When Care Becomes Collateral: Capital One, Discovery, and the Start of the Unraveling of the Eating Disorder Industrial Complex?

Capital One’s hostile takeover of Discovery Behavioral Health should be understood for what it is: a financial repossession of eating disorder care. When a credit card issuer and its private credit allies remove a healthcare company’s board and take command, this is not stewardship. It is enforcement. And it exposes the eating disorder treatment industry for what it truly is … an over leveraged, lender dependent system now entering its reckoning phase.

The article discussing this event can be found here:

Capital One Seizes Control of Discovery Behavioral Health After Defaulting on Debt

Discovery’s default on roughly $280 million in debt triggered a response that private equity veterans recognize immediately. Capital One did not negotiate, recalibrate, or defer to clinical leadership.

After quickly defeating Discovery’s attempt to maintain control through litigation, Capital One replaced Discovery’s board and began preparing the company for a sale. Discovery is likely to be segregated into various organizational parts and sold off … the most valuable centers with the highest return of investment being first on the chopping block.

This sequence is not about patient outcomes or workforce stability; it is about recovery value. In this model, treatment centers are exposed for what they truly are … assets, programs are cost centers, and patients are throughput as mere corporate commodities.

Center for Discovery, long marketed as a premier national provider of eating disorder treatment, now operates under lender rule. Its future is murky at best and will be decided by utilization curves, lease exposure, and labor ratios … not by clinicians or evidence-based standards of care. Residential eating disorder treatment, the most resource intensive and least forgiving line item, sits squarely in the crosshairs.

In the recent past, Discovery closed dozens of facilities while continuing to pay rent and utilities on shuttered locations … textbook symptoms of a platform built on leased real estate and debt fueled expansion. Picture if you will, your owners force you to close certain locations due to financial underperformance. But you are still required to pay rent and associated costs of those closed facilities to a third party. The victims of this reality are first the employees. But ultimately, it is the family which suffers.

Under Capital One’s control, further closures are not a risk; they are a certainty. Residential programs that fail to meet margin thresholds will be cut, regardless of community impact or patient displacement.

This lender takeover sends a shockwave far beyond Discovery. Banks and credit card issuers are not passive financiers in behavioral health. They are deeply embedded power brokers. Through senior credit facilities, syndicated loans, and bank affiliated private credit platforms, they sit atop capital stacks that allow them to seize control the moment projections wobble. Discovery is simply the first visible collapse. It won’t be the last.

The uncomfortable part is that Capital One is not a lone outlier. The largest banks increasingly partner with direct lenders and private credit firms to deploy multi‑billion dollar pools into sponsor backed corporate debt … the same financing architecture that private equity uses to acquire and roll up treatment centers. When banks and private credit join forces, the sector’s “owners” are no longer just sponsors; the lenders become co‑architects of the business model, its risk tolerance, and when it breaks, its dismantling.

Reported bank private credit alliances are now a recurring feature of the market: arrangements in which major banks supply distribution and balance sheet capacity while alternative managers supply origination and higher yield credit products. The effect is predictable: more leverage flowing into health services, more covenant heavy structures, and more lender leverage to step in when a platform misses forecasts.

Layered on top of bank capital is the role of alternative asset giants whose credit arms routinely finance sponsor owned healthcare: firms such as Apollo, Blackstone, KKR, Ares, Blue Owl, and others compete to underwrite “sponsor backed” direct loans. These lenders are not clinical stakeholders; they are yield investors. Their incentives are to price risk, enforce covenants, and extract value, often by forcing restructurings, controlling boards, and selling platforms in pieces when the numbers stop working.

Large corporations can also become upstream pressure points even when they are not formal lenders. National insurers and managed care intermediaries effectively act as financial gatekeepers through utilization management and reimbursement policy. When those payors tighten authorization standards for residential eating disorder care, they can trigger the exact revenue compression that pushes a leveraged provider into default, handing lenders the pretext to “exercise remedies.”

Other treatment centers owned by private equity entities are not immune from the financial impact of Discovery’s financial failure. Discovery’s downfall will undoubtedly tighten underwriting across the sector, raise borrowing costs, and embolden lenders to intervene earlier and more aggressively. Private equity sponsors may talk about long term value, but lenders control the clock and the exits.

The fallout will not stop with operators. Industry trade groups and advocacy bodies are already showing signs of strain. The Residential Eating Disorder Consortium (REDC), long positioned as the collective policy voice of residential providers, did not make any direct payments to Center Road Solutions, its lobbyist in 2025, the first such lapse in over a decade. In fact, between 2018 through 2024, the REDC paid its lobbyist a total of $940,000.00 That silence is telling.

REDC’s failure to directly fund lobbying for the first time in over ten years suggests an industry retrenching, not advancing. When providers are closing facilities, negotiating with lenders, and fighting payor denials, political advocacy becomes expendable. But the absence of advocacy has consequences: weaker influence over utilization standards, reimbursement policy, and regulatory scrutiny just as the sector becomes more fragile.

A weakened REDC also signals something more troubling. If residential providers can no longer collectively finance representation in Washington, it implies declining margins, internal fragmentation, or both. In a moment when lender control is expanding and residential capacity is shrinking, the industry’s policy voice appears to be fading exactly when it is most needed.

The most likely future for Center for Discovery is not stabilization but disassembly: selective shutdowns, geographic retreat, a pivot toward lower cost outpatient and virtual models, and an eventual fire sale engineered to satisfy lenders. The branded “continuum of care” will fracture as financial triage replaces clinical cohesion.

The Discovery takeover exposes an ugly reality that the eating disorder field has tried to avoid: this sector is no longer governed by clinicians, ethics, or patient need. It is governed by debt documents. When banks can repossess treatment platforms like distressed retailers, eating disorder care becomes optional infrastructure … maintained only so long as it pays.

Discovery is not an anomaly.

It is a warning.

Soul Hearted … or Soul Sold?

There is a peculiar alchemy in modern healthcare marketing: mix equal parts corporate speak and earnest platitudes, stir in some pastel graphics, and poof! … you’ve created the illusion of transformation. Trying to cover up a tarnished past with a new logo and glossy verbiage has a name: reputation laundering.

The latest to attempt this reputation laundering is Castlewood/Alsana. Marketed as a “Soul Hearted” renaissance rooted in “clinical integrity” and “whole-heartedness,” Castlewood/Alsana’s bumbling attempt is as follows:

“Today, we’re honored to share a letter from Jordan and Keesha:

For the past year, we have been writing a new story for Alsana. We have been listening hard and leaning in. Thinking and planning, building and dreaming. Connecting, collaborating, and creating change within our organization. We have been working together with our teams as well as with our trusted mentors to build what we believe is most needed in the eating disorder field — and honestly, what is needed in the world.

Based on our collective 35 years of experience in the field — countless hours treating clients and working alongside providers — this new beginning for Alsana is our offering to each of you. A love letter of sorts to this work we all hold so dear. It is equal parts an homage to the grassroots efforts of the field’s founders and aspirational intentions for a brighter future.

The way we want to approach this privileged work of healing clients and partnering with providers is something we call Soul Hearted.

We value clinical integrity, whole-heartedness, mutual respect, thoughtful engagement, and rooted reliability. Today, and in the coming weeks, you will see the visual manifestation of this change: a new brand experience, including a new website with updated information on our mission and vision, as well as the new clinical framework that we’ve implemented this past year.

We invite you to follow along. Use our link in bio to visit our new website or read more about our Soul Hearted story.

With this new beginning, we aim for every person who encounters Alsana to feel seen in their authenticity and to know their worth. This is our way to give flowers to those who have come before us, those who will come after us, and all the souls we have the honor of supporting in between. Because each of you deserves flowers. This field deserves flowers.

With Gratitude,

Jordan Watson, Chief Executive Officer, Keesha Amezcua, LMFT, CEDS-C, Chief Clinical Officer” and [Unattributed, Chat GPT]

Castlewood/Alsana is so clueless, it required ChatGPT to craft its message. You may be wondering how we know it was a ChatGPT creation? Simple enough.  Look at the overuse of the “em dash.” ChatGPT frequently overuses the em dash (—), often mistaken for a “long hyphen” or “ChatGPT hyphen” to simulate natural rhythm, add emphasis, link clauses, and replace commas or parentheses. It serves as a stylistic shortcut to mimic human spontaneity and structure thoughts. 

In the public announcement, hyphens are used four (4) times.  Needlessly so. But what better way to mimic human compassion than by having a soulless program draft your heartfelt announcement. While pretending it was “soul hearted.”

Chat’s messaging apparently attempts to include a new logo … a soft beige square with a delicate serif “A” and the soothing promise “You deserve flowers.”

But, if logos could tell the truth Castlewood/Alsana’s new logo would not be a soft beige square with a delicate serif “A” and the soothing promise “You deserve flowers.”

Instead, Castlewood/Alsana’s logo would be a cracked castle, its stones crumbling, sitting uneasily at the edge of the woods … because Castlewood/Alsana is not a new entity at all. Alsana merely remains as an assumed name, a pasteboard mask, a coat of paint applied to an old, failed structure whose legal name remains Castlewood Treatment Center, LLC. And its owner, The Riverside Company, desperately attempting to meet the needs of the investors behind this failed financial experiment.

As for its rebranding?

It is almost poetic how the rebrand leans hard into aspiration: “Because each of you deserves flowers.”

That’s lovely … until you realize that flowers are not a substitute for meaningful clinical outcomes, transparent safety data, and ethical accountability.

“You deserve flowers” is a lovely sentiment.

But flowers are not:

  • peer-reviewed treatment modalities
  • transparent adverse event reporting
  • independent oversight
  • staffing ratios
  • informed consent
  • ethical discharge planning

Flowers do not stabilize electrolytes. Flowers do not reverse medical neglect. Flowers do not replace cognitive behavioral therapy, family-based treatment, or medically competent monitoring.

Sure, everyone loves flowers. But the people truly harmed by substandard care don’t need floral metaphors, they need accountability.

When a treatment provider leans harder on aesthetic reassurance than clinical proof, the public should ask why.

Because in medicine, feelings are not outcomes.

And so, let us move on from the basics of that which the marketing materials disclose to that which they omit.

“Alsana” is not a standalone organization. It remains an assumed business name used by Castlewood Treatment Center, LLC, a company long associated with controversy in the eating disorder treatment space, particularly tied to its former Missouri operations.

If you review the Alabama Secretary of State’s business organization site for any mention of “Alsana” you will find … nothing. But, if you include Castlewood Treatment Center, LLC … bingo! Its registration as a Missouri based limited liability company appears.

This effectively means that Alsana cannot stand alone without Castlewood. The two are inextricably intertwined.

Castlewood’s legal entity did not disappear. The liabilities did not evaporate. The allegations did not dissolve into pastel tones. Only the branding changed.

That distinction matters to patients, families, clinicians, insurers, and regulators, because accountability follows the entity, not the font.

In its rebranding announcement and on its new website, Chat GPT on behalf of Castlewood/Alsana’s leadership describes the transformation as a “love letter,” rooted in “Soul Hearted” values: authenticity, worth, gratitude, and flowers for everyone involved. What’s striking is what the letter does not include. It does not include:

  • Acknowledgment of past harm
  • No discussion of documented controversies
  • No explanation of why multiple senior leaders left
  • No data on outcomes, safety, or reform

In healthcare, especially eating disorder treatment, language without evidence is not healing. It is mere marketing.

Eating disorder patients are uniquely vulnerable to authority, suggestion, and coercion. That is precisely why the field should emphasize evidence-based care, transparency, and ethical restraint. Replacing those guardrails with inspirational language is not soulful. It’s dangerous.

And this specific danger was disclosed by former officers.

While Castlewood/Alsana’s press release paints a warm and fuzzy picture of healing, flowers, and listening deeply, bubbling up beneath the surface are sworn allegations from Castlewood/Alsana’s former high-ranking officers that paint a far grimmer picture. One of prioritizing growth and revenue above clinical care. Of threats, vindictiveness, and internal intimidation tactics that a credible clinical community would find alarming.

One cannot help but wonder if those former officers who came before will be receiving flowers? Or another subpoena.

Let’s be clear about something: it is one thing for critics on the outside to claim a treatment provider is more focused on profit than patients. That may be dismissed with a knowing smile and social media posts. It is quite another when former executives, the people who once ran the place, say the same thing under oath.

In sworn declarations multiple former officers, including its chief operating officer and chief clinical officer resigned or were terminated because they objected to the company’s direction, specifically its shift toward revenue targets at the expense of clinical quality and ethical integrity.

These aren’t anonymous critics with an axe to grind. These are the very people once entrusted with leadership. Under the penalty of perjury, they swore their concerns were met not with reform, but with threatening letters and what they describe as vindictive conduct from the company, conduct that made them fear for their own future if they voiced dissent.

Castlewood/Alsana’s former CEO, Jennifer Steiner, under oath, testified as follows: “As its CEO, I reported to the Company’s Board of Directors (the “Board”). The Riverside Company (“Riverside”), a private equity company, has been the majority owner of Alsana since December 2016, and it was the majority owner during my tenure as Alsana’s CEO.”

“Despite all of my success, however, significant issues with Alsana, its Board and Riverside developed over time, which ultimately caused Alsana to terminate me. Specifically, I became concerned with the direction of the company and what I considered to be Alsana’s decision to maximize growth and revenue above all else. When I refused to go along with certain decisions of Alsana’s Board, including decisions that I believed would jeopardize patient care, I was terminated.”

“Alsana’s bad faith and tortious conduct, which I believe was intentionally designed to frustrate my business and unfairly compete with me, has caused me to suffer both monetary damages and adverse mental health consequences.”

Multiple officers stated under oath that Alsana was prioritizing growth and revenue above all other goals to the detriment of patient care and the integrity of the business. Alsana was sending threatening letters to those former Officers. Alsana was directing aggressive and vindictive courses of conduct against former Officers. Alsana was not providing its officers with the information they needed to do their jobs. That an atmosphere of fear and not collaboration had been created. Alsana was engaged in tortious and bad faith conduct. That when the highest ranking Officer refused to abide by decisions of Alsana’s Board, decisions which she believed would jeopardize patient care, she was terminated. Creating fear and anxiety.

Again, these words are NOT mine. But former Officers.

And that is the same organization now promising every visitor to feel “seen in their authenticity.” It is amazing how visibility becomes selective.

And yet, Castlewood/Alsana’s sordid story gets richer.

The now closed Missouri residential treatment center, originally known as Castlewood Treatment Center had a long and reprehensible history. This history included:

  • Multiple malpractice and injury lawsuits alleging traumatizing psychological practices and harmful conduct at the facility.
  • Investigations and press reports of alleged inappropriate conduct by staff and internal complaints about practices that led to halting admissions.
  • Advocacy groups and former patient coalitions detailing a troubling legacy of psychological harm and exploitation at the same physical location that Alsana claims as part of its continuum of care.

This isn’t folklore, it’s part of the public record associated with the entity they now claim is reborn with “soul and heart.”

The eating disorder field is one where evidence-based practice literally saves lives. Compassion matters, but it is not a replacement for clinical rigor. When a provider’s most senior clinicians quit over ethical concerns, then get sued and threatened with additional legal action, that is not a “slow shift” toward quality, it is a red flag.

And yet Castlewood/Alsana’s public face leans into “connecting” and “creating change” without ever acknowledging the change that insiders say was needed but dismissed. Compliments and brand mantras do not a quality program make.

The eating disorder community doesn’t need another corporate monologue about authenticity and worth. It needs transparency about outcomes, commitments to evidence-based standards, and answers to why its former leaders felt compelled to walk away and speak out.

Because in the world of mental health care, soul isn’t a clinical safeguard. And heart isn’t a substitute for evidence.

It’s time to demand more than marketing.

Castlewood Treatment Center, LLC can call itself Alsana. It can talk about soul, heart, gratitude, and flowers. It can commission new logos and refresh its website.

But what it cannot do is rebrand away:

  • its legal identity,
  • its documented history,
  • the testimony of its former leaders, or
  • the unresolved questions surrounding patient harm.

For families seeking help, for patients fighting for recovery, and for clinicians trying to practice ethically, clarity matters more than comfort. Families deserve more than flowers. Families deserve truth, evidence, and accountability.

And until Castlewood/Alsana confronts its past instead of decorating over it, the castle, no matter how softly lit, no matter how hard its vacuous marketers attempt to put Humpty Dumpty back together… will fail.

No matter how many flowers it attempts to throw out designed to cover its corruption and misdeeds, those flowers are thrown over its own grave.

And if they are still looking for a new logo, I suggest this may be very apropos:

A Runaway Dog, Holiday Depression and … Community

In years past, during what is supposed to be the season of light and wonder, I have written about Morgan, my daughter. About our traditions. About the ritual of choosing a Christmas tree, the inevitable frustration of getting it into the house, the way it would sometimes tip and fall, shattering irreplaceable ornaments, or dry out far too soon until it stood there, brittle and skeletal, a hollow reminder of that which was once was alive. Depression was inevitable.

And yet, every year, some type of life preserver manifested. A sign. A message. Always gentle. Always loving. Something that steadied me, strengthened me, urged me to keep going when I did not know how.

One year it was candles being lit across the world—not just for Morgan, but for all those lost to eating disorders and other invisible battles of the mind.

Sacred, silent evenings filled with remembrance and fragile hope. Tears shed in the dark. Songs whispered more than sung.

But not this year.

This year there was no message. No inspiration. No carefully chosen words meant to lift the spirit or point toward brighter tomorrows. I would not, could not, manufacture hope when I did not feel it myself.

Yes, traditions were still observed. The familiar Christmas movies played on cue, laughed at in some places, cried over in others. A beautiful tree stood glowing in the house.

Every room dressed for the season. We hosted extravagant gatherings, opening our humble home to many. The food was exquisite. The drinks flowed freely.

And yet something was missing.

Something intangible. Something incorporeal.

An emptiness. A darkness that wrapped itself around me and pulled slowly, relentlessly toward a deep well of despair. I felt myself drowning in heartache.

Perhaps it was the sharper reality settling in: that Morgan is truly, irrevocably gone from this plane of existence. She is forgotten. And forgotten by a community who should remember. Perhaps it was the growing, unavoidable realization that no matter how many facts are presented, no matter how often the truth is spoken, the eating disorder “community” is a lost cause.

Lost to corruption. To incompetence. To ego and tribalism. To misused funding, hatred, ignorance, and endless divisiveness.

My daughter Morgan and so many others seemed to have been taken in vain. And the community charged with caring simply did not care. We parents of children who have been taken are living reminders of the community’s greatest failure. And because of that, we are meant to be silenced. At any and all cost.

That so-called community now barely exists at all. Perhaps in name only. It has shattered itself against the rocks of politics and radicalism. And it makes one wonder whether any true community can survive when it attempts to include people of differing beliefs, faiths, and backgrounds.

And just when you begin to believe the answer is no something unexpected happens.

Something small. Something ordinary. Something that quietly, stubbornly brings the glimmer of hope for greater tomorrows.

I am the owner of a two-year-old Vizsla. If you know the breed, you know this is fifty-five pounds of muscle, speed, enthusiasm and intelligence … paired with an almost absurd need to be pressed against your side like living Velcro. This is Beauregarde:

Because Vizslas require exercise, constant, vigorous exercise, my significant other (who is nothing short of a saint) found a nearby dog park. And so, every morning at about 7:15 a.m., we take this wood-headed dog to the park.

There, he runs. He taunts other dogs into chasing him, fully aware he can outrun them all. He greets strangers with unfiltered joy, as if each one might be the most important person he has ever met. And the people at the dog park, each owned by their own dogs welcome all with open arms.

These dog park people come from every imaginable walk of life.

One served aboard a Navy destroyer during the Vietnam War. When his house burned this past March, people from the dog park wrapped their arms around him and his family offering help, presence, and compassion without hesitation.

Another is an aeronautical engineer who worked on some of the most advanced aircraft ever built, and who carries his Alabama roots with well-earned pride. The depth and range of his intellect are astonishing.

There are others who are owned by their dogs. A sound engineer. A lighting engineer who toured with internationally known rock stars. A person who did space planning and construction for high-end retail outlets, including Neiman Marcus and whose resemblance to Burl Ives is uncanny. A dear, dear woman whose larger-than-life husband was cruelly taken from her just twenty months ago. A salesperson for a major lumber retailer, a hardcore Dallas Stars fan, (envision Santa Claus about 200 pounds lighter) married to a wife classically trained as a singer and musician. Another who works security for school districts and private companies, and who has trained his dog for those very same protective tasks. There is a married couple—he a brilliant PhD in business, she with a rich history of national-level sports activity and a lifetime spent caring for animals of every kind.

And there is an incredible woman who has battled anorexia for more than thirty years—who carries that struggle every single day, and yet brings resolve, wisdom, and quiet reminders of perseverance simply by showing up.

All of these individuals, of different ages, races, political beliefs, upbringings, and life experiences have inexplicably found themselves drawn to one place.

A dog park.

Drawn there by love for their animals. And in that shared love, they learned to look past their differences … because what united them was so much greater than what could ever divide them.

And so, we took our dog park meetings to a higher level.

First, we met for drinks. Then for dinner. And this Holiday Season, we welcomed the dog park group into our home.

The laughter was constant. The conversations effortless. The warmth unmistakable.

And then came the moment that revealed, without question, just how real, how solid, how deeply bound this community truly is.

On a cold Monday evening in North Texas, unknown to us, strong winds blew open one of our fence gates. We let Beauregarde into the side yard, unaware that his path to freedom had quietly opened.

Ten minutes passed. Perhaps more. Then we realized he wasn’t in the house. A quick search outside revealed the open gate—and the awful certainty that he was gone.

We live in a dense residential area. Texas Department of Transportation records indicate over thirty thousand (30,000) cars pass through nearby streets every day! Coyotes and bobcats roam nearby creek beds.

In short, it was a recipe for disaster.

We jumped into the car, driving frantically through the neighborhood, calling his name, scanning every shadow and street corner. And then it struck me …  The dog park people have a group text.

A frantic message went out explaining that Beauregarde had escaped and was missing.

What happened next overwhelmed me.

Instantly, messages poured in. How can we help? Where are you? We’re on our way.

Three people who lived closest to us immediately left their homes, getting in their cars, driving the neighborhood, or heading straight to our house.

And then less than ten minutes after the message was sent, a miracle appeared on my phone:

“I found him. I have Beauregarde.”

The woman who has fought anorexia for decades. The woman who has worked with horses and animals her entire life. The woman raised in Siberia, South Africa, and beyond, had found our wood-headed dog walking down the middle of a busy street.

When she called to him, he came to her immediately. And nothing could have been more symbolic than that reclamation of a lost loved one.

As I raced home for the reunion, a wave of relief and gratitude washed over me so powerful it was almost physical.

Soon after, one person from the dog park arrived at our house. Then another. And Beauregarde greeted each person with unrestrained joy—jumping, wagging, recognizing his people.

These were people who left their warm homes on a cold night. Who stepped away from their own lives to search for a dog. Who came without being asked, knowing full well the search might be fruitless.

They came because of community. Representing the very best in life.

We have so many differences. And yet none of that mattered. And it never has.

Because we were bound by something far greater than our differences. Something deeper than ideology or background or belief. Something strong enough to cut through despair and fear.

Perhaps that is where the answers lie.

Not in our differences.

But in embracing that which we share. In honoring our common humanity. In choosing love … again and again.

That night, we shared something sacred.

We shared our love.

We shared our community.

DSM Steering Committee Proposal

The DSM Steering Committee is recommending changes to the severity specifier levels of anorexia nervosa, bulimia nervosa, and binge eating disorder. The changes are intended to emphasize the importance of symptom severity, functional impairment, and illness-related medical complications rather than relying on a range of BMI levels (anorexia nervosa), episodes of inappropriate compensatory behaviors (bulimia nervosa), and episodes of binge eating (binge-eating disorder). The updated severity levels will also be more comparable to the severity of other disorders in the DSM.

The recommended changes can be found here:

https://www.psychiatry.org/psychiatrists/practice/dsm/proposed-changes#:~:text=Description%20of%20Proposed%20Change:,other%20disorders%20in%20the%20DSM

So, what does this actually mean?

First, the American Psychiatric Association has not yet agreed to change the DSM severity criteria for anorexia, bulimia, and binge eating disorder. This is a proposal, not an adoption.

Let’s review what the APA adoption process looks like.

Proposals are submitted: Changes to diagnostic criteria, additions, deletions, etc., are submitted by clinicians and researchers through the APA’s DSM proposal portal.

Next comes the Steering Committee Review. The DSM Steering Committee and specialized Review Committees assess the proposals for scientific evidence, clinical utility, and reliability. If the Steering Committee finds a proposal promising, it is posted for public comment.

The next step is the Final Steering Committee Recommendation. The Steering Committee issues a formal recommendation (either for approval or rejection/modification).

Finally, Steering Committee recommendations must then be approved by the APA Board of Trustees and Assembly before changes are incorporated into the DSM or DSM-5-TR.

With this review procedure in place, let us now look at how often proposals are rejected.

First, I could not locate any websites which show a published rate of rejection. But empirical examples from analyses of the initial iterative revision experience following DSM-5 publication exist.

In a report on the first 3 years of the iterative revision process twenty-nine (29) proposals were received.

These proposals resulted in a few successful changes: addition of prolonged grief disorder, modifications to existing criteria (e.g., ARFID), and inclusion of new codes.

One proposal was explicitly rejected by the APA Board.

17 proposals were returned to the submitters with requests for additional supporting data but not adopted as submitted.

Two proposals were rejected without further review due to conceptual issues.

Others were deferred or still under review.

Therefore, of the 29 proposals in the first three (3) years, it appears as if at least twenty (20) were not approved for inclusion in the DSM-5 or DSM-5-TR. While not a formal percentage, a substantial proportion of proposals (in this case, more than half of those submitted) did not directly result in adopted changes in that period — either rejected outright, deferred for more evidence, or modified significantly before acceptance.

Key points to understand from this process are approval is multistage. Even if the Steering Committee recommends a change, it still must pass approval by the APA Board of Trustees and Assembly. Importantly and statistically, the greatest impediment appears to be lack of data. The majority of proposals are returned for additional evidence rather than adopted, showing how stringent the criteria are on empirical support. Finally, the iterative process means ongoing evaluation: The APA’s current model for DSM revision is deliberately iterative and evidence-driven, which tends to minimize adoption of weakly supported proposals.

Also, the DSM is just a general guideline tool. APA’s practice guideline includes a “Statement of Intent” “… that the guideline should not be considered a statement of the standard of care and does not mandate any particular course of medical care and is not a substitute for independent clinical judgment.”

The DSM guidelines are NOT a generally accepted standard of care. In fact, there is no generally accepted standard of care (“GASC”) for eating disorders. This is a huge negative factor which has been haunting the eating disorder community for years.

That factor was decisive in the Wit v. UBH case.

In Wit v. United Behavioral Health, the district court held (and the Ninth Circuit largely left intact for this purpose) that:

An insurer’s internal guidelines are enforceable if they do not conflict with generally accepted standards of care.

Crucially, Wit did not require insurers to mirror professional association guidance, nor did it require guidelines to be optimal or patient-favorable … only that they not contradict the GASC.

This creates a binary inquiry:

If GASC exists and the insurance guideline contradicts it → unenforceable

If GASC is absent, unsettled, or heterogeneous → insurer discretion survives

That premise is decisive for eating-disorder claims. Unlike many medical conditions, eating disorders suffer from persistent standard of care fragmentation. There is no universally accepted level-of-care criteria. There are competing frameworks (APA, AACAP, SAHM, insurer-developed tools, proprietary LOC criteria). There is variation in reliance on: BMI; % expected body weight; Vital sign instability; Functional impairment; Psychiatric risk; Trajectory vs. snapshot severity.

Because no unified GASC exists, insurers can plausibly argue, “Our guideline does not contradict generally accepted standards—because no single standard exists to contradict.”

That argument has been repeatedly successful in eating-disorder denial litigation.

On a positive note, the Steering Committee proposal would reframe DSM severity specifiers for AN, BN, and BED. It would emphasize: Functional impairment; Symptom severity; Medical complications; Explicitly de-emphasize single-metric severity determinations (BMI/frequency counts).

However, and importantly:

It does not eliminate BMI for insurance company consideration;

It does not establish level-of-care rules;

It does not declare BMI-based criteria invalid;

It does not override APA’s SOC disclaimers.

So even if adopted, it would be diagnostic and descriptive, not prescriptive advisory nor normative.

Under Wit v. UBH, the DSM Steering Committee’s proposal, while clinically significant, would not materially constrain insurer claim handling absent a broader, enforceable consensus standard of care for eating disorders, which still does not exist.

Regarding the Steering Committee Proposal, there is a one-month public comment window [Until January 9, 2026]. It is critical that the APA hears from intelligent voices. Voices which supply objective data, medical evidence and information, independent authoritative research studies.

Undoubtedly, activists will also be submitting their lived experience stories claiming they are dispositive. And whereas they are certainly a part of the equation, collaborative messaging which shows unity and a collective strong voice is more important than ever before.

If you are struggling with the substance of the comments you wish to make, The International Federation of Eating Disorder Dietitians on its website has suggested comments. This page also has extensive background on the evolution of this initiative. (And yes, thanks to Jessica Setnick should definitely go out!):

IFEDD Advocacy Initiatives

That is the only way in which true evolution and change are possible.

Ai-Generated “Therapists”: Promise, Peril, and What’s Next?

In November 2025, Joe Braidwood, a co-founder of “Yara Ai” chose to shutter his Ai therapy product after concluding it posed unacceptable risks for people with serious mental health issues. This is but the latest chapter in the cautionary tale for the proliferation of Ai therapy.

Mr. Braidwood stated in part: “We stopped Yara because we realized we were building in an impossible space. Ai can be wonderful for everyday stress, sleep troubles, or processing a difficult conversation. But the moment someone truly vulnerable reaches out – someone in crisis, someone with deep trauma, someone contemplating ending their life – Ai becomes dangerous. Not just inadequate. Dangerous.”

“The gap between what Ai can safely do and what desperate people need isn’t just a technical problem. It’s an existential one. And startups, facing mounting regulations and unlimited liability, aren’t the right vehicles to bridge it.”

“… the mental health crisis isn’t waiting for us to figure out the perfect solution. People are already turning to Ai for support. They deserve better than what they’re getting from generic chatbots.”

After Mr. Braidwood terminated Yara Ai, to his immense credit he jumped into the next chapter … how to make Ai programs safer. Mr. Braidwood announced the opening of  GLACIS Technologies – their attempt to contribute to the infrastructure of AI safety:

https://www.linkedin.com/pulse/from-heartbreak-infrastructure-why-were-building-glacis-joe-braidwood-uzulc/

Read his words again “… someone in crisis, someone with deep trauma, someone contemplating ending their life – Ai becomes dangerous. Not just inadequate. Dangerous.” “… [it] isn’t just a technical problem. It’s an existential one. And startups, facing mounting regulations and unlimited liability, aren’t the right vehicles to bridge it.”

An existential, dangerous problem which startups are not equipped to handle. Consider that reality. And yet, the underlying issue is snowballing at an alarming rate.

This past year, the Harvard Business Review research found the top use of Generative Ai was … “Companionship and Therapy.”

The global Ai in healthcare market is projected to grow rapidly from approximately $37.09 billion in 2025 to over $427 billion by 2032, a compound annual growth rate (CAGR) of over 40%.

In 2025, 22% of healthcare organizations reported having already implemented domain-specific AI tools, a significant increase from just 3% two years prior. A 2024 survey noted that 66% of U.S. physicians were using some form of AI, up from 38% in 2023.

The U.S. Food and Drug Administration (FDA) has authorized over 1200 Ai or machine learning-enabled medical devices to date, indicating increasing regulatory acceptance and the transition of Ai from research to clinical practice.

On October 21, 2025, Menlo ventures released an extensive article on Ai in healthcare.

2025: The State of AI in Healthcare

So, to whom shall we entrust this existential, potentially dangerous issue? Or for that matter does it really matter to whom society “entrusts” the development of this generational, life altering technology? We already know which industry will pioneer the way, developing the technology which will “address” our mental health needs in the future. And their motivation is far from altruistic.

Insurance companies.

Insurance companies are already increasingly investing in Ai driven mental health tools which are “intended” to offer immediate, scalable support.

So why does the insurance industry want Ai programs in the mental health field?

The Case For: Why Insurers Want Ai in Mental Health

1) Access, Speed, and Convenience. In many regions, patients wait weeks for an initial appointment. A 24/7 platform can provide immediate support, especially for low-acuity needs such as stress management, sleep hygiene, and mild-to-moderate anxiety symptoms.

2) Standardization and Protocol Fidelity. Ai systems can deliver structured interventions consistently, reduce clinician “drift” from evidence-based protocols, and prompt ongoing practice of therapeutic skills. For payers, this is attractive because standardization is measurable and scalable.

3) Measurement-Based Care at Scale. Ai can administer screeners, track symptom trends, and support follow through between sessions. When used under clinician governance, this can improve continuity and help identify deterioration earlier.

4) Cost Containment and System Efficiency. The economic case is straightforward: lower-cost interventions for appropriate cases, and potentially fewer downstream costs if early support prevents escalation.

The Case Against: Clinical, Legal, and Ethical Risks

1) Therapy Without Clear Clinical Accountability. When a human clinician provides psychotherapy, licensing and standards of care create identifiable responsibility. [Responsibility which seems to be increasingly overlooked or ignored.] With Ai-only services, accountability becomes diffuse; vendor, insurer, developer, or “the user” which is a poor fit for high-stakes mental health care.

2) Safety in High-Risk Scenarios. Crisis states such as suicidality, self-harm, psychosis, and domestic violence are exactly where failure is most consequential. Ai systems can miss context, misinterpret signals, or provide responses that inadvertently increase risk.

3) Mistriage and Oversimplification. Even good clinicians mistriage. Ai can compound the problem if it lacks nuance around comorbidities, trauma histories, neurodiversity, or cultural context. False reassurance is dangerous; excessive escalation can overwhelm human systems.

4) Privacy and Conflict of Interest. Insurance is structurally sensitive. It sits where health data meets claims management and utilization decisions. If therapy content feeds decision making, or even creates a reasonable fear that it could, patients may self-censor, undermining care.

The “Fortune / Yara” Inflection Point … and the Counter-Lesson

The Yara shutdown, as reported, is primarily cited for a blunt conclusion; that even with guardrails, Ai therapy may be too dangerous for people with serious mental health issues. In today’s derivation of Ai therapy, that is an accurate and alarming concern.

A more practical reading is more nuanced and more actionable: the most defensible lane is Ai augmented care, not Ai-as-therapist … yet. The difference is not semantic, it is operational. If an insurer deploys Ai, safety must be built as a system: constrained scopes, explicit disclosures, continuous monitoring, and fast human escalation that works in real life not just on paper. But safety can be very expensive.

And we know when operational constraints meet financial constraints, history dictates operational constraints will be compromised.

Human Frailties, Ideological Drift, and Why This Can Fuel Ai Adoption

A less discussed but increasingly influential driver of Ai adoption is patient dissatisfaction with human variability … including the perception that some therapists allow personal politics or social ideology to shape the therapeutic relationship. [The “ism” police is prevalent among many therapists.]

While many clinicians practice ethically, a subset of patients report experiences where therapy felt judgmental or moralizing, or where they felt pressured into a social or political framework that did not fit their needs. Even if these experiences are not yet the norm, they can be highly salient: a single negative encounter can permanently reduce willingness to seek traditional care.

As clinicians continue to incorporate radical belief systems like White Supremacy Culture, fatphobia, Indigenous Person’s Land Use Acknowledgements, zero sum game thinking, anti-Semitism, the patriarchy and radical political and social justice views into their everyday lexicon, they lose the ability to listen to their patients, to meet their patients where they are in exchange for ethical, insightful therapeutic regimens where the patient’s needs are prioritized.

This dynamic can and will accelerate Ai adoption in several ways:

  1. Demand for predictable, skills-based support. Many users primarily want coping tools rather than worldview driven interpretation. Ai systems can be positioned as consistent, nonjudgmental, and oriented around concrete skill building. For mild-to-moderate conditions, that positioning will attract patients who want help without interpersonal friction.
  2. Institutional preference for auditability and uniformity. Employers and insurers are sensitive to reputational risk and complaint volume. Ai systems can be constrained, logged, and audited in ways that are difficult with individualized human practice. That makes Ai attractive to institutions seeking standardized delivery, especially for early-stage care pathways. Like insurance companies.
  3. A political paradox: “neutrality” becomes a marketing claim—and a target. Ai is not truly neutral. Training data, safety policies, and vendor tuning encode normative assumptions. Over time, the debate will shift from “therapists inject beliefs” to “platforms embed beliefs.” The perceived advantage of Ai (less idiosyncratic bias) may become a liability if users discover a consistent, system-level bias scaled across millions.
  4. Fragmentation into “values aligned” therapy styles. Some users will prefer “politics-free” skills support; others will want culturally specific or worldview aligned care. Ai platforms can offer configurable styles, but that introduces the risk of “therapeutic filter bubbles,” where systems affirm a user’s worldview rather than challenge maladaptive beliefs when appropriate.

The net effect is that concerns about human bias will inevitably increase appetite for Ai mental-health platforms, but they will also intensify demand for transparency, choice, and oversight. Values will not disappear. Instead, they are moved upstream into product design.

Practical Guardrails for Ethical and Defensible Deployment

In the unlikely event insurance companies seriously embrace issues other than financial viability, if insurers want Ai therapy to be sustainable, guardrails must be more than disclaimers. For example, they must adopt and enforce:

  • Truthful labeling: don’t call it “therapy” if it isn’t clinician-delivered.
  • Disclosure: repeated, clear notice when the user is interacting with Ai.
  • Clinical governance: licensed oversight of protocols, risk signals, and escalation criteria.
  • Real escalation: quick handoffs to humans with operational accountability.
  • Data minimization and segregation: limit retention and wall off therapy content from coverage decisioning.
  • User choice: Ai should be an option, not a prerequisite for human care when clinically indicated.
  • Independent audit: safety, bias, and outcomes evaluation.

Nonetheless, the insurance industry is already using Ai. Its growth and usage will be unprecedented.

Conclusion

Ai mental health platforms can widen access and improve measurement-based care, but they also create nontrivial risks: safety failures, blurred accountability, privacy conflicts, and scaled bias. Air-gapped systems may reduce external security concerns and speed institutional adoption, yet they heighten the need for strict internal governance, because the most important question becomes not only what the Ai says—but what insurers do with what members reveal.

Ultimately, patient experiences with human inconsistency, including perceived ideological drift, will accelerate demand for Ai support. But that same demand will fuel a new expectation: transparency about values embedded in systems, meaningful patient choice, and enforceable protections that keep “care” from becoming merely a more sophisticated form of utilization management.

Ai is here and it is only in its infancy. And we are right to question ultimately whether we will remain the master of Ai … or whether Ai will become our overlords. Sadly, I believe it inevitable that we will approach that point in time when we give the command, “Open the pod bay doors, HAL.” And the chilling reply will be, “I’m sorry, Dave. I’m afraid I can’t do that”.

When Activism Becomes Your Identity Recovery Suffers

Eating disorder (ED) treatment sits at an uneasy intersection: medicine and meaning, physiology and identity, personal suffering and social narrative. In that terrain, clinician activism can be a force for good, reducing stigma, broadening access, and challenging harmful norms.

But there is a predictable failure mode when activism frameworks become not just a tool, but a clinician’s very identity. In the eating disorder community, particularly where more militant clinician activists strongly endorse the Health at Every Size (HAES) principles which have been long abandoned by the ASDAH and “White Supremacy Culture” frameworks, identity fusion can undermine clinical objectivity and, in turn, inhibit recovery.

The Core Dynamic: Identity Fusion in Clinician-Activism

Identity fusion (also described as role engulfment, overidentification, or enmeshment) occurs when “the cause” becomes inseparable from “the self.” The clinician activist no longer merely uses a framework; they become and are the framework. They view disagreement or complexity as an existential threat not to an idea, but to their very own identity. In doing so, professional, objective debate becomes impossible since the disagreement is no longer about an eating disorder issue. It is perceived to be about the person.

In that state, clinical questions are vulnerable to moralization:

  • A clinical disagreement becomes “harm.”
  • A treatment trade off becomes “violence.”
  • A patient’s ambivalence becomes “internalized oppression.”
  • A colleague’s caution becomes “complicity.”

None of this requires malice although identity fusion is inevitably morphing into a malice-based reality. It arises from the same impulse that draws many clinicians into ED work: a commitment to relieve suffering and protect vulnerable people. The problem is that fused identity tends to produce epistemic lock-in, a narrowing of what counts as legitimate evidence, clinically relevant language, and/or acceptable outcomes.

And this results in harming patients.

7 Ways Militant Identity-fusion Harms Patients

1) Disagreement is improperly perceived as harm

When a professional fellow clinician asks about vitals, level of care, growth curves, or weight trajectory and your first move is moral accusation (“harmful,” “violent,” “unsafe”), you’ve replaced clinical reasoning with social control.

Impact: Teams stop speaking plainly. Errors persist longer. Patients inevitably deteriorate.

2) “Weight-neutral” becomes “weight-blind”

Stigma reduction is not the same as refusing clinically relevant data.

If your practice has blanket taboos, “never weigh,” “never discuss weight adjacent information,” “never document it,” “never acknowledge weight change even when medically relevant” … you are letting ideology override physiology.

Impact: Delayed recognition of instability, delayed escalation, preventable crises.

3) The framework becomes the differential diagnosis

If every case collapses into one explanation (diet culture, oppression, stigma) and alternative hypotheses are treated as betrayal, you’re no longer practicing medicine or psychotherapy … you’re practicing narrative enforcement.

Impact: Missed complexity of the intersection of ARFID, OCD, Autism, Trauma, substance use, GI-endocrine resulting in impaired and slower recovery.  

4) “Internalized ____” is used as a trump card

If a patient’s goals or fears are explained away as “internalized fatphobia,” “internalized white supremacy,” etc., without genuine exploration, you’re doing something coercive: you’re disqualifying the patient’s agency by definition.

Impact: Performance over honesty; more secrecy, more dropout, less change.

5) Outcomes are replaced with virtue

If you spend more time policing language, “calling in/out,” and attempting to establish moral positioning rather than tracking response to treatment, you’re drifting from care to identity maintenance.

Impact: Plans don’t update when they aren’t working. Patients stay stuck longer.

6) You punish measurement instead of fixing measurement

Measurement can be stigmatizing. The solution is not to ban it; it’s to do it professionally and competently:

  • blinded weights when indicated
  • trauma-informed procedures
  • clear consent scripts
  • a focus on vitals, labs, function, behaviors, impairment
  • explicit thresholds for escalation

Impact when you ban instead: You lose safety signals and invite late-stage emergencies.

7) Institutions are treated like enemies, not systems to improve

If “White Supremacy Culture” language becomes a cudgel (to win arguments) rather than a tool (to identify disparities), it stops improving care and starts producing fear and paralysis.

Impact: Staff self-censor, teams fracture, equity work becomes theater rather than outcome based.

Why ED Recovery Is Especially Vulnerable to Identity Fusion

ED recovery is rarely linear and almost never purely ideological. It typically requires:

  • honest assessment of risk (medical, behavioral, psychiatric)
  • tolerating discomfort and ambiguity
  • confronting avoidance and cognitive rigidity
  • willingness to test beliefs against real-world outcomes

Identity-fused activism can unintentionally reinforce the very rigidity that EDs thrive on—only now it’s dressed up as ethics.

This type of identity activism generally manifests in at least five (5) different mechanisms.

Mechanism 1: Skewed Assessment—When “Weight-Neutral” Becomes “Weight-Blind”

When HAES was relevant, a HAES approach could help reduce shame and prevent naïve weight moralizing. But when weight neutrality becomes identity instead of strategy, it drifts into weight blindness. This is a refusal to engage with weight-adjacent data even when medically and diagnostically relevant.

That matters because ED medical risk is often not negotiable and manifests in:

  • bradycardia, hypotension, syncope
  • electrolyte abnormalities
  • refeeding risk
  • growth suppression in adolescents
  • medication dosing and side effect profiles tied to physiological status

A blanket avoidance of weight trajectories, growth curves, or energy deficit indicators can lead to:

  • under recognition of medical instability
  • delayed escalation to higher levels of care
  • misinterpretation of deterioration as “diet culture panic” rather than clinical decline

Paradoxically, this can increase the likelihood of crisis, i.e., forcing coercive interventions later that could have been avoided with earlier, calmer medical clarity.

Mechanism 2: Ideology First Treatment Planning—One Lens for Every Patient

Recovery requires individualized formulation: what maintains the disorder for this person, with this body, history, and risk profile?

When activism is fused with identity, the framework can become pre-emptive and totalizing:

  • the formulation is decided in advance (oppression, diet culture, stigma)
  • the clinical plan becomes a demonstration of ideological consistency
  • alternative hypotheses are filtered out

In practice, this can look like:

  • prioritizing worldview alignment over stabilization sequencing
  • treating weight change (in either direction) as inherently suspect or unspeakable
  • minimizing patient-specific drivers (trauma, OCD, autism/ARFID presentations, bipolarity, GI/endocrine issues, substance use, family dynamics)

The result is not “anti-oppressive care.” It is reduced differential diagnosis and reduced responsiveness to real-time clinical feedback—two reliable ways to prolong illness.

Mechanism 3: Speaking Taboos and Team Brittleness—When Consultation Becomes Risky

High quality ED treatment depends on teams: medical providers, therapists, dietitians, psychiatrists, higher levels of care and the family. Teams improve outcomes when they can speak plainly about risk, behaviors, and response to treatment.

Identity-fused activism can create taboo trade-offs: certain words and outcomes become morally contaminated. For example:

  • “weight loss” and “weight gain” become unsayable even when clinically relevant
  • “Obesity” cannot ever be said
  • “medical necessity” is treated as a pretext for bias rather than sometimes a reality
  • case presentations omit key data to avoid value conflict

Teams then develop avoidance patterns:

  • clinicians don’t raise concerns that might trigger ideological conflict
  • supervision becomes performative
  • “safe/unsafe person” sorting replaces “strong/weak hypothesis”

When honest consultation becomes socially risky, subtle deterioration is easier to miss and recovery slows.

Mechanism 4: Therapy Turns into Recruitment—Undermining Autonomy and Informed Consent

A less recognized harm of identity-fused clinician activism is coercivealignment. Patients pick up on what a clinician needs them to believe to be considered “good,” “safe,” or “not harmful.”

This can inhibit recovery by:

  • replacing curiosity with compliance
  • encouraging patients to outsource thinking to ideology
  • shaming patients for goals they genuinely hold (including weight-related goals, either direction)
  • pathologizing disagreement as “internalized” something, rather than treating it as an authentic value conflict

In ED recovery, where identity and control are already central themes, this dynamic can be particularly damaging. The patient’s job becomes to perform correctness rather than do the hard work of change.

Mechanism 5: “White Supremacy Culture” as a Total Explanation … From Equity Tool to Clinical Shortcut

Equity frameworks can illuminate real disparities: who gets believed, who is labeled “noncompliant,” whose pain is minimized, whose ED is recognized early, and who can access care. Used well, these frameworks can sharpen clinical accountability.

Used as identity, they can become a clinical shortcut:

  • a slogan substitutes for specific behavioral analysis
  • staff anxiety about “getting it wrong” reduces honest assessment
  • outcome metrics get replaced by moral language

In the worst case, the framework becomes an interpretive monopoly: if a patient isn’t improving, the explanation is always the system or diet culture, never the possibility that the chosen intervention isn’t working for this person.

Recovery requires feedback loops. Any framework that discourages revising the plan when the data demand it will predictably inhibit recovery.

What This Looks Like to Patients

Patients tend to experience the downstream effects in concrete ways:

  • Confusion: “We’re not tracking the things that make me feel unsafe—why?”
  • Silence: “Certain topics make my clinician tense, so I avoid them.”
  • Pressure: “If I don’t adopt the right worldview, I’m seen as the problem.”
  • Delay: “We stayed in the wrong level of care too long because talking about risk felt taboo.”
  • Discouragement: “Treatment became about theory, not about me.”

And for many patients, the ED seizes on the contradiction: if the clinician won’t name physiological reality, the disorder will.

Guardrails: Keeping Advocacy Without Losing Objectivity

The remedy is not “less compassion.” It’s more structure; clinical, ethical, and team based.

1) Separate roles explicitly

Use an internal “two hats” model:

  • Advocate hat: values, access, dignity, stigma reduction
  • Clinician hat: differential diagnosis, risk, measurement, falsifiable hypotheses

2) Require a “facts-only” case summary

Before any formulation, write a short paragraph of observable data:

  • vitals, labs, behaviors, impairment, psychiatric risk, trajectory
    Then add the narrative and equity lens.

3) Pre-commit to falsifiers

Ask: “What would make us change the plan within 2–4 weeks?”
Define escalation criteria clearly, including medical thresholds.

4) Build structured dissent into the team

Rotate a designated “alternative hypothesis” role in case conference. Formulate on alternative platform. This has the effect of reducing groupthink without moral conflict.

5) Make informed consent real

If a clinic centers a framework, say plainly what it means in practice:

  • how monitoring is handled (e.g., blinded weights when needed)
  • what outcomes are targeted
  • what happens if the patient’s goals differ
  • what alternatives exist

6) Translate equity frameworks into measurable clinic behaviors. In emphasizing this aspect, this keeps antiracism clinical rather than rhetorical.

Focus on:

  • access inequities
  • bias in diagnosis rates
  • differential treatment dropout
  • pain and symptom dismissal patterns
  • culturally competent engagement.

Conclusion: Recovery Needs Reality, Not Ritual

Activism in the ED field has certainly helped some patients feel less shame and more seen. But when clinician activism becomes identity fusion—particularly around HAES and “White Supremacy Culture” frameworks, the risk is that treatment becomes less falsifiable, less individualized, and morally brittle.

ED recovery thrives on flexible thinking, accurate assessment, and iterative change. Any approach that turns clinical conversation into taboo, ideology into identity, or disagreement into harm will predictably inhibit recovery by narrowing what can be said, measured, reconsidered, and healed.

The goal is not to remove values from care. It is to keep values in their proper place and perspective: guiding dignity and equity, while preserving the clinician’s first obligation in ED treatment … to see clearly, respond to data, and help the patient recover in their own life, not inside someone else’s ideology.

The Quiet Blessings of Thanksgiving

In the past, the days leading up to and including Thanksgiving Day used to be both simple and yet complex. For my family, it was an annual event when siblings and family would fly to Dallas. The numerous trips to the airport. Every bedroom being filled.

On Wednesday, the night before Thanksgiving as the turkey was being brined, we would frequent a local Mexican food restaurant. Sometimes as many as 16 or more. There were times when I simply looked around at this family with love, with wonder, with puzzlement … this wacky, dysfunctional, mostly loving family. And yet looking back now, I realize that I never had a true understanding of the magic and wonder of “family.”

Thanksgiving Day would see my much more athletic brother run in the local Turkey Trot. An event my son, daughter and I participated in once as well. And then returning home to start the cooking, and drinking, and football.

Thanksgiving is so much about our senses … tasting, feeling, listening and particularly smelling incredible aromas.  The turkey roasting, homemade cranberry sauce, mashed potatoes, and all sorts of other food to fill the stomach and satisfy all senses. Fragrant candles lit in each room.

There would be full plates and loud rooms, mismatched chairs pulled from every corner of the house, the laughter of children rising above the noise like a bright ribbon in the air. At times, Morgan’s laugh being the loudest of all.

And then … as this message was channeling through me, I was distracted and then intrigued by the squealing laughter of children outside. I walked outside and saw 5 – 6 children playing in a small front yard about 3 houses away. This was surprising since the neighborhood I inhabit consists of many, many blue hairs, elderly people … geezers if you will. Nonetheless, the children’s sweet, innocent laughter rang loud and joyous. And it reminded me of that which once was.

Now, nine years have passed since anorexia took Morgan from us, and for me, the holiday will never be simple again.

Yet, with time, grief evolves and has its own way of teaching a person how to see … how to look beyond absence and despair and perhaps, if you’re lucky enough, to discover the blessings that remain, even when they come wrapped in sorrow.

Some people say time heals. I don’t believe that. Time doesn’t heal; what it does is carve space. In that space, memory begins to settle gently instead of cutting sharply. I no longer remember only the hospital rooms, the fear, the battles we lost all passing as if in slow motion. I am blessed to be able to still distinctly remember Morgan’s humor, her stubborn streak, her compassion for every stray creature that crossed her path. I remember her kindness … and that is a blessing.

Memory is what lets me keep being her daddy, long after the world perhaps stopped seeing me as one.

After Morgan’s death, I immersed myself in the eating disorder community. I needed to understand. I thought my assistance would be welcomed. I needed to make sure that no other parent stood where I now stood, at the quiet cliff edge of the unthinkable.

Throughout my journeys, I have met brave parents, resilient survivors, clinicians who cared with their whole hearts, and advocates who fought every day against the silence that kills. People who have inspired me. And humbled me with their intelligence and grace. These people became my extended family. Their courage is a blessing I name out loud.

But to be honest, and Thanksgiving is a time for honesty, there is another side. A side that overwhelms me still. The corruption, the unchecked egos, the nonprofit politics, the professional turf wars, the bizarre stupidity that leaves vulnerable people without the care they desperately need. After nearly a decade in this world, I have seen how dysfunction can metastasize around suffering, how institutions can forget the very people they were created to serve.

Sometimes it feels like trying to clean the ocean with a teaspoon.

And yet, these hard lessons too, teach gratitude. Because it reminds me why I stay. It reminds me that my daughter’s life deserves more than resignation. It reminds me that the brokenness of a system does not erase the goodness of individuals. It reminds me that meaningful change, even when slow, is still possible. And that hope, no matter how bruised, is still a blessing.

Grief gave me a mission I never asked for. No parent should ever have to become an expert in eating disorders because their child died from one. But here I am. And on my best days, I believe that purpose is a gift … and a blessing.

I have learned to speak loudly for those who are silenced by shame. I have learned to ask hard questions, even when the answers are inconvenient for people in power. I have written articles with a tone that is off putting. I have made dear friends. And others have made themselves staunch enemies. That alone has surprised me. After all, aren’t we all working toward the same goal?

Valuable lessons are learned each day. One of the most important lessons I learned is that love can outlive a child, not because it replaces them, but because it honors them.

Every time a family finds help, every time a young person reaches recovery, every time someone feels less alone because of something I may have shared or that Morgan provided to them … this is my daughter’s legacy. These are her blessings.

There is an empty chair at my Thanksgiving table. It will always be empty. But every year, that space teaches me something new.

It teaches me tenderness. It teaches me to pay attention to the fragile, invisible battles others carry. It teaches me that gratitude does not require a life without heartbreak; it only asks that we keep our hearts open anyway.

Some years, that feels possible. Some years, it doesn’t. But the blessing is in the trying.

If I could give thanks for only one thing, it would be love. I am grateful that love is not undone by death. I am grateful that being Morgan’s daddy did not end the day she took her last breath. I am grateful that grief, painful as it is, is simply love in its most honest form.

This Thanksgiving, I give thanks for my daughter’s life, for those young people she helped, for the people fighting the good fight in a broken system, for the parents who keep going, for the survivors who refuse to be defined by their illness, and for the unseen blessings that rise from sorrow like morning light after a long night.

Nine years later, the gratitude is softer. More complicated. More real.

But it is there. And that, too, is a blessing.

Gratitude for ?

In years past — usually every November — Sierra Tucson and its Overlord and Master, Acadia Healthcare, would descend upon the Dallas–Fort Worth area to host their annual “Gratitude for Giving” Event.

This event purported to honor individuals and organizations making a positive impact in the mental health community. A noble endeavor, at least in theory — recognizing the resilient, compassionate mental health professionals who do thankless work while corporate giants circle overhead, feeding off their labor.

So without further ado, let’s get to this year’s honorees. They are …

Uh … well … uh…

Make no mistake: North Texas is overflowing with mental health heroes who deserve recognition — especially the ones humble enough to insist they are not worthy of it.

And yet, Acadia chose to honor …

That is undoubtedly due in large part to the fact that Acadia is not hosting a Gratitude for Giving Event in North Texas this year.

Why? Oh, the reasons are plentiful. Embarrassingly plentiful.

Possible Reasons

It could be … that Acadia’s once-respectable stock price — around $82 per share in September 2024 — is now living, if one can call it that, on life support at a pathetic $15.00. That’s not a dip; that’s a financial face-plant. Ouch.

It could be the ongoing Department of Justice fraud investigation that refuses to die … much like the problems Acadia keeps pretending don’t exist. Nothing says “gratitude” like having federal agents rummaging through your corporate laundry.

It could be in November 2025, Acadia shelled out a cool $179 million to settle one of the many fraud lawsuits brought by its own shareholders. When your investors sue you, you know you’ve achieved a special level of corporate rot.

It could be the numerous other pending lawsuits against Acadia owned entities for allegedly physically and sexually abusing people entrusted to its care(?).

It could be the abrupt closure of multiple Acadia facilities over the past year — not because they suddenly discovered ethics, but because the abuse was too egregious or the profits weren’t fat enough. Facilities like Options Hospital, Carolina House, Timberline Knolls, Montecatini.

It could be the number of victims under the “watchful” eye of Acadia who died at their facilities.

It could be the fact that the Department of Veteran’s Affairs is investigating Acadia for allegedly engaging in Medicaid fraud.

It could be that shareholders have filed other fraud lawsuits against Acadia alleging that Acadia engages in medically unnecessary involuntary hospitalization of psychiatric patients. Because nothing says “healthcare” like trapping people to bill insurance.

It could be that Acadia’s methadone clinics are under investigation for falsifying medical records to meet productivity quotas — and billing insurers and Medicaid for therapy sessions that never happened. Productivity over people, as always.

It could be that in June 2024, the US Senate issued a scathing report regarding Acadia and 3 other entities alleging in part that vulnerable children are being used as pawns to maximize the profits of these facilities – and American taxpayers are footing the bill. The report further states, “More often than not, these kids aren’t even getting the basic care they need and instead are in many cases experiencing serious neglect and abuse.”

This is not a wave of bad publicity. It is a tsunami of scandal, abuse, fraud, and moral bankruptcy. And so Acadia — desperate for even a flicker of positive PR — chooses to honor…

Shouldn’t we wonder why? Is it because its head isn’t screwed on just right? Could it be perhaps, that its shoes are too tight? But, perhaps the most likely reason of all … is that its heart is two sizes too small!

But let’s drop the Seussian metaphors for a moment. We all know the real reason.

When an entity places profits over patient care, the inevitable results are mistreatment, abuse and tragedy. At its quarterly shareholders’ meetings, the number of beds are discussed, quarterly revenue, adjusted EBIDTA, capital expenditures, market trends, and issues pertaining to its revenue. What is not discussed is the lack of QUALITY care given, the harm to families it is causing, the abuse, or how the lack of oversight of its facilities is being addressed.

Life and death issues being cavalierly dismissed. After all, we can’t let a few deaths and some abuse detract from Acadia’s CEO’s annual salary of $7 million! That daily paycheck of $19,178.00 needs to keep rolling in!

With this long history of abuse, assault, fraud, unethical profiteering, lack of transparency, shuttering facilities and gross mismanagement, who should be referred to any Acadia facility?

Sadly, that will not stop eating disorder organizations from continuing to accept Acadia’s dirty money and marketers continuing to refer families to Acadia’s chambers of abuse … More’s the pity.

The Best of Times … the Worst of Times: Real Life in the Age of Social Media

“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of light, it was the season of darkness, it was the spring of hope, it was the winter of despair.”

Charles Dickens, A Tale of Two Cities,

Dickens’ well-known quote reflects the contradictory nature of the era it describes, the French Revolution and the Industrial Revolution, where societal extremes of wisdom and foolishness, belief and doubt, and hope and despair coexisted. The phrase is often used today to describe any period of conflicting circumstances, where seemingly opposite conditions exist simultaneously. 

Dickens captured an era riven by contradiction—one that is strikingly familiar in our decaying, digital age. Today, we move through a world that offers extraordinary access, unprecedented connectivity, and boundless opportunities for expression. Yet those same spaces are shaped by curated identities, algorithm-fed anxieties, and an ever-growing sense of distance among people who are, paradoxically, more connected than ever.

The fears, insecurities and cowardice which define the essence of keyboard warriors have come to define their very lives. And pushes them even further from humanity.

It Was the Best of Times: The Goodness of Real Life

Real life … messy, unpredictable and intimate remains the realm where meaning truly accrues and matters.

When I am out in public, be it the local dog park, a mixed-use shopping retail development, restaurants, the courthouse, bars, going for walks, I interact with people from all walks of life. Men, women, numerous races and ages. Each time, there is laughter, discussions centered on our families, our pets, the holidays, our health, the beauty of the day. I have dear friends from both ends of the political spectrum. We socialize, party together, laugh together.

In real life, conversations are not filtered through screens or stripped of tone and nuance. A friend’s laughter, the warmth of a handshake, the look in someone’s eyes when they understand you … these moments carry a weight no number of “likes” can replicate. Human relationships deepen through vulnerability, shared experience, and presence. Real life offers the “age of wisdom,” where insight grows not from viral posts but from quiet reflection, trial and error, and authentic connection.

Real experiences ground us. They tether us to something permanent and tangible: the smell of freshly cut grass in the springtime, the scent of the Christmas tree, the chaos of family gatherings, the comfort of routines, the joy of unexpected kindness. These are the “seasons of light,” moments illuminated by genuine human engagement.

It Was the Worst of Times: The Digital Landscape of Angst and Despair

Yet we live simultaneously in a world where social media defines culture. Platforms promise connection but often deliver its hollow imitation.

To properly illustrate the decay of society, one need only understand that the financial goal of the five (5) wealthiest corporations in the United States is attained by enticing us to immerse ourselves completely in our personal devices, to remove ourselves from real life and to exist solely on social media. To isolate ourselves. To limit our face-to-face human interaction. That insures their financial success while insuring the destruction of our well-being.

Here, the “age of foolishness” reigns … where impulsive opinions eclipse thoughtful dialogue and where appearance overshadows substance. Belief contorts into echo chambers, while incredulity becomes a reflex to any idea that challenges our curated worldview. We scroll endlessly, absorbing news of tragedies, political battles, and social comparisons until the world feels saturated with crisis. Cowardice and fear are the watchwords. If you do not agree with someone’s viewpoints? You need only “block them” on social media. With a keystroke, you have eliminated intelligent discourse and the expanding of your mind.

We are inundated with political parties disagreeing for the sake of disagreeing. Promulgating the power of their own party over the needs of the Republic. Indeed, politics has become a new religion rather than an enlightened arena where we can engage in intelligent conversation with a shared goal, the well-being of our nation. Politics is now pop culture. Name calling. Inflammatory labeling. Each tribe remaining in the safety and comfort of their own echo chamber. Pundits opining that we are closer to a civil war now than at any time since the end of the Civil War.

There is the parade of angst, personal attacks, tribal entrenchment, absolutism, and fear … the very worst of our qualities.

This is the “season of darkness.” Online, despair grows quietly: the loneliness of constant comparison, the fear of missing out, the anxiety of measuring oneself against the polished illusions of others. Validation is quantified, self-worth becomes algorithmic, and interactions feel more transactional than relational.

However, when people experience “real life” and interact personally with their fellow humans, more often than not, it is our goodness which shines brightly. Not our disagreements. When pain, anxiety and fear are disclosed, it is in the context of a safe place to be shared and cared for by people who want only the best for you. It is tragic that we have unnecessarily permitted social media to diminish our human connection.

In this winter of digital despair, everything is visible, yet little feels real.

The Spring of Hope: Rekindling Humanity in a Connected Age

Despite its cold edges, social media also holds the “spring of hope.” It has connected the isolated, amplified marginalized voices, and spread information at breathtaking speed. But harnessing its good requires remembering that platforms are tools, not substitutes, for human connection.

We can reclaim the best of both worlds by grounding ourselves in real relationships while using digital spaces intentionally. Social media should supplement our lives, not consume them. It should extend community, not replace it.

Choose Light Over Darkness

Just as Dickens depicted an age torn between extremes, we too, navigate a world of contrasts. The best of times and the worst of times coexist in our hands … literally, in the glowing rectangles we carry everywhere.

The goodness of real life lies in its humanity. The manner in which our souls seek out to connect with others. The despair of social media lies in its impersonality. By choosing presence over performance, conversation over commentary, and authenticity over algorithms, we can keep the light from being swallowed by the dark.

In the end, it is up to us to determine which “season” defines our era.

Board Certification Chaos: How Disunity and Private Equity Diluted the Community

Few areas of mental health care illustrate dysfunction as clearly as the eating disorder board certification industry.

What began decades ago as a grassroots movement of passionate clinicians, dietitians, and advocates has metastasized into a labyrinth of overlapping credentials, proprietary “certifications,” and glossy corporate training programs.

Today, the United States alone boasts well over one hundred distinct eating disorder related certifications. This is more than that which exist for all other major psychiatric conditions … combined. For schizophrenia, there are fewer than a dozen. For depression, arguably the world’s most common mental illness, maybe two dozen. For autism, a total of ten programs. For eating disorders?

This is a table listing eating disorder related certifications:

The eating-disorder field, serving a far smaller patient population, is drowning in certificates, credentials, and branded “specialist” designations. And more are seemingly arriving every month.

This glut is not a sign of progress. To the contrary. It is the predictable outcome of a profession with no unified standards, no central accrediting authority, no ethical oversight, and an increasingly privatized treatment economy driven less by patient outcomes than by returns on investment and profiteering perpetrated by individuals and their egos.

The Great Credential Free-for-All

Unlike psychiatry or psychology fields with centralized boards and accreditation bodies, the eating disorder community has no single regulatory anchor. Instead, numerous competing organizations (IAEDP, AED, NEDA, ANAD, APT, and others) define “competence” differently and seldom recognize each other’s credentials.

The result is a credential arms race. Clinicians seeking legitimacy often accumulate multiple certifications, not because each adds new expertise, but because no one can agree which ones actually matter. Every theoretical school, CBT-E, DBT, FBT, ACT, somatic, trauma-informed, HAES®, intuitive eating, and more has spawned its own “certifying institute.”

With no governing framework, anyone can create a credential. And many have. Do you want to include social justice and political issues? Blame White Supremacy Culture? Blame the white man for all mental health issues? Create a certification program which does not include any information on ethics, or state-of-the-art medical and biological treatment? No involvement of diverse persons in creating a certification program? Extensively utilize information that is well known and has been in the community for many years? Sure! Why not? Who is going to say you cannot?

When Certification Becomes a Branding Exercise

This fragmentation might have remained a benign inconvenience if not for a second, more corrosive force: monetizing eating disorder certification through the rise of private equity.

Over the last decade, investment firms have used their monopoly power to control the narrative and then, consolidated the treatment landscape. In doing so, they squeezed the very life out of the field one dollar at a time. Large PE-backed treatment centers now own a majority of residential and intensive outpatient programs in the United States. And yet, at least one CEO of private equity owned treatment center testified in a sworn affidavit that the private equity owners prioritized profit over patient care. And patient care was compromised.

Private equity’s influence reshaped everything, from staffing ratios to program philosophy, but nowhere is the shift more visible than in education and credentialing. Under investor ownership, training is no longer an act of professional stewardship; it’s a marketing opportunity. Corporate chains launch internal “training academies” that sell branded certifications to staff and outside clinicians. Certification has become the new advertising … a low-cost, high-margin product that projects authority and generates revenue.

The loans to the investors are not simply going to pay themselves. Additional streams of revenue must be found to meet the financial demands.

Disunity as a Business Model

Eating Disorder organizations have failed to coordinate standards because fragmentation serves their financial interests. Each group has its own alleged proprietary curriculum, fees, and renewal dues. Collaboration would mean shared intelligence, information, revenue and control. Research and data would be collaboratively shared. For the first time the term, “evidence-based” would have substantive merit instead of simply being a vacuous catch phrase without any real meaning, without definition and without regulation.

Private equity masterfully exploits this vacuum. Without a single regulating body to enforce quality benchmarks, PE-backed centers can market themselves as the “gold standard” simply by aligning with whichever certification best fits their brand narrative. Or better yet, simply create your own standard of demonstrating expertise. No matter how many patients are abused, groped, or treated as if they were mere grist ground down by the mill of greed and incompetence, any treatment center can claim they are the “gold standard.”

Since they are privately owned, they can operate in the shadow of secrecy with information, which at best may be shared with their fellow PE owned overlords at quarterly meetings. Meetings which are conducted clandestinely, never to be disclosed to the families which need the highest level of care.

The Human Cost of Credential Inflation

For patients and families, the consequences are not academic, they’re life-altering. A parent searching for specialized care for a child with anorexia may encounter a clinician advertising six or more “certifications,” yet none of those credentials guarantee the provider has completed supervised ED training, worked within a multidisciplinary team, or met any validated competency benchmarks.

This blurring of standards enables underqualified practitioners to enter the field under the guise of expertise. Genuine experts are forced to buy legitimacy through redundant credentials simply to remain competitive in a marketplace driven by SEO and optics rather than outcomes.

The Wellness Economy and the Collapse of Accountability

The eating disorder arena overlaps with the $5 trillion wellness industry, which thrives on micro-credentialing. Nonclinical players, nutrition coaches, yoga instructors, and social media influencers alike obtain “eating disorder informed” certifications online, sometimes in less than a weekend.

Education has been replaced by branding. Evidence based care is replaced by radical social justice brain washing. If a person is offended by society, they need only slap an inflammatory label on the issue and not worry about its nuances. Congratulations! You have just become certified as an “Inclusive” board certified expert. The result is a field saturated with worthless credentials but starved for accountability.

Questions which should be asked are not being asked. For example, what new information does your certification program provide that was not already public knowledge in the community? Did, and does, your certification program include research professionals, medical doctors, dietitians, mental health experts, or even any men on its advisory board? Did you collaborate with any organizations or treatment centers when you were creating your program? What specialized knowledge does your organization have which other organizations do not possess? Do you have any agendas outside of providing necessary care for families suffering from eating disorders? How is your certification program going to lower the appalling mortality rate of eating disorders? Objectively speaking, how and why is your certification program an improvement over that which is already in the public domain?

Without substantive answers to these questions, professionals are left with a meaningless diploma … and simply more innocuous initials to put after your preferred pronouns.

A Perfect Storm of Profit and Disunity

Disunity and privatization feed each other. Lack of collaboration creates a vacuum; private equity monetizes it. The proliferation of proprietary programs generates revenue and brand differentiation but erodes professional credibility. Without regulation, there is no penalty for low standards, only rewards for market dominance.

The tragedy is that eating-disorder professionals entered this field to help patients including those most often marginalized by healthcare systems and diet culture. Yet through disunity and commodification, the field has allowed itself to become a marketplace rather than a discipline. Every new certification minted without oversight or accountability is another crack in the foundation of public trust.

Until collaboration replaces competition, and professionalism and the priority of patients triumph over profit, the eating disorder treatment industry will remain a cautionary tale: proof that when market logic outruns moral logic, vapid expertise becomes just another product for sale.