The Only Way Out is Through – Part One

Exposure and Response Prevention and Eating Disorders
John Rapp, LCSW

Therapist, McCallum Place

At the McCallum Eating Disorder Recovery Centers we utilize a variety of therapies and approaches in the treatment of eating disorders with a special emphasis on evidence-based treatments. This includes Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and Interpersonal Therapy. Another evidence-based therapy, Exposure with Response Prevention (ERP) is a powerful tool in the treatment of anorexia, bulimia and binge-eating, particularly when addressing fear-foods, avoidance of weight gain and aspects of eating disorders that involve high-level anxiety. The goal of each of these therapeutic approaches is to alleviate life-interfering beliefs and behaviors, resulting in a higher quality of life for the patient.

In cognitive-behavior therapies, there are generally four strategies for creating change:

  1. Learning new skills and desired healthy behaviors
  2. Changing problematic thoughts and beliefs
  3. Changing the environment in which problems occur
  4. Using exposure to decouple healthy behaviors from punishing emotions that suppress them.

Some examples may be helpful. If someone struggles with assertiveness he or she may benefit from learning how to be assertive and practicing the skill via role-plays and therefore correct a skill deficit. Others may benefit from challenging distorted beliefs about what it means to be assertive, experiencing change as their thoughts are realigned with reality. However, for someone who understands how to be assertive, but avoids doing so because of anxiety or other punishing negative emotions paired with assertiveness, more skill instruction or thought restructuring is likely to be of little benefit. In order to break the link between assertive behavior and anxiety or guilt, exposure is the most useful change strategy.

Exposure and Response Prevention is a specific exposure therapy used for anxiety disorders and is a principal treatment for Obsessive Compulsive Disorder (OCD) and related problems. It involves facing increasingly anxiety-provoking situations, thoughts, or other stimuli (the exposure) while refraining from escape or avoidance behaviors normally used to manage anxiety (the response prevention). While such behaviors neutralize anxiety in the short-term, they are destructive in the long-run. They send the subversive message of, “This situation is truly dangerous. I need to continue to fear and avoid it. Anxiety is intolerable and must be avoided” to the fear response centers of the brain. Over time, the anxiety persists and often worsens.

Anxiety disorders like OCD and eating disorders often have many similarities. Both involve obsessive thoughts and irrational fears. Eating disorders often involve an irrational fear of fatness, weight gain or becoming ‘contaminated’ through unacceptable foods. Just as someone with OCD may have an irrational fear of germs or making mistakes, an individual with anorexia may experience an irrational fear of rejection by others if they gain weight. Thus, “Fatness” becomes associated with feared consequences like loss of control or being unlovable. Both OCD and eating disorders involve avoidance behavior and compulsive behaviors which represent an effort to neutralize anxiety. In both disorders, the obsessions and compulsive behaviors marginalize other areas of life and interfere with building a life filled with joy and meaning.

In a somewhat sinister fashion, in both eating disorders and OCD, anxiety has a way of overriding rational thinking and derailing effective behavior, even when the patient understands they are not behaving skillfully or their fear is unfounded. The inability to control fear with logic and words alone is often a source of frustration and even shame for those facing anorexia and bulimia. “I know I’m not really fat, logically, but deep down I still feel like I am” is a common refrain. The disconnect between rationality and anxiety may also bewilder loved ones, who may offer simplistic suggestions such as, “Why don’t you just eat?!” The power of ERP is in facing one’s fear head-on and providing more power to change than talking about it in an office.

Exposure therapies bridge the gap between one’s wise mind and one’s gut feelings that interfere with overcoming fears. If you have noticed that simply talking in therapy is not leading to behavioral change outside of the session, an increasing emphasis on exposure and behavioral experimentation may be helpful to you.

In Part 2 of this blog we will explore the concept of habituation and why it is such a powerful healing agent in anxiety and eating disorders.

John Rapp, LCSW
Therapist at McCallum Place
John received a Bachelor of Science degree in Microbiology from the University of Wisconsin-Madison and a Master of Social Work degree from the George Warren Brown School of Social Work at Washington University in St. Louis. His approach to treatment draws from Cognitive-Behavior Therapy, Dialectical Behavior Therapy, and Interpersonal Therapy. John is committed to collaborating with individuals suffering from eating disorders to better understand the meaning and function of their symptoms, build their motivation for and confidence in recovery, learn and experiment with healthier coping skills and ways of thinking, and ultimately cultivate a life of joy and meaning.