As eating disorders on college campuses become more prevalent, the demand for effective on campus assessment and treatment is equally growing. It has been a standard in the eating disorder community to form a team of a doctor, nutritionist, therapist, psychiatrist, and parents to encircle the eating disordered client. But university students are difficult to keep in the circle so mimicking the team approach conveniently on campus is becoming a way to meet everyone’s needs.
Colleges and universities across the country are expanding health centers to include more mental health resources. And teams of professionals need to work together sharing information to treat the whole student and not just pieces of that student, says A.J. Rubineau, M.D. of Cornell’s Gannett Health Services. When a student comes in with a random complaint that signals a potential eating disorder, the person who sees that student first will alert the team and refer for additional evaluation to gather as much information as possible to get the best understanding of that student.
This is the premise behind Cornell’s overall health care philosophy that underlies its successful integrated team approach to working with eating disordered students.
Rubineau and her colleague Carolyn Hodges Chaffee, M.S. RD, presented details of Cornell’s flagship model Friday at the Renfrew Foundation Eating Disorders Conference in Philadelphia. Their program is becoming the benchmark for other college and university health centers and they were happy to share particulars of it which includes one physician, one physician’s assistant, six therapists, one psychiatrist, two nutritionists, 1 athletic trainer, and rotating therapist trainees.
At its core, the Cornell program, depends on shared medical and session notes, 90-minute weekly team case management meetings, collaboration with athletics and administration, and individual “hooks” that personalize treatment for each student.
“College is a perfect storm of eating disorders,” Rubineau explains, and all of them are different.
These students have histories of bulimia and anorexia or develop them at college after a break up, separation anxiety, or the chaos of freshman year when they haven’t slept for three days and have no awareness of what to do next without parental oversight. And then there are sororities, high risk groups sometimes known for group binge/purges. The numbers are scary. National Eating Disorder Association statistics show 25 percent of college girls binge and purge to lose weight, use laxatives, or restrict in some form.
Rubineau says the team has to get aggressive at times to save the student’s life including recommending the student take a leave of absence from school to focus on health and weight restoration in an in-patient facility or with intensive outpatient and group treatment which usually meets 3 times a week for 3 hours each time.
Rubineau says the “hook” is a way to get the attention of students, families, and even administrators from time to time when treatment compliance is iffy. If the student is an athlete, promoting optimum health for optimum performance frames the argument towards weight restoration. The team will work with the coach or trainer to assist in compliance. If the student wants to travel abroad, getting gastrointestinal issues under control can make the experience more satisfying. Assistance from the study abroad department might be required.
Sometimes a “hook” has to be clever - like getting an administrator to help facilitate a leave of absence by suggesting to him or her the college could be violating national guidelines by allowing an unhealthy student on campus. Or, convincing the student that treatment will be easier now rather than later when they have a job, loans and rent to pay after graduation, Rubineau says.
This approach often works to get the student invested in treatment as if it were their own idea. The team then serves as facilitators to the student and their families as they navigate through the mental health treatment options while keeping the link between external treatment and the university support system strong.
A testimony to the benefits of the team approach is documented in the Fall 2013 issue of Cornell’s quarterly magazine, EZRA, in a story about a student who credits the multi-disciplined team with saving her life. The student had lost more than 20 pounds by the end of her sophomore year and her left foot became numb and weak. She went to Rubineau and her team for evaluation and was told the numbness was due to the absence of fat around nerve endings on the bottom of her foot causing “dropped foot” syndrome. The loss of fat was attributed to restricting food and eating disorder treatment was recommended. The student denied having an eating disorder, resisted additional help and left.
Afterwards, because the “integration” concept is alive and well throughout campus, Rubineau and the team received concerned calls from a range of faculty and friends alarmed by the student’s frailty and fearful she could die. The calls provided leverage for Rubineau to insist on a follow up meeting at which point the student was convinced to admit herself into an inpatient treatment center. Today, she is recovered from her eating disorder, graduated from Cornell, and has a master's degree in clinical nutrition from Columbia.
A “dropped foot” may have been treated as a single complaint had a team not been in place that could recognize the scope of this young woman’s distress. Together the team identified a more severe, life-threatening issue and set to work getting her help and supporting each other in a very complex health crisis.
The 23rd annual Renfrew Center Foundation Eating Disorders Conference runs through Nov. 10 here in Philadelphia. Diane Girardot, a Chester County based psychotherapist and health care journalist, will blog daily from the conference that this year focuses on complex patients, treatment variations, and the essential role of wisdom within the therapeutic relationship.
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