Tag Archives: wellness

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

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

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

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

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

What the book does very well

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

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

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

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

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

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

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

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

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

Room for Improvement or Greater Clarity

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

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

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

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

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

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

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

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

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

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

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

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

That is rare.

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

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.

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.

EQUITABLE MENTAL HEALTH CARE AWAITS

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.

COLLABORATE OR PERISH

June 2, 2025, was World Eating Disorders Action Day. (“WEDAD”) According to the organizers, “… over 300 organizations … stepped up—hosting events, launching social media campaigns and podcasts, conducting interviews, and working across borders and disciplines to make an impact on this one crucial day.”

Dra. Eva Trujillo, (whom I like and respect) was one of the drivers of WEDAD. Her quotes included:

“When we act together, our impact is stronger.   We are looking for new voices, perspectives, and passionate professionals ready to serve.”  

“Are we, as a field, ready to begin healing the divides within our own community? Or are we too overwhelmed trying to survive?” 

“It’s a question that haunts many of us, and it’s time we face it with courage and honesty. We can’t build meaningful change externally if we remain fragmented internally. This is a moment for us—clinicians, educators, researchers, advocates, sufferers, and caregivers—to come together—not in perfect agreement but in shared purpose.” 

“We must start connecting. Not by taking sides, but by building bridges, amplifying what unites us, listening more than speaking, and doing the hard work of healing, both within and beyond our professional circles.” 

An officer from another organization stated:

“So, how do we begin to heal our community?” 

“As organizations, we begin by reaching out to one another, recognizing each other’s strengths, sharing our own, and uniting our efforts to broaden services and support.” 

“Together, we are stronger.” 

Fine words. Grand words. But … just words. So, how do we put into action the concept behind those words and turn them into reality?

A few weeks ago, I attended ICED 2025 in San Antonio. [As an aside, ICED 2026 is scheduled for June 3 – 5 at … The Hague. And by wonderful coincidence, the Formula 1 Grand Prix in Monaco is scheduled for June 5 – 7! Can you say Bucket List? Super yachts in Monaco Bay. Black tie casino gambling. Incredible parties. But … I digress.]

Most of my time at ICED 2025 was spent darkening the Exhibit Booths, listening to a few presentations, swilling whiskey and having my tail handed to me playing chess in the hotel lobby.  But, in my wanderings, I noticed the following organizations did not have a booth, or for that matter, any presence: NEDA, iaedp.

They were not listed as sponsors. They were not listed as exhibitors. Their CEOs were not there. (or if they were, they kept out of sight).

Perhaps that is where we must start. Or does it go deeper than that?

Let us pose some questions which surely must be asked:

  1. Does the eating disorder community really need three (3) independent organizations, AED, iaedp and NEDA?
  2. If so, why? Especially since all three appear to be flailing if not failing.
  3. Isn’t it in the best interest of the families suffering from this illness that one unified, strong entity comprised of the best of those organizations be formed?

The problems and issues at each of the organizations are alarming.

iaedp is engulfed in a lawsuit which, if successful, will result in its demise and possibly the end of board certification. Iaedp also has a very large financial burden for past due taxes, penalties and interest. On its last F0rm 990, it showed a loss of $284,806.00. Since membership is no longer required to maintain board certification, its membership is dwindling. A number of iaedp individual chapters have dissolved. Its next symposium is being held in Baltimore … in the middle of winter. Iaedp’s “Members at Large” a/k/a Board of Directors is comprised of persons with no outside corporate or legal experience.

The issues at AED are also troubling.  From 2020 through 2023, AED reported a total combined loss of -$658,156.00. The cancellation of billions of dollars in NIH grant funding resulted in many university professionals unwilling and unable to attend AED’s ICED and not renewing their membership. A contentious relationship with international chapters plagues AED.

NEDA, unlike AED and iaedp, showed a profit on its last Form 990. On its 2023 Form 990, it showed net revenue of $1,836,601. However, in the three prior years, it showed three consecutive losses in a combined amount of $1,913,492.00. NEDA sold its telephone helpline to the National Alliance. But, besides conducting its fun walks and awarding some grants, (for which it should be commended), has time eroded NEDA’s impact in the community?

Therapists are intimidated by research professionals. Research professionals do not have the wisdom gained from being on the front lines, that is, in the actual therapy rooms. Medical clinicians are frustrated waiting for research findings to be released. Uninformed and misguided fat activists are just causing chaos. And the wheel turns round and round with little, if any progress being made.

Dra. Trujillo acknowledged the divides which exist in the community. So, where does progress start?

Perhaps we begin with transparency. An element so missing in the eating disorder community. No organization or person in the community is inventing a cure for cancer or devising the next generation of Ai/Robotics technology. Certainly, private organizations and companies generally do not disclose financial information or voluntarily broadcast future expansion or retraction plans. But we are dealing with a mental health illness with a high mortality rate. Families are severely impacted every day. It seems as if eating disorder organizations and entities have lost sight of that reality.  

And so, transparency and collaboration must start at the organizational leadership level. To start to accomplish this, accommodation and grace must be given.

Starting with iaedp’s next Symposium to be held in Baltimore in February 2026, iaedp must allow NEDA, AED, FEAST to have exhibit booths and have at least their three highest ranking officers to attend … at no cost. During the Symposium, the leaders from all organizations must meet to discuss all issues they have in common. Issues unique to each organization. The future is discussed. Planning is shared. Finally, at the end of the meeting, an open forum is convened both in person and via zoom. A forum that any concerned person can attend and ask questions, live or via the internet. The leaders share with everyone the topics of discussion and the plan of moving forward.

In 2027, at AED’s ICED to be held in Phoenix, Arizona, it is AED’s turn to host the other organizations utilizing the same format.

In 2028, these collaborative meetings may not be necessary. That is because by 2028, hopefully all major organizations will have realized that the tribal way they have done business in the past is not effective and does not work. In fact, the piecemeal, isolationist way each organization currently attempts to operate has failed. The six figure financial losses every year. Membership dwindling. As has been noted, people leading organizations have admitted that division exists in the community and needs to be healed. But these divisions cannot be healed singularly.

The old way of doing business has failed. The mortality rate worsens. The number of loved ones and families suffering continually increases. Each organization in their own way has failed and contributed to worsening the situation. So, how can we possibly proceed in the future?

The best way, the path which provides the greatest likelihood of success is to have these organizations merge into one entity. One large, collaborative organization. Therapists, medical doctors, research professionals, advocates all under one tent. Talking together in the spirit of professionalism and respect. Combining the greatest minds of different tracts to share knowledge, wisdom and ideas. Casting individual egos aside for the greater good. Bringing in corporate and legal experts to assist in reorganizing and providing many additional outlets for fundraising.

One large, all-encompassing yet diverse organization. An organization which would be able to lobby more effectively to address the true needs of the community. An organization which would be able to approach large corporations and foundations to engage their substantial resources for the purpose of working toward true breakthroughs in our understanding and treatment of eating disorders.

Now make no mistake. The obstacles are many and the challenges are great. There are those who will oppose this collaborative entity merely because it threatens their self-importance. There is a faction in the eating disorder community which actively fights against progress unless that progress exclusively involves their own pedantic points of view.

Nonetheless, the handwriting is on the wall. The commendable accomplishments of individual organizations in the past have been relegated to the past. The old way of doing business no longer works. It is not effective. That is shown by the deteriorating financial condition of these organizations, the deep divisions which exist in the community and most importantly, the number of our loved ones who continue to be taken.

Our loved ones who continue to die in ever increasing numbers.

That should be the first, middle, last and only concern of these organizations. The time is now. The future awaits. Collaboration beckons.

AWARENESS WITHOUT ACTION EQUATES TO FAILURE

Awareness.

Awareness.

Have you ever wondered what comes after awareness?

In any event, once again it is Eating Disorder Awareness Week 2025. Almost all eating disorder organizations and treatment providers will be mentioning this on their social media outlets.

Some buildings will be lit in the blue and green colors adopted by NEDA. This is the St. Louis Planetarium complete with statue in the shape of what society deems an anorexic body type:

Did I just body shame a statue?

Some therapists and advocates, treatment centers and organizations will hold special “virtual” sessions highlighting their pet eating disorder interest. People self-identifying as experts will pontificate on many and varyed aspects of eating disorders. The same radical tired voices will repeat the same radical tired messages to the same radical tired crowd measuring in the tens of people.

As in year’s past, the eating disorder community will feel good about itself for the week, will pat itself on the back and then … will slink back to its customary irrelevancy in the medical and mental health fields. Next year will be rinse and repeat. Or as Herman’s Hermits once sang, “Second verse same as the first.”

However, this year is different. For a number of reasons. These reasons threaten to not just shake but could very well crumble the very foundation of the eating disorder community. Not surprisingly, these reasons and issues will not be discussed this week and the community will ignore its awareness of these issues.

These issues will not be discussed in part because the issues are just too difficult. They are uncomfortable. In addition, the firmly entrenched corruption and rot in the community will mandate that some of the issues be ignored. When for a price, even the most reprehensible predator can buy a place at the table.  Regardless, the issues are incredibly serious and require serious people with serious IQs to ponder and then take rational, serious action.

Let’s review some of these serious issues.

NIH funding collapsing

On Friday, February 7, 2025, the National Institute of Health (“NIH”) announced it was pausing all grant funding pending review and placing a 15% cap on funding “indirect research costs.” Indirect costs, also known as facilities and administrative (F&A) costs, are used to cover research expenses such as equipment and facilities maintenance, IT services, and administrative support.

The freeze has impacted the funding of all continuing grants at NIH. These grants fund ongoing research, including many studies involving human subjects in clinical trials. Universities are already reacting in a manner consistent with believing that those funding grants will not be reinstated. Some universities have already frozen hiring and taken other budgetary measures. These measures include a spending freeze on travel, procurement, capital projects and events.

So, how will this impact the eating disorder community? University based eating disorder professionals are likely to have their budgets slashed making travel to conferences unlikely. This includes travel to San Antonio for the ICED conference. This could also include a reduction in membership in AED. With AED’s financial woes already being very deep, a steep decrease in membership and low attendance at its ICED event could be the death knell for that organization.

But more importantly, this issue means that there will be significantly less research conducted into our understanding of the biological and genetic aspects of eating disorders. Possible state of the art treatment requiring a research basis will not be experimented upon and implemented. “Evidence-based” will become an even greater cartoon slogan.

Which will result in the mortality rate continuing to climb.

At least we now have awareness on that issue.

Iaedp

Iaedp’s many issues and problems have been highlighted for over a year. Tax fraud. Forgery on official documents. An overall lack of transparency. Possible violations of antitrust laws regarding the certification process. I understand that attendance at the recently concluded Symposium was disappointing.

A class action lawsuit hanging over its head.

A number of chapters have dissolved.

Rumors that the 2026 Symposium will be virtual.  Perhaps because of a lack of funds? After hosting an in-person conference for a number of years, a virtual conference means virtually nothing.

All of which makes iaedp’s continued survival problematic. And if iaedp does not survive, what of the certification process? Would that mean we are left with another certification process which starts out with an idiotic Indigenous Persons land use acknowledgement? Because nothing says “eating disorders and the highest quality certification process” like an Indigenous Persons Land Use Acknowledgement!

At least we have awareness on these issues now.

Residential Treatment Center issues

The great eating disorder residential treatment center experiment appears to be floundering.

Recently, Castlewood (Make no mistake, it was Castlewood all along. Alsana was merely its pasteboard mask.) closed its operations in the State of Missouri … where it all began. Now, Alsana may find itself having issues with the California Medical Board for the unauthorized practice of medicine in that state.

Acadia shuttered Timberline Knolls after numerous issues and abuse came to light.

Cielo House.  Shoreline Center. Fairhaven. Evolve. All closed.

Some of the residential treatment centers which remain open seem to be exploring adopting an addiction treatment model.

Accanto Health’s CEO, Dr. Tom Britton is the former CEO of American Addiction Centers. Accanto Health owns the Emily Program. Information has been circulating that medical doctors at Accanto Health/Emily Program have been laid off or asked to take lesser roles.

Virtual treatment programs, with no independent, third-party studies supporting their efficiency have sprung up and their growing presence cannot be denied. They are less expensive to operate. Purportedly, the growing influence of virtual programs is impacting attendance at residential treatment centers.

At least we have awareness of these issues now.

Acadia Healthcare

Then, there is Acadia Healthcare.  I once wondered why treatment centers and organizations were not incensed at the harm being perpetrated by Acadia. Why they did not stand up for the vulnerable and hold Acadia accountable. Of course, the answer is obvious.

They have accepted money from Acadia Healthcare. They are bought and paid for consorts for Acadia.

Since iaedp did not have enough troubles, at its recent symposium, one of its primary sponsors was Acadia Healthcare.

The National Alliance on Eating Disorders lists Acadia Healthcare as one of its “Diamond Supporters.” [its highest level]

Montecatini, McCallum Place and Carolina House are not going to stand up. They live on their knees subservient to the whims of its overlord and master, Acadia.

Acadia, knowing the eating disorder community is long on radicalism and short on common sense, embedded itself by throwing money around. It was an effective strategy. And it still is.

And to think at one time, AED would not accept money from any pharmaceutical company or health and wellness company because of concerns about conflicting interests.

Sadly, when an organization accepts dirty money, it acquiesces to whatever heinous acts are being perpetrated by the predator.

And so, we have that awareness now too!

Many other issues about which we need to be aware

Many other serious issues exist which plague the eating disorder community.

No generally accepted standards of care. 

No collaboration with any medical or mental health communities to speak of.

No collaboration within the eating disorder community.

When was the last time NEDA, iaedp, AED and the other entities got together and stated, “Enough is enough. We are going to hold a joint conference. We are going to collaborate. We cannot have true progress if we remain separate and instead, we must collaborate. But, egos prevent that.

Ai is to be feared and cancelled.

Eating disorder legislative bills to increase research funding?  Nope.

Then there is the beating of the drums by the Militant Fat Activists who have been allowed to poison the community with their own unique brand of craziness.

How many times have we read or heard that pediatricians, medical doctors and other medical professionals do not understand eating disorders and do not know what to look for? That lack of awareness falls on the shoulders of the eating disorder community.

The eating disorder community has had over ten (10) plus years to accomplish that! Instead?  They failed. Completely. Miserably.

So, we go back to awareness?  Awareness of what? Our own failures?

A focus on awareness has only resulted in failure. And this failure is measured by the lives of more children, adolescents and loved ones being taken.

The next step in awareness is … taking action. Since awareness without action is only cowardice and ignorance.

Ordinarily I would hope that at this time next year, we will be embracing Eating Disorder Action Week. But when as a community you instead embrace the known predators in the community, you have destroyed the hope which must exist within families.

So, ring in the new year. I am sure Eating Disorder Awareness Week 2026 will be the same vacuous song and dance.

The same radical tired voices will repeat the same radical tired messages to the same radical tired crowd measuring in the tens of people.

As the predators increase their profit margin, our children will continue to die.

Happy Eating Disorder Awareness Week 2025.