Treatment as involuntary, incompatible, and intimidating: exploring dropout processes in a randomized controlled trial for eating disorders.

Background: Ambivalence to treatment and dropout are particularly common in Eating Disorder (ED) treatment, hindering recovery and posing a serious threat to the external validity of outcome research. Attrition may bias findings of randomized controlled trials (RCTs), and exacerbates the risk that complex cases are underestimated, which is serious since RCTs inform the development of evidence-based practices. An increased understanding of dropout processes may contribute to increased patient retention, still, patients' perspectives on voluntary dropout are rare.

Aim: We explore the treatment responses involved in voluntary dropout processes in an RCT. Six female, cis-gendered non-completers were interviewed after dropout; rich descriptions from few informants rendered Interpretative Phenomenological Analysis suitable.

Results: We developed three Master Themes with two subthemes each: «I had no choice» (fear of disappointing, other-orientation), «I did not fit in» (alienation, poor fit of treatment), «I left to survive» (Existing through the illness, Need to regain control of self) under the overarching Core Master Theme «Treatment as involuntary, incompatible, and intimidating».

Discussion: Our findings underscored the centrality of perceived coercion, feeling pressured to choose recovery, alienation, misalignment with treatment goals, and the seemingly existential and critical urge to regain control of self during overwhelming emotions evoked when confronted with mandatory treatment components. RCT non-completers' accounts corroborate previous patient-as-expert research on dropout experiences in naturalistic settings. Refined methods are called for to bridge the research-practice gap.