Denying autonomy in order to create it: the paradox of forced treatment

I was on the great Neuroscience and Society website at the University of Pennsylvania, looking up more information on the 2010 Neuroscience Boot Camp (which I really hope to attend, provided I can snag both an admission spot and a scholarship), when I checked out their full-text research articles published by members of the program. One, titled Denying autonomy in order to create it: the paradox of forcing treatment upon addicts, immediately caught my eye.

(Just to warn you: the article is full-text, but it's really blurry. It appears they scanned in printed pages to create the .pdf files, so you can't copy and paste the text into word to get a better look. And no, printing it doesn't help either. I apologize if there are any errors in my transcription of the text.)

The author, Arthur Caplan, writes:

People who are truly addicted to alcohol or drugs really do not have the full capacity to be self-determining or autonomous. Standard definitions of addiction cite loss of control, powerlessness and unmanageability. An addiction literally coerces behavior. And addict cannot be a fully free, autonomous agent precisely because they are caught up in the behavioral compulsion that is addiction. If this is so, at least for some addicts, then it may be possible to justify compulsory treatment involving medication or other forms of therapy, if only for finite periods of time, on the grounds that treatment may remove the coercion causing the powerlessness and loss of control.

Addicts, just as many others with metal illnesses and disabilities, are not incompetent. Indeed, to function as an alcoholic or cocaine addict one must be able to reason, remember complex information, set goals and be oriented to time, place, and personal identity; but competency by itself is not sufficient for autonomy. Being competent is a part of autonomy, but autonomy also requires freedom from coercion. Those who criticize mandatory treatment on the grounds that an addict is not incompetent and thus ought not to be forced to endure treatment are ignoring this crucial fact. Addiction, bringing in its wake as it does loss of will and control, does no permit the freedom requisite for autonomy or self-determination.

The parallels to eating disorders are striking and, to me anyways, rather obvious. I believe that legal coercion should be a last resort measure. No one wants this- not the sufferer, not their family, and typically not society either. Buy-in is important in a therapeutic relationship, but if you never get sober, down from your Mt. Everest-level highs or begin a normal pattern of nutrition, "buy-in" is kind of irrelevant.

Coercion, even if it's not of the legal variety, is a commonly used tactic in both addiction treatment and eating disorders treatment. Done right, it can be seen as beneficial, even to the sufferer. Loving coercion could be financial ("I'm not paying for college if you're not healthy"), practical ("I don't think you should drive the car until you are doing better"), and even emotional (refusing to engage the person's disordered behaviors). Most sufferers, myself included, typically don't respond to these efforts with joy and praise, but that doesn't mean that they're not necessary. Many ED sufferers who felt they were coerced into inpatient treatment ultimately admitted they needed to be hospitalized.

In the end, what's worse: a few months of coerced treatment or a lifetime of an eating disorder?

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Ashes said...

I have been to inpatient and I "did need to be hospitalized" because if I hadn't been I would have died within the next week. Does that mean it was right for anyone to think they had the right to coerce me and force me in to an ED unit? Fuck no! I wasn't cured, I became a thousand times worse and I went from one stable eating disorder to playing Russian roulette. And I'm not a rare case. Most people who go to IP or OP treatments relapse within 6 months of leaving and going back to normal.

An eating disorder is a way to control your body, having well meaning and socially and emotionally stupid people force you in to something (because coercion is just a gentler way to say forced) will do nothing to help you and will only make you hold on to a life you've proven you don't want. I'm not saying that in the end I'm not glad I survived, I met my best friend who helped get me eating again, but I wouldn't have been sad if my step-father had just let me keep going and than helped me die when it just got to painful.

You can't take away autonomy to give autonomy. Emotions and organics are not numbers, they are not capitalist constructs that can be given or taken at will and than made better. It just doesn't work like that.

Not to mention that all these treatment options are just ways to give someone else the power to sexually and emotionally abuse you in ways that mommy and daddy didn't. Stopping a person from being able to control their own actions (when they use the bathroom, how much they eat, when they go to bed) are all really fucking subtle ways to sexually abuse someone, because you're telling them to do something with their bodies they don't want to do. I know for a fact that it sure as hell reminded me of my own rape and sexual trauma and I was put in to the third best eating disorder short term inpatient clinic in the world. I can only imagine how much worse it must be to be in outpatient and never be able to get away from a society that says you have no bodily integrity and and the doctors that are taking your body away from you every time you have to see them.

Cathy (UK) said...

Um, well, I have mixed views on this. I can see your point Carrie, but I can also see the points Ashes makes.

The way some impatient treatment centres operate is inhumane. This was especially so in the 1970s when I developed anorexia nervosa at age 11-12 yrs. Although I do have inherent susceptibility to anxiety, obsessions and compulsions, the trigger for my illness was sexual abuse. Such abuse can leave a person feeling TOTALLY out of control of their body and may strip the them of all sense of personal autonomy or power.

For many years I was treated as if I was a 'naughty girl' who was acting up to gain attention by not eating. At age 12 (and indeed - until I was 41 yrs old) I could never speak of the abuse I experienced (which, I will add, was not done by my parents; they are lovely, caring people). I was terribly ashamed, and I felt that no-one would believe me. I was threatened by some doctors with punishments for not eating, which were effectively further removal of my autonomy.

Ultimately, people start to recover from EDs when they are motivated to do so. Coercian merely drove me further into my illness and even more frightened of the world. Eventually, after 28yrs of anorexia nervosa, I became motivated to fight the illness because I had so many physical ailments, including heart defects. In addition to this self-motivation, I have had a very supportive, ethical and kind psychiatrist who has shown empathy for my situation and employed encouragement rather than dismiss my personal circumstances or my personal competence.

I do know of some people with anorexia nervosa who have thanked professionals for sectioning them and removing their autonomy, but such people are quite few and far between. Perhaps the situation varies in accordance with the primary ED trigger - and hence the role the ED plays in the person's life....

Katie said...

hmm such a difficult thing to be certain about.
i don't really know where i stand.
i spose, when my parents forced me into therapy for bulimia i was so angry but in the end it was for the best.
on the other hand, i'd hate it if someone forced me to lose control over my body and force fed me. yuck.

i see your point, i also see ashes' point.. its a tough one.

Harriet said...

I think this is spot on, Carrie.

It reminds me of those controversial mental health ads that ran a while back, purporting to be ransom notes from various mental illnesses that were holding children and teens hostage.

I wonder why we don't discuss the concept of buy-in when we're talking about, say, treatment for cancer. Or an ulcer.

Eating disorders are complex, but we know that a big part of the devastating cycle of an ED is physical and biological. If we can interrupt that, reverse malnutrition, stop purging, etc., the person with the ED has a much better shot at true buy-in and healing.

Anonymous said...

This is a very interesting post followed by equally interesting comments. Thank you for sharing your opinions and experiences, everyone.

I tend to agree to an extent to both sides of this. I've never been to IP; however, I have had frequent out patient appointments and been surrounded by people who forced my meal plan down me every day. For a long while, I "obeyed" as best I could because, when I didn't eat well, it upset my friends and I didn't like seeing them upset. THat said, I ended up doing things before wanting to do them. I ended up feeling untrusted, watched, and overly fed. Obviously this had good physical effects. However, I actually think it made my ED thoughts get worse and, the second I could (the second I was away from everyone), I went back to restrictive ED behaviors. I truly feel like if everyone had just backed off and given me some space, I could have achieved health at a just fine rate. It would have alleviated a lot of pressure and misery and feelings of failure if people had backed off (i.e., not take things away until I eat). I knew it was out of care, but I did not feel cared for. I felt infantalized, disrespected, and devalued.

On the other side, one time when I was relapsing, my therapist and RD were "in my face" a lot, requiring me to "buck up" and "do the work" to "Get better" otherwise it was "Getting dangerous." I remember sitting in my therapist's office telling her that this (recovery) wasn't going to work because I didn't want to change anything. I admitted I know I'm being unhealthy, I know it's bad to not want recovery, but I am afraid people are going to take my behaviors away from me. Her response was: "It's really great when people are motivated to recover. That's a nice thing. But we don't have time to sit around and wait for you to want to get better. If a kid can't read, we don't sit around and wait for him to start wanting to read before we tutor him, do we? So, whether you want to or not is irrelevant to me." And then she went on to give me some damn good frequent therapy - which included eating as well as talking as well as checking in several times throughout the day (whether I wanted her to check in or not). The result of this damn good therapy was me reconnecting with the part of me that does want to recover, thus continuing on the recovery path and engaging in less destructive behaviors. That is not the same type of coercion you are talking about... but it is an example of good things that can happen when the treatment provider doesn't sit around and "wait for the person to be motivated." In the end, I'm so glad my therapist held the belief that my motivation was irrelevant.

Harriet said...

Anonymous, I think that's EXACTLY the kind of "coercion" I'm thinking about. Your T sounds awesome.

I would reframe it as loving support for someone who needs it. Not punitive. Not coercion.

Carrie Arnold said...

I'm not saying coercion is "right" or even the "best" option. But the argument that we don't want to take away the autonomy of someone with an addiction isn't the best because they really aren't autonomous if they are struggling with an eating disorder or addiction.

Coerced treatment isn't a cure for EDs; I've been through the treatment doors many times for that. Relapse is common- really common. That doesn't mean that IP treatment isn't effective, just that most places suck at ensuring good follow-up care. Having an open door to return to a more structured environment even before you actually start using chemicals/ED behaviors can be really powerful, in my opinion.

But to me, I wasn't trying to control my body with anorexia. It was the other way around: anorexia was controlling my life. And I needed (even wanted, although I probably never would have admitted it) someone to take away all my choices but recovery. Because anorexia was doing the same thing: it took away all of my choices but starvation and death.

I wasn't capable of making good decisions about my health and well-being when I was ill with AN. Not only that, I wasn't able to recognize that I wasn't making good decisions. I needed the loving sign-yourself-in-or-we'll-do-it-for-you. The ED had me backed in a corner, so this was not really all that different, except it also offered a way out.

I'm not saying coercion should be the standard of care in ED treatment. Not by a long shot. But when we always rule out mandated treatment (whether legal or done lovingly by caregivers) because we don't want to diminish autonomy, I think we need to get better at recognizing that the autonomy is already diminished due to the addiction and it's not going to increase without treatment.

Adrianna said...

If I had any other mental illness, I would be free unless I was an immediate danger to myself or others. I think this would be a good way to approach eating disorders too, whether it's medical complications we're talking about or a mental health emergency like suicidal ideation.

If someone has a heart attack, I can call 911 and if eating disorder complications are the culprit, they can be refed. Even though the patient won't be thrilled and may not stay in treatment, they can at least be exposed to what's happening and maybe consider it.

If I were to attempt suicide by overdosing on pills, no ER physician would not treat me because, obviously, I wanted to die. They would save me and put me in suicide watch for a while. A treatment plan will be devised and hopefully, I will follow it.

It's not ideal by any means, but there needs to be a balance between treatment and autonomy.

Cathy (UK) said...

Hi Carrie

Thanks for your comment (above). I note that you stated "I wasn't trying to control my body with anorexia. It was the other way around: anorexia was controlling my life."

I would imagine that anyone (everyone?) who has been anorexic would agree that anorexia controlled their life such that the logical mind was no longer in control.

I mentioned (as did Ashes) that an ED is (effectively) a way to control one's body - and for people with a history of sexual abuse or rape then the issue of control (or rather, powerlessness = no control) is a pertinent driving force. Of course it's not conscious control as such; the behaviours become very automatic. Often it is only when those behaviours have been taken away from the patient that they consciously perceive there to be a loss of control - and a loss of autonomy.

Your point about follow-up care is really, really important, and that is where many ED units fail. Sometimes their objective is to re-feed as rapidly as possible and then (more-or-less) leave you to try to survive in the world, with no perceived sense of control - and possibly severe PTSD. I experienced rapid re-feeding in my teens - i.e. by removal of the behaviours that provided me with a sense of control - and I felt close to suicide. What I needed was concomitant or post-weight gain trauma therapy, yet no-one even broached the issue of prior sexual abuse - and I was far too fearful to mention it.

Again, I would stress that I think a crucial issue in this matter is probably that of 'what triggered the ED'.

CG said...

This is spot on, carrie. we are often powerless in the grip of the ED, even if we can pretend to appear functioning and ok, and we often need outside intervention to even realise that. your follow-up treatment point is also key. xoxo

Amanda said...


Thank you for this blog. I am writing a similar blog (I am recovered from an eating disorder as well) and I have been looking for other smart, evocative blogs like yours. I look forward to reading future entries.

Amanda Bruce, M.A.

Carrie Arnold said...

Thank you everyone, for your thoughtful comments. I was aware that my thoughts were a little controversial (and I was right- LOL!) but I'm glad to have an honest, respectful discussion of the issue.

indianist said...

can someone suggest me the best need eating disorders treatment centers ????? plzz…..

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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