Clients and Clinicians Facing Fears: Exposure Therapy for Eating Disorders
By Kelsey E. Clark, MS
Background
Fear is a normal emotional response that occurs when we feel threatened. We perceive a threat, and to protect ourselves we try to avoid the feared situation. In some cases, fear and avoidance lead to significant distress and interfere with our daily lives. For example, they can get in the way of work/school or damage our relationships. When this happens, this may indicate a person has a mental illness. Many individuals with eating disorders have fears related to eating, shape, and weight. A person may fear fatness or may fear perceived consequences of fatness, such as social rejection. Such fears are often behind eating disorder thoughts and behaviors.
Exposure therapy immerses individuals in situations so they confront experiences they fear or avoid. This facilitates learning new associations with the feared/avoided things. Exposure therapy is strongly supported by research for treating anxiety and fear-based disorders such as specific phobias, obsessive-compulsive disorder, post-traumatic stress disorder, panic disorder, and social anxiety disorder. For example, imagine exposure therapy for someone who has a specific phobia of spiders: The therapy client and clinician would work together to decide on situations so the client can face their fear. They might look at photographs of spiders, videos of spiders, be in the same room as a spider, and even hold a spider. This way, the client’s feared expectancies about what will happen can be challenged. Clients can see that they are able to tolerate anxiety, distress, and uncertainty.
Exposure therapy also has a growing evidence base for treating eating disorders. In eating disorders treatment, exposure therapy looks different from one person to another. A client might eat feared/avoided foods, induce urges to binge eat, induce urges to use inappropriate compensatory behaviors such as purging, or induce physical sensations such as feelings of fullness. They could also break eating rituals, confront their reflection in the mirror, imagine and describe in detail the experience of gaining weight, or stop using a body checking behavior. This explores and challenges the client’s feared outcomes. Feared outcomes look different from one person to another. Clients might fear they will immediately or ultimately gain weight, will be unable to stop eating, will experience unrelenting physical discomfort, or will experience never-ending emotional distress. Facing these fears violates these expectancies! Clients then learn they can tolerate and make it through these uncomfortable situations. By riding out the wave of fear, clients can reach treatment goals and live the life they want to live.
The Problem
Despite strong research support, many clinicians do not use exposure therapy. Research has found that many clinicians are nervous about exposure therapy. Apprehension is understandable—at first glance, exposure therapy sounds like the opposite of what clinicians want to do! Exposure therapy makes clients uncomfortable and distressed, when clinicians’ goal is to help clients to feel better and live by their values. Many clinicians fear that exposure therapy will cause clients to drop out of treatment, that they won’t be able to complete exposures, or that it will be intolerable to clients. Prior studies have debunked such concerns that exposure therapy is infeasible or unacceptable. Yet, exposure therapy remains underused.
The Research Study
As part of a larger eating disorders treatment study, we developed a novel three-session exposure therapy module. This treatment is individualized to address clients’ core fears. The treatment also provides opportunities for clients to practice skills they learn in treatment: emotion awareness, emotion regulation, and emotion tolerance. The present study aims to explore the feasibility and acceptability of this eating disorders exposure therapy module and explore the concerns of clinicians. We predicted that the exposure therapy would be feasible—that is, practical to use and able to be fully delivered as planned. We predicted that it would be acceptable—that is, judged as suitable and useful, and that clients would respond positively to it. A sample of adults with bulimia nervosa completed the exposure module. The treatment module included three exposures and one mood induction exercise intended to heighten emotions for the exposure. We used a mixed methods approach to comprehensively examine qualitative and quantitative data. We completed video coding of therapy sessions and analyzed questionnaires clients and clinicians answered before and after each session.
The Results
Broadly, our results indicated that the treatment is feasible and acceptable, as we hypothesized. On average, clinicians were able to complete the exposures as planned. Clients brought necessary supplies with them for exposures most of the time. We found that no clients dropped out of treatment immediately following the exposure sessions. We found that clients appeared to understand the rationale behind exposures and believed it was helpful. Clients expressed strong satisfaction with the exposure session content and strong satisfaction with their clinicians. One client stated that exposure was an “uncomfortable experience but also powerful.” Another client reported that exposure therapy was “extremely helpful, because [they] had to learn to sit with negative feelings.” These results support that it is possible to treat eating disorder clients with exposure therapy and that clients will judge it positively. With these initial results, we will be able to update and refine the treatment before examining the treatment in future research studies and disseminating it on a larger scale.
The Research Implications
Our findings support previous research and indicate that exposure therapy has untapped potential in treating eating disorders. Future work will continue to explore the efficacy of exposure therapy and explore why exposure therapy works. We will also explore how to spread the word about exposure therapy so that more clients and clinicians are aware of it. We will learn how best to address myths and misconceptions about this type of treatment. Our results indicate that instead of avoiding exposure therapy, clinicians should approach exposure therapy with the same degree of psychological flexibility they aim to foster in their clients.
Conclusion
The idea of facing our fears certainly sounds frightening! This is true for clients and clinicians alike! However, exposure therapy is based on the idea that continually avoiding things we fear robs us of the chance to learn that our fears won’t necessarily come true. This avoidance perpetuates our problems when fear/avoidance get in the way of the life we want to live. By approaching the things we fear instead of avoiding them, we learn how to accept the discomfort and uncertainty that are a normal part of life.
About the Author:
Kelsey E. Clark, MS is a third year clinical psychology doctoral candidate at Drexel University in Philadelphia, Pennsylvania, working under the mentorship of Adrienne Juarascio, PhD. Kelsey is active in eating disorders research, clinical work, and advocacy. Kelsey has been awarded an Academy for Eating Disorders RSH Scholarship and The Renfrew Center Foundation David H. Barlow Award for Research Excellence. Kelsey’s research is focused on improving eating disorders treatment and understanding emotion-related processes that maintain eating pathology. Kelsey serves on the Academy for Eating Disorders Research-Practice Committee and has advocated with the Eating Disorders Coalition and the National Eating Disorders Association. Follow her on Twitter: @KelseyEClark
At the 29th Annual Renfrew Center Foundation Conference for Professionals in November 2019, Kelsey E. Clark, MS received the David H. Barlow Award for Research Excellence for her work described above. For more information, click here. Research reported in this article was supported by the National Institute of Mental Health (K23 MH105680; PI: Juarascio).
References:
Becker, C. B., Farrell, N. R., & Waller, G. (2019). Exposure Therapy for Eating Disorders.
US: Oxford University Press. doi:10.1093/med-psych/9780190069742.001.0001
Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing Exposure Therapy: An Inhibitory Learning Approach. Behaviour Research and Therapy, 58, 10-23. doi:10.1016/j.brat.2014.04.006
Farrell, N. R., Brosof, L. C., Vanzhula, I. A., Christian, C., Bowie, O. R., & Levinson, C. A. (2019).
Exploring mechanisms of action in exposure-based cognitive behavioral therapy for eating disorders: The role of eating-related fears and body-related safety behaviors. Behavior Therapy, 50(6), 1125-1135. doi:10.1016/j.beth.2019.01.008
Levinson, C. A., Vanzhula, I. A., & Christian, C. (2019). Development and validation of the eating
disorder fear questionnaire and interview: Preliminary investigation of eating disorder fears. Eating Behaviors, 35, 101320. doi:10.1016/j.eatbeh.2019.101320
Murray, S. B., Loeb, K. L., & Le Grange, D. (2016). Dissecting the Core Fear in Anorexia Nervosa: Can We Optimize Treatment Mechanisms? JAMA Psychiatry, 73(9), 891-892. doi:10.1001/jamapsychiatry.2016.1623
Olatunji, B. O., Deacon, B. J., & Abramowitz, J. S. (2009). The Cruelest Cure? Ethical Issues in the Implementation of Exposure-Based Treatments. Cognitive and Behavioral Practice, 16(2), 172-180. doi:10.1016/j.cbpra.2008.07.003
Olatunji, B. O., Cisler, J. M., & Deacon, B. J. (2010). Efficacy of Cognitive Behavioral Therapy for Anxiety Disorders: A Review of Meta-Analytic Findings. Psychiatric Clinics of North America, 33(3), 557-577. doi:10.1016/j.psc.2010.04.002
Pallister, E., & Waller, G. (2008). Anxiety in the Eating Disorders: Understanding the Overlap. Clinical Psychology Review, 28(3), 366.
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. doi:10.1002/eat.22761
Steinglass, J. E., Sysko, R., Glasofer, D., Albano, A. M., Simpson, H. B., & Walsh, B. T. (2011). Rationale for the Application of Exposure and Response Prevention to the Treatment of Anorexia Nervosa. The International Journal of Eating Disorders, 44(2), 134.
von Ranson, K. M., Wallace, L. M., & Stevenson, A. (2013). Psychotherapies provided for eating disorders by community clinicians: Infrequent use of evidence-based treatment. Psychotherapy Research : Journal of the Society for Psychotherapy Research, 23(3), 333.
Waller, G., Stringer, H., & Meyer, C. (2012). What Cognitive Behavioral Techniques Do Therapists Report Using When Delivering Cognitive Behavioral Therapy for the Eating Disorders? Journal of Consulting and Clinical Psychology, 80(1), 171.
Wright, C., & Waller, G. (2019). The impact of teaching clinicians about implementing exposure therapy with patients with eating disorders: A nonrandomized controlled study. International Journal of Eating Disorders, doi:10.1002/eat.23171