Would you have known I was anorexic if you saw me in the street?
I don't know how to judge that. Am I supposed to say yes or no?
- I don't know. - I want you to say yes.
If you say "I didn't,"
then I would just stop eating again, until you say yes.
So that's why I'm not going to answer that.
- I know, I noticed that. - I don't want to play that game.
- Yeah, it's a game. - Just by having this, you know, fleeting encounter,
I've sort of been...
..sucked into this psycho drama.
Things that would be ordinary conversations, suddenly are charged.
You know, I might say something that could make your illness worse.
You could say something that could stop me eating for a week.
You could say something that will stop me going out for a week and not
realise you said it, but that's not your fault.
I'm the one with the problem, not you.
I've been spending time among people afflicted by a most mysterious
and sometimes fatal mental disorder.
Anorexia, a pathological fear of eating and gaining weight.
I can't see a future.
- Why? - Because I don't think I'll be alive long!
I was hoping to get some insight into its causes.
How it affects patients and families.
- SHE SOBS - Sh, sh, sh.
And, with a bit of luck, some understanding of a way out.
The only way is up now and you're in the right place.
Yeah.
At Saint Ann's Hospital in North London, I was on Phoenix Wing.
An inpatient ward for people with eating disorders.
Hi, Rosie. How are you?
I'm good.
A dentist's assistant,
Rosie had admitted herself for treatment three months earlier.
What's it like being here?
- BACKGROUND: - Prison!
"Prison", someone said!
Yeah, pretty much.
- Prison. Kath... - Did you mean that? - Yes, she did.
She did.
Yeah, like, it's definitely military, like, very time-consuming.
Yes, there's a routine.
- It's a structure. - It's a strict schedule.
That's your schedule, is it?
- Yeah. - It starts around 8:30am.
We had breakfast and then we had snack - is 10:10am till 10:25am.
And then from half eight till half nine we have supervision period,
which is taken in the lounge.
Toilets are locked, as well.
After mealtimes?
During mealtimes and after for that half-an-hour period.
Some of us are on one-to-ones,
which means, after supervision, when you do go to the toilet,
a member of staff will come in that toilet with you.
Because they've got to make sure you're not just eating the meals
- but keeping... - Them down. - Keeping them down.
- Yeah. - And so with you it was more a case of, sort of,
not eating food in the first place?
Yeah, I got a thrill out of... Not eating, starving myself, yeah.
Just skipping meals, just because I didn't think it was necessary.
- Really? Did you say you got a thrill out of it? - Mm.
Would you call it a thrill?
Now, looking back on it, no, but at the time, yeah.
I suppose I'm curious to know how long you've been ill.
That's one question I have.
- I would say the illness started in October of last year. - Uh-hm.
It got to Christmas and I still was in denial how much I was losing,
but everyone around me was like, "You're losing a lot now,
"we can see it." And then February, just went crashing down.
I lost all physical movement.
I couldn't walk, I was crawling up the stairs,
I was having to get my dad to carry me up the stairs.
I lost eyesight, I lost my hearing.
In late February, we're talking?
- Yeah. - Due to malnutrition, basically.
You can lose your eyesight and your hearing because of diet
- and lack of food? - Yeah.
If I didn't come in that day, I could have died.
I was nearly at cardiac arrest.
And you've been living here ever since.
- Yeah. - As an inpatient, but going home at weekends.
Yeah, I do do overnights and weekends at home.
When I get weighed on the Monday and Thursday, I feel happy that I'm
putting on, but it does scare me, like, I don't want to...
If I'm being honest, I don't want to come out of here
and then get to the point where I'm overweight.
And obviously I've got a target to aim towards.
So I never want to go over that because then I'll freak out.
Hello.
Every fortnight, doctors and therapists meet
to discuss their patients' progress and monitor their weight.
I was meeting Rosie's team.
That's a graph of Rosie's weight, is it?
- Yes. - Basically. And it's dropping precipitously until a certain point.
And what does that point represent?
I think the lowest weight on that weight chart is where we...
At the point of admission.
So, she was dropping weight at quite a rate
when she was an outpatient.
So you could see that there was a need for a change of approach?
What is the line that's going off at a steeper angle...
Steeper gradient?
So, the bottom line is half a kilo weight gain a week,
so generally if people are falling within the two lines,
then the rate of weight gain is what we would expect.
Right. And that's interesting, isn't it?
Because she's hugging that lower benchmark amazingly closely,
almost as though she's sort of deliberately doing the minimum
- acceptable weight gain. - Even yesterday, after the session,
she said to me, "Sometimes I still don't believe
"that I've got this illness."
Inpatient units like Phoenix Wing cater
to the most serious cases of anorexia.
What's your name?
- Ifzana. - Louis. - Nice to meet you.
The condition has been on the increase in the UK,
amongst women and men, whether because of fashion images,
social media or other more complex reasons.
Have you done inpatient recovery of this sort before?
Oh, yes. I'm a veteran.
OK.
Treatment revolves around a timetable of three meals
and three snacks every day, all strictly supervised.
I don't particularly want to eat this cake and ice cream
but I know that I have to. It's part of my treatment.
Patients also receive therapy and classes in shopping for
and preparing food, to help them build a healthier relationship
with eating.
Are you aware that you need some fats in your diet?
The aim is for patients to regain their weight
and return to living in the outside world.
At a clinic in West London, called Vincent Square,
I was meeting a daytime patient called Jess.
- How's it going? - Hiya. - We met very briefly before, didn't we?
- Yeah. - Louis.
- Jess. - Am I all right here?
Yeah, of course.
Jess had been in treatment for nine years.
Joining us was her nurse, James Kelly.
So how long have you been here?
I've been here just over a year.
A year last week, I had my anniversary.
- How old are you? - I'm 27.
- 27. - 28, next week.
And when did you first get diagnosed?
I was 19.
OK.
Jess, is it the last six birthdays you've spent in hospital?
- Yeah, last five. - Last five. - Yeah.
And this kind of pattern of kind of going round again has been your life
for the last five, six years.
What's your sense of how Jess is doing?
Things are slipping and deteriorating kind of physically.
- Jess is struggling. - And how do you define that?
Less food and more walking.
You've been doing more walking.
Yeah, I do quite a lot of walking and other exercise, as well.
I really struggle with exercise.
It's amazing. I'm still quite new to this.
The idea of struggling with exercise to me still means
that you need to do more!
But you actually mean that you need to do less?
Yeah, I mean, I do star jumps, as well, which is a bit of an issue.
I've been doing them for years and years and never been able to break
- the habit. - How many star jumps do you do? Here?
Well, at the moment, I do, like, 2,000 day.
I feel really ashamed.
It's made you feel ashamed, talking about that?
Yeah, and... Quite...
I don't know.
It's quite hard to admit it and to let people know about it.
Feels like a bit of a shameful secret that I have to hide.
But in your case it seems to me that they are a symptom of your illness.
Again, to which no shame should be attached.
- That's an illness. - Yeah.
Jess came from a family of successful lawyers.
She dreamed of becoming a teacher.
Although she'd graduated from university,
she'd never had a full-time job, due to her illness.
That's my sister's graduation, when I was nearly a healthy weight.
- Which one are you? - This one. - Wow.
- Is that you? - Yeah.
- Same time? - No, that was when I was about 17.
- Can I keep going? - Yeah, I guess.
Not going to find anything weird.
No, it's not going to be weird.
That's a joke.
A lot of people kind of say things to me, like,
you used to be so pretty, or you'd be so beautiful
if you gained some weight, and that's just missing the point
entirely because I'm under no illusion that I'm attractive
as I am now or that I would be any more attractive if I lost weight,
but I still want to lose weight.
It's not about being attractive.
What do you think the misconceptions are?
I guess that it's, perhaps, a self...
An attention-seeking thing and that it's all because the media portrays
this image that the ideal size is a size zero and all that stuff
and it's not about that at all, like...
People just don't get it.
If you accept it's not about a size zero,
although probably those images aren't helpful...
- Yeah. - Do you have any sense of where it does come from?
I think it's a mixture of things.
It's partly a self-punishment thing,
thinking that I don't deserve to eat,
I don't deserve nice things, I don't deserve to enjoy myself and...
..I restrict food and exercise as a punishment to myself.
But then, conversely,
it's also a control thing and an anxiety thing that at times
it actually makes me feel better.
I guess what I'm curious about is what sort of emotions
or what feelings you would get from eating, for example.
I feel so guilty and disgusting.
I just want to, like, physically tear the skin off me
and the fat off me and just... It's just awful.
In my head, I shouldn't like food,
it's disgusting and greedy and horrible to like food
and that makes me a fat, greedy pig and I shouldn't let the world know
that, actually, I do like the taste of some foods!
As at Phoenix Ward,
patients at Vincent Square spend most of their time eating meals
and attending therapeutic groups.
The average stay is around four months,
but it's not uncommon for inpatients to stay a year or longer,
and many return.
The clinical director is Dr Frances Connan.
Anorexia is a mental illness, that's correct, isn't it?
Yeah. And one of the things we always say about anorexia
as a mark of its seriousness, is it has the highest mortality
of any psychiatric disorder.
And that's staggering.
Do we know what causes it?
None of us can really say we know what the cause
of anorexia nervosa is.
There are biological factors as well as psychological factors that
contribute. So it's things like personality type.
People who have more obsessive-compulsive type
personality traits, perfectionism, and those interact
with life experience to come together to cause the expression
of the illness.
So how do you help...
How do you treat the people that you see here?
So, one of the ways we can help you get better and stay well is to help
build resilience in emotional coping and interpersonal coping, so that you
don't have to rely on not eating as a way of coping with the world
and as a response to stress.
People with anorexia tend to experience their first symptoms
in their late teens and early 20s.
Many go on to wrestle with the illness throughout their lives.
I was meeting 63-year-old Janet.
- Hi, Janet. - Hi, Louis, how are you? - Louis. - Thank you for coming.
Thank you, thank you for having me.
You're welcome.
- Come in. - Show me the way.
OK. All right.
Mind the step.
I've just had my breakfast.
- Did you? - Yes, which took, like, two seconds.
- What did you have? - I had that much of bread and a tiny bit of cheese.
But now I feel like I have to walk it off.
- Why? - Because I can't bear the calories inside me.
Janet first experienced symptoms aged 18.
She was diagnosed at 33 and has spent most of her life since as an
outpatient at Vincent Square, while living at home
and working at a job centre.
These are crackers. I cannot eat a whole cracker.
If I eat a whole cracker, the guilt is horrendous.
I can't do it. So what I do, I shake it up...
Shake it up, right?
And then I just take a little bit.
So that I would have for lunch.
- That's my lunch. - Are you serious?
Yeah, I'm being serious.
Would I joke about something like this?
I have to go for a walk, an hour's walk after I've eaten this.
Or for a change, I might have that.
I don't want to get bored with the same thing.
Yeah? Or one of these.
But that, I would have to break in half because I couldn't cope with
- eating the whole one. - You said you loved the biscuit
- but you don't enjoy eating it. - Because of the guilt.
But you love eating it?
There's two sides to me.
There's one that's anorexic, and one that isn't.
One that's trying to get better, and one that is the anorexic.
And one is saying, you shouldn't be doing this.
And the anorexic is saying, but this is all I've ever known.
I'm your best friend.
- Which side is bigger? - The anorexic.
How much bigger?
A lot bigger. 99%.
Are those chocolates?
Yeah. I'm allowed one a month.
The first of every month I get so excited because I'm allowed
a little bit of ice cream and one chocolate.
Do you want one?
- Are you going to have one? - No.
No, because it's not the 1st of July yet.
- Where did that rule come from? - I don't know.
But that's what I let myself have, one a month.
My sweets. I can't eat a whole one.
I have to boil it down, and I'll suck it again a bit later.
That will last me a week.
- Really? - That's four weeks' worth of sweets there.
Hard sweets.
- Really? - Why have you got several on the go at once?
Because then psychologically I don't feel like I'm eating too many.
They call me nuts!
LAUGHTER
Look at my hands.
What's happened to your nails?
Because I'm not eating, the circulation is not working now.
- My body's packing up. - That's why they're red like that, reddy-purple?
Purple.
- They're quite cold. - Mm.
It's a nightmare, this is a nightmare.
I've had it since I was 18. I'm 63.
But there's something stopping you from eating.
What is it?
I feel if I eat then I've lost control and if I eat...
When you're starving, it gets so bad that you feel pain.
It numbs everything.
It numbs your thinking, you can't think straight.
If something happens, like when my mum died and my sister died,
I didn't feel the pain, because I was numb - I was so hungry.
You want to be well.
- I do. - I'm getting very mixed messages.
It's not an easy one.
It's really confusing.
I don't feel I deserve...
I don't feel I deserve.
Is that what it is? Unworthiness?
I'll eat off the floor, I'll eat out my bin.
But if somebody buys me something, I'll throw it away.
I don't feel I deserve nice clothes.
When my sister died, I thought it should have been me.
It was striking that Janet,
with 40 years of experience with the illness and insight into its
workings, was still struggling.
- Do you want to do it? - Yeah, let's go. - You lead the way.
Less than a year into her anorexia,
Rosie was still coming to terms with the illness.
It was the weekend. Rosie's dad, Paul, was picking her up
for her home leave.
- Paul. Louis. - Nice to meet you, Louis. - How's it going?
- All right, thank you. - Nice to meet you. - And you.
The life-changing nature of anorexia means that it puts huge strains
on families.
I was curious to hear the perspective of her parents.
- Hi, Heather, Louis. - Hi, Louis, all right?
- Yeah, how are you doing? - I'm fine, you?
- Nice to meet you. - And you. - Thanks for having us. - That's all right.
- Go on, then. - No, oh, God, no.
- Glasses. - Yeah, I do wear glasses.
That's a nice look, I think.
It is not!
You were going to show me that one up there.
That's my one of last year.
I was going out on a night out.
And, yeah, that's usually on a typical night out.
- What I do is... - Take about 30 pictures.
Take about 30 pictures.
And put them on Instagram?
- Or just choose the best one? - Choose the best one, yeah.
So, there was nothing in the background,
no inkling that you might have this illness in your future.
Nothing at all.
If I thought I would be here in a year's...
Like, a year before, I would have just laughed at you.
- But you nearly died, in fact. - Mm.
Yeah.
- You were working... - I kind of wanted to.
You wanted to die?
- Why? - Because I gave up.
I gave up, I couldn't do it any more.
Kept telling my mum and dad I wanted myself dead.
- You all right? - Yeah.
Fine. Yeah, coping.
- Coping. - Must be difficult.
We just take day by day.
Day by day now. We couldn't have coped no longer at home.
Couldn't have done no longer.
It must have been shattering to go through.
It was... God...
You couldn't sleep at night, thinking, thinking, thinking,
thinking all the time.
You know, what do we do?
What do we do? Where do we take her?
Terrible, terrible times.
It's like a living, living, living hell.
It all started when I feel like I got rejected by someone
and I just felt like I had to change, but then,
now I think back, why did I?
Why did I change?
You must have known something was up.
I did, but I was just hoping and praying,
please stop going to the gym.
I thought once she'd stopped the gym,
perhaps it might have gotten back.
This might have all just stopped.
I thought it was just a phase.
And the trouble is, you're just trying to keep her happy because,
at the end of the day, that's what she wanted to do
and I was frightened if I...
- They were scared of me. - Why?
- They were scared of me. - A lot of anger.
A lot of anger.
Not scared, in a way... But I was frightened that she...
- No, you were, you were scared. - She much turn around and go, well,
if you don't do this for me, then I'm just going to leave
- and what have you. - I'm going to harm myself or do something...
- Silly. - You sound very confident saying they were scared of you.
- Based on...? - Yeah.
I know they were scared. They were scared to say no.
- Why? - Because they know that if I didn't get what I wanted...
..then I would just lose my temper.
I knew how to push their buttons.
- It give you a lot of power, I suppose. - Mm.
It doesn't matter how much we argue,
you can't go through life going to me, bye, I've blocked you,
I've done this, I've done that.
But then again, that's her...
But I just feel like you're not proud of me.
When I do gain weight, you never go, "Oh, well done."
- I do, babe. - But then when I'm going down in weight,
you just assume it's always me, that it's always my fault.
Yeah, it's my fault but I've tried.
You need to say, "Well done, you've tried."
You can't go, "Oh, well, you've not eaten enough."
You're not there to support me, really,
so that's what their problem is now at the unit,
that you're not supporting me enough in terms of meals.
Whilst on home leave,
Rosie was expected to stick to the hospital's meal plan,
to ensure she continued to gain weight.
The sense I get is, it's quite easy to say the wrong thing.
Yeah, it is. Yeah.
Every day's...
You tread on eggshells.
And then you tiptoe around and then she's aware of that and that makes
- it worse. - Yes. - She feels infantilised, it's like you're being too careful.
Yeah, yeah. Every single time you open your mouth,
you just don't know what reaction you're going to get from her.
Nice?
That's a mixture, Rose?
I still look at her and I still don't think she's right.
- In what way? - She's still looking at her phone, plates of food.
What do you mean, looking at her phone?
She seems to get the phone and just, all different meals,
she just sits there looking at them, scrolling through them all the time.
We don't say anything as we walk past her,
but we can see what she's doing, like a habit.
How do you feel, having just had a snack?
- Do you feel all right? - Yeah.
You seem more relaxed, suddenly.
- Yeah. - Right now.
What's that about?
Because...
I think I know I've had it and I've had it at the right time and
- everything like that. - Where you getting tense before
because of the snack?
I worry mainly for my measurements that it's the right...
- That it's enough. - Are you worried about having too much or too little?
Too little.
Given that, basically, the idea is for you to put weight on,
you could have extra and it certainly wouldn't
get you into trouble, but there's something in you
- that's stopping that. - Yeah.
Rosie's anorexia had afflicted the entire family.
Even with Rosie seemingly doing well in recovery,
the illness and its demands were still a daily struggle
for all of them.
One of the most striking features of anorexia is the difficulty many
patients have in seeing themselves as ill.
I feel that people are judging me by
my body and looking at me and thinking,
"Oh, what is she doing here?
"She's too fat to be here.
"Why? What the hell is she doing here?"
Many of those in inpatient treatment are there against their will.
Among them, was Ifzana.
- Hiya. - Hello.
Hi, Rosie. How are you?
Nice to see you. Hi, Ifzana, how are you?
I'm OK, thank you.
You've done my bloods before, you usually get it in one.
- You're really good at it. - Now you're going to give it bad luck, though.
No pressure!
That looks good.
She's really good at taking blood.
An assistant in an operating theatre,
Ifzana had been brought into Phoenix Wing two weeks earlier,
after being sectioned.
It was her third round of residential treatment.
When did people start noticing that you had an issue around food?
I've had it probably about five years.
I was at a much, much lower weight.
My ECG, yeah, it kind of basically looked similar to someone
who'd had a heart attack.
It sounded like you nearly died.
Yeah. Even now when they say that, part of me's a bit like,
"Oh, you guys are just being melodramatic," but...
I don't want to dwell on it too much because they're going to obviously stick to
their opinion, I'm going to stick to my mine.
We're not going to move any way.
- You wanted to leave. - Yes. - Even when you were in hospital, nearly dying?
Does that seem odd to you?
I guess because I couldn't physically feel it...
Could you see it in the mirror?
- No. - You thought you looked fine?
Yeah.
Do you accept that you have anorexia?
I guess. Obviously, if I had to go into an inpatient hospital
for nine months in Cambridge and then come out and then go back
into hospital, then there was obviously a reason for it.
You were sectioned to come here.
- Uh-hm. - If you hadn't been, would you be here? - No.
- OK, thank you very much. - You're welcome. - Thanks.
Wish me luck.
How old are you?
I like when people guess.
Well, sometimes I do.
Don't think so hard.
You're 23.
How the hell do you know? You probably saw my notes beforehand
- or something. - No. Are you 23?
I'll be 24 in July.
God, I feel old.
Hi, sorry to keep you waiting.
- No problem. - Do you want to come in? - Yes.
I was joining Ifzana for her fortnightly review.
She had requested leave from the ward.
I was hoping this weekend, either get Saturday and Sunday,
one to three on both days or on one day, one to five.
In terms of the leave, then,
I think what you need to do is go out in the wheelchair.
Oh, no, we're not going back to that.
- Yeah. - No. - I think, Ifzana, just because we want to minimise
the activity level and because of the low blood pressure.
We're going to be looking...
But that's what I'm saying, to do my blood pressure beforehand.
OK, if it's low, then I'll go out in the wheelchair,
but I don't want to be told, yeah, you're going out in the wheelchair,
because if it isn't low, then I feel like...
Is it to minimise activity and therefore not too many calories
- are getting burned? - That's right, yes.
It's not that you think Ifzana necessarily is going to keel over.
No, it's partly because of the low blood pressure but I think that's
getting better. But partly it is because of activity levels.
What we want to do is we want to limit that as much as possible
- so that is... - Yes, but yesterday I went for my leave,
and I went without the wheelchair and my weight still went up
so I think...
I've been here before, so I think there should be a level of trust.
What we could also do is have a look at sort of how the blood pressure
goes sort of today,
tomorrow and Wednesday in terms of how things are looking.
OK, fine. And we'll do that, as well.
Ifzana had also been attempting to burn calories by standing.
Would you like to take a seat?
- Not really. - They did say you should sit down more.
Yeah, they say a lot of things.
You don't want to sit down?
- No. - Do you want to try?
I can sit down.
Let's see what happens.
Nothing's going to happen.
I sat down at snack.
Do it now and see how it feels.
- No. - Just for a second.
Here.
- Stay sitting down. - You said a second!
Now for ten seconds.
How does that feel now?
I know, short term, it doesn't really feel like anything.
It kind of feels like an inconvenience, to be honest.
What are you doing? You look uncomfortable.
I'm just trying to...
HE CLEARS THROAT
- Do you want to sit down again? - No.
I'm not an animal or a...
I have to jump through their hoops,
I'm not going to jump through yours, as well!
I have the impression she's not really sure
whether she really has the illness.
I mean, that's not sort of uncommon with a lot of our patients,
in that they... On some level, they can see that they're unwell,
but on other levels it's quite difficult for them to.
Or even if, maybe, she accepts she has got the illness,
but perhaps she'd just...like to have the illness.
We'd always encourage people to go for recovery,
but if it's too difficult, what we say is, right, OK,
let's go somewhere in between.
You don't give up the eating disorder because you need it for whatever reason.
It's a way of managing something and so we help you just manage things in
the community, so you can actually have some sort of quality of life.
So, with Ifzana, strictly speaking, you're not aiming
- for a full recovery. - No.
That's because Ifzana doesn't want that at the moment.
If you did nothing at all, if there was no treatment whatsoever,
what would happen?
I think there'd be a very high risk of death, essentially.
I began to settle into the routine of life in the clinics.
We've got cottage pie or we've got vegetarian cottage pie.
I'll try the veg, the vegetarian.
It was baffling to find people seemingly so insightful
and full of promise who were, at the same time,
in the grip of something so irrational.
- How are you doing? - Yeah, not bad.
Especially when it's hot, but there you go.
Making it all the more strange was the way patients valued
and held on to symptoms that could end up killing them.
While recovery was nearly always viewed with ambivalence and fear.
I've never cooked in my life.
You're cooking right now.
Despite the support of clinical staff and families,
it was hard to see how patients would ever break the cycle.
Once I leave hospital, give me long enough and eventually things will
start going backwards.
At Phoenix Wing, change was in the air.
Rosie had let me know she would be making an announcement
in her fortnightly review.
- Hello. - Buongiorno! How's it going?
- Very well. Yourself? - Good to see you.
- You, too. - Light hug?
Very light, distant?
- There we go. - There you go.
Feel like it's been a while.
Yeah. How you doing?
OK. I've been waiting for this all day, so, yeah...
- Have you? - Yeah. - Do you like your ward rounds?
When I get a good outcome, yeah.
If I don't, then you'll see.
- Do you know what they're going to say? - Erm, not really.
A bit anxious.
And you've submitted in writing...
- Yeah. - ..a rough sense of what's on your agenda.
Yeah. Yeah. So I'm just worried about the outcome.
Hope it's all positive, I really do.
- What's on your agenda? - That'd be telling, wouldn't it?
You'll have to wait and see.
- Oh, I like it. - Yeah.
I love surprises.
Yeah.
Hello.
Right, so, yeah, so your ward round...
- So let's go through the points. - What I wanted to discuss with you...
..is immediate discharge into a well-equipped environment
and a supportive family and work with the outpatient services
and also continue my family therapy, as I find it very proactive
and helpful. Sorry...
I do worry about immediate discharge,
if I'm completely honest with you.
You are informal.
This is... I would say, if we discharge you today,
it's against medical advice.
Rosie had decided she was done with inpatient treatment,
but the clinical staff were concerned
that as someone still relatively new to the illness,
she was more unwell than she realised.
You've just decided you've had enough, haven't you?
I have. I just don't belong here any more.
Maybe you don't think you really have an eating disorder.
I feel like I've overcome it.
That could be the anorexia telling you that.
I think at this stage it isn't, it's me.
The following morning, it emerged that staff had decided not to grant
Rosie's discharge, but instead give her an extended leave.
I know.
Shhhh.
ROSIE SOBS
Come on.
Don't get upset.
It did take us by surprise yesterday that Rosie wished to self-discharge,
so what I have done is I've gone back to the notes
and just to kind of follow her, kind of... How she coped with the leave.
And since May, it felt that the home leave...
She has consistently lost weight.
Based on what I've seen here, I don't feel
that you're ready for discharge.
I couldn't help but empathise with Rosie, denied her freedom
but also with the clinical team put in the position of making decisions
in the interests of patients but against their will.
Can I take that, the advice that we've given,
this medical recommendation is something that you are in agreement
- with at the moment? - I feel like I have no choice.
It looks from the beginning of May that she has been
consistently losing the weight and the weight that she has managed...
- At home? - At home, yeah.
It is very apparent that, you know, overnight leave is a problem
and it doesn't feel that she has mastered it.
She has managed shorter periods of leave but not the longer one.
These big decisions,
we have to think about them very, very carefully.
And I feel there will be sufficient grounds to say that,
if she did insist to leave,
it can be that we will get a second opinion from a mental health...
I haven't said that because Rosie did agree.
- You mean a section? - Yeah.
So basically if she's resisting - "I don't care what you think,
"I'm still going home."
You would seriously consider getting a section?
- Yeah. - Initiating the process.
- Yeah, yeah. - Yeah. Big decision.
I suspect whether there is a fear of continuing recovery,
whether there's a realisation that it's not as easy
as I thought it would be.
Rosie's apparent confidence that she was well again, spoke to what
may be anorexia's most insidious characteristic.
How it hijacks patients' thinking,
tricking them into allowing it control of their lives
and their decisions and making recovery elusive.
Thank you.
At Vincent Square, I discovered Jess was in difficulties.
- How's it going? - All right, a bit stressful.
I think you're going to do some medical stuff with Aki,
- and then we'll take it from there. - Ready? - Yeah. - OK, sure.
Despite the 12 hours a day of being fed and monitored as a
day patient on the unit, she was still losing weight.
It had been decided she needed to come back into full-time care.
- How are you feeling today? - Erm...
Quite stressed. I'm just feeling a bit despondent
that I'm doing this again.
Feels like maybe you're not making progress?
I just feel a bit embarrassed, like I've failed, really.
She's somebody who has been ill for an incredibly long time.
She's had lots of admissions to hospital and every time she leaves hospital,
she loses weight really fast and really dramatically.
Recovery takes a long time.
People often have to go round and round more than once,
through loops of, you know, restoring weight,
having a go at losing, coming back round again
before something works that helps them move on.
Right, Jess. How do you feel about doing a squat for me?
- Do you think you can do that? - Yeah.
And back up.
Well done.
This past week, as I understand it, you've lost more weight.
Do you think that's because you
knew you were coming back in, in some way?
You kind of start thinking there's no point in fighting
because you know you're going to be, like...
Force fed and have to eat loads of really scary foods and stuff
and it's just, like, why put myself through the pain of forcing myself
to eat, when I know what's coming?
There's a safety net, almost like someone going in to alcohol rehab.
In the week leading up, they're going to get as drunk as they can.
As a last hurrah, almost.
It takes a hell of a lot more strength to eat
and recover from this illness, than
it does, for me anyway, to indulge in it.
This would be Jess's eighth stay as an inpatient.
I'm really sorry that it's been such a struggle.
I just feel like I need a break.
Just some time out to clear my head.
Sounds like you're struggling a bit.
What's in your head?
It's just so hard having to eat and deal with the feelings that that
brings up and not have my usual ways of coping.
And do you feel you are committed to your recovery?
It kind of ebbs and flows at times.
Like, I know I hate this illness, I hate my life at the moment,
but I just don't really believe that I can recover.
- I mean, are you OK? - Yeah, I'm OK.
I just... I'm so sorry that you're going through this.
Thank you.
Jess has had this disorder for a long time now.
How realistic is recovery?
Part of what's difficult for Jess,
part of the snag that pulls her back is the world's now quite a scary
place. And you can kind of relate to that.
If you think, if you've lived a lot of your life in and out of hospital,
people telling you what to do all the time,
your illness telling you what to do all the time,
she's missed out on a lot of the normal development opportunities
through which you kind of learn to feel more confident in yourself
and how you manage the world. I don't think she's somebody who,
she's going to come into hospital and this episode of admission
is going to be, that's it, boom and she's suddenly recovered
and everything's OK.
I do think that this admission can contribute to her journey
of getting to a place from which she can recover.
It had been four weeks since I'd last seen Ifzana.
In spite of the fact she was still sectioned,
she seemed to be more engaged with her treatment.
- Hiya. - Hello.
How are you doing?
OK, how are you? Been busy?
- Yeah. - How's everything, have you had your hair cut?
- Yeah. - See, I notice things.
- Have you had a haircut? - No.
But I changed it because it's, like, really hot,
so it leaves my neck a bit cooler.
What do you think of the banana drink?
It's just a banana drink.
What do you think of it?
It's neither hot nor cold.
SHE SNIGGERS
- Don't tell that to the staff(!) - What is it supposed to be? - It's hot.
- It's supposed to be hot? - Did you ask for it hot?
I didn't really... I just said, "Give me what Ifzana's having."
Well, then, it's supposed to be hot.
I suppose I should just be grateful to have anything.
I was curious to know if Ifzana was now more on board
with the idea of being well.
How do you feel you're doing?
I definitely think things are moving forward.
In what way?
Well, obviously physically, my weight is obviously going up.
Is it? I mean, you say, "obviously", I'm no expert but...
And without prying in any way, so it is...
You're sort of getting weighed regularly
and they tell you it's going up,
- is that right? - They don't exactly tell you.
I kind of can see from the scales.
- They show you the numbers. - Yeah.
And how do you feel about the numbers going up?
Well, I guess I'm always in two minds.
The eating disorder part of me is obviously not thrilled,
but the other side of me knows that it has to
and I don't really have a choice.
Ifzana had told me she'd been bullied as a child
and that a few years earlier, she'd refused an arranged marriage.
I wondered if she felt either experience had played a role
in her illness, or whether the causes were more obscure.
Where do you think it comes from?
I think it's a mixture of things.
SHE SNIFFLES
I don't think there's one definite sort of pinpoint.
Are you all right? I haven't made you upset, have I?
- No, it's fine. - Have you got the sniffles?
- Yeah, a bit. - Thinking about what?
Everything changes.
Everything... I usually don't like reflecting on things,
especially with this whole process.
It's kind of like... Because it obviously makes me upset and I can't
- control it. - Oh... I'm sorry.
- I'm really sorry. - It's not your fault.
You are choosing to be here and I think you staying here
is a kind of victory. I mean, I know you've got all different...
..thoughts in your head, pulling you in different directions, but...
Looked at in the healthy way, you're doing really well.
The disorder's pulling you back, isn't it?
There's a part of you telling you...
..that you don't really want recovery.
- And telling you that it feels wrong. - Yeah.
One of the paradoxes of physical recovery from anorexia
is that it can lead patients to feel worse.
No longer numb, they have to face emotions
they had suppressed by starvation.
Often, this leads to relapse.
The average recovery time from anorexia is seven years.
Hello.
It's hot out there, isn't it? Nice to see you.
- How's it going? - OK. And you?
Good.
In the 40 years Janet had been ill,
she'd never managed full recovery.
- Hi, I'm Sophie. - Nice to meet you. - Nice to meet you.
Hoping for some insight into why she'd found it so hard,
I was joining her for a therapy session,
which started with a weigh-in.
- OK. - I've done well, haven't I?
You've done very well.
So you put a little bit on?
Yeah, I'm not happy, so now I feel like I have to starve myself.
I'm not happy.
- I don't know why I've put on... - But it's - ..loads, haven't I?
Not loads, Janet, but I think this is...
- I have! I was... - This is very reflective, isn't it,
of the two parts of you that we kind of identified?
The part of you that wants this to get better
and the part of you that's really anxious about that.
From your experience in this field,
do you have any sense of where this problem is coming from?
I think, for Janet, this started a long, long time ago,
at a time where maybe Janet felt she needed some control over something.
I mean, Janet, would you agree with that?
- 100%, yeah. - Control, why were you looking for control?
Because I couldn't control anything else...
In your life?
- Why? - In my religion.
I'm Jewish and in my religion in those days, 30 years ago,
40 years ago, you had to get married young, have children and do well.
I didn't want to get married.
I didn't want to grow up, I wanted to be a child.
I was terrified of going to work, terrified of leaving home.
It all scared me so much.
The anorexia was my best friend because I didn't have to do anything
because I was sick all the time.
It was my own little world that I could hide inside.
I think there's probably a lot in that.
It's come from my gut. Not all this psychological stuff.
You just do not want to grow up.
You're just too scared.
You can't cope, end of.
- Maybe the fact that I want to tell you to eat... - You're frustrated.
I'm sort of, I feel like maybe that's another way...
Maybe that in some level...
- You're frustrated. - Is that how you want me to respond, maybe?
So that I'm like a parent to you.
He's good, isn't he?
LAUGHTER
No, I don't think so!
Sometimes we do find that with anorexia there is something
that keeps people stuck in it, where they do elicit lots of care
from others. You know, maybe that's making up for something
that they haven't quite had.
I was struck by Janet's observation about not growing up.
- This is you. - Yeah.
It may be part of the seduction of anorexia that it keeps life
at arm's length.
That was my ex, a musician, Paul.
- He looks groovy. - We got engaged. - What, and it didn't work out?
- No. - Have you been married? - No.
Engaged, twice.
- And what happened? - I broke it off.
- Why? - Eating with them became an issue.
- Is that you? - Yeah.
Eating became an issue in the relationship?
- Yeah. - In what way?
Because they said I wasn't eating enough
and I didn't want to eat more and I had to sit down every evening,
because we lived together, for a meal and I wasn't eating enough
and it used to start arguments
and I felt they were putting too much pressure on me.
I didn't like it. I'd rather not have them and not eat.
For those who feel a lack of control in their lives,
anorexia offers the illusion of ultimate control,
at the price of the years of missed opportunities.
I was back in East London with an appointment to see Rosie,
now living at home, while being treated as an outpatient.
Of the people I'd met, she was the one who had seemed most confident
of recovery.
I wondered if things were still looking up.
- Hello. - Hello!
- How are you doing? - Good, how are you?
Yeah, good. I was going to say, you look great and then I was like,
"Hang on, I don't even know if I'm supposed to say that."
- Different? - You know, what is it therapeutically advisable to say?
You look...how you look.
- That sounds weird. - Yeah.
I think I know what you mean.
- Yes. - Come in. - How are you doing?
Yeah, I'm well.
I'll come in.
- Nice to see you. - Yeah, you, too. - Cheers.
- You've been discharged now. - Yeah, officially.
Obviously, they gave me the two-week trial.
I done the first week and my weight had stayed the same,
but that was a positive.
Then I done another week at home and I had gained 0.7, so...
Wow. That's great, congratulations.
Thank you.
Some of the people I speak to, who have eating disorders,
they're much more in two minds about putting on weight
or looking more healthy.
Yeah. I know I need to do this,
I know I need to put on the weight because otherwise...
I really do not want to go back there.
I do not want to step back in that ward.
And I'm motivated, you know?
I know where I've been before and I know I can do it, but...
It's just, you know, you are always in two minds.
If I've taken away anything from all of this, it's that the healthy
and the unhealthy impulses get intertwined
to such an extent that it's sometimes hard to separate the two.
Yeah.
MICROWAVE BEEPS
Rosie's future was hard to predict.
I could only hope that she would be among that group of patients
who make a full recovery and return to the normal life
she'd known only a year before.
Are you still going to watch me eat?
- Is that going to make you uncomfortable? - Yeah, I'd rather not.
- Really? - Yeah.
- You want me to leave? - Sorry.
She doesn't want us there when she's having her tea.
It's still stressful for her.
Very stressful, indeed.
Very, very stressful.
She's still battling.
Yeah.
In her mind, she is, yeah.
- Would you agree, Heather? - You know, like, she goes,
"I can't do this no more. I can't..."
I say, "Deep breath, count to ten,
"think of something nice and that feeling will go."
And that's what she does.
She gets upset sometimes because she thinks she's failing again.
You think there's a little voice in her still saying,
"Don't put on any more, you've done enough?"
- No, she knows. - That voice is still there, I think.
- I think so. - A little bit.
You don't have it to that extent for all those months
and then have it go like that.
No, that's right. I think it's still...
- Oh, yeah. - It's still there.
- It's lurking.
- Yeah. - Yeah.
But she'll get there. I can see a big, huge difference.
And you think she's serious.
- Oh, yeah. - About doing it?
- Oh, yeah. Definitely. - Definitely now.
She said to me, "I never, ever want to go back, ever."
DOOR OPENS
- Hello. - Hello.
- I keep forgetting you've had your hair done! - Yeah.
We were talking about you.
I thought my ears were burning.
- Good, I hope. - All good.
Yeah.
- Of course. - It's not always good, so I don't know why you're pretending.
- No, it was. It was all good. - OK.
Do you think that it's part of the human condition in some way?
I mean, it's always been with us and will always be with us.
Yeah, I think both. I think it's always been with us,
it will always be with us and there are things about our culture
currently that increase the prevalence.
So the genetic vulnerability we're born with interacts
with the experiences that we have as children and growing up
and those are experiences of family, experience of peer groups
and the social world that we live in.
But the interaction between all of these factors, for some,
will trigger the illness.
Anorexia is an illness associated with appearances.
But in my time speaking to people with the disorder,
I've been struck by how much it had to do with the deepest feelings
of powerlessness and lack of self-worth.
It intertwines itself with positive qualities,
like conscientiousness and self-discipline
and makes them poisonous.
Demanding from those who have it, a daily heroism in facing down
an illness often indistinguishable from their own selves.