The eating disorder field has spent decades asking families to trust it. Trust the treatment center. Trust the intake coordinator. Trust the website. Trust the words “evidence based.” Trust the branded clinical model. Trust the promise that the program knows what it is doing because the patient is too sick, the parents are too frightened, and the stakes are too immediate for careful comparative shopping.

But trust is not a standard of care. And neither are marketing, credentials, nor an impactful website. In a medical and psychiatric illness with substantial mortality risk, high relapse rates, serious medical complications, and profound psychiatric comorbidity, the absence of enforceable, generally accepted standards of care is not a theoretical defect. It is an operating condition that places patients in danger.

The eating disorder community has long understood the problem, even when it has not solved it. In 2008, the Academy for Eating Disorders Credentialing Task Force produced draft recommendations for residential and inpatient eating disorder program accreditation. Some of the most respected, knowledgeable professionals participated in this collaboration.

The document did not read like an aspirational brochure. It read like a blueprint for patient protection. It called for standards in assessment and treatment planning, treatment delivery, quality improvement, specialized protocols, outcome measurement, and accreditation. Its stated purposes were to safeguard patients and families seeking inpatient and residential care, improve the quality of care offered by programs, and provide a benchmark for third party payers. That language is important. It shows that the field knew, at least by then, that eating disorder treatment required more than general mental health licensure and more than ordinary institutional accreditation.

The AED standards also identified the core duties that any serious eating disorder program should recognize. Screening and intake should assess medical stability, psychiatric status, nutritional status, substance use, special needs, and developmental appropriateness. Admission should be a comprehensive interdisciplinary process involving medical, psychiatric, psychological, nutritional, and biopsychosocial assessment. Treatment planning should be timely, documented, individualized, and regularly reviewed. Continuity of care should include prompt communication with appropriate providers. Discharge planning should begin at admission and include specific follow up care. Treatment delivery should include psychological, medical, nutritional, and psychiatric care. Programs should accurately describe their licensure, staffing, levels of medical care, treatment team composition, emergency protocols, costs, insurance participation, treatment duration, discharge criteria, staff qualifications, and continuing education. Outcomes should be measured, not guessed. Quality improvement should be ongoing, documented, and tied to actual patient results.

The field knew what a safety framework looked like. It knew patients needed medical screening, physician access, psychiatric care, nutrition expertise, discharge planning, family involvement, trained staff, outcome measurement, and transparent program information. It knew residential and inpatient programs were not ordinary therapy offices with beds. They were controlled treatment environments for patients with complex medical and psychiatric illnesses. Yet these standards were abandoned.  They were never adopted nor enforced. And that is the indictment.

Building up to 2008.

This was before the Mental Health Parity Act of 2008 was passed into law. It was before the Affordable Care Act was enacted. It was before the scourge of COVID. It was also largely before the private equity gold rush into the eating disorder industry began.

When a field lacks generally accepted standards of care, it does not become more flexible. It becomes less accountable. Every treatment center can claim excellence. Every program can call itself evidence based. Every operator can define “appropriate care” around its own staffing model, payer contracts, census pressures, and clinical philosophy. A family trying to decide where to send a medically fragile child or adult is left to compare slogans. A physician trying to refer a patient is forced to rely on reputation, relationships, and sales materials. An insurer can exploit ambiguity by denying care as unnecessary. A treatment center can exploit ambiguity by selling care as indispensable. The patient is then caught between two industries, each invoking medical necessity when it serves its financial interest.

The phrase “evidence-based treatment” illustrates the collapse. In any responsible medical field, evidence-based care should mean that a treatment is supported by research, delivered with fidelity, matched to diagnosis and level of care, monitored for safety, and evaluated by outcomes. In eating disorder treatment, the phrase has too often become a branding device. It may refer to CBT, DBT, FBT, exposure work, nutrition rehabilitation, medical monitoring, group therapy, experiential therapy, or a proprietary blend of whatever the program happens to offer.

Without a standard which requires programs to identify which treatment is being used, why it is appropriate, who is trained to deliver it, how fidelity is monitored, and what outcomes are achieved, “evidence based” becomes a label detached from evidence.

The harm is not semantic. Eating disorders kill. They injure. They produce cardiac instability, electrolyte abnormalities, endocrine disruption, bone loss, gastrointestinal complications, renal stress, refeeding risk, suicidality, and profound psychiatric comorbidity. They also deceive systems that rely on visible severity. A patient can appear medically stable until the lab work, EKG, weight trajectory, purging history, exercise behavior, or refeeding risk says otherwise. A patient can be in a larger body and still be medically unstable. A patient can be “normal weight” and dying. A patient can be discharged because insurance will not pay, retained because a bed must be filled, stepped down because the program has no capacity, or admitted because the program has capacity even when a different level of care would be safer.

The absence of standards increases mortality risk because it removes the guardrails that prevent predictable harm. Certainly, the lack of standards does not cause every death. It does not explain every bad outcome. But it allows dangerous variation in medical screening, level of care decisions, staff training, treatment planning, discharge readiness, and continuity of care. In a lethal illness, dangerous variation is not a neutral administrative problem. It is a patient safety failure.

The mortality problem is compounded by misunderstanding. Culturally, eating disorders are still often reduced to vanity, dieting, thinness, control, adolescence, or female distress. That public misunderstanding persists partly because the professional system has not spoken with one disciplined voice. If the field itself cannot agree on what competent care requires, it cannot expect legislators, medical schools, insurers, journalists, families, or courts to understand the illness with precision. Fragmentation creates confusion. Confusion creates delay. Delay creates medical deterioration. In the space between first symptoms and competent intervention, patients become sicker.

The legal system has already exposed the danger of this absence. In the behavioral health coverage battles surrounding generally accepted standards of care, eating disorders should have been central. Yet when courts and insurers search for recognized standards, eating disorder specific standards have often appeared fragmented, inconsistent, or conspicuously absent from the sources treated as authoritative. That absence sends a devastating message. The illness is deadly enough to require intensive treatment, expensive enough to bankrupt families, complex enough to require interdisciplinary care, but not organized enough to present one enforceable standard to the systems that control access and accountability.

Nor did private equity create this issue. It simply entered a disorderly field and found opportunity.

That distinction matters. The eating disorder field’s failure to establish enforceable standards predated much of the private equity consolidation. But once investment capital entered the residential and intensive treatment market, the absence of standards became commercially useful. A PE backed platform benefits from scalability. Scalability requires replicable operations, predictable margins, payer strategy, labor control, census management, and brand extension. In a field with enforceable clinical standards, those pressures collide with mandatory staffing, outcome reporting, medical coverage, training, supervision, discharge criteria, and transparent patient safety obligations. In a field without enforceable standards, those pressures can be converted into business judgment.

The AED standards make the private equity question sharper, not softer. By 2008, the field had articulated the need for eating disorder specific accreditation, prompt medical screening, interdisciplinary assessment, four core treatment components, nutritional rehabilitation goals, trained staff, continuing education, transparent financial information, discharge planning, quality improvement, and outcome measurement. Any serious investor entering or expanding in the eating disorder treatment market after that point had industry notice that residential and inpatient eating disorder care required specialized safeguards. The blueprint existed. The failure was not a lack of imagination. It was a lack of enforcement.

Measured against those standards, private equity’s role was not merely ownership. It was the commercialization of ambiguity. PE backed entities could acquire respected clinical brands, consolidate markets, add locations, advertise comprehensive care, pursue higher levels of reimbursement, and present themselves as national solutions without being forced to prove standardized outcomes across the platform. They could market compassion while operating under financial structures that reward growth, utilization, and eventual sale. They could describe themselves as evidence based without submitting to a universally accepted, independently audited eating disorder standard that measured whether the care advertised was the care delivered.

This is also why standards are important. Standards do not guarantee recovery. They do not eliminate clinical judgment. They do not reduce complex human beings to checklists. Properly designed, they do the opposite. They preserve clinical judgment by defining the minimum conditions under which judgment can be trusted. They require that a patient be medically assessed before placement. They require that a program be honest about its capabilities. They require that treatment be individualized, documented, and reviewed. They require that medical, psychiatric, psychological, and nutritional care all exist in fact, not only in marketing. They require that programs measure outcomes in a way that survives scrutiny. They make it harder for a center to sell a level of care it cannot safely provide. They make it harder for an insurer to deny a level of care the patient medically needs. They give families a way to distinguish treatment from theater.

The eating disorder community has paid a severe price for its failure to impose those minimum conditions. Families have been left to investigate facilities while in crisis. Patients have been moved through levels of care without clear, enforceable criteria. Clinicians have been forced to operate in a landscape where “specialist” can mean rigorous training or little more than self- selection. Payers have been able to exploit inconsistency. Treatment centers have been able to exploit fear. Private equity has been able to exploit both.

The result is a field that too often asks for deference without submitting to discipline. It asks insurers to pay for care while failing to create uniform proof of what competent care requires. It asks families to trust programs while permitting those programs to define their own excellence. It asks physicians to refer into higher levels of care while failing to ensure that those levels of care meet eating disorder specific standards. It asks the public to understand eating disorders as serious medical and psychiatric illnesses while tolerating a treatment marketplace that sometimes behaves as though seriousness can be inferred from price.

Purportedly, this topic has been discussed on numerous occasions by various organizations and individuals. On a few occasions, the topic has even gone past the discussion stage. In 2022, the American Psychiatric Association drafted new Practice Guidelines for the Treatment of Eating Disorders. On February 27, 2023, the APA announced it had adopted these guidelines. But there was a proviso. The press release also stated, “APA’s own “Proper Use of Guidelines” section says the guidelines are not a statement of the standard of care, do not mandate a particular course of medical care, do not substitute for clinician judgment, and are voluntary.”

In late 2025, the DSM Steering Committee proposed new eating disorder severity guidelines to be adopted and included in the DSM-V-TR or the next derivation of the DSM.  Again, the warning language appears, The previously mentioned limitations apply equally to this proposal.

Effectively meaning … there has been some discussions. But, no effective, collaborative, broad-based action. Talk? Some. Solutions? None.

The solution is not another voluntary badge. It is not another proprietary credential. It is not another conference panel, white paper, or consensus statement that can be ignored by the next operator with a marketing budget. The solution is enforceable, eating disorder specific standards of care tied to accreditation, licensure, reimbursement, outcome reporting, and medical education. The standards must require medical risk assessment, refeeding competence, interdisciplinary treatment, trained staff, transparent levels of care, family involvement where appropriate, discharge planning, continuity of care, independent outcome measurement, and external accountability. They must apply to nonprofit programs, academic programs, independent centers, and PE backed platforms alike. They must be forward thinking taking into account the seismic changes which have occurred in the last five years impacting eating disorders.

The field does not need to start from scratch. The AED standards showed the beginning of the map. Later guidelines and center of excellence proposals added other pieces. The scientific literature has expanded. The public burden data have become harder to ignore. The litigation record has grown. Families have told the truth at great cost. The missing ingredient is not knowledge. It is institutional will.

An eating disorder treatment system without generally accepted standards of care is not a system. It is a marketplace. In that marketplace, the sickest patients are the least able to judge quality, the most desperate families are the easiest to persuade, the most expensive care is not always the most effective, and the most polished brands are not always the safest. That is not medicine. That is exposure.

The eating disorder community must decide whether it exists to protect patients or to protect the institutions that claim to serve them. If it chooses patients, it must accept enforceable standards, transparent outcomes, real accountability, and scrutiny of financial structures that place growth over care. If it refuses, then the verdict writes itself: the system knew the danger, possessed the tools to reduce it, and chose fragmentation over protection.