Eating disorder care at Yale faces an uphill battle

This week marks the debut of a new feature in Herald News. Periodically, the Herald will provide additional information on some of the topics addressed in the previous week's cover story. Last week, the Herald ran a cover story on eating disorders at Yale.

For students at Yale struggling with eating disorders, Yale has a potentially crucial advantage, according to Professor of Psychiatry and Calhoun Master William Sledge. "Yale is in such a good position to be helpful because students have adults all around them who are experts in their fields and grownups who know how to deal with this problem," he said. Yet paradoxically, treatment of eating disorders at Yale often does not take advantage of all Yale has to offer. In fact, Yale University Health Services (YUHS) rarely directs students to a specialized treatment facility literally right in Yale's own backyard.

COURTESY OFFICE OF PUBLIC AFFAIRS Silliman Master Kelly Brownell, the director of the Yale Center for Eating and Weight Disorders, would like to raise awareness of the Center among undergraduates.

Silliman Master Kelly Brownell is the director of the Yale Center for Eating and Weight Disorders (YCEWD), a center devoted to research, training, and treatment that has been managed through Yale's psychology department for over 10 years. Despite the center's stated mission to "serve men and women who experience problems related to food, eating, weight, and body image," Brownell said students are almost never referred to the Center for treatment or even informed of its existence. "The fact is, there is a resource sitting right here that is not being taken advantage of," Brownell declared. "For the sake of the Center, we don't need more business; but as a college Master I feel in a bind, because the default path runs through [YUHS], yet I have seen cases where we could provide more specialized and effective treatment."

If YCEWD is indeed "internationally renowned, with excellent research and treatment," as New Haven therapist Linda Goodman asserts, why is it seemingly unrecognized by Yale's own treatment facilities? "I am not them, I can't read their minds," Brownell said. He suggested that because the Yale Health Plan is a Health Maintenance Organization (HMO), it may therefore discourage the use of outside resources such as YCEWD. "An HMO has to pay if someone goes outside to use other resources," rather than take advantage of the health plan's own offerings, Brownell explained.

Sledge pointed out that YCEWD's excellence as a renowned private center independent of Yale's own healthcare system can in fact be something of a built-in deterrent to those at Yale who could benefit most from its services. "Yale's total student medicine program is very well-versed," he explained. "It is inappropriate, I think, for the University to meet its responsibilities to look after students by referring them to an outside agency or group they are not in control of—this is shirking their responsibility, in a sense." In addition, while all Yale students are entitled to six months of free counseling through Yale Mental Hygiene, individual therapy sessions at YCEWD range from $75 to $100, constituting a substantial cost burden to students.

Lorraine Siggins, clinical professor of psychiatry and chief of psychiatry at YUHS, insisted, however, that the lack of referrals to YCEWD is because "we do all services in-house, and we feel we offer a comprehensive program." She explained that Yale's Mental Hygiene department takes an approach to its eating disorder patients that is both individualized for each student and at the same time characteristic of the department's approach to all its patients. "We discuss the individual treatment plan with the student, and we feel an integrated approach is best: we offer individual, and group therapy, we have on-site people who can prescribe medication, internists in the same facility, a nutritionist—we have a large enough staff to cover a wide range of conditions."

Siggins acknowledged that eating disorders are often complicated to treat because they potentially represent threats to the notion of "health" in the widest sense possible. In addition to very real physical consequences, those who suffer from eating disorders often carry a double burden psychologically, for anorexia and bulimia often coincide with other men-tal disorders. The American Psychological Association lists "affective disorders" such as depression and "anxiety disorders" such as obsessive-compulsive disorder as among the most common. Siggins pointed out that such a constellation of health concerns associated with eating disorders is why a comprehensive facility such as YUHS is especially well-suited for the task of "covering all health problems, whatever the condition."

Perhaps the greatest advantage of Mental Hygiene for students seeking treatment is its visibility to those helping students concerned about and coping with eating disorders. Freshman Counselor Christina Frey, SY '00, said that freshman counselors are given eating disorder awareness training as part of their preparation. She added, however, that "eating concerns are put in with mental health in general—we get a lecture on general mental health concerns, and we basically refer them to Mental Hygiene or ECHO (Eating Concerns Hotline and Outreach). She said neither the introductory lecture nor the manual of freshman counselor resources lists YCEWD as a facility to turn to for either treatment or consultation. Lauren Leikin, SY '00, director of ECHO, pointed out that "eating disorders are talked about in passing as a general mental health concern, but it does not yet seem to be recognized as the essential issue it is."

When it comes to the specific treatment of eating disorders, the whole is often greater than the sum of its parts. Olivia^* is a student uniquely qualified to discuss the intimacies of Yale's health services offerings. As a freshman who arrived at Yale with an eating disorder, Olivia's extracurricular activities centered around daily weigh-ins, weekly check-ins, electrolyte-level testing, blood and urine monitoring, and hormones to combat early-onset osteoporosis, courtesy of YUHS. She was finally hospitalized for a month at Yale Psychiatric Institute, and underwent subsequent repeated re-hospitalizations at YUHS's inpatient care facilities. Yet not once over the course of her entire journey through Yale's health system was she ever informed that there was a facility available to address the conditions specific to her disorder.

Olivia's case was relatively unique, however, in that she readily pursued treatment at all while at Yale. Hard numbers about the number of students suffering from eating disorders and the number of students seeking treatment at Yale are virtually unavailable, according to Brownell and Siggins. The Herald approached more than 10 people with eating disorders for this article, and of the students contacted, Olivia was the only one who pursued treatment. One of the hardest aspects to address with eating disorders stems from a basic problem with all mental disorders—for someone to accept treatment, he or she has to recognize that he or she has a fundamental problem. In the case of eating disorders in particular, Goodman pointed out that "an eating disorder is often used as a coping mechanism, and can take on a life of its own." While a person struggling with an eating disorder may recognize his or her emotional struggles and desire help, he or she may separate this from the desire to maintain certain eating behaviors and physical ideals, Goodman explained.

"It is extremely difficult to make someone get psychologically better," Goodman said. Brownell added, "We can encourage people to seek treatment, but the decision is ultimately theirs." A student struggling with eating problems can resemble something of a Venn diagram, with overlapping circles representing cultural ideals, family dynamics and mental history, food and self-esteem anxieties, and traits that often characterize many eating disordered patients. Trying to anticipate an effective approach to treatment makes consistency difficult. Dean of Student Affairs Betty Trachtenberg explained that the Yale College Dean's office is often approached by residential college Deans, Masters, and students seeking guidance or treatment recommendations. She said such concerns are "dealt with on a case-by-case basis, because each is different. If you have a mechanical way to deal with these things, many will fall by the wayside." However, Brownell pointed out, "What is much more common than a student who is obviously in immediate physical danger is the type of disorder that affects well-being and daily functioning. If you ask females about this, my guess is they will say Yale has done pretty much nothing systematic about this."

While it may not be systematic, Yale's administrative safety net of treatment and care efforts is similar to its treatment programs in its piecemeal approach. "The Dean's office responds to all aspects of a student's illness, and we take eating disorders very seriously," Trachtenberg said. She explained that the Dean's office maintains contact with YUHS and Mental Hygiene; advises residential college Deans, Masters, and students; and is now beginning to work with student athletes. Trachtenberg also announced that she and a college Dean will soon meet with various team captains to discuss eating disorder awareness. She noted that the psychology department and members of YCEWD with whom she has worked have been extremely helpful, but conceded that the Dean's office does not currently draw upon YCEWD's facilities and research staff on a consistent basis. "My office has not done that proactively, but this is something we should perhaps think about doing," Trachtenberg conceded. Freshman counselor and ECHO staff member Lisa Kinney, ES '00, explained that the fundamental difficulties of finding adequate treatment may be independent of Yale itself. "It's hard to know where Yale could really step in further—the first step is really getting people into any kind of treatment in the first place."

*Name has been changed to protect anonymity.

FACTS AND FIGURES ON EATING DISORDERS AND TREATMENT

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