How MED-DBT Shapes My Practice: Principle over Protocol
Written by Charlotte Thomas, LCSW, LISCW.
This blog begins a short series on how MED-DBT has profoundly shaped my work as a clinician treating severe anorexia nervosa in outpatient care. In particular, I reflect on the ethical and clinical tension between rigid eating disorder treatment protocols and a principle-driven approach grounded in dialectical behavior therapy.
In January, I was reading the January Research Round-Up on the MED-DBT listserve. As I read through the summary of Byrant, E et al. (2026) article “Anorexia nervosa: 150 years of critical theory”, so many of my client experiences came to mind. However, for the purposes of this blog, I will focus on one particular client relationship. This client happens to love trees, so we will call her Willow. Much like the tree I’ve named her after, Willow has weathered (behavioral) floods, droughts, ice storms, choking smoke blown-in from forest fires, the traumatic loss of many tree-friends in her community, and the passage of time. Without going into unnecessary detail, I can summarize Willow’s eating disorder experience as severe, long-term, multi-faceted, and transacting with multiple other challenges including childhood and adult trauma, a multitude of treatment episodes at all levels of care (LOC), neurodivergence diagnosed only recently, financial and employment insecurity, profound loneliness, and actively compounding medical complications. Standard eating disorder treatment protocols would prescribe again and again (and again) that the only ethical course of action for me, as an outpatient therapist, was to insist that Willow admit to and remain in a high LOC until her behaviors were greatly reduced and weight was close to restored. These same protocols suggest that keeping the client in my care is unethical; that I would be causing harm. I have had so many moments of professional doubt, insecurity, guilt and shame over the many years of working with Willow because of these guidelines.
The reasons for my decision to not refer back to higher LOC are many. Willow has very limited financial means and there are no options in our state for residential LOC that accept her state-provided medical insurance. We have on many occasions attempted admissions to local lower LOC clinics, but they will not accept her due to severity and/or insurance. She was able to attend the inpatient program at Princeton Medical Center (big shout out to Dr. Rebecca Boswell and her team!) but travel costs were a significant burden for her family and she couldn’t tolerate being in the inpatient setting for long-enough to generate stable change. The transition home without an appropriate LOC step-down (reference my earlier statements about local lack of access) was more destabilizing to her eating disorder and her Life Worth Living than beneficial. I suspect that many clinicians experience this dilemma: the best treatment (settings or protocols) in the world can’t embed and stabilize benefits if the structures of appropriate step-down care are not accessible. This can feel like an impossible bind. Willow and I have had to radically accept again and again that there are no realistic options other than figuring it out together.
Two weeks ago, Willow said to me, “My mom said she loves you, Charlotte”. When I asked why, she responded it was because I’ve saved her life and that without me Willow would have been lost. SO, how can I explain this dialectic? On one hand, I’ve been continuing to provide care for someone in a way that many members of my professional community would view as unethical and perhaps dangerous. On the other hand, there is Willow. Willow-- who, after decades (literally) of severe AN B/P, now has 9-ish months of binge/purge B/P abstinence under her belt, is battling to increase her caloric and nutritional content and rebuild her chronically weakened body so she can be safe and present for an ICED 2026 poster presentation in which she is a co-author and an expert by experience. She is saving her own life.
This is beyond wonderful. But, what does it have to do with MED-DBT? While I could provide a laundry list of MED-DBT strategies that I have employed in my work with Willow, I will instead say this: principle over protocol. I know all the protocols to apply, and for that matter, so does Willow. So I, with her informed consent, shifted our focus to supporting her in finding the ways that allowed her to meet the principles of her treatment needs. I’ll pause here for a minute to explain what principle over protocol means to me. In MED-DBT we have a catalog of evidence-based protocols which are demonstrated in the literature to be key to the structure of effective and safe treatment. These protocols are based on standard DBT and evidence based treatment and management, both clinical and medical, of eating disorders. AND, we choose to emphasize the principles of acceptance and validation to allow adjustment of the treatment to fit the individual needs of the client. The protocols are applied in a way which supports the principles. For Willow, principle over protocol meant shifting focus from protocol-centered to her explicit life worth living (LWL) goals and this made a significant difference. Even though her LWL goals seemed unachievable when considered with the severity of her symptoms, I used MED-DBT’s philosophical framework to move away from arbitrary goals (“you need to stop purging or else….”) and instead targeted symptoms that interfered directly with the LWL vision we had crafted. Instead of a binary recovery/relapse, we focused on dialectical abstinence (e.g., planning to not purge while simultaneously planning for the inevitable purge). We built a skill set around her wise mind and practiced observing and describing it when it spoke. I managed my fear and listened for the voices of my mentors to bring me back to my own wise mind. I have actively sought consultation and validation from MED-DBT colleagues to support me. And I have remembered that change which happens with the movement of one grain of sand as the water moves over a rock is sometimes more sustainable than a behavioral sledgehammer.
And, friends, colleagues, guess what? It’s working. We aren’t done. Not by a long shot. But it’s working.
