David Tait

OBJECTIVE: This paper addresses the question of the circumstances which lead clinicians to use legal coercion in the management of patients with severe anorexia nervosa, and explores similarities and differences between such formal coercion and other forms of 'strong persuasion' in patient management. METHOD: Logistic regression and other statistical analysis was undertaken on 75 first admissions for anorexia nervosa from a sample of 117 successive admissions to an eating disorder facility in New South Wales, Australia, where an eating disorder was the primary diagnosis. Admissions with other primary diagnoses, such as bulimia nervosa (25 episodes), and entries with a co morbid diagnosis (e.g. depression or opiate overdose), were discarded, leaving 96 admissions by 75 individuals. RESULTS: Resort to measures of legal coercion into treatment was found to be associated with three main indicators: the patient's past history (number of previous admissions); the complexity of their condition (the number of other psychiatric co morbidities); and their current health risk (measured either by Body Mass Index or the risk of re-feeding syndrome). CONCLUSIONS: Our study is consistent with the few earlier studies about indicators for legal coercion in anorexia nervosa management, and suggests that clinicians use legal coercion very sparingly, distinguishing legal coercion from other forms of close clinical management of patients.

Abstract: Background: The high mortality of severe anorexia nervosa causes clinicians to consider any legal avenues for coercing acutely ill-patients to remain in treatment or re-feeding programs, such as mental health laws or adult guardianship laws. Method: Review of pattern of laws for coercing treatment in various jurisdictions and retrospective file analysis over 4.7 years for a specialist anorexia unit in the State of New South Wales, Australia, to isolate attributes associated with resort to two different avenues of legal coercion. Results: Coercion is most likely indicated for patients with more chronic histories (prior AN admissions), already known to the unit, where they present with other psychiatric illnesses and a low BMI index. Compared to voluntary admissions, coerced patients were significantly more likely to experience the refeeding syndrome (an indicator of being seriously medically compromised). They were more likely to be tube fed and placed on a locked unit. Limitations: sample size, limited variables and retrospective analysis method. Conclusions: The study suggests that, where available, clinicians will use legal coercion to help treat severe medical crisis situations, or manage behaviours such as vomiting, excessive exercise/sit-ups, or of absconding to no fixed abode when patients are very young.

OBJECTIVE: This paper explores similarities and differences between formal coercion and other forms of 'strong persuasion' in clinical decision-making about medical management of patients with severe anorexia nervosa. METHOD: The paper builds on findings from analysis of data from 117 successive admissions to an eating disorder facility, where an eating disorder was the primary diagnosis. RESULTS: The study implications of particular interest in this paper are the findings that legal coercion into treatment was associated with three main indicators: the patient's past history (number of previous admissions); the complexity of their condition (the number of other psychiatric co morbidities); and their current health risk (measured either by Body Mass Index or the risk of re-feeding syndrome). CONCLUSIONS: We conclude that clinicians use legal coercion very sparingly in treating severe anorexia nervosa, distinguishing legal coercion from other forms of close clinical management of patients. While we agree with Monahan et al and others, that there are similarities between legal coercion and other forms of strong clinical management (or power), our results suggest that NSW clinicians recognise the importance of maintaining, rather than blurring that distinction.

Anorexia nervosa is often chronic, with one of the highest death rates for psychological conditions. Law can compel treatment, but is rarely invoked, at least formally (though the strategic possibilities of orders confers internal authority within the clinical setting). Instead, 'control' (or management) is exercised diffusely, through disciplinary practices embedded in everyday clinic life, such as daily routines of eating and washing, behavioural 'contracts', regular surveillance and measuring, interactions with staff, visits and activities. The regulatory regime not only touches on such 'practices' but also targets 'identities' (including self-image, and attitudes to the body) and what Goffman called the 'moral career' of the patient (eg learning to play the 'patient role', to 'be' an 'anorexic'). We argue that it is not the clumsiness of the law, or the success of less restrictive options which explains why law is so infrequently engaged. Rather, based on an interpretation of Foucault, we concluded that the regulatory regimes that shape treatment of anorexia nervosa, is 'the law', in a sense. The regime of governmentality within the clinic is shaped by practices which operationalise 'duty of care', or translate medical expertise into medical authority, or show how interactions between 'experts', 'carers' and patients are mediated through conventions and rules, or which conscript 'empowerment' as control. The patient learns to provide consent 'freely', to make the 'correct' choices, to accept the 'empowerment' regime that is made even more convincing by the threat of legal intervention. In time the constraints learned in this way become part of the new role, that of the 'recovering' patient. The 'fiction' of acting 'responsibly', employed so hesitantly at first, becomes part of the new identity. The patient has become an active participant in the governance of self.

Anorexia nervosa is often chronic, with one of the highest death rates for psychological conditions. Law can compel treatment, but is rarely invoked, at least formally (though the strategic possibilities of orders confers internal authority within the clinical setting). Instead, "control" (or management) is exercised diffusely, through disciplinary practices embedded in everyday clinic life, such as daily routines of eating and washing, behavioural "contracts", regular surveillance and measuring, interactions with staff, visits and activities. The regulatory regime not only touches on such "practices" but also targets "identities" (including self-image, and attitudes to the body) and what Goffman called the "moral career" of the patient (eg learning to play the "patient role", to "be" an "anorexic"). We argue that it is not the clumsiness of the law, or the success of less restrictive options which explains why law is so infrequently engaged. Rather, based on an interpretation of Foucault, we concluded that the regulatory regimes that shape treatment of anorexia nervosa, is "the law", in a sense. The regime of governmentality within the clinic is shaped by practices which operationalise "duty of care", or translate medical expertise into medical authority, or show how interactions between "experts", "carers" and patients are mediated through conventions and rules, or which conscript "empowerment" as control. The patient learns to provide consent "freely", to make the "correct" choices, to accept the "empowerment" regime that is made even more convincing by the threat of legal intervention. In time the constraints learned in this way become part of the new role, that of the "recovering" patient. The "fiction" of acting "responsibly", employed so hesitantly at first, becomes part of the new identity. The patient has become an active participant in the governance of self.