Red Flags: How to Spot Ineffective Eating Disorder Treatment

I have blogged before about how to choose a good therapist. In this post, I will approach the therapist selection / retention issue from the opposite side – how to spot a bad therapist. Please note that many bad therapists are very good people with good intentions. People do not become therapists for money, fame, or the recognition – most of them genuinely care about people and want to help them. By “bad therapist” I mean “ineffective therapist.”

It seems that there are quite a few ineffective therapists who treat eating disorders (ED’s), and this is particularly dangerous given that EDs have such a high mortality rate and are associated with many medical and psychiatric complications.

I have had the privilege of working with many ED patients and families who have received ineffective or actively harmful treatment in the past. In talking with these patients and families about their prior treatment experiences, I have come to recognize many red flags that are very commonly associated with ineffective or harmful ED treatment.

Red Flags re: Etiology

1.) The professional informs the patient or family that the ED is “not about the food.”

2.) The professional informs the patient or family that the ED “is about control.”

3.) The professional is not knowledgeable about recent science regarding the etiology of EDs.

4.) The professional emphasizes psychosocial “causes” of EDs (e.g., family dynamics, societal pressures, identity issues) while ignoring, discounting, or minimizing the genetic and biological underpinnings.

Red Flags re: Family

1.) The professional blames the parents (either subtly or overtly) for causing or “contributing to the development of” the patient’s ED.

2.) The professional advises the parents: “Don’t be the food police.”

3.) The professional does not keep parents of minor patients (< 18 years) fully informed and actively involved in their child’s treatment.

4.) The professional views parents with suspicion or keeps them at arm’s length, without reasonable cause.

Red Flags re: Treatment

1.) The professional is not knowledgeable about evidence-based treatment for EDs.

2.) The professional cannot, or does not, explain the treatment method she uses and / or the rationale behind it.

3.) The professional recommends or allows individual psychotherapy without ongoing nutritional restoration, weight restoration, and medical monitoring.

4.) The professional is very interested in exploring “underlying issues” in an acutely symptomatic patient.

5.) The professional insists on addressing the patient’s co-morbid conditions without also (either first or simultaneously) addressing the ED symptoms.

6.) The professional has never heard of Maudsley / Family-Based Treatment (FBT), or has heard the term but knows nothing about it.

7.) The professional asserts that Maudsley / FBT “will not work” for this particular patient, without giving a convincing explanation for this assertion.

8.) The professional blames the patient (either subtly or overtly) for having an ED.

9.) The professional advises parents to send their child or adolescent away to a residential treatment center without first trying Maudsley / FBT, unless it is clearly contraindicated.

Red Flags re: Recovery

1.) The professional asserts that the acutely ill patient “has to want to eat” or “has to want to recover.”

2.) The professional emphasizes the adolescent or young adult patient’s need for control and independence as more important than her recovery from ED.

3.) The professional sets or allows a target weight range based on population indices (e.g., BMI of 18.5) or percentiles (e.g., 50th percentile for age/height) without consideration of the individual patient’s build, weight history, or optimal weight.

4.) The professional declares the patient “recovered” based on weight alone, without regard for her behavior or mental state.

5.) The professional asserts that one never recovers from an eating disorder.

This list of red flags may be useful when you are looking for or ruling out a professional or treatment program based on information on their website; it may also be useful in interviewing potential new therapists. If you or your loved one have been in treatment for a while without making progress, you can also use these red flags to help you assess the situation and determine whether to go elsewhere for a second opinion.

My advice? If you see one or two of these red flags in your therapist or treatment program, investigate and proceed with caution. If you see three or more, find a new therapist.

21 Replies to “Red Flags: How to Spot Ineffective Eating Disorder Treatment”

  1. While I agree with most of what you say are red flags, I do disagree with several assertions. But for brevity, I want to focus on the last one. I think that the average reader will not notice the specificity of the comment, that “no one ever recovers” from an ED. This is true of course and as therapists we learn to avoid dichotomous thinking and absolutes. But this could be miscontrued that if a therapist states that the higher percentage of patients who are in recovery from the behaviors have recurrence of thoughts that drive them to self-negating behaviors including their ED is misinformed or pessimisstic and possibly even a bad ED therapist. Awareness of the chance of relapse and for the need for education of the family for signs of this are among my highest priorities. The thoughts, like those who suffer OCD or other impulse-driven or cognitive compulsion disorders, are lifelong and hard-wired and will come and go depending on stress, hormones, age, environment or other triggers. Yes, I’ve seen some people claim they are in-long recovery, but life keeps going and only time will tell. Lastly, I think there are only early understandings of the differences between anorexia, bulimia and BED, and that most effective treatment is still being teased out in the treatment of each.

  2. Dr. Ravin, As I read this, I am ready to break down and cry. My child was in and out of therapy and treatment centers for years and I can look at each one of items on your list and say that each one of these ineffective items were with everyone we encountered. My child is in Recovery, but only when I pulled her away from the professionals and used motherly and common sense. Food was her medicine and we did it. She is in the longest recovery that she has ever been in and is living independently as a productive human being. She is college educated, smart, wonderful person that now had a chance. We looked everywhere for help and found nothing helped and we as a family were always excluded. I reposted this on my website and hope this is ok. I hear and read everyday about years of therapy that didn’t work, therapists that put their fingers in their ears when the patient talked – yes a patient told me that today. Thank you for all you do. I admire you and consider you our Leader in the field. Thank you. Thank you. Thank you. Karen Barber or

  3. Andrew Whalen’s comment above proves my point. No one person could possibly understand what he is saying. You can not talk that way to patients or families, but I suspect he does. PLAIN ENGLISH please.

  4. Andrew,

    Thank you for your comment. I agree with everything you have written. The predisposition to ED is hard-wired and lifelong, and developing a relapse prevention plan is an important part of recovery. Patients and families must always be mindful of signs and triggers and aware of the potential for relapse. But many people do achieve full recovery despite having this lifelong predisposition. There is a qualitative difference (more than just semantics, in my opinion) between having a lifelong predisposition and having a lifelong illness.

    And I completely agree that our understanding of EDs is in its infancy.

  5. I am curious about how relevant these are to older adults? Adults who are mothers and have children of their own, and therefore the Maudsley method is simply not a viable option- how does this change your recommendations?

  6. It’s quite clear you’ve never had an eating disorder yourself. If you had, you would understand that how you’re choosing to fill in the gaps in scientific knowledge is completely crap. Please do not treat patients if you plan on dismissing anything you don’t understand.

  7. Ha, that describes almost every therapist and treatment programme I was involved with for almost 10 years. It took moving to another country to find a more promising path of treatment, which I’ve finally come to embark upon this year. I really, really hope that my previous (very well-intentioned!) practitioners are able to educate themselves about the new science regarding the neurobiological etiology of EDs.

  8. Many thanks for this post, Dr Ravin…

    As someone who had a 30 year history of restricting anorexia nervosa (AN) with exercise-dependence, but is now ‘in remission’, I definitely agree with the biological pre-disposition towards this illness. I am so weary of the psycho-social ‘explanations’ for AN; coupled with the way that AN is confused with the NORMAL body image issues that almost ALL young people have and the airy-fairy ‘love-your-body’ pop-culture stuff.

    By the way, I describe myself as being ‘in remission’, because the neurological pathways that drive my urge to restrict food when anxious or depressed are now firmly hard-wired. In recovery, my brain has had to forge new neurological connections and at times the ‘old’ and ‘new’ pathways still compete. But I know that eating is non-negotiable.

    One thing that I did want to point out, however, is that anorexic patients who were treated professionally in the 1970s and early 1980s were often subjected to a brutal re-feeding regime with threats of punishment associated with ‘refusal’ to eat. Perhaps the opinion, at the time, was that AN is a conscious ‘choice’ and that young people with the illness are rebellious ‘brats’ who are deliberately misbehaving. I was 11 when my AN started and was as confused by my anorexic thoughts as were my parents.To be threatened with punishment for not eating caused me to become phobic of all professionals who treat EDs – and made me feel even worse about myself because I thought of myself as a ‘bad person’.

    I guess the key to successful re-feeding, which is vital to recovery from AN, is calm, supportive, yet (kindly) firm encouragement to eat – to enable the person with AN to become de-sensitised to the distress associated with eating. Threats of punishment merely increase anxiety levels and can put a person off eating for life.

  9. Hm,

    The red flags I list in this post are red flags regardless of the patient’s age.

    For older adult patients, the professional would simply explain that Maudsley FBT is an evidence-based treatment for patients under 18, and has not yet been studied thoroughly on older adults. That is an accurate and convincing explanation.

  10. Dr. Ravin,

    While I am hesitant to fully disagree with you (as I can fully understand every one of your points), I spent the good majority of my summer in a treatment facility this year. I have struggled with anorexia nervosa for 20 years (I am 28) to the point of near-death. That said, I fought tooth and nail with the doctors and staff at the hospital where I knowingly chose to go. I was dying, Dr. Ravin, and I still turned that facility on its ear.

    I suppose what I’m not-so-succinctly saying is that perhaps before one makes blanket assertions about therapists, one should into account the patient, too. The individuals not only put up with me; they saved my life. They helped me save my own life. I’m not cured; but by doing nearly every one of your “Red Flags”, I’m on my way.

  11. Tiffany,

    You are right – I am making blanket assertions without taking into account the individual patient. There are exceptions to every rule, and it sounds as if you are one of them. I am so glad that you have found treatment to save your life and help you along the road to health, regardless of how you got there. Best of luck in your recovery.

  12. Dr Ravin, so much of what you have said resonates with me. I have been told my anorexic daughter needs to choose to get well, I need to step back and leave her to make her own choices. Her therapist has spent hours discussing family trees, causation, and tied herself in knots looking for “underlying issues”. They’ve recommended family therapy, CBT, DBT, CRT, CAT – you name it, they’ve recommended it. The only thing they haven’t recommended is food. Oh and by the way, they consider a BMI of 18.5 to be healthy…. All I can say is in my humble opinion, I’d rather listen and learn from someone like yourself, steeped in the latest evidence based research than all the smoke and mirrors we’ve had to deal with.

  13. Thank you for posting this Dr. Ravin. I like that there are places for discussion. And to Karen, I agree that I didn’t really read through my post carefully and it was more stream of conscience (and when I was tired to boot). Put more plainly, I think people need to be taught that recovery is a life-long process, and that the family needs to keep an eye out for trouble. I’m in recovery from bulimia/compulsive exercise/restriction/binge eating myself, and am very open about my journey into and out of my eating disorder. I also come at it as a therapist in the field since 2006. More than anything, I think finding a competent, educated, and empathic therapist AND dietitian were critical to my recovery. The ones who purport to be ED therapists and don’t know the literature can do more harm than good, and I’m glad that Dr. Ravin has posted some good red flags. And I think we agree on, the best treatment protocols are still being developed and understood. But most important is to take each patient and develop the best treatment team and plan possible for their individual needs. To all who are reading, I wish you a wonderful and peaceful New Year in recovery.


  14. Andrew – well done. I really like your last post and it gives me a lot of hope.

    I’m about to start inpatient treatment in a couple of weeks, in a different setting to all of my previous treatments. I really hope I can get help on the road towards remission from my ED, I really do.

    What I appreciate, though, is that I have loving friends and family who aren’t expecting a miracle cure. They know that IP is just a jump start to help me start the process of nourishing myself regularly and sleeping regularly and putting a dent in correcting some of the physical and physiological deficits. And, yes, getting a start on therapy alongside it.

    But they also know that I’m going to need support when I return home, and I know that they’re committed to giving it. I’m really lucky. At other points in my life, I didn’t have support from friends and family and between that, and a treatment protocol that wasn’t well-tailored to me, relapse was almost immediate.

    I absolutely love reading blog posts from Dr. Ravin, from Dr. O’Toole at Kartini Clinic, from Carrie Arnold of, and Laura Lyster-Mensch of . These 4 blogs are required reading for me every day. I keep the tabs open and hit refresh, hoping that at least one of them has a new post. The new research and ideas they’ve opened my eyes to has given me SO MUCH HOPE, more than I’ve ever had before. This year was the first time in 12 years that I really thought I had any shot of finding anything resembling a remission or recovery.

    More than that, with the new research, I’ve been able to stop blaming myself and focus my energy on what matters – getting me healthy.

    Thanks, Dr. Ravin, for everything you’ve posted. My one comment above was the only comment I’ve ever made on your blog, but I’m a faithful reader. I’ve read your entries and cried and shouted, “Yes!” at the computer, because I was happy, so happy, to finally find a practitioner who UNDERSTANDS and can back up her treatment approach with cold, hard science and research studies and fact, and not a rehash of the same old theories that never rang true for me.

  15. Sara

    Same about the blogs thing. Can I suggest you add Extralongtail to your list. Her “fluffy bunnies” blog is just fantastic.


    Thank you for the explanation. It makes much more sense now.

    Dr Ravin

    You rock – you know that but you need reminding.

    Here in the UK, we are unable to choose our treatment providers. This is one of the downsides of the wonderful NHS. However, this does not mean we cannot go about educating them whilst our children and loved ones are being cared for.

    I had a long conversation with Janet Treasure the other day in which I accused her (very politely!) of emphasising too much about the feelings and not talking about the food. Her reply was that she dealt with older patients and that weight restoration was a given. Many of her patients have been in and out of treatment for years, even decades and have been told ad infinitum that weight restoration is the cornerstone of successful treatment. What she hadn’t realised is that this was not a given in other treatment facilities and she has set about re-emphasising the whole weight restoration issue, in the hope that it will trickle down through our system.

    I am hoping that Dr Ravin’s red flag list will become a useful tool for grizzled old campaigners like me to take to our NHS funded treatment facilities and explain to them where, why and how they need to change.

    Thank you.

  16. Charlotte –

    I saw a video from Dr. Treasure about weight-restoration a while back, and it really blew my mind. So anything she publishes, I’m totally open to reading. Seriously, I am so grateful for this new scientific research and the professionals and advocates who are disseminating the information!!

    re: extralongtail – ooh, I discovered her about 2 weeks ago and i was very impressed – forgot to mention her, as I’ve not been reading her for as long as the others. But what stood out to me about her story is that she felt like she never really fit the criteria that books and practitioners hail as hallmarks of AN. I always felt that way, myself, but I played along, because they’re the professionals, right?

    Now that I’m living in Europe, I find that practitioners are a lot more understanding about my ‘atypical’ traits and such. Maybe they’re more open to that sort of thing, anyway, given that I come from another continent, from another cultural and ethnic background than they’re used to interacting with. But I feel like they’ve been more openminded in general, not pigeonholing me or other patients into the same old stereotypes.

    I do give credit to the facilities and practitioners here that I’ve been exposed to – the first order of business is weight restoration/stabilisation. Even though I didn’t mesh well with the first facility I tried here, they did have some good points. Like, the first week, they’re all about taking in nutrition, a very significant amount of calories (after the first 2 days), and patients don’t start therapy until a minimum of a week after admission, if not later, if a patient is super emaciated. Resting is also emphasised.

    The idea is to get physical healing on the ball, the mindset being that a starved brain isn’t going to be really able to participate fully in the therapeutic experience right off, anyway. (Well, actually, after the first week, patients can participate in an art group, but it’s not art therapy, with a discussion of the creative works – just a creative outlet. Once again, the work of therapy doesn’t come until patients are at a certain point physically.)

    I am so grateful that I’ve seen next to none of the red flags on the list here in my experience (well, some at the last IP facility, which is why I high-tailed out of there, but they had their good points as well). So I’m really optimistic about my next experience.

  17. I wish I’d had this list 10-12 years ago when we were being told to “back off” and not talk about food and and that she needed to have “control” over something. Ugh, we might have a fully recovered daughter by now had we not listened to that nonsense.

    I’ve been sharing this with the parents I serve. Thank you Dr. Sarah Ravin. Parents are always asking for help in finding quality providers. This is a great resource.
    Becky Henry
    Hope Network, LLC

  18. Dr. Ravin,

    I featured this blog post in my weekly newspaper “Anorexia Suffering and Recovery”

    Also, I referred an Eating Disorder sufferer to you for a referral in her area. She is quite ill, been in and out of therapy for years and years, but the kicker is that her husband thinks she is making a conscious decision to not eat. I fear she will die if she does not get help. I hope you are able to send her to a respectable professional or center. I wouldn’t know who in the world to send her to, even though my daughter was in and out of Inpatient Outpatient, Individual Therapists, nutritionists, none of which I would recommend to a monkey (I like monkeys). Keep up the great word you are doing and give us all the information you can. Thank you!!!! Karen Barber

  19. Hi My name is Susan i a 59 yrs old. I struggled with anorexia and depression for over two decades. I was in and out of treatments. Nothing worked because I didn’t’ work them. Everyone was about to give up on me, Dr. was suggesting I was beyond help and to check myself into a nursing home! Long story short, I arranged my last treatment, left in recovery 3/19/2010 never looked back. I am about to graduate from iPEC Coaching Institute. I am a coach/owner of Purple Wings of Recovery Coaching. I coach women take flight from their eating disorders without fear. If you would like to take that first step toward the life you imagine, I offer a 30 min complementary sessions.

Comments are closed.