Iatrogenic harm and premature treatment discontinuation in eating disorders: a lived experience response to Wade and Schmidt (2026)

Abstract

Premature discontinuation from eating disorder (ED) treatment is commonly interpreted through adherence, motivation, ambivalence, treatment fit, or symptom change. Wade and Schmidt make an important contribution by identifying seven strategies intended to improve retention and by moving beyond explanations located solely within the patient. They explicitly frame retention as a route through which people may obtain greater therapeutic benefit. This commentary argues that continued participation does not, by itself, establish benefit, safety, acceptability, treatment quality, or recovery. Some discontinuation may reflect treatment non-response or circumstances unrelated to care. In other cases, it may communicate poor treatment fit, coercion, relational rupture, cultural or identity-related misattunement, or iatrogenic harm. These possibilities cannot be distinguished reliably when adverse effects are poorly defined, inconsistently monitored, and inadequately reported, or when patient accounts of iatrogenic harm are discounted. We propose an expanded framework in which retention is evaluated alongside collaboratively defined benefit, treatment safety, reasons for staying and leaving, and patient-reported experiences during treatment and follow-up. Mixed-methods research, informed consent about potential negative effects, repeated confidential feedback, repair-oriented responses to reported harm, and lived experience-led co-production are required to determine whether care is safe and worth continuing. Retention records participation. Its clinical value depends on the care in which people are retained.

Background and scope

Wade and Schmidt published a Forum article on premature discontinuation from face-to-face eating disorder (ED) therapy in the International Journal of Eating Disorders [1]. It is best understood as an agenda-setting contribution rather than a systematic review or definitive evidence synthesis. They distinguish patient-initiated withdrawal, therapist-initiated treatment termination related to non-response or non-engagement, therapist-initiated withdrawal related to deterioration, early completion, and logistical withdrawal. They then propose seven strategies to improve retention: waitlist support, coordinated multidisciplinary care, recovery-oriented augmentation, treatment choice, session measures with feedback, personalisation, and attention to therapeutic ruptures [1].

Their rationale assigns retention a clear positive clinical value. Wade and Schmidt state, “Our challenge is how to better engage and retain people in therapy so that they can gain more benefit from therapy” [1]. They do not formally define retention and benefit as identical constructs. They nevertheless position retention as a desirable route to benefit and organise their paper around strategies intended to increase it. Our concern is not that retention is irrelevant. Continued participation may create an opportunity for benefit, but it does not demonstrate that benefit occurred or that treatment was safe [2]. Before increased retention is promoted as a clinical objective, the safety, acceptability, and patient-defined benefit of the care being continued must be prospectively assessed at repeated intervals rather than assumed [2].

The scope of Wade and Schmidt’s article also matters [1]. The evidence discussed is drawn mainly from face-to-face outpatient ED psychological treatment, with substantial reliance on cognitive behavioural therapy-oriented studies and datasets [1]. These studies provide important information about treatment attendance and completion. They offer less information about potential iatrogenic harms that were not prospectively defined, patient experiences that were not measured, or populations poorly represented in the underlying evidence [2]. Qualitative and lived experience-led scholarship shows that treatment discontinuation may be shaped by treatment fit, misattunement, therapeutic alliance rupture, invalidation, coercion, unmet support needs, cultural incongruence, treatment-related trauma, and loss of trust in healthcare providers, as well as by illness-related or practical factors [2–4].

This commentary first examines what retention can and cannot show. It then considers what discontinuation may communicate about treatment fit and safety, explains why iatrogenic harm and epistemic injustice complicate interpretation of treatment discontinuation, and sets out implications for research, clinical practice, and publication.

What retention can and cannot show

Retention records that a person remained in contact with treatment for a specified period [1]. It does not explain why they stayed or whether care was safe or beneficial [2–4]. Continued attendance may reflect trust and helpful care, but it may also reflect fear of an unnegotiated escalation to a higher level of care, including inpatient admission or compulsory treatment, loss of multidisciplinary support or administrative discharge, or being labelled non-compliant, difficult, attention-seeking, manipulative, or treatment-resistant [1–8]. Apparent engagement or behavioural change may also reflect trauma-related appeasement, masking, or strategic compliance undertaken to meet perceived clinician expectations, avoid the clinician’s anger, disappointment, or frustration, preserve the therapeutic relationship, or prevent withdrawal of therapy [2, 5, 7–12]. In a quasi-experimental inpatient ED study, replacing an externally pressured admission approach with one maximising patient choice reduced early discontinuation without changing later discontinuation or weight gain [13]. Transdiagnostic real-world data likewise showed that retention and attendance were only moderately associated with service-defined therapeutic discharge, whereas session count was unrelated and categorical cut-offs reduced predictive accuracy [14]. High retention therefore requires interpretation rather than automatic classification as progress [1–14].

Benefit is not self-defining. ED studies often prioritise ED-focused symptom reduction, weight restoration, behavioural change, medical stabilisation, or treatment completion [1, 2]. Lived experience research also identifies autonomy, identity, authenticity, hope, meaningful relationships and community belonging, existential purpose, quality of life, and the ability to live according to personal values as important dimensions of recovery [15–17]. These outcomes can converge with clinician-selected targets, but they can also conflict. Benefit should therefore be determined collaboratively, with the person receiving care having substantive authority over which changes matter in their life [15–17].

Recovery may be nonlinear, and difficult therapeutic work may contribute to later change [15–17]. This does not make distress inherently beneficial. Expected therapeutic difficulty, transient symptom intensification, deterioration arising from the underlying condition, and harm caused or intensified by treatment are distinct possibilities [18–21]. None can be inferred from symptom or behavioural change alone. Distinguishing them requires prospective assessment of the treatment process, the person’s account, the clinical context, iatrogenic harm, and subsequent outcomes [18–21].

Recent research on longstanding anorexia nervosa illustrates why treatment experience matters. Kiely et al. found that participants with illness lasting seven years or longer reported more treatment episodes, longer delays before treatment, and poorer subjective treatment experiences than those with shorter illness duration. Helpful care was characterised by listening, relational trust, safety, compassion, respect, personalisation, autonomy, and appropriate pacing, whereas unhelpful care was associated with trauma, loss of hope, dehumanisation, and reduced self-worth [22].

Lubieniecki et al. provide complementary mixed-methods evidence. People with longstanding EDs described diagnostic exclusion and overshadowing, coercive or inflexible treatment practices and protocols, invalidating clinician interactions, weight-based gatekeeping and stigma, and mismatch between treatment models and their support needs as barriers to treatment engagement. Empathic relationships, individualised, neurodiversity-affirming, trauma-informed care, autonomy, peer support, and collaborative pacing and goal-setting facilitated treatment engagement [4]. These studies thus support a specific conclusion: treatment experience can shape whether care is sustainable, and treatment discontinuation should prompt examination of the clinical practices and treatment context rather than automatic attribution to patients’ lack of insight or motivation [2, 4, 22].

Person-centred and recovery-oriented principles have long existed. The 2014 Royal Australian and New Zealand College of Psychiatrists guideline recommends informed decision-making, self-determination, meaningful choice, dignity of risk, least restrictive care, cultural responsiveness, collaboration, and safety [23]. Asaria’s CHEAP principles of compassion, hope, empathy, appreciation of identity, and patience provide a practical relational foundation [24]. Formal endorsement, however, is not evidence of consistent implementation. In a qualitative study of inpatient care, participants reported that care “actually deepened the suffering” and that questioning or expressing concerns about their care risked being dismissed as “manipulative” or “difficult” [25, p. 5]. Autistic participants and parents described family-based treatment (FBT) and cognitive behavioural therapy (CBT) as “particularly mis-attuned” because the approaches attempted to override autistic traits; some reported that these approaches were “harmful and resulted in treatment-related trauma” [26, p. 11]. Spadaccini and Schweizer provide a further lived experience example of this implementation gap. Their narrative describes inpatient ED treatment in which a trans adolescent’s gender identity was pathologised, institutional power was used to enforce cisnormative pubertal development, and gender-affirming medical care was withheld. The first author writes that the experience “broke me down to the point that I gave up advocating for help” [27, p. 6]. The paper reports enduring psychological harm and almost a decade of disengagement from healthcare [27, pp. 4–6]. Canadian participants likewise described power imbalances, distrust, and administrative discharge without adequate follow-up, while emphasising that staff “just needed to be human with me” [5, p. 6]. These accounts show that treatment may meet immediate medical objectives while failing to provide psychologically safe, identity-affirming, and person-centred care, exposing a gap between formal principles and their consistent implementation [5, 25–27].

What disengagement may communicate

Wade and Schmidt use terms such as “therapy-interfering behaviours” for repeated lateness, cancellations, refusal of medical monitoring, and non-completion of between-session tasks that may lead to therapist-initiated withdrawal [1]. These behaviours may reflect ambivalence, illness-related difficulty, practical barriers, or inability to undertake treatment demands [1–4]. They may also communicate disagreement about treatment goals, poor fit or misattunement, or diminished confidence in treatment and trust in providers following previous experiences of coercion, relational rupture, or iatrogenic harm [2–4, 6, 10]. Labels such as “therapy-interfering behaviour” can narrow interpretation by constructing the person primarily through an illness-defined identity [10, 11]. Malson et al. showed how “the eating disordered patient” was constituted both in participants’ self-accounts and in descriptions attributed to healthcare workers [11]. Such behaviours should therefore be treated as signals for further inquiry rather than explanations in themselves [1–4, 6, 10, 11].

Qualitative ED research links premature treatment termination to unmet needs, poor treatment fit, feeling misunderstood, negative service experiences, and struggles over control [2–4, 6, 28]. In web-based CBT, participants who later discontinued reported poorer alliance and treatment experiences while still attending and cited insufficient personalisation, lack of personal contact, treatment burden, protocol content, and perceived ineffectiveness [29]. Olofsson et al. similarly found that treatment was experienced as involuntary, incompatible, or intimidating [28]. Repeated involuntary treatment can also have enduring effects on autonomy, trust, and willingness to engage [7]. Therapist focus groups showed that readiness judgements, treatment demands, and resource constraints shape continuation, and that some clinicians viewed discontinuation as part of a longer recovery process [30]. At 36-month follow-up, people who discontinued did not differ significantly from completers in clinical status, although completers improved more and those who discontinued reported greater dissatisfaction [31]. These findings neither make discontinuation inherently beneficial nor remove its risks; they show that it may communicate how treatment was delivered and experienced [3, 6, 7, 28–31].

Initial help-seeking and access to treatment are outside the scope of this commentary and Wade and Schmidt’s analysis; both focus on engagement and continuation after therapy has commenced [1]. This distinction matters because barriers to entering care and the factors that shape continued participation once treatment begins are related but analytically different. The present argument does not claim that marginalised communities are statistically overrepresented among people who discontinue treatment. Rather, it asks whether those who enter care encounter treatment that is culturally safe, affirming, accessible, responsive to neurodivergence or other forms of disability, and sufficiently attuned to their identities, circumstances, and communication needs. Culturally incongruent, non-affirming, exclusionary, inaccessible, neuronormative, or otherwise misattuned care may undermine trust, contribute to iatrogenic harm, and make continued engagement or later return to treatment less likely [9, 26, 27, 32–37]. In such circumstances, disengagement should not automatically be interpreted as an individual failure of motivation or commitment; it may also reflect how treatment was designed, delivered, and experienced. Access to care, retention after treatment begins, and willingness to return following iatrogenic harm should therefore be examined as distinct stages of the care pathway. Collapsing them into a single concept of engagement risks obscuring where exclusion or harm occurred and attributing service-related disengagement solely to the patient [2–4, 32–38].

Recent evidence illustrates why the safety and benefit of treatment cannot be assumed to transfer unchanged across populations. A systematic review of outcomes for trans and gender diverse people found that ED symptoms may improve while depression, anxiety, and suicidality remain elevated and may sometimes worsen [32]. This underscores the need to evaluate gender dysphoria, minority stress, and affirming care rather than weight restoration or ED symptoms alone [32]. First Nations and Māori scholarship identifies discrimination, historical mistrust, cultural incongruence, and limited culturally specific guidance as barriers to safe ED care [33, 34]. Indigenous-led research further shows that Western psychological models, particularly CBT, may omit culture, kinship, community, Country, spirituality, and the traumatic effects of colonisation and displacement on mental health [35, 36]. Autistic people and parents have likewise described absent accommodations and recovery defined through neuronormative assumptions [9, 26, 37]. These studies do not establish that any treatment is universally harmful. They identify dimensions of treatment fit and safety that standard outcome measures may fail to capture [9, 26, 27, 32–37].

Iatrogenic harm and epistemic injustice

We use iatrogenic harm to mean harm caused or intensified, in whole or in part, by healthcare practices, omissions, misdiagnosis, treatment protocols, clinical environments, or institutional systems [18, 39, 40]. The term identifies the source or contribution of healthcare. It does not, by itself, imply deliberate intent, negligence, professional incompetence, or individual moral blame [18, 39, 40]. Iatrogenic harm encompasses harm arising from deliberately imposed clinical practices whose harmful consequences were not intended, boundary violations, and discriminatory or exclusionary care shaped by transphobic, neuronormative, culturally incongruent, or weight-stigmatising assumptions [4, 8, 9, 12, 18, 26, 27, 32, 37–39, 41]. It therefore preserves attention to the contribution of healthcare rather than the presumed intentions of professionals [18, 39, 40].

The available evidence does not permit a confident or comprehensive assessment of the safety of ED psychotherapy, including CBT, because iatrogenic harm has not been assessed with the same conceptual and methodological seriousness as benefits [18–21, 40]. In a systematic review of 23 psychotherapy clinical trials for anorexia nervosa, only three defined unwanted events. None assessed deterioration beyond weight loss or ED symptom worsening, and only one included patient-reported satisfaction with treatment and experiences of iatrogenic harm [19]. Across psychological interventions more broadly, systematic reviews identify inconsistent definitions, limited prospective monitoring, and rare reporting of iatrogenic harm [20, 21]. This problem has long been recognised in psychology without the establishment of routine methods for identifying and monitoring iatrogenic harm [40]. Absence of recorded treatment-related harms is not evidence of their absence when they are not prospectively defined, monitored, classified, attributed, and reported [19–21, 40].

Treatment benefit and treatment safety are separate concepts. Symptom improvement can coexist with relational rupture, loss of trust, identity invalidation, self-stigmatisation, emotional overwhelm, avoidance of future care, or other forms of treatment-related harm [18, 38, 39, 41, 42]. Lived experience scholarship makes this coexistence explicit. Elwyn writes that experiences in inpatient and outpatient ED care, including outpatient CBT, “compounded my trauma, and ultimately maintained my AN” [41, p. 4]. Measures can assess positive and negative treatment experiences together rather than treating benefit as sufficient evidence of safety [42].

Treatment safety also begins with meaningful informed consent. Continued treatment participation should not be treated as evidence that consent was freely given, particularly where refusal may lead to restraint, escalation of care (e.g., involuntary treatment), administrative discharge, or loss of multidisciplinary support [5, 7, 8]. Furgalska’s study of psychiatric survivors shows how the concept of “insight” can function as an extra-legal proxy for coercion masked as consent and argues for real opportunities to give informed consent [8]. In a mixed-methods study of 500 adults, most participants wanted information about potential negative effects of psychological treatment. Among participants with previous psychological treatment experience, substantially fewer recalled receiving information about negative effects than potential benefits, and disclosure was not associated with reduced willingness to begin treatment [43]. Transparent discussion of potential risks of iatrogenic harm can support realistic expectations, preparedness, trust, agency, and informed choice [8, 43].

Patient safety extends beyond the prevention of physical injury. Disrespectful, demeaning, invalidating, stigmatising, or humiliating care can cause preventable psychological and dignitary harm, undermine trust, and erode patients’ sense of agency and worth [5, 44]. The World Health Organization advocates open and transparent safety cultures, meaningful patient feedback, honest disclosure of adverse events, investigation of serious harm, psychological support, and systems capable of learning from patients’ feedback [45]. These principles apply not only to technical errors and boundary violations, but also to psychological, relational, cultural, and identity-related harms [9, 18, 27, 39, 44, 45].

Epistemic injustice helps explain why reports of iatrogenic harm may not receive meaningful uptake. Testimonial injustice occurs when prejudice reduces the credibility assigned to a speaker. Hermeneutical injustice occurs when available concepts and interpretive practices do not allow an experience to be understood or communicated adequately [46]. In psychiatry, professional knowledge may receive credibility excess while patient testimony is discounted through assumptions about insight, motivation, resistance, or psychopathology [8, 47, 48]. Hermeneutical humility requires clinicians to approach patients’ accounts with curiosity and remain open to interpretations that challenge established assumptions, diagnostic frameworks, or professional training [49]. Applied to Wade and Schmidt’s framework, the question is whether patient reports that challenge a treatment protocol, such as FBT or CBT, are treated as information about fit and safety or reclassified as non-engagement, poor insight, resistance, or “therapy-interfering behaviour” [1, 11, 18, 39].

Clinician reactions can influence how disagreement, treatment disengagement, and reports of iatrogenic harm are handled. Countertransference refers here to clinicians’ emotional and relational responses within treatment. A scoping review of 27 studies identified negative reactions including helplessness, anger, fear, frustration, and feelings of incompetence, while showing that such reactions are shaped by therapist characteristics, patient presentations, relational processes, and treatment-setting conditions [50]. Countertransference may also involve impulses to take action, overinvolvement, distancing, or a wish to regain control. Recognition, reflection, supervision, and team support are therefore important to prevent clinicians’ emotional responses from being enacted within care [50].

Researcher, clinician, service, and institutional defensiveness are distinct from countertransference and may present differently across contexts. Clinician defensiveness may involve disbelief, minimisation, dismissiveness, or attributing a patient’s report of iatrogenic harm to psychopathology, defiance, manipulation, or resistance. Researchers may privilege favourable outcomes, treat reports of iatrogenic harm as merely anecdotal, resist examining adverse effects, or interpret criticism as a rejection of the treatment’s entire evidence base [2, 18]. Treatment services may narrow the scope of complaints, defend established protocols, avoid accountability, or fail to offer acknowledgement and repair-oriented responses. Institutions may prioritise legal, regulatory, or reputational protection, restrict transparency, or resist findings that could implicate organisational culture or governance [51–53]. These responses may be intensified when professional identity, clinical training, treatment-model allegiance, career-long intellectual investment, or institutional reputation depends on the perceived legitimacy and success of the treatment. Such investments do not necessarily imply bad faith, but they may create blind spots and reduce willingness to recognise limitations, adverse effects, poor treatment fit, or differential acceptability across patient groups. Downs writes, “I have met a profound resistance to recognising that it is even possible that I may have been harmed by treatment” [51, p. 266]. Clinicians, researchers, services, and institutions should therefore examine how their distinct professional and organisational investments shape whether reports of iatrogenic harm are heard, investigated, acknowledged, and acted upon [18, 39, 51–53].

Iatrogenic harm can occur in any area of healthcare. A distinct ethical responsibility arises once a patient reports that treatment has caused harm. Although the original harm may have been unintended, the subsequent response is a deliberate professional and institutional choice. Dismissing, minimising, or defensively reinterpreting the report, or failing to investigate and pursue appropriate repair, may compound the harm, further erode trust, impede healing and service learning, and contribute to prolonged disengagement from healthcare [18, 38, 39, 51–53]. Downs reports that inadequate acknowledgement of previous iatrogenic harm “made it more difficult for me to engage in treatment again” and made subsequent treatment “less effective and – at times – retraumatising” [51, p. 265]. Elwyn provides a complementary lived experience account in which failure to recognise trauma responses and implement support needs documented in a Psychiatric Advance Health Directive contributed to invalidation and retraumatisation [54].

Recognition of iatrogenic harm may occur during treatment or retrospectively. Coercion, invalidation, cultural incongruence, boundary violations, or non-affirming care may be recognised contemporaneously, although their significance may be only partly understood. Other forms of iatrogenesis become intelligible after cumulative effects emerge, after treatment ends, or when the person later recognises trauma responses, erosion of trust in self or service providers, disengagement, or avoidance of future care [18, 26, 27, 38, 39, 51]. Awareness at the time of treatment is not a prerequisite for identifying iatrogenic harm; delayed recognition does not invalidate the patient’s account nor the seriousness of the harm. Conversely, acknowledgement can support repair. Downs describes a later therapeutic relationship in which “I felt listened to and was granted interpretive authority of my own,” and links this recognition to meaningful progress after more than two decades of living with an ED [39, p. 7].

Implications for research and practice

Wade and Schmidt’s seven strategies may have clinical value, but their success cannot be determined through retention alone [1, 14]. Retention should be reported alongside symptom and medical outcomes, quality of life, progress towards collaboratively defined goals, treatment acceptability, iatrogenic harm, and patients’ reasons for remaining in or leaving care [1, 2, 14, 18–21, 40, 42, 43]. Increased attendance cannot be considered successful if it is accompanied by worsening self-esteem, safety, autonomy, or trust in healthcare providers and systems [2, 18, 42].

Wade and Schmidt’s proposal for session measures with feedback provides a useful starting point, but evaluation should be prospective, repeated, and mixed-methods [1]. Quantitative measures can assess early and later symptom change, medical risk, functioning, quality of life, adverse events, and clinically significant deterioration [19–21, 42]. The Positive and Negative Experiences of Psychotherapy questionnaire (PNEP) provides a practical starting point because it assesses positive and negative experiences together, including symptom escalation, emotional distress, treatment and therapeutic relationship quality, self-stigmatisation, and dependency [42]. It also allows patients to attribute an experience to therapy, other circumstances, or both. Because the PNEP is a recently developed measure and is not specific to ED treatment, it should complement qualitative interviews, open-ended feedback, patient-reported experience measures, and individualised outcomes [42, 55–58]. These approaches may identify relational, cultural, identity-related, and trauma-related experiences that standard symptom measures overlook [5, 9, 26, 27, 29, 37, 42, 55–58]. Assessment should occur at treatment commencement, during care, when treatment changes or concerns arise, at termination, and at follow-up [18–21, 29, 45, 55–58].

Patients also need confidential and accessible ways to report concerns outside the immediate therapeutic relationship when disclosure to the treating clinician feels unsafe [18, 39, 51–54]. They should not be required to prove that treatment caused harm while still receiving care [18, 39, 51, 54]. Reports of deterioration or iatrogenic harm should prompt a timely, collaborative review. This should consider the underlying condition, treatment demands, clinical change, relational processes, treatment fit and attunement, accessibility, cultural fit, the person’s goals, and any possible treatment contribution. Treatment should be adapted, changed, paused, or stopped where indicated. Services should specify who reviews concerns, how decisions are documented, how patients are protected from retaliation or loss of care, and what acknowledgement, apology where appropriate, and repair-oriented support will be offered. Collecting feedback without acting on it risks reproducing the epistemic injustice these processes are intended to address [18, 39, 45, 51–53].

Co-production should be embedded throughout ED research and service development. People who have discontinued treatment, experienced iatrogenic harm, or been excluded by services should have meaningful decision-making power in defining benefit, harm, safety, acceptable and attuned care, and meaningful treatment outcomes. Co-production should shape research questions, study design, outcome selection, interpretation, governance, dissemination, and service responses, rather than being limited to consultation after key decisions have been made [59, 60]. Practical guidance is available for embedding lived experience expertise in ED research and addressing access, communication, and power in co-production with lived experience communities [60–62].

Reflexivity should apply reciprocally across forms of expertise. Clinical training, institutional roles and cultures, disciplinary assumptions, methodological commitments, treatment-model allegiance, reputational interests, and lived experience can all shape what research questions are prioritised and how findings are interpreted and used for translational service development [60, 63–65]. Lived experience should not be treated as uniquely biasing, while clinical and academic positions appear neutral. All clinicians and researchers should consider how their professional, experiential, disciplinary, and institutional positions influence their work, while lived experience authors retain control over whether and how personal information is disclosed [60, 61, 63].

Person-centred principles also require operational support. The CHEAP principles provide a relational minimum, and resource constraints should not excuse dismissiveness, invalidation, or failure to respect identity [24]. Compassion, careful listening, openness to correction, and critical self-reflection do not depend on additional funding [24]. These obligations coexist with the need for adequate staffing, continuity of care, accessible treatment options, affirming and culturally responsive expertise, routine assessment of benefit and harm, confidential reporting pathways, and independent accountability [5, 23–27, 45, 51–53].

Investment is necessary to support these conditions, but it does not itself establish that care is safe or responsive to reports of harm [23, 24, 30, 51–53]. Beale distinguishes resource constraints from an exclusion culture in which denial of care and organisational self-protection may be rationalised as clinically appropriate [53]. Downs describes an “ignorance culture” in which patient feedback and dissent are suppressed or reinterpreted as evidence of psychopathology [52, p. 2]. As Downs states, “When the healthcare system fails to listen, it fails to learn” [52, p. 4]. Defensive responses, tokenistic lived experience involvement, and claims of organisational learning that do not produce change can protect established assumptions [52, pp. 3–5]. These problems “will not be resolved only by attending to pressing resource constraints” [52, p. 6]. Institutional culture, professional reflexivity, and willingness to acknowledge responsibility therefore shape whether reported harm is meaningfully addressed [51–53].

Publication practices also influence whose interpretations enter the scholarly record and become more visible in the field. Peer-reviewed academic journals in eating disorders, mental health, psychiatry, psychology, and related healthcare fields should provide transparent and accessible routes for responses to published research. This is particularly important where findings or interpretations may shape clinical practice, policy, or public understanding, or where people with lived experience were not involved in the original work. Providing such opportunities is a matter of ethical responsibility and procedural fairness, and it supports the critical scholarly debate through which scientific knowledge is tested, refined, and advanced. Scholarly dialogue should not depend solely on invitation or access to established academic networks. Transparent routes for response also strengthen reflexive scholarship [60, 63, 64].

Conclusions

Wade and Schmidt are right that premature discontinuation warrants closer attention and that ED services should improve treatment choice, personalisation, feedback, multidisciplinary coordination, and relational rupture repair [1]. Our argument extends rather than rejects those proposals, but evaluates them against a broader standard of safety, acceptability, inclusivity, and patient-defined benefit.

The field should not ask only how to keep people in treatment. It should ask whether the care is safe, acceptable, responsive to the person’s psychosocial context, and capable of producing benefit that matters to them. Some difficult treatment experiences may be useful, some deterioration may arise from illness, and some discontinuation may be unrelated to treatment itself. Other instances of premature treatment discontinuation may communicate misattunement, cultural incongruence, relational rupture, or iatrogenic harm [2–4, 18, 38, 39]. These possibilities require systematic assessment and monitoring [18–21, 40, 42, 43]. Retention is clinically meaningful when people remain in care that is safe and worth continuing.

Abbreviations

CBT

Cognitive behavioural therapy

ED

Eating disorder

EDs

Eating disorders

FBT

Family-based treatment

PNEP

Positive and negative experiences of psychotherapy questionnaire

Author contributions

LC: conceptualisation, formal analysis, investigation, project administration, writing–original draft, writing–review and editing. RE: conceptualisation, formal analysis, investigation, writing–original draft, writing–review and editing.

Funding

No funding was obtained for this work.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This work does not involve the collection of human data.

Competing interests

The authors declare no competing interests.