Eating disorder treatment and recovery are often framed as matters of individual responsibility, with change positioned as dependent on the person’s motivation, insight, and willingness to recover. While agency remains important, this paper argues that such framings are too narrow and can obscure the wider conditions that shape both illness and the possibility of recovery. Drawing on ecological systems theory, ecosocial approaches to health, evolutionary psychiatry, and lived experience, this paper develops an account of eating disorders as phenomena that arise within interacting systems of biological vulnerability, interpersonal relationships, sociocultural pressures, institutional arrangements, and political economy. It argues that individualistic models of illness and recovery may contribute to shame, stigma, epistemic injustice, and what is described here as hyper-responsibilisation, particularly where care is fragmented, delayed, or unequally distributed. In contrast, an ecological perspective allows eating disorders to be understood as embodied and socially patterned forms of suffering that cannot be adequately addressed through individual behaviour change alone. The paper concludes that if eating disorders are ecological in their production and maintenance, then responsibility for responding to them must also be ecological. Recommendations are made to support more collective, relational, and structurally informed approaches to prevention, treatment, and recovery. Eating disorders are often talked about as if recovery mainly depends on the individual trying hard enough, wanting to get better, or being motivated to change. This paper argues that this is too simplistic. Eating disorders do not develop or continue only because of personal choices or psychology. They are shaped by a much wider set of influences, including biology, relationships, life experiences, social pressures, stigma, access to care, and the environments in which people live. Drawing on theory, research, and lived experience, the paper shows that recovery is also affected by whether people are recognised, believed, and supported in ways that fit their actual circumstances. When too much responsibility is placed on the individual, important parts of the picture can be missed and people may be blamed for struggles that are not fully within their control. The paper argues for a more collective approach, where responsibility for prevention, care, and recovery is shared more honestly across services, communities, and society.

Aims: To review the utility of the traditional Mental State Examination (MSE) in identifying feeding or eating disorders (FEDs), and to propose a modernised approach that incorporates assessment of eating behaviours, nutrition, weight, and body image disturbance to improve detection and patient safety. Methods: A narrative review of existing MSE frameworks was undertaken, examining their historical development and relevance to contemporary psychiatric presentations. The unique diagnostic challenges of FEDs were considered, alongside common barriers to detection such as stigma, ego-syntonic psychopathology and structural inequalities in the medical establishment. Our co-author provided lived experience accounts to provide a patient-led perspective on the limitations of the MSE in modern practice. Based on these gaps, a proposal was developed to integrate semi-structured questions on diet, weight, and compensatory behaviours into routine MSE practice. Results: The emphasis of the current MSE is seen to be heavily weighted towards traditional psychiatric presentations such as psychosis and affective disorders, inadequately capturing key psychopathology associated with FEDs such as eating behaviours, nutritional status, andbody image disturbance. This omission risks delayed diagnosis and compromised patient safety. Incorporating targeted, semi-structured questions into the MSE offers a feasible and systematic way to improve early recognition of FEDs across diverse populations. Additional benefits will be gained in safe psychotropic drug monitoring with early recognition of nutritional side effects. Conclusion: Modernising the MSE to explicitly include assessment of eating behaviours and related psychopathology may enhance early detection of FEDs, reduce stigma through routine enquiry, and improve clinical outcomes and patient safety. Updates to medical training and everyday psychiatric practice are required in tandem to reflect the diverse presentations of modern mental health disorders.

While links between eating disorders and post-traumatic stress disorder are well established, dominant frameworks have tended to locate trauma primarily outside healthcare, offering limited tools for understanding how neglect, exclusion, coercive practices, and epistemic misrecognition within care may contribute to ongoing distress. Drawing on empirical research, ethical scholarship, and reflexive lived experience analysis, this Comment paper examines how trauma-related symptoms in eating disorders may arise not only from early life adversity, but also through harmful relationships with healthcare, including eating disorder services themselves. Three interrelated domains of iatrogenic trauma are examined: exclusion and neglect within care pathways; traumagenic dynamics within clinical encounters; and epistemic injury, where individuals are undermined as credible interpreters of their own experience. Together, the author suggests that these processes may contribute to disturbances in self-organisation, dissociation, mistrust, and increased reliance on disordered eating behaviours as coping strategies. The paper argues that failure to recognise trauma arising within healthcare risks misattributing system-generated distress to individual psychopathology, reinforcing disengagement and treatment impasse. Recognising iatrogenic trauma has important implications for assessment, formulation, and treatment planning, and requires greater attention to acknowledgement, epistemic justice, and collaborative, formulation-driven models of care. Efforts to refine the links between eating disorders and trauma therefore require explicit attention to healthcare-related harm if they are to support more ethical, effective, and humane practice. Many people with eating disorders experience trauma-related difficulties such as fear, dissociation, and problems trusting others. Most research explains this by focusing on traumatic experiences earlier in life, such as abuse or neglect in childhood. While these experiences are important, trauma can also develop or worsen through people’s experiences within healthcare, including eating disorder services. The author looks at research, ethics, and their own lived experiences to show how harm can arise through ongoing contact with services. This includes long delays in care, repeated exclusion from treatment, coercive or unsafe clinical encounters, and situations where people are not believed or taken seriously when they try to explain their distress. Experiences like these may lead to ongoing feelings of threat, mistrust, and disconnection, and can increase reliance on eating disorder behaviours themselves. Over time, this pattern can look very similar to complex forms of post-traumatic stress, even when trauma is assumed to lie only in the past. When harm arising within healthcare is not recognised, distress may be wrongly understood as part of the individual’s illness, making engagement and recovery more difficult. Recognising trauma linked to healthcare experiences is important for understanding people’s difficulties more accurately and responding more safely. This includes acknowledging past harms, taking people’s accounts seriously, and working collaboratively to develop shared understandings of distress. Paying attention to healthcare-related harm is essential if eating disorder care is to become more ethical, effective, and humane.

Aims and method The Mental State Examination (MSE) is a core component of psychiatric assessment and medical training, yet it was developed before feeding or eating disorders (FEDs) were widely recognised. FEDs are now common, clinically severe and frequently missed in routine assessments. We conducted a narrative review of the historical development of the MSE, current UK medical education standards and relevant literature, supplemented by a lived-experience perspective, to examine whether the MSE adequately captures eating behaviour, nutritional status and body image disturbance. Results We identified no published studies examining the explicit inclusion of FED-related psychopathology within the MSE. Current frameworks lack systematic prompts for eating behaviours and nutrition, contributing to under-recognition. Contributing factors include historical MSE design, limited curriculum coverage, clinician uncertainty and patient non-disclosure. Clinical implications Embedding brief, semi-structured prompts into the MSE is a feasible training-aligned approach to improve detection, support curriculum modernisation and enhance patient safety.

This book review considers Federici and Wisniewski’s Treating Eating Disorders with DBT: The MED-DBT Protocol (Guildford Press, 2026). Drawing on their lived experiences, the authors examine the book’s unique approach to complex and multidiagnostic eating disorders, particularly its adapted biosocial model, account of invalidation and use of dialectical dilemmas. The book offers a humane and clinically credible alternative to prevailing treatment models and overly-individualising concepts such as “treatment resistance”. The development of additional patient- and caregiver-facing resources could extend its value as an important contribution to contemporary eating disorder care.

Objective To systematically review educational interventions for staff working on acute paediatric wards aimed at improving the care of children and young people (CYP) admitted for mental health support. Design We conducted a systematic search of PubMed, The Education Resources Information Centre, PsychInfo and Web of Science from 2000 to March 2026 using terms related to healthcare professionals, training/education, mental health and children/young people. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Interventions were classified using the Kirkpatrick model and the Behavioural Change Technique Taxonomy (BCT V.1) to identify mechanisms underpinning effective change. Results We found nine studies meeting inclusion criteria, across a range of teaching methodologies and settings. Most interventions were designed and applied for nurses. Overall quality of evidence was poor. Although no single intervention could be recommended, analysis identified potentially useful components tailored to different learner needs, mapped through the Kirkpatrick and BCT frameworks. A notable gap was a lack of codesign with CYP and carers with lived experience and the absence of strategies to engage ambivalent or reluctant learners who might not attend educational interventions voluntarily. Conclusions Existing educational interventions contain elements that may support behavioural and practice change among staff caring for CYP with mental health needs. However, future research should prioritise high-quality, framework-based evaluations developed through codesign with CYP and carers. Interventions should also address how to engage learners who may be reluctant to participate in training for this area of clinical practice.

Summary Despite co-produced guidelines and actions recommended by statutory bodies, there has been a persistent lack of progress in improving the quality of healthcare for those with eating disorders in the UK. Drawing on multiple evidence sources, including lived experience, the author analyses reasons for this. The concept of an ‘ignorance culture’ is theorised as a key barrier, defined as cultural practices that uphold systemic failures by ignoring concerns that harm clinicians, patients, caregivers and wider society. A shift towards a ‘responsibility culture’ is proposed, with recommendations aimed at creating greater accountability, shared learning, transparency and reflexivity. Prioritising cultural change is central to improving the quality of care for everyone affected by eating disorders.

Aims and method This article explores how clinical language used to describe long-standing and severe eating disorders shapes treatment experiences and outcomes. Drawing on critical discourse theory and the authors’ lived experiences, the paper analyses the impacts of language through intrapersonal, interpersonal and systemic lenses. Results The analysis highlights how the language used to describe illness can foster therapeutic nihilism, internalised hopelessness and disengagement from treatment for both clinicians and patients, reducing the impetus for developing or accessing better care. These labels may obscure systemic shortcomings in treatment provision and can become self-fulfilling, undermining clinician motivation and patient recovery. Clinical implications The authors propose a paradigm shift toward recovery-oriented, co-created language that centres epistemic justice. Clinical discourse should promote therapeutic optimism and support inclusive, patient-centred care. Recovery-focused language can strengthen engagement, improve outcomes and support a treatment culture grounded in mutual respect and hope.

The concept of “Restrictive Intake Self-Harm” (“RISH”) has recently been introduced to conceptualise divergent and/or complex presentations of restrictive eating behaviours as a form of self-harm, rather than symptoms of an eating disorder. Whilst this may represent a well-intentioned response to poorly met clinical needs, it also raises significant conceptual, ethical, and clinical concerns. This paper, written by authors with clinical, academic, and lived experience, situates “RISH” within a broader history of classificatory innovation in eating disorders, whereby new terminology has been introduced with insufficient empirical support and a lack of co-production with people with lived experience. Our analysis highlights the unintended consequences of this approach and how conflating restriction with self-injurious behaviour risks conceptual ambiguity, diagnostic misclassification, and the diversion of patients away from specialist services and evidence-based treatments that may benefit them. We advocate an empirical, data-driven approach to understanding the heterogeneous nature of restrictive eating and its diverse psychological, social, and cultural drivers across diagnoses. In clinical practice, greater skill in differential diagnosis and collaborative, individualised formulation is needed, alongside reform of service design to facilitate more integrated care. Vitally, terminology and care pathways for disordered eating need to be meaningfully co-produced with the people who need them, recognising the plurality and legitimacy of experiential knowledge as central to creating more inclusive and attuned care.

Written by a researcher with lived experience of long-standing bulimia nervosa, this Matters Arising piece commends Robinson et al. (2024)’s study for its focus on exploring the subjective experiences of patients who are often overlooked in clinical and academic discussions. However, several concerns can be raised about the epistemological, methodological, and ethical foundations of this research. These include the limited engagement of participants with the terminology used to describe their experiences, and the use of language which remains contested. The author highlights how this approach risks imposing external narratives on participants, arguing instead for more equitable co-production methodologies which include participants as epistemic agents in their own right. Recommendations for future research include the equitable inclusion of people with lived experience, recognising the limits of current evidence, respecting and promoting diversity, and prioritising reflexivity and rigour in qualitative research. These recommendations aim to ensure that future studies reflect the complexity and heterogeneity of lived experiences while maintaining scientific and ethical integrity.

BACKGROUND:Men are underserved in research on eating, exercise and body image psychopathology (EEBIP), and remain underrepresented within healthcare settings despite growing clinical need. One barrier to men's help-seeking for EEBIP-related concerns is that public-facing healthcare information/resources often appear unwelcoming to them, suggesting the need for more inclusive, gender-sensitive resources that engage men and address their specific needs. This study aimed to explore men's perspectives on the design of inclusive EEBIP resources, to inform the iterative co-design of guidance for future resource development. METHODS:This study employed a lived experience-led approach, integrating a modified nominal group technique with participatory research methods, as part of an iterative co-design of a guidance document. Six men with lived experience of EEBIP ranked their preferred features of male-inclusive resources from a broader list of content and format ideas generated through a survey of 42 men. Interview and focus group discussions followed, exploring the underlying reasons why the men with EEBIP experience believed these content and format ideas would support men's help-seeking for EEBIP. Finally, a draft guidance document, underpinned by the results of the discussions, was designed and iteratively edited, following feedback from healthcare organisation representatives, academics, and men with lived experience. RESULTS:Thematic analysis of the discussions identified five themes to inform the development of future resources. The five themes are titled: (1) Designing accessible resources that navigate men's readiness; (2) Authentic voices: inclusive, conversation-led outreach; (3) Self-realisation: refraining from labelling men as 'unhealthy' or 'disordered'; (4) Purpose and progress driven resources; (5) Images: the line between helpful and harmful isn't always clear. These themes are discussed alongside EEBIP and men's mental health help-seeking literature. CONCLUSIONS:This is the first study to centre men's experiential knowledge to explore how healthcare organisations can facilitate men's help-seeking for EEBIP-related concerns via public-facing resources. The themes generated in this study reflect findings of studies exploring the facilitation of men's general mental health help-seeking, whilst contributing novel EEBIP-specific findings. The results of this study can support EEBIP healthcare organisations to develop public-facing resources that are more inclusive of men.

Participation and co-production are increasingly framed as methodological and ethical imperatives across mental health research, policy and clinical practice. Despite this, lived experience is often incorporated through procedural or individualised models that strip it of the relational, cultural and historical contexts through which it is formed. This paper draws on relational ethics, participatory scholarship and reflexive illustration from the author's lived experience to examine the epistemic and ethical consequences that can arise when participation is treated as an individualised or decontextualised act, rather than as a situated practice shaped by place, language, power and institutional norms.The analysis is developed through the Welsh concept of 'cynefin', a term that resists direct translation into English but is associated with belonging, situatedness and relational identity. Used here as an ethical orientation rather than a framework to be implemented, cynefin affords the author a lens to examine what is lost when participation is abstracted from lived context, drawing attention to the wider conditions that shape how people participate, whose voices are recognised and how processes of co-production unfold. The paper concludes by considering the implications of this perspective for research, policy and clinical practice, arguing that sustained attention to context is not an optional enhancement but a necessary condition of meaningful co-production across the mental health field.

Enhanced cognitive behaviour therapy (CBT-E) remains a cornerstone of evidence-based treatment for eating disorders (EDs). While effective for many individuals, its conceptual and procedural scope may not fully capture the clinical realities of some autistic, neurodivergent, multidiagnostic, and treatment-experienced populations. Drawing on recent research and clinical experience, we describe how ED behaviours in these groups are often shaped by sensory and interoceptive processes, neurobiological threat responses, chronic invalidation, trauma histories, and difficulties with emotional and interpersonal regulation that may operate alongside, or independently of, weight and shape concerns. When such mechanisms are under-specified, behaviour is more likely to be misinterpreted as resistance or non-compliance, and lived experience may lack uptake within dominant treatment frameworks. The challenge for the field is not to replace CBT-E, but to recognise the limits of any single model and to develop integrative treatment architectures that incorporate neurobiological, biosocial, and contextual determinants of behaviour. Using Multidiagnostic Eating Disorders-Dialectical Behavior Therapy (MED-DBT) an adaptation of DBT designed for individuals with eating disorders and co-occurring high-risk and regulatory difficulties, as an illustrative example, we outline a dialectical approach that supports epistemic humility, reduces misinterpretation, and promotes more inclusive and effective care for individuals least well served by existing models.

Background Mental health research has long been structured around qualitative and quantitative methodologies, often marginalising experiential knowledge and reinforcing hierarchies of expertise. Although coproduction has gained traction as a participatory approach, its methodological status remains contested, leading to inconsistent practices and risks of tokenism.Objective This paper explores whether coproduction should be recognised not merely as a participatory ideal but as a third methodological pillar in mental health research, with distinct philosophical, ethical and practical foundations.Methods This paper critically integrates interdisciplinary sources from empirical research and theoretical literature to examine coproduction as a distinct methodological paradigm in mental health research. The analysis is informed by the author’s reflexive engagement as a lived experience researcher.Findings Five inter-related challenges to meaningful coproduction are identified: persistent tokenism; the emotional labour required of lived experience contributors; power imbalances in decision-making and recognition; structural exclusions in participation and systemic barriers within academic governance and norms. In response, the paper proposes five strategies for integrating coproduction as a distinct methodological paradigm: creating sustainable fora for dialogue across difference; establishing coproduction as a core research competency; embedding a relational culture of care; fostering methodological innovation and evaluation; and challenging narrow definitions of academic value, authorship and output.Conclusions Reframing coproduction as a third methodological pillar offers a way to address the exclusion of knowledge derived from lived experience and can enhance the rigour, relevance and inclusivity of mental health science. This shift requires systemic changes in how research is conceptualised, taught, funded and evaluated.Clinical implications Embedding coproduction as a core methodology can improve the relevance and responsiveness of research to clinical realities. Grounding research in lived experience offers insights that enhance service design, build trust and support more equitable, person-centred care, ultimately contributing to better clinical outcomes and more inclusive mental health systems.

This Perspective article explores the complex role of motivation in mental health treatment, drawing from the author's personal experiences as a patient. Motivation is often viewed as a prerequisite for treatment success, or for accessing care at all. However, this ceonceptualization can overlook the multifaceted challenges patients face which can impact their motivation in the first place—such as prolonged waits for treatment, systemic barriers to care, and the nature of mental illness itself. Misunderstandings about patient motivation can reinforce harmful narratives that stigmatize individuals, ultimately undermining their recovery efforts. The author emphasizes the need for clinicians to adopt a more reflexive approach—examining their own motivations and biases in order to improve features of treatment and foster more empathetic relationships with patients. A shift towards a more nuanced and compassionate understanding of patient motivation will be supported by: (1) recognizing patient strengths through validation; (2) enhancing trust in treatment through consistency; (3) responding to trauma; (4) creating more acceptable and flexible treatment models via co-production; and (5) seeing ambivalence as a therapeutic opportunity. By redefining motivation as a fluid and shared experience, mental healthcare can itself become more motiviating—creating treatment that is more inclusive, equitable, and supportive of recovery.