Hospitalisation and Recovery from Anorexia
Reflections on inpatient treatment for anorexia
Posted Dec 31, 2011
For some people, starting to eat more again isn't enough, the weekly or twice-weekly support of a therapist isn't enough, even an all-day outpatient programme isn't enough, and a period of hospitalisation is the only way to recover from anorexia. For many such people, this fact becomes clear only after several failed recovery attempts on their own or with some form of outpatient or daypatient support. For some people, weight loss is so dangerously rapid and/or extreme that inpatient care is quite clearly the only safe option (though safety is of course only relative).
Hospitalised treatment of anorexia may occur on a ward in a general hospital or in a specialised eating-disorders unit. In either case, the primary point - the major advantage as well as potential disadvantage - is that the control over what is eaten is taken away from the patient and is in the hands of the professionals who are entrusted with that patient's recovery.
The advantages of this shift of control over recovery from the patient to professional medics are obvious: as I've discussed in a recent post, at a critically low weight, refeeding is often uncomfortable, and can be dangerous, and medical guidance through the first difficult days and months can therefore be invaluable. Nutrition can be tailored to minimise the risks and unpleasantness of the side-effects of refeeding the body, and help is at hand if anything goes wrong. Psychologically, there are people to whom one is accountable in a direct and continuous sense, and there are also other sufferers with whom one may be encouraged to share experiences (difficulties, fears, questions, progress) in group sessions. (For discussion of an interesting little incident that happened when I took part in such a session as a recovered guest contributor, see here.)
On the other hand, this loss of control - such a great contrast from the high but illusory level of control the illness gives you - might be problematic. It bears no resemblance to the life which will have to be led once out of hospital, and the transition - even if made gradually through day-care treatment and shorter therapy sessions - does prove too much for some people to cope with successfully. Emerging back into the world of kitchens, supermarkets, restaurants, cookery shows, recovered in the sense of having reached a healthy weight, but being long unpractised in feeding oneself, it may be difficult to maintain weight, because that requires extending and transforming the motivation cultivated in the hospital setting to the radically different context beyond its walls.
The relationship between physical weight and mental health is something I've discussed in detail elsewhere (for instance, here and here), and can seem the cruellest of anorexia's chicken-and-egg paradoxes: mental recovery cannot occur unless weight has been regained, but regaining weight requires a certain degree of mental recovery. Inpatient treatment initially takes some of the sharpness from this paradox: as long as the decision can be made to follow, and keep following, the appropriate programme of treatment, the regaining of weight can proceed with less constant testing of psychological resolve than occurs with outpatient treatment or therapy. But the sharpness returns with the end of the treatment, when it may become clear that psychological progress has not kept pace with the physical. Of course, in any recovery process the two take turns to rush ahead and lag behind, but the narrower confines of the clinic may encourage more lasting differences in pace. This may be one reason why evidence for the efficacy of inpatient as compared to outpatient treatment is equivocal (see e.g. Madden et al., 2015; though the more significant reason may be that little research has been done, and none seems to have been done that even attempts to take into account the complexities of individual variation.)
However much assistance work is done in terms of tackling ingrained thought patterns and behaviours; finding beneficial strategies for changing attitudes to weight, shape, and other aspects of body image; practising shopping and cooking, and so on - living independently is impossible to practise fully on an eating-disorders ward. The presence of other ill people can also be a hindrance rather than, or as well as, a help: anorexia is in most people a competitive illness, whether the competition is primarily against oneself or others, and where many sufferers are brought together, deceptive tricks to avoid eating and avoid being accurately weighed can be shared instead of instructive reflections on illness and recovery. This can kill motivation as effectively as anything in the world, so that patients become victims or prisoners rebelling against their guards - even their torturers - rather than appreciating their doctors, nurses, therapists for the life-giving help those people wish, and are able, to give.
This was what always horrified me most about the idea of inpatient treatment: the other people. I've not written at length on this subject before because I never felt quite qualified to, not having experienced any time in hospital myself. But the threat of hospitalisation was made by my parents several times, most notably on my 21st-birthday skiing trip, when we struck a bargain that I would avoid being flown home to hospital, curtailing my year abroad in Germany, by embarking on a concerted programme of weight gain on my own. As I've mentioned before, for me, hospitalisation would have felt as much of a failure as uncontrolled weight gain: my aim was always to balance on the knife-edge of survival, never compromising my strength or my mental faculties quite enough to bring upon myself the demeaning experience of being practically force-fed back to something nearer health.
This attitude of mine, unarticulated though it was, did I suppose make inpatient treatment unnecessary for me, because now and then it galvanised me into actions determined (or desperate enough) to remove me from the most urgent danger. After the first summer of rapid weight loss aged sixteen, I only ever lost weight gradually, almost imperceptibly even to me, and this meant that the physical damage was somewhat limited, and I continued to be able to live a minimal life: walking, cycling, sleeping, and above all working. Those whose bodyweight drops more quickly or is more unstable, or for whom the threat of hospital is less fearful a spur, are more likely to be completely incapacitated by illness, and to find hospital treatment more unavoidable an option. But of course that treatment I avoided by repeated hair's breadths might, of course, have helped: it might have made the cycle of improvement and relapse repeat itself fewer times. It might have stripped me, sooner, of some of my many delusions.
It's also important to remember that the dangers involved in inpatient treatment that I've speculated about here are only potential, not inevitable, and must be weighed up against the inevitable, unquestionable dangers of remaining ill and remaining unable to increase one's bodyweight. The benefits of living for a substantial period with a routine that is no longer anorexic, and of regaining weight swiftly but stably enough to ensure physiological damage begins properly to be reversed, are real and immeasurably valuable. It is also, of course, a great privilege to be able to choose to accept professional help to eat more, and for the food - and the help - to be there for the taking.
This may not seem like a particularly fitting New Year's Eve post, but a recent reader's question has made me think about it, and I thought it actually not unsuited to being broached at the end of one year and the start of another. To achieve true recovery from anorexia, it is necessary to confront all sorts of things about oneself, about one's life or what is left of it, and about the nature of one's illness. If your weight is critically low and you feel unable to do anything about your condition on your own, seeking inpatient treatment may be the wisest and kindest thing you ever do, for yourself and for others, and the beginning of a new year may be an easier time than others to make this decision.
There are always ways round the difficulties and potential problems of such treatment: one key fact to bear in mind is that with physical recuperation, with the regeneration of the body and brain, comes inevitably some degree of mental and emotional recovery. This is never really believable before it happens, because starvation keeps the mind turning in the same old circles that deny the possibility of change, let alone through something as mundane as more cake. But you only have to look at the Minnesota Starvation Study volunteers to see what undernutrition does to cognitive-emotional functioning - and what tortured knots refeeding undoes.
And finally, as I said earlier, the control that you have as an anorexic is a hollow sham: while you are ill, you are in the grip of an illness that controls you and robs you of your individuality. Relinquishing that illusion, staring your loss of control in the face, and willingly placing control in the hands of those who are trained to help, can be a daring, admirable, and life-giving act.
Why not at least ask yourself the question? Your reasons for concluding yes or no will be just as important as the answer.
Madden, S., Hay, P., and Touyz, S. (2015). Systematic review of evidence for different treatment settings in anorexia nervosa. World Journal of Psychiatry, 5(1), 147-153. Full text here.