How AN Patients View Compulsory Treatment

Reprinted from Eating Disorders Review
March/April 2010 Volume 21, Number 2
©2010 Gürze Books

Compulsory treatment of anorexia nervosa (AN) is still a controversial issue. Due to the serious risk of physical harm or even death, it may sometimes be necessary to hospitalize AN patients without their consent. Dr. Jacinta O. A. Tan and colleagues at Oxford University, Oxford, UK, wanted to know how AN patients themselves view compulsory treatment—is it appropriate and if so, when? Twenty-nine women 15 to 26 years of age who currently had AN or recently had AN were recruited for the study (Int J Law Psychiatry 2010; 33:13).

The Oxford researchers used a qualitative interview study to examine the views of people with AN and their parents. The interview format was conducted with a topic guide, which acted as a springboard for further narratives and discussions, and participants were encouraged to talk about their personal experiences with treatment. A sample topic question was, ‘Do you think it is ever acceptable to make people have treatment when they don’t want it or don’t agree to it?’ The interviews were audiotaped and transcribed, with names and places removed. The participants were recruited from four different centers in southern England, which included private and National Health Service centers, adolescent and adult treatment services, specialist eating disorders centers and general mental health units. All information came directly from patients, and their medical records were not accessed.

Of the 29 women, 8 were inpatients in mental health units although none was detained under The Mental Health Act of 1983. Eighteen were day patients or outpatients using mental health services; 1 was waiting to have treatment; and 1 had been discharged from the eating disorder service after refusing an offer of inpatient treatment because of low weight. Another patient declined treatment after an adverse experience as an inpatient.

Among the 8 inpatients, 5 described themselves as having been admitted without free choice, either due to parental pressures or under implied an overt threat from the mental health professionals of a Mental Health Act 1983 (compulsory detention order for treatment of a mental disorder). Only 3 of the 18 said they had made a choice to enter and remain in treatment on their own; 6 described being coerced into having treatment against their will; 9 others reported that pressure from professionals and their parents or decisions made on their behalf by doctors or relatives with their tacit agreement had led to their inpatient treatment.

All agreed: formal compulsory treatment is called for in some cases

All the women agreed on one thing: formal compulsory treatment was justified for some individuals, such as those with schizophrenia, to protect the patients and others from harm. The participants all agreed that in the case of AN, overriding treatment refusal, including formal compulsory treatment, was required if it was in order to save a life. That is, they thought no one should be allowed to die from AN. Many noted that while they had initially fought against treatment, in hindsight they were grateful for it. The central reason they gave was that no one should die from a treatable condition, and such a death would be a waste of life.

The participants also did not universally view “leverage” and other nonlegal forms of restriction of choice as negative or unethical; in fact, most thought informal leverage, from family and professionals, was preferable to formal compulsion to treatment. And most thought that going through treatment and reaching recovery required some degree of consent and cooperation from the person herself—there was a commonly held view that compulsion could be harmful in itself.

Relationships were all-important

The participants’ relationships with parents and professionals emerged as an important factor in decision-making. Having freedom of choice was often less important to the women than were their relationships and the attitudes of those around them and of those treating them. Most described decisions based on trust and good relationships rather than on the basis of elements highlighted by most clinical, legal and theoretical descriptions of capacity. Some participants who had not been given free choice about treatment did not seem to resent this fact or their experiences or to perceive them as coercion. Instead, they viewed the strong influence, pressure supervision, or restrictions imposed on them by parents and professionals as helpful, caring, and supportive. For those who did resent the supervision and restrictions imposed on them during treatment, the key reason for their resentment and sense of being coerced was the feeling that they had been ‘dismissed, belittled, or punitively treated’ –rather than the restrictions themselves.

The authors suggest that the central issue surrounding compulsory treatment for AN is not whether and when a person lacks the capacity to consent to or refuse treatment. Instead, they feel that the central issue concerns the context and relationships involved in good and compassionate psychiatric care.

No Comments Yet

Comments are closed