“I knew I needed help when I caught myself out of control, eating pudding with my hands in my truck,” says Tim S., a truck driver who was in treatment one year ago. “I knew this needed to stop.”
When patients leave our residential or partial hospitalization program
, they frequently say that the most difficult — yet most influential — component of eating disorder treatment is Exposure Response Prevention (ERP). Tim shared with us, “ERP was a real confidence boost; it was basically proving to myself that I can do it. Because of that, I haven’t binged or punished myself with food since treatment.”
What is ERP?
Historically, Exposure and Response Prevention has been most frequently employed in anxiety disorder and substance use disorder treatment
. However, there is strong evidence that it is a powerful addition to Cognitive Behavioral Therapy (CBT) for eating disorders.
In fact, patients treated with ERP in addition to CBT have higher rates of abstinence and longer-term abstinence from eating disorder behaviors.
The ultimate goal with ERP is to get patients engaging in recovery-focused behaviors even when they feel bad. This helps them move towards their longer-term goals and values and away from avoidance.
An ERP therapist helps patients:
- Examine their lives
- Understand how they may overestimate how awful their affective (emotional) experiences will be
- Understand how they may underestimate their ability to cope with their experiences
ERP is not a cookie cutter treatment by any means; it allows patients to take control over their recovery and create an individualized road map to guide their treatment. ERP is most typically used to treat anxiety disorders but has been proven to be successful in treating eating disorders as well.
How does ERP work for eating disorders?
With ERP, patients are able to practice the skills that they are learning in a controlled setting while being exposed to triggers that lead them to their eating-disordered behaviors.
ERP is used to target and decrease fear of feeling negative emotions and the avoidance that results when patients fear feeling uncomfortable.
Experiential avoidance is avoiding anything that makes you feel bad – specifically thoughts, feelings, memories, physical sensations, and other internal experiences that bring up any negative feelings in you.
Experiential avoidance is targeted in treatment because when we avoid things that make us feel bad, we are often avoiding activities and experiences that make us feel good and are consistent with our longer-term goals and values.
For example, Tim said that he was avoiding eating ice cream because he feared becoming out of control with the ice cream. His exposure, therefore, was to eat a single-sized portion of ice cream, leave the rest and tolerate the anxiety with help from his newly-learned skills. He said, “Eating half of a Ghirardelli’s ice cream sundae and walking away was a big deal for me because I had a support system to fall back on. I still have a picture of that ice cream!”
Most people find it painful to experience bad feelings; some people find it easier to avoid them than to allow negative feelings. And, some people use binge eating to avoid bad feelings because it temporary relieves distress and turns one's focus to food instead of feelings.
How we use ERP for binge eating
- Patients are asked to create an “exposure hierarchy” in order to work towards decreasing avoidance/distress in certain areas.
- Depending on a patients’ treatment plan, they may choose to focus on pre-binge or pre-purge cues, anxiety, body image or another area of treatment focus.
For Tim, as a truck driver, one of his top binge triggers
was feeling bored while driving his truck. This was problematic as he had long shifts driving across the country. He said prior to treatment he was unable to be in the truck with any food at all without losing control. So, Tim’s exposures focused on his trigger area (being bored in the truck with and without food) and being able to tolerate the distress of boredom without bingeing. Tim said he always remembers this exposure because he is confronted with this trigger, driving his truck, on a daily basis. He says, “Driving around with McDonalds in my car with the radio off was really helpful. It built my confidence as I know I could do this again if I needed to.”
Moving towards recovery with ERP
ERP is a difficult yet very rewarding component of treatment. For many of our patients, ERP is a new and unique treatment modality and a valuable adjunct to traditional talk therapy. Tim praises ERP, saying, “It is really the cornerstone of your recovery – it is your first physical progress you can make in treatment and I can always put it in my back pocket and take it with me."
Patients often tell me that they never knew what they were able to do before they engaged in ERP — and that they are much more confident in their ability to manage recovery when they leave. Many patients can abstain from eating disordered behaviors when they are contained in a higher level of care setting (like residential or PHP). However, treatment gains should be generalized to their home environment if recovery will be sustained.
Laura Lange, LCSW is Director of the Binge Eating Treatment and Recovery Program at Eating Recovery Center, Illinois.