CBT Protocol

Following is a simple protocol which I use to treat clients with emetophobia. Most take 16-20 sessions to feel significantly more able to face and cope with their phobia.

Session 1

Initial Assessment/Diagnosis/Get-To-Know-You

  • Introductions
  • Tell me about your phobia, when it started, how it affects you today
  • What was it like growing up in your family?
  • Homework: Relaxation Recordings*

*I am big on clients learning large muscle relaxation. Along with proper deep, slow, relaxed breathing this tool will help the brain switch back from the sympathetic nervous system to the calm, at-rest, parasympathetic. I point clients toward relaxation recordings on YouTube (of which I and my musician friend made three) and ask them to keep a log of the number of times they’ve listened to them. I suggest 90 times before they can actually relax their bodies on demand. NINETY. That’s once a day for 3 months, or twice a day for 6 weeks or 10 times a day for nine days. It’s up to them. I liken it to playing a piano concerto. Of course you can’t play it if you’ve never had lessons and never practiced. It might seem impossible. But it clearly isn’t.

SOARING ©Anna Christie & Miri Lee

BREATH © Anna Christie & Miri Lee

FLOATING © Anna Christie & Miri Lee

15 Minute Relaxation (from “Between Sessions”)

Progressive Muscle Relaxation (audio)

8 Minute Relaxation  (from “Between Sessions”)

Guided Imagery Walk Through the Forest-Audio

There are many more recordings of guided imagery on YouTube if a client gets bored with these.

Session 2

Family Diagram

As I am originally trained in Bowen Family Systems Theory, I take the second session to create a “Family Diagram” which is somewhat like the more familiar “Genogram” or “Family Tree.” Note that I do not adhere to every element of Family Systems as described by Bowen, nor do I use his therapy techniques. However, I have found that a picture of a client’s family is invaluable for me to have in their file. I refer to it often. It is also very comforting to a client to see that their phobia was not created in a void, and that there is some evidence that anxiety is even carried through the genes, lending some credence to Bowen’s theory of “Multigenerational Transmission Process.”

Blank Family Diagram. “*” indicates the (female) client

When I ask clients for information about their families to fill in the diagram, I usually say something like this: “I am most interested in 1) any physical or mental illness, and 2) the relationship between certain people. I will ask you to list any siblings in order of birth.” After seeing over 100 clients, I have found that every one of them enjoys this session, answering the questions, and seeing their family diagram filled out.

Family Diagram of a Fictional Family

Look this fictional family diagram over carefully. Notice that the client (“*”) is very close to her mother, and in conflict with her father, yet father is close to the client’s brother who seems to have “gotten off Scot-free” when it comes to mental illness. The client’s mother is an anxious person, and the client went through the trauma of her mother’s suicide attempt when the client was only 9 years old. Mother had her own traumas to endure, as did her parents and grandparents. Father’s side shows cutoff with his schizophrenic brother, and his own father’s cutoff with his grandfather. You can almost see why he started drinking.

When this diagram is shown to the client, complete with notes that the client herself has provided, it can be quite comforting for her to see a picture of where her anxiety, in the form of emetophobia, came from.

Homework: Relaxation Recordings

Session 3

The Brain Made Easy/Hierarchy Building

Although we do not know what causes emetophobia, or any phobia, but rather only some factors that contribute to it, it is still helpful for the client to understand what is happening in their brain. After checking in, I begin the session by giving what I call the “$2 Lecture” on how our brains work. Made easy. Very very easy. If you’re a neuroscientist, please stop reading now. I will upload a video of my $2 lecture soon. Meanwhile, here are a few points:

  • Brains have three “areas” – neocortex, midbrain, reptilian brain (amygdala)
  • The neocortex is where logic, reason, mathematics, executive function takes place
  • The midbrain has emotional systems, art, music, plus various parts for seeing, walking, talking, etc.
  • The reptilian brain is the “oldest” part, from an evolutionary perspective. It is responsible ONLY for keeping you alive. When it gets triggered, it causes a body response called the “sympathetic nervous system” to engage. In other words, it sends out the signal “DANGER! YOU’RE GOING TO DIE!” (even though you know in your neocortex that you’re not going to die, but it will FEEL as if you’re going to die).
  • The amygdala fires is 1/5000th of a second
  • The neocortex is much slower
  • The good news is that we CAN teach your neocortex to communicate with your amygdala, and “shut it off” but it is a slow process and takes time and practice. It’s worth the time, ya?
  • The way to teach your amygdala that you’re not actually in danger is to slowly and gently expose you to things you fear, beginning with the thing you fear most and working your way up the ladder, rung by rung, until you reach the top. So if you are in the presence of something feared (rather than running away), and you can be calm, and let your neocortex rule your thoughts, then the amygdala will learn that it was nothing to fear in the first place. This is known as gradual desensitization.
  • The process of getting better, therefore, depends on 1) slowly changing your behaviour (Behavioural Therapy) by being exposed to what you fear, and not using any safety behaviours afterward (ERP), and 2) changing the way you think about vomit/vomiting (Cognitive Therapy)

Hierarchy Building

Sessions 4-20 (or less)

Exposure and Response Prevention

In the following twelve to sixteen sessions, I meet with the client weekly to work through the exposure hierarchy, always beginning at Level 1 despite what the client may say about already having seen several levels that “don’t bother him.”

  • Begin with a baseline SUD (Subjective Units of Distress) Level from 0-10 “with zero being no anxiety, and 10 being the worst panic possible.” Describing 10 as “the worst panic possible” will prevent the client from saying “11” or higher.
  • Show the client the level (word, picture, video) and record whether the number changed from the baseline. If it has risen more than 4 points, have them go back and scroll up the page to the lovely scene with the waterfall. Record their anxiety level. If it is still high, have the client engage in slow breathing, muscle relaxation, and/or positive imagery while repeating the phrase “Vomiting is not dangerous or harmful. It can’t hurt me, so I don’t need to fear it.” Alternately, the client may choose to repeat a phrase more in the positive such as “I am perfectly safe at all times.” When the client’s anxiety comes down, repeat this level until it does not rise at all. You may have to assign it as homework.
  • If the client’s anxiety does not rise when looking at a word, picture or video, ask her to try to make it go up, and to tell you the number when it’s as high as it will go. If that doesn’t work, ask a second time for them to try harder – think scary thoughts. This normally works. Once she tells you the number, ask her to breathe and relax until the number goes down. Repeat the exercise until she cannot make her anxiety go up no matter what she’s thinking about. Praise her for “controlling her anxiety!” She made it go up, come down, go up, come down. Previously, her anxiety was controlling her!

For homework, have the client work through her in vivo hierarchy, taking careful measure not to use any safety behaviours. For example, have her eat some yogurt that is one day past its expiring date. Then practice calming down with breathing and relaxing, or just noticing her anxiety level and not engaging with it as it will soon enough go away.