THE DANGEROUS FICTION OF EATING DISORDER COACHES

The complexities of eating disorders require medical monitoring, psychiatric oversight, nutritional rehabilitation and clinical judgment. Eating disorders demand the highest level of expertise and professionalism from medical and mental health providers.

And yet, in a rapidly expanding corner of the wellness marketplace, they are being addressed by people who are not licensed, not regulated and, in many cases, not clinically trained at all.

They call themselves “Eating Disorder Coaches.”

There is no statutory definition of that role. No minimum education requirement. No mandated supervision. No governing board. No uniform ethical code enforced by law. It is merely a name. A brand. A vacuous title.

And no reliable mechanism to stop them if they cause harm.

Now make no mistake … there are “Eating Disorder Coaches” who are compassionate, intelligent professionals whose services are invaluable in working with a cohesive treatment team. But, in a community which rarely imposes consequences or adverse ramifications for reprehensible conduct, the danger of incompetent eating disorder coaches is far too real.

A Title Anyone Can Use

In most US states and in the UK, the title “eating disorder coach” is not protected. Anyone can adopt it. There is no state exam. No residency. No clinical hours requirement. No continuing education mandate enforced by a licensing authority.

A former state licensing board investigator describes the situation bluntly:

“From a regulatory standpoint, ‘coach’ is a marketing term. It does not confer legal authority, and it does not trigger professional oversight.”

If a licensed psychologist commits misconduct, a complaint can be filed. A board can investigate. A license can be surrendered, suspended or revoked.

If a coach commits misconduct, unless they also hold a license and the conduct falls squarely under licensed practice, there is often no comparable public accountability mechanism.

In practical terms, this means individuals with minimal training can advise medically fragile clients about food exposure, weight restoration, purging behaviors, exercise patterns and relapse decisions … issues that in clinical settings, are handled by multidisciplinary teams.

The danger is not theoretical.

A psychiatrist who specializes in eating disorders warns:

“Improper intervention can reinforce pathology. Poorly managed refeeding can have medical consequences. Missing suicide risk is catastrophic. These are not coaching issues. These are clinical issues.”

Yet the marketplace does not reflect that distinction.

The Coaching Loophole

The structural problem becomes especially stark when licensed professionals move into the unregulated coaching space.

Karin Lewis, an eating disorder clinician and founder of the Karin Lewis Eating Disorder Center in Boston, surrendered her Massachusetts therapy license while under investigation following two pending ethics complaints … including one filed by the therapist who began treating a former client after that client left Lewis’s care.

Separately, that client filed a civil lawsuit against Lewis for Lewis’ alleged unethical business practices. That case was resolved for an undisclosed payment.

However, Lewis’ licenses in New York and Rhode Island currently remain active… at least for the time being.

More recently, Lewis publicly presented herself on social media as an “Eating Disorder Coach.”

https://www.facebook.com/share/v/1DCba3vVBq/?mibextid=wwXIfr

The legal reality is striking: surrendering a license in one state does not prevent someone from operating as a coach. Coaching requires no license to surrender.  Instead, it is explained away as a personal and professional transition. In Lewis’ words, “I’m shifting to a coaching and consulting model.” Perhaps the rest of that sentence should have read, “Because I am prohibited from engaging in my chosen profession in my home state.”

Good Lord. From a profession where at least there is some oversight to a role that has no oversight, no requirements and no accountability. What could possibly go wrong?

Especially when you can belong to a community which will protect you no matter what so long as you hold the same idealistic, radical views espoused by others. Surrender your license? Not a problem. You can still serve on Advisory Boards of eating disorder treatment centers. No consequences. No accountability.

However, this is not a commentary on one individual alone. It exposes a systemic failure: professionals can exit regulated roles and continue working in adjacent, unregulated ones without a unified accountability framework.

This type of unregulated model is illustrated in a much larger context, that is, eating disorder board certification. [However, this article will not focus on certification. That is for a future date. It is only briefly included for context.]

Certification: The Illusion of Reform

Despite growing criticism, eating disorder certification programs have multiplied to an extent that would make rabbits blush. Like coaching, certification programs are unregulated, there is no oversight and anyone can create them. A person can include any private issue they like in a certification program … from Indigenous Person’s Land Use Acknowledgements to railing on White Supremacy Culture.

Project HEAL has expanded programming and provider networks while advocating for improved access to care. Inclusive Eating Disorder Education (IEDE) offers tiered credentials and training tracks. The Eating Disorder Institute (?) f/k/a The Institute of Contemporary Eating Disorder Education (ICEE) provides coursework and professional certificates. Iaedp’s certification program is undergoing broad changes because of litigation.

These initiatives often present themselves as raising standards in the field.

But certification is not regulation.

No state licensing board oversees these programs. No legislature defines their scope. No independent authority can revoke a certificate and legally bar someone from continuing to practice as a coach.

A healthcare policy scholar who studies professional licensure draws a clear line:

“A certificate means you completed a course. A license means the state has granted you legal authority to treat vulnerable people — and can remove that authority if you violate standards. They are fundamentally different.”

Certification programs may require coursework. They may encourage ethical guidelines. They may foster community norms.

But they do not create enforceable public protection.

And in some cases, critics argue, they risk compounding confusion.

“Consumers see badges, seals and credentials and assume oversight exists,” says a former hospital-based eating disorder program director. “But there is no disciplinary body behind most of these titles. It’s structural theater.”

These same issues exist with eating disorder coaching.

Coaching as De Facto Treatment

The most troubling development is not that coaching exists. Peer support has long played a role in recovery communities.

The problem arises when coaching becomes indistinguishable from treatment and therapy.

Coaches advertise meal plan guidance. Exposure support. Relapse prevention strategies. Accountability check-ins. Crisis navigation. Body image interventions.

These are not lifestyle adjustments. They are components of clinical care.

Eating disorders affect cardiac function, bone density, electrolyte balance and suicidality. Weight restoration can trigger refeeding syndrome. Purging behaviors can destabilize potassium levels to fatal effect.

In licensed treatment settings, these risks are monitored by medical professionals.

In coaching settings, oversight varies widely … and for the most part, does not exist at all.

A clinical ethicist frames the issue starkly:

“When someone markets themselves as capable of guiding recovery from a life-threatening illness, the absence of regulation is not an oversight. It is a policy failure.”

A Marketplace Built on Vulnerability

The expansion of coaching cannot be separated from systemic failures in access to care. Waiting lists are long. Insurance battles are common. Specialized treatment is expensive.

Desperate families look elsewhere.

The coaching industry has attempted to fill that void with polished websites, testimonials and social media authority. It operates largely outside insurance systems, outside hospital networks and outside state oversight.

In a traditional healthcare model, authority flows from licensure and statutory accountability.

In the coaching marketplace, authority flows from branding.

That shift should concern regulators.

As one former licensing official puts it:

“Regulation exists because vulnerable people cannot be expected to vet complex medical competencies on their own. When we remove regulation, we shift the burden of risk onto the patient.”

The Unanswered Question

Eating disorder coaching today exists in a regulatory grey zone that benefits providers more than patients.

Certification programs provide optics. Professional branding provides credibility. But neither substitute for enforceable oversight.

The core question remains unresolved:

Should individuals treating — or functionally treating — one of the most lethal psychiatric disorders operate without statutory accountability?

Until lawmakers address that question directly, through scope of practice laws, title protections or regulatory oversight, eating disorder coaching will remain what it is now:

A parallel system of quasi-clinical care, built on vulnerable populations, sustained by market demand, and largely immune from the guardrails that define the rest of healthcare.

And in medicine, immunity from oversight is rarely a virtue. It is a roadmap for catastrophic results.

Why we Acknowledge Awareness Week

It is Eating Disorders Awareness Week. A week in which organizations attempt to “raise awareness.” Presentations are made. The microscopically small niche on social media occupied by eating disorder advocates spout their messages using rote, familiar language while ignoring the most alarming statistic.

It is far easier to refine language than to examine outcomes. But outcomes are how we are judged. Outcomes determine our humanity. Our soul. Our fight for survival. And nowhere was this more apparent than in the incredible journey of Kaila Blackburn.

Everything I know about Kaila Blackburn I got from her strong, resilient, incredible mother, Debi and father, Tom. And what I read on social media.

Kaila was born on June 13, 1994, in Virginia, and on September 27, 2025, eating disorders took her life. Eating disorders took her from her family and her loving parents. But while she was with us, how she graced us with her strength.

Kaila was a natural student and athlete. She swam, dove, played softball, and ran with such breathtaking speed and grace that she earned the nickname “Flash.” Her dedication and talent carried her to Virginia Tech, where she proudly competed as a Division I runner.

From what I read, Kaila’s faith was the foundation of her life. From an early age, Kaila loved Jesus, and through her 31 years she remained steadfast, often teaching others through her wisdom and grace. Even in her hardest battles, she clung to her Savior with courage and unwavering trust.

Kaila’s parents wrote this about her, “We will not say that Kaila is “resting in peace.” Instead, we proclaim that she is Running in Paradise—whole, free, and forever embraced by the love of her Savior. That is exactly what Kaila would have wanted.”

I did not know Kaila. I never had the chance to meet her. But, I do take comfort knowing that my Morgan is probably showing her the ins and outs of the next plain of existence. And they are smiling, laughing and at peace.

This week, a Virginia television station did a story on Kaila. It can be found here:

https://www.wtvr.com/on-air/virginia-this-morning/observing-eating-disorder-awareness-week-kaila-blackburns-story

My heart goes out to Debi and Tom and her family. We belong to a horrific club that no parent should ever have to join.

Maybe this week, eating disorder awareness week, we should take just a moment, close our eyes, remember and honor those who have been taken. And in that moment of silence, perhaps we should reflect upon what our priorities should be going into the future.

As a parent who had a loving child taken by eating disorders, I hope and pray every day that Morgan’s life, that Kaila’s life, and the lives of many others, were not extinguished in vain. That perhaps the memory of them will inspire us all to do better. To set aside our petty differences. To pledge to strive forward together … with intelligence, wisdom, grace and collaboration.

So that in the future, there will be fewer Morgans and Kailas and Kellys and many others.

We parents remember. We mourn. We grieve. And yet, we continue to hope. And we continue to love.

And love should be the overriding message of awareness week.

The Illusion of Normal: Why Eating Disorder Mortality Remains the Quietest Fact in the Room


The most recent iteration of the iaedp symposium just concluded in Baltimore. Speakers, many of whom are the same familiar faces appeared giving similar presentations as in years past. And many people will go back to their practices secure in the feeling of a job well done. And the normalization continues.

We know that eating disorders are among the deadliest psychiatric illnesses in medicine. That is the uncomfortable truth that very few are willing to discuss.

That is not debated in the literature. It is not speculative. It is not marginal data. And yet the urgency one would expect around a lethal psychiatric disorder is conspicuously absent from the professional culture that surrounds it.

There are no sustained national funding drives proportionate to mortality risk. Federal research allocations remain disproportionately low compared to other psychiatric and medical illnesses with lower fatality rates. The disparity between lethality and attention is measurable.

So is the normalization.

Inside treatment systems, the language feels technical and reassuring:

Levels of care.
Step-down programming.
Compliance metrics.
Utilization review cycles.
Coverage determinations.

The vocabulary signals coordination. It implies rigor. It suggests that decisions are anchored in standardized expertise. How wrong that is.

On the surface, the system does not appear malicious. It appears procedural. Structured. Measured. Confident. Each provider can justify decisions within guidelines. Each insurer can defend criteria. Each organization can cite consensus statements.

The illusion is not cruelty.

The illusion is normal.

Normal treatment duration.
Normal discharge criteria.
Normal reimbursement ceilings.
Normal consensus frameworks.

Individually, nothing appears aberrant. Collectively, the structure produces outcomes that mortality data have been warning about for decades.

Which raises an uncomfortable question:

If eating disorders carry one of the highest mortality rates in psychiatry, why is that reality not the organizing principle of our professional gatherings?

The Silence Around Mortality

At major symposiums, such as the recent iaedp symposium in Baltimore, the agenda is full. Panels are polished. Continuing education credits are awarded. Networking flourishes.

Eating disorder awareness week is upon us. It will be acknowledged by a crowd measuring in the tens. Some media outlets will pay lip service to it. Again, the same faces will talk about the same messaging. Events will be broadcast on social media attended by the same people, again, measuring in the tens. At the end of the week, the community will pat itself on the back and go back to bickering about social justice issues being allowed in treatment rooms.

But where is the sustained, central, data-driven reckoning with mortality?

Where are the plenary sessions that open with longitudinal survival curves?

Where are the transparent discussions of long-term relapse and death rates across levels of care?

Where are the public audits of whether treatment durations align with neurobiological recovery timelines rather than insurance reimbursement windows?

Mortality is referenced, occasionally acknowledged, sometimes framed as a reminder of seriousness. But it is rarely dissected structurally.

Why?

Because a full confrontation with mortality data does not just indict illness. It forces scrutiny of systems.

It forces questions about whether reimbursement structures shape clinical standards, whether “medical necessity” criteria are actuarial compromises rather than survival-based thresholds, whether discharge decisions are tethered to coverage limits rather than durable recovery, and whether professional consensus has been influenced by economic sustainability of treatment centers.

Where are the public questions and demands about how a credit card company is now going to oversee and operate an eating disorder residential treatment center? And how is that even legal? Let alone in the best interests of our families.

Those are not comfortable conference topics.

For that matter, why wasn’t that topic discussed at the REDC meeting which took place in Baltimore in a public forum with families who are suffering ? What matters more? Families and the mortality rate? Or protecting one of your fellow REDC members from public scrutiny? Profit margins or saving lives?

It is far easier to discuss innovation in therapeutic modalities than to ask whether overall mortality has shifted meaningfully in decades.

It is far easier to host panels on emerging frameworks than to ask why families still encounter rationed care for a disorder with documented lethal risk.

It is far easier to refine language than to examine outcomes.

If symposium speakers are drawn repeatedly from the same professional circles, presenting iterations of the same frameworks year after year, the ecosystem becomes self-reinforcing.

Professional consensus carries weight. But consensus is not formed in a vacuum. It is shaped by committees, insurers, funding realities, dominant voices, and organizational politics.

If dissenting clinicians, particularly those who challenge reimbursement norms or treatment duration standards are marginalized rather than platformed, scrutiny narrows.

If social positioning and internal professional politics consume oxygen that should be directed toward structural reform, then optics begin to substitute for outcomes.

Meanwhile, mortality remains stubborn.

And rarely centered.

The most powerful stabilizing force in the treatment ecosystem is not bad intention. It is normalization.

If revolving door admissions are normal, no one is failing.

If truncated treatment is normal, no one is responsible.

If mortality is described as “multifactorial or complex” urgency diffuses.

But when a system designed to treat a known lethal disorder operates for decades without materially altering lethal outcomes, and that fact does not dominate its most visible professional forums, something deeper is occurring.

The silence itself becomes data.

How is it possible that a field organized around a disorder with one of the highest psychiatric mortality rates can gather annually without centering that mortality as the primary measure of success or failure?

If mortality is not the headline metric, what is?

Attendance numbers?
Program growth?
Expanded diagnostic inclusivity?
Brand alignment?

Those may matter. But survival matters more.

Progress should be visible in survival curves.

Progress should be reflected in transparent long term remission and mortality data published without marketing filtration.

Progress should include open debate about reimbursement models, discharge standards, and treatment duration norms.

Instead, the field risks mistaking activity for advancement.

The same speakers.
The same frameworks.
The same consensus language.

And the mortality rate remains among the highest in mental health.

How Is That Progress?

If a system repeatedly fails to prevent lethal outcomes and still considers itself structurally sound, normalization has replaced urgency.

The institutions may be populated by compassionate individuals. Many clinicians care profoundly. But compassion operating within a misaligned architecture cannot compensate for structural design.

When families trust that care is calibrated toward survival, and insurers trust that criteria are defensible, and professional organizations trust that consensus equals correctness, scrutiny diminishes.

And when scrutiny diminishes, reform stalls.

The question is not whether people inside the system intend harm.

The question is whether the system is calibrated toward survival … or toward its own stability.

Until mortality is treated not as a sidebar statistic but as the central accountability metric, at symposiums, in reimbursement negotiations, in guideline committees, the illusion of normal will persist.

And children, adolescents, women, and men with eating disorders will continue to face a lethal illness inside a system that rarely speaks about death loudly enough.

That is not progress.

It is normalization of unacceptable outcomes.

WE MUST DO BETTER FOR FEMALES

The annual iaedp symposium is this upcoming weekend. Now imagine the above presentation being made.

If these three AI generated men were scheduled to headline a session entitled “We Need to Do Better for Our Females,” the outrage would be extreme and deafening.

There would be denunciations. There would be protests. There would be demands to center women’s voices. There would be ethics complaints. There would be boycotts. Accusations of toxic masculinity would be loud. White Supremacy Culture. The patriarchy. Mansplaining!

After all, what do men known about women’s issues surrounding eating disorders? How many times have we heard the siren call of listening to “lived experience?”

Despite the extreme nature of the inevitable protest, the objections raised would have some merit.

So why is the inverse treated as normal?

Why is it acceptable for an industry that openly and notoriously excludes men from leadership, treatment and research studies to present a lecture about “doing better for males?” If representation matters, it must matter universally. Otherwise, it is not principle.

It is biased preference.

Instead of the AI generated presentation above [and yes, those are AI generated images], there is an iaedp approved session entitled:

“We Need to Do Better for Our Males.”

The obvious questions are …. where are the men on the panel? Where are the male experts? Galen Hope lists 4 men as part of their expert team. Yet none could be bothered to present on this panel?

Other men who are experts in the field of eating disorders certainly exist. I could easily name more than ten strong, experienced, respected men in the fields of research and treatment of eating disorders who could have co-presented. Recognizable names. Giants.

And yet … there are none.

Aren’t we are certainly justified in asking … Why?

When we look at the staff and leadership for Galen Hope, answers to that question start to become clear.

Galen Hope’s “expert team” consists of 33 women and 4 men, one of whom is listed as a consulting psychologist and one of whom is listed as a psychiatrist consultant.

The numbers alone are concerning.

Perhaps Within Health, the virtual platform associated with Galen Hope can provide more objective numbers… uh… no.

Within Health’s care team consists of 127 women and 9 men. [As an aside, of these 136 people, 135 embrace virtue signaling by including pronouns after their name.] Within Health’s Board of Advisors consists of 8 women and 1 man. One of the advisors recently voluntarily surrendered her license instead of facing on-going ethics complaints. Another advisor financially ruined BEDA, was fired from NEDA and led the opposition to a summit consisting of some of the most respected leaders in the eating disorder community because it had been organized by … men.]

This equates to 92% of the combined leadership at Galen Hope/Within Health are women.

Let’s review how this number compares to the rest of the eating disorder community.

The Executive Leadership for AED consists of 5 women and 1 man.

The Staff Leadership at NEDA includes 5 women and 1 man.

The Executive Committee at iaedp consists of 5 women and ZERO men. Its Members at Large consist of 8 women and ZERO men. Its Executive Director is a woman.

The “Team” at the National Alliance for Eating Disorders consists of 18 members … 15 women, 1 man, and 2 dogs. Yes, 2 dogs. But at least its 2 dogs are named Teddy and Jack indicating they may be male. So, we have that going for us.

ANAD’s Board and Staff consist of 22 women and 3 men.

There are 69 leadership positions listed in these organizations.

61 are women. 6 are men. 2 are dogs.

So, 88.4% women.

8.69% men.

2.89% dogs.

So iaedp accepted a person/organization whose percentage of employing men is even worse than the community average and is allowing 2 of the co-founders to give a presentation on “We Must Do Better for Males.”

Perhaps if you want to start to do better for boys and men, one of the more obvious solutions is to start to employ men in your own organization!

Eating disorders are not “women’s issues.” They are certainly not social justice issues. Instead, they are lethal biologically based psychiatric illnesses.

They impact and kill girls and women.

They impact and kill boys and men. Quietly, invisibly, and with institutional indifference so entrenched it has become routine.

The eating disorder industry has spent decades pretending otherwise.

This is not a misunderstanding. This is not an oversight. This is a systemic, historical failure, and boys and men are paying for it by enduring years of suffering or in some cases, having their lives taken.

And the community responds by allowing the person/organization with one of the worst track records of employing men to lead this presentation.

Boys and men represent millions of eating disorder sufferers, yet they are virtually absent from the power structures that claim to serve them.

Men represent millions of sufferers, yet they are virtually absent from the power structures that claim to serve them.

This has historically been the case. Year after year. Board after board. Conference after conference.

This inequity is of great concern since leadership drives research priorities. Leadership drives conference programming. Leadership drives funding. Leadership drives treatment design.

If men are nearly absent from leadership, their exclusion from priority is not surprising. It is predictable. It is reprehensible. And it has been the case historically.

THE CONFERENCE RECORD — 275 SESSIONS, TWO ON MALES

Despite its numerous problems, iaedp calls itself “representative of leadership in the field.” It points to its annual symposium as evidence of excellence.

Instead, these symposiums present evidence of exclusion and absence.

From 2015 through 2019 at iaedp’s symposium, iaedp approved the following number of sessions and in each year, the number of sessions on boys and men are delineated:

2015: 48 sessions — 1 on men

2016: 54 sessions — 0 on men

2017: 55 sessions — 0 on men

2018: 58 sessions — 1 on men

2019: 60 sessions — 0 on men

Total: 275 educational sessions.

Meaningful sessions on boys and men: Two.

THIS EQUATES TO LESS THAN ONE PERCENT (1%) OF EDUCATIONAL SESSIONS DURING A FIVE-YEAR PERIOD DISCUSSED BOYS AND MEN AFFLICTED WITH EATING DISORDERS.

LESS THAN ONE PERCENT.

While boys and men were suffering and dying, professionals could attend workshops on sand play therapy, musical theater, veganism, and art therapy … but not on male eating disorders.

That is not leadership nor education. That is abandonment.

Numerous treatment centers historically did not admit boys or men, or structured care almost entirely around female populations, including:

Timberline Knolls (now closed)

Clementine

Clearview Women’s Center

Magnolia Creek

Oliver-Pyatt

Renfrew

Montecatini (now closed)

Certain Monte Nido facilities

Boys and men who find admission are often placed as one or two males among dozens of women.

This is not parity. This is institutional discrimination.

The industry cannot claim ignorance. The statistics are known. The mortality rate is known.

The male patient population is known.

Yet men remain absent from leadership, programming, and institutional priority.

Eating disorders have one of the highest mortality rates of any psychiatric illness. Boys and men die from cardiac arrest, organ failure and suicide related to eating disorders.

They die while leadership remains nearly 90% female.

They die while 275 sessions produce two focused discussions on males.

They die while representation must be digitally fabricated to make a point.

Boys and men are not being served.  They are being erased.

ENOUGH.

Boys and men are not optional. Boys and men are not a niche demographic. Boys and men are dying. And women leaders, whose treatment centers epitomize the very problem which exist, who are part of the problem, and yet who dare to lecture us on, “we need to do better for males,” are merely paying lip service. Words with no substance. Words with no action behind them. Words which will not change anything.

There is a name for that.  It is called … hypocrisy.

This article is your presentation on “We Must Do Better for Males.” The reality. The numbers. The statistics. The reprehensible omission of boys and men. That is your presentation. Anything else is formulaic.

Until structural change occurs, in leadership, research, programming, and treatment infrastructure, the eating disorder industry is not merely failing boys and men.

It is complicit.

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”.