Tag Archives: health

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.

Soul Hearted … or Soul Sold?

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

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

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

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

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

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

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

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

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

With Gratitude,

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

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

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

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

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

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

As for its rebranding?

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

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

“You deserve flowers” is a lovely sentiment.

But flowers are not:

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

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

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

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

Because in medicine, feelings are not outcomes.

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

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

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

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

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

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

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

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

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

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

And this specific danger was disclosed by former officers.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

It’s time to demand more than marketing.

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

But what it cannot do is rebrand away:

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

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

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

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

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

DSM Steering Committee Proposal

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

The recommended changes can be found here:

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

So, what does this actually mean?

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

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

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

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

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

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

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

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

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

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

One proposal was explicitly rejected by the APA Board.

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

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

Others were deferred or still under review.

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

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

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

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

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

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

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

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

This creates a binary inquiry:

If GASC exists and the insurance guideline contradicts it → unenforceable

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

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

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

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

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

However, and importantly:

It does not eliminate BMI for insurance company consideration;

It does not establish level-of-care rules;

It does not declare BMI-based criteria invalid;

It does not override APA’s SOC disclaimers.

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

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

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

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

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

IFEDD Advocacy Initiatives

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

2025: The State of AI in Healthcare

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

Insurance companies.

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

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

The Case For: Why Insurers Want Ai in Mental Health

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

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

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

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

The Case Against: Clinical, Legal, and Ethical Risks

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Practical Guardrails for Ethical and Defensible Deployment

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

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

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

Conclusion

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

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

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

When Activism Becomes Your Identity Recovery Suffers

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

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

The Core Dynamic: Identity Fusion in Clinician-Activism

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

In that state, clinical questions are vulnerable to moralization:

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

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

And this results in harming patients.

7 Ways Militant Identity-fusion Harms Patients

1) Disagreement is improperly perceived as harm

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

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

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

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

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

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

3) The framework becomes the differential diagnosis

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

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

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

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

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

5) Outcomes are replaced with virtue

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

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

6) You punish measurement instead of fixing measurement

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

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

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

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

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

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

Why ED Recovery Is Especially Vulnerable to Identity Fusion

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In practice, this can look like:

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

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

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

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

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

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

Teams then develop avoidance patterns:

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

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

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

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

This can inhibit recovery by:

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

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

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

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

Used as identity, they can become a clinical shortcut:

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

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

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

What This Looks Like to Patients

Patients tend to experience the downstream effects in concrete ways:

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

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

Guardrails: Keeping Advocacy Without Losing Objectivity

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

1) Separate roles explicitly

Use an internal “two hats” model:

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

2) Require a “facts-only” case summary

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

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

3) Pre-commit to falsifiers

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

4) Build structured dissent into the team

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

5) Make informed consent real

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

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

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

Focus on:

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

Conclusion: Recovery Needs Reality, Not Ritual

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

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

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

Gratitude for ?

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

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

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

Uh … well … uh…

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

And yet, Acadia chose to honor …

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

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

Possible Reasons

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

HOW TO FIGHT DENIAL OF YOUR HEALTH INSURANCE CLAIM

An insurance company denying your legitimate, desperately needed health insurance claim has become all too common, an ordinary way of life … and a large profit center for those insurance companies.

Finally one attorney, Brian Hufford, has dedicated his practice to addressing this widespread problem. But first, let’s look at the alarming statistics.

In 2023, insurers on the HealthCare.gov marketplace denied an average of 19% of in-network claims and 37% of out-of-network claims. Denial rates varied widely by insurer, ranging from as low as 1% to over 50%.

Surprisingly, the most common reason for denial isn’t related to medical necessity at all. A full 34% of denials fall under the nebulous category of “Other”—an unspecified catch-all that gives insurers maximum flexibility and patients minimum clarity. When these vague denials are appealed, they’re overturned approximately 55% of the time, suggesting that the majority have no solid justification.

Administrative issues account for another 18% of denials. These include coding errors, missing information, or duplicate claims—technical issues having nothing to do with whether the care was appropriate or covered under the policy. These denials have the highest overturn rate at 78%, as they’re often simple misunderstandings or clerical errors that can be easily corrected.

Claims categorized as “service not covered” make up 16% of denials. While these have a lower overturn rate of about 35%, successful appeals often demonstrate that the service actually does fall under covered benefits when policy language is properly interpreted or when the medical necessity is clearly established.

Prior authorization issues cause 9% of denials, with patients receiving care without getting the insurer’s permission first. These have a 65% overturn rate when appealed, particularly when the care was urgently needed or when the provider can demonstrate they attempted to secure authorization.

Perhaps most concerning are the “not medically necessary” denials, which represent 6% of cases. These denials essentially second-guess your doctor’s judgment about what care you need. Yet when patients and their doctors challenge these determinations, they succeed approximately 70% of the time—an alarming discrepancy that raises questions about how these decisions are made in the first place.

Despite these high denial rates, fewer than 1% of denied claims are ever appealed by consumers. A survey found that 85% of patients never file a formal appeal, often due to a lack of awareness of their appeal rights or the complexity of the process.

When consumers and providers do appeal, they have a strong chance of success. According to a recent KFF survey, patients who took the time to appeal their denials experienced a 44% success rate with initial internal appeals—meaning nearly half of all challenges succeeded in the first round. For those whose internal appeals were rejected and who proceeded to external review, an additional 27% succeeded at that level.

When healthcare providers manage the appeal process, over 54% of initially denied claims are ultimately paid after multiple rounds of review. Some sources suggest that up to 80% of appeals can be successful when pursued effectively.

In summary, despite the fact that while claim denials are common, and patients and providers who navigate the appeals process often succeed in getting the denial reversed, the vast majority of denials go unchallenged. 

The 2023 KFF Survey of Consumer Experiences with Health Insurance found that 58% of insured adults said they have experienced a problem using their health insurance, including denied claims. Four in ten (39%) of those who reported having trouble paying medical bills said that denied claims contributed to their problem.

Each denial costs medical practices, on average approximately $43 to process, creating over $19 billion in administrative waste annually across the healthcare system. Small practices often spend more than 12 hours weekly wrestling with insurance companies over denied claims.

By making the process difficult and opaque, they ensure most people simply give up and pay out-of-pocket, or worse, forgo necessary medical care altogether. The financial result is billions in unpaid claims that boost insurance company profits while shifting costs to patients.

And at least one man, one attorney has had enough. Brian Hufford was one of the lead attorneys in the Wit v. UBH case still pending in California.

Briefly, David Wit along with other insureds brought a class action lawsuit challenging United Behavioral Health’s (UBH) use of flawed, financially motivated internal guidelines to deny coverage for mental health and substance abuse treatment, rather than applying generally accepted standards of care. The district court initially found during a class action trial that UBH violated the terms of its health insurance policies and breached its fiduciary duties under ERISA, ruling that UBH’s internal guidelines were defective and more restrictive than generally accepted standards of care. The Court of Appeals reversed this decision on the benefit claim and dismissed those class claims but sent it back to the district court to determine if the fiduciary duty findings should remain. Upon reconsideration, the district court again found that UBH breached its fiduciary duties. The case is on-going.

Despite that case still being active, Brian left his firm to start his own practice. After spending a career founding and running health insurance dispute practices at private firms, representing patients and clinicians against insurance companies, Brian opened his own practice as of July 1, 2025, to focus on public policy and advocacy.

His primary work is to expand help for people appealing health insurance denial. As the statistics show, this is a service that is wholly lacking in our current system. To address this matter, Brian is working with law schools to provide pro bono opportunities to law students who assist with health insurance appeals, working under his supervision. He is coordinating this effort through the People’s Action nonprofit, which is pursuing a Care Over Cost campaign, and Brian is serving as legal advisor to its National Appeals Team. Brian is also working as Senior Legal Advisor to Claimable, Inc., a start-up that is using AI to systematize health insurance appeals (www.getclaimable.com/).

If you have people who have been subjected to denials and need help with appeals, feel free to contact Brian (which is pro bono through his law school project). Depending on the number of patients who reach out, he may also connect people to Claimable for assistance.

Brian’s website is below, which has a link to a form patients can fill out. The form is automatically forwarded to Brian, and he will then follow up. You can contact Brian with any questions you may have.  

This crucial resource for our families is so incredibly important. And could very well mean the difference between you getting the necessary care you or your loved one need versus suffering from an unjust system.

Embrace a better future.

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