“My ballet teacher warned me I’d lost so much weight my muscles were wasting away,” she says. She went from one treatment to another – including one-to-one counselling and family therapy. “I didn’t want to get better,” Zoe admits.
It wasn’t until December 2007 that Zoe, then 19, faced up to her illness and agreed, on the recommendation of her doctor, to spend four months at a new long-stay addiction rehabilitation clinic, Montrose Place in Cape Town. Founded by South African businessman and former alcohol and cocaine addict Johnny Graaf, it offers a new approach to the management of eating disorders.
Zoe, now 22, and a choreographer living in north London, is one of 100 patients from the UK who have been successfully treated for anorexia at Montrose in the past three years. The clinic boasts a 70 per cent success rate, based on follow-ups after one year for those who completed its 90-day programme. Now, it is about to open a centre in London to prepare patients for treatment in South Africa or to help them afterwards.
Some experts are holding up the Montrose method as a model for the future, elements of which should be adopted by the NHS. Consultant psychiatrist Alessia Ciani, a senior lecturer in eating disorders at Imperial College, London, who also practises at the Priory Hospital, has sent patients to Montrose. ''The clinical team is very good,” she says. “There is nothing comparable on the NHS. Funding in the UK does not allow residential treatment for anyone unless they are extremely ill with a BMI (Body Mass Index) of below 13 (20-25 is the healthy range). All other treatment is conducted via outpatients.’’
So what makes Montrose different? The centre rejects many of the traditional “boot camp” methods of treatment such as behaviour modification therapies, in which patients are “punished” for not eating. Instead, they are encouraged to explore their freedom. Therapy classes may occupy their weekday timetable, but at weekends they climb Table Mountain, try shark-diving, or do community work in the townships.
Equine-assisted psychotherapy is a cornerstone of therapy. “Being around horses requires patience, compassion and respect – all qualities which anorexics lose sight of,” says psychiatrist Dr Greg McCarthy, Montrose’s chief medical adviser. “Seeing horses respond to their behaviour helps the patients become more self-aware.”
Anorexia, which largely affects those between the age of 12-20, is a severe mental illness affecting 1 per cent of young women. About 10 per cent of sufferers are men, according to the charity Beating Eating Disorders.
Anorexics typically weigh less than 86 per cent of their expected healthy weight, with a BMI of 18 or under. They are terrified of gaining weight, and in denial about the long-term consequences of their behaviour such as osteoporosis, gastrointestinal complications and dental problems. The condition has one of the highest mortality rates and suicide rates of any psychiatric disorder.
It is tricky to treat because it often co-exists with other illnesses and addictions. Drug therapy, with anti-depressants for example, may not work, partly because the body needs a certain number of calories before it can start to metabolise the drugs. Cognitive behavioural therapy (CBT) or other “talking” cures may fail because many anorexics are often above average intelligence and can reason their way out of counselling,’’ says Dr McCarthy.
Yet while early detection and treatment are vital, and residential treatment programmes considered the gold standard by many clinicians, they are available to very few patients. Montrose, for example, costs £10,000 a month. The National Institute for Health and Clinical Excellence (NICE) continues to recommend that sufferers are treated as NHS outpatients unless at high risk of death, but perhaps it is time reconsider treatment strategy in the light of progress being made elsewhere.
Certainly, Janet Treasure, director of the Eating Disorder Unit and professor of psychiatry at Guys, Kings & St Thomas Medical School, believes there is room for improvement in the way the NHS manages such patients. However, she is not convinced that residential treatment holds all the answers. Some younger patients may become even more isolated, she says.
The therapeutic approach at Guys, she adds, has much in common with Montrose. “We use motivational techniques and lashings of affirmations to improve [patients’] self-esteem. We try especially to help the patients become less rigid in their thinking.”
Zoe says she still has bad days but that overall her life has changed. She believes that the in-patient programme was crucial to her recovery. “It gave me time to learn to trust the team,” she says. “There’s no final cure and the illness will always be there, but now I’ve got friends and get on well with my family. My quality of life has improved so much.”