The data related to the perspectives of the healthcare professionals were organized into four main themes, and an overlap between the themes was observed. The following illustration illuminates a portion of the findings that emerged from the data of the professionals. Additional file 1: Matrix 1: Deductive reasoning of the themes, subthemes, codes and interview transcripts of the professional respondents.
Professionality
The theme professionality had three subthemes: demonstrating how healthcare professionals interact with their professional image, their experience of resistance working with the SEED-AN, and their knowledge and expertise. The subtheme 'Image' significantly influenced participants’ perceptions. The professionals experienced a certain image related to chronicity in psychiatric illness in general, as perceived by other healthcare workers. Thus, FACT professionals do not experience this affinity when working with the SEED-AN individual, which is labeled ‘resistance’. An excerpt from R14 underpins the theme: Anxiety arises among the staff due to the often-precarious physical circumstances as a result of the condition. The last subtheme recognized the ‘knowledge and expertise’. Potentially, FACT professionals can improve patient care excellence, as they are available for all kinds of clients.
Imaging
The theme imaging was built on two subthemes: incompetence versus competence. The subtheme 'incompetence' is related mainly to the experience of FACT workers and is related to the knowledge gap between them and the SEED-AN. Thus, it is difficult to acquire the right knowledge. FACT professionals struggle with determining what kind of care the SEED-AN client should receive. The excerpt R2 illustrates the issue: “you need people who are willing to learn about the phenomenon of eating disorders”. However, the knowledge gap and lack of expertise of the SEED-AN are recognized. However, FACT professionals are eager to increase their knowledge and expertise in eating disorders, specifically, the SEED-AN. There is a wish to collaborate with SEDU professionals to achieve this goal.
Theme: Collaboration
Collaboration is built on a dichotomous perspective. Most of the interviewees mentioned the lack of collaboration between the specialists. The majority of the interviewees desired to exchange methods through psychoeducation and training in the field of eating disorders and mentioned networking as a method to improve collaboration between specialists. R11 specifically mentions the strength of the FACT team: networking!
Theme: Autonomy
The theme autonomy is built on one main subtheme, ‘vision’, and can best be described as the desire to act autonomously as a therapist. Several subthemes support this theme: Indignation, courage, lack of vision, and annoyance. These themes correspond with the current healthcare policies. Several respondents struggled with policies as a result of a strict separation of care versus cure trajectories. The excerpt from R15 stated this issue: ‘I feel pressure from the management to discharge SEED-AN clients’. However, R11 emphasized that good communication with management is crucial, suggesting that support from management is essential for implementing more client-centered choices. The majority of the respondents experienced a gap between policy choices and choices made referring to appropriate treatment.
The data related to the client respondents were organized into four main themes: 1.) trust in the treatment relationship, 2.) Organization of care, 3.) Care needs and theme 4.) Motivation and meaning. Additional file 2: Matrix 2: Deductive reasoning of the themes, subthemes, codes and interview transcripts of the client respondents.
Theme: Trust in the therapeutic relationship
This theme is built on the subthemes ‘being seen’, ‘the therapist knows me well’, ‘long-term professional relation’ and ‘attitude’. All the respondents experienced negative treatment, mostly related to eating disorders. The protocolized treatment did not suit them; individuals felt powerless and unseen; and one respondent mended that treatment was not offered to English speakers. Then, respondents needed time to regain their lost trust in treatment. All spoke positively about the therapeutic relationship with their FACT therapists. All the respondents subsequently felt that they were being seen by their therapists, and moreover, the therapist was willing to invest in a long-term therapeutic relationship. Four respondents mentioned a collaboration within the therapist in the fight against the eating disorder or in recovery. Regarding the attitude of the therapist, a desired combination of being kind or empathetic versus strict was mentioned. Then, the firmness that is necessary for therapists to confront, set boundaries or mirror back to clients was mentioned. Three respondents stated that therapists quickly understand them, and therapists seem to know the client better than they know themselves.
Theme: Organization of care
All respondents mentioned the following subthemes: accessibility, availability, and low-threshold approach. The text message, phone, or email was mentioned. When needed, therapists were available, and the possibility of meeting at home or elsewhere was offered. The predictability and commitment of multiple healthcare providers were perceived as pleasant. A change in healthcare providers was considered very undesirable. The treatment team pays attention to various complaints and offers several treatment methods, including emotion regulation therapy and trauma treatment. The possibility of obtaining supporting care, such as housing support, dietetics, social skills training, or autism support, was mentioned elsewhere. Three respondents found it pleasant to practice guided eating.
Theme: Care needs
Theme care need is supported by the subthemes ‘frequency’, ‘stress regulation’ and ‘autonomy’. The nature, form, and frequency of conversations were adjusted according to the patients’ care needs. All the respondents reported ambivalence toward eating problems, which is highly related to stress regulation. The following statement refers to this. R4: “I try to indicate in my own way that, yes, I do need support, but even then, it is a continuous battle between the healthy part of me and the unhealthy part, the anorexia part, which then thinks if they just do not respond, you do not need help”. Three respondents mentioned the importance of understanding why eating is necessary. Being confronted or mirrored, discussing patterns, or pointing out unconscious behavior were mentioned five times. Involving dietetics was also mentioned, as was receiving insights and tools to be able to continue one's own. Three respondents also indicated receiving trauma treatment within the FACT team. Pharmacotherapy is available for all treatments. With respect to autonomy, two respondents appreciated the involvement of their partners; others did not want anyone involved. Suggestions for improving the care included offering services in English, providing buddy or peer support workers, addressing physical complaints, and enhancing communication with other healthcare providers from different organizations.
Theme: Motivation and meaning
The subthemes ‘suffering’, ‘wish to live’ and ‘meaning’ underpinned the main theme. Life is experienced as a heavy burden. The following statement is an example of this: R1: 'Without them, I would not be here anymore; they help me to survive.' The strength to persevere is not constant. Some respondents repeatedly noted suicide attempts. A relationship was established between motivation and the realization of not wanting to die, a desire to have children, a partner, how to live your life, a social role or participation, (self)acceptance and/or improving quality of life. All the respondents mentioned that the experience of daily and weekly activities was essential, and hobbies and (volunteer) work were mentioned. One respondent mentioned her assistance dog, on which she depended, and provided motivation to persevere in more difficult moments.