How to Treat Patients with ARFID via Telehealth

Stage 3: Modularized Exposures

Now, I said stage three is really the heart of the treatment. This is where we provide a lot of exposures for patients. And what we're trying to do is to really target those negative feelings and predictions about the consequences of eating by providing them with new experiences that might lead them to new conclusions. So with sensory sensitivity, we want them to try like ton of different foods, just like throwing the spaghetti against the wall, see what sticks and so that they can realize that even if they dislike a lot of vegetables, some new foods actually might taste okay and they just hadn't experienced that yet.

Similarly, with the fear of aversive consequences, we want them to realize that they might be overestimating either the likelihood of that feared outcome occurring, like maybe vomiting is actually less likely than they think, or they might be underestimating their own ability to cope with what would happen if that outcome did occur. So, hey, maybe you might vomit, but are you going to be okay afterwards? Can you carry on? And then lastly, for folks who have that lack of interest, we want them to realize that maybe it won't feel quite as bad as they think to feel full and actually there might be circumstances under which eating can feel pleasant.

CBT-AR Stage 3: Sensory Sensitivity Module

For folks who have the sensory sensitivity, we try to help them to select new foods to learn about that will increase their representation across the five food groups, things that will help them correct nutritional deficiencies, and then things that might help them to reduce psycho-social impairment. So in that one, they might want to be adding pizza, for example, so that they can do sleepovers with friends, or I had a patient whose family was from Africa and he wanted to incorporate some special African dishes that were important to his family that he himself had not really been eating. And so in stage three first in the sensory module, we start off by having patients do repeated exposures to very small portions of these foods. And then later we try to help them incorporate larger portions into their meals and snacks.

Stage 3: Seonsory Sensitivity

And this is an example of a handout from our workbook, which again, you can download for free, and this is how we do the exposures in the solution. We ask patients to bring in five foods to the very next session and we ask them, let's go through these new foods. Rather than being judgemental and saying, oh, this bell pepper looks gross, we want you to actually step back and be really neutral and give yourself an opportunity to mindfully observe what is going on with this food. What does it look like? What does it feel like? What does it smell like? What does it taste like? And what's the texture like?

So really we want them to kind of experience this food through all the five senses, slow down the process and actually see if this might be food that they could taste some of and that they might be willing to continue practicing between sessions. And it might be that of the five foods, they pick three that they want to carry forward and practice for homework. Maybe they pick all of them. You just never know what will happen.

The telehealth tip here is that some patients with sensory sensitivity have had an extremely limited diet for their entire lives. So if a patient wants to try new food that has a high allergy potential, so let's say peanuts for someone who has never had peanuts before, that would be a good idea to check with their primary care doctor or a pediatrician first to make sure that's safe. If it's a high risk item, another thing that we've done is to have somebody do the exposure, like in a doctor's office, with us on the phone to make sure that they're going to be okay.

Another telehealth tip, a way that it is sort of an advantage to provide the CBT-AR over telehealth is it is actually impossible for patients to forget their items for tasting in an at-home therapy situation. In the clinics, sometimes people will say, "Oh, I had committed that I was going to bring certain items to this tasting session." But in telehealth, even if they have forgotten, you can just send them to their own fridge or kitchen to get some replacement items. So that's like a positive as well.