Exposure and Response Prevention (ERP) for Eating Disorders

Exposure therapies are often misunderstood and conjure images of people being forced into elevators, snake pits, or whatever is the “worst-case-scenario” of their deepest fears.

While exposure therapies will obviously involve exposures to fears, they are not as cavalier and harshly presented as many perceive.

For individuals with eating disorders, exposure therapies allow them to gradually face the fears that contribute to their disorder and replace maladaptive behaviors with effective methods of coping.

What is Exposure and Response Prevention Therapy?

Exposure and Response Prevention Therapy (ERP) is a type of Cognitive Therapy that was created based upon a two-factor theory of fear and avoidance. This theory posits that “individuals experience anticipatory anxiety in the presence of environmental stimuli that are associated with painful or aversive experiences through classical conditioning. Subsequent avoidance of the feared stimuli serves to alleviate people’s anxiety, which in turn reinforces the avoidant behavior through operant conditioning [1].”

Essentially, individuals experience uncomfortable emotion-states related to certain stimuli or experiences and begin engaging in maladaptive skills to avoid this. “ERP aims to break this cycle of symptoms by eliminating rituals and avoidance, thereby teaching patients how to tolerate distress without engaging in counterproductive behaviors and providing ‘corrective information’ that challenges people’s existing fear response [1].”

Exposure and Response Prevention Therapy Steps

ERP can be simplified to two steps that are specified in the name: exposure followed by response prevention. The Exposure aspect involves individuals being faced with a fear or anxiety-producing person or situation. The process of Response Prevention involves preventing the maladaptive responses an individual develops and replacing them with more effective behaviors.

Looking into these two steps more deeply, the first step of ERP is the assessment and treatment planning phase. During this phase, “patient and clinician work together to identify external (situations, objects, people, etc.) and internal (thoughts and physiological reactions) stimuli that trigger the person’s obsessive thoughts and subsequent distress [1].” Therapist and Patient also work to identify the beliefs behind engaging in the maladaptive responses and what fears exist in the individual’s mind if they did not engage in the maladaptive behavior.

Once these aspects are identified, the individual and therapist will “work collaboratively to rank different situations in order from least to most distressing (as measured by subjective units of distress or SUDs), which results in a fear hierarchy [1].”

Beyond this, sessions include exposure to the situations and experiences specified on the fear hierarchy, beginning with the least distressing. As the individual is exposed to these fearful circumstances, they are encouraged not to use previous maladaptive behaviors and to, instead, replace these with effective skills for coping.

The individual’s ability to cope effectively with anxiety and fear-inducing stimuli increases as they work through their hierarchy.

Forest View

Exposure and Response Prevention Therapy and Eating Disorders

ERP is an effective treatment method for eating disorders because eating disorder behaviors are often rooted in avoidance of feelings of anxiety and/or distress. Many experience distress and emotional dysregulation related to having weight, eating foods, not meeting societal beauty standards, etc. and use disordered eating and exercise behaviors to avoid these feelings. They might also experience discomfort being in their body due to experiences of trauma that cause distress and use eating disorder behaviors to numb or disconnect from these feelings.

In eating disorder treatment, ERP often involves exposure to those things the eating disorder has allowed one to avoid. An individual might create a “fear food hierarchy” and slowly begin exposing themselves to their fear foods without using eating disorder behaviors and using effective coping skills when this exposure results in distress.

The same process might occur in engaging in exposures to clothing that cause an individual distress about their body or safety. They might wear the challenging clothing and practice using cognitive reframing and grounding skills to reduce distress as well as reconsider their beliefs about these clothes being unsafe or inappropriate for their bodies.

Exposure and Response Prevention Therapy in residential treatment might also mean individuals engaging in binge and/or binge/purge exposures. For example, an individual that struggles with bingeing and purging behaviors might be given the food they would typically binge on and encouraged to eat it in their bedroom with the bathroom door unlocked. This challenges individuals with the ability to use their past maladaptive skills and the opportunity to make more effective skill choices despite having this access.

Individuals in eating disorder treatment are also often exposed to interpersonal dynamics naturally due to the treatment setting having multiple staff and patients around. The individual might work with their Therapist to consider their maladaptive interpersonal communication skills and practice utilizing more effective communication skills when challenging interactions arise in treatment.

ERP is effective in treating eating disorders because it does not allow individuals to avoid that which causes them distress and triggers their eating disorder behaviors. Instead, these individuals face these experiences and learn to cope effectively within them so that, should they arise in their daily life, they know recovery-focused methods of coping.

Resources

[1] Hezel, D. M. (2019). Exposure and response prevention for obsessive compulsive disorder: a review and new directions. Indian Journal of Psychiatry. 61:1.

Author: Margot Rittenhouse, MS, LPC, NCC
Page Last Reviewed on February 7, 2022 and Updated By: Jacquelyn Ekern, MS, LPC