Perceptions of health professionals in providing care for people with anorexia nervosa and bulimia nervosa: a systematic review and meta-synthesis of qualitative studies

Abstract: This study sought to synthesize and reinterpret findings from primary qualitative studies on the experience of health professionals in caring for people with anorexia nervosa and bulimia nervosa. We conducted a systematic review of the literature with the SPIDER search strategy assessing six databases. A meta-synthesis was performed with data from qualitative studies. Two independent reviewers screened and assessed the articles, extracted data from the articles and elaborated thematic synthesis. Nineteen articles met the inclusion/exclusion criteria. The meta-synthesis revealed three descriptive themes: Going outside the comfort zone: hard relational experiences of health professionals in providing care for people with anorexia nervosa and bulimia nervosa; Reflecting on treatment: relevance of discussion, communication, and flexibility in health professionals’ work with anorexia nervosa and bulimia nervosa; and Dealing with ambivalences: experiences of health professionals with family members of people with anorexia nervosa and bulimia nervosa. We elaborated two analytical themes: Making work with eating disorders palatable: malleability necessary for health professionals in bonding with people with anorexia and bulimia nervosa and their families; and Leaving the professional comfort zone: transition from multi to interdisciplinary. Thus, mental health professionals who work with people diagnosed with anorexia and bulimia nervosa cope with hard emotional experiences that makes them feel out of their comfort zone, requiring flexibility to benefit a good therapeutic alliance, but there are still difficulties in promoting interdisciplinarity.


Introduction
This systematic review and metasynthesis sought to synthesize and reinterpret results of primary qualitative studies about the experience of caring for people with eating disorders from the perspective of health professionals.People diagnosed with eating disorders present significant alterations in their eating behavior pattern 1,2,3 .Two subtypes stand out due to great social visibility: anorexia nervosa and bulimia nervosa.The main characteristics described in both cases are significant changes in eating behavior in order to avoid weight gain, accompanied by intense distortion of body image 4 .
Due to the severity and persistence of symptoms, the specialized literature recommends that people with eating disorders should receive intense and continuous treatment conducted by professionals such as doctors, psychologists, nutritional, psychiatrists, among other health professionals.Thus, it is recommended that such therapeutics should be carried out by a multidisciplinary team with interdisciplinary practices 5,6 .In addition to dictating a team composition with different specializations, an interdisciplinary approach is one in which different knowledge areas can establish exchanges and dialogues, implementing a specific therapeutic plan for each patient 7 .Furthermore, care for people with eating disorders should be conducted with family members 8 , and coordinated with other health services (general, social, or specialized services), promoting comprehensive care for the population 9 , along with an attitude that considers the social context in health practices 10 .
Despite extensive research in the area, high rates of non-compliance and difficulties in adhering to specialized treatment still prevail 11,12,13,14 .The tenacity with which people with anorexia and bulimia nervosa resist therapeutic strategies may be related to the failure to recognize eating disorder as a problem, since restrictive eating patterns can be experienced as a lifestyle.Studies also indicate that these people may have additional difficulties in forming and maintaining emotional relationships with their family members, friends, as well as with healthcare professionals themselves 7,15,16 .
Research shows that therapeutic alliance is one of the most important variables related to treatment outcome, especially in anorexia nervosa cases 16,17 .Despite recognizing the importance of therapeutic alliance for treatment, health professionals face difficulties in forming this relationship, which often makes them feel frustrated, hopeless, and incompetent in facing the persistence of symptoms 18,19 .
Working with anorexia nervosa/bulimia nervosa people can aggravate stressful situations, which make health professionals a vulnerable population regarding mental health 20 .This is because doctors, nurses, and other health workers are subjected to situations of exhaustion and intense work for a long period of time, extreme situations linked to death and finitude, among other factors that can increase the risk of mental illness 20,21 .Professionals who work with eating disorders are subjected to several challenging moments in their work, which can even compromise their emotional availability in caring for patients 12,22 , which is essential when caring for people with these diagnoses 16,17 .
Therefore, knowing that the scientific evidence is about how health professionals perceive and experience care for people with eating disorders can provide important clues for understanding the potentials and difficulties encountered when establishing a therapeutic bond.This knowledge can provide subsidies to refine treatment planning, as well as strengthen the mental health and well-being of professionals.Metasyntheses have already been published about the experience of patients in treatment 23,24 , as well as family members who accompany them in health services 25,26,27 .However, a consistent review of qualitative studies regarding the experience of health professionals in the care provided to people with anorexia nervosa/bulimia nervosa has not yet been conducted.We expect that systematically gathering qualitative evidence from selected studies following a rigorous methodological process can promote a new conceptual understanding of the summarized results, transcending previous results and allowing us to formulate new understandings 28 .
In view of the above, this study aims to synthesize and reinterpret the results from primary qualitative studies about the experience of caring for people with anorexia nervosa/bulimia nervosa from the perspective of health professionals.

Method Design
The systematic research trajectory followed 10 steps: (1) Elaboration of the research question guided by the SPIDER strategy; (2) Definition of selection and exclusion criteria, and choice of appropriate databases for the research area; (3) Elaboration of the search strategy based on specific descriptors for each database; (4) Searching the databases, with validation by another researcher who independently evaluated the information; (5) Screening and selection from titles and abstracts, also comparing the results with the second independent reviewer and using the Rayyan tool (https://www.rayyan.ai/);(6) Calculation of the kappa index of inter-rater agreement; (7) Reading the selected articles in full and final selection of the analysis corpus; (8) Qualitative analysis of the methodological procedures of the studies studied based on the Critical Appraisal Skills Program (CASP) 29 ; (9) Coding the results of selected articles using the QDAMiner 9.0 Lite program (https://provalisresearch.com/); (10) Description and analysis of the material.
This study was registered on the PROSPERO platform 30 (under the protocol CRD42022311740).The Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guide was used to report the essential elements that must compose a qualitative evidence synthesis 31 .

The SPIDER strategy ([S] sample; [PI] phenomenon of interest; [D] study design; [E] evaluation;
[R] research type) was chosen because it is considered an adequate tool for reviewing studies with qualitative methods, providing greater rigor to the research 32 .Thus, the following research guiding question was elaborated based on the SPIDER strategy: What is the qualitative evidence available in the literature about the experience of health professionals in the care of people with eating disorders?Eligibility criteria were defined as follows: Inclusion criteria: (a) primary qualitative studies; (b) studies consistent with the research question developed with the SPIDER strategy; (c) articles that include the perception of health professionals, trainees, or workers in the Results section as a category or subcategory.Exclusion criteria: (a) qualitative, mixed, secondary, literature review, or theoreticalreflective studies; (b) gray literature, such as theses, dissertations, monographs, books, or chapters; (c) letter to the editor, editorial, commentary, opinion articles, and abstracts; (d) studies that do not include health professionals (only patients and/or their families); (e) studies published in languages other than Portuguese, English, Spanish, or French; (f) studies regarding eating disorders that do not meet the diagnostic criteria for anorexia or bulimia.
After defining the databases regarding their relevance to the knowledge area and seeking to encompass the national and international research scenario, the search terms were selected, which meant choosing the appropriate descriptors for each database.The SPIDER search strategy was defined by combining the descriptors of each acronym, suitable for each database.No date restriction was applied.The search used the Boolean operators OR between the descriptors of the same acronym and AND between each one of them, as follows: (S1 OR S2 OR Sn...) AND (Pi1 OR Pi2 OR Pin...) AND (D1 OR D2 OR Dn...) AND (E1 OR E2 OR En...) AND (R1 OR R2 OR Rn...).The "advanced search" tool was used in the databases.A track of descriptors assembled from DeCS/MeSH is shown in Supplementary Material 1 (https://cadernos.ensp.fiocruz.br/static//arquivo/suppl-1-e00223122_2723.pdf).

Study search and selection
The study based on the described strategy was conducted by two reviewers independently in February 2022 in six databases: LILACS, PsycINFO, PubMed, CINAHL, Scopus, and Web of Science.A total of 3,247 articles were identified in this first stage.From this first sieve, the selection of articles was refined with the support of the Rayyan software for systematic reviews 33 .The use of a software makes the study selection process more transparent and reliable 34 .Duplicate articles were excluded (n = 55).In the next phase, the same independent reviewers applied the eligibility criteria described above.The two reviewers blindly selected the articles they considered to be included or excluded.
Cad. Saúde Pública 2023; 39(7):e00223122 After this step, removing the blinding of the Rayyan tool, it was possible to see the concordances and disagreements between the reviewers.
The kappa index calculation was performed to ensure a sufficiently good agreement rate between reviewers 35 .We obtained a value of 0.825 herein, demonstrating excellent agreement between the lists produced by the evaluators.As a result of this process, 23 articles met the eligibility criteria.Figure 1 shows the number of materials excluded according to each criterion.Thus, we proceeded to the next step: full reading of the recovered materials.The two reviewers read the remaining articles in full, except for one which was only published in full in Japanese.After the full reading, the two reviewers discussed again the eligibility of each article.From the agreement of the reviewers, four articles were also excluded at this stage.The references that were excluded after their full text was reviewed and the reason for exclusion is shown in Supplementary Material 2 (https://cadernos.ensp.fiocruz.br/static//arquivo/suppl-2-e00223122_9940.pdf).Therefore, the final corpus of this metasynthesis consisted of 19 articles.
The selection and exclusion process of articles is described in the flowchart (Figure 1) developed from the PRISMA strategy (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 36 .
The data from the 19 studies were described based on extracting the following variables: first author, year of publication, country where the study was conducted, the study objective, design, data collection and analysis forms, as well as the number and characteristics of participants (Box 1).

Methodological quality of the articles
The CASP Qualitative Checklist was used to qualitatively evaluate the methodological properties of the studies.It is a checklist which considers the description and relevance of the objectives, adequacy of the methodological choice and study design, the description of the data collection and analysis strategy, if the ethical procedures were well described and if the data were presented in a sufficiently satisfactory manner 29 .The analysis of these aspects was performed by two independent reviewers.The two lists were subsequently compared, and disagreements could be discussed until consensus was established.As described in Box 2, all studies presented their objectives clearly, and these proved to be appropriate for qualitative studies.Despite this, most of the retrieved and analyzed articles did not explicitly discuss the researchers' implication and relationship with the participants.

Data analysis
Thematic analysis was performed according to the following methodology 37 : (1) Reading the selected studies in full using the QDAMiner Lite software to perform the coding line by line; (2) Grouping the codes into similar themes, called descriptive themes, which describes the results of the analyzed primary studies; (3) Development of the analytical theme: at this stage, new interpretations and constructs are elaborated from the original data.The analytical topic is discussed and validated with the help of the research group, to which the researchers are linked.
A total of 235 participants composed the total sample of this metasynthesis, including the 19 studies.The samples included several specializations in the health area, such as: clinical service managers, psychiatrists, consultant doctors, general practitioners, endocrinologists, occupational therapists, nurses, dieticians, counseling psychologists, clinical psychologists, social workers, and family therapists.These participants had anywhere from 28 years of experience to almost none (residents and undergraduate, intern, and final-year nursing school students and residents).Source: prepared by the authors.
The thematic synthesis process revealed 42 codes referring to the results of the 19 studies.These were synthesized and described in three descriptive themes: (1) Going outside the comfort zone: hard relational experiences of health professionals in providing care for people with anorexia nervosa/ bulimia nervosa; (2) Reflecting on treatment: relevance of discussion, communication and flexibility in health professionals' work with anorexia nervosa/bulimia nervosa; (3) Dealing with ambivalences: experiences of health professionals with family members of people with anorexia nervosa/bulimia nervosa in the therapeutic context.From this, two analytical themes were developed: (1) Making work with eating disorders palatable: malleability necessary for health professionals in bonding with people with anorexia nervosa/bulimia nervosa and their families; (2) Leaving the professional comfort zone: transition from multi to interdisciplinary (Box 3).

Theme 1: Going outside the comfort zone: hard relational experiences of health professionals in providing care for people with anorexia nervosa/bulimia nervosa
This theme highlights how the therapeutic relationship between professionals and patients is experienced, as well as the emotional experiences of the professionals.Despite being valued, the therapeutic alliance proves to be difficult for the participants of the retrieved studies.These obstacles are related to the complex and multifactorial characteristics of eating disorders 38,40,42,43,44,45,46,47,48,50,54,55,56 , the non-recognition of eating disorder as a disease 39,41,42,43,44,45,47,54,55 , and the difficulty of communicating with patients 42,43,44,47,49,50,51,54 .From the perspectives of the people studied, this scenario causes feelings such as: doubt, frustration, incompetence, anxiety, and fear 38,39,41,42,43,44,48,49,50,54,55 .The professionals reinforced the importance of engaging the person with anorexia nervosa/bulimia nervosa in the treatment.When there is a good link between professional and patient, the studies highlight the professional's openness to feelings of empathy, improving the quality of care offered 38,40,43,50,52,56 .
Despite the difficulties in establishing a therapeutic alliance, these represents an important aspect for professionals in caring for people with eating disorder.The retrieved studies highlight 38,39,43,49,50,51,52,53,56 the relationship between health workers and patients during the course of treatment in the sense of promoting a welcoming posture: "a relational space that allows for the development of

Box 3
Codes and themes generated by the process of thematic synthesis.
Source: prepared by the authors.
The impasses in establishing a therapeutic relationship with the person with anorexia nervosa/ bulimia nervosa in some studies are linked to the need to convince them to do something that goes against their own will, as is evident in the following report: "you're making these kids do something that absolutely horrifies them.I saw this as very... very difficult and upsetting" 43 (p. 685).This idea is also related to the patients' lack of motivation with the treatment 54,55,56 , making it "difficult to persuade patients to accept specialist care" 54 (p.463).
Thus, from the perspective of the professionals participating in the recovered studies, the attitude of patients in the services which makes the therapeutic relationship most difficult is the denial of eating disorder as a disease 39,41,42,43,44,45,47,54,55 , as in the following report of a professional: "It can be challenging with the patients who don't have the insight into their illness, because they don't necessarily want your help" 44 (p. 6).As a result, patients are described by participants in several studies 38,39,42,43,44,45,48,53,54,55 as non-collaborative and manipulative.A practitioner summarizes the content of contact with patients as follows: "I found it hard..." 46 (p. 556).
The selected studies also suggest that the difficulty in communicating with people with eating disorders may be a factor that hinders establishing a therapeutic alliance.Participants state that there is little emotional openness, distrust, and little ability to express feelings 42,43,44,47,49,50,51,54 .The narrative of nurses participating in one of the studies highlights that not establishing eye contact is a non-verbal element that underlines the emotional closure of patients: "She speaks coldly and doesn't even look at me" 42 (p.1390).Studies suggest that there is a difficulty in establishing effective communication, which raises doubts in participating professionals about the best way to talk to patients 43,46,51 .A professional expressly questioned herself: "God, what if I say the wrong thing to the service user?" 43 (p.684).In view of this, survey participants reported feeling nervous: "I used to be quite nervous about saying anything" 39

(p. 426).
(p. 34).In other investigations 41,44,45,46,50,56 professionals felt they did not have enough knowledge to work with eating disorders, they needed to read more studies or receive specialized training in the area.
In addition, some of the retrieved studies revealed that professionals felt worried and anxious at times of relapse and worsening of the patient's condition 38,39,40,41,44,47,48,50,54 .One professional ponders: "but if the person is far away and then, suddenly, they deteriorate severely, then it would be very difficult" 41 (p.448).Although concerned about the worsening of the clinical picture, a patient's improvement also always seems very fragile, being anxiogenic for health professionals: "It could just take the littlest thing for you to say to completely regress in their recovery" 43 (p.685), bringing anguish to professionals: "There's and anxiety there about holding that risky responsibility" 38

(p. 6).
Another prevalent feeling in these moments concerns frustration 38,39,42,44,48,50,54,56 .In addition, questioning the possibility of improvement associated with this frustration is also noticed: "How much can I help them?They've had this disease for months, if not years, and they're going to have this for the rest of their lives" 50 (p.e39), showing the difficulty of remaining hopeful in this context: "Trying to sustain hope and remembering that recovery is possible... (...) can be quite challenging" 38 (p. 7).
The complexity and severity involved in the cases of the analyzed studies, as well as the difficulty in forming and maintaining a good therapeutic relationship with the patients are added to the various variables involved in dealing with any individual, such as: culture 39,46 , gender 47 , comorbidities with other conditions 51 , or care at specific moments in their life 41,53,55 .These specificities bring another perspective shown by the studies: the importance of individualized care, one that is tailored to each patient 38,40,41,42,44,45,46,47,48,51,52,53,56 .Some speeches by professionals show this idea: "treatment needs Cad.Saúde Pública 2023; 39(7):e00223122 to be tailored accordingly, to meet individual needs through a personal treatment plan that is focused on the person rather than the diagnosis" 56 (p. 395).

Theme 2: Reflecting on treatment: relevance of discussion, communication, and flexibility in health professionals' work with anorexia nervosa/bulimia nervosa
This topic is about the experiences of professionals in health services, especially regarding their work experiences with a specialized multidisciplinary health team, as well as in the daily practices of care in the services based on the protocols and available resources.The indispensability of working in a multidisciplinary team is highlighted when mentioning the difficulties of the care scenario.On the other hand, the difficulty of communication between professionals of the same team or between different professionals of the health system seems to be an obstacle to a good service to service users.
Many studies 38,39,41,44,45,48,50,53,56 have highlighted the importance of a multidisciplinary team in the health services responsible for providing care to people with eating disorders, covering all aspects of the patient (psychological, physical, and social), in a "diverse team with diverse skills" 38 (p.8), which work with coordinated actions in decision making."It's the division of the responsibilities (...) where I feel confident to be able to talk with families and explain" 50 (p.e38), so that "we decide together" 45 (p. 5).
Other publications also point out that working in a team can help to overcome the difficulties found in working with eating disorder patients with tips, supervision, and observing the more experienced 44,48 : "talking to my other consultant colleagues, especially with regard to approaching family and conflicts" 44 (p. 4).However, other articles 40,50 also highlighted barriers found in teamwork such as communication difficulties and the fact that professionals do not feel comfortable asking questions, making dialogue difficult: "sometimes I didn't feel that comfortable in asking questions" 43 (p. 684).
Communication obstacles are also present between different health centers: between general practitioners/pediatricians and specialized services or in the communication between two different specialized services in moments of transition 38,41,45,53 .In the experience of professionals, they should work together so that better care provided to users is possible.One professional pointed out: "... other times you don't hear back from people, and that can be really difficult" 41 (p. 447).
Other impasses in the daily practice of health services are related to the structures of the places where the services are located: hospitals, clinics, and specialized outpatient clinics.For example, the lack of financial resources, the great demand for services, reducing the time dedicated to each patient, and the challenges to find an adequate setting or lack of specialized professionals 38,41,42,50,56 .Some speeches by professionals underline the lack of funding: "I think one of the problems is when the funding runs out" 56 (p.394); "More funding for more staff would be the best to be able to provide more care for more patients" 38 (p. 8).
The overload of the services, and consequently of the professionals, also leads the multidisciplinary team to lack time for study, dedication, and reflection about the work carried out 39,41,42,56 .This appears in reports of several studies: "I don't know if its linking gaps in my knowledge or if it's the time to think that might be more of what's missing sometimes" 39 (p.425).
Some healthcare institutions have stricter diagnostic guidelines, protocols, and improvement criteria.In some studies, workers experienced the protocols or guides as support in facing doubts, thus facilitating care practice 41,44,48,50,56 , giving consistency: "It's definitely a disease process that needs consistency and regular planning" 50 (p.e39), as well as standardized conducts: "It might be helpful to have some kind of training program or something that would mean everyone was going out to the families and doing the same thing" 48 (p. 34).
On the other hand, others experienced the protocols and guides as instruments with parameters that are too rigid, which makes the practice inflexible and limits the possibilities of adjusting to the needs of each one 39,40,45,46,47,53,54 ."The actual clinical work wanted diversity.They want to use different models" 39 (p.425); "my fear is that there is a guide, but people are individuals" 40 (p. 730).
Differential diagnosis was also mentioned in the studies retrieved, and doubts were reported in formulating diagnostic criteria, especially when there are comorbidities or in the case of atypical anorexia nervosa 40,52,53,54 .Some of the study participants stated that "patients' weight behavior and family circumstances are presented as uncertain evidence of diagnosis" 54 (p.462); and that they feel "uneasy and unsure about the implications of using a fixed set of criteria recovery" 40

(p. 731).
Cad. Saúde Pública 2023; 39(7):e00223122 Personal resources that help in the daily practice of health services were also mentioned, such as previous knowledge and experience in the area, making them confident in providing interventions 43,46,47,48 ."I feel more confident knowing the physical, medical side" 47 (p. 4).Other interventions that have proved successful in the perception of professionals are practices with groups 43,46,47,53,56 providing mutual support among patients 38 , and those aimed at the development of daily skills, promoting the development of autonomy 38,48,49,50,51,52,53 .
Theme 3: Dealing with ambivalences: experiences of health professionals with family members of people with anorexia nervosa/bulimia nervosa in the therapeutic context This theme deals with the experience of professionals with family and companions of patients treated at the health service and the importance of this support network for the treatment.Despite recognizing the importance of family members of people with anorexia nervosa/bulimia nervosa, the participants in the analyzed studies also felt that they can contribute to maintaining symptoms, hindering, above all, the accountability and autonomy of patients.Therefore, they demonstrate ambivalent feelings about working with family members.
Many professionals who participated in the recovered studies reinforced the importance of the family actively participating in the treatment, seeing it as "crucial" and even "central" 38,41,42,43,44,45,48,5 0,51,52,53,55 , since "they play such a key role" 43 (p.684).One professional said: "They're going to be the ones to keep an eye out for warning signs.So, it's important to involve them in the care as well" 44 (p.5).
On the other hand, the family can be seen by these workers as an obstacle to treatment due to their controlling attitudes and often symbiotic patterns of attachment, making it difficult for patients to take responsibility and develop autonomy, and often contribute to the maintenance of symptoms 38,39,44,45,48,50,53,54,55 .One professional says that: "With one patient, I felt the family was contributing to the ED [eating disorder]" 50 (p.e39).Studies which investigated the transition of patients from pediatric to adult outpatient clinics 55 and the entry of people with eating disorders into college 41 report on the parents' difficulty in dealing with their children, who start to have greater legal control over the decisions made, and the anxieties arising from these moments of growth and separation: "This has been a big issue where parents have gotten together and said even though they are 18 we can still make decisions" 55

(p. 764).
The professionals participating in the studies therefore recognize that the family is essential in the treatment, but can be a factor which contributes to maintain the chronicity of symptoms.This reinforces that eating disorders care services must include the family in the therapeutic plan.In the words of a professional: "we are bringing the family closer together as well and, kind of, empowering them to support the patient" 38 (p. 8).One study also mentions the relevance of looking at family members as people who are cared for: "I think that as a service we have to support the families because their lives really do change" 41 (p. 449).
In view of the results explained in the previous descriptive themes, two analytical themes were developed.

Analytical theme 1: Making work with eating disorders palatable: malleability necessary for health professionals in bonding with anorexia nervosa/ bulimia nervosa patients and their families
According to the analyzed studies, working with patients with anorexia nervosa/bulimia nervosa is a challenging experience and unpalatable from the professionals' reports.In leaving their comfort zone, workers are faced with the rigidity of these patients and the tenacity with which they cling to the symptoms, not recognizing the eating disorder as a problem, not seeking help, and not collaborating with communication.This scenario leads to feelings of frustration, insufficiency, fear, and ambivalence, among others.In this analytical theme, we emphasize that the difficult feelings that these patients and their families place on professionals require flexibility to deal with the difficulties imposed by the clinical encounter and seek hope, regardless of the obstacles.
The professionals showed that flexibility was necessary because of communication difficulties, seeking the best way to talk to patients, as well as dealing with their own feelings when in the contact Cad.Saúde Pública 2023; 39(7):e00223122 with the users of the health services.Malleability can be an adaptive way for professionals to deal with the typical rigidity of these patients, promoting greater openness to the therapeutic alliance.From these studies, we can see that a lot of flexibility in clinical management is also needed when dealing with the many variables of each unique patient and with family difficulties.Considering the impasses within the care scenario, professionals may have protocols and guidelines, but they had to adapt them to each case, work as a team to think about the complexity of each person assisted/treated, with flexibility to work with other professionals or even other services.However, this malleability presupposes that professionals are guaranteed minimum working conditions, such as human and technological resources, time for study, discussion, and adequate care and training.

Analytical theme 2: Leaving the professional comfort zone: transition from multi to interdisciplinary
Caring for people with anorexia nervosa/bulimia nervosa requires professionals to leave their known world and be flexible when dealing with patients and their families.However, they still cling to the comfort zone of staying within their own specialization.In the experience of the professionals participating in the studies, it is possible to perceive that there is an intense difficulty in dialogue because there is no integration between the disciplines, there is no openness to the various new skills necessary when working with eating disorders.
Therefore, although the professionals of the analyzed studies emphasize the importance of a multidisciplinary team, in practice they do not function as interdisciplinary.This brings obstacles to creating knowledge in practice, which takes place during care in a different way from what they learned before.This lack of interdisciplinarity may be another factor that has implications for the fact that working with eating disorders is considered difficult and "unpalatable", and potentially for the difficulty of seeing family members as a target population of care.

Discussion
This review allowed us to synthesize qualitative evidence on the experience of health professionals in caring for people with anorexia and bulimia nervosa.Three descriptive themes were developed considering the intense and difficult experience of working with this type of demand which requires great flexibility from professionals, leaving their comfort zone, both in terms of caring for the patient and their families, as well as in facing a care scenario within the health services which does not always favor the professional's work.
The specialized literature in the area of eating disorders 16,17,18 shows us that although the therapeutic alliance is essential to treatment, it is considered an achievement which is built on unsafe terrain, bringing fragility and instability in the professional-patient relationship.The primary qualitative data gathered herein are congruent with previous literature review studies, demonstrating this difficulty in contacting patients 18,19 and their families 26 .
The justifications offered by the professionals of the studies analyzed herein include: the complex and multifactorial characteristics of the eating disorders; non-recognition of the need for help on the part of the patient; the difficulty of communication 38,40,42,43,44,45,46,47,48,50,54,55,56 ; and non-recognition of eating disorder as a disease 39,41,42,43,44,45,47,54,55 , all of which are in line with other previous reviews 18,19 .This shows us that there is already some acknowledgement to these obstacles and difficulties.However, what are the resources spent by professionals to deal with this unpleasant scenario that raises so many difficult feelings?
This first analytical theme brings us clues to its answer.People with anorexia nervosa/bulimia nervosa have very rigid personality characteristics, with little control over impulsivity and high intensity of emotional reactions.Which may also be the reason for some of their sociability difficulties 3,6 .Therefore, people with eating disorders often experience considerable adversity in interpersonal relationships, including with health professionals 7,15 .
Participants in the analyzed studies found themselves forced to leave their comfort zone and deal with this rigidity in a malleable way.According to the investigations 42,43,44,47,49,50,51,54 , profes-Cad.Saúde Pública 2023; 39(7):e00223122 sionals demonstrate care and parsimony in their dialogue with patients with anorexia nervosa/ bulimia nervosa.An ability to position oneself in a more open and intimate way has the potential to favor the openness of patients who perceive the availability of the professional as favoring the therapeutic alliance 57,58 .
With this careful and open attitude towards the other -going beyond the adjustment of a protocol or seeking a "success" and "improvement" factor in the treatment -emotional frankness and availability to be with patients has the potential to be a factor that facilitates the bond 16,59 , allowing for a more favorable outcome in the treatment 17 .In the meantime, it is worth noting that what can be considered an improvement in the treatment of eating disorders is a topic which is still much discussed in the academic and clinical fields 59,60 .
In the same sense, professionals in the analyzed studies 39,40,41,45,46,47,48,50,53,54,56 describe the availability of protocols as something that can help them, but that must also be used sparingly and malleably, since the people served have unique cultural and social variables.This data reinforces that professionals understand the relevance of healthcare thought from the uniqueness of each patient without failing to place it in its social context and the complexity that the multiple facets of illness demand 10,61 .
Therefore, this view favors appreciating comprehensiveness in the care provided to the patient, taking into account a notion of bio-psycho-social health 10,61 .In doing so, there is space for professionals to not only look at the person with anorexia nervosa/bulimia nervosa regarding descriptive diagnostic criteria, but with the possibility that they engage in everyday tasks and have enriched interpersonal relationships, according to some of the articles analyzed in this review 38,41,43,46,47,48,49,50,51,52,53,56 .This point of view also reinforces care for family members since it values community engagement in health practices 8,62,63 .
It is important to point out that this necessary malleability in dealing with patients and their families assumes that health workers are guaranteed minimum working conditions, such as human and technological resources, study time, discussions, and adequate care and training.Many of the studies analyzed 38,39,41,42,50,56 consider the precariousness of these conditions, which can make work more strenuous, increasing the vulnerability of professionals to illness in facing the difficult feelings cited by professionals 20,21 .
Although the professionals in the studies that composed the corpus of this analysis reported "getting out of their comfort zone" when in contact with patients, this was little observed in regard to openness to communication and practices with other professionals, which can be an obstacle to an interdisciplinary approach, the second analytical theme of this study.Professionals recognize that they need to collaborate with the various knowledge areas involved in the care of people with anorexia nervosa/bulimia nervosa, as recommended by the specialized literature 6 .Nevertheless, the research gathered in this review indicates that professionals find it difficult to maintain dialogue with other areas or they feel insecure when doing so 42,43,44,47,49,50,51,54 .
As we can see in this study, other studies reaffirm the obstacles faced by physicians in implementing interdisciplinarity 64,65 .Authors in the area argue that the difficulty in maintaining a climate of horizontality which enables a true integration between knowledge areas refers to the legacy of the model founded in the 19th century that intensified specialization of the disciplines 65 .
The attitude of the healthcare team, from an interdisciplinary perspective, can also favor opening the professional to the perception of the family as a target of care, not only making them responsible for treating the member diagnosed with anorexia nervosa/bulimia nervosa 26,66 .In the described studies 38,41,42,43,44,45,48,51,53,55 , the participants recognize that the family is essential in the treatment, while also acknowledging that they can be a factor which contributes to maintain chronic symptoms.This ambivalence can be an impediment in the view of the family member as a target of care, which also demands listening to the interdisciplinary team 26 .

Conclusion
This study illuminates aspects within clinical practice regarding treatment of eating disorders, which can bring relevant implications for such practices in the following senses: health professionals must be trained to favor flexibility and affective openness to bond with patients with eating disorders, understanding that the professional's rigidity can intensify the austerity of the patients treated.The training of health workers/professionals must also raise awareness on the importance of working in an interdisciplinary way, encouraging the professional to being open to listening, transforming, and building new care actions together with other professionals, leaving the comfort zone of the discipline itself and of their own knowledge.
The comprehensive and interdisciplinary look also leads to another way of understanding the families of affected people.From this, we include a third implication of this study for health practices: the relevance of including the family in the therapeutic scenario as a care recipient, and not only in the role of caregiver.For all of this to be possible, it would be extremely important that health services are properly equipped and provided with spaces for discussion, training for the obstacles placed in the care scenario, guaranteeing minimum conditions for health workers.
Despite the rigorous methodological procedure, this study has some limitations.The corpus analysis did not include Latin American publications.From the point of view of the methodological quality of the analyzed studies, it was observed that there are flaws in the reflexivity criterion, meaning that several studies do not explain the position or influence on the researcher in the context of performing the investigations.Another limitation of this review regards the exclusion of grey literature, such as dissertations and theses.These aspects can illuminate the need for future studies, especially focusing on the national perspective.

Contributors
B. B. Maia contributed to the study conception, bibliographic survey, theoretical-methodological design, data collection and analysis, and writing; and approved the final version.F. G. Campelo contributed to the bibliographic survey, data collection, and review; and approved the final version.E. C. G. Rodrigues contributed with the methodological design, data analysis, and writing; and approved the final version.É. A. Oliveira-Cardoso contributed with the methodological design, data analysis, and review; and approved the final version.M. A. Santos contributed with the study conception, theoreticalmethodological design, data collection and analysis, and writing; and approved the final version.

Figure 1 PRISMA
Figure 1 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) diagram of study selection process.

(
2021/England) To explore therapists' perspectives on how ethnic minority females diagnosed with eating disorders access specialist eating disorder services and what are the therapists' experiences of working with ethnic minority females diagnosed with eating disorders in these services cognitive behavioral therapists, a cognitive analytical therapist, a psychotherapist, a dietician, an occupational therapist 100% female Years of experience: 3 (minimum) Cruzat et al. 52 (2013/Spain) To describe the aspects identified as facilitators in order to achieve a positive therapeutic alliance from the perspective of anorexic patients and their positive therapeutic alliance from the perspective of anorexic patients and their therapists Relational-descriptive study; In-deep interview; Grounded theory 2 Therapists of two patients diagnosed with anorexia nervosa Years of experience: not specified Dimitropoulos et al. 53 (2013/Canada) To identify how FBT practitioners applied FBT for atypical anorexia nervosa for adolescents in their clinical practice, and if there were any implementation challenges and adaptations to the model for this population Fundamental qualitative description; Semistructured interview; Thematic content analysis 23 Practitioners of family-based treatment with adolescents with atypical anorexia nervosa Years of experience: 3 to 19 Cad.Saúde Pública 2023; 39(7):e00223122 Mental; Personal de Salud; Trastornos de Alimentación y de la Ingestión de Alimentos Submitted on 22/Nov/2022 Final version resubmitted on 04/May/2023 Approved on 25/May/2023 Quality appraisal of included studies according to the Critical Appraisal Skills Program (CASP).