles Daily Bruin, Sep. 23, 2006,
http://www.dailybruin.com/index.php/article/2006/09/body-image-issues-affect-colle .)
Although the majority of society suffering from or having past experiences with eating
disorders are women, men are victims too. In the United States, 36 million people live with
anorexia, bulimia nervosa, and binge eating disorder. Ten million females and 1 million males
are fighting for their lives against anorexia or bulimia nervosa. (Vicki Isacowitz, Millions of

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people struggle with eating disorders, Sierra Sun, Aug. 18, 2005,
http://www.sierrasun.com/article/20050818/life/108180005 .)
B. Eating Disorders Are Serious Medical Conditions with a High Mortality Rate
Costin notes in her Source Books: The mortality rate for anorexia nervosa is higher than that of
any other psychiatric disorder. (Ex. A, p. 3.) [A]norexia nervosa and bulimia nervosa are two of the
most life-threatening of all psychiatric illnesses. (Id., p. 12.) Of the entire gamut of psychological
disorders treated by clinicians, anorexia nervosa and bulimia nervosa are the ones most frequently
punctuated by accompanying medical complications ... The mortality rate for these disorders exceeds
that found in any other psychiatric illness and approaches 20 percent in the advanced stages of anorexia
nervosa. (Id., p. 13; also repeated verbatim in the 2007 edition, Ex. B, p. 4.) Eating disorders are
progressive and debilitating illnesses requiring medical, nutritional, and psychological intervention.
(Ex. A, p. 14.) The Court may take judicial notice of this mortality statistic ( 3(d)), which has been
widely reported in daily newspapers throughout California ( 2):
Eating disorders have the highest mortality rate of any mental illness. (Grisby, supra.)
[A]norexia nervosa is one of the most deadly psychiatric disorders, killing 5.6% of patients
for every decade that they remain ill. (Ex. C, p. 2.)
These conditions present severe physical and mental health problems for patients.
(Dechant, supra.)
[A]pproximately 25 percent of all untreated anorexia nervosa cases result in death. UCSD,
supra.
C. Men Lack Treatment Options for Eating Disorders
Costin has chronicled in her Sourcebook ( 3(a)-(b)): Worse still, eating disordered males
seeking treatment are turned down when requesting admission to most of the programs in the country
because these programs treat females only. (Ex. A, p. 4.) News reports reflect this:
Few eating-disorder programs treat men. Those that do, like the Renfrew Center in
Philadelphia, severely restrict the programs offered to males. The problem with all of these
treatment centers is that they are gender-biased, said Arnold Andersen, professor of
psychiatry and director of the Eating Disorder Programs at the University of Iowa and an

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expert on anorexia and bulimia. They either exclude men or claim they don't know how to
treat them. (Ex. E, p. 1.)
[E]xperts say there is a dearth of treatment options for male patients . . . Many centers are
reluctant to treat men at all . . . [E]ating-disorder experts and male patients say the current
lack of treatment programs has a profound impact on the chances of recovery. (Ex. F, p. 1.)
D. Treatment for Men and Women is Essentially the Same
Costin has endorsed the position that [t]here is a broad consensus that eating disorders in
males are clinically similar to, if not indistinguishable from, eating disorders in females. (Ex. A, p. 5)
(citing research summaries provided by Tom Shiltz, M.S., C.A. D.C., from Rogers Memorial
Hospital's Eating Disorder Center in Oconomowoc, Wisconsin ( 3(a)-(b)). She goes on to note that,
for males with eating disorders, the basic principles for treatment currently promoted are similar to
those for treating females and include: cessation of starvation, cessation of binge eating, weight
normalization, interrupting binge and purge cycles, correcting body image disturbance, reducing
dichotomous (black-and-white) thinking, and treating any coexisting mood disorders or personality
disorders. Short-term studies suggest that the prognosis for males in treatment is comparable to that for
females (Ex. A, p. 8.) Costin repeats the observation that, for men with eating disorders, the basic
principles for treatment are similar to those for treating women in her 2007 update to the same text.
(Ex. B, p. 2.)
E. Residential Eating Disorder Treatment Differs Significantly from Inpatient Treatment
Per Costin, the Defendant residential program[s] are designed to meet the individual needs of
clients and their families in a way that gives them a higher level of responsibility and teaches them how
to recover. (Ex. A, p. 14; Ex B., p. 14.) The programs offered by her Monte Nido and Monte Nido
Vista residential treatment centers are designed to provide clients with a lifestyle they can continue on
discharge. Along with traditional therapy and treatment modalities, we deal directly and specifically
with eating and exercise activities that can't be adequately addressed in other settings but, nevertheless,
are crucial for full recovery, (Ex. A, p. 15; Ex. B, p. 15), including, e.g.: [p]lanning, shopping, and
cooking meals are all part of each client's program. Dealing with these activities is necessary since they
will have to be faced on returning home. (Id.)

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Costin elaborates on this concept by noting that many programs have complete control over
food and exercise and are not set up to let clients shop for, cook, portion, or prepare food, all skills they
will need to maintain their weight. When I worked in hospital treatment settings, I watched too many
clients leave/treatment and immediately lose weight or binge and purge when they had to shop for all
their food, make meals alone, and try to eat at times other than their inpatient schedule. This is one of
the reasons I opened my residential program, Monte Nido. Teaching clients to live in the world, with all
the day-to-day things they have to do, including buying, preparing, cooking, and eating food, is critical.
Learning how to accept ones weight and maintain it, while getting on with life, is the ultimate aim.
Leaving treatment without practicing the skills of eating and living where they really count is like
learning the skills of baseball without ever playing in a game. (Ex. B, p. 3.)
The Court is respectfully requested to take judicial notice of the difference in cost, restriction,
and opportunity provided by inpatient versus residential treatment facilities, as further explained by
Costin: Inpatient treatment, or 24-hour care in a hospital setting, can take place in a medical or
psychiatric facility. The cost is usually high (Ex. B, p. 7.) Residential treatment facilities offer an
excellent alternative to hospitals, providing round-the-clock care in a nonhospital setting and are usually
less expensive than hospital-based options. Many of these programs are much smaller and feel more
personal than hospital programs. Some are housed in former private residences or estates that have been
converted into treatment facilities, which allows for a homelike environment. (Ex. B, pp. 7-8.)
Residential treatment is becoming increasingly popular as a choice for treating eating disorders.
Some individuals go directly to residential treatment programs, while others spend time in a hospital
and then transfer to a residential program. Many of these programs offer crucial and important features
that are not possible in a hospital setting. Clients have the opportunity to be increasingly involved in
meal planning, shopping, cooking, exercise, and other daily living activities that simulate what they will
need to do when they return home. These are problem areas for eating disorder individuals that cannot
be practiced and resolved in a hospital or even in a large residential facility. Small, homelike facilities
offer treatment and supervision of behaviors and daily living activities, providing clients with increasing
responsibility for their own recovery. (See the description of the Monte Nido Treatment Facility ...
(Ex. B, p. 8.)

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F. Insurance Criteria May be Met for a Residential, but not Inpatient, Level of Care
The Court is requested to take judicial notice of the varying criteria applied by, e.g., insurance
companies, when determining the level of care (inpatient, residential, or otherwise) necessary and
thus covered for an insured, by noting, e.g., the different medical and behavioral criteria required by
prominent California insurer Anthem Blue Cross for inpatient coverage (Ex. G, pp. 6-7) versus
residential coverage (Id., pp. 8-9). ( 3(g).)
Costin herself describes these differences ( 3(a)-(b)), noting: insurance companies often deny
coverage for this treatment. I have known clients who did not meet the low weight criteria for inpatient
care, so they proceeded to lose enough weight to get the treatment they needed. The newest version of
the APA guidelines is attempting to address this issue by eliminating low weight requirements
recommended for residential or inpatient care. If a treatment provider suggests this level of care, clients
and/or their loved ones might have to fight their insurance company. (Ex. B, pp. 5-6.) Bingeing, self-
induced vomiting, laxative abuse, compulsive exercise, and restricted eating do not necessarily lead to
acute medical instability and thus, by themselves, do not qualify as criteria for hospitalization. Since
insurance coverage often requires the individual to be medically compromised, clients can have many of
these behaviors and still not qualify for insurance coverage. (Ex. B, p. 7.)
G. The Defendant Facilities Provide Substantial Health Services
The Court is also requested to take judicial notice of the fact that the Defendant residential
treatment centers provide: [i]ndividual, group, and family therapy (cognitive behavioral and
psychodynamic therapies) ... psychiatric evaluation and treatment [and] medical monitoring. (Ex. A, p.
16.) (This fact can also be immediately and accurately determined by, e.g., inquiring of the facilities
administrative staff by calling (310) 457-9958. 3.)
H. Similar Facilities Do Not Discriminate and Treat Men Alongside Women, Including
Trauma Survivors
Finally, Plaintiff respectfully requests the Court take judicial notice of the fact that other
facilities, including at least one in California, with physical plants and privacy considerations
functionally identical to those of the Defendant facilities, nonetheless accept male clients. Judicial notice
is appropriate under Bowker, supra ( 3(f)), and because these facts may be immediately and accurately

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determined by, e.g., consulting the facilities brochures and/or websites, and/or making an inquiry of
the facilities staff at the phone numbers provided ( 3, 3(e)):
In La Caada-Flintridge, California, [t]he Bella Speranza (The Beautiful Hope) offers care
for both adults and adolescents . . . Although the majority of those suffering from eating
disorders are female, [Bella Speranza] treat[s] both males and females [in] a six bed
residential facility. (Ex. I, p. 1.) The Bella Vita provides a full continuum of care for eating
disorders treatment for adults and adolescents, male and female, including a transitional
living facility. (Id., p. 2.) The Bella Speranza staff may be contacted by telephone at
(877) 9123552 (877-91BELLA).
In Wickenburg, Arizona and Santa Monica, California
2
, the Rosewood Centers for Eating
Disorders provide a full-continuum of care at our facilities . . . helping individuals, male and
female adults and adolescents, suffering from anorexia nervosa, bulimia nervosa, binge eating
disorder and other complex disorders. (Ex. H, p. 3.) This includes treatment at the acute
inpatient level of care (Id., p. 6), a partial hospitalization program with residential living (Id.,
p. 10), and transitional living services at Tempe House for males and females, 18 years of
age or older. . . Tempe House is a quaint five bedroom, three bathroom home [where a]
Rosewood staff member provides overnight and weekend supervision for those living in the
house. (Id., p. 13.) The Rosewood centers work with trauma that may be comorbid with an
eating disorder: Id., p. 6 ([t]rauma recovery work); p. 13 (services to address Post
Traumatic Stress Disorder and Trauma). These facts may be verified by contacting
Rosewood Centers staff via telephone at (800) 845-2211, and/or by visiting the Rosewood
Centers website, available at http://www.rosewoodranch.com/
In Ballwin, Missouri, the Castlewood Treatment Center treats [m]en and women (Ex. J,
p. 4) in a ten bed converted single-family home: The Residential program only has a
maximum of 10 clients Each bedroom is attractive, uniquely decorated and has its own en
suite bathroom. There are no more than two clients to a bedroom. (Id., p. 12; see also p. 33.)

2
A New Journey is an affiliate of Rosewood Centers for Eating Disorders located in Wickenburg, AZ, which can be
verified by visiting http://www.anewjourney.net/locations-photos/ and http://www.rosewoodranch.com/locations/new-
journey, and/or by calling (800) 845-2211.

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Castlewoods program is specifically designed to treat all types of eating disorders as well as
co-existing disorders, including trauma (Id., p. 9), specifically including [u]nresolved
experiences of child sexual abuse or rape. (Id., p. 25; see also p. 33.) These facts may be
verified by contacting Castlewood staff by telephone at (636) 386-6611 or (888) 822-8938,
and/or by visiting the Castlewood website, available at http://www.castlewoodtc.com

Dated: February 28, 2012 Respectfully submitted,
By:

John Doe, Plaintiff in pro per

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SUPPORTING DECLARATION OF JOHN DOE
I, John Doe, the undersigned, declare that:
1. I am the plaintiff in pro per in the matter of John Doe v. Carolyn Costin, et al., Los
Angeles Superior Court Case no. SC109466. I am a competent individual over the age of 18, and my
identity has been provided to the Court in this matter. I have personal knowledge of the facts set forth
herein, and if called upon to do so, I could and would competently testify thereto.
2. I personally purchased a copy of Carolyn Costin, The Eating Disorder
Sourcebook (2d ed., Lowell House 1999), and personally made the photostatic copies of the relevant
pages I have attached hereto as Exhibit A; the original text remains in my possession and can be made
available for the Courts review upon request.
3. I personally purchased a copy of Carolyn Costin, The Eating Disorder
Sourcebook (3d ed., McGraw-Hill 2007), and personally made the photostatic copies of the relevant
pages I have attached hereto as Exhibit B; the original text remains in my possession and can be made
available for the Courts review upon request.
4. I personally retrieved and made an archival copy of the article Treating Anorexia
Nervosa, L.A. Times, Sep. 25, 2009, a true and correct copy of which is attached hereto as Exhibit C.
This article was presented with the byline Courtesy of Harvard Mental Health Letter, and was
previously available at:
http://www.latimes.com/entertainment/sns-health-anorexia-nervosa,1,355883,print.story (retrieved
Apr. 15, 2011). A longer version of the same text appears to be available at
http://harvardpartnersinternational.staywellsolutionsonline.com/HealthNewsLetters/69,M0809a
(retrieved Feb. 26, 2012).
5. I personally visited the L.A. Times website and made an archival copy of the article
Denise Gellene, Men found to be anorexic, bulimic also, L.A. Times, Feb. 1, 2007,
http://articles.latimes.com/2007/feb/01/science/sci-eating1, a true and correct copy of which is
attached hereto as Exhibit D.

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6. I personally searched for and retrieved from the Lexis periodicals database the article Jon
Stenzler, Anorexic Men Combat Gender Bias in Treatment, Too, Contra Costa Times, Apr. 18, 2000,
a trust and correct copy of which is attached hereto as Exhibit E.
7. I personally visited the Wall Street Journals website and made an archival copy of the
article Elizabeth Bernstein, Men, Boys Lack Options to Treat Eating Disorders, Wall Street Journal,
Apr. 17, 2007, http://online.wsj.com/public/article/SB117676525698871913-
Mps4eTnhJWSE6kHqo5szACPLNuc_20070516.html?mod=tff_main_tff_top#printMode, a true and
correct copy of which is attached hereto as Exhibit F.
8. I personally visited the web site for Anthem Blue Cross and retrieved their Behavioral
Health Medical Necessity Criteria (Effective January 1, 2012) for California policyholders, true and
correct copies of relevant pages from which I have attached hereto as Exhibit G. This document is
available at http://www.anthem.com/ca/provider/f1/s0/t0/pw_e175468.pdf (retrieved February 26,
2012).
9. On February 25, 2012, I personally visited the website for the Bella Speranza, available at
http://www.thebellavita.com/residentialtreatment.htm , and made an archival copy, a true and correct
copy of which is attached hereto as Exhibit H.
10. On July 11, 2011, I received from Ethen LeFever, Intake Director for the Rosewood
Centers, a Portable Document Format (PDF) copy of the Rosewood Centers brochure, a true and
correct copy of which is attached hereto as Exhibit I.
11. On March 10, 2011, I retrieved from the Castlewood Treatment Center website a PDF
copy of its brochure, a true and correct copy of which is attached hereto as Exhibit J; this brochure is
available at http://www.castlewoodtc.com/pdf/Castlewood-Treatment-Brochrure.pdf [sic].
I declare under penalty of perjury under the laws of the State of California that the foregoing is
true and correct. Executed on February 28, 2012, at Beverly Hills, California.

John Doe

Exhibit A
LIBRARY OF CONGRESS CATALOGING-IN-PuBLICATION DATA
Costin, Carolyn.
The eating disorder sourcebook I by Carolyn Costin.
p. em.
Includes bibliographical references and index.
ISBN 1-56565-853-1
ISBN 1-7373-0102-3 (2nd edition)
1. Eating disorders, Title.
RC552.E18C67 1996
616.85'26-dc20
Copyright 1996, 1997, 1999 by Carolyn Costin.
96-32363
CIP
Published by Lowell House, a division of NTC/ Contemporacy Publishing Group, Inc.
4255 West Toiuhy Avenue, Lincolnwood, Illinois, 61646-1975 U.S.A
All rights reserved. No part of this work may be reproduced, stored in a retrieval sys-
tem, or transmitted in any form or by any means, electronic, mechanical, photocopy-
ing, recording, or otherwise without prior permission of NrC/ Contemporary
Publishing Group, Inc.
Requests for such permissions should be addressed to:
Lowell House
2020 Avenue of the Stars, Suite 300
Los Angeles, CA 90067
Printed and bound in the United States of America
International Standard Book Number: 1-7373-0102-3
10987654
Ex. A p. 1
INTRODUCTION
A
s an eating disorder specialist for the last twenty years, and as
someone who has suffered and recovered from anorexia ner-
vosa myself, I have witnessed an epidemic increase in the number of
cases of eating disorders being reported, in the number of books on
eating disorders being written, and in the number of treatment pro-
grams devoted to and prevention efforts aimed at eating disorders.
As I compiled this second edition of The Eating Disorder Sourcebook,
I had to ask if we are better off in the areas . of understanding, pre-
venting, and treating eating disorders than we were three years ago.
I think the answer is, fortunately, yes. Unfortunately, my outpatient
and residential programs cannot handle the number of people seek-
ing treatment for themselves or their wives, daughters, and (increas-
ingly) sons who have been stricken with one of the eating disorders.
Eating disorders are still taking a terrible toll on far too many indi-
viduals and families.
But there is increased hope. Our treatment strategies are improv-
ing, and the reported success rates are growing. We have known for
a long time that anorexia nervosa is deadly, but one recent compre-
hensive study of anorexia nervosa showed rates of full recovery as
high as 76 percent and of partial recovery at 86 percent (Strober et
al. 1997). The important factors were
1. not discharging the patient fromtreatment too soon, that is, prior
to sufficient weight gain; and
2. lengthening the full period of treatment to as much as fifty-seven
to seventy-nine months.
This information encourages us not to give up, to fight insurance
companies for longer lengths of stay in treatment programs, and to
xvii
Ex. A p. 2
THE EATING DISORDER SOURCEBOOK
plus 4 percent suffering from atypical eating disorder would total
6.5 percent ofthe population).
PROGNOSIS
Eating disordered patients can fully recover. However, it is important
for clinicians, patients, and loved ones to understand that such recov-
ery can take many years and that it is not possible to predict at the
outset who will be successful. Nevertheless, the following features
may improve a patient's chances: early intervention, less comorbid
psychological diagnoses, infrequent or no purging behavior, and sup-
portive families or loved ones. Most medical consequences of eating
disorders are reversible, but there are some conditions that may be
permanent, including osteoporosis, endocrine abnormalities, ovarian
failure, and, of course, death.
ANOREXIA NERVOSA
The mortality rate for anorexia nervosa is higher than that of any
other psychiatric disorder. It is by twelvefold the leading cause of death
in young women fifteen to twenty-four years of age (Sullivan 1997).
The original American Psychiatric Association guidelines for the treat-
ment of eating disorders reported that hospitalized or third-stage refer-
ral populations of anorexics show that about . 44 percent have "good"
outcomes (i.e., weight was restored to within 15 percent of recom-
mended weight, and menstruation was regular) four years after the
onset of illness. "Poor" outcomes were reported for 24 percent, whose
weight never approached 15 percent of that recommended and whose
menstruation remained absent or sporadic. Intermediate outcomes
were reported for 2 8 percent of the anorexics, whose results were
somewhere between those of the "good" and ''poor" groups.
A long-term study conducted since the last edition of this book
sheds new light on the prognosis of anorexia nervosa (Strober,
Freeman, and Morrell1997). The objective of the study was to assess
the long-term course of recovery and relapse as well as predicators of
outcome in anorexia nervosa Ninety-five participants, ages twelve to
seventeen, were selected from a specialized university treatment pro-
20
Ex. A p. 3
2
NOT FOR FEMALES ONLY
I
t is generally assumed that the problem of -eating disorders is a
female issue because, after all, appearance, weight, and dieting are
predominately female preoccupations. Magazine articles, television
shows, movies, books, and even treatment literature dealing with eat-
ing disorders focus almost exclusively on females.
Binge eating is seen somewhat differently than the classic eating
disorders anorexia and bulimia Males have always been included in
the literature and in treatment programs for compulsive overeating.
Compulsive overeating, however, has only recently been recognized
as its own eating disorder-binge eating disorder-and it still is not
accepted as an official diagnosis. Because anorexia and bulimia are
official diagnoses, the term eating disorder usually refers to one of
these two disorders. Males do develop anorexia and bulimia, and,
rather than being a new phenomenon, this was observed over three
hundred . years ago. Among the first well-documented accounts of
anorexia nervosa, reported in the 1600s by Dr. Richard Morton and
in the 1800s by the British physician William Gull, are cases of males
suffering from the disorder. Since these early times, eating disorders
in males have been overlooked, understudied, and underreported.
'Worse still, eating disordered males seeking treatment are turned
down when requesting admission to most of the programs in the
country because these programs treat females only.
The number of females suffering from eating disorders far
exceeds that of males, but in the last few years reported cases of
males with anorexia nervosa and bulimia nervosa have been steadily
increasing. Media and professional attention have followed suit A
1995 article in the Los Angeles Times on this subject entitled "Silence
25
Ex. A p. 4
and Guilt" stated that roughly one million males in the United
States suffer from eating disorders. A 1996 article in the San Jose
Mercury News shocked readers by reporting that Dennis Brown, a
twenty-seven-year-old Super Bowl defensive end, revealed that he
used laxatives, diuretics, and self-induced vomiting to control his
weight and even underwent surgery to repair bleeding ulcers made
worse by his years of bingeing and purging. "It's always been the
weight thing," said Brown. "They used to get on me for being too
big." In the article, Brown reported that after making such state-
ments in an NFL-sponsored interview session, he was pulled aside
and reprimanded by coaches and team officials for" . . . embarrass-
ing the organization."
The following research summaries, provided by Tom Shiltz, M.S.,
C.A.D.C., from Rogers Memorial Hospital's Eating Disorder Center in
Oconomowoc, Wisconsin, are included here to provide insight into
the various biological, psychological, and social factors influencing
male eating disorders.
26
Approximately 10 percent of eating disordered individuals
coming to the attention of mental health professionals are
male. Ther-e is a broad consensus, however, that eating
disorders in males are clinically similar to, if not
indistinguishable from, eating disorders in. females.
Kearney-Cooke and Steichen-Asch found that men with eating
disorders tend to have dependent, avoidant, and passive-
aggressive personality styles and to have experienced negative
reactions to their bodies from their peers while growing up.
They tend to be closer to their mothers than to their fathers.
The authors concluded that "in our culture, muscular build,
overt physical aggression, competence at athletics,
competitiveness, and independence generally are regarded as
desirable for boys, whereas dependency, passivity, inhibition
of physical aggression, . smallness, and neatness are seen as
more appropriate for females. Boys who later develop eating
disorders do not conform to the cultural expectations for
masculinity; they tend to be more dependent, passive, and
Ex. A p. 5
non-athletic, traits which may lead to feelings of isolation and
disparagement of body."
Anational survey of 11,467 high school students and
60,861 adults revealed the following gender differences:
Among the adults, 3 8 percent of the women and
24 percent of the men were trying to lose weight
Among high-school students, 44 percent of the females and
15 percent of the males were attempting to lose weight
Based on a questionnaire administered to 226 college
students (98 males and 128 females) concerning weight, body
shape, dieting, and exercise history, the authors found that
26 percent of the men and 48 percent of the women
described themselves as overweight. Women dieted to lose
weight whereas men usually exercised.
A sample of 1,373 high-school students revealed that girls
(63 percent) were four times more likely than boys (16 per-
cent) to be attempting to reduce weight through exercise and .
caloric intake reduction. Boys were three times more likely
than girls to be trying to gain weight (2 8 percent versus 9 per-
cent). The cultural ideal for body shape for women versus men
continues to favor slender women and athletic, V-shaped,
muscular men.
In general, men appear to be more comfortable with their
weight and perceive less pressure to be thin than women. A
national survey indicated that only 41 percent of men are
dissatisfied with their weight as compared with 55 percent of
women; moreover, 77 percent of underweight men liked therr
appearance as opposed to 83 percent of underweight women.
Males were more likely than females to claim that if they
were fit and exercised regularly, they felt good about their
bodies. Women were more concerned with aspects of their
appearance, particularly weight.
DiDomenico and Andersen found that magazines targeted
primarily to women included a greater number of articles and
advertisements aimed at weight reduction (e.g. , diet, calories)
and those targeted at men contained more shape articles and
27
Ex. A p. 6
advertisements (e.g., fitness, weight lifting, body building, or
muscle toning). The magazines most read by females ages
eighteen to twenty-four had ten times more diet content than
those most popular among men in the same age group.
Gymnasts, runners, body builders, rowers, wrestlers,
jockeys, dancers, and swimmers are vulnerable to eating
disorders because their professions necessitate weight
restriction. It is important to note, however, that functional
weight loss for athletic success differs from an eating disorder
when the central psychopathology is absent.
Nemeroff, Stein, Diehl, and Smilack suggest that males may
be receiving increasing media messages regarding dieting, ideal
of muscularity, and plastic surgery options (such as pectoral
and calf i.J:llplants).
The increase in articles and media reports on males witheating
disorders is reminiscent of the early years when eating disorders in
females first began to get public attention. One wonders if this is our
early warning of how frequently the problem with males really
occurs.
The studies indicating that somewhere between 5 and 15 per-
cent of eating disorder cases are males are problematic and unreli-
able. Identifying males with eating disorders has been difficult for
several reasons, including how these disorders are defined.
Consider that until DSM-IV, the diagnostic criteria for anorexia ner-
vosa included amenorrhea, and since originally bulimia nervosa
was not a separate illness but rather absorbed into the diagnosis of
anorexia nervosa, a gender bias existed for both. of these disorders
such that patients and clinicians held the belief that males do not
develop eating disorders. Walter Vandereycken reported that in a
1979 study, 40 percent of internists and 25 percent of psychiatrists
surveyed believed that anorexia nervosa only occurs in females,
and that in a 1983 survey 25 percent of psychiatrists and psychol-
ogists considered femaleness fundamental to anorexia nervosa.
Being overweight and overeating are culturally more acceptable
and less noticed in males; therefore, binge eating disorder also
tends to go underrecognized.
28
Ex. A p. 7
ies are more frequently the targets of advertising campaigns, leanness
for men is increasingly being emphasized, and the number of male
dieters and males reporting eating disorders continues to rise.
One final note is that, according to Andersen, eating disordered
men differ from eating disordered women in a few ways that may
be important for better understanding . and treatment.
1. They tend to have genuine histories of pre-illness obesity.
2. They often report losing weight in order to avoid weight-related
medical illnesses found in other family members.
3. They are likely to be intensely athletic and to have begun diet-
ing in order to attain greater sports achievement or from fear of
gaining weight because of a sports injury. In this respect, they
resemble mdividuals referred to as "obligatory runners." In: fact,
many eating disordered men may fit another proposed but not
yet accepted diagnostic category, referred to as compulsive exer-
cise, compulsive athleticism, or a term coined by Alayrie Yates,
activity disorder. This syndrome is similar to but separate from .
the eating disorders and is discussed in this book in chapter 3.
TREATMENT AND PROGNOSIS FOR MALES
Although more research needs to be done on the specific psycho-
logical and personality features of males with eating disorders, the
basic principles for treatment currently promoted are similar to
those for treating females and include: cessation of starvation, ces-
sation of binge eating, weight normalization, interrupting binge and
purge cycles, correcting body image disturbance, reducing dichoto-
mous (black-and-white) thinking, and treating any coexisting mood
disorders or personality disorders.
Short-term studies suggest that the prognosis for males in treat-
ment is comparable to that for females, at least in the short term.
Long-term studies are not available. However, empathetic, informed
professionals are necessary, due to the fact that males with eating
disorders feel misunderstood and out of place in a society that still
33
Ex. A p. 8
doesn't understand these disorders. Even worse, males with eating
disorders are often made to feel uncomfortable and otherwise
rejected by females similarly aftlicted. Although it may turn out to be
true, it is. often mistakenly assumed that males with eating disorders,
most particularly anorexia nervosa, are more severely disturbed and
have a poorer prognosis than females with such disorders. There are
good reasons why this may appear to be the case. First, since males
often go undetected, only the most severe cases come into treatment
and thus under scrutiny. Second, there seems to be a contingent
of males with other serious psychological disorders, most notably
obsessive-compulsive disorder, where food rituals, food phobias, food
restriction, and food rejection are prominent features. These individ-
uals end up in treatment mostly due to their underlying psychologi-
cal illnesses, not for their eating behavior, and they tend to be
complex, difficult-to-treat cases.
34
STRATEGIES FOR PREVENTION AND EARLY INTERVENTION
OF MALE EATING DISORDERS
Recognize that eating disorders do not discriminate on the
basis of gender. Men can and do develop eating disorders.
Learn about eating disorders and lmow the warning signs.
Become aware of your community resources (e.g., treatment
centers, self-help groups, etc.). Consider implementing an
Eating Concerns Support . Group in the school .setting to pro-
vide interested young men with an opportunity to learn more
about eating disorders and to receive support. Encourage
young men to seek professional help if necessary.
Athletic activities or professions that necessitate weight
restriction (e.g., gymnastics, track, swimming, wrestling, row-
ing) put males at risk for developing eating disorders. Male
wrestlers, for example, present with a higher rate of eating
disorders than the general male population. Coaches need
to be aware of and disallow any excessive weight control
or body building measures employed by their young male
athletes.
Ex. A p. 9
respond to the propaganda and are on a diet at any given moment .
Weight loss programs, diet books, and media advertisements for diet
products have been steadily increasing, resulting in a multibillion dol-
lar industry. As diet commercials have increased, the body size of
Playboy centerfolds and Miss America contestants has decreased to the
point where many of these individuals, according to recent studies,
meet the weight criteria for anorexia nervosa! Is it any wonder that at
the same time there has been a significant increase in the prevalence
of eating disorders? As stated in Eating Disorders, The journal of
Treatment and Prevention in the spring of 1993, "It may be that the
media pressure to diet is a major influence on the occurrence of eat-
ing disorders in otherwise vulnerable women and men." Since the cul-
turally prescribed body weight is so unrealistically low and since
mountains of evidence show that diets don't work (approximately 98
percent of those who lose weight gain it back), it follows that some
individuals will resort to extreme measures such as starving or purg-
ing in order to deal with their dissatisfaction over their figures or sizes,
striving to obtain "Just the Right Shape."
Most ads and diet products are directed toward females, but
males are no longer spared. Males are increasingly portrayed as orna-
mental objects and targeted for the purchase of beauty and weight
loss products, as women have been since advertising began. (Is it a
coincidence that the incidence of males with eating disorders is also
increasing?) Still, eating disorders remain a predominantly female
problem, with females accounting for approximately 90 to 95 per-
cent of all known cases. In regard to this gender distribution, it may
seem obvious, but cannot be minimized, that historically men are
judged more for what they do and women for how they look. Of the
many Life magazine covers that have featured women over the last
fifty years, only nineteen featured women who were not actresses or
models-that is, women who were not on the cover because of their
beauty (Wolf 1991). Women have always been taught that their value
is associated with their appearance and their bodies.
Young girls or women who are disturbed by the way they expe-
rience their own body weight or shape have learned to do so only
in context with what is acceptable and what is not. The current cui-
54
Ex. A p. 10
ASSESSING THE SITUATION
ASSESSMENT STRATEGIES AND GUIDELINES
It is-important to .get necessary informationfrom clients while at the
same time establishing-rapport and creating a trusting,- supportive
environment If - less-information is gathered in the first interview
because of this, that is acceptable, as long as the information is even-
tually obtained. It is of primary importance that .the client knows that
you are there to help and-that you understand what she is going
through. The following guidelines for gathering information will help:
1. Data: Gather the most important identifying data-age, name,
phone, address, occupation, spouse, and so on.
2. Presentation:.How does the client look, act, and present herself?
3. Reason for seeking treatment: What is her reason for coming for
help? Don't assume that you know. Some bulimics are coming
because they want to be better anorexics. Some clients are
coming for their depression or relationship problems. Some
come because they think you have a magic answer or a magic
diet to help them lose weight. Find out from the client's own
words!
4. Family information: Find out illformation about the parents and/ or ,
any other family members. Find out _this. information from the
client and,_ if possible, from tb.e. family members, too. How do they
get along? How do they see the problem? How have they, or do
they, attempt todeal with the client _and the problem?
5. Support systems: Who does the client usually go to for help?
From whom does the client get her normal support (not neces-
sarily regarding the eating disorder)? With whom does she feel
comfortable sharing things? Who does she feel really cares? It is
helpful to have a support system in recovery other than the treat-
ing professionals. The support system can be the family or a
romantic partner but doesn't have to be. It may turn out that
members of a therapy or support group and/or a teacher, friend,
or coach provide the needed support. I have found that clients
with a good support system recover much faster and more thor-
oughly than those without.
81
Ex. A p. 11
ASSESSING TilE SITUATION
There are other assessment tools available. In assessing body
image it is important to keep in mind that body image is a multifac-
eted phenomenon with three main components: perception, attitude,
and behavior. Each of these components needs to be considered.
Other assessments can be done to gather information in the
various domains, such as the "Beck Depression Inventory" to assess
depression, or assessments designed specifically for dissociation or
obsessive-compulsive behavior. A thorough psychosocial evaluation
should be done to gather information on family, job, work, rela-
tionships, and any trauma or abuse history. Additionally, other pro-.
fessionals can perform assessments as part of a treatment team
approach. A dietitian can do a nutrition assessment and a psychia-
trist can perform a psychiatric evaluation. Integrating the results of
various assessments allows the clinician, patient, and treatment
team to develop an appropriate, individualized treatment plan. One
of the most important assessments of all that needs to be obtained
and maintained is the one performed by a medical doctor to eval-
uate the individual's medical status.
MEDICAL ASSESSMENT
The information on the following pages is an overall summary of
what is needed in a medical assessment. For a more d ~ t a i l e d and
thorough discussion of medical assessment and treatment, see
chapter 15, "Medical Management of Anorexia Nervosa and
Bulimia Nervosa."
Eating disorders are often referred to as psychosomatic disor-
ders, not because the physical symptoms associated with them are
"all in the person's head," but because they are illnesses where a dis-
turbed psyche directly contributes to a disturbed soma (body). Aside
from the social stigma and psychological turmoil that an eating dis-
order causes in an individual's life, the medical complications are
numerous, ranging all the way from dry skin to cardiac arrest. In fact,
anorexia nervosa and bulimia nervosa are two of the most
life-threatening of all psychiatric illnesses. The following is a sum-
mary of the various sources from which complications arise.
91
Ex. A p. 12
15
MEDICAL MANAGEMENT OF
ANOREXIA NERVOSA AND
BULIMIA NERVOSA
COAliTHORED BY PHILIP S. MEHLER, M.D.
Note: This chapter is written to benefit both professional and non-
professional readers and is geared specifically to anorexia neroosa and
bulimia neroosa. The reader is referred to other sources for information
on binge eating disorder. An overoiew of the general medical concerns of
these eating disorders is provided, as well as guidelines for a thorough
medical assessment, including laboratory tests that must .be performed.
An in-depth discussion of the problems related to amenorrhea and bone
density has also been added to this most recent edition.
O
f. the entire of disorders treated by clini-
Cians, anoreXIa nervosa and bulimia nervosa are the ones most
frequently punctuated by accompanying medical complications.
Although many of these are more annoying than serious, a distinct
number of them are indeed potentially life threatening. The mortal-
ity rate for these disorders exceeds that found in any other psychi-
atric illness and approaches 20 percent in the advanced stages of
anorexia nervosa Thus, a clinician cannot simply assume that the
physical symptoms associated with these eating disorders are just
functional in origin. Physical complaints must be judiciously
gated and organic disease systematically excluded by appropriate
tests. Conversely, it is important, from a treatment vantage point, to
avoid subjecting the patient to expensive, unnecessary, and poten-
tially invasive tests.
Competent and comprehensive care of eating disorders must
involve understanding the medical aspects of these illnesses, not
just for physicians but for any clinician treating them, regardless of
227
Ex. A p. 13
Since different patients will be looking for different t h i n ~ in a
treatment program, providing the "right" answers to the above ques-
tions is not possible. Individuals considering a treatment program for
themselves or a loved one should ask the questions and. get as much
information as they can from various programs in order to compare
options and select which program is most suitable. A list and brief
summary of various treatment programs specializing in eating disor-
ders are supplied in Appendix A
The following information on Monte Nido, my residential pro-
gram in Malibu, California, provides an idea of the philosophy, treat-
ment goals, and schedule of a twenty-four-hour care facility
specializing exclusively in anorexia nervosa, bulimia nervosa, and
activity disorders;
MONTE NIDO TREATMENT CENTER
PROGRAM OVERVIEW
Eating disorders are progressive and debilitating illnesses requiring
medical, nutritional, and psychological intervention. Individuals suf-
fering from eating disorders often need a structured environment to
achieve recovery. However, all too often a person does well in a
highly structured, regimented environment only to fall into relapse
upon returning to a less structured situation. Our residential program
is designed to meet the individual needs of clients and their families
in a way that gives them a higher level of responsibility and "teaches"
them how to recover. The atmosphere at Monte Nido is professional
and structured, but it is also warm, friendly, and family like. Our ded-
icated staff, many of whom are recovered themselves, serve as role
models, and our environment inspires people to commit to overcom-
ing obstacles that are interfering with the quality of their lives.
The program at Monte Nido is designed to provide behavior and
mood stabilization, creating a climate where destructive behaviors
can be interrupted. Clients can then work on the crucial underlying
issues that caused and/ or perpetuate their disordered eating and
other dysfunctional behaviors. We provide a structured schedule with
education, psychodynamic, and cognitive behavioral therapy; correc-
266
Ex. A p. 14
WHEN OUTPATIENT TREATMENT Is NOT ENOUGH
tive eating patterns; healthy exercise; life skills training; and spiritual
enhancement, all in our beautiful, serene country setting.
Our treatment philosophy includes restoring biochemical func-
tioning and nutritional balance, implementing healthy eating and
exercise habits, changing destructive behaviors, and gaining insight
and coping skills for underlying emotional and psychological issues.
We believe that eating disorders are illnesses which, when treated
correctly, can result in full recovery where the individual can resume
a normal, healthy relationship to food.
Nutrition and exercise are not simply a part of our program. We
recognize these as crucial areas of recovery. Therefore, we require
assessments on nutritional status, metabolism, and biochemistry, and
we teach patients what this information means in terms of their
recovery. Our exercise physiologist and fitness trainer perform thor-
ough assessments and develop a fitness plan suitable for each client's
needs. Our detailed attention to the nutrition and exercise compo-
nent of treatment reveals our dedication to these areas as part of a
plan for a healthy, lasting recovery.
Every aspect of our program is designed to provide clients with
a lifestyle they can continue on discharge. Along with traditional
therapy and treatment modalities, we deal directly and specifically
with eating and exercise activities that can't be adequately addressed
in other settings but, nevertheless, are crucial for full recovery.
Planning, shopping; and cooking meals are all part of each client's
program. Dealing with these activities is necessary since they will
have to be faced on returning home.
Clients participate in exercise according to individual needs and
goals. Exercise compulsion and resistance are addressed with the
focus on developing healthy, noncompulsive, lifelong exercise habits.
We are uniquely set up to meet the needs of athletes who require
specialized attention in this area.
Activities include weight training, water aerobics, yoga, hiking,
dance, and rehabilitation for sports injuries.
Individual and group therapy establish and solidify the other treat-
ment components. Through intensive individual sessions and group
267
Ex. A p. 15
WHEN OUTPATIENT TREA1MENT Is Nor ENOUGH
11. Discharge with plan for transitional living or other aftercare
TREA1MENT COMPONENTS
Individual, Group, and Faniily Therapy (Cognitive Behavioral
and Psychodynamic Therapies)
Psychiatric Evaluation and Treatment
Medical Monitoring
Communication and Life Skills Training
Meal Planning, Shopping, and Cooking
Nutrition Education and Counseling
Exercise, Fitness, and Rehabilitation Program
Art Therapy and Other Experiential Therapies
Occupational, Career Planning
Biochemical, Nutritional Stabilization
Body Image Treatment
Sexuality, Relationships, Co-Dependency
Recreation and Relaxation
Education Groups-Topics include: stress, psychological
development, self-esteem, compulsive behaviors, sexual abuse,
spirituality, anger, assertiveness, relapse, shame, women's
issues
TREA1MENT OBJECTIVES
Our objective is to help each client achieve a clear understanding of
her eating disorder, its effect on her life, and what is necessary for
her personal recovery. Our goal is to develop and initiate a plan for
recovery that will be able to be maintained on discharge. We assist
clients to:
1. Eliminate starving, bingeing, purging, and compulsive eating
2. Establish nutritious, healthy eating patterns
3. Get into balance nutritionally, biochemically, and metabolically
4. Gain insight into disordered thinking
5. Gain insight into the underlying causes of the eating disorder
behaviors
271
Ex. A p. 16
6. Learn appropriate expression of anxiety regarding fooq and
weight issues
7. Work toward achieving an "ideal body weight" within an
accepted range
8. Gain insight into destructive attitudes and behaviors
9. Develop a balanced weight maintenance plan involving food and
exercise
10. Improve body image
11. Use journal writing and self-monitoring
12. Discover and utilize alternative coping skills other than the eating
disorder or any other self-destructive acts
13. Work with their significant others in the development of improved
understanding and improved communication in order to break
patterns that enable the eating disorder to continue
14. Alleviate depression and anxiety and improve self-esteem
15. Identify and constructively express emotions and receive support
in developing coping strategies for living free of destructive
behaviors
16. Use independent experiences and therapeutic passes in order to
create a lifestyle that can be continued on discharge
17. Develop relapse prevention techniques
272
Ex. A p. 17
17
INCREASING AWARENESS
AND PREVENTION
I'd like to see a world where it would be a compliment to say to
someone, "Hi, you look great, you've put on fat. Levine,
President, Eating Disorders Awareness and Prevention (EDAP)
disd . I ty d
E
ating or ers are rampant m our soCie , yet a equate pre-
vention programs do not exist. Extensive programs aimed at
preventing alcoholism and drug abuse have proven their value and
been accepted into school curricula. 9n the other hand, very few
schools or colleges have programs on education and pre:vention of
eating disorders.
The increase in eating disorders, the high cost of treatment, the
longevity of these illnesses, and the high mortality rate make it
imperative that programs be implemented to prevent them. Since 86
percent of victims report the onset of their illness by age twenty,
education programs should focus on early ages in order to maximize
preventive efforts. With the increasing number of elementary school
children ending up in eating disorder hqspital programs, the need for
early education and prevention efforts is crucial.
Prevention programs and literature cannot be targeted exclu-
sively to females. It is a mistake to think of eating disorders as a
"female issue," for several reasons. As described in chapter 2, males
do suffer from eating disorders, and the number of these cases is on
the rise. Furthermore, we need to educate males as to the significant
role they have in the prevention of eating disorders in the general
population. Males, often without realizing it, objectify females even
at an early age, making comments about and overemphasizing looks
and weight. Fathers have to learn to relate better to their daughters,
husbands to their wives, brothers to their sisters, boyfriends to their
male coaches to their athletes, and so on. We all have to work
I
275
Ex. A p. 18
HEALTH
"Provides a unique personal and professional viewpoint on eating
disorders ... this goes further than most in providing a sympathetic
view of eating disGrders and their diagnoses."
-Midwest Book Review
E
ating disorders have become an alarmingly common problem, both in the United
States and around the world. For some, society's preoccupation with appearances
contributes to a physically and emotionally destructive quest for an imagined state of
physical perfection. For others, compulsive dieting is seen .as a way to gain some con-
trol in a life that seems otherwise out of control. Anorexia nervosa, bulimia nervosa,
and binge-eating disorder affect a growing number of young women, children, and,
increasingly, men.
Fifty percent of females between the ages of eleven and thirteen see them-
selves as overweight.
Twenty-five to 35 percent of college-age? women are engaging in binge-
ing and purging as a technique.
Roughly one million males in the Uillted States suffer from eating disorders.
As these numbers grow, however, so does cause for hope. An increasing body of
knowledge about eating disorders, including new information about the biology and
psychology involved, is leading to new, innovative treatments for these always harmful
and sometimes fatal disorders.
This new edition of The Eating Disorder Sourcebook provides the most up-to-date
information on the possible underlying causes of eating disorders and their treatments,
as well. as information on re.cognizing disordered eating patterns in yourself or a loved
one. A complete overview of treatment options, including group therapy, one-on-one
counseling, the uses of and inpatient treatment, is provided, along with a
thorough listing of treatment centers and other resources around the country.
Individuals suffering from eating disorders often report feeling isolated ami alone
in their condition. To these individuals, The Eating Disorder Sourcebook offers under-
standing, reassurance, and finally, a message of hope: Others have faced these disorders
and won. So can you.
CAROYLN COSTIN, M.A., M.Eo., M.F:C.C., has recovered
from anorexia netvosa and has been a specialist in the field of
eating disorders for twenty years. She is currently the ru;ector of
the Monte Nido Residential Treatment Facility in Malibu,
California. Her o.t):ler books include Your Dieting Daughter and
Anorexia and Bulimia (with Alexander Schauss, Ph.D.).
Cover design by Laurie Young
Photograph by Kvon/Schmaltz/Photonica
US $17.95 I CAN $25.95
Ex. A p. 19

Exhibit B
The McGrawHi/1 Companies .
library of Congress Cataloging-in-Publication Data
Costin, Carolyn.
The eating disorder sourcebook by Carolyn Costin. - 3rd ed.
p. em.
Includes bibliographica l references.
ISBN 0-07-147685-7
1. Eating disorders. I. Titl e.
RC552.E18C67 2007
616.85'26-dc22 2006036808
Copyright 2007 by Carolyn Costin. All rights reserved. Printed in the United States of
America. Except as permitted under the United States Copyright Act of 1976, no part of this
publication may be reproduced or distributed in any form or by any means, or stored in a
database or retrieval system, without the prior written permission of the publisher.
6 7 8 9 10 11 12 13 14 15 16 17 18 19 QFR/QFR 1 5 4 3 2 1
ISBN-13: 978-0-07-147685-0
ISBN-10: 0-07-147685-7
McGraw-Hill books are available at special quantity discounts to use as premiums and sales
promotions, or for use in corporate training programs. For more information, please write
to the Qirector of Special Sales, Professional Publishing, McGraw-Hill, Two Penn Plaza, New
York, NY 10121-2298. Or contact your local bookstore.
Thi s book is printed on acid-free paper.
Ex. B p. 1
r oung, Whtte, and Female: Myth or Reality? 43
tion, and the use of !extreme and even to
the body constitute a definite parallel with eatmg disorders m
women.
Treati ent and Prognosis for Males
Although more research is needed on the specific psychology of
men with eating the basic principles for treatment are
similar to those for /treating women.
Short-term stuf ies suggest that the prognosis for males in
treatment is compa/rable to that for females, atleast in the short
term. Long-term sttudies are not available. Empathic, informed
professionals are nkcessary; because males with eating disorders
feel misunderstood! and out of place in a society that still doesn't
understand these Although it may turn out to be true, it
is often mistakenly assumed that men, most particularly those with
anorexia nervosa, i re more severely disturbed and have a poorer
prognosis than woben with these disorders. This appears to be
the case because fi t st, since males often go undetected, the most
severe cases are pro
1
bably those who enter treatment and thus come
under scrutiny. along the same lines, there seems to be
a contingent of malles with other serious psychological disorders,
most notably disorder, in which food rituals,
food phobias, food restriction, and food rejection are prominent
features . These individuals end up in treatment mostly because of
their underlying illnesses, not for their eating behav-
ior, and they tend Jo be complex, difficult-to-treat cases.
The field contihues to search for an understanding of the bio-
. logical, psychologipal, social, and cultural factors that contribute
to a spectrum of b<f>dy image, eating, and weight management dis-
orders in boys an1 men. As we gain more knowledge and as the
problems gain more recognition, it is hoped that optimal preven-
tion and treatmenJ protocols will be revealed. .
Ex. B p. 2
222
I
THE EATING DrsoRDER SouRCEBOOK
I
I
I
Weight Maintenance
I
Weight maintenanqe is the ultimate goal for all clients. Many know
how to lose or gain, but learning how to live normal lives and
maintain their hedlthy weight is another set of skills altogether.
All too often clienJs leave treatment before they have time to prac-
tice this important/ and necessary skill. This is particularly true of
those in programs. First, they are often discharge,d for
financial/insurance reasons before they have time to deal emotion-
ally with their ne, body weight or practice maintaining it. Second,
many programs have complete control over food and exercise and
are not set up to let clients shop for, cook, portion, or prepare food,
all skills they will to maintain their weight.
When I worked in hospital treatment settings, I watched too
many clients leave/treatment and immediately lose weight or binge
and purge when they had to shop for all their food, make meals
alone, and try to f at at times other than their inpatient schedule.
This is one of the reasons I opened my residential program, Monte
Nido. Teaching clients to live in the world, with all the day-to-day
things they have rp do, including buying, preparing, cooking, and
eating food, is crifical.
Learning how to accept one's weight and maintain it, while
getting on with liFe, is the ultimate aim. Leaving treatment without
practicing the skills of eating and living where they really count is
like learning the Jkills of baseball without ever playing in a game.
One might learn hit a ball, but coming to bat with bases loaded
and having to hif. , run, and slide into third before being tagged
out is another st9ry and uses other skills altogether. For clients to
fully recover, the)!l not only need help to learn skills and accomplish
weight goals, but to learn how to play the game of life and main-
tain their goals eyen when life throws curveballs.
I
Establishing a Healthy Body Weight
I
Various sources, /such as the Metropolitan Life Insurance weight
tables, the Robinson formula, and the Devine formula, have been
established to prbvide ideal weight ranges. The best source to dis-
1
Ex. B p. 3
Medical Assessment and Management 229
understand the medical complications and monitoring involved in
an eating and will help ensure that you (or a loved one) get
a proper medica[ evaluation and care. If you are a physician, I hope
this informatiorl helps guide and inform you in your treatment of
I
these perplexing and life-threatening disorders.
I
Guidelines for Medical Evaluation
Aside from a tJ orough assessment, the physician must treat any
medical or conditions that contribute to the eating dis-
order as well as /any symptoms that arise as a result of it. He or she
must also rule out any other possible explanations for symptoms,
such as malabsf rption, primary disease, or an like
cancer or severe depression that results m a loss of appetite.
Additionallf , medical complications may arise as the eating
disorder progresses or as a consequence of the treatment itself; for
example, patierlts may experience refeeding edema (swelling that
results from starved body's reaction to eating again) or com-
plications from/ prescribed medications. Ongoing, periodic assess-
ment and treaqnent are necessary as part of overall treatment
strategy, and physicians should work closely with other members
of the treatme1t team. . . .
Of the entire gamut of psychological disorders treated by cli-
nicians, eating[ disorders are those most frequently punctuated
by accompanying medical difficulties. Although many of these
are more than serious, a distinct number of them are
potentially life-threatening. The mortality rate for these disor-
ders exceeds tllat found in any other psychiatric illness and may
approach 20 in the advanced stages of anorexia nervosa.
Physical must be investigated judiciously and organic
disease excluded by appropriate tests. Conversely,
from a treatmelnt point of view, the physician has to avoid subject-
ing the patient to expensive, unnecessary, and potentially invasive
tests.
Physicians /are often the professionals called upon to do their
\ i?est to assess l:lietary practices, nutrition intake and status, and
Ex. B p. 4
I
I
I
I
I
I
I
i 15
I
When Outpatient Treatment
I
/Is Not Enough
MosT EATING DISORDER treatment takes place on an outpatient
basis, but there / may come a time when outpatient treatment is
insufficient due to the severity of the eating disorder. Tre.atment in
a structured setting may be chosen as a better means than outpa-
tient therapy to recovery or be required when symptoms
are severe, out dt control, and/or the medical risks are significant.
This chapter pr
1
bvides an overview of various treatment options
and guidelines fpr making an appropriate choice.
I
!Determining Level of Care
The mechanisms for choosing a level of care that is more struc-
tured than outpktient treatment vary. In many instances, people are
referred to an ibpatient setting by one or more of their outpatient
clinicians who Heem it necessary or optimal. The treatment team
should criteria for such referrals in advance to avoid panic
and confusion. fin other cases, individuals with an eating disorder
or their family members will choose to try a structured treatment
program even t1hough the client is not yet seriously compromised.
I often wonlder why treatment programs are not sought earlier.
Part of the answer lies in the sad fact that insurancecompanies
'- I
265
Ex. B p. 5
266 THE EATING D I SORDER SOURCEBOOK . .
.
often deny for this treatment. I have known clients who
did not meet the lor weight criteria for inpatient care, so they pro-
ceeded to lose enough weight to get the treatment they needed. The
newest version of nhe APA guidelines is attempting-to address this
issue by eliminatibg low weight requirements recommended for
residential or inpatient care. If a treatment provider suggests this
level of care, clients and/or their loved ones might have to fight their
insurance compady. (The National Eating Disorders Association
website at nationaleatingdisorders.org has more information:)
I
Not a Last Resort
Unfortunately, programs are often regarded as a last
resort to be used only when all else fails. Professionals and loved
ones should avoid[ remarks such as, "If you get too bad, or if you
don't improve, you are going to have to go into treatment." Treat-
ment programs sHould not be feared or seen as punishment. It is
better for individuals to be told, "If you are unable to battle your
eating disorder outpatient therapy alone, additional help can
be found in a treatment program where you will be provided the
I
care, nurturing, and added strength you need to overcome your
disorder." programs can be viewed as a welcome, albeit
scary, choice indiJ iduals make from the healthy part of them that
wants to get better.
Treatment Program Options
A variety of settiAgs provide more intense levels of care than out-
patient therapy. 'j'hen looking for a treatment program, the treat-
ment team and client must understand the difference between the
intensity and stru(!;ture of these different levels. The various options
include 24-hour live-in facilities (hospital or residential programs),
partial hospitalizJtion or day-treatment programs, intensive outpa-
tient programs, and transitional or recovery houses.
I
Ex. B p. 6
When Outpatient Treatment Is Not Enough 267
Hospital Facilities
Inpatient trea!tment, or 24-hour care in a hospital setting, can take
place in a me!dical or psychiatric facility. The cost is usually high,
around $1,400 to $1,800 per day or more. Inpatient treatment
at a medical hospital is usually a short-term stay to treat medical
conditions complications that have arisen as a result of the eat-
ing disorder. !Psychiatric hospitals often take eating disorder clients
but, unless they have a specialized eating disorder track, should
be used for stabilization purposes (e.g., allowing someone
to overcome /a suicidal episode). Treatment in a hospital, whether
medical or psychiatric, without specialized staff and treatment
protocols fot eating disorders will not only be unsuccessful, but
can cause mbre harm than good.
I
I Residential Facilities
The majorit)j of eating disorder individuals are not actively suicidal
or medically/unstable and do not require hospitalization. However,
there may b
1
e a substantial benefit to these individuals of having
supervision fand treatment on a 24-hour-a-day basis. Bingeing,
vomiting, laxative abuse, compulsive exercise, and
restricted eating do not necessarily lead to acute medical instability
and thus, bx/ themselves, do not qualify as criteria for hospitaliza-
tion. Since insurance coverage often requires the individual to be
medically clients can have many of these behaviors
and still norl qualify for insurance coverage.
Howevdr, eating disorder behaviors can become so h<:tbitual or
addictive thkt trying to reduce or extinguish them on an outpatient
or even basis can be impossible. Residential treat-
ment facilities offer an excellent alternative to hospitals, providing
round-the-dlock care in a nonhospital setting and are usually less
expensive than hospital-based options. Many of these programs
are much sthaller and feel more personal than hospital programs.
Some are hbused in former private residences or estates that have
Ex. B p. 7
268 THE EATING Drsb, DER SouRCEBOOK
\
been converted into treatment facilities, which allows for a home-
like environment. [
Residential facilitif s vary greatly in the level of care provided,
so each program musn be investigated thoroughly. Some facilities
offer sophisticated, iAtensive, and structured treatment similar
to that of a hospital ihpatient program but in a less sterile, more
relaxed, and more nafural setting. Other facilities are less struc-
tured, provide far less treatment, and are often centered around
group therapy. These programs are closer to transition or recovety
houses (see section with this title). The treatment team and patient
should thor.ou.ghly exr
1
lore the various levels of treatment and ser-
vices offered and find out about the expertise of the professionals
who provide them.
Residential treatment is becoming increasingly popular as a
choice for treating eafing disorders. Some individuals go directly
to residential treatment programs, while others spend time in a
hospital and then trar1sfer to a residential program. Many of these
programs offer crucial and important features that are not possible
in a hospital setting. Clients have the opportunity to be increas-
ingly involved in mea planning, shopping, cooking, exercise, and
other daily living activities that simulate what they will need to do
. I
when they return horne.
These are problef areas for eating disorder individuals that
cannot be practiced and resolved in a hospital or even in a large
residential facility. srhall, homelike facilities offer treatment and
supervision of and daily living activities, providing cli-
ents with increasing r
1
esponsibility for their own recovery. (See the
description of the Monte Nido Treatment Facility at the end of this
chapter.)
Partial Hofpitalization or Day Treatment
Often individuals nee/d a more structured program than outpatient
treatment but do not /need 24-hour care. Additionally clients who
have been in an inpatient or residential program can often step
down to a lower level/ of care but are not ready to return home and
begin outpatient treaj ment. In these cases, partial hospitalization
Ex. B p. 8

or day-treatq.ent programs be indicated and in a variety
of types, usJally offering serv1ces from five to e1ght hours a day.
Clients are often in the program during the day and return home
in the but some of these programs include dinner and
evening groJ ps. Day-treatment and partial hospitalization pro-
grams are bJcoming more prevalent, partially because of the cost
of full 24-hJ ur inpatient programs and partially because clients
can receive great benefits from these programs without the addi-
tional burdeh or stress of having to leave home entirely.
Day treaJment programs vary in the amount of structure they
provide. HiJ her success rates have been reported in day-treatment
I
programs where the treatment is intensive and involves clients at
least five a week for approximately eight hours a day. Due to
the amount @f variation in these programs, it is not possible to give
a fee range. One example is the Eating Disorder Center of. Califor-
nia, which six days per week from five to eight hours a day.
Readers can find details of this program at edcca.coin.
Intensive Outpatient Programs
These progr
1
ams offer even less structure and treatment than day-
treatment of partial programs, but they are a good step up from
outpatient dare alone. Intensive outpatient programs (lOPs) vary
but usually [involve clients three times a week for . three or more
hours. If tried early, lOPs can be useful when a client is not improv-
ing with ouJpatient treatment or a useful step down as a transition
from a highbr level of care.
Transitions or Recovery Houses
Some people may confuse a transition or recovery house with resi-
dential treat ment. Recovery houses have far less structure and are
inappropriate for individuals who are still engaging in ongoing
behav-iors require supervision. Recovery houses are best used
as transitional living situations after residential or inpatient treat-
ment. GenJrally, recovery homes provide group therapy and/or
other recovlery meetings and the clients who live there are under
Ex. B p. 9
270 THE EATING DrsoRDER SouRcEBooK
-\
the supervision of a 't ouse parent." This option is far less expen-
sive than hospitals 9r residential facilities, but these programs
provide minimal or no treatment unless they are connected to a
day-treatment facilid that residents are required to attend.
When to Seek 24-Hour Care
It is always the best <Sircumstance when an individual choosesto
enter into a treatmerlt program by choice or before it becomes a
necessity. A person decide to seek treatment in a hospital or
residential setting to get away from the normal daily tasks and dis-
tractions and focus e1clusively and intensely on recovery. However,
it is often as a result of medical evaluation or a crisis situation that
the decision to go toJ or put a loved one in, a treatment program
is made. To avoid and confusion, it is important to establish
criteria for and of any hospitalization in case such a situ-
ation arises. It is that the therapist, physician, and any
other treatment teaT members agree on hospitalization criteria
and together client sees a nt, c-omplementary,
and consistent treat ent team. The cntena and goals should be
discussed with the client and significant others and, when pos-
sible, agreed upon at fhe beginning of treatment or at least prior to
admission. hospitalization should be considered only
when the patient's is in danger.
In relation to th specific eating disorder behaviors, the pri-
mary goal of care for the severely underweight individual
is to institute and weight gain. For the binge eater or
person with bulimiaJ the primary goal is to establish control over
excessive bingeing a4d/or purging. Twenty-four-hour care may be
needed to treat coexisting conditions such as depression or severe
anxiety that are impl iring the individual's ability to function. Fur-
thermore, many indtviduals with an eating disorder experience
suicidal thoughts an
1
d behaviors and need to be hospitalized for
protection. A person may be hospitalized strictly for a medical con-
dition or complicatidn such as dehydration, electrolyte imbalance,
Ex. B p. 10
\
fluid retention, or chest pain, in which case a medical hospital may
be sufficient. f he decision regarding. to go for treatment
must be decid1d on a case-by-case basts. It 1s tmportant to look for
a pr.ogram or hospital in the care
of pattents wtth eatmg d1sorders. The followmg are some reasons
why a to seek 24-hour care might be made.
of Reasons for Hospital or Residential Care
1. Postural hypotension (low blood pressure)
2. dysfunctions such as irregular heartbeat,
or prolonged QT ventricular. ectopy
(A ph:ysician should help determme when certam levels
of caJdiac abnormality should be referred to a hospital
settiJ g.)
3. Pulse/less than 45 beats/minute (BPM) or greater than
100 RPM (with emaciation)
4. DehyHration/electrolyte abnormalities such as a serum
potaJsium level less than 2 milliequivalents per liter,
fasti rlg blood glucose level less than 50 milligrams per
100 Tilliliters, creatinine level greater than 2 milligrams
per 1p0 milliliters .
5. Weigft loss of more than 25 percent of 1deal body
weight (could need 24 hour care with even less weight
rapid, progressive weight loss (1 to 2 pounds per
wee[ ) in spite of competent psychotherapy
6. Binge/purge behaviors are happening multiple times per
day J.rith little or no reduction in outpatient forms of
treatlnent
7. OutJ atient treatment failure when client is unable
to cdrnplete an outpatient trial, for example, can't
I b .
physically drive to or remem er sess10ns, or treatment
has six months with no substantial improvement
8. for diagnosis and/or medication trial
9. thoughts or or .self. harm. behavior .
10. Cha<Dtic or abusive family Situation m whiCh the famlly
treatment
Ex. B p. 11
272 THE EATING DISORDER SouRCEBOOK
- \
11. Increases in impulsivity such as shoplifting, risky sexual
behavior, hnd so forth
12. Inability tJ perform activities of daily living .
should not be regarded as an easy or a final
solution to an eating disorder. Minimally, hospitalization should
provide a structut ed environment to control behavior, supervise
I
feeding, observe the client after meals to reduce purging, provide
close medical morlitoring, and, if necessary, provide medicahreat-
ment. However, treatment programs for eating disorders
offer an protocol and a trained staff and milieu that
provide empathy, hnderstanding, education, and support, facilitat-
ing cessation or d+ matic reduction of eating disorder thoughts and
behaviors. This kmd of treatment should not have to wait until a
crises situation should be discussed early on with some clients
and their families r
Letting eating disorder individuals be included in all of their
treatment decisio1s, including when to go to a treatment program,
is valuable. Contr
1
ol issues are a consistent theme seen in individu-
als with eating dirorders. It is important not to let a "me against
them" relationship develop between the therapist or treatment
team and the with the eating disorder. The more control
individuals have in their treatment, the less they will need to act
out other means of control, (for example lying to the therapist,
sneaking food, or purging when not being observed). Furthermore,
if an individual has been included in the decision making process
regarding a highdr level of treatment, there is less trouble getting
compliance when admission is necessary.
Curativf Factors of Day Treatment or
24-Holur-Care Treatment Programs
A good eating disorder program provides not only structure and
monitoring, but J number of curative factors that facilitate recov-
ery as well.
Ex. B p. 12
1. It sepamtes the client from home life, family, and friends.
Rem+ ing the client from the family may help
deterTine the "role" the client plays iri the family, the
role family played in of eating
and secondary gams to havmg an eatmg
disorf er.
Being away from normal routines and responsibilities

school, children, etc.) can help clients focus

atten ion where it is needed.
2. It provi , es a controlled environment.
Exposing the patient's true patterns and behaviors
(e.g., /food rituals, mood at mealtimes, food rigidity) is
necessary to deal with these issues and find alternative,
mor1 suitable behaviors.
A controlled structured environment assists in
breat l ing addictive patterns. Popcorn and frozen yogurt
diets cannot be continued. Vomiting is diffic'ult to
acco plish when there is supervision after snacks and
meais. A healthy, realistic meal plan and schedule can
be and practiced.
Mediication can be monitored for compliance, side
effedts, and effectiveness, particularly in inpatient or
I
settings.
3. It offe s support from peers and a healing environment.
The camaraderie, support, and understanding of others
are I ell-documented healing factors.
Stafr members can be positive role models for self-care
and can be an example of a healthy "family" system.
The treatment team can provide a good experience
of the balance between rules, responsibilities, and
free8om.
The duraLn of rime spent in a treatment program will depend
on the sevedy of the eating disorder, any complications, and the
treatment go
1
1s. These programs can help break addictive patterns
or cycles and start a new behavioral process for the client, but they
Ex. B p. 13
useful information. Be skeptical of any program that will
not arrange f
1
br this.)
I)o you conduct outcome data, and if so, what are the
results? (ProJ rams should be interested in outcome data
to ensure thalt they are actually helping clients, and they
should be abie to discuss their data with potential clients.)
The Monte Nido Residential Treatment Center
The following on Monte Nido-my residential pro-
gram in Malibu, Oalifornia-provides an idea of the philosophy
I
and treatment goals of a 24-hour residential facility specializing
exclusively in anorJxia nervosa, bulimia nervosa, and activity dis-
order. For more contact montenido.com.
Program Overview
All too often a person does well in a highly structured, regimented
environment only Ito relapse upon returning to a less structured
situation. Monte is designed to meet the individual needs of
clients and their fapilies in a way that gives them a higher level of
responsibility and )' teaches" them how to recover. The atmosphere
at Monte Nido is 11rofessional and structured, but it is also warm,
friendly, and famdy-like. Our staff, many of whom are recovered
themselves, serve las role models, and our environment inspires
people to commit rio overcoming obstacles that are interfering .with
the quality of theil! lives.
The program
Monte Nido is designed to provide behav-

ior and mood creating a climate where destructive
behaviors can be interrupted. Clients can then work on the crucial
underlying issues fhat caused and/or perpetuate their disordered
eating and other dr sfunctional behaviors. We provide a structured
schedule with education, psychodynamic, and cognitive behavioral
therapy; corrective[ eating patterns; healthy exercise; life skills train-
and f nhancement in a serene natural setting nestled
m Jhe footh1lls, cl ' se to Malibu Beach.
Ex. B p. 14
278 THE EmNG D"Or ER SOURCHOOK
Our treatment philosophy includes restoring biochemical
function and balance, implementing healthy eating
and exercisehabits, changing destructive behaviors, and gaining
I
insight and coping skil ls for underlying emotional and psychologi-
cal issues. We believe that eating disorders are and that,
when treated correct y, individuals can become fully recovered,
where they can resumf a normal, healthy relationship to food.
We recognize nutntion and exercise as crucial areas of recovery.
Therefore, we requird assessments on nutritional status, metabb-
lism, and and we teach clients what this information
means in terms of recovery. Our fitness trainer performs a
thorough assessment 6nd develops a fitness plan suitable for each
client's needs. /
Every aspect of our program is designed to provide clients with
a lifestyle they can coytinue after leaving our program. Along with
traditional therapy artd treatment modalities, we deal directly and
specifically with eatihg and exercise activities that can't be ade-
quately addressed in settings due to size or structure; we feel
these activities are crilicial to facilitate full recovery.
Planning, and cooking meals are all part of each
client's program. directly with these activities is a unique
part of our programJ We believe developing skills in these areas
is necessary because {hey will all have to be faced upon returning
home. Clients will have independent, individualized goals in this
area and gain increaJed responsibilities for their own care.
Cl
. . .I . . d. . d" .d I d
tents m exercise accor mg to m tvt ua nee s
and goals. After an exercise assessment, a fitness trainer, in con-
junction with the tredtment team, develops an individualized exer-
cise plan for each ciiJnt. This is continually monitored, evaluated
and adapted treatment. Exercise and activity disorders
are addressed with the focus on developing healthy, noncompul-
sive, lifelong exerciscl and activity habits. We are set up to meet
the needs of athletes I and compulsive exercisers who require spe-
cialized attention in his area.
Ex. B p. 15
Exercise and leisure activities. Our goal is to provide a
variety of activities that nourish both body and soul. We have
scheduled outind two to three times per week and special events
periodically. Our/ recreational outings can involve going to an art
studio, to the beach, to a museum, to a miniature golf course, or
anywhere that appropriate. Occasionally, we attend special
events, like dande performances, concerts, and plays. We also
utilize a variety J f recreational activities that have a direct thera-
peutic value sucH as ropes courses and equine therapy.
SpiritualitJ and mindfulness. We believe that in healing eat-
ing and exercise disorders we must engender purpose and meaning
in our clients' liJes by providing nondenominational spirituality.
In this aspect program, we work with eating and exercise
disorder symptop s as the voice of a disconnected soul and we
listen carefully af d learn from them. At the same time we work to
instill soulfulness and a spiritual dimension back into the lives of
our clients. OncJ reconnected to the spiritual, sacred, and soulful
aspects of life, tt e need for the symptoms diminishes.
therapy is a critical component of the program.
Clients need indi.vidual sessions to work on their own particular
problems and that have caused or perpetuate their disor-
dered thinking Jnd/or behavior. Clients meet at least three times
per week with Jheir primary therapist and also have individual
sessions with clinical director, dietitian, and psychiatrist.
Group thL apy solidifies the other treatment components.
Through intens+ e group work, clients receive and offer support,
gain insight int3 their problems, and develop the ability to trans-
form them. Increasing confidence is gained by being able to iden-
tify feelings, cob municate, deal with conflict, express needs in
effective ways, 1nd deal with shame and anger. All of this helps
clients develop Jppropriate skills in order to deal with underlying
issues and life's challenges without resorting to eating disorder
behaviors.
Ex. B p. 16
280 THE EATI NG Dr s oRDER SouRCEBOOK
Outings and paL s are provided for skill building and to
assess each client's grdwth in handling real-life situations. Once
clients are stabilized ayd it is determined that they are capable of
it, they are allowed t1 obtain passes to go to restaurants, shop-
ping, participate in soa: ial activities, and even go home for several
hours or a couple of aays (insurance permitting). On returning
from an outing or clients process their experience in both
individual and group sessions to learn from the experience and
plan for the future.
Level System
The Monte Nido levl l system allows for increased freedom and
responsibility as clienfs progress in the program. All clients have
a written contract, they help create with their therapist and
in a special group called "contract group." In this group, all the
clients meet with thejclinical director or other staff members and
discuss together theitf goals for the upcoming week. The contract
shows the current they are on and spells out the goals for that
level. Each client's is individualized, although there are
certain activities, reading assignments, and other standard require-
ments for every leveL /A copy of the contract is given to each client,
one is posted, and one is kept in the client's chart.
Special If deemed appropriate, clients may have
special privileges spelled out in their contract that allow for things
not usually spelled otht for their current level. For example, a client
may ask for and be 1llowed to independently cook her own meal
on Level III even thJ ugh this is a Level IV activity.
Level changes( When clients feel they are ready, they can
request a move to tpe next 'level. Level change requests are dis- .
cussed in sessions and in contract group, where they
receive feedback the staff and peers. The treatment team
will make final deer sions regarding all contract issues and level
requests in the staff meeting. All clients and staff then meet to go
over each client's fi al contract for that week.
Ex. B p. 17
About the Author
Carolyn Co/stin, M.A., M.Ed. , M.F.T., has been a specialist in
the field of eating disorders for nearly thirty years. The owner
and directoF of the Monte Nido Residential Treatment Facility in
Malibu, and all of its affiliates, she is also is the clinical
advisor to the Parent Family Network of the National Eating Dis-
order and an editor of Eating Disorders: The journal
of Treatmeht and Prevention. She speaks nationally on the treat-
ment and p1evention of eating disorders and is known for her posi-
tion that pelople with eating disorders can be fully recovered. She
is also the author of Your Dieting Daughter and 100 Questions
About Disorders.
Ex. B p. 18

Exhibit C
latimes.com/entertainment/sns-health-anorexia-nervosa,1,6231013.story
latimes.com
Treating Anorexia Nervosa
Anorexia nervosa affects nearly one in 200 Americans in their lives, three-
quarters of them female.
Courtesy of Harvard Mental Health Letter
September 25, 2009
Treating Anorexia Nervosa - latimes.com 1 of 3
http://www.latimes.com/entertainment/sns-health-anorexia-nervosa,1,355883,print.story
Ex. C p. 1
advert i sement
cl i ck here t o f i nd out more!
The Agency for Healthcare Research and Quality (AHRQ) reported that
hospitalizations for eating disorders have increased in the new millennium.
The most common diagnosis was anorexia nervosa, accounting for 37% of hospitalizations in 2005 to
2006, an increase of 17% over those reported for 1999 to 2000. The next most common diagnosis was
bulimia nervosa, characterized by binge eating followed by purging, which accounted for 24% of
hospitalizations in the year ending 2006.
Anorexia nervosa affects nearly one in 200 Americans in their lives (three-quarters of them female).
The term "anorexia" is derived from two Greek words, usually translated as "without appetite" -- but
that is something of a misnomer. Patients with this disorder do not lose their appetite; they struggle to
subdue it. They are simultaneously afraid of gaining weight and convinced they are too fat, even when
signicantly underweight. As a result, they starve themselves to the point that they put their lives at
risk.
In the most severe cases, patients develop life-threatening complications, such as cardiac arrhythmias,
kidney failure, and liver failure. This is one reason that anorexia nervosa is one of the most deadly
psychiatric disorders, killing 5.6% of patients for every decade that they remain ill. Treatment is
challenging because starvation not only severely damages the body, but also harms the brain --
causing changes in thinking, emotions, and behaviors that may be difcult to reverse.
Anorexia nervosa is one of the most deadly psychiatric disorders.
A multidisciplinary approach is best, but treatment is challenging because starvation may cause
permanent changes in thinking and behavior.
Although medications are often prescribed, little evidence supports their use in treating anorexia
nervosa.
Risk Factors and Diagnosis
Anorexia nervosa is a complex, multifaceted disorder that may develop from about age 8 onward,
most often beginning between ages 15 and 18. A large, nationally representative U.S. study found no
new cases after respondents reached their mid-20s. This suggests that when adult patients seek
treatment for anorexia nervosa, they usually have struggled with this disorder before.
Studies in twins suggest that anorexia nervosa is about 71% heritable (about the same as obsessive-
compulsive disorder), indicating that genes contribute to susceptibility more than environmental
factors do. In addition, certain personality traits, such as perfectionism, body dissatisfaction, and
obsessive thoughts and behaviors may predispose patients to developing anorexia nervosa. Other risk
factors include a past history of anxiety, depression, or substance abuse, or physical or sexual abuse.
Ex. C p. 2
Environmental factors, such as magazines that feature gaunt models and Web sites that share
"thinspiration" pictures and stories, may initiate anorexia nervosa. These external cues may lead a
susceptible individual to lose weight, which in turn sets in motion an escalating obsession with
restrictive eating and body size.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) lists specic
criteria for diagnosis (see below), and describes two subtypes of anorexia nervosa. In the restricting
subtype, patients drastically reduce food consumption. In the binge-eating/purging subtype, patients
lose weight by forcing themselves to vomit or by using laxatives, diuretics, or enemas. Patients with
anorexia nervosa may also exercise excessively in an effort to lose weight.
Once weight decreases to the threshold required for a diagnosis of anorexia nervosa, patients may
experience changes in thinking processes, such as difculty concentrating. They may develop odd
food rituals, such as cutting food into tiny pieces, eating only at certain times, and weighing food.
Weight gain may eventually improve these psychological problems, but it seldom eliminates them
completely -- which is why maintenance treatment is so important.
Diagnostic Criteria for Anorexia Nervosa
Body weight less than 85% of normal for height and age
Signicant fear of gaining weight or growing fat, despite being underweight
Misperception of own weight or body shape and undue preoccupation with weight
Absence of at least three consecutive periods in females who previously menstruated
Copyright 2011, Tribune Media Services
Ex. C p. 3

Exhibit D
8/ 28/ 10 5:14 PM Men f ound t o be anorexi c, bul i mi c al so - Los Angel es Ti mes
Page 1 of 2 ht t p:/ / art i cl es.l at i mes.com/ 2007/ f eb/ 01/ sci ence/ sci - eat i ng1
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Eating Disorder Treatment
Bulimia Therapy Center Specializing In
Teen Girls & Adults
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Men found to be anorexi c, buli mi c also
February 01, 2007 | Deni se Gellene, Ti mes Staff Wri ter
Contrary to the long-held beli ef that anorexi a and buli mi a are female affli cti ons, the fi rst nati onal survey on eati ng
di sorders has found that one-quarter of adults wi th the condi ti ons are men.
The study esti mated that about 850,000 men had suffered from the di sorders and, despi te two decades of i ntense
attenti on to the condi ti ons, had gone largely undetected.
"Thi s i s a very i mportant fi ndi ng," sai d Ruth Strei gel -Moore, an eati ng di sorders expert at Wesleyan Uni versi ty who
was not connected wi th the study. "I t suggests a need to move away from gender-based explanati ons."
The researchers sai d the fi ndi ngs, whi ch appear today i n the j ournal Bi ologi cal Psychi atry, i ndi cated men are
vulnerable to the same soci al pressures that lead some women to uncontrollably bi nge and purge on food and others
to starve themselves.
"Body i mage has become more i mportant among men," sai d co-author Dr. Harri son G. Pope Jr., a professor of
psychi atry at Harvard Medi cal School. "There's a large, si lent populati on of men who mi ght be qui te i ll."
Overall, the survey found that 4.5% of adults, or 9.3 mi lli on people, have struggled wi th an eati ng di sorder someti me
i n thei r li ves. Anorexi a accounted for 1.3 mi lli on of the cases, and buli mi a 2.1 mi lli on. Bi nge eati ng, a di sorder of
frequent, uncontrollable peri ods of gorgi ng, accounted for the largest number of cases, 5.9 mi lli on.
The study, conducted by researchers at Harvard Uni versi ty Medi cal School, was based on i nformati on obtai ned from
the Nati onal Comorbi di ty Survey Repli cati on, a mental health survey of nearly 9,000 adults across the U.S.
Fundi ng for the study came from several sources, i ncludi ng the Nati onal I nsti tutes of Health and pharmaceuti cal
compani es Eli Li lly & Co. and Johnson & Johnson, both of whi ch sell drugs that are used as off-label treatments for
eati ng di sorders.
The survey found the prevalence of eati ng di sorders has been ri si ng si nce World War I I . The li feti me ri sk of 18-year -
olds developi ng an eati ng di sorder i s twi ce that of thei r parents, accordi ng to the report.
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Role of fast food
Researchers haven't pi npoi nted the cause of eati ng di sorders but sai d heredi ty and the envi ronment, i ncludi ng a
soci etal obsessi on wi th thi nness and the proli ferati on of calori e-laden fast food, are factors.
People wi th anorexi a are obsessed wi th thei r body wei ght and di et to the poi nt that they become dangerously thi n.
Half of the people wi th the di sorder bi nge on food and then purge by vomi ti ng or usi ng laxati ves or di ureti cs.
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Ex. D p. 2
8/ 28/ 10 5:14 PM Men f ound t o be anorexi c, bul i mi c al so - Page 2 - Los Angel es Ti mes
Page 1 of 2 ht t p:/ / art i cl es.l at i mes.com/ 2007/ f eb/ 01/ sci ence/ sci - eat i ng1/ 2
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February 01, 2007 | Deni se Gellene, Ti mes Staff Wri ter
(Page 2 of 2)
The other half restri cts the food they eat and excessi vely exerci ses. The di sorder i s fatal i n 10% of cases.
People wi th buli mi a eat a lot of food i n a short amount of ti me and then try to prevent wei ght gai n by vomi ti ng or
taki ng laxati ves to get ri d of the food.
Buli mi cs also may exerci se or use di ureti cs to keep off extra pounds, but they generally mai ntai n a normal body
wei ght. I t also can be fatal.
Dr. Walter H. Kaye, di rector of the eati ng di sorders program at UC San Di ego, who was not i nvolved i n the research,
sai d that men wi th eati ng di sorders may have escaped attenti on because they are less li kely to seek psychologi cal help
i n general and because the extent of thei r i llnesses may not be as severe.
"I t could be that eati ng di sorders are associ ated wi th women, so men may not even recogni ze eati ng di sorders i n
themselves," he sai d.
Buffeted by fi tness craze
Pope sai d the fi ndi ngs showed that men too had been buffeted by the fi tness craze of recent years.
"The cyni cal i nterpretati on would be that all the i ndustri es that have preyed upon women have saturated the female
market and are turni ng thei r attenti on to the other 50% of the populati on," he sai d.
One of the key fi ndi ngs of the survey was the length of ti me that the di sorders persi sted.
I t found that buli mi a and bi nge eati ng persi sted for an average of ei ght years, whi le anorexi a was far more transi ent,
typi cally lasti ng for one year.
Kaye, who i s researchi ng the geneti c basi s of eati ng di sorders, sai d the fi ndi ng about anorexi a was puzzli ng. The
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Eating Disorder Treatment
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medi cal communi ty has long regarded anorexi a as a chroni c condi ti on, he sai d.
"I have been doi ng thi s for 25 years, and I know a number of people who have di ed and have been chroni cally i ll for
many years," he sai d.
Jeani ne Cogan, poli cy di rector of the Washi ngton-based Eati ng Di sorders Coali ti on, worri ed the fi ndi ng mi ght cause
some to di smi ss the severi ty of the di sorder. "Anorexi a i s not j ust a passi ng phase," she sai d.
Bi nge eati ng i s not consi dered a li fe-threateni ng condi ti on. Nearly 15% of people wi th bi nge-eati ng di sorder are
severely obese, whi ch can lead to heart di sease, di abetes and other seri ous health problems.
More than half of bi nge eaters are women.
As wi th anorexi a and buli mi a, bi nge eati ng i s associ ated wi th mood di sorders.
Pope sai d that bi nge eati ng i s not the same as eati ng too much. "These are people who si t down to have a couple
potato chi ps and all of a sudden they can't stop eati ng, and they want somethi ng sweet, and they want somethi ng
salty, and the next thi ng they know they are completely stuffi ng themselves," he sai d. "I t i s qui te di fferent from the
munchi ng you would do watchi ng the Super Bowl."
Bi nge-eati ng di sorder i sn't classi fi ed as an offi ci al medi cal di agnosi s i n the Di agnosti c and Stati sti cal Manual of
Mental Di sorders, or DSM, the bi ble of the psychi atri c professi on.
Dr. James I . Hudson, lead author of the report, sai d the latest fi ndi ngs argued that i t should be i ncluded, whi ch would
allow pati ents to recei ve i nsurance rei mbursement for treatment.
*
deni se.gellene@lati mes.com
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Ex. D p. 4

Exhibit E
915 of 1277 DOCUMENTS
Copyright 2000 Contra Costa Times
All Rights Reserved
Contra Costa Times (California)
April 18, 2000 Tuesday FINAL EDITION
SECTION: TIME OUT; Pg. D03
LENGTH: 668 words
HEADLINE: ANOREXIC MEN COMBAT GENDER BIAS IN TREATMENT, TOO
BYLINE: Jon Stenzler
BODY:
CHERRY HILL, N.J. Rich Brandon rubbed his aching legs. He had run 17 miles the day before, more than usual.
He had to, he said, because he had eaten three bowls of corn flakes instead of his usual one.
Feelings of guilt over the extra 500 calories forced the 24-year-old to extend his grueling ritual by five miles. Now,
a day later, his legs were sore.
"I had to run those extra miles," Brandon said as he entered his spotless kitchen in Cherry Hill and opened the
refrigerator. Inside were four types of fat-free mustard and a two-liter bottle of Diet Orange Slice. Nothing else.
Brandon grabbed the soda and swallowed two tablets of Aleve, a painkiller. Despite the soreness that day, he went
out and ran 12 miles. As he always does.
Every morning.
Because he has to.
Rich Brandon suffers from anorexia and what experts on eating disorders call "exercise bulimia." Instead of
vomiting after eating, he works out. Religiously. Zealously. He fights a daily battle with his body, making sure the few
calories that he permits himself are burned, so he never gains a pound.
"Sometimes when I'm out there running I say to myself, I don't want to do this anymore.' But if I didn't, the feelings
of failure, inadequacies and guilt would be too overwhelming for me to deal with."
Researchers estimate that 5 million Americans suffer from eating disorders, about 90 percent of them women.
Experts say that in recent years more and more men are being diagnosed with anorexia or bulimia and can spend years
wandering aimlessly through the nation's health-care system.
Few eating-disorder programs treat men. Those that do, like the Renfrew Center in Philadelphia, severely restrict
Page 238
Ex. E p. 1
the programs offered to males.
"The problem with all of these treatment centers is that they are gender-biased," said Arnold Andersen, professor of
psychiatry and director of the Eating Disorder Programs at the University of Iowa and an expert on anorexia and
bulimia. "They either exclude men or claim they don't know how to treat them."
For Brandon, the first hints of anorexia came during the second semester of his sophomore year at Rutgers
University in New Brunswick, in 1995.
It was there that the 18-year-old with a penchant for cheesesteaks and beer started cutting out fast food and began
jogging in an effort to shed a few pounds. He weighed 175.
Soon the weight came off. The runs doubled in length. And it wasn't just fast food that was out, it was anything
with fat.
Brandon became a "calorie counter," and from 1995 on has been a disciple of "The Complete Book of Food
Counts," using it to carefully tally the exact amounts he allows to pass his lips.
By the end of that first summer, Brandon was hooked on control.
Thomas Holbrook is a psychiatrist and medical director of the Residential Eating Disorder Center at Rogers
Memorial Hospital in Oconomowoc, Wis., the only residential treatment program in the country geared specifically to
men. Ironically, Holbrook himself suffered with undiagnosed anorexia for 10 years while he was counseling patients for
the same disease.
"I saw a lot of doctors over the years because I developed various medical and physical problems because of my
eating disorder," said Holbrook. "Yet I was never diagnosed."
Brandon was. And still, he has to run.
As of March 31, he had run 68 out of 69 days. His weight in the five years that he has battled the disease has
roller-coastered from a high of 155 pounds to a low of 118 last spring and summer. It was at that point, when he would
take two pain relievers before running, that Brandon, at the urging of friends and family, sought help.
In June, Brandon called his health insurer, U.S. Healthcare, which referred him to Garden State Behavioral Health
in Marlton, which specializes in psychiatric treatment.
After six months of weekly counseling sessions that ended in November, Brandon said that he and the clinical
social worker assigned to him decided that the sessions were not working.
GRAPHIC: Knight-Ridder Newspapers
LOAD-DATE: January 30, 2002
Page 239
ANOREXIC MEN COMBAT GENDER BIAS IN TREATMENT, TOO Contra Costa Times (California) April 18,
2000 Tuesday FINAL EDITION
Ex. E p. 2

Exhibit F
8/ 28/ 10 4:01 PM Men, Boys Lack Opt i ons t o Treat Eat i ng Di sorders - WSJ.com
Page 1 of 5 ht t p:/ / onl i ne.wsj .com/ publ i c/ art i cl e/ SB117676525698871913- Mps4eTnhJWSE6kHqo5szACPLNuc_20070516.ht ml ?mod= t f f _mai n_t f f _t op#pri nt Mode
See a sample reprint in PDF format. Order a reprint of this article now
APRIL 17, 2007
Dow Jones Reprints: This copy is for your personal, non-commercial use only. To order presentation-ready copies for distribution to your colleagues, clients or
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Men, Boys Lack Options to Treat Eating Disorders
As Number of Male Patients Rises, Research and Diagnosis Remain Focused on Females
World U.S. New York Business Markets Tech Personal Finance Life & Culture
Opinion Careers Real Estate Small Business
By ELI ZABETH BERNSTEI N
For years, Brad Huffaker obsessively exercised, up to five hours a day. Then he stopped eating for up to 12
hours a day. Eventually, he began gorging each evening on any food he could find in the house and making
himself vomit it all back up -- a cycle he repeated up to eight times throughout the night.
Finally, last summer, Mr. Huffaker realized he had an eating disorder and needed help. But after scouring the
Internet and researching 20 in-patient facilities, he found only one that specialized in treating men. Mr.
Huffaker, a 24-year-old in Knoxville, Tenn., says finding a male-focused center was important because he felt
ashamed dealing openly with his problem in front of women. "It's much easier for me to eat in front of guys,"
he says.
Even amid a growing understanding of the incidence of eating disorders in men and boys, experts say there is a
dearth of treatment options for male patients. Only a handful of residential treatment centers have programs
that focus on men and boys. Many centers are reluctant to treat men at all. And there has been virtually no
research done on males with anorexia or bulimia.
Because these conditions are still considered female problems, even the criteria for identifying eating disorders
are female-oriented. The diagnostic guidelines many professionals use include questions about menstruation
and female body image. There are efforts to change these guidelines to be more inclusive of men's issues. But
eating-disorder experts and male patients say the current lack of treatment programs has a profound impact on
the chances of recovery.
For many years, conventional wisdom held that one-tenth of patients with eating disorders were male. But in
February -- in the first national survey of eating disorders -- Harvard researchers reported that males represent
as many as one-quarter of anorexia and bulimia patients and close to 40% of binge eaters. That would mean
300,000 men in the U.S. over 18 get anorexia at some point in their lives, and two million become binge eaters,
the researchers say. No one knows if the numbers of male eating-disorder patients are actually growing, or if
more men and boys are simply coming forward to seek treatment. But the few programs that specialize in men
say they are seeing increased enrollment.
Both males and females with eating disorders experience similar biological and psychological problems, say
experts. But men and boys often manifest their symptoms differently. While females obsess over calories and
weight, males typically focus on muscle and body fat. Mr. Huffaker, who is 6 feet 7 inches tall and got down to
180 pounds, liked that he had defined muscles, taut skin and just 5% body fat.
Ex. F p. 1
Unlike females, males have a variety of body images they may be trying to obtain. "Some want to be wiry like
Mick Jagger; some want to be lean like David Beckham, and some want to be really buff and bulked, like Arnold
Schwarzenegger," says psychiatrist Arnold Andersen, director of the eating-disorders program at the University
of Iowa in Iowa City.
The stigma of having an eating disorder can be even greater for males than for females, which typically makes
them even more reluctant to seek treatment. "Society sees this as a girl's disease," says Lynn Grefe, chief
executive of the National Eating Disorders Association, a Seattle-based nonprofit. "If a guy suffers, he's
embarrassed."
Researchers at the University of North Carolina at Chapel Hill reviewed clinical trials for eating disorders
conducted between 1980 and 2005, and the findings -- recently published by the International Journal of
Eating Disorders -- are striking: The 32 clinical trials for anorexia included 816 females and 23 males; 47
studies of bulimia looked at 2,985 females and 69 males; 26 studies of binge eating disorder included 1,008
females and 87 males. The eight medication studies on anorexia included 293 females and only one male.
"We have abandoned men," says Cynthia Bulik, one of the authors of the review and director of the eating-
disorder program at the University of North Carolina at Chapel Hill.
In the primary handbook for diagnosing mental disorders -- the fourth edition of the Diagnostic and Statistical
Manual of Mental Disorders, known as the DSM-IV -- the criteria to assess for anorexia involve female-specific
traits, such as amenorrhea, or menstrual irregularity.
Experts say
that the
screening
tests
developed
by
researchers
for the
disorders
are gender-
biased, too.
"Most
questions
are
designed
with female
concerns in
mind," says
Dr.
Andersen.
" 'Do you
worry
about
hips?' 'Do
your thighs
jiggle?' Instead of, 'Do you worry about muscle?' "
In response, several experts, including Dr. Andersen, are developing gender-neutral screening tests. And there
is a committee being formed by the American Psychiatric Association to examine the eating-disorder criteria in
the DSM-IV and determine what should be revised in the next edition -- DSM-V, to be published in 2012. That
committee is likely to look at gender differences, says William E. Narrow, DSM-V task force research director.
Ex. F p. 2
committee is likely to look at gender differences, says William E. Narrow, DSM-V task force research director.
Because of the lack of gender-specific research, eating-disorder experts say they have no proof that the
treatment for males should differ from that for females. A successful regimen of care is often individualized and
involves psychotherapy, family therapy and antidepressants.
"The bigger problem arises if the male patient needs to be treated in a group setting," says B. Timothy Walsh, a
psychiatrist and director of the eating-disorders research unit at the New York State Psychiatric Institute at
Columbia University Medical Center in New York City. "It can be difficult for a young man if he is the only one
going through the process with a group of young women."
Mark Grennell experienced this first hand. As a teenager, he began restricting his food, in an effort to look lean
and "cut" (with well-defined muscles). This behavior led to fasts that lasted days at a time and, ultimately, an
inability to keep food down. Three years ago, when the 5-foot-10 young man weighed 93 pounds, he decided to
seek treatment. He chose an eating-disorder center in Southern California that accepts males but treats mostly
females.
At times, he was the only male in a therapy group. Often, he says, he had trouble relating to how the women felt
fat. He wasn't focused on his weight as much as on controlling his body. And he was troubled by what he calls
the "feminist slant" of the therapists, blaming men and media images for pressuring women. "They said that
society teaches women to be thin, to be ashamed of their bodies," says Mr. Grennell, 24 years old. "That really
made me uncomfortable because that's not my experience."
Such issues are often cited by experts who say single-sex group therapy is preferable. At Remuda Ranch in
Wickenburg, Ariz., which treats only women, David Wall, director of psychological services, says that women,
for instance, often find it difficult to talk about issues such as sexual abuse and body image in front of male
patients.
Indeed, some experts say that single-sex groups can be powerful tools to healing for men. "They provide a safe
place, a way for men to come in and talk about issues relevant to men," says Brad Kennington, a therapist in
Austin, Texas, who formed a therapy group for men with eating disorders last year that met for several months.
"Women will talk about how they are no longer ovulating, which is not a symptom in men," says Mr.
Kennington. "Men will talk about the role of men in a relationship and how that role gets questioned when they
have an eating disorder."
Although men are often reluctant to seek treatment, some eating-disorder centers are seeing an increase in
male patients. At Rogers Memorial Hospital, in Oconomowoc, Wis. -- which has one of the best-known all-
male eating-disorder programs -- the number of male eating-disorder patients has grown 50% in the past
three years; males now represent 25% of the 200 or so eating-disorder patients a year in the residential
program.
Rogers, which is where Mr. Huffaker sought help, treats about seven males at a time. They live separately from
the female patients. Ted Weltzin, a psychiatrist and director of the eating-disorder programs, says males have
different body-image issues than females, need more help overcoming their compulsive exercise habits and
often have a harder time understanding the emotions behind the disorder.
Male-only therapy lets them "see other males cry in group therapy and then go to dinner and talk about
sports," he says.
Only a handful of other clinics around the country have specific programs for males. At River Oaks Hospital, in
New Orleans, males have their own group and body-image sessions. But they share other group activities with
females, including anger-management sessions and post-meal therapy. "I believe the mix of males and females
is helpful," says Susan Willard, clinical director of the hospital's eating-disorders treatment center. "It
broadens the perspective for both populations."
Ex. F p. 3

Printed in The Wall Street Journal, page D1
Copyright 2009 Dow Jones & Company, Inc. All Rights Reserved
This copy is for your personal, non-commercial use only. Distribution and use of this material are governed by our Subscriber Agreement
and by copyright law. For non-personal use or to order multiple copies, please contact Dow Jones Reprints at 1-800-843-0008 or visit
www.djreprints.com
The University of Iowa's eating-disorders program, where 14% of the patients are male, has a separate
psychotherapy group and strength-training for males, and men can have testosterone replaced if they need it.
Men who are malnourished may have low testosterone, says Dr. Andersen, which makes it difficult to build and
maintain muscle.
At the Center for Eating Disorders at Sheppard Pratt, in Baltimore, which has four to six male patients in
residence at a time, double the number from five years ago, doctors hold male-only group sessions when they
have enough patients. "We focus on what it's like for males to live in a society that focuses on these disorders as
women's issues," says Harry Brandt, director of the center.
Write to Elizabeth Bernstein at elizabeth.bernstein@wsj.com
Ex. F p. 4

Exhibit G

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life
and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a
registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks
of the Blue Cross Association.

The Office of Medical Policy and Technological Assessment (OMPTA) has developed policies that serve as one of the sets of
guidelines for coverage decisions. Benefit plans vary in coverage and some plans may not provide coverage for certain services
discussed in the policies. Coverage decisions are subj ect to all terms and conditions of the applicable benefit plan, including specific
exclusions and limitations, and to applicable state and/ or federal law. Policy does not constitute plan authorization, nor is it an
explanation of benefits.
Policies can be highly t echnical and complex and are provided here for informat ional purposes. The policies do not
const it ut e medical or behavioral healt h advice or care. Treat ing healt h care providers are solely responsible for diagnosis, t reat ment
and advice. Healt h plan members should discuss t he informat ion in t he policies wit h t heir t reat ing healt h care providers.
Technology is const ant ly evolving and t hese policies are subj ect t o change wit hout not ice. Addit ional policies may be developed
from t ime t o t ime and some may be wit hdrawn from use. The policies generally apply t o all fully-insured benefit plans, alt hough
some local variat ions may exist . Addit ionally, some benefit plans administ ered by t he healt h plans, such as some self-funded
employer plans or government al plans, may not ut ilize t hese policies. Members should cont act t heir local cust omer service
represent at ive f or specific coverage informat ion.

Behavioral Health
Medical Necessity
Criteria

Effective January 1, 2012
Revised and approved on 8/18/2011

Anthem Blue Cross
21555 Oxnard St. Woodland Hills, CA 91365
Toll free: 1-800-274-7767
Ex. G p. 1
i
Introduction
This document lists our evidence-based criteria for medical necessity for the treatment of
psychiatric and substance-related disorders (behavioral health medical necessity criteria).
Behavioral Health administers mental health and substance abuse care benefits for Covered
Individuals so that they can receive timely and appropriate care in a cost-effective manner and
setting. Benefit coverage decisions are made while we consider both our medical necessity
criteria and the information available regarding each individual case.

Please call Anthem Blue Cross (hereafter referred to as the Plan) at 1-800-274-7767 if you
require additional information.

NOTE: While the behavioral health medical necessity criteria are guidelines used by utilization
review and care management staff (licensed registered nurses or licensed independent behavioral
health practitioners, and physicians) to determine when services are medically necessary, federal
and State law, as well as the Covered Individuals contract language, including definitions and
specific contract provisions/exclusions, take precedence over the criteria, and must be considered
first in determining eligibility for coverage. For details, providers should consult the Provider
Manual and Covered Individuals should consult their plan documents.

Medical Necessity
The behavioral health medical necessity criteria have been developed for the company by an internal
committee of case managers and psychiatric advisors based upon current psychiatric literature
including the criteria of the American Psychiatric Association, the American Academy of Child and
Adolescent Psychiatry, and the American Society for Addiction Medicine, or other relevant
evidence-based literature or information. On an annual basis or more frequently as needed, the
behavioral health medical necessity criteria are reviewed and approved by a panel of outside
practicing clinicians serving on a behavioral health subcommittee (BH Subcommittee) of The
Medical Policy & Technology Assessment Committee (MPTAC), and recommendation by the BH
subcommittee to change or modify the behavioral health medical necessity criteria, or establish new
criteria, are reviewed and approved by MPTAC.

NOTE: PLEASE SEE THE DEFINITION OF "MEDICALLY NECESSARY" OR
"MEDICAL NECESSITY" IN THE COVERED INDIVIDUAL'S PLAN DOCUMENT
FOR THE PURPOSE OF MAKING BENEFIT DETERMINATIONS. THE DEFINITION
BELOW MAY NOT BE THE DEFINITION OF MEDICALLY NECESSARY WITHIN
THE COVERED INDIVIDUAL'S PLAN DOCUMENT. THIS DEFINTION SHOULD
NOT BE USED FOR BENEFIT DETERMINATIONS FOR A COVERED INDIVIDUAL.

Medically Necessary or Medical Necessity shall mean health care services that a
medical practitioner, exercising prudent clinical judgment, would provide to a Covered
Individual for the purpose of preventing, evaluating, diagnosing or treating an illness,
injury, disease or its symptoms, and that are (a) in accordance with generally accepted
standards of medical practice; (b) clinically appropriate, in terms of type, frequency,
extent, site and duration, and considered effective for the Covered Individuals illness,
injury or disease; and (c) not primarily for the convenience of the Covered Individual,
physician, or other health care provider; (d) and not more costly than an alternative
service or sequence of services at least as likely to produce equivalent therapeutic or
diagnostic results as to the diagnosis or treatment of that Covered Individuals illness,
injury or disease. For these purposes, generally accepted standards of medical practice
Ex. G p. 2
ii
means standards that are based on credible scientific evidence published in peer-reviewed
medical literature generally recognized by the relevant medical community, national
Physician Specialty Society recommendations and the views of medical practitioners
practicing in relevant clinical areas and any other relevant factors.*

When clinical information given meets these criteria, the cases may be certified by the utilization
review or care manager (licensed registered nurse or licensed independent behavioral health
practitioners and physicians). When cases do not meet these criteria, cases must be sent to a
psychiatrist reviewer/peer clinical reviewer for an assessment of the case. For experimental and
investigational procedures and services, refer to the applicable medical policy and Covered
Individuals plan document on such procedures and services.

The attached behavioral health medical necessity criteria for each level of care include three
categories, Severity of Illness, Intensity of Service and Continued Stay. Severity of Illness criteria
includes descriptions of the Covered Individuals condition and circumstances. Intensity of
Service criteria describes the services being provided, and these criteria must be met for
admission and continued stay. For continued authorization of the requested service, Continued
Stay criteria must be met along with Severity of Illness criteria.

A provider who is requesting services must be afforded the opportunity for a peer-to-peer
conversation regarding an adverse decision. The psychiatrist reviewer/peer clinical reviewer
should use the behavioral health medical necessity criteria in reviewing a requested service for
consistency, but must also use his or her discretion and professional judgment to make exceptions
to the criteria when indicated by a members unique clinical circumstances. The mental health
services should not be primarily for the avoidance of incarceration of the Covered Individual or to
satisfy a programmatic length of stay (refers to a pre-determine number of days or visits for a
programs length instead of an individualized determination of how long a member needs to be in
that program). There should be a reasonable expectation that the Covered Individuals illness,
condition, or level of functioning will be stabilized, improved, or maintained through treatment
known to be effective for the Covered Individuals illness. Custodial care is not typically a
Covered Service. See Custodial Care (CG-MED-19) Clinical UM Guideline for further guidance.

These behavioral health medical necessity criteria are not meant to be exhaustive and will not
cover all clinical situations. In the absence of behavioral health medical necessity criteria for a
specific clinical indication, case-by-case individual review is undertaken. A psychiatrist
reviewer/peer clinical reviewer designated by the company will use his/her professional judgment
and take into account credible scientific evidence published in peer-reviewed medical literature
generally recognized by the relevant medical community, physician specialty society
recommendations, the views of physicians practicing in relevant clinical areas, and other relevant
factors, as they relate to the Covered Individuals clinical circumstances or characteristics of the
local delivery system (such as the availability of alternative levels of care).

It is noted that there is variation in the availability of services in different geographic and regional
areas. If an indicated service is not available within a Covered Individuals community at the
level of service indicated by the criteria, authorization may be given for those services at the next
highest available level.

In some geographical areas, state regulations allow non-physicians to treat Covered Individuals at
inpatient facilities. In these behavioral health medical necessity criteria, such non-physicians with
prescriptive authority who are operating within the scope of their license may be substituted
where the criteria specifies a physician.
Ex. G p. 3
iii

Outpatient treatment is to be provided by behavioral health providers licensed to practice
independently. When individual psychotherapy, family therapy and group therapy are provided as
part of a facility's inpatient, sub-acute, or intensive outpatient program, appropriate supervision of
individuals who are not licensed to practice independently must be provided.

Confidentiality
Keeping a Covered Individuals medical information confidential is of the utmost importance.
We take a number of measures to help insure that information is treated confidentially and
privacy is respected. We request sufficient information to allow a reviewer to make an
independent judgment regarding the medical necessity of a requested treatment Confidentiality of
Covered Individual information is protected by federal and state law and by our corporate policy.

Diagnosis
Appropriate diagnoses are required for utilization management. Treatment approved for
reimbursement by the Plan must have an appropriate diagnosis that is covered under the Covered
Individuals Health Benefit Plan. Mental disorders are defined by the Diagnostic and Statistical
Manual of Mental Disorders, 4
th
Edition (DSM-IV)* and Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition Text Revision (DSMIV-TR).**
*Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC,
American Psychiatric Association, 1994.
**Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision.
Washington, DC, American Psychiatric Association, 2000.

Level of Care Descriptions
Acute Inpatient Hospitalization Acute inpatient psychiatric hospitalization is defined as
treatment in a hospital psychiatric unit that includes 24-hour nursing and daily active treatment
under the direction of a psychiatrist and certified by The Joint Commission or the National
Integrated Accreditation for Healthcare Organizations (NIAHO) as a hospital. Acute psychiatric
treatment is appropriate in an inpatient setting when required to stabilize Covered Individuals
who are in acute distress and return them to a level of functioning in which a lesser level of
intense treatment can be provided. A need for acute inpatient care occurs when the Covered
Individual requires 24-hour nursing care, close observation, assessment, treatment and a
structured therapeutic environment that is available only in an acute inpatient setting.

Residential Treatment Residential treatment is defined as specialized treatment that occurs in
a residential treatment center. Licensure may differ somewhat by state, but these facilities are
typically designated residential, subacute, or intermediate care facilities and may occur in care
systems that provide multiple levels of care. Residential treatment is 24 hours per day and
requires a minimum of one physician visit per week in a facility based setting. Wilderness
programs are not considered residential treatment programs.

Partial Hospitalization Partial hospitalization (sometimes called day treatment) is a structured,
short-term treatment modality that offers nursing care and active treatment in a program that is
operable at a minimum of six (6) hours per day, five (5) days per week. Covered Individuals must
attend a minimum of 6 hours per day when participating in a partial hospitalization program.
Covered Individuals are not cared for on a 24-hour per day basis, and typically leave the program
each evening and/or weekends. Partial hospitalization treatment is provided by a multidisciplinary
treatment team, which includes a psychiatrist. Partial hospitalization is an alternative to acute
Ex. G p. 4
iv
inpatient hospital care and offers intensive, coordinated, multidisciplinary clinical services for
Covered Individuals that are able to function in the community at a minimally appropriate level
and do not present an imminent potential for harm to themselves or others.

Intensive Outpatient Treatment Intensive outpatient is a structured, short-term treatment
modality that provides a combination of individual, group and family therapy. Intensive
outpatient programs meet at least three times per week, providing a minimum of three (3) hours
of treatment per session. Intensive outpatient programs must be supervised by a licensed mental
health professional. Intensive outpatient treatment is an alternative to inpatient or partial hospital
care and offers intensive, coordinated, multidisciplinary services for Covered Individuals with an
active psychiatric or substance related illness who are able to function in the community at a
minimally appropriate level and present no imminent potential for harm to themselves or others.

Outpatient Treatment Outpatient treatment is a level of care in which a mental health
professional licensed to practice independently provides care to individuals in an outpatient
setting, whether to the Covered Individual individually, in family therapy, or in a group modality.
Traditional outpatient treatment ranges in time from medication management (e.g. 15 20
minutes) to 30 50 minutes or more for the psychotherapies.

Ex. G p. 5

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over
Medical Policy and must be considered first in determining eligibility for coverage. The members contract benefits in effect on the date that
services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in
adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

27

EATING DISORDER
ACUTE INPATIENT
(Co-morbid disorders may influence choice of Level of Care)

A. ADMISSION CRITERIA
SEVERITY OF ILLNESS (SI)
Clinical Findings: Current DSM Axis I or ICD-9 Eating Disorder Diagnosis that is consistent with symptoms. All services must
meet the definition of medical necessity in the Covered Individuals plan document.
Must have one of 1-3 and both 4 and 5 to qualify:
1. Medical Complications attributable to the eating disorder, which typically include the following:
a. Vital Sign abnormalities: For adults, pulse rate <40, orthostatic pulse change >20, blood pressure <90/60,
orthostatic bp change >10-20, temp <96-97 F. For children/adolescents, pulse rate <50 daytime, 45 nighttime,
orthostatic pulse change >20, blood pressure <80/50, orthostatic bp change >10-20 and temp <96-97 F.
b. Electrolyte abnormalities, including hypokalemia or hypophosphatemia.
c. Cardiac compromise, including dysrhythmias or prolonged QTc.
d. Organ damage requiring treatment, including renal, hepatic, GI or cardiovascular.
e. Acute dehydration as shown by physical and lab findings requiring medical rehydration.
2. For Anorexia Nervosa, BMI <15 or < 75% of individually estimated ideal body weight range, or, rapid weight loss combined
with active refusal to eat on a trajectory showing that this BMI or weight will occur within a few days.
For Bulimia Nervosa or Eating Disorder NOS medical abnormalities (see SI 1) must be demonstrated and can be safely
treated in a psychiatric unit and do not require intensity of a medical unit.
3. Severe eating disorder comorbid with psychiatric symptoms that would in themselves require inpatient treatment, such as
suicidal ideation with intent or a feasible plan or other conditions that would meet Inpatient Psychiatric Severity of Illness
criteria (if other Eating Disorder Inpatient criteria not met, Inpatient Psychiatric service should be used).
4. Worsening symptoms and behaviors despite current treatment in a structured outpatient ED service (IOP or PHP, or 2-3
times a week OP treatment involving an ED BH clinician, nutritionist and a qualified physician where intensive services not
geographically available) with the likelihood that Inpatient treatment will result in improvement this criterion not necessary
if the Covered Individual is actively resistant to treatment, actively uncooperative and/or has severely impaired insight and
does not recognize any need for treatment.
5. Supervision required during and after all meals and in the evening to prevent restricting or excessive exercising/purging
behaviors; for children/adolescents, family not able to supervise due to severe conflict or treatment resistance.
INTENSITY OF SERVICE (IS)
Must have all of the following to qualify:
1. Multidisciplinary assessment with a treatment plan which addresses nutritional, psychological, social, medical, and substance
abuse needs.
2. Relevant medical tests including lab tests (electrolytes, chemistry, CBC, thyroid) and ECG done on admission and follow up
tests done if any abnormality requiring intervention.
3. Documentation of treatment by a qualified physician seven (7) days a week, including management of psychiatric medication
if indicated, or documentation as to why not used if indicated.
4. Individual therapy by a licensed provider at least once per week, family therapy by a licensed provider at least once per week
for adults and twice per week for children/adolescents (unless contraindicated, with documentation for the reason).
5. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individuals PCP,
providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members, is
documented.
6. Nutritional plan with target weight range and refeeding plan to achieve gain of 1-2 pounds per week (if low body weight
Ex. G p. 6


28
reason for admission).
7. 24-hour skilled nursing (by either an RN or LVN/LPN).
8. Discharge plan with recommended aftercare including coordination with outpatient treatment team or development of an
outpatient treatment plan if not already present.
Ex. G p. 7


30
EATING DISORDER
RESIDENTIAL TREATMENT CENTER (RTC)
(Co-morbid disorders may influence choice of Level of Care)

A. ADMISSION CRITERIA
SEVERITY OF ILLNESS (SI)
Clinical Findings: Current DSM Axis I or ICD-9 Eating Disorder Diagnosis that is consistent with symptoms. All services must
meet the definition of medical necessity in the Covered Individuals plan document.
1. If Anorexia Nervosa and weight restoration is goal, BMI between 15-18 or weight between 75%-85% of estimated ideal
weight range and no signs or symptoms of acute medical instability that would require daily physician evaluation.
2. Comorbid psychiatric disorders are controlled or stable enough for the primary focus of treatment to be the eating
disorder.
3. For Anorexia Nervosa, continued restricting and purging is leading to weight loss that is likely to lead to medical
instability and need for inpatient treatment despite receiving structured outpatient ED treatment (IOP or PHP, or 2-3
times a week OP treatment involving an ED BH clinician, nutritionist and a qualified physician where intensive services
not geographically available) with the likelihood that residential treatment will result in improvement; for Bulimia
Nervosa, continued purging or excessive exercising is likely to cause medical instability or dehydration that would need
inpatient treatment despite receiving the same level of outpatient treatment described above; or for either condition, the
Covered Individual has had multiple inpatient admissions within the past six (6) months with a failure to stabilize with
outpatient aftercare.
4. Significant functional disruption from usual/baseline status in at least two domains (school/work, family, activities,
ADLs) related to the eating disorder.
5. Based on past treatment history, usual level of functioning and comorbid psychiatric disorders, there is a reasonable
expectation that the Covered Individual will benefit from this level of care.
6. Living environment and support are characterized by either significant deficits or significant conflict or problems that
would undermine goals of treatment such that treatment at a lower level of care is unlikely to be successful, and this can
potentially be improved with treatment.
INTENSITY OF SERVICE (IS)
1. Evaluation by a qualified physician or equivalent professional within 72 hours of admission and at least once weekly
visits documented.
2. Physical exam and lab tests done within 72 hours if not done prior to admission, and 24 hour on site nursing and
medical availability to manage medical problems if risk for medical instability identified as a reason for admission to
this level of care.
3. Programming provided will be consistent with the Covered Individuals language, cognitive, speech and/or hearing
abilities.
4. Coordination of care with other clinicians, such as the outpatient psychiatrist, therapist, and the Covered Individuals PCP,
providing treatment to the Covered Individual, and where indicated, clinicians providing treatment to other family members,
is documented.
5. Within seven (7) days, an individualized problem focused treatment plan completed, including nutritional,
psychological, social, medical and substance abuse needs to be developed based on a complex bio-psychosocial
evaluation, and this needs to be reviewed at least once a week for progress.
6. Treatment would include the following at least once per day and each lasting 60-90 minutes: community/milieu group
therapy, group psychotherapy and activity group therapy plus at least once weekly individual therapy with a properly
licensed provider.
7. Family supports identified and contacted within 72 hours and family/primary support person participation at least
weekly for adults, twice weekly for children and adolescents, unless contraindicated.
8. Discharge planning initiated within one (1) week of admission including identification of community/family resources,
connection or re-establishment of connection to an outpatient treatment team and coordination with that team.
Ex. G p. 8


31
9. The treatment is individualized and not determined by a programmatic timeframe. It is expected that Covered
Individuals will be prepared to receive the majority of their treatment in a community setting.
Ex. G p. 9

Exhibit H
The Bella Speranza Residential Healing Center for the Treatment for Eating Disorders
1/2 www.thebellavita.com/residentialtreatment.htm
Home
The Bella Speranza Residential Healing Center for the
Treatment for Eating Disorders
Unlike other treatment facilities that may feel confrontational,
controlling and rigid, we promise to ease the pressure you feel,
giving you an environment that is structured; yet nurturing. We desire
to make your experience more conducive to learning the skills that
enable you to begin living healthier lives. Residential treatment is
24/7 care.
The Bella Speranza (The Beautiful Hope) offers care for both adults
and adolescents. This level of care, as with all others, is determined
during the initial consultation. Although the majority of those suffering
from eating disorders are female, we treat both males and females.
The program focuses on your individual needs, encouraging you to
take an active role in expressing your feelings, thoughts and goals.
The Bella Speranza Residential Healing Center includes monitoring of unstable vitals and labs, starvation
effects, purging and non-purging behaviors, such as, excessive exercise, vomiting and laxatives, and
substance abuse with a focus on the individual's nutritional goals while attending educational and
therapeutic groups.
The Bella Speranza housed is a charming Cape Cod residence in the sought out community of La Caada
Flintridge, California. The beautifully decorated and spacious home is a six bed residential facility. It is
tastefully decorated with a grand living room, formal dining room, kitchen nook, meditation room and
entertainment room, including a computer and internet access. Each bedroom is comfortably and tastefully
decorated with unique themes from our outdoor jungle mural and motif to a room for sophisticated tastes to
a rustic tone. Our grounds are likened to an Italian garden with fresh herbs amidst our lavender bushes,
trees, shrubbery and flowers. Our French doors lead to an open patio with fountain for calm and relaxation.
Our quaint garden courtyard is yet another opportunity to escape to being rejuvenated. The facility is within
walking distance of specialty stores, drug store with pharmacy, grocery stores, newly opened Town Center
shopping, activities and city events.
The length of stay varies according to the needs of the individual. Residents are asked to commit to a
minimum stay of one to two months in order to interrupt eating disorder patterns. Potential residents must
have a recent medical evaluation to determine medical stability for a residential setting.
Services Provided:
Complete psychodiagnostic evaluation of eating disorders and other psychological issues.
Individualized, multidisciplinary treatment plans.
Behavioral program to institute changes in eating behaviors.
Individual psychotherapy three times weekly.
Art therapy.
Yoga.
Cognitive-Behavioral and Dialectical Behavior group therapy.
Mindfulness and Mediation groups.
Psychiatric and Medical Consultation and Follow-up.
Nutritional and fitness education with counseling.
Family education.
Ask Dr. Pitts
Dr. Patricia Pitts is the Chief Executive Officer of
The Bella Vita established in 1985. She is a
nationally renowned expert in the treatment of
anorexia. Read more
Dr. Pitts Radio Show
Dr. Patricia Pitts is the Chief Executive
Officer of The Bella Vita established in
1985. She is a nationally renowned
expert in the treatment of anorexia.
Read more
Patient Forms Find Us On:

Los Angeles: 323.255.0400
Woodland Hills: 818.676.1540
The Bella Speranza Residential Healing: 877. 91 BELLA
The Bella Verita: 877.91 BELLA
Sign up for
our newsletter

Get The Help You Need
Contact Us Today
Name
Email
Phone
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Home About Eating Disorders Treatments Meet Dr. Pitts News Testimonials Locations Blog Contact Us
Ex. H p. 1
2/2 www.thebellavita.com/residentialtreatment.htm
Family therapy if indicated.
Menu planning, grocery shopping and meal preparation.
Self esteem and coping skills group.
Relapse prevention groups.
Life enhancement and creativity groups.
Recreational activities.
Reentry into Life.
Discharge planning.
The Bella Speranza's well-developed curriculum is designed to help patients deal with the physical danger
they are currently in. Our program will assist patients to establish clear personalized goals and treatment
plan; integrative programming of therapy, groups, activities and experiences to achieve the stated
objectives; and discharge in an appropriate time frame coordinating continuity of care with family,
school/work and community.

Full Continuum of Care
The Bella Vita provides a full continuum of care for eating disorders treatment for adults and adolescents,
male and female, including The Bella Speranza Residential Treatment, The Bella Vita Transitional Living
and Extended Care in La Caada Flintridge, as well as, The Bella Vita in Los Angeles and The Bella Vita in
San Fernando Valley Partial Hospitalization and Intensive Outpatient programs with outpatient services.
The Bella Vita facilities offer our patients the comfort of personally knowing their attending staff, as we offer
the same treatment team through all levels of care. The Bella Speranza Residential Treatment attending
Medical Doctor, Psychiatrist, Nurses, Mental Health Workers, Psychologists and Master Level Therapists
are available to our resident patients through out their 24 hours a day, 7 days a week stay.
Effectiveness of treatment is promoted through team communication and strong medical doctor
involvement, directing the case and evaluating results. We encourage strong involvement as part of our
philosophy of treatment, and work closely with care managers and doctors to ensure measurable
documented goals that the patient understands and is committed to achieving.
Nutritional Rehabilitation and Psychological Growth
Typically, anorexics and bulimics that enter The Bella Speranza Residential Treatment Program do so in
severe condition. Food is seen as medicine. We target 1 2 pound of healthy weight gain per week over
the course of the residents stay with us. We establish and involve both nutritional and psychological goals
from the start of treatment, in the course of a tier-structured plan that helps the patient to reduce anxiety,
understand the mechanisms of healthy eating, and sustain emotional well-being. Along with emotional and
cognitive integration, we focus on connection of the body, mind and spirit, developing mindfulness to
access intuition and wisdom to manage and cope effectively without the focus on food.
Even in the course of anticipating the patient's discharge, we are thinking forward and suggesting multi-
disciplinary approaches to recovery, such as follow-up with a primary care physician, psychiatrist,
registered dietitian or therapist.
Please inquire with The Bella Vita, A Beautiful Life Psychology Group, Inc., if you or someone you know
may be at risk, or showing symptoms of Eating Disorder. Don't hesitate to contact us if you have any
questions.
To learn more about The Bella Vita in Los Angeles facility offering partial hospitalization and intensive
outpatient programs in tandem, you can read more here.
To learn more about The Bella Vita in San Fernando Valley facility offering partial hospitalization and
intensive outpatient programs in tandem, you can read more here.
Home : About : Eating Disorders : Treatments : Meet Dr. Pitts : In The News : Testimonials : Locations : Patient Forms : Site Map : Contact : Blog : Additional Sites
The Bella Vita, A Beautiful Life Psychology Group, Inc. : Our Privacy Policy
Ex. H p. 2

Exhibit I
Rosewood
Centers
CENTERS FOR EATING DISORDERS
Ex. I p. 1
Ex. I p. 2
osewood Centers for Eating Disorders
has been distinguished as a leader in eating
disorder treatment for more than a decade.
We understand the intricate medical,
emotional, and psychological complications
associated with someone with an eating
disorder. Our programs and staff are
dedicated to providing a core recovery
program that addresses and treats the
eating disorder, the underlying issues, and
co-occurring disorders.
Rosewood is committed to providing its
residents with a rare blend of traditional and
innovative healing modalities in a nurturing
environment.
We provide a full-continuum of care at our facilities: Rosewood Ranch, Rosewood Capri, and Rosewood
Tempe. Our continuum of care provides an opportunity for individuals to get the help, support, and
structure they need at any time on their journey to recovery. An individual may enter any of our
eating disorder treatment centers and move between the various levels of care, based
on their individual needs.
Our treatment programs focus on helping individuals, male and female adults and adolescents, suffering
from anorexia nervosa, bulimia nervosa, binge eating disorder and other complex disorders. Rosewoods
well-established model of care, experienced multidisciplinary staff, and intimate setting make us uniquely
qualifed to efectively treat those with eating disorders, co-occurring psychiatric conditions, addictions, and
serious medical conditions.
R
Ex. I p. 3
M
I
S
S
I
O
N
TreaTmenT - Our resi denTs:
Rosewoods mission is to provide the highest level
of quality care to male and female adults and
adolescents with anorexia nervosa, bulimia nervosa,
binge eating disorder, and other related issues. We
offer physical, emotional and spiritual restoration in
a full-continuum of care.
Our commitment to you includes:
- Honoring your physical, emotional, and spiritual
well-being
- Helping you deal with lifes pressures, influences
and hardships
- Helping you experience the freedom of being
yourself
- Providing you with the knowledge and skills
you need to live a healthy lifestyle
educaTi On - cOmmuni Ty and PrOfessi Onal:
Rosewood aggressively participates and contributes
to the education and prevention of these disorders
on both a national and international level. In
addition, Rosewoods mission in education extends
to professionals and organizations as the leading
expert that defines the best model for treating
eating disorders.
Ex. I p. 4
A
c
c
r
e
d
i
t
A
t
i
o
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li CEnsi ng and aCCrEdi tati on:
Rosewood Centers for Eating Disorders programs are licensed through the Arizona
Department of Health Services. The Arizona Department of Health Services promotes
and protects the health of Arizonas residents and sets the standard for personal and
community health.
Rosewood Centers for Eating Disorders has as earned the much sought and well-
regarded accreditation from The Joint Commission, the nations leading healthcare
accrediting organization. The organizations accredited by The Joint Commission are
those that have demonstrated that they meet the highest standards in their field.
pg 5
Ex. I p. 5
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adult i npati Ent program and adolEsCEnt rEsi dEnti al program:
Facilities at Rosewood Ranch provide acute care for male and female adults and adolescents.
It is located in Wickenburg, AZ on 13 beautiful acres high in the Sonoran desert with breath
taking views of the Bradshaw Mountains. Rosewood Ranch offers state-of-the-art facilities that
are very secluded and private, providing the perfect atmosphere for treatment and healing
from eating disorders.
adult i npati Ent KEy program FEaturEs:
- Males and females 18 years of age or older
- On-site 24-hour medical care for acute needs
- Licensed detoxification
- Integrated addictions track
- Comprehensive nutritional program
- Trauma recovery work
- Body image programming
- Expressive arts programming
- Intensive 5-day Family Program
- Full-time, on-site psychiatrists
- Individual sessions with multidisciplinary team members
- Daily schedule that includes process groups, experiential activities, and psycho-educational
programming
- Alumni support program and aftercare follow-up
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Ex. I p. 6
adult samplE dai ly sChEdulE:
6:006:30 Vitals
6:307:00 Personal Hygiene
7:158:00 Breakfast and Processing
8:009:00 Goals Group
9:0010:00 Clinical Lecture
10:0010:30 Break/Morning Snack
10:30Noon Yoga/Equine
12:151:00 Lunch and Processing
1:001:30 Bookstore/Assignments/Games
1:303:00 Primary Group
3:003:30 Break/Afternoon Snack
3:304:45 Psychodrama
4:455:15 Walk/Break
5:156:00 Dinner and Processing
6:006:45 Assignments/Journaling/Games
6:457:00 Meds/Bathroom
7:008:00 Open Art
8:159:15 Evening Snack, Reflections, and Goal Review
9:3010:30 Personal Hygiene/ Lights Out
Ex. I p. 7
adolEsCEnt rEsi dEnti al KEy program FEaturEs:
- Males and females 12-17 years of age
- On-site 24-hour medical care for acute needs
- Full-time, on-site adolescent psychiatrists
- Ability to treat co-morbid psychiatric conditions
- Ability to treat chemical dependencies
- Multiple therapy modalities employed during treatment including cognitive behavioral
therapy and dialectical behavioral therapy
- Weekly case review with family
- Intensive on-going family program
- Weekly family visiting hours
- Daily schedule that includes academics, process groups, experiential activities, and
psycho-educational programming
- Accredited on-site school facility
- Supervised meals
- Body image programming
- Life skills training
- Alumni support program and aftercare follow-up
- Non-smoking facility
aCadEmi Cs:
It is important to us that our residents do not fall behind in school while in treatment and
remain on track for graduation. Each resident attends our on-site school for a few hours
each morning.
Our school facilitator helps residents learn a variety of academic subjects from our on-line
curriculum. If the resident chooses to participate in the on-line curriculum, they will work
on a variety of coursework from the extensive core curriculum library. Residents also have
the option to bring current coursework from their home school.
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Ex. I p. 8
adolEsCEnt samplE dai ly sChEdulE:
6:006:45 Vitals, Personal Hygiene, Medication
6:457:30 Walk/Breakfast
7:308:00 Meal Process/Bathroom
8:009:00 Equine Therapy
9:00Noon School
Noon1:00 Lunch/Cleanup/Meal Process
1:002:00 Primary Group
2:003:00 Assignments/Snack
3:004:00 Dietary Challenge
4:004:45 Relapse Prevention
5:006:00 Mindful Dinner and Processing
6:007:30 Art Therapy
7:309:00 Personal Reflection and Assignments
9:009:30 Personal Hygiene/Lights Out
Ex. I p. 9
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parti al hospi tali zati on program Wi th rEsi dEnti al li vi ng:
Located minutes from Rosewood Ranch, in Wickenburg, AZ, Rosewood Capri offers a
comprehensive treatment program, following the same model of treatment as Rosewood
Ranch, in a less structured setting. Capri offers residents the opportunity to practice real
life skills during their treatment and can serve as either a point of entry for primary treatment
or as a step down from a more intensive program.
While living at Capri, residents participate in an onsite structured, comprehensive day
treatment program facilitated by our skilled multidisciplinary team of clinicians, dietitians
and psychiatrists. Residents learn coping skill strategies while participating in real world
activities such as, meal planning, cooking, grocery shopping, meal outings and wellness activities.
KEy program FEaturEs:
- Males and females 18 years of age or older
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Individualized and group counseling
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Supervised meals
-
Meal processing
-
Meal planning
-
Body image programming
-
Expressive arts programming
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Integrated-family program
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Daily schedule that includes process groups, experiential activities, and
psycho-educational programming
-
On-site support groups
-
Alumni support program and aftercare follow-up
Ex. I p. 10
Capri samplE dai ly sChEdulE:
6:006:30 Vitals
6:307:00 Personal Hygiene
7:158:00 Breakfast and Processing
8:009:00 Goals Group
9:0010:00 Yoga/Equine
10:0010:30 Break/Morning Snack
10:30Noon Psychodrama
12:151:00 Lunch and Processing
1:001:30 Bookstore/Assignments/Games
1:303:00 Relapse Prevention
3:003:30 Break/Afternoon Snack
3:304:30 Addictions Lecture
4:455:15 Walk/Break
5156:00 Dinner and Processing
6:006:45 Assignments/Journaling/ Games
6:457:00 Meds/Bathroom
7:008:00 Open Art
8:159:15 Evening Snack, Reflections, and Goal Review
9:3010:30 Personal Hygiene/Lights Out
Ex. I p. 11
i ntEnsi vE outpati Ent samplE sChEdulE:
Monday:
5:005:30 Dinner
5:307:00 Goals Group: Introductions/
Process Group/Integrity Check
7:007:15 Break/Snack
8:008:30 Process
Tuesday:
5:005:30 Dinner
5:307:00 DBT/CBT Group
7:158:00 Body Image
8:008:30 Process
Wednesday:
5:006:00 Meal Outing/Catered Meal
6:007:00 Food and Feelings Group
7:158:00 Nutritional Group
8:008:30 Process
Thursday:
5:005:30 Dinner/Family Introductions for
those participating
6:308:00 Family Experiential Group
8:008:30 Family Process
Friday:
11:3012:30 Yoga/Meditation
12:301:00 Lunch - Meal Challenge
1:001:30 Meal/Yoga Process
1:302:15 Relapse Prevention Weekend
Skills Group
2:303:00 Process
i ntEnsi vE outpati Ent sErvi CEs:
Intensive treatment programming is available Monday through Friday for male and female
adults and adolescents. Programming consists of specialized process groups, nutritional meal
planning, supervised evening meals, meal processing and educational presentations. All
programming is designed to provide individuals with the tools and skills they need to support
the recovery process.
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Ex. I p. 12
transi ti onal li vi ng
Because the first few months of recovery can be the most challenging,
Rosewood Tempe is pleased to offer transitional living services at Tempe
House for males and females, 18 years of age or older. Tempe House
provides a supportive environment that is conducive to a successful
recovery process. Located in a quiet, charming residential neighbor-
hood just blocks away from Rosewood Tempe.
Tempe House is a quaint five bedroom, three bathroom home, with
a full-kitchen, dining room, and great room, creating the perfect environ-
ment for recovery. Tempe House promotes the development of daily
living and recovery skills. These skills include: Meal planning, grocery
shopping, meal preparation, and relapse prevention.
At Tempe House, residents are encouraged to work, attend school, or
volunteer as a way to engage with the community. A Rosewood staff
member provides overnight and weekend supervision for those living
in the house. Residents will develop confidence in their recovery skills
within the supportive environment of Tempe House.
Rosewood incorporates an integrated, holistic approach to outpatient
services. Our highly trained multidisciplinary team of therapists,
dietitians, and psychiatrists provide the following services for individuals,
families and couples:
- Dialectical Behavioral Therapy (DBT)
- Cognitive Behavioral Therapy (CBT)
- Guided Imagery
- EMDR
- Exposure Therapy
- Stress and Anger Management
- Emotional Regulation
- Behavioral Modification
- Nutritional Assessment and
Program Development
- Art Therapy
- Family Therapy
- Marital Counseling
outpati Ent sErvi CEs:
Rosewood ofers a wide variety of outpatient counseling and therapeutic
services to address various mental health issues. These issues include
but are not limited to:
- Depression
- Anxiety
- Anger Management
- Addictions
- Mood Disorders
- Post Traumatic Stress Disorder (PTSD)
- Codependency
- Family or Relationship Issues
- Obsessive Compulsive Behaviors
- Trauma
Ex. I p. 13
ExpEri Enti al thErapi Es:
Our comprehensive array of experiential therapies are offered as
part our eating disorder treatment programs. The physical and
recreational activities are non-strenuous and supervised. Activities
may include: on-site equine program, tai chi, yoga, journaling,
meditation, drumming, art therapy, and low-ropes course,
among others.
nutri ti onal program:
Our nutritional program is designed to assist residents in identifying
food rituals and to construct a comfortable, safe and enjoyable
association with food. At each level, our team of registered
dietitians works with the resident to create an individualized meal
plan and provide support during challenges. We focus on teaching
each resident new skills for healthy eating and how to plan for and
prepare balanced meals and snacks, either at home or dining out.
Fami ly i ntEgratEd CarE:
At every level of care, our treatment programs are designed to
address family issues, provide information on communication, the
recovery process, and lay the foundation to mend the family system.
Our program incorporates educational presentations, group
processes and experiential activities. Family involvement is very
important to the healing and recovery of our residents.
We strive to provide a safe and intimate environment where
residents and families can experience renewed hope for the future.
The expert and compassionate clinical and medical staff teaches
residents, families and loved ones essential tools they need to
return home with renewed clarity and confidence to live healthy
and productive lives.
Conti nui ng CarE:
Aftercare planning begins as soon as residents are admitted to any
of our programs. Our treatment team works together to evaluate
ongoing needs and to prepare residents for their return home. Our
residents discover the power within themselves. They take an active
role in planning their aftercare and establishing a support system
for their continued recovery.
To further prepare themselves, individuals participate in weekly
relapse prevention sessions. During these sessions, they learn
strategies to cope with the inevitable struggles that they will
experience on their journey through recovery.
Our alumni coordinator will contact each resident numerous times
within the first year after treatment to ensure they are staying on
track with their recovery. If additional resources are needed, our
team of staff members is simply a phone call away.
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Ex. I p. 14
At Rosewood, our mission is to help each resident in their journey towards personal healing.
We do this with the utmost respect and admiration for each individual because of the profound
courage it takes to face an eating disorder. Seeking help is the first and most difficult step in
recovery from eating disorders.
The admission process at Rosewood begins with a phone call to one of Rosewoods skilled intake
coordinators. Available to talk twenty-four hours a day, seven days a week, our intake coordinators
will conduct a thorough assessment with each potential resident and/or referring professional,
discuss different treatment options, and helps choose the program best suited to meet the
potential residents unique needs.
Treatment at Rosewood Centers is covered by many insurance plans. To speak with our intake
staff or to inquire about Rosewoods full continuum of treatment services, call 800-845-2211
or visit rosewoodranch.com.
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Ex. I p. 15
Rosewood Centers for Eating Disorders
36075 S. Rincon Rd.
Wickenburg, AZ 85390
800-845-2211 Fax: 928-684-09562
info@rosewoodranch.com
rosewoodranch.com
Insurance Accepted. Accredited by The Joint Commission.
2010 Rosewood Ranch, LP. All rights reserved. 6/10
CENTERS FOR EATING DISORDERS
Ex. I p. 16

Exhibit J
In the middle of the country, on the bluffs overlooking
a gently fowing river, nestled against forested parkland,
is a treatment center unlike any other
St. Louis, Missouri
636-386-6611 | 888-822-8938
www.castlewoodtc.com
Ex. J p. 1
Castlewood Treatment Center
is a creative collaboration of the owners
clinical experience and personal and
professional evolution. The result is
a residential treatment program for
eating disorders that allows for the unique
treatment of each individual with an
emphasis on compassion, respect and
empowerment.
Ex. J p. 2
Our vision required that the structure itself
be beautiful, unique, and natural, blending harmoniously
with its surroundings. Most of all, it had to have the
ambiance of a healing community, a sanctuary.
After years of searching, we discovered this
secluded gem, high on a ridge, overlooking endless acres
of state woodlands and the scenic Meramec River.
Ex. J p. 3
Men and women who
come to Castlewood
are not anorexic; they are
not bulimic; they are not
compulsive overeaters.
At Castlewood we begin
with the premise that
each person who walks
through our doors defes
simple categorization.
Though we naturally wish to restore our clients
to health and functionality as effciently as
possible, we do not place a 30 or 60-day time
limit on our residents stays. Our mission is not
merely to churn out weight-restored women
or men who look healthy to others, but whose
internal wounds, if unaddressed, will readily
result in relapse. Experience has taught us that
the full measure of health rests upon more
than a temporary absence of symptoms.
Castlewood therefore provides an individualized
treatment approach tailored to meet the precise
needs of each client. We understand that eating
disorder clients tend to be more different than
similar. This is why at Castlewood, each clients
treatment plan is highly individualized.
AN EATING DISORDER is both originated
and maintained by a constellation of factors.
For each client, every step of the way, we are
continually inquiring as a treatment team and
in collaboration with the client: what are the
necessary and suffcient components of treat-
ment needed to restore this person, not only to
decreased symptoms, but to a life that is both
live-able and worth living?
In addition to the eating disorder, some clients
have psychiatric diagnoses; some have multiple
addictions and some have a history of severe
childhood traumas. Some clients will see a
specialist for adjunctive therapy, such as seeing
our anxiety specialist if needed, in addition to
their primary therapist. Whatever is required
to help the client, we attempt to provide.
When new clients arrive at Castlewood we
never know how his/her treatment will end
up looking, because therapeutic strategies
evolve as we get to know them and identify the
pertinent factors that are contributory to the
issues they present. Clients say this fexibility
distinguishes Castlewood from prior treatments
and often constitutes the difference that allows
their recovery efforts to at last succeed.
Ex. J p. 4
E
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D
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Eating Disorders constitute the most
life-threatening category of mental
health issues.
eating
disorders
Eating Disorders
Ex. J p. 5
Eating disorders often occur along with the compounding and
further debilitating symptoms of depression, anxiety, addiction
(to drugs or alcohol), perfectionism, and stress response syndromes.
Family and friends may fnd aspects of the eating disorder
perplexing in the tenacity of the hold it exerts on their loved one, the
sufferers lack of awareness of their degree of debilitation over time,
and the deception that can begin to enter once-honest relationships.
Ex. J p. 6
Eating Disorder can result
as a symptom of many
different syndromes with many
developmental pathways.
For some clients, there is fear of growing up
and assuming adult responsibilities. For others,
external functioning seems great while inside,
they are confused, distressed and need a
symptom to yell: help! Some become trapped
in the role of pleasing others, perfectionism,
and being the good child. For some clients,
there was a major loss during childhood, such
as a mother with post-partum depression or
other experiences of separation from a key
loved one. Others have experienced tremen-
dous pain in their social interactions in school
or with peers that has led to an ongoing sense
of anxiety and isolation. Some clients families
are themselves disengaged, without suffcient
emotional connections, or shame-based with
many intergenerational secrets and/or layers
of unresolved intergenerational trauma. Some
are enmeshed, without appropriate boundaries,
resulting in overindulged children who get
things rather than parenting. Some clients have
perfect families, in appearance, and feel over-
whelmed because they cannot live up to the
parents perceived achievements or expectations.
Once the eating disorder takes hold as a
survival strategy of sorts, it can begin to take
on a life of its own, as a recourse from, while
simultaneously a perpetuator of, anxiety and
isolation. As the illness progresses, various types
of disequilibrium occur in mind and body,
which cyclically, cause the individual to rely
more heavily on the eating disorder symptoms
to maintain an illusory sense of stability amidst
the increasing chaos. As the cycle of the eating
disorder continues, habituation results, as in
any addiction, and it takes more of the same
behavior to achieve the desired effect of feeling
temporarily o.k. more restriction, more food,
more binging and purging, diet pills, laxatives,
exercise, etc.
When reliance on the eating disorder is discon-
tinued, a clients whole world can feel upside-
down, out-of-control and initially, impossible to
manage. This unfortunate, yet understandable
predicament is what Castlewood exists to address.
Our goal is to provide a container for the initial
and inevitable distress, to provide the support of
community, in lieu of that seemingly provided
by the eating disorder, and to assist the client to
learn and re-learn the skills necessary to stabilize
and rebuild their lives.
WHAT CAUSES EATING DISORDER?
Ex. J p. 7
Core Symptoms
Weight loss or gain with endocrine
or metabolic abnormalities
Fat phobia/food phobia
Rituals around body checking,
exercise and food
Purging (undoing and punishing) by
fasting, vomiting, diuretics and exercise
Dissociation/lack of autonomy from
craving and rituals/addiction
Body dissatisfaction, body image
distortion
Binge eating, secretive eating,
hoarding and stealing food
Chewing and spitting food as
an attempt to control weight
Taking in excessive amounts of fuid
or restricting fuid intake
Use or abuse of diet pills, herbal
supplements or teas
Increased isolation, spending less and
less time with family and friends
Refusing or avoiding eating with
family and friends
Ex. J p. 8
T
r
e
a
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m
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t
offers comprehensive and highly
individualized treatment planning.
The program is specifcally designed
to treat all types of eating disorders
as well as co-existing disorders,
including trauma, addictions, body
dysmorphia, self-harm and other
frequently co-occurring issues.
treatment
components
Components
Ex. J p. 9

EACH CLIENT RECEIVES:
A total of six sessions weekly with skilled
and experienced clinicians.
Daily work with Dr. Mark Schwartz, and
Lori Galperin, each nationally known for their
clinical expertise, workshops and publications on
eating disorder, childhood trauma and addictions.
Four individual sessions per week with
the primary therapist.
A weekly session with his/her nutritionist
who eats meals with clients.
A weekly session with our psychiatrist.
A small, well-chosen therapeutic community.
Levels of care that allow for increasing
autonomy with continuing support
Excellent aftercare programming, including
follow-up visits offered at Castlewood.
Castlewood maintains a high staff-to-
patient ratio providing for greater
individualized care. Many of our clients
have had treatment at other programs
and have found recovery at Castlewood.
Working with a qualifed
nutritionist, who has a solid
background in eating disorders is
the cornerstone of our program.
Our residential nutritionist is a
former eating disorder client
herself and understands the
process as only someone who
has been through the recovery
process can.
Our therapy begins with a solid individual relationship with
the primary therapist, psychiatrist and our nutritionist.
Ex. J p. 10
R
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i
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Our Residential level of care is
designed for stabilization and
restoration of healthy eating habits.
At the Residential level, we work to
establish and foster a therapeutic
community that can allow each
client to feel supported and to work
on building social connections while
establishing a stronger sense of self.
residential
treatment
residential
Ex. J p. 11
The Residential program only has a maximum
of 10 clients. Each client sees his/her primary
therapist four times a week as well as having
weekly sessions with the dietician and the
psychiatrist. The program itself consists of
40 hours of group therapy. Staff is on site 24/7.
Each bedroom is attractive, uniquely decorated
and has its own en suite bathroom. There are
no more than two clients to a bedroom.
Community space is likewise comfortable and
inviting with inspiring views.
Ex. J p. 12
Thursday
7:30 8:00 Breakfast
8:15 9:15 Process Group
9:30 10:30 Core Group
10:30 11:00 Snack
11:00 12:00 Core Group II
12:30 1:30 Chef s Choice
1:30 2:30 Pilates
3:00 3:30 Snack
3:30 4:30 Cognitive Group
4:30 6:00 Individual Sessions/Free Time
6:15 7:00 Dinner & Post Meal
Free Time
9:00 9:30 Snack
Friday
7:30 8:00 Breakfast
10:00 10:30 Snack
10:30 12:15 Eating Disorder Group
12:30 1:30 Lunch & Post Meal
1:30 2:30 Body Image
2:30 3:00 Snack
3:00 4:30 Art Therapy
Movie Outing
9:00 9:30 Snack
Saturday
7:30 8:00 Breakfast
9:30 10:30 Gender Sexuality Intimacy & Relationships
10:30 11:00 Snack
11:00 12:00 Literary Interpretation/Shame Group
Outing & Visitors
Free Time
9:00 9:30 Snack
Sunday
7:30 8:00 Breakfast
10:30 11:00 Snack
11:00 12:15 Music Therapy
Visitors & Passes
5:00 6:00 Addictions Group
6:15 7:00 Restaurant Outing or Family Style Meal
Free Time
9:00 9:30 Snack
Monday
7:30 8:00 Breakfast
8:30 10:30 Core Group Weekend Check-in & Goals
10:30 11:00 Snack
11:00 12:15 Core Group II
3:00 3:30 Snack
3:30 4:30 Yoga Group
Compulsory Play
9:00 9:30 Snack
Tuesday
7:30 8:00 Breakfast
10:00 10:30 Snack
10:30 12:00 Movement Group
1:30 3:00 Expressive Therapy
3:00 3:30 Snack
3:30 4:30 DBT Group
7:15 8:15 Pre-Contract
9:00 9:30 Snack
Wednesday
7:30 8:00 Breakfast
8:15 9:15 Eating Disorder Expressive Group
9:15 9:45 Menu Group
9:45 10:30 Nutrition Group
11:00 12:00 Treatment Module
1:30 2:30 Sexual Healing or Containment
2:30 3:00 Snack
4:00 5:00 Relapse Prevention
Compulsory Play
9:00 9:30 Snack
Residential Program Weekly Schedule
Ex. J p. 13
The people at Castlewood Treatment Center
saved my life. But they did more than that.
They opened up my eyes to what life is all about,
to all that I have to look forward to.
I came in closed off from the world.
The people here helped me fnd my strength.
They didnt just give me wings, they helped me fnd
my own, and let me realize that I had the power to
fy inside me all the time.
Im not just alive today because of the people here,
but Im actually living life as well.
MB

Ex. J p. 14
S
t
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Our Step Down program is usually
a transition from residential care.
stepdown
stepdown
Ex. J p. 15
The Stepdown program focuses less on stabili-
zation and more on practice, with an emphasis
on acquiring the necessary life skills to facilitate
long-term recovery. Coping skills and healthy
eating habits learned in residential are built
upon and tried out in circumstances more
closely resembling what clients will encounter
post treatment. There is greater autonomy,
encouragement of self responsibility, yet with
help, support, guidance and community.
We understand that each new phase in a clients
recovery process entails novel challenges. We
endeavor to provide the feedback, opportunities,
support and skill-building necessary to navigate
each sequential hurdle. Our Stepdown nutritionist
has successfully helped hundreds of clients nav-
igate the pitfalls of eating in the real world.
Again, this program is tailored to ft the indi-
viduals situation. Some clients in Stepdown, will
begin to work a certain number of hours, some
to attend academic courses or to volunteer with
local agencies or organizations. Learning
to sustain a balanced lifestyle that includes:
appropriate nutrition, work or school, supportive
relationships, recreational activities and self-care
simultaneously, is often a foreign concept con-
trasted with how clients were functioning prior to
treatment. The more opportunity to practice in
this manner, the greater the odds for a sustained
recovery post discharge.
During the Stepdown phase, a meal and exer-
cise plan is developed for the individual client
by the nutritionist with client input and goals
considered. Clients frequently say that our
dietician and nutritionist are the BEST theyve
ever worked with. We consider this a supreme
compliment and a variable that makes the
process of recovery so much smoother!
Ex. J p. 16
D
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T
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m
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t
day
treatment
day treatment
Castlewood offers a full spectrum
of care. Our Day Treatment program
is open to clients living in or around
the St. Louis area who require more
than outpatient treatment but who
may be able to meet his/her treatment
goals without a residential stay.
Ex. J p. 17
Day Treatment

In order to achieve a level of stabilization and
symptom reduction, some clients require a level
of care beyond outpatient.
Our Day Treatment program is provided for
clients living in or around the St. Louis area
who can commute to treatment and for whom
an overnight stay is not a necessary treatment
component.
The program is available on either a 5- or 7-day
basis. Clients become part of the therapeutic
community and participate in all residential
groups and programming. Depending upon
whether in the 5 or 7 day version, clients
receive 3-4 individual sessions with the primary
therapist, one with the psychiatrist and one
with his/her dietician weekly.
Day Treatment is often the treatment of
choice when a program of intensive
outpatient care has not been adequate in
effectively assisting the client to reach and/or
maintain treatment goals.
Ex. J p. 18
I
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O
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p
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Our IOP Program is for clients needing
more structure than individual
outpatient therapy alone can provide
or for the client who is transitioning
back to life, work or school after
treatment at a higher level of care,
such as Residential or Stepdown.
intensive
outpatient
IOP
(intensive outpatient program)
Ex. J p. 19
Castlewoods IOP Program consists of both group
and individual therapy held four evenings each
week. A supervised meal also comprises one facet
of each evenings programming.
For motivated and less severely compromised clients,
IOP may be the treatment of choice. There are
four types of groups offered in the program.
offers a complete menu of
outpatient services with expert
individual therapists for eating
disorders, nutritional counseling,
marital and relational therapy
and trauma-resolution therapy.
For more information please call:
1-888-822-8938.
Ex. J p. 20
SKILLS GROUP
The SKILLS GROUP is a structural psycho-
educational group that provides clients with
practical skills for coping with challenges and
helps create alternative strategies to reliance
on the eating disorder symptoms. Instead of
binging and purging, utilization of self-sooth-
ing, distraction, and problem solving. Instead
of restricting, patients examine unhealthy
thought processes, body image distortion and
underlying feelings and needs. Clients are
taught to use their voice rather than symptoms
to communicate internal states and to facilitate
problem solving, communication and to devel-
op relationship skills and resources. The groups
focus on body acceptance, behavior therapy,
enhancing motivation, diminishing anxiety,
appropriate nutrition, mindfulness, spirituality
and self care.
GENERAL PROCESS GROUPS
The PROCESS GROUP allows an opportunity
to discuss emotions and underlying dynamics
that maintain eating-disorder symptoms. Feed-
back from group members, particularly those
farther along or those who have had similar
experiences is useful. Assignments are often given
to lend focus and assist clients in identifcation
and exploration of symptom-maintaining cir-
cumstances and issues.
MEAL PROCESS GROUP
In the MEAL PROCESS group, individuals
are helped to recognize hunger and fullness, to
learn to prepare or portion satisfying meals with
variety, nutrition and in appropriate servings.
The therapists eat with the clients, and clients
are challenged and supported to confront their
anxiety incrementally.
EXPERIENTIAL GROUP
In EXPERIENTIAL GROUP, clients deal
directly with circumstances or situations having
to do with body, movement and strong emotions.
Clients often say these types of groups are the
most challenging, but also the most useful.
Clients may role play diffcult situations to pro-
vide insight and mastery. Through behavioral
rehearsals, clients lessen anxiety and increase
effcacy in dealing with new or challenging
situations they face.
Castlewood Program Coordinators (from left to right)
Amy Kayda IOP Coordinator & Therapist
Emily Williams Step Down Coordinator & Therapist
Deanna James Assistant Program Director & Therapist
Ex. J p. 21

SUPPORT GROUP
Castlewood sponsors a free weekly sup-
port group for people in recovery from
Anorexia Nervosa, Bulimia and Binge
Eating Disorder. The group is open to
anyone regardless of stage of recovery.
The purpose of the group is to establish
a safe, reliable setting that emphasizes
positive aspects of recovery. The format
offers time for participants to briefy
check in about the week, followed by an
open discussion that focuses on various
issues or topics that are common during
the recovery process. Examples include:
relapse prevention, negotiating boundaries,
and utilizing healthy coping tools. Par-
ticipation in support group requires that
the individual be engaged in outpatient
therapy, as the support group is not in-
tended to replace on-going therapy or as a
stand-alone form of support. Castlewood
welcomes inquiries by both clients and
therapists about appropriateness of the
Support Group for you or for your client.
Information about the Support Group
is available from Nancy Albus at
636-386-6611.
From the very frst day I was warmly
welcomed and though terrifed I found
support. The groups were extremely
diffcult but vital to my recovery. I
formed friendships on a level I had
never experienced before and found hope
that had been covered by layers of fear.
I cant begin to explain the care that
the staff at Castlewood had for me. At
times it was overwhelming to think that
anyone could care that much. From my
relentless and kind therapist that helped
me through my most diffcult days, the
psychiatrist that respected my every
boundary, the directors whos intuition
still amazes me today, the staff whos
safety I remember when I was strug-
gling the most, and lets not forget the
dieticians that I would have never
imagined to be my biggest allies. With
all of that, the structure of flled days
of groups, the focus on the fear and
trauma that was fueling my behaviors,
and the many levels of step down I
found my path to recovery. And most
importantly I found myself.

The groups were
vital to my recovery.
Ex. J p. 22
T
r
a
u
m
a

R
e
s
o
l
u
t
i
o
n
Clients need to return to
the root of what happened
trauma
resolution
trauma resolution
therapies
Ex. J p. 23
With one foot in the present and one
foot in the past, the client re-examines the
memories, re-associates the emotions, and
changes the trauma-based or childhood
attributions used to make meaning of
the experience at the time to an adult
perspective of enhanced clarity, wisdom
and compassion. The event no longer
exerts the same infuence over behavior,
choices and sense of self it did previously.
Ex. J p. 24
Unresolved experiences of child sexual abuse or rape, for example, will almost
always result in symptoms. Where traumatically-originating symptoms prevail or
complicate the individuals ability to achieve a fuller recovery, therapies such as
EMDR, Attachment-based Psychotherapy or Internal Family Systems therapy
can be utilized to facilitate and speed up the necessary shifts in processing once
some degree of safety, containment and stabilization exist.
EMDR
Clients who have suffered for years from anxiety
or distressing memories, nightmares, insomnia,
abuse or other traumatic events can often
gain relief from a revolutionary therapy called
EMDR (Eye Movement Desensitization Repro-
cessing). Research shows that EMDR is rapid,
safe and effective. EMDR does not involve
the use of drugs or hypnosis. It is a simple,
non-invasive patient-therapist collaboration
in which healing can happen effectively. This
powerful short-term therapy is highly effective
for a wide range of disorders including chronic
pain, phobias, depression, panic attacks, eating
disorders and poor self-image, stress, worry,
stage fright, performance anxiety, recovery
from sexual abuse and traumatic incidents.
Attachment-based
PSYCHOTHERAPY
When a client has experienced early attachment
defcits with their caretakers in the frst few years
of life due to sensory hyperactivity or parental
unavailability, they will evidence attachment dis-
orders later in life. They will become dismissive
of, or preoccupied with, securing love. So often,
eating disorder results from a hunger for love,
and the person is either too afraid to seek love
(dismissive) or approaches partners with a binge
mentality (preoccupied), or both (disorganized).
Castlewood utilizes directive interventions to
work with attachment diffculties.
Ex. J p. 25
INTERNAL FAMILY SYSTEMS
THERAPY
Internal Family Systems (IFS) therapy is a
therapy that is very applicable to clients who
have complex traumatic stress disorders and
allows for a reworking of those experiences with
one foot in the present, and one foot in the past.
IFS has in common with Ego State therapies
the idea that each individual has multiple selves
or self-states. IFS, like Ego State therapies, is
predicated on the notion that having self-states,
(generally referred to as parts) is not (solely)
a function of a dissociative process in need of
therapeutic correction, but rather the normative
state of all human beings. Working with these
parts can be a very effcient and potent method
of resolving past events and freeing the indi-
vidual to rely more fully on his/her own innate
capacities for change, growth and healing.
RICHARD C. SCHWARTz, Ph.D.,
the originator of Internal
Family Systems Therapy,
is integral to Castlewood in
both his training of our staff
and as a clinical consultant.
Ex. J p. 26
S
t
a
f
f
The staff at Castlewood is passionate.
Their skill and dedication are
surpassed only by their compassion
for the hard work involved in each
clients process of recovery.
castlewood
staff
castlewood staff
Ex. J p. 27
Our therapists include highly trained
master- and doctoral-level professionals
with numerous specialties who are
unequivocally committed to helping
people heal. They understand the
obsessive, often labyrinthine thought
processes that create and maintain our
clients cognitive distortions.
Mark Schwartz, Sc.D.
Clinical Co-Director
Mark earned his doctorate
in Psychology and Mental
Health from Johns Hopkins
University. He is a licensed
psychologist and an adjunct
professor in the departments of Psychiatry at
St. Louis University School of Medicine. Over
the past 25 years, Dr. Schwartz has achieved
international recognition for his contribu-
tions in a variety of clinical arenas including
the treatment of intimacy disorders, marital
and sexual dysfunction, sexual compulsivity,
sexual trauma and eating disorders. He lectures
nationally and internationally on these topics
and has authored numerous articles and book
chapters, as well as the books, Sexual Abuse
and Eating Disorders and Sexual Compulsive
Behavior, Sex and Gender. Dr. Schwartz is cur-
rently on the Editorial Board of the Journal of
Eating Disorders.
Lori Galperin
M.S.W., L.C.S.W.
Clinical Co-Director
Ms. Galperin initially
earned her undergraduate
degree in Psychology and
later completed her gradu-
ate degree in Clinical Social Work at Tulane
University. She is an accomplished contributor
in the felds of marital and sexual dysfunction,
sexual compulsivity, sexual trauma, dissociative
and eating disorders, lecturing nationally and
internationally on these topics. She has au-
thored various journal articles and book
chapters, is trained in Clinical Hypnosis,
EMDR, Internal Family Systems, Expressive
and Attachment-based therapies. Over the
past 22 years Ms. Galperin has treated several
thousand inpatients and trained more than
100,000 clinicians throughout the United
States, Canada and Europe.
Nancy Albus
M.Ed., L.P.C.
Program Director
Nancy earned her Master
of Arts degree in Counsel-
ing from the University of
Missouri-St. Louis. She is
a licensed Professional Counselor and trained
in Internal Family Systems. In addition to her
interest in eating disorders, Nancy works with
femininity and sexuality issues, including facili-
tating the Femininity and Sexuality group in
Residential Treatment. Nancy joined
Castlewood in 2002 as a therapist and is also
the program director for the treatment center.
Ex. J p. 28
Theresa Chesnut
M.S.W., L.C.S.W.
Therapist
Theresa initially earned
her undergraduate degree
in Family Life and Com-
munity Services from
Kansas State University and later completed
her graduate degree in Clinical Social Work at
the University of Kansas. Theresa has been
on staff at Castlewood since 2000 and has held
various positions: Primary Therapist, Program
Director and currently as the Marketing Direc-
tor. Theresa has also been on staff for the
Menninger Clinic and she has over 15 years
experience in lecturing on college campuses
and to psychiatric professionals about the signs,
symptoms and prevention of eating disorders.
Currently, her area of research, focus and
lecturing is on the recovery process and various
intervention strategies as well as providing In-
services for elite athletes, coaches and trainers.
James Gerber
M.A, A.T.R., Ph.D.
Therapist
Dr. Gerber earned a
Masters Degree in Art
Therapy/Counseling at
Southern Illinois University,
Edwardsville. He earned his Ph.D. at Saint
Louis University in Counseling and Family
Therapy. Dr. Gerber has worked extensively
with adults and adolescents in a variety of
clinical areas including sexual/marital dysfunc-
tion, family therapy, sexual abuse, trauma and
compulsivity. He has published and presented
papers on sexual aggression, sexual abuse and
trauma.
Samantha Young
M.Ed., L.P.C.
Intake Coordinator/
Therapist
Samantha Young earned
a Masters of Science
Degree in Counseling
from Missouri Baptist University. She is a
Licensed Professional Counselor and is trained
in Internal Family Systems, Dialectical Be-
havioral Therapy and EMDR. Samantha has
worked at Castlewood Treatment Center since
2002 working with trauma and eating disorders.
Deborah Hinds, D.T.R.
Nutritionist
Deborah earned her de-
gree in Dietetic Technolo-
gy with an emphasis in Nu-
tritional Care at Florissant
Valley College in Missouri.
She is a registered and licensed Dietetic Tech-
nician in the State of Missouri, and has experi-
ence in clinical nutrition, outpatient counseling,
mental health, and facilitating groups on eating
disorders and addiction. Deborah is trained
in the Internal Family Systems Model and has
exclusively treated individuals with eating dis-
order for nearly 10 years. Deborah works with
residential, intensive outpatient, and outpatient
clients to develop custom meal plans and to
provide grocery shopping assistance and nutri-
tional counseling.
Ex. J p. 29
Anna M. Jurec, M.D.
Psychiatrist
Anna M. Jurec, M.D.
graduated from Medical Uni-
versity in Gdansk, Poland and
completed her Psychiatry
Residency Program at Saint
Louis University Department of Neurology and
Psychiatry. She has been a member of the Ameri-
can Psychiatric Association since 2004. She is cur-
rently working as a full time psychiatrist at Castle-
wood Residential Treatment Center. She is also a
consultant with Places for People a non-proft
organization in St. Louis, treating severely and
persistently mentally ill patients.
I enjoy helping to bring out the potential of the human
mind in those affected by mental illness. I strive to treat
the patient as an integral combination of body, mind and
spirit and to allow patients to choose the best individual
treatment based on scientifc and clinical evidence.
My particular professional interests are directed toward
psychosomatic medicine (eating disorders in particular,)
as well as mood and anxiety disorders.
Iness Panni, RN, MSN
Nurse Manager
Iness earned a Bachelors
Degree in nursing from
Avila University and a
masters degree in nursing
from University of Kansas.
Iness Panni has worked with eating disorders
and addictions for over 25 years. She brings
a special sensitivity to the medical, physical,
emotional, psychological, social, and spiritual
aspects involved in the complexity of treating
eating disorders. As Nurse Manager of
Castlewood Treatment Center since 2002,
Iness provides a holistic oversight of the care
and well being of each client.
We chose Castlewood very carefully.
When my daughter started I had
hope, bits of optimism, and of course
some relief in seeing her downward
spiral arrested. Almost a month later
I still felt those same things, but my
daughter was voicing some optimism
of her own. The degree to which the
staff blend their roles/results/
perspectives, etc. for each client,
including my daughter, is what
returned her to life, and life to her.
You were the reason she believed she
might, then could, then would make
it: and the strength she borrowed
when hers wasnt quite there.
DM

Ex. J p. 30
W
h
y

C
a
s
t
l
e
w
o
o
d
A small Residential community
fosters greater participation
and affords more individualized
treatment planning and care within
a strong, cohesive therapeutic milieu.
Castlewood is located just 25 minutes
from St. Louis Lambert International
Airport. In addition to state-of-the-
art care, our facility, set in a tranquil,
secluded environment, is a testimonial
to the healing inherent in natures
ever-renewing beauty.
why
castlewood
why castlewood
Ex. J p. 31
Unlike so many treatment centers, Castlewood
helps clients heal the pain that underlies their
eating disorders rather than just manage the
symptoms. The place is beautiful, not just in
its physical setting, but also in the compassionate
way the staff views and relates to the clients.
I wish I could send them all my traumatized
clients, not just those with eating disorders.
RiChaRd C. sChwaRtz, Ph.d.
Developer of the Internal Family Systems model.

Ex. J p. 32
1. we are small.
Only ten clients in-house with 33 staff permits
highly individualized intensive treatment. We
provide a great deal of support at the table and
have locked access to food.
2. we individualize care.
Whether you have obsessive-compulsive disor-
der, body dysmorphic disorder, social anxiety
disorder, major depression, multiple addictions
or dissociative disorder, we provide specifc treat-
ment for the eating disorder as well as these
often concurrent issues.
3. we specialize in
trauma-resolution therapies.
For clients with a history of childhood or adult
trauma, we offer state of the art therapies for
resolution of experiences that were overwhelm-
ing. Trauma may consist of a one time incident
that led to Post Traumatic Stress symptoms, or a
series of developmentally prevalent occurrences
that generated avoidance, constriction or reen-
actment phenomena.
4. we utilize internal Family systems
therapy.
All of our therapy staff have had training in
Internal Family Systems therapy which allows
us to work as a team to understand the contex-
tual function of the individuals eating disorder
symptoms in order to help each client discover
truly viable alternative survival strategies.
5. our focus is more than simply
re-feeding or control of symptoms.
Our goal is to help launch a person in his/her
development toward a full life. This includes
support to transition to or re-enter college, job
and relationship.
6. we provide a full continuum of care.
We have found that almost all clients slip fol-
lowing the support and safety of the in-house
program. To allow clients more freedom and
independence to practice recovery and rebound
from the inevitable slips we began a Stepdown
Program. It is a supportive environment where
clients receive support from peers, implement
relapse prevention plans and continue with his/
her individual therapy. We can further step a
client down to Partial Hospitalization or the
Intensive Outpatient Program to provide a full
spectrum of recovery experiences alongside
reintegration into daily life and activities.
7. we encourage family involvement
whenever appropriate and possible.
We schedule family weekends every 6-8 weeks,
which involves the clients inviting all interested
family members to 3 days of group and indi-
vidualized treatment. Additional individualized
family therapy and couples therapy with spouses
or signifcant others are scheduled between
Family Weekends as well, as it seems contribu-
tory to the clients overall treatment goals.
8. we create a safe environment.
People with bulimia,binge eating disorder and/
or anorexia, are constantly punishing themselves
internally with negative self talk. When working
towards recovery,one needs people who under-
stand this phenomenon and offer refection with
compassion rather than criticism.
WHY CHOOSE CASTLEWOOD TREATMENT CENTER?
Ex. J p. 33
For the Professional
Castlewood utilizes an evidence-based approach with 1-year follow-up with
all clients. We have found that treatment effectiveness is highly dependent on:
1. Bringing the client from a premotivational
to a motivational state.
2. Assessing psychiatric co-morbidity including
OCD, social anxiety, body dysmorphia,
co-addiction, post-traumatic stress disorder,
and dissociaton.
3. Working with pertinent family dynamics,
burdens the family carries intergenerationally
that manifest in: over-control, over-indulgent
enmeshment, engulfment or other addictive
and secretive dynamics. Often, we need to
have the entire family in for intensive work.
4. Couples work. A spouse, if not brought on
board to what will be necessary to continue the
recovery process, can unravel a great deal of
even the most effective in-residence work.
5. Keeping a strong focus on food-related behav-
ior and establishing control over out of control
behavior, but not as part of a good girl over-
compliancy but rather with a real self, honest
and nonreactive stance toward relationships.
6. Looking for the deeper function of the symp-
toms. There are good reasons each client de-
velops an eating disorder. We dont get rid of
the eating disorder, but instead help integrate a
stronger self that no longer requires the illusion
of control that comes from engagement in the
eating disorder.
7. Integration. Our therapists and Treatment
Team will involve the referring therapist in the
treatment and recovery process. Let us know
how you would like to be kept updated on
your clients treatment and progress and we
will provide you with the clinical information.
8. Addressing body image diffculties in both
group therapy and in individual therapy through
sensory exercises and experiential therapy.
Clinicians help clients move toward connecting
with his/her body and help them learn how to
tolerate the connection.
9. Finally, a powerful relationship with the
primary therapist and nutritionist, that
allows for suffcient trust to incrementally
let go of the eating disorder.
Ex. J p. 34
We invite you to compare program quality and costs and to call us
for a telephone or in-person assessment and tour. Our intake coordinator,
Samantha Young, can be reached at 1-888-822-8938.
800 Holland Road
St. Louis, MO 63021
636-386-6611 phone
636-386-6622 fax
888-822-8938 toll-free
Ex. J p. 35
800 Holland Road
St. Louis, MO 63021
phone 636.386.6611
toll-free 888-822-8938
fax 636-386-6622
Ex. J p. 36

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Monte Nido is designed to provide behav-

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