Exposure-Based Therapy & Eating Disorders – Overview
It has, really, only been in the last two or three decades that we’ve done some work looking at unique applications of Exposure-Based Therapy in the context of eating disorders.
The good news is this important work that’s been done over the last two to three decades suggests it is a very highly effective strategy in treating individuals with eating disorders.
Let’s talk about some of the reasons why this treatment tends to work well by looking back at the three core objectives of Exposure-Based Therapy mentioned above
First of all, we know exposure tends to work well because it leads to a phenomenon that we call “habituation” which is just another way of saying that when we repeatedly confront feared situations, our fear responding tends to diminish over time.
As such, increased exposure to fear situations leads to decreased fear responding.
Examples of this that we try to help patients to understand this phenomenon of habituation include ways that we’ve all probably overcome natural fears that we may have as children.
Riding a roller coaster, pedaling a bike for the first time without the aid of training wheels, jumping into the deep end of the swimming pool.
These are things that, upon the first exposure to the scenario, we tend to experience a really high degree of fear and urges to avoid but, with increased exposure, we tend to learn the situation is generally safe and tolerable. This leads to decreased fear responding.
A more contemporary view of how Exposure-Based Therapy exerts its therapeutic influence is centered around this concept that’s been called “the violation of expectancies.”
Here, the active mechanism of Exposure-Based Therapy is viewed as helping patients to experience that disconfirmation of their catastrophic belief.
So, what patients generally learn from exposure is that the likelihood or the severity of the negative outcomes that they anticipate is generally overestimated on their part.
Finally, we know that patients who undergo this treatment tend to experience really significant increases in self-efficacy and gain a sense of confidence that one is more capable than they had imagined of tolerating or just enduring really distressing situations.
So, we’ve discussed how Exposure-Based Therapy applies to anxiety and fear-based conditions, now let’s look at how we can view eating disorders, or come to conceptualize eating disorders, as really being synonymous with anxiety and fear-based problems.
First of all, we know that very similar to our anxiety disorders, there are several core conditions in eating disorders that tend to cut across the various eating disorder diagnoses.
Some of those core features are things that I’m sure you are familiar with across the eating disorder diagnosis.
We certainly see a myriad of unhealthy behaviors aimed at trying to control weight and shape, an extreme degree of preoccupation with topics around food or body shape or one’s weight, a lot of intense body image related distress, and general low self-esteem.
What we could view though as perhaps one of the most central features that spans across all of the eating disorder diagnosis is this kind of intense fear of a variety of potential consequences related to eating or one’s body shape or weight.
Of course, across eating disorders, we see a variety of safety, or what we’ve termed in the eating disorder field as compensatory, behaviors.
These are generally aimed at trying to influence or diminish the likelihood of these feared consequences from occurring.
We know that, as they do in anxiety disorders, in the realm of eating disorders, these safety behaviors tend to serve as one of the most directly maintaining factors, strengthening these fears.
Let’s use the same model that I walked you through before but applying it, step-by-step, to somebody with a fairly straightforward eating disorder.
Imagine an adult male patient who might endorse the catastrophic belief of “people are going to reject me, maybe abandoned me, unless I have this very ideal, lean, muscular, athletic figure,”
As we talked about before, this is going to draw this individual’s attention towards threatening cues naturally.
This male’s attention might be drawn more toward his body shape so that when he encounters some kind of perceived threat in the environment, like the prospect of having a slice of cake at a birthday party.
This might be met with a threat forecast of “if I eat that cake, if I allow myself to routinely consume foods like that, that’s going to lead me to become more flabby or to lose the muscular figure I’m trying to achieve and, of course, then I’ll probably wind up losing all my friends and end up hopeless and alone.”
This is what’s going to fuel the anxiety and fear in the situation and, of course, drive the safety behaviors.
This might be the individual deciding “I’m just going to skip eating the cake at the birthday party” or “I’m going to compensate for it in some way by skipping the next meal or spending an extra hour at the gym burning off the calories from the cake.”
It’s this engagement in safety behaviors that we know directly contribute to the maintenance and the strengthening of this catastrophic belief.
In this case, this male individual may believe with greater intensity that people truly are going to wind up rejecting him unless he is ideally lean and muscular.
Let’s walk through how we go about applying Exposure-Based Therapy in the treatment of eating disorders with male patients.
What exposure involves in a lot of these cases is helping male patients confront the very types of feared scenarios that they’re trying so desperately to either avoid or cope with effectively.
A lot of these feared scenarios surround eating, body image, and weight.
Typical Exposure-Based scenarios might include gradual exposure to feared foods or even challenging eating-related scenarios such as eating in a crowded public restaurant or even in a more intimate setting with a few friends or family members.
Also, exposure might involve scenarios that one might typically avoid out of body image related stress or anxiety.
This could be activities or even types of clothing that one might avoid out of anticipated scrutiny from others with regard to body image.
Given the heightened prevalence of binge eating episodes in males with eating disorders, Exposure-Based Therapy can be applied to treat binge eating successfully as well where individuals are encouraged to gradually encounter cues, or things in the environment that have, over time, become associated with the onset of a binge eating episode, which we’ll touch on a bit more later.
Of course, as mentioned earlier, these exposure activities have to be completed in concert with the prevention of safety behaviors, so, we have to encourage these patients to do away with any kind of weight or shape influencing behaviors that they might have been engaging in previously
This may mean engaging in a lot of restraint in their diet and compulsive forms of exercising.
A lot of checking or avoidance surrounding body shape and weight and body image avoidance may take the form of dressing in a certain way to conceal body image from other people.
Another critical safety behavior that we know we have to hone in on in treatment is ritualized eating patterns that we see in a lot of our patients with eating disorders.
Whether this is taking exceedingly small bites of food eating at a deliberately slow pace, maybe putting together kind of odd mixtures of foods such as two-three multiple food options that wouldn’t ordinarily go together.
We have to work with male patients to diminish the engagement in these safety behavior rituals.
Virtual Presentation by Dr. Nicholas Farrell in the Dec. 7, 2017 Eating Disorder Hope Inaugural Online Conference & link to the press release at https://www.prnewswire.com/news-releases/eating-disorder-hope-offers-inaugural-online-conference-300550890.html
About the Presenter: Dr. Nicholas R. Farrell, Ph.D. is a licensed clinical psychologist who directs and supervises the treatment of patients in eating disorder programs at Rogers Memorial Hospital. Dr. Farrell specializes in the use of empirically-supported cognitive behavioral therapy (CBT) treatment strategies that are used to help patients in our eating disorders programs.
Additionally, Dr. Farrell is a regular contributor to scientific research on the effectiveness and dissemination of CBT for eating, anxiety, and mood disorders and has published over 20 peer-reviewed journal articles and book chapters. Dr. Farrell has been the gracious recipient of federal grant funding to study the role of social stigma in the context of eating disorders.
About the Transcription Editor: Margot Rittenhouse is a therapist who is passionate about providing mental health support to all in need and has worked with clients with substance abuse issues, eating disorders, domestic violence victims, and offenders, and severely mentally ill youth.
As a freelance writer for Eating Disorder and Addiction Hope and a mentor with MentorConnect, Margot is a passionate eating disorder advocate, committed to de-stigmatizing these illnesses while showing support for those struggling through mentoring, writing, and volunteering. Margot has a Master’s of Science in Clinical Mental Health Counseling from Johns Hopkins University.
The opinions and views of our guest contributors are shared to provide a broad perspective of 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 on June 10, 2018.
Reviewed by Jacquelyn Ekern, MS, LPC on June 10, 2018.
Published on EatingDisorderHope.com