The Only Way Out is Through – Part Two

Exposure and Response Prevention and Eating Disorders
John Rapp, LCSW

Therapist, McCallum Place

As mentioned in Part 1 we looked at the core concepts of Exposure with Response Prevention and why it is critical to healing from anorexia, bulimia and binge-eating. In the following paragraphs we will explore the central role of habituation and how it functions in ERP treatment.

ERP works via neuroscience, not magic. Successful exposure promotes a process called “habituation”. After habituation has occurred, what once produced fear and anxiety instead become neutral or boring. Facing a fear long enough for it to dissipate sends a powerful message to a part of the brain that is less accessible with words, education, or cognitive interventions. The brain’s fear centers slowly learn that because a fear was faced and not avoided AND nothing bad actually happened, perhaps the situation is not actually dangerous. For example, if an eating disorder patient habituates to eating anxiety inducing foods on a regular basis the brain begins to recognize that these foods are not actually harmful, nor will they experience the feared consequences. Over time, the fear diminishes, as the body has a vested interest in not activating fear response system (a taxing process on the body) when no actual danger is present.

Habituation occurs when three criteria are met:

  1. The fear is faced frequently enough.
  2. The exposure is hard enough to activate the fear response system, raising anxiety levels to at least a 7 or 8 out 10.
  3. The sufferer sits with the anxiety long enough for it to reduce by a noticeable degree (generally 50%) merely by the passage of time, rather than by using avoidance or compulsions to force down anxiety levels.

At McCallum Place in St. Louis and Cedar Springs Austin, patients in our Residential and Partial Hospital programs eat multiple times a day while being supported by staff and peers. In doing so they are meeting all three criteria of habituation.

One might wonder why eating disorder patients and anxiety disorder sufferers do not habituate to their anxiety naturally. Certainly they experience significant anxiety on a frequent basis. Thus, it is the third criterion that is not naturally satisfied. A therapist trained in exposure therapy or a supportive loved one are often necessary to assist the sufferer in sitting with their anxiety long enough to habituate. As treatment progresses, eventually the anxiety sufferer can be empowered to be their own exposure therapist and keep up with exposures individually after treatment has ended. Help is often needed to overcome the initial, natural tendency to avoid what we fear and what makes us uncomfortable. We have witnessed mirror exposures allow patients struggling with body image to instead say, “I guess I’m not thrilled with my body, but I think I can tolerate or even accept it.” Patients once tormented by obsessive thoughts, after repeatedly confronting them by reading exposure scripts, remark, “Now that I hear the thoughts out loud they seem kind of silly. And I think it’s sad that I’ve had to suffer from them for so long.”

If you struggle with obsessive thoughts, irrational fears, anxiety, intrusive memories, compulsive behaviors, or avoidance, it is likely that a treatment with an emphasis on exposure will assist you in freeing yourself from these troubling symptoms, perhaps in ways that purely talking-based therapies have not in the past. It is no accident that the three treatments for PTSD with the most empirical support (Prolonged Exposure Therapy, Cognitive Processing Therapy, and EMDR) are all essentially exposure therapies. Consider finding a therapist knowledgeable in the principles of exposure in order to help you gain true control over your anxiety and create a sense of empowerment and confidence. Additionally, when seeking treatment for an eating disorder, it is important to find a treatment program that understands and incorporates principles of ERP into its treatment plan. If you believe you may need more intensive treatment please visit our website.

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.