A Different Perspective on Treating Eating Disorders

By Jennifer Mellace

A young patient who has been diagnosed with an eating disorder is preparing for a summer beach vacation with her family. One of her wishes for this vacation is to enjoy popcorn at the boardwalk. The young girl works with her therapist to prepare herself by bringing a bag of popcorn to her session. In the first session, the therapist holds the bag of popcorn while sitting close to her patient and then asks the girl to hold the bag while discussing her anxiety level and what she could do to reframe her thoughts and decrease her anxiety. In the first session, the young girl could only hold the bag, but she couldn’t eat any of the popcorn. During the next session, the girl comes in and immediately pops one piece of popcorn in her mouth. She had mentally prepared herself for eating that piece but couldn’t bring herself to go beyond that. The therapist validates the hard work this young patient did to get to this point and they continue with the exposure therapy.

“For patients with an eating disorder, vacation is out of their comfort zone,” says Kim Coppola, LCSW, MSW, of Kindred Nutrition and Wellness in Frederick, MD. “They will be eating meals out, eating with the family, and being presented with foods that they would not normally eat, which causes a lot of anxiety. This anxiety is often so strong that patients will avoid it at all costs, and so we work to help that person tolerate the discomfort and learn that she can survive and it’s not going to harm her.”

This exposure therapy, which involves repeatedly exposing the patient to those things that trigger fear the most until their anxiety lessens, is a form of treatment that is often used for people who live with obsessive-compulsive disorder (OCD). So why is it being used to treat patients with eating disorders?

An Integrative Approach

According to the National Eating Disorders Association, statistics show that people with eating disorders are more vulnerable to comorbid diagnoses such as anxiety disorders and OCD. A study done in 2004 demonstrated that 41% of those affected by an eating disorder also face OCD. Research demonstrates that between 25% and 69% of women with anorexia nervosa and between 25% and 36% of women with bulimia also have OCD.

While this isn’t new information, the use of integrative therapies to treat eating disorders is becoming more widely discussed. Recently, The Renfrew Center offered a webinar, “OCD and ED: The Alphabet Soup No One Will Eat,” presented by Lewis Jones, PsyD. In it, Jones discussed the similarities and differences between OCD and eating disorders, and how using integrative therapies vs. one standardized treatment model can be beneficial to patients with eating disorders.

“Some of the overlapping behaviors we see between OCD and eating disorders are anxiety, dread, perfectionism, and rigidity,” Jones says. “Individuals with OCD and eating disorders both experience a feeling of dread when the need arises to have to sit with the thought of what will happen next after an event. That dread causes anxiety and when someone becomes anxious, they want to avoid. But the more you avoid, the bigger the problem becomes.”

In his discussion, Jones speaks about the importance of differentiating between OCD and eating disorders and the need to understand the behavior as well as the motive behind it. For example, throwing out food—is it because there is worry that it has expired or is the person discarding the food to restrict calories? Another is avoiding public eating—is it because there is worry about contamination or is the person afraid of their lack of control or judgement about the food? And yet another is washing hands—do individuals feel the compulsion for cleanliness or do they feel the need to wash their hands to rid themselves of oils and fats on their fingers from eating that feels triggering?

When treating OCD, a patient is often exposed to the anxiety-provoking stimulus, and Jones illustrates how a therapist can also do this with eating disorders. So, for instance, using exposure therapy more than distraction, a technique that’s often been used in treating patients with an eating disorder.

Coppola was intrigued by this. “What I found interesting is that distraction techniques aren’t recommended, because patients still avoid their distress during mealtimes with distraction,” she says. “Some research shows distraction isn’t effective, but I believe a lot of treatment centers still encourage clients to use distraction during mealtimes.”

Jones explains that distraction when you are anxious can cause you to avoid the problem that’s causing the anxiety. “The more and more you avoid, the bigger the anxiety becomes,” he says. “We don’t want to enable avoidance, and this is where distraction at mealtime could be a problem. When working with anxiety, you expose patients and this helps them get in touch with the emotion and underlying feelings and thoughts.”

Jones further explains that one does need to lay a foundation so patients can learn to use coping skills, and he discusses exposure hierarchy—a list that is used to guide a patient’s progression through exposure therapy by detailing the main situations or sources of anxiety that trigger the fear. This hierarchy is arranged in order of how severe each fear is from 0 (completely relaxed) to 100 (the worst anxiety you can imagine feeling) when you encounter the thing you fear.

“We work with a feared-foods hierarchy,” Jones says. “And, instead of distraction, we use exposure therapy. For example, take a bag of M&M’s. Perhaps that bag causes a 3 out of a 10 on the hierarchy scale. We can help patients ride out the wave of anxiety they experience when they see or hold that bag.”

The Right Balance

Jones acknowledges that just because exposure therapy seems to work, it doesn’t mean there isn’t a time and place for distraction. “There are times when distraction is needed,” he says. “What we need to teach is knowing when to use distraction and coping skills and when to expose yourself and seek challenges so you can control the variables. This comes with time and doing exposure therapy successfully in session before seeking outside situations.”

Jones stresses the need to teach people that this process isn’t a straight line and that patients need to expect obstacles and mistakes. “It can be very hard for someone who is used to rigid perfection to make a mistake.”

Another form of therapy Jones discusses is interoceptive exposure. Often used to treat panic disorders, this technique uses exercises that bring about physical sensations of a panic attack and then look to remove the patient’s conditioned response from the physical sensation that caused the attack. “For instance,” Jones says, “sometimes a patient with anorexia will have the fear of touching anything unhealthy. In a situation like this, we might first repeatedly expose the patient to a video of someone eating a bacon cheeseburger and allow the patient to feel the sensations of fear behind seeing that. The next step might be to let the patient hold a bacon cheeseburger and feel the grease on their hands and process the fears that go with it. By doing this, patients can learn that they won’t gain weight from touching the burger and maybe come to understand that they don’t have to listen to their rigid avoidance.”

The main belief behind Jones’ study is that people limit themselves by just avoiding behaviors and that being able to expose themselves to the truth in a structured, safe way can help test the rules and beliefs they have around their eating disorder.

Coppola agrees, saying that while she works from a cognitive behavioral therapy standpoint, she likes to stay open to thought-provoking ideas and ways to incorporate new concepts into her therapy. She points to The Renfrew Center’s recent article on how “loss” might be one element keeping patients with an eating disorder from making positive changes.

Coping With Loss

Beth Hartman McGilley, PhD, FAED, CEDS-S, author of Same-Same: The Blessings and Burdens of Therapeutic Change, writes that one of her clients (who also happens to have clinical training) thinks therapy is all about loss. She tells McGilley, “You shed what you once learned, now maladaptive, to grow a new skin, one that fits. But it is excruciatingly painful, and if you are giving up your numbing agents, be it an eating disorder, substance misuse, inappropriate anger, etc., you are going to be pretty damn raw while your new skin heals on.” She goes on to say that this loss or shedding needs to be recognized and dealt with by the therapists to help a patient heal.

“I think this thought of loss is so interesting,” Coppola says. “When you have an eating disorder, you sometimes can’t exercise, so you lose that piece of identity that you connect with. You lose out on the things that once made you feel good. You lose time, a career, trust with friends and family.

“Someone who has an eating disorder also has to say goodbye to something they may have been dealing with for years,” Coppola continues. “A way of life that has, in their mind, kept them safe. Then it does become a loss. And how do you say goodbye to it and cope and grieve that loss?”

Coppola points out that treating eating disorders is super complex. “Eating is necessary to stay alive. Think of how counterintuitive it is to go against your ability to survive? It’s tricky helping someone relearn how to have a healthy relationship with food, and I think it’s important for me, as a therapist, to be open to new ideas.”

— Jennifer Mellace is a Frederick, MD–based freelance writer.