Compulsory treatment in anorexia nervosa
Anorexia nervosa is a psychiatric disorder with a very high mortality rate. If the eating disorder reaches life-threatening severity, for example through a body mass index lower than 13 kg/m (2), the possibility of compulsory treatment has to be considered. However, civil commitment of patients and forced feeding against their will may reduce self confidence and self esteem. This impedes the important goal of motivating patients to undergo psychotherapy. Furthermore, compulsory treatment is regarded as a contravention of the patient's physical inviolability as enshrined in the German Constitution. Up to now only a few studies about the use of guardianship legislation for anorexia nervosa have been published. The present paper reviews psychiatric literature and significant judgements of German courts on this topic. It finishes by examining clinical issues on forced feeding and possible consequences for psychotherapy.
Available from: Terry Carney
- "Finally, section 1906(1) of the Civil Code (Bürgerliches Gesetzbuch) imposes a " best interests " restraint on the exercise by a guardian of the power to admit their ward to a period of involuntary hospitalisation or treatment, 8 and section 1906(2) insists on obtaining judicial orders for all such committals (immediately after the admission in the case of an emergency). Mental health (and related) committals, however, are authorised under the laws of the different German Länder ( " States " ) which confine admissions narrowly to a mental illness that would lead to the concrete and direct endangering of that person or another person (Thiel and Paul, 2007: 130). In contrast, until recently, the use of force under guardianship provisions was unclear within German federal law. "
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ABSTRACT: Anorexia nervosa poses particular challenges for medicine, for ethics and human rights, and for the law. These challenges are emblematic of wider dilemmas across mental health and adult guardianship law and its administration. They arise both in public law (legislation and tribunals), as well as in private planning (e.g. advance directives) and indeed also within civil society (extra-legal or ‘informal’ family and private arranging). It is suggested that those challenges are heightened by shrinkage in the role of the state, including services and public resources, under the guise of neoliberal governance and the ‘new public management’. Many of these public policy dilemmas are complex, finely balanced, and thus difficult to resolve with much conviction. This paper argues that there is some role for law in authorising coercive interventions on an ‘emergency’, life-saving basis in acute instances of severe anorexia nervosa, along with a wider role for adult guardianship orders as the preferred initial measure when intervention is required. While the law may be creatively reformed (or administered) to facilitate realising positive rights such as access to needed treatment and quality services, it is argued that the role of law in policing the legislatively-determined boundary between voluntary and involuntary detention and/or treatment remains its most critical contribution. It is suggested that only lip-service is paid to the discharge of this task at present, because insufficient time or resources are available to the review tribunals undertaking this work. Addressing such under-resourcing is posited as the most pressing and most immediate challenge in anorexia nervosa cases, as it is in mental heath and substitute decision-making systems generally.
Available from: David Veale
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ABSTRACT: Over-valued ideas are truly a neglected area of psychopathology with few experimental studies published. There is a different emphasis in the USA and Europe regarding their definition. For authors in the USA an over-valued idea has become shorthand for 'poor insight' in the middle of a continuum of obsessional doubts to delusional certainty. Compared to negative thoughts, obsessions and delusions, they are often more resistant to any treatment. A better understanding of over-valued ideas is required if advances are to be made in therapy and for the development of appropriate measures to evaluate the efficacy of novel treatments. A cognitive behavioural model of over-valued ideas is presented which draws upon the philosophical distinction between beliefs and values. It is argued that over-valued ideas are associated with idealised values, which have developed into such an over-riding importance, that they totally define the 'self' or identity of the individual. Idealised values are also characterised by the rigidity with which they are held. Such patients are unable to adapt to different circumstances and ignore the consequences of acting on their value. This analysis leads to a discussion of predictions that can be tested and various strategies that can be used in cognitive behaviour therapy.
Available from: David Tait
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