43) Collaborating on the exposure hierarchy to food freedom

Sasha has been doing pretty well these days.  Meltdowns have been more sporadic, he has been losing a little weight over the last few weeks and we have not had any disasters or received bad news from school about his behavior.  Whew.  We know that he still engages in some food seeking behaviors (taking extra food out of the fridge) but we think that the food seeking may be out of habit and anxiety, rather than hunger. For this reason, we feel compelled to test out oxytocin's ability to control his excess hunger and to see how he handles having increased access to food.  As a psychologist who often treats patients with anxiety disorders, I know that the best way to make it successful for us is to expose him very gradually to tasks with increasing difficulty.  This is called an "exposure hierarchy" and is used to help people overcome phobias and other avoidant behavior.

The principle of doing an exposure hierarchy is to practice the task, rate the level of anxiety/difficulty, and repeat the task until the anxiety or level of perceived difficulty decreases. If and when the anxiety/perceived difficulty is steadily rated at a lower number, it may indicate that the person has achieved some mastery over the task and is ready to move to the next slightly more challenging task.

I started by drafting a list of tasks for Sasha to practice. Last week in his therapy session, he was asked to rank them in order of difficulty.  With the guidance of his therapist, Sasha ranked them in order of difficulty and presented the list to me.  After I studied the list, I noticed that some of the tasks that he ranked lower on the scale would have definitely been ranked as highly anxiety provoking to me!  For example, he put "unpacking groceries with light supervision" as #4 of 15 tasks but I would rank that as a much harder task, perhaps more like #12 of 15 tasks.  It was then that I realized that the exposure hierarchy is as much my exposure hierarchy as it is Sasha's!  I re-ranked the list in accordance to how anxious I felt and showed the list to Sasha and his therapist in today's session.  I explained to Sasha that if we are to be successful in making progress in the exposure sessions, both he and I would need to come to some agreement about the ranking of the tasks.  If he were to try a task that I deemed was easy but he deemed was too hard, he would surely fail and vice-versa, if he were to try a task that I deemed was easy and he felt was too hard, the same failure would ensue.

Before digging into the exposure tasks, Sasha and I needed to define the goals and guidelines of the exercise and they are as follows:

The goal is to increase Sasha's free and legitimate access of food in order to:

• help Sasha learn how to monitor his intake and make healthy eating choices with increasing independence 
• give Sasha more control over his own food choices so that he can overcome his anxiety about food scarcity and learn to trust his own true hunger instincts (rather than his conditioned urges to hoard food due to his habituated state of having excess hunger and food obsessions)
• develop trust in Sasha's ability to manage his food intake (both quantity and quality) so parents feel less need to police him and can decrease policing of Sasha around food

The definition of a successful exposure are as follows:

• anxiety rating decreases over time as the task is repeatedly practiced
• number of "meltdowns" decrease over time as the task is repeatedly practiced
• Sasha abides by the "guidelines of engagement" 
• Parents abide by the "guidelines of engagement 

The exposure will be rated on the following measures:

• Pre-exposure anxiety/difficulty level of the anticipated task=0-3 (rated by Sasha and parents)
• Post-exposure anxiety/difficulty level of the practiced task=0-3 (rated by Sasha and parents)
• Meltdown intensity= 0-3 Sasha's emotional reactions of anger/anxiety, etc. and tension/anxiety felt and expression by parents (rated by parents)
• Guideline respect by Sasha = 0-3 (rated by parents)
• Guideline respect by parents=0-3 (rated by Sasha)

Exposure hierarchy list (agreed upon by Sasha and both parents):

1. Leave fridge unlocked while Sasha is preparing a meal (with light supervision by parents)
2. Leave snack cabinet unlocked while Sasha is preparing a meal (with light supervision)
3. Leave fridge unlocked for 1 hour during/after a meal
4. Leave fridge unlocked for 1 hour during/after snack
5. Leave fridge and cabinet unlocked for 1 hour during/after meal or snack
6. Take Sasha to grocery store with light supervision (and a pocket check after shopping)
7. Let Sasha make a meal with no supervision (fridge unlocked)
8. Let Sasha make a meal with no supervision (cabinet unlocked)
9. Let Sasha make a meal with no supervision (fridge and cabinet unlocked)
10. Let Sasha bake with light supervision (and unlocked fridge)
11. Having Sasha unpack groceries with light supervision (unlocked fridge and/or cabinet)
12. Bringing Sasha to a potluck/buffet dinner with light supervision
13. Unlock fridge and cabinets more than 2 hours from meals (9-11 AM or 3-5 PM)
14.  Unlike fridge overnight
15. Bring Alex to potluck/buffet with no supervision

Guidelines of engagement for Sasha:

• Food accessed during the exposure must be eaten in the moment and not stashed away for later consumption.
• Food must be eaten in approved areas in the house (kitchen, dining room only- not in bedroom or bathroom).
• If Sasha is found eating food outside of permitted areas, he will be asked to finish the rest of the food in the dining room or kitchen.
• If Sasha is found to be eating food outside of regular meal/snack time or exposure session or if stashed food is found (in his room or backpack), he will be asked to put the food back until the next meal/snack time or exposure session.  If he doesn't comply, that food will be counted as his snack for the morning/afternoon/evening.
• Parents will reserve the right to check his room, pockets or backpack periodically to ensure that the guidelines about "no food stashing" are being respected.

Guidelines of engagement for Parents:

• Parents are not to micromanage via questions, nagging or criticizing of Sasha's eating as long as he is abiding by his guidelines during exposure session.
• Parents constructively review the exposure log with Sasha after every few sessions.
• If Parents disrespect their guidelines, Sasha reserves the right/duty to give parents constructive feedback about his observations

This exposure goals and guidelines are meant to help set expectations so that there is as much clarity as possible for both parties.  Even so, I fully expect it to be very challenging for us and Sasha as we navigate these choppy waters.  In today's session, we discussed how this model actively encourages Sasha to be as forthright and transparent as possible with us since sneakiness will no longer be necessary during the exposure if he wants to eat something.  Sasha understands that his open communication with me will help decrease my anxiety about his food sneaking and my decreased anxiety will help decrease the risk of having Kitchen Bitch around which would help decrease the chances of his meltdowns.  All of this, of course, would not be possible if I didn't believe that oxytocin has helped to decrease his intense focus on food.  I am only hoping that oxytocin has decreased it enough so that the extra food he will very likely end up eating will NOT result in a huge weight gain or backsliding in his metabolic health.  

I suppose we will need to evaluate this exposure hierarchy project closely to tell whether or not we are really ready for it... and if the guidelines are persistently broken or if Sasha fails to progress up to increasingly more challenging tasks- well then, perhaps we will try the Naltrexone or just take it with even more gradual baby steps.  No matter what happens, I do know that we won't know if the oxytocin experiment is working unless we try the exposure hierarchy first... 

Ready or not, here we come!