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The Eating Disorder Treatment Meltdown

Like everyone else on Facebook, I recently read Larry Lonero’s post, “What happened to Southwest Airlines?”

It felt like déjà vu. This has been going on in the eating disorder field for almost as long as I’ve been in it.

“The frontline employees have been watching this meltdown coming like a slow motion train wreck for some time…. We’ve been begging our leadership to make much needed changes.”

The CEO was “more focused on finances and less on operations” and “did not spend time on the front lines” or “engage front line employees… neither do the lower levels of leadership.” The COO “had little or no operational background.”

“The focus was on finances not operations… We began to warn our leadership. We educated them, we informed them and we made suggestions to them,” but there was no change because, “After all, the stock price was up so what could be wrong?”

“We were a motivated, willing and proud employee group wanting to serve our customers… watching in frustration and disbelief as our once amazing airline was becoming a house of cards.”

I bet some of that sounded familiar to you, too. It may even be the exact reason you left your treatment center job.

If you didn’t know, many eating disorder treatment facilities are already owned by either mega-large hospital chains that don’t understand eating disorder care, or by private equity firms that don’t differentiate between eating disorders and ping pong balls as long as they can sell what they bought for more than they paid.

In both situations, there’s lots of good work still being done. But it’s inconsistent. You don’t know what you’ll get from different locations of the same company, from unit to unit or month to month.

Literally everything Southwest Airlines experienced from the top – focus on short-term balance sheets, leadership with the wrong kind of experience and dismissive attitude toward staff who saw the problems – has been happening in our field for over a decade. The meltdown was already in full swing long before COVID-19 ratcheted up the stress, censuses and acuity levels.

When administrators haven’t worked as a dietitian (and some haven’t even worked in the field at all), they can’t possibly know what it’s like if they don’t listen to their staff. Specifically that you can’t use the same dietitian staffing patterns of a general hospital, addiction treatment center, or state behavioral health unit. You can’t just say “our license requires one dietitian per 48 patients.” Eating disorder care is just different.

It’s no secret that at many facilities caseloads are too high, expectations are too broad, and burnout is relentless. There’s no coverage for vacations or education days, someone just has to pick up the slack. Conscientious dietitians stay late to get their work done.

Just like at Southwest, often no one is listening when dietitians speak up. It’s always “this is the way we’ve always done it,” “I don’t have the authority to change that,” or “it’s not in the budget.” No one is willing to rock the boat or champion the department. Sometimes the dietitians themselves are blamed – for bad attitudes, not working hard enough, or other made-up reasons.


The results are unsurprising:

Places where dietitians are valued – not just paid well but also included in decision-making, program design and leadership – and programs started or run by dietitians thrive.

Elsewhere, undervalued, underpaid, experienced dietitians leave. Recruiting starts. New grads are hired, or part-timers from unrelated fields. Chronically understaffed, there’s no time for adequate training, such as shadowing and case-by-case supervision. Treatment quality and patient satisfaction suffer, AMAs (early discharge Against Medical Advice) increase.

The same administrators who caused the high turnover shift blame off themselves with a false narrative of “everyone leaves anyway.” They can’t or won’t accept that the financial and intangible costs of near constant recruiting, relocating, and onboarding are more expensive than keeping good staff happy, even though that’s business leadership 101.

There are definitely treatment center exceptions, but even they pay a price for bad decisions made by others. That price is a lack of trust from consumers. Just like travelers who’ll think twice now before booking Southwest, or maybe choose to drive instead, we’re already thinking about what might go wrong when making a referral to higher level care.

It hurts the people who need help, too – patients and families who hesitate because of what they or someone else went through at a not-good treatment program, or even a fine treatment program that was temporarily short-staffed.

And for those institutions we’ve come to trust, they can’t just admit every caller. Facilities known for consistently good care and communication will continue to have wait lists, so outpatient dietitians will have less well patients for longer.

I’ve been thinking about all of this for a while. And what the rest of us can do to cope.


Here are the ideas I’ve come up with so far while we wait for things to settle:

Spend some of your session time with patients calling treatment facilities together. Ask to speak with someone on the care team if intake personnel don’t have the answers. Demonstrate the process of evaluating what they offer and moving past objections that aren’t important. There will always be reasons not to go; help your patient discern between valid reasons and distractions.

Consider how to increase support for unwell patients when wait lists for your preferred program(s) are long. Weekly medical check-ins? Multiple visits with you per week? In-home care? Online support? Clarify with each patient if this is the new normal or crisis-management till a bed is available.

Find more medical providers in your area who are competent with eating disorder care, or willing to be mentored by someone who is. Expand your search to nurse practitioners, physician assistants, and cardiologists. Offer them these resources until they find someone in their field to guide them.

The Eating Disorders Clinical Pocket Guide

Management of Eating Disorders

Medical Care Standards Guide – Academy for Eating Disorders (

Eating Disorders Levels of Care Guidelines


Require your patients to be in the care of one of these ED-competent providers if their primary care provider is not.

Ask patients to get written parameters from their medical provider for going to the emergency room. You do not want them relying on you/their own judgment. Tell patients to call their medical provider on their way to emergency to see if that person can call ahead. Hopefully then whoever sees them will have some background information and won’t make things worse.

Set guidelines for intake staff or whoever answers your phone (including if it’s you) for what requirements prospective or returning patients must meet in order to be seen. Practice saying, “We don’t accept patients who have left a treatment program Against Medical Advice or by Administrative Discharge” and “You’ll need to have a medical provider and therapist in place before we can schedule your next appointment.” Read The Sleepless Dietitian’s Guide for more helpful soundbites and advice.

Start a training program within your practice for new dietitians. Supervise them closely and offer the Eating Disorders Boot Camp Group Training Package. Protect yourself: sign contracts that clarify where patients will go and how you will be compensated for the training you provided if those dietitians decide before a certain date to branch out on their own.


If you’re working somewhere less than ideal, planning your exit so you’re ready to go when your workload gets absurd or your boss knows less than you, the Eating Disorders Boot Camp Ultimate Training Package will boost your confidence that you’re ready for private practice eating disorder nutrition counseling. And if you feel like venting, I’m always happy to lend an ear.

If you’re new to private practice and unsure of what you’re doing, let’s plan a supervision call so I can be the wind beneath your wings. Or try The Sleepless Dietitian’s Guide for a real-time confidence boost when you’re stressing out.

That’s what I’ve got so far. What are you doing to handle the meltdown of our treatment facilities? And do you see it getting worse or better? I’d love to hear your thoughts, even if you disagree.


Posted in Jessica Setnick

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