Virtual Hierarchy
The ERP Resources Page of this website provides an excellent hierarchy of fears for emetophobics. The therapist will need to assess which levels to work on, in which order, based on the client’s choices. I have worked with over one hundred clients and generally they can all work through the list the way it is laid out.
Even though many clients will have seen these resources already, and may tell you, “I can look at them all,” can is the operative word in that sentence. Granted, many clients can “white knuckle” their way through the resources, but the wise therapist will begin at the beginning, carefully tracking the SUD numbers at each level, and asking the client if they can raise and lower their anxiety.
In Vivo Hierarchy
Simultaneously with working on the Virtual Hierarchy, and generally for homework, clients may work on their in vivo hierarchy at home. To generate the hierarchy, simply have the client make a list of their AVOIDANCE and SAFETY BEHAVIOURS. Then work through the list as they are able, carefully working from the least to the most anxiety-producing.
If the client cannot move from one in vivo item to the next on the hierarchy, try to find a step in between which is more manageable. For example, I consulted on one emetophobia client who needed to take medication but could not take a pill of any kind due to her anxiety. The psychologist at the in-patient facility could not even convince her to take a gummy vitamin. So I suggested she cut the vitamin in half, or quarters, or eighths, or sixteenths. Whatever the client could manage, and work her way up. She agreed to try a quarter of a vitamin, then the next day took the whole thing, and the next day she took Tylenol. After about a week she was able to take her prescription medication.
Ensure that the client does not use safety behaviours while working on avoidance behaviours. ERP (Exposure and Response Prevention) means that response prevention (preventing oneself from using safety behaviours) is just as important as the exposure.
Sample Avoidance Behaviours:
- Cooking and/or eating chicken
- Restaurants, or certain restaurants
- Milk, yogurt at or past “best before” date
- Certain clothing or items
- Grocery shopping
- The dentist
- Doctor visits
- Hospitals
- Traveling in the car with others
- Public restrooms
- Children
- Schools
- Nursing homes
- Boats
- Cruise Ships
- Air travel
- Church
- Theatre
- Movies
- Prescriptions you need to take
Sample Safety Behaviours:
- Washing hands
- Hand sanitizer/wipes
- Showering more than once/day
- Throwing away clothing or other items
- Laundering clothing/bedding excessively
- Over-the-counter medicines (Pepto, Tums, Dramamine (Gravol), Divol, etc.)
- Prescription anti-nausea medicines (Ondansetron/Zofran, etc.)
- Xanax or Ativan (prescription tranquilizers)
- “Safety kit” in purse or briefcase
- Carrying a plastic bag with you
- Eating finger food with a fork
- Cleaning with bleach, especially too concentrated
- Carrying or having a “vomit clean-up kit.”