Many people with eating disorders make a full recovery. This means that they no longer experience any symptoms of eating disorders, including behavioural, emotional, and physical symptoms.

However, for some people, full recovery – at the present time – is unlikely. This is especially true for individuals with severe and enduring eating disorders (SEED) such as severe and enduring anorexia nervosa (SEAN). Individuals with SEED have usually received treatment multiple times but have been unable to find sustained recovery.

For some people with SEED, the best available treatments today are unlikely to lead to symptom-free recovery. In these cases, some doctors and other health professionals advocate for harm reduction methods. 

Harm reduction approaches aim to help individuals with eating disorders reduce the frequency, intensity, and risk of behaviours that may threaten their lives. Instead of seeking full recovery, they acknowledge that someone with SEED may maintain some eating disorder symptoms and try to reduce the harm that results from them.

Importantly, harm reduction approaches don’t mean that health professionals stop looking for alternative treatments that may lead to full recovery. Instead, harm reduction methods are used while we wait for researchers to develop new, better treatments. Medics don’t deny or discourage receiving a new treatment if one appears but recognise that it can be harmful to keep trying treatment methods that will almost certainly fail.

What Are SEED and SEAN?

People with severe and enduring eating disorders have experienced an eating disorder for six to twelve years (or more). They have a low chance of full recovery with the treatment methods that are now available and require the ongoing support of a mixed team of professionals.

People with SEED have severe symptoms of eating disorders, such as a very low body weight. They usually experience serious medical complications caused by their eating disorder, such as osteoporosis or bowel disease. Symptoms of SEED have a deep and pervasive effect on an individual’s quality of life.

Severe and Enduring Anorexia Nervosa (SEAN)

Severe and enduring anorexia nervosa (SEAN) is a type of severe and enduring eating disorder. SEAN develops in about 1 in 5 people diagnosed with anorexia nervosa. Anorexia has the highest mortality rate of any mental health disorder.

People with SEED often experience physical health conditions such as liver failure, cardiac failure, and osteoporosis. They usually require frequent medical interventions for physical complications as well as mental health care. 

While many people recover from eating disorders (and with recovery, most of the medical complications of anorexia can be resolved), recovery is most likely when someone receives treatment early in the course of their illness. This means that people with SEAN will face more challenges in reaching full recovery.

For example, individuals with anorexia often experience body dysphoria that becomes worse as their body weight decreases. As a result, symptoms of anorexia can intensify as it progresses and recovery becomes more difficult. People also usually develop more co-occurring disorders, which complicate the treatment process.

People with SEAN are often admitted to intensive treatment programs several times. However, as the number of times they enter treatment increases, it may become harder for clinicians to provide effective treatment.

Moreover, some individuals with SEAN don’t want to enter recommended treatment programs themselves. Because of attitudes that lie at the core of eating disorder pathology (such as a fear of gaining weight), they may be unable to accept the weight gain and increased energy intake sought by symptom-free recovery programs. While involuntary admissions can be effective in some cases (especially early on in the course of their illness), some research suggests that in the long term, involuntary treatment is less effective than voluntary treatment. 

What Are the Principles of Harm Reduction?

Hawk et al. (2017) proposed six principles of harm reduction for healthcare settings: humanism, pragmatism, individualism, autonomy, incrementalism, and accountability without termination. Harm reduction approaches don’t aim to fully overcome a health problem but to prevent the likelihood and severity of serious harm. 

Harm reduction methods are most commonly used in treatment for individuals with substance use disorders. For example, instead of trying to support an individual to completely abstain from a drug, a harm reduction approach may offer education on how to safely use sterilised equipment and avoid fatal overdoses.

In the past, harm reduction approaches were rarely considered for eating disorder treatment. But in the last decade, advocates for harm reduction methods under certain circumstances have increased. 

According to the Clinical Practice Guidelines for the British Columbia Continuum of Services, a harm reduction approach may be helpful to improve the quality of life of people with severe and enduring eating disorders. The authors note that while some people with SEED are unwilling to work towards full recovery, they still want to pursue goals that are meaningful to them and improve their quality of life. 

There are very few practical guidelines that set out what a harm reduction approach for SEED looks like in practice. But some proposals include:

• Allowing an individual to maintain a below-average weight, but one where they can still have some quality of life
• Acknowledging that a person may continue to use disordered eating behaviours like binging, restricting, or purging but trying to reduce the harm these behaviours cause
• Encouraging individuals with eating disorders to follow certain practices that will reduce harm and improve their quality of life
• Validating a person’s experiences, giving hope and support and using motivational interviewing
• Providing new treatment options and resources for someone to consider

How Is Harm Reduction Different from Palliative Care?

Harm reduction approaches don’t only focus on managing pain and symptoms. In addition to aiming to improve someone’s quality of life, they may also seek a degree of recovery that helps an individual avoid the most serious harm and live the kind of life they want. 

In What Circumstances Might Harm Reduction Play a Role in ED Treatment?

Harm reduction approaches are usually considered for people with SEED who:

• are unable or do not want to meet the requirements of other eating disorder programs, which tend to focus on increased energy intake and weight gain
• are unlikely to reach completely symptom-free recovery

Advocates of harm reduction methods do not support their use for every individual with SEED but argue that in certain circumstances it offers a person-centred, compassionate approach that may enable a person to live a better quality of life.

Why Do Some People Support Harm Reduction in Certain Circumstances?

There are several reasons that some experts support harm reduction approaches for eating disorders in certain circumstances. For example:

• Harm reduction approaches may respect an individual’s autonomy over their treatment and the way they want to live their life. Instead of imposing the most recommended treatment programs against a person’s will, they may seek to find a compromise in treatment that both clinicians, the individual, and family members or loved ones can accept.
• When the treatment approaches that are available are ineffective, they may cause someone with SEED additional harm. Harm reduction methods might constitute a compassionate approach that enables a person to have a better quality of life.
• Harm reduction methods may help people with SEED to maintain trust in healthcare providers. Because harm reduction approaches are inherently non-judgmental and non-stigmatising, they may enable people to stay in care and in contact with trusted clinicians who are willing to respect their personal needs and perspectives. This can be very important for people with SEED who may need medical interventions over the course of their illness.
• Some people with SEED may be able to live for longer and with a better quality of life by following harm reduction principles rather than pursuing treatment approaches that are most likely ineffective.

Is There a Case for Harm Reduction Methods Among Young People with Eating Disorders?

Young people with eating disorders often have specific experiences of eating disorders and eating disorder treatment. These experiences may constitute additional reasons to justify harm reduction policies in some cases.

One aspect of eating disorder treatment that’s especially relevant to young people is time spent away from the family. When teenagers and young adults repeatedly attend residential treatment programs, they may spend months away from parents, siblings, and other loved ones. 

This can cause young people psychological harm that affects their emotional and social development, takes away their closest support system, and exacerbates other mental health conditions. Co-occurring disorders, in turn, tend to make eating disorders more difficult to treat and may intensify symptoms.

As a result, harm reduction policies can help to prevent psychological pain while keeping a young person safe from the most harmful consequences of eating disorders. By accepting that some aspects of their eating disorder will stay the same while encouraging changes that protect them from the most serious harm, harm reduction approaches may give young people a safer and better quality of life.