“I will never forget one girl asking me: ‘Why do you hate me? Why are you torturing me?,” sighs Dr Sara McCluskey, a consultant psychiatrist at the Priory Hospital in Hayes Grove, Kent. “She asked me: Why have you brought me into this unit with all these other thin people when I am really fat?’ She weighed less than six stone. They think I'm just being mean.”
Hayes Grove is a private mental health hospital, set in a classic redbrick building with an ivy-covered exterior and a beautifully-furnished interior. It is just one cog in the wheel of The Priory company - which is the UK's largest network of mental health clinics - and specialises in treating adult eating disorders and patients with Asperger's Syndrome. The psychiatric facility has 46 beds, and, as a result, feels intimate and homely, a stark contrast to the often impersonal, cold corridors of traditional hospital buildings.
Anorexia Nervosa, as McCluskey points out, has the highest mortality rate of any mental health disorder. Research has found 20% of anorexia sufferers will die prematurely from the illness. Only around 46% of anorexia patients fully recover from the illness.
SUBSCRIBE AND FOLLOW
Get top stories and blog posts emailed to me each day. Newsletters may offer personalized content or advertisements. Learn more
"There's a very poor recovery rate," McCluskey continues. "Those with severe enduring eating disorders (SEED) might stay for briefer periods, say up to six weeks, but they will come back every year to 'top up' their BMI.
"But I am so blessed. It is the most incredibly satisfying job anyone could have. You can make such a difference. You are a team of people who is saving someone’s life. I really enjoy it."
McCluskey has what she calls a "hope board" in her office, overspilling with letters, drawings, baby pictures and graduation pictures of beaming youths.
"Patients write to me," she explains, breaking into a smile. "One still writes to me 20 years after I treated her. I point to the board and say to my patients: that will be you soon, sending me pictures. It’s great because I’m not bullshitting. You can say to them ‘you can get better’ - and you can really mean it.
"It is very touching when people send me pictures so many years after, as the journey to recovery can be so distressing."
The hospital employs 15 consultants, each with different specialities, Marc Sycamore, clinical services manager and my personal tour guide for the day explains, and it is highly regulated by the Care Quality Commission.
"Teenagers are driving each other to extreme ends - such as suicide pacts - and its being made even easier thanks to social media," Roger Skipp, the hospital's director, tells me.
"But there's still a huge misunderstanding around mental health. Our therapy content is much higher than the NHS', it is not out of a book. Nevertheless, there is a huge gap in the public's knowledge of mental health. You don't ever really know how bad an eating disorder or an addiction is.
"For an eating disorder patient, a piece of toast is terrifying."
No matter who I speak to at the hospital, from ward nurse to director, the Priory staff's dedication to their patients is unmistakable. These patients are not just numbers to boast of in a boardroom or figures in the bank; they are real people who form deep connections with their support workers.
On my way to the Eating Disorders Unit (EDU), we climb a flight of stairs - an odd way to reach a ward treating patients for weight issues, I wonder aloud. I am soon informed new patients have to use the lift until they start to put on weight - and only then can they use the stairs as a privilege.
I'm buzzed through a set of double doors. It’s eerily quiet, and there a lot of locked doors - all with silver-plated numbers denoting which rooms they are. It’s almost like being in a hotel.
The rooms which are open are being cleaned or sit empty, waiting for their next inhabitant to be admitted.
"Eating is not an option here," Aisha Kibirige, the EDU's acute ward manager, states firmly. The nurse, who has worked at Hayes Grove for 14 years, immediately strikes me as a no-nonsense kind of woman.
"Sometimes we have to feed them through the nose or a hole through their tummy to feed them that way," she explains. "They haven't eaten for a very long time so we have to introduce them, we have to teach them how to eat. They may have been taking laxatives or exercising every time they eat so it's difficult for them to eat normally."
Some patients are admitted to Hayes Grove with BMIs of under 10, with many coming straight from the ITU. A "normal" BMI is between 18.5 and 24.9. There's "definitely" a risk of death, as Sycamore puts it.
Aisha runs me through the daily logistics of the ward with the air of a hardened businesswoman. However, when I ask what it feels like to see her patients get better, she can't help but break into a heart-warming smile.
"The most rewarding thing is when they come in skeletal, on death's door, and they start to get better. You see this beautiful woman and you think: 'Where has she been hiding? Where has she come from?'"
She shakes her head and quietly chuckles: "You just sit back and think 'wow. You're beautiful'."
The ward is run on a tight schedule and I'm soon moved on through the next set of password-protected doors to the progression unit, which is currently running at its full capacity of 13 patients.
There’s a tangible change in atmosphere; a hubbub of noise, and food smells waft into the living room area. I look at my watch; it’s lunchtime. It’s like stepping into student halls. Several women, some who look as if they are barely out of their teens, others who look well into their 60s, are ambling around or relaxing on the sofas, reading magazines or watching the chat show on the communal TV.
The press officer accompanying me on the tour expresses her surprise at the ages of the patients, assuming they would be over 18 as it's an adults ward. It is, Karishma, the resident healthcare assistant, patiently explains; many of them look younger because they are so underweight.
"Even I find it scary how young and fragile they look," Sycamore admits.
One young woman sits on a couch in tracksuit bottoms and a hoody, reading a magazine. A pretty normal scene - apart from the fact she has a tube through her nose. “It’s attached to a machine which slowly release food through the nasal passage,” Karishma explains once we’re in a side room, with the door firmly closed. “Some patients will keep these in for a while because it is a very traumatic process to remove and re-insert it.”
In the progression ward the patients cook their own meals and make menu plans. They’re tasked with the responsibility to make good food choices - and not just choose to eat the lightest option. “It’s a big jump for them," Karishma explains.
I query why there are so many frail-looking patients if it this is the “progression” area.
“It’s not necessarily about their BMI," Sycamore explains. "It’s more about mentally being in the right place. They’ve got to be improving. There will be some patients who have relapsed but it’s a massive blow to suddenly be sent back to the acute ward next door. So we try and keep them here.
"Here, they're moving onto therapy. Next door," Sycamore adds matter of factly, "is about preserving life."
I think about the quietness, the stillness of the previous ward and feel a twinge of guilt for walking through so nonchalantly, completely ignorant to the fact patients in there were literally fighting for their lives.
"I thought of eating disorders as a ‘young’ illness when I first started out,” admitted Karishma, who has been at the ward for six months. “But it can be an illness which spans a lifetime."
Recently, one of the hospital’s elderly patients died. “It was a very difficult, traumatic time,” reflects Sycamore. “She was a well-loved patient. She just deteriorated within 12 hours, and passed away in hospital. She was bedridden, but she used to wave to everyone when they walked past. It was very hard on the other patients.
“But,” he continues. “There is a positive spin. It gave them a reality check that this illness kills.”
I’m surprised to see the women are allowed phones, and even more so to find there’s wifi in the ward. “We try to be unrestrictive," Karishma, a health care assistant on the ward explains. "They’re allowed magazines, TV; it’s what they’d face out in the real world and they need to get used to it.
"It would be very easy to keep patients locked up but that won’t help them get better. We let them go into town to go to Costa, because it helps them go back to a normal life."
Those ones who are allowed into Hayes town centre often get upset when they overhear members of the public talking about weight issues. “One woman came back and said she heard a girl talking about how fat she felt she was," Karishma recalls. "It made her very distressed. But they need to get used to those kind of conversations. Because when they leave here, they won’t be sheltered from them."
Although getting the patients to eat together means they have a support network, negative feelings can be catching.
“If one person is having a negative day, it makes everyone anxious," Karishna says. "But it can go the other way too, and they can encourage each other to eat."
Some of the patients in the ward use a peg; a machine, which fits into a rucksack, and is attached to a tube entering the stomach, meaning its user can go out in public without drawing attention to themselves in the same way a tube through their nose would.
For many patients, they simply cannot stomach food, or they have conditioned themselves to vomit after eating, so a feeding tube is their only option. The hospital will only force feed patients under the 1983 Mental Health Act, but its staff do have to physically restrain patients so the tube can be administered.
I ask Sycamore how many patients in the acute ward are sectioned under the act. "It's four out of the 23 we have here," he answers.
I begin to express some positivity about the number being relatively low when he interrupts me.
"No, I mean there are only four in 23 patients who aren't here under the mental health act." My mouth drops open in surprise and Sycamore adds: "Two years ago, that figure would have been at least 12 out of 23."
There are certain “anti-ligature rooms" in the EDU, which are assigned to high-risk patients. Smart, but with a homely feel, pristine-made beds and sparkling bathrooms, the rooms wouldn't look out of place in a business hotel. Except for how they're furnished; a mirror - shatterproof, Sycamore tells me - and a wardrobe, which appears normal to the eye, but on closer inspection is doorless and has a curved top.
There's a few moments of silence which passes between us as the full meaning of "anti-ligature room" sinks in.
"There are some who will always find a way," Sycamore explains gently. "Patients will pick up on such simple things and use them to harm themselves." Some patients will go so far as to monitor staff - even the cleaning staff - in order to act on any opportune moments which may arise.
"There will always be those patients who will find almost.." here Sycamore mulls over his words carefully, before adding: "Almost - and I hate to use this word - ingenious ways to harm themselves.
"They can be very determined, especially the CAMHS [children and adolescents in mental health services], and they're very inventive. Even within 15 minutes. They have an end goal and they have the drive to get there."
But, as I find out, it's not just the patients who put themselves in danger; working in a mental health hospital is a risk in itself.
"It is a high risk environment," director Skipp says simply. "It's a lot of responsibility for staff."
"Our patients cannot choose to eat," McCluskey says when I ask about whether anorexia nervosa is taken seriously as an illness. "It's purely and simply an educational issue. It would be like some people not believing in depression. There's a difference between a bit of dieting and anorexia.
The psychiatrist, who has been practicing since 1983, highlights pro-anorexia groups as a "terrible" influence on young people who are just starting to diet.
"It's important to add there are some great pro-recovery sites out there, but the others are very damaging. Even though some of our patients weigh five stone, they still think they are fat. And these kind of sites do not help. There's also a media obsession with weight which has contributed to these problems.
"We want patients to see the costs of their illness," she continues. "Sometimes it requires a lot of talking to make patients even realise they have a mental illness, and a lot of time to help them change their views on life.
"Some of our patients might accept they are ill and need help, but their thoughts are just too strong to allow them to eat and recover.
"One analogy I like using is from Professor Chris Fairburn. Imagine if you went to sleep one night, and in the middle of the night someone put a pair of anorexia glasses on you. You woke up with these glasses on, but you didn't know you had them on, and you saw the world trough these glasses, in a different way to everyone else. And you didn't even know your view of the world had changed."
It's a thought-provoking analogy, and one which lays bare the helplessness of anorexia patients.
"Unfortunately, it is easier to spot anorexia in teen girls as their periods stop," McCluskey continues. "Whereas male patients.. they are more focused on having a lean sporty body; they may be eating well but compulsively exercising. One in 10 sufferers is male but it is much more unusual for us to treat male patients. It is crushingly difficult for men to seek help from their GP. If they say 'I have an eating disorder', GPs just don't know how to react to it.
"Some eating disorder services won't even accept patients below a certain weight which is horrifying."
At the Priory, patients have a bespoke programme tailored to each patient, and McCluskey admits the staff are "incredibly lucky" to be able to offer such a wide range of therapies.
Despite her own vast expertise, McCluskey is full of admiration for the nursing staff at Hayes Grove. "The team we have here are so skilled and compassionate and that makes all the difference," she gushes. "I don’t know how they do it. Nurses sit hour after hour cajoling someone to eat.
"It would be like trying to make someone eat a plate of live worms. That is what it is like for someone with an eating disorder to try and eat a plate of spaghetti.
"It is not a job for everybody. You have people who either stay here six months or 16 years [McCluskey has herself been at Hayes Grove for 18 years). Nurses here can be extremely physically compromised. It is my duty to ensure they are safe."
There's also a sense of family at the hospital. The people who work here are not just colleagues in the typical sense of the word. They support and guide each other through hard times - of which there are many.
"We have psychotherapists talking things through with our nurses. We have to look after our own mental health and needs - otherwise what good are we to anyone?
"I start emailing at 6am in the morning but then I stop when I leave. You have to have boundaries or else you would be ineffective."
Her words correlate with something Karishna touched upon when she spoke about settling in to Hayes Grove. "It's very difficult to leave everything at work," she confided in me. "It does resonate for a bit when you go home. You've got to mentally strong. I came in knowing nothing really - textbooks can't teach you about this. You can't see what it does to a person, their family, until you work somewhere like this."
McCluskey strongly advocates "talking a lot", in order to keep emotions in check. "We need to be honest with each other about how we are feeling," she says. "It can be very hard, very exhausting work. We talk a lot. We have to talk about the negative and the positive feelings because it can get too much.
"We work very closely as a team, nobody should feel totally responsible for one patient - we all work together. They’re all our responsibilities. We also make sure we have nights out together. It is important to get out of the hospital together and bond."
At that moment, Sycamore comes in to whisk me off to our next appointment.
"That reminds me", McCluskey adds, "aren’t we supposed to be going to the Warren?"
"Yes, yes, I'm phoning them to book today," Sycamore smiles. He turns to me, adding: "I’ll never hear the end of it otherwise."
As McCluskey is showing me out of the door two of them, to ensure soundproofing, she adds: “People do find it very hard to believe but you do switch off when you go home. You have to.”