Eating Disorders Service Inpatient Unit National Services

National Services
Eating Disorders Service
Inpatient Unit
Providing expert assessment, treatment and management of eating
disorders for more than 25 years.
South London and Maudsley NHS Foundation Trust
» I have experienced many therapeutic approaches in the history
of my illness. I think I now have an understanding of why, but
understanding does not lead in itself to change. Only through
having cognitive behavioural therapy, which focuses on my
actual behaviours and the irrational thoughts behind them, has
the process of change been able to begin. « Jennifer, 24
Cover illustration by a patient in the Eating Disorders Inpatient Unit, 2010
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National Services: Eating Disorders Service, Inpatient Unit
Contents
Service overview
4
Our philosophy
5
Who is our service for?
6
Interventions
8
Outcomes
16
Research
18
Our facilities
20
Our team
22
Training and consultancy
28
Case studies
30
Referring to our service
34
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South London and Maudsley NHS Foundation Trust
Service overview
The Eating Disorders Service is a specialist facility for people who have anorexia nervosa, bulimia
nervosa, binge eating disorder or mixed eating disorder symptoms. Our unit provides a safe
healing space where people can explore their difficulties and gain control over their eating
disorder, working one-to-one, within a group and as part of their family.
A wide range of evidence-based care packages are available,
and can be tailored to suit specific needs. The agreed
therapeutic aims will vary, but may involve gaining weight and
establishing regular eating patterns.
An important part of our work involves family members and
carers, helping them come to an understanding of eating
disorders, their likely causes and their consequences. We also
offer an extensive programme of training and consultancy for
eating disorder professionals, voluntary workers and teams.
» The reflection groups after
dinner helped me to de-stress
and let go of any problems
or issues. « Megan, 19
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National Services: Eating Disorders Service, Inpatient Unit
Our philosophy
The Eating Disorders Service is a leading centre in the clinical management of eating disorders and
professional training. We address life-threatening issues and deliver a service that is focused on
the person, working with each individual to match a treatment package to their stage of recovery.
We recognise that having an eating disorder, and experiencing
the thoughts and feelings that go with it, can be extremely
confusing and distressing. Our psychological therapies are
focused on providing a space where people can begin to
make sense of what has happened to them before they work
towards change. Above all, we aim to empower people by
giving them the skills they need to live a more fulfilling life.
We strive to:
›› Provide a clinical service that is based on the best
available evidence, taking into account the needs and
wishes of all concerned
›› Work in partnership with all relevant parties to help
a person achieve recovery from their eating disorder,
maximum wellbeing and any other appropriate
treatment goals
›› Disseminate knowledge and skills to people with eating
disorders, their families, healthcare professionals and other
relevant parties
›› Work towards improved treatments and care through
research and auditing
» It wasn’t until my daughter
was undergoing treatment
through SLaM that I
felt valued as a carer.
Previously, it was a struggle
to be listened to, to get
any support, and to get
appropriate help for my
daughter. The service has
been wonderful and the
collaborative care approach
is excellent. Thank you! «
Joan, carer
Our unit is active in research and development across all aspects
of eating disorders treatment, biology and clinical problems.
We have won an NHS Innovation Award for developing
methods of administering treatments for anorexia nervosa.
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South London and Maudsley NHS Foundation Trust
Who is our service for?
The inpatient unit admits people who are diagnosed as having an eating disorder according to ICD
10 criteria. Referrals are accepted from consultant psychiatrists, subject to funding agreements.
» At times, when this illness
shattered and destroyed any
kind of relationship within
my family, therapy slowly
helped pick up the pieces
and start to put them back
together again. The staff are
so experienced and never let
you give up the battle against
anorexia, which only sets out
to kill its victims. « Rachel, 21
6
Eligibility
››
››
››
››
››
››
››
››
››
18+ years
Female
Low weight, need for refeeding
BMI <15
Need to meet the diagnostic criteria for severe
anorexia nervosa and related conditions
Formal and informal clients
Physical complications associated with rapid
weight loss including unstable biochemistry
Eating disorders not otherwise specified
Support from local CMHT care co-ordinator
and local consultant psychiatrist
Exclusion
›› R
isk assessment may exclude those with
moderate or severe learning disabilities, severe florid
psychosis, or a forensic history
›› Obesity
National Services: Eating Disorders Service, Inpatient Unit
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South London and Maudsley NHS Foundation Trust
Interventions
Following the initial assessment and admission to the ward,
people may participate in group work, family work and
tailored therapies.
There are a number of groups and therapy sessions
available, including:
››
››
››
››
››
››
››
››
Assessment of daily living skills
Cognitive behavioural therapy (CBT)
Cognitive remediation emotional skills therapy
Collaborative family work and carer support
Dietetic support and nutritional rehabilitation
Group work
Motivational enhancement therapy
Occupational therapy
Groups and sessions
A range of individual treatments are available alongside a
comprehensive group programme. Patients are encouraged to
attend groups, occupational therapy and psychological therapies
throughout the day when they are a resident on the ward.
Assessment of daily living skills
Assessments are performed in two parts by members of the
psychology team. The first part involves a set of psychological
tasks that assess cognitive style, which helps the team to
define specific problems and work on solutions. The second is
an interview to explore current circumstances, the history and
events leading up to admission, and to understand difficulties
and future goals. The person may be asked to complete a
short questionnaire. Some tasks or questionnaires may be
repeated closer to discharge to monitor changes over the
course of the admission, and to help plan the transition to the
next stage of treatment.
Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy is recognised as one of the most
promising treatments for eating disorders (National Institute
for Clinical Excellence – NICE, 2004). It is also highly effective
in the treatment of a number of other psychological disorders,
including depression, obsessive-compulsive disorder and anxiety.
CBT is an active, short to medium term psychological therapy
that focuses on understanding the link between thoughts,
feelings, physiological state and behaviours. In treating eating
disorders, our patients are encouraged to become aware of
unhelpful patterns of thinking and behaviours that maintain
their eating disorder. By understanding patterns, they can work
towards changing unhelpful thoughts and, in turn, change
feelings and behaviours. CBT also addresses a person’s core
beliefs about themselves and the world, and each person is
encouraged to set goals. This therapy is offered in a one-to-one
or group setting.
Cognitive remediation therapies
Through this innovative therapy, we aim to give our patients
the skills and understanding they need to challenge less
flexible behaviours and thinking styles, which can make
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National Services: Eating Disorders Service, Inpatient Unit
engaging with recovery difficult. This therapy incorporates a
series of puzzles, cognitive exercises, discussion and reflection.
The emphasis is on thinking processes and style, rather than
the content of thoughts. It is offered in a one-to-one and
group setting.
Collaborative family work and carers support
Our service has pioneered innovative ways for clinicians to
work with the families and carers of people with eating
disorders. The Collaborative Care New Maudsley Model,
begins with the premise that no one is to blame for the
illness, and that collaborative working between parties is
the most helpful way to challenge it. Through a variety of
skills-based interventions, we share our understanding of the
impact of the illness on the person and their family or carer,
before experimenting with alternative responses to address
the behaviours that the person may have adopted. We offer
individual and group family work. We also run a facilitated
carer support group, and offer outreach support for families.
Dietetic support and nutritional rehabilitation
The ward programme is supported by a specialist dietician,
who works closely with our catering service to ensure the
food we provide is suitable for re-feeding in the early stages.
A range of options are provided to cater for food preferences,
nutritional rehabilitation and weight restoration. We cater for
the needs of vegetarians, vegans, people with special food
requirements for religious and cultural reasons, and special
medical diets. The dietician also meets people individually to
discuss their food needs, and support them as they gradually
take more responsibility for feeding themselves.
Group work
An extensive programme of group therapies is offered on the
ward. Separate groups cover self esteem, relapse prevention,
flexibility, diet, anxiety management, compassion, relaxation
and body image. All patients are encouraged to attend
groups, and homework is often completed between sessions.
Motivational enhancement therapy
Motivational enhancement therapy is an evidence-based
treatment that incorporates the behavioural change strategies
outlined in recent NICE guidelines, including; outcome
expectancies, personal relevance, positive attitude,
self-efficacy, descriptive norms, personal and moral norms,
intention formation and concrete plans, behavioural contracts
and relapse prevention.1 The aim is to support people in
identifying the problems they are facing that could be
changed. People are also encouraged to explore and increase
their motivation to make these changes.
Occupational therapy
A wide-ranging and varied occupational therapy programme
is available. We offer aikido, digital photography, drumming,
karaoke, organic kitchen, pottery and textiles. Occupational
therapy provides people with an eating disorder the
opportunity to explore and develop their interests, and set
practical and healthy goals. We encourage group activities
where people can interact with others, which assists with
building and developing social skills.
1National Institute for Health and Clinical Excellence (NICE), Behaviour change at population, community and individual levels (NICE Public Health Guidance, London, 2007).
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South London and Maudsley NHS Foundation Trust
Weekly programme
TIME
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
06.00 – 07.30
Weigh in
Weigh in
Weigh in
Weigh in
Weigh in
Weigh in
Weigh in
07.30 – 07.45
Medication
Medication
Medication
Medication
Medication
Medication
Medication
07.45 – 08.30
Breakfast
Breakfast
Breakfast
Breakfast
Breakfast
Breakfast
Breakfast
08.30 – 09.30
Rest period
Rest period
Rest period
Rest period
Rest period
Rest period
Rest period
Local ward /
management
round
09.30 – 12.00
Community
meeting
09.00 – 09.40
National ward /
management
round
09.30 – 12.00
Community
meeting
09.00 – 09.40
Activity time 09.00 – 10.00 10.00 – 10.15
Snacks
Snacks
Snacks
Snacks
Snacks
Snacks
Snacks
10.15 – 10.35
Rest period
Rest period
Rest period
Rest period
Rest period
Rest period
Rest period
Craft group
10.30 – 11.30
Relapse
prevention
group
10.15 – 11.15 11.40 – 12.00
Medication
Medication
Medication
Medication
Medication
Medication
Medication
12.00 – 12.45
Lunch
Lunch
Lunch
Lunch
Lunch
Lunch
Lunch
Rest period
Rest period
Canteen group
12.00 – 13.00
12.45 – 13.45
10
Rest period
Rest period
Rest period
Rest period
Rest period
Relaxation
12.45 – 12.50
Relaxation
12.45 – 12.50
Relaxation
12.45 – 12.50
Relaxation
12.45 – 12.50
Relaxation
12.45 – 12.50
National Services: Eating Disorders Service, Inpatient Unit
» Practical and emotional support was given, and we
were encouraged to support each other. « Aisha, 20
TIME
MONDAY
TUESDAY
WEDNESDAY
Body image
group
13.15 – 14.30
Retreat group
13.00 – 14.00
Dietician’s
group
13.00 – 13.50
THURSDAY
FRIDAY
Aikido
14.00 – 15.00
Swimming
14.00 – 15.00
Flexibility
or emotions
group
14.00 – 15.00 SATURDAY
SUNDAY
Activity time
13.00 – 14.00 15.00 – 15.15
Snacks
Snacks
Snacks
Cooking group
15.00 – 19.00
Snacks
Snacks
Snacks
Snacks
15.15 – 15.35
Rest period
Rest period
Rest period
Rest period
Rest period
Rest period
Rest period
Worry group
15.30 – 16.30 17.30 – 18.00
Medication
Medication
Medication
Medication
Medication
Medication
Medication
18.00 – 18.45
Dinner
Dinner
Dinner
Dinner
Dinner
Dinner
Dinner
18.45 – 19.45
Rest period
Rest period
Rest period
Rest period
Rest period
Rest period
Rest period
19.00 – 19.30
Shift reflection
group
Shift reflection
group
Shift reflection
group
Shift reflection
group
Shift reflection
group
Shift reflection
group
Shift reflection
group
22.00 – 22.15
Snacks
Snacks
Snacks
Snacks
Snacks
Snacks
Snacks
22.15 – 22.35
Rest period
Rest period
Rest period
Rest period
Rest period
Rest period
Rest period
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South London and Maudsley NHS Foundation Trust
Our care model
FAMILY AND CARERS
›› Skills-based training in caring for a loved
one with an eating disorder
›› Joint understanding of the illness
›› Understanding medical risks
›› Basic facts about the eating disorders
EDUCATION, VOCATIONAL
OPPORTUNITIES
›› Support to achieve or continue
with further education
›› Support to start voluntary
work during admission
PATIENT
RISK MANAGEMENT
›› Maintaining medical needs
›› Routine blood investigations
›› Understanding of blood results
›› Psychological and physical
risk management
›› Discharge planning
›› Recommendation for managing
the illness in the community
›› Appropriate use of MHA, MCA
and DOLS legislation
›› Gentle re-feeding and
weight restoration
›› Developing a new language to
communicate emotional needs
›› Developing an independent life,
away from the illness
›› Support to develop social skills
›› Reintegration into community
›› Experimental home leave
›› Attention to spiritual needs
ASSESSMENT
›› Multidisciplinary formulations
›› Neurological assessments with feedback
12
THERAPIES
›› Psychological therapies
›› Occupational therapy
›› Problem solving techniques
›› Relapse prevention group
›› Body image group
›› Complementary therapies
›› Convalescence controlled exercise
›› Drama therapy
DIETETIC SUPPORT
›› Assessment
›› Individual diet plan
›› Dietetic group support
›› Consultations with the patient, and
family or carer about maintenance
and a discharge diet plan
National Services: Eating Disorders Service, Inpatient Unit
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South London and Maudsley NHS Foundation Trust
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» Cooking and canteen groups
have seriously helped me to find
confidence in eating socially, and
have allowed me to find a new
relationship with food. « Hannah, 18
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National Services: Eating Disorders Service, Inpatient Unit
Our care pathway
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South London and Maudsley NHS Foundation Trust
Outcomes
Our service aims to help people gain control over their eating disorder and enables patients and
carers to develop an understanding of eating disorders, their likely causes and consequences.
Expected outcomes include:
››
››
››
››
››
››
Weight restoration
Establishing regular and balanced eating patterns
A clarification of diagnosis
Stable biochemistry
Identifying and exploring underlying emotional problems
Improved psychological functioning
Our results
Graph 1 shows a comparison of the body-mass index (BMI)
of former inpatients on admission and after a three year
follow-up. Overall, people experienced an improvement in their
body-mass index (BMI) and eating disorder symptoms, which
remained present for as long as three years after admission.
Graph 2 shows the level of depression, anxiety and stress
experienced by patients on admission and discharge. All three
of these were significantly reduced on discharge.
Graph 3 displays results from our general health
questionnaire (GHQ) given to carers. GHQ measures the
general level of distress and anxiety experienced by carers
between the time of admission and discharge.
16
1.Patients’ BMI at admission 2000 – 2005
and 3 year follow-up
20
18
16
14
12
10
INDIVIDUAL
GROUP
TYPE OF FAMILY WORK
BMI admission
BMI 3 year follow-up
Average
National Services: Eating Disorders Service, Inpatient Unit
» The level of psychological treatment you can access is brilliant. «
2.Depression, Anxiety, Stress Scores (DASS)
Jo, 26
3.General Health Questionnaire (GHQ) for carers
40
20
35
30
25
20
15
15
10
5
0
DASS
TOTAL
DASS
DEPRESSION
DASS
ANXIETY
DASS
STRESS
10
GHQ
BASELINE
GHQ
3 MONTH
FOLLOW-UP
GHQ
3 YEAR
FOLLOW-UP
Admission
Individual family work
Discharge
Multiple family work
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South London and Maudsley NHS Foundation Trust
Research
Our unit works closely with the Institute of Psychiatry, King’s College London, on eating disorder
research. This means we are continually improving our understanding of these illnesses. By
finding out more about the causes of anorexia, bulimia and other eating disorders, we are able
to develop new and better treatments, as well as effective ways to support families and carers.
Our link to the Institute of Psychiatry allows us to respond to
the most recent research findings, and gives us direct access to
expert knowledge, consultation and training.
Ongoing research topics include:
››
››
››
››
››
Thinking styles and eating disorders
Males with eating disorders
Emotional and social understanding in eating disorders
Eating disorders: the environment and genes
Carers of people with eating disorders
For results of recent research findings, visit
www.eatingresearch.com.
» The ward saved my life and has
enabled me to achieve things I
never thought possible. « Leena, 18
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National Services: Eating Disorders Service, Inpatient Unit
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South London and Maudsley NHS Foundation Trust
Our facilities
Our inpatient unit is based at Bethlem Royal Hospital.
Bethlem Royal Hospital has a long history of providing the
highest quality care for people recovering from mental health
issues. The hospital offers the perfect therapeutic environment
for promoting recovery, set in 270 acres of green space, with
woodland and meadows that are designated as a ‘site of
importance for nature conservation’.
Facilities at the Bethlem include a swimming pool, art gallery,
walled garden, a chapel, nature walks and an extensive
occupational therapy programme, utilised by many of our
patients. This programme provides a wide choice of creative
20
activities, which gives people the opportunity to rekindle old
skills, learn from new experiences and build their confidence
on their path to recovery.
The inpatient unit has:
›› 17 beds
›› Two living areas
›› Dining area for meals and snacks
›› Kitchen for supervised cooking
›› Family rooms
›› Group and individual therapy rooms
National Services: Eating Disorders Service, Inpatient Unit
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South London and Maudsley NHS Foundation Trust
Our team
Our specialist team includes professors, psychiatrists, nurses, psychologists, occupational
therapists, health care assistants and administrators.
Our patients benefit from a multidisciplinary approach, and
the wealth of diverse skills that are on offer allow us to design
specialist care plans that are tailored to individual needs.
Each person has an allocated team, plus one-to-one care from
a primary nurse.
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National Services: Eating Disorders Service, Inpatient Unit
Key staff members
Professor Janet Treasure PhD, FRCP, FRCPsych
Director of the Eating Disorder Unit | Professor of Psychiatry
Professor Janet Treasure is a psychiatrist who has specialised in
the treatment of eating disorders for more than 25 years.
She is currently director of the Eating Disorders Service, a
leading centre in the clinical management of eating disorders
and training.
Other roles
Professor Treasure holds, or has held, the following posts:
›› Chief medical advisor for Beat, the UK’s primary eating
disorder charity
›› Patron of the Sheffield Eating Disorders Association
›› Fellow of Academy of Eating Disorders
›› Former Chair for the physical treatment section of the UK
National Institute for Health and Clinical Excellence (NICE)
Guideline Committee
Background
In 2007, Professor Treasure received an Eating Disorders
National Award from national eating disorder charity Beat.
She delivers information and training via DVD, face-toface workshops and seminars, for professional and nonprofessional carers. She has also developed an e-learning
module on motivational interviewing.
Research
Professor Treasure has been active in research and has over
150 peer reviewed papers.
In 1984, she was awarded the Gaskell medal from the Royal
College of Psychiatrists. In 2004, she was awarded the
Academy for Eating Disorders (AED) Leadership Award in
Research. The award honours an individual who has, over
substantial period of time, used research to develop new
knowledge about eating disorders.
In addition to her work with eating disorders, she has been
involved in treatment trials for people with type 1 diabetes
through cognitive behavioural therapy (CBT) and motivational
interviewing. She is also developing an intervention for
working with the carers of adolescents with type 1 diabetes.
Professor Janet Treasure has trained over 20 PhD students in
research on eating disorders.
During her career, she has edited seven academic texts on
eating disorders and authored three self-help books, including,
Getting better bite by bite on bulimia nervosa, Anorexia
nervosa, a survival guide for families, friends and sufferers, a
book for people with anorexia nervosa, parents and teachers,
and Caring for a loved one with an eating disorder: a skillsbased manual of the new Maudsley method, for families and
parents of people with an eating disorder.
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South London and Maudsley NHS Foundation Trust
Our team continued
Dr Kate Tchanturia PhD
Consultant Clinical Psychologist | Senior Lecturer in
Eating Disorders
Dr Tchanturia is the lead psychologist in the Eating Disorders
Service at the Trust. She is also module leader of the Mental
Health Studies Programme (women’s mental health module) at
the Institute of Psychiatry, King’s College London.
Other roles
As part of her work at the Institute of Psychiatry, Dr Tchanturia
supervises PhD students, DClin Psychology trainee placements,
dissertation projects and MSc dissertation projects. Since
2005, she has been chair of the specialist interest group in
neuropsychology at the Academy of Eating Disorders, the
largest international organisation covering eating disorders.
She has been a member of the Maudsley Forum organising
committee for a number of years.
Background
Dr Tchanturia completed her psychology training in 1982 and
gained her PhD in experimental psychology in 1991.
She is a Chartered Clinical Psychologist and member of
several professional bodies including The British Psychological
Society (BPS), the British Association for Behavioural and
Cognitive Psychotherapies (BABCP) and the Academy for
Eating Disorders (AED).
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National Services: Eating Disorders Service, Inpatient Unit
Dr Nadia Micali MD, MRCPsych, PhD
Consultant Psychiatrist | Clinical Scientist
Dr Nadia Micali is a consultant psychiatrist with the Eating
Disorders Service at Bethlem Royal Hospital.
She is also a clinical scientist for the National Institute for
Health Research (NIHR).
Other roles
Dr Micali is a member of the Academy of Eating Disorders and
an associate member of the Child Psychiatry Research Society.
For the past seven years, she has also been on the organising
committee for the Maudsley Forum, an annual course for
european and international psychiatrists run by the Institute
of Psychiatry.
Background
Dr Micali studied medicine in Italy before a year in France as a
clinical fellow.
She trained as a child and adolescent psychiatrist at the
Maudsley Hospital, where she specialised in eating disorders.
She then became a clinical lecturer in child and adolescent
psychiatry at the Institute of Psychiatry, where she completed a
PhD in child and adolescent psychiatry and eating disorders.
She has received a Young Investigators Award from NARSAD,
the international brain and behaviour research fund, and the
Margaret Davenport prize from the Royal College of Psychiatrists.
Research
Her current research interests include eating disorders and
pregnancy, and the risk factors of eating and feeding disorders
during adolescence, with a particular focus on longitudinal
research. She is investigating these risk factors as part of
the Avon longitudinal study of parents and children and the
Copenhagen county children cohort.
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South London and Maudsley NHS Foundation Trust
Our team continued
Lynn St Louis RN (Mental Health), MSc, CAT practitioner
Specialist Clinical Lead | Registered Mental Health Nurse
Lynn St Louis is the specialist clinical lead for the inpatient
Eating Disorders Service at Bethlem Royal Hospital. She
manages the clinical work, teaching and research of eating
disorders. She is responsible for liaising with referrers, primary
care trusts and commissioners. She also provides training,
supervision and organisational consultancy to the Trust and
external stakeholders.
Other roles
During her time at SLaM, she has worked alongside leading
professors and nurses in the eating disorders field. She has
played a key role in therapy groups run at the inpatient unit,
including motivational interviewing, cognitive analytic therapy,
CBT and psychodynamic therapy. Over the years, she has also
supported the team through the introduction of national
referrals and the development of care packages to meet the
needs of people with a severe form of anorexia nervosa and
complex personalities.
Background
Lynn has worked in the eating disorders field since 1986. She
opened outpatient and day care services for Croydon residents
at Bethlem Royal Hospital.
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National Services: Eating Disorders Service, Inpatient Unit
Lynn completed her master’s degree in mental health studies
in 2007. In 2002, she completed her diploma for the cognitive
analytic therapy practitioner qualification. She also completed
a development programme for women managers in the NHS
between June 1999 and February 2000.
Research
Her research interests include cognitive remediation therapy
and its application to people with anorexia nervosa on an
inpatient unit specialising in eating disorders.
Sue Greenwood
Administration Lead
Sue Greenwood is the senior administrator for the Eating
Disorders Service.
She provides a professional lead to administration staff
and develops, implements and reviews standards for good
administrative practice.
She co-ordinates all referrals to the inpatient service at
Bethlem Royal Hospital and liaises with commissioners and
primary care trusts to arrange funding for inpatient admissions
and assessments. She also arranges all CPA (care programme
approach) meetings for inpatients and co-ordinates the panel
reports for all national patients on a monthly basis.
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South London and Maudsley NHS Foundation Trust
Training and consultancy
We offer an extensive programme of training courses and consultancy in the assessment,
treatment and management of different aspects of eating disorders. These courses are suitable
for eating disorder professionals and teams, voluntary and professional groups and range from
basic to advanced levels or master classes. Bespoke training to suit different services or needs
is also available.
The purpose of the training is to enhance treatment
compliance with local teams, reduce relapse rates, enhance
the role of carers, and disseminate research knowledge and
skills to people and teams nationally and internationally.
For more information about available training, contact
Gill Todd on 07969 587 031 or email [email protected].
» All in all, I thought the service
was outstanding. The combination
of the programme and the team,
together, helped me face up to
the biggest battle of my life, and
set me on the road to recovery. «
Claire, 20
28
National Services: Eating Disorders Service, Inpatient Unit
29
South London and Maudsley NHS Foundation Trust
Anna
“Anorexia was a big part of my
life for nearly 10 years”
I got ill around the age of 16. So, when I moved out of
the family home and up to London, I went straight into a
hospital. It was a building block – it didn’t completely work
– but it was a start. I also had a few issues with drugs and
alcohol at the time... trying to cope with the anorexia.
Things then went downhill when I got my own flat.
Having my own place meant I could do exactly what I
wanted and it could go completely unnoticed.
“I didn’t want to go back home
again though, as that’s where my
problems started”
I’m trying to think what happened. I made enquiries
myself... I knew things had gone downhill, so I got
in touch with the Bethlem and saw a social worker
for a few outpatient appointments. Motivational
Enhancement Therapy sessions brought lots to the
surface, but I probably wasn’t ready at the time and my
weight dropped further.
Actually, I wasn’t at my lowest point at that stage, but I
agreed to an admission for a few months to focus on my
weight. Then I joined the day-patient’s service and was
back in the community again.
30
“I was struggling on my own though”
I went downhill again, quite a lot, so the second time
around I was sectioned under the Mental Health Act. It
was a relief in a way – the decision had been made for
me – but it was a tough time. I was high on the outside
when I wasn’t eating, and of course I didn’t want to lose
that high when I started eating and putting on weight.
At that stage, if you’d given me an inch I’d have taken
a mile. I was in a bad headspace and had already made
a few suicide attempts, so the Bethlem was the safest
place for me. You know with kids and boundaries?
They make out they don’t like them, but they do need
them. I needed strict guidelines... you then know what’s
expected of you.
I was there for a year this time and did lots of
psychotherapy. When I came out, I was in contact with
day-patients... my weight was still a little low, but steady.
“I’d really had enough of feeling ill”
Eight months later, I went back to the Bethlem
voluntarily. I did more CBT, which focused on challenging
the kinds of beliefs I had about myself. I also agreed to
some work with my family. I knew this part was going to
be the hardest to deal with, but it was the thing I needed
to work on.
National Services: Eating Disorders Service, Inpatient Unit
Being around my family – and my early experiences
with them – was affecting how I viewed myself. I’m
not saying that all of this was down to them, but I do
think the experiences had a role to play in me staying
ill. I remember one psychologist saying that I was like a
square peg trying to fit a round hole in my family. And
that’s really how I felt.
“The family work was going to happen –
with or without me”
Now I’ve got a really different structure to my life and
have had a job for nearly two years. Work is one of the
things that really helped me to take a big leap forward
– I don’t even remember when food stopped being my
primary impulse.
“I know the decision to ask for help is hard,
because your biggest fear is to put on
weight, lose control and get fat”
I did feel a bit trapped into the family work at the start
– the idea of sitting in a counselling room with them felt
like hell – but in my heart I knew I had to do it... and I’m
so pleased I did.
With anorexia though, there’s nothing to lose. In my
case, the further downhill I went, the more trapped I
realised I was getting. And that’s when the benefits of
help really start to outweigh the negatives.
Staff at the Bethlem knew the relationship with my
family was a difficult one, so it was introduced gradually.
We started with me and my dad; then with my sister;
then we had a three-day family session. The days were
really intense and lots of stuff came to the surface, but
it could all be expressed in a contained environment – it
was clear that all hell wasn’t going to break loose.
I’ve had a mixed relationship with the Bethlem really.
I really struggled being there at times, but it was the
safest place for me to be. They always work towards you
coming in voluntarily, which means you’ve got more of
a choice.
Lots of change came from doing this family work.
And there really is no way I would have done it off my
own back.
I owe a lot of gratitude to the place. I may have given up
on myself at times, but they never did.
“It’s taken a long time, but now I’m very
removed from being ill”
The staff at the Bethlem really got to know me well
and knew a way to work with me and my family. It was
tough at the time, but it worked. I’ll probably never be
as I was before I became ill... but we all have our own
idiosyncrasies, don’t we. It’s OK.
31
South London and Maudsley NHS Foundation Trust
Melanie
“Anorexic... me? No way”
Thin, yes. But anorexic, never. I was a dancer.
With hindsight, I think I’d been ill for a long time, but at
the time I wouldn’t be told. I ducked, dived and lied...
anything to keep out of hospital. Admitting something
was wrong would be admitting failure and I didn’t want
that. I wanted to be perfect.
My first contact with services was when I was 16. The
problems started long before then, but I quickly learnt to
hide and cover up the illness I refused to be associated
with. This went on for years. I ran from services, never really
committing, but I grew tired and was struggling to cover
things up. A friend took me to outpatients in October, and
that November I had an emergency admission.
“It all seemed so drastic – so extreme
and unnecessary”
I still didn’t want to give in... didn’t want to admit
anything. I thought I could persuade everyone – the
doctors, nurses, my family and friends – that I didn’t have
a problem. I certainly didn’t need to be locked away.
It wasn’t working though and I lacked the energy to
fight. I agreed to a voluntary admission because a section
was the only alternative. My new plan: I’d put on weight
and leave a.s.a.p. I was still in control.
“I wasn’t sick like the others”
32
The first couple of months felt like a daze. I wondered
‘why am I here?’ I’d been holding down a good job in
the City before, travelling into London every day. I felt
lucky in comparison to the others and didn’t feel I had
the characteristics of someone I’d associate with an
eating disorder.
I hated it. I hated the system. I hated that I had no control.
I felt the whole unit – the staff, the other patients, the
rules – were against me. I resented being kept there. I
resented being trapped with no space to breathe. And this
resentment pushed me into trying to break and dodge the
rules. It was a long time before I realised I needed to put
something into the programme myself.
“They work damn hard to get people out
of their traps, but it takes time to build
up trust”
As soon as I changed my approach, the staff gave me
the support back ten times over. The combination of
people there is really helpful. There’s someone to talk to
anytime day or night if you need it.
It was a good while before l started to talk about things
that weren’t just all rosy though. I’ve always been social,
but didn’t speak about anything too deep. One nurse
kept prodding. She was the worst... the strictest... I used
to avoid her. She didn’t stop, so I started with one or two
things from under the exterior. Actually, I trusted and
respected her and some difficult things started coming
out. That’s when I felt others started understanding
where I was coming from.
National Services: Eating Disorders Service, Inpatient Unit
I was also speaking to a psychologist on a regular basis,
which was really useful. I hadn’t spoken to someone
regularly like that before. I was developing self-awareness,
understanding and skills to equip myself with healthier
ways to cope.
“We were all going through our
own journeys”
Talking was starting to help, but I was emotional and
upset and couldn’t see why. I was always busy before, so
I never had free time like I did there. I had nothing and
that was hard to cope with.
Art was suggested as part of the occupational therapy
programme. At first I thought the idea was patronising,
but then started to enjoy it. It kept me grounded and
away from the compulsion to exercise. It gave me a
purpose and I started to feel more like a person than an
illness in other peoples’ eyes.
“The friends I made there got me through”
I think I just wanted to make others better at first, but I
started focusing on myself and it got to the point where I
was extremely vulnerable.
It was horrendous opening up actually. I was speaking
about things I never wanted to address. I’d shoved
these things in the deepest closet, right at the back.
Before, when I was upset, I didn’t eat so I could control
the situation. It’s draining going through your own
experiences, but if I hadn’t my problems would have
remained. I built up a good relationship with the others
and still meet up with them today.
“I have a different philosophy now”
Since leaving, I’ve been working as an intern at Crisis,
the national charity for homeless people, which I love. I
have a boyfriend; I’ve been on several holidays; I’m doing
an art A-Level this year, and have applied to university.
I’ve changed my priorities a lot. I had a very rigid career
path before, driven by money, success and prestige. I was
doing well on paper, but life’s too short for all of that.
I’ll always be me: someone who’s passionate, energetic
and not happy just doing a nine-to-five job. But I’m more
laid back now. I don’t need such a structure or plan. I’m
focused, but it’s channelled in a different direction.
“Without the admission, I’d still be running
down that same road”
I didn’t always agree with the people there – so much
felt unfair and there was so much I couldn’t understand
– but I realise now that it had to happen. I could have
died and the service gave me the courage to pull myself
out. It was the catalyst to take stock, draw a line under
the past and start over.
It was the hardest thing I’ve ever had to do.... it really tore
me apart. But they didn’t leave me in a mess. They pulled
me back together and made me stronger than ever.
I had to go through that situation. I needed that group of
people and was really lucky I went through it all with so
much help. Amazing.
33
South London and Maudsley NHS Foundation Trust
Referring to the unit
Referrals are accepted from NHS consultant psychiatrists.
All referrals to the inpatient service
require funding authorisation from
the relevant primary care trust.
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Eating Disorders Service
Inpatient Unit
Tyson West 2
Bethlem Royal Hospital
Monks Orchard Road
Beckenham BR3 3BX
A2
Bethlem
Royal
Hospital
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T: 020 3228 4402
F: 020 3228 4995
[email protected]
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Printed on Soporset by Crucial Colour
Photography: David Hares Design: Piers Rutterford
Published: March 2010
Eating Disorders Service
Inpatient Unit
Tyson West 2
Bethlem Royal Hospital
Monks Orchard Road
Beckenham BR3 3BX
» The aim is simple; to help
each patient with their
recovery, using the most
current, evidence-based
therapies available to
us. Our eating disorders
service strives to provide
treatment to people at all
stages of their illness. «
Professor Janet Treasure