Behavioural Therapy from Hell by Adam James

Debbie Holden was 16 when she first started to slip into the lonely, nightmare world of anorexia. She won a competition with school friends over who could lose the most weight. And it was from this ominous beginning that the eight stone teenager became trapped in a cycle of binging, vomiting and laxative abuse.

Over the months and years her weight dropped steadily. So that by the time she was 20 Holden weighed just five-and-a-half stone, and doctors feared she was so frail she would die. So they sectioned her and admitted her to North Manchester General Hospital. This should have marked a turning point in Holden’s life, when the staff of Ward G3 would support Holden in overcoming her eating disorder.

Instead Holden describes it as when “her period of hell” began. She was heavily sedated, fitted with a nasal drip and confined to one room. Psychiatrists then initiated a ‘behavioural therapy’ programme, based on the principle that if anorexic patients are ‘rewarded’ after gaining weight they would be more willing to eat voluntarily. Holden remembers with horror: “Fifteen nurses entered my room.

Without speaking to me they removed every possession I had, including Get Well cards, clothes, and cigarettes. “They just marched off with everything. My doctor then came in and asked me what I wanted. I said I wanted to be out of the room and with my mum.” Allowed just a nightie to wear Holden was told that as her weight increased she would be granted ‘privileges’, including use of a telephone and television, clothes, baths, make-up, visitors and access to the ward’s toilet.

She was prohibited from leaving the room she came to call her “glass cage”, and was denied reading or writing materials until weight was gained. “I remember one day screaming and begging my dad who came to visit not to leave me,” recalls Holden who objected to being force fed and saw the treatment as a ruthless system of deprivation and punishment. “I kept pulling out the drip because sedatives were being put through it into my stomach. Yards and yards of the plastic tubing used to come out. I was so heavily medicated I could open my mouth but could not speak. I was a vegetable.”

While doctors assured confused Holden the treatment was for her own good, they warned that if she continued to rip out the drip another would be inserted into a vein in her neck. Holden saw this treatment which went on for five weeks as psychological torture. And as the liquid food dripped into Holden’s stomach her weight ballooned by three stone. “I felt I was raped because the whole shape of my body was changed so crudely without my permission,” says Holden.

Holden was treated in 1983. But force-feeding and isolating anorexics while employing behavioural techniques is still practised today. “It is often the under resourced busy hospitals which tend to use this stricter form of behavioural therapy,” says Dr Jill Welbourn, who headed a Bristol eating disorder team for 25 years.

“It may be used in the kind of hospital where there are perhaps just three nurses for 26 patients. Although strict behavioural therapy is less popular now it can depend on the luck of the draw as to where you live. There are whole areas in the country which are total deserts in term of more contemporary less confrontational approaches to anorexia.” Holden believes the humiliation she suffered damaged her so much it compounded her anorexia and distress.

Even now she fears confined spaces. “I was put in that hospital room not for five weeks but for 10 years. I think it was unnecessarily cruel,” asserts Holden from her terraced home in Middleton, Manchester. “You can not expect anyone to go through something like that and for it to have no effect. If it was about saving my life then surely I should feel happy about it.” It was only in 1993 after becoming pregnant that Holden found the inner resolve to beat her eating problems.

Against medical advice she came off all her medication as she believed it would damage the baby she was carrying. “I knew that I had to get well for my daughter. I had a responsibility towards another life and could not afford to be ill. Whereas previously I would vomit after eating, I learnt to force myself to swallow the food which I had vomited up in to my mouth.” By 1995, after Holden had returned to a healthy weight of nine stone, she sought legal redress for her “glass cage torment”.

Holden was encouraged when granted legal aid to pursue a case of medical negligence against North Manchester Health Authority. As part of the preliminaries, Holden’s medical notes were sent to the distinguished Dr Arthur Crisp, author of Anorexia Nervosa – Let me be. He supported Holden’s version of events, writing that her therapy “contained an unacceptable punitive element which may have led to specific abuse on some occasions… Ms Holden’s treatment is more likely than not to have caused her damage.”

In addition a psychotherapist concluded the humiliation Holden experienced in the hands of the hospital should be understood “as though it were a Post-Traumatic Stress Disorder.” But despite such condemnations, Holden learnt earlier this year that she would probably lose a medical negligence claim. Her legal counsel concluded the authority would be able to demonstrate “with some ease” that other doctors would endorse Holden’s treatment. It also believed the authority would be able to trace doctors who at the time followed similar regimes on anorexia patients. In effect this judgement put into doubt whether anorexic patients have legal come back against experiencing trauma as a result of compulsory treatment.

Terry Simpson, of mental health user group The UK Advocacy Network says: “I think this represents a sad indictment of the mental health service. Research into anorexia has never looked at how compulsory treatment effects patients. “Compulsory treatment often leads to further problems. It can be very humiliating and stigmatising for a patient and can take many years to work out how such treatment has damaged you.” While Dr Welbourn agrees that many anorexia patients feel aggrieved after compulsory treatment, she believes desperate measures are necessary to save lives.

She says she has known more anorexia patients starve to death than to complain afterwards. “Compare it with someone who suffers a cardiac arrest,” she argues. “A doctor might shove their hand into a person’s chest and squeeze the heart to get it going because the patient is about to die. Now that could be an assault.” “Sectioning does save lives and some of my patients have been grateful for being saved. But for others compulsory treatment has become their recurring nightmare.

One does not know at the beginning how it is going to go.” Dr Ross Connan of the eating disorder unit at The Bethlem Royal and Maudsley Hospital believes most professionals recognise the distress caused by compulsory feeding. She says the pros and cons of such practice have to be weighed up before going ahead with it. “You can spend the whole day arguing with a patient on what they should eat. But there comes a point when a patient needs to be fed.” she concedes. “And often feeding works best when external control is enforced. Many severely ill patients find making the choice to feed themselves very frightening.”

Finally she acknowledges gloomily: “Patients have and will continue to feel they have barbaric experiences. “No body likes to be treated against their will, and inevitably it will leave people feeling trapped and helpless.” Meanwhile Holden, now 37 and with no outward sign of her anorexia years, believes her turbulent family relationships lay at the root of her eating problems and that doctors failed to talk these issues through with her. “Is there really a doctor out there who would stand up in court and support the hideous treatment I went through. Doctors without a proper understanding of anorexia should learn that they can make it worst.” A North Manchester General Hospital psychiatrist who knew Holden’s case chose not to comment.