The latest hobgoblin to perplex the eating disorder community is the use of GLP-1 medications. Competing presentations and articles are being published. Accusations of bias are already bandied about. This raises the inevitable question … was the talk or article biased or was it simply incomplete?

That distinction matters more than it may first appear. To call a presentation “biased” is to suggest a fundamental defect. It implies bad faith, intellectual contamination, or a failure so basic that the speaker’s credibility is diminished. The word often operates as an accusation, and once it enters the lexicon, the conversation itself changes. People retreat into defensive positions. Groups harden. The possibility of productive engagement narrows.

But to refer to a presentation as “incomplete” is different. “Incomplete” does not excuse weakness. It identifies it with precision. It says the subject required more voices, more context, more rigor, more disciplines, more lived experience, more challenge. It leaves room for the possibility that the presenter was building something rather than distorting something. It invites participation rather than condemnation. It allows the field to ask; What is missing? Who was not included? What assumptions were left untested? What would make this stronger?

That distinction, bias versus incompleteness, goes to the heart of a systemic problem within the eating disorder community.

Too often the field does not possess the structures necessary to metabolize disagreement. It does not consistently bring opposing views into disciplined, accountable deliberation. Instead, it allows major questions to emerge through fragmented presentations, isolated publications, advocacy statements, rebuttals, counter-rebuttals, and public controversy. The result is not consensus. It is not clarity. It is not reform. It is serial reaction and in some cases, overreaction.

Terminal anorexia, weight stigma, obesity, residential treatment, involuntary care, medical stabilization, private equity, insurance denial and the role of families. The debate over GLP-1 medications is only the latest example.

Given the stakes, the introduction of GLP-1s into the eating disorder conversation should have triggered a process proportionate to the seriousness. These medications raise profound clinical, ethical, metabolic, psychological, social and even spiritual questions. They implicate body weight, appetite, medical risk, obesity treatment, relapse vulnerability, access to care, stigma, autonomy, coercion, and the meaning of recovery itself.

A mature field would have responded by convening a serious, multidisciplinary process. Not a panel designed to affirm one position. Not a paper written from one perspective. Not a series of advocacy reactions after the fact. A real process.

That process should have included eating disorder clinicians, obesity medicine specialists, psychiatrists, endocrinologists, researchers, ethicists, patients, families, disability-rights advocates, theologians, legal scholars, and people with lived experience across different diagnostic and body size realities. It should have directly examined assumptions. It should have asked what is known, what is unknown, what is being inferred, and what risks are being underestimated. It should have distinguished clinical concern from ideological reflex. It should have clarified where caution is warranted and where fear may be substituting for evidence.

Instead, the field did what it too often does. It processed the issue through fragmentation.

One group speaks. Another group objects. A paper appears. A blog responds. A statement circulates. A conference panel frames the issue one way. A counter-panel frames it another. Advocates describe harm. Clinicians defend nuance. Researchers ask for data. Patients feel unseen. Families remain confused. Positions harden before the field has created a shared table at which those positions can be tested.

And nothing durable is built. This is not structured deliberation. It is intellectual trench warfare. This trench warfare has become the eating disorder field’s primary method of adjudication.

What does not emerge is institutional architecture capable of absorbing disagreement and converting it into accountable consensus. That absence is not a minor procedural flaw. It is one of the field’s central weaknesses.

A field dealing with a life-threatening illness cannot rely on sequential publication as its primary conflict resolution mechanism. Publication has value. Scholarship matters. Commentary matters. Advocacy matters. But none of those alone can substitute for a legitimate consensus building structure. Papers do not cross-examine assumptions in real time. Advocacy statements do not reconcile competing clinical realities. Conference talks do not create binding standards. Public rebuttals do not necessarily produce shared definitions.

They often produce only more hardened factions.

A system that can only process new and consequential concepts through this fragmented process is not demonstrating intellectual vitality. It is demonstrating procedural weakness. It is showing that it lacks the mechanisms needed to test its most important ideas before they migrate into practice, policy, treatment settings, insurance decisions and public discourse.

That matters because ideas in this field are not abstract. They become clinical posture. They influence whether patients are hospitalized or discharged. They shape how risk is understood. They affect whether families are included or marginalized. They determine whether weight loss is celebrated, feared, treated, or ignored. They define whether a patient is viewed as resistant, autonomous, hopeless, harmed, empowered, or in need of urgent intervention.

Language becomes practice. Practice becomes outcome. Outcome becomes life or death.

The eating disorder community cannot continue treating disagreement as contamination. It cannot keep mistaking opposition for hostility. It cannot continue allowing each faction to speak from its own platform while pretending that the existence of multiple platforms equals meaningful discourse. It does not.

Real discourse requires structure. It requires shared rules. It requires the willingness to sit beside a person who sees the issue differently and remain engaged long enough to understand why. It requires humility from researchers, clinicians, advocates, families, and patients alike. It requires the recognition that no single constituency owns the truth. Separate truths may coexist. A serious field must be able to hold both simultaneously.

The current model does not do that well. The current model rewards position taking more than integration. It rewards rapid response more than disciplined synthesis. It rewards moral clarity, even when the underlying issue is clinically and ethically complex. It allows organizations to issue statements, scholars to publish frameworks, advocates to mobilize outrage, and clinicians to continue practicing amid uncertainty … without requiring the field as a whole to reconcile competing truths.

That is not consensus. That is convenience.

The path forward is not silence. It is not politeness for its own sake. It is not pretending that all views are equally supported by evidence. Some arguments are stronger than others. Some claims are dangerous. Some assumptions deserve to be challenged directly. But the challenge must be structured.

The field needs a new model for consequential disagreement. When the next major issue arises the response should not be another isolated paper followed by predictable backlash. It should be a convened process with opposing experts, clear questions, transparent assumptions, defined evidentiary standards, patient and family participation, ethical review, and a published consensus document that identifies agreement, disagreement, uncertainty, and practical guidance.

Not every issue will end in unanimity. It should not. Forced consensus can be as dangerous as fragmentation. But a credible process can at least clarify the boundaries of disagreement. It can say … here is what we know; here is what we do not know; here is where clinical caution is justified; here is where ideology may be exceeding evidence; here is where patient safety requires action; here is where further research is essential; here is how families and clinicians should proceed in the meantime.

That would be progress.

The eating disorder field does not suffer from a lack of passion. It suffers from a lack of integrative structure. It has brilliant clinicians, committed researchers, courageous patients, grieving families, thoughtful advocates, and people of genuine moral seriousness. But intelligence distributed across factions does not automatically become wisdom. Wisdom requires architecture.

The eating disorder community must move beyond the zero-sum game. It must stop treating incompleteness as bias and disagreement as betrayal. It must build the institutional capacity to hold complexity without collapsing into camps. It must recognize that the goal is not for one tribe to defeat another. The goal is to produce better care, better standards, better evidence, better ethics, and better outcomes.

Lives depend on whether the field can learn to do that.

WHAT AM I BID FOR …

For people in the eating disorder community, this is not an abstract finance story. This is Center for Discovery, one of the most recognizable names in eating disorder treatment, a brand that for years presented itself as a leader in residential and outpatient care for adolescents and adults, and a major component of the larger Discovery Behavioral Health platform. That platform reportedly expanded across 16 states and more than 150 treatment centers at its peak.

On May 11, 2026, in the offices of a New York City law firm, shattered pieces of the Discovery Behavioral erstwhile empire, including Center for Discovery, are set to be sold in a private auction, “as-is, where-is,” to address nearly $270 million in debt.

The “as is, where is” phrase matters.

Families were sold something very different; expertise, safety, continuity, and clinical necessity. What is now being sold is the underlying reality. Center for Discovery was not just a treatment program. It was primarily collateral inside a leveraged financial structure.

Discovery’s history makes the point. Investors behind Webster Equity Partners, a private equity firm, bought the company in 2011. It later recapitalized and merged assets into what became Discovery Behavioral Health. It then went on an acquisition spree across eating disorder, psychiatric, and substance-use treatment. In 2021, Discovery reportedly refinanced with a $163 million term loan, a $30 million revolver, and an $86 million delayed draw commitment from HPS and Capital One. This was not organic growth because outcomes were so compelling the field could not ignore them. This was private equity doing what private equity does … consolidating a fragmented market, leveraging the platform, and expanding first while leaving proof and sustainability for later.

Then later arrived.

Discovery’s former CEO reportedly acknowledged in 2024 that its six-bed residential model had become unsustainably expensive because labor and operating costs were rising while payer reimbursement was not keeping up. That is not a side note. It is the business model speaking plainly. One of the very models the eating disorder world has been taught to regard as intimate, specialized, and clinically superior was also financially fragile. It worked until the math stopped cooperating.

After covenant breaches, missed reporting obligations, and an accounting reclassification that lenders viewed as a maneuver to avoid default, HPS and Capital One seized control in December 2025. It abruptly replaced leadership and moved the business toward sale. So yes, after years of telling families that these institutions existed to save lives, the market has finally clarified the arrangement.

What am I bid for Center for Discovery?

We are justified in asking who are the likely bidders. No one outside the process should pretend certainty, but the most obvious possibilities are: the lenders themselves through a credit bid; distressed healthcare investors; private equity buyers looking for selected assets at a discount, and; strategic operators who want individual programs, licenses, or regional footprints rather than the whole platform.

In other words, the bidders are unlikely to be grieving families or clinicians trying to preserve a mission. They are likely to be people asking a cold-hearted question … which pieces are still worth something, and on what terms?

So what happens to Center for Discovery after that? Again, no one should pretend certainty. But the usual possibilities are not mysterious. CFD may continue under new ownership. CFD may be rebranded. It may be consolidated with other treatment centers. It may be stripped of its most valued assets, if any, for sale to the highest bidder. It may close if it does not fit the buyer’s economics.

That is what happens when a treatment network is revealed to be a portfolio before it is a public trust.

But there is one undeniable truth. CFD has failed and has betrayed the families it pledged to help.

So, at this point families may be asking if they should leave their loved ones in Center for Discovery facilities. That answer is not simple and anyone pretending otherwise is being reckless. Families should not panic and abruptly remove a loved one without a continuity plan especially if that person is medically fragile. Sudden disruption in eating disorder treatment can be dangerous. But families also should not passively assume that a recognizable, failed brand name still guarantees stability. At a minimum, they should be demanding direct answers to the following questions from facility leadership …

Is this specific program being sold, transferred, or retained?

Will clinical staff remain in place?

Is there any risk of closure, consolidation, or transfer?

What is the contingency plan for continuity of care?

Who will notify families if ownership changes?

Are there any changes in medical coverage, supervision, or discharge planning?

If a facility cannot answer those questions clearly, families should understand that as a warning sign, not an inconvenience … and act accordingly. Nothing is more important than the health and life of your loved one.

And no one in the eating disorder system should pretend that this is only about Center for Discovery.

Center for Discovery is simply the first case dramatic enough to make the architecture visible. If the treatment system depends on high-cost residential care, rising labor costs, payer resistance, lease drag, and heavy debt, there is no serious reason to think Center for Discovery will be the last emblem of the private equity era to fall in public. It may only be the first one wheeled into the auction room while the rest of the industry stares determinedly at the floor.

That is what makes this moment so important for the eating disorder community. Center for Discovery was not outside the system. It was one of the institutions that helped define it. One of the brands that normalized residential expansion. One of the names families were taught to trust.

Trust. The eating disorder system defined it. The eating disorder system betrayed it.

If Center for Discovery can be repossessed, stripped, and marketed for sale, then perhaps the question is no longer whether the system is unstable.

Perhaps the question is how long everyone intends to keep pretending this is an exception. Because there will be others. Center for Discovery is merely the first domino. Which brings us back to the first question …

What am I bid for … Center for Discovery?

Sick Enough (Second Edition) by Dr. Jennifer L. Gaudiani

Dr. Jennifer Gaudiani’s first book, Sick Enough became one of the most influential medical texts on eating disorders for a mixed audience of clinicians, patients and families. Her recent Second Edition considerably expands its reach. It is broader in diagnostic scope, more explicit in its rejection of weight stigma, and more attentive to populations historically marginalized within eating disorder discourse, patients in larger bodies, those with ARFID or atypical anorexia, athletes, neurodivergent individuals and others.

The second edition is a substantial, clinically ambitious and humane book. This is an updated guide with a wealth of information for patients, families, and clinicians. It has an expanded coverage of weight-inclusive care, “unmeasurable” medical problems such as Positional Orthostatic Tachycardia Syndrome (POTS) and Mast Cell Activation Syndrome (MCAS) and includes specific populations such as athletes, people in perimenopause, and those with PTSD or ADHD.

Its table of contents also shows a broader scope than a narrow anorexia only manual. The Second Edition covers purging, BED, ARFID, atypical anorexia, recovery and several special populations.

It is one of the strongest medically oriented eating disorder books for a mixed audience. Especially if the reader wants a text that combines clinical seriousness with anti-stigma framing. Its greatest strength is that it repeatedly emphasizes that eating disorders are medically dangerous across body sizes and presentations. However, one of its limitations is that it can be too expansive, too clinician-shaped, and at times too structurally diffuse for readers who want either a purely patient facing guide or a tightly organized medical handbook.

What the book does very well

The Second Edition directly attacks the “not sick enough” myth. This is the book’s central moral and medical achievement. Dr. Gaudiani makes the case that eating disorders are not validated by emaciation alone and that serious risk can exist in larger bodies, in atypical anorexia, in purging disorders, and in undernutrition that is not socially legible. The Second Edition’s explicit emphasis on weight stigma and weight inclusive philosophy is one of its defining strengths.

That matters because many books on eating disorders still smuggle in a hierarchy of seriousness. Sick Enough pushes against that hierarchy. It is corrective in the best sense, not merely compassionate, but clinically corrective.

The book also bridges medicine and lived experience better than most clinician authored books. The book emphasizes case presentations, stories, metaphors, practical strategies, and approachable science. That combination seems to be the key to the book’s reputation. An independent professional reviewer noted that Dr. Gaudiani combines expertise with a compassionate tone and keeps the book accessible without drowning newer readers in jargon.

This is important because eating disorder medicine can quickly become alienating. A text can be medically accurate yet useless to frightened patients or exhausted families. Dr. Gaudiani appears to avoid that trap by translating physiology into understandable language without trivializing it.

The table of contents shows a book that does not stop at restrictive anorexia. It includes chapters on purging, BED, ARFID, atypical anorexia, recovery, neurodiversity, diabetes, athletes/REDs, males, gender and sexual minorities, sexual and reproductive health, substance use, older age, and gastrointestinal or autonomic complications.

That breadth makes it unusually useful in real world practice where some patients rarely present as textbook stereotypes. The Second Edition seems designed to reflect the heterogeneity of eating disorders rather than forcing everyone into one familiar clinical script.

The Second Edition explicitly includes a section on “The Unmeasurables,” including MCAS and POTS. Whether every reader will agree with the framing, this signals one of the book’s core virtues. It approaches in a professional manner, the messy borderlands of eating disorder medicine where symptoms may be debilitating even when medicine has not produced neat explanatory boxes.

That gives the book emotional and clinical credibility. Patients with complicated, long-standing illness often feel erased by handbooks that only recognize what fits clean laboratory or diagnostic boundaries.

A number of medical treatises are technically solid but ethically thin. Sick Enough seems to understand that care is not just about identifying bradycardia, electrolyte derangement, endocrine suppression, or GI dysfunction. It is also about how bias delays treatment. The weight stigma material is not simply ornamental. That makes the book more than a manual. It is also an intervention into how clinicians think.

Room for Improvement or Greater Clarity

As with all books, papers, studies and treatises there are areas for greater explanation and clarity.

The organization of the Second Edition may frustrate readers who want a classic systems-based handbook. One independent review from a dietitian praised the book but made a sharp structural criticism, that it did not organize material primarily by body system, so a reader trying to track for example, cardiovascular or GI consequences across diagnoses may need to jump between chapters.

That is a meaningful weakness. For a clinician in a hurry or a student trying to build a clean mental map, a systems based structure can be more efficient. Dr. Gaudiani’s presentation-by-presentation approach may feel more human and clinically realistic, but it is not always the fastest for cross-referencing.

The Second Edition also may be too medical for some patients and too general for some specialists. This is a classic hybrid text problem. By trying to serve patients, loved ones, and clinicians at once, the book likely lands a little imperfectly for each subgroup. For patients early in illness or recovery, the sheer amount of medical detail may feel overwhelming. For subspecialists already steeped in eating disorder medicine, some sections may read as broad synthesis rather than cutting edge dispute. That does not make the book weak. It makes it broad. But broad books inevitably trade some depth for reach.

One of Dr. Gaudiani’s strengths is having a strong clinical voice. The downside of that voice, in any physician authored guide, is that it can sometimes produce a subtle asymmetry. The reader is being expertly guided, but nonetheless guided. For some readers, especially those wary of medical paternalism, this can feel comforting; for others, it can feel managed.

There are also some topic choices which may invite debate. [Debate has never been a weak spot for Dr. Gaudiani.] The inclusion of conditions such as MCAS and POTS under “unmeasurables” will resonate deeply with some readers and prompt skepticism from others, especially readers sensitive to how contested syndromes are discussed in medicine.

That is not necessarily a flaw. But it does mean the book is not purely conservative in scope. It steps into areas where interpretation, causality, and framing are complicated. Some will see that as brave and patient honoring. Others will worry it risks overextension.

Sick Enough does underscore the lethality of eating disorders and makes clear that anorexia nervosa carries the highest mortality rate of any psychiatric illness, citing markedly elevated death rates relative to healthy peers and a significant contribution from suicide. However, the book does not organize this point as a sustained comparative analysis across diagnoses. Instead, it embeds the explanation within its broader medical framework. The cumulative effects of prolonged undernutrition, multi-system physiological deterioration, and heightened suicide risk. In this way, Dr. Gaudiani establishes the mortality hierarchy clearly, but explains it implicitly through the biology of starvation and clinical risk rather than through a dedicated, diagnosis-by-diagnosis examination of mortality mechanisms.

The best features and biggest improvements in the Second Edition appear to be: a stronger emphasis on weight stigma and weight-inclusive care; broader recognition of ARFID, atypical anorexia, BED, and diverse patient groups; added treatment of neurodiversity and psychiatric complexity; inclusion of POTS, MCAS, and complex digestive issues, and; more explicit attention to athletes, males, gender/sexual minorities, sexual and reproductive health, and older adults.

That is exactly the sort of expansion a Second Edition should make. Not just “more studies,” but a wider and more current model of who gets sick and how illness presents. The Second Edition may be structurally imperfect as a reference manual, occasionally vulnerable to being too broad for specialists and too dense for lay readers, and open to debate in some of its more complex “unmeasurable” territory.

However, it is authoritative, compassionate, modern in its anti-stigma stance, broad in diagnostic scope, and far better than most medical books at explaining why a person can be very ill without “looking sick.” It seems especially strong on translating eating disorder medicine into language usable by non-specialists.

Although not flawless, [what book is?] it is the kind of book that can genuinely change how people understand eating disorders: medically, morally, and diagnostically.

That is rare.

Which makes the Second Edition a must read for medical and mental health professionals and not just those in the eating disorder community.

What Chiles and the Meta Cases Mean

Therapists have expressed concern about the recent Supreme Court decision in Chiles v. Salazar and what it means for their practice. They see this decision as a ruling about conversion therapy. But that framing is far too narrow. What the Court actually determined is far more consequential for your practice. The opinion partially redefined psychotherapy as protected speech under the First Amendment. In doing so, it changed where accountability for therapists will now live.

Before this decision, states could draw bright lines; certain therapeutic practices were simply prohibited, and licensing boards enforced those prohibitions directly. That framework is now constitutionally unstable if it depends on viewpoint.

After Chiles, the rule is now closer to … the state cannot ban what you say in therapy based on ideology. But it can still hold you accountable for how your speech functions as treatment. That is not a small adjustment … it is a structural shift.

The Court’s reasoning elevates therapy into one of the most protected categories in constitutional law. Because therapy is not casual speech. It occurs inside a fiduciary-like relationship, a context of trust and dependence and a setting where influence is not incidental, it is the point. So while your speech is protected from government censorship, it is not insulated from professional responsibility or liability. That distinction will define the next decade of litigation.

Courts will be moving away from asking, “Is this category of therapy allowed?”And toward asking, “Did this therapist, in this specific case, use their professional authority in a way that caused harm?” That means no more categorical bans as the primary tool. Instead, it will mean more malpractice claims, board complaints, and fact-specific investigations. Critically the question is no longer what you believe … it is how you operationalize those beliefs in treatment.

Let’s also review what the opinion did NOT do. The Court did not resolve whether all therapeutic modalities are speech, e.g., behavioral therapy vs. talk therapy. The Court did not explicitly declare that psychotherapy is fully protected speech in all respects. Instead, it held that when psychotherapy consists of conversational exchange, the state cannot regulate it based on viewpoint.

The Court rejected the idea that therapy is merely “conduct with incidental speech” and instead treated it as speech-based activity that falls within core First Amendment protection. This is a major shift because it undermines prior cases that treated therapy as regulable professional conduct. For many clinicians, especially those grounded in progressive, client centered practice, the instinctive reaction may be concern about losing regulatory protections against harmful approaches. That concern is valid. But it is only half the story.

The other half is this, as formal regulation weakens, individualized legal and professional scrutiny intensifies.

The Practical Reality for Therapists

Think of it this way. Before the decision, the state could say, “You are not allowed to use this type of therapy.” Now, the state generally cannot say, “You are not allowed to express this particular idea or perspective in therapy.” For example, the state cannot interrogate you on the following topics, “You cannot question gender transition,” or “You cannot support gender transition” or “You cannot explore certain identity outcomes.” Why?

Because that would be viewpoint based. It is picking which ideas are allowed and which are not. The Court says that violates the First Amendment. But the state can still say, “You are responsible for how your therapy affects your client.”

What You Are Now More Free to Do

After the Chiles decision, you have more freedom to explore controversial ideas, discuss difficult or politically sensitive topics, work outside strict ideological boundaries or use approaches that are not explicitly endorsed by the state. In short, you have more freedom in what you can say and explore in session. Indigenous person’s land use acknowledgement? Knock yourself out. Blaming all of society’s ills on the evil white man? Go ahead.

But that freedom comes with a very important limitation. You are still responsible for how your work impacts the client. So, the real question is no longer, “Is this allowed?” It becomes, “Can I justify this as responsible, appropriate care for this client?”

The takeaway is the biggest risks are not about having views. They are about how those views show up in therapy. You may be at risk if you present your beliefs as the “correct” answer instead of helping the client explore their own thinking. Or, if you steer or pressure the client especially on major identity or life decisions. Or, if you move outside generally accepted standards of practice without explaining it and without making sure the client understands what you’re doing. Or, if the client is vulnerable and things get worse and your approach played a role in that.

This reality aligns with broader trends impacting your mental health practice. Across recent cases involving Meta and Google, courts have been reluctant to restrict speech outright, but increasingly willing to scrutinize actors who shape outcomes for vulnerable audiences. That framework translates almost perfectly to therapy. You are not a passive speaker. You are not a neutral platform. You are a professional with structured influence over a vulnerable individual.

This places therapists into what is effectively a “high-responsibility speech” category. Yes, speech is protected. But responsibility increases with power, trust, and foreseeability of harm. Paradoxically, greater speech protection can mean greater exposure. This is because you no longer operate under clear categorical rules and instead operate under case-by-case scrutiny. Risk concentrates in situations where personal ideology is presented as clinical necessity, client autonomy is subtly overridden, approaches depart from recognized standards without justification and vulnerable clients (especially minors) experience deterioration.

In those cases, the issue will not be, “Was this viewpoint allowed?” It will be, “Was this professional conduct defensible?”

The therapy room is now more protected from government interference but more exposed to individualized scrutiny … by courts, boards, and clients. You have greater freedom to speak. But you are also more accountable for how you use your authority, how you justify your methods and how your interventions affect vulnerable people.

The most important change is not what therapists are allowed to say. It is what they must now be prepared to defend. And that defense will not be ideological. It will be clinical, evidentiary, and grounded in whether what happened in the room can be justified as responsible care.

The March 25, 2026 jury verdict in Los Angeles against Meta and Google, paired with the $375 million New Mexico verdict against the same companies the day before, mark a structural shift in how courts conceptualize harm arising from social media platforms. These cases do not merely expand liability. They reframe the legal ontology of digital platforms from neutral intermediaries into potentially defective consumer products.

In this article, we will explore what this means for the way in which we look upon eating disorders … and what therapists and clinicians should know.

For eating disorders, conditions already deeply entangled with algorithmic amplification, body image distortion, and compulsive engagement, the shift in liability for digital platforms is particularly consequential. The emerging litigation theory may provide for the first time a coherent legal pathway to attribute causation and duty in eating disorder related harm.

The recent Meta/Google verdicts succeeded because plaintiffs changed the theory of liability. The old framing was, “You allowed harmful content to exist.” Federal statutes provided immunity for this reasoning. Case dismissed.

The new framing is now, “You designed a system that predictably causes harm.” This is the doctrinal pivot. The plaintiffs were able to bring forth evidence that the platforms knew about harm (e.g., to teens, body image, ED risk) but continued optimizing engagement anyway. This evidence supports claims of negligence, recklessness and malice. This also strengthens the argument that the wrongdoing lies in corporate decision making not user content.

Why This Matters Specifically for Eating Disorders

Eating disorder harm fits the “Design, Not Content” model argued in courtrooms. Eating disorders are not typically triggered by a single post. But by repeated exposure, escalating comparison and behavioral reinforcement. These are clearly algorithmic phenomena.

Unlike traditional media, social media platforms can identify users engaging with dieting and body comparison content. This increases the likelihood of exposure. This frames a plaintiff’s argument that harm is not incidental. It is systematically intensified. There is also substantial evidence that social comparison leads to body dissatisfaction and repeated exposure leads to disordered eating behaviors

This makes it easier to argue that harm was predictable, foreseeable and safer alternatives were available but disregarded.

The recent verdicts are also significant not because they establish a medical causation of eating disorders, but because they elevate platform design and algorithmic exposure into the realm of foreseeable mental health risk.

In effect, the verdicts reinforce three propositions that are directly relevant to clinical practice:

Digital environments can function as risk-amplifying exposures, particularly for adolescents;
Algorithmic curation is not neutral, but can intensify engagement with appearance focused or psychologically harmful content; and
Harm need not arise solely from user intent but may be driven by product design features.

From a standard-of-care perspective, these propositions are likely to influence what constitutes “reasonable” clinical conduct.

Even in the absence of formalized guidelines, foreseeability plays a central role in negligence analysis. As juries begin to recognize social media design as a source of mental health harm, clinicians may be expected to:

Screen for social media use with greater specificity (not merely duration, but type of content and engagement patterns);
Identify platform-related triggers (e.g., comparison behaviors, exposure to body-ideal content, reinforcement loops);
Incorporate digital environment management into treatment planning; and
Provide anticipatory guidance to patients and families regarding online risk factors.

Failure to do so over time may be framed as a deviation from evolving professional norms even in the absence of codified standards.

Evolution of Standard of Care Through Litigation Rather Than Consensus

In fields lacking clear clinical standards, the standard of care often evolves through case law, expert testimony, and institutional practice patterns.

The Meta and Google verdicts may accelerate this process by:

Providing a judicially recognized framework for linking platform design to mental health harm;
Encouraging plaintiffs to incorporate digital exposure into causation narratives; and
Pressuring professional organizations to issue more explicit guidance in response.

In this sense, the verdicts may function as de facto catalysts for standard formation even if formal consensus lags behind.

Clinicians and treatment programs that proactively integrate digital-risk assessment may therefore position themselves more favorably relative to an emerging baseline of care.

Implications for Causation Frameworks in Eating Disorders

Historically, eating disorders have been understood through a multifactorial model, incorporating genetic predisposition, temperamental traits, family dynamics, trauma and sociocultural influences. The recent verdicts do not displace this model. However, they may recalibrate the weight assigned to environmental and systemic contributors, particularly those mediated through technology. Importantly, this shift may influence not only clinical practice, but also the narrative frameworks used in litigation and public discourse.

Anticipated Expansion of Social Justice and Structural Etiology Arguments

One of the more complex implications of these developments is the possible expansion of social justice based etiological frameworks, including arguments that locate eating disorders within broader systems of oppression.

Within certain academic and advocacy contexts, eating disorders have increasingly been linked to:

Eurocentric beauty standards,
Fatphobia,
Structural inequities in healthcare access, and
Cultural norms associated with what has been termed “White supremacy culture” (e.g., perfectionism, control, individualism).

The Meta and Google verdicts may indirectly reinforce these perspectives in several ways:

1. Externalization of Harm

By attributing liability to platform design rather than solely to individual behavior, the verdicts support a broader shift toward externalizing causation. This aligns with social justice frameworks that emphasize systemic over individual factors.

2. Validation of Environmental Influence

The recognition of algorithmic amplification as harmful lends credibility to arguments that cultural and media environments actively shape pathology, rather than merely reflecting it.

3. Expansion of Duty Beyond the Individual

If platforms can be held liable for contributing to mental health harm, analogous arguments may be advanced that cultural systems, institutional practices, and dominant norms also bear some responsibility for shaping risk.

As a result, Plaintiffs may increasingly incorporate cultural and systemic critiques, expert testimony on media ecology and sociocultural pressure, and arguments linking platform content to broader ideological frameworks as part of causation narratives.

Tension Between Clinical Rigor and Expanding Etiological Narratives

While these developments may broaden the scope of inquiry, they also introduce tension. From a clinical and evidentiary standpoint multifactorial models require specificity and measurable variables and overly diffuse causation theories risk diluting analytical precision.

From a legal standpoint courts require evidence that is not only plausible, but attributable and proximate. Expansive social frameworks (e.g., “White supremacy culture”) may be more difficult to operationalize in a manner that satisfies evidentiary standards. Accordingly, while social justice perspectives may gain rhetorical and academic traction, their translation into clinical standards or legal causation will likely depend on the development of measurable constructs, empirical validation, and clear linkage to individual harm.

Increased Eating Disorder Liability

For eating disorder related claims, liability may no longer depend on identifying specific harmful posts. Instead, plaintiffs can target recommendation algorithms, engagement loops (likes, scroll, autoplay) and behavioral reinforcement systems. This aligns directly with how eating disorder pathology operates; repetition, reinforcement, and escalation, not isolated exposure.

Historically, eating disorder related litigation struggled with causation; eating disorders are multifactorial (genetics, trauma, culture) and Courts viewed platform influence as too attenuated.

The recent verdicts suggest juries are now willing to accept alternatives. The Los Angeles case framed harm through addiction mechanics; compulsive use, reinforcement loops and diminished control. This maps closely onto eating disorder pathology; compulsive restriction, bingeing, or purging, reinforcement through comparison and validation and escalating behavioral cycles.

Unlike traditional media, social media platforms learn user vulnerabilities and optimize content delivery accordingly. For eating disorder claims, this enables arguments that platforms did not merely expose users to harmful content. They systematically increased exposure based on detected susceptibility.

This is a qualitatively different form of causation, not passive distribution, but active behavioral shaping.

Among potential harm categories, EDs are uniquely positioned for litigation success due to a high predictability of harm. There is extensive internal and external research linking social comparison to body dissatisfaction to disordered eating. We now know that social media platforms can track repeated viewing of weight loss content, thinspiration and calorie restriction narratives. This creates a potential evidentiary record of foreseeable harm combined with continued amplification.

Courts are especially receptive to harms affecting minors and failure to implement protective measures. Eating disorder onset often occurs during adolescence, aligning directly with peak social media usage and peak psychological vulnerability.

Long-Term Structural Changes

As a result of these cases, we may see an emergence of “Digital Duty of Care” particularly for minors. Social media platforms may be held to standards similar to product safety law and pharmaceutical risk disclosure. Courts may formalize liability tied to predictive amplification of harm. And we may see potential legislation impacting youth specific design standards, limits on engagement optimization and/or mandatory transparency for algorithmic systems.

We may also see evolving clinical implications for eating disorders. Eating disorders may increasingly be viewed not only as psychiatric conditions but environmentally induced or exacerbated disorders linked to platform design.

Clinicians should begin to document social media exposure patterns and incorporate platform use into diagnostic frameworks. This could strengthen litigation evidence and insurance coverage arguments.

In addition, eating disorders may be reframed as partially technology-mediated disorders. This parallels lung cancer (tobacco) and opioid addiction (pharmaceutical design and distribution).

The Meta and Google verdicts do not merely increase litigation risk, they signal a paradigm shift in how harm from digital systems is understood and adjudicated. For eating disorders, the implications are profound:

A viable legal theory now exists
Causation barriers are weakening
Platform design is becoming justiciable
Large-scale settlement frameworks are increasingly likely

Most importantly, these developments may redefine eating disorders not only as clinical phenomena, but as foreseeable outcomes of engineered environments optimized for engagement at the expense of psychological safety.

If this trajectory holds, the next phase of litigation will not ask whether platforms contributed to eating disorders, but to what extent, and at what cost.

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.

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.

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

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

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

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

This is a table listing eating disorder related certifications:

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

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

The Great Credential Free-for-All

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

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

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

When Certification Becomes a Branding Exercise

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

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

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

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

Disunity as a Business Model

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

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

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

The Human Cost of Credential Inflation

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

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

The Wellness Economy and the Collapse of Accountability

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

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

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

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

A Perfect Storm of Profit and Disunity

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

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

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

A DAD'S JOURNEY WITH EATING DISORDERS

Musings on Mental Health and the Eating Disorder Industry

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Tag Archives: anxiety

WHAT AM I BID FOR …

Sick Enough (Second Edition) by Dr. Jennifer L. Gaudiani

What Chiles and the Meta Cases Mean

THE DANGEROUS FICTION OF EATING DISORDER COACHES

Why we Acknowledge Awareness Week

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

DSM Steering Committee Proposal

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

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