How MED-DBT Shapes My Practice: Radical Acceptance
Written by Charlotte Thomas, LCSW, LISCW.
This is the second blog post in a short series on how MED-DBT has profoundly shaped my work as a clinician treating severe anorexia nervosa in outpatient care. Read part 1 here where I reflect on the ethical and clinical tension between rigid eating disorder treatment protocols and a principle-driven approach grounded in dialectical behavior therapy.
I’m going to start this off with a little background. My journey as a MED-DBT clinician started almost 20 years ago. It was the unintended consequence of a less-than-wise house purchase and an absolutely wise decision to abandon my almost complete PhD in neuropharmacology in favor of an MSW. I learned about using DBT to treat eating disorders from the best and was lucky enough to have 4 years with the incredible team of people who worked with Dr. Lucene Wisniewski and Dr. Mark Warren. A couple of cross-country moves later, I found myself in the Pacific Northwest, and working with another incredible DBT team at Portland DBT Institute, where I was the Eating Disorder (ED) team lead for many years.
One of the things that I discovered early in my journey as a clinician is that I have a passion for the clients who have multi-layered presentations or have heard from previous treatment settings that they are “too much”. When you treat people with EDs using DBT, more often than not, this includes managing life threatening behaviors (LTB). In MED-DBT, we extend the definition of LTB beyond that of standard DBT. In standard DBT, imminent risk refers to suicidal or non-suicidal self-injurious behavior (NSSI), however, in MED-DBT we include ED behaviors that cause imminent and medically-defined threat to life. For example, low potassium, orthostasis, or bradycardia are typically causes for acute medical care. This means that in the MED-DBT environment, it’s not uncommon to have someone with many different LTB’s that need to be actively targeted and managed simultaneously.
This brings me to what I really want to write about today: how we apply the skill of radical acceptance to the very real risk that we may one day lose a client to LTB regardless of how well we have applied the evidence-based treatment. Radical acceptance is one of those DBT skills that must be consistently nurtured and practiced because it is rarely comfortable. It is defined as the practice of fully accepting reality as it is, with body, heart, and soul, while letting go of resentment, bitterness or judgement. It is the root of willingness and finding a path forward when there seems to be only barriers or impossibilities. This is perhaps one of the hardest things to learn as a MED-DBT clinician, and it may be something we don’t talk about enough.
Standard DBT was originally developed to help women who were experiencing chronic suicidal or self-harming behavior and were considered “treatment resistant". Linehan modeled what it meant to not give up and accordingly developed a revolutionary treatment. MED-DBT proudly builds on this history and knowledge to give us a framework to effectively “not give up” and to provide therapy that promotes change and hope, while treating all of the LTB’s that show up for our patients.
And yet, as clinicians, we feel justified fear. It would be folly to ignore the fear, to invalidate it as unreasonable or to let it overcome us. Our practice of radical acceptance is the antidote to this fear. It gives us permission to keep trying, to pull for change and hold acceptance, to see beyond the scariness of what our clients are battling. It reminds us to mindfully balance risk with constantly nurtured expertise and consultation. It allows us to hold space for urges to escape this hard work and determination to support all of our clients in their individual battles. And our practice of radical acceptance prepares us for the absolutely devastating moment when a client dies because of LTB, should that ever occur. Radical acceptance gives us permission to dialectically grieve and feel pride for the fiercely fought battle for life.
I am and will be forever grateful for my mentors who introduced me to DBT and eating disorders, who nurtured my early and matured love of this work, guided me in developing my expertise, and demonstrated how to approach the risk of our work with integrity and self-care.
