Exploring The Harm Reduction Model And Abstinence Strategies For Help With Eating Disorders–A Nuanced Approach

Written by: Angela Derrick, Ph.D. & Susan McClanahan, Ph.D.

Date Posted: June 10, 2024 6:17 am

Exploring The Harm Reduction Model And Abstinence Strategies For Help With Eating Disorders–A Nuanced Approach

The harm reduction model in the context of eating disorder recovery is an approach that aims to minimize the negative health effects associated with disordered eating behaviors without requiring the complete cessation of these behaviors. The harm reduction approach recognizes that for many individuals, the goal of outright abstinence from disordered eating may not be wanted or immediately achievable and may even be counterproductive.

Leaning into the harm reduction model might mean that complete or ideal weight restoration has not yet occurred. Also, the individual may not reduce exercise patterns as much as we might want optimally. There may be decreased but not total elimination of purging behaviors or laxative use. Ultimately, we are moving toward recovery over time with improved coping skills and an increased ability to tolerate difficult feelings.

In contrast, the abstinence approach aims to end disordered eating behaviors entirely. The abstinence model is rooted in the belief that certain behaviors, such as binge eating, purging, or restrictive dieting, are inherently harmful and must be eliminated for recovery to occur.

We realize that the concept of harm reduction can seem scary, especially if this is the first time you are learning about the practice. We, too, felt a twinge of fear when we were first introduced to the idea. Harm reduction is, after all, quite a challenge to the long-held belief in abstinence-only practices. A 2020 study in the American Journal of Bioethics gives an example of how harm reduction can treat someone with severe and enduring anorexia nervosa (SEAN). While less likely to fully recover, a person in this category still needs and deserves help. Harm reduction principles dictate that the pathway toward recovery be paved with dignity, empathy, and respect for everyone.

What Might Harm Reduction Look Like For You?

• Individualized Care: Harm reduction emphasizes personalized treatment plans that cater to each individual’s unique needs and circumstances. This approach acknowledges that the path to recovery is not linear and can differ significantly from person to person.
• Incremental Progress: Harm reduction focuses on gradual improvements and incremental changes rather than aiming for immediate and total abstinence from disordered eating behaviors. Examples include reducing the frequency or severity of behaviors like binge eating or purging.
• Nonjudgmental Support: A key component of harm reduction is providing nonjudgmental support. Therapists and healthcare providers work to create a safe, supportive environment where individuals feel understood and respected rather than shamed or judged for their behaviors. In such an environment, individuals will likely be more forthcoming and not hide behaviors.
• Empowerment: Harm reduction empowers individuals by involving them in the decision-making process about their treatment. This collaborative approach helps people feel more in control of their recovery journey.

What are the Benefits of Harm Reduction?

• Realistic Expectations: Setting achievable goals helps prevent discouragement and feelings of failure produced when trying to maintain perfectionistic standards.
• Reduced Risk: Even small reductions in harmful behaviors can significantly improve health. Examples include reduced risk of heart disease, fewer gastrointestinal problems, and balanced electrolytes.
• Sustainability: Harm reduction can lead to more sustainable changes. Gradual, incremental progress is often easier to maintain long-term than the drastic changes an abstinence-only approach requires.
• Improved Mental Health: Harm reduction can improve overall mental well-being by focusing on positive, achievable steps. It can also reduce the anxiety and depression associated with eating disorders.
• Increased Self-Compassion: Practicing self-compassion through harm reduction strategies can help us combat perfectionistic belief systems inside ourselves. Self-compassion teaches us to embrace our humanity and give ourselves a break!

Principles & Benefits of Abstinence

• Clear Boundaries: The abstinence approach sets clear goals and boundaries around eating behaviors, often defining specific actions to avoid entirely.
• Total Cessation: The primary goal is to achieve total abstinence from disordered eating behaviors. This approach often involves rigorous monitoring and a structured treatment plan.
• Accountability: Abstinence-based programs typically involve high accountability. Regular check-ins and progress tracking ensure adherence to the treatment plan and reduce the risk of relapse.
• Structured Support: Support systems in abstinence programs are highly structured. They give individuals clear guidelines and a framework that provides a strong sense of accomplishment. This, in turn, reinforces their commitment to recovery.
• Comprehensive Recovery: By eliminating disordered eating behaviors, the abstinence approach leads to what some may consider a more thorough recovery.

What are Some of the Challenges of Harm Reduction Compared to Abstinence?

Harm reduction and abstinence are often seen as opposing methods. Rather than take this view, we understand that integrating elements of both approaches can sometimes provide the most effective treatment strategy. For instance, a treatment plan might begin with harm reduction to achieve initial improvements and gradually incorporate more abstinence-based goals as the individual progresses. Visualizing harm reduction and abstinence as two end-points on the same continuum can be helpful.

It is worth noting that many in the ED community contend that when it comes to disordered eating, full-on abstinence should not be the goal and will likely set us up for failure. When our goal is abstinence, a relapse could cause us distress that is so intense it could lead to giving up altogether. If we take a more measured and person-centered approach, we will likely retain our motivation as we move back and forth on that continuum while heading toward our ultimate goal of health and well-being.

Harm Reduction Challenges

If we dig a little deeper, we can see that ambiguity in measuring progress, the potential for a slower recovery, and pushback from societal and institutional quarters are real challenges to the harm reduction approach. Our culture values success as defined by perfectionistic ideals, a more is better work philosophy, and black-and-white thinking; things are either good or bad, right or wrong, and so on. These stringent measurements do not consider the human condition and pose a real challenge to implementing harm reduction strategies. How do we overcome this intense pressure and find a better life?

Abstinence Challenges

With abstinence-based programs, there is a higher risk that relapsing can result in feelings of failure and discourage further attempts at recovery. The rigorous demands of maintaining abstinence can put a psychological strain on the individual and exacerbate anxiety and other mental health issues. Abstinence programs can be less accessible to individuals who may not be ready or able to commit to such a strict regimen, leaving some without viable treatment options. Finally, The black-and-white thinking promoted by abstinence can be detrimental, as it does not accommodate the complex, nuanced nature of eating disorder recovery.

What Might a Hybrid Approach Look Like?

• Flexibility and Structure: Combining the flexibility of harm reduction with the structure of abstinence can provide a balanced framework that supports individuals at various stages of their recovery.
• Customized Care: A hybrid approach allows for highly customized care, adapting to the individual’s evolving needs and providing the most appropriate support at each stage of recovery.
• Enhanced Support: By incorporating elements of both approaches, healthcare providers can offer more comprehensive support, addressing both the immediate and long-term needs of individuals with eating disorders.
• Sustained Recovery: The combination of gradual progress and clear goals can lead to more sustained recovery outcomes, reducing the risk of relapse and promoting long-term health.

Controversy With The Harm Reduction Approach Explained

Objection: Harm reduction will undermine the traditional principle of abstinence-only recovery.

Response: Traditional models of treating eating disorders often emphasize complete abstinence from disordered behaviors as the goal. Harm reduction challenges this by accepting that some level of disordered behavior may continue as part of the recovery process. While total abstinence may sound good, it focuses on a desired destination rather than the reality of a nuanced and complicated journey. At times, that journey does lead to total abstinence, but sometimes it does not. In both circumstances, harm reduction can play a vital role in overall health.

Objection: Harm reduction condones or accepts harmful behaviors. Any approach not aiming for complete abstinence may inadvertently signal that these behaviors are acceptable, thereby leading to normalization.

Response: Here is the reality. Those with eating disorders require and deserve a safe and judgment-free environment in which to recover. The temptation to impose a set of firmly held beliefs on the one who is suffering does not aid in their recovery. Labeling behaviors as “good” or “bad” and requiring complete abstinence can hamper recovery and may put an end to it altogether. As psychologists, we understand that families and society at large have deeply held beliefs and also fears surrounding those who suffer from eating disorders, substance abuse, and other mental health issues. Still, when it comes to recovery, it is best to realize that you are not in control and that your fear of normalizing “bad” behavior is not a helpful stance toward the sufferer. In fact, you are free to practice acceptance and respect the autonomy of the one who suffers without worry that it is the same as normalizing or condoning harmful behaviors.

Objection: Because measuring the success of harm reduction is difficult, we can’t be sure that true recovery is being achieved.

Response: Measuring success for eating disorders or any mental health disorder is complicated and multi-layered, containing both subjective and objective parameters. Research is ever-evolving and adding to our knowledge of efficacy in harm reduction models. As psychologists, we understand the seriousness of eating disorders. We realize that an abstinence-only stance may leave too many people without hope and outside the tent of recovery. Harm reduction can offer specific benefits to those who cannot or will not be able to achieve total abstinence. Harm reduction can also be helpful in an individual’s journey towards abstinence. It’s not a zero-sum game, and we acknowledge that not everyone can recover at the same rates, levels, or quantities.

Objection: Aren’t you just enabling bad behavior?

Response: Harm reduction approaches can be misunderstood by the public and even within the medical community. Harm reduction is often stigmatized as enabling or ineffective and faces significant cultural resistance, making it harder to implement effectively. We came across a Psychology Today article, “Why We Need a Harm Reductionist Approach to Eating Disorders,” that tackles how difficult it is to gain acceptance for this method. The article defines harm reduction as “an approach to public health issues that prioritizes body autonomy over forcing a person to meet the external standard of ‘healthiness’…it acknowledges that trying to force an outcome or behavior change on a person who doesn’t want it is not only destined to fail, it’s a violation of their consent and dignity.” The author, Devon Price, Ph.D., makes an impassioned and humane plea for why we need to lean into harm reduction in eating disorder treatment. We find their perspective compelling.

Objection: If you prioritize short-term safety, harm reduction strategies will undercut the pursuit of long-term recovery.

Response: Harm reduction acknowledges that not all individuals are ready for complete abstinence. Meeting individuals where they are, rather than forcing them into a specific kind of recovery, can be more effective in the long run.

Objection: Allocating funds and resources toward non-traditional approaches is not prudent.

Response: Even though harm reduction often requires significant resources, including time, personalized care, and ongoing support, this approach can reach and help more individuals than abstinence-only treatment methods. Implementing harm reduction methods not only opens up recovery to more people but also provides hope and help to those who have been left behind or were previously unreachable.

How to Mitigate The Stigma and Societal Pressures Associated With Harm Reduction

Dealing effectively with stigma and societal pressures can help us embrace harm reduction with confidence and resilience. Our actions can lead to a more personalized and sustainable path to eating disorder recovery. Below is a list of steps to help us succeed in our harm reduction journey.

Engage with Like-Minded Individuals:

Join support groups (in-person or online) where harm reduction is practiced and respected. These groups provide a safe space to share experiences and gain encouragement. Likewise, seek out therapists and healthcare professionals who understand and specialize in harm reduction for eating disorders. Their expertise and support can be invaluable.

Own Your Decisions & Set Boundaries:

Be clear and assertive with your communications about your treatment approach when discussing it with others. Include why you have chosen harm reduction and how it benefits your recovery work. Set boundaries with individuals who may not understand or respect your approach. Politely but firmly request that they avoid making judgmental or unsolicited comments about your path toward healing.

Celebrate Small Wins:

Keep a journal or use apps to track your progress, document your activities, write gratitude items, and celebrate small victories. Focusing on your achievements, no matter how big or small you might think they are, can boost your confidence and resilience. Practice self-compassion and remind yourself that recovery is a journey with ups and downs. Acknowledge your efforts and be kind to yourself.

Practice Self-Care and Mindfulness:

To manage stress and maintain emotional balance, engage in mindfulness practices such as meditation, yoga, or deep breathing exercises. Also, develop a self-care routine that includes activities you enjoy and that help you relax and recharge.

Seek Guidance:

A qualified therapist can help you process internal conflicts as well as pressures and triggers from family, friends, and an ill-informed public. We can learn good coping strategies, set boundaries, reframe negative thoughts, define our values, and stay focused on our goals. Thoughtless comments or societal pressures might, at times, derail us. Getting back on track depends on a solid toolbox of well-practiced, healthy responses and processing procedures.

Media Literacy:

Be critical of media messages that promote unrealistic body standards or stigmatize harm reduction approaches. Limit exposure to triggering or harmful content. Do not hesitate to block these accounts to protect your peace. Seek out and consume media that promotes body positivity and health at every size (HAES) and challenges toxic diet culture.

Cultivate a Positive Environment:

Surround yourself with people who support your recovery and respect your treatment choices. Positive relationships can provide strength and encouragement. Create or find physical and online spaces where you feel safe and accepted, free from judgment and societal pressures.

Building Resilience:

Attend workshops or training sessions on resilience, self-advocacy, and harm reduction principles. Build skills that enhance your belief in yourself, making you more confident in managing your recovery and dealing with societal pressures.

Engage in Advocacy and Awareness:

Share your story and experiences through blogs, social media, or public speaking engagements. Advocacy can help normalize harm reduction and reduce stigma. Work with organizations that support harm reduction to raise awareness and educate the public about the benefits of this approach.

Final Thoughts

Eating disorders are severe and complex mental health conditions. Ultimately, the most effective healing approach will vary depending on the individual’s unique circumstances, needs, and readiness for change. A harm reduction approach will respectfully meet a person where they are at, while an abstinence-only program will focus more on compliance. While harm reduction offers a flexible, person-centered approach—it also challenges conventional treatment models that prioritize complete abstinence. These differences highlight the need for a nuanced understanding of eating disorders. We also need a willingness to explore diverse treatment strategies explicitly tailored to individual needs.

About SpringSource

At SpringSource Psychological Center, we strive to provide the most effective and compassionate care for individuals struggling with eating disorders. We also provide evidence-based recovery for anxiety, depression, trauma, and relationship issues.

We believe there are many paths to healing and look forward to helping facilitate your individual recovery journey. With offices in downtown Chicago and Northbrook, we offer in-person and virtual support.

Call SpringSource today at 224-202-6260⁠ | info@springsourcecenter.com | We offer free 15-minute initial consultations—schedule here.