Exposure-Response Therapy and Eating Disorder Treatment

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Many people with eating disorders have anxiety about food or food-related situations, such as eating in restaurants or around friends [1]. Fear foods are a common barrier for people with eating disorders and Exposure and Response Prevention (ERP or Exposure-Response Therapy) can help reduce reactions to them. Fear foods are foods that cause a significant level of anxiety. These fears often include anxiety before a meal, fear of food contents, or the potential effects of that food on body shape or size [1].

This fear can contribute to a variety of eating disorder behaviors, such as restricting or purging. It is important to decrease the anxiety related to fear foods in order to increase the chances of lasting recovery. One approach to accomplishing this is ERP. Exposure-response therapy is an evidence-based approach that focuses on reducing anxiety with eating through behavioral changes [1].

Exposure-response therapy intentionally challenges people to confront their food-related fears. However, this is done gradually and with support from a professional. Doing this treatment at a gradual pace allows someone to develop skills to cope with anxiety and to trust the professional they are working with. ERP therapy is done in steps. These are the steps of Exposure-response therapy for eating disorders:

Assessment & Fear Hierarchy

The first session with an ERP therapist or dietitian will include receiving information about the treatment approach and identifying beliefs about eating and foods (or food-related situations such as eating in a restaurant or with other people) that cause anxiety.

The first session will also likely include a discussion about avoidance behavior. An example of avoidance behavior is if someone is afraid of eating food that they did not prepare themselves, they might bring their own food to a party or a restaurant. More subtle examples of avoidance behavior are eating food in a certain order or taking very small bites.

The treatment professional will provide support to create a fear hierarchy. A fear hierarchy is a list of fear foods or food-related situations that cause anxiety. Creating the hierarchy will include rating these fears from least fear-inducing to most fear-inducing on a scale of one to ten.

Exposure-Response Therapy Sessions

Client going through an Exposure Response Therapy SessionThe next step would include exposure-based sessions. These exposures would be planned collaboratively between the client and the professional. This means that the ERP therapist will nudge the client towards a goal, but ultimately the client is in control. These exposures are conducted with the client’s consent.

The first few exposure sessions start with the least anxiety-provoking foods or situations. Before beginning the exposure, the clinician checks in with the client about current anxiety levels and coaches the client to begin the exposure. Depending on the anxiety level, the exposure may be looking at the food, touching it, or talking about how it tastes.

The clinician will coach the client to move towards feared situations in order to purposefully increase their anxiety without relying on avoidant behaviors or harmful coping skills [1]. This approach can help someone confront their fear and change any irrational thoughts that contribute to their anxiety.

For example, someone may believe that if they allow themselves to eat what they want, they will never be able to stop eating. With support, someone can try this food and realize that they will not automatically lose control of their eating behavior.

A professional will provide support before, during, and after an exposure in order to increase awareness of emotions, confront avoidant behavior, and provide support to implement coping skills. This process will be repeated as someone moves up the hierarchy and confronts more fearful situations.

Confronting these fears and beliefs can reduce anxiety over time as someone regains control of their beliefs and emotions. This approach has shown the be effective in helping people recover from eating disorder behavior [1].


[1] Glasofer, D.R., Albano, A.M., Simpson, H.B., Steinglass, J.E. (2016). Overcoming fear of eating: A case study of a novel use of exposure and response prevention. Psychotherapy, 53(2), 223-231. http://dx.doi.org/10.1037/pst0000048


About the Author:

Samantha Bothwell PhotoSamantha Bothwell, LMFT, is a licensed Marriage and Family Therapist, writer, explorer, and lipstick aficionado. She became a therapist after doing her own healing work so she could become whole after spending many years living with her mind and body disconnected. She has focused her clinical work to support the healing process of survivors of sexual violence and eating disorders. She is passionate about guiding people in their return to their truest Self so they can live their most authentic, peaceful life.


The opinions and views of our guest contributors are shared to provide a broad perspective on eating disorders. These are not necessarily the views of Eating Disorder Hope, but an effort to offer a discussion of various issues by different concerned individuals.

We at Eating Disorder Hope understand that eating disorders result from a combination of environmental and genetic factors. If you or a loved one are suffering from an eating disorder, please know that there is hope for you, and seek immediate professional help.

Published September 15, 2020, on EatingDisorderHope.com
Reviewed & Approved on September 15, 2020, by Jacquelyn Ekern MS, LPC

About Baxter Ekern

Baxter is the Vice President of Ekern Enterprises, Inc. He is responsible for the operations of Eating Disorder Hope and ensuring that the website is functioning smoothly.