A therapist's perspective: inside an NHS inpatient anorexia nervosa treatment centre
I write about the psychology of eating disorders. I have personally recovered from bulimia and have worked as a therapist for 20 years. I hope to inspire, educate and improve understanding about eating disorders through my writing. Names used are fictional and stories shared are a combined insight of many client experiences. I believe that full recovery is possible for everyone.
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I worked as a therapist in an NHS adult eating disorder service on and off between house moves, babies and life, between 2004 and 2023. You might wish to read my earlier article HERE talking about 9 learnings from this.
In this article, I talk specifically about the inpatient experience.
My role was predominantly in outpatient services, but I also saw inpatients, who were spending anything from three months to a year, receiving intensive recovery support for anorexia nervosa.
This support included psychiatry, psychology, nutrition and refeeding meal support, exercise management, plus many additional therapeutic groups.
Here I share 9 reflections from my experience.
1. Choice or force?
Thankfully, for 99% of individuals, patients are not forced into hospital against their own will.
On rare occasions, if someone is extremely unwell and possibly at risk of death, then they will be sectioned under the Mental Health Act.
This means being detained in hospital for treatment because someone is considered to be a danger to themselves or others, and they are unable to make wise decisions about their treatment. Essentially, this is a last resort to preserve life.
Even though most patients are ‘choosing’ to opt for treatment, they might feel deeply ambivalent about this decision.
They may feel terror about eating, and simultaneously, they may feel a sense of deep relief. The torture of starvation and relentless routines have been stopped by surrendering to an authority, which they wouldn’t have permitted themselves.
By ‘choosing’ to accept the help, this is an essential component of motivational approaches, to helpfully engage someone in the healing process.
In contrast, forcing someone into a corner rarely produces effective results – either downright rebellion or pleasing by ‘eating to get out’, to only relapse again.
Ideally, a hospital admission should be the last call, when outpatient therapy is inadequate, and someone is spiralling downwards.
Where possible, outpatient community support is preferable, to minimise life disruption and to encourage responsibility in recovery.
2. Types of eating disorders
In the USA, patients of all body shapes and sizes, with differing eating disorder diagnoses are treated together. I see much value in this approach.
As struggles with food can include all kinds of eating behaviours with the underlying core issues being similar. Body weight is irrelevant.
In the UK, it is usually only patients with anorexia nervosa that access inpatient hospital treatment.
This comes with its drawbacks. Anorexia is a deeply competitive illness, and placing many sufferers in one location can amplify competition and the sharing of dysfunctional food habits.
3. Beds
Historically, particularly in the pandemic, there were a distinct lack of hospital beds for eating disorder patients, meaning that individuals could be sent far away from their families and support system. This caused intense distress for everyone involved.
Now, at least in adult services, this is happening less. Patients should be able to access support geographically close to home. The speed of accessing the right support is still sometimes slow and arduous.
The aim is for someone to be assessed early-on, in their eating disorder journey and then offered therapy, dietetic support and risk management as an outpatient.
This enables the person to continue with education, work, structure and relationships.
To stay in touch with friends and the fabric of day-to-day life that offers belonging and meaning.
But sometimes an inpatient stay is the only viable option, when anorexia has a tight grip.
Sadly, too many people reach this stage due to late diagnosis and misunderstandings about eating disorders. This is slowly improving.
4. Pros and cons of inpatient treatment
Inpatient support can feel like the saviour, the helicopter rescue to safety, when lost in the depths of the jungle.
When someone is too unwell physically and entrenched in the coping of the eating disorder, they need the intensity and help that only inpatient can offer.
But it is not a magic pill or cure. Hospital can sometimes amplify positive identity issues around an eating disorder and expose people to learning unhelpful habits.
The inpatient stay offers 24-hour monitoring and rigorous support around eating and routines. Patients receive therapy, dietetic support and occupational health intervention. This can be transformative and life-changing, as skills are relearned.
The downsides of inpatient are also worth noting. The removal of people from the ‘normality’ of day-to-day life can result in them becoming institutionalised and the ed characteristics becoming entrenched.
Anyone who has experienced a lack of emotional or physical care in early life, may find the inpatient ward offering cosy, wrapped-up-in-cotton-wool type bliss as responsibilities are removed and care is deeply attentive.
Not to say that an inpatient stay is blissful by any means. It is hugely challenging on many levels.
Patients can feel simultaneously feel drawn to the care whilst also feeling over controlled and smothered.
5. Ward round
Ward round happens at least once a month for each patient, during the admission.
This is a time when all the professionals, family members and patient come together and meet, to review progress.
It can be taxing and useful in equal measure.
There is a pressure to show that treatment is working, to accelerate departure from the ward and to grant privileges.
It can be anxiety provoking and intense for patients, although not intended this way.
As a therapist, I would frequently attend to give therapy feedback.
I always enjoyed this opportunity to uplift and encourage my patients, as this experience could often become very weight numbers focused, as the barometer of worth.
6. Transition to the community and family support
Families are hugely important in the recovery process. Many patients return to their family home, post treatment.
It’s incredibly stressful for families to deal with a loved one struggling with anorexia.
The New Maudsley Animal Model (you can read more about this HERE) provides a framework to support loved ones to support helpfully. The model offers guidance within a framework of empathy, listening and encouragement.
In most instances, ongoing therapy and dietetic support was offered post discharge.
This was a crucial part of the journey, as it is an intense shock to move from a hospital environment to going-it-alone.
In preparation for discharge, patients would be given home leave and incrementally longer periods at home to adjust.
7. Hiding food, falsifying weight
Predictably, there are dramas and mishaps on an anorexia inpatient ward.
People with anorexia are adept at secretive exercise and the hiding of food. Food is covertly thrown out of the windows at mealtimes or hidden in handkerchiefs or up sleeves.
Secretive room pacing is not uncommon.
Frustrations can run incredibly high, as anorexia is a ruthless and unforgiving illness.
Patients sometimes falsify their weight by drinking copious amounts of water or hiding weights in their underwear.
People will sneak off the premises for walks, if they can get away with it.
8. Staff
Working in an eating disorder service can be incredibly stressful and overwhelming for staff.
The hours are long, and the patient dynamics can be complex.
Nursing staff often make up the bulk of the workforce on an inpatient ward.
Nurses don’t tend to get the therapeutic supervision, as therapists do. This means that they can be left emotionally exhausted and carrying a huge weight of responsibility.
Therefore, staff turnover is high and temporary staff often fill the posts. This can be extremely disruptive for patients in their continuity of care.
9. Conveyor belt
Thankfully, for most patients, one or two admissions is enough to support someone to shift and move beyond an acute eating disorder diagnosis.
Someone is not cured through weight restoration alone. It is an ongoing journey to heal and learn new ways of coping.
Although patients do receive therapy whilst on the ward, it is likely that they will need ongoing support post admission or later.
Some patients do end up having multiple admissions; they may experience mixed feelings about this.
The inpatient ward can offer a familial safe haven to escape to, when life feels overwhelming, and the ward can feel over-controlling and prison-like.
It’s often not helpful for someone to have too many hospital admissions, as they can become institutionalised and disconnected from real life.
For a minority of people, they may live a life with chronic anorexia nervosa, in the community, but managing symptoms and receiving GP support.
Do you relate?
Have you had experience of treatment within an NHS inpatient eating disorder service?
Have there been particularly positive or negative experiences you have had?
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