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Coercing With Compassion

News from the Johns Hopkins Department of Psychiatry and Behavioral Sciences

Dr. Guarda

Dr. Angela Guarda

A gaunt Darice Caine*, 41, came to Hopkins’ Eating Disorders Program weighed down by nearly three decades of anorexia nervosa. She’d been hospitalized at least 22 times at four different inpatient programs and a state psychiatric hospital, among others. Weighing 60 pounds, Caine was in grave danger. She carried the wounds of her illness: osteoporosis, sluggish heart rate, bruised, thinning skin, teeth eroded from vomiting. And she sat in admissions, telling director Angela Guarda, M.D., “I really don’t need to be here.”

Denying illness and ambivalence toward treatment, Guarda says, are hallmarks of anorexia. Most people with AN, in fact, never seek specialized treatment. It’s in the nature of eating disorders—in line with substance abuse or sexual disorders—to promote personal sabotage. The drive to continue starving stems from the gut feeling—Guarda uses the word egosyntonic—that it’s the right thing to do. “You could say these are diseases of self-deception,” she says. And that self-deception’s severe, given that more patients die from anorexia nervosa than from any other major psychiatric illness—as high as 10 percent over 10 years.

So Guarda became interested in seeing how necessary being motivated for treatment is to recovery. She also wanted to see if patients pressured into treatment change their feelings and accept the need for it later on.

Her study, recently published, hinges on the fact that coercion figures into most admissions to an eating disorders inpatient program. It can be pressure from family, friends, bosses, therapists. Or, occasionally, if the situation’s life-threatening, there’s involuntary admission—a court-based process to protect psychiatric patients in immediate danger. Caine’s father, for example, brought her to Hopkins under an ultimatum: Go or you can’t live at home. She signed herself in only after hearing that her severe condition warranted her being involuntarily admitted if she refused.

“Pressuring patients into treatment is very controversial,” Guarda explains. “It’s widely held that they have to feel ‘ready’ for treatment in order to benefit.” Or the idea’s there that if you pressure patients, they’re somehow harmed. “But we don’t see that,” says Guarda.

Patients do come reluctantly and I-don’t-need-to-be-here is the rule, she says. “They typically lack insight.” Within a week, however, “once they’ve engaged with their peers and formed an alliance with our clinical team, we often hear, ‘I know I need this.’” They gain weight and learn to eat more normally. That’s the trend her research supports.

In the study, Guarda’s team asked 139 teen-to-adult patients with eating disorders to complete a modified version of the MacArthur Inventory—a tool given psychiatric patients to measure perceived coercion—when first admitted and again two weeks later. Nearly half of patients who denied needing treatment had “converted” in the two weeks, with more adults switching over. Now the team’s collecting data on a larger group for a longer time period.

“All this suggests that judicious, thoughtful persuasion and leverage can be valuable and may be necessary to help people with eating disorders,” says Guarda. As for Caine, who’s now become a nurse, her letter says it best.  


* Not her real name

For information, call 410-955-3863.

Winter 2008 IndexHopkins Newsletter Archive