The Pressures Facing College Women
Featured Guest: Courtney Grimes
The social pressures and cultural expectations that college women face are immense. So how can clinicians better assess this population that presents such a polished veneer? We’ll tackle this with psychotherapist Courtney Grimes on this episode of Recovery Unscripted.
Interviewer: I’m here with Courtney Grimes. Thank you so much for being with us.
Courtney: Absolutely, it’s my pleasure.
Interviewer: You spoke here yesterday at the conference, of course, so glad to have you here at Innovations in Behavioral Healthcare. Let’s start by having you tell us a bit about your own personal story and the journey you took to doing what you’re doing in mental health behavior and health.
Courtney: Sure, it’s a long story but I’ll condense it as much as I can. I grew up in a pretty intense home life. Grew up in Atlanta Georgia, a military family, deeply religious family, very guilt-driven family. I learned how to be pretty perfect early on in my life as a survival tactic, to survive as much of the abuse and guilt as I possibly could. By the time I graduated high school, I was very unsure who I even was.
Interviewer: Because you’d been fitting this mold.
Courtney: Because I’d been a chameleon for my whole life trying to twist and dodge any kind of hurt. By the time I got to college I was extremely vulnerable, extremely malleable to be whatever anybody wanted to me to be ever. About that time in my life, there was a crossroads with freedom, with alcohol, with exercise. There was a freedom with food that I’d never had before. I developed a very unhealthy relationship with food, all to cope with what was happening inside of me. As I moved through my 20s, I was in the music industry for a long time, which really, final nail in the coffin as far as my–
Interviewer: Were you– As an artist or just in the business?
Courtney: No. I did PR and I did radio promotions for different artists at record labels for a long time. Then the comparisons started. All these women are so amazing, they’re so beautiful. They walk in a room, everybody turns. I want somebody to love me like that. Because I felt nobody really did, that feeling of never quite being good enough got stronger and stronger and stronger.
I, at that point, had developed a pretty intense eating disorder and had dropped a significant amount of weight. Was using and abusing alcohol on the reg, was searching for anything to turn my brain off and check out a little bit. By the time a girlfriend of mine called me worried, she said, “We’re so worried. We’ve all been talking about it and you’re just so thin. You drink way too much. We never see you anymore.” She made me go to a doctor who could not find a heartbeat.
Interviewer: Because your body was so weak?
Courtney: My body was so weak. When a human body doesn’t have any more fat on it to burn, it starts to eat its own muscle and your heart is a big strong muscle that it can pull energy from. I think I was maybe 23 at the time– 24 at the time. My heart had disintegrated and eaten itself down to maybe like a third of the size of a normal healthy 23-year–
Interviewer: [chuckles] I’ve never even heard of that.
Courtney: It was around Halloween when that happened. I remember that doctor looked me in the eye and said, “Honey, I don’t know what you’re doing to yourself. You are welcome to keep doing it, but you won’t be alive by Christmas.” He said, “This heart has less than 60 days on it.” My life changed from there.
Interviewer: What did you do?
Courtney: I went to recovery, I started recovery. I went to therapy. We didn’t have eating disorder treatment clinics at the time that were in our area that were available. The treatment back then was not what it is now. The options weren’t there. People weren’t talking about it the way that we’re talking about it right now. There were options for alcoholism, but that wasn’t my primary addiction, an eating disorder was. When I went through the recovery process and got to the other side, this is such a power a whole life over here, this is so full of joy and possibility. I quit everything that I have ever done, went back to school, got a whole second round of degrees and I am committed to pull other people out of that hole because this is how amazing it is out here. [chuckles]
Interviewer: Just give us a brief overview of what you’re doing now. Now you’ve got those degrees and then what did you get into?
Courtney: I’m a psychotherapist. I now work with people who struggle with addiction, who want to be involved in the recovery process in any way. I specialize in eating disorder treatment. Oftentimes eating disorders are co-occurring with things like drug and alcohol abuse. I see a lot of that. Lots of depression and anxiety go hand in hand with this stuff. I treat all of these folks. I’m also the clinical director for a nonprofit here in town called Renewed and we are eating disorder resources.
My primary job, I think I’m the only one definitely in the southeast but maybe one of the only ones in the country, who I can place– If you call me looking for eating disorder support or treatment, I can find you a therapist, a nutritionist, somebody who takes your insurance. I can find a bed for you, I can get you hooked up with a treatment center. I refer. We began that operation as a source of hope for people who realize there’s a problem, but they have absolutely no idea what it’s called, what to do about it. They just know that something —
Interviewer: Don’t know what the next step is.
Interviewer: Then you’re also doing some work with the Eating Disorders Coalition in Tennessee, is that the same thing?
Courtney: Yes, same thing. We rebranded maybe a few years ago.
Interviewer: Okay, then don’t worry about that. [laughs] I guess here, in Tennessee, what are some of the specific challenges or trends or barriers that you’re seeing in this local population? Because that’s mostly what you deal with, people who are calling in are local?
Courtney: Are local. Most of them are local. [clears throat] Most of them, the ones that I treat, are college women, women in their 20s. Eating disorders don’t affect only women. They, of course, affect men too. I think the latest statistic is like 30 million people in the United States suffer from an eating disorder, and that’s just what’s reported. That’s just what we know. Within the local population I see a lot of these kids coming from Vanderbilt, from Lipscomb —
Interviewer: High acheiving.
Courtney: Very high achieving, very verbal, very articulate, very perfectionistic. Girls just like me.
Interviewer: Kind of like you.
Courtney: Exactly. I see a lot of women who feel they’re never quite good enough or they’ve lost hope in any kind of future. These women are incredibly hard on themselves. “I feel guilty for absolutely everything and use food or body manipulation as a way to gain some sense of control,” when everything else feels like they can’t control anything else in their life. Lots of times they’ll lock down on their bodies because that’s the one thing– [crosstalk]
Interviewer: Because that’s the one thing they can control.
Courtney: You got it.
Interviewer: They can’t help how someone else is treating them-
Courtney: You got it.
Interviewer: -they can’t help how they’re making them feel, but that’s one thing that nobody has to know. They’re just, they’re in control.
Courtney: That’s exactly right.
Interviewer: We’ll get back to that and your presentation in a second, but I also read that you do some work as a psychotherapist for professional athletes, is that right?
Interviewer: I guess, how did you get into that?
Courtney: With the sports psychology. [clears throat] I was connected through old music industry contacts with a lot of celebrities and athletes and things like that. I think that they gravitate towards towards my work as a psychotherapist because I’ve been in the world and I understand where they’re coming from. You want to talk about a high pressure world, you want to talk about high stakes, you want to talk about perfectionistic. Good night–
Interviewer: Everyone’s looking at your body like, “Okay, you’re–” [crosstalk]
Courtney: The whole world’s looking at you, the whole world. Sometimes I’ll need to meet with an athlete and his family maybe before a game. Sometimes I need to meet with him and his kids off season. Maybe sometimes I need to help him create just something like a mantra in his head that he can say in the locker before they go out. Grounding techniques, helping them center, helping them not think about all the other drama-
Interviewer: All the eyes on them.
Courtney: -all the eyes on them, all of the expectation, and go out there and play the game. With celebrities, with these women, for some reason, thinner equals better. I’m not sure why, but that’s the general concept in this world. It’s never enough. You have to be better than everybody else.
Interviewer: It just becomes a competition.
Courtney: It’s so competitive, everybody’s comparing. It can get really really toxic. On the outside, these people are so put together and they’re so polished. They’re just like my college girls, they’re just like them, except they’re professionals and the whole world’s watching them.
Interviewer: There’s musical artists?
Courtney: Yes. On the inside, they’re dying. They’re shriveling. They feel like they’re never good enough. They feel if anything happens to them, they’ve got 16 people who are going to go down with them and lose their jobs. They feel so responsible and stuff like that. It’s a tough world to navigate but it’s very fulfilling. It’s very exciting to offer hope to some of these folks, when I think a lot of times they don’t know where to find it.
Interviewer: All right. We’ll get into your conference presentation you did yesterday, which was specifically focused on challenges facing college-aged women when it comes to these issues and how these issues impact their behavioral health. Could you start by just describing why are college-aged women such a high-risk population?
Courtney: College-aged women are such a high-risk population because I think a lot of these women come from smaller ponds where they were big fish.
Interviewer: Sure, it’s a good point.
Courtney: The girls that I work with, even at Vanderbilt, a lot of these Vanderbilt girls, a lot of the Lipscomb girls, local colleges, they’re coming to these really esteemed universities where everybody else is just like them, but they’re coming from these smaller ponds where they were the best.
Interviewer: They were the big ones.
Courtney: They were the best.
Interviewer: They were the special one.
Courtney: They were the special one. They were the valedictorian, they were the prom queen, they were the star athlete, and then, all of a sudden, they’re in a new pond where the game has completely changed. They’re not special anymore. Everybody else is just like them and they don’t know what to do with themselves. Their identity gets all messy. They feel very lost in the shuffle. Nobody’s watching anymore and the competition is just sky high. There’s competition, competition, competition and comparison, comparison. “She’s got this, she’s got that. I don’t have that. Oh my God.” [makes purring noise]
Interviewer: Going to get left behind.
Courtney: Absolutely, and no one wants to be invisible.
Interviewer: It’s interesting, as I was prepping for this interview, it reminded me I did a talk with someone else who was talking about– They work with young adult men and they were talking about the rites of passage and how that has been lost and how modern society is distorted that and lost some of that. Do you see some of that with women as well where cultural shifts related to that have negatively changed how they navigate into adulthood?
Courtney: Absolutely. What’s confusing to me about it, and I think what’s confusing to a lot of people about it is, [clears throat] historically, women go to college to meet a husband. Historically. Women began to become educated after high school, women began to work, they joined the workforce, but marriage and children and home has always been the gender role for women in America.
Many decades ago, when women started to work more, when women started to make their priority and focus outside of the home more often, that, I think, has compounded, in a pretty overwhelming way for some of the girls, a lot of the girls probably, who are college-aged now, because the expectation now is that they have a career, that they go to grad school, that they make a lot of money, and that they find a husband, bear a bunch of children, be able to stay home with them, and, and, and and. As one culture– Not culture shift but one-
Courtney: -yes, rite of passage-
Interviewer: Rite of passage.
Courtney: -expectation got higher, nothing else got lower. There wasn’t-
Interviewer: They just piled on?
Courtney: -any compensatory– Yes. I think that can be very overwhelming for a lot of these girls.
Interviewer: Looking at the college environment right now, what are some trends that you’re seeing that– They’re making it especially challenging for women who are there?
Courtney: Prescribed drugs. [laughs] I think prescribed drugs–
Interviewer: Seeing that as a solution?
Courtney: It is a huge issue. I think they see it as a solution. They go after– Adderall is the big one, everybody wants Adderall, everybody’s on Xanax, things like that. They want the uppers and they want the downers to help them sleep, to navigate this landscape, this collegiate landscape. I’ve got a lot of kids who take medications that aren’t prescribed to them, take medications that are their boyfriends or their roommate’s, stuff like that. To the point where a lot of them are crushing it up. Adderall, they’ll crush it up and snort it. I don’t know why, why would you do that? I have no idea why you would do that. That sounds terrible but it’s this–
Interviewer: But if they hear that somebody else is doing it, “Look at them, okay–“
Courtney: “I guess that’s how I’m supposed to do it.” These drugs are helping them maintain this insane expectation, these standards. It’s helping them stay up and on and focused and not have to sleep and get everything done and be– It’s aiding that. Whereas, even back when I was in school, that was not a thing. That was not part of our landscape. The expectations were all still there, I feel like when I was in college, but now it’s this whole different element.
Now, they’ve got this very specific device to aid in the discord, to enable all that dysfunction. That’s a big one. Sexual assault’s a big one. That’s a huge issue on college campuses. That also goes hand in hand with the drugs, the prescription drugs and things like that. These girls will take a lot of whatever whatever at this party and they will–
Interviewer: They’ll be more vulnerable?
Courtney: Yes. A lot of that–
Interviewer: Then they’ll have to deal with the trauma and the repercussions of that and cope?
Courtney: Yes, sir. You got it. Absolutely right. It’s a cycle. I think it’s a cycle that a lot of people aren’t paying attention to, because again, these people are so polished. They’re so put together on the outside. I think that a lot of even clinicians see this population, we think, “We don’t have to worry about them. They’re fine. They’re clearly– They are okay.”
Part of what I was talking about yesterday in the general session was make sure if one of these women ends up in your office, comes to you for help, comes to you for medicine, before you get into any of that, know the right questions to ask. Make sure you don’t fall for that gorgeous, polished veneer, and make sure that you are assessing what you need to assess on the inside before moving on.
Interviewer: What are some of the right questions?
Courtney: I always want to poke around at past trauma, I always want to know family history. The age group that they– We’re dealing with maybe 18 to 22, 23, around in there. This particular age group doesn’t know life outside of the home yet. They haven’t had a worklife yet. They haven’t had their own apartment yet. They haven’t moved to another city yet. They only know life in that home. Whatever has been going down at home is– Has dictated where they are at this phase of their life.
We’ve got to know family history. We’ve got to know, “Hey, tell me what your dad is like. Hey, tell me what your mom is like. What’s going on there? Your brother? You got a brother? Is he cool? What’s his story?” Make sure you poke around at family dynamic, I think that’s going to be huge. “Tell me about high school. What was high school like for you?” Watch their face, because a lot of times they’re affect does not match what they’re saying. “High school was awesome. I had the best time, prom was the best. Oh my gosh, I had this great boyfriend and I made straight A’s,” but it looks like she’s about to cry.
Interviewer: They’re just trying to remember the good parts?
Courtney: Yes, and they’re trying to convince me, so I’ll just say what they want me to say and they can go on. Pay attention to affect, I think that’s very important. Listen to what they say but also to what they don’t say too.
Interviewer: You’ve touched on this a little bit, but how does some of these concepts like perfectionism, like body image and the pressure that goes along with that, how do you see that impacting the mental health of college-aged women?
Courtney: Oh man. Eating disorders spike very, very high when kids get to college. Statistically, they spike, there’s a huge spike there. Body image is, again, very much about control. It’s very much about the one thing I know that I’m good at. I hear that a lot, “Well, I’m good at this. I know I’m good at this.” You’ll see all of these girls transfer identity over to body, over to appearance because, “I can control this. I’m really, really good at not eating. I’m really, really good at– I’m really good at this,” I hear that a lot.
They’re coming from high school where they were really, really good at athletics, or they were really, really good at academics, or they were really, really good at whatever. Now, they’re at this university where everybody’s good at all that stuff. Body image can creep in. “I’m just going get rid of this little bit right here and then I’m going to feel so special and so good.” So they’ll lose a little bit of weight. “I still don’t feel how I want to feel. I know, I had the number wrong. I need to drop a couple more pounds.” Then they’ll drop it, and it’s never quite enough. It’s never quite perfect.
Everyone wants to look like one ideal body shape, like they’ve walked out of the Ukraine somewhere. That’s the ideal. Not everybody’s built that way, some of us are Irish, some of us are Dutch, some of us are Russians. We’re not all going to look that way. The ideal doesn’t change, even though logic and reality dictate otherwise, and they know it, but they don’t stop trying. That’s about control. That’s about control all day. What happens is when a brain becomes malnourished, the chemistry starts to change.
Things like body dysmorphia start to show up. We’ll see that a lot, where they actually look in the mirror and see an image that’s not there because the data coming in through her eyes is getting distorted and lost through the disconnect.
Interviewer: They don’t know that because their brain is seeing that way.
Courtney: Correct. When I say, “Honey, you don’t look the way you see feel.” “But I can see it. Courtney, look at that. I can see it right there.” I believe that they believe that, so my job is to meet them where they are and say, “Okay. Got it. What do you think about that? Why does that matter so much?” Things like that.
Interviewer: How do you go about starting to combat that, because they’re bombarded from all sides by all this other stuff? How do you get in there?
Courtney: Takes a long time and it can be exhausting. That’s why a lot of people don’t treat eating disorders. I wish more clinicians would because we desperately need more people, more boots on the ground, more folks on the front line. It takes a very long time to work your way out of this addiction. It’s not like my drug and alcohol folks where I can say, “Okay, don’t ever touch drugs and alcohol again.” This is food. [crosstalk]
Interviewer: “You can detox from food for 30 days,” or whatever.
Courtney: You have to develop a working relationship with the substance that you abuse. It takes a very long time. First and foremost, we’ve got to get them nutritionally sound. [clears throat] If they continue to stay malnourished, I can’t work– Their brain isn’t up and online. I can’t work with them, so I need to bring in a nutritionist to do some nutrition therapy and get– Teach them how to eat. I had a nutritionist that had to teach me how to eat. How to take a fork, spear a piece of food and put it on my mouth without having a total come apart.
Interviewer: Just because you’d gotten so far down that road?
Courtney: So far down that road. So phobic of food, terrified. It was like, “Courtney, I need you to eat this piece of food,” but I hear, “Courtney, I need you to eat this live spider.” It was terrifying. A lot of these women feel this way, so we’ve got to get them nutritionally sound, get them eating, get eating disorder behaviors down. Then, we can start retooling their relationship with food and their bodies.
Interviewer: Then, at that point, once you are starting that retooling, what are some of the techniques, some of the therapies? I saw you mentioned acceptance and commitment, does that factor in at this point?
Courtney: Yes. Absolutely. CBT, cognitive behavioral therapy, is a huge, huge piece of this. I like to blend modalities and I don’t like to just commit to one. A lot of this is going to be rethinking, reframing how you see food, how you see yourself, how you see your place in the world. A lot of it is distress tolerance. We bring in some DBT. The dialectic behavioral therapy. It helps these women learn how to sit in feelings like shame, sit in feelings like discomfort, sit and feelings like guilt, without trying to starve them out of themselves, purge the feelings out, cut the feelings out. Don’t do anything. Feel that, build some tolerance to that pain.
Interviewer: Because that’s going to keep coming, you’re going to experience that over and over.
Courtney: Your whole life, absolutely. So, a lot of our work is teaching people that pain is okay. None of us are guaranteed a life free from pain, but it does help to know how to handle it, if and when it comes your way. These girls have been avoiding pain their whole lives, so by the time they end up with us, we need to teach them, we’ve got to give them tools to take with them long after they leave therapy.
Interviewer: Because it’s a lifetime?
Courtney: It’s lifetime. It’s their whole life, because I don’t want them going back into some type of addiction to cope with pain in their future either. I mentioned that in the talk yesterday. I call it whack-a-mole where all the whack-a-moles pop up on the board. One is called food, and one is called exercise, and one is called booze, and one is called drugs, and one is called shopping, and one is called sex. It’s all kind of the same thing. It’s all ways to manage something rumbling around underneath that board that’s pushing all of these whack-a-moles up in the first place.
As clinicians, I feel we do a disservice to our clients if we simply teach them how to push that whack-a-mole back down into the board. Eventually, another one’s going to pop up. We need to address the underlying issue, and a lot of that is distress tolerance. We’ve got to deal with shame, deal with hopelessness, deal with guilt, deal with feelings of inadequacy, stuff that drives these moles up in the first place, and teaching these folks how to sit with that, how to process that, how to not judge that. Welcome it.
“Okay, I feel horrible about myself.” That’s not good or bad, but why? Where does that come from? Why is it here? Why do I need to learn from this so that this will close up and I can move on? ACT, I love. Acceptance and commitment therapy, I absolutely love. It’s a treatment modality I don’t quite get into with eating disorder patients until maybe the last third of treatment, because if I ask someone fresh in the door what their values are, they, “To be skinny.”
Interviewer: [laughs] “What do you think I’m trying to do here?”
Courtney: “Lady, what do you want from me?” So, I got to wait and get the eating disorder out a little bit before we can start doing values work, which is a great way to taper out and close out eating disorder therapies.
Interviewer: That’s like helping them realize what’s really important to them?
Courtney: Yes, truly important, lifetime important, and not placing so much value on the veneer.
Interviewer: What are some practical ideas that you hope that treatment providers may take away from this discussion as they go and deal with some of these people who are dealing with these issues, that can help them understand what’s going on, how to individualize their care and reach them better?
Courtney: I would say education, education, education. It’s so important. I think a lot of people aren’t educated on eating disorder treatment. A lot of people don’t quite understand what it is. I’ll get referrals from other clinicians with patients they’ve been working with for two or three years, but quote-unquote food issues start to come up and they don’t know how to deal with that. They want to refer over to me. I would so much rather that patient stay with that therapist, because that’s the relationship, that’s the rapport. I would so much rather that therapist educate him or herself on this illness, on–
Interviewer: As opposed to passing them off.
Courtney: As opposed to passing them off, and there being not that continuity in care. I would say education is absolutely in the forefront for clinicians in terms of eating disorder treatment. Know what you’re dealing with, know the signs of it, know what questions to ask, and learn how to treat it. Learn what the eating disorders are, learn treatment modalities that work for each one, and get ready because you’re going to be in it for the long haul. [chuckles] Above all, hope. Learn to instill hope in a lot of these patients because they– Most of them have lost it along the way. Teach them that they are responsible for their hope, because a lot of them, the hope lies in weight loss. The hope lies in-
Interviewer: How someone else values them.
Courtney: -how someone else sees me, things like that. That comes from you and you alone. Retooling relationships with hope, I think, is really important for clinicians, and empathy. Offer empathy, obviously, to the client, but also offer empathy to things like the shame, offer empathy to things like the insecurity, to the fear. Those feelings are there for a reason.
Our brains are nothing, if not efficient. Anything that the brain offers you is there for a reason. It’s probably there to protect you somehow, so offer empathy to some of the feelings. Don’t demonize these– “This is horrible. We need to get rid of this.” No. Almost personify. “Why are you here? What’s going on? Shame, what are you trying to teach me? What is this? How are you trying to keep me safe?”
Interviewer: Like treating it as if it’s in the room with you?
Courtney: Yes, absolutely.
Interviewer: And understanding why it’s there?
Courtney: And understand.
Interviewer: Interesting. I just have one last question. Is there anything else that you wanted to make sure we cover?
Courtney: I wanted to make sure everyone knows about the nonprofit, about Renewed, and make sure everyone knows that if you or someone that you’re working with or someone that you know in your personal life is struggling with eating disorder behaviors, maybe you notice that they’re in a weird relationship with food or exercise. Maybe they seem really, really preoccupied, like all they can talk about and think about is food, things like that. Not real sure what’s going on, or what to do, call me.
Call us over there. I can talk people through it. I can teach you how to approach that person. I can help find care. We do a lot of speaking, we have a speaker’s bureau that we’ll send out into the community. Schools, churches, professional groups, teaching folks. We do a program with the Y where we teach people what to look for, teach people what to say, teach people how to approach. Whatever resource you feel that you need, call us.
Interviewer: Is that anywhere or more local?
Courtney: We are locally based. The speakers’ bureau is in Nashville, but if anyone needs care, eating disorder care or treatment, I work with-
Interviewer: You can connect them–?
Courtney: -all over the country. Yes.
Interviewer: Very cool. Okay. Thanks for mentioning that. All right. We’ll just wrap up with this last question. You’re devoting a lot of your life, your time, your energy to advocate for those with these mental health behavioral health issues. Could we wrap up by having you summarize why this mission is so important to you? I know, obviously, your personal connection.
Courtney: Wow, that’s a great question. I have 100% dedicated my lifetime body of work to pulling other human beings out of that kind of despair in any way that I can, in any possible way that I can. The biggest reason why this is so important to me is because I– That despair literally, within days, almost took my life. If that can happen to me, that can happen to anybody. When I first started this recovery process, I started thinking like, “I wonder how many other people feel like this?”
I thought it was just me. I had nobody to talk to. I didn’t know that there were other people suffering from this, and the further and further and further I get into this career, the more and more and more epidemic I realize this stuff is and I’m thinking, “There’s so much suffering.” If there’s anything that I can do to either prevent someone from getting to that precipice that I did, or if there’s anything I can do to pull someone back from that precipice, I’m going to do it. I feel called to do that with my time on this earth. [chuckles] That’s what I’m here to do.
Interviewer: Absolutely. All right. Courtney, thank you so much for sharing that with us.
Courtney: Thank you so much for having me.