Carolyn Black Becker, Nicholas R. Farrell, and Glenn Waller, joined us for an interview on their book, Exposure Therapy for Eating Disorders. What follows are our questions in italics, and their thoughtful responses.
In brief, what is exposure therapy?
Facing a feared object or situation, staying with the fear and focusing it, and either learning that the fear fades as we sit with it and/or that we can tolerate the fear and function well in spite of it. That way, we become more confident in our ability to approached feared objects and situations. Paradoxically, as we engage more with what we fear, we become less and less fearful over time.
Exposure is probably the single most effective psychological intervention that we have for anxiety-based disorders and for the majority of eating disorder symptoms.
How has a deeper understanding of anxiety disorders helped in the treatment of eating disorders?
So many aspects of anxiety disorders share common features with eating disorders – particularly the use of safety behaviors and avoidance – that it is no surprise that anxiety and eating disorders are strongly comorbid. All three authors are all used to stealing ideas from the anxiety literature to enhance our understanding of the pathology and treatment of eating disorders. For example, we have operationalized the use of inhibitory learning approaches to eating disorders, based on recent innovations in the anxiety disorders’ literature. That pattern of appropriation is helped enormously by the fact that CB and NF have contributed separately and substantially to the treatment of anxiety-based disorders outside of eating disorders.
Eating disorder therapists have a tendency to play it safe relative to anxiety disorder therapists when it comes to encouraging our patients to approach what they fear. One example of what the eating disorders field can take from anxiety disorders is recognizing that our patients are stronger than we think and can tolerate more anxiety, which will help them get better faster.
Can you please tell us about the research supporting the use of exposure therapy for eating disorder recovery?
The book details the evidence about exposure therapy and eating disorders. From a broad point-of-view, there are a surprisingly high number of studies that attest to the efficacy of exposure-based treatment interventions in eating disorders, whether as a standalone approach or an as adjunct to more comprehensive treatment “packages.” Overall, we are able to point to the way that CBT (with its exposure elements) is the most effective approach for adults, and can be useful in younger cases. The direct evidence base is stronger in some areas (e.g., mirror exposure; food intake; cue exposure) than others, and a lot more research is needed to back up our clinical experience. Fortunately, we know that there are a lot of exciting studies being undertaken out there that should test our assumptions, and we can use the evidence relating to exposure with anxiety disorders to support our case.
What factors should a clinician consider before using exposure therapy with an eating disorder patient?
The first thing that the clinician should ask themselves is: ‘Why would I not use this extremely effective method to help my patients?’.
The real issue to consider is in what ways we should be applying exposure therapy, and that comes down to the patient’s symptoms and how they fit the case formulation. Of course, we need to explain exposure therapy to the patient and be honest about their need to tolerate some anxiety while they learn, but that is usually not a big challenge (see below).
Additionally, as outlined in our book, clinicians need to understand what truly constitutes exposure therapy and to be able to impart this understanding in their patients. For example, many clinicians mistakenly assume that because patients are highly distressed while undergoing refeeding and weight restoration in an inpatient hospital setting, this means they are doing exposure therapy. However, we contend that because exposure is a volitional treatment that requires active engagement from the patient in all phases (e.g., education, planning, conducting exposure), most courses of refeeding do not constitute exposure therapy, even if the patient is highly anxious throughout.
How can a therapist help a patient diagnosed with an eating disorder “buy into” the use of exposure therapy?
An important first step is to review the patient’s previous therapy, and to see what was missing from the evidence-based approach. Even where patients have been told that they were being given CBT for eating disorders, many report that they did not have key exposure-based interventions (e.g., being weighed openly; substantial dietary change; mirror exposure). That is not to say that all CBT is done poorly – just that the patients who have had weak CBT in the past are more likely to come back for treatment, as they were less likely to recover. When we can identify what was not done before, we can give the patient an understanding of why their previous therapy did not work, and what they need to do now.
Then, we explain how avoidance and safety behaviors (e.g., avoiding food, blocking emotions) play a huge role in maintaining and strengthening the patient’s eating disorder cognitions and the distressing emotions that accompany these cognitions. This naturally leads into a brief description of how exposure therapy is vital to address those features.
Finally, in the book, we present many case examples and analogies to explain how exposure therapy works. Our favorite is probably the one about how teaching your child to dip a toe in the swimming pool and then run away will never teach them to get in the water. Most people can immediately see that the only way for the child to learn is to summon up their courage and get in the water, then stay there until it feels comfortable. That helps them to see that they are going to need to face their own fears, in the same way (e.g., eating breakfast and sitting with the anxiety).
Can the family play a role in exposure therapy?
Of course. The family can play a role as co-therapists, helping their loved one to stay on track with tasks such as changing eating, trying out different locations to do exposure work, and reviewing what has been done (remember, even talking about the feared object can be exposure therapy).
However, just as importantly, the family can facilitate exposure therapy by what they do not do. In particular, families can ensure that they do not mess up the exposure therapy. Our job as clinicians often involves teaching family members not to impair exposure by trying to protect or calm the patient when they are facing their anxiety (e.g., don’t avoid the foods that you would normally buy when you shop for groceries; don’t cover up all the mirrors in the house). The desire to calm the patient is understandable, but a family that understands the rationale for exposure therapy is empowered to help the patient to recover.
What are some common fears clinicians have regarding exposure therapy?
The most important fear is that clinicians worry that they will be seen as being ‘harsh’, ‘strict’ or ‘uncaring’, and that the patient will have a bad experience. That leads therapists to avoid asking the patients to take the risk of making change (e.g., getting on the scales, so that they could learn that their weight is actually relatively stable). Putting that in CBT terms, the clinician’s own safety behaviors can get in the way of therapy, for the sake of reducing our own anxiety.
In a similar vein, Paul Meehl talked about the notion of the ‘spun glass theory of the mind’ – the idea that we treat our patients as being so fragile (like a glass Christmas tree ornament) that we avoid pressuring them to change. That way, the patient does not have a stressful session with the therapist, but the downside is that they do not learn any new skills, and hence stay unwell.
We all have these fears about being seen as harsh or distressing the patient (including the authors). However, we know that a really good exposure therapist tolerates their own anxiety, to give the patient the best chance to learn and recover. The term is ‘Exposure therapy for exposure therapists.’
About the authors:
Carolyn Black Becker is a Professor of Psychology at Trinity University and licensed clinical psychologist who specializes in the treatment of PTSD, anxiety disorders, and eating disorders. She is board certified in behavioral and cognitive therapy, and specializes in the implementation of scientifically-supported interventions in clinical and real-world settings. Dr. Becker has published numerous peer-reviewed papers, and she also co-authored three books and several intervention manuals. Dr. Becker is a fellow of the Academy for Eating Disorders, the Association for Behavioral and Cognitive Therapies (ABCT), and the Association for Psychological Science. She is past president of both the Society for a Science of Clinical Psychology and the Academy for Eating Disorders, and currently serves on the Board for the Association for Behavioral and Cognitive Therapies. Dr. Becker has received numerous awards including the Lori Irving Award for Excellence in Eating Disorders Prevention and Awareness granted by the National Eating Disorders Association and the Academy for Eating Disorders Research-Practice Partnership Award.
Nicholas R. Farrell, Ph.D. is a licensed clinical psychologist and the Network Director of Clinical Training and Development for NOCD where he provides clinical leadership and direction for teletherapy services. Prior to joining NOCD, he was a clinical director at Rogers Behavioral Health where he oversaw the treatment of individuals with eating disorders as well as other mental health conditions, including anxiety and mood disorders. He specializes in the use of empirically-supported treatments that have been developed based on psychological science. In particular, he has received specialized training and experience in using exposure-based therapy methods, and he has also authored many peer-reviewed articles, book chapters, and other clinical intervention guides on the topic of exposure therapy. He regularly gives workshops and other presentations related to exposure-based treatment of eating and anxiety disorders at various international conventions. He was the recipient of the Alex DeVinny Memorial Scholarship awarded by the Academy for Eating Disorders for excellence in research investigating the overlap between eating disorders and obsessive-compulsive disorder.
Glenn Waller is Professor of Clinical Psychology at the University of Sheffield, UK. His clinical and academic specialisms are evidence-based CBT for eating disorders, and why clinicians drift from effective treatment. He has published over 325 peer-reviewed papers, 20 book chapters and four books in the field, and regularly presents workshops at national and international meetings. He is Chair of the BABCP Scientific Committee. He is past president of the international Academy for Eating Disorders, and is on the editorial board of Behaviour Research and Therapy. He was a member of the NICE Eating Disorders Guideline Development Group, responsible for the 2017 update to the eating disorders guideline.