Treating Eating Disorders 271others pursue the less coercive process of assisted feeding, which involves
spoon-feeding a patient while she is restrained and comforted by a nurse.
It is argued by some that anorexia is a conscious “hunger strike” (Orbach,
1986), a political statement and/or a way of coping within the family, and
that the patient is therefore making a conscious choice not to eat. Within
this framework it is seen as abusive to disregard this right and impose forced
or coerced feeding. In contrast, the refusal to eat is considered by others
to be part of the illness which increases with starvation, and the UK Court
of Appeal ruled in 1992 in a case concerning a young girl that “anorexia
...destroyed the ability of the sufferer to make a rational decision and Lord
Justice Nolan said that the court had an inescapable responsibility to over-
rule J’s wishes” (Roberts, 1992). In the first randomized control trial of tube
feeding, Rigaud et al. (2007) randomly allocated malnourished patients with
AN to receive either tube feeding or standard care. The results showed that
tube feeding resulted in greater increases in weight, fat-free mass, and energy
intake and a reduction in bingeing. Most patients also believed that the
tube feeding had improved their eating disorder. In addition, the relapse-
free period was longer in those who had been tube fed. Thiels (2008) explored
the clinical and ethical reasons behind forced feeding and analyzed data
from Australian and German patients to assess its effectiveness. He reported
that forced feeding tended to be used for those with lower BMIs on admis-
sion and at times may be justifiable. However, he recommended that
highly skilled nursing is preferable and that patients should be admitted if
possible before their weight drops below a BMI of 13 to avoid the need for
force feeding. This recommendation is reflected in the practice of specialized
inpatient units, where the question of force feeding is avoided by effective
nursing and the power of behavioral strategies. At times, however, inpa-
tient units may use more controversial techniques, particularly if there is
a life-threatening medical emergency.
Effectiveness of inpatient treatmentThe primary aim of inpatient treatment is weight restoration, and
studies of its effectiveness indicates that inpatient treatment in a specialist
unit is more effective than in a nonspecialized unit (Royal College of
Psychiatrists, 1992), with an average weight gain of 12.7 kg versus 5.9 kg.
Likewise, Crisp et al. (1992) reported that the standardized mortality
for patients seen at a specialized inpatient unit was 136 compared to 471
for patients seen in an area without specialized units. Specialized inpatient