the scene of the disordered senses (katconfessional) wrote in ed_ucate,
the scene of the disordered senses

Ethical/Legal Issues in Treating AN (Part II)

I'm posting Part II and then I'll post Part I so they're not out of order in the community so you'll probably read this after reading the first.

Notes from katconfessional: a) If you think that these are a waste of time/space, tell me and I'll stop doing it because it takes a while to copy/paste from PDF files; b) If there are any topics that you want to read about, I have basically unlimited access to medical journals, so let me know and when I have time I'll find them; c) My interest happens to be in anorexia nervosa (especially issues of identity, "forced" treatment, fixing the DSM so that the DSM-V doesn't create so many problems for those with EDs, and transference/countertransference issues); this does not mean that articles on bulimia, ED-NOS, or other issues related to EDs do not exist and that the medical literature is skewed toward these topics, so please don't get "offended" by being "unrecognized." Because you're not.


The preceding discussion on anorexia and on the duty to protect leads to
the following key points:

• Anorexia is a diagnosable mental condition in both the DSM-IV-TR and the
ICD-10 (World Health Organization, 1992).
• People with anorexia have a high mortality rate because of medical complications
associated with the disorder and because of suicide.
• An ethical duty to protect exists when a client is a potential harm-to-self
(although the actual intervention is dependent on the standard of care for that
clinical situation).
• TheAPA(2002) ethics code permits the breaking of confidentiality to protect a
person from self-harm.
• Possibilities exist for involuntary hospitalization of a person whose self-harm
is not necessarily intentional but is the result of a mental disorder or grave
• Involuntarily hospitalized persons can refuse treatment unless declared

It is in this context that the counselor may be faced with the clinical, ethical,
and legal dilemma of how to protect a client with anorexia from the life threatening
impact of the disorder while maintaining the client’s autonomy
(which is especially significant given that control typically is such an important
issue for individuals with eating disorders).

If a client with anorexia is explicitly suicidal, then a duty to protect likely
exists (for studies specifically on suicidality among people with eating disorders,
see Bulik, Sullivan,&Joyce, 1999; Favaro & Santonastaso, 1996, 1997;
and Viesselman & Roig, 1985). However, the issue to be examined next is the
broader one of whether the eating-related behaviors associated with anorexia
nervosa in and of themselves activate the duty to protect. In other words, in
the discussion that follows, we are not saying that client behaviors associated
with severe anorexia amount to suicidality but rather that the client’s disorder related
actions may at some point put her health at significant risk and this is
what engenders the duty to protect.

Given that low-burden standard interventions (e.g., increasing session frequency,
adding a therapeutic modality) are not likely to be controversial, the
focus here is on the most forceful actions: involuntary hospitalization and
compulsory treatment. These must be discussed, even if these interventions
are used relatively rarely, because (given the arguments made above) a duty
to protect exists with clients who have anorexia, and the counselor must be
willing to implement any ethically and legally acceptable intervention to
meet that duty and protect the client.

Because the possibility that the behaviors of clients with anorexia nervosa
may engender a duty to protect requiring extreme intervention has been discussed
more frequently outside the United States (Appelbaum & Rumpf,
1998), we review this literature first. Analysis specific to the United States
follows, along with responses to concerns about these interventions.

International Perspectives

In the international literature, the issue of what to do when faced with a client
whose anorexia is quite severe is usually examined in terms of compulsory
treatment. Distinguishing between involuntary hospitalization and compulsory
treatment is important. In the treatment of eating disorders,
involuntary hospitalization refers to the client’s being placed into a restrictive
environment where she is able to partake of the same treatment program as
voluntary clients. Compulsory treatment is more specific and may include
forced or nasogastric feeding. This distinction is not always made clear in the
literature, but it is significant in the United States because of the assumption
that a person is competent, and therefore able to refuse treatment, unless
proven otherwise in court.

Therapists and physicians in the United Kingdom and Australia have been
the most attentive to the issue of compulsory treatment. Tiller, Schmidt, and
Treasure (1993; see also Lanceley & Travers, 1993) considered whether
compulsory treatment for anorexia nervosa was compassion or coercion.
They mentioned the case of a 16-year-old female who had appealed to an
English court to refuse treatment for her anorexia (see also Brahams, 1997;
Dolan, 1998). Tiller and colleagues said that given the mortality rate for
anorexia, they found it hard to understand why compulsory treatment was so
controversial. They concluded that compulsory treatment should be considered
when the person is at a BMI below 13.5 (e.g., 5’5” and 81 pounds) and
has considerable physical complications and concomitant psychiatric diagnoses.
Serfaty and McCluskey (1998) reviewed instances of people receiving
compulsory treatment in their specialty unit, and they, too, used the criteria of
a BMI below 13.5 and serious physical complications.

English researchers Ramsay, Ward, Treasure, and Russell (1999) examined
the conditions associated with compulsory inpatient treatment. They
compared 81 compulsory patients (16% of all admissions), virtually all of
whom had anorexia nervosa, with 81 voluntary patients. The investigators
gave four reasons for compulsory treatment:

(i) Detention was necessary in the interest of the patient’s health, for example by
virtue of extreme weight loss and persistent avoidance of food;
(ii) Detention was in the interest of the patient’s safety, for example he or she was
making suicidal plans or had already attempted self-harm;
(iii) The detention was in the interest of both health and safety;
(iv) Other reasons (e.g., aggression or violence). (p. 148)

Note that both anorexic behaviors in and of themselves as well as specific
plans for self-harm were considered acceptable reasons for compulsory treatment.
Ramsay’s team found that those individuals who received compulsory
treatment did not significantly differ from the voluntary patients in admission
weight or BMI, but the members of the compulsory group were significantly
more likely to have a history of childhood physical/sexual abuse, prior admissions,
longer hospitalizations, and explicit self-harm.

Another study on compulsory treatment comes from Australia (Griffiths,
Beumont, Russell, Touyz, & Moore, 1997). Griffiths and colleagues (1997)
reviewed the cases of 15 female patients with anorexia nervosa who had been
admitted to four different units in New South Wales between 1991 and 1994.
They compared the 15 involuntary with 73 voluntary patients. The involuntary
inpatients had a mean BMI of 13.4 (versus 14.3 for the comparison
group), and all but 1 required special medical consultation because of physical
morbidity associated with anorexia (73% of the voluntary patients needed
to see a medical specialist). One of the involuntary patients died before followup,
but none of the members of the other group had died. This outcome would
be expected, given the more complicated histories of the members of the former
group. Compulsory treatment in Australia has been examined in other
articles (Beumont, 2000; Griffiths & Russell, 1998; P. B. Mitchell, Parker,&
Dwyer, 1988).

United States

The literature in the United States has also attended to the dangers associated
with anorexia, but the focus has been on mandatory withdrawal from a
university (e.g., Glenn, Pollard, Denovchek, & Smith, 1986; Pavela, 1985)
and involuntary hospitalization (Appelbaum & Rumpf, 1998; Dresser,
1984a, 1984b; see also Goldner et al., 1997). Of special relevance to counseling
psychologists who work on college campuses, Pavela (1985) asserted that
students with eating disorders made up one of three groups that may warrant
involuntary withdrawal from a university because of the effects of the condi-
tion on the person, the impact on the university community, or the fact that the
student could not receive adequate treatment on campus (the other groups
were suicidal students and students with mental disorders who commit
offenses without awareness of the nature of their actions). He stated that after
other measures have been tried, “Unresponsive patients with potentially life
threatening complications should be committed to a medical facility for
prompt intervention, if necessary” (p. 60); but he did not indicate when such
action would be “necessary.” Glenn and colleagues (1986) provided four levels
of interventions for students with eating disorders. The highest-level
intervention is warranted when a student is “behaving in ways that are a threat
to the life or health of self or others” (p. 164). They reported that there were
two instances at their university where intervention began at the highest level
because of the severity of the students’ behavior.

Recently, Appelbaum and Rumpf (1998; see also Dresser, 1984a; Dresser
& Boisaubin, 1986; Fost, 1984) discussed the prospect of involuntary hospitalization
for people with anorexia. These authors explicitly stated that civil
commitment in the case of anorexia is analogous to “other areas of mental
health practice, involving the treatment of overtly suicidal patients or those so
gravely disabled as to be unable to meet their basic needs” (p. 225). Yet the
authors noted that it appears rare for people with anorexia to be involuntarily
hospitalized (see also Fost, 1984), perhaps because many therapists do not
consider a client with anorexia, who is not explicitly suicidal, to be a harm-to self
and, therefore, do not consider attempting involuntary hospitalization if
other interventions fail. However, as previously reviewed, neither overt
suicidality nor intent to harm oneself is necessary for the duty to protect to
apply. Furthermore, given the mortality data previously cited, it should be
clear that

the effect of anorexic behavior can be fully as lethal as the more direct suicidal
actions of a severely depressed patient. Thus, the focus on expressed intent is
misleading and potentially harmful to the patient. . . . Even without the intent to
end their lives, anorexics often act in ways that make that outcome likely. (p. 227)

As a result, Appelbaum and Rumpf concluded, therapists should consider
involuntary hospitalization if a client’s anorexia-related behaviors are severe
enough to suggest that the individual’s life is in jeopardy.

Objections to Involuntary Hospitalization

Although a few authors have made the case that some individuals with
anorexia may be acting in ways, or have progressed far enough in their disease
process, to warrant strong interventions, others object to the consider-
ation of involuntary treatment for these clients. Reasons most often cited
include potential violation of client rights, questionable efficacy of enforced
treatment, and the likely deterioration of the therapeutic relationship.

One of the primary concerns regarding the use of involuntary hospitalization
or compulsory treatment is that this imposition violates the client’s right
to decide for herself—her autonomy is taken away. This violation of client
rights is seen as running counter to good therapeutic practice and believed to
be counterproductive in both the short and long run (Dresser, 1984a, 1984b;
Rathner, 1998). Although this may be true in principle, experts in anorexia
indicate that clients are often grateful for such intervention once they are not
in the downward spiral of the disorder (Fost, 1984; Goldner et al., 1997;
Griffiths & Russell, 1998).

Experts have also suggested that involuntary hospitalization serves the
temporary purpose of medical stabilization but does not actually treat the eating
disorder because this requires the cooperation of the client (Rathner,
1998). Although short-term results are positive, the long-term success rates
of involuntary treatment have been less clear. Only three studies to date have
assessed the outcome of involuntary treatment (Griffiths et al., 1997; Ramsay
et al., 1999; Watson et al., 2000). Although the investigations were not
directly comparable, Russell (2001) summarized the results of research from
these three outcome studies (one each in Australia, London, and Iowa). All
three indicated that the involuntary patients experienced successful
refeeding, although the results took longer than with the voluntary patients
(mean 113 days compared to mean 88 days, respectively). Long-term followup was
not done, but mortality comparisons were made with the London data.
At an average of 5.7 years postadmission, the involuntary patients had a
higher mortality rate (10 of 70 involuntary patients had died compared with 2
of the 70 voluntary patients). This was believed to be the result of the more
severe pathology of the involuntary patients (Russell, 2001). How many
deaths were prevented by the hospitalization, however, is unknown. More
research is required to determine the long-term therapeutic impact of involuntary

Another concern about involuntary treatments is that such efforts could
irreparably damage the therapeutic relationship and make it less likely that
the client would seek treatment in the future (Richmond, 2001). There are no
data to suggest that this is true, however, and some authors offer anecdotal
evidence that clients are more likely to be grateful for the intervention once
they are medically and psychologically stable (Andersen, Bowers, & Evans,
1997; Fost, 1984). Furthermore, it is argued, mere admission does not mean
the person will necessarily improve (Dresser, 1984a), and if all that is
achieved through hospitalization is medical stabilization without treatment
for the actual disorder(s), positive treatment outcome is less likely. Once a
person’s weight is stabilized, however, the benefits of psychological and
pharmacological treatment are more likely to accrue.Arecent study (Watson
et al., 2000) comparing voluntary and involuntary in-patients with eating disorders
demonstrated that treatment outcomes were not significantly different
and that the involuntary patients were just as likely to benefit from the treatment
as were the voluntary patients. Long-term follow-up is still needed to
determine whether these positive outcomes are sustained.

Objections to Applying the Duty to
Protect With Clients Who Have Anorexia

Although we have attempted to make the case that counselors have a duty
to protect with clients who have anorexia and that discharging this duty may
even lead to attempts at involuntary hospitalization and compulsory treatment,
readers may object to this line of reasoning. Some may argue that
because the incidence of anorexia is lower than that of other mental disorders,
even a mortality rate of 10% represents a relatively small number of deaths
compared to those associated with other conditions. However, the number of
deaths associated with anorexia is not the issue; the probability of death is the
key. Because anorexia will lead to death if the course is not interrupted, the
clinician has a duty to intervene if the course has progressed far enough (i.e.,
to the point of medical jeopardy).

Another concern related to the application of the duty to protect with clients
who have anorexia is, essentially, where to draw the line with other
behaviors that may eventually lead to death, such as substance abuse (see
Frederick, 1980) or cigarette smoking (see Lichtenstein & Bernstein, 1980).
The overarching issue of when the duty to protect applies with individuals
whose behavior is putting them at risk of harm is beyond the scope of this article
but has been discussed recently by Werth and Rogers (2003; see also
Werth, 2002). For the present purposes, comparisons with other behaviors
are appealing, but these “indirect self-destructive behaviors” (Farberow,
1980; see also McIntosh & Hubbard, 1988) are different from the situation
with anorexia as it has been presented in this article in at least two significant
ways (of course, if such individuals are not different in these significant ways,
then intervention would be appropriate). First, individuals engaging in these
other behaviors typically are not hospitalizable because they cannot be considered
gravely disabled or incompetent; second, they are not in imminent
danger of death.We leave it to others to make the case that additional disorders
warrant intervention and to develop guidelines for when such intervention
should occur.

Finally, some may see us as bringing legal issues into yet another area of
clinical practice and therefore promoting the idea that counselors need to be
more sensitive to potential malpractice claims than to the client. However, we
actually are advancing the opposite argument. The assertion here is that therapists
need to be more aware of the dangers faced by their clients with
anorexia and more active in protecting the clients from the harm associated
with the person’s condition. As advocated for in this article, being more
proactive is not based on fear of legal reprisal but rather on the significant
potential for client death. Instead of deferring to nonclinical decision makers,
we present below a set of criteria that can help the counselor determine when
the duty to protect applies and what level of intervention is appropriate.


Based on the foregoing, we contend that there is a duty to protect with clients
who have anorexia and, therefore, the counselor must be prepared to
attempt involuntary hospitalization with clients whose conditions warrant
extreme intervention. Regardless of whether a therapist considers the behaviors
associated with anorexia nervosa to be overtly suicidal or to be the result
of a condition that has compromised the ability to think clearly and care for
oneself, it would appear obvious that such behaviors are dangerous and the
counselor needs to intervene in some way. How to intervene is shaped, in
part, by whether a duty to protect exists. Because the diagnosis of anorexia
nervosa alone is not sufficient, the duty to protect applies when the client’s
behaviors have become extreme or are associated with significant health
risks. The uninterrupted course of anorexia will inevitably lead to medical
jeopardy and death. The goal of treatment is to slow the progression of symptoms
until the client is able to develop healthy coping mechanisms.
Depending on the client’s response, decisions will need to be made about
whether to maintain the current course of treatment or to develop a more
aggressive plan, which would include more protective measures.

An example of how the physical and psychological decompensation of a
client with anorexia can lead to (a) significant health concerns, (b) consideration
as to whether the duty to protect applies and, if so, (c) decisions about
what interventions are necessary illustrates the dilemma for the counselor.

Jan was an 18-year-old first-year student at a large university. She had been
treated for eating disorder behaviors in an outpatient clinic during high school
and, although not fully recovered, she was attending college 1,500 miles from
home. She lived in the residence hall on campus. Despite her best intentions to
maintain her progress, she started restricting her food intake shortly after
classes began in the fall. Initially friendly, she began to withdraw from her new
friends and roommates, particularly avoiding activities that involved meals. By
late fall, her roommates expressed their concern about Jan’s avoidance and
declining weight to the resident assistant. The residence hall staff referred her
to the campus counseling center. She began counseling and medical monitoring
through student health services as part of a multidisciplinary treatment
team and remained stable through winter break. After returning to campus in
the spring semester, her weight continued to drop. Although she agreed to have
her parents notified that she was in counseling, she denied the extent of her
decline both medically and psychologically. She had developed a strong therapeutic
relationship with her counselor but was terrified of making any changes
in her eating behavior. In an attempt to maintain her autonomy and avoid a
power struggle, treatment options were discussed with her, but she refused
inpatient treatment and refused to leave school voluntarily. Despite her weakened
condition, she was seen by acquaintances exercising excessively. She had
alienated her friends and had reduced her contact with her family.

The treatment team worked carefully to maintain Jan’s engagement and
cooperation in the treatment process. Although she maintained her counseling
and medical appointments, her disorder continued to progress. Her mood
became more dysphoric, she had little energy, and her memory showed impairment.
Furthermore, her weight had fallen to 95 pounds (given her height of
5’5”, this equated to a BMI of 15.8), so her therapist and physician constructed
a behavioral contract that included more frequent counseling sessions, nutritionist
appointments, weight expectations and monitoring, and activity restrictions.
She signed the contract to avoid being involuntarily withdrawn from
school, although she continued to claim that she was medically stable and functioning
well. Jan felt some pressure to sign the contract, but by allowing the
team physician to monitor the medical consequences, the counselor was able to
maintain an empathic connection and address Jan’s fears. As a result, the therapeutic
relationship did not seem to suffer by implementing the contract.

By spring break, Jan had been taken to a local emergency room twice: once
for rehydration after fainting and once because of cardiac dysrhythmia. Her
treatment team had already escalated interventions in response to her physical
and psychological condition and, again, determined that more aggressive treatment
was necessary to preserve her life. As outpatient treatment on campus
proved insufficient in reversing the course of her disorder, and her BMI
dropped to 15 (90 pounds), they decided to call her parents to make arrangements
for more intensive treatment, with or without Jan’s consent.

Although counselors routinely intensify treatment with clients who are
decompensating, it is unclear in the literature when counselors engage in an
assessment of the need to protect the client from the probable death associated
with continued anorexic behavior. Although no one has specifically
identified a set of criteria that would implicate the duty to protect when a client,
such as Jan, has anorexia nervosa, a tentative list of conditions may be
generated based on the research and analysis associated with compulsory
treatment in the United Kingdom and Australia (Griffiths et al., 1997;
Griffiths & Russell, 1998; Ramsay et al., 1999; Serfaty & McCluskey, 1998),
the reviews of civil commitment in the United States (Appelbaum & Rumpf,
1998; Dresser, 1984a, 1984b; Goldner et al., 1997), and discussions of the
physical complications associated with and treatments for anorexia nervosa
(American Psychiatric Association, 2000a; Andersen et al., 1997; Becker,
Grinspoon, Klibanski, & Herzog, 1999; Brotman & Stern, 1983; Casper &
Davis, 1977; Garner & Needleman, 1997; J. E. Mitchell, Pomeroy, & Adson,
1997; see also Stein et al., 2001). Unfortunately, the rate of progression
toward medical danger in anorexia is difficult to predict. Death in these cases
is often the result of a cardiac event for which there was no warning (Birmingham,
1989; Brotman & Stern, 1983).

Given the medical risk associated with this disorder, the therapist must
work closely with medical personnel or as part of a multidisciplinary treatment
team in evaluating the health risk of the individual patient (Kalodner,
1998). In fact, the American Psychiatric Association (2000b) guidelines prescribe
that eating disorder treatment decisions be made by a multidisciplinary
team. The American Psychiatric Association guidelines also highlight certain
characteristics that would warrant immediate hospitalization: increase in
pulse of greater than 20 beats per minute (bpm) or a drop in blood pressure of
greater than 20 mm Hg/minute standing, bradycardia less than 40 bpm,
tachycardia greater than 110 bpm, or inability to sustain body core temperature
above 97.0 degrees. Having no motivation for recovery is also cited as an
indicator for inpatient hospitalization. Short of these emergent physical
signs, the risk factors listed below indicate more protective/aggressive treatment
strategies are necessary, which may include behavioral contracts, intensive
outpatient treatment, and, ultimately, voluntary or involuntary

High-risk indicators include

1. BMI below 15 (e.g., 5’2” and 82 pounds; 5’5” and 90 pounds; 5’8” and 98
2. Any of the following medical conditions: cardiac arrhythmia, seizures,
syncopol episodes, organic brain syndrome, bradycardia (less than 40 bpm),
exercise-induced chest pain, reduced exercise tolerance, dysrhythmias, renal
dysfunction, tetany, blood volume depletion
3. Abnormalities in electrolyte levels
4. Rapid weight loss into dangerous weight range for height
5. Comorbid psychiatric conditions (e.g., major depression, obsessive-compulsive
disorder, bipolar disorder, post-traumatic stress disorder, substance abuse)
6. History of self-harm or prior hospitalizations
7. Cognitive impairment that interferes with judgment to the point that the person
is incompetent or gravely disabled

The clinician who has a client meeting one or more of the above criteria (in
particular, 1, 2, or 7) should consider herself or himself to have an affirmative
duty to take explicit action to protect the health of the client (if the client is a
minor, special duties apply; see Dresser, 1984a, 1984b, for a discussion of
these). Any combination of the above risk factors should alert the clinician
that more aggressive treatment is warranted. Because the progression of
symptoms is typically gradual, it will be the cumulative clinical judgment of
the treatment team that determines whether a duty exists to intensify the interventions.
In general, the counselor might proceed from establishing a behavioral
contract, to using intensive outpatient treatment, to instituting partial
hospitalization or day treatment. When these efforts have failed to bring
about sufficient change, voluntary or involuntary hospitalization should be

Appelbaum and Rumpf (1998; see also Gutheil & Bursztajn, 1986) made
a compelling case that the most aggressive form of intervention—civil commitment—
is a possible course of action for therapists working with clients
whose health is in jeopardy because of the behaviors associated with anorexia
nervosa. Although framed within the auspices of the duty to protect,
Appelbaum and Rumpf did not discuss other, less extreme, interventions that
may be both appropriate and necessary under this duty. Ideally, the therapist
should proceed from the least restrictive (e.g., verbal contract) to more
restrictive treatment options (e.g., breaking confidentiality) and only consider
involuntary hospitalization when other treatment attempts have failed
or medical risks necessitate (Andersen et al., 1997).

Other authors have provided similar potential courses of action. Both
Pavela (1985) and Glenn and colleagues (1986) said that mandatory withdrawal
from a university and potential hospitalization should only be
attempted after less extreme avenues have failed. However, these recommendations
were targeted at university staff and primarily focused on decision making
guidelines for non-counseling-center personnel. They did not
provide recommendations for the counselor. The most helpful advice in
this literature comes from Goldner (1989), who listed 14 treatment principles
(see Table 1; see Goldner et al., 1997, for an expansion of these principles)
that emphasize maintaining an alliance while attempting to intensify treatment.
These principles, although designed to guide clinical decisions in cases
of treatment refusal, are relevant in the negotiation for and imposition of duty
to protect interventions. Combining this approach with the types of interventions
typically associated with suicidal clients (e.g., making a contract,
increasing session frequency; Bongar, 2002; Westefeld et al., 2000) will help
guide the therapist toward meeting his or her responsibility to properly intervene
to protect the client from self-harm. Again, we emphasize that counselors
in such situations would be remiss if they failed to consult with an expert
in the treatment of anorexia and to work closely with a physician or health
care team in implementing a treatment plan. Thorough documentation is also
essential because involuntary hospitalization may eventually be indicated
(Gutheil & Bursztajn, 1986).

TABLE 1: Treatment Principles for Duty to Protect Interventions

1. Seek to engage in a sincere and voluntary alliance.
2. Identify reasons for treatment refusal.
3. Provide careful explanation of treatment recommendations.
4. Be prepared for negotiation.
5. Allow the patient to retain autonomy.
6. Weigh risks versus benefits of treatment imposition.
7. Avoid battle and scare tactics.
8. Convey balance of control versus noncontrol.
9. Ensure methods of treatment are not inherently punitive.
10. Involve the family.
11. Obtain legal clarification and support.
12. Consider legal means of treatment imposition only when refusal is judged to constitute a serious risk.
13. Consider differential treatment in chronic anorexia nervosa.
14. Conceptualize refusal/resistance as an evolutionary process.


To practice up to the standard of care when working with clients who are at
risk of self-harm, psychologists must take some action to protect the person
(Bongar, 2002). We have asserted that when a counselor is seeing a client
with anorexia, the therapist may eventually have a duty to take action to protect
the client’s health even if the client is not explicitly suicidal and is not
engaging in anorexic behaviors with the explicit intent of self-harm. The specific
diagnosis is not the key; the behaviors associated with the diagnosis are
what trigger the duty. For example, just as a diagnosis of major depression
does not automatically require intervention to protect the well-being of the
client unless the behaviors or potential behaviors associated with the depression
(e.g., suicidal ideation with a plan or attempt) signaled that significant
harm was believed likely, the diagnosis of anorexia in and of itself is not sufficient.

However, if the behaviors associated with the condition are such that
the therapist, after medical consultation, perceives the client’s life to be in
danger, then the duty would apply.

The goal of this article is to make explicit what may have been implicit: At
times, there is a duty to protect with clients who have anorexia nervosa. The
medical danger associated with this condition invokes the ethical and legal
responsibility to protect clients in an acute state of the disorder. Counseling
psychologists and trainees would benefit from an increased understanding of
the overlap of clinical and ethical dimensions of decision making and treatment
planning with clients with anorexia. We hope that this article will
prompt others to examine this issue and that researchers will work to further
define the conditions under which the duty to protect applies. Until then,
counselors are reminded that even if their clients with anorexia nervosa are
not explicitly suicidal, the behaviors associated with this condition do put
these clients at risk of significant self-harm and death, and the therapist therefore
may have an affirmative duty to protect clients with anorexia.

References omitted due to length. If you want a reference cited anywhere in the paper, contact me and I'll give you the source.
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