There must be all kinds of unexplored applications for harm reduction, but the one I always come back to is bulimia. This is partly because, like drug use, it revolves around a specific behavior—easy to isolate and name—and partly because I’ve been bulimic for about 12 years now, so it’s on my mind a lot. But it turns out that harm reduction maps quite well onto any disordered eating behavior. For a lot of people, it stands to produce better results than conventional treatment. It’s just not being offered.
Mental disorder diagnoses are typically chronic, approached not as things you recover from so much as things you live with and learn to manage. But because many people do recover from eating disorders (ED) and substance use disorders (SUD), recovery is considered the only acceptable goal. You don’t try to live with them; either you die, or you stop.
ED and SUD have much in common: physically stereotyped, to the detriment of all involved; alternately stigmatized and romanticized depending on who’s doing them; increasingly diverse, even if media coverage and clinical research focus on the subgroup with the highest mortality rate (anorexia nervosa and opioid use disorder, respectively); fictionalized as linear-progression stories where people hit rock bottom, then get better. They’re both usually okay to disclose as something from your past that you recovered from, but make people super uncomfortable if you say you do this stuff currently and have no immediate plans to stop.
The differences are more material. You can’t compare harms associated with ED to those associated with SUD because only one of these is criminalized. People with ED don’t have the risk of increased blood-borne disease transmission, incarceration or death from a poisoned supply.
What they also don’t have is harm reduction.
“No one who I’ve met, in my clinical work or otherwise, says that they are an eating disorder nurse, psychiatrist, clinician, who applies a harm reduction lens. Nobody,” Andria Bianchi, a Toronto-based bioethicist who has studied harm reduction for anorexia nervosa (AN), told Filter.
“They should be in existence, so that people can get treatment and still maintain a good quality of life. And that may end up being a quality of life that’s good with an eating disorder.”
This is the prevailing mindset: that harm reduction is not ethically defensible so long as abstinence still has any chance of working.
There is some precedent for clinical ED harm reduction, but it’s been limited to a very small subset of patients. Specifically, harm reduction has been used as a last-resort treatment for people with chronic, severe AN who have so persistently not responded to abstinence-based treatment that the only remaining outcomes are for the clinician to compromise or for the patient to die. Only then is harm reduction considered.
Harm reduction has not been clinically considered for AN patients who are younger or whose illness presents atypically, nor for anyone with any of the other seven feeding and eating disorders recognized in the DSM-V, the best-known of which are bulimia nervosa (BN) and binge-eating disorder (BED). (Lots of people engage in behaviors attributed to more than one ED, just as lots of people with SUD use more than one substance. And just as SUD often goes unnoticed among people outside a physical stereotype, anyone at any weight can have any ED).
“I have to say, the harm reduction model applies much more directly to anorexia nervosa than binge-eating and bulimia nervosa,” Michael Strober, editor-in-chief of the International Journal of Eating Disorders and director of UCLA’s Eating Disorders Program, told Filter.
Strober, who has held both positions since the early ’80s, said this is because “binge-eating, which includes bulimia nervosa, is much more amenable to treatments, generally speaking, than anorexia nervosa. You can have binge-eating for a considerable period of time, after which it can go into remission for long periods of time. So [harm reduction] for bulimia nervosa is not as easy to support as it is in anorexia nervosa—where it is known that if the disorder continues into the third decade the likelihood of a full recovery becomes very, very low. But that’s not true in bulimia.”
What about people with ED other than refractory AN who aren’t ready for, or simply don’t want, full recovery—but who do want to address some symptoms, and reduce some risks? Is there an applicability of harm reduction for them?
“Well, I’m sure there is,” Strober said. “But that begs the question, when somebody says they’re not ‘ready to give it up,’ what that means. And whether they’ve had the appropriate care to address that.”
This is the prevailing mindset in the ED field: that harm reduction is not ethically defensible so long as abstinence still has any chance of working. A patient might say they don’t want full recovery, but that’s only because they don’t really know what they want.
Personally, I think what I want is choice. We should question the validity of a treatment model that goes against the patient’s own goals. We should question the ethics of letting anyone spend decades in a cycle of unsuccessful abstinence treatments until they finally hover close enough to death to merit being informed of their other options. We should question the justification for not extending harm reduction to everyone.
“Clinicians sometimes are really uncomfortable if patients make decisions that are ‘clinically’ harmful,” Bianchi said. “But there are also harms to not working with someone while they’re engaging in those harmful behaviors. There are different types of harms.”
What Could ED Harm Reduction Look Like?
Dr. Josie Geller works in a tertiary care ED program at a hospital in Vancouver reserved for patients, mostly with AN, who haven’t responded to lower-intensity care. After 20 years in the field, it’s her view that not only can harm reduction be appropriate, “very often it’s the best treatment”—for any type of ED, not just severe AN.
ED treatment models have traditionally used two patient variables to determine what regimen to assign: medical acuity (whether they need immediate hospital care) and life interference. In 2013, Geller authored British Columbia’s current ED Clinical Practice Guidelines and added a third variable: readiness and motivation for change.
“It was quite a new way at the time—and it still is to a large extent—of thinking about treating different types of individuals with eating disorders,” Geller told Filter.
Geller had discovered that the best predictor of patient outcomes was neither how sick they were nor how much hospitalization they required. It was the scores that came out of an interview she’d devised to assess their baseline interest in making change. Over the past two decades, that interview has been the single most consistent outcome predictor across all her hospital’s ED programs.
Centering someone’s readiness for change is a counseling strategy called motivational interviewing (MI). It strengthens autonomy and motivation in ambivalent patients—a term that refers not to being uninterested in treatment, but to simultaneously wanting and not wanting to change.
Along with MI, Geller emphasized the importance of including a patient’s loved ones when possible, and addressing concerns they might have over a plan that doesn’t push for full recovery. Their ambivalence can be as big a factor as the patient’s. Not everyone has a support network, and not everyone wants one. But for ED patients who do, outcomes are better when they get to choose who they want involved and what that involvement looks like, rather than when clinicians make those choices for them.
Each time Linda was admitted, she’d be pushed to gain more weight than she was comfortable with. So rather than recovery, Geller…
Read More:Harm Reduction Is for Eating Disorders, Too