August 10th, 2008

diana kamalova wide-eyed

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.

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

Ethical/Legal Issues in Treating AN (Part I)

When Does the "Duty to Protect" Apply with a Client Who has Anorexia Nervosa?
James L. Werth, Jr., Kimberly S. Wright, Rita J. Archambault and Rebekah J. Bardash
The Counseling Psychologist 2003; 31; 427

The role of counseling psychologists has expanded from the historical
emphasis of providing services to individuals with primarily developmental
concerns, typically in university settings (Gelso & Fretz, 2001), to include
working with individuals who have serious illnesses with both mental health
and medical implications (Roth-Roemer, Kurpius, & Carmin, 1998). This
evolution has served to blur the distinction between some of the mental health
disciplines in clinical practice. For example, persons with eating disorders,
once considered clients to be helped by clinical psychologists or psychiatrists,
are now treated in a variety of settings and by a variety of clinicians
including counseling psychologists. The need for counseling psychologists
to be familiar with eating disorder treatment was highlighted in a recent issue
of The Counseling Psychologist (TCP). Kashubeck-West and Mintz (2001)
asserted that “a working knowledge of [eating disorders] is critical for all
counseling psychologists working in applied settings including, but not limited
to, college counseling centers, private practices, and community agencies”
(p. 627).

Persons with eating disorders are challenging to treat, even for seasoned
clinicians, and this TCP major contribution was a welcome addition to the literature
that addressed many aspects of this area of practice. However, some
clinicians may be reluctant to work with clients with eating disorders, either
because they can be difficult to treat or because counselors do not feel sufficiently
trained. A survey of therapists in Florida revealed that one third did
not want to treat clients with eating disorders, primarily because they felt
frustrated and had minimal empathy for these individuals (Burket &
Schramm, 1995). An earlier study of Canadian psychiatric training centers
found that 88% of the students believed that they had been inadequately
trained to treat persons with eating disorders (Ghadirian & Leichner, 1990).
The inclusion of articles about eating disorders in the mainstream literature
means that more practitioners, when faced with clients who have eating disorders,
will have access to information without having to seek it in specialty
journals (Hotelling, 2001). With more information, training, and guidance,
perhaps clinicians will feel more prepared to provide treatment to these clients,
whose conditions can leave them so significantly impaired.

While the literature abounds with protocols that will assist the counselor
in case conceptualization and treatment (see Stein et al., 2001), a minimally
addressed issue is the ethical and legal quagmire that ensues as the health of
clients with eating disorders, particularly those with anorexia nervosa,
declines. For the therapist, the task is to balance the therapeutic needs of these
clients, particularly autonomy, with concerns about the person’s health.
Allowing clients to make their own decisions about treatment and recovery
may facilitate the therapeutic relationship but may increase the risk of medical
deterioration. Maintaining the balance between respecting the client’s
autonomy and protecting the client’s health is especially challenging. It is
within this context that practitioners, trainers, and supervisors could benefit
from a discussion of their ethical, legal, and clinical obligations when a client
with anorexia is in medical jeopardy (i.e., her or his life is in danger).

The purposes of this article are to (a) discuss the intersection between the
duty to protect (i.e., an obligation to take some action when a person is engaging
or considering engaging in a behavior that may lead to self-harm) and the
treatment of people with eating disorders, specifically anorexia nervosa; and
(b) provide some general guidelines for intervention. To determine whether
there may be an essentially heretofore neglected duty to protect in the case of
counseling with people who have certain eating disorders, this article first
provides a brief overview of anorexia nervosa and then reviews the incidence
of mortality in people with this condition. The next section outlines the duty
to protect in instances of self-harm and discusses legal options when a person
is considered to be at risk. Then, based on the information about anorexia and
the ethical and legal issues associated with the duty to protect, the question of
when this duty applies with clients who have anorexia is examined. The article
concludes with implications of this analysis.

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