When to Use Cognitive Therapy Techniques to Enhance the Effects of Exposure

Given that one of the main objectives of exposure therapy is to alter individuals’ cognitions related to feared stimuli, cognitive therapy can be effectively used as an adjunctive strategy to exposure. However, it is important to note that behavioral change methods show greater effectiveness in reducing eating disorder symptoms as compared to cognitive therapy. There are also circumstances in which utilizing cognitive therapy as an adjunct to exposure is not warranted. Accordingly, clinicians need to use careful consideration when deciding whether to engage eating disorder patients in cognitive therapy. As a general rule of thumb, clinicians are encouraged to employ cognitive therapy techniques when a patient is demonstrating significant hesitancy to begin exposure or is deriving notably suboptimal benefit from exposure.

Cue Exposure for Binge Eating

Many patients who have experienced difficulties with binge eating continue to do so even after nutritional stabilization. This can happen because they experience learned cues that trigger strong food cravings. Cue exposure can be useful to address such binge eating. This technique involves confronting the cues that typically elicit heightened food cue reactivity (i.e., cravings), while preventing the subsequent response of bingeing. In this process, patients learn that their binge cues are no longer predictive of an actual episode of binge eating. That learning has the effect of substantially weakening cravings that occur in association with exposure to binge eating cues.

Why Do People Get Better With Exposure Therapy?

This chapter outlines a theoretically based rationale for using exposure consistently in the treatment of individuals with eating disorders. Due to the substantial overlap between eating disorders and anxiety disorders (both in symptom content and in comorbidity between the conditions), exposure therapy is a sound choice for therapeutic intervention. Indeed, the most evidence-based treatments for eating disorders contain a number of exposure-based strategies that drive much of the therapeutic benefit. The chapter discusses habituation, systematic desensitization, and inhibitory learning and differentiates exposure therapy from systematic desensitization. Using a case study to consider how exposure therapists can help patients learn to tolerate their anxiety by leaning into it rather than engaging in safety behaviors, this chapter lays the foundation for the application of exposure therapy to patients with eating disorders.

Dealing With Clinicians’ Fears About Using Exposure

In addition to the institutional barriers to exposure that are often present in higher levels of care for eating disorders, there are also clinician-level barriers that need to be addressed across clinical settings. In particular, there is a well-documented tendency for clinicians to endorse concerns about the safety and tolerability of exposure therapy, and these concerns are unfortunately predictive of suboptimal delivery of the treatment. This chapter provides guidance for clinicians in effectively navigating their concerns, with remedial strategies pulled from empirical research on reducing clinician concerns about exposure-based therapy. Clinical supervisors are also encouraged to be mindful of the potential for their own concerns about exposure to negatively influence their supervisory style.

Novel Ways to Use Exposure for Eating Disorders

Three relatively novel approaches to the use of exposure for eating disorders are considered. Each is relatively experimental in treating eating disorders but is well established in treating anxiety-based disorders. Interoceptive exposure can be used to treat distress over bodily cues (e.g., fullness). Imaginal exposure can be used to elevate and treat anxiety as a prelude to in vivo exposure, although it should be used only when necessary. Finally, exposure can be used to address “magical thinking,” such as thought–shape fusion. These methods show promise with eating disorder treatment but are in the early stages of conceptualization and development. Their use should be treated as experimental at present, and clinicians should be alert to their impact in clinical practice.

Explaining Exposure Therapy to Your Patients

Providing a rationale for exposure therapy to patients is a key element to successful exposure, especially when it has not been used previously or has been used inadequately. Patients who do not understand what is involved with exposure therapy are less likely to commit to what can seem like a scary departure from their normal patterns of avoidance and safety behaviors. Unless there is a clear reason not to do so, clinicians need to explain exposure to eating and food at the beginning of therapy and be prepared to come back to it later in treatment when using exposure for other targets (e.g., emotions, body image). The explanation itself can include direct education, analogies, historical review, and comparison with other disorders. Even psychoeducation itself can have an exposure element.

How Well Does Exposure Therapy Work for Eating Disorders?

This chapter provides an overview of the current evidence supporting the use of exposure therapy for eating disorders. Although further research is needed (because the existing research base is relatively small compared to large exposure literature for anxiety disorders), exposure is an effective approach for addressing key transdiagnostic features in eating disorders, including eating-related fear and avoidance, body image anxiety, compulsive body checking and avoidance, and binge-eating and purging behaviors. Results are drawn from a range of study types, from single case studies to large, methodically rigorous controlled trials. Importantly, several of the studies reviewed in this chapter showed that exposure was helpful for patients who had been previously unable to derive benefit from viable alternative treatments. Thus, exposure may offer a critical “missing element” in treatment protocols that have a reasonably strong evidence base and yet leave room for improvement in outcomes.

Eating Disorders

Eating disorders are serious mental health disorders that are associated with significant morbidity and mortality. This chapter provides eating disorders clinicians with the necessary understanding of both the differences associated with specific ED diagnoses and the transdiagnostic features that commonly present across diagnoses. Many, if not all, of the common features can be targeted using exposure therapy, which is discussed in subsequent chapters. The authors specifically address the most common features of anorexia nervosa, bulimia nervosa, and binge-eating disorder, as well as avoidant/restrictive food intake disorder and other specified/unspecified eating disorders. Key transdiagnostic features of eating disorders, including eating-related fear and avoidance, body image disturbance, and binge eating, are addressed through a brief case study.

Functional Assessment of Eating Disorders and Their Maintenance

One shared feature between eating disorders and anxiety-based disorders is the functional relationship between fears and associated avoidance and safety behaviors. Patients with eating disorders are individuals; thus, they will experience different symptoms. The clinician’s task is to understand those symptoms and plan treatment accordingly. That understanding is much easier when clinicians’ focus their assessment on both the short- and long-term functions that eating disorder behaviors serve. Identifying those functions allows clinicians to engage their patients and their family in making changes, because patients and families will understand that their existing responses are not working and are worsening the ED symptoms.

Why Exposure for Eating Disorders?

This chapter provides the rationale for using exposure therapy for eating disorders. Exposure is a very intuitive, albeit anxiety-provoking, intervention. Over the years, a number of models have been proposed to explain how exposure works. Although no one knows for sure exactly how exposure works, the recent inhibitory learning model offers a number of concrete, and logical, strategies for strengthening safety learning. Importantly, many of these strategies (e.g., varying the context of exposure and anxiety tolerance) have been clinically used by experienced exposure therapists for a long time. As such, they are backed by both the science (and logic) of the inhibitory learning model and clinical wisdom.