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Examining the Role of Exposure Therapy in Eating Disorder Recovery

In modern eating disorder treatment practice, many kinds of therapy can be applied. Some, like CBT (Cognitive Behavior Therapy) and DBT (Dialectical Behavior Therapy) are mainstays of virtually every program. Others, such as animal-assisted therapy or faith-based programs are less used and more specialized. However, one form of therapy has been proven an excellent way to help individuals overcome their disordered eating behaviors – exposure therapy.

Since many types of disordered eating patterns are caused by anxiety about a particular type of food or eating-based situation, gradually exposing a person to those situations in a controlled fashion can help the individual overcome those fears. Each eating disorder has well-defined behavioral characteristics, outlined in the DSM-V, and though the typical behaviors are different, each can be addressed using exposure therapy. Some of the major eating disorders that exposure therapy can aid include:

  • Binge eating disorder (BED), although not as publicized as other disorders like anorexia nervosa, is one of the most common eating disorder subtypes in the United States. According to the National Eating Disorder Association, it’s three times more common than anorexia nervosa and bulimia nervosa combined. Defined as a compulsion to engage in binge eating episodes in which the individual eats a large amount of food in a short time, often past the point of comfort, binge eating disorder can be severely detrimental to their health. Binge eating disorder treatment usually involves multiple types of therapy, like group therapy and mindful meditation. One specific useful type of treatment to help achieve binge eating disorder recovery is exposure therapy.
  • Bulimia nervosa (BN) also features repeated binge eating episodes, although, unlike binge eating disorder, the individual will purge the food afterward. The most common way to do so is by self-induced vomiting, although other methods such as taking laxatives or excessively exercising are common as well. In extreme cases, the individual may purge after meals as well. These behaviors are usually triggered by the individual’s poor self-image or body dysmorphia, a distorted body image. Unlike the stereotype of people with eating disorders, people with bulimia nervosa are not usually drastically underweight.
  • Avoidant Restrictive Food Intake Disorder (ARFID), unlike the other disorders listed here, is not driven by body image issues or the desire to lose weight. Instead, people with ARFID strictly avoid certain types of food or food groups because of anxiety about its potential for danger or harm. This might manifest as a fear of choking, food poisoning, or other unhealthy effects. Although ARFID is not triggered by fear of gaining weight, the practical effect is often the same as with anorexia nervosa; severe weight loss and imbalanced nutrition are not uncommon in advanced cases of ARFID. Exposure therapy is almost always used in ARFID recovery treatment.
  • Anorexia nervosa (AN) is perhaps what most people think of when they hear the phrase “eating disorder.” This disorder, also driven by negative body image and fear of gaining weight, involves an individual restricting the amount of food they eat to an extreme degree. Typically, the individual sees themselves as overweight and otherwise “flawed” despite being underweight for their age and height. In extreme cases, the individual can lose so much weight that their body can no longer function properly, causing myriad health problems or even death. Exposure therapy for individuals with anorexia nervosa usually involves gradually introducing public meals and greater amounts of food over time.

What Is Exposure Therapy?

Exposure therapy is a form of behavioral therapy that tries to assist people with anxiety or fears about a particular situation by putting them in controlled instances of that situation. Exposure therapy is commonly part of treatment for varying types of disorders relative to anxiety, such as phobias and obsessive-compulsive disorder. It’s also a frequent component of treatment for PTSD. This is especially pertinent for eating disorders, in which trauma is a common causative factor and trigger for relapse.

During exposure therapy, people have to “face their fears,” although it’s not as harsh as that might sound. For example, someone who has anxiety relative to spiders would be exposed to pictures of spiders, spiders behind glass at the zoo, or even a spider being held by another person. With each session of exposure therapy, the individual is exposed to a larger or more up-close gradient of their specific fear. Over time, and with practice, the person can become able to face it without significant fear holding them back.

It can be applied to a wide array of mental health conditions, especially anxiety-related ones. For example, a person with social anxiety disorder might use a form of exposure therapy consisting of meeting with one person they already know, then a stranger, and then a room full of strangers, etc. Or a person with PTSD after a car accident might be asked to sit in the back of a non-moving car, then sit in the passenger seat, moving on up to actually driving the car again. The principles behind daily exposure therapy make it logical for use in eating disorder treatment because they are often anxiety-driven.

So How Does Exposure Therapy Work During Eating Disorder Recovery?

Daily exposure can help people during eating disorder therapy because it addresses one of the more common causative factors behind most eating disorders: anxiety. People with eating disorders often engage in these behaviors in private and feel guilt or shame about their disordered behaviors. Through daily exposure therapy, people with eating disorders can slowly and carefully get exposure to the things that they feel anxious about. This might mean the “fear food” for someone with ARFID, eating until full without purging for someone with bulimia nervosa, or eating without counting calories for someone with anorexia nervosa.

For example, someone with binge eating disorder who binged specifically on a certain type of food may be exposed to that food regularly in a controlled situation. They, with the help of a trained therapist, talk through what they were feeling throughout the exposure. Certain situations and actions are also addressed in this type of therapy – it can be used to help with other anxiety-driven behaviors, such as eating alone, practicing certain eating-related rituals, and more.

Normally, exposure therapy is not started by the therapists at an eating disorder treatment facility until certain criteria have been met. First, the incoming client must be medically and psychiatrically stabilized before any therapy can begin. Eating disorders can leave an individual with many medical issues that can be life-threatening, and psychiatric crises are not unusual. Secondly, the client should be making progress in their group and individual therapy sessions and beginning to normalize regular eating patterns. Pushing someone into exposure therapy before they are ready is counterproductive and can cause setbacks in their progress. Finally, although some forms of therapy such as journaling can be self-guided, exposure therapy must be conducted under supervision in case the individual’s fear becomes overwhelming.

Self-Understanding and Graded Exposure Therapy

Exposure therapy can be implemented using a variety of therapeutic techniques. One of those variations is graded exposure therapy. Graded exposure therapy requires the client to make a list of the things that cause anxiety from least frightening to most. Reviewing the list, the therapist will start with exposure to the things that would be easiest to work through according to the list the client made.

A typical list of fears being addressed might include things like:

  • Fear of eating in the presence of others.
  • Fear of foods that contain high-fat content.
  • Fear of not being able to stop eating when more food is present.
  • Fear of a specific kind of food.
  • Fear of eating without counting calories.
  • Fear of eating until satiated or full.

During graded exposure therapy in an eating disorder treatment setting, the therapist will start with the least feared item. As an example, a client recovering from anorexia nervosa may be asked to eat a small amount with the therapist present. Then they might move on to eating a full meal, then onto a group meal, and so on. Once the client is comfortable eating in the presence of others, the therapist will work on providing those triggering foods in with the meal. Each source of anxiety can be systematically addressed in this fashion.

In combination with other forms of therapy, exposure therapy contributes to a well-balanced continuum of care. The aforementioned CBT and DBT help clients objectively identify their disordered thoughts and feelings about eating, setting a baseline for confronting those fears in exposure therapy situations later on. Nutritional education provided by nutritionists and dieticians can supplement the client’s understanding of how the body and mind react to nutritional imbalances, providing further motivation to face their fears. Finally, experiential therapies like art therapy or journaling can help them gain a newfound perspective on their emotional state. Together, all these therapies add up to a treatment program that can address any eating disorder.

Wrapping Up

Overall, exposure therapy can be a highly effective way to help people during eating disorder therapy. Before going into any kind of eating disorder treatment, residential or day treatment, you should make sure to do all the research possible about what kind of help you can expect to get. Each program can be tailored to your needs, with a full continuum of care. If you would like to know more about the different types of therapy used in binge eating disorder treatment programs, reach out to your doctor or an accredited eating disorder treatment center for more information.

Melissa Orshan Spann, PhD, LMHC, RTY 200, is Chief Clinical Officer at Monte Nido & Affiliates, overseeing the clinical operations and programming for over 50 programs across the U.S. Dr. Spann is a Certified Eating Disorder Specialist and clinical supervisor as well as an accomplished presenter and passionate clinician who has spent her career working in the eating disorder field in higher levels of care. She is a member of the Academy for Eating Disorders and the International Association of Eating Disorder Professionals where she serves on the national certification committee, supervision faculty, and is on the board of her local chapter. She received her doctoral degree from Drexel University, master’s degree from the University of Miami, and bachelor’s degree from the University of Florida.