ERP Sessions With Your Dietitian

Exposure Response Prevention Sessions With Your Dietitian

One of my favorite types of sessions to have with patients is an exposure snack or meal, or an Exposure Response Prevention (ERP) snack/meal. Though these aren't generally my patient's favorite things in the world (I get it, I get it), more often than not they leave feeling empowered that they were able to challenge their eating disorder rules and anxiety head on!

Here's a small glimpse of how this happens. The most important tool in my toolkit is patient rapport. If I don't build that, there will be no way we can create this lasting success. I will spend a couple sessions food-free (unless I deem necessary sooner), and we will talk about foods their eating disorder took away from them, rules their eating disorder makes them follow, and how maddening and exhausting it can all feel. I will provide medical nutrition therapy, nutrition education and diet-culture debunking throughout each session.

During these early sessions I have my patients create a “food hierarchy list.” When I ask them to tell me foods they still feel afraid of, I am often faced with wide eyes and wheels turning with “I am SO not going to tell her I haven’t had pasta in a year, I know she’s going to make me eat that! I’ll tell her I’m afraid of oatmeal, I like oatmeal. I’m feeling way too anxious for this, I would rather just leave now….”

That’s why I like these lists. I have each patient start with a list of 5-10 foods, ranging from the most anxiety inducing to the least, having the least be a food that feels challenging, but it’s also tolerable in this exact moment. We will start with the least scary food situation, and progress onward as the patient seems ready. I always strive to set my patients up for success by meeting them where they are at. This instills confidence and self-assurance. This builds trust, so we can team-up against their eating disorder together.

ERP therapy provides a slow, incremental exposure to the stimuli (or in this situation, feared food/food behavior) which causes the individual to feel significant anxiety. Feeling this anxiety is good, it means we are making their eating disorder uncomfortable! The more we challenge the eating disorder, the more power we take away from it! By doing this, a trained disordered eating clinician will provide a safe space for patients to reduce distress by developing tolerance.

ERP snack/meal exposures aren’t always foods one would “assume.” I will list some exposures I have had the pleasure to help my patients grow from:

- Granola bars

- Eating 1 bite of food after 8 pm

- Gatorade

- Drinking water

- Eating “out of order,” taking a bite of everything before completing one item

- Eating in front of peers

- Not leaving “bits” or “bites” behind on the plate

- Reese’s cups

- Fresh fruit (challenging the fear of bugs being in the fruit, fear around foodborne illness, texture aversions)

- Peppermint Ice Cream during the holidays

- Touching a sticky food item

- Pasta

- Not knowing the ingredients in an item, and then going through each ingredient after the fact where I (the dietitian) provide them education on what the purpose of this ingredient is (flavor, food chemistry, shelf-stability)

I have been doing this for 3 years now, and as you can imagine the list continues. This reminds us that each individual struggling with an eating disorder has a very unique story and should be working with clinicians trained in the field.