Treatment resistance: Persuasion, perceived coercion and compulsion

Ambivalence towards treatment and treatment resistance are characteristic of eating disorders, particularly anorexia nervosa. Because attempts at normalizing weight and eating patterns threaten the ego-syntonic nature of dieting behavior, patients with anorexia nervosa rarely enter treatment of their own accord. Instead, some degree of pressure, or coercion, ranging from gentle persuasion to legal certification, is often applied to oblige resistant patients into treatment. Coercion is controversial however, and there is limited research to guide practitioners on the ethics and clinical management of treatment refusal. This chapter will discuss ambivalence and treatment resistance as core phenomenological features of eating disorders with emphasis on anorexia nervosa. The literature on treatment refusal, including competency and capacity to consent to treatment, perceived coercion about the admission process and compulsory treatment will be reviewed as well as empirical evidence regarding the therapeutic value and role, if any, of coercive interventions, ranging from mere persuasion to the extreme of compulsory inpatient treatment. Finally, the chapter will close with a case study, a suggested approach for managing treatment resistance and a discussion of directions for future clinical research.