Legally Forced Treatment of Patients with Eating Disorders: Pros and Cons

The law has a long and varied history with respect to mental health treatment, especially involuntary hospitalization of the mentally ill. The pendulum has swung from patient rights to public safety many times, balancing the personal liberty of the mentally ill against the danger these people may pose to the public.

The latest significant swing of these rights was the eviction  of tens of thousands of patients from state hospitals after most of these institutions closed in the 1980's. There were clear pros such as greater personal liberty and cons, many of these people ending up in the prison system.

The continued effect on patient safety and well-being is that it has become harder to hold patients in a hospital if they are deemed a danger to themselves or others and very difficult for the most ill patients to go to longer term state hospitals, a treatment option that can provide considerable safety, stability and long-term benefit.

Recent decades opened new debates about the role of the court in the treatment of patients with life threatening eating disorders. These laws were created for patients with illnesses that threaten both their well-being and those around them, typically psychiatric episodes that include losing touch with reality. However, people with eating disorders don't lose touch with reality and don't cause any harm to the public. The overarching question is how far should the state safety net reach in eating disorder treatment?

Some states allow involuntary treatment of these patients due to the severe medical consequences, including death, of their illness while other states don't. A requirement for the court to grant a legal order to hold someone against their will is that the patient be at risk for severe immediate harm and not understand the condition and ramifications of their illness, legally termed competence. 

It's easier to make this legal case for patients with schizophrenia or a severe bipolar episode since the symptoms of the illness show a clear break with reality. No one will question the competence of a patent who believes the FBI planted a chip in their head. It's also likely that medications will at least mitigate the psychiatric symptoms quickly and effectively enough to avoid immediate danger. Indeed these laws were intended to address this type of psychiatric emergency.

But many of the sickest eating disorder patients understand the severity of their illness, even at the most dire moments, and still cannot eat. Unlike a patient with schizophrenia, someone with an eating disorder is typically much more aware that the state is mandating treatment against their will and demonstrate competence by comprehending and being able to repeat back their predicament. In addition, a few weeks of nutrition is unlikely to alter the course of a severe eating disorder, so the potential benefit of the legal decision is much more cloudy. The process used for other psychiatric situations doesn't apply as directly or effectively for patients with eating disorders.

The purpose of a court-ordered involuntary treatment is twofold: protecting the patient from immediate harm from the illness and protecting the public from the patient. In the case of eating disorders, the first has questionable effect and the latter is not relevant, but there is a third, more subtle component to the decision. The concept of dying from not eating is anathema to most of the public, and this loophole allows a legal, immediate resolution. 

The act of publicly forcing a patient to eat is a paternalistic approach to a perturbing, stubborn, growing public health problem in modern society. There's no evidence that forced treatment will do more than improve nutrition and health for a few weeks, but the act of involving the court allows hospital staff and administration to believe everything has been done to help this patient. In fact, any forced eating typically triggers more anger and self-punishment for the patient which leads that person back to worsening eating disorder symptoms. 

Eating disorders are serious medical illnesses as much as psychological ones. Although the psychological symptoms must be addressed for full recovery, all the physical symptoms are a result of poor nutrition and starvation, which affect all of the body's organ systems, including the brain. First and foremost, recovery involves restoring adequate nutrition. Without that step, the patient can make progress but can't step into full recovery. 

That being said, eating disorders are also lethal illnesses. Other psychiatric illnesses cause so much suffering that they can lead to suicide. That happens to patients with eating disorders as well, but eating disorders themselves also kill people. Any clinician treating these patients must accept this fact. Short-term forced treatment is a mere blip in the course of a longstanding eating disorder, and often a harmful one at that. Using the legal system to force feed a patient can engender a deep loss of trust in clinicians, including ones not involved in the decision, and in fact derail long-term recovery.

There are instances when court-ordered treatment has a place for patients with eating disorders, but I think these circumstances apply only when the patient cannot comprehend the severity of her condition, the more rare instances when they are not competent. That will limit the utility of the legal avenue to the type of patients the law intends to help and will diminish the negative effect of enforced treatment on a patient's recovery.


Discharge Planning

Treatment programs have a valuable but very specific role in recovery from an eating disorder. The focused and intense time spent on getting better empowers people to realize that full recovery is a viable endpoint. People learn an enormous amount about their illness. The immediate gains are obvious and, in a positive environment, even points of pride.

In addition, spending time with a group of people all zeroing in on treatment is a relief after months or years of isolation from being sick. Above all, a sustained period of being nourished diminishes the physical, emotional and psychological symptoms of an eating disorder drastically. More often than not, people complete a program in a better place than when they started. Although that may seem like an obvious statement, intuition is often not helpful when it comes to choosing treatment for people with eating disorders so this is a crucial fact to remember.

Still, entering a program isn't the best choice for everyone despite the likely short-term improvement. Research and experience prove that these gains don't last more than a few months for most people for several reasons.

Eating disorder treatment is time-consuming and expensive. Much thought needs to go into the decision both in terms of potential benefit and the likelihood of treatment kick-starting true, long lasting recovery. No one has enough resources to make repeated hospitalization a viable option: it only reinforces that an eating disorder is a chronic, incurable illness.

A quick relapse can be incredibly demoralizing and delay recovery for months and years. Too many people who go to treatment programs prematurely just cycle through the different options for treatment without any true progress. Granted, medical emergencies such as being severely malnourished or low potassium from purging may necessitate urgent inpatient treatment; however, it behooves clinicians and patients to consider likely outcomes before committing blindly to a detrimental course of treatment.

Any reasoned approach to residential treatment must include discharge planning at the very start of the treatment. Too many programs are so intently focused on the day-to-day operation of their bubble that they neglect to fully consider how challenging the transition is from 24 hour support to just a few hours per day at most. Even the best programs struggle to include the outpatient team in treatment decisions and discharge planning, even though it's the outpatient team that will implement the treatment and that knows how reasonable and realistic the plan is. Outpatient clinicians feel they can take a break when a patient goes into residential treatment, but that only worsens long-term outcome.

Discharge planning needs to start on the day of admission to residential treatment. Doing so will force inpatient and outpatient teams to communicate right away. That interaction will uncover basic assumptions of both teams and allow for debate and thorough consideration of all possibilities.

Moreover, it will give time to present the options to the patient so she can have a say in the process as well. A patient involved in these decisions will have ownership of the treatment and will be much more like to follow through. 

Since the benefit of these steps is pretty obvious, the real question is why doesn't this happen automatically? I don't have a good answer. Part of it may be the disjointed nature of care for people with eating disorders. There are no guidelines for transitions in and out of residential programs. Also there tends to be a sense of superiority in American clinical care which enables competition between various stages of eating disorder treatment, not collaboration. Finally, the lack of any centralized health care agency means there is no accountability for clinicians in their decision making, a necessity to keep clinicians honest and humble.

The bottom line is that discharge planning and continuity of care needs to be of primary importance. It's the key component for treatment programs to be steps in recovery, rather than brief blips of wellness.