Exploring the ruling relations of eating disorder treatment in Ontario

Despite nearly 50 years of calls for change, service users in eating disorder (ED) treatment too often continue to experience care as controlling under time-limited directive models, requiring compliance/adherence to rules that uphold a specific form of recovery. Recently the Government of Ontario released new quality standards for ED treatment, which promise to alter how the system operates. This has occurred against a backdrop of an unprecedented surge in the volume of people with EDs seeking help following the onset of the COVID-19 pandemic which has deepened the strain on an already under-resourced treatment system. As such, we contend there is a need to explore how clinicians do carework in treatment spaces to better understand what organizational, procedural, and discursive factors coordinate/ regulate their capacities to care in the current moment and explore what new pathways might be forged. Taking an Institutional Ethnography (IE) approach, our study explores the ruling relations coordinating clinicians’ carework in Ontario inpatient, day-patient, and live-in ED treatment programs. Methods included in-depth interviews with six clinicians and textual analysis of core documents informing or directing treatment. Clinicians included one psychiatrist, two dieticians, one psychologist, one social worker, and one psychotherapist. Our analysis drew from accepted IE analytic procedures, and included indexing, mapping, and writing accounts. Our IE identifies a tension experienced by clinicians, particularly in publicly-funded treatment between their desire to practice collaborative care and the demand to enforce stringent mandates in an environment dominated by highly standardized, time-limited treatment directives that seek to ration care. We explicate how the discourses of care-as-cure and gold standard (evidence-based) treatment coordinate clinician’s carework in moments of treatment non-adherence, as they operate through practices of informal coercion and the broader politics of evidence-based research. As the first IE in the ED field, our work traces connections between practice, texts, and institutional discourses in a novel way, adding compelling findings to the limited Canadian ED treatment literature and the urgent need for change. Our IE findings underscore the need to de-centre biometrics and recentre relationality by developing alternative care pathways that attend to the diversity of service user needs and address gaps in care. Despite nearly 50 years of calls for change, eating disorder (ED) treatment in Canada and beyond has seen little meaningful change. In 2023, the Government of Ontario released new quality standards for ED treatment that offer a promise for change and improved outcomes. Our study explores how hospital mandates, evidence-based treatment guidelines, and cultural discourses influence and restrict the care practices of clinicians in ED treatment programs. Our findings show that clinicians often experience a tension between their desire to provide collaborative care and the mandate to ensure services users adhere to all rules. This can result in care practices that cause harm for both service users and clinicians. Our findings illustrate that forces far beyond individual clinicians influence such practices, requiring large-scale change. We identify the need to forge alternative care pathways in the current under-resourced and highly-standardized treatment system to ensure that all service users can find options for treatment that meet their varied needs.

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