Client experiences of involuntary treatment for anorexia nervosa. A review of the literature and implications for social work practice.

Client experiences of involuntary inpatient treatment for anorexia nervosa: A review of the
literature and implications for social work practice.
ABSTRACT
Despite improvements in contemporary treatment approaches, anorexia nervosa continues to be
one of the most misunderstood and challenging disorders for health professionals to effectively
address. The aim of this paper was to identify the subjective experiences of clients during their
inpatient admission for anorexia nervosa. A systematic review of the literature identified eight
qualitative studies from the clients’ perspective, which were analysed and compared to discover
key themes and areas of contention. While there are many negative client experiences of
significant concern to be addressed in current inpatient settings, positive experiences were also
discovered within this environment. Findings suggest that more holistic, empathic and
collaborative approaches to clients with anorexia nervosa - that value and validate their
perspectives of their condition and individual recovery needs - can enhance clinical treatment
experiences in future.
Keywords: anorexia nervosa, clients’ views, experiences, inpatient treatment, social work

AnorexiaNervosaandSocial Work
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Anorexia Nervosa (AN) is a complex, life-threatening mental illness, for which there is currently
no cure. Limited services and the multifaceted nature of AN make early detection and
intervention difficult, with many AN clients who social workers encounter in their practice being
involuntary inpatients. By this stage, the individual will have already experienced significant
physical, social and psychological disturbances (Butterfly Foundation, 2012). Inpatient services
provide a vital, life-saving intervention for people in the acute stage of AN, however the
influence of inpatient treatment towards meaningful long term recovery has become increasingly
questionable and scrutinised (Bosanac, Newton, Harari & Castle, 2010).
High rates of relapse, readmission and increased risk of suicide reflect disturbingly poor
outcomes for those diagnosed and treated for AN (Harbottle et. al., 2008, cited in Hay, Touyz &
Sud, 2012).Within inpatient settings, core social work values of client participation, self-
determination and empowerment can be compromised by limited treatment efficacy, high levels
of risk and professional doubt towards the competency of the client to refuse and accept
treatment (Kendall & Hugman, 2013). A historical lack of acknowledgement for the voice of the
AN individual in both research and practice further compromises this group, with the majority of
studies focusing on mixed eating disorder (ED) populations, despite differences in views of
treatment existing between ED diagnoses (Smith, Chouliara, Morris, Collin, Power, Yellowlees,
Grierson, Papageorgiou, Cook, 2014). These issues warrant urgent efforts to better understand
the clients’ experiences of clinical treatment. The purpose of this review was to explore clients’
subjective experiences of inpatient treatment for AN, and bring attention to the perspectives of
an often unheard, overlooked population. In contrast to the widely accepted assumption that
individuals with AN lack the competence and mental capacity to make informed decisions in
their best interests, this paper also serves to highlight the insightfulness of study participants’

3
towards their condition and treatment. Implications of the review’s findings for social work
practice will be discussed, with suggestions for future research.
METHOD
Search Strategy
A systematic electronic search was completed using Sage, Taylor & Francis and Wiley databases
in April and May 2014. Searches were refined to include peer reviewed journal articles published
in the last twenty years, between January, 1994 and December, 2014.
Key words for each search attempt were ‘anorexia’, ‘nervosa’ and ‘inpatient’. To enhance the
likelihood of finding further relevant sources, “anorexia” AND “nervosa” were then combined
with the following terms in various combinations: experience, personal, subjective, perspective,
view, inpatient, involuntary, hospital, coercion, compulsory, and control.
Titles were assessed regarding their relevance to anorexia nervosa and the inpatient treatment
experiences of clients. Abstracts were then assessed for relevance. The reference lists of each
relevant article were then searched for other potential sources. In total this strategy identified
eight articles relevant for the second stage of review.
Inclusion Criteria
Qualitative studies of participants who have been clinically diagnosed with AN, including both
restricting and binge eating/purging AN subtypes, were selected for review. Participants could
either be within inpatient treatment at the time of the study, or be providing retrospective
accounts of past inpatient treatment. Sources were required to be peer reviewed journal articles,
presenting original research and available in English. No restrictions were placed on participant

4
age, gender, AN chronicity or duration of treatment. Due to the limited Australian research
available, international research was included.
Exclusion Criteria
A majority of sources yielded by the search terms were excluded, often due to their focus on
other treatment regimes, such as outpatient services, day programs, family and group therapies.
Studies of other eating disorders or mixed eating disorder groups, such as Binge Eating Disorder,
or AN and Bulimia, were also excluded from this review.
Studies focusing on clinical treatment outcomes, such as weight, rather than personal experiences
of the treatment itself were also excluded. Studies including the subjective experiences of others
to inpatient treatment, such as nurses and doctors, were also excluded from review.
Data Extraction and Yield
Across all three databases, eight articles were identified as relevant for full-text evaluation and
analysis. Reasons for excluding the majority of articles the search yielded included were: having
a focus on eating disorders in general or others (rather than being AN specific), studying the
clinical outcomes rather than subjective experiences of treatment, studying treatment
environment other than inpatient, and/or for studying the experiences of others instead of the
client with AN.
KEY FINDINGS
Control

5
The concept of control and the challenges experienced by clients in negotiating new levels of
autonomy with their eating disorder and their treatment environment, were identified as major
themes within the literature. Several studies reported positive client experiences of handing over
control to their treatment team. Participants reported a loss of personal control to their AN prior
to treatment, experiencing a sense of relief from the responsibility of their disordered eating once
admitted to hospital (Smith et. al, 2014; Offord, Turner & Cooper, 2006). Overtime as weight
outcomes progressed, having gradual reductions in treatment restrictions and having greater
control over treatment choices were experienced as positive, empowering and helpful transitions
for recovery (Smith et. al, 2014).
While these examples demonstrate positive transitions of control, for other participants, having
to hand over the responsibility of their ED to others resulted in negative feelings and
experiences. Two studies reported re-feeding and mealtimes to be generally negative and
sometimes traumatic experiences, contributing to intense feelings of losing control and
powerlessness for some participants (Fox & Diab, 2013; Long, Wallis, Leung, Meyer, 2011). In
Offord et. al’s study, the early handing over of control was commonly experienced as helpful,
however as treatment progressed this was increasingly experienced as unnecessarily paternalistic
and over-controlling (2006). In the same study, having control removed in other areas of
treatment, such as restricted access to phones and family visits, exacerbated clients’ sense of
helplessness and inadequacy (2006).
Service decisions regarding the location and continuity of a client’s treatment were also
experienced negatively. Participants reported feelings of uncertainty, rejection and abandonment
when they were moved on to other units (Fox & Diab, 2013; Ross & Green, 2011). Having to

6
regain personal control over their AN and prepare to leave the security of inpatient treatment was
experienced by some participants as difficult and frightening (Ross & Green, 2011).
Staff-client relationships
All eight articles emphasised the importance of positive staff-client relationships and the
influence these may have upon the inpatient treatment experience. Across studies, participants
highly valued supportive staff, who were able to demonstrate empathy and understanding
towards the difficulties of their illness and recovery (Smith et al, 2014; Fox & Diab, 2013;
Colton & Pistrang, 2004). Supportive staff qualities were found to increase clients’ engagement
with treatment, by promoting help seeking behaviour and disclosure (Smith et al, 2014), while
also helping clients’ to realise their self-worth and the value of depending on others in times of
need (Ross & Green, 2011).
Inconsistencies in staff knowledge and approaches to AN clients were experienced negatively.
Participants reported that staff often failed to provide adequate reasoning for certain practices,
leading participants to feel upset, confused and frustrated (Offord et. al, 2006). Particular staff
were viewed as more lenient than others when enforcing meals (Long et al, 2011), and as more
easily manipulated by participants (Boughtwood & Halse, 2010). Participants in one study also
highlighted the issue of experiencing ‘pampering’ by certain staff (Gulliksen, Espeset, Nordbo,
Skarderud,Geller, Holte, 2012). Although participants wanted to experience acceptance and
understanding from staff, being treated over-sympathetically was experienced negatively, as a
reinforcer for some ED behaviours and counter-productive to recovery (Gulliksen et. al, 2012).
Across studies, participants emphasised the importance of perceived professional knowledge and
expertise within their treatment team, alongside their ability as clients’ to realise who does or

7
does not possess experience in AN treatment. Having trust and belief in the expertise of staff was
expressed as critically important to participants’ sense of being effectively cared for (Fox &
Diab, 2013). In Gulliksen et. al’s study, participants valued expertise as a preferred characteristic
in health professionals (2012). Participants linked expertise to previous clinical experience with
AN clients, and felt that these professionals were able to better help participants to understand,
manage and accept themselves (Gulliksen et. al, 2012). Adolescent girls in Boughtwood and
Halse’s study viewed previous AN experience in doctors as essential, feeling scepticism towards
younger doctors and new graduates involved in their treatment. As one participant recalls “He
said he had a lot of experience with eating disorders even though he looked about 10, heh, heh,
no about 20 or something, like straight out of College sort of thing. So I was, I was really
sceptical...” (research participant, as cited in Boughtwood & Halse, 2010). In order to feel
understood in an environment where genuine, effective treatments for their AN could take place,
participants required staff to demonstrate professional capacity and experience.
The importance of being viewed as a person
Being viewed and treated by staff as a unique person, rather than an AN diagnosis, was a
common wish and challenge for many of the studies’ participants. Participants who disclosed
concerns regarding aspects of their treatment, such as being watched while eating, reported
unsympathetic staff responses that dismissed their disagreement as symptom expression of AN,
rather than a genuine complaint to address (Long et al, 2011). As a participant in Colton &
Pistrang’s study illustrates, “it’s just like everything’s anorexic and everything you do’s
anorexic…everyone always says you can’t trust an anorexic.” (2004, 312). Feeling judged and
stereotyped by staff caused participants to feel rejection and a lack of identity (Gulliksen et. al,
2012).

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Across studies, participants expressed their approval for individualised care, with concern
towards inflexible practices that generalized AN clients rather than taking into account personal
differences and preferences. Some participants reported being monitored by staff when using the
toilet in case of purging or exercising, despite having no history or urge to demonstrate these
behaviours (Boughtwood & Halse, 2010, Offord et. al, 2006). Participants also emphasised the
importance of treatment to address not only address the physical symptoms of their AN, but also
the underlying psychological issues (Smith et. al., 2014; Offord et. al, 2006). Individual
counselling sessions were felt to be essential and helpful to recovery, yet for most participants’
access to this therapy felt irregular and limited (Colton & Pistrang, 2004; Smith et. al., 2014).
Battle grounds vs collaborative environment
Experiencing inpatient treatment as a battle ground was a common theme found within the
literature. When treatment was perceived as rigid, un-collaborative and over-controlling,
participants were more likely to demonstrate resistance to treatment (Offord et. al, 2006).
Participants described the experience of constant conflicting thoughts towards their AN,
treatment and recovery as a continuous internal battle (Long et. al, 2011). Participants expressed
their desire to comply and recover with treatment, alongside wanting to actively resist and rebel
(Colton & Pistrang, 2004). As a seventeen year old girl explains “…Some days I just think, just
do everything that’s required…But then other days I’m just battling against this place” (research
participant, as cited in Colton & Pistrang, 2004, 313).
Collaborative approaches to care were valued by participants. In providing ideas for service
improvement, participants in Long et. al’s study commented on the lack of collaboration they
experienced, requesting they be given more active roles and responsibilities in future decision

9
making (2011). Participants believed they were capable of collaboration in menu design and
cooking, and that these shared responsibilities would prepare them better for life outside of
inpatient treatment (Long et. al, 2011). Contrastingly, most participants in Colton and Pistrang’s
study felt that although aspects of their treatment was collaborative and that they would like
greater responsibilities, they also expressed greater self-doubt and anxiety in their own capacity
(2004).
Peer relationships: Vital support vs unhelpful influence
Peer relationships within inpatient settings were identified as a vital yet contradicting source of
support for many participants across most studies.
Participants reported the isolating nature of their AN prior to admission, valuing the acceptance
and genuine understanding experienced among their peers in treatment (Smith et al, 2014). Some
participants felt less alone with a strong sense of peer identity and community (Offord et. al.,
2006). Through positive peer interactions and shared learning of effective coping skills,
participants reported a sense of hope towards their recovery (Smith et. al, 2014). Having the
freedom to discuss AN with peers provided participants with a strong sense of relief and
acceptance (Colton & Pistrang, 2004).
While these experiences can be viewed as positive influences upon a client’s wellbeing and
recovery, participants also expressed concerns towards the impacts of exposure to peers in
treatment. Some participants felt more aware and vulnerable to negative peer influences upon
their behaviour than others (Smith et. al., 2014; Offord et. al., 2006). Frequently comparing their
physical appearances and behaviours with peers led some participants to demonstrate
competitive ED thoughts and behaviours. Participants in Long et. al’s study reported a sense of

10
rivalry between peers, with attempts to be the slowest eater during supervised mealtimes (2011).
Participants in Colton & Pistrang’s study felt competiveness to be the thinnest among their peers,
as illustrated by a young girl, “…A lot of people come in here and it’s sort of like who’s the best
anorexic.’(Colton & Pistrang, 2004, 311). These comparisons sometimes led participants to
question the severity and relevance of their own AN diagnosis (Smith et. al., 2014; Long et. al.,
2011; Offord et. al., 2006), while increasing participants’ sense of being watched and scrutinised
(Long et. al., 2011)
Comparisons to newly admitted clients often led to feelings of guilt and greed during re-feeding
treatment (Smith et. al., 2014, Offord et. al., 2006), however for some participants in the later
stages of recovery, these comparisons were found helpful as motivation to continue treatment
and avoid regression (Offord et. al., 2006).
Exposure to peers in distress was commonly experienced negatively and viewed by participants
as hindering to their recovery. Living alongside distressed and unmotivated peers made some
participants feel conflicted in wanting to provide support, while also wanting to stay focused on
their own personal recovery (Smith et al, 2014). Observing others in distress caused participants
to feel frightened and disturbed, with self-harm incidences creating fear for the safety of oneself
and others (Colton & Pistrang, 2004). Some participants reported learning new eating disordered
behaviours from their peers (Long et al, 2011) and adverse coping strategies, such as self-harm
(Colton & Pistrang, 2004; Offord et. al., 2006).
DISCUSSION
Implications for social work practice

11
The findings of this review highlight important implications for contemporary mental health
social workers and professionals to consider in their practice.
A central issue voiced by participants was their desire to be viewed as unique people, rather than
simply as an illness by their treatment team. While some reported feeling understood by
particular empathic staff and in some units more than others, findings suggest that overall,
feeling misunderstood and stereotyped are common experiences for many AN inpatient clients.
The influence of the biomedical model of health may partly explain the development of such
attitudes held by staff towards AN clients. As Kendall & Hugman argue, much of the debate
concerning the ethical treatment of AN clients has been dominated by biomedical understandings
and discourses of the illness (2013). Through a biomedical perspective, explanations for the
development and maintenance of illnesses such as AN lie within the individual, rather than the
family or society (Russell-Mayhew, 2007). A lack of staff empathy towards the difficulties
experienced by AN clients in treatment, may then be linked to a prevailing assumption that the
individual is at fault and responsible for their current condition.
Although several participants across studies emphasised the need for services to address the
underlying psychological issues of their disorder, and expressed their desire for greater access to
individualised therapy, participants experienced inpatient treatment as being primarily focused
on the physical aspects and symptoms of AN. Weight restoration was experienced as the key
outcome of treatment, despite participants experiencing significant psychological, emotional and
behavioural difficulties. As Fedyzyn & Sullivan suggest, the strong focus on symptoms typical
of AN treatment services reflects the biomedical model’s rigid definition of illness, as being the
presence of irregularities or deficits in human functioning that must be corrected (2007). By

12
pathologising the individual, attention can be taken away from the social and cultural forces
outside of the individuals’ control, that create and maintain the conditions in which AN can
manifest and thrive (Richmond, 2001). Important short term goals of weight gain and medical
stability can be achieved during inpatient admission, yet when we consider these physical
outcomes alongside higher rates of relapse and readmission, alongside the call from participants
to access more therapeutic interventions as inpatients, the efficacy of a medical focus in
supporting meaningful recovery for individuals with AN is questionable. It is important that
social workers continue to be critical of the factors which client and professional knowledge are
created and sustained by, and the disempowerment that may be experienced by vulnerable
groups as a result.
A diagnosis of AN may impact upon professional attitudes and judgements regarding a client’s
competence and decision making capacity, influencing the importance placed on client
experiences, knowledge and participation in the treatment process (Kendall & Hugman, 2013).
Establishing and maintaining a therapeutic alliance is an important goal of all social worker-
client interactions. While the quality of relationships with staff was identified as a key influence
on client experiences of treatment, the inpatient environment can be viewed as a challenging
arena for alliances to form and grow. The increasing focus of contemporary psychiatric settings
to manage and reduce risk, rather than to provide individualised, therapeutic care, directly
impacts upon the availability of social workers and other staff to build trust with clients and
families (Kendall & Hugman, 2013). The dynamic and high-risk environment in which AN
inpatients are treated - in which death can be a very real outcome - further exacerbates the
conflicting pressures staff may experience in wanting to provide clients with more power and

13
autonomy in their treatment, while also wanting to protect clients from the genuine dangers of
AN.
Treatment refusal is widely accepted as a defining clinical feature of AN (Gans & Gunn, 2003;
Swain-Campbel et. al., 2001; Tan, Hope, Stewart, & Fitzpatrick, 2003, cited in Fedyzyn &
Sullivan, 2007). This expert knowledge can then be used to invalidate negative client
experiences of treatment. For example, a participant in Long et al’s study reported to staff the
common human experience of discomfort whilst being closely watched during a meal “They said
I would say that,” (Long et al, 424, 2012) illustrates the lack of empathy and understanding
towards AN clients in voicing genuine concerns, only for their complaints to be minimised as
expressions of typical AN behaviour.
In contrast to the assumption that AN individuals are incapable of making rational, informed
decisions regarding their best interests in treatment, this review identified a range of highly
insightful and meaningful subjective accounts of inpatient clients with AN. Participants in
several studies identified times when they appreciated external decision making of their AN, and
times when they felt ready and eager to re-gain responsibility over their illness. Not all
participants rejected all aspects of inpatient treatment, and those who demonstrated resistance
were able to identify internal and external reasons for this behaviour.
Issues in negotiating power and control were identified as common experiences within the
literature. It is vital that social workers acknowledge the significant power imbalances clients’
may have experienced prior to admission, as a result of the stigma associated with their mental
illness, the isolating nature of AN and the constant internal struggle for control and identity
alongside AN. Providing clients with greater transparency regarding the directions of their

14
treatment, correct information and opportunities to evaluate service experiences could greatly
assist clients’ in feeling respected and validated as people. As identified in the literature, clients’
appreciate access to opportunities that assist them to gradually build their confidence and levels
of control over their disorder, in preparedness for re-entering the real world and the
responsibilities this transition requires. Finding the right balance in handing over control to AN
clients has been identified as difficult and there are many inconsistencies in how staff and units
approaches this challenge. Inpatient treatment has the potential to empower clients in their
recovery, so long as efforts are continuously made to provide services that are empowering,
rather than reflecting the controlling, punishing nature of AN itself. Client participation in
making treatment decisions is central to the promotion of self-determination, autonomy and
empowerment of disempowered individuals in authoritarian settings (Kendall & Hugman, 2013),
and must be viewed more as a treatment priority and right for clients with AN, rather than an
option.
Limitations
Having an individual researcher may have increased bias throughout the review process. Ideally,
at least one other researcher would have participated throughout the process to negotiate areas of
ambiguity and contention.
By limiting study samples to AN clients treated as inpatients, findings cannot be generalised to
other eating disorder populations and treatment settings.
Due to time and resource constraints, other relevant sources have potentially remained
unidentified. Relevant articles not available in English and published prior to 1994 may have
been found if included. A more extensive search involving more than three databases and a hand-

15
search of journals may have also yielded further sources for review, and further reduced database
bias.
This paper included clients of all ages. However as Smith et. al (2006) highlight, treatment
approaches used in adolescent inpatient services often differ to those used in adult, and these
differences may impact upon a client’s experience.
Researchpriorities
Finding qualitative research on the subjective experiences of clients’ during inpatient AN
treatment proved to be difficult, with this review identifying eight relevant sources in the last
twenty years, one being Australian. Much of the literature focused on the experiences of the
family or treatment team, usually from the perspectives of nurses’. While the views of all
involved in the AN treatment process are important to better understand and consider, the
experiences of the client continue to remain a largely unexplored and misunderstood area.
As highlighted, staff and peer relationships are of significant influence in the treatment
experience of inpatient AN clients. Although several qualitative studies of nurses and doctors
were identified, further research that expands upon these studies and investigates a wider range
of professions, including social work, could enhance our understandings of clinician experiences
in multidisciplinary, inpatient AN treatment.
A significant lack of research focusing on males with AN is evident in the literature. In all eight
articles, only females featured as participants. While the incidence of AN in males is much lower
than females, increasing prevalence is being discovered in both groups (Russel-Mahew, 2007).
The unique experiences and challenges for male clients, within a primarily female diagnosis and
treatment environment, could therefore be an important endeavour for future research to address.

16
Expanding upon the qualitative studies identified in this review could further assist the
development of more effective services for AN individuals in the future. Further local and
international research into the experiences of AN clients could expand upon the findings of this
review.
CONCLUSION
For many individuals treated for AN, there are a range of positive and negative experiences
within the inpatient treatment environment. Positive experiences of inpatient treatment were
possible when participants’ felt understood by empathic, knowledgeable and flexible staff. When
facilitated gradually and transparently, transitions of control, from being controlled by AN - to
handing control over to staff - to regaining control in preparation for discharge, enabled
participants to feel empowered and able to depend on others to support them. Living alongside
peers undergoing treatment for the same diagnosis, helped participants to feel less isolated. Peers
were able to provide participants with new effective ways of coping with their AN, and non-
judgemental support during treatment. These positive experiences and strengths may be built
upon to further enhance the effectiveness of inpatient treatment in fostering meaningful recovery
and relationships.
Negative experiences reported by participants raise serious concerns for the recovery and
wellbeing of inpatient individuals. Being stereotyped and judged staff lead to feelings of
frustration and disengagement from treatment. Some individuals’ made valid requests or
complaints to staff, only to have these comments minimised as expressions of AN symptoms.
Participants reflected on the importance of others stepping in and taking control over their AN
during times of distress and danger. Over time, however, staff control was often experienced as

17
oppressive and punitive, rather than necessary and reflective of individual progress in treatment.
Across studies, participants valued the opportunity to participate in therapies that addressed their
AN holistically, and collaborative approaches to their treatment. Access to these, however, was
mostly experienced as limited during inpatient treatment. Participants reported the negative side
of peer inpatient relationships, with exposure to distressed and self-harm experienced as
disturbing and hindering to individual recovery. Participants would often engage in or observe
competitive behaviours among their peers, increasing their sense of being judged, watched and
delayed further in their pursuit of recovery.
In identifying these range of experiences, it is evident that the inpatient environment is a
complex and challenging setting for individuals with AN, with the potential to generate both
positive and negative client experiences. Social workers and all inpatient treatment staff have a
responsibility to better seek and validate the perspectives of every individual client they
encounter within their practice.

Client experiences of involuntary treatment for anorexia nervosa. A review of the literature and implications for social work practice.

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