پذیرش غیر ارادی: مورد بیماری بی اشتهایی عصبی

Involuntary treatment of psychiatric disorders has always been controversial; this is especially true for eating disorders. Patients with anorexia nervosa of life threatening severity frequently refuse psychiatric hospitalization. Ambivalence toward treatment is characteristic of eating disorders and patients are often admitted to inpatient programs under pressure from family and doctors. In this article, we report research on the positive or negative impact of involuntary admission in the treatment of eating disorders, its application and effectiveness as well as the adverse consequences of coercive treatment in eating disorders. A literature review was done. From a total of 134 publications which were retrieved from the literature search, 50 studies were directly relevant to the scope of this review and fulfilled all inclusion criteria. There are trends and arguments for both sides; for and against involuntary treatment in anorexia nervosa. The scientific literature so far is inconclusive, although in the short term, involuntary hospitalization has benefits. This review has also shown that involuntary hospitalization can have adverse long-term consequences for the patient–therapist allegiance. We conclude that in some cases, involuntary treatment can save lives of young patients with anorexia nervosa; however, in other cases, it can break the psychotherapeutic relationship and make the patient abandon treatment. It is the clinician who has to decide for whom and when to approve involuntary treatment or not.

1.1. Background and aim Anorexia nervosa (AN) is a serious psychiatric disorder characterized by body image distortion, an intense fear of weight gain, and self-induced weight loss leading to physical and mental abnormalities. Despite the profound effects of AN on the patient's physical, emotional, and social well-being, many sufferers refuse treatment, even stating they would rather die than gain weight. Because AN is an ego-syntonic disorder, meaning the patient feels the “disorder” is a part of her and does not want it to go away, it is a uniquely treatment resistant condition (Guarda, 2008). In this way, issues of consent and capacity arise in the treatment of patients suffering from AN (Bryden, Steinegger, & Jarvis, 2010). Involuntary treatment of any psychiatric disorder has always been controversial, especially for eating disorders. Patients with an eating disorder of life threatening severity frequently refuse hospitalization. Ambivalence toward treatment is characteristic of eating disorders, and patients are often admitted to inpatient programs under pressure from clinicians, family, friends, educators, or employers (Guarda et al., 2007). The aim of this review is to report the positive or negative impact of involuntary admission in the treatment of anorexia nervosa, its application and effectiveness as well as the adverse consequences of coercive treatment in eating disorders. 1.2. Legal issues Since the 50s, developments in Mental Health care and the activities of human rights movements changed the focus from a prescriptive type of treatment and control to one that takes into consideration the views and respects the human rights of mentally ill people. Consequently, individuals suffering from a psychiatric disorder are currently regarded as vulnerable individuals, requiring protection as well as access to treatment programmes that provide humane care and a substantial degree of choice and respect for autonomy (Harding, 2000). As the previous procedures leading to compulsory treatment have been considered to be jeopardising the rights of mentally ill people (International Commission of Jurists, 1992) and to constitute a fundamental infringement of their civil liberties (McIvor, 1998), the legal framework for involuntary admission and treatment has been reformed in many countries around the world (Brahams, 1997, Dressing and Salize, 2004, Dyer, 1993, Grubb, 1994, Harding, 2000, Stromberg and Stone, 1983, Surgenor, 2003, Swanson et al., 2000 and Wachenfeld, 1992). International organizations have published official documents outlining the safeguards that need to be implemented in compulsory admission legislation and practice in order to protect patient's individual rights. In particular, the Steering Committee on Bioethics (CDBI) produced in February 2000 a white paper on the protection of human rights and dignity of people suffering from mental disorders. In 2003, the World Health Organisation also published a mental health policy and service guidance package. These documents attempt to balance three, often conflicting interests: first, the basic human rights of the person who suffers from mental illness, secondly, his/her need for adequate treatment and finally the right of the public for safety (World Health Organization, 2003). To achieve this, they offer broad suggestions and attempt to describe “good and politically correct practice”. Furthermore, a dimension frequently not considered stems from the United Nations (UN) Convention on the Rights of Persons with Disability (2006) where in article 12 referring to “equal recognition before the law” paragraph 4 mentions “respect of rights, will and preferences” that if applicable to individuals with eating disorders adds to the pressure to justify involuntary treatment (U.N. Office of Legal Affairs, 2006). One could argue that this UN Declaration not only adds to the argument for better justification of involuntary treatment but also since eating disorder is considered to be a chronic condition and chronic mental disorders approach the concept of disability, adds weight to the arguments against involuntary treatment. Mental capacity is a multidimensional construct that is a central determinant of an individual's ability to make autonomous decisions. Its assessment has become increasingly important with the move away from the paternalistic role of healthcare professionals towards a greater emphasis on an individual's own treatment decisions. The American Psychiatric Association has developed a model statute which uses a mental capacity test (Stromberg & Stone, 1983). In other national jurisdictions the assessment of mental capacity and mental health legislation have developed along different lines in order to accommodate the needs of specific groups of patients (Okai et al., 2007). All WHO countries have mental health legislation in place. At the time of the WHO report (2008), from a total of 42 countries, 20 (47%) have adopted new mental health legislation or updated their legislation since 2005. Most countries' mental health legislation is relatively new. Almost seventy per cent of the countries have dedicated mental health legislation, and 31% have provisions about mental health as part of general health legislation (World Health Organisation, 2008). In this article, we have reviewed the relevant scientific literature on the use of involuntary admission for anorexia nervosa and present their findings.

As it discussed, the results are controversial. There is no scientific consensus on the correct course of action. In some cases, involuntary treatment can save lives especially of young patients with anorexia nervosa who are, extremely emaciated and refuse to accept physical treatments (e.g., for restoration of their electrolyte balance) or in cases of pregnancy when an acute exacerbation of anorexia can damage the fetus. However, in other cases, such an approach can break the psychotherapeutic relationship and make the patient abandon treatment altogether. If a general conclusion were to be drawn one can say that if there is real and immediate danger of death then involuntary admission and treatment should be implemented to save the life of the patient. On the other hand, this forceful approach can have negative consequences for the therapeutic relationship and adverse consequences in the long term. It is the clinician who has to decide for whom and when to approve involuntary treatment or not.