Why are anorexia sufferers still treated so badly?

In her 1986 book Hunger Strike, the feminist psychotherapist Susie Orbach highlighted the problem of hostile, abusive and above all ineffective treatments for anorexia sufferers. Such treatments, she wrote, are “predicated on conflict with the patient”, who is viewed as “wilful and stubborn in her refusal to eat”. Rather than seek to understand sufferers, practitioners “throw up their arms in despair or mechanically ‘treat’ the sufferer as though she were at best an oddity, at worst an offending object”:

In trying to get her to eat and to become the “right size” they negate her protest. They unwittingly deny the meaning of her symptom and in so doing contribute to its perpetuation. They become part of the problem rather than part of the solution.

As someone who experienced anorexia “treatment” one year after Hunger Strike’s publication, I can vouch for this. The doctors and nurses I encountered in both a standard hospital and an adolescent psychiatric care unit were open in their hostility. Their interest was in weight gain, nothing more, with regular reminders of how selfish, stupid, vain, controlling etc. it was to refuse to eat. Force-feeding was accompanied by incentives for weight gain — getting out of bed, having people speak to you, gaining access to reading materials — with the proviso that these could always be withdrawn should weight be lost or, as it turned out, merely if a member of staff found you a bit annoying. 

Almost forty years on, I no longer have anorexia; I still have many of the rituals and compulsive obsessions I developed while spending weeks in isolation with nothing whatsoever to do. I wasn’t mad when I entered treatment, but having to stare at one wall, then another, for hours on end nearly drove me insane. 

If I tell people about this experience today, I tend to get one of two responses. The first is “times have changed”. That was the eighties. Karen Carpenter had only just died, Lena Zavaroni was still alive, and most people still called anorexia “slimmer’s disease”. There’s so much less mental health stigma so no one would be so unkind today! The second is “yes, but at least you’re alive”. There is a logic whereby, if people know others — especially respected, trusted others, such as doctors — did something extreme, they must have had their reasons. If the treatment was harsh and brutal, that must surely be a measure of how unreachable you were. If no one tried talking to me (and no one did), that proves I can’t have had anything coherent to say. 

I had hoped treatment for anorexia — and attitudes towards anorexia sufferers — would be better by now

In many ways, it is easier for me to agree with such responses than to challenge them. They leave me with nothing to rage at. It’s over, gone, and anyhow, I’m still here. For a while I used to think this, desperate to believe that we truly had entered the age of mental health enlightenment, with empathy available for all. When Lauren Greenfield produced her 2006 documentary Thin, focussed on a US treatment centre, I told myself that yes, it wasn’t perfect, but attitudes were improving, weren’t they? Almost two decades later, I’m not sure I think this anymore. 

A new BBC Disclosures documentary, Kids on the Psychiatric Ward, describes teenagers admitted to Skye House, an NHS psychiatric unit in Glasgow, being treated with a harshness that seems very familiar to me. They recount being called “pathetic” and “disgusting”, while one anorexia sufferer, Cara, talks of being physically restrained without any member of staff attempting to speak to her “as a first port of call”. Both she and another sufferer, Jenna, recall staff using force-feeding via a nasogastric tube not just as a lifesaving measure, but as a means of punishment, with staff either using excessive force to put the tube in or making the liquid flow so fast that the patient would vomit. Both found the experience traumatising, as one might expect.

Not all of the adolescents in the BBC documentary are anorexia sufferers — and there are certainly broader issues to explore — but these accounts chime with other recent reports on anorexia care. In 2021, the journalist Eve Simmons compared her own treatment for anorexia with that of her friend Shushila Phillips, who died of the disease. Though ten years apart, their experiences were similar, with Simmons describing “fragile girls pinned to the ground by staff members to stop them “exercising”, and nursing staff screaming at patients who had used the shower ‘too early’ or asked for a different flavour of yogurt”. Once again, failure to gain weight led to punishment: “parents would be banned from visiting or we’d be stopped from going outside for fresh air”. Simmons notes that many practitioners endorsed regressive stereotypes about anorexia sufferers as “habitual liars who are resistant to change”, with “a review of 20 studies looking at preconceived ideas that staff in eating disorder clinics had about sufferers [finding] that most saw them as stubborn, demanding, selfish and, ultimately, hopeless cases”. As Simmons points out, such attitudes can make hopelessness a self-fulfilling prophecy.

In 2024’s Dead Weight, looking at the US, Emmeline Clein tells of a medical establishment still choosing to “demonize eating disorder sufferers”.

They are cast as manipulative, malingering, wilfully ill people with “self-inflicted illnesses,” in the words of one clinician quoted in [Rebecca J. Lester’s] Famished [ … ] A former employee of an eating disorder clinic told me that many treatment staff consider eating disorder patients “stubborn” and “spoiled.” A nurse writing about their experience on an eating disorder ward called patients “manipulative” and prone to “playing mind games to get what they want.”

The “manipulative liar” tag seems particularly prevalent. From my own experiences in treatment, I am well aware that fear of food and calories can lead sufferers to misrepresent what they are eating (call it “an open sandwich” so you only have one slice of bread, say you’re “eating French Fries” when it’s a 78-calorie bag of crisps etc.) but this does not mean sufferers are liars who lie about everything. The routine character assassinations to which they are subjected can, on the other hand, make it harder to get to the truth of why so many of them do what they do.

Why do so many practitioners still behave in this way? It is not enough to claim, as the health board responsible for Skye House has done, that low staffing and inexperienced bank staff are to blame. The trouble is, those who mistreat sufferers are reflecting broader cultural attitudes towards them, one which persist no matter how much lip service is paid to how much more mental health aware we have become. For instance, Amazon review comments on the anorexia documentary Emma Wants To Live describe the subject — who died at 18 — as “whiny and annoying”, “selfish and unlikeable”, “a malignant narcissistic girl who killed herself to hurt her family”, “very spoiled” and “a Bratty Attention Seeking Child”. There is something very gendered about all this. While sufferers can be of either sex and of any age, the association of the disease with adolescent girls ties it to a very particular sort of misogyny. Teenage girls are seen as trivial, vain, manipulative, therefore anorexia — no matter who actually has it — is seen as a disease of the trivial, the vain, the manipulative (I’ve watched the documentary and Emma is no more “whiny” than anyone else in the process of dying very slowly and painfully while tortured by their own mind). 

I had hoped treatment for anorexia — and attitudes towards anorexia sufferers — would be better by now. Instead, the idea of the “hopeless case” anorexic is quickly merging with that of the “terminal” anorexic. An individual’s lack of trust in the usefulness of any further treatment is increasingly viewed as a measure of the severity of her sickness — but couldn’t it also be viewed as a judgement on the treatment itself? If treatment has become a source of terror, is that all down to the disease, or could it be partly related to the behaviour of those offering “care”? And couldn’t that behaviour be much improved?

In light of the stories coming from Skye House and elsewhere, I think these are questions worth asking. There is life after anorexia, for some of us at least. It would be great if this could be thanks to the treatment that’s offered. Sometimes, though, it seems to be in spite of it.