*4.5. Experiences of Experts with the Contingency Contract Process*

Although there was great variation in emotions experienced by the participating experts during the contingency contract process, on average there was no extremely negative or positive emotions which evidently accompanied this process. Additionally, it could be shown that the emotional burden for experts decreased with the years of experience, which coincides with clinical impressions. We found no significant differences between occupational groups (physician versus psychologist) or therapeutic orientation (behavioral versus psychodynamic psychotherapy). It would be interesting, however, to also investigate the emotional experiences of nurses and other caregivers in the inpatient environment.

#### *4.6. Limitations and Prospects*

The main limitation of the study is its descriptive nature; as no causal conclusions about the reported associations and group differences can be drawn. Furthermore, only specialized university centers were included which heightened the risk of a selection/recruitment bias. Although a fair amount of specialized university centers in Germany participated, not all could be included, raising the question of representativeness. However, given that this is the first study attempting to describe the contingency contract process in specialized centers in Germany, this account provides a valuable contribution to the evidence base.

The usefulness of contingency contracting practice styles for patients with AN in other countries would also be of high interest. Taking into account that patients in other countries might be treated in outpatient or day-patient settings more frequently, it might be more difficult to track positive and negative consequences. However, this would also entail the chance for greater collaboration between patients and therapists, potentially lessening the chance of patients fearing 'to be controlled' and enabling them to gain more autonomy. There are some reports about the utilization of contingency contracts around the world [18], however to the best of our knowledge, studies about practice styles that go beyond the treatment program of one specific clinic, are missing.
