Extinction Bursts in Eating Disorder Treatment: It Gets Worse Before It Gets Better

Not the headline you wanted to read, am I right? You’re thinking, ‘OK this person is telling me it gets WORSE than this? I thought I was FINALLY getting the help I needed to get my child better? To make the screaming LESS! To make the dinner table NOT a WWE match again.

I know how frustrating and scary it can be to hear from a professional at your first eating disorder treatment appointment that your child’s behaviors will likely get worse. You have been working so hard all on your own, searching for the right care and help, only to hear, the uphill battle continues. There is no break to catch your breath or moment to rest.

That’s what eating disorders require- constant perseverance by adult caregivers when they think they have no strength left.

All of that said, unfortunately it’s true. Behaviors typically get worse after starting treatment, before the begin to get better. The good news is, this is true of ALL behavior change, not just eating disorders. Scientists and behaviorist have studied and researched this pattern and we know how to handle it- stay the course. Behaviors may increase, they may escalate, they may get more intense- and we continue on, without making changes to our plan or veering off course. We continue taking control, we continue with the plan and EVENTUALLY, behaviors will begin to become less severe and less frequent. We will begin to see a change if we are able to remain consistent through the period of “worse” behavior, or what we call an “extinction burst”.

Extinction bursts refer to the expected and temporary escalations in the frequency, duration, and/or intensity of the maladaptive “target” behavior (i.e., restricting).

When we begin an intervention or change in our usual system, the behavior will increase in intensity in response to that change, in order to see how far it has to go to “hold on” or continue. Eventually, when the behavior learns that the new system is not going to budge in response to the escalation, the behavior will adjust to the new system and decrease in frequency and intensity.

 

Let’s look at a common real-life example:

You take your toddler to the grocery store. They want a sucker and you give them one. The next time, the same thing happens, until eventually it’s become a pattern. You realize you are spending a lot of money on grocery store candy and want to break this habit, so you decide no sucker today. They want a sucker and you say no. They scream and cry until you are embarrassed by their behavior and give them the sucker to get them to stop tantruming. They just learned that in order to get that sucker, they must scream and cry. They increased their behavior (extinction burst) in response to the change (not giving them a sucker). The next time, they may throw themselves on the floor and kick to get you to give in to the sucker. If you do, the behavior will continue to increase in intensity in order to get the desired outcome (the sucker). The key, is to ride out the first tantrum, no matter how difficult or embarrassing or draining, and not give them a sucker if that is what you have decided. They might continue to tantrum on the next few trips to the store. You must continue to not reinforce this behavior (give them a sucker). Eventually, after a few exhausting grocery trips, they will no longer tantrum as loud or as long, because they have learned the new rule is not going to change. After a while, there will be no tantrums or crying at all, because you have set the new normal and they know what it is. There may be a tantrum or two on days where they are tired and cranky, but overall, the behavior of tantruming for a sucker will have stopped, if you were consistent with enforcing the change.

When it comes to eating disorder treatment for teens or eating disorder treatment for children, a similar example can demonstrate an extinction burst. You may start FBT or Family Based Treatment based on the advice of your eating disorder therapist or eating disorder treatment team. This means you begin to take full control of your child’s meals. The first day you do this, your child’s table behaviors will likely increase in frequency, intensity or duration. They may scream, cry, yell, throw things, refuse to eat or a variety of other intense behaviors you may not have seen before. This is because in response to the change (you taking control of food choices) the eating disorder has to increase in intensity in order to get you to give in (let them chose food, eat less, etc.). If you do give in to the eating disorder escalation (which, you are human, it’s OK if you do!), the eating disorder learns, “OK next time I need to yell and scream and cry because that is what worked last time to get my way”. If you remain calm and consistent with your messaging during this extinction burst, the eating disorder will eventually learn that screaming and crying don’t do anything to change your rules and it is not worth the effort to fight. This may take days or weeks of the eating disorder trying everything possible to get you to bend or give in.

This is the hardest part! This is the “It gets worse before it gets better” part.

During the extinction burst phase, or the “Getting worse” phase, it is important to remain consistent with the plan and have consistent messaging from all parties involved (parents, caregivers, extended family, siblings). Everyone needs to be on the same page, or the eating disorder will attempt to find a weak link in the chain and will use their escalating behavior to attempt to break the chain. This is why it is so important to have a strong eating disorder treatment team that can support you through the difficult times and encourage you to keep going and stick with the plan. You may question if you are doing the right thing. You may feel like you are hurting your child or causing them pain. These are all normal emotions to feel when watching your child struggle with an eating disorder. It may be the hardest thing you ever do!! And it will be worth it.

The behaviors WILL decrease- science shows us that behavior change works. Your treatment team and eating disorder therapist or providers will be with you every step of the way.

If you or someone you know needs eating disorder treatment in Ohio, please visit my site to learn more about eating disorder treatment in Ohio. I provide virtual eating disorder therapy services from Columbus, Ohio and work with teens and young adults in college. I treat anorexia nervosa and bulimia nervosa in adolescents in Ohio.

Schedule a free consultation call.

This blog is intended to be educational and informational and does not substitute for professional medical and therapeutic help, which is highly recommended when treating an eating disorder. If you would like help treating your child’s eating issues or want to learn more, Schedule a free consultation call today.