The German and Dutch treatment protocols are comparable. Both countries have a strong medical focus and family based therapy is the first intervention. But in practice, we see a great variance. A big difference between Germany and the Netherlands is how the care system is organized. In the Netherlands, care is more focussed on outpatient care aiming at the child as well as their surroundings including parents, schools etc in the treatment. In Germany, the system is organized around the clinics and patients are more often being treated in the clinics. There are less options to involve parents or the surrounding system in the treatment.

• While treating patients with severe anorexia nervosa, professionals see themselves confronted with significant ethical, medical, and emotional questions and dilemma’s.
• From strong emotions to feeling numb
• People change their job because of the impact
• Fighting outside opinions: defending a treatment they don’t want to do
• Division between professional and teams (care team vs therapeutical team), parents, patients
• Feels like there is no alternative

• Open communication with colleagues, parents, patients (build trust and confidence)
• Supervision/intervision: individual and team level (emotional processing, new perspectives, feel supported)
  
• Agency: The option to not do a procedure because it is too much to handle. While in most cases it was possible to decline having to perform FTF, in other cases it was seen as “part of the job”. By giving professionals agency they are not forced into performing procedures they are not comfortable with.
• More staff
• Follow up contact with patients: With regards to patient contact, follow-up contact with patients were mentioned as supportive to professionals. It helped them reflect on the treatment process and to just see how their patients are doing after treatment. While this can be a difficult and confronting experience by professionals as well as patients, it can significantly help in the emotional processing and healing of both.
• Focus groups were intervention in itself, Sharing experiences, perspectives, and clinical approaches with colleagues from another country can help gain new insights.
• Prevention/ketenzorg: Professionals want more collaboration with other institutions involved in caring and educating children. Prevention through educating GPs, paediatricians and independent psychologists in the region can help prevent children to develop unnecessarily severe conditions of their disorder. A closer connection with schools could also help with the reintegration of children with AN and providing more effective and value care.