What is CBT? Does it help Emetophobia?
“CBT” stands for “Cognitive-Behavioural Therapy.” This therapy is quite well-known because it’s known as “evidence-based” meaning there is good evidence that it works. It is well-researched as a treatment for both depression and anxiety, including anxiety disorders, phobias and Obsessive-Compulsive Disorder (“OCD”).
Evidence of the effectiveness of CBT is discovered by way of a proper research study. Typically, researchers find a group of people with the same disorder – let’s say spider phobia. They test the whole group to get a numerical score as to how severe their phobia is. They then divide the group randomly into two and treat half the group with CBT while the other half sits on a waitlist. After the first group has been treated, both groups will be tested again. Study after study has found that the CBT group gets significantly better, while the waitlist group generally does not. The researchers will then treat the waitlist group out of courtesy to them for being involved in the study. To date over 1,000 research studies have been done on CBT.
CBT is made up of two originally separate theories and types of therapy. You guessed it – cognitive, and behavioural. Cognitive therapy was first theorized by Dr. Aaron Beck who at this writing is still alive at the age of 99 years. He was lecturing until about five years ago. Dr. Beck is also known as the father of CBT.
The basis of cognitive theory is that a person’s thoughts about a situation or topic relate more to their anxious or depressed reaction than the situation or topic itself. In other words, you are afraid of something because of your thoughts about it, not because it is inherently dangerous. Most emetophobic people I work with believe, for example, that vomiting is a huge, horrible, catastrophic event akin to a bloody murder scene. In reality (the reality of everyone who does not have emetophobia), vomiting is a normal, natural event that happens rarely which nobody likes but everyone feels better afterward.
Simply pointing out reality to a phobic person does not help them, as each of you reading this knows all too well. The logical, rational part of our brains knows the truth, but the part of our brains that is responsible for our survival does not know. For some reason, and the reasons are varied, vomiting or the thought of it triggers this survival instinct and we feel like we are dying even though we know full-well we are not.
Enter Behavioural therapy. Behaviour is often a word associated with children, but in this context, it sort of means actions or what you do. Early behaviourists include Ivan Pavlov (remember his dogs?) and Dr. B.F. Skinner. Behaviourism says that you will keep doing things that reward you or make you feel good, and you will not do things that punish you or make you feel bad/uncomfortable. With emetophobia you may avoid yogurt past its expiry date because if you eat it you will feel anxious. When you’re nauseous, one behaviour might be to suck on mints because they make you feel better and therefore less anxious. Avoiding what’s bad and doing what feels good may be fine for a neurotypical person, but for a phobic whose brain wiring is a bit criss-crossed it has the opposite effect. Every time you avoid the yogurt you feel better, so it reinforces that you should always do that. When you suck mints and then don’t vomit, you feel better, more relieved and calmer. This reinforces that you should do this every time you feel sick. Unfortunately, these avoidance and safety behaviours make your phobia get reinforced and it continues to get much much worse.
CBT for emetophobia means that your therapist will help you to slowly turn your behaviours around to the other direction. They will begin with something easy, such as looking at the word “vomit” on a page, then just allowing your anxiety to raise slightly and then lower to the baseline level, training your brain that this non-avoidance can also make you feel good, relieved and calm. Then you’ll slowly go up the ladder to look at things and do things you wouldn’t normally do. The whole time, your therapist will be with you and watching you to ensure you don’t get overwhelmed. They will also be helping you examine your thoughts along the way to ensure that you will, by the end of treatment, be able to say with confidence “Vomiting isn’t dangerous or harmful. It’s ok if it happens because I can cope with it.”
Lori Riddle-Walker, a colleague of mine who sadly died of cancer after completing her research study, was the first person[1] to study the efficacy of CBT on emetophobic patients. The preliminary findings were that it did indeed help people with a fear of vomiting get significantly better.
[1] The study was done in conjunction with Dr. David Veale who is the world’s leading researcher on emetophobia in the English-speaking world.