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.
IS THERE A DUTY TO PROTECT
WITH CLIENTS WHO HAVE ANOREXIA?
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
• 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.
References omitted due to length. If you want a reference cited anywhere in the paper, contact me and I'll give you the source.