Starved for Assistance: Coercion finds a place in the treatment of two eating disorders

Many people with serious eating disorders seek mental-health care only after they are pressured into it by concerned clinicians, family, friends, and employers. Although these cases make psychiatrists uncomfortable, a new study suggests that coercion plays a valuable role in jump-starting participation in the treatment of eating disorders.

A team of psychiatrists studied people with eating disorders who had denied a need for treatment when they were admitted to a hospital clinic. Nearly half changed their minds and acknowledged the necessity of treatment within 2 weeks of being hospitalized, reports Angela S. Guarda of Johns Hopkins Hospital in Baltimore.

The predominantly female patients included many with anorexia nervosa and bulimia nervosa. In the former disorder, a person typically loses weight through starvation and exercise. People with bulimia alternate food-eating binges with induced vomiting.

The new study, published in the January American Journal of Psychiatry, focused on 139 patients admitted to a Johns Hopkins treatment program for eating disorders between January 2000 and February 2003. Patients ranged in age from 15 to 35. The program concentrates on establishing proper eating habits, restoring weight, and developing healthy attitudes toward food and personal appearance.

Each patient completed a 13-item questionnaire upon entering the program and again after 2 weeks of treatment. The questionnaire asked patients whether they needed hospitalization, whether they were coerced to join the program, and what their perceptions were of the hospital-admission process.

Of the 139 patients, 46 said at first that they were being coerced and didn’t need hospitalization. Of that number, 20 switched after 2 weeks of treatment to saying that hospitalization had been justified.

The participants who changed their minds consisted of 14 of 34 anorexia patients and 6 of 12 bulimia patients.

Anorexia patients, who are often grossly underweight, reported more perceived coercion and less satisfaction with the admissions process than the bulimia patients did.

Guarda suspects that as these patients are tracked for longer periods during and after hospitalization, even more of them will switch to endorsing the treatment. The Johns Hopkins program lasts an average of 6 weeks.

Although the participants weren’t legally bound to stay in the treatment program, none left during the first 2 weeks. Among those who had felt coerced, their willingness to stay “illustrates the ambivalence towards treatment that characterizes eating disorders,” Guarda says.

“Many patients with anorexia nervosa remain untreated because no one pressured them into seeking treatment, and a significant proportion of them die,” Guarda says. “The rest often lead isolated and very impaired lives.”

It’s compassionate to coerce individuals with eating disorders into treatment aimed at altering their potentially fatal pursuit of weight loss and thinness, comments psychiatrist Arnold E. Andersen of the University of Iowa Hospitals and Clinics in Iowa City.

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