Mental health clinicians make decisions based on their respective ethical codes daily. Certain ethical standards, such as abstaining from sexual relations with clients, are clear. Other decisions, particularly those involving nuanced clinical judgment, can be more complex. Psychologists who treat clients struggling with an eating disorder frequently face common ethical dilemmas such as therapist competence, self-disclosure, and particular treatment challenges in non-urban locations. Due to the medical implications of eating disorders—including potential death— these psychologists often find themselves making treatment decisions that dramatically affect a client’s physical and mental health. Such decisions must be guided by the Ethical Principles of Psychologists and Code of Conduct (Code; American Psychological Association, 2010). Determining whether to implement coercive tactics in treatment or palliative care for chronic eating-disordered clients requires careful evaluation and consideration of the psychological principles in the Code, particularly Beneficence and Nonmaleficence, Fidelity and Responsibility, Integrity, and Respect for People’s Rights. In addition, various standards of the Code should be consulted.
When providing services, psychologists are expected to work within “the boundaries of their competence” (Code, Ethical Standard 2.01). The ethical standard of competence (Standard 2 of the Code) has a variety of implications for those treating eating disorders. Because eating disorders greatly impact physical health, as well as mental health, they are especially complicated to treat. The American Psychiatric Association asserts that best standards of practice generally involve a treatment team consisting of a psychotherapist, medical provider, and dietitian (American Psychiatric Association, 2006). A therapist or psychologist with limited specialized training or knowledge of the medical ramifications, effect of nutritional deficiencies on cognitive functioning, and the complex underlying reasons of an eating disorder may likely be practicing beyond their “scope of practice.” The clinician may also underestimate the importance of the treatment team, instead focusing solely on mental health concerns. Not only is this ineffective treatment, but a simplistic approach that can cause harm to the client.
In an effort to maintain competence while treating eating disorders, as well as ensuring nonmaleficence, it is crucial that psychotherapists working in this arena continually evaluate their influence on patients.
Jacobs and Nye (2010) explain that “size, appearance, weight, dress, and overall presentation of one’s physical self are fundamental statements we present to our patients and can be conceived of as indirect forms of self-disclosure” (p. 166). In order to practice as competent clinicians, eating disorder therapists need to consider and be willing to explore how transference and countertransference issues related to appearance may impact recovery progress and the therapeutic relationship.
Overt forms of self-disclosure such as thoughts on diet, exercise, or personal struggles with an eating disorder (past or present) can also have a profound effect, potentially impeding a client’s recovery. Therapists must be mindful about offering seemingly offhand comments or casual advice drawn from either personal experience or pop culture. It is not difficult to imagine a scenario in which a passing remark about the latest nutritional trend—”I know folks who swear by coconut oil” or “Quinoa worked wonders for that celebrity”—could be taken as tacit permission to engage in food rules and restricted eating, rather than focusing on the underlying therapeutic work. Far from being beneficial, this type of implicit or explicit endorsement of problematic thinking patterns or behavior may negatively impact the recovery process.
Disclosing one’s own eating disorder and recovery could have an even greater impact than simple “nutrition advice.” Similar to those working in the field of addiction treatment, many therapists specializing in eating disorders are themselves recovered (Barbarich, 2002). A recovered anorexic herself, Carolyn Costin is a well-respected professional in the eating disorder field. Costin (2010) explains “even though they (the therapist) think they understand what a client means or is going through because they have ‘been there’ it is critical that their understanding of each client is not being overly colored by their own personal experience” (p. 168).
Whether stating an opinion on the latest nutrition trend or disclosing personal recovery status, therapists must monitor and evaluate their comments, and their patients’ perceptions of them, on an ongoing basis. Even if the therapist did not intend to cause harm, “if her patients experienced lowered self-esteem, body image and/or mood disturbances because of these interactions, the therapist’s approach had to be reexamined” (Jacobs & Nye, 2010, p. 172).
Before disclosing any personal thoughts on weight, nutrition, or past experiences, clinicians have an ethical obligation to evaluate the purpose of self-disclosure, as well as the potential benefit or harm to the client.
Treatment of eating disorders in rural settings presents particular ethical considerations. As stated above, because eating disorders involve both mental health and critical physiological factors, as well as considerable resistance to change, it is important for the clinician to have some training in standards of practice and effective treatment modalities. Unlike larger metropolitan areas, where numerous practitioners and treatment centers may offer relevant services, smaller locations often lack professionals who have specialized experience and training. Thus, it is likely that a therapist without adequate experience in eating disorders may work with a client with an eating disorder. For a clinician to maintain competency and do no harm, it is essential to recognize deficits, consult with more experienced practitioners, and pursue specialized training, even if this means driving long distances or utilizing online resources to obtain such consultation and training.
All psychologists contend with ethical decisions related to issues such as competency, multiple relationships, and self-disclosure; in addition, eating disorder treatment involves specific ethical dilemmas unique to this particular mental illness. Both Matusek & Wright (2010) and Vandereycken (1998) describe difficult ethical issues concerning informed consent, freedom of choice, autonomy, and the judgment of the patient’s competence. These ethical quandaries include the use of coercive tactics (overt or covert); the imposition of treatment, up to and including enforced feeding; issues of competence, particularly among clients whose capacities may be compromised due to medical complications; and potentially differing levels of duties to minor and adult clients (Matusek & Wright, 2010).
When considering whether or not overt and covert coercive tactics should be implemented in treatment, a psychologist must consider several General Principles from the Code, including Nonmaleficence (Principle A) and Respect for People’s Rights and Dignity (Principle E), which underscores the ethical tension between balancing client autonomy and a duty to protect at-risk clients. Principle E states: “Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair autonomous decision making.” In addition, psychologists have a responsibility to “protect client’s welfare when a clinician knows that a client poses an imminent risk of danger towards him or herself” (Matusek & Wright, 2010, p. 436).
These two ethical principles can be conflicting when applied to coercive treatment interventions such as involuntary hospitalization (for both adults and adolescents), tube feeding, monitoring bathroom privileges to prevent purging, exercise restriction, surveillance of mealtimes, enforced nutritional replacements, and blind weigh-ins. Enforcing compulsory treatment, whether on the level of outpatient or inpatient, is often in direct conflict with a client’s wishes and therefore threatens autonomy. Many professionals argue that, with these types of interventions, it may be “more destructive and counterproductive for the client’s autonomy to be usurped,” leading to feelings of being out of control and therefore more drastic eating-disordered behaviors (Matusek & Wright, 2010, p. 439). It also threatens to rupture the therapeutic alliance and may decrease the likelihood of the client continuing treatment.
Conversely, others argue that the duty to protect and prevent imminent harm often warrants compulsory treatment. Eating disorders have the highest mortality of all psychiatric conditions (Matusek & Wright, 2010). To prevent a client from becoming medically compromised or dying, structure and close monitoring may be necessary. Malnourishment, coupled with the ego-syntonic nature of eating disorders, causes impaired reasoning and limits cognitive capacity. These distortions may result in a client’s inability to break dangerous behavioral patterns regardless of intention, creating a potentially permanently harmful situation that itself may inhibit or prevent effective “autonomous decision making.” Due to a likelihood of serious medical complications that may increasingly limit client competency, a clinician’s duty to protect may override the presumption of client autonomy under these conditions.
Discerning the best course of action involves a complex decision-making process that examines the ethical dilemmas described above, as well as potential outcomes. In general, before a recommendation is made, several steps are necessary, including completion of a comprehensive health assessment on the part of the client; consideration of all practical treatment options and their likely effectiveness; and discussion with the client and his or her family or close support system.
Specifically, the clinician should consider “at what point does an individual’s disturbed relationship with food render her incompetent in making treatment decisions?” (Matusek & Wright, 2010).
Two considerations that can help determine cognitive capacity, and therefore competence, relate to lack of insight related to the gravity of the “disorder and health status, as well as the presence of organic impairments” (Manley, Smye, & Srikameswaran, 2001). Related to health concerns, determining whether there is a “duty to protect” is dependent on immediate health risk, as well as longer-term physical risk. Because eating disorder patients have a high rate of suicide, suicidality should also be closely monitored (Matusek & Wright, 2010).
Whether working in an outpatient or inpatient treatment setting, clinicians working with eating disorders will make countless decisions regarding treatment interventions and the therapeutic process. Although the treatment of eating disorders presents unique challenges, as with all psychologists, practitioners in this area of specialization will face ethical issues involving self-disclosure, potential multiple relationships, competence (of both the clinician and the client), autonomy, and duty to protect. To prevent harm, respect client autonomy, and provide effective treatment within appropriate ethical boundaries, it is important that clinicians consult with other professionals and keep the ethical guiding principles and standards in the forefront of decision-making.