Eating Disorder Recovery Isn’t Linear—Let’s Talk About Harm Reduction

"Eating disorders have some of the most complex and pervasive barriers to treatment," Chelsea Kronengold, communications manager at the National Eating Disorders Association, previously told Well + Good, adding that stigma and treatment costs create real barriers to seeking care. "Many people struggling have internalized guilt that they're not 'sick enough' or that they can overcome their eating disorder through willpower," she explained.

“As providers—or anyone attempting to help—we need to do our very best to meet those struggling where they are at when it comes to the healing process.” — Gabrielle Morreale, MA, LPC, DBT-C

So how do we reduce stigma and move away from ED recovery as linear? That’s where harm reduction comes in. “Harm reduction is a therapeutic model—often used in treating substance use and eating disorders—that aims to help individuals gradually stop engaging in harmful symptoms over time, thus setting them up for long-term healing,” says Gabrielle Morreale, MA, LPC, DBT-C, the owner and clinical director of Recovered and Restored Eating Disorder Therapy Center in SimplePractice’s network of practitioners. 

Morreale explains that, since eating disorder behaviors are enmeshed in someone’s life, it’s not realistic to expect them to quit cold turkey. “As providers—or anyone attempting to help—we need to do our very best to meet those struggling where they are at when it comes to the healing process.”

Harm reduction acknowledges that lessening ED behaviors, or at least working on avoiding them, is better than engaging in them. As the term implies, these techniques strive to reduce harm where possible.

What harm reduction in ED recovery looks like

Harm reduction, like any other treatment model, should be specific to each individual and change throughout their journey. “Harm reduction can show up in a variety of ways,” says Marina Harris, PhD, a licensed psychologist who specializes in eating disorders and performance psychology and is an in-house expert for EQ. “One of the great things about harm reduction is that you can get really creative.”

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Harris shares that these potential interventions can include waiting 15 minutes if someone wants to purge. Or, if someone wants to restrict their food, they might try adding a small snack—like an apple—to their meal instead of having nothing. Morreale says that harm reduction practices can also involve intentionally exercising less often or reducing the length of a workout. It might involve aiming to use a scale less often (or not at all), or striving to purge fewer times a week.

Taking these steps may sound easy, but they aren’t effortless (or purposeless). “Sometimes harm reduction practices sound simple, but their long-term effects can be profound,” Morreale adds. “For someone who is suffering, they are far from simple—they are brave.”

Why harm reduction is so helpful (even if it seems otherwise)

When you love someone who’s in eating disorder recovery, the idea that they're engaging in these behaviors at all can be terrifying. Shouldn’t we get them to stop completely, especially when they're so dangerous?

While harm reduction can seem scary, the benefits are more extensive than some of us may realize. A 2020 study in the American Journal of Bioethics argued harm reduction can help people with severe and enduring anorexia nervosa (SEAN), who are less likely to make a full recovery (but still need help). Treating people with dignity, empathy, and respect is crucial and can be a helpful pathway toward recovery. Here are more reasons to implement harm reduction practices:

Harm reduction builds trust between the therapist and client

Morreale explains that suggesting harm reduction can help patients feel less judged, safer, and more trusting of their therapist, which builds a meaningful alliance. It also acknowledges that clients are the experts on themselves, she says, and helps level the playing field in which the client feels like an equal.

“A strong therapeutic alliance is full of compassion and accountability,” she says. “These are foundational in relational work, which is the model in my practice that has been proven over and over again to promote the best results.”

It prevents all-or-nothing thinking

When you engage in an ED behavior or slip up in recovery—which is common—pulling yourself out of it can be difficult. “With long-term challenges like eating disorder behaviors, it can be easy to lapse in recovery, which can lead to all-or-nothing thinking,” Dr. Harris explains. She gave this example: “I already binged, so I might as well keep eating.”

The harm reduction model helps people avoid that mentality more easily. “Harm reduction offers a middle path, which makes it easier for people to ‘get back on the wagon’ after a lapse,” Dr. Harris says. “Harm reduction also reduces shame, and is an approach many people find easier than abstinence.”

It meets people where they are

Many people in ED recovery don’t want to get better. Harm reduction is basically a way to compromise and make progress. “Harm reduction attempts to meet people where they are while helping them challenge and recover from their disorders over time,” Morreale says. “It keeps individuals out of higher levels of care,” (which have been shown to be traumatizing), “and allows them to learn to heal from their disorder while living their everyday life.”

Morreale says many people with eating disorders have experienced trauma and loss, in which they need all the “wins” that harm reduction gives space for. “These wins translate into resilience and grit, both of which are key in eating disorder recovery.”

All in all, Morreale sees this model as an integral part of recovery. “Harm reduction, from my perspective—as both a therapist and eating disorder survivor—just makes sense.”

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