Exposure & Response Prevention Therapy for Bulimia 

Exposure and response prevention therapy (ERP) can be a challenging but effective way to confront situations that may trigger eating disorder symptoms.

Author | Margot Rittenhouse, MS, PLPC, NCC
Reviewed By | Bridget Clerkin

5 sources cited

This type of treatment, which involves exposing a patient to triggers and working to change their response to those objects or events, can help someone learn to accept their own body and the foods that go into it and make them less inclined to turn to disordered eating behaviors as a coping mechanism.

What is Exposure & Response Prevention Therapy?

Exposure and response prevention (ERP) is modeled on the idea of facing your fears. It helps people confront objects or situations that have previously triggered unhelpful thoughts or behaviors, but it allows them to confront these factors in a safe, controlled environment under the supervision of a mental health professional.

Together, the patient and therapist will flesh out what, exactly, it is about the object or event that’s so disturbing, and a patient will be given healthier coping strategies to help them manage their emotions around the trigger.

The idea is that, as the patient is continuously exposed to the trigger, they’ll learn to see it more objectively and be less likely to experience negative emotions or engage in unhealthy behaviors when exposed to it in the future.

When is Exposure and Response Prevention Used?

ERP is perhaps most associated with obsessive-compulsive disorder (OCD). It was first developed for treating OCD by helping patients manage their compulsive behaviors or other unhealthy repetitive behaviors.

Since its development, it has been adapted to help with other mental health conditions, including anxiety-related disorders, body dysmorphic disorder, and other eating disorders, including bulimia nervosa (BN). When used for eating disorder treatment, it generally helps to normalize how a person feels around food or when looking at their own body

Repeated exposure to a triggering situation can be a stressful form of individual behavior therapy, and the technique is not recommended for everyone. A therapist will do an initial evaluation to determine whether they think ERP is right for a patient.

But for those who do go on to use ERP therapy to treat bulimia nervosa, research shows the potential for positive treatment outcomes, particularly when the technique is paired with other types of cognitive therapy. [2]

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How Does Exposure & Response Prevention Therapy Work?

Depending on which mental disorders it’s being used to treat, a course of ERP therapy will look slightly different. But the basic structure of the treatment is fundamentally the same, regardless of which triggers a patient is working to overcome.

Generally, a course of treatment will last at least 12 sessions. In the first few sessions, a therapist will gather the facts of a patient’s specific case and history with their trigger. The therapist may also offer some background information on the patient’s mental health condition and how it can encourage compulsive behaviors, repetitive behaviors, avoidance behaviors, or other unhelpful responses to certain objects or events. [2]

Once triggers are identified, you’ll be exposed to them in a safe and controlled manner.

Once triggers are identified, the therapist and patient discuss how to expose the patient to those triggers in ways that feel safe and under control. The process will likely be gradual. Someone may start out simply imagining an object or event, move on to short periods of exposure to the trigger, and, eventually, be exposed for longer periods or more directly to their trigger as they progress. [3] 

To ensure the process is helpful but safe, the patient is consulted throughout, and the level of exposure may be tweaked throughout the process, depending on a patient’s specific needs and progress. But overall, the goal is to help the patient change how they respond, both in terms of thinking and behavior, to the trigger.

How Can Exposure & Response Therapy Help With Bulimia Nervosa Recovery?

There are several ERP methods that can be used to help someone with bulimia nervosa. Again, the preferred method for a particular patient is extremely personal and determined based on a number of factors.

If a patient has a high rate of body dissatisfaction or is particularly triggered by certain aspects of their body or appearance, a therapist may recommend mirror exposure therapy. [4]

The treatment involves looking at oneself in a mirror for a prolonged period under the guidance of a mental health professional. A patient may talk through what they see or answer prompts from their therapist about why they feel the way they do when looking in the mirror.

Mirror exposure therapy works to help a patient develop a more normalized and benign (or, ideally, positive) view of their body. In essence, it has the goal of making a person more comfortable in their own skin, helping them to find their body less triggering, and improving their self-image.

This type of ERP is frequently paired with cognitive behavioral therapy (CBT), a psychotherapy treatment found to be highly effective at helping people with BN and other mental health issues.

Another subtype of ERP commonly used to help people with BN and other eating disorders is in vivo feared food exposure. In this type of treatment, a patient will directly confront feared foods or food-related situations with the help of their mental health professional. [5]

Patients may work with their therapist to slowly feel less disgusted by food and be more willing to eat it. This likely won’t start with something as intense as eating, but something more like being near feared foods. Another common strategy is learning to go to restaurants without feeling triggered. This could involve simply ordering food, with a patient working to eventually eat some of their meal while out. 

Vivo feared food exposure is often thought to be a more intensive form of ERP for people with BN, but like all exposure therapy techniques, it’s designed to start with smaller requests and exposures before building up to more intensive situations.

Risks of Exposure and Response Prevention Therapy

Exposure and response prevention therapy can be an inherently challenging form of mental health treatment because it involves directly confronting triggering situations.

Intentional exposure to triggers can undeniably cause stress and anxiety, but the goal is to create a session that causes discomfort while remaining safe and tolerable through adherence to certain principles.

Create a Controlled Environment

It’s important to note that ERP therapy is highly controlled. Therapists must be licensed specifically for this practice and are taught in their training the importance of balancing stress with rest.

A therapist should only work in an environment in which the patient feels comfortable and safe. They should ask the patient beforehand if there is anything in the office, restaurant, or other settings that may be uncomfortable for the patient, and talk through everything they’re doing and why to ensure the patient that the session is totally under control and can be stopped at any point.

A major facet of creating a controlled environment is always seeking a patient’s consent to continue with therapy or certain situations. Exposure treatment is meant to push boundaries, but it must always be a consensual process from which the patient can withdraw at any time.

The danger is that pushing someone too hard can cause more harm than good or further damage someone’s relationship with their trigger. To avoid this, patients should be as open and honest as possible with their therapist throughout their sessions. 

It’s also possible to adjust levels of treatment at any point during therapy. But if that isn’t working either, a patient always retains the right to leave treatment.

Exposure and response prevention therapy has been heavily dramatized in fiction, and its portrayals are often inaccurate. This can create a damaging view of the process for many people.

Sessions will always start with the lowest level of exposure that a patient is ready for. This sometimes doesn’t even involve interacting with feared items or scenarios directly but simply imagining them.

Therapists will guide patients through every step of their progress, and patients retain the right to adjust their level of treatment at any point.

Finding Treatment for Bulimia Nervosa

If you or a loved one are struggling with bulimia nervosa or another type of eating disorder, it’s important to seek out help, whether or not you think ERP therapy may be right for you.

A therapist, physiatrist, primary care physician, or other trusted medical professional is a great place to start. These experts are typically educated about eating disorders and may be able to point you in the direction of a useful treatment center or program.

If you’d rather not ask about such a sensitive situation face-to-face, there are a number of eating disorder and mental health hotlines that allow callers to receive additional advice, information, and resources while remaining anonymous.

But regardless of where you look for help or the type of therapy you ultimately seek out, the most important part of the journey is taking that first step.

Bulimia nervosa is a dangerous condition and can be potentially deadly if left untreated. But recovery is entirely possible. Seeking out help is the key to letting go of unhelpful thoughts and behaviors and embracing a healthier future.

Within Health offers personalized remote eating disorder treatment backed by years of experience.

Within’s IOP and PHP programs offer meal kit deliveries, a numberless scale, a convenient app to attend therapy sessions and view your schedule, and so much more.

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  1. Butler, R. M., & Heimberg, R. G. (2020). Exposure therapy for eating disorders: A systematic review. Clinical Psychology Review, 78(101851).
  2. Exposure and Response Prevention. (2022, December 5). Psychology Today. Accessed January 2023.
  3. Carter, F., Bulik, C. (1994). Exposure Treatments for Bulimia Nervosa: Procedure, Efficacy, and Mechanisms. Advances in Behavior Research and Therapy, 16(2), 77-129.
  4. Griffen, T., Naumann, E., Hildebrandt, T. (2018). Mirror exposure therapy for body image disturbances and eating disorders: A review. Clinical Psychology Review, 65, 163-174.
  5. Reilly, E. E., Anderson, L. M., Gorrell, S., Schaumberg, K., & Anderson, D. A. (2017). Expanding exposure-based interventions for eating disorders. The International Journal of Eating Disorders, 50(10), 1137–1141.

Last Update | 05 - 1 - 2023

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