I still remember my first lunch support group. Four of us sat around a square, white Formica table, at the Eating Disorders day program in New York City. The clinician in charge removed plastic containers from plastic bags and placed one in front of each of us. She did this casually, removing plastic silverware and paper napkins. Inside the container sat a burrito filled with chicken, brown rice and vegetables. A glob of sour cream sat on top.
I saw the food sitting there, but I could not comprehend that I needed to eat it. My eating disorder was in charge and all it saw was a heaping amount of calories. “I don’t eat carbs” I thought. The therapist eventually told us to eat. I glared at the food. The girls and I stared at each other. Is she serious? I wanted to cry and scream. I wanted to be anywhere but here.
I took a bite. The morsel was excruciating to swallow. I felt it sit in my stomach like a rock. It literally felt like I gained weight with one bite. The girls and I ate in silence. I finished about half the burrito. I have no idea how I actually got it down. I would like to say that part of me was scared to continue to live a life that was so meaningless and hollow, but I think at that moment I just did not want to die.
Little did I know, exposing myself to challenging foods and different situations in my eating disorder recovery would save my life. Recovery is an ongoing experience of feeling discomfort and moving through it anyway. Your eating disorder wants to keep your life small. Exposure allows you to make your life big again.
What is Exposure Therapy?
Exposure and response prevention (ERP) is a therapeutic behavioral technique used in eating disorders recovery. ERP involves a client exposing herself to high-risk stimulus/triggers (i.e. a certain food or situation). The goal is to eat the food or be in the experience without engaging in any eating disorder behaviors such as restricting, purging or binge-eating. Typically the exposures happen in small increments. Over time, the stimulus or trigger has less power as the individual learns that they can survive and thrive in the situation.
In treatment, we were exposed to a large variety of foods for this sole purpose. Oftentimes, people with eating disorders want to stay comfortable and only eat foods that they feel are safe. Foods that will not result in weight change, foods that they can easily purge, foods that they believe won’t lead to a binge. For me, it was apples and protein bars. However, if these rules and restrictions are not challenged, full recovery is difficult to obtain.
What Are Fear Foods?
Fear foods (challenging foods) are foods that someone finds difficult to eat. For most, fear foods are scary and ignite negative thoughts or feelings related to the food and its nutritional value. Fear foods can be one food, such as pizza or an entire category of foods such as “fried foods” or complete food groups such as “fat.”
For people with eating disorders, fear foods are associated with feelings of shame or guilt when eaten and consumption of these foods is seen as “bad.” Some fear that they will gain weight right there in the moment or they will lose all control and not be able to stop eating that particular food. Thus, fear foods are either avoided or significantly restricted.
Why do Fear Foods Develop?
Fear foods develop via our personal experiences, messages we receive from our loved ones or friends and the memories we experienced with them. We are also inundated by cultural messages about food and dieting from the media. In our weight- and weight-loss obsessed society, the majority of people go on diets and on these diets they are taught that certain foods are “good” or “bad,” “on” or off” the plan or diet. They try and cut out the “bad” foods and correlate them with the notion of cheating, and with guilt and shame. Engaging in many different diets or meal plans with different rules over time has the potential to foster a variety of different fear foods. For example, a person may initially simply cut calories, move on to severely restricting carbs, cutting out gluten completely, and so on. As such, fear foods may exist prior to the development of an eating disorder, and may become more pervasive over the course of the eating disorder.
Consequences of Avoiding or Eliminating Fear Foods?
- Isolation from family and friends
- Heightened anxiety
- Lack of pleasure in food
- Rigidity in the variety of food eaten
- Fosters a negative relationship with food/sees food as the enemy
- Increased preoccupation and thoughts about the fear food and/or situation
- Continuation of eating disorder symptoms
- A potential for relapse following recovery
How is Fear Exposure Used in Eating Disorder Recovery?
An important part of the exposure process is creating a hierarchy of feared foods and/or situations. The client works with their therapist to identify a list of foods that are scary, that they avoid, and foods that they may eat only during a binge where they feel out of control. The list should be as detailed as possible (i.e. what brand of bread, what time of day, the situation). Then the list should be placed in order from the least feared food/situation to the most feared food/situation. Starting with the least feared food helps to build confidence, and then, building on these success experiences, more feared foods can be targeted. Exposure therapy can be completed in sessions with the therapist, during a meal support group, and outside of treatment. Given the heightened anxiety inherent in exposure, it is vital that the client create a “tool box” of coping strategies with a plan to use them during this process. Some coping strategies may involve breathing techniques, mindfulness, distraction and cognitive restructuring.
Shannon Smith, MA, LPC, NCC, ACS, DRCC, Program Director of Center for Discovery of the Bridgewater Outpatient Location, tells her clients in recovery from eating disorders that to recover we need to go through the discomfort. She states, “We practice exposure to re-create real-life experiences that our clients will encounter.” For example, a client may be asked to go out to dinner with friends, but avoids it due to fear of pressure to consume feared foods. Recovery may involve “restaurant night challenges” where the client is presented with the challenge to going out to dinner without warning, perhaps with the added challenge of ordering a new/feared food each time. After exposing themselves over and over again clients start to feel more secure in this situation and can start to re-engage in their life in this way again.
The foods/situations are ordered in a graduated hierarchy the least to the most anxiety/fear provoking. If ice cream is a primary feared and avoided food, then assignments can be broken into small, manageable tasks. One task may be to go with friends to the ice cream parlor and be social. The next step may be to go with friends and try a spoonful of ice cream and then the next time to order a scoop of ice cream.
Hilary Raciti, RDN, Truce Nutrition, LLC, specializes in nutrition management for eating disorders recovery and uses ERP with her clients to gradually normalize challenging foods. She reported, “I usually create a food hierarchy with my clients and explore the subjective units of distress (SUDs) associated with these foods, situations or behaviors.” She clarified that she uses ERP with one food or food behavior at a time and typically starts with the least challenging and then works up. She expressed that “I find that exposing my clients to the touch, smell and simply the presence of a food is a great way to start. We play with the food in the office- feel, smell, break apart, smash it- demonstrating how this food is just an object, piece of mass- despite all the fear and emotions attached to it.”
After structured treatment, it is still vital to continue to do exposure therapy. Recovery does not have a definite end.
Goals of Exposure Therapy?
Ultimately, the goal of exposure therapy is to experience discomfort and sit in it, knowing that the feelings will pass. “Over time the extreme discomfort becomes just slightly uncomfortable to neutral to potentially positive. As a food loses its power, it can be incorporated in a balanced, flexible way and that’s what we desire in eating disorder recovery” says Raciti. Through engaging in exposure therapy you can:
- Learn to sit with feelings of discomfort and anxiety
- Understand that the feelings are temporary and will eventually dissipate
- With repeated exposure, fear foods becoming less scary and eventually incorporated into eating plans
- Increase the kinds and variety of foods you incorporate into recovery
- Gain confidence to be around feared foods without the fear that you will lose control
- Increase opportunities for socialization with others
- Experience less distress during social situations involving food
- Prevent relapse
Real Life Recovery
I was blessed that I attended eating disorders treatment. I was also lucky that my program was in New York City. I’ve never seen so many types, kinds and varieties of food in one place. In less than a block you could have a burrito, salad, slice of pizza or vegan dish within seconds. I was thrust into a world of exposure. Gone were safe foods and comfort. Each day I was exposed to different meals, new foods, and new cultural cuisines.
After I completed an intensive outpatient program in my recovery I consistently challenged myself to eat “less safe” foods. Each week I went to a new local restaurant for lunch with a friend. I exposed myself to different types of cuisines and my friend was there to support me. I also use exposure therapy when I find myself in certain situations- if I’m in a bagel store I order a bagel; if I’m at a birthday party I have a slice of cake; If I’m at a Christmas Party I eat cookies and if its Halloween I eat some candy.
Even to this day, I will expose myself multiple times per week:
- The other day in spinning class we were celebrating the instructor’s birthday and were given mini cupcakes. I had one.
- I was at my friend’s Holy Communion two weeks ago and ate mac and cheese and other comfort foods instead of sticking to the lower calorie items I may have chosen during my eating disorder.
- My brother ordered a pizza over the weekend and I had a hot slice and enjoyed the pleasure of the tastes and textures.
I find that I need to consistently expose myself to fear foods and situations to maintain my recovery. It’s crucial in recovery that we challenge the distorted thought that food is “bad” and has extreme power over you. I take back my power through repeated exposures. And typically the more power we give to food, the more we obsess about it and the more likely we will binge on it.
Eating disorders take things away from life – relationships, careers, families, pleasure, vacations, joy- incorporating fear and challenging food to your recovery helps to maximize and strengthen your recovery. How can you challenge yourself today?
Chewing and Spitting Food
Challenging and Changing Eating Disorder Thoughts
Working Through the Weight Restoration Phase of Anorexia Nervosa
Treating Eating Disorders
Eating at Restaurants While in Recovery from an Eating Disorder
The Urge To Diet After an Eating Disorder
About The Author:
Meredith O’Brien is a licensed clinical social worker and a certified intuitive eating counselor. Her private practice is located in Red Bank, New Jersey, and offers outpatient counseling. She writes about her personal recovery from anorexia in her blog.
Mitchell, M.D. Ed (1997) The Outpatient Treatment of Eating Disorders: A Guide for Therapists, Dietitians, and Physicians. Minnesota, Minneapolis: University of Minnesota Press.
American Psychiatric Association, Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
Clemmer, K. (2016) December. What is a feared food? The Eating Disorder Center blog. https://eatingdisorder.org/blog/2016/12/what-is-a-fear-food/
Written – 2019