Psychosocial barriers to engagement with an eating disorder service: a qualitative analysis of failure to attend.

Patient non-attendance and failure to engage with health services may be costly to the individual in terms of the delays in obtaining appropriate treatment and the unnecessary suffering and discomfort this may entail. Non-attendance is also costly to health services because of administrative and clinical time lost and the opportunity costs of not treating other patients. Patients who have been referred to eating disorders clinics by general practitioners appear to have high rates of non-attendance or dropping out immediately after assessment. The reasons behind their failure to engage are poorly understood. After undertaking a comprehensive audit in a major eating disorder unit in London we undertook a qualitative study of non-attenders in order to obtain the reasons behind non-engagement. We found that while participants tend to open their explanations with practical difficulties (e.g., child-minding) or service- related factors, what commonly emerged from their narratives were profound social-psychological problems and the ambivalence of confronting or losing a relationship with food that was both comforting and debilitating. Some participants described a world of imprisonment which precluded the likelihood of firm engagement with services. We suggest that such people may require better identification and outreach provision.