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.
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!):
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:
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.
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:
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.
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.
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.
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”.
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 andare 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.
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.
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
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
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.
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.
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.
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.
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.
On October 30, 2016, my beloved daughter Morgan died after battling eating disorders for seven (7) long years. She was 23 years old when she was taken. At the moment of her death, when a daddy hears those dark words, “She’s gone” though he may not know it at the time, the better part of him is also ripped away.
Morgan was brilliant, kind, and fiercely determined to get well. She thought of others, often before her own needs. Her own words, “I can seem to help everyone else … I just can’t help myself” is her legacy. And yet, those very words still haunt her daddy every day.
When those words and the reality of a loss no parent should ever have to suffer are combined with the state of the eating disorder community today, you realize that there will be many more of our loved ones condemned to share the same fate which took my daughter… unless a seismic change is forthcoming.
A System Without a Compass
Even at that time, the system that claimed to know how to help Morgan had no map, no unity, and tragically, no accountability. Nearly a decade later, the eating disorder community is in even greater disarray. There are still no generally accepted treatment guidelines … no consensus on what works, no uniform standards for care, no consistency from one program to another and no accountability nor consequences. If you send your child for treatment, what happens next depends less on science and more on which center you happen to find, and what ideology dominates that space.
The Vanishing of Science and the Rise of Ideology
The dire crisis in the community has worsened as grant funding for research dries up. Federal and private funders have largely turned their attention to other mental health priorities, leaving eating disorder research chronically underfunded. Few new studies are being published, and the next generation of researchers is dwindling. Research professionals and medical clinicians on the front lines rarely collaborate. In this vacuum, ideological movements have filled the void … often louder, more absolutist, more absurd and less accountable to data or outcomes.
Militant factions within the “body liberation” movement now control far too much of the public conversation in the community. They label professionals, clinicians and even families in a gross, inflammatory manner. Anyone who speaks about weight restoration or malnutrition is labeled as “fatphobic.” White Supremacy Culture. Invasive species. Utilizing every “ism” word possible. Complex medical and psychiatric illnesses are reframed as political identity issues. The result? A silencing of nuance and a dangerous confusion between eating disorder treatment and radical social activism. Inflammatory labeling has become the substitute for reasoned professional, collaborative communication. And our loved ones suffer.
Private Equity and the Hollowing Out of Care
At the same time, private equity–owned treatment centers, once the great hope for scaling access, are collapsing under the weight of their own failed business models. Many have failed outright or are surviving only by slashing costs: laying off medical doctors who served as full time employees, replacing them with part time independent contractors and inexperienced working staff. Running skeletal programs that cannot provide the continuous, multidisciplinary care our loved ones require. The result is a race to the bottom: more marketing, fewer doctors, more “coaches,” less medicine. No accountability nor consequences.
Families are left navigating glossy websites and sales teams instead of evidence-based programs. If a family wishes to speak with the medical director of a program before entrusting their child to that program … good luck. Insurance denials come faster than ever. Inpatient stays are shorter. Step-down programs are often nonexistent.
When Morgan was fighting for her life, I wondered whether the lack of care was a failure of coordination. I no longer wonder. It has never been clearer that it was and continues to be, a failure of values.
A Community in Financial and Moral Crisis
The largest eating disorder nonprofit organizations, long believed to be the moral anchors of the community, are collapsing financially some losing more than $200,000 per year. Echo chamber thinking and associated conduct have replaced outreach to professionals who respectfully disagree with their view. Where at one time, these organizations were led by persons of vision, true giants of the community, now with very few exceptions, they are led by boards who shrink away from transparency, oversight and responsibility. These organizations host conferences and awareness campaigns, but their impact is negligible at best and failing at worst.
Their messaging has grown vacuous and timid, shaped more by the politics of social media than the needs of our loved ones. Once they were advocates for treatment access and medical rigor; now too often, they stand meekly on the sidelines … mere bystanders to the on-going carnage.
The Human Cost
The price paid for the wholesale failure of the community is measured by the dearest blood possible … the lives of our loved ones. The mortality rate for eating disorders, already the highest among psychiatric illnesses [apart from opioid addiction] has worsened. Suicide and medical complications are climbing. The promise that “recovery is possible” rings increasingly hollow to families who can’t even get a proper diagnosis, let alone a full course of the highest quality medical and mental health care. Which results in:
Behind every number is a person, a victim. Behind every person is a family like mine, standing outside a treatment center, a hospital, a counselor’s office, desperately holding on to the only thing they can … that is, the fading hope that this time will be different.
Where Do We Go From Here?
Families are entitled to transparency. Accountability. Honesty. From our doctors, clinicians, and counselors. Families should demand nothing less. But, to accomplish this reality, we not only need an evolution of thought and wisdom … we require a bold reckoning. The eating disorder community must reclaim science, ethics, and accountability. The community can only provide those necessary qualities by demanding:
The adoption of national treatment guidelines grounded in evidence, not ideology.
Federal, state and philanthropic investment in clinical research and longitudinal outcomes.
Oversight of private treatment companies that market medical care that is not forthcoming as it sheds experienced medical practitioners and licensed staff.
Strong, bold, new leadership in nonprofit organizations that prioritize patients over politics.
Measured inclusion of all reasonable, rational, intelligent viewpoints and persons.
But these steps require a courage of conviction… conviction which is sorely lacking.
Not just Morgan, but all those who have died from eating disorders cannot die in vain. But until we admit that this system and community are broken, until we expose the silence, the failures, the charlatans, thed fraud and the fear … we will keep losing more daughters, more sons, more loved ones, more years of life.
The eating disorder community once promised healing. Today, it must fight simply to survive. For survive it must. But in an evolved, intelligent, collaborative manner.
Two of the more troubling topics confronting mental health communities are: (1). Lack of Minority Representation in the Mental Health Workforce and (2). Limited Accessibility of Mental Health Care in Minority Communities.
We will be focusing on exploring real world, workable solutions instead of using inflammatory labels, pointing fingers and embracing the litany of “isms” being cavalierly thrown around.
Any solution necessarily begins with starting and having open, collaborative conversations. While recognizing that a start is just that … a start and not a solution. And yet, from that start perhaps seeds are planted from which bold, forward-thinking initiatives grow which could ultimately result in a better world.
Increasing Minority Representation in the Mental Health Workforce
No one disputes that minority representation in the mental health workforce is grossly lacking. So, let’s address some of the issues which produced this inequity and explore possible solutions.
1. Financial Pathway Support
Problem: The cost and duration of training (graduate degrees, licensure) are major barriers for minority students.
Possible Solutions:
Targeted scholarships and loan repayment programs for minority students in psychology, psychiatry, counseling, and social work (e.g., HRSA’s Behavioral Health Workforce Loan Repayment Program could be expanded or localized).
Paid internships and residencies in community-based organizations serving minority populations.
Employer-based tuition reimbursement tied to post-graduation service commitments in underserved areas.
2. Pipeline Programs (High School → Graduate School)
Problem: Minority students are underrepresented early in the pipeline.
Possible Solutions:
Create “Grow Your Own” mental health workforce programs in high schools and community colleges — exposure to mental health careers, mentorship, and clinical shadowing.
Partner with HBCUs, HSIs, and Tribal Colleges to create joint degree or accelerated pathways into counseling, psychology, and psychiatric nursing.
Establish bridge programs for paraprofessionals (e.g., caseworkers or peer specialists) to obtain advanced clinical credentials.
3. Licensure and Training Reform
Problem: Licensure barriers disproportionately impact minority and bilingual professionals.
Possible Solutions:
Reciprocity agreements among states to ease cross-state licensing for clinicians serving telehealth clients.
Allow supervised hours to include culturally competent community-based or telehealth work, not just traditional clinical settings.
Bilingual competency credits or pathways for professionals providing care in multiple languages.
4. Mentorship and Professional Networks
Problem: Isolation and lack of role models lead to attrition.
Possible Solutions:
Fund minority mentorship programs through professional associations (e.g., APA, NASW, NBCC).
Develop online professional communities for peer support and continuing education focused on serving minority communities.
There are no “zero sum game” arguments. No white people must step aside. No looking backward as to what was previously done wrong. No obsessing on the past.
Simply a possible roadmap to start discussions to increase minority mental health providers.
This is going to become even more important in the future as research scientists increasingly discover additional biological links between the brain and mental health issues. We could be at the genesis of a bold new frontier regarding how mental health issues are studied, researched and treated. We need all persons to be involved in this process.
With this reality facing us, how do we increase accessibility of mental health care?
Increasing Accessibility of Mental Health Care to Minority Communities
Mental health care providers, resources and treatment centers must become more available and accessible in minority communities. Let’s explore how we can start to address this issue.
1. Community-Based and Culturally Anchored Services
Problem: Mainstream clinical settings in minority communities are few and far between and when they do exist, can feel unwelcoming or irrelevant.
Possible Solutions:
Fund community-based organizations, churches, and cultural centers to offer embedded mental health services (e.g., co-located clinics).
Recruit faith leaders, barbers, and cultural ambassadors as mental health liaisons trained in Mental Health First Aid or peer support.
Support mobile crisis units staffed with culturally and linguistically matched professionals.
2. Telehealth Expansion and Equity
Problem: Digital divides and lack of culturally competent telehealth platforms persist.
Possible Solutions:
Subsidize broadband and devices for patients in rural or low-income minority areas.
Require telehealth platforms to support multilingual access and easy interfaces.
Train clinicians in telehealth cultural competence (e.g., cross-cultural communication online).
3. Insurance and Reimbursement Reform
Problem: Minority-serving clinics often cannot sustain services due to poor reimbursement rates.
Possible Solutions:
Equal reimbursement for behavioral health and physical health under parity laws (and enforce it). [This requirement is already provided by federal law. Insurance companies have found ways to avoid or get around this requirement. These loopholes must be closed by legislative bodies.]
Expand Medicaid coverage for peer support specialists and community health workers.
Incentivize integrated care models (behavioral + primary care) in federally qualified health centers (FQHCs) and minority-owned practices.
4. Public Awareness and Trust-Building
Problem: Stigma and mistrust are major deterrents.
Possible Solutions:
Fund anti-stigma campaigns featuring diverse community voices and lived experiences.
Partner with trusted local messengers (e.g., influencers, pastors, tribal elders).
Offer mental health literacy programs in schools and workplaces, especially in minority-majority areas.
Of course, all of this is not probable unless there is greater policy, corporate, institutional and legislative support. This support could resemble the following:
Policy and Institutional Support
Data collection and accountability: Require reporting of workforce demographics, service access, and outcomes disaggregated by race/ethnicity.
Federal and state grants: Prioritize funding for programs demonstrably improving minority recruitment and retention.
Cross-sector collaboration: Involve education, housing, and criminal justice systems in joint mental health equity initiatives.
An “Integrated Implementation Model” could be structured as follows:
Minority Mental Health Workforce Accelerator (state-level example):
Provides full scholarships and living stipends to minority students pursuing behavioral health degrees.
Requires 3–5 years of post-graduation service in designated shortage areas.
Operates mentorship and continuing education programs led by culturally competent practitioners.
Partners with community-based agencies that receive reimbursement incentives for hosting trainees.
The mental health field, particularly the eating disorder community, talks of the need to increase minority mental health providers and the necessity of having greater access to mental health care for minorities. The community is absolutely correct. But that is as far as rational discussions go.
More often than not, discussions take place in an echo chamber. The community points fingers at the patriarchy, white supremacy culture, the diet culture and apply many other inflammatory labels … and nothing is accomplished. The community is defined by the past. A failed past. Instead of embracing a bold future.
Solutions to provide mental health care for our minority population can only be found by looking to the future. A future filled with hope and unlimited possibilities.
The mental health system in the United States is inundated with inequities and is hindered by limited access to care. Universal complaints about mental health include gross underfunding of services, provider shortages, fragmented care between mental and physical health, inadequate insurance coverage and widespread stigma that creates policy and opportunity barriers for people with mental illness. No one disputes that reality.
When significant cultural issues confront us and change is demanded, generally there are two types of people.
There are those people who lead, who are people of vision. They recognize and identify the problems and then commit to explore workable, rational, obtainable, collaborative solutions. These people who will negotiate with Satan himself if it leads to more people receiving the help they so desperately need.
Then there are “the ROYS.” In Texas, that acronym stands for “Rest of Y’alls.” This constitutes the vast majority of people. Those who are content with only complaining about the problems without being willing to invest in finding a rational, reasoned, collaborative solutions. When facing those issues, they immerse themselves deeper in their tribes safely ensconced in the comfort of their echo chamber. They are satisfied with whining and applying inflammatory labels to the issues. Their egos and fears drive their lack of vision. They refuse to interact with anyone who does not agree with them.
With that backdrop, how may we presume the eating disorder advocacy/therapist community responds to the daunting issues confronting mental health in general, and eating disorders specifically?
In the past few years, I have spoken with research professionals, medical doctors, therapists and advocates about the state of the eating disorder community. All seem to be unanimous in their view that things have never been worse in the eating disorder industry and communities.
As such, it should come as no surprise that the community seems largely content to address daunting, societal mental health issues by fostering divisiveness through utilizing inflammatory labels on their websites, publications and even a purported certification program. In general, inflammatory labels are cavalierly directed toward other people in the community, but only from a person’s keyboard.
So, what is inflammatory labeling? Inflammatory labeling is just as it sounds. It is when we assign highly negative or even cruel labels to people or organizations.
Focusing on inflammatory labels instead of solutions in social justice movements, or for that matter in any context, hinders progress by reducing complex issues to oversimplified caricatures. This practice intensifies social divides, alienates potential allies, and prioritizes outrage over tangible reforms. While rhetoric is central to advocacy, the way it is framed can either drive constructive dialogue or deteriorate into unproductive polarization.
Studies on social movements have found that extreme or inflammatory rhetoric, including labeling, tends to decrease public support for a cause. This is because such tactics reduce the average person’s sense of identification with the movement, making it difficult to find common ground. Inflammatory labels simplify people into negative stereotypes, making it harder to recognize their full humanity.
This reflects the sociological concept of “labeling theory,” which posits that assigning a negative label can lead to a self-fulfilling prophecy and further entrench deviance. Labeling opponents with charged terms can create a binary “us vs. them” mentality, making it difficult to challenge ideas through reasoned debate. Instead of addressing the complexities of an issue, discourse devolves into a culture war of labels, name calling, and finger pointing all of which obscures real policy solutions.
By way of example, radical eating disorder activists casually throw out inflammatory labels like:
There are so many others: White Privilege, Whitestream Research, toxic masculinity. These inflammatory terms of derision are directed at anyone who does not agree with their viewpoints as well as the mainstream medical and mental health communities. In addition, the term “invasive species” is even being used to define or refer to the same White Supremacy Culture and people and organizations which fall under that umbrella. And that is supposed to be productive?
As for any proposed practical, realistic collaborative solutions to address the inequities in mental health care? They propose none.
A few years ago, a small group of people published a letter directed at eating disorder organizations and treatment centers. Amongst the demands made in the letter included: providing reparations to Black People, Indigenous people and People of Color, (“BIPOC”) especially queer and transgender BIPOC; hiring a transgender consultant to revise your marketing material; establishing sliding fee scales for BIPOC, transgender and gender diverse clients; redistributing wealth from the for-profit ED treatment world; providing access to Hormone Replacement Therapy.
Other radical activists equate mental health research and treatment as a zero sum game. That BiPOC, LGBTQ+, fat therapists and professionals must be centered and that there is no space for white, straight and thin people to jump in. Or that white, liberal female therapists should focus more of their attention on social justice issues and political reform in all they do.
Of course, in the unlikely event the latter ever happened, those therapists would then be labeled as White Saviors and would be publicly eviscerated in the town square ala Lindo Bacon.
There must be a way. Other than inflammatory labeling, whining and complaining, what possible solutions exist which could be explored to address some of the inequities in mental health care systems?
Inequities which include far too few medical doctors, therapists, counselors and other medical and mental health professionals who are BIPOC. Minority and BIPOC communities are far underserved. Medical school training largely ignores eating disorders and BIPOC issues. Far too few BIPOC persons receive mental health care. Access to meaningful mental health care is severely limited for BIPOC persons. Research has not included significant BIPOC participation. Mental health care can be prohibitively expensive.
These complex, daunting issues require collaborative wisdom. And when progress is made on these issues, as they surely must be, this necessarily will result in a more enlightened society. So, the question must be asked again … how are name calling, tribal mentality and inflammatory labeling going to be remotely effective in addressing these serious issues? Answer … they aren’t.
A roadmap does exist for systemic mental health reform in the U.S., prioritizing enforceable, high-impact interventions first while building toward longer-term initiatives. The roadmap assumes some federal and state collaboration, leveraging funding, licensing, audits, and measurable metrics. But it is possible. It will not be easy. It will require participation, wisdom and sacrifice from society as a whole. It will require us looking past our human frailties and being bold and forward thinking. But it is possible.
2025 Weight Stigma Awareness Week (“WSAW”) is upon us. Much of what it stands for was clarified in 2023. That year, WSAW produced a white paper entitled, Impact Council White Paper (“ICWP”).
The ICWP states it, “… hosted an Impact Council roundtable with advocates, educators, clinicians, and leaders in healthcare, non-profit organizations, and media to discuss the greatest roadblocks to accessibility and inclusivity, as well as goals for the future.”
The ICWP has two major premises:
Premise 1 — “The medical community has done significant damage by promoting the idea that ‘obesity’ is a greater risk to individual and public health than weight stigma and anti-fatness are.”
Premise 2 — “Lived experience should be treated as credible data and prioritized (as much as or more than textbooks and quantitative research) for clinical recommendations and treatment plans.”
These are foundational, core premises at the heart of the weight stigma awareness movement. If these premises can be objectively proven to be accurate, then the corresponding recommendations and information arguably have more substance and merit and need to be thoroughly explored by a collaboration of organizations and professionals.
However, if the foundation, the core premises collapses, so does everything built upon them. The corresponding recommendations would be grounded in science fiction, not science, and if ever adopted, would inevitably result in doing greater harm to patients.
So, let’s explore more closely these two premises.
Premise One
“The medical community has done significant damage by promoting the idea that ‘obesity’ is a greater risk to individual and public health than weight stigma and anti-fatness are.”
There is no dispute that weight stigma is itself harmful to health. Stigma increases stress, social isolation, depression and anxiety, and can worsen cardiometabolic outcomes through behavioral (avoidance of care, disordered eating) and physiological (stress-axis) pathways. When clinicians stigmatize patients, it reduces trust and adherence and discourages preventive care (fewer screenings, delayed care).
Certainly, focus on BMI alone oversimplifies risk. BMI is an imperfect proxy for health; it doesn’t capture fitness, fat distribution, socioeconomic drivers, or comorbidities. Over-reliance on BMI can miss metabolically healthy people who need care and wrongly pathologize others.
Social determinants and structural drivers matter. Emphasizing individual “weight control” can obscure food access, economic inequality, built environment, racism, trauma, and other upstream determinants that shape both weight and health.
Even with this reality, the obvious flaws in the first premise are legion.
First, the medical and scientific communities without exception embrace the reality that there are measurable health risks associated with higher adiposity for many people. Epidemiologic studies link higher BMI (particularly when accompanied by central adiposity) to type 2 diabetes, osteoarthritis, some cancers, and cardiovascular disease. Discounting these risks wholesale would be irresponsible.
Further, there is a false dichotomy risk at issue. Framing this issue as “either stigma is the main harm or obesity is” sets up a false binary. In reality, both can be true: stigma causes harm and excess adiposity can increase risk for some outcomes. Policies must address both.
There is the aspect of public-health communication challenges. Minimizing messages about risk could reduce motivation for preventive behaviors in those who would benefit. Public health must balance non-stigmatizing language with clear information about risk and actionable steps.
There are other factors involved. There is heterogeneity of evidence and population differences. The magnitude of adiposity-related risk varies by age, sex, race/ethnicity, and metabolic profile. Broad absolute statements risk ignoring subgroups with high absolute risk.
One of the biggest flaws and drawbacks from the ICWP, is that the people behind the ICWP represent that the medical community has caused more damage by emphasizing that obesity is a greater risk to health than weight stigma and anti-fatness. They have phrased this issue using an absolute criterion while needlessly pointing fingers to assess blame. They have placed their own beliefs and interpretation of their own life experience at the forefront of this issue. They erred.
There are different study designs and evidence strength. The obesity→mortality evidence includes very large pooled prospective cohorts and individual-level meta-analyses (GBMC/Di Angelantonio et al.) with millions of participants and long follow-up that estimate dose–response relationships and cause-specific mortality. That level of evidence supports an accepted causal inference for some outcomes.
Contrarily, much of the stigma literature is smaller, newer, and more heterogeneous: cross-sectional studies, smaller cohorts, and observational work using self-reported stigma measures. Even the stronger longitudinal analyses are far smaller in scale than the pooled obesity cohorts. This difference in scale and design limits how directly you can compare effect magnitudes.
Second, there are measurement differences and misalignment of outcomes. Studies of obesity typically measure objective exposures (BMI, waist circumference, body composition) and hard outcomes (incident diabetes, MI, cancer, all-cause mortality).
Studies of stigma usually rely on self-reported experiences (e.g., “have you experienced weight discrimination?”) or internalization scales — valuable but inherently subjective and vulnerable to recall bias and reporting differences. Outcomes often include psychological measures, behavior change, intermediate biomarkers, or, in a few cases, mortality. These are not directly isomorphic to the obesity literature’s end points.
Third, there are confounding and directionality / causality problems. People who experience weight discrimination are, unsurprisingly, often higher weight; disentangling whether worse outcomes are caused by stigma per se or by the underlying higher adiposity (or by shared upstream causes) is difficult. The study conducted by Sutin et al. adjusted for BMI and some covariates and still saw an association, but residual confounding (socioeconomic factors, comorbid illness, lifetime exposures) and reverse causation (illness leading to both weight change and discrimination) remain plausible. Further, establishing causality (stigma → disease → mortality) requires randomized or natural-experiment evidence or sufficiently rich longitudinal mediation analyses; those are scarce.
Fourth, population attributable burden has not been estimated comparably. To claim, “stigma causes more harm than obesity,” we need comparable population-level metrics (e.g., population attributable fraction of mortality or years of life lost due to stigma vs due to elevated BMI). Those metrics exist for BMI (GBMC estimated mortality burden across BMI categories), but do not exist in a comparable, robust form for weight stigma.
The study by Sutin et al. reports an HR for mortality but translating that into population attributable mortality would require representative exposure prevalence estimates, reliable adjustment for confounders, and replication across populations.
What the best current evidence shows: Weight stigma is independently associated with worse mental health, adverse behaviors (disordered eating, activity avoidance), physiological stress markers, and — in at least two cohorts — higher mortality after adjustment for BMI and some covariates.
What the evidence does not show: There is no robust, widely accepted, population-level set of criteria demonstrating that weight stigma causes more total harm to population health (e.g., more deaths, more DALYs) than obesity itself. The obesity→mortality/evidence base is far larger, multi-cohort, and quantifies dose–response relationships; stigma literature is convincing in signaling independent harm but is currently smaller, less consistent, and lacks comparable population attributable estimates.
Clearly, the goal should be to move clinicians toward respectful, trauma-informed care; strengthen social-policy responses (food access, housing, anti-discrimination); and develop interventions that improve health without weight stigma.
So, should we be asking with this shared goal, why would the people behind the ICWP frame this issue as an absolute? Especially when they have no reputable, scientific, medical or socio-economic studies to support their position that an emphasis on obesity has caused more harm than anti-fat bias?
Without any reputable, third-party studies, they framed this issue as an absolute to fit their narrative. The tragic, unfortunate reality is the solution was right in front of them. All they had to do was rephrase this issue in a strong, evidence-based, factual manner … such as …
“Weight stigma and anti-fatness are inextricably intertwined with obesity and should be collectively classified as a public health issue. This would require the medical and scientific research communities to increase their research, study, understanding and treatment of these serious health issues on an equal basis.”
What is there to disagree with in that phraseology? This would have removed the finger pointing blame game perpetrated by the ICWP and would have provided a collaborative way forward together. But that was not to be. And the reasons for that lack of vision are set forth in our analysis of Premise No. 2.
Premise No. 2
“Lived experience should be treated as credible data and prioritized (as much as or more than textbooks and quantitative research) for clinical recommendations and treatment plans.”
The second central premise—that lived experience should be prioritized above textbooks and quantitative data—turns medical practice into witch doctory and personal storytelling. This is not a serious framework for healthcare; it is activism dressed up as evidence.
The problems with this premise are legion.
There are obvious methodological problems. Anecdotes do not constitute medical evidence. Individual stories can be powerful but lack controls, generalizability, and statistical rigor. Treatment guidelines based on lived experience risk being skewed by outliers or vocal subgroups.
There are also bias and recall issues. Patients may unintentionally misreport causes, timelines, or treatment responses due to memory bias, emotional interpretation, or secondary gain.
We are also required to consider over-representation of advocates and activists. Those most active in advocacy or online discourse are often not representative of the broader patient population, creating sampling bias.
Then there is the risk of undermining evidence-based care. There is “treatment drift.” Prioritizing anecdotes could encourage clinicians to substitute “what worked for one person” for protocols validated across thousands in trials.
The medical community must also consider neglect of biological mechanisms. Obesity and eating disorders involve complex neurobiological, metabolic, and genetic components. Patient narratives may not reflect these dimensions.
There is also false equivalence. Equating lived experience with systematic research elevates subjective impressions over reproducible science, undermining evidence hierarchies critical for patient safety.
For obesity, some narratives reject all weight management as “harmful,” ignoring evidence that structured interventions improve metabolic outcomes. This can fuel distrust of effective therapies.
The medical and scientific research communities would inevitably experience ethical and legal challenges and concerns.
There is standard of care liability. If guidelines deviate from established evidence to favor lived experience, clinicians risk malpractice exposure when outcomes are poor.
There are also equity gaps. Vocal groups whose experiences get prioritized, may dominate marginalized, silent or less empowered populations.
Potential conflicts of interest exist. Patient advocates with financial or ideological agendas could influence treatment norms, displacing objective science.
The systemic consequences of this misguided belief are obvious and notorious. This belief would lead to an erosion of research investment at a time when research grants have been eradicated. If lived experience is placed on equal or higher footing, incentives to conduct rigorous trials would diminish, weakening long-term scientific progress.
It would also result in fragmentation of care standards. Different doctors, clinics and treatment centers might prioritize different anecdotal narratives, leading to inconsistent, non-comparable practices.
Most alarmingly, obesity and eating disorders already carry high morbidity and mortality; steering care away from empirically validated interventions risks worsening public health outcomes.
Again, we should be asking why would the people behind the ICWP frame this issue as an absolute? Especially when they have no scientific, medical or socio-economic studies to support their position?
The ICWP had the ability to reconcile both premises into a practical clinical and policy approach. They chose not to. Perhaps one of the co-founders of Weight Stigma Awareness Week gave us the reason for this ill-fated, Quixotic position when she said, “It bothered me that all the air was taken by a white perspective … This is no space for white, straight and thin folks to jump in … Those of us who have done the work around our internalized biases no longer trust the medical establishment to actually help us.” … Public health in this country is getting it so wrong and there is a better way, but we need to be willing to actually listen to those being harmed.”
These people are not embracing science. They are embracing science fiction.
Perhaps the answer to all legitimate questions asked above is simply … to maintain their voice, to assuage their feelings of pain, self-loathing and anger, the maladjusted, militant fat activists must embrace their own reality because society will not.
The ICWP fails
The ICWP fails at the starting line. Its first major claim—that medicine has caused more damage by warning about obesity than by neglecting weight stigma—is not just wrong, it is reckless. It is divisive. It dismisses decades of clinical evidence linking obesity to disease and early death, replacing science with ideology.
Its second central premise—that lived experience should be prioritized above textbooks and quantitative data—turns medical practice into guesswork and personal storytelling. This is not a serious framework for healthcare; it is radical advocacy dressed up as evidence.
Beyond the flawed premises, the rhetoric in the ICWP itself gives the game away. The authors rely on moralizing language and sweeping accusations, framing the medical community as a monolithic villain rather than engaging with the nuance of scientific debate. Raw emotion is substituted for data, using anecdotes and identity politics to demand deference in place of proof. This kind of rhetorical sleight of hand may stir outrage, but it does not withstand scrutiny.
When the core assumptions collapse, so does everything built upon them. The ICWP is not grounded in science but in science fiction. Far from being an authoritative white paper, it is merely a manifesto masquerading as scholarship, and it deserves to be treated as such.
Tragically … it did not have to be like that. But, when so-called leaders place the manifestations of their own mania before reputable, medical and mental health based criteria, their message is lost. The Power of the Message is lost.
And all that is left is chaos, shattered dreams, and the final, weak beats of a Tell-Tale Heart.
A DAD'S JOURNEY WITH EATING DISORDERS 