Barriers and Facilitators to Treatment in Severe and Enduring Eating Disorders: A Mixed- Methods Study of Access, Engagement, and Lived Experience

Barriers and Facilitators to Treatment in Severe and Enduring Eating Disorders: A Mixed- Methods Study of Access, Engagement, and Lived Experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Barriers and Facilitators to Treatment in Severe and Enduring Eating Disorders: A Mixed- Methods Study of Access, Engagement, and Lived Experience Gabriel Lubieniecki, Isabella McGrath, Gemma Sharp This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6843067/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Sep, 2025 Read the published version in Journal of Eating Disorders → Version 1 posted 9 You are reading this latest preprint version Abstract Objective : An estimated 20 to 30% of individuals with eating disorders (EDs) experience protracted illness trajectories, often referred to as severe and enduring eating disorders (SEED). Research examining the systemic, relational, and experiential factors that influence access to and engagement with care in this population remains limited. This mixed-methods study aimed to explore the structural, clinical, and interpersonal barriers and facilitators shaping treatment experiences among individuals with longstanding EDs. Method: An explanatory sequential mixed-methods design was employed with 41 participants. Stage One involved an online survey assessing demographic characteristics, diagnostic history, treatment exposure, and symptom severity, with descriptive statistics used to characterise the sample. Stage Two comprised of in-depth semi-structured interviews exploring lived experiences of treatment access and engagement. Qualitative data were analysed using reflexive thematic analysis informed by transcendental phenomenology. Results : The sample was heterogeneous in terms of diagnostic profiles, illness duration, recovery stage, and treatment exposure. Two higher-order qualitative themes were identified; “Barriers to Care” included diagnostic and conceptual exclusion, weight-based bias, systemic access constraints, coercive practices, and misalignment between treatment models and patient needs. “Facilitators of Engagement and Recovery” comprised compassionate, individualised, and trauma-informed care, peer connection, and the integration of lived experience and advocacy. Discussion : Individuals with SEED are a diverse population who report frequent exposure to structural, relational, and treatment-related barriers, while also identifying salient facilitators that support therapeutic engagement and recovery. Findings from this exploratory study suggest that more responsive, inclusive, and person-centred models of care may help address the complex needs of individuals with SEED. Trauma-informed and neurodiversity-affirming approaches, particularly those that integrate lived experience, may help mitigate the systemic and clinical barriers identified across both access and treatment contexts. Eating Disorders Severe and Enduring Eating Disorder (SEED) Treatment Access and Barriers Treatment Facilitators Patient Perspectives. Plain English Summary People with longstanding eating disorders often face significant difficulties when seeking help. These challenges may include being excluded from treatment based on their weight, diagnosis, or life stage, or encountering services that feel rigid, unsafe, or invalidating. This study explored the barriers and facilitators to care experienced by 41 adults in Australia with a range of eating disorder diagnoses and at different stages of recovery. Using a combination of surveys and in-depth interviews, we found that participants commonly described delayed or denied access to care, particularly when their needs did not fit expected treatment pathways. Experiences of stigma, misdiagnosis, and trauma within healthcare settings were also frequently reported. These experiences led to a loss of trust in services and contributed to feelings of exclusion and hopelessness. However, participants also shared what had helped them engage with care. Supportive relationships with clinicians, connection with peers, and being offered choices in their treatment were especially important. Participants emphasised the value of trauma-informed, person-centred, and neurodiversity-affirming approaches that responded to their unique needs and respected their autonomy. Our findings show that to improve care for people with longstanding eating disorders, we must move beyond one-size-fits-all models and meaningfully address the structural and relational barriers that many continue to face. Introduction Severe and enduring eating disorders (SEED) constitute a complex and heterogeneous subset of eating disorder (ED) presentations, typically characterised by persistent symptomatology, functional impairment, and prolonged illness duration, often exceeding seven years (1-5) While early intervention using evidence-based modalities is associated with improved outcomes (6), approximately 20 to 30 percent of individuals develop protracted illness trajectories marked by chronicity and repeated, often unsuccessful, treatment attempts (1, 2). Despite increasing clinical and scholarly recognition, SEED remains inconsistently defined, with considerable variability in criteria relating to illness duration, diagnostic status, and treatment responsiveness (7). Individuals with SEED frequently encounter multifactorial barriers to care, including diagnostic exclusion, stigma, and inflexible service models that fail to accommodate the complexity of their presentations (8-11). In contrast, emerging evidence suggests that certain relational and structural factors, such as trauma-informed approaches, individualised care, and peer support, may act as critical facilitators of therapeutic engagement and recovery (12-14). Stigma, in particular, has emerged as a pervasive and multifaceted barrier to care for individuals with SEED. It is broadly defined as a process of social devaluation characterised by labelling, stereotyping, and status loss within unequal power structures (15). In the context of EDs, stigma is typically experienced across four interrelated domains: structural, public, anticipated, and internalised (16, 17). Systematic reviews and scoping syntheses have documented widespread societal beliefs that individuals with EDs are personally responsible for their condition, which, in turn, elicits blame and emotional responses such as frustration or disdain (18-20). Such attitudes are also evident among clinicians, particularly those without specialist training, who may view individuals with EDs as “manipulative”, “treatment-resistant”, or “at fault” for their illness (18, 21). Structural stigma is embedded within institutional policies that employ narrow diagnostic or weight-based thresholds, leading to the exclusion of those in higher-weight bodies, individuals with neurodevelopmental conditions, and those with complex presentations (8, 10, 18, 22). Public stigma, shaped by enduring sociocultural narratives, positions individuals with longstanding illness as attention-seeking, non-compliant, or beyond help (21-23). These external perceptions contribute to anticipated stigma, wherein individuals delay or avoid seeking help due to fear of invalidation, dismissal, or punitive treatment (20, 24). Over time, repeated exposure to invalidating or coercive treatment experiences may culminate in internalised stigma, manifesting as self-blame, diagnostic label avoidance, and disengagement from services (17, 20, 25). These challenges may be further enhanced by the dominance of manualised treatment frameworks, which frequently function as a barrier to care by lacking the flexibility required to accommodate the complexity and chronicity of SEEDs (14, 26, 27). Enhanced cognitive behaviour therapy (CBT-E), while efficacious for some, emphasises symptom reduction, nutritional restoration, and behavioural adherence, and was not originally designed to accommodate the complexities associated with longstanding illness, comorbidity, or neurodevelopmental diversity (28, 29). Increasingly, qualitative and co-designed studies have drawn attention to the mismatch between these standardised protocols and the lived realities of those with enduring illness. For example, Sharp et al. (30) and Kiely et al. (13) have emphasised the limitations of existing models in addressing the needs of individuals in midlife or with intersecting psychosocial challenges, advocating for flexible, life stage-appropriate, and collaboratively defined treatment goals. Reay et al. (27), through mixed-methods service development work, further demonstrated the preference among those with SEEDs for care pathways that prioritise autonomy, psychological safety, and quality of life over symptom-focused metrics. These findings collectively illustrate the risks of prescriptive, one-size-fits-all treatment models, particularly when applied to individuals with complex and enduring illness trajectories, and how such approaches may inadvertently exacerbate disengagement, especially among those whose experiences fall outside normative recovery expectations. Further complexity is introduced by neurodevelopmental conditions, which remain markedly under recognised and under accommodated within mainstream ED services, constituting a significant barrier to appropriate and effective care despite growing empirical evidence of their prevalence and clinical relevance (31-34). Individuals with neurodevelopmental conditions, particularly autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), appear to be substantially overrepresented in ED populations. Westwood et al. (35) reported that between 8 and 37 percent of individuals with anorexia nervosa (AN) met criteria for ASD, with elevated rates persisting even after nutritional rehabilitation. A more recent review by Cobbaert et al. (33), estimated the prevalence of ADHD to be as high as 16 percent in individuals with AN, and up to 35 percent in those with bulimia nervosa (BN) or binge eating disorder (BED). Such neurodevelopmental conditions are frequently associated with interoceptive difficulties, sensory sensitivities, impairments in executive functioning, and challenges in emotion regulation. These characteristics can significantly interfere with therapeutic engagement and adherence within conventional ED treatment environments (31-33, 36), with their prevalence and impact in SEED presentations remain underexamined. Despite growing recognition of the prevalence and clinical impact of neurodivergence in ED populations, most existing treatment models remain grounded in neurotypical assumptions and rarely incorporate the cognitive, sensory, or relational adaptations necessary to support neurodivergent individuals (31, 33, 34). Recently, Kinnaird et al. (31), in a survey of 56 individuals with ASD and EDs, reported significant dissatisfaction with existing services, particularly the lack of individualised accommodations and the limited understanding of autistic traits among clinicians. These findings emphasise a critical gap in treatment design that may act as a barrier to engagement and contribute to dropout, therapeutic rupture, and poorer outcomes among neurodivergent individuals. These challenges may be further compounded by the high prevalence of trauma-related psychopathology among individuals with SEEDs, which can present additional barriers to effective and sustained engagement with care. While the role of trauma in the development of EDs is well established, increasing attention has been directed toward the impact of complex, cumulative, and iatrogenic trauma on illness persistence and treatment trajectories (10, 37, 38). Day et al. (39) reported that 28.4 percent met diagnostic criteria for probable complex posttraumatic stress disorder (CPSTD), with a further 32.1 percent presenting with clinically significant trauma-related symptoms. These included affective dysregulation, negative self-concept, and relational disturbances, with complex trauma particularly common in residential and intensive day treatment settings. Despite these findings, trauma is frequently underassessed and inadequately addressed in standard treatment environments. Inpatient and intensive programs often prioritise behavioural compliance and weight restoration, with limited integration of trauma-informed principles or attention to psychological safety (27, 40, 41). Recent qualitative studies have described how standardised practices, such as compulsory feeding, public meal supervision, and discharge decisions based on weight thresholds, are experienced by service users as coercive, invalidating, and retraumatising, particularly in the absence of collaborative care planning (10, 42, 43). Kotilahti et al. (11) and Kiely et al. (13) reported that both service users and clinicians perceived a lack of guidance on how to adapt ED treatment to address trauma histories and associated relational vulnerabilities. These findings are reflected in a broader body of scholarship calling for fundamental reform of conventional treatment paradigms (12). Traditional models, when implemented without adaptation, may act as a barrier to engagement by undermining autonomy, relational safety, and patient-defined recovery goals, thereby compounding harm, eroding therapeutic trust, and perpetuating cycles of disengagement (10, 11, 13, 44). Notwithstanding sustained calls for reform, empirical investigation into the lived experiences of individuals with SEED remains limited, contributing to the ongoing marginalisation and unmet needs of this. Specifically, there is a notable absence of research that systematically examines how structural and clinical barriers are encountered and negotiated across the illness trajectory, or how therapeutic engagement is facilitated within the context of chronicity, trauma exposure, and diagnostic complexity. Addressing this gap is essential to helping to inform service development that is both clinically effective and ethically responsive. This mixed methods study sought to enhance understanding of the treatment experiences of individuals with SEEDs by exploring the barriers and facilitators that influence access, engagement, and continuity of care. This exploratory study sought, through a mixed methods approach, to deepen understanding of the structural, clinical, and relational factors that shape access to care, treatment engagement, and recovery experiences among individuals with SEED. In doing so, it aimed to identify key barriers and potential facilitators to more inclusive, responsive, and person-centred models of care. Through the integration of quantitative survey data and in-depth qualitative interviews, the study offers insight into the systemic and clinical conditions that may function as barriers to, or facilitators of, care for individuals with SEEDs. Methods Study Design This study (which forms part of a larger study (45)) adopted a two-stage explanatory sequential mixed-methods design. In this design, an initial quantitative phase (Stage One) informed and contextualised a subsequent qualitative phase (Stage Two), thereby enhancing the interpretive depth of the findings. Stage One consisted of an online survey that captured descriptive data on participants’ demographic and clinical characteristics, symptom severity, and treatment experiences. These data were then used to guide Stage Two, which comprised in-depth, semi-structured interviews exploring barriers, facilitators, and lived experiences of treatment among individuals SEED. The qualitative component of the study an inductive thematic analysis (46, 47) philosophically underpinned by a transcendental phenomenological framework (48), which prioritises first-person narratives and seeks to bracket researcher preconceptions through the process of epoche. This approach was selected due to the heterogeneity of treatment trajectories and the potential for medical trauma in this population (49). It enabled detailed exploration of both the content (textural) and contextual (structural) dimensions of participants’ experiences, ensuring that the analysis was grounded in participant accounts rather than predefined theoretical constructs Participants Participant eligibility criteria and recruitment procedures have been detailed in a companion paper currently under review (45). A total of 41 participants were included in the study, with the final sample size determined based on principles of theoretical data sufficiency (50). To enhance contextual understanding of the sample, demographic and clinical information was drawn from survey responses, providing insight into participant characteristics relevant to the qualitative findings. Ethics This study received ethical approval from the Monash University Human Research Ethics Committee (Project ID: 42453). Data Collection Expression of Interest Survey The survey was administered via Qualtrics to collect demographic, clinical, and experiential data. The survey comprised four key domains: (1) demographic characteristics (age, gender identity, geographic location, cultural background, neurodivergence status); (2) ED history (diagnostic status, ED diagnoses, duration of illness, current recovery status and symptom severity); (3) treatment engagement (treatment sought, service types accessed, frequency of treatment, and perceived satisfaction); and (4) perceived barriers and facilitators to care. The fixed-response barrier and facilitator items were informed by a review of existing literature on access to ED treatment and reflected common structural, clinical, and relational factors identified in prior studies (8, 20, 27). Participants were also given the option to elaborate via open-text responses. Free-text responses were analysed thematically using a content-coding approach, with recurring concepts grouped under higher-order categories to supplement quantitative findings by GKL and IM. The full survey instrument, including all fixed-response and open-ended items, is provided in Appendix A. Symptom severity was assessed using the Eating Disorder Examination Questionnaire (EDE-Q) (51), a validated 28-item self-report measure evaluating core ED psychopathology over the preceding 28 days. The EDE-Q yields a global score and four subscale scores: Restraint (5 items; e.g., “Have you tried to limit the amount of food you eat?”), Eating Concern (5 items; e.g., “Have you felt guilty after eating?”), Shape Concern (8 items; e.g., “Has your shape influenced how you think about yourself as a person?”), and Weight Concern (5 items; e.g., “Have you been dissatisfied with your weight?”). Items are rated on a 7-point scale ranging from 0 ("no days"/"not at all") to 6 ("every day"/"markedly"), with higher scores indicating greater symptom severity. Subscale scores were calculated as the mean of relevant items, and the global score was derived as the average of the four subscale scores. Internal consistency for the EDE-Q in the current sample was high. Cronbach’s alpha coefficients indicated excellent reliability for the global score (α = .90), Shape Concern (α = .93), and Weight Concern (α = .92), acceptable reliability for Restraint (α = .78), and lower internal consistency for Eating Concern (α = .44). The latter is consistent with prior findings of variability in this domain, particularly in smaller or diagnostically heterogeneous samples (52). Upon survey completion, participants received an email from the first author (GKL) containing a summary of their EDE-Q results, explanatory information, mental health resources, and an invitation to participate in the qualitative interview phase. A total of 50 individuals completed the survey. Of these, 41 proceeded to interview. Three individuals were unable to participate in the interview due to personal circumstances, and two did not respond to follow-up contact. Four responses were excluded as they did not meet eligibility criteria for being based in Australia. The final interview sample was composed of 41 participants. Semi-Structured Interview An open-ended interview guide (Appendix B) was used to explore participants’ treatment histories, experiences of barriers, facilitators and meaning making. The structure was intentionally flexible to facilitate participant-led discussion and enable the emergence of unanticipated themes. A semi-structured schedule was used for all participants, with scope for individualisation based on responses to the Expression of Interest survey. Survey data were reviewed prior to each interview and used to contextualise participants’ treatment histories, guide probing questions, and explore specific barriers or facilitators previously endorsed. This approach ensured consistency across interviews while allowing for depth, relevance, and participant-centred inquiry. Semi-structured interviews were conducted via Zoom by the first author (GKL). Interviews ranged from 21 to 147 minutes in duration (M = 50 minutes). Three interviews were notably brief (under 25 minutes), all involving participants who had never accessed treatment, which influenced narrative depth. Informed consent was reconfirmed verbally at the start of each session. All interviews were audio-recorded, transcribed using a secure automated transcription service, manually reviewed for accuracy, and anonymised. For their contribution, participants received a $20 AUD Prezzee voucher at the conclusion of the study. Data Analysis Quantitative Analysis Quantitative data from the Qualtrics survey were analysed using SPSS. Descriptive statistical analyses were conducted to summarise participant demographics, EDE-Q scores, and treatment history. Measures of central tendency and dispersion were calculated for continuous variables, while categorical variables were analysed using frequencies and percentages. Statistical analysis was conducted by GKL in collaboration with GS to identify key patterns within the data. Qualitative Analysis Interview transcripts were analysed using reflexive thematic analysis, following Braun and Clarke’s six-phase framework (46, 47). Thematic coding was inductive and grounded in participants’ narratives. Initial coding was conducted by GKL, with co-coding of a subset of transcripts by IM. Themes were iteratively refined through analytic memoing, collaborative discussion, and engagement with the full dataset. This process ensured analytic rigour, interpretive transparency, and fidelity to participants’ accounts. Results Quantitative Phase The final sample comprised 41 participants. Most identified as female and were in their early 30s, with Anorexia Nervosa the most commonly reported diagnosis. The majority had received treatment, often across multiple modalities and service settings. Descriptive data on demographics, diagnoses, treatment history, and symptomatology are presented in Table 1. Table 1 Participant Demographics, Diagnostic Profiles, Treatment History, and Eating Disorder Symptomatology Characteristic n (%) or M (SD), Min-Max Gender Female 35 (85.4%) Male 4 (9.8%) Non-Binary 1 (2.4%) Not Specified 1 (2.4%) Age (years) M = 31.66 ( SD = 8.014), Min–Max: 21-56 Neurodivergence Status Yes, formally diagnosed by health professional 17 (41.5%) Yes, self-diagnosed 12 (29.2%) Currently being assessed for diagnosis 3 (7.3%) Not neurodivergent 9 (22%) Cultural Background* Australian 22 (53.7%) North East Asian 2 (4.9%) British 12 (29.3%) Western European 6 (14.6%) Northern European 2 (4.9%) Southern European 1 (2.4%) Jewish 2 (4.9%) Northern American 2 (4.9%) Irish 4 (9.8%) New Zealand 2 (4.9%) Mainland South East Asian 1 (2.4%) Indian 1 (2.4%) Maritime South East Asian 1 (2.4%) Other (not described) 1 (2.4%) Eating Disorder Diagnosis Type Formally Diagnosed by health professional 33 (80.5%) Self-diagnosed 8 (19.5%) Eating Disorder Status Current Eating Disorder Symptoms 24 (58.5%) No Eating Disorder symptoms, but do not identify as in recovery or recovered 2 (4.9%) No Eating Disorder symptoms, in recovery 9 (22%) No Eating Disorder symptoms, fully recovered 6 (14.6%) Eating Disorder Duration 7 - <10 years 10 (24.4%) 10 - <15 years 9 (22%) 15 - <20 years 13 (31.7%) 20 - <25 years 5 (12.2%) 25 - <30 years 1 (2.4%) 30 - <40 years 3 (7.3%) Eating Disorder Diagnosis* Anorexia Nervosa (AN) 29 (70.7%) Atypical Anorexia Nervosa (AAN) 9 (22%) Bulimia Nervosa (BN) 12 (29.3%) Binge Eating Disorder (BED) 7 (17.1%) Avoidant/Restrictive Food Intake Disorder (ARFID) 6 (14.6%) Other Specified Feeding or Eating Disorder (OSFED) 3 (7.3%) Other 1 (2.4%) Eating Disorder Examination Questionnaire (EDE-Q) Scores Global EDE-Q Score M = 3.12 ( SD = 1.66), Min-Max: .00–5.80 EDE-Q Restraint Subscale M = 3.03 ( SD = 1.87) Min-Max: .00-6.00 EDE-Q Eating Subscale M = 2.56 ( SD = 1.66), Min-Max: .00-5.40 EDE-Q Shape Subscale M = 3.52 ( SD = 1.83), Min-Max: .00-6.00 EDE-Q Weight Subscale M = 3.34 ( SD = 1.78), Min-Max: .00-6.00 Treatment Seeking Have Sought Treatment 37 (90.2%) Have Not Sought Treatment 4 (9.8%) Types of Treatment Sought* Public In-patient** 19 (46.3%) Private In-patient** 22 (53.7%) Public Out-patient** 17 (41.5%) Private Out-patient** 19 (46.3%) Day Program 16 (39%) Therapy (Psychologist, Counsellor, Mental Health Worker) 31 (75.6%) Dietetics 30 (73.2%) Medical Intervention (General Practitioner or Psychiatrist) 25 (61%) Peer Support 10 (24.4%) Eating Disorder Coach 11 (26.8%) Group Support 13 (31.7%) Community Support Organisations 16 (39%) Other (not specified) 7 (17.1) Note: *Participants could select multiple cultural backgrounds, multiple diagnoses over their eating disorder life cycle and multiple treatment types sought. As multiple selections were allowed, percentages do not sum to 100%. ** In the Australian healthcare context, public services refer to government-funded treatment programs accessible through the public health system (often at no or reduced cost), whereas private services refer to those accessed through private health insurance or out-of-pocket payment. Participants identified a range of barriers and facilitators influencing access to and engagement with ED treatment. The most commonly reported barriers were financial inaccessibility and invalidating clinician interactions. In contrast, the most frequently endorsed facilitators of treatment engagement included empathy and understanding from treatment providers and the presence of a supportive clinician. A summary of all reported barriers and facilitators is provided in Table 2. Table 2 Summary of Perceived Barriers and Facilitators Barriers to Treatment n (%) Cost of Treatment 29 (70.7%) Invalidation by Treatment Providers 25 (61.0%) Long Wait Times 22 (53.7%) Stigma 21 (51.2%) Single Focus on Weight or BMI 20 (48.8%) Services Focused on Adolescents, Not Adults 19 (46.3%) Lack of Specialised Services 18 (43.9%) Rigid Criteria for Treatment 18 (43.9%) Manualised Therapy (lack of person-centred care) 16 (39%) Geographical Distance 13 (31.7%) Other Barriers Identified by Participants (provided in free text box) Trauma and Negative Treatment Experiences 6 (14.6%) Practical Barriers (Work, Study, Life Commitments) 3 (7.3%) Parental Neglect and Early Life Factors 3 (7.3%) Internal Barriers (Shame, Lack of Awareness of ED 2 (4.9%) Barrier: Lack of Neurodivergent Care 1 (2.4%) Facilitators Empathy and Understanding from Treatment Providers 27 (65.9%) Supportive Clinician 24 (58.2%) Family and Friend Supports 23 (56.1%) Tailored Treatment 19 (46.3%) Positive Treatment Experience 19 (46.3%) Accessible Location 12 (29.3%) Personalised Care Plan 16 (39%) Collaboration Across Treatment Providers 15 (36.6%) Financial Support 12 (29.3%) Access to Recovered Lived Experience 11 (26.8%) Other Facilitators Identified by Participants (provided in free text box) Clinician-Related Factors (Understanding Trauma, Checking in) 2 (4.9%) Policy and Systemic Factors (Medicare, Telehealth) 2 (4.9%) Other Community and Peer Support 2 (4.9%) Financial Privilege 1 (2.4%) This table presents barriers and facilitators reported by participants. As multiple selections were allowed, percentages do not sum to 100%. Qualitative Phase Two overarching themes were identified, each comprising multiple subthemes that represent the intersecting structural, clinical, interpersonal, and identity-related factors influencing participants’ access to care, engagement with treatment, and trajectories of recovery. These include: (1) Barriers to Care , encompassing diagnostic and conceptual barriers, weight-based exclusion and bias, access and equity issues, coercive treatment practices, and treatment misalignment; and (2) Facilitators of Engagement and Recovery , which comprised of compassionate, individualised and trauma-informed care, peer connection and support, and advocacy and lived experience contribution. Participant quotes illustrating each subtheme are presented in Table 3. Table 3: Themes and Relevant Participant Quotes Theme Quote Number Illustrative Quote Participant ID and Characteristics Theme 1 Barriers to Care Subtheme 1.1 Systemic Exclusion and Constraints 1.1.1 Diagnostic and Conceptual Exclusion 1 “I felt like people’s eyes rolled when they were like, ‘Oh, here’s another one… she’s got BPD but thinks she has an eating disorder.’… Financial barriers weren't my issue; it was being given the BPD label almost immediately. This diagnosis became a huge barrier, causing clinicians, psychologists, and psychiatrists to not take my distress seriously.” Participant 1, female, age 32, AN and BN diagnoses, fully recovered. 2 “I was labelled with BPD, and it clouded every clinician's judgment. They saw 'borderline' and assumed I was manipulative. They didn't recognise trauma or distress; everything was immediately seen as attention-seeking behaviour. I wasn't even informed about the diagnosis initially, yet it drastically affected how I was treated in emergency rooms and inpatient settings … If someone had done even minimal digging, they'd realise it was undiagnosed neurodivergence and an out-of-control eating disorder. Instead, I ended up being restrained, sedated, and labelled as borderline for simply being distressed.” Participant 5, female, age 29, AN, AAN and ARFID diagnoses, current eating disorder. 3 “They didn’t even properly assess me; they just slapped labels on me that didn't fit. It took years to finally be properly diagnosed, and in the meantime, I was treated as difficult and resistant” Participant 8, non-binary, age 32, AN and ARFID, not currently experiencing eating disorder but not yet recovered. 4 “No one ever sat me down and was like, 'Right, here are the criteria for BPD, let’s see if you meet them.' It was just like, you’ve got this one behaviour [cutting], therefore you’ve got this diagnosis… If someone had just dug a little deeper, they would have seen that I was struggling with being autistic and ADHD. But instead, they decided I was just being ‘difficult’.” Participant 33, any gender, age 43, AAN, BN and OSFED, fully recovered. 5 “…the psychiatrist tried diagnosing me with borderline. My parents were pulled into a meeting, confused and asking what borderline even meant. It didn't fit my actual issues; PTSD, anxiety, and disordered eating. This misdiagnosis severely impacted my treatment. Once labelled as BPD, everything about my eating disorder and trauma was minimised.” Participant 27, female, age 33, AN diagnosis, fully recovered. 6 "I have BPD on my record, and I've been discharged early because they assume I'm just wanting attention and care, which isn't the case. My psychologist thinks it's more likely complex trauma, but clinicians see 'BPD' and immediately treat me differently." Participant 9, female, age 26, AN and AAN diagnosis, current eating disorder. 7 "My psychologist explicitly said, 'No, she doesn't have BPD,' which significantly impacted my treatment. Before that, every clinician assumed my distress meant borderline personality." Participant 47, female, age 55, AN diagnosis, current eating disorder. 8 "I have ADHD and severe anorexia, and I've constantly been described as 'treatment-resistant.' But the reality is that the treatments offered didn't accommodate neurodiversity. They used rigid meal plans and expected executive functioning I didn't have. Each time I withdrew because the programs didn’t adapt, clinicians used my withdrawal as proof I was resistant." Participant 32, female, age 45, AN diagnosis, current eating disorder. 9 "Clinicians have frequently said they suspect autism, but they keep telling me, 'You can't know until you've recovered from your eating disorder.' Meanwhile, my distress or sensory issues get labelled as personality problems, which makes treatment harder." Participant 29, female, age 22, AN diagnosis, current eating disorder. 10 They wouldn’t diagnose me [with autism] because I had an eating disorder.” Participant 30, female, age 22, AN diagnosis, current eating disorder. 11 "I've repeatedly been told I'm 'treatment resistant' and basically been sent off to handle things myself. Clinicians seemed to give up easily because my symptoms didn't neatly fit their categories or expectations." Participant 26, female, age 33, AN diagnosis, fully recovered. 12 “I was when I was last inpatient… my psychiatrist wanted me to get an assessment for ADHD, but I wasn’t allowed to undergo the assessment because of my anorexia.” Participant 23, female, age 22, AN diagnosis, current eating disorder. 1.1.2 Weight-Based Exclusion and Bias 13 "I went to the doctor feeling dizzy and weak, and he told me, 'You meet all the criteria for anorexia [bar BMI], but I can't diagnose you with that.' It felt like he was protecting his reputation. Without the diagnosis, I wasn't able to access treatment. I was left unsure of what to do next." Participant 50, female, age 21, AAN diagnosis, fully recovered. 14 “The first time I tried to seek help… I knew that I'd wanted to bring up my eating for a while. And then when I did, [the psychologist] told me pretty much instantly, ‘You don’t have an eating disorder’… ‘You’re not malnourished, you’re fine.’” Participant 6, female, age 26, AN and ARFID diagnosis, current eating disorder. 15 “I was considered on the upper end of a healthy body weight, it kept getting pushed under the rug that I could potentially have an issue. My eating problems were never taken seriously because I was a 'healthy weight.' … By the time I was finally recognised as having an eating disorder, I was severely underweight and medically unstable." Participant 13, female, age 29, AN, AAN and BN diagnoses, current eating disorder. 16 "Just because a person hasn't been hospitalised or doesn't have an extremely low weight doesn't mean it's not severe. Personally, I've struggled significantly with bulimia, exercising excessively, and using laxatives daily for years, but wasn't able to get appropriate help because my weight didn't reflect the stereotypical image of severity." Participant 4, female, age 35, BN diagnosis, in recovery. 17 "As a male with an eating disorder, my weight loss was overlooked for a long time. People didn’t see the severity because they expect eating disorders to present a certain way. The lack of obvious, stereotypical low weight delayed my treatment significantly… I was told, ‘Binge eating isn’t serious’… so I didn’t qualify for help…they told me it [bingeing] was just a moral failing. No one ever looked at why I was doing it.” Participant 42, male, age 29, BN diagnosis, current eating disorder. 18 "I was diagnosed with atypical anorexia, despite exercising obsessively; five hours of cardio daily, plus weights and compulsive movement. But because my weight loss wasn't initially dramatic enough, my condition was downplayed. Clinicians often minimize it if your BMI doesn't match their perception of severity… The eating disorder statistics would be higher in males if we weren't consistently misdiagnosed. If you're male and distressed, clinicians tend to see personality issues or resistance rather than actual suffering." Participant 45, male, age 28, AN diagnosis, not currently experiencing eating disorder but not yet recovered. 19 Everything revolved around BMI numbers and rigid surveillance. The psychiatrist abruptly discharged me with false promises, and when I didn't meet their strict BMI criteria, I was refused re-entry to treatment, worsening my distress significantly." Participant 27, female, age 33, AN diagnosis, fully recovered. 20 “Because I was in a healthy body, I wasn't taken seriously. Being at a 'healthy BMI' was reinforced over and over as proof I was fine.” Participant 9, female, age 26, AN and AAN diagnosis, current eating disorder. 21 "A psychiatrist once told me bluntly that my weight was too high for someone with an eating disorder. She didn't understand my distress or behaviours at all. Her advice was to 'eat bland food,' and I never returned because it was humiliating." Participant 40, female, age 30, AN diagnosis, in recovery. 1.1.3 Structural Access and Equity Barriers 22 "My family moved to remote WA... I was left medically unstable for most of my teenage years without access to formal mental health support." Participant 27, female, age 33, AN diagnosis, fully recovered. 23 "I had to leave Perth… so I moved to Newcastle, two hours from Sydney, quite a regional area. My first interaction with services was through an emergency department in a regional hospital that had very limited knowledge about eating disorders or refeeding. They were completely unequipped, and it really impacted my treatment negatively." Participant 5, female, age 29, AN, AAN and ARFID diagnoses, current eating disorder 24 "Geographical distance was a massive barrier for me. I resorted to online research and communication because physical access to professional care was so limited. Even hospital visits were difficult to manage due to the long distances involved." Participant 10, male, age 40, BED diagnosis, current eating disorder. 25 “It was pretty much couched as, ‘Oh, you're not sick enough for a higher level of care.’ So you'll just have to wait, because the waiting lists are really long at the moment.” Participant 6, female, age 26, AN and ARFID diagnosis, current eating disorder. 26 "Some significant barriers for my care were definitely cost and long wait times. The expense of treatment and the difficulty accessing services because of waiting lists made consistent care almost impossible for me… I didn’t have private cover, so I was told to go to the emergency department. That’s not care. That’s crisis management " Participant 20, female, age 21, AN and ARFID diagnoses, current eating disorder. 27 “The waitlists were huge… and even when I got to see someone at uni, they said, ‘We don’t really deal with this… I didn’t know where to start… I was scared to waste time and money on someone who wouldn’t understand.’” Participant 31, female, age 34, BN diagnosis, in recovery. 28 "There was nowhere for me to go when I got out. No follow-up, no outpatient, nothing close. I was just expected to be better." Participant 23, female, age 22, AN diagnosis, current eating disorder. 29 "Treatment was inaccessible because of cost. My trust in healthcare was undermined because support simply wasn’t affordable." Participant 50, female, age 21, AAN diagnosis, fully recovered. 30 "I had to pay upfront, and the only way I could afford it was by working full-time while studying full-time..." Participant 27, female, age 33, AN diagnosis, fully recovered. 31 “It’s $5,000 a week. Some [people] had their parents paying for it. I had to find that myself. That’s extreme.” Participant 25, female, age 37, AN diagnosis, current eating disorder. 32 "Being male, I’ve faced additional stigma in accessing treatment, but the financial resources required to get professional support have always been a huge barrier. Without adequate financial backing, proper treatment has been out of reach." Participant 43, male, age 36, BED diagnosis, current eating disorder. 33 "The cost of recovery is massive, especially if you're navigating between private and public systems. Without adequate financial resources, it's almost impossible to receive the compassionate, individualised care necessary for recovery… My parents remortgaged their house to send me to treatment interstate." Participant 13, female, age 29, AN, AAN and BN diagnoses, current eating disorder. 34 "My GP didn't even know about the eating disorder care plan, which created a significant financial burden.” Participant 45, male, age 28, AN diagnosis, not currently experiencing eating disorder but not yet recovered. 35 "Financial barriers have significantly impacted my treatment journey. The difference in quality between public and private treatment was huge, but without the funds, you’re stuck relying on the public system, which can be invalidating and traumatising." Participant 9, female, age 26, AN and AAN diagnosis, current eating disorder. 36 "It was like being punished for where I lived and how much money we didn’t have..." Participant 32, female, age 45, AN diagnosis, current eating disorder. 37 "It felt like the system was saying I wasn’t worth the resources. That if I couldn’t pay, I didn’t matter." Participant 26, female, age 33, AN diagnosis, fully recovered. 38 “Not everyone has access… to give every single treatment a six-month go.” Participant 33, any gender, age 43, AAN, BN and OSFED, fully recovered. 39 "I had to give up my studies because I couldn’t get help when I needed it. Everything just spiralled from there." Participant 21, female, age 27, AN diagnosis, current eating disorder. 40 “Financial challenges significantly impacted my ability to access care, especially given my shift work as a nurse. Cultural expectations compounded financial pressures, limiting my treatment options and making me hesitant to seek help openly." Participant 44, female, age 35, AN and BED diagnoses, in recovery. 41 “I tried to get help… saw my GP and got a referral… but I didn’t hear anything from [the hospital]. Not even a ‘sorry we can’t fit you in.’ Just radio silence… I think if I looked different, like if I was thinner or a woman, it might have been taken more seriously.” Participant 42, male, age 29, BN diagnosis, current eating disorder. 42 "We need proper outpatient pathways, especially for regional people. Not just discharge and good luck” Participant 37, female, age 26, BN diagnosis, current eating disorder. Subtheme 1.2: Harmful and Disempowering Treatment Experiences Subtheme 2.1 Coercion, Control and Loss of Autonomy 43 "Adult treatment was incredibly traumatic, involving restrictive practices, frequent restraints, and forced medication. Each admission was terrifying, and the constant fear of being restrained or sedated increased my trauma and made engaging in treatment impossible... I experienced daily restraints, forced nasogastric tubes, and medication against my will. This fear-based approach was horrific. It was treatment through trauma; an experience that significantly heightened my distress and trauma responses." Participant 29, female, age 22, AN diagnosis, current eating disorder. 44 "Adult treatment was incredibly traumatic, involving nightmares I still have today. It involved a lot of restrictive practices, restraint, forced medication; really ugly, horrible things that went on repeatedly during my admissions." Participant 30, female, age 22, AN diagnosis, current eating disorder. 45 "A nurse got her [a fellow patient] to stand up in front of the whole eating room and said, ‘I just want to point out that she hasn’t finished her butter, so I’m going to make her lick it out in front of everyone’... It was public humiliation. I said, ‘No normal person would be forced to do that.’ They genuinely believed we had chosen to starve ourselves, so we should carry the burden of that." Participant 14, female, age 36, AN, AAN, ARFID and OSFED diagnoses, in recovery. 46 “I would have panic attacks. I'd try to find a small, safe place, usually the bathroom. But some nurses would threaten me, assuming I'd harm myself, and they'd call security to forcibly drag me out. If they did, I'd rip my NG tube out; it felt like my only control. Security would then restrain me, wheel me to radiology, hold me down forcibly, and replace the NG tube. It was traumatic, dehumanising, and increased my distress enormously... I’ve been told that so many times it's ridiculous… ‘you’re treatment resistant’ or ‘you’re too complex.’” Participant 23, female, age 22, AN diagnosis, current eating disorder. 47 " The rigidity of hospital rules stripped away autonomy completely, making me feel less than human … It's just a recipe for disaster. Approaching treatment with threats and feeling very monitored made me close up completely, build resistance, and ultimately not want help at all " Participant 20, female, age 21, AN and ARFID diagnoses, current eating disorder. 48 " They locked the bathrooms for weeks at a time... Nurses would stand outside listening. It was humiliating. I felt like less than a child ." Participant 18, female, age 37, AN diagnosis, in recovery. 49 "Everything was dictated to me in hospital; sit here, be watched by nurses, drink this, eat now. The constant surveillance and intense monitoring created an atmosphere of extreme distress and anxiety… They told me I was chronic, and that meant I wasn’t ready for treatment. But I was. I just wasn’t what they wanted me to be ." Participant 32, female, age 45, AN diagnosis, current eating disorder. 50 "You had to eat six meals a day and put on weight, or you didn’t belong in the program. There’s no room for struggle." Participant 47, female, age 55, AN diagnosis, current eating disorder. 51 "The structured eating plan I was placed on felt incredibly rigid and unrealistic. There was no room for flexibility or individualised adjustments. It made compliance impossible, which led clinicians to label me as non-compliant rather than understanding the genuine barriers." Participant 49, female, age 33, BED diagnosis, in recovery. 52 "The thing I hated the most about my inpatient stay was going into that room twice a week with all those professionals, who would just rip shreds off you. It was so humiliating. I had so much anxiety about it. One day, I just got up, walked out of the room, ran away, and hid. That's not how a woman in her 50s should be behaving, but I just felt so stupid and humiliated that I had to escape." Participant 46, female, age 56, AN and BN diagnoses, current eating disorder. 53 " Hospitalisation was incredibly controlling. The rules felt suffocating. I understand why structure might help some, but it felt like control was more important to clinicians than actually addressing my needs or understanding the reasons behind my behaviours." Participant 45, male, age 28, AN diagnosis, not currently experiencing eating disorder but not yet recovered. 54 "There's a barrier system around me now due to fear of stigma and negative reactions from people. This fear has made me internalise everything, trying to cope alone rather than risk judgement or overly intrusive monitoring." Participant 37, female, age 26, BN diagnosis, current eating disorder. 55 "In treatment, there's always an underlying fear of compulsory treatment orders. The constant feeling of surveillance and being monitored creates a distressing atmosphere that makes it hard to be honest or open about what's truly going on." Participant 41, female, age 22, AN, AAN, BN and BED diagnoses, current eating disorder. 56 " After those admissions, I became terrified of hospitals. I avoid reaching out now, even when I really need help ." Participant 13, female, age 29, AN, AAN and BN diagnoses, current eating disorder. 1.2.2 Misalignment Between Treatment Models and Patient Needs 57 "The protocol is the most rigid and traumatic thing I've ever experienced. You have to be medically critical to access it, but once admitted, everyone undergoes a fixed eight-day NG feeding regime, regardless of individual needs or trauma histories. That's not trauma-informed, it's trauma-inducing." Participant 29, female, age 22, AN diagnosis, current eating disorder. 58 “The structured nature of it didn't help; it actually amplified my feelings of failure and distress." Participant 42, male, age 29, BN diagnosis, current eating disorder. 59 “I sat in hospital for months and months, not really having any idea of what happens next… I wasn’t an active participant in my own treatment.” Participant 1, female, age 32, AN and BN diagnoses, fully recovered. 60 "It felt like I kept failing the programs, when really they were failing me. The treatment models didn’t recognise my needs around trauma, sensory processing, or my neurodivergence. It was demoralising and isolating." Participant 21, female, age 27, AN diagnosis, current eating disorder. 61 "Structured programs always seemed to overlook the emotional or mental aspects of my eating issues. Treatment focused purely on control around eating, which didn't address my underlying distress. The strict focus on food and rules only made me feel more isolated." Participant 43, male, age 36, BED diagnosis, current eating disorder. 62 “When I expressed frustration at treatment not addressing my needs, the response was always, 'This is typical borderline behaviour.' No one considered my sensory issues or that the interventions were inappropriate for someone who’s autistic. They insisted on one-size-fits-all methods and then blamed me for the treatment failing.” Participant 8, non-binary, age 32, AN and ARFID, not currently experiencing eating disorder but not yet recovered. 63 "The treatment was built around compliance and strict behavioural targets rather than compassion or understanding. My attempts to articulate my unique needs were dismissed as resistance." Participant 26, female, age 33, AN diagnosis, fully recovered. 64 “I’m older. I didn’t need that much control. They didn’t meet me where I was. There was no flexibility based on my stage of life or my needs.” Participant 25, female, age 37, AN diagnosis, current eating disorder. 65 “I was still trying to work and, like, do life… but the therapist said, ‘You’re not prioritising this.’” Participant 9, female, age 26, AN and AAN diagnosis, current eating disorder. 66 “I don’t experience hunger and fullness in the same way that neurotypical people do… but no one’s really thought about how to cater to neurodiverse people.” Participant 6, female, age 26, AN and ARFID diagnosis, current eating disorder. 67 “I was being forced into this treatment that was designed for neurotypical people… everything was about body image, but that wasn’t really my core issue.” Participant 30, female, age 22, AN diagnosis, current eating disorder. 68 “Treatment didn’t really accommodate the fact I had autism… everything was about motivation and insight… but sometimes I just couldn’t process the task the way they wanted.” Participant 22, female, age 27, AN, AAN, BN and ARFID diagnoses, current eating disorder. 69 “Every gate failed… CBT was her [psychologist] approach, but CBT is not working.” Participant 33, any gender, age 43, AAN, BN and OSFED, fully recovered. 70 “[I was] outpatient at a clinic that focused mainly in CBT-E, but I did not respond to CBT-E” Participant 7, female, age 32, An and AAN diagnoses. 71 “We went to the same therapy everyone else did and that was just your standard. Like introduction to CBT, recycle, recycle, recycle, recycle, nothing that was tangible.” Participant 8, non-binary, age 32, AN and ARFID, not currently experiencing eating disorder but not yet recovered. 72 “It [CBT-E] just does not work [for SEED]. Participant 23, female, age 22, AN diagnosis, current eating disorder. 73 “Eating disorder treatment is very CBT, very gaslight-y. It’s like, ‘Have you just thought about not being that way? Have you just thought about eating?’ That kind of response becomes a huge barrier, because you know that’s what you’re going to be met with, and you also know it doesn’t work…It makes you feel like your experiences aren’t real, you’re just being gaslit. So you stop wanting to access treatment altogether. You go and sit in the dietitian’s chair and say, ‘Yep, yep, I’ll do that. I’ll keep a food diary.’ And then you come back the next week with a forged food diary and say, ‘Yep, I did it.’ And then you leave again. It’s just the same shit. It’s not helpful.” Participant 26, female, age 33, AN diagnosis, fully recovered. 74 “It [CBT] was very manualised treatment. I felt like, ‘This is what we’ve got to offer; take it or leave it.’ It was based on cognitions and behaviours, and it really failed to account for the range of emotions I was experiencing. There was such a strong emphasis on making a link between thoughts and behaviours, but it didn’t actually help me bridge the gap between knowing what I was doing and knowing how to change it. I was left without the tools to make real change. It felt very black-and-white, rigid and simplified, when what I actually needed was something more nuanced and supportive.” Participant 29, female, age 22, AN diagnosis, current eating disorder. 75 “There was no consideration of my trauma history, just food and weight, food and weight… It felt like everything I said was used as evidence against me being ‘non-compliant.’”” Participant 16, female, age 34, AN, BN and OSFED diagnoses, current eating disorder. Theme 2 Facilitators of Engagement and Recovery Subtheme 2.1 Compassionate, Individualised and Trauma-Informed Care 76 “It’s really important to find people who see you as a person. That’s what made the difference… even made me feel like a human again.” Participant 25, female, age 37, AN diagnosis, current eating disorder. 77 “I remember a social worker asking my mum in therapy, ‘Why is she in hospital?’ and then saying, ‘We don’t admit people for the sake of it, she is really unwell.’ That was the first time someone said something like that to me, and to her.” Participant 1, female, age 32, AN and BN diagnoses, fully recovered. 78 "My social worker knows exactly how much she can push me without pushing me over the edge, which creates a real sense of safety and trust. Having someone who understands trauma and how to navigate it compassionately changed everything for me." Participant 29, female, age 22, AN diagnosis, current eating disorder. 79 "When my clinician recognised and adapted to my sensory sensitivities and trauma responses, it made treatment feel safe and accessible. It was the first time I felt truly understood in a clinical setting." Participant 18, female, age 37, AN diagnosis, in recovery. 80 “I had a dissociative panic attack, and this psychologist…she came and sat with me for almost an hour just trying to get me out of that dissociative state. We didn't talk initially; she just sat down with some pens and paper, and we drew next to each other. Slowly, as I came out of it, we could talk a bit about what had happened. By the end, I was feeling okay. That was rare... Experiences like that were really useful. It was those clinicians who saw you, not doing treatment by the book, but just seeing you where you were, listening, providing empathy, and just being human for a bit…. There was one support worker who just asked, ‘What does safety mean to you?’ I nearly cried.”" Participant 16, female, age 34, AN, BN and OSFED diagnoses, current eating disorder. 81 “I did find one GP who just sat and listened. Didn’t rush me. Didn’t ask for numbers. Just asked what I needed…Having professionals who treated me with compassion and as an equal partner was incredibly healing. It restored my faith in healthcare providers and motivated me to keep engaging."” Participant 42, male, age 29, BN diagnosis, current eating disorder. 82 "It wasn’t until I had a psychologist who said, ‘It’s okay. I’m not going to dob on you. I see you, and that’s okay’… That changed everything. After such a long time feeling like therapy was a threat, I finally felt like I could trust someone. Participant 23, female, age 22, AN diagnosis, current eating disorder. 83 " My therapist genuinely listened and believed me. Instead of forcing rigid plans, she helped me articulate my needs and build a recovery plan that felt manageable and respectful." Participant 27, female, age 33, AN diagnosis, fully recovered. 84 "Even though I didn't know I was neurodivergent at the time, my psychologist was flexible enough not to force me into treatment boxes... That flexibility felt empowering, she wasn’t trying to make me fit into a box, just offering support tailored to me." Participant 33, any gender, age 43, AAN, BN and OSFED, fully recovered. 85 “It’s supportive and feels safe, especially considering my autism. Even though inpatient treatment can be incredibly challenging, having a team that genuinely understood me and adapted the approach to my needs made such a significant difference." Participant 22, female, age 27, AN, AAN, BN and ARFID diagnoses, current eating disorder. 86 "It was that neurodiverse approach that made it the most successful admission I had out of all of them. It built trust and helped me actually want to work with the clinicians." Participant 20, female, age 21, AN and ARFID diagnoses, current eating disorder. 87 “One psychologist recognised that my struggles weren't typical, that my eating disorder wasn't about…body image. She saw my uniqueness and was willing to adapt the program specifically for me. I had to advocate a bit, but once they tailored it, removing rigid weight gain requirements, I felt heard. This flexibility was key to engaging with treatment again” Participant 32, female, age 45, AN diagnosis, current eating disorder. Subtheme 3.2 Peer Support and Connection 88 “I knew that a friend of mine who I'd studied with had had an eating disorder when she was a teenager… she was someone I could speak to about it, and she was pretty instrumental in me going, ‘No, I can actually go to my GP, regardless of what the psych has said.’” Participant 6, female, age 26, AN and ARFID diagnosis, current eating disorder. 89 " Peer support gave me a space where I could be me; my neurodivergence and trauma weren’t questioned or pathologised. It was empowering to find people who truly understood my experiences without judgment… It’s just where I found my community " Participant 30, female, age 22, AN diagnosis, current eating disorder. 90 " Connecting with others who had similar experiences created a profound sense of belonging and reduced feelings of shame and isolation. These connections gave me hope that recovery was possible and achievable ." Participant 21, female, age 27, AN diagnosis, current eating disorder. 91 “You lose so many people through this [eating disorders]. It’s isolating. But at residential, I saw people who had recovered, and I thought, ‘Maybe this is possible.’” Participant 25, female, age 37, AN diagnosis, current eating disorder. 92 " After I was repeatedly turned away from clinical treatment, I ended up joining a support group. That group changed everything for me. It wasn’t clinical, it was peer-led, and it felt like the first time I could speak openly without being judged or dismissed…People just got it. The validation I received there was more helpful than anything I’d gotten from clinicians up to that point. It helped me understand that I wasn’t alone, and that what I was experiencing wasn’t irrational; it was real, and shared by others who had been through similar struggles… Through peer support, I learned strategies and coping skills that felt realistic and relatable. It bridged the gap left by formal treatments, providing emotional understanding and practical advice ." Participant 32, female, age 45, AN diagnosis, current eating disorder. 93 " "It was peer support that helped me reframe recovery on my own terms. It wasn't about being compliant; it was about being real, and being safe enough to want to stay alive… The friendships I formed through peer support groups provided ongoing emotional support and motivation, reinforcing my commitment to recovery even when clinical services were inaccessible or insufficient ." Participant 26, female, age 33, AN diagnosis, fully recovered. 94 “I read stories online where people had the same symptoms as me… it made me feel less broken… Reading people’s blogs helped me feel seen. I want to do that for someone else one day.” Participant 31, female, age 34, BN diagnosis, in recovery. 95 “The lived experience community was really important to me. We could plan our lives together… people had futures; one was going to med school, one doing a PhD… It helped me think beyond the eating disorder.” Participant 1, female, age 32, AN and BN diagnoses, fully recovered. 96 "I really found peer mentoring helpful. Talking to someone who had been through it, who genuinely understood, was such a comfort. It was different from talking to a clinician. It made me feel less alone and gave me hope that recovery was possible, even when I felt stuck." Participant 46, female, age 56, AN and BN diagnoses, current eating disorder. 97 "The most helpful support I got wasn’t always from professionals, it was from others who had gone through similar experiences. Just being able to talk honestly in support groups, without needing to explain every little thing, was a huge relief." Participant 4, female, age 35, BN diagnosis, in recovery. 98 "I was constantly being judged in hospital. I only started to feel like recovery was possible when I met someone who had been through it too. It made me feel seen for the first time." Participant 27, female, age 33, AN diagnosis, fully recovered. Subtheme 2.3 Integration of Lived Experience and Advocacy 99 “I only just started recovery last year, but I’ve been thinking about studying psychology. Maybe working with eating disorders, or just being someone people can talk to… The compassionate care I received inspired me... I want to support others by providing the same respectful and trauma-informed treatment I was lucky enough to experience." Participant 24, no gender, age 24, AN diagnosis, current eating disorder. 100 "My recovery was significantly shaped by clinicians who saw me as a whole person. This experience motivated me to study psychology so I can offer similar empathy and understanding to others struggling… I had to fight so hard to be taken seriously. The misdiagnosis, the dismissive attitudes… it made me want to work in mental health to make sure others don’t have to go through what I did." Participant 37, female, age 26, BN diagnosis, current eating disorder. 101 “I envision doing something in the field one day. I want to build a facility that truly meets people where they’re at. Recovery shouldn't be a privilege.” Participant 25, female, age 37, AN diagnosis, current eating disorder 102 “I’m studying medicine now… because I know how deeply physical and mental health are connected. I want to be the kind of doctor that listens.” Participant 43, male, age 36, BED diagnosis, current eating disorder. 103 "Experiencing genuinely compassionate, trauma-informed care changed my life… I advocate strongly for more widespread adoption of these practices, knowing firsthand their transformative potential ." Participant 14, female, age 36, AN, AAN, ARFID and OSFED diagnoses, in recovery. 104 "Being treated with genuine empathy and respect made all the difference in my recovery. It not only helped me heal but also shaped my vision of what good care looks like, motivating me to actively participate in changing clinical practices." Participant 9, female, age 26, AN and AAN diagnosis, current eating disorder. 105 “I think about being a peer worker sometimes… maybe there’s a way to stop someone else from going through what I did.” Participant 42, male, age 29, BN diagnosis, current eating disorder. 106 “I want to use my lived experience to advocate for more compassionate and inclusive treatment environments… to be that person in between a therapist and a lived experience support. Someone who can let others speak freely and feel heard. Especially for men, because we’re still not seen." Participant 45, male, age 28, AN diagnosis, not currently experiencing eating disorder but not yet recovered. 107 “I think it probably has a lot to do with my own struggles and wanting to make a difference myself… wanting to be the person that perhaps makes a difference… not having people struggle for as long.” [on being a psychologist] Participant 40, female, age 30, AN diagnosis, in recovery. 108 “I think just really passionate about changing the way the system operates… improving care for people like myself… I'm a part of probably about 10 advisory groups at the moment… just having my voice heard and being able to speak out and advocate about myself, but also learning about myself… The advocacy space, both mental health and disability, it's the first time I've actually ever understood what community means.” Participant 30, female, age 22, AN diagnosis, current eating disorder. 109 “It’s not advocacy in the formal sense, but I think when you share your story in a safe way, it helps people. That matters to me.” [on sharing their lived experience journey] Participant 16, female, age 34, AN, BN and OSFED diagnoses, current eating disorder. 110 “Because I’m autistic myself… I gravitate towards them [autistic clients]… I want to help advocate for them; for us.” Participant 22, female, age 27, AN, AAN, BN and ARFID diagnoses, current eating disorder. 111 "I ended up writing the psychiatrist a letter at the end of my admission. I told him that compassion is what’s going to heal people. The system forces clinicians to compromise, but it’s that genuine compassion that changes lives. I think that’s why I want to go into this work." Participant 13, female, age 29, AN, AAN and BN diagnoses, current eating disorder. 112 "The care I received from professionals who treated me as a person, not just a patient, completely changed how I thought about recovery. It made me want to become one of them, to do for others what they did for me." [on studying nursing] Participant 29, female, age 22, AN diagnosis, current eating disorder. 113 "When I joined the sector, it was a really different place. I was in the space as a person with lived experience and no clinical background, and I always felt a bit vulnerable… like I was just a peer worker. But it showed me how much the system needed people like us; to reflect the 20-year eating disorder I’d lived through. I’ve stayed in the field ever since." Participant 33, any gender, age 43, AAN, BN and OSFED, fully recovered. 114 "I'm a social worker now, and I believe I'm a really key part of teams, though that's still not commonly seen. I had a recovery coach at the beginning of my journey, and I think when used correctly, they can be a game-changer. We need more people with lived experience on these teams” Participant 26, female, age 33, AN diagnosis, fully recovered. 115 "I'm writing a book of my recovery from anorexia…. I'm also planning another book of art therapy work that I've done…alongside my story." Participant 32, female, age 45, AN diagnosis, current eating disorder. 116 "[Becoming a psychologist] really changes how I see the system now. The invalidation I got, being seen as a revolving-door patient, those experiences are why I’m passionate about personalised, trauma-informed care. If I’d had that earlier, maybe things would have been different." Participant 27, female, age 33, AN diagnosis, fully recovered. 117 "I did experience a lot of frustration…. But that frustration now feeds my desire to do things differently, to actually listen to people properly and not let them fall through the cracks like I did." [on being a mental health professional] Participant 1, female, age 32, AN and BN diagnoses, fully recovered. Theme 1: Barriers to Care All participants articulated a complex pattern of interrelated barriers that impeded their ability to access timely, appropriate care for SEED. These barriers were not discrete or isolated, but were described as cumulative, pervasive, and structurally embedded, reflecting the sustained interaction of diagnostic, systemic, clinical, and sociocultural dynamics. Rather than representing singular points of resistance, these obstacles were experienced as chronic patterns of exclusion and invalidation, which undermined psychological safety, delayed treatment access, disrupted recovery trajectories, and eroded trust in healthcare systems. Participants repeatedly emphasised the enduring nature of these experiences, often spanning multiple care episodes and settings. This overarching theme comprises two interrelated subthemes: ( 1) Systemic Exclusion and Constraints , which captures macro-level structural and conceptual factors limiting access and inclusion, and (2) Harmful and Disempowering Treatment Experiences , which reflects barriers embedded within clinical practices and therapeutic environments. Each subtheme includes distinct sub-subthemes representing the nuanced mechanisms through which care was hindered or compromised. Subtheme 1.1: Systemic Exclusion and Constraints 1.1.1 Diagnostic and Conceptual Exclusion Most participants reported experiences of misdiagnosis or inadequate clinical conceptualisation that significantly impeded access to appropriate and effective care. A common pattern involved the premature or inappropriate application of Borderline Personality Disorder (BPD) diagnoses (Quotes 1-7). This was often in the absence of comprehensive assessment or due consideration of alternative or co-occurring explanations, such as neurodevelopmental conditions, complex trauma histories, or the enduring and multifaceted nature of their EDs. These forms of diagnostic overshadowing, where an individual’s ED symptoms or behaviours were misattributed to other co-occurring conditions (e.g., personality pathology, neurodevelopmental traits), or vice versa, were described as having profound implications for participants’ trajectories through the healthcare system (Quotes 8-12). The attribution of BPD was frequently associated with exclusion from ED services, assignment to unsuitable treatment pathways, and stigmatising clinical encounters. Participants recounted instances in which their distress, emotional regulation difficulties, or interpersonal communication styles were pathologised as manipulative or attention-seeking. This was particularly pronounced among neurodivergent participants, who described how traits, such as sensory sensitivities, cognitive inflexibility, executive functioning difficulties, or social communication differences, were misunderstood and misattributed to personality pathology. Several participants noted that the prioritisation of ED symptomatology within care settings often precluded assessment or recognition of neurodevelopmental needs. In some cases, participants were explicitly informed that diagnostic clarification (e.g., ASD or ADHD assessment) could not proceed until their ED was resolved. Participants reported that such experiences were epistemically invalidating, compounding psychological distress and undermining confidence in the capacity of services to engage holistically with complex clinical presentations. 1.1.2 Weight-Based Exclusion and Bias Across participant accounts, weight and body size were consistently described as central determinants of diagnostic legitimacy and access to treatment. Individuals in higher-weight or weight-restored bodies frequently reported being dismissed, disbelieved, or excluded from services, regardless of the psychological severity or chronicity of their condition. The pervasive reliance on visible emaciation as a marker of clinical urgency was experienced by participants as both reductive and harmful, reinforcing internalised beliefs that only certain bodies are worthy of care and that suffering must be physically observable to warrant intervention (Quotes 13-16). Some participants described being explicitly informed that they were “not sick enough” to qualify for treatment, with some noting the use of strict BMI thresholds as exclusion criteria. Others recounted being discharged once they achieved weight restoration, despite persisting psychological distress and ongoing ED behaviours. These experiences contributed to the perception that recovery was equated with physical appearance alone, while the underlying psychological and behavioural components of the disorder were deprioritised or ignored. Several participants described how their EDs were overlooked or minimised when their physical presentation did not align with dominant clinical archetypes, particularly in cases where individuals were not visibly underweight. In these contexts, restrictive behaviours, medical instability, and psychological distress were often dismissed or deemed insufficiently severe. As such, these experiences were perceived by participants as contributing to diagnostic invalidation, erosion of trust in clinicians and services, and delays in receiving appropriate support. Participants also described the influence of gendered and normative body expectations in shaping their access to care (Quotes 17-21). Male and gender-diverse participants reported that their ED concerns were often minimised or overlooked due to assumptions that such conditions primarily affect cisgender women in underweight bodies. For these individuals, body-based stereotypes and narrow diagnostic heuristics acted as structural barriers to recognition, validation, and timely treatment. 1.1.3 Structural Access and Equity Barriers Most participants described a range of structural and systemic barriers that restricted their access to timely, appropriate, and ongoing ED treatment. These barriers were evident across both public and private sectors, with participants reporting prohibitively long waitlists for publicly funded services (Quotes 25-27), and limited availability or unaffordable costs in the private system. The absence of specialist services in regional and rural areas further compounded these challenges, often requiring participants to travel long distances, relocate, or forgo care entirely (Quotes 22-24, 28,42). Access to treatment was also mediated by socioeconomic privilege (Quotes 29-31, 33-40). Some participants described receiving financial support from family members, such as parents paying for therapy or families remortgaging homes to fund private hospital admissions, which enabled them to access care. Others, by contrast, reported needing to maintain employment or continue studying throughout treatment due to financial insecurity or the absence of family support. These individuals described limited treatment flexibility and a lack of service models that accommodated their broader life circumstances. Participants identifying as male, gender-diverse individuals, or from culturally and linguistically diverse backgrounds also reported feeling marginalised within systems that were perceived as normatively structured around thin, white, cisgender female experiences (Quotes 32, 40, 41). These experiences of exclusion were not only logistical, but were experienced as compounding feelings of inequity, contributing to long durations of untreated illness, disengagement, and reinforcing mistrust in healthcare services. Subtheme 1.2: Harmful and Disempowering Treatment Experiences 1.2.1 Coercion, Control and Loss of Autonomy Many participants reported that treatment settings imposed significant restrictions on their autonomy and were often experienced as coercive or punitive, particularly in inpatient and compulsory community care contexts. Involuntary interventions, such as forced nasogastric feeding, involuntary detainment under mental health legislation, and unilateral treatment decisions made without patient consultation, were commonly described (Quotes 43-56). These practices were often associated with heightened psychological distress and, for some, re-traumatisation. Across narratives, participants emphasised the lack of collaborative engagement in treatment planning, describing environments in which their preferences, needs, and personal values were routinely dismissed or overridden. Accounts of close monitoring of participants’ movements and behaviours were frequently described, particularly in relation to mealtimes, rest periods, and toileting (Quotes 45-51). Several participants reported being denied access to private bathroom use or being required to urinate under direct supervision, which was described as degrading and humiliating. Public reprimands for behavioural infractions further contributed to experiences of humiliation and perceived punitive control. Most participants described experiences of fear, surveillance, and psychological withdrawal. Participants also described clinical responses to emotional distress, such as dissociation, sensory overwhelm, or shutdown, as escalatory, with frequent recourse to sedation, physical restraint, or security intervention. These responses were perceived as punitive rather than supportive, and in some cases exacerbated participants’ distress or contributed to further emotional dysregulation (Quotes 52-56). Participants with neurodivergent traits noted that their communication differences and sensory needs were often misunderstood, resulting in increased monitoring or behavioural management rather than accommodation or support. Several participants described withdrawing from treatment or avoiding future care as a direct result of these experiences. 1.2.2 Misalignment Between Treatment Models and Patient Needs Many participants reported a significant misalignment between their individual needs and the treatment models offered across both inpatient and outpatient settings (Quotes 57-75). Treatment was frequently described as highly standardised, structured around manualised interventions, and insufficiently responsive to psychological, neurocognitive, or relational complexity. A predominant reliance on CBT frameworks, particularly in their enhanced or group-based formats, was commonly cited (Quotes 69-74). Several participants reported that these approaches were overly structured, cognitively demanding, and inadequately tailored to individuals with trauma histories, neurodivergent processing styles, or longstanding illness trajectories (Quotes 57-64, 66-68, 75). Inpatient meal environments were frequently cited as a significant source of distress. Participants reported being required to eat in shared settings under close observation, often within overstimulating physical environments that included fluorescent lighting, unpredictable noise, and minimal sensory accommodations. Mealtimes were described as typically time-bound, highly monitored, and often accompanied by clinical commentary, which contributed to anxiety, emotional shutdown, and withdrawal from care. Participants with neurodivergent traits frequently reported that features such as ritualised eating behaviours, rigid routines, sensory-based food aversions, and executive functioning challenges were not acknowledged or accommodated within prevailing treatment models (Quotes 60, 62, 66-68). Several individuals with ADHD described difficulties with planning meals, grocery shopping, and remembering to eat, difficulties that were interpreted by clinicians as non-compliance or lack of motivation. These responses were frequently described as invalidating or stigmatising. Structural features of treatment delivery were also identified by participants as barriers. Requirements associated with inpatient admissions, day programs, and intensive outpatient treatment were frequently described as incompatible with participants’ competing responsibilities, including employment, caregiving duties, educational commitments, and the management of co-occurring physical or mental health conditions (Quotes 57-68). Participants who were unable to meet rigid attendance expectations reported being characterised as non-compliant or uncommitted. Participants frequently reported that available services appeared tailored to a narrow patient demographic, often excluding those with complex or non-normative life circumstances, such as disability. This perceived mismatch between service design and individual context was associated with disengagement and a sense of exclusion from appropriate care pathways. Theme 2 Facilitators of Engagement and Recovery Despite encountering systemic and treatment-related challenges, many participants identified a range of factors that psychological safety, fostered hope, and enabled sustained engagement with recovery. These facilitators were frequently grounded in relational connection, compassion, and the validation of lived experience. Participants described specific interpersonal and systemic factors that supported re-engagement with recovery and counteracted the effects of exclusion, stigma, and trauma. For many, these moments of support did not emerge from formal treatment settings but through peers, advocacy, or instances of genuinely attuned care. These accounts provided a counter-narrative to the dominant story of barriers and exclusion, illustrating the significance of trust, collaboration, and personalisation in promoting recovery trajectories. This theme comprises three subthemes: (1) compassionate, individualised and trauma-informed care, (2) peer support and connection, and (3) integration of lived experience and advocacy . Subtheme 2.1 Compassionate, Individualised and Trauma-Informed Care Many participants described infrequent but highly significant experiences of care that were characterised by empathy, attunement, and responsiveness to individual need. These encounters were characterised by attentiveness to participants’ preferences, flexibility in clinical approach, and a willingness to adapt treatment in accordance with the individual's lived experience. Even brief episodes of therapeutic attunement, such as being offered concrete choices regarding treatment modalities, levels of care or meal planning, having emotional distress acknowledged without pathologisation, or experiencing consistent relational warmth, were described as pivotal to participants’ broader recovery trajectories and foundational to the development of a strong therapeutic alliance (Quotes 76-82). Participants identified trauma-informed practices, including respect for autonomy, collaborative decision-making, and the prioritisation of psychological safety, as instrumental in facilitating treatment engagement. Clinicians who acknowledged and accommodated neurodivergence, complex trauma histories, or co-occurring psychiatric diagnoses were regarded as particularly effective in fostering trust and therapeutic rapport. Participants described how the explicit validation of identity and lived experience countered prior clinical invalidation and supported a renewed willingness to engage in care (Quotes 76-87). Adaptations to support communication preferences, emotional regulation, or sensory sensitivities were viewed as critical to enhancing treatment accessibility and sustaining engagement across time. Subtheme 2.2 Peer Support and Connection Most participants described informal peer connection, with others who had lived experience of an ED, as a meaningful source of validation, empathy, and emotional safety (Quotes 88-98). These interactions typically occurred outside of formal treatment settings, including through online communities, lived experience networks, peer support groups, or personal relationships with others who had experienced EDs. Peer interactions were frequently described as offering a depth of understanding and acceptance that participants felt was often absent in professional services. For many, connecting with others who shared similar lived experiences helped to reduce feelings of shame, stigma, and social isolation. Many participants reported that peer relationships created spaces where they felt understood without the need for extensive explanation, and where their struggles were met with compassion rather than judgment. These connections were described as providing emotional relief and belonging, particularly following invalidating or coercive experiences within treatment settings. Exposure to others’ recovery narratives, especially those of individuals further along in their recovery journey, was described as a powerful source of hope. Hearing about recovery was perceived by most participants as motivating, reinforcing the belief that meaningful change was possible and supporting re-engagement with treatment. For some, contact with peers marked a critical turning point in their recovery trajectory, renewing confidence in help-seeking and fostering sustained connection to support networks. Subtheme 2.3 Integration of Lived Experience and Advocacy Many participants described engaging in advocacy, education, or professional roles as an extension of their lived experience with SEED (Quotes 99-117). These contributions included peer mentoring, lived experience consultancy, involvement in service co-design and research, public speaking, and participation in mental health workforce initiatives. Engagement in these roles typically followed partial or full disengagement from traditional treatment services and was framed as a meaningful avenue for contributing to systemic change. For some, these roles served as a form of constructive re-engagement with the healthcare system, motivated by a desire to address the barriers, harms, and limitations they had encountered during their own treatment journeys. Several participants reported that their decision to pursue careers as clinicians, researchers, or support workers was directly informed by previous experiences of compassionate and individualised care, and a desire to replicate those practices in their own work. These activities were consistently described as personally meaningful and empowering, particularly among participants who had previously felt dismissed, pathologised, or excluded from formal care. The opportunity to contribute lived expertise was reported to be associated with increased self-efficacy, a sense of purpose, and renewed motivation for ongoing recovery. Participants emphasised the importance of embedding lived experience within the development, delivery, and reform of ED services, citing its potential to improve relevance, inclusivity, and responsiveness to diverse and complex needs. Discussion This mixed-methods study offers a novel contribution to the empirical understanding of treatment access and engagement among individuals with SEED, a population that remains markedly underrepresented in existing research. By employing an explanatory sequential design, this study extends prior work by integrating descriptive quantitative data with rich qualitative accounts to elucidate how systemic barriers and enabling conditions operate across the illness trajectory. Findings suggest that systemic exclusion and clinical inflexibility may reinforce disengagement and therapeutic rupture, whereas relational attunement, contextual responsiveness, and the integration of lived experience may function as protective factors supporting sustained recovery engagement. The study advances the field by centring the voices of those with SEED, offering evidence-informed directions for the development of more inclusive, person-centred models of care. Quantitative analyses indicated that the sample was characterised by diagnostic heterogeneity, protracted illness duration, and elevated symptom severity, with most of participants endorsing financial inaccessibility, half reporting exclusion based on diagnostic or BMI criteria, and a third citing geographic distance as key impediments to care. These trends were triangulated and expanded through thematic analysis. Specifically, participants described diagnostic and conceptual exclusion in ways that reflect broader critiques of categorical diagnostic systems, such as the DSM-5, which often fail to capture atypical, intersecting, or enduring symptom presentations (5, 7). Consistent with literature on the iatrogenic effects of weight-centric frameworks, BMI thresholds were reported to function as structural gatekeepers that delayed intervention and exacerbated internalised stigma (9, 10, 18). Similarly, the financial and geographic inequities identified in the survey were contextualised by participants’ narratives of service fragmentation, reliance on out-of-pocket private treatment, and the absence of specialist care outside urban centres. These findings parallel longstanding concerns about rural mental health disparities (53) and the prohibitive cost burden of ED care both nationally and internationally (54, 55). Inadequate service responsiveness to adult-specific needs, particularly among midlife individuals with complex, enduring illness trajectories, reflects challenges uniquely salient in SEED populations. This finding aligns with emerging evidence of treatment discontinuities and systemic gaps across the lifespan, particularly for individuals whose illness persists into later adulthood (10, 13, 30, 56). Treatment-related barriers were salient across data sources. Almost half of respondents identified manualised protocols as barriers to engagement, while stigma and invalidation by treatment providers were frequently endorsed for undermining their treatment participation. These patterns were reinforced by qualitative accounts of coercion, surveillance, and decontextualised care. Participants reported that control-oriented treatment environments replicated prior trauma and eroded therapeutic trust. Such findings are consistent with a growing literature on iatrogenic harm within risk-averse, behaviourally prescriptive inpatient settings (9, 24, 42, 43, 57) and reinforce the importance of integrating trauma-informed principles and affective safety into treatment design (34, 38). Participants also articulated a substantial misalignment between their needs and prevailing treatment models. Standardised cognitive-behavioural protocols were frequently experienced as rigid, cognitively overwhelming, and fundamentally misaligned with the needs of neurodivergent individuals. Participants described these models as lacking relational attunement and failing to accommodate common co-occurring conditions, including ASD, ADHD, and CPTSD. These findings advance a small but growing body of research which emphasise the inadequacy of conventional treatment frameworks in meeting the cognitive, sensory, and relational needs of neurodivergent individuals with SEED (20, 31-33, 36, 58). Despite the prevalence of structural and clinical adversity, the study also identified factors that supported therapeutic re-engagement and recovery maintenance. Relational safety and clinician attunement were the most frequently cited facilitators, with a majority of participants highlighting the importance of empathy, and over half referencing supportive therapeutic relationships. These findings align with robust evidence linking therapeutic alliance to positive treatment outcomes across mental health domains (59-62). Participants also emphasised the role of peer connection and lived experience integration, describing these interactions as uniquely validating, credibility-enhancing, and identity-affirming. These narratives support emerging frameworks positioning lived experience as an epistemic asset in both service delivery and reform (63, 64). While less frequently reported, structural enablers such as telehealth access, Medicare-subsidised psychological services, and clinician advocacy were cited as meaningful supports for continuity of care. These findings suggest that even incremental systemic adaptations, when embedded within affirming therapeutic contexts, may have substantial benefits for engagement among individuals with SEED (12, 55). The integration of quantitative and qualitative data revealed convergence across key domains, particularly with respect to structural and relational barriers to care. This methodological triangulation enhances the credibility of the findings and reinforces the salience of these barriers within SEED populations. While some variation was observed, for instance, in the perceived utility of specific treatment approaches, this likely reflects the diversity of participant experiences of the sample rather than inconsistency across methods. These results support the value of mixed-methods designs in elucidating the layered and contextually situated nature of treatment access and engagement for individuals with longstanding EDs. In sum, this study contributes to a growing critique of conventional treatment models for individuals with SEED, highlighting the need for system-level reform and clinical innovation. Participants strongly endorsed trauma-informed, neurodivergent-affirming, and person-centred approaches as crucial to effective care. Specifically, they emphasised the importance of relationally attuned frameworks that promote autonomy, acknowledge complexity, and affirm difference without pathologisation. While limited in generalisability, these data provide empirically grounded direction for future intervention development, workforce training, and policy advocacy. Continued evaluation of co-designed, context-sensitive care models is warranted to advance equity, safety, and efficacy in SEED treatment. Strengths and Limitations This study offers several methodological and conceptual strengths. The use of an explanatory sequential mixed-methods design enabled the integration of descriptive quantitative data with in-depth qualitative insights, supporting a nuanced understanding of treatment access and engagement among individuals with SEED. Reflexive thematic analysis, grounded in established methodological principles (46, 47), allowed for inductive theme development while maintaining analytic rigour. The inclusion of participants across diverse diagnoses, illness durations, and stages of recovery enhanced sample heterogeneity and ecological validity. Critically, the study foregrounded lived experience perspectives, contributing to a deeper understanding of relational and structural processes often underrepresented in clinical trials or service evaluations. Nevertheless, limitations must be acknowledged. The reliance on retrospective, self-reported data may have introduced recall bias and subjective interpretation. Recruitment through online platforms and advocacy networks may have contributed to self-selection bias, potentially overrepresenting individuals with digital access, higher health literacy, or prior engagement in treatment. Certain identities, particularly Aboriginal and Torres Strait Islander peoples, culturally and linguistically diverse populations, and gender-diverse individuals, were underrepresented, limiting generalisability. Moreover, as the study was conducted within the Australian healthcare system, which differs in structure, funding, and service provision from systems in other countries, caution should be exercised when extrapolating results to international contexts. Finally, the cross-sectional design precluded examination of longitudinal trajectories or causal mechanisms underpinning treatment engagement and recovery. Future Directions The findings highlight several critical gaps warranting further empirical investigation. Longitudinal and prospective studies are needed to explore how structural exclusion, clinical stigma, and relational disconnection influence recovery trajectories over time. Given the identified limitations of standardised, risk-averse, and neurotypical treatment paradigms, future research should evaluate alternative models, including trauma-informed, neurodivergent-affirming, and harm-reduction approaches, using mixed methods and implementation-focused designs. There is a particular need to further examine the mechanisms by which peer-led, co-designed, and lived experience-informed interventions foster therapeutic engagement and relational safety, particularly in SEED presentations. Emerging programs, such as single-session digital tools and structured peer mentoring initiatives, have shown early promise in enhancing perceived understanding, reducing stigma, and supporting sustained connection to care (64-66). Future studies should also attend to the intersecting impacts of structural marginalisation, such as Indigeneity, cultural identity, gender diversity, and socioeconomic precarity, on access and outcomes in SEED populations. Participatory or emancipatory methodologies may be especially valuable in elevating marginalised voices and resisting deficit-based framings. Finally, given the pervasive accounts of coercion and iatrogenic harm, future inquiry should critically examine clinician attitudes, institutional risk practices, and the ethical complexities of care provision in SEED contexts. Conclusion This exploratory mixed-methods study provides important insight into the barriers and facilitators shaping treatment access and engagement for individuals with SEED. By integrating quantitative and qualitative data, the study contributes to a more nuanced understanding of the structural, clinical, and relational dynamics that may influence care trajectories within the Australian context. Participants’ accounts nominated challenges such as diagnostic exclusion, weight-based gatekeeping, coercive or inflexible treatment environments, and limited accommodation of neurodivergent and trauma-related needs. At the same time, the findings identified potential facilitators of therapeutic engagement, including empathic clinician relationships, individualised care, peer support, and the integration of lived experience. While caution is required in extending these findings to all SEED populations, they offer valuable considerations for service design and future research. Addressing these barriers and enhancing identified facilitators may support the development of more inclusive, affirming, and contextually responsive models of care for individuals with complex and long-standing EDs. Abbreviations AAN Atypical Anorexia Nervosa ADHD Attention-Deficit/Hyperactivity Disorder AN Anorexia Nervosa ARFID Avoidant/restrictive food intake disorder ASD Autism Spectrum Disorder BED Binge Eating Disorder BMI Body Mass Index BN Bulimia Nervosa BPD Borderline Personality Disorder CBT-E Enhanced Cognitive Behaviour Therapy CPTSD Complex Post Traumatic Stress Disorder ED Eating Disorder EDE-Q Eating Disorder Examination Questionnaire I-CBT-E Integrated Enhanced Cognitive Behaviour Therapy OSFED Other Specified Feeding or Eating Disorder PTSD Post Traumatic Stress Disorder SEED Severe and Enduring Eating Disorder Declarations Ethics Approval and Consent to Participate This study received ethical approval from the Monash University Human Research Ethics Committee (Project ID: 42453). Consent for Publication All authors of the study consent to the publication of the current manuscript. Participants involved are aware of the planned publication and have given their consent. Availability of Data and Materials The datasets generated and analysed during the current study are not publicly available under the participant confidentiality conditions of ethics approval from the Monash University Human Research Ethics Committee. Declaration of Conflicting Interests The authors have declared no potential conflicts or competing interests with respect to the research, authorship, and publication of this article. Funding This work was not sponsored or funded. The views expressed herein are the authors’ opinions and do not reflect any official positions of the institutional affiliations or funding bodies. Author Contributions Gabriel Lubieniecki : Conceptualisation (lead); Writing – Original Draft; Methodology; Formal Analysis (lead); Writing – Review & Editing (equal). Isabella McGrath : Formal Analysis (supporting); Writing – Review & Editing (supporting). Gemma Sharp : Conceptualisation (equal); Methodology (equal); Formal Analysis (equal); Resources (lead); Validation (lead); Writing – Review & Editing (lead); Supervision (lead). Acknowledgements We extend our sincere gratitude to the 41 individuals who participated in this study, generously sharing their experiences. We also wish to thank those who supported the recruitment process by circulating information about this research. References Hay P, Touyz S. Treatment of patients with severe and enduring eating disorders. Current Opinion in Psychiatry. 2015;28(6):473-7. Eddy KT, Tabri N, Thomas JJ, Murray HB, Keshaviah A, Hastings E, et al. Recovery From Anorexia Nervosa and Bulimia Nervosa at 22-Year Follow-Up. J Clin Psychiatry. 2017;78(2):184-9. Robinson P. Severe and enduring eating disorder (SEED): management of complex presentations of anorexia and bulimia nervosa: John Wiley & Sons; 2009. Robinson P. Severe and enduring eating disorders: recognition and management. Advances in Psychiatric Treatment. 2014;20(6):392-401. Wonderlich SA, Bulik CM, Schmidt U, Steiger H, Hoek HW. Severe and enduring anorexia nervosa: Update and observations about the current clinical reality. International Journal of Eating Disorders. 2020;53(8):1303-12. Treasure J, Duarte TA, Schmidt U. Eating disorders. The Lancet. 2020;395(10227):899-911. Broomfield C, Stedal K, Touyz S, Rhodes P. Labeling and defining severe and enduring anorexia nervosa: A systematic review and critical analysis. Int J Eat Disord. 2017;50(6):611-23. Daugelat MC, Pruccoli J, Schag K, Giel KE. Barriers and facilitators affecting treatment uptake behaviours for patients with eating disorders: A systematic review synthesising patient, caregiver and clinician perspectives. Eur Eat Disord Rev. 2023;31(6):752-68. Elwyn R. A lived experience response to the proposed diagnosis of terminal anorexia nervosa: learning from iatrogenic harm, ambivalence and enduring hope. Journal of Eating Disorders. 2023;11(1). Musolino C, Warin M, Wade T, Gilchrist P. Developing shared understandings of recovery and care: a qualitative study of women with eating disorders who resist therapeutic care. Journal of Eating Disorders. 2016;4(1). Kotilahti E, West M, Isomaa R, Karhunen L, Rocks T, Ruusunen A. Treatment interventions for Severe and Enduring Eating Disorders: Systematic review. International Journal of Eating Disorders. 2020;53(8):1280-302. Bryant E, Marks P, Griffiths K, Boulet S, Pehlivan M, Barakat S, et al. Treating the individual: moving towards personalised eating disorder care. Journal of Eating Disorders. 2025;13(1). Kiely L, Hay P, Robinson P. Severe and Enduring Eating Disorders (SEED). Springer International Publishing; 2023. p. 1-21. Van Den Eijnde-Damen IMC, Maas J, Burger P, Bodde NMG, Simeunovic-Ostojic M. Towards collaborative care for severe and enduring Anorexia Nervosa – a mixed-method approach. Journal of Eating Disorders. 2024;12(1). Link BG, Phelan JC. Conceptualizing Stigma. Annual Review of Sociology. 2001;27:363-85. Corrigan PW, Watson AC. The Stigma of Psychiatric Disorders and the Gender, Ethnicity, and Education of the Perceiver. Community Mental Health Journal. 2007;43(5):439-58. Corrigan PW, Watson AC, Barr L. The Self–Stigma of Mental Illness: Implications for Self–Esteem and Self–Efficacy. Journal of Social and Clinical Psychology. 2006;25(8):875-84. Brelet L, Flaudias V, Désert M, Guillaume S, Llorca P-M, Boirie Y. Stigmatization toward People with Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder: A Scoping Review. Nutrients. 2021;13(8):2834. Doley JR, Hart LM, Stukas AA, Petrovic K, Bouguettaya A, Paxton SJ. Interventions to reduce the stigma of eating disorders: A systematic review and meta‐analysis. International Journal of Eating Disorders. 2017;50(3):210-30. Lubieniecki G, Fernando AN, Randhawa A, Cowlishaw S, Sharp G. Perceived clinician stigma and its impact on eating disorder treatment experiences: a systematic review of the lived experience literature. Journal of Eating Disorders. 2024;12(1). Dimitropoulos G, Freeman VE, Muskat S, Domingo A, McCallum L. “You don’t have anorexia, you just want to look like a celebrity”: perceived stigma in individuals with anorexia nervosa. Journal of Mental Health. 2016;25(1):47-54. Kurdak H, Tiyekli E, Özcan S, Özer ZY, Nur Topuz A. Eating disorders, primary care, and stigma: an analysis of research trends and patterns. Frontiers in Psychiatry. 2023;14. Ruesch N. The stigma of mental illness : strategies against social exclusion and discrimination. Amsterdam: Elsevier; 2022. Menzies RE, Richmond B, Sharpe L, Skeggs A, Liu J, Coutts‐Bain D. The ‘revolving door’ of mental illness: A meta‐analysis and systematic review of current versus lifetime rates of psychological disorders. British Journal of Clinical Psychology. 2024;63(2):178-96. Boyd JE, López MM, González-Sanguino C, Harris JI, Sampson IT. Consequences of the Self-Stigma of Mental Illness. In: Vogel DL, Wade NG, editors. The Cambridge Handbook of Stigma and Mental Health. Cambridge Handbooks in Psychology. Cambridge: Cambridge University Press; 2022. p. 88-110. Byrne SM, Fursland A. New understandings meet old treatments: putting a contemporary face on established protocols. Journal of Eating Disorders. 2024;12(1). Reay M, Holliday J, Stewart J, Adams J. Creating a care pathway for patients with longstanding, complex eating disorders. Journal of Eating Disorders. 2022;10(1). Fairburn CG. Cognitive behavior therapy and eating disorders2008. Byrne S, Wade T, Hay P, Touyz S, Fairburn CG, Treasure J, et al. A randomised controlled trial of three psychological treatments for anorexia nervosa. Psychological Medicine. 2017;47(16):2823-33. Sharp G, Fernando AN, Davis SR, Randhawa A. Developing an educational resource for people experiencing eating disorders during the menopause transition: A qualitative co-design study. Journal of Eating Disorders. 2024;12(1). Kinnaird E, Norton C, Stewart C, Tchanturia K. Same behaviours, different reasons: what do patients with co-occurring anorexia and autism want from treatment? International Review of Psychiatry. 2019;31(4):308-17. Brede J, Babb C, Jones C, Elliott M, Zanker C, Tchanturia K, et al. “For Me, the Anorexia is Just a Symptom, and the Cause is the Autism”: Investigating Restrictive Eating Disorders in Autistic Women. Journal of Autism and Developmental Disorders. 2020;50(12):4280-96. Cobbaert L, Millichamp AR, Elwyn R, Silverstein S, Schweizer K, Thomas E, et al. Neurodivergence, intersectionality, and eating disorders: a lived experience-led narrative review. Journal of Eating Disorders. 2024;12(1). Tchanturia K, Dandil Y, Li Z, Smith K, Leslie M, Byford S. A novel approach for autism spectrum condition patients with eating disorders: Analysis of treatment cost‐savings. European Eating Disorders Review. 2021;29(3):514-8. Westwood H, Mandy W, Tchanturia K. Clinical evaluation of autistic symptoms in women with anorexia nervosa. Molecular Autism. 2017;8(1). Babb C, Brede J, Jones CRG, Serpell L, Mandy W, Fox J. A comparison of the eating disorder service experiences of autistic and non‐autistic women in the UK. European Eating Disorders Review. 2022;30(5):616-27. Molendijk ML, Hoek HW, Brewerton TD, Elzinga BM. Childhood maltreatment and eating disorder pathology: a systematic review and dose-response meta-analysis. Psychological Medicine. 2017;47(8):1402-16. Brewerton TD, Alexander J, Schaefer J. Trauma-informed care and practice for eating disorders: personal and professional perspectives of lived experiences. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity. 2019;24(2):329-38. Day S, Hay P, Basten C, Byrne S, Dearden A, Goldstein M, et al. Posttraumatic stress disorder (PTSD) and complex PTSD in eating disorder treatment‐seekers: Prevalence and associations with symptom severity. Journal of Traumatic Stress. 2024;37(4):672-84. Boughtwood D, Halse C. Other than obedient: Girls' constructions of doctors and treatment regimes for anorexia nervosa. J Community Appl Soc Psychol. 2010;20(2):83-94. Dawson L, Mullan B, Rhodes P, Touyz S. Developing a measure to assess motivation and self-efficacy in anorexia nervosa using the Theory of Planned Behaviour. Journal of Eating Disorders. 2014;2(S1):O46. Mac Donald B, Gustafsson SA, Bulik CM, Clausen L. Living and leaving a life of coercion: a qualitative interview study of patients with anorexia nervosa and multiple involuntary treatment events. Journal of Eating Disorders. 2023;11(1). Sharpe SL, Adams M, Smith EK, Urban B, Silverstein S. Inaccessibility of care and inequitable conceptions of suffering: a collective response to the construction of “terminal” anorexia nervosa. Journal of Eating Disorders. 2023;11(1). Broomfield C, Rhodes P, Touyz S. Lived experience perspectives on labeling and defining long-standing anorexia nervosa. Journal of Eating Disorders. 2021;9(1). Lubieniecki G, McGrath I, Sharp G. A Lifeline or a Label? Patient Perspectives on the Severe and Enduring Eating Disorder (SEED) Classification in Eating Disorder Treatment. 2025. [pre-print available 10.21203/rs.3.rs-6231293/v1] Braun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006;3(2):77-101. Braun V, Clarke V. Thematic analysis: A practical guide. 2021. Moustakas C. Phenomenological research methods: sage; 1994. Hall MF, Hall SE. Managing the Psychological Impact of Medical Trauma. 1 ed. New York: Springer Publishing Company. Schwab JR, Syed M. Qualitative inquiry and emerging adulthood: Meta-theoretical and methodological issues. Emerging Adulthood. 2015;3(6):388-99. Fairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord. 1994;16(4):363-70. Jennings KM, Phillips KE. Eating Disorder Examination–Questionnaire (EDE–Q): Norms for Clinical Sample of Female Adolescents with Anorexia Nervosa. Archives of Psychiatric Nursing. 2017;31(6):578-81. Flavel, Kedzior, Isaac, Cameron, Baum. Regional health inequalities in Australia and social determinants of health: analysis of trends and distribution by remoteness. Rural and Remote Health. 2024. Miskovic-Wheatley J, Bryant E, Ong SH, Vatter S, Le A, Aouad P, et al. Eating disorder outcomes: findings from a rapid review of over a decade of research. Journal of Eating Disorders. 2023;11(1). Mulders-Jones B, Mitchison D, Girosi F, Hay P. Socioeconomic Correlates of Eating Disorder Symptoms in an Australian Population-Based Sample. PLOS ONE. 2017;12(1):e0170603. Tully SM, Bucci S, Berry K. “My life isn't my life, it's the systems”: A qualitative exploration of women's experiences of day‐to‐day restrictive practices as inpatients. Journal of Psychiatric and Mental Health Nursing. 2023;30(1):110-22. Munt C, Littlechild B. The Lived Experience of Coercion. Springer Nature Switzerland; 2024. p. 3-25. Herle M, Carter Leno V, Mandy W. Recommendations for Advancing Understanding of Eating Disorders in Neurodivergent People: A Commentary on Inal‐Kaleli et al. 2024 and Nimbley et al. 2024. International Journal of Eating Disorders. 2025;58(4):677-9. Geller J, Fernandes A, Srikameswaran S, Pullmer R, Marshall S. The power of feeling seen: Perspectives of individuals with eating disorders on receiving validation. Journal of Eating Disorders Vol 9, 2021, ArtID 149. 2021;9. Birch E, Downs J, Ayton A. Harm reduction in severe and long-standing Anorexia Nervosa: part of the journey but not the destination—a narrative review with lived experience. Journal of Eating Disorders. 2024;12(1). Kenny TE, Lewis SP. More than an outcome: a person-centered, ecological framework for eating disorder recovery. Journal of Eating Disorders. 2023;11(1). Thornicroft G, Sunkel C, Aliev AA, Baker S, Brohan E, Rabih el C, et al. The Lancet Commission on ending stigma and discrimination in mental health. The Lancet. 2022;400(10361):1438-80. Hanly F, Torrens-Witherow B, Warren N, Castle D, Phillipou A, Beveridge J, et al. Peer mentoring for individuals with an eating disorder: a qualitative evaluation of a pilot program. Journal of Eating Disorders. 2020;8(1). Raspovic A, Duck R, Synnot A, Caldwell B, Phillipou A, Castle D, et al. A peer mentoring program for eating disorders: improved symptomatology and reduced hospital admissions, three years and a pandemic on. Journal of Eating Disorders. 2024;12(1). Sharp G, Dwyer B, Xie J, McNaney R, Shrestha P, Prawira C, et al. Co-design of a single session intervention chatbot for people on waitlists for eating disorder treatment: a qualitative interview and workshop study. Journal of Eating Disorders. 2025;13(1). Sharp G, Dwyer B, Randhawa A, McGrath I, Hu H. The Effectiveness of a Chatbot Single-Session Intervention for People on Waitlists for Eating Disorder Treatment: Randomized Controlled Trial. Journal of Medical Internet Research. 2025;27:e70874. Additional Declarations No competing interests reported. Supplementary Files Appendixs.docx Cite Share Download PDF Status: Published Journal Publication published 12 Sep, 2025 Read the published version in Journal of Eating Disorders → Version 1 posted Editorial decision: Revision requested 20 Jul, 2025 Reviews received at journal 20 Jul, 2025 Reviews received at journal 16 Jul, 2025 Reviewers agreed at journal 17 Jun, 2025 Reviewers agreed at journal 12 Jun, 2025 Reviewers invited by journal 10 Jun, 2025 Editor assigned by journal 10 Jun, 2025 Submission checks completed at journal 10 Jun, 2025 First submitted to journal 07 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6843067","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":469778885,"identity":"e4f0702e-f9ef-48fc-b1fc-0bac3cb85eb4","order_by":0,"name":"Gabriel Lubieniecki","email":"data:image/png;base64,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","orcid":"","institution":"Monash University","correspondingAuthor":true,"prefix":"","firstName":"Gabriel","middleName":"","lastName":"Lubieniecki","suffix":""},{"id":469778886,"identity":"a5066363-f59e-40a4-bbf9-32dd1e9a3a1f","order_by":1,"name":"Isabella McGrath","email":"","orcid":"","institution":"University of Queensland","correspondingAuthor":false,"prefix":"","firstName":"Isabella","middleName":"","lastName":"McGrath","suffix":""},{"id":469778887,"identity":"db9a5580-2ada-4cd5-84a6-a03625879718","order_by":2,"name":"Gemma Sharp","email":"","orcid":"","institution":"Monash University","correspondingAuthor":false,"prefix":"","firstName":"Gemma","middleName":"","lastName":"Sharp","suffix":""}],"badges":[],"createdAt":"2025-06-07 13:23:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6843067/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6843067/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40337-025-01393-w","type":"published","date":"2025-09-12T15:57:09+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91359053,"identity":"0573b60c-7e6f-4afd-8a6e-8656d44c602e","added_by":"auto","created_at":"2025-09-15 16:04:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2332358,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6843067/v1/91fa4910-1c2b-40a6-bc13-b7bdb6f7841d.pdf"},{"id":84489117,"identity":"b3a270d1-eced-4e14-919d-d6e447959306","added_by":"auto","created_at":"2025-06-12 14:19:21","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":34430,"visible":true,"origin":"","legend":"","description":"","filename":"Appendixs.docx","url":"https://assets-eu.researchsquare.com/files/rs-6843067/v1/fab660442d7fca81a36a81e1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers and Facilitators to Treatment in Severe and Enduring Eating Disorders: A Mixed- Methods Study of Access, Engagement, and Lived Experience","fulltext":[{"header":"Plain English Summary","content":"\u003cp\u003ePeople with longstanding eating disorders often face significant difficulties when seeking help. These challenges may include being excluded from treatment based on their weight, diagnosis, or life stage, or encountering services that feel rigid, unsafe, or invalidating. This study explored the barriers and facilitators to care experienced by 41 adults in Australia with a range of eating disorder diagnoses and at different stages of recovery. Using a combination of surveys and in-depth interviews, we found that participants commonly described delayed or denied access to care, particularly when their needs did not fit expected treatment pathways. Experiences of stigma, misdiagnosis, and trauma within healthcare settings were also frequently reported. These experiences led to a loss of trust in services and contributed to feelings of exclusion and hopelessness. However, participants also shared what had helped them engage with care. Supportive relationships with clinicians, connection with peers, and being offered choices in their treatment were especially important. Participants emphasised the value of trauma-informed, person-centred, and neurodiversity-affirming approaches that responded to their unique needs and respected their autonomy. Our findings show that to improve care for people with longstanding eating disorders, we must move beyond one-size-fits-all models and meaningfully address the structural and relational barriers that many continue to face.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eSevere and enduring eating disorders (SEED) constitute a complex and heterogeneous subset of eating disorder (ED) presentations, typically characterised by persistent symptomatology, functional impairment, and prolonged illness duration, often exceeding seven years (1-5) While early intervention using evidence-based modalities is associated with improved outcomes (6), approximately 20 to 30 percent of individuals develop protracted illness trajectories marked by chronicity and repeated, often unsuccessful, treatment attempts (1, 2). Despite increasing clinical and scholarly recognition, SEED remains inconsistently defined, with considerable variability in criteria relating to illness duration, diagnostic status, and treatment responsiveness (7).\u0026nbsp;Individuals with SEED frequently encounter multifactorial barriers to care, including diagnostic exclusion, stigma, and inflexible service models that fail to accommodate the complexity of their presentations\u0026nbsp;(8-11). \u0026nbsp;In contrast, emerging evidence suggests that certain relational and structural factors, such as trauma-informed approaches, individualised care, and peer support, may act as critical facilitators of therapeutic engagement and recovery\u0026nbsp;(12-14).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStigma, in particular, has emerged as a pervasive and multifaceted barrier to care for individuals with SEED. It is broadly defined as a process of social devaluation characterised by labelling, stereotyping, and status loss within unequal power structures (15). In the context of EDs, stigma is typically experienced across four interrelated domains: structural, public, anticipated, and internalised (16, 17). Systematic reviews and scoping syntheses have documented widespread societal beliefs that individuals with EDs are personally responsible for their condition, which, in turn, elicits blame and emotional responses such as frustration or disdain (18-20). Such attitudes are also evident among clinicians, particularly those without specialist training, who may view individuals with EDs as “manipulative”, “treatment-resistant”, or “at fault” for their illness (18, 21). Structural stigma is embedded within institutional policies that employ narrow diagnostic or weight-based thresholds, leading to the exclusion of those in higher-weight bodies, individuals with neurodevelopmental conditions, and those with complex presentations (8, 10, 18, 22). Public stigma, shaped by enduring sociocultural narratives, positions individuals with longstanding illness as attention-seeking, non-compliant, or beyond help (21-23). These external perceptions contribute to anticipated stigma, wherein individuals delay or avoid seeking help due to fear of invalidation, dismissal, or punitive treatment (20, 24). Over time, repeated exposure to invalidating or coercive treatment experiences may culminate in internalised stigma, manifesting as self-blame, diagnostic label avoidance, and disengagement from services (17, 20, 25).\u003c/p\u003e\n\u003cp\u003eThese challenges may be further enhanced by the dominance of manualised treatment frameworks, which frequently function as a barrier to care by lacking the flexibility required to accommodate the complexity and chronicity of SEEDs (14, 26, 27). Enhanced cognitive behaviour therapy (CBT-E), while efficacious for some, emphasises symptom reduction, nutritional restoration, and behavioural adherence, and was not originally designed to accommodate the complexities associated with longstanding illness, comorbidity, or neurodevelopmental diversity (28, 29). Increasingly, qualitative and co-designed studies have drawn attention to the mismatch between these standardised protocols and the lived realities of those with enduring illness. For example, Sharp et al. (30) and Kiely et al. (13) have emphasised the limitations of existing models in addressing the needs of individuals in midlife or with intersecting psychosocial challenges, advocating for flexible, life stage-appropriate, and collaboratively defined treatment goals. Reay et al. (27), through mixed-methods service development work, further demonstrated the preference among those with SEEDs for care pathways that prioritise autonomy, psychological safety, and quality of life over symptom-focused metrics. These findings collectively illustrate the risks of prescriptive, one-size-fits-all treatment models, particularly when applied to individuals with complex and enduring illness trajectories, and how such approaches may inadvertently exacerbate disengagement, especially among those whose experiences fall outside normative recovery expectations.\u003c/p\u003e\n\u003cp\u003eFurther complexity is introduced by neurodevelopmental conditions, which remain markedly under recognised and under accommodated within mainstream ED services, constituting a significant barrier to appropriate and effective care despite growing empirical evidence of their prevalence and clinical relevance (31-34). Individuals with neurodevelopmental conditions, particularly autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), appear to be substantially overrepresented in ED populations. Westwood et al. (35) reported that between 8 and 37 percent of individuals with anorexia nervosa (AN) met criteria for ASD, with elevated rates persisting even after nutritional rehabilitation. A more recent review by Cobbaert et al. (33), estimated the prevalence of ADHD to be as high as 16 percent in individuals with AN, and up to 35 percent in those with bulimia nervosa (BN) or binge eating disorder (BED). Such neurodevelopmental conditions are frequently associated with interoceptive difficulties, sensory sensitivities, impairments in executive functioning, and challenges in emotion regulation. These characteristics can significantly interfere with therapeutic engagement and adherence within conventional ED treatment environments (31-33, 36), with their prevalence and impact in SEED presentations remain underexamined.\u003c/p\u003e\n\u003cp\u003eDespite growing recognition of the prevalence and clinical impact of neurodivergence in ED populations, most existing treatment models remain grounded in neurotypical assumptions and rarely incorporate the cognitive, sensory, or relational adaptations necessary to support neurodivergent individuals (31, 33, 34). Recently, Kinnaird et al. (31), in a survey of 56 individuals with ASD and EDs, reported significant dissatisfaction with existing services, particularly the lack of individualised accommodations and the limited understanding of autistic traits among clinicians. These findings emphasise a critical gap in treatment design that may act as a barrier to engagement and contribute to dropout, therapeutic rupture, and poorer outcomes among neurodivergent individuals.\u003c/p\u003e\n\u003cp\u003eThese challenges may be further compounded by the high prevalence of trauma-related psychopathology among individuals with SEEDs, which can present additional barriers to effective and sustained engagement with care. While the role of trauma in the development of EDs is well established, increasing attention has been directed toward the impact of complex, cumulative, and iatrogenic trauma on illness persistence and treatment trajectories (10, 37, 38). Day et al. (39) reported that 28.4 percent met diagnostic criteria for probable complex posttraumatic stress disorder (CPSTD), with a further 32.1 percent presenting with clinically significant trauma-related symptoms. These included affective dysregulation, negative self-concept, and relational disturbances, with complex trauma particularly common in residential and intensive day treatment settings. Despite these findings, trauma is frequently underassessed and inadequately addressed in standard treatment environments. Inpatient and intensive programs often prioritise behavioural compliance and weight restoration, with limited integration of trauma-informed principles or attention to psychological safety (27, 40, 41). Recent qualitative studies have described how standardised practices, such as compulsory feeding, public meal supervision, and discharge decisions based on weight thresholds, are experienced by service users as coercive, invalidating, and retraumatising, particularly in the absence of collaborative care planning (10, 42, 43). \u0026nbsp;Kotilahti et al. (11) and Kiely et al. (13) reported that both service users and clinicians perceived a lack of guidance on how to adapt ED treatment to address trauma histories and associated relational vulnerabilities. These findings are reflected in a broader body of scholarship calling for fundamental reform of conventional treatment paradigms (12). Traditional models, when implemented without adaptation, may act as a barrier to engagement by undermining autonomy, relational safety, and patient-defined recovery goals, thereby compounding harm, eroding therapeutic trust, and perpetuating cycles of disengagement (10, 11, 13, 44).\u003c/p\u003e\n\u003cp\u003eNotwithstanding sustained calls for reform, empirical investigation into the lived experiences of individuals with SEED remains limited, contributing to the ongoing marginalisation and unmet needs of this. Specifically, there is a notable absence of research that systematically examines how structural and clinical barriers are encountered and negotiated across the illness trajectory, or how therapeutic engagement is facilitated within the context of chronicity, trauma exposure, and diagnostic complexity. Addressing this gap is essential to helping to inform service development that is both clinically effective and ethically responsive. This mixed methods study sought to enhance understanding of the treatment experiences of individuals with SEEDs by exploring the barriers and facilitators that influence access, engagement, and continuity of care. This exploratory study sought, through a mixed methods approach, to deepen understanding of the structural, clinical, and relational factors that shape access to care, treatment engagement, and recovery experiences among individuals with SEED. In doing so, it aimed to identify key barriers and potential facilitators to more inclusive, responsive, and person-centred models of care. Through the integration of quantitative survey data and in-depth qualitative interviews, the study offers insight into the systemic and clinical conditions that may function as barriers to, or facilitators of, care for individuals with SEEDs.\u003c/p\u003e\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eStudy Design\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis study (which forms part of a larger study (45)) adopted a two-stage explanatory sequential mixed-methods design. In this design, an initial quantitative phase (Stage One) informed and contextualised a subsequent qualitative phase (Stage Two), thereby enhancing the interpretive depth of the findings. Stage One consisted of an online survey that captured descriptive data on participants’ demographic and clinical characteristics, symptom severity, and treatment experiences. These data were then used to guide Stage Two, which comprised in-depth, semi-structured interviews exploring barriers, facilitators, and lived experiences of treatment among individuals SEED. The qualitative component of the study an inductive thematic analysis (46, 47) philosophically underpinned by a transcendental phenomenological framework (48), which prioritises first-person narratives and seeks to bracket researcher preconceptions through the process of epoche. This approach was selected due to the heterogeneity of treatment trajectories and the potential for medical trauma in this population (49). It enabled detailed exploration of both the content (textural) and contextual (structural) dimensions of participants’ experiences, ensuring that the analysis was grounded in participant accounts rather than predefined theoretical constructs\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipant eligibility criteria and recruitment procedures have been detailed in a companion paper currently under review (45). A total of 41 participants were included in the study, with the final sample size determined based on principles of theoretical data sufficiency (50). To enhance contextual understanding of the sample, demographic and clinical information was drawn from survey responses, providing insight into participant characteristics relevant to the qualitative findings.\u003c/p\u003e\u003cp\u003e\u003cem\u003eEthics\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis study received ethical approval from the Monash University Human Research Ethics Committee (Project ID: 42453).\u003c/p\u003e\u003cp\u003e\u003cem\u003eData Collection\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eExpression of Interest Survey\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe survey was administered via Qualtrics to collect demographic, clinical, and experiential data. The survey comprised four key domains: (1) demographic characteristics (age, gender identity, geographic location, cultural background, neurodivergence status); (2) ED history (diagnostic status, ED diagnoses, duration of illness, current recovery status and symptom severity); (3) treatment engagement (treatment sought, service types accessed, frequency of treatment, and perceived satisfaction); and (4) perceived barriers and facilitators to care. The fixed-response barrier and facilitator items were informed by a review of existing literature on access to ED treatment and reflected common structural, clinical, and relational factors identified in prior studies (8, 20, 27). Participants were also given the option to elaborate via open-text responses.\u0026nbsp;\u0026nbsp;Free-text responses were analysed thematically using a content-coding approach, with recurring concepts grouped under higher-order categories to supplement quantitative findings by GKL and IM.\u0026nbsp;The full survey instrument, including all fixed-response and open-ended items, is provided in Appendix A.\u0026nbsp;\u003c/p\u003e\u003cp\u003eSymptom severity was assessed using the Eating Disorder Examination Questionnaire (EDE-Q) (51), a validated 28-item self-report measure evaluating core ED psychopathology over the preceding 28 days. The EDE-Q yields a global score and four subscale scores: Restraint (5 items; e.g., “Have you tried to limit the amount of food you eat?”), Eating Concern (5 items; e.g., “Have you felt guilty after eating?”), Shape Concern (8 items; e.g., “Has your shape influenced how you think about yourself as a person?”), and Weight Concern (5 items; e.g., “Have you been dissatisfied with your weight?”). Items are rated on a 7-point scale ranging from 0 (\"no days\"/\"not at all\") to 6 (\"every day\"/\"markedly\"), with higher scores indicating greater symptom severity. Subscale scores were calculated as the mean of relevant items, and the global score was derived as the average of the four subscale scores. Internal consistency for the EDE-Q in the current sample was high. Cronbach’s alpha coefficients indicated excellent reliability for the global score (α = .90), Shape Concern (α = .93), and Weight Concern (α = .92), acceptable reliability for Restraint (α = .78), and lower internal consistency for Eating Concern (α = .44). The latter is consistent with prior findings of variability in this domain, particularly in smaller or diagnostically heterogeneous samples (52).\u003c/p\u003e\u003cp\u003eUpon survey completion, participants received an email from the first author (GKL) containing a summary of their EDE-Q results, explanatory information, mental health resources, and an invitation to participate in the qualitative interview phase. A total of 50 individuals completed the survey. Of these, 41 proceeded to interview. Three individuals were unable to participate in the interview due to personal circumstances, and two did not respond to follow-up contact. Four responses were excluded as they did not meet eligibility criteria for being based in Australia. The final interview sample was composed of 41 participants.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSemi-Structured Interview\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eAn open-ended interview guide (Appendix B) was used to explore participants’ treatment histories, experiences of barriers, facilitators and meaning making. The structure was intentionally flexible to facilitate participant-led discussion and enable the emergence of unanticipated themes. A semi-structured schedule was used for all participants, with scope for individualisation based on responses to the Expression of Interest survey. Survey data were reviewed prior to each interview and used to contextualise participants’ treatment histories, guide probing questions, and explore specific barriers or facilitators previously endorsed. This approach ensured consistency across interviews while allowing for depth, relevance, and participant-centred inquiry.\u003c/p\u003e\u003cp\u003eSemi-structured interviews were conducted via Zoom by the first author (GKL). Interviews ranged from 21 to 147 minutes in duration (M = 50 minutes). Three interviews were notably brief (under 25 minutes), all involving participants who had never accessed treatment, which influenced narrative depth. Informed consent was reconfirmed verbally at the start of each session. \u0026nbsp;All interviews were audio-recorded, transcribed using a secure automated transcription service, manually reviewed for accuracy, and anonymised. For their contribution, participants received a $20 AUD Prezzee voucher at the conclusion of the study.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cem\u003eData Analysis\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eQuantitative Analysis\u003c/em\u003e\u003c/p\u003e\u003cp\u003eQuantitative data from the Qualtrics survey were analysed using SPSS. Descriptive statistical analyses were conducted to summarise participant demographics, EDE-Q scores, and treatment history. Measures of central tendency and dispersion were calculated for continuous variables, while categorical variables were analysed using frequencies and percentages. Statistical analysis was conducted by GKL in collaboration with GS to identify key patterns within the data.\u003c/p\u003e\u003cp\u003e\u003cem\u003eQualitative Analysis\u003c/em\u003e\u003c/p\u003e\u003cp\u003eInterview transcripts were analysed using reflexive thematic analysis, following Braun and Clarke’s six-phase framework (46, 47). Thematic coding was inductive and grounded in participants’ narratives. Initial coding was conducted by GKL, with co-coding of a subset of transcripts by IM. Themes were iteratively refined through analytic memoing, collaborative discussion, and engagement with the full dataset. This process ensured analytic rigour, interpretive transparency, and fidelity to participants’ accounts.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eQuantitative Phase\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe final sample comprised 41 participants. Most identified as female and were in their early 30s, with Anorexia Nervosa the most commonly reported diagnosis. The majority had received treatment, often across multiple modalities and service settings. Descriptive data on demographics, diagnoses, treatment history, and symptomatology are presented in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1 Participant Demographics, Diagnostic Profiles, Treatment History, and Eating Disorder Symptomatology\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%) or M (SD), Min-Max\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e35 (85.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e4 (9.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eNon-Binary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eNot Specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e\u003cem\u003eM\u003c/em\u003e = 31.66 (\u003cem\u003eSD\u003c/em\u003e = 8.014),\u0026nbsp;\u003cbr\u003e\u0026nbsp;Min\u0026ndash;Max: 21-56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeurodivergence Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eYes, formally diagnosed by health professional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e17 (41.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eYes, self-diagnosed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e12 (29.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eCurrently being assessed for diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e3 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eNot neurodivergent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e9 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCultural Background*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eAustralian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e22 (53.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eNorth East Asian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e2 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eBritish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e12 (29.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eWestern European\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e6 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eNorthern European\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e2 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eSouthern European\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eJewish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e2 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eNorthern American\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e2 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eIrish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e4 (9.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eNew Zealand\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e2 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eMainland South East Asian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eIndian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eMaritime South East Asian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eOther (not described)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEating Disorder Diagnosis Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eFormally Diagnosed by health professional\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e33 (80.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eSelf-diagnosed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e8 (19.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEating Disorder Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eCurrent Eating Disorder Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e24 (58.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eNo Eating Disorder symptoms, but do not identify as in recovery or recovered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e2 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eNo Eating Disorder symptoms, in recovery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e9 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eNo Eating Disorder symptoms, fully recovered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e6 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEating Disorder Duration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003e7 - \u0026lt;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e10 (24.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003e10 - \u0026lt;15 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e9 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003e15 - \u0026lt;20 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e13 (31.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003e20 - \u0026lt;25 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e5 (12.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003e25 - \u0026lt;30 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003e30 - \u0026lt;40 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e3 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEating Disorder Diagnosis*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eAnorexia Nervosa (AN)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e29 (70.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eAtypical Anorexia Nervosa (AAN)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e9 (22%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eBulimia Nervosa (BN)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e12 (29.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eBinge Eating Disorder (BED)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e7 (17.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eAvoidant/Restrictive Food Intake Disorder (ARFID)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e6 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eOther Specified Feeding or Eating Disorder (OSFED)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e3 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEating Disorder Examination Questionnaire (EDE-Q) Scores\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eGlobal EDE-Q Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e\u003cem\u003eM\u003c/em\u003e = 3.12 (\u003cem\u003eSD\u003c/em\u003e = 1.66),\u0026nbsp;\u003cbr\u003e\u0026nbsp;Min-Max: .00\u0026ndash;5.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eEDE-Q Restraint Subscale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e\u003cem\u003eM\u003c/em\u003e = 3.03 (\u003cem\u003eSD\u003c/em\u003e = 1.87)\u003cbr\u003e\u0026nbsp;Min-Max: .00-6.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eEDE-Q Eating Subscale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e\u003cem\u003eM\u003c/em\u003e = 2.56 (\u003cem\u003eSD\u003c/em\u003e = 1.66),\u003cbr\u003e\u0026nbsp;Min-Max: .00-5.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eEDE-Q Shape Subscale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e\u003cem\u003eM\u003c/em\u003e = 3.52 (\u003cem\u003eSD\u003c/em\u003e = 1.83),\u003cbr\u003e\u0026nbsp;Min-Max: .00-6.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eEDE-Q Weight Subscale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e\u003cem\u003eM\u003c/em\u003e = 3.34 (\u003cem\u003eSD\u003c/em\u003e = 1.78),\u003cbr\u003e\u0026nbsp;Min-Max: .00-6.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment Seeking\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eHave Sought Treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e37 (90.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eHave Not Sought Treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e4 (9.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTypes of Treatment Sought*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003ePublic In-patient**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e19 (46.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003ePrivate In-patient**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e22 (53.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003ePublic Out-patient**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e17 (41.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003ePrivate Out-patient**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e19 (46.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eDay Program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e16 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eTherapy (Psychologist, Counsellor, Mental Health Worker)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e31 (75.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eDietetics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e30 (73.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eMedical Intervention (General Practitioner or Psychiatrist)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e25 (61%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003ePeer Support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e10 (24.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eEating Disorder Coach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e11 (26.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eGroup Support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e13 (31.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eCommunity Support Organisations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e16 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 63.1933%;\"\u003e\n \u003cp\u003eOther (not specified)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 36.8067%;\"\u003e\n \u003cp\u003e7 (17.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u0026nbsp;\u003cbr\u003e\u0026nbsp;*Participants could select multiple cultural backgrounds, multiple diagnoses over their eating disorder life cycle and multiple treatment types sought. As multiple selections were allowed, percentages do not sum to 100%.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e** In the Australian healthcare context, public services refer to government-funded treatment programs accessible through the public health system (often at no or reduced cost), whereas private services refer to those accessed through private health insurance or out-of-pocket payment.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants identified a range of barriers and facilitators influencing access to and engagement with ED treatment. The most commonly reported barriers were financial inaccessibility and invalidating clinician interactions. In contrast, the most frequently endorsed facilitators of treatment engagement included empathy and understanding from treatment providers and the presence of a supportive clinician. A summary of all reported barriers and facilitators is provided in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 Summary of Perceived Barriers and Facilitators\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarriers to Treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eCost of Treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e29 (70.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eInvalidation by Treatment Providers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e25 (61.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eLong Wait Times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e22 (53.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eStigma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e21 (51.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eSingle Focus on Weight or BMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e20 (48.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eServices Focused on Adolescents, Not Adults\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e19 (46.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eLack of Specialised Services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e18 (43.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eRigid Criteria for Treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e18 (43.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eManualised Therapy (lack of person-centred care)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e16 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eGeographical Distance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e13 (31.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cem\u003eOther Barriers Identified by Participants (provided in free text box)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eTrauma and Negative Treatment Experiences\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e6 (14.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003ePractical Barriers (Work, Study, Life Commitments)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e3 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eParental Neglect and Early Life Factors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e3 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eInternal Barriers (Shame, Lack of Awareness of ED\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e2 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eBarrier: Lack of Neurodivergent Care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFacilitators\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eEmpathy and Understanding from Treatment Providers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e27 (65.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eSupportive Clinician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e24 (58.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eFamily and Friend Supports\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e23 (56.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eTailored Treatment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e19 (46.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003ePositive Treatment Experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e19 (46.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eAccessible Location\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e12 (29.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003ePersonalised Care Plan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e16 (39%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eCollaboration Across Treatment Providers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e15 (36.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eFinancial Support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e12 (29.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eAccess to Recovered Lived Experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e11 (26.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 100%;\"\u003e\n \u003cp\u003e\u003cem\u003eOther Facilitators Identified by Participants (provided in free text box)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eClinician-Related Factors (Understanding Trauma, Checking in)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e2 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003ePolicy and Systemic Factors (Medicare, Telehealth)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e2 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eOther Community and Peer Support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e2 (4.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 66.0566%;\"\u003e\n \u003cp\u003eFinancial Privilege\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.9434%;\"\u003e\n \u003cp\u003e1 (2.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eThis table presents barriers and facilitators reported by participants. As multiple selections were allowed, percentages do not sum to 100%.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Phase\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo overarching themes were identified, each comprising multiple subthemes that represent the intersecting structural, clinical, interpersonal, and identity-related factors influencing participants\u0026rsquo; access to care, engagement with treatment, and trajectories of recovery. These include: \u003cem\u003e(1) Barriers to Care\u003c/em\u003e, encompassing diagnostic and conceptual barriers, weight-based exclusion and bias, access and equity issues, coercive treatment practices, and treatment misalignment; and \u003cem\u003e(2) Facilitators of Engagement and Recovery\u003c/em\u003e, which comprised of compassionate, individualised and trauma-informed care, peer connection and support, and advocacy and lived experience contribution. Participant quotes illustrating each subtheme are presented in Table 3.\u0026nbsp;\u003c/p\u003e\u003cp\u003eTable 3: Themes and Relevant Participant Quotes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"1021\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuote Number\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIllustrative Quote\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eParticipant ID and Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 1021px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 1 Barriers to Care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 1021px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSubtheme 1.1 Systemic Exclusion and Constraints\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 1021px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e1.1.1 Diagnostic and Conceptual Exclusion\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I felt like people\u0026rsquo;s eyes rolled when they were like, \u0026lsquo;Oh, here\u0026rsquo;s another one\u0026hellip; she\u0026rsquo;s got BPD but thinks she has an eating disorder.\u0026rsquo;\u0026hellip;\u003c/em\u003e \u003cem\u003eFinancial barriers weren\u0026apos;t my issue; it was being given the BPD label almost immediately. This diagnosis became a huge barrier, causing clinicians, psychologists, and psychiatrists to not take my distress seriously.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 1, female, age 32, AN and BN diagnoses, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I was labelled with BPD, and it clouded every clinician\u0026apos;s judgment. They saw \u0026apos;borderline\u0026apos; and assumed I was manipulative. They didn\u0026apos;t recognise trauma or distress; everything was immediately seen as attention-seeking behaviour.\u003c/em\u003e \u003cem\u003eI wasn\u0026apos;t even informed about the diagnosis initially, yet it drastically affected how I was treated in emergency rooms and inpatient settings \u0026hellip;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eIf someone had done even minimal digging, they\u0026apos;d realise it was undiagnosed neurodivergence and an out-of-control eating disorder. Instead, I ended up being restrained, sedated, and labelled as borderline for simply being distressed.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 5, female, age 29, AN, AAN and ARFID diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;They didn\u0026rsquo;t even properly assess me; they just slapped labels on me that didn\u0026apos;t fit. It took years to finally be properly diagnosed, and in the meantime, I was treated as difficult and resistant\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 8, non-binary, age 32, AN and ARFID, not currently experiencing eating disorder but not yet recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;No one ever sat me down and was like, \u0026apos;Right, here are the criteria for BPD, let\u0026rsquo;s see if you meet them.\u0026apos; It was just like, you\u0026rsquo;ve got this one behaviour [cutting], therefore you\u0026rsquo;ve got this diagnosis\u0026hellip; If someone had just dug a little deeper, they would have seen that I was struggling with being autistic and ADHD. But instead, they decided I was just being \u0026lsquo;difficult\u0026rsquo;.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 33, any gender, age 43, AAN, BN and OSFED, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip;the psychiatrist tried diagnosing me with borderline. My parents were pulled into a meeting, confused and asking what borderline even meant. It didn\u0026apos;t fit my actual issues; PTSD, anxiety, and disordered eating. This misdiagnosis severely impacted my treatment. Once labelled as BPD, everything about my eating disorder and trauma was minimised.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 27, female, age 33, AN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I have BPD on my record, and I\u0026apos;ve been discharged early because they assume I\u0026apos;m just wanting attention and care, which isn\u0026apos;t the case. My psychologist thinks it\u0026apos;s more likely complex trauma, but clinicians see \u0026apos;BPD\u0026apos; and immediately treat me differently.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 9, female, age 26, AN and AAN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;My psychologist explicitly said, \u0026apos;No, she doesn\u0026apos;t have BPD,\u0026apos; which significantly impacted my treatment. Before that, every clinician assumed my distress meant borderline personality.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 47, female, age 55, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I have ADHD and severe anorexia, and I\u0026apos;ve constantly been described as \u0026apos;treatment-resistant.\u0026apos; But the reality is that the treatments offered didn\u0026apos;t accommodate neurodiversity. They used rigid meal plans and expected executive functioning I didn\u0026apos;t have. Each time I withdrew because the programs didn\u0026rsquo;t adapt, clinicians used my withdrawal as proof I was resistant.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 32, female, age 45, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Clinicians have frequently said they suspect autism, but they keep telling me, \u0026apos;You can\u0026apos;t know until you\u0026apos;ve recovered from your eating disorder.\u0026apos; Meanwhile, my distress or sensory issues get labelled as personality problems, which makes treatment harder.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 29, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003eThey wouldn\u0026rsquo;t diagnose me [with autism] because I had an eating disorder.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 30, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I\u0026apos;ve repeatedly been told I\u0026apos;m \u0026apos;treatment resistant\u0026apos; and basically been sent off to handle things myself. Clinicians seemed to give up easily because my symptoms didn\u0026apos;t neatly fit their categories or expectations.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 26, female, age 33, AN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I was when I was last inpatient\u0026hellip; my psychiatrist wanted me to get an assessment for ADHD, but I wasn\u0026rsquo;t allowed to undergo the assessment because of my anorexia.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 23, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 1021px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e1.1.2 Weight-Based Exclusion and Bias\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I went to the doctor feeling dizzy and weak, and he told me, \u0026apos;You meet all the criteria for anorexia [bar BMI], but I can\u0026apos;t diagnose you with that.\u0026apos; It felt like he was protecting his reputation. Without the diagnosis, I wasn\u0026apos;t able to access treatment. I was left unsure of what to do next.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 50, female, age 21, AAN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The first time I tried to seek help\u0026hellip; I knew that I\u0026apos;d wanted to bring up my eating for a while. And then when I did, [the psychologist] told me pretty much instantly, \u0026lsquo;You don\u0026rsquo;t have an eating disorder\u0026rsquo;\u0026hellip; \u0026lsquo;You\u0026rsquo;re not malnourished, you\u0026rsquo;re fine.\u0026rsquo;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 6, female, age 26, AN and ARFID diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I was considered on the upper end of a healthy body weight, it kept getting pushed under the rug that I could potentially have an issue. My eating problems were never taken seriously because I was a \u0026apos;healthy weight.\u0026apos; \u0026hellip; By the time I was finally recognised as having an eating disorder, I was severely underweight and medically unstable.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 13, female, age 29, AN, AAN and BN diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Just because a person hasn\u0026apos;t been hospitalised or doesn\u0026apos;t have an extremely low weight doesn\u0026apos;t mean it\u0026apos;s not severe. Personally, I\u0026apos;ve struggled significantly with bulimia, exercising excessively, and using laxatives daily for years, but wasn\u0026apos;t able to get appropriate help because my weight didn\u0026apos;t reflect the stereotypical image of severity.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 4, female, age 35, BN diagnosis, in recovery.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;As a male with an eating disorder, my weight loss was overlooked for a long time. People didn\u0026rsquo;t see the severity because they expect eating disorders to present a certain way. The lack of obvious, stereotypical low weight delayed my treatment significantly\u0026hellip; I was told, \u0026lsquo;Binge eating isn\u0026rsquo;t serious\u0026rsquo;\u0026hellip; so I didn\u0026rsquo;t qualify for help\u0026hellip;they told me it [bingeing] was just a moral failing. No one ever looked at why I was doing it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 42, male, age 29, BN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I was diagnosed with atypical anorexia, despite exercising obsessively; five hours of cardio daily, plus weights and compulsive movement. But because my weight loss wasn\u0026apos;t initially dramatic enough, my condition was downplayed. \u0026nbsp;Clinicians often minimize it if your BMI doesn\u0026apos;t match their perception of severity\u0026hellip; The eating disorder statistics would be higher in males if we weren\u0026apos;t consistently misdiagnosed. If you\u0026apos;re male and distressed, clinicians tend to see personality issues or resistance rather than actual suffering.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 45, male, age 28, AN diagnosis, not currently experiencing eating disorder but not yet recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003eEverything revolved around BMI numbers and rigid surveillance. The psychiatrist abruptly discharged me with false promises, and when I didn\u0026apos;t meet their strict BMI criteria, I was refused re-entry to treatment, worsening my distress significantly.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 27, female, age 33, AN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Because I was in a healthy body, I wasn\u0026apos;t taken seriously. Being at a \u0026apos;healthy BMI\u0026apos; was reinforced over and over as proof I was fine.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 9, female, age 26, AN and AAN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;A psychiatrist once told me bluntly that my weight was too high for someone with an eating disorder. She didn\u0026apos;t understand my distress or behaviours at all. Her advice was to \u0026apos;eat bland food,\u0026apos; and I never returned because it was humiliating.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 40, female, age 30, AN diagnosis, in recovery.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 1021px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e1.1.3 Structural Access and Equity Barriers\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;My family moved to remote WA... I was left medically unstable for most of my teenage years without access to formal mental health support.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 27, female, age 33, AN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I had to leave Perth\u0026hellip; so I moved to Newcastle, two hours from Sydney, quite a regional area. My first interaction with services was through an emergency department in a regional hospital that had very limited knowledge about eating disorders or refeeding. They were completely unequipped, and it really impacted my treatment negatively.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 5, female, age 29, AN, AAN and ARFID diagnoses, current eating disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Geographical distance was a massive barrier for me. I resorted to online research and communication because physical access to professional care was so limited. Even hospital visits were difficult to manage due to the long distances involved.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 10, male, age 40, BED diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It was pretty much couched as, \u0026lsquo;Oh, you\u0026apos;re not sick enough for a higher level of care.\u0026rsquo; So you\u0026apos;ll just have to wait, because the waiting lists are really long at the moment.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 6, female, age 26, AN and ARFID diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Some significant barriers for my care were definitely cost and long wait times. The expense of treatment and the difficulty accessing services because of waiting lists made consistent care almost impossible for me\u0026hellip; I didn\u0026rsquo;t have private cover, so I was told to go to the emergency department. That\u0026rsquo;s not care. That\u0026rsquo;s crisis management \u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 20, female, age 21, AN and ARFID diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The waitlists were huge\u0026hellip; and even when I got to see someone at uni, they said, \u0026lsquo;We don\u0026rsquo;t really deal with this\u0026hellip; I didn\u0026rsquo;t know where to start\u0026hellip; I was scared to waste time and money on someone who wouldn\u0026rsquo;t understand.\u0026rsquo;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 31, female, age 34, BN diagnosis, in recovery.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;There was nowhere for me to go when I got out. No follow-up, no outpatient, nothing close. I was just expected to be better.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 23, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Treatment was inaccessible because of cost. My trust in healthcare was undermined because support simply wasn\u0026rsquo;t affordable.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 50, female, age 21, AAN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I had to pay upfront, and the only way I could afford it was by working full-time while studying full-time...\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 27, female, age 33, AN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s $5,000 a week. Some [people] had their parents paying for it. I had to find that myself. That\u0026rsquo;s extreme.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 25, female, age 37, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Being male, I\u0026rsquo;ve faced additional stigma in accessing treatment, but the financial resources required to get professional support have always been a huge barrier. Without adequate financial backing, proper treatment has been out of reach.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 43, male, age 36, BED diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The cost of recovery is massive, especially if you\u0026apos;re navigating between private and public systems. Without adequate financial resources, it\u0026apos;s almost impossible to receive the compassionate, individualised care necessary for recovery\u0026hellip; My parents remortgaged their house to send me to treatment interstate.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 13, female, age 29, AN, AAN and BN diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;My GP didn\u0026apos;t even know about the eating disorder care plan, which created a significant financial burden.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 45, male, age 28, AN diagnosis, not currently experiencing eating disorder but not yet recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Financial barriers have significantly impacted my treatment journey. The difference in quality between public and private treatment was huge, but without the funds, you\u0026rsquo;re stuck relying on the public system, which can be invalidating and traumatising.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 9, female, age 26, AN and AAN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;It was like being punished for where I lived and how much money we didn\u0026rsquo;t have...\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 32, female, age 45, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;It felt like the system was saying I wasn\u0026rsquo;t worth the resources. That if I couldn\u0026rsquo;t pay, I didn\u0026rsquo;t matter.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 26, female, age 33, AN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Not everyone has access\u0026hellip; to give every single treatment a six-month go.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 33, any gender, age 43, AAN, BN and OSFED, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I had to give up my studies because I couldn\u0026rsquo;t get help when I needed it. Everything just spiralled from there.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 21, female, age 27, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Financial challenges significantly impacted my ability to access care, especially given my shift work as a nurse. Cultural expectations compounded financial pressures, limiting my treatment options and making me hesitant to seek help openly.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 44, female, age 35, AN and BED diagnoses, in recovery.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I tried to get help\u0026hellip; saw my GP and got a referral\u0026hellip; but I didn\u0026rsquo;t hear anything from [the hospital]. Not even a \u0026lsquo;sorry we can\u0026rsquo;t fit you in.\u0026rsquo; Just radio silence\u0026hellip; I think if I looked different, like if I was thinner or a woman, it might have been taken more seriously.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 42, male, age 29, BN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;We need proper outpatient pathways, especially for regional people. Not just discharge and good luck\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 37, female, age 26, BN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 1021px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSubtheme 1.2: Harmful and Disempowering Treatment Experiences\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 1021px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSubtheme 2.1 Coercion, Control and Loss of Autonomy\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Adult treatment was incredibly traumatic, involving restrictive practices, frequent restraints, and forced medication. Each admission was terrifying, and the constant fear of being restrained or sedated increased my trauma and made engaging in treatment impossible... I experienced daily restraints, forced nasogastric tubes, and medication against my will. This fear-based approach was horrific. It was treatment through trauma; an experience that significantly heightened my distress and trauma responses.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 29, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Adult treatment was incredibly traumatic, involving nightmares I still have today. It involved a lot of restrictive practices, restraint, forced medication; really ugly, horrible things that went on repeatedly during my admissions.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 30, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;A nurse got her [a fellow patient] to stand up in front of the whole eating room and said, \u0026lsquo;I just want to point out that she hasn\u0026rsquo;t finished her butter, so I\u0026rsquo;m going to make her lick it out in front of everyone\u0026rsquo;... It was public humiliation. I said, \u0026lsquo;No normal person would be forced to do that.\u0026rsquo; They genuinely believed we had chosen to starve ourselves, so we should carry the burden of that.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 14, female, age 36, AN, AAN, ARFID and OSFED diagnoses, in recovery.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I would have panic attacks. I\u0026apos;d try to find a small, safe place, usually the bathroom. But some nurses would threaten me, assuming I\u0026apos;d harm myself, and they\u0026apos;d call security to forcibly drag me out. If they did, I\u0026apos;d rip my NG tube out; it felt like my only control. Security would then restrain me, wheel me to radiology, hold me down forcibly, and replace the NG tube. It was traumatic, dehumanising, and increased my distress enormously... I\u0026rsquo;ve been told that so many times it\u0026apos;s ridiculous\u0026hellip; \u0026lsquo;you\u0026rsquo;re treatment resistant\u0026rsquo; or \u0026lsquo;you\u0026rsquo;re too complex.\u0026rsquo;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 23, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eThe rigidity of hospital rules stripped away autonomy completely, making me feel less than human\u003c/em\u003e\u0026hellip; \u003cem\u003eIt\u0026apos;s just a recipe for disaster. Approaching treatment with threats and feeling very monitored made me close up completely, build resistance, and ultimately not want help at all\u003c/em\u003e \u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 20, female, age 21, AN and ARFID diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eThey locked the bathrooms for weeks at a time... Nurses would stand outside listening. It was humiliating. I felt like less than a child\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 18, female, age 37, AN diagnosis, in recovery.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Everything was dictated to me in hospital; sit here, be watched by nurses, drink this, eat now. The constant surveillance and intense monitoring created an atmosphere of extreme distress and anxiety\u0026hellip; They told me I was chronic, and that meant I wasn\u0026rsquo;t ready for treatment. But I was. I just wasn\u0026rsquo;t what they wanted me to be\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 32, female, age 45, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;You had to eat six meals a day and put on weight, or you didn\u0026rsquo;t belong in the program. There\u0026rsquo;s no room for struggle.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 47, female, age 55, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The structured eating plan I was placed on felt incredibly rigid and unrealistic. There was no room for flexibility or individualised adjustments. It made compliance impossible, which led clinicians to label me as non-compliant rather than understanding the genuine barriers.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 49, female, age 33, BED diagnosis, in recovery.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The thing I hated the most about my inpatient stay was going into that room twice a week with all those professionals, who would just rip shreds off you. It was so humiliating. I had so much anxiety about it. One day, I just got up, walked out of the room, ran away, and hid. That\u0026apos;s not how a woman in her 50s should be behaving, but I just felt so stupid and humiliated that I had to escape.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 46, female, age 56, AN and BN diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eHospitalisation was incredibly controlling. The rules felt suffocating. I understand why structure might help some, but it felt like control was more important to clinicians than actually addressing my needs or understanding the reasons behind my behaviours.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 45, male, age 28, AN diagnosis, not currently experiencing eating disorder but not yet recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;There\u0026apos;s a barrier system around me now due to fear of stigma and negative reactions from people. This fear has made me internalise everything, trying to cope alone rather than risk judgement or overly intrusive monitoring.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 37, female, age 26, BN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;In treatment, there\u0026apos;s always an underlying fear of compulsory treatment orders. The constant feeling of surveillance and being monitored creates a distressing atmosphere that makes it hard to be honest or open about what\u0026apos;s truly going on.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 41, female, age 22, AN, AAN, BN and BED diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eAfter those admissions, I became terrified of hospitals. I avoid reaching out now, even when I really need help\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 13, female, age 29, AN, AAN and BN diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 1021px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e1.2.2 Misalignment Between Treatment Models and Patient Needs\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The protocol is the most rigid and traumatic thing I\u0026apos;ve ever experienced. You have to be medically critical to access it, but once admitted, everyone undergoes a fixed eight-day NG feeding regime, regardless of individual needs or trauma histories. That\u0026apos;s not trauma-informed, it\u0026apos;s trauma-inducing.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 29, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The structured nature of it didn\u0026apos;t help; it actually amplified my feelings of failure and distress.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 42, male, age 29, BN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I sat in hospital for months and months, not really having any idea of what happens next\u0026hellip; I wasn\u0026rsquo;t an active participant in my own treatment.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 1, female, age 32, AN and BN diagnoses, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;It felt like I kept failing the programs, when really they were failing me. The treatment models didn\u0026rsquo;t recognise my needs around trauma, sensory processing, or my neurodivergence. It was demoralising and isolating.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 21, female, age 27, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Structured programs always seemed to overlook the emotional or mental aspects of my eating issues. Treatment focused purely on control around eating, which didn\u0026apos;t address my underlying distress. The strict focus on food and rules only made me feel more isolated.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 43, male, age 36, BED diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;When I expressed frustration at treatment not addressing my needs, the response was always, \u0026apos;This is typical borderline behaviour.\u0026apos; No one considered my sensory issues or that the interventions were inappropriate for someone who\u0026rsquo;s autistic. They insisted on one-size-fits-all methods and then blamed me for the treatment failing.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 8, non-binary, age 32, AN and ARFID, not currently experiencing eating disorder but not yet recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The treatment was built around compliance and strict behavioural targets rather than compassion or understanding. My attempts to articulate my unique needs were dismissed as resistance.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 26, female, age 33, AN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m older. I didn\u0026rsquo;t need that much control. They didn\u0026rsquo;t meet me where I was. There was no flexibility based on my stage of life or my needs.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 25, female, age 37, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I was still trying to work and, like, do life\u0026hellip; but the therapist said, \u0026lsquo;You\u0026rsquo;re not prioritising this.\u0026rsquo;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 9, female, age 26, AN and AAN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t experience hunger and fullness in the same way that neurotypical people do\u0026hellip; but no one\u0026rsquo;s really thought about how to cater to neurodiverse people.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 6, female, age 26, AN and ARFID diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I was being forced into this treatment that was designed for neurotypical people\u0026hellip; everything was about body image, but that wasn\u0026rsquo;t really my core issue.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 30, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Treatment didn\u0026rsquo;t really accommodate the fact I had autism\u0026hellip; everything was about motivation and insight\u0026hellip; but sometimes I just couldn\u0026rsquo;t process the task the way they wanted.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 22, female, age 27, AN, AAN, BN and ARFID diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Every gate failed\u0026hellip; CBT was her [psychologist] approach, but CBT is not working.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 33, any gender, age 43, AAN, BN and OSFED, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;[I was] outpatient at a clinic that focused mainly in CBT-E, but I did not respond to CBT-E\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 7, female, age 32, An and AAN diagnoses.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;We went to the same therapy everyone else did and that was just your standard. Like introduction to CBT, recycle, recycle, recycle, recycle, nothing that was tangible.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 8, non-binary, age 32, AN and ARFID, not currently experiencing eating disorder but not yet recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It [CBT-E] just does not work [for SEED].\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 23, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Eating disorder treatment is very CBT, very gaslight-y. It\u0026rsquo;s like, \u0026lsquo;Have you just thought about not being that way? Have you just thought about eating?\u0026rsquo; That kind of response becomes a huge barrier, because you know that\u0026rsquo;s what you\u0026rsquo;re going to be met with, and you also know it doesn\u0026rsquo;t work\u0026hellip;It makes you feel like your experiences aren\u0026rsquo;t real, you\u0026rsquo;re just being gaslit. So you stop wanting to access treatment altogether. You go and sit in the dietitian\u0026rsquo;s chair and say, \u0026lsquo;Yep, yep, I\u0026rsquo;ll do that. I\u0026rsquo;ll keep a food diary.\u0026rsquo; And then you come back the next week with a forged food diary and say, \u0026lsquo;Yep, I did it.\u0026rsquo; And then you leave again. It\u0026rsquo;s just the same shit. It\u0026rsquo;s not helpful.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 26, female, age 33, AN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It [CBT] was very manualised treatment. I felt like, \u0026lsquo;This is what we\u0026rsquo;ve got to offer; take it or leave it.\u0026rsquo; It was based on cognitions and behaviours, and it really failed to account for the range of emotions I was experiencing. There was such a strong emphasis on making a link between thoughts and behaviours, but it didn\u0026rsquo;t actually help me bridge the gap between knowing what I was doing and knowing how to change it. I was left without the tools to make real change. It felt very black-and-white, rigid and simplified, when what I actually needed was something more nuanced and supportive.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 29, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;There was no consideration of my trauma history, just food and weight, food and weight\u0026hellip; It felt like everything I said was used as evidence against me being \u0026lsquo;non-compliant.\u0026rsquo;\u0026rdquo;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 16, female, age 34, AN, BN and OSFED diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 1021px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 2 Facilitators of Engagement and Recovery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 1021px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSubtheme 2.1 Compassionate, Individualised and Trauma-Informed Care\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s really important to find people who see you as a person. That\u0026rsquo;s what made the difference\u0026hellip; even made me feel like a human again.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 25, female, age 37, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I remember a social worker asking my mum in therapy, \u0026lsquo;Why is she in hospital?\u0026rsquo; and then saying, \u0026lsquo;We don\u0026rsquo;t admit people for the sake of it, she is really unwell.\u0026rsquo; That was the first time someone said something like that to me, and to her.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 1, female, age 32, AN and BN diagnoses, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;My social worker knows exactly how much she can push me without pushing me over the edge, which creates a real sense of safety and trust. Having someone who understands trauma and how to navigate it compassionately changed everything for me.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 29, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;When my clinician recognised and adapted to my sensory sensitivities and trauma responses, it made treatment feel safe and accessible. It was the first time I felt truly understood in a clinical setting.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 18, female, age 37, AN diagnosis, in recovery.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I had a dissociative panic attack, and this psychologist\u0026hellip;she came and sat with me for almost an hour just trying to get me out of that dissociative state. We didn\u0026apos;t talk initially; she just sat down with some pens and paper, and we drew next to each other. Slowly, as I came out of it, we could talk a bit about what had happened. By the end, I was feeling okay. That was rare... Experiences like that were really useful. It was those clinicians who saw you, not doing treatment by the book, but just seeing you where you were, listening, providing empathy, and just being human for a bit\u0026hellip;.\u003c/em\u003e \u003cem\u003eThere was one support worker who just asked, \u0026lsquo;What does safety mean to you?\u0026rsquo; I nearly cried.\u0026rdquo;\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 16, female, age 34, AN, BN and OSFED diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I did find one GP who just sat and listened. Didn\u0026rsquo;t rush me. Didn\u0026rsquo;t ask for numbers. Just asked what I needed\u0026hellip;Having professionals who treated me with compassion and as an equal partner was incredibly healing. It restored my faith in healthcare providers and motivated me to keep engaging.\u0026quot;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 42, male, age 29, BN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;It wasn\u0026rsquo;t until I had a psychologist who said, \u0026lsquo;It\u0026rsquo;s okay. I\u0026rsquo;m not going to dob on you. I see you, and that\u0026rsquo;s okay\u0026rsquo;\u0026hellip; That changed everything. After such a long time feeling like therapy was a threat, I finally felt like I could trust someone.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 23, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eMy therapist genuinely listened and believed me. Instead of forcing rigid plans, she helped me articulate my needs and build a recovery plan that felt manageable and respectful.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 27, female, age 33, AN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Even though I didn\u0026apos;t know I was neurodivergent at the time, my psychologist was flexible enough not to force me into treatment boxes... That flexibility felt empowering, she wasn\u0026rsquo;t trying to make me fit into a box, just offering support tailored to me.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 33, any gender, age 43, AAN, BN and OSFED, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s supportive and feels safe, especially considering my autism. Even though inpatient treatment can be incredibly challenging, having a team that genuinely understood me and adapted the approach to my needs made such a significant difference.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 22, female, age 27, AN, AAN, BN and ARFID diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;It was that neurodiverse approach that made it the most successful admission I had out of all of them. It built trust and helped me actually want to work with the clinicians.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 20, female, age 21, AN and ARFID diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;One psychologist recognised that my struggles weren\u0026apos;t typical, that my eating disorder wasn\u0026apos;t about\u0026hellip;body image. She saw my uniqueness and was willing to adapt the program specifically for me. I had to advocate a bit, but once they tailored it, removing rigid weight gain requirements, I felt heard. This flexibility was key to engaging with treatment again\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 32, female, age 45, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 1021px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSubtheme 3.2 Peer Support and Connection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I knew that a friend of mine who I\u0026apos;d studied with had had an eating disorder when she was a teenager\u0026hellip; she was someone I could speak to about it, and she was pretty instrumental in me going, \u0026lsquo;No, I can actually go to my GP, regardless of what the psych has said.\u0026rsquo;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 6, female, age 26, AN and ARFID diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003ePeer support gave me a space where I could be me; my neurodivergence and trauma weren\u0026rsquo;t questioned or pathologised. It was empowering to find people who truly understood my experiences without judgment\u0026hellip;\u003c/em\u003e \u003cem\u003eIt\u0026rsquo;s just where I found my community \u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 30, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eConnecting with others who had similar experiences created a profound sense of belonging and reduced feelings of shame and isolation. These connections gave me hope that recovery was possible and achievable\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 21, female, age 27, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;You lose so many people through this [eating disorders]. It\u0026rsquo;s isolating. But at residential, I saw people who had recovered, and I thought, \u0026lsquo;Maybe this is possible.\u0026rsquo;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 25, female, age 37, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eAfter I was repeatedly turned away from clinical treatment, I ended up joining a support group. That group changed everything for me. It wasn\u0026rsquo;t clinical, it was peer-led, and it felt like the first time I could speak openly without being judged or dismissed\u0026hellip;People just got it. The validation I received there was more helpful than anything I\u0026rsquo;d gotten from clinicians up to that point. It helped me understand that I wasn\u0026rsquo;t alone, and that what I was experiencing wasn\u0026rsquo;t irrational; it was real, and shared by others who had been through similar struggles\u0026hellip; Through peer support, I learned strategies and coping skills that felt realistic and relatable. It bridged the gap left by formal treatments, providing emotional understanding and practical advice\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 32, female, age 45, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003e\u0026quot;It was peer support that helped me reframe recovery on my own terms. It wasn\u0026apos;t about being compliant; it was about being real, and being safe enough to want to stay alive\u0026hellip; The friendships I formed through peer support groups provided ongoing emotional support and motivation, reinforcing my commitment to recovery even when clinical services were inaccessible or insufficient\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 26, female, age 33, AN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I read stories online where people had the same symptoms as me\u0026hellip; it made me feel less broken\u0026hellip; Reading people\u0026rsquo;s blogs helped me feel seen. I want to do that for someone else one day.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 31, female, age 34, BN diagnosis, in recovery.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The lived experience community was really important to me. We could plan our lives together\u0026hellip; people had futures; one was going to med school, one doing a PhD\u0026hellip; It helped me think beyond the eating disorder.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 1, female, age 32, AN and BN diagnoses, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I really found peer mentoring helpful. Talking to someone who had been through it, who genuinely understood, was such a comfort. It was different from talking to a clinician. It made me feel less alone and gave me hope that recovery was possible, even when I felt stuck.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 46, female, age 56, AN and BN diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The most helpful support I got wasn\u0026rsquo;t always from professionals, it was from others who had gone through similar experiences. Just being able to talk honestly in support groups, without needing to explain every little thing, was a huge relief.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 4, female, age 35, BN diagnosis, in recovery.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I was constantly being judged in hospital. I only started to feel like recovery was possible when I met someone who had been through it too. It made me feel seen for the first time.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 27, female, age 33, AN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 1021px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSubtheme 2.3 Integration of Lived Experience and Advocacy\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I only just started recovery last year, but I\u0026rsquo;ve been thinking about studying psychology. Maybe working with eating disorders, or just being someone people can talk to\u0026hellip; The compassionate care I received inspired me... I want to support others by providing the same respectful and trauma-informed treatment I was lucky enough to experience.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 24, no gender, age 24, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;My recovery was significantly shaped by clinicians who saw me as a whole person. This experience motivated me to study psychology so I can offer similar empathy and understanding to others struggling\u0026hellip;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003eI had to fight so hard to be taken seriously. The misdiagnosis, the dismissive attitudes\u0026hellip; it made me want to work in mental health to make sure others don\u0026rsquo;t have to go through what I did.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 37, female, age 26, BN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e101\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I envision doing something in the field one day. I want to build a facility that truly meets people where they\u0026rsquo;re at. Recovery shouldn\u0026apos;t be a privilege.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 25, female, age 37, AN diagnosis, current eating disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e102\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;m studying medicine now\u0026hellip; because I know how deeply physical and mental health are connected. I want to be the kind of doctor that listens.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 43, male, age 36, BED diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e103\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Experiencing genuinely compassionate, trauma-informed care changed my life\u0026hellip; I advocate strongly for more widespread adoption of these practices, knowing firsthand their transformative potential\u003c/em\u003e.\u0026quot;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 14, female, age 36, AN, AAN, ARFID and OSFED diagnoses, in recovery.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;Being treated with genuine empathy and respect made all the difference in my recovery. It not only helped me heal but also shaped my vision of what good care looks like, motivating me to actively participate in changing clinical practices.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 9, female, age 26, AN and AAN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think about being a peer worker sometimes\u0026hellip; maybe there\u0026rsquo;s a way to stop someone else from going through what I did.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 42, male, age 29, BN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I want to use my lived experience to advocate for more compassionate and inclusive treatment environments\u0026hellip;\u003c/em\u003e \u003cem\u003eto be that person in between a therapist and a lived experience support. Someone who can let others speak freely and feel heard. Especially for men, because we\u0026rsquo;re still not seen.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 45, male, age 28, AN diagnosis, not currently experiencing eating disorder but not yet recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think it probably has a lot to do with my own struggles and wanting to make a difference myself\u0026hellip; wanting to be the person that perhaps makes a difference\u0026hellip; not having people struggle for as long.\u0026rdquo;\u003c/em\u003e [on being a psychologist]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 40, female, age 30, AN diagnosis, in recovery.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think just really passionate about changing the way the system operates\u0026hellip; improving care for people like myself\u0026hellip; I\u0026apos;m a part of probably about 10 advisory groups at the moment\u0026hellip; just having my voice heard and being able to speak out and advocate about myself, but also learning about myself\u0026hellip; The advocacy space, both mental health and disability, it\u0026apos;s the first time I\u0026apos;ve actually ever understood what community means.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 30, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e109\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s not advocacy in the formal sense, but I think when you share your story in a safe way, it helps people. That matters to me.\u0026rdquo; [on sharing their lived experience journey]\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 16, female, age 34, AN, BN and OSFED diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Because I\u0026rsquo;m autistic myself\u0026hellip; I gravitate towards them [autistic clients]\u0026hellip; I want to help advocate for them; for us.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 22, female, age 27, AN, AAN, BN and ARFID diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I ended up writing the psychiatrist a letter at the end of my admission. I told him that compassion is what\u0026rsquo;s going to heal people. The system forces clinicians to compromise, but it\u0026rsquo;s that genuine compassion that changes lives. I think that\u0026rsquo;s why I want to go into this work.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 13, female, age 29, AN, AAN and BN diagnoses, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e112\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;The care I received from professionals who treated me as a person, not just a patient, completely changed how I thought about recovery. It made me want to become one of them, to do for others what they did for me.\u0026quot; [on studying nursing]\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 29, female, age 22, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;When I joined the sector, it was a really different place. I was in the space as a person with lived experience and no clinical background, and I always felt a bit vulnerable\u0026hellip; like I was just a peer worker. But it showed me how much the system needed people like us; to reflect the 20-year eating disorder I\u0026rsquo;d lived through. I\u0026rsquo;ve stayed in the field ever since.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 33, any gender, age 43, AAN, BN and OSFED, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e114\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I\u0026apos;m a social worker now, and I believe I\u0026apos;m a really key part of teams, though that\u0026apos;s still not commonly seen. I had a recovery coach at the beginning of my journey, and I think when used correctly, they can be a game-changer. We need more people with lived experience on these teams\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 26, female, age 33, AN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I\u0026apos;m writing a book of my recovery from anorexia\u0026hellip;. I\u0026apos;m also planning another book of art therapy work that I\u0026apos;ve done\u0026hellip;alongside my story.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 32, female, age 45, AN diagnosis, current eating disorder.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e116\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;[Becoming a psychologist] really changes how I see the system now. The invalidation I got, being seen as a revolving-door patient, those experiences are why I\u0026rsquo;m passionate about personalised, trauma-informed care. If I\u0026rsquo;d had that earlier, maybe things would have been different.\u0026quot;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 27, female, age 33, AN diagnosis, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 67px;\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 670px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026quot;I did experience a lot of frustration\u0026hellip;. But that frustration now feeds my desire to do things differently, to actually listen to people properly and not let them fall through the cracks like I did.\u0026quot; [on being a mental health professional]\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 227px;\"\u003e\n \u003cp\u003eParticipant 1, female, age 32, AN and BN diagnoses, fully recovered.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 1: Barriers to Care\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants articulated a complex pattern of interrelated barriers that impeded their ability to access timely, appropriate care for SEED. These barriers were not discrete or isolated, but were described as cumulative, pervasive, and structurally embedded, reflecting the sustained interaction of diagnostic, systemic, clinical, and sociocultural dynamics. Rather than representing singular points of resistance, these obstacles were experienced as chronic patterns of exclusion and invalidation, which undermined psychological safety, delayed treatment access, disrupted recovery trajectories, and eroded trust in healthcare systems. Participants repeatedly emphasised the enduring nature of these experiences, often spanning multiple care episodes and settings. This overarching theme comprises two interrelated subthemes: (\u003cem\u003e1) Systemic Exclusion and Constraints\u003c/em\u003e, which captures macro-level structural and conceptual factors limiting access and inclusion, and \u003cem\u003e(2) Harmful and Disempowering Treatment Experiences\u003c/em\u003e, which reflects barriers embedded within clinical practices and therapeutic environments. Each subtheme includes distinct sub-subthemes representing the nuanced mechanisms through which care was hindered or compromised.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSubtheme 1.1: Systemic Exclusion and Constraints\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.1.1 Diagnostic and Conceptual Exclusion\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost participants reported experiences of misdiagnosis or inadequate clinical conceptualisation that significantly impeded access to appropriate and effective care. A common pattern involved the premature or inappropriate application of Borderline Personality Disorder (BPD) diagnoses (Quotes 1-7). This was often in the absence of comprehensive assessment or due consideration of alternative or co-occurring explanations, such as neurodevelopmental conditions, complex trauma histories, or the enduring and multifaceted nature of their EDs. These forms of diagnostic overshadowing, where an individual\u0026rsquo;s ED symptoms or behaviours were misattributed to other co-occurring conditions (e.g., personality pathology, neurodevelopmental traits), or vice versa, were described as having profound implications for participants\u0026rsquo; trajectories through the healthcare system (Quotes 8-12). The attribution of BPD was frequently associated with exclusion from ED services, assignment to unsuitable treatment pathways, and stigmatising clinical encounters. Participants recounted instances in which their distress, emotional regulation difficulties, or interpersonal communication styles were pathologised as manipulative or attention-seeking. This was particularly pronounced among neurodivergent participants, who described how traits, such as sensory sensitivities, cognitive inflexibility, executive functioning difficulties, or social communication differences, were misunderstood and misattributed to personality pathology. Several participants noted that the prioritisation of ED symptomatology within care settings often precluded assessment or recognition of neurodevelopmental needs. In some cases, participants were explicitly informed that diagnostic clarification (e.g., ASD or ADHD assessment) could not proceed until their ED was resolved. Participants reported that such experiences were epistemically invalidating, compounding psychological distress and undermining confidence in the capacity of services to engage holistically with complex clinical presentations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.1.2 Weight-Based Exclusion and Bias\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAcross participant accounts, weight and body size were consistently described as central determinants of diagnostic legitimacy and access to treatment. Individuals in higher-weight or weight-restored bodies frequently reported being dismissed, disbelieved, or excluded from services, regardless of the psychological severity or chronicity of their condition. The pervasive reliance on visible emaciation as a marker of clinical urgency was experienced by participants as both reductive and harmful, reinforcing internalised beliefs that only certain bodies are worthy of care and that suffering must be physically observable to warrant intervention (Quotes 13-16). Some participants described being explicitly informed that they were \u0026ldquo;not sick enough\u0026rdquo; to qualify for treatment, with some noting the use of strict BMI thresholds as exclusion criteria. Others recounted being discharged once they achieved weight restoration, despite persisting psychological distress and ongoing ED behaviours. These experiences contributed to the perception that recovery was equated with physical appearance alone, while the underlying psychological and behavioural components of the disorder were deprioritised or ignored.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeveral participants described how their EDs were overlooked or minimised when their physical presentation did not align with dominant clinical archetypes, particularly in cases where individuals were not visibly underweight. In these contexts, restrictive behaviours, medical instability, and psychological distress were often dismissed or deemed insufficiently severe. As such, these experiences were perceived by participants as contributing to diagnostic invalidation, erosion of trust in clinicians and services, and delays in receiving appropriate support. Participants also described the influence of gendered and normative body expectations in shaping their access to care (Quotes 17-21). Male and gender-diverse participants reported that their ED concerns were often minimised or overlooked due to assumptions that such conditions primarily affect cisgender women in underweight bodies. For these individuals, body-based stereotypes and narrow diagnostic heuristics acted as structural barriers to recognition, validation, and timely treatment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.1.3 Structural Access and Equity Barriers\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost participants described a range of structural and systemic barriers that restricted their access to timely, appropriate, and ongoing ED treatment. These barriers were evident across both public and private sectors, with participants reporting prohibitively long waitlists for publicly funded services (Quotes 25-27), and limited availability or unaffordable costs in the private system. The absence of specialist services in regional and rural areas further compounded these challenges, often requiring participants to travel long distances, relocate, or forgo care entirely (Quotes 22-24, 28,42). Access to treatment was also mediated by socioeconomic privilege (Quotes 29-31, 33-40). Some participants described receiving financial support from family members, such as parents paying for therapy or families remortgaging homes to fund private hospital admissions, which enabled them to access care. Others, by contrast, reported needing to maintain employment or continue studying throughout treatment due to financial insecurity or the absence of family support. These individuals described limited treatment flexibility and a lack of service models that accommodated their broader life circumstances.\u003c/p\u003e\n\u003cp\u003eParticipants identifying as male, gender-diverse individuals, or from culturally and linguistically diverse backgrounds also reported feeling marginalised within systems that were perceived as normatively structured around thin, white, cisgender female experiences (Quotes 32, 40, 41). These experiences of exclusion were not only logistical, but were experienced as compounding feelings of inequity, contributing to long durations of untreated illness, disengagement, and reinforcing mistrust in healthcare services.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSubtheme 1.2: Harmful and Disempowering Treatment Experiences\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.2.1 Coercion, Control and Loss of Autonomy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany participants reported that treatment settings imposed significant restrictions on their autonomy and were often experienced as coercive or punitive,\u0026nbsp;particularly in inpatient and compulsory community care contexts. Involuntary interventions, such as forced nasogastric feeding, involuntary detainment under mental health legislation, and unilateral treatment decisions made without patient consultation, were commonly described (Quotes 43-56). These practices were often associated with heightened psychological distress and, for some, re-traumatisation. Across narratives, participants emphasised the lack of collaborative engagement in treatment planning, describing environments in which their preferences, needs, and personal values were routinely dismissed or overridden.\u003c/p\u003e\n\u003cp\u003eAccounts of close monitoring of participants\u0026rsquo; movements and behaviours were frequently described, particularly in relation to mealtimes, rest periods, and toileting (Quotes 45-51). Several participants reported being denied access to private bathroom use or being required to urinate under direct supervision, which was described as degrading and humiliating.\u0026nbsp;Public reprimands for behavioural infractions further contributed to experiences of humiliation and perceived punitive control. Most participants described experiences of fear, surveillance, and psychological withdrawal. Participants also described clinical responses to emotional distress, such as dissociation, sensory overwhelm, or shutdown, as escalatory, with frequent recourse to sedation, physical restraint, or security intervention. These responses were perceived as punitive rather than supportive, and in some cases exacerbated participants\u0026rsquo; distress or contributed to further emotional dysregulation (Quotes 52-56). Participants with neurodivergent traits noted that their communication differences and sensory needs were often misunderstood, resulting in increased monitoring or behavioural management rather than accommodation or support. Several participants described withdrawing from treatment or avoiding future care as a direct result of these experiences.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e1.2.2 Misalignment Between Treatment Models and Patient Needs\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany participants reported a significant misalignment between their individual needs and the treatment models offered across both inpatient and outpatient settings (Quotes 57-75). Treatment was frequently described as highly standardised, structured around manualised interventions, and insufficiently responsive to psychological, neurocognitive, or relational complexity. A predominant reliance on CBT frameworks, particularly in their enhanced or group-based formats, was commonly cited (Quotes 69-74). Several participants reported that these approaches were overly structured, cognitively demanding, and inadequately tailored to individuals with trauma histories, neurodivergent processing styles, or longstanding illness trajectories (Quotes 57-64, 66-68, 75).\u003c/p\u003e\n\u003cp\u003eInpatient meal environments were frequently cited as a significant source of distress. Participants reported being required to eat in shared settings under close observation, often within overstimulating physical environments that included fluorescent lighting, unpredictable noise, and minimal sensory accommodations. Mealtimes were described as typically time-bound, highly monitored, and often accompanied by clinical commentary, which contributed to anxiety, emotional shutdown, and withdrawal from care. Participants with neurodivergent traits frequently reported that features such as ritualised eating behaviours, rigid routines, sensory-based food aversions, and executive functioning challenges were not acknowledged or accommodated within prevailing treatment models (Quotes 60, 62, 66-68). Several individuals with ADHD described difficulties with planning meals, grocery shopping, and remembering to eat, difficulties that were interpreted by clinicians as non-compliance or lack of motivation. These responses were frequently described as invalidating or stigmatising.\u003c/p\u003e\n\u003cp\u003eStructural features of treatment delivery were also identified by participants as barriers. Requirements associated with inpatient admissions, day programs, and intensive outpatient treatment were frequently described as incompatible with participants\u0026rsquo; competing responsibilities, including employment, caregiving duties, educational commitments, and the management of co-occurring physical or mental health conditions (Quotes 57-68). Participants who were unable to meet rigid attendance expectations reported being characterised as non-compliant or uncommitted. Participants frequently reported that available services appeared tailored to a narrow patient demographic, often excluding those with complex or non-normative life circumstances, such as disability. This perceived mismatch between service design and individual context was associated with disengagement and a sense of exclusion from appropriate care pathways.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 2 Facilitators of Engagement and Recovery\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite encountering systemic and treatment-related challenges, many participants identified a range of factors that psychological safety, fostered hope, and enabled sustained engagement with recovery. These facilitators were frequently grounded in relational connection, compassion, and the validation of lived experience. Participants described specific interpersonal and systemic factors that supported re-engagement with recovery and counteracted the effects of exclusion, stigma, and trauma. For many, these moments of support did not emerge from formal treatment settings but through peers, advocacy, or instances of genuinely attuned care. These accounts provided a counter-narrative to the dominant story of barriers and exclusion, illustrating the significance of trust, collaboration, and personalisation in promoting recovery trajectories. This theme comprises three subthemes: \u003cem\u003e(1) compassionate, individualised and trauma-informed care, (2) peer support and connection,\u0026nbsp;\u003c/em\u003eand\u003cem\u003e\u0026nbsp;(3) integration of lived experience and advocacy\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSubtheme 2.1 Compassionate, Individualised and Trauma-Informed Care\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany participants described infrequent but highly significant experiences of care that were characterised by empathy, attunement, and responsiveness to individual need. These encounters were characterised by attentiveness to participants\u0026rsquo; preferences, flexibility in clinical approach, and a willingness to adapt treatment in accordance with the individual\u0026apos;s lived experience. Even brief episodes of therapeutic attunement, such as being offered concrete choices regarding treatment modalities, levels of care or meal planning, having emotional distress acknowledged without pathologisation, or experiencing consistent relational warmth, were described as pivotal to participants\u0026rsquo; broader recovery trajectories and foundational to the development of a strong therapeutic alliance (Quotes 76-82). Participants identified trauma-informed practices, including respect for autonomy, collaborative decision-making, and the prioritisation of psychological safety, as instrumental in facilitating treatment engagement. Clinicians who acknowledged and accommodated neurodivergence, complex trauma histories, or co-occurring psychiatric diagnoses were regarded as particularly effective in fostering trust and therapeutic rapport. Participants described how the explicit validation of identity and lived experience countered prior clinical invalidation and supported a renewed willingness to engage in care (Quotes 76-87). Adaptations to support communication preferences, emotional regulation, or sensory sensitivities were viewed as critical to enhancing treatment accessibility and sustaining engagement across time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSubtheme 2.2 Peer Support and Connection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost participants described informal peer connection, with others who had lived experience of an ED, as a meaningful source of validation, empathy, and emotional safety (Quotes 88-98). These interactions typically occurred outside of formal treatment settings, including through online communities, lived experience networks, peer support groups, or personal relationships with others who had experienced EDs. Peer interactions were frequently described as offering a depth of understanding and acceptance that participants felt was often absent in professional services. For many, connecting with others who shared similar lived experiences helped to reduce feelings of shame, stigma, and social isolation. Many participants reported that peer relationships created spaces where they felt understood without the need for extensive explanation, and where their struggles were met with compassion rather than judgment. These connections were described as providing emotional relief and belonging, particularly following invalidating or coercive experiences within treatment settings. Exposure to others\u0026rsquo; recovery narratives, especially those of individuals further along in their recovery journey, was described as a powerful source of hope. Hearing about recovery was perceived by most participants as motivating, reinforcing the belief that meaningful change was possible and supporting re-engagement with treatment. For some, contact with peers marked a critical turning point in their recovery trajectory, renewing confidence in help-seeking and fostering sustained connection to support networks.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSubtheme 2.3 Integration of Lived Experience and Advocacy\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany participants described engaging in advocacy, education, or professional roles as an extension of their lived experience with SEED (Quotes 99-117). These contributions included peer mentoring, lived experience consultancy, involvement in service co-design and research, public speaking, and participation in mental health workforce initiatives. Engagement in these roles typically followed partial or full disengagement from traditional treatment services and was framed as a meaningful avenue for contributing to systemic change. For some, these roles served as a form of constructive re-engagement with the healthcare system, motivated by a desire to address the barriers, harms, and limitations they had encountered during their own treatment journeys. Several participants reported that their decision to pursue careers as clinicians, researchers, or support workers was directly informed by previous experiences of compassionate and individualised care, and a desire to replicate those practices in their own work. These activities were consistently described as personally meaningful and empowering, particularly among participants who had previously felt dismissed, pathologised, or excluded from formal care. The opportunity to contribute lived expertise was reported to be associated with increased self-efficacy, a sense of purpose, and renewed motivation for ongoing recovery. Participants emphasised the importance of embedding lived experience within the development, delivery, and reform of ED services, citing its potential to improve relevance, inclusivity, and responsiveness to diverse and complex needs.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis mixed-methods study offers a novel contribution to the empirical understanding of treatment access and engagement among individuals with SEED, a population that remains markedly underrepresented in existing research. By employing an explanatory sequential design, this study extends prior work by integrating descriptive quantitative data with rich qualitative accounts to elucidate how systemic barriers and enabling conditions operate across the illness trajectory. Findings suggest that systemic exclusion and clinical inflexibility may reinforce disengagement and therapeutic rupture, whereas relational attunement, contextual responsiveness, and the integration of lived experience may function as protective factors supporting sustained recovery engagement. The study advances the field by centring the voices of those with SEED, offering evidence-informed directions for the development of more inclusive, person-centred models of care. \u003c/p\u003e\n\u003cp\u003eQuantitative analyses indicated that the sample was characterised by diagnostic heterogeneity, protracted illness duration, and elevated symptom severity, with most of participants endorsing financial inaccessibility, half reporting exclusion based on diagnostic or BMI criteria, and a third citing geographic distance as key impediments to care. These trends were triangulated and expanded through thematic analysis. Specifically, participants described diagnostic and conceptual exclusion in ways that reflect broader critiques of categorical diagnostic systems, such as the DSM-5, which often fail to capture atypical, intersecting, or enduring symptom presentations (5, 7). Consistent with literature on the iatrogenic effects of weight-centric frameworks, BMI thresholds were reported to function as structural gatekeepers that delayed intervention and exacerbated internalised stigma (9, 10, 18). Similarly, the financial and geographic inequities identified in the survey were contextualised by participants’ narratives of service fragmentation, reliance on out-of-pocket private treatment, and the absence of specialist care outside urban centres. These findings parallel longstanding concerns about rural mental health disparities (53) and the prohibitive cost burden of ED care both nationally and internationally (54, 55). Inadequate service responsiveness to adult-specific needs, particularly among midlife individuals with complex, enduring illness trajectories, reflects challenges uniquely salient in SEED populations. This finding aligns with emerging evidence of treatment discontinuities and systemic gaps across the lifespan, particularly for individuals whose illness persists into later adulthood (10, 13, 30, 56).\u003c/p\u003e\n\u003cp\u003eTreatment-related barriers were salient across data sources. Almost half of respondents identified manualised protocols as barriers to engagement, while stigma and invalidation by treatment providers were frequently endorsed for undermining their treatment participation. These patterns were reinforced by qualitative accounts of coercion, surveillance, and decontextualised care. Participants reported that control-oriented treatment environments replicated prior trauma and eroded therapeutic trust. Such findings are consistent with a growing literature on iatrogenic harm within risk-averse, behaviourally prescriptive inpatient settings (9, 24, 42, 43, 57) and reinforce the importance of integrating trauma-informed principles and affective safety into treatment design (34, 38). Participants also articulated a substantial misalignment between their needs and prevailing treatment models. Standardised cognitive-behavioural protocols were frequently experienced as rigid, cognitively overwhelming, and fundamentally misaligned with the needs of neurodivergent individuals. Participants described these models as lacking relational attunement and failing to accommodate common co-occurring conditions, including ASD, ADHD, and CPTSD. These findings advance a small but growing body of research which emphasise the inadequacy of conventional treatment frameworks in meeting the cognitive, sensory, and relational needs of neurodivergent individuals with SEED (20, 31-33, 36, 58).\u003c/p\u003e\n\u003cp\u003eDespite the prevalence of structural and clinical adversity, the study also identified factors that supported therapeutic re-engagement and recovery maintenance. Relational safety and clinician attunement were the most frequently cited facilitators, with a majority of participants highlighting the importance of empathy, and over half referencing supportive therapeutic relationships. These findings align with robust evidence linking therapeutic alliance to positive treatment outcomes across mental health domains (59-62). Participants also emphasised the role of peer connection and lived experience integration, describing these interactions as uniquely validating, credibility-enhancing, and identity-affirming. These narratives support emerging frameworks positioning lived experience as an epistemic asset in both service delivery and reform (63, 64). While less frequently reported, structural enablers such as telehealth access, Medicare-subsidised psychological services, and clinician advocacy were cited as meaningful supports for continuity of care. These findings suggest that even incremental systemic adaptations, when embedded within affirming therapeutic contexts, may have substantial benefits for engagement among individuals with SEED (12, 55).\u003c/p\u003e\n\u003cp\u003eThe integration of quantitative and qualitative data revealed convergence across key domains, particularly with respect to structural and relational barriers to care. This methodological triangulation enhances the credibility of the findings and reinforces the salience of these barriers within SEED populations. While some variation was observed, for instance, in the perceived utility of specific treatment approaches, this likely reflects the diversity of participant experiences of the sample rather than inconsistency across methods. These results support the value of mixed-methods designs in elucidating the layered and contextually situated nature of treatment access and engagement for individuals with longstanding EDs. In sum, this study contributes to a growing critique of conventional treatment models for individuals with SEED, highlighting the need for system-level reform and clinical innovation. Participants strongly endorsed trauma-informed, neurodivergent-affirming, and person-centred approaches as crucial to effective care. Specifically, they emphasised the importance of relationally attuned frameworks that promote autonomy, acknowledge complexity, and affirm difference without pathologisation. While limited in generalisability, these data provide empirically grounded direction for future intervention development, workforce training, and policy advocacy. Continued evaluation of co-designed, context-sensitive care models is warranted to advance equity, safety, and efficacy in SEED treatment.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStrengths and Limitations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study offers several methodological and conceptual strengths. The use of an explanatory sequential mixed-methods design enabled the integration of descriptive quantitative data with in-depth qualitative insights, supporting a nuanced understanding of treatment access and engagement among individuals with SEED. Reflexive thematic analysis, grounded in established methodological principles (46, 47), allowed for inductive theme development while maintaining analytic rigour. The inclusion of participants across diverse diagnoses, illness durations, and stages of recovery enhanced sample heterogeneity and ecological validity. Critically, the study foregrounded lived experience perspectives, contributing to a deeper understanding of relational and structural processes often underrepresented in clinical trials or service evaluations. Nevertheless, limitations must be acknowledged. The reliance on retrospective, self-reported data may have introduced recall bias and subjective interpretation. Recruitment through online platforms and advocacy networks may have contributed to self-selection bias, potentially overrepresenting individuals with digital access, higher health literacy, or prior engagement in treatment. Certain identities, particularly Aboriginal and Torres Strait Islander peoples, culturally and linguistically diverse populations, and gender-diverse individuals, were underrepresented, limiting generalisability. Moreover, as the study was conducted within the Australian healthcare system, which differs in structure, funding, and service provision from systems in other countries, caution should be exercised when extrapolating results to international contexts. Finally, the cross-sectional design precluded examination of longitudinal trajectories or causal mechanisms underpinning treatment engagement and recovery.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFuture Directions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe findings highlight several critical gaps warranting further empirical investigation. Longitudinal and prospective studies are needed to explore how structural exclusion, clinical stigma, and relational disconnection influence recovery trajectories over time. Given the identified limitations of standardised, risk-averse, and neurotypical treatment paradigms, future research should evaluate alternative models, including trauma-informed, neurodivergent-affirming, and harm-reduction approaches, using mixed methods and implementation-focused designs. There is a particular need to further examine the mechanisms by which peer-led, co-designed, and lived experience-informed interventions foster therapeutic engagement and relational safety, particularly in SEED presentations. Emerging programs, such as single-session digital tools and structured peer mentoring initiatives, have shown early promise in enhancing perceived understanding, reducing stigma, and supporting sustained connection to care (64-66). Future studies should also attend to the intersecting impacts of structural marginalisation, such as Indigeneity, cultural identity, gender diversity, and socioeconomic precarity, on access and outcomes in SEED populations. Participatory or emancipatory methodologies may be especially valuable in elevating marginalised voices and resisting deficit-based framings. Finally, given the pervasive accounts of coercion and iatrogenic harm, future inquiry should critically examine clinician attitudes, institutional risk practices, and the ethical complexities of care provision in SEED contexts.\u003c/p\u003e\n\n"},{"header":"Conclusion","content":"\u003cp\u003eThis exploratory mixed-methods study provides important insight into the barriers and facilitators shaping treatment access and engagement for individuals with SEED. By integrating quantitative and qualitative data, the study contributes to a more nuanced understanding of the structural, clinical, and relational dynamics that may influence care trajectories within the Australian context. Participants’ accounts nominated challenges such as diagnostic exclusion, weight-based gatekeeping, coercive or inflexible treatment environments, and limited accommodation of neurodivergent and trauma-related needs. At the same time, the findings identified potential facilitators of therapeutic engagement, including empathic clinician relationships, individualised care, peer support, and the integration of lived experience. While caution is required in extending these findings to all SEED populations, they offer valuable considerations for service design and future research. Addressing these barriers and enhancing identified facilitators may support the development of more inclusive, affirming, and contextually responsive models of care for individuals with complex and long-standing EDs.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAAN\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp; Atypical Anorexia Nervosa\u003c/p\u003e\n\u003cp\u003eADHD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Attention-Deficit/Hyperactivity Disorder\u003c/p\u003e\n\u003cp\u003eAN\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Anorexia Nervosa\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eARFID\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Avoidant/restrictive food intake disorder\u003c/p\u003e\n\u003cp\u003eASD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Autism Spectrum Disorder\u003c/p\u003e\n\u003cp\u003eBED\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Binge Eating Disorder\u003c/p\u003e\n\u003cp\u003eBMI\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Body Mass Index\u003c/p\u003e\n\u003cp\u003eBN\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Bulimia Nervosa\u003c/p\u003e\n\u003cp\u003eBPD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Borderline Personality Disorder\u003c/p\u003e\n\u003cp\u003eCBT-E\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Enhanced Cognitive Behaviour Therapy\u003c/p\u003e\n\u003cp\u003eCPTSD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Complex Post Traumatic Stress Disorder\u003c/p\u003e\n\u003cp\u003eED\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Eating Disorder\u003c/p\u003e\n\u003cp\u003eEDE-Q\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Eating Disorder Examination Questionnaire\u003c/p\u003e\n\u003cp\u003eI-CBT-E\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Integrated Enhanced Cognitive Behaviour Therapy\u003c/p\u003e\n\u003cp\u003eOSFED\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Other Specified Feeding or Eating Disorder\u003c/p\u003e\n\u003cp\u003ePTSD\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Post Traumatic Stress Disorder\u003c/p\u003e\n\u003cp\u003eSEED \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Severe and Enduring Eating Disorder\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from the Monash University Human Research Ethics Committee (Project ID: 42453).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors of the study consent to the publication of the current manuscript. Participants involved are aware of the planned publication and have given their consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available under the participant confidentiality conditions of ethics approval from the Monash University Human Research Ethics Committee.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Conflicting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have declared no potential conflicts or competing interests with respect to the research, authorship, and publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was not sponsored or funded. The views expressed herein are the authors’ opinions and do not reflect any official positions of the institutional affiliations or funding bodies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGabriel Lubieniecki\u003c/strong\u003e: Conceptualisation (lead); Writing – Original Draft; Methodology; Formal Analysis (lead); Writing – Review \u0026amp; Editing (equal). \u003cstrong\u003eIsabella McGrath\u003c/strong\u003e: Formal Analysis (supporting); Writing – Review \u0026amp; Editing (supporting). \u003cstrong\u003eGemma Sharp\u003c/strong\u003e: Conceptualisation (equal); Methodology (equal); Formal Analysis (equal); Resources (lead); Validation (lead); Writing – Review \u0026amp; Editing (lead); Supervision (lead).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our sincere gratitude to the 41 individuals who participated in this study, generously sharing their experiences. We also wish to thank those who supported the recruitment process by circulating information about this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHay P, Touyz S. Treatment of patients with severe and enduring eating disorders. Current Opinion in Psychiatry. 2015;28(6):473-7.\u003c/li\u003e\n\u003cli\u003eEddy KT, Tabri N, Thomas JJ, Murray HB, Keshaviah A, Hastings E, et al. Recovery From Anorexia Nervosa and Bulimia Nervosa at 22-Year Follow-Up. J Clin Psychiatry. 2017;78(2):184-9.\u003c/li\u003e\n\u003cli\u003eRobinson P. Severe and enduring eating disorder (SEED): management of complex presentations of anorexia and bulimia nervosa: John Wiley \u0026amp; Sons; 2009.\u003c/li\u003e\n\u003cli\u003eRobinson P. Severe and enduring eating disorders: recognition and management. Advances in Psychiatric Treatment. 2014;20(6):392-401.\u003c/li\u003e\n\u003cli\u003eWonderlich SA, Bulik CM, Schmidt U, Steiger H, Hoek HW. Severe and enduring anorexia nervosa: Update and observations about the current clinical reality. International Journal of Eating Disorders. 2020;53(8):1303-12.\u003c/li\u003e\n\u003cli\u003eTreasure J, Duarte TA, Schmidt U. Eating disorders. The Lancet. 2020;395(10227):899-911.\u003c/li\u003e\n\u003cli\u003eBroomfield C, Stedal K, Touyz S, Rhodes P. Labeling and defining severe and enduring anorexia nervosa: A systematic review and critical analysis. Int J Eat Disord. 2017;50(6):611-23.\u003c/li\u003e\n\u003cli\u003eDaugelat MC, Pruccoli J, Schag K, Giel KE. Barriers and facilitators affecting treatment uptake behaviours for patients with eating disorders: A systematic review synthesising patient, caregiver and clinician perspectives. Eur Eat Disord Rev. 2023;31(6):752-68.\u003c/li\u003e\n\u003cli\u003eElwyn R. A lived experience response to the proposed diagnosis of terminal anorexia nervosa: learning from iatrogenic harm, ambivalence and enduring hope. Journal of Eating Disorders. 2023;11(1).\u003c/li\u003e\n\u003cli\u003eMusolino C, Warin M, Wade T, Gilchrist P. Developing shared understandings of recovery and care: a qualitative study of women with eating disorders who resist therapeutic care. Journal of Eating Disorders. 2016;4(1).\u003c/li\u003e\n\u003cli\u003eKotilahti E, West M, Isomaa R, Karhunen L, Rocks T, Ruusunen A. Treatment interventions for Severe and Enduring Eating Disorders: Systematic review. International Journal of Eating Disorders. 2020;53(8):1280-302.\u003c/li\u003e\n\u003cli\u003eBryant E, Marks P, Griffiths K, Boulet S, Pehlivan M, Barakat S, et al. Treating the individual: moving towards personalised eating disorder care. Journal of Eating Disorders. 2025;13(1).\u003c/li\u003e\n\u003cli\u003eKiely L, Hay P, Robinson P. Severe and Enduring Eating Disorders (SEED). Springer International Publishing; 2023. p. 1-21.\u003c/li\u003e\n\u003cli\u003eVan Den Eijnde-Damen IMC, Maas J, Burger P, Bodde NMG, Simeunovic-Ostojic M. Towards collaborative care for severe and enduring Anorexia Nervosa \u0026ndash; a mixed-method approach. Journal of Eating Disorders. 2024;12(1).\u003c/li\u003e\n\u003cli\u003eLink BG, Phelan JC. Conceptualizing Stigma. Annual Review of Sociology. 2001;27:363-85.\u003c/li\u003e\n\u003cli\u003eCorrigan PW, Watson AC. The Stigma of Psychiatric Disorders and the Gender, Ethnicity, and Education of the Perceiver. Community Mental Health Journal. 2007;43(5):439-58.\u003c/li\u003e\n\u003cli\u003eCorrigan PW, Watson AC, Barr L. The Self\u0026ndash;Stigma of Mental Illness: Implications for Self\u0026ndash;Esteem and Self\u0026ndash;Efficacy. Journal of Social and Clinical Psychology. 2006;25(8):875-84.\u003c/li\u003e\n\u003cli\u003eBrelet L, Flaudias V, D\u0026eacute;sert M, Guillaume S, Llorca P-M, Boirie Y. Stigmatization toward People with Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder: A Scoping Review. Nutrients. 2021;13(8):2834.\u003c/li\u003e\n\u003cli\u003eDoley JR, Hart LM, Stukas AA, Petrovic K, Bouguettaya A, Paxton SJ. Interventions to reduce the stigma of eating disorders: A systematic review and meta‐analysis. International Journal of Eating Disorders. 2017;50(3):210-30.\u003c/li\u003e\n\u003cli\u003eLubieniecki G, Fernando AN, Randhawa A, Cowlishaw S, Sharp G. Perceived clinician stigma and its impact on eating disorder treatment experiences: a systematic review of the lived experience literature. Journal of Eating Disorders. 2024;12(1).\u003c/li\u003e\n\u003cli\u003eDimitropoulos G, Freeman VE, Muskat S, Domingo A, McCallum L. \u0026ldquo;You don\u0026rsquo;t have anorexia, you just want to look like a celebrity\u0026rdquo;: perceived stigma in individuals with anorexia nervosa. Journal of Mental Health. 2016;25(1):47-54.\u003c/li\u003e\n\u003cli\u003eKurdak H, Tiyekli E, \u0026Ouml;zcan S, \u0026Ouml;zer ZY, Nur Topuz A. Eating disorders, primary care, and stigma: an analysis of research trends and patterns. Frontiers in Psychiatry. 2023;14.\u003c/li\u003e\n\u003cli\u003eRuesch N. The stigma of mental illness : strategies against social exclusion and discrimination. Amsterdam: Elsevier; 2022.\u003c/li\u003e\n\u003cli\u003eMenzies RE, Richmond B, Sharpe L, Skeggs A, Liu J, Coutts‐Bain D. The \u0026lsquo;revolving door\u0026rsquo; of mental illness: A meta‐analysis and systematic review of current versus lifetime rates of psychological disorders. British Journal of Clinical Psychology. 2024;63(2):178-96.\u003c/li\u003e\n\u003cli\u003eBoyd JE, L\u0026oacute;pez MM, Gonz\u0026aacute;lez-Sanguino C, Harris JI, Sampson IT. Consequences of the Self-Stigma of Mental Illness. In: Vogel DL, Wade NG, editors. The Cambridge Handbook of Stigma and Mental Health. Cambridge Handbooks in Psychology. Cambridge: Cambridge University Press; 2022. p. 88-110.\u003c/li\u003e\n\u003cli\u003eByrne SM, Fursland A. New understandings meet old treatments: putting a contemporary face on established protocols. Journal of Eating Disorders. 2024;12(1).\u003c/li\u003e\n\u003cli\u003eReay M, Holliday J, Stewart J, Adams J. Creating a care pathway for patients with longstanding, complex eating disorders. Journal of Eating Disorders. 2022;10(1).\u003c/li\u003e\n\u003cli\u003eFairburn CG. Cognitive behavior therapy and eating disorders2008.\u003c/li\u003e\n\u003cli\u003eByrne S, Wade T, Hay P, Touyz S, Fairburn CG, Treasure J, et al. A randomised controlled trial of three psychological treatments for anorexia nervosa. Psychological Medicine. 2017;47(16):2823-33.\u003c/li\u003e\n\u003cli\u003eSharp G, Fernando AN, Davis SR, Randhawa A. Developing an educational resource for people experiencing eating disorders during the menopause transition: A qualitative co-design study. Journal of Eating Disorders. 2024;12(1).\u003c/li\u003e\n\u003cli\u003eKinnaird E, Norton C, Stewart C, Tchanturia K. Same behaviours, different reasons: what do patients with co-occurring anorexia and autism want from treatment? International Review of Psychiatry. 2019;31(4):308-17.\u003c/li\u003e\n\u003cli\u003eBrede J, Babb C, Jones C, Elliott M, Zanker C, Tchanturia K, et al. \u0026ldquo;For Me, the Anorexia is Just a Symptom, and the Cause is the Autism\u0026rdquo;: Investigating Restrictive Eating Disorders in Autistic Women. Journal of Autism and Developmental Disorders. 2020;50(12):4280-96.\u003c/li\u003e\n\u003cli\u003eCobbaert L, Millichamp AR, Elwyn R, Silverstein S, Schweizer K, Thomas E, et al. Neurodivergence, intersectionality, and eating disorders: a lived experience-led narrative review. Journal of Eating Disorders. 2024;12(1).\u003c/li\u003e\n\u003cli\u003eTchanturia K, Dandil Y, Li Z, Smith K, Leslie M, Byford S. A novel approach for autism spectrum condition patients with eating disorders: Analysis of treatment cost‐savings. European Eating Disorders Review. 2021;29(3):514-8.\u003c/li\u003e\n\u003cli\u003eWestwood H, Mandy W, Tchanturia K. Clinical evaluation of autistic symptoms in women with anorexia nervosa. Molecular Autism. 2017;8(1).\u003c/li\u003e\n\u003cli\u003eBabb C, Brede J, Jones CRG, Serpell L, Mandy W, Fox J. A comparison of the eating disorder service experiences of autistic and non‐autistic women in the UK. European Eating Disorders Review. 2022;30(5):616-27.\u003c/li\u003e\n\u003cli\u003eMolendijk ML, Hoek HW, Brewerton TD, Elzinga BM. Childhood maltreatment and eating disorder pathology: a systematic review and dose-response meta-analysis. Psychological Medicine. 2017;47(8):1402-16.\u003c/li\u003e\n\u003cli\u003eBrewerton TD, Alexander J, Schaefer J. Trauma-informed care and practice for eating disorders: personal and professional perspectives of lived experiences. Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity. 2019;24(2):329-38.\u003c/li\u003e\n\u003cli\u003eDay S, Hay P, Basten C, Byrne S, Dearden A, Goldstein M, et al. Posttraumatic stress disorder (PTSD) and complex PTSD in eating disorder treatment‐seekers: Prevalence and associations with symptom severity. Journal of Traumatic Stress. 2024;37(4):672-84.\u003c/li\u003e\n\u003cli\u003eBoughtwood D, Halse C. Other than obedient: Girls\u0026apos; constructions of doctors and treatment regimes for anorexia nervosa. J Community Appl Soc Psychol. 2010;20(2):83-94.\u003c/li\u003e\n\u003cli\u003eDawson L, Mullan B, Rhodes P, Touyz S. Developing a measure to assess motivation and self-efficacy in anorexia nervosa using the Theory of Planned Behaviour. Journal of Eating Disorders. 2014;2(S1):O46.\u003c/li\u003e\n\u003cli\u003eMac Donald B, Gustafsson SA, Bulik CM, Clausen L. Living and leaving a life of coercion: a qualitative interview study of patients with anorexia nervosa and multiple involuntary treatment events. Journal of Eating Disorders. 2023;11(1).\u003c/li\u003e\n\u003cli\u003eSharpe SL, Adams M, Smith EK, Urban B, Silverstein S. Inaccessibility of care and inequitable conceptions of suffering: a collective response to the construction of \u0026ldquo;terminal\u0026rdquo; anorexia nervosa. Journal of Eating Disorders. 2023;11(1).\u003c/li\u003e\n\u003cli\u003eBroomfield C, Rhodes P, Touyz S. Lived experience perspectives on labeling and defining long-standing anorexia nervosa. Journal of Eating Disorders. 2021;9(1).\u003c/li\u003e\n\u003cli\u003eLubieniecki G, McGrath I, Sharp G. A Lifeline or a Label? Patient Perspectives on the Severe and Enduring Eating Disorder (SEED) Classification in Eating Disorder Treatment. 2025. [pre-print available 10.21203/rs.3.rs-6231293/v1]\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qualitative research in psychology. 2006;3(2):77-101.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Thematic analysis: A practical guide. 2021.\u003c/li\u003e\n\u003cli\u003eMoustakas C. Phenomenological research methods: sage; 1994.\u003c/li\u003e\n\u003cli\u003eHall MF, Hall SE. Managing the Psychological Impact of Medical Trauma. 1 ed. New York: Springer Publishing Company.\u003c/li\u003e\n\u003cli\u003eSchwab JR, Syed M. Qualitative inquiry and emerging adulthood: Meta-theoretical and methodological issues. Emerging Adulthood. 2015;3(6):388-99.\u003c/li\u003e\n\u003cli\u003eFairburn CG, Beglin SJ. Assessment of eating disorders: interview or self-report questionnaire? Int J Eat Disord. 1994;16(4):363-70.\u003c/li\u003e\n\u003cli\u003eJennings KM, Phillips KE. Eating Disorder Examination\u0026ndash;Questionnaire (EDE\u0026ndash;Q): Norms for Clinical Sample of Female Adolescents with Anorexia Nervosa. Archives of Psychiatric Nursing. 2017;31(6):578-81.\u003c/li\u003e\n\u003cli\u003eFlavel, Kedzior, Isaac, Cameron, Baum. Regional health inequalities in Australia and social determinants of health: analysis of trends and distribution by remoteness. Rural and Remote Health. 2024.\u003c/li\u003e\n\u003cli\u003eMiskovic-Wheatley J, Bryant E, Ong SH, Vatter S, Le A, Aouad P, et al. Eating disorder outcomes: findings from a rapid review of over a decade of research. Journal of Eating Disorders. 2023;11(1).\u003c/li\u003e\n\u003cli\u003eMulders-Jones B, Mitchison D, Girosi F, Hay P. Socioeconomic Correlates of Eating Disorder Symptoms in an Australian Population-Based Sample. PLOS ONE. 2017;12(1):e0170603.\u003c/li\u003e\n\u003cli\u003eTully SM, Bucci S, Berry K. \u0026ldquo;My life isn\u0026apos;t my life, it\u0026apos;s the systems\u0026rdquo;: A qualitative exploration of women\u0026apos;s experiences of day‐to‐day restrictive practices as inpatients. Journal of Psychiatric and Mental Health Nursing. 2023;30(1):110-22.\u003c/li\u003e\n\u003cli\u003eMunt C, Littlechild B. The Lived Experience of Coercion. Springer Nature Switzerland; 2024. p. 3-25.\u003c/li\u003e\n\u003cli\u003eHerle M, Carter Leno V, Mandy W. Recommendations for Advancing Understanding of Eating Disorders in Neurodivergent People: A Commentary on Inal‐Kaleli et al. 2024 and Nimbley et al. 2024. International Journal of Eating Disorders. 2025;58(4):677-9.\u003c/li\u003e\n\u003cli\u003eGeller J, Fernandes A, Srikameswaran S, Pullmer R, Marshall S. The power of feeling seen: Perspectives of individuals with eating disorders on receiving validation. Journal of Eating Disorders Vol 9, 2021, ArtID 149. 2021;9.\u003c/li\u003e\n\u003cli\u003eBirch E, Downs J, Ayton A. Harm reduction in severe and long-standing Anorexia Nervosa: part of the journey but not the destination\u0026mdash;a narrative review with lived experience. Journal of Eating Disorders. 2024;12(1).\u003c/li\u003e\n\u003cli\u003eKenny TE, Lewis SP. More than an outcome: a person-centered, ecological framework for eating disorder recovery. Journal of Eating Disorders. 2023;11(1).\u003c/li\u003e\n\u003cli\u003eThornicroft G, Sunkel C, Aliev AA, Baker S, Brohan E, Rabih el C, et al. The Lancet Commission on ending stigma and discrimination in mental health. The Lancet. 2022;400(10361):1438-80.\u003c/li\u003e\n\u003cli\u003eHanly F, Torrens-Witherow B, Warren N, Castle D, Phillipou A, Beveridge J, et al. Peer mentoring for individuals with an eating disorder: a qualitative evaluation of a pilot program. Journal of Eating Disorders. 2020;8(1).\u003c/li\u003e\n\u003cli\u003eRaspovic A, Duck R, Synnot A, Caldwell B, Phillipou A, Castle D, et al. A peer mentoring program for eating disorders: improved symptomatology and reduced hospital admissions, three years and a pandemic on. Journal of Eating Disorders. 2024;12(1).\u003c/li\u003e\n\u003cli\u003eSharp G, Dwyer B, Xie J, McNaney R, Shrestha P, Prawira C, et al. Co-design of a single session intervention chatbot for people on waitlists for eating disorder treatment: a qualitative interview and workshop study. Journal of Eating Disorders. 2025;13(1).\u003c/li\u003e\n\u003cli\u003eSharp G, Dwyer B, Randhawa A, McGrath I, Hu H. The Effectiveness of a Chatbot Single-Session Intervention for People on Waitlists for Eating Disorder Treatment: Randomized Controlled Trial. Journal of Medical Internet Research. 2025;27:e70874.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Eating Disorders, Severe and Enduring Eating Disorder (SEED), Treatment Access and Barriers, Treatment Facilitators, Patient Perspectives.","lastPublishedDoi":"10.21203/rs.3.rs-6843067/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6843067/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: An estimated 20 to 30% of individuals with eating disorders (EDs) experience protracted illness trajectories, often referred to as severe and enduring eating disorders (SEED). Research examining the systemic, relational, and experiential factors that influence access to and engagement with care in this population remains limited. This mixed-methods study aimed to explore the structural, clinical, and interpersonal barriers and facilitators shaping treatment experiences among individuals with longstanding EDs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod:\u003c/strong\u003eAn explanatory sequential mixed-methods design was employed with 41 participants. Stage One involved an online survey assessing demographic characteristics, diagnostic history, treatment exposure, and symptom severity, with descriptive statistics used to characterise the sample. Stage Two comprised of in-depth semi-structured interviews exploring lived experiences of treatment access and engagement. Qualitative data were analysed using reflexive thematic analysis informed by transcendental phenomenology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The sample was heterogeneous in terms of diagnostic profiles, illness duration, recovery stage, and treatment exposure. Two higher-order qualitative themes were identified; “Barriers to Care” included diagnostic and conceptual exclusion, weight-based bias, systemic access constraints, coercive practices, and misalignment between treatment models and patient needs. “Facilitators of Engagement and Recovery” comprised compassionate, individualised, and trauma-informed care, peer connection, and the integration of lived experience and advocacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion\u003c/strong\u003e: Individuals with SEED are a diverse population who report frequent exposure to structural, relational, and treatment-related barriers, while also identifying salient facilitators that support therapeutic engagement and recovery. Findings from this exploratory study suggest that more responsive, inclusive, and person-centred models of care may help address the complex needs of individuals with SEED. Trauma-informed and neurodiversity-affirming approaches, particularly those that integrate lived experience, may help mitigate the systemic and clinical barriers identified across both access and treatment contexts.\u003c/p\u003e","manuscriptTitle":"Barriers and Facilitators to Treatment in Severe and Enduring Eating Disorders: A Mixed- Methods Study of Access, Engagement, and Lived Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-12 14:19:16","doi":"10.21203/rs.3.rs-6843067/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-20T13:02:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-20T11:01:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-16T22:41:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79591247707793201357928960839383512952","date":"2025-06-17T18:05:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64577771547621256169143551695336370413","date":"2025-06-13T00:56:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-11T00:38:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-10T23:05:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-10T23:04:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Eating Disorders","date":"2025-06-07T13:18:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-eating-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joed","sideBox":"Learn more about [Journal of Eating Disorders](http://jeatdisord.biomedcentral.com)","snPcode":"40337","submissionUrl":"https://submission.nature.com/new-submission/40337/3","title":"Journal of Eating Disorders","twitterHandle":"@JEatDisord","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ac55e3da-1b60-40ce-8b11-8dec3d655ed8","owner":[],"postedDate":"June 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-09-15T16:01:12+00:00","versionOfRecord":{"articleIdentity":"rs-6843067","link":"https://doi.org/10.1186/s40337-025-01393-w","journal":{"identity":"journal-of-eating-disorders","isVorOnly":false,"title":"Journal of Eating Disorders"},"publishedOn":"2025-09-12 15:57:09","publishedOnDateReadable":"September 12th, 2025"},"versionCreatedAt":"2025-06-12 14:19:16","video":"","vorDoi":"10.1186/s40337-025-01393-w","vorDoiUrl":"https://doi.org/10.1186/s40337-025-01393-w","workflowStages":[]},"version":"v1","identity":"rs-6843067","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6843067","identity":"rs-6843067","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}