Magazine Preview: In Class, In Treatment
Written by Bwog Staff
Columbia and Barnard have different administrative strategies when it comes to students with eating disorders. In this article from the upcoming issue, The Blue & White explores those differences by talking with the students who have navigated them.
“When you arrive on campus as freshman, you’re keenly aware of your freedom, but when you arrive on campus with a history of an eating disorder, you’re keenly aware that no one’s watching you,” says Alisha, a Columbia College junior with a history of anorexia. “You’re away from parents and that close intimate, network of people who can monitor your mental and physical health on a passive, day-to-day basis.” Columbia has never been known as a particularly nurturing environment for fragile students, but the sudden freedom of any college environment can exacerbate preexisting eating disorders. Every school must devise a strategy to handle students who suffer from them—treating those who can be treated on campus, advising and sometimes forcing leave for those who cannot be.
Inside and outside of the academy, the treatment of eating disorders is discussed in a somewhat standardized language of cases, management, units of weight, and concurrent programs. The common terms allow for what Dr. Julia Sheehy, associate director of the Counseling Center and head coordinator of Barnard’s Eating Disorder Treatment Team, deems the “absolute necessity of collaborative care, especially when there are questions about a person’s medical status or a person who is very symptomatic or at a very low weight.” The team strategy has the advantage of addressing the many aspects of a patient’s life that might be affected by an eating disorder—from their medical and mental health to their academic and social habits.
The typical roster of an eating disorder treatment team includes four to five key players—the therapist, the psychiatrist, the nutritionist, the medical doctor, and, of course, the patient—and can be compared to the starting line-up of a basketball team. Instead of fending off an eating disorder using aggressive man-to-man defensive strategies, an eating disorder team uses a zone system of defense. Each player focuses on an area of the disorder, but cases vary—some require more defense in one area, and some require overlapping, coordinated counseling between one doctor’s office and the next. The players on the ED team may also shift their tactics according to the developments of the patient. “We design the treatment to the patient so that it changes as their symptoms change,” says Dr. Marjorie Seidenfeld, the medical director of Barnard Health Services. “As a team, we set goals with the student and we all work together to make sure we’re all on board with those goals.”
Like Barnard, Columbia Health Services tackles eating disorders using the team approach. Though both Columbia’s doctors and Health Services administrators declined to discuss their program in detail with The Blue & White, the information that Columbia Psychological Services and Health Services make publicly available indicates the coordinated involvement of medical doctors, therapists, and nutritionists in the treatment of eating disorders. Both schools, however, acknowledge, either implicitly or explicitly, the limits of any on-campus treatment program, which are by definition short term. Seidenfeld feels that the medical coverage Barnard offers students with eating disorders is comparable to the care they might receive at an out-patient facility off-campus. But her colleague Dr. Mary Commerford, director of the Barnard’s Rosemary Furman Counseling Center, is quick to acknowledge the limitations of the Barnard program: not only must students leave campus for any in-patient care, any out-patient help that Health Services can provide is by definition “a short-term basis of care.”
Columbia’s program for students with eating disorders is also time-limited. Columbia Psychological Services offers only eight sessions to students before referring them elsewhere on the condition that a Columbia therapist deems them stable. What is defined as “stable” is unclear; Ruthie, a 2009 Columbia College alumna with a long history of anorexia, for one, was assigned a therapist at her first visit to CPS for anorexia who told her, “We’re here for you. There will be eight sessions and then we’ll refer you out.” Ruthie made progress over the course of the eight sessions and remembers her counselor as “incredibly helpful” and someone with whom she might have developed a relationship over time. After the cursory eight session limit, however, the counselor informed Ruthie “We don’t think you’re in such a bad place that you need serious care.” After her final session, CPS never followed up with Ruthie.
Barnard’s Furman Center limits its patients to 10 therapy sessions, which Dr. Commerford explains is necessary “because there is such a high demand for what we do and we want to see as many patients possible.” CPS wouldn’t comment on its eight session policy, but Alisha, who has recently been diagnosed with bipolar disorder in addition to anorexia, assumes that the explanation is the same. “CPS is so over run with students,” she said, “It’s is wonderful that so many people are going, but it’s impossible to get appointments.” Despite her enthusiasm for the services CPS offers, she sees the session limit as a Catch-22, “they need to expand the offices and increase their staff, the more people who can get help the more chances we have from losing people to their psychological instabilities, to leaves of absences, or even suicide.”
If Barnard or Columbia doctors judge a case as serious enough, the last session may lead to more than the recommendation of another therapist. In extreme situations both schools can force a patient to take an involuntary leave of absence. By and large, Barnard and Columbia only require involuntary leaves of students who have violated university policies academically or legally, but the administration may force students who are at imminent medical or psychological risk to take leaves as well. Involuntary leaves of absence for psychological or medical reasons fall under the same umbrella policy at Barnard, and are implemented only if a student is “unable to receive reasonable institutional care, if she is a threat to the safety of herself or others, or if she is disruptive to the normal college activity in such a way that the community itself is harmed,” said Barnard Dean of Students Karen Blank.
Students suffering from eating disorders at Columbia, however, are subject to a special category of involuntary leave, “Required Medical Leave for Students With Eating Disorders.” No one at Columbia would discuss the specifics of the targeted form of leave, but Columbia’s Essential Policies Web site states that involuntary leaves are usually implemented when a student requires hospitalization or medical treatment beyond what is available on campus, or when the student is disrupting the learning environment of the university. These criteria are markedly similar to the those found in Barnard’s single, broad policy for involuntary leave. But Barnard’s Dean Blank, a copy of Ourselves, Our Bodies resting on her bookshelf, emphasizes that “we try very hard not to suggest that some sort of illness is better or worse, or that one reason for taking a leave is more legitimate than another.” The question of why students with eating disorders are singled out at Columbia remains.
Alisha, who took a voluntary leave of absence last year to focus on her mental health, understands where the policy is coming from. Taking leave helped her get back on track, and today she would recommend that any student with an eating disorder at least consider taking leave. She explains that leave can be the best option because in order to treat eating disorders specifically, “you have to make sure the body is physically healthy before you can start tackling the mental issues, and sometimes we don’t have the resources to do that on campus. Sometimes it might be in everyone’s interest for a student not to be on campus.”
As Alisha says, in some extreme cases, leave may be the most appropriate course of action. Columbia’s dean of students Kevin Schollenberger confirms that “these situations are rare and only occur after consultation with student affairs and health services staff, the student, and the student’s family.” But the rigid policy with which Columbia singles out students with eating disorders is indicative of a larger trend—despite employing a potentially versatile team approach to treatment, the Eating Disorder Team of Health Services at Columbia follows a rather formulaic procedure for all students suspected of having an eating disorder.
Ruthie, for example, who scheduled an appointment at CPS when her anorexia symptoms were the worst they had been since she was hospitalized in middle school, was permitted to disappear into the murky world of outside referrals after completing her eight sessions. By that point, her weight, though low, was not low enough to merit more treatment. Her extreme fear of gaining weight had not abated much by the end of her treatment at CPS, but she never did see the doctor CPS referred her to outside of the university, and CPS never followed up to ask if she had.
The use of the patient’s weight, more specifically their Body Mass Index, to determine the seriousness of an eating disorder produced the opposite effect for Mara, a Columbia College sophomore who scheduled an appointment with Health Services after unintentionally losing weight. She wanted to make sure that there was no underlying reason for the weight loss besides stress and a recent run in with the flu, but after being weighed upon arrival at Health Services, a doctor began a litany of strange, seemingly unrelated questions: “Do you get frequent headaches? Are you often cold? Are you aware of how low your BMI is?” Mara has never displayed any of the behavioral characteristics of an eating disorder, but at the time her BMI was low enough to merit in-patient clinical treatment. “I felt like the doctor wasn’t even listening to what I was saying. She wouldn’t even look up from the form,” Mara says of her medical evaluation last semester.
The doctor explained that she had to rely on these empirical questions despite Mara’s assertions because students with eating disorders deny their illnesses in initial stages of treatment and cannot be trusted to evaluate themselves accurately. Her options were clearcut, Mara says: “You either get on board with our program or we’ll refer you to an in-patient treatment center.” Before Mara could even comprehend that the doctor was alluding to a leave of absence, “she began telling me which treatment centers she thought would have empty beds,” Mara adds. Medical records and a family doctor eventually attested to her natural thinness and Health Services dropped the option of involuntary leave.
Part of being “on board” with Health Services’ “program” involved signing a contract which required Mara to gain a set number of pounds per week, in addition to seeing a doctor, therapist, and nutritionist regularly. Mara was uncomfortable signing a contract, but she was even more uncomfortable taking a leave of absence. “I felt like I didn’t have very many options,” she said.
Barnard’s eating disorder team approaches students with a completely different ethos. Dr. Sheehy takes pride in the care her team provides, but she stresses that a student may wish to pick only one piece of the care package they offer. “It’s not my job to impose my recommendations on the students,” she said. “People are free agents and they need to find out for themselves what their needs are.” When talking to a patient about her options, Dr. Sheehy says she always tries “to emphasize to them that they’ll feel better about themselves, less irritable, and less depressed when they’re nourishing themselves.” But even before offering a package to a patient, Dr. Sheehy maintains that, “We do things on a case by case level for each student as opposed to having broad policies that immediately apply to all students with eating disorders.”
Unfortunately, when discussing eating disorders and psychological problems which in extreme cases can lead to death, a less rigid, more sensitive system is also a more risky one. Though Barnard’s self-described “individualistic” process may better identify which students are most in need, failing to impose any aspect of a plan for recovery on a student with an eating disorder is inherently dangerous. One could argue that sending anyone who has admitted to or been suspected of an eating disorder out into the world with a referral after eight or 10 sessions is risky as well.
Forced leave is designed to attenuate the risk, but policies like Columbia’s can sometimes have the opposite effect. Alisha, a staunch supporter of voluntary leave to deal with eating disorders, worries that the practice of forcing students to take leave might keep them from seeing treatment in the first place. She also worries that students might not take voluntary leave if the university is sending the a rigid message of intolerance for students with eating disorders. “They’re worried they won’t be able to come back because the school will see them as a liability,” said Alisha. Sonya, a Columbia College senior, also feels that many students with eating issues like herself might avoid going to Health Services of CPS because of a fear she once had of rigid, standardized treatment: “I was worried that they would try to simplify what I thought was a complicated issue; that instead of working with me, instead of listening to my own explanation of what was going on, they would impose their own clinical views, their own prescriptions.”
Columbia’s rigid approach to eating disorders can be discouraging and often unhelpful for those who don’t perfectly fit clinical definitions. But Columbia also doesn’t take any risks. Barnard’s drastically different individualistic approach is not only tailored to individual students, it also gives a good deal of control to the individual student who may be in no place to make good decisions about their own health. Adam, a Columbia College sophomore with a history of anorexia, emphasizes that treating eating disorders is difficult regardless of clinical approach. Many people with eating disorders cling to their symptoms because controlling their weight gives them a sense of control over their lives, he says. “You don’t want to be forced to surrender control, and you don’t want to be forced to recognize your problem.” Often “if a doctor tries to convince someone that they have an eating disorder, they’re not going to listen, they’re just going to get angry—at the doctor, but primarily at themselves, and that’s only going to intensify the problem.”
But still, Adam does not approve of Columbia’s rigid policy, especially the special policy of involuntary leave for eating disorders: “You don’t want to be forced to surrender control, you don’t want to be forced to recognize your problem, and being forced to take a leave of absence is forcing you to do both. If you’re at Columbia and you have a lot of drive and then someone comes along and says ‘you’ve got an eating disorder, you’re out of here,’ you lose everything that you’ve been working so hard to get here for. That could only cause someone to massively break down.”
Illustration by Setenay Akdag
EDITOR’S NOTE: Names of students have been changed for their privacy.