Perceived Coercion and Change in Perceived Need for Admission in Patients Hospitalized for Eating Disorders

Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University Hospital, Meyer 101, 600 N. Wolfe St., Baltimore, MD 21287, USA.
American Journal of Psychiatry (Impact Factor: 12.3). 02/2007; 164(1):108-14. DOI: 10.1176/appi.ajp.164.1.108
Source: PubMed


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. This study evaluated patient perceptions of the admissions process and perceived need for hospitalization and assessed whether these perceptions remain stable in the short term.
A total of 139 patients with eating disorders completed a 13-item self-report scale on the admission experience when they were admitted to a behavioral inpatient specialty program and again 2 weeks into their hospitalization.
Patients with anorexia nervosa reported higher levels of perceived coercion and pressure and a lower sense of procedural justice than did those with bulimia. Patients under 18 (N=35) reported more perceived coercion than did adult patients (N=104), and a trend was noted for them to disagree that they needed hospitalization. Perceptions of coercion, of pressure by others toward hospitalization, and of procedural justice were stable in the short term. However, of the 46 patients (30 of them adults) who initially did not endorse needing admission, 20 patients (17 of them adults) changed their minds by 2 weeks into hospitalization and agreed that they needed hospital admission.
Nearly half of patients with eating disorders who denied a need for treatment on admission converted to acknowledging that they needed to be admitted within 2 weeks of hospitalization. Since treatment avoidance is associated with poor outcome, these findings suggest a need for studies assessing the long-term outcome and ethics of pressuring patients with eating disorders into treatment.


Available from: Angela S Guarda, Sep 08, 2015
    • "serious consideration by their treatment teams (Guarda et al., 2007;Svindseth, Nøttestad, & Dahl, 2013). Importantly, these findings on lower and higher perceived coercion link to earlier findings on autonomy and patient-staff relationships, which then link to positive and negative outcomes associated with involuntary confinement and treatment. "
    [Show abstract] [Hide abstract] ABSTRACT: The authors reviewed and synthesized scholarly literature on the topic of involuntary confinement and treatment for severely mentally ill adults. Objectively, all facets of the issue are reported, including recurrent positive outcomes, negative outcomes, and patient experiences in common. Patient experiences are organized into related subthemes of autonomy, patient satisfaction, relationships with staff, perceived coercion, traumatization, and humiliation. The literature suggests that short-term involuntary hospitalization is sometimes necessary in order to prevent the mentally ill from psychiatrically decompensating or harming themselves or others. Understandably, hospitalization is often experienced by the mentally ill as a demoralizing violation of their rights and tends to lead them to disengage further from the professional help they need in order to recover. In turn, disengagement leads to further decompensation and resulting risk for rehospitalization. In order to intervene in this cycle and instill severely mentally ill patients with hope in the recovery process, the use of coercive tactics must be decreased in favor of cooperative engagement measures to the greatest extent possible. Patients must be empowered to make choices within the limits of their illnesses through positive interactions with staff, particularly in potentially negative, autonomy-compromising situations. Cooperative measures may help to minimize the potentially traumatic and humiliating effects of being involuntarily hospitalized and medicated. In turn, trusting patient-provider relationships may develop. Thereafter, the severely mentally ill may become more likely to seek professional help on their own volition in the future. (Bulletin of the Menninger Clinic, 79[3], 255-280).
    No preview · Article · Sep 2015 · Bulletin of the Menninger Clinic
    • "Given the health-threatening consequences of malnutrition and emaciation, nutritional rehabilitation and weight restoration constitute the first step in the treatment for AN (National Institute for Health and Care Excellence, 2004). However, many patients admitted to inpatient care feel pressured or coerced to do so (Guarda et al., 2007). They are ambivalent about change and often terminate treatment prematurely (Woodside et al., 2004). "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Patients with Anorexia Nervosa (AN) experience high levels of social difficulties and anxiety. These problems might be underpinned by negatively biased processing of social stimuli. The aim of this study was to examine the feasibility of using a novel Cognitive Bias Modification (CBM) training to target information processing biases in patients with AN. Methods: Twenty-eight patients with AN completed a baseline and end of intervention assessment of mood and social appraisals. The CBM training consisted of 5 sessions and included an attentional probe task to train attention towards positive social stimuli and an ambiguous scenarios task to train benign or neutral interpretations of ambiguous social scenarios. Results: At baseline patients displayed an attention and interpretation bias towards negative social stimuli. At the end of intervention there was a medium sized increase in attention to positive faces and fewer negative interpretations of ambiguous social stimuli. There were also lower levels of anxiety and higher levels of self-compassion in response to a judgemental video clip. Limitations: The lack of a control group is the main limitation to this preliminary study as the changes obtained may have resulted from non-specific aspects of the inpatient treatment. Conclusions: A novel CBM training is associated with more positive processing of social information in AN. It would be of interest to test the hypothesis that reducing cognitive biases towards social stimuli impacts on wider features of an eating disorder.
    No preview · Article · Sep 2015 · Journal of Affective 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. "
    [Show abstract] [Hide abstract] ABSTRACT: 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. Copyright © 2015 Elsevier Ltd. All rights reserved.
    No preview · Article · Feb 2015 · International Journal of Law and Psychiatry
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