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When Someone with an Eating Disorder Refuses Help

Reprinted from Eating Disorders Today
Fall 2002 Volume 1, Number 4
©2002 Gürze Books

It isn't unusual for people with eating disorders to resist or refuse treatment. As a result, symptoms of anorexia nervosa, bulimia nervosa, or other eating disorders may be present for months or even years before patients feel ready for change. These individuals are usually pressured by family members, friends, or coworkers to seek help, and often do so with reluctance and resentment.

Why do patients resist treatment?
According to Drs. Elliott M. Goldner and C. Laird Birmingham, and Victoria Smye, MHScB, of the University of British Columbia, people struggling with eating disorders may have many reasons for refusing treatment. Some don't think they have an eating disorder at all and feel that their family or friends are exaggerating the problem or are mistaken about the symptoms.

Others may be well aware that they are struggling but are ashamed of their symptoms and afraid of being discovered. Many fear the potential effects of treatment, such as weight gain or interference with their drive to exercise, restrict food intake, purge, or lose weight.

Patients at risk
In some cases, physicians must consider imposing treatment even when the patient actively resists. Individuals who may be at increased risk include: (1) young patients who have recently developed symptoms; (2) patients who are in immediate danger because of medical consequences of the illness or the risk of suicide; and (3) those with rapidly increasing symptoms.

When physicians decide to "order" treatment, they fully believe that treatment will be beneficial. Many patients in these situations are likely to benefit even if they don't recognize or support the plan.

When treatment is imposed against a person's wishes, the consequences may be great. Thus, physicians carefully weigh the potential benefits versus any risks before beginning. Sometimes, physical and chemical restraints are used, along with tube feeding and restriction of activity. In such settings, patients are often profoundly distressed and as a result avoid further treatment.

Legal considerations
All jurisdictions have laws upholding the rights of individuals; thus, an individual's right to refuse treatment may be supported by the court. Minors and other individuals who are deemed incompetent (a legal term meaning that a person is mentally incapable of making his own decisions) may be temporarily denied the right to refuse treatment.

While they are competent in all other areas, individuals with eating disorders are often considered incompetent in certain specific areas of their lives, including decisions about their ability to gain weight or their current health and need for treatment. However, patients have a legal right to dispute this, and health-care providers must then turn to the legal system to support the need for imposed treatment. Other-health care providers will be asked to give a second opinion, and to estimate the risks involved if the patient were to have no treatment.

Life-threatening conditions
Depending on the circumstances, individuals with eating disorders may be at risk of a number of life-threatening medical conditions (see chart). These conditions call for emergency assessment and response. Although medical professionals can identify an emergency situation in progress, it is hard to detect an impending medical crisis. Given the high rates of suicide in patients with eating disorders, a careful assessment of suicide risk should be undertaken.

Recommendations
Because of the many consequences when a patient doesn't want to be treated, and the effects on families as well, health-care professionals often use a careful process in order to convince the patient to be treated before seeking legal means to accomplish this.

1. First, try to engage the patient in a voluntary partnership.

2. Explore the reasons that the patient is resisting treatment. It may be a fear of the unknown or he or she may be frightened by psychiatric or medical interventions in general. Other patients are severely depressed or have cognitive impairment. Most often, refusal to be treated is caused primarily by a cognitive disturbance or such things as a fear of gaining weight.

3. Before starting treatment, some facilities such as Dr. Goldner's use a pre liminary intervention. During these sessions, his group provides information to the patients and family members, identifies goals of treatment, introduces staff members, and talks about specific concerns a patient may have. They also thoroughly explain why a certain treatment is recommended, and what it is. This helps enhance motivation for change.

4. Involving the family in a realistic treatment plan usually improves the effects of therapy. Dr. Goldner's group uses a narrative approach to family interventions that is helpful in defusing family conflicts and lessening resistance to treatment. With narrative therapy, the family is encouraged and supported in developing a personal story, or "narrative" about recovery. This approach lessens power struggles and adapts treatment to the unique qualities and characteristics of each family.

5. Negotiations may be necessary. In order to promote the health and safety of the patient, professionals may need to make changes to the proposed treatment plan. Individuals with eating disorders are much more likely to respond to a professional who is approachable, flexible, and comfortable dealing with conflict.

6. All treatment plans should minimize the use of intrusive interventions, such as involuntary commitment to an inpatient unit, tube feeding or programs of behavior modification. Whenever possible, outpatient programs, day programs, and residential treatment should be used instead of inpatient treatment.

7. A realistic appraisal of the probable outcome of treatment versus no treatment will help guide the clinician to a rational plan. Imposing treatment should be considered only when the possible benefits outweigh the risks of not intervening.

8. Power struggles between the patient and the health-care team usually worsen symptoms and break down the therapeutic partnership. Patients who feel frightened or trapped may battle staff, have angry outbursts, or withdraw. It is important for health care professionals to remain respectful and avoid threats or destructive criticism. Treatment should support self-esteem.

9. Due to potential risks, it is generally agreed that legal means of imposing treatment should be reserved for cases in which doing nothing would lead to a serious and immediate danger.

10. Patients who have struggled with eating disorders for a long time often need a different approach than those who have been ill for a shorter time. Chronic illness may indicate a particularly resistant eating disorder and it may be inappropriate to approach treatment of the chronic anorexic patient with a more aggressive plan for intervention.

11. Refusal or resistance to treatment can be viewed as an evolutionary process. Indeed, individuals who refuse treatment at first may later accept it. Usually the gradually increasing recognition of the negative impact of an eating disorder on a person's life is accompanied by a wish to recover. After refeeding has begun, patients may need less treatment due to improvements in emotional and cognitive processes.

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Additional Resources:
Prematurity, Birth Trauma Linked to Risk of Anorexia Nervosa
Psychosocial Treatment of Binge Eating Disorder: An Update
Reasons most weight-loss programs don't stand a chance
Recognizing and Responding to Binge Eating in Children
Regaining Weight in a Healthy Way