Ethical Considerations for Patients With Eating Disorders

From the mid-1990s until 2014, I founded and was the Executive Director of Cedar Associates, an outpatient treatment center for eating disorders with two locations in Westchester County, New York. We were a group of qualified eating disorder specialists joined together for a common cause—to provide coordinated and expert care to our patients.

One ethical issue we pondered was whether or not we had created a cottage industry for those most vulnerable. We wondered if we were somehow taking advantage of those in need as we were part of the new 'niche' industry created by the rapid increase in the prevalence of eating disorders. There was now a steady influx of patients in desperate need of help. Having an eating disorder is terrifying, debilitating, and costly for patients and their families. Eating disorders remain the leading cause of death among all mental health conditions.

Our dilemma was about money. We simultaneously believed that we were entitled to a solid living wage and that patients were entitled to solid and expert care; both could be true and acceptable. Most healthcare practitioners struggle with healthcare services' delivery, costs, and payment. These ethical issues remain unresolved due to the politicization of healthcare, the complexity of insurance, and other factors. However, clinicians have always been able to assert their training, competency, and expertise in providing treatment unequivocally; these bona files remain ethically foundational.

We now have a choice of mental health care delivery, which has created new ethical considerations. COVID-19 set precedence for conducting sensitive meetings virtually, especially in health care. Whether to see a patient in-person or virtually is now part of the clinical decision-making mix. Deciding whether or when to treat in person versus virtually takes a mindful and clinically astute clinician.

Some factors to consider when deciding between in-person and virtual meetings:

• Establishing a prudent care plan involves routinely choosing the type of treatment based on the patient's clinical needs. Eating disorders, like others with complex symptoms, occur among the most psychologically vulnerable people. Assessing the level of severity can be very difficult. Keep in mind all the factors that help in assessment: type, frequency, and use of the symptom are all important, as well as assessing the level of depression, how isolated the person is, the family dynamics, and the level of support the person has in the recovery process.

• Since eating disorders manifest in many and with various constellations of symptoms, it isn't always easy to tell by looking at someone what state they are in. Patients can conceal their bodies through layered clothing and hide the truth about their behavior due to shame, anger, and fear.

• Eating disorders are also disorders of relationships—the ones we have with our self-concept and our relationships with others. (Zerbe, 2008, Scheel, 2011). Is the clinician confident that a relationship that fosters support, safety, and appropriate boundaries is possible virtually? Is the clinician comfortable not experiencing the most nuanced communication during online sessions? Since eating disorders are the vehicle for communication about relationships, internal conflicts, and lability in mood, does seeing a person virtually contribute to further relational disconnect? Is a real relationship possible virtually?
• Eating disorder clinicians often must face working with families in despair, who would never have consented to the treatment had it not been for their child, adolescent, or adult child in physical distress. The family member with the eating disorder is often the family symptom-bearer. Family members can blame and attack those who are most trying to help; they can sometimes bully school officials and therapists and can resist recommendations or, worse, manipulate or lie about therapeutic interventions to save their reputations. Is the clinician prepared to coordinate care among various professionals while being able to reduce or eliminate divisiveness among family members and other involved professionals? It can be enormously complex for family members to accept the psychological underpinnings of the eating disorder and the metaphoric use of the symptom to talk about family dynamics and issues. Will virtual sessions impede this process of discovery?

In the past, clinicians relied solely on their transparency to patients about their training in treating eating disorders. Although this remains true today, there is a certification process and credentials for clinicians to treat eating disorders, further qualifying competency and commitment to ethical treatment standards (IAEDP). Certified eating disorder specialists (CEDSs) now provide the care, and most clinicians incur additional costs in ongoing training, supervision, and personal therapy.

We need competent and expert therapists. More therapists are receiving advanced training; however, training in evidence-based treatment alone cannot allow someone to understand the complexities of a severe condition. Trauma, major depression, debilitating anxiety, borderline personality disorder, and a high degree of family dysfunction surround and underlie the development of an eating disorder. Do virtual appointments add another layer to an oversimplification of the needs of this population?

Skills in here-and-now approaches like cognitive behavioral therapy, acceptance and commitment therapy, short-term interpersonal therapies, mindfulness, and motivational approaches are insufficient in treating eating disorders. Therapists require additional training in understanding human motivation, even the use of the eating disorder as a symbol and metaphor. Are virtual appointments ethically consistent with providing a holistic treatment protocol for a patient with an eating disorder? (Freeman, 2007)

Telehealth contributions and considerations:

Telehealth has allowed vast populations to have access to mental health treatment, sometimes for the first time. Medically and psychologically home-bound people, rural communities with difficult access to larger towns, adult family members who cannot easily drive their child to treatment, and many others praise telehealth's ability to service specific populations and meet the demands of more and more people considering psychotherapy for the very first time.

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• Is some form of therapy, like telehealth, better than no therapy? Absolutely, but with the caveat that these treatments are best suited for those who are not suffering from major depressive conditions, significant anxiety, personality disorders masquerading as 'merely' relationship issues, or those with severe symptoms like an eating disorder. Often, patients with minor anxiety do very well in teletherapy because of the protective veil of physical distance and how the camera orients eye contact.
• Mental health issues confront one in every five Americans (CDC). Adding a layer of disconnect via telehealth requires prudent decision-making to proceed, especially when the therapist is new to the field of eating disorders, or new to the field of treating mental health conditions.
• Serious assessment and consideration are required to determine which patients may be most suited to benefit from telehealth and those for whom it poses risks.

We are in an age of disconnect from human contact, with artificial intelligence, virtual meetings, and connections based and maintained on social media. If only we could extract our humanity from being human, we might be in better mental health living in a virtual world.