How to free your son or daughter of rules: exposure therapy for an eating disorder

Last updated on August 4th, 2022

Our children can remain stuck in an eating disorder while they’re scared of certain foods or situations. In this chapter I describe how they can be desensitised to their fears through systematic exposure. Then I give you a practical example of a desensitisation session.

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, I also provide a 'Phase 2' workshop I run regularly, in which I cover exposure to fearful foods or situations
  • And there are several audios on exposure work and fear foods in my Bitesize audio collection. For instance in the clip below I suggest ways to talk with your child about exposure work:

You can also get an entire free helpsheet on extinguishing fears with exposure.



Desensitising to fear foods

Our children usually need our help to let go of the long list of foods they cannot eat. Weight recovery isn’t enough. Think of it as ‘practicing ordinary’, or ‘practicing normal’. The more a new behaviour is used, the more it becomes normal. The brain has plasticity. It rewires itself. Recovery means enjoying ordinary food in normal situations, such as pizza with friends in a restaurant that doesn’t display calories (then in one that does). Eating disorders, especially anorexia, promote rigidity and rules, so your child will need your help to re-learn flexibility and freedom from rules. Bear in mind that our children are often yearning for the very foods that they deny themselves with such intensity.

Fear foods need not stay fearful

When to introduce fear foods

It depends:

  • Dealing with fear foods is not your priority when you’re desperate for your child to eat or drink anything because he’s terribly unwell. Just the act of eating is fearful. So before you bring in extra-scary foods you could wait until you’ve established a bit of a feeding habit.

  • If your child is terrified of everything except apple and kale, you have no choice: weight gain is the priority, so you must serve high calorie foods. 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.

  • Likewise, if your child has cut out entire food groups, such as carbohydrates or fats, you will need to re-introduce them urgently because they are essential to a functioning body and mind.

  • During the weeks of refeeding, notice if your child starts to resist foods that they used to tolerate. Quiche used to work, but now they fight anything with egg in it? If the eating disorder is pulling your child down, you will have to step up your efforts in the opposite direction. Not only should you continue serving eggs, you probably should increase the range of meals.

  • If your child’s weight and mood are steadily improving while you serve a limited range of dishes, you have a choice. Experiment with some fear foods, or stick to what you know is working until your child is close to weight recovery. The downside of delaying fear foods is that your child’s rigidity might increase with time. But what happens more often is that weight and nutritional restoration has made their mind more relaxed and flexible, so fear food work is actually a lot easier.

  • If weight and mood are on the up, I suggest you experiment with some fear foods while prioritising weight gain. You can always pull back if it’s awful. If it works, you’re on the road to faster progress. I saw this with my daughter: desensitising her to fear foods and fear situations seemed to get her un-stuck. As she managed more and more of ‘ordinary’, her mental state improved. I put it down to her being generally less frightened, and to enjoyment and a sense of freedom and empowerment.

  • When your child has reached a weight conducive to health, your priorities switch over. Systematically work through every fear food and situation, even if this results in some meals failing altogether, with the occasional small dip in weight. Don’t leave this to chance or your child may stay trapped by miserable eating-disorder rules even while everyone considers them recovered.

The magic of desensitisation

A common treatment for phobias is exposure to the object of fear.[i] Repeated exposure desensitises us. It’s like we get bored. We know nothing bad happened, so we stop being alert. The brain creates new connections, and fear reactions don’t get activated any more.

This is why a fairground ride loses its edge when you go on it several times. First time, you come out of it with your body shaking even while you’re laughing and telling everyone else they absolutely must have a go. Second time, it’s fun. Third time, the attendant says, ‘You’ve been here before,’ smiles innocently and spins you hard. You come out shaking and raving about it all over again.

What the attendant knows is that after two exposures, there’s not much fear to be had. The nervous system has worked it out. ‘This is OK. It feels like you’re falling and you scream and your heart rate shoots up, but nothing bad happens.’

I found the same when I went for some MRI scans. I feared I might be claustrophobic, so first time round I had to work quite hard at keeping calm. I was pleased with myself when the scan finished, but the procedure wasn’t over. After injecting some chemical, they put me back in for another 20 minutes. I’d been lying there for a while when I noticed I was daydreaming. When I had a third scan a few months later I practically fell asleep.


Plan or surprise?

Exposure therapy for eating disorders
Expose your child to fear foods for complete freedom from the eating disorder

One approach to desensitisation is to help your child list all their ‘no’ foods in order of scariness. If your child finds it helpful to be involved in meal plans, you’ll want fear foods to feature on them. For example, you could agree that once a week you’ll serve one new food from the scary list, starting with the easiest. Presumably you’ll also start with small portions. I know of teens with a decent amount of motivation who are willing to plan and be challenged. For a while I assumed this approach would be hopeless with a young child, but I’ve learned of a seven-year-old for whom it works.

Another method is for you to decide which foods to introduce and when – no discussion. I talked about the Magic Plate system in Chapter 6. This is what we used because our daughter got no benefit from consultation and forewarning. She’d had all that in hospital, and after a year the range of foods she could tolerate was still very small.

Fear foods are, by definition, fear-inducing, and fear is a horrible emotion. You can forgive youngsters for wanting to aim very low. As a parent you can aim higher and help your child cope in the moment.

I experienced this myself when my daughter became an outpatient and I had regular one-to-one phone conversations with our Family-Based Therapy specialist. I’d consider scrapping the stupid butter portions, I’d say I would think about ditching the troublesome meal plan, but at that particular moment, I did not feel at all brave enough to commit. In my mind, these were ideas to consider for several weeks down the line. Then often as not, a perfect opportunity would present itself that very same day, and I’d implement the change without a flutter of hesitation.

My daughter could cope much better with a fait accompli than with advance information. So in her case we did not introduce foods in order of scariness, but varied the difficulty. When we presented her with something easy, it gave her a pleasant, confidence-building break, and when we gave her something particularly scary, she had no reason to believe that the next challenge would be even harder.

Your own child may be totally different:

“If she knows what is coming for the next day, she seems to get most of the feelings out at that time and then sitting down for the meal is OK. It's like she needs to rage against it before it is OK for her to eat it.”

Exposure therapy and desensitisation to fear foods - eating disorder
Ripping the Band Aid, or 'flooding' can give fast results if your child manages the challenge

Rip or Tug the Band Aid?

Exposure therapy is normally used with people who are highly motivated to free themselves of a phobia and are willing to put some work into it. With an eating disorder, where there may be zero motivation, our children need our support. Most commonly, exposure therapy is gradual, starting with the least scary situation and moving towards the most terrifying one. Each new situation is like a step up a ladder. You move up a step when you’ve become desensitised to the previous step. That way you never have to cope with a huge amount of fear.

Another approach is ‘flooding’ – a full-on exposure to the object of fear. It could be scarier, but if it works it’s of course faster. Sometimes you can be pleasantly surprised that your child was actually quite ready for a new food. If flooding turns out to be awful you can always return to a ladder approach, breaking down a challenge into small gradual steps. You want those steps to be achievable, but not so small that you’re effectively going backwards.

For example, when my daughter was dependent on her old hospital meal plan, we replaced her beloved, packaged, butter portions (which were hard to get hold of) with butter cut from a normal packet. We stooped as low as telling her we were weighing the damn butter, in a futile attempt to reassure her that the quantity was identical. At this stage, the move from packaged to home-portioned butter was the only change to her meal. In terms of phobia desensitisation, that’s a pretty small step up the fear ladder. But her eating-disorder voice thought differently. An entire meal could become excruciating for her because the butter on the side of the plate was not a hospital portion.

We did a kind of flooding, or ‘ripping off the Band-Aid’, when we told her we were not weighing foods any more. Any foods. Ever again. Of course she was distressed and fought it for a few meals, but then, she had fought just as hard over just one piece of butter. The downside with flooding is you may have chaos for anything from a day to a week. In her case, it’s a risk we could live with because by then she was pretty healthy. And we had some confidence in our abilities to manage mealtimes come hell or high water. Within a few days, she’d overcome a whole lot of anxieties and stopped expecting her food to be weighed. This paved the way for the next challenges, such as eating food outside the home.

A family-based approach leaves it up to parents whether they want to flood or go more gradually. The message, basically, is that either is fine. An example in the FBT manual of a small-steps approach would be to give your child the correct amount of food for weight gain, but once a week ask her to eat one new food, for example, cheese. The type of cheese could be up to her.

If that’s giving you a good rate of progress, and if your child is able to gradually climb up the ladder of fears without too much resistance, then enjoy it. But if you have high drama at every step, consider making use of all that pain to go for big gains.

“We ripped. Every food was a fear food. Go with your gut and what you think will work.”

If you cannot achieve weight gain without fear foods, you cannot afford to spend weeks serving kale:

“When we were aiming for weight gain, we ripped. When we were working through the list of fear foods, we tugged.”

Because there is no proven approach that consistently works with all children, you can experiment with the ladder approach and with flooding. As long as you handle ‘failure’ with a positive, supportive, compassionate stance, you can try various combinations without taking huge risks.

If your child doesn’t manage a fear food, after a while you could say, ‘OK, that was a good effort for a start. It’s understandable that pizza is difficult – you’ve not had pizza for so long. Let’s leave it for now and I’ll get you a sandwich.’ No blame, no drama. Let’s remember a fear food truly can feel horrendous to our poor children.

What if she throws out the entire meal, swearing she won’t eat for the rest of the week? Keep your cool. Once refeeding has started to work, our children tend to only miss one meal – sometimes two, rarely any more. If your child cannot afford to fail a meal, then don’t flood. Serve a tiny amount of the fear food alongside an easy meal. Or stick to easy foods for a while longer, if you can do so while providing sufficient nourishment.

If a slice of pizza failed, the next day you have choices: repeat with the same size, or serve a tiny piece along with some other, easy food. You can also try serving it at a different time of day, or in a different place, because for all you know, in your child’s head there may be a rule about particular foods at particular meals. If a tiny piece is impossible, a small step would be to ask your child to just touch it to her lips. Even just looking at it might page the way to the next step tomorrow.

We took our daughter through many fear foods once we could afford to have some meals fail. If a full portion of a fear food failed one day, I learned to try it again the next day because then it usually worked. It’s as though the difficulties of the first day had prepared her for success. If that failed, then I went for small steps.

Respond flexibly to present needs

You can pick your battles. Hold on to your freedom to respond to your child’s needs and abilities as well as your own. There may be some very hard challenges that you can leave for later, when your child is generally better or has enjoyed the experience of success. Some foods may look easy to you but in your child’s mind be associated with a strong ‘no’ created at a time of high stress. The ‘no’ may melt away as she overcomes other fears.

“We started with ‘tugging the Band Aid’ to minimize the stress at meal time as husband was having a very hard time with the constant battles. Our FBT therapist was not in favor of this but it was putting weight on our daughter at a reasonable rate and not tearing our family apart. After about 6 weeks our daughter complained about the lack of variety.  I took this as my cue to go ahead and rip: she scarfed down a bacon and cheese omelette. Now we are introducing fear foods almost daily.”

Can challenges be too stressful for your kid?

You may have got into the habit of walking on eggshells. If you demand something ‘too difficult’ of your child, will she have a tantrum and eat even less? Can you stress your kid too much? Will she sink further into depression or become more rebellious?

“My daughter's mood went from upbeat and happy (when we first started refeeding) to absolute rages and depression about 7-10 days later.  She was the lowest of the low at that point…..but it was the beginning of the long climb out.  At the time, I remember thinking, ‘This isn't helping…it's only making her worse!’  But, the FBT therapist assured me it was within the bounds of normal, and that it was, in fact, a positive sign that the ED was on the run, and on the defensive.”

Sometimes we can be bolder than we thought possible:

“We’d been hesitant to push our daughter, not knowing if we would push too far and afraid of what might happen. During our multi-family therapy week, seeing the trained team push her and have confidence in her ability to meet the challenge, was empowering for us. There were a few times she was pushed to her limit and she did explode, but we felt safe being coached and knowing there was consistent support nearby. Now that we know what she can do, our comfort zone for expectations has been widened.”

Occasionally a parent tells me that a shift happened in their child, and that they are the ones pushing themselves. Oh joy!

For a whole year I thought the only acceptable way was one small step at a time. It’s not that I was a timid or lacked courage, but I’d taken to heart books that implied that one can go too fast, that the person must move along a readiness scale, or that my role was to gently nudge. At last, several weeks after my daughter had been discharged from hospital, I got bolder: she was heading downhill and we had nothing to lose. We were by then under the care of an eating disorders specialist to whom I will be eternally grateful for empowering me. When I phoned her about going the whole hog and throwing away the hospital’s meal plan, she calmly assured me that was perfectly safe. I suspect she was doing a victory dance.

Once I had dealt with my own fears that challenging my daughter’s anorexic behaviours might somehow harm her, I did a far better job of supporting her. I also believe that on many occasions, when I presented her with a food she secretly longed for, beyond her fear there was relief.


[Jumping to another section of the chapter…]

Fear and eating disorders
Remember to be both kind and persistent: your child is genuinely terrified of their fear foods

Exposure therapy for other anxieties or phobias

Once your child has no problem choosing between a chocolate and a fruit yoghurt, she may still be gripped by fear when she has to decide on food types or quantities. You could then define the issue as a fear of choice, more than a fear of food. Perhaps time will sort this out quite naturally, but if your kid is in her late teens and soon to fly the nest, then you might want to make decision-making and meal-planning one of the challenges to work on. I give an example of this in the form of a scenario at the end of this chapter.

Exposure techniques work for a lot more than food. You can tackle all sorts of eating-disorder behaviours with desensitisation if you find they’re not shifting fast enough on their own. This could apply to OCD-type behaviours (my understanding is that exposure is a treatment of choice for OCD), but also to your kid being unable to sit, or her attachment to big baggy ultra-covering clothes, or to the way she chews. You could use exposure to tackle her fear of eating in company, of moderating her exercise, and even to her hateful or rejecting behaviour towards a parent. If your child is driven to purge, helping her to delay or resist acting on it is a form of exposure therapy. If once a week your child is shown how much she weighs and learns to cope with the number, I imagine that too is about desensitisation.

[End of extract from the chapter]

In this chapter:

  • Desentising to fear foods
  • When to introduce fear foods
  • The magic of desensitisation
  • Plan or surprise?
  • Rip or tug the Band-Aid?
  • Respond flexibly to present needs
  • Can challenges be too stressful for your kid?
  • Virtuous circles and lasting improvements
  • Example: working systematically through a list of fear foods
  • Example: from packaged food at home to the ability to order anything in a restaurant
  • When can exhausted parents take a break?
  • Exposure therapy for other anxieties or phobias
  • How to make exposure work for you
  • Be a fly on the wall: a desensitisation session

* Go to: Table of contents *

* Next:  chapter 10: The work towards full recovery *

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Endnotes

[i] A type of exposure therapy used with anorexia is exposure and response prevention, abbreviated as ERP or EXPR. We weren’t given any particular approach, but made it up as we went along.

3 Replies to “How to free your son or daughter of rules: exposure therapy for an eating disorder”

  1. HI again Eva
    will you be putting a page number reference after your comment of 'I talked about the Magic Plate system earlier? This is totally addictive reading, now have a numb bum and need to dance:)

  2. Eva, this is the best description of exposure therapy for eating I have read. We've been at this for a while, and I still learned so much from your experience. I feel recharged!

    1. Recharged!! Oh wow, Iris, this so validates everything I'm wanting to do. Thank you for letting me know.
      I'm sorry you've been at this for a while and send my wishes for you to reach the end of the tunnel very soon.

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