October 29th, 2023

Broken Recovery: Eating Disorders at Harvard

By Julian J. Giordano

Read the article here:

“Please eat something,” she said.

My friend meant well. Eyes widened in a stunned fury that could have burned holes through my stomach, I knew she was yelling at me because she cared.

But at that moment, I felt like crawling into the wall. Letting it absorb and freeze me in its time capsule until the moment I was ready to deal with this conversation. I didn’t have a problem. Why couldn’t she see that? Why was it any of her concern in the first place? Fine, I might’ve skipped a few meals when I was busy, but I hadn’t entirely stopped eating.

“Okay. Okay,” I replied, grabbing the first thing in sight — a granola bar — to get her off my back.

I ignored her as she enumerated the extensive list of possible side effects of eating disorders. I knew them all too well already.

I didn’t like the implication in her voice that I wanted to be this way. I didn’t want to be this way. Every time I didn’t eat for a day, it got harder to eat the next day. Every time I didn’t like the options in the dining hall, it was harder to force them down for the sake of having something in my stomach. Every time I woke up feeling unwell, on the precipice of vomiting, it was harder to keep anything down when I finally ate. I didn’t want to be this way. It was just easier.

That’s how I felt my whole first year of college. Trapped between what my mind was telling me to do and what my body needed.

I realize now that, as isolated as I felt, I was not alone.

A 2013 survey found that an estimated 10 to 20 percent of women and 4 to 10 percent of men in college struggle with eating disorders — an underestimate due to low reporting and difficulties developing identifying criteria. Comorbid with many mental health disorders, eating disorders can have lifelong, even fatal, health consequences.

Michael Daly, a researcher who published a study in 2022 examining changes in eating disorder trends since 2013, found that the prevalence of eating disorders has only gotten worse. Eating disorder risk on U.S. college campuses has increased from 14.9 percent to 28 percent in the past decade. Much of that increase occurred during the pandemic.

Disordered eating is not an issue that’s unique to Harvard, but it is one that’s complicated by the current state of visibility and resources at the College.

I set out to write a piece about eating disorders at Harvard; how they manifest and the discourse surrounding them, but I was afraid no one would be willing to speak with me on such a sensitive and deeply personal issue. While the College and its student-led peer counseling group, Eating Concerns Hotline and Outreach, do not share how many cases of eating disorders on campus are brought to their offices, I was pleasantly surprised with the number of people who were willing to share their stories. They gave me the strength to share my own story and assurance that it would resonate with others. In my research for this piece, I talked to many people who struggled with the exact same things I did. From anxieties about eating in Annenberg to busy schedules to specific dietary restrictions, one of the most essential tasks of daily life — nourishing ourselves — became a recurring difficulty for all of us. They’ve shared with me their frustrations, but also their progress, their solitary and self-directed recoveries, and the people who helped or hindered them.

For this scrutiny, I also met with professionals to talk about the larger social changes that factor into eating disorders more broadly; I decided to focus not just on the ways that students are hurt by the systems and culture at Harvard, but also on how the College fails to address the problem holistically.

College spokesperson Jonathan Palumbo did not respond to a request for comment.

Not Enough Time

At the time of our interview, about four weeks into the semester, Violet, who has been given a pseudonym to protect her identity, estimates that she had eaten approximately 10 meals in the dining hall.

“I’ve always had a weird relationship with food,” Violet begins.

“I feel like I just had a weird rhetoric around food at home,” she says. “I remember when I was in like third grade probably was the first time that my dad pointed at my body and said, ‘That does not look right.’”

Starting in middle school, Violet would go through periods of time where she didn’t eat anything or ate significantly less than she should have been. But they were always temporary, and she could usually self-correct her eating habits. Self-correction became more difficult after she arrived at Harvard.

She found the food unappetizing. Coupled with the way those around her approached eating — rushing to finish their plates — she learned to see eating as a chore, not as something she should want to do. As her desire to eat decreased, she found it harder to motivate herself to go to the dining hall.

Without the routine of sitting down to meals with members of her family, and no luck coordinating the busy schedules of her friends, she started skipping meals to avoid eating by herself.

“I ate a lot of meals out of the vending machine,” she says. During the second semester of her freshman year, she was primarily sustaining herself off of a stockpile of snacks in her room. It was at this point that she realized her eating habits weren’t healthy. Yet they would only continue to get worse.

Due to concerns about her gut health, Violet saw a gastroenterologist at the beginning of this year and was informed that she had digestive issues, prompting her to enact several dietary restrictions on her eating habits. Because of her restrictions, her food options became even narrower.

Violet scheduled an appointment with Counseling and Mental Health Service, but she ended up having to cancel it as a result of her busy schedule. Currently, she feels herself to be stuck in a bind.

“I don’t have time to fix that or even really think critically about that because I just don’t have time, period,” she says.

I know the feeling she talks about well — the desire to reach out for help but the inability to find time. I struggled to manage my schedule freshman year — until my selective ignorance of my health brought me to a point where I had no choice but to seek help.

By the time I woke up for my 9 a.m. class that Thursday morning in freshman year, I was already late. I tried repeatedly to get up, each time feeling the onset of waves of nausea and dizziness. I knew it wasn’t typical morning tiredness. My body was being weighed down by invisible cinderblocks and any energy I had left to fight back was draining quickly.

Something felt very wrong. I’d like to believe that I sensed how much I needed help, and that’s why I went to Harvard University Health Services. The truth is, I was a frightened freshman who had missed an important class, and I needed a medical excuse to explain my absence. I called the urgent care number at HUHS expecting them to schedule me for some time later that day. Instead, they told me that if I came now, they could meet with me right away.

I still have no idea how I managed to drag myself to the Smith Campus Center. It took every last ounce of fight I had left in me, and I remember collapsing into the chair of the waiting room as soon as I could. I had no idea what to expect. Every other time I’d been to HUHS, they’d sent me on my way back to my dorm with no more than a piece of paper telling me to drink tea.

The doctor did a few typical procedures to medically evaluate me, but they came up clear. Still looking for an answer, she started asking me a series of questions. My answers were all normal.

“When was the last time you ate?”

I don’t remember how I answered this question. Knowing me, I was probably torn between telling the truth and watering down the facts just enough to not raise any major red flags. She left the room and returned carrying Gatorade and snacks.

She asked me if I wanted a referral to CAMHS. I was nervous at first. Hadn’t I already missed enough classes that day? I didn’t have the time to go sit in the CAMHS waiting room. But every time I would try to say a version of “not today,” I saw her face wrinkle with concern.

I gathered my courage. This could finally be my chance. I had tried scheduling appointments with CAMHS before but always had to schedule them so far in advance due to their high demand. When the time came around for them, I would have conflicting commitments.

The doctor accompanied me to the elevator, taking me to CAMHS and only leaving me once I was sitting in the waiting room with a confirmed appointment. It was empty. I felt like a child — someone who needed to be taken care of, someone who needed to be watched carefully.

I sat there for hours. As the time ticked closer to my 1:30 p.m. lecture, I wondered if I should just give up and go to class. No, I have to see this through.

‘Just a Really Dysfunctional System’

My struggle with disordered eating started long before I arrived at Harvard.

I must have been in my freshman or sophomore year of high school the first time I tried laxatives. I believed they would help me — or at least that’s how I rationalized it. Now, about five years later, all I can do is look back with the knowledge I’ve accrued over time and paint my past mistakes as mysteries to my own mind. Maybe it was because it came from the mouth of a friend, rather than a slick-haired salesman I could see coming from a mile away.

My friend, my best friend at the time in fact, casually mentioned a kind of drink, which I didn’t even know could be categorized as a laxative. I didn’t think anything of it. It was just another weight loss tool — like all the other pills and teas that inundated my Instagram feed accompanying beautiful faces set with perfect teeth. I didn’t know that the abuse of laxatives and diuretics was a symptom of bulimia nervosa.

But no matter how much I try to plead naivety, looking back, I feel the shadow of accountability. It stands behind me, placing its hand on my shoulder in a gesture only I can feel. It feels wrong somehow to talk about the pain I’ve endured when I also feel like the catalyst.

It would start with a burning. A singe so deep in my gut I might mistake it for period cramps. The pain would build until it radiated through my body, and hunched over, I would grasp at my bed railings, the table, anything to help me along. I would wait until the pain washed out of my body like a wave so smoothly I almost forgot it was there in the first place. I forgot that pain is a sign something is wrong.

But before I knew of the pain, I was listening to my best friend describe how she’d miraculously managed to lose weight without exercise. Always one for a shortcut, I trusted her. When I put my trust in her, I should have realized she could be just as misguided as me.

If eating disorders are contagious, mimicry is their mode of transmission. They’re passed on from idols, caregivers, and friends.

When I spoke to Elena, whose name has been changed to protect her identity, I realized I wasn’t the only one whose struggles had been amplified by the influence of a close friend.

A 2019 study found that friends are more likely to exhibit “body image concerns and disordered eating habits” that are similar to each other.

Elena doesn’t label her circumstances as an “eating disorder” per se, but she does acknowledge that she has exhibited disordered eating symptoms.

She never felt comfortable enough to reach out to a professional, but while locked down at home during the pandemic, she says she began to lose perception of time. Days would blend together, and she didn’t notice she wasn’t eating.

“I guess I was always struggling with mental health issues. And then when all of a sudden my entire community was cut off from me, I just decided to almost unplug from the world,” she says.

She’d wonder at times why she felt so awful, but without the normalcy of her daily routine, she was missing a crucial support system to help her recognize and overcome her situation.

When she entered college, she became more aware of her disordered eating habits. But her awareness did little to prompt a change.

It was easy, at first, to skip meals without drawing any attention.

“No one had noticed. I didn’t want anyone to notice,” she says. Since it wasn’t something she discussed with anyone, she never felt pressured to take steps toward recovery — that is until a close friend of hers started exhibiting some of the same behaviors.

“Then all of a sudden, this person who I spent a lot of time with, who was also struggling with disordered eating, started making their health linked to mine.”

They would text her regularly, asking to go to the dining hall together. Her friend only felt comfortable going to the dining hall if accompanied, and if Elena was unavailable or had already eaten, they wouldn’t eat at all. According to Elena, the dining hall structure was an obstacle for three main reasons: the pressure to take excessive amounts of food as you go through each station, the temptation to compare your own plate to that of others, and the inconvenient hours.

As Elena struggled with the ups and downs of her disordered eating, her friend mirrored those ups and downs, too.

“It was very emotionally taxing to feel like someone’s mental health was relying on my mental health, which was not stable,” she says. Elena began speaking to her Peer Advising Fellow one day, not about her own eating habits, but about those of her friend. Her concerns were taken up through several levels of administration and culminated in her friend being taken to the hospital.

“That was also then served as a wake-up call for me of, ‘You can’t go down that hill,’” she says.

Throughout the entire process, Elena also came to the realization of exactly how many levels of administration she had to go through to seek help for her friend. After telling her PAF, they told her proctor who told her resident dean who told the College dean who then talked to CAMHS.

“Why am I waiting for like the seventh email chain before I can really figure out a concrete step?” she says.

Elena explained to me that even once it was determined her friend needed to be hospitalized, the next steps were not made clear to them. Though they were told an ambulance would come to pick up Elena’s friend, they decided that they would Uber to the hospital instead. When they called CAMHS to inform them of that choice, they were told a police officer would come to escort them. The police officer never showed up.

CAMHS did not respond to a request for comment.

“Never, at any point, did I feel like they didn’t care. It was just more so, this is just a really dysfunctional system,” she says.

When I asked her if she had ever considered reaching out to resources regarding her own disordered eating after this incident, she explained to me that she had tried reaching out to CAMHS in the past — not for disordered eating, but for broader mental health concerns — and felt too much like the process of getting an appointment was completely self-directed.

“If I’m doing everything anyways, let me just do it on my own,” she says. So that’s exactly what she did. Elena started researching mindful meditation-based training, read up on Cognitive Behavioral Therapy, and began using an over-the-counter serotonin precursor called 5-HTP.

Hannah L. Niederriter ’26 has also created that stability for herself. Throughout our conversation, she lists all of the various ways she’s taught herself to self-regulate. She’s learned to self-therapize too, preferring to process her emotions by herself first before turning to her friends.

Niederriter can’t pinpoint a moment when her struggles with eating became urgent; for her, it was more gradual. In elementary school, she was dealing with stressors at home, bullying at school, and depressive symptoms.

“I can’t pinpoint a specific day, but towards the beginning of when I started having eating concerns, I did have a couple suicide attempts. After that is when I really started to check in with myself more because I recognized the reason I ended up in that situation is because I wasn’t checking in,” she explains. “Around that time I started developing an interest in becoming a psychiatrist. Wanting to be the person that wasn’t there for me.”

Niederriter has found other outlets: she loves to paint, she loves video games, she loves the openness of the queer community she’s found at Harvard. “My favorite thing to paint is people. Being able to capture what some might consider imperfections, but other people might consider beautiful. I think there’s something really beautiful about that. People are so expressive and there’s always more to a story, and there’s always more to our story. So I liked the idea of being able to translate that to a campus.,” she explains.

While Niederriter, through her self-direction, has gotten to a place where she can share her story honestly, she notes the silence at Harvard at large.

“I think body dysmorphia can be very prevalent on a campus like this if you don’t really see a lot of people that are open about struggling with eating concerns,” she told me as I began asking her about how her experience changed when she got to Harvard. “I’ve had a conversation with maybe two people here about eating concerns, and that’s it. I feel like it’s not discussed at all, really.”

‘Difficult Question to Answer’

My conversation with Daly, the researcher who studied the increasing trend in eating disorders among U.S. college students, is the first time I hear about the SCOFF scale. A measure used by researchers to identify and measure the prevalence of disordered eating symptoms, the SCOFF scale is composed of five questions pertaining to behaviors of disordered eating.

He sends them to me.

Do you ever make yourself sick because you feel uncomfortably full?

Do you worry that you have lost control over how much you eat?

Have you recently lost more than 15 pounds in a three-month period?

Do you believe yourself to be fat when others say you are too thin?

Would you say that food dominates your life?

I think about where I was two years ago. How many of those questions would’ve elicited a “yes”? Daly surveyed almost 270,000 students to find out their own answers. Many of the students who affirmed his questions may have never found themselves comfortable addressing what they had as an eating disorder, or seeking a diagnosis. But Daly isn’t measuring the number of diagnosed eating disorders on campuses.

Instead, he used these questions to measure behaviors that lead to or indicate an eating disorder. His study’s figure of 28 percent, then, represents not just those who are self- or medically identified as having an eating disorder, but the percentage of college students in the U.S. who exhibit disordered eating behaviors.

Daly found that eating disorders appear to be increasing across all demographic groups — regardless of age, sex, race, or ethnicity. Given the significant increases he observed in his data, Daly wondered if another factor might also be at play.

“One question we have on this is whether there has been a change in how people respond to survey questions, if there’s more mental health awareness, more recognition of symptoms,” he says. But that doesn’t seem to be entirely the case, according to Daly. He cites two recently published papers tracking emergency admissions for adolescents with eating disorders, suicide-related issues, and other mental health issues. “Those two papers are essentially saying, it’s not all just some sort of self-report bias, we’re seeing similar trends in emergency department visits.”

When I ask him what might be driving the upward trend in disordered eating, the first factor he mentions is the rising rate of anxiety and depression since 2008.

In addition, he cites a growing body of evidence linking academic pressure and social media to the rise of disordered eating. These connections are more tenuous and difficult to measure, according to Daly. In the broader field of eating disorder research, the correlation between social media and body image is still an open question.

“When we do survey work, we tend to ask people, how many hours did you spend in the last week on social media? And it’s an incredibly difficult question to answer,” he explains. Self-reported times are often significantly different from data collected directly from phone tracking, he tells me. And, he says, it’s not always clear whether the hours on social media necessarily contain content that would affect body image.

While most of the factors Daly names are personal, other researchers look to broader cultural structures to explain the prevalence of eating disorders.

The role of sociocultural factors in determining predisposition to eating disorders is a topic I would return to again later when I interviewed anthropologist and psychiatrist Dr. Anne E. Becker ’83.

Though Becker’s research into eating disorders in the 90’s focused on an Indigenous population in Fiji, it demonstrates the pertinence of community dynamics in resilience to the development of eating disorders. Becker observed that beauty standards in the community were based not on the attractiveness of body shape, but on how the body reflected the presence of a strong community and caregiving.

Eating, and the weight gain that accompanies it, were seen as signs that adequate care and attentiveness were being received. In this Fijian community, affection is demonstrated through the provision of food gifts, and the collective nature of caregiving promotes a communal responsibility for the eating habits and health of children. She places this communal idea of body image in direct juxtaposition to the United States’ autonomous sense of the body and self-presentation.

When I inquire further into the cultural resilience of this community, Becker reveals to me that the introduction of television caused a rapid shift. The economic and social transition that occurred in Fiji — around the time television arrived — drove increases in distress and changes in psychopathology. In 1994, as the first permanent commercial television broadcasting network was founded, the Indigenous populations were introduced to Western standards of beauty.

In one cohort of high school-aged girls Becker studied in 1995, zero percent reported vomiting to lose weight. When another cohort of girls at the same age and from the same schools was asked the same question just three years later, 11 percent reported vomiting to lose weight — at that time, about the same percent as a Massachusetts secondary school, Becker tells me.

The images gleaned from media produced in the U.S., Australia, and New Zealand consistently depicted almost uniformly thin bodies and images of successful people with cars and jobs in the civil service sector. With the backdrop of the economic transition from agricultural to civil jobs and growing pressures to participate in the new economy in Fiji, television programming began building an association between having a thin appearance and having a successful career.

The community was split between its prior values and a newfound urge toward fitting in with a thinner beauty standard — and some engaged in behaviors that stimulated appetite while engaging in other methods to induce purging.

Becker tells me she was interested in this cognitive dissonance that arose between what people were supposed to do and what they were supposed to be.

It’s a dissonance that’s recognizable in many forms of eating disorders — knowing what is good for you, but persisting in the behaviors you believe will help you achieve your “goal.”

While researchers may still be investigating the question of what factors contribute to the development of eating disorders, a few of the potential answers that Daly and Becker proposed stood out to me — academic pressure, sociocultural pressure, and mental illness. These are themes that came up frequently with the people I interviewed as they discussed their own histories of disordered eating — Violet’s busy schedule, Elena’s fomenting friendship, Niederriter’s depressive symptoms.

Making the Record Board

Many have made note of a trend toward disordered eating on campus. In a 2011 Crimson article titled “(Not) Eating at Harvard” an unidentified student given the pseudonym “Megan” lends her perspective to the link between academic stress and disordered eating, saying, “You’ll put your problem off and deal with this next week when activities die down but time passes and you don’t ask for help.”

But busy schedules aren’t the only issue. According to the students cited in the piece, social pressures also play a significant role.

In the same article, student Nell S. Hawley ’11 is quoted saying, “Academically, socially, and extracurricularly the way to show you have it under control is to be skinny.”

According to the Eating Disorder Foundation, one of the most common contributing factors to the development of eating disorders is a temperament characterized by “obsessive thinking, perfectionism, sensitivity to reward and punishment.”

At a college where so many are taught to aim for high goals, a setting that conditions them to pursue success, obsessive and perfectionistic thinking are traits that are common among Harvard students.

But a response to the article suggests a different framing. Below the article, an anonymous commenter writes “Let’s remember that eating disorders include the struggles of those who don’t eat, but also those who have a similarly bad relationship with food and body image but deal with it by compulsively overeating or binging.”

In my research for this piece, I was only able to find people whose disordered eating habits aligned with symptoms of anorexia or bulimia, but it’s important to acknowledge there are more presentations of eating disorders than the stereotypical.

Despite the article’s narrow focus, it still provides a glimpse into the ways campus conditions implicitly facilitate eating disorders.

Three decades earlier, Caroline A. Miller ’83 experienced these same conditions after joining the Harvard women’s swim team.

By the time Miller arrived at Harvard in the fall of 1979, she had already been struggling with bulimia for years. On her team, disordered eating was commonplace.

“When I got to Harvard, the one name on the record board who had every single record in freestyle had a notoriously horrendous eating disorder,” Miller says.

Miller cites the weigh-ins as one of the most detrimental aspects of the team culture. Before meets, the athletes on the team would be weighed publicly. Miller shared with me in an email statement that her teammates would make comments when they believed someone was “gaining weight or looking bigger.” The athletes were encouraged neither to lose or gain weight ahead of these weigh-ins. So despite her “successful” teammate’s widely known struggles with disordered eating, no one seemed to want to intervene.

When I meet Miller on Zoom, the first thing I notice is her bright background filter. It’s a bright teal circle rimmed with orange, and in the center it says, “Goals and Grit.”

Grit, as Miller explains to me, is something that hasn’t been conditioned into my generation. Instead, we’ve been softened by quick fixes and grade inflation. The sentiment reminds me of Jonathan Haidt’s “The Coddling of the American Mind” — a book brought to my attention when I talked to Michael Daly. Haidt’s 2018 book, co-written with Greg Lukianoff, focuses on recent changes in the upbringing of adolescents. His argument points to the protection of adolescents from stressors throughout their lives and an increase in emotional methods of reasoning as the catalyst for modern trends in mental health disorders. These larger claims of cultural shifts, as Daly tells me, are hard to test. But it’s still a sentiment I’ve come across multiple times now in my research — and one Miller espouses to me without hesitation.

To Miller, grit is the quality that helped her overcome her eating disorder — an eating disorder that had ended her athletic career at Harvard — despite the notable absence of resources at the College to help her at the time, or rather, what she characterizes as the College’s resistance to addressing eating disorders directly.

During Miller’s time at the college, the Center for Population Studies conducted a study on female athletes. They requested that each of the athletes on the women’s track and swim teams turn in food diaries and menstruation logs, submit to temperature checks, and undergo several other evaluations of their health. The study culminated in the discovery of the “female athlete triad,” a syndrome defined by eating disorders, amenorrhea (the absence of menstruation), and loss of bone density. Though the syndrome is characterized as a “triad,” both amenorrhea and the loss of bone density are often side effects of anorexia and bulimia.

According to Miller, despite the results identifying the presence of multiple eating disorders on the swim team, there was never any action taken by the data collectors nor the coaches on the team to seek help for the struggling athletes.

There also weren’t many resources available on campus for those who sought treatment themselves. Miller recalls a non-Harvard affiliated therapist who came to speak in Kirkland House her junior year about treatment options for eating disorders. According to her, plenty of students wanted to seek help but didn’t have the avenues to do so.

“The room was packed with people,” she says, “But it was still not a disease that anyone had their arms around.”

The lack of resources was only exacerbated by convenient conditions for binging.

“It was so easy to binge because of all-you-can-eat food, tons of private bathrooms, and the prevalence of eating disorders all over campus,” she said.

With so little information to guide the conversation about eating disorders, the burden fell on those who suffered from them to become authorities on the subject. So Miller turned to the Schlesinger Library, looking for books on eating disorders, but never checking them out for fear of outing herself if someone should find her reading them. However, Miller found that her private research could only take her so far.

She tells me about the “idiotic approaches” taken to treating eating disorders in the early days of bulimia research. She recalls reading a book that instructed her to put a pillow under her shirt to mimic pregnancy because the author believed that people with bulimia binged because they wanted to be, or to appear, pregnant.

After these futile efforts to find support resources, Miller still found her disorder was worsening. She began to conceive of recovery at the College as “hopeless.”

McKenna Comes to Town

During her time in college, Miller never found a resource to help her recover. But a year after she graduated, Harvard finally hired a clinician for the specific purpose of forming an eating disorder team at Harvard University Health Services — Margaret S. McKenna ’70.

McKenna, who had previously worked with seriously ill patients with eating disorders at McLean Hospital, said that she “knew that Harvard wasn’t doing anything — wasn’t thinking about it” at the time she got hired.

McKenna was at the vanguard of the field — bulimia nervosa had only just become a diagnosis in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders in 1980, only four years before McKenna started working on eating disorder diagnosing at Harvard.

“When people would come in seeking help for bulimia there were two things that stood out. One was that everybody thought that they were alone, that nobody else was suffering with this. And the other thing was that there was enormous shame,” she says now, almost 40 years later.

Over her time at HUHS, McKenna found students with bulimia were much more likely to come forward and seek help than those with anorexia. This is perhaps due to the ego-dystonic nature of disorders like bulimia and binge eating and the ego-syntonic nature of anorexia. Patients with ego-dystonic forms are more likely to view the symptoms of their disorder negatively and seek help to alleviate them. Patients with ego-syntonic anorexia are, in contrast, more likely to value their symptoms. For the latter cases, McKenna says she often found herself facing uncooperative patients after being prompted to intervene by deans or roommates. But after years of working with patients, she began to witness a change.

“People with anorexia were coming in and were more distressed,” she says. Unfortunately, despite increased awareness and concern for eating disorders, research into eating disorders still hasn’t found consistently successful medical interventions for such illnesses.

“Many people have tried many different pharmacologic interventions. There still is nothing that’s really been demonstrated to be helpful,” she says. Proposed treatments, such as administering medications undesigned for eating disorders, but with the desired side effect of weight gain, are limited by the ethical dilemma of placing patients on medications for which most of the effects are unnecessary and potentially harmful. The comorbidities associated with eating disorders — namely anxiety, depression, and obsessive-compulsive disorder — only make them even more complex to treat.

“The medicine that you need is food,” McKenna says. It’s a medicine that even the patients most eager and dedicated to recovery may still be unable to take. According to McKenna, students were required to take an involuntary medical leave of absence to receive treatment if they were known to have a BMI of 16 or below and were unable to increase their BMI for several months.

“I was the person who had to say you have to take a leave,” McKenna says, “And it was really a salient part of my clinical experience in that I had a lot of people who hated my guts.” To this day, many students fear taking a leave of absence — which typically involves at least a full semester away from Harvard’s campus — given the time away from friends and activities, and the barriers they’d later face to returning.

While some people came to experience gratitude after being forced to leave, even coming back to Harvard to thank McKenna, the University’s legal team excluded eating disorders from their leave of absence policy in 2011 on the grounds that the conditions HUHS used to determine when a student required a leave of absence did not meet the definition for “acute risk.”

McKenna retired from HUHS the year after.

The standards for placing students on a leave of absence haven’t gotten clearer over the years. Recently covered in The Crimson, the Student Handbook states that the College considers “the nature, duration and severity of the risk” when determining whether a student should be placed on an involuntary, medical leave of absence — without defining what “the risk” means in this context. For McKenna’s patients, the “risk” of their eating disorder was deemed too ongoing and chronic to be considered “acute,” she says. Nevertheless, the possibility of being deemed a “risk” and persistent distrust of resources prevent many students from reaching out with mental health concerns to this day.

Harvard’s Counseling and Mental Health Service in particular has been criticized for “weekslong wait times and a perceived lack of diversity among care providers,” as reported in a recently published Crimson article.

The peer counseling service Eating Concerns Hotline and Outreach is one of many groups that aim to address the gaps left by a lack of institutional resources and was founded around the same time McKenna was hired.

The current co-directors of ECHO, Alexandra R. Cherf ’25 and Cindy Wang ’24, both joined ECHO because of the important role that discussions surrounding food and body image have played in their lives. Cherf, a member of the women’s heavyweight rowing team, describes growing up with warped expectations of body image. She says her introduction to collegiate athletics completely changed her perspective — unlike Miller’s past experience. She began to view food as an essential fuel rather than something used to fit into conventional standards of beauty.

For Wang, her desire to become involved in discussions surrounding body image was motivated by her upbringing.

“I’m Chinese-American. And growing up in our community, there was a lot of discussion, very open discussion about body image, and eating and exercise and sort of comparing bodies, very ingrained in the culture,” Wang says. She wanted to learn how she could integrate more positive ways of talking about the body and food in her own life.

The students that work for ECHO are not licensed clinicians, and as such, avoid giving directive advice, but they do “strive to make a space where people feel like they can be comfortable talking about these issues,” Wang says.

Each ECHO counselor receives training from clinicians who supervise the program.

“We ask questions and provide validations and sort of help carry the conversation and unpack whatever they’re going through,” Wang continues. “And if they’re looking for resources, we can point them to resources, but we don’t offer direct solutions.”

The office, located in room T-24 of the Eliot House basement, is staffed five nights a week and the hotline is active every night. Though Wang has noticed a degree of eating disorder stigma remaining on campus, she says a decent number of students do reach out and utilize the resource.

Not everyone is seeking professional support, Cherf and Wang express to me, but ECHO is there for anyone who just needs a space to be heard or someone to help them navigate finding professional support.

But unfortunately, even with these resources to fill in the gaps, some students still don’t seek help. It’s not surprising — Elena, Niederriter, and Miller all found themselves searching for recovery without support, and though I was referred to CAMHS, so did I. I’ve learned how hard it is to not only connect with resources for support, but to keep up the process of recovering given that each step has to be taken alone.

‘A Work in Progress’?

After more than 30 years of being eating disorder-free, Caroline Miller attended an Overeaters Anonymous meeting where she decided to make a small, but significant change — labeling herself as “recovered,” rather than “in recovery.”

“And that caused a small riot in the eating disorder field that I broke from that [language],” she says.

The field of eating disorder recovery uses language that runs parallel to that of Alcoholics Anonymous or Narcotics Anonymous — you always introduce yourself as someone still in recovery, no matter how many years have elapsed. This method of introduction is used to indicate that people in recovery may still have a tendency or compulsion to addiction. The messaging is clear — this is something you’ll always have to deal with.

Miller’s divergence from this rhetoric was a crucial point of contention. “I didn’t believe it was helpful to always see yourself as a work in progress,” she says.

Almost 40 years prior to our meeting, Miller attended her first Overeaters Anonymous meeting in Baltimore. There she met another woman who had struggled with bulimia who became a crucial impetus in Miller’s journey toward recovery. She tells me that the community she gained from going to the meetings gave her the motivation she needed to keep going with her recovery.

She started to read books on psychology and stayed close with other compulsive eaters in recovery. She explained to me that the thing that changed the most was her mindset. She became more honest with herself about the destructive nature of her eating habits and she got sober at the same time. In 1988, she published her first book, “My Name is Caroline,” on her struggle with bulimia.

“One of the best things that happened to me was bottoming out at the age of 21,” she says. The experience allowed her to relearn nutrition and portion sizes. “I really do believe my life probably started at the age of 22.”

“I haven’t weighed myself in 40 years,” she says. “My doctors weigh me, but I weigh myself standing backwards with my ears plugged.” Miller even ventured back into athletics — competing in masters swimming and obtaining a black belt in martial arts. “But I don’t do anything obsessively,” she says.

For her, going back to swimming was more symbolic, “I had to close the loop on all the things I lost to my eating disorder. And that’s been the way that I’ve been able to heal.”

As she tells me this, the sentiment makes me smile. But the thought of being able to call myself fully recovered seems so distant to me. I can’t imagine 30 years of no regression, no relapse. Though I’m in a better place today than I was in my freshman year. I’m still careful, and I’m still intentional about my eating habits.

A piece of advice I hear often in my recovery is “Listen to your body.”

Your body will tell you when you need more food and when you’ve had enough. But here’s the thing: my body doesn’t. I’ve spent years alternating between telling my body it doesn’t need food and forcing it to consume excessive amounts of it. I pushed my body to the limits until it didn’t know what a proper portion size felt like.

I have to remind my body that I haven’t eaten all day and eating two bites of food at dinner isn’t enough to counteract that. I have to fight it, tooth and nail, to eat when I feel nauseous. My body doesn’t know that, though it may be tough to keep it down now, because of the nausea and the faintness if I suffer through the plate or keep my stomach full, the pain will subside with time. I can’t listen to my body. It has to listen to me, and I have to stay dedicated to a goal that may take me 30 years to achieve.

I’m tempted to write that my disordered eating habits are my fault, that they’re a set of repeated failures. But I’ve met others who have felt the same and dealt with the same issues. And I don’t blame them the way I blame myself. Maybe this temptation is the same voice in my head that pushed me to strive for perfection, the one that blames me for what I could not achieve. Maybe it still blames me for carrying the weight of my history like a burden — nerves tingling in the dining hall, embarrassed to eat in front of others, but afraid they’ll judge me for eating too little — for not being able to move on and be healthy.

But this piece has taught me about myself, too. I know now that my experience with negative body image is mitigated by factors outside of my control — mental disorders, societal pressures, the influence of struggling friends, and the stigma around voicing the problem. I know now that I can conceive of an issue as both something that I did and something that happened to me.

I know now that talking about my own experiences instead of burying them in shame can help provide empathy and comfort to others — knowing that the journey to recovery is lonely, but they’re not walking it alone.

— Associate Magazine Editor Jem K. Williams can be reached at jem.williams@thecrimson.com. Follow her on Twitter @jemkwilliams.

— Associate Magazine Editor Maya M. F. Wilson contributed reporting.

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Caroline Adams Miller

Caroline Adams Miller, MAPP is a pioneer with her ground-breaking work in the areas of goal-setting/accomplishment, grit, happiness and success. Caroline is the author of eight books, including Positively CarolineMy Name is Caroline,  Creating Your Best Life and Getting Grit. Live Happy Magazine named Creating Your Best Life one of the top ten goal-setting books ever published and Getting Grit one of the ten books that will change your life in 2017.  Her new book, Big Goals, is anticipated for release in the fall of 2024.  Caroline has been featured in BBC World NewsThe New York TimesThe Washington Post, USA Today, U.S. News &World Report, ABC, CBS, NBC, NPR and CNN.  She is a graduate of Harvard University and holds a Master’s degree in Applied Positive Psychology from the University of Pennsylvania.

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