Exposure Therapy in Eating Disorder Treatment
Written by CCTC Staff Writer
The ultimate goal in eating disorder treatment is to address and overcome the many fears that keep someone stuck in their eating disorder. These fears can hold someone back from achieving full recovery if the fear of food, weight gain or changes, and one's body and appearance as a whole are still lurking in the background unaddressed.
What is Exposure Therapy?
Exposure Therapy, or Exposure with Response Prevention, is one of the earliest psychotherapy techniques developed. Originally, ERP was used to help those with anxiety disorders to overcome the things, activities or situations that are avoided or feared.
Now, exposure therapy has been proven to be helpful for a larger range of mental health conditions including phobias, panic disorder, social anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder and eating disorders.
Why does Exposure Therapy work?
When people experience fear or anxiety around something, that leads to continued avoidance. This avoidance is motivated by the short-term relief felt by reducing the feelings of fear. Unfortunately, this avoidance only worsens the fear in the long-term. Exposure therapy helps to break the pattern of avoidance to ease anxiety and decrease the use of maladaptive coping mechanisms in response to fear.
With exposure therapy, people find that their reactions to feared objects or situations decrease, and learned associations between fear and objectives, activities or situations and bad outcomes no longer arise. There is also a sense of confidence when someone is able to step back and realize they are conquering things they once feared intensely.
What are the different strategies of exposure therapy?
There are four different strategies of exposure therapy.
In vivo exposure: Directly facing a fear in real life whether it is an object, situation or activity.
Imaginal exposure: The process of vividly imagining a situation, object, or activity.
Virtual reality exposure: In some situations, virtual reality simulations may be used as exposure for situations that are not accessible at the current moment or to prepare for situations that may provoke anxiety or uncomfortability.
Interoceptive exposure: Intentionally bringing on physical sensations that are unpleasant or feared, but are harmless.
Pacing of Exposure Therapy
The pacing of exposure therapy is an important thing to consider when deciding how to tackle these anxiety-provoking situations. For some people, taking a slower approach may be right, while for others jumping into it quickly may be better. There are 3 different approaches to consider:
Graded exposure means using a hierarchy list starting with the most difficult things at top, and least difficult at the bottom. Here you would start with mild exposures and move your way up the list.
Flooded exposure means starting with the most feared items, and working through the rest of the list of more manageable ones.
Systematic desensitization is when relaxation techniques are used during the exposure, so that eventually the relaxation is associated with the originally feared object, situation or activity rather than the fear.
Why does exposure therapy work in the treatment of the eating disorder?
For individuals with eating disorders, exposure allows them to gradually face the fears that contribute to their disorder and replace maladaptive behaviors with effective methods of coping.
Ways Exposure Therapy May Be Used in Eating Disorder Treatment
From eating-related fear and avoidance, to body image distortions or hyper-focus on weight, the use of exposure can help aid in the breaking of distorted thoughts and disordered eating behaviors.
1. Conquering Fear Foods
What are Fear Foods?
Fear foods are the foods that make you feel anxious, afraid or uncomfortable. Fear foods are often rooted in irrational thoughts about how specific foods impact your body and weight. Those with all types of eating disorders and disordered eating typically have some type of food rules dictating what and when to eat. This type of food moralization and labeling leads to disordered eating behaviors
What is the problem with Fear Foods?
This type of anxiety leads to an increase in thoughts spent thinking about food, how to eat or avoid eating certain things. Overall, without challenging and overcoming fear foods, full recovery from an eating disorder is not possible.
How to use exposure therapy to tackle Fear Foods
Reintroducing these ‘forbidden’ foods is an important step in recovery. Food-based exposures may include eating fear foods, not looking at nutrition labels, not weighing food, deleting calorie counting apps, eating in front of others, eating in a restaurant or ordering at a take out place. You may work with your therapist or dietitian to make a list of the fear foods you have to begin tackling them one by one.
Here are a few additional examples of exposure therapy to help improve your relationship with food:
If you fear eating in public, you may go with your support system to a restaurant, food court or have a picnic in a public park.
If you fear grocery shopping, you may go grocery shopping with support to navigate triggers and anxiety.
2. Coping with Negative Body Image
What is Negative Body Image?
Negative body image can be defined as being overly focused on your size, shape and appearance.
What is the problem with Negative Body Image?
A negative body image can lead to unhealthy self-talk, low self-esteem and disordered eating.
How to use exposure therapy to deal with Negative Body Image
Those with negative body image may struggle with weighing oneself, body checking, avoiding certain clothing, and not being able to enjoy activities such as shopping for new clothes or going to the beach or pool in a swimsuit. To try to combat these negative thoughts and work through the fear associated with each, you may try gradually decreasing the amount of times you weigh yourself or body check to conquer the fear that if you don’t, you will lose control of your body. You may challenge yourself to wear a form-fitting outfit you typically would avoid for a few hours at a time. You may go shopping with a friend or support from your family to pick out new clothes, or try wearing a swimsuit at a friend's house and work your way up to a public pool or beach. The goal is to expose yourself to the discomfort to give you the opportunity to practice reframing your negative body image thoughts and relying on your coping skills to reduce distress.
Emerging Exposure Therapy in Eating Disorder Treatment
Mirror Exposure Therapy (ME) is an emerging concept to help those struggling with negative body image. In this exposure, a therapist guides a client through looking at themselves in the mirror and describing every inch of their body over the course of an hour. Tom Hildebrandt, chief of the Division of Eating & Weight Disorders (Center of Excellence) at Mount Sinai and associate professor of psychiatry at the Icahn School of Medicine at Mount Sinai, said “We found that not only did we see improved body image for all the folks that were in the ME group, but that the effects were durable.” According to one 2018 study, the response to the therapy regarding body image was largely positive, citing improvement in mood and body satisfaction after sessions, though studies still need to be conducted with different control groups to see just how effective it can be.
Interested in trying Exposure Therapy?
In many eating disorder treatment programs including inpatient, residential and outpatient programming, different exposures are done in a controlled and safe environment with clinicians. This can help individuals struggling to navigate any difficult feelings and emotions that arise, and also provide a safe place to process the exposure with the clinician.
If you are not currently in programming, but would like to explore how Exposure Therapy can support you in your recovery, you could discuss with a therapist or dietitian that specializes in eating disorders how exposures may aid you.
You may work with your therapist or dietitian to identify the different fears you currently have around food, your weight and your body. From there, you can rank which causes the most anxiety to the least and determine what goals you have, and what type of support is needed to work through challenges. Your sessions can then be a place to talk about how these exposures went, what you hope to achieve next time, and celebrate the wins you are conquering against your eating disorder.
ERP gives those in eating disorder treatment an opportunity to fight back their eating disorders with support and gain the skills they need to eventually return to their lives ready to face old triggers and anxieties without jeopardizing recovery.
If you or a loved one is suffering from an eating disorder, take the first step today and talk to someone about recovery or simply learn more about the holistic eating disorder recovery programs we offer.