When your patient requests involuntary treatment: A case report of a collaborative approach to treatment under the mental health act in anorexia nervosa and borderline personality disorder

To the Editor

Use of involuntary treatment (IT) in anorexia nervosa (AN) occurs most commonly to treat severe physical compromise as a result of starvation or eating disorder behaviours. Arguments cautioning the use of IT include concerns it can lead to damage to treatment alliance, loss of autonomy and imposition of control over the individual (Douzenis and Michopoulos, 2015). We describe a case where IT was requested by the patient and how this request was managed. The patient gave informed consent for her case to be described.

Ms L was a 23-year-old female with a 4-year history of severe AN and borderline personality disorder (BPD).

Ms L was admitted to the inpatient eating disorders unit (EDU) as a voluntary patient following 4 kg of weight loss (body mass index of 14.8 kg/m²) and concomitant mild medical compromise. She was precontemplative regarding recovery from AN, however had requested admission as she acknowledged she needed assistance with normalising her eating. Previous admissions had been complicated by deliberate self-harm and Ms L feeling ‘out of control’ of her treatment.

Ms L requested IT to facilitate naso-gastric tube (NGT) feeds. She described receiving NGT feeds using IT as a ‘relief’ and that it reduced ‘guilt’ and anxiety related to ‘choosing’ to receive nutrition.

Considerations in using IT included wanting to avoid restrictive treatment, discourage dependence and encourage Ms L’s ability to take an active role in her recovery. The potential benefits of this approach were the collaborative decision-making and Ms L feeling able to ask for help.

The team planned with Ms L for a time-limited use of IT, with clear graduations to an oral meal plan and situations in which IT would be ceased (e.g. emergence of suicidality).

Progress included weight restoration with the assistance of NGT feeds and transition to an oral meal plan over 6 weeks. The IT order was discontinued prior to discharge. Ms L expressed a sense of satisfaction regarding her progress. Ms L required another brief admission 3 months later and did not require IT.

Ms L’s case raised common themes because both AN and BPD include control and ambivalence towards treatment (Bohon and McCurdy, 2014; Goldner et al., 1997). It has previously been described that patients may describe relief at having others assume the decision-making role in regard to treatment (Goldner et al., 1997). This approach using IT was collaborative, non-coercive and highlighted the guilt and ambivalence in AN that can prevent some patients from accessing treatment voluntarily.