Exposure Therapy for Eating Disorders: Trying New Things and Stopping Old Behaviors
Written by ‘Ai Pono Hawaii Staff Writer
When you’re in the depths of an eating disorder, things that seem so easy for everyone else feel impossible to do. Situations like going out to eat, eating a fear food, or eating what someone else serves you may cause you so much anxiety that you just can’t face them. And some eating disorder habits that you’ve built up seem impossible to stop. If you were to stop doing things like weighing yourself, weighing your food, or counting calories, you might feel an overwhelming amount of anxiety.
What is one of the best ways to stop feeling so much anxiety in these situations? Exposure therapy.
What is Exposure Therapy?
Exposure therapy was originally used to treat people with anxiety disorders. Individuals with anxiety avoid the things that cause their anxiety, which may help them manage those intense feelings in the short term. But research has proven that, in the long term, consistently avoiding something can make someone fear that object, activity or situation even more than they originally did.
One of the best ways to minimize anxiety is to face that fear — which, in therapy, is known as an exposure. An exposure in an event in which you are exposed to a situation, object, or activity that you fear, over and over again until you don’t fear it anymore. There are several forms of exposure therapy.
Exposure Therapy Strategies
In vivo exposure: Directly facing a fear in real life. For example, if you fear eating at restaurants, you may go with your support system (or order takeout, depending on the status of COVID-19 restrictions) to experience the thing you fear.
Imaginal exposure: The process of vividly imagining a situation, object, or activity. For example, vividly imagining walking down the street in a form fitting outfit. How would you really be perceived by others? How is that different than what you think would happen?
Virtual reality exposure: In some situations, virtual reality simulations may be used as exposure for situations that are not accessible at the current moment. For example, you may use simulations when preparing to go on a trip to the beach and want to do a bathing suit exposure before going.
Interoceptive exposure: Intentionally bringing on physical sensations that are unpleasant or feared, but are harmless. For example, you may be instructed to hold food if you fear or feel uncomfortable about eating with your hands. You will then learn that eating with your hands is not something that needs to be tied to any emotion. It’s just something you do.
Exposure Therapy Pacing
You can be exposed to something you feel anxious about slowly, in several steps over several therapy sessions. You can also do an exposure quickly.
Graded exposure: A clinician helps you create a hierarchy of fear list, where the first item on the list is something that causes strong anxiety, and the last one is only mildly fearful. You start with mild exposures, and move all the way up your list until you are exposed to your most feared objects, situations, or activities.
Flooded exposure: Instead of starting with mild exposures, you start by doing an exposure of the most feared items on your hierarchy of fear list. Once you know you can do the thing you fear most, it’s easier to continue on down the list.
Systematic desensitization: In some instances, when you do an exposure, you can also use relaxation techniques. If you continue doing exposures of a certain feared object, situation, or activity and use the same relaxation techniques, over time you may associate this exposure with relaxation, instead of fear.
In many treatment settings, exposures are done in a controlled environment with clinicians. This is done for two reasons: if an exposure is too anxiety inducing, a trained professional will be there to help the struggling individual. And if an exposure is completed successfully, they are able to later process the exposure with a clinician.
Why Exposure Therapy Helps
Doing exposures can help you break a cycle of avoidance, or break a behavior. If you can’t break a behavior all at once (which is very difficult) doing exposures is a way to slowly achieve a goal. Any negative associations, distorted thoughts, and expected outcomes can be removed when you do an exposure. The bad thing you thought would happen doesn’t actually happen after doing the exposure, so you stop assuming that the thing you feared is going to happen.
If you continue doing exposures, they start impacting you less as time goes on. You also, by consistently facing challenging exposures, may start to feel like you are more in control of your emotions than you thought. You realize that you can face hardship in your life, and you can handle it without your eating disorder.
How Exposure Therapy is Used in Eating Disorder Treatment
Anxiety plays a major role in the development and treatment of an eating disorder. A person with an eating disorder may engage in ritualistic behaviors to minimize their anxiety about other life situations. They may use food as a way to cope with an anxiety disorder.
Once eating disorder behaviors become habits, it’s really difficult to stop engaging in them. Avoiding things like eating with others, eating certain foods, and wearing form fitting clothes for so long has made them even more scary to someone with these eating disorder habits.
And letting go of other habits, like excessive weighing, counting calories, and knowing the nutritional content of foods is anxiety inducing. All the uncertainty that comes along with stopping these behaviors: uncertainty about what exactly you’re consuming and exactly how much you weigh, is so difficult that it’s really, really hard to immediately stop eating disorder rituals forever. Exposures can be done to help you get used to uncertainty. For example, having someone else order food for you will help you tolerate uncertainty about what you will be eating.
Innovations in the Conception and Usage of Exposure Therapy in Eating Disorder Treatment
While a large contributing factor of an eating disorder is anxiety, eating disorders are distinctly different from an anxiety disorder. For this reason, researchers have started to reconceptualize what exposures should focus on and how they should be done specifically for treating an eating disorder.
Anxiety disorders are characterized by an irrational fear of an object or situation. For example, someone with an anxiety disorder may have an irrational fear that any plane they step foot on will crash. This is very unlikely to happen, and one of the goals of doing exposures is to prove how unlikely this is.
But a person with an eating disorder usually fears things like weight gain, eating a variety of foods, or overeating. These are all things that are likely to happen, either during eating disorder treatment or afterwards. It’s not possible, then, to do an exposure that shows these feared situations (weight gain, a balanced diet, etc.) are probably not going to happen. In recovery, all of these things are very likely to happen, and for many, are even a goal in recovery.
It has been suggested, then, that exposures focus more on getting comfortable with what is and what will be. For example, imaginal exposures can be done when someone is weight restored. They may vividly imagine their life in their healthy bodies, and imagine the possibility of gaining weight later on in life. In this way, an individual can process their fear and discomfort with their body.
Researchers have also noted that disgust plays a role in eating disorders: disgust with one’s body, with foods, with certain behaviors. Exposures can be done to target this feeling and minimize the sensation of disgust. For example, a person may do exposures to help them tolerate the feeling of being full. For that individual, feeling full is disgusting. Over time, however, that disgust will weaken and eventually, go away entirely.
Food-Based Exposures
Food based exposures you may do in treatment:
Working through a list of fear foods
Not looking at nutrition labels or calorie contents in food
Not weighing food
Deleting calorie counting apps
Eating in front of others
Eating at a restaurant
Body-Image Focused Exposures
Body image focused exposures you may do in treatment:
Reducing (and hopefully stopping) the number of times you weigh yourself
Handing in any and all scales
Minimizing (and hopefully stopping) body checking
Wearing more form fitting/colorful clothing
Wearing a bathing suit
Making Exposure Therapy Work for You
If you or an eating disorder professional you’re working with think exposures may be helpful to your recovery:
Make a list of the anxiety inducing situations that hold you back in your recovery. Order them from most to least difficult.
Decide with your treatment provider how you should pace your exposures. You may respond to flooding. But you may really benefit from doing exposures slowly.
Make quantifiable goals for yourself. If you want to stop weighing yourself, you may start with only weighing yourself five times a week. The next week, you may do it three times. Then, only once, until you no longer feel the need to weigh yourself.
Choose to do exposures that will be really impactful if they are successful. For example, if you want to be able to eat sweets during the holidays, you should practice eating the sweets you will during holiday events.
Continue to do exposures! Doing an exposure once, and tolerating high levels of anxiety once, isn’t the point. You want to be able to incorporate that exposure in your life, whether it’s being able to eat certain foods, go out with people, or stop compulsive behaviors. You have to face the discomfort over and over again, until it’s not extremely difficult to manage in your everyday life.
Keep track of your feelings during and after exposures. Over time, you should see them becoming less intense.
Use your distress tolerance skills to manage anxiety during and after exposures.
Related: Not sure how to use distress tolerance skills, or what distress tolerance even is? Click here to learn more.
It is not recommended to do exposures if you are feeling manic, depressed, suicidal, are or have recently engaged in self harm, or do not have the support you need to safely complete exposures. Exposures are challenging, and can be dangerous if you are not in the frame of mind to take on these challenges.
As challenging as they are, exposure therapy can be really worth it. You can increase your ability to tolerate distressing situations, decrease eating disorder behaviors, and practice being in situations that you never thought you could be. By doing exposures, you’ll find that you can handle more than you ever thought you could.
If you or a loved one is suffering from an eating disorder, take the first step today and talk to someone about recovery or simply learn more about the holistic eating disorder recovery programs we offer.