Free your son or daughter of fears and rules with exposure

Our children remain stuck in an eating disorder while they fear certain foods or situations. Practical tips for parents to extinguish fears and restore flexibility.

This is a section from Chapter 9 of 'Anorexia and other eating disorders – how to help your child eat well and be well'

• For some more 'live' help on this, I also provide a workshop
• And a free helpsheet
• I can also meet parents individually.
• And you can listen to audios on the topic in my Bitesize audio collection

For instance in the Bitesize clip below I suggest ways to talk with your child about exposure work:

Extinguishing fears, returning to flexibility

Our children are bound by rules and rituals. While these are frustrating for us, they make sense to our child: they provide short-term protection from surges in anxiety or disgust. We’re all drawn to short-term relief, even though long-term this makes life fearful, rigid, rule-bound, and small. In this chapter I’ll propose ways for us, as parents, to help our children become free so that they can enjoy a rich, expansive life.

I’ll refer to this as ‘coaching’. Even though our children can lack insight and motivation, coaching often works very well.

In contrast, when I talk of ‘exposure therapy’ I’ll refer to well-researched methods used by specialised professionals, whom I’ll call ‘exposure therapists’. Their methods require your child’s willingness to engage. Therapy is not something that can be done to them.

Most of our youngsters don’t have access to an exposure therapist. Also, your child may, like so many, be unable or unwilling to engage with their treatment. No worries: with coaching, our youngsters can make rapid progress and become free of their fears and rules. That’s what this chapter is about.

The safety-seeking behaviours our children cling to

In this chapter we’re talking about ‘safety behaviours’, such as counting calories, chewing slowly, doing star jumps after a meal and other compulsions. We’ll include ‘avoidant behaviours’: avoiding ice cream, avoiding resting, and avoiding eating in public. And any reactions driven by disgust. These behaviours are all self-reinforcing. ‘The bad things that I am scared of didn’t happen when I followed my rules, so that means my rules work. Without the rules, the bad things would certainly happen.’ Our children may recognise that their rules are not logical, and that in the longer term, safety behaviours make life harder. We want them to learn that they can safely abandon the rules and behaviours. But until they experience that those are not needed, they tend to cling on to them.

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[Jumping to another section of the chapter…]

When is a good time to challenge a safety behaviour?

If your underweight child is terrified of everything except carrots and kale, you have no choice: you must serve high-calorie foods, and you must serve those feared carbs and fats. It’s a life-saving intervention. Console yourself with the thought that your child would have resisted a useless low-fat yoghurt just as fiercely as they fought your creamy pasta.

The start of treatment also presents an opportunity to set the parameters: no purging, no sport, parents taking the lead on meals, and so on. This way, many safety behaviours are nipped in the bud before they get entrenched. And at the same time, we can’t achieve complete normality from week one, when it’s so hard for our children to eat anything. In those early days, they may not cope with a wide range of terrifying foods. So it’s likely you’ll leave some tasks till later, when you will tackle them gradually.

Once our children’s brains are better nourished, there’s a decent chance they’ll be less fearful, more flexible, and braver. Some of the work towards normality may even happen all by itself:

“I do remember worrying about the fact that my daughter became very stuck on the same diet plan and we never introduced any fear foods. I needn’t have worried because actually she went from the very restricted diet plan to eating everything literally overnight.”

So do as much as is feasible at the start, and remember to work on the rest later. But… you can probably shake things up and work on bringing back the old ‘normal’ earlier than you think, so read on!

One situation where exposure work is urgent (along with the work towards independence – see Chapter 10) is if your child intends to leave home soon. They’ll need time to consolidate before they’re safe to go.

Regarding formal exposure therapy, that requires the person’s willingness to engage. While that’s not happening, you can still drive progress with coaching.

Weight gain isn’t enough

Careful! There’s a misconception that all fearful thoughts and rigid behaviours disappear with weight gain. If your child gets discharged too early, purely because they’ve reached a target weight, ask the therapist to empower you to continue providing exposure work and coaching.

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[Jumping to another section of the chapter…]

But first, a light-hearted take on it:

View this post on Instagram

A post shared by Anthony Voulgaris (@undiagnosedanthony)

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[Jumping to another section of the chapter…]

Should you collaborate with your child?

With exposure therapy, the person must be willing to engage and do the work. They are never ‘forced’. Exposure isn’t done to them. Everything is a collaboration – even the agreement that the therapist may bring some surprises. There are preparatory sessions to explain the method, identify the person’s fears, and get their buy-in. After an exposure, there’s a debrief about the lessons learned. All this allows challenges to be pitched at a high level, challenging the biggest fears and the most distorted beliefs.

In treatment for ARFID, collaboration is the norm, and some parents of autistic youngsters say that getting buy-in is the only way to be both safe and effective.
With parent coaching, ideally we would collaborate with our child. And happily, some youngsters are willing to relinquish at least some of their safety behaviours.

“My son had started to have an OCD ritual where he runs up and down our front stairs every night before bed […] He had been a bit sick with a cold and said to me ‘I don’t want to run up and down the stairs but I know I have to’. I said to him, ‘Maybe you don’t have to. I think you can manage not doing that tonight, how about you share with me one of your favourite funny videos instead tonight?’ And we did that, and have been doing it every night since.”

My daughter realised that she couldn’t possibly have the Christmas she wanted with the wider family, if she couldn’t sit for one hour in the car. She was (reasonably) motivated to find the courage to practice sitting during short car journeys.

On the other hand, in the inpatient unit, she had 11 months of being consulted on her meal plan, and her range just shrunk.

To bring back flexibility despite our children’s resistance, we parents often have to make the decisions. This means we can’t yet give them independence (Chapter 10).

We took our daughter through many fear foods in spite of her protests, and it worked well and fast. Her mental state improved tremendously. I put it down to her being generally less frightened, to enjoyment and a sense of freedom and empowerment. If we had waiting for her willingness to eat a cookie or eat in a café, I suspect she’d have stayed ill a very long time.

Occasionally a parent tells me that their child, who had long resisted collaboration, is now motivated to take on all kinds of challenges. Oh joy! So why not let them take the lead. Be alert, though. Don’t let them have blind spots (‘I don’t need unhealthy food!’) and don’t let them go so slowly that they’re standing still.

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[End of extract from the chapter]

In this chapter:

• Extinguishing fears, returning to flexibility
• The safety-seeking behaviours our children cling to
• How exposure works
• When is a good time to challenge a safety behaviour?
• Weight gain isn’t enough
• List those fears
• Should you collaborate with your child?
• ‘Why are you torturing me with ice cream?’
• Should your child feel the fear or be soothed?
• Pick an item from the list
• What does your child actually fear? Target that.
• Example: from packaged food at home to eating anything anywhere
• Gradual steps, or dive in?
• Ideas to make the steps gradual
• Watch out for compensatory behaviours
• Repeat and vary
• A flowchart to guide your exposure work
• When your child doesn’t manage
• Moving through the exposure list
• Forewarn or surprise?
• Your persistence
• Success breeds success
• Will exposure work fix everything?
• When can exhausted parents take a break?

Where to next?

* Go to: Table of contents *

* Next:  Chapter 10: The work towards full recovery and independence *

* How to get your child to cope with calories on menus (and get free of the eating disorder) *

* If your child has ARFID, there are specific approaches. See 'The main eating disorders: binge eating, bulimia, anorexia, ARFID and OSFED' *

* If your child is autistic, you may be inspired by these experiences parents have shared with me: 'Autism and eating disorders: individualising treatment for your autistic child or teen' *