INTEGRATING DIALECTICAL BEHAVIOR THERAPY WITH OA
A colleague and long-time benefactor of OA, Molly Carmel, who coincidently directs an eating disorder clinic in NYC, introduced me to the concept of “dialectical abstinence.” Although I had never heard of the phrase, it seemed to have a familiar “ring” to it. In fact, I’m certain it’s an adaptation of Dialectical Behavior Therapy [DBT] tailored for the eating disordered and OA population. In any case, I credit my friend with reminding me of a classic slogan originating from the various rooms of 12-step programs: “Progress not Perfection.” Since DBT has been accepted as an “evidence based” treatment for several psychological and psychiatric conditions, it seems worth consideration. Applied to the compulsive overeater as well as eating disordered population at large, it warrants a discussion of integrating a key principle of this approach, namely harm reduction or “dialectical abstinence.”
Dialectical Abstinence as I now understand it is based on the concept of harm reduction. As part of the DBT [Dialectical Behavior Therapy] movement, harm reduction is intended to serve as an alternative to more severe forms of self-destructive or self-harming behaviors. Conceptually it appears to be the “lesser evil” with ones’ repertoire of reactions to a negative emotion or experience. Within the realm of intense negative emotional states like anger or fear or a physical craving, DA might still involve the misuse of food but to a lesser extent. For instance, someone may have a history of overeating a considerable amount of junk food when angered or tired. Ideally recognizing the urge to eat is not emanating from physical need but rather masquerading as hunger, then restraining from eating is the “ideal” [abstinent response]. In other words, not eating is synonymous with keeping abstinent while ingesting an apple or “protein bar” is deemed equivalent to a full blown relapse. As a professional having my share of experiences treating compulsive eaters, this defies common sense. DA suggests there exists a gray area between relapse and reasonable adherence to the principles of a recovery food plan. This shaded area has been depicted as a small circle with allowances for the reality of imperfection. Moving to the “dark side” of relapse then becomes a large circle filled with binge eating and any permutation of disordered / pathological eating or dieting. In my experience there exists a slippery slope [excuse the pun] between adherence to a realistic definition of abstinence and one that is both rigid and unforgiving of anything short of perfection. To paraphrase another friend in the field “a recovery food plan must fit like a comfortable suit of clothes. Should you tailor it as a strait jacket you can expect someone to never stop struggling to get out of it.”
At our eating disorder clinic in Florida, I define abstinence with two distinctions, the first being the medical perspective and the second related to one of OA’s Tools of Recovery. The first would suggest abstinence is a matter of not engaging in any compulsive eating or eating disordered behavior[s]. For most, not binging, grazing, purging, restricting, or engaging in related self-destructive behaviors constitutes abstinence. The second way of defining abstinence comes in the form of what we refer to as an abstinent food plan. Not to be confused with the concept of a diet per se, an abstinent food plan is a set of guidelines [or boundaries if you prefer] around the types of food one consumes, frequency of meals, and amount / volume eaten. For many of our patients we begin with eliminating highly processed, sugar and flour laden foods and ask people to weigh and measure portions while in the program. In the treatment setting we utilize a registered dietitian to work with individuals. The process of “tweaking” an initial food plan typically involves small variations around this theme or set of limits. As mentioned, we encourage the intent of perfection but recognize the reality of imperfection. The probability of long term abstinence then becomes a matter of keeping the circle of imperfection small.
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 [OA in particular and for some, continued professional care] I’ve come to suggest the acronym – S.E.R.F. at our center. The letters stand for “Spirituality, Exercise, Rest, Food Plan.”
At this juncture, I would refer the professional to read the “Dignity of Choice” food plans OA offers as a suggested path to eating. It is written by a good friend of OA, Theresa Wright who is an experienced dietitian with most of her practice consisting of OA members. That said, I know from working with Theresa she practices DA without even knowing it. In a sense, it’s not so much “one size fits all” for crafting a recovery food plan or, for that matter, practicing the remaining OA steps on a fixed schedule. It begins and never ends with self-honesty and the humility of accepting the helping hand of OA.
Several seasoned eating disorder professionals have long relied on OA as an invaluable resource. Certainly I am among them for the past thirty plus years. Doing so has made all the difference between those enjoying long-term recovery and those on the merry-go-round of repeated relapse. In fact, having OA as a support group and combining it with professional intervention is usually a game changer. As with many “12-step” oriented programs, OA has evolved since its’ inception  into a more diverse and inclusive fellowship. Its’ members represent several “flavors” of disordered eating – bulimia, binge eating, food addiction, and some forms of anorexia. It has a rich tradition of asking only that attendees have a sincere desire to end their compulsive or addictive relationship with food and, in some instances, compulsive dieting. As with treating other forms of compulsion or addictive illnesses, many of us on the front lines credit OA for “beating the odds” and doing for our patients what we could not do alone. Addressing all that OA offers goes beyond the scope of this article. Having the experience of speaking with a few members would do much to enlighten anyone working with or suffering from an eating disorder. I know as a professional, attending a few of the “open” meetings showed me just how valuable OA can be to those who still suffer with the tyranny of addictive eating.
Marty Lerner, PhD.