What is exposure therapy?
Exposure therapy is a form of cognitive behavioral therapy (CBT) originally developed to help treat anxiety. In the eating disorder space, exposure therapy helps to reduce anxiety around food, eating, exercise, and the body, in order to overcome disordered eating habits.
Exposure therapy is based on the concept of habituation, which is the brain and body’s tendency to get used to things they’re exposed to frequently over a long period of time. Repeated exposure to the thing that’s causing anxiety reduces feelings of anxiety. With eating disorders, individuals experience extreme anxiety around food, eating, mealtime sickness, and how they view their bodies. (1) In general, when someone is afraid of something, they try to avoid it. For some fears, such as sharks or extreme heights, avoiding the fear won’t interfere with a person’s life. However, people with eating disorders have concerns associated with food and eating, which are things they must do daily to stay alive.
While avoidance can relieve emotional discomfort in the short term, avoiding food or eating for extended periods can be life-threatening. Someone with avoidant restrictive food intake disorder (ARFID) or anorexia nervosa (AN) may not be consuming enough nutrients to nourish their body properly. This food avoidance can lead to fatigue, irritability, psychological and medical complications, and even organ failure and death. Someone with binge eating disorder may avoid all social situations and isolate themselves because they’re ashamed of their body, which impacts their mental health and can lead to suicidal thoughts and ideation.
How to treat eating disorders with exposure therapy
People living with eating disorders may experience uncontrollable stress related to food, eating, and their bodies. This can include aversion to certain foods, reluctance to eat in public, and fear of gaining weight, as well as heightened concern about how their bodies look and what others think about their bodies. Exposure therapy is one way to treat individuals with eating disorders, helping to manage their feelings toward food, eating, and their bodies.
For people with eating disorders, the primary goal of exposure therapy is to lessen or eliminate the discomfort associated with specific objects or situations and learn how to accept that the thing they fear–gaining weight, for example–may happen. This involves helping the individual explore their fears and relationship with food, eating, and their body: to face their fears, feel the underlying emotions, learn to tolerate the fears and emotions, and learn how to reduce or eliminate the fear avoidance urge over time through gradual, repeated exposure to the object or situation causing their fear.
For example, someone with ARFID may avoid hamburgers, because of a traumatic incident in their childhood, such as choking on a hamburger, being forced to eat whole hamburgers when they were full and vomiting, or having to make hamburgers themselves every time a parent got sick and burning themselves on the stove. Someone with binge eating disorder (BED) may be afraid to eat one of their preferred “binge” foods for fear of not being able to stop, or be afraid of looking at themselves in a mirror, or not want to wear shorts, because they hate the way they look in them. Someone with bulimia nervosa (BN) may be afraid of not being able to stop eating or purging certain foods. Someone with anorexia nervosa (AN) may be afraid to eat without counting calories or may weigh themselves compulsively to see if they’re gaining weight.
What to expect in exposure therapy
A trained exposure therapist can help outline an individualized treatment plan depending on the client’s needs, but it’s often administered through multiple sessions.
Each session builds on the one before it. During the first few sessions, a therapist may ask the person with the eating disorder to imagine eating foods they tend to avoid and express how it makes them feel. Then, a later session may include touching or smelling an avoidant food. Eventually, the person with the eating disorder may have to taste or eat the food and talk about their feelings.
Exposure therapy sessions may continue for weeks, months, or years. It’s all dependent on the person’s journey and relationship with their eating disorder.
Types of exposure therapy
There are different types of exposure therapy used to treat eating disorders. Some exposure therapists will use multiple types, while others may only use one.
- Imaginal exposure: Imaginal exposure is when a person imagines a scenario that induces fear. Someone with an eating disorder could imagine eating large portions of food or indulging in the food they typically avoid.
- Interoceptive exposure: Interoceptive exposure incorporates physical sensations. For a person who fears gaining weight, interoceptive exposure could be holding or smelling food they typically avoid. While this sensation may cause anxiety, holding the food won’t cause the person to gain weight. This type of exposure helps the person disassociate holding food with gaining weight. Interoceptive exposure is also most used in addressing the triggering sensations found in ARFID.
- In vivo exposure: In vivo exposure is when a person confronts a feared option or situation. In the case of someone fearing weight gain, in vivo exposure encourages the person to eat foods they avoid and acknowledge weight gain is possible but is also beneficial for their body.
- Virtual reality exposure: Virtual reality exposure uses technology to stimulate a fear-induced situation. Some people may find it easier to overcome challenges with virtual reality exposure than in vivo exposure and may use it first in exposure therapy.
Evaluating exposure therapy as an effective eating disorder treatment
Eating disorders affect each person differently, and exposure therapy may not be the right choice for everyone. Before starting exposure therapy, an individual needs to consider the benefits and limitations of the treatment.
What are the benefits of exposure therapy
The primary purpose of exposure therapy is to eliminate or reduce uncomfortable triggers a person associates with food, but this treatment offers many other advantages. Exposure therapy can help someone:
- Break avoidance patterns: Exposure therapy can help people with eating disorders break avoidance patterns with food, such as skipping meals or not eating until a specific time of day.
- Go at their own pace: There’s no limit for how many sessions a person needs to complete in exposure therapy. People can take sessions slowly, or if they’re feeling comfortable, they can go through different exposure steps in one session.
- Gain control: Some people with eating disorders don’t feel in control of their bodies and choices. Exposure therapy can help individuals feel more in control of their behaviors around food.
What are the limitations to exposure therapy
If not implemented properly by a trained professional, exposure therapy may make eating disorder symptoms worse. In most cases, exposure therapy is gradual. A trained exposure therapist will have the person with the eating disorder start small, maybe imagining a fear food in their mind, and build up to seeing it, touching it, and tasting it.
However, in some cases, the person with the eating disorder will rush through exposure therapy without really working through their fear. Running through sessions often happens when a person is so fearful, they want to finish their sessions. When that happens, the person doesn’t gain the full benefits of exposure therapy.
The efficiency of exposure therapy in healing eating disorders
Research finds exposure therapy best for people with eating disorders when used with other treatments such as cognitive-behavioral therapy. (2) This same research finds that in vivo exposure can be most successful in reducing anxiety and increasing caloric intake.
It is important to note that exposure therapy works differently for everyone, and results may vary with each case. Exposure therapy may not eliminate fears and anxieties around food, but reducing stress and fear with time is an excellent achievement on the road to recovery.
Exposure therapy at Within Health
At Within Health, our clinicians incorporate exposure therapy into most eating, and movement sessions. Every single meal with our clients is a part of an exposure. The nutritionists at Within Health develop a meal plan, and choose which food is sent to our clients in their meal box, while our clinicians support clients through the unboxing, cooking, and eating exposures. Within Health also has movement classes which are part of an exposure group. Movement exposure may include stopping the movement, if someone is struggling with an exercise addiction, or increasing the movement, if someone has a fear of exercise.
Our team at Within works to create thoughtful individual exposures to support each of our clients. This is a mentality shared by our clients, which makes our methods incredibly special. All of our care programs included trauma-informed care, attuned to the client’s specific needs. If you would like to learn more about the eating disorder treatment methods available at Within, or the first steps, please call our team today.
Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.
- Web MD. (2021) What is Exposure Therapy https://www.webmd.com/mental-health/what-is-exposure-therapy
- National Library of Medicine. (June 2020) Exposure therapy for eating disorders: A systematic review https://pubmed.ncbi.nlm.nih.gov/32224363/
- American Psychological Association. (n.d.). What is exposure therapy? American Psychological Association. Retrieved from https://www.apa.org/ptsd-guideline/patients-and-families/exposure-therapy
- Reilly, E. E., Anderson, L. M., Gorrell, S., Schaumberg, K., & Anderson, D. A. (2017). Expanding exposure-based interventions for eating disorders. International Journal of Eating Disorders, 50(10), 1137–1141. https://doi.org/10.1002/eat.22761
- Black Becker, C., Farrell, N. R., & Waller, G. (2019). Exposure therapy for eating disorders. https://doi.org/10.1093/med-psych/9780190069742.001.0001
- Thomas, J. J., Wons, O. B., & Eddy, K. T. (2018). Cognitive–behavioral treatment of avoidant/restrictive food intake disorder. Current Opinion in Psychiatry, 31(6), 425–430. https://doi.org/10.1097/yco.0000000000000454