Exposure Therapy At Home Exceeds Expectations

Exposure therapy is a core component of treatment for a number of mental health issues, including eating disorders. Based on its experience of treating more than 7,000 patients virtually, ERC Pathlight has now made exposure therapy a key part of its Eating Recovery At Home virtual intensive outpatient program (IOP).

“When a patient is in a higher level of care for eating disorders on-site, they’re in a highly structured environment, surrounded by therapeutic support,” explains Kaila Peak-Rishel, LCSW, LMFT, CEDS-S (she/her/hers), Clinical Director of Child & Adolescent Services at Eating Recovery and Pathlight At Home. “The beautiful thing with virtual IOP is that we’re able to loop in their support system at home, and the support person can help the patient use those skills when we’re not there.”

“What I love as a clinician is that virtual IOP allows us to leverage the true exposures of patients in day-to-day life,” says Kristie Simmons, MS, RD, CEDRD-S (she/her/hers), Nutrition Director at Eating Recovery and Pathlight At Home. “It helps them create a setting in their home environment that supports their recovery.”

How It Works

Exposure treatment can be used for most eating disorders, including anorexia, binge eating disorder and avoidant restrictive food intake disorder. “We have each patient create a hierarchy of feared foods or activities on a scale of one to ten from least to most anxiety provoking. We start at the lower end of the hierarchy and work our way up as patient mastery progresses. This provides an opportunity for the patient to build tolerance and confidence to be able to move further up the hierarchy,” explains Deborah Michel, PhD, CEDS-S, FAED (she/her/hers), National Clinical Director at Eating Recovery and Pathlight At Home.

Eating Recovery and Pathlight At Home exposure treatment is based on exposure and response prevention (ERP), which is the gold standard for obsessive compulsive disorder treatment and has also been found highly effective for eating disorders. ERP sessions consist of the patient and a therapist and/or a registered dietitian. A family member or other support person may also be present.

“For example, at a session I might say ‘Let’s do a binge exposure with chips’ and ask them to rate the level of their anxiety,” says Peak-Rishel. “What works best for patients in ERP is direct prompts: ‘Open the cupboard, pull out the bag of chips and take one bite’ or ‘Just open the cupboard and look at the bag of chips,’ depending on what stage the patient is at.”

The therapist will periodically check in with the patient about their anxiety level. When the number is half of what the original number was, the session wraps up with a debrief on the patient’s experience.

“You want the patient to be doing this type of exposure within their support system multiple times a week, even multiple times a day if appropriate,” Peak-Rishel says. “It’s a lot of work, but it’s fast moving if the patient is motivated to work on it.”

ERP can be done in conjunction with other evidence-based modalities used for coexisting conditions. Cognitive behavioral therapy challenges the patient’s thoughts, dialectical behavior therapy teaches coping skills to soothe the nervous system and acceptance and commitment therapy deals with choosing behaviors that fit our values. “And of course, family therapy is a critical intervention for any eating disorder, because mental illness doesn’t happen in a vacuum,” Peak-Rishel says.

Addressing Food Fears

Dietitians and therapists work as a team in virtual IOP. “While the therapist focuses a bit more on the cognitive aspect, the dietitian specializes in the experiential pieces—what I call the nuts and bolts,” Simmons says.

Each patient gets weekly one-on-one time with their dietitian, where they receive education and discuss challenges they’re facing. Patients also make and eat meals together virtually with the regular members of their pod.

With the appropriate HIPAA and patient safety protocols in place, a dietitian can even “go along” with a patient as they face their fears, for example, being present for support on the phone if a patient goes to a bakery, buys a croissant and takes it back to their car to eat.

“We tailor whatever we do to that particular individual,” Simmons says, “with the goal of allowing them to get back to a free and flexible life.”

“Virtual exposure treatment can really be the equivalent of, if not better than, in-person care,” she says. “It’s been a real perspective shift for our field, and I’m excited to see where this goes as we all learn more. It can only be good for patients.”

Recovery Spotlight: From Eating Disorder to Finding the Joy in Food

Chef Emily Hersh developed anorexia and binge eating disorder during her college years. During intensive outpatient treatment at the ERC location near her home, she had a revelation: “I realized that whatever I did in my eventual career, I wanted to be able to help people who are struggling,” she says. She was delighted by a cooking class she attended while receiving treatment at ERC. “Everyone was laughing and having so much fun. It was the first time I’d felt really passionate in a long time.”

Cooking is now Hersh’s career. She’s done virtual cooking classes for ERC support groups and has created a YouTube series called The Self-Help Chef. She also recently helped open Pure Grit BBQ, a plant-based fast-casual restaurant in New York City, and acted as Culinary Director and Executive Chef. 

“I’m open about my story because I hope it will resonate with people who are struggling in secret with their eating disorder,” Hersh says. “They need to know that help and a community are available for them. And when you face your eating disorder head-on, you feel invincible—like a warrior!”

Watch her video series The Self-Help Chef or check out her recipe for Spicy & Smokey Black Bean Bang Bang Burgers.

Learn more about Eating Recovery At Home and Pathlight At Home, our virtual intensive outpatient programs for eating disorders and mood and anxiety disorders. Available and accessible across the nation, these programs are covered in-network by most commercial insurance plans.