# “Normal” vs. “difficult” cases with eating disorders: the therapists’ perspective

## TL;DR

This study explores what makes some eating disorder patients harder to treat from therapists' perspectives, focusing on patient traits like ambivalence and personality.

## Contribution

The study identifies patient-related factors, such as ambivalence and antagonism, as key predictors of treatment difficulty in eating disorders.

## Key findings

- Difficult cases are marked by patient ambivalence, antagonism, and somatic complications like electrolyte imbalance.
- Ambivalence is the strongest predictor of treatment difficulty, followed by patient personality traits.
- Therapist or workplace characteristics do not influence whether a case is perceived as normal or difficult.

## Abstract

Patients with an eating disorder (ED) are considered difficult to treat. We aimed to identify the characteristics of patients with an ED, which are considered especially challenging to treat from the therapist’s perspective.

Psychotherapists with experience in ED treatment were asked to describe a “normal” as well as a “difficult” case they treated lately, using an online-survey. They described their patients by filling in a list of symptoms and their severity, on personality traits and functioning as well as a list of possible therapeutic challenges experienced over the course of treatment.

127 psychotherapists were recruited. “Difficult” cases were characterized by variables which could be related to three areas: patients´ motivation (higher level of ambivalence), interactional behavior/personality traits (more antagonism) and somatic complications, such as electrolyte imbalance. Ambivalence was the strongest predictor of case difficulty, followed by patient personality. Therapist or work place characteristics were not associated with experiencing treatments as “normal” or “difficult.”

In particular, aspects related to the therapeutic process and relationship characterize the group of “difficult” cases from a therapist’s view.