Exposure therapy can help with eating disorders
By: Masha Sardari MS, RD, LDN
Published: February 20, 2024

Exposure therapy—whereby a person is “exposed” to controlled doses of what they fear, as a way to overcome that fear—has long been associated with the treatment of trauma and phobias. It can be effective for eating disorders as well.

In fact, we use it every day with our residents at Koru Spring.

In a very real sense, treatment for an eating disorder is one large dose of exposure therapy. People are directly confronting their fears in a safe setting when they come to us.

But we also use exposure therapy in a more targeted, personalized way to help our residents become less anxious around food and eating.

Exposure therapy explained

Exposure therapy was developed as a way to help people confront and overcome a particular fear or memory. When people fear something, they tend to avoid it. This avoidance can decrease the fear in the short term, but it often increases the fear in the long term. And it doesn’t go away.

Exposure therapy helps break that pattern of avoidance and fear. A patient is exposed to the fear using words, pictures, or experiences in a safe, supervised environment. When this is repeated, and nothing bad happens, fear and anxiety decrease over time.

In more scientific terms, the idea with exposure therapy is to confront the person with a feared stimulus without the occurrence of the feared response. Eventually, the connection between the stimulus and response breaks down, and fear recedes.

Exposure therapy applied to eating disorders

After getting a person’s buy-in to start exposure therapy (no one should ever be forced to do it), the initial fear/anxiety response can sometimes be strong. But it almost always decreases quickly as treatment progresses.

The key is to try and stay with it. I sometimes explain to our residents that it’s like getting into a cold swimming pool or the ocean. After a few moments, it doesn’t feel nearly as cold. But you need to stay in. If you get out right away, it’ll feel just as cold when you get back in the next time. For exposure therapy to work, you need to stay in. That’s what allows the fear to recede.

It’s true that exposure therapy does involve a certain amount of anxiety along the way. That said, a person will likely feel a lot more fear and anxiety living with their eating disorder than they do when they challenge it.

When maintaining an eating disorder, a person rarely gets better at dealing with it. In the long run, that amounts to a lot more fear than when you challenge it.

Related point: Some people with EDs live with their condition for years. ED behaviors and thought patterns become fixed. Therefore, confronting those behaviors in treatment is difficult, and doing a reset takes time.

In these situations, people are literally being asked to rewire their brains when they’re in treatment. Even in those challenging instances, we may see progress in a matter of weeks. Exposure therapy is often key to that improvement.

Also, exposure therapy always works best when it is highly tailored to the individual. Here’s what that means: First, the intensity level of the exposure is matched with the person. If a resident is making consistent progress and is ready, we can increase the difficulty of the exposures.

A second variable is frequency of exposure. Some people do better with an exposure session every day. Others prefer every other day, and so on. A third variable is the speed of ramp-up. As people get used to their exposure therapy and begin responding well to it, they can often tolerate more during each successive session. Others prefer to ramp up more gradually.

Exposure therapy in action

At Koru Spring, one method we use is to ask a resident to come up with a list of fear-inducing foods or food-related activities. We then ask the resident to rank them 1 through 10, with 1 being least fearful and 10 being most fearful. When we choose the first exposure session, we usually go with an item listed at level 5 or thereabouts. In other words, something in the middle of the fear range.

Let’s say that item is going out to a restaurant to eat pizza. We will then take that resident to a restaurant with a small group of other residents. Or it’ll be the resident and two of our therapists. Still other times it’s just one-on-one. We tailor these groupings based on what is most therapeutic for the resident.

We talk briefly before heading out, and we reassure the resident that this will be a safe, secure, and supported outing.

After the meal, we discuss how it went. It usually goes quite well! We build on that the next time, and the time after that as the resident progresses through their list of fearful items.

The “spillover effect” is real

As people progress with their exposure therapy, some great things may happen. To use the abovementioned example, once a person accomplishes going out for a pizza dinner, going out to eat in general often gets easier.

As residents overcome certain items on their fear list, the remaining items may lose their power to cause fear or anxiety.

This spillover effect extends to other areas of life. With time, people become more tolerant and less fearful of anxious situations. They become more flexible in their daily habits. And they become more comfortable with feeling a certain level of fear or stress, and discover new, more constructive ways to deal with those feelings.

All of that progress and discovery can sometimes start with a single session of exposure therapy.

If you or someone you know is struggling with an eating disorder, consider this therapy. It could jumpstart the journey to long-term recovery, and a more contented life.

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