Eating Disorder Harm Reduction With Neurodivergent Clients
Considerations for a harm-reduction approach to treatment.
Neurodiversity and neurodivergence are terms often used interchangeably but they have different implications.
Harm reduction is practical strategies to reduce negative consequences and improve quality of life.
Deficit-based narratives are problematic and should be replaced with growth-based initiatives.
Neurodiversity and neurodivergence are terms people tend to use interchangeably even though they have different implications. Neurodiversity is an inclusive term meaning that, just as there are many variations in hair and eye color, there are variations between people’s brains.
Neurodivergence is an exclusive term describing individuals whose minds work differently from what society has deemed the standard. Neurodivergent individuals may experience differences in how they interpret, experience, and digest the world around them.
Think of it this way. Everyone can be neurodiverse, but not everyone is neurodivergent.
What Is Harm Reduction?
Harm reduction is a practical set of strategies and interventions aimed at reducing negative consequences and improving overall quality of life. Typically, harm reduction is a term people associate with substance abuse treatment. However, it can be applied to the treatment of various mental health disorders and physical diseases.
Harm Reduction in Eating Disorder Treatment
Much of the literature regarding harm reduction in eating disorder treatment centers around individuals with severe and enduring anorexia, or SEAN. The literature makes an argument for the implementation of harm-reduction approaches when a patient “will not” or “cannot” find full recovery or remission of life-threatening or life-shortening symptoms.
The literature focuses on the patient’s severity and lack of ability to approach recovery, while also emphasizing that harm reduction doesn’t only offer pain and symptom management but also aims to modify the disease to ensure survival and acquire a more sustainable quality of life.
The emphasis on words such as patient, symptoms, severity, harm, and cannot signal clinicians proposing harm reduction in eating disorder treatment may be doing so from a deficit-based mindset. What is a deficit-based mindset? A deficit-based mindset suggests providers are expecting less from patients due to the assumption that their circumstances prevent them from achieving more.
It is important to highlight the concept of deficit-based thinking when treating any client, as there is research to suggest that deficit-based narratives are problematic and should be replaced with growth-based initiatives.
Think of switching from deficit to growth like changing the perspective from “glass half-empty” to “glass half-full.” In practice, this would look like reconnecting the language used in harm-reduction treatment approaches back to the guiding principles summarized in the section below.
The 6 Principles of Harm Reduction
Humanism: Providers value, care for, and approach clients as individuals with dignity.
Pragmatism: The knowledge that none of us will ever be able to achieve perfect health behaviors and that “perfect” health behaviors are impossible to define.
Individualism: The idea that every individual is allowed to present their own needs and strengths with a spectrum of health behaviors and receptivity for intervention.
Autonomy: Though one of the roles of health care providers is to improve clients’ health literacy by providing suggestions and education on treatment options, clients ultimately make their own choices regarding their treatment to the best of their abilities, beliefs, resources, and priorities.
Incrementalism: The knowledge that any positive change in the client is a step toward improved health and that positive health changes take time to achieve. By acknowledging small successes and reinforcing progress, clients remain more engaged in treatment and believe they have access to trusted providers in times of crisis.
Accountability without termination: Clients are responsible for their own health choices and outcomes, but providers never “fire” them from care.
Deficit-Based Mindset With Neurodivergent Individuals
I wanted to take a moment to also connect the deficit-based mindset back to neurodivergent individuals. There are many accounts of neurodivergent individuals going to get an assessment for an official diagnosis and feeling hurt by the overemphasis on what is “wrong” or “not working” for them in their lives. It is as if in order to be given an official diagnosis, they must lead with how their brain’s wiring has led them to a place of suffering.
This can be particularly harmful when a person with neurodivergence is born with a mind that works differently from what society has deemed the standard. This is who they are. However, the symptom-focused approach attempts to take a neurodivergent brain and make it “fit” within a neurotypical world as a way to reduce their suffering. In other words, who they are is “wrong” or “not working.”
Harm Reduction in Neurodivergent Individuals With Eating Disorders
In the section above, I used the word harmful for a reason. I wanted to point out a potential discrepancy between harm-reduction treatment approaches and the emphasis on increasing a client’s quality of life. I mentioned how the literature surrounding harm reduction in eating disorders appears to be using deficit-based language.
Now, it is one thing to discuss the potential problems for approaching neurotypical individuals with eating disorders in this way. Another layer is added when we bring in neurodivergent individuals with eating disorders and approach their treatment from a deficit-based mindset.
In previous posts, I have discussed the intersection of neurodivergence and eating disorders. I have written about how experiences, such as intense sensory processing and executive functioning differences, can lead to the development of disordered eating patterns.
There is a strong overlap between unique experiences with food, eating, and hunger, and neurodivergent minds—meaning that symptoms seen in neurodivergent individuals with eating disorders that are reducing their quality of life may also be entangled in the way they experience and interpret the world.
Therefore, a harm-reduction approach to eating disorders with neurodivergent individuals may need to propose two more principles:
Provider reflection: The provider should first reflect on how their own narrative around what is a “symptom” may be informed by a neurotypical definition of recovery and could be failing to consider how their client's experience of recovery may vary from their previous education or assumptions.
Client collaboration: After a personal reflection regarding potential assumptions being brought into the treatment plan, it is important for both the clinician and the client to collaboratively form a harm-reduction plan and definitions of quality of life. Collaboration efforts are crucial because they suggest that the harm-reduction approach to treatment applies not only to the neurodivergent individual but also to the clinician in their way of showing up during the treatment process. This means that the clinician is committed to reducing the harm they may bring into the treatment process, and the client is committed to making recovery-focused changes that align with their experience of the world.
Please know that there is an abundance of considerations attached to this topic, and this article only begins to scratch the surface. But you can keep an eye out for more content and elaboration on these topics in my future posts.
Morgan Blair, M.A., LPCC - Website
Hawk, M., Coulter, R.W.S., Egan, J.E. et al. Harm reduction principles for healthcare settings. Harm Reduct J 14, 70 (2017). https://doi.org/10.1186/s12954-017-0196-4
Joel Yager (2021) Why Defend Harm Reduction for Severe and Enduring Eating Disorders? Who Wouldn’t Want to Reduce Harms? The American Journal of Bioethics, 21:7, 57–59, DOI: 10.1080/15265161.2021.1926160
Peter Beresford (2002) Thinking about 'mental health': Towards a social model, Journal of Mental Health, 11:6, 581–584, DOI: 10.1080/09638230020023921