Dropout from eating disorder psychotherapy as a relational and contextual process: a critical perspective

Dropout from eating disorder (ED) psychotherapy remains a significant clinical challenge, yet treatment discontinuation has historically been conceptualised primarily through patient-centred frameworks emphasising ambivalence, resistance, illness severity, or poor motivation. This perspective paper critically examines dominant conceptualisations of dropout and explores how lived experience literature and research on adverse treatment experiences may broaden current understandings of disengagement. Drawing on qualitative, lived experience-led, conceptual, and empirical scholarship, the paper highlights how relational rupture, epistemic injustice, coercion, cultural and relational unsafety, misattunement, and iatrogenic harm may contribute to treatment withdrawal for some individuals. The paper additionally examines structural and systemic contributors to disengagement, including culturally incongruent care, and inequitable access to services. Implications for research and clinical practice are discussed, including routine monitoring of treatment-related harm, reconsideration of retention-focused frameworks, and greater incorporation of co-produced approaches within ED care.