Forced treatment or forced urgency?

Forced treatment of patients with anorexia

" may be better to admit the patient before the BMI drops below 13"

When are we going to "admit" we have mistaken a grave illness for a willful behavior and stop waiting until people's bodies have been ruined before we take action?


  1. I read that comment, too. And all that went through my mind was "Gee, ya think?"

  2. I read this too. . .

    Made me feel bad about my BMI which is 14.9 -- was thinking -- well then. . .not like I am very bad right now. . .

    As someone who has recently been weight restored and then thrown in the recovery towel only to pick it up again, I can say I had a problem at a BMI of 19 and 18 and 17. . .you get the picture.

    Why wait until medically instability and risk of death to admit someone? Similarly, why wait until a relapse of 17.5BMI before declaring the patient "anorexic" once again. The whole diagnositic criteria/prognosis/diagnostic migration/relapse/recovery definitions of the illness need to be CLARIFIED and DEFINED.

    At a BMI of 13 the patient is already pretty far gone and the heart/other bodily systems are at risk. Have professionals forgotten that there have been AN deaths at BMI's ABOVE 13?



  3. I think the salient issue is compulsory treatment. If the patient is admitted during a crisis, or following a doctor's appointment, and then agrees to sign in ... that is one thing. If the patient is petitioned for court commitment, then it risks raising resentment that can fuel ready relapse upon discharge.

    I know some studies found that some patients felt grateful, in retrospect, while others found no significant recovery/maintenance outcome among those who had been involuntarily held vs. voluntary patients.

    If life is in immediate danger or there is emergent specific medical instability, the occasion of those crises can sometimes prompt a patient to embrace treatment.

    Control and trust are pretty universal concerns among people with eating disorders, so it would be important to weigh whether the break in self-determination (or perceived loss of such) and the potential for clinician/treatment avoidance in the future balances the positives.

    If the patient dies or suffers permanent disability, it matters little if she is so anxious about being "locked up" against her will and distrusts that doctors and supporters won't do that ... but if she survives, which many manage to do even in the face of extreme circumstances, the ability to form a therapeutic alliance is so important.

    Eating disorders need treatment support for long periods of time, and you just don't want patients to reject the helpers out of fear beyond the usual fear of ceding ED behavior and "control."

    I can see how compulsory treatment could be more effective in young patients with a short history since diagnosis ... and because I have heard many adolescents say they wanted their parents' attention and wanted them to "show they cared enough" to take charge/do something.

    On the other hand, there are many adult patients who have said they spent numerous childhood hospital admissions playing games and fighting the system, parents, etc., ... and wish that they hadn't ... that they might not yet be struggling with a disorder. If collaboration is possible, or the perception of collaboration, that seems preferable.

    Also underscoring the positive potential of compulsory (but not court-ordered) treatment, is the experience of an acquaintance ... who was invested enough in keeping her team that she grudgingly signed in the hospital every time her weight or health didn't meet "contract" criteria.

    After awhile, she said, it didn't seem worth it to continue "undoing" the gains of the previous admission ... so those inpatient stays *did* end up achieving some stability ... and she is an older patient with a history of chronicity and multiple admissions to many different programs, so that is a significant achievement.

    Some patients, however, will just walk away and never come back ... or doctor-hop, making "forced" treatment an ineffective approach.

    I think this will continue to be an issue of debate and fine-line decision-making among providers and families.

  4. I have a different take on this, Anon Mom, and I think A's comments help clarify this. Patients aren't exercising free will when they are ill, and they are as ill at low BMIs as at a healthy weight until they've had time to recover at that weight and relearned how to live and eat normally.

    I don't believe in free will during the illness, and I don't believe it is forced or coercive treatment to assure a patient is getting full nutrition every day and every meal until they are FULLY able to be healthily independent. That's not forced or coerced: that's humane.

  5. There's no question that sooner-more complete treatment (including "full nutrition" and weight/health restoration) is better and more successful.

    I think I was looking, mostly, from a strictly legal (vs. moral, ethical, personal) standpoint. And to piggyback that issue ... financial considerations (though I know we can't put a price on human life ... or suffering).

    It remains that in America, if you can even get someone to pay for a patient to be fully fed and weight-restored (outside of the home/family), it will be a long day in courthouses everywhere knocking at the door of civil liberties.

    The bar is pretty high, and probably should be, to compel treatment and, ultimately, well-being. And why advance-directives and right-to-die cases attract so much attention. It could have the effect of imposing the will of the state or medicine on families who may or may not agree but will bear the burden of the cost (or the cost of shouldering financial responsibility).

    Probably, a best-practices document of some sort could go a long way toward accomplishing this ... official, uniform professional guidelines that can show clear benefits, suggested protocols, clearly outline health parameters, and family planning/involvement ... that also, perhaps, utilize a statment-of-compulsory-care policy in permission-to-treat documents.

    For instance, NYSPI advised potential patients that they wouldn't be required to sign in to the research unit, but once they did, if they tried to leave at less than 75 percent of IBW ... they would be court-ordered to stay until at least that weight.

    Beyond pure debate about what is good or right or best, full restoration at the facility-level has so many factors to consider ... where to house these patients who are (expensive patients to start with) staying longer in an era of de-institutionalization (on smaller floors of fewer units than would be needed); how to manage long wait-lists for patients who need help; train enough staff competent to care for ED patients, medically, behaviorally and psychiatrically; and how to compel acute-care hospitals to admit eating-disorder patients who don't present with an emergent, continuing condition.

    Our local hospitals won't just admit a patient b/c the patient or her family wants hospitalization. They will treat dehydration, cardiac issues, etc., but they won't keep a patient just because she/he is low weight or has low blood pressure. Once BP and pulse stabilize or hydration is achieved, EKG passes the decent-enough test, the patient is discharged. Or sent to an ED unit, if there is a bed and insurance benefits available. Or a general psych unit, which is also a short-term proposition (and likely not a beneficial one). Or a nursing home (which may or may not be covered ... and they often don't take ED patients). Or to home health and a feeding pump, which still depends on reimbursement from third-party payers to be even close to affordable.

    So, one could conclude that FBT is one of the more promising and cost-effective approaches, but families still need plenty of professional support ... and many won't have the time, patience, ability, desire, tenacity to be on-call 24/7 for as long as it takes.

    Even the seemingly simple answers to a complex disease end up being quite complex, I think.

  6. You are so right. Both about the complexity, and about how much MORE support families need.

    If I could, I would enable a system where every level of support was available on a continuum for whatever that one patient needs, at whatever stage they are in at the time. A continuum of science-based, humane, long-term care with the goal of FULL recovery.

  7. "the ability to form a therapeutic alliance is so important". My rather angry take on this is that the ability to form an alliance with a professional team is vital to achieving treatment because the PROFESSIONALS give up if they don't get on with their clients - don't see results, don't feel collaborated with, get sworn at. With adult patients at least, professionals are all too keen to wash their hands of the uncooperative, to label with personality disorders or as "non-compliant" and to ditch them from treatment. Apparently when he was very elderly Winston Churchill was asked to speak at a college ceremony. The organisers worried that he wouldnt make it to the podium he was so frail, and were anxious as to whether the great man would mumble or similarly disgrace himself but he tottered to the podium, clearly addressed the assembled crowd with the words "Never give up" and sat down again. The only college speech that the whole audience would remember in its entirity - and one I really feel the whole medical community should embrace when treating EDs or indeed any difficult to treat illness.


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