Prevalence & Features of Eating Disorders in Males – Part 6

Exposure-Based Therapy & Eating Disorders – Exposure Hierarchy Examples & Coaching Techniques for Eating Disorders in Males

Let’s discuss a few examples of what a couple of hierarchies might look like. What’s important to point out is that these hierarchies don’t have to focus on just one kind of feared area or domain. We can include multiple domains within the same hierarchy so the

The first example is of a hierarchy that is simultaneously addressing a patient’s fear of eating dessert-related foods as well as wearing more form-fitting types of clothing items.

You can see that, from the bottom of this list to the top, the nature of the exposure activity becomes increasingly a revoking based on the fear rating that the patient has hypothetically provided in the column on the right.

This patient might work up from something beginning at a lower level, such as having just one spoonful of ice cream after dinner then work up to the top of the hierarchy.

All the way at the top, at a level seven, this patient might be encouraged to gradually work toward the goal of being able to go out and eat ice cream with friends following dinner.

One of the things that I neglected to mention before, about the fear rating scale, is that we ask patients to score the degree of anxiety or fear that would be present with these exposure activities ranging from zero to seven, zero being the least possible anxiety that one could imagine and seven being the most intense anxiety or fear that one could imagine.

One more example is a hypothetical hierarchy that’s been created to simultaneously address fears of another person, or other people seeing one’s stomach, as well as binge eating cues.

First, looking at the exposure that’s listed at the level three fear rating is just to sit with and hold an open package of cookies, these being a common binge queue.

Then, at level seven, is doing that same activity: holding an open package of cookies but while the individual is significantly upset.

Here, they were pairing an environmental cue which has been a cue for binge eating in the past, being in the presence of an open package of cookies, and pairing that with another environmental cue, feeling intensely upset or a really intense negative emotion.

We know that being able to pair those two cues together is a very potent exposure strategy. When we create the exposure hierarchy, before we go about even beginning with active exposure exercises, patients have to be reminded of the importance of doing away with and eventually eliminating, safety behaviors.

Patients are encouraged, throughout the course of this treatment, is to completely abstain from safety behavior usage to the best of their ability.

In a lot of cases, it is a little unrealistic to expect that a patient is going to be completely willing to forego any and all safety behaviors from day one.

In those cases, we may have to take a more gradual, fading approach in the course of doing this treatment.

It is common that we have to prioritize some of the higher risk behaviors such as self-induced vomiting, laxative abuse, or extreme or intense forms of exercise.

This is particularly important for those patients who are at risk for significant injury if they continue in that extreme form of exercise.

In prioritizing some of the higher risk behaviors, we really encourage the patient and develop a plan to move towards elimination of these behaviors as soon as possible.

One of the things that we know to be helpful in the safety behavior prevention process is using daily monitoring systems whereby patients can, on a daily basis, track their progress. This doesn’t have to be anything elaborate.

It can be as simple as keeping a little notebook or even a sheet of paper or note card in one’s pocket where they keep a running tally of how often they notice that they’re engaging in safety behaviors and how often they notice that they’re able to successfully prevent a safety behavior when they experience an urge to engage in one.

What’s nice about this process is that, as patients make progress and achieve prevention of safety behaviors, a majority report noticing that the overall urge that they experience to continue using or relying on safety behaviors tends to gradually fade and decrease over time.

What we explained to patients at the outset of treatment, again, before any active exposure activities have been initiated, is that each of the safety behaviors that we’re asking them to put forth the effort to prevent is something that we know to be directly involved in the maintenance of the eating disorder.

It naturally follows that eliminating the use of these safety behaviors is going to contribute greatly to eating disorder symptom relief in the long term.

Conducting & Coaching Exposure

In terms of how a clinician goes about their role of implementing and coaching exposure-therapy activities, again, when we have the exposure hierarchy completely formulated and ready to go, we tend to begin with exposure activities on the hierarchy that are identified by the patient as ones that would be challenging yet manageable.

What this gets at is, for this treatment to be effective, we know that the exposure has to be accompanied by some anxiety and fear, but we don’t want to completely throw the patient to the wolves or overwhelm them from day one.

So, we try to begin at a place in the hierarchy that largely comes down to what the patient views as an appropriate place to begin challenging themselves in a manageable way.

The patient is encouraged, in each exposure activity that they complete, to remain engaged in the situation and to stay in confrontation with the fear until their peak fear reduces by at least 50%.

So, again, on that zero to seven scale, if the individual notices that, when they’re engaged with the exposure activity, their fear peaks at a four, we want them to stay engaged in that until the fear is reduced by at least 50%, in this case to a two.

Whenever possible, we want the exposure tasks to be repeated consistently so, day-after-day, multiple times a day as well as in a variety of different contexts.

As you can imagine, this is a treatment approach that involves a good deal of homework activities that the patient is encouraged to complete independent of their therapy sessions with you.

The role of the clinician during exposure activities is to serve as coach and cheerleader, offering consistent praise and encouragement throughout the exposure activity and using several different strategies to hold the patient’s attention in the situation.

Rather than just sitting in complete silence, you want to be asking the patient about their unique experience that they’re having in the exposure activity. Questions such as:

• What is it like?
• What are you noticing as you taste this food or try on that clothing that fits your body a little bit more uncomfortably than you would like.
• Tell me what the experience is like.
• What thoughts are going through your head?
• Where do you feel the anxiety?

Of course, as clinicians, we want to be discouraging the use of safety behaviors or even more subtle such as encouraging tuning out cognitively or emotionally. It all comes back to wanting to hold our patients’ attention in the situation.

We don’t want or have to turn a blind eye to any sort of cognitive or emotional avoidance; we want our patients to be as engaged with the experience as they can be.

Immediately following the completion of each exposure activity, can be helpful for the clinician to facilitate a brief review of the outcome, helping the patient identify areas of progress that they’ve accomplished, helping them to see whether or not the feared assumption that they had anticipated at the outset of exposure was violated.

And, helping patients to gather from their experience that they are able to better tolerate or endure the distress and anxiety they encountered better than they anticipated at the outset.

In terms of how we progress throughout the hierarchy during one’s course of treatment, when a patient completes exposure activities repeatedly and experiences that fear reduction between different exposure activities, we then move up and initiate some of the more difficult or higher up exposure activities on the hierarchy.

This often begs the question, “at what point has a patient’s fear sufficiently reduced? At what point is it safe to make that upward step in the hierarchy?”

There really isn’t a great answer to this but below are a couple of guiding principles:

1. If the exposure activity that the patient is engaged in is consistently only causing the minimal fear on that zero to seven scale, around the mark of one or two, that’s a good indication it’s time to take that next step upward in the hierarchy.
2. In a lot of cases, we see that the patients themselves are endorsing not only increased or improved capability at being able to tolerate the anxiety they’re experiencing, but that, coupled with the willingness on the patient’s part to go ahead and move up to the next level in the hierarchy to take on that more challenging exposure activity.

The goal throughout the course of treatment is to gradually move throughout the entirety of the hierarchy such that, by the end, we’ve completed all of the activities on the hierarchy, including those that were identified as the most anticipated fear at the outset of treatments, then, being coupled with complete, maximal, elimination of engagement and safety behaviors.

Please See

Prevalence & Features of Eating Disorders in Males – Part 1
Prevalence & Features of Eating Disorders in Males – Part 2
Prevalence & Features of Eating Disorders in Males – Part 3
Prevalence & Features of Eating Disorders in Males – Part 4
Prevalence & Features of Eating Disorders in Males – Part 5

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Source:

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

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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.

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About the Transcript 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.

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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 14, 2018.
Reviewed on June 14, 2018 by Jacquelyn Ekern, MS, LPC

Published on EatingDisorderHope.com