Hard to swallow: compulsory treatment in eating disorders

Paper No.3
Janet Treasure and Rosalind Ramsay
Institute of Psychiatry, King's College, London



The courts have frequently been used to resolve disputes between psychiatrists and their eating disorder patients and families. New legislation developed to protect the rights of children has been at the forefront of some of the recent controversies. The issues for debate are: whether patients with anorexia nervosa are competent to decide about their treatment, and whether the treatment involved (food as well as psychotherapy) is allowable under the Mental Health Act, and finally whether the treatment given is ethical, humane and effective. Some commentators have spoken out against psychiatric treatment of anorexia nervosa in general and, in particular, against compulsory treatment.
In our view anorexia nervosa is a severe mental illness and at times, some patients may not be competent to make decisions about their welfare. More than one judge has ruled that food can be regarded as treatment under the Mental Health Act in anorexia nervosa. This contrasts with the legal ruling on hunger strikers which is that doctors have no role to play in forcible feeding. Unfortunately psychiatric "mistreatment" of these patients occurs. Research findings have not been incorporated into general psychiatric practice. Too often general psychiatrists resort to strict behavioural regimes which use conditions amounting to seclusion for weeks at a time without addressing the cognitive and emotional aspects of the disorder. Such practices are unethical and inhumane. Hospice treatment is inappropriate for anorexia nervosa as a hospice's expertise is in the palliative care of medical rather than psychosocial disability. Treatment for anorexia nervosa should be matched to need. Compulsory treatment should involve compulsory exposure to a specialist therapeutic milieu. In such an environment less than 1% of compulsorily treated patients require tube feeding. Patients with chronic anorexia nervosa should be offered rehabilitative treatment similar to that given to patients with other forms of severe psychiatric disorder. The focus should be psychosocial support as this is the main area of disability.