DIALECTICAL ABSTINENCE – HARM REDUCTION FOR EATING DISORDERS

A colleague and good friend of mine, Molly Carmel, LCSW who directs an eating disorder clinic in NYC [The Beacon Program] introduced me to the concept of “dialectical abstinence.” Although I don't know of any source the concept appears, I will credit Molly with adding this to my understanding of living with acceptance of imperfection with recovery. Illustrating DA on a white board one afternoon, it become apparent teaching this concept of recovery can be a game changer. So…I’ll pass it along to those of you who may be reading this article. Here goes.

Dialectical Abstinence as I now understand it is based on the concept of harm reduction. Part of the DBT [Dialectical Behavior Therapy] movement, harm reduction is intended to serve as an alternative to more severe forms of self-destructive behavior[s] or self-harm. Conceptually it appears to be the “lesser evil” in ones’ repertoire of reactions to a negative emotion or experience. Within the realm of intense and painful emotional states like anger, boredom, anxiety, and especially self-hate, harm reduction amounts to finding the gray area of self harm. Holding onto an ice cube instead of intentionally cutting an arm or leg serves to lessen the consequence of a self destructive response. For someone with an eating disorder, perhaps bulimia, it might be to deviate from their typical food plan or opt to skip the next meal. Better this than lapsing into the endless cycle of binging and purging. In both instances the choices may represent less than perfect ones, but nonetheless are an improvement over the old and more destructive behaviors.

To be clear, the concept of Dialectical Abstinence is not a license to abandon the “attempt” to be perfect with one’s food, weight, or eating but rather to accept the reality that doing so perfectly is an ideal and not a mandate. To be sure, making a commitment to ED recovery usually involves a set of limits and healing disciplines. Independent of the flavor of disordered eating, here are a few suggestions: 1. following a reasonable and healthy food plan [preferably prescribed by an experienced dietitian or eating disorder professional], 2. adhering to a moderate and recommended schedule of exercise, 3. striking a realistic balance between work, play, and self-care, and 4. practicing the principles of an on-going recovery program [DBT therapy, Support Group, etc.] In a earlier article, I proposed utilizing an acronym - S.E.R.F. The letters stand for “Spirituality, Exercise, Rest, Food Plan.” Borrowing from the original text of a popular 12-step support group “progress not perfection.”

The point here, as my friend put it,is to start the day with the intention of “pitching a perfect game, making each frame a strike” but realizing perfection is different than “near perfect.” Like-wise, having a food plan calling for “abstinence” from sugar, flour, highly processed food products, as well as weighing and measuring portions is best approached with the intention of doing so without exceptions on a day to day basis. However, and this is the crux of the DA concept, to label yourself as having failed or ruined your recovery for any infraction of these “absolutes” might be viewed relative to whether a misdemeanor or felony, slip or full blown relapse. In other words, failing to weigh and measure a meal / portion because of being in a restaurant or stuck at an airport, consuming something like a protein bar because you were upset, eating an apple in the middle of the night, consuming too much coffee or diet soda, and so on might be considered maintaining dialectical abstinence. How’s that you ask? Because the usual and customary behaviors in this scenario would have been a massive episode of binge eating and purging or, perhaps a renewed pattern of compulsive eating, or worse, a complete abandonment of a commitment to recovery. As is often said, fall down twice, up three times.

No one here is suggesting one pick and choose when to go off and on with a purpose of engaging in part time binging or restricting. The difference may rest with intention. You start out wanting to pitch a perfect game but accept the probability being less than perfect without adding insult to injury.

Although somewhat controversial among those of us attending abstinent programs like Alcoholics Anonymous and Overeaters Anonymous, collecting “chips” or marking days of abstinence is the proverbial double edged sword. Despite what most may believe, recovery is often two steps forward and one back. Substance dependencies like alcohol and narcotics seem to be more of the “all or none” variety, and, in some respects offer a clearer path than having to make multiple food choices throughout the day – most times in sync with recovery and sometimes pushing the envelope. It is for this reason I encourage my patients to measure their recovery not so much in terms of time but to start anew each morning they get out of bed, suit up, and begin to pitch what they hope will be a perfect game.