Feb

28

Magazine Preview: In Class, In Treatment

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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.”

—Mariela Quintana
Illustration by Setenay Akdag

EDITOR’S NOTE: Names of students have been changed for their privacy.

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52 Comments

  1. hmmm  

    too long, didn't read

  2. really,  

    though, the amount of time it takes to be diagnosed by Columbia's system is entirely unacceptable.

    Columbia keeps its specialists hidden away behind a network of paperwork and inferior doctors, who are reticent to let you get in to see anyone actually helpful until excessive amounts of psychological screenings are performed.

    If either school wants to be effective in treatment, their services need to be more accessible, period.

    • ummm  

      Inferior doctors? They've been great since I've been here. What kind of specialist do these upper class 22 year-olds need, exactly?

      • Please  

        do not project your own class guilt onto this issue. These individuals need help, regardless of their economic status. Yes, we are privileged, but that does not mean this is a frivolous issue.

      • wow  

        when has anyone actually had a good experience with health services? every time I've been in, the doctors have practically drowned me in questions about if I'm depressed, practically ignored any real concerns, and then rushed me out when they realize I'm not, since that's the easiest diagnosis to make around here...

      • what  

        does economic class have to do with degree of psychological distress? I am pretty sure their brains are as susceptible to illness as everyone else's. do "privileged" people not get sick either? have some special "rich person" immunity?

    • I agree  

      CPS has similarly poor policies when it comes to other diagnoses as well.

      I am currently seeing treatment for severe depression and anxiety and it took over 3 weeks to get an appointment with either a counselor or psychiatrist. Getting an appointment is strangely complicated involving multiple steps and administrators. Granted, I'm no longer particularly suicidal, but had I been, such a wait would have been quite a problem. And the eight session limit is ridiculously short, nobody really can get anything done in that time, especially since sessions are only 40 minutes long. Just like the article suggests, most people I know do not try to navigate through referrals but just give up on their treatment. CPS never checks up on them at all.

      I don't understand why a university associated with both a medical school and a social work school has such a shortage of practitioners.

      • what?  

        When I hit the wall with major depression, it took a half week for me to see a counselor and a week after that to see a psychiatrist. You're often sped up the appointment ladder if you go into one of the residence hall office hours.

        • wow  

          that's impressively fast. I just called the appointment hotline to do it and yeah, they wouldn't give me an appointment for three weeks. even though I told them I had a history of suicidal thoughts during the phone interview.

      • word to the wise

        If you tell a professor that you're depressed, I'm pretty sure they can get the process expedited. Not that you should have to do things this way, but I've heard it works.

      • question  

        if you answer "Yes" to any of the "Suicidal thoughts" questions, do they make you take "time off"?

        • colt 45  

          i've had two stints with CPS. The first time, I was suicidal. It didn't take very long to get an appointment and I was consistently able to get regular appointments once or even twice a week. The second time around, I was merely depressed. It took me a month to get my first appointment and i would often have to wait 3 weeks between subsequent appointments. so, yes.

        • Anonymous

          This page should be helpful: http://facets.columbia.edu/voluntary-leave-absence-policy

          A medical leave of absence is one of the types of voluntary leaves that you can take (except in the case of an eating disorder, apparently). You can't be forced to take one. Columbia needs your written consent. I was very reluctant to take a leave of absence when I was dealing with depression/feeling suicidal, and no one forced me to. I didn't have a lot of contact with CPS until after I'd already declared my intention to take a medical leave of absence, so I wasn't asked the suicide question until then. It was during a sort of sterile interview over the phone that was supposed to determine whether my leave of absence was for medical reasons or not, so it was just one of yes/no check-the-box questions that was supposed to do that. I really, really doubt that CPS would make you take time off if you indicated that you were feeling suicidal (in fact, I wish they had been more forceful with me, for whatever that's worth). As an aside, though everyone has to decide what's right for themselves, I think taking time off when you're dealing with suicidal thoughts or other psychological issues is extremely helpful. I was worried that it would mess up my future or something, but it definitely changed my life for the better.

          • j2

            If I may ask, what kinds of things did you do during your time off? I'm taking a voluntary leave for similar reasons, but I've had a hard time making my time... salutary.

          • Anonymous

            The absolutely most important thing I did during my time off was see a good psychologist. I really didn't want to at first, because I come from a proud line of repressed Irish Catholics who drink themselves into oblivion instead of admitting their problems...so, getting over that hurdle was important. Just talking about it with someone who knows what the fuck they're doing can be really helpful. Never feel guilty about asking for help! You can ask your family doctor for recommendations if you're not sure where to go. If you're worried about paying for a psychologist/psychiatrist, Columbia lets you use the student health insurance plan during your time off. Also, if you're trying to work out what medications to take, just keep faith that you'll find a regimen that works. Also, staying in touch with friends (even when I kind of didn't want to) was important. Other than that, I kept a journal (to sort of get everything out and then feel like I could put it away - I typed it out and then put it in wingdings and hid the file) and I went hiking a lot. I also got a junky job once I stopped sleeping for like 20 hours at a time, just to get on a schedule and feel productive (I eventually quit because my boss was a fucking nutcase, but that's beside the point...). Lying around the house all day made me feel worse a lot of the time. Just try to do things that you enjoy and try to find new things that catch your interest and get you excited - I found that less cerebral things like hiking or cooking made me feel the best. Just take it one day at a time, as cliched as that sounds. It takes time, but you can get through this. Hope this was helpful

          • Anonymous  

            start small. anything to break the cycle of rumination and get you doing something. maybe something you've wanted to do, but never had time because of school or something. best of luck

  3. Anonymous  

    Very well written article. Barnard definitely has a big up on Columbia when it comes to eating disorder treatment. Unfortunately, this is an issue that we cannot be lacking expertise in.

  4. damn  

    we men gotta tell girls they're pretty as they are. they're told their whole lives (tacitly) that they're ugly. but like "Adam" said, it's about control, and eating disorders aren't about what guys think of girls.

    so girls, stop reading Vogue and talking shit on each other. it's killing you. and dudes don't find that attractive. i like my girls healthy-looking. with ass.

    lastly, can anybody explain why eating disorders are so much more prevalent among richer and whiter girls?

    • yeah  

      so true. and girls gotta stop the fat-talk. complaining about how you're going to "get fat if I eat this" is just making everyone feel bad about themselves.

      • mememe  

        they also gotta stop looking at these emaciated models all day. that is just gross. they all look like they're about to die and girls think they're actually good looking. it's boggles the mind.

        • colt 45  

          yes, because the blame should all be heaped upon the victims and not on the people responsible for putting those images out there in the first place. jesus christ.

          • you're right  

            i wasn't trying to blame people who suffer from this. but like any positive movement, it takes victims willing to rise up. as long as skinny girls are profitable, the media will utilize that image.

    • Throughout a life of ease, success, and admiration, they feel entitled to having an interesting problem or two.

    • hmmm  

      As much as I think that you were trying to pay a compliment, you just came off sounding confused and ill-informed. If "eating disorders aren't about what guys think of girls" then why would us ladies care about your taste in women. Like you started off saying, it really has nothing to do with what "dudes" find attractive.
      I also don't think that the disorder can be simplified to a strictly "female problem", since in my experience, I have known an equal amount of anorexic men as anorexic women. And let's not forget how excessive working-out can be another manifestation of the disorder that can be seen in both sexes alike.

    • Anonymous  

      because richer and whiter girls are usually the ones who can afford to seek treatment

    • Blarg  

      most lower class minority females have tough lives. they grow thick skin. they learn to not give a shit about having to be skinny. or they just have too much other shit to worry about.
      Plus, white culture is more focused on thin=pretty. In black and hispanic culture, being super curvy (what many white dudes would call chubby or fat) is sexy.
      Ehhh what do I know. just some thoughts.

      • Due respect...

        But, while on the surface eating disorders may be a body image issue, to link anorexia and bulimia exclusively to upper middle class white women's desire to be "skinny and pretty" or desirable to men is just plain ignorant. This is not merely a skewed perception, but a mental illness, linked strongly to desire for control and perfection. This perfection is not just physical, but also lies in the perception of perfected will power: not eating as a triumph of one's will, as a manifestation of one's power. This is part of why it is very common among women of a specific socio-economic background, who tend to feel driven towards perfection in their lives, social, professional, academic, or otherwise. However, if efforts in those pursuits fall short (please note, I am not indicating that a break-up or a B will bring on an eating disorder), diet, exercise, and net calories can be a way to recoup that control.

        And to those complaining about Darfur, you're right. This is a problem exclusive to the developed world. But, that doesn't negate the emotional or physical suffering that people with eating disorders undergo. I think it's a bit silly to try and compare the two, as though they are remotely similar phenomena.

    • your  

      and many other bwog commenters' knowledge of the psychology of eating disorders is astoundingly limited.

    • Anonymous  

      Oh, please. Get the hell over yourself. Body image issues are hardly things that can be solved just by putting down the fashion magazines. They're a problem that's been ingrained in our society basically since petticoats and corsets stopped being fashionable.

      And don't kid yourself into thinking that anorexia is caused by wanting to attract guys. What most eating disorders come down to are self esteem issues, which sometimes can outwardly manifest themselves as wanting to be accepted by the opposite sex, but are really about your own self-image. The fact that you as a guy like your girls "with ass" doesn't actually mean that much to a girl with a skewed sense of self.

    • shortsighted  

      Although the stereotypical profile for eating disorders are middle class white girls, recently girls of all ethnicities (particularly if they are middle class or upper middle class) are becoming more likely to have eating disorders.

      By limiting your concern to "white girls" you (and maybe even health practioners who think like you) miss out on the problems of these women because "black girls don't have eating disorders."

      This was a huge problem when I was trying to get help for my eating disorder two years ago. Shame on you for perpetuating these sorts of misconceptions.

  5. barnard anorexia survivor  

    Interesting article on the campus approach to treating eating disorders. As a BC senior who's dealt with an ED, I'd like to clarify some things:

    1) Eating disorders are NOT Just about the food, wanting to look a certain way or hoping to attract others. They are illnesses with genetic roots and often deep emotional causes, such as anxiety, depression, trauma...the list goes on. I can only speak to my personal experience with anorexia, and a lot of it had to do with an intense fear of not living up to my own unrealistically high expectations. I didn't want to take up too much space--physical or emotional, and, to over-simplify it here, basically didn't want needs.

    2) Barnard and Columbia are, as we all know, at times incredibly stressful. Thin is in, especially in NYC and especially in places like this where there is an unusually high concentration of over-achievers and perfectionists. The stress of coming to college is intense, and is a legitimate trigger for eating-disordered symptoms. Mine definitely escalated once I got here, and there needs to be a bigger movement on campus emphasizing loving your body and taking care of yourself. We need to start stressing moderation.

    3) The treatment options on campus are limited, but there are some great, affordable outpatient treatment centers close by, such as the Columbus Park Collaborative and the Institute for Contemporary Psychotherapy. You can find more treatment options at edreferral.com

    4) You CAN recover from an eating disorder!
    4)

    • to clarify  

      When I said that I didn't want needs, what I meant to say was that I didn't want to need anything, such as food, sleep, or friends. I basically lived off of adrenaline. Having an eating disorder is exhausting.

      Oh, and also, if you suspect that someone you know is suffering from an eating disorder, try to talk to them about it. The sooner someone with an ED gets help, the better

  6. thank you for this article  

    I am a junior in the college currently receiving treatment for an ED that kicked in my senior year of high school and took over my life my freshman year of college. The help I got at Health Services was a good opening start, but I didn't start receiving really helpful therapy until this past October. I have been through hell and back with this disease and hope that others can receive the help they need.

  7. Love Your Body Week  

    I think "Love Your Body Week" is a great concept and needs to advertise more especially on the Columbia campus.

    also, side note, there are eating disorders that aren't strictly Anorexia or Bulimia (Eating Disorder not otherwise specified= EDNOS). Although some dismiss this as not as serious, it is, and just as dangerous. So that friend who drastically restricts calories yet doesn't look bone thin is still hurting her/himself. That friend who doesn't eat dinner to allot calories for alcohol (and perhaps making her/himself throw up later) also has a serious problem. Basically dysfunctional behavior towards food is a sign.

  8. Anonymous  

    Look at all these comments! This is clearly a poignant issue and I am so glad to see a piece on it. Great job.

  9. LYBW Organizer  

    Thanks for your support about Love Your Body Week! The unofficial student organization that ran the past two LYBWs has not been running this year due to low participation rates, but I believe that the Furman Counseling Center will be holding some events. It's good to know that people are interested and support our cause!

  10. anonymous

    Knowledge of eating disorder psychology and epidemiology seems pretty limited in these comments.
    Eating disorders have been documented in developing countries as well, particularly China. The difference is that these are identified in the clinical community as "non fat-phobic" eating disorders based on different cultural influences. The symptoms and behaviors are generally the same otherwise. More evidence in favor of the side that says anorexia and bulimia are actual mental disorders that develop as coping mechanisms rather than something you can "catch" by watching a runway show.

  11. Anon

    No, classically recognized EDs are not seen in Darfur (though who is checking in Dafur for EDs is a good question) but you can bet that depression, anxiety disorders, and PTSD are prevalent.
    One mental disorder isn't more deserving of recognition than another- it's only the cultural context that can influence one particular disorder over another. The genetic vulnerability and problematic thinking styles that lead to mental illness remain the same in most populations. So if "white, rich" girls tend to get eating disorders, other groups tend to get other mental disorders.

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