Exposure Therapy

I’ve been “talking” with emetophobia folks online since 2000. Over these twenty years I’ve seen more people misinformed about what exposure therapy is than I’ve seen people who’ve tried it. It’s probably better to start off with what exposure therapy is not.

Exposure therapy is not just randomly running into a situation that exposes you to someone vomiting, or you, yourself feeling very ill. Yes, if you go to a birthday party and a kid is suddenly sick in front of you then I suppose you have been exposed to what you fear most. But the “therapy” part is missing. Therapy comes from the root word for “healing” and just randomly being exposed to vomiting and having the bejeezus scared out of you does nothing for your healing. In fact, it may make your phobia worse by re-traumatizing you.

For exposure to be therapeutic, it has to be structured. If you go to a CBT (Cognitive Behavioural Therapy) therapist they will normally build a hierarchy with you. Since this is difficult for most emetophobics to do, I have a good hierarchy that works for pretty much everyone right here on my website under “Resources” – “Exposure.” The current literature on anxiety and exposure therapy says that a list is as good as a hierarchy anyway. So you make a list of everything that frightens you. Or go to my website exposure section. Then you would normally begin with the least frightening thing, and progress slowly to the most frightening (which is normally watching explicit videos, hearing sounds or mixing up something that looks and smells like vomit).

Seriously. Don’t freak out. The final, most difficult steps ALWAYS seem impossible when you’re just starting out. But that’s the beauty of exposure therapy – it begins with something SO EASY and you go SO GRADUALLY that by the time you get to the difficult stuff, you hardly notice. Think of it like this: you’ve fallen down a hole, are terrified and you can’t get out. Then you notice there are a set of steps to climb up to get out. If you go one step at a time it’s easy to get up and out, but if you just look at the top step and think “I can’t possibly get up there” then you may not even try to take that first step. You’ll just sit at the bottom in the hole and cry. I did that for about thirty years.

The first steps in my online hierarchy are as simple as looking at the word “vomit.” There. You just did it. You may not have liked it, but you’re ok right now, ya? Then we look at some other words. If those are too difficult then we might just begin by imagining a scene where you’d be a little afraid.

In addition to the exposure resources I have online, I get all my clients to make a list of everything they avoid and all the safety behaviours they have. An example of an avoidance behaviour is perhaps not making medical appointments. An example of a safety behaviour is feeling nauseous and taking ginger or mints.

I usually wait until we’ve looked at all the words and drawings and cartoons and pictures and then have my clients begin to approach things they previously avoided, and/or stop using a safety behaviour. I assign this work as homework and check in each week. Then at the next session we begin looking at videos, which also start with simple things like a baby spitting up.

It’s not enough to just look through all my exposure resources to prove that you “can.” Anyone can white-knuckle it through the list and then feel great relief that the exercise is over. Your phobia will not improve. In fact, it will make your phobia worse to do that because the part of your brain that’s giving you all the trouble will say, “Wow, it sure feels good NOT to looking at that stuff now. To continue feeling good, I’ll avoid it forever.”

At each stage of the exposure, you must look at an item, record your fear level 0-10, and then either try to tolerate the fear level (if it is below 7) while still looking at the picture or use previously-learned skills to bring the number down below 7 where it can be tolerated. So you keep looking at the item until you are no longer afraid.

Sometimes if clients are recording rather low numbers for a few pictures in a row, I ask them to purposely raise their anxiety level. This ensures that the client is not “white-knuckling” their way through the pictures.

So….is it scary? The answer is yes, a little. But normally my clients’ anxiety levels only go up to about 5, maximum. That’s how I like to work with people. It’s a little scary, but it can be tolerated. Before long, they come to realize that all anxiety can be tolerated with a little practice.