None.

The aim of this paper is to reflect on the way that we as clinicians may play an inadvertent role in perpetuating eating disordered behaviour. This is considered within the theoretical framework of Schmidt and Treasures' maintenance model of anorexia nervosa (AN). The model includes four main domains; interpersonal factors, pro-AN beliefs, emotional style and thinking style. Interpersonal reactions are of particular relevance as clinicians (as with family members) may react with high expressed emotion and unknowingly encourage eating disorder behaviours to continue. Hostility in the form of coercive refeeding in either a hospital or outpatient setting may strengthen conditioned food avoidance and pessimism may hamper motivation to change. Negative schema common to eating disorders, for example low self-esteem, perfectionism and striving for social value may augment existing or initiate new eating disorder behaviour. Services can become a reinforcing influence by providing an overly protective, palliating environment which ensures safety, security and acceptance whilst reducing loneliness and isolation. This stifles the need for an individual to develop their own sense of responsibility, autonomy and independence allowing avoidance to dominate. Furthermore, the highly structured environment of inpatient care supports the rigid attention to detail and inflexibility that is characteristic of people with eating disorders, and allows these negative behaviours to thrive. Careful planning of service provision, reflective practice, supervision and regular team feedback is essential to prevent iatrogenic harm.

Further high quality evidence is needed in this area in order to provide practical guidance to clinicians. However, the main challenge is to persuade adequate numbers of AN patients to participate in research trials.