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.

Dr. Aaron Beck

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.

From Getselfhelp.co.uk

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.

Emetophobia and Control

One of the things that I absolutely hated being called, ever, was a “control freak.” For one thing, if I were such a thing (and I don’t think I am) why does it have to have the word “freak” in the expression? Who likes to be called a freak? If someone is insistent on being in control, that does not necessarily make them a freak, a weirdo, an oddball or, as my mother used to say in 1950 “a queer duck.” People who are very disciplined, or very careful, or very responsible, or even very manipulative, authoritarian, or natural leaders are not all known as freaks. So ya. I hate that expression.

I think it is because I hate the expression “control freak” that I have done a lot of thinking over the years about emetophobia and control. The infamous Dr. Phil believes that all phobias, and most other anxiety disorders are about control. Don’t get me wrong, I kind of like Dr. Phil. He sure sees things clearly, which can be helpful, even though I don’t think anyone would want him for their therapist and he pretty much agrees with that. I don’t, however, think he’s right about everything and I definitely don’t think he’s right about this.

Many of my emetophobic clients talk to me about control. They don’t like the fact that vomiting seems to be out of their control. And furthermore, it’s a bodily function that’s out of their control. I point out to them that most bodily functions are out of their control: breathing, heart beating, blood circulation and oxygenation, digestion, urination and defecation. Sure you can hold your urine, your feces or your breath for a time but not forever. At some point, your body would take over and you would not be able to control it.

You can also control vomiting to a certain extent as well. I remember reading an article many years ago by Dr. David Veale, the world’s leading researcher on emetophobia (or as he likes to refer to it, “SPOV” or Specific Phobia of Vomiting.) He believed at the time that there was absolutely nothing that you could do to stop you from vomiting, so there was no point in any safety behaviours such as hand sanitizers, avoiding sick people, taking mints, ginger or over-the-counter (OTC) medications. After doing part of a research study some years later he discovered that people with emetophobia do indeed vomit less than the general population. So we do have some control over it, although if you get sick enough or poisoned enough you will vomit, no matter what you try to do to prevent it.

People who are often labelled as control freaks, in my opinion, are just people who want things under control. They don’t want the whole situation to be chaotic, out-of-control, crazy. Sometimes situations do get that way, and so people who have natural leadership qualities tend to take charge to get things under control. Many people labelled control freaks are quite happy to sit back if someone else who is a responsible leader is the one getting things under control. If they jump in and take charge regardless, I believe that they’re just scared. If you’re all on a raft heading down the river to Niagara Falls and the leader is not coaching everyone to row to shore, then you’re going to freak out and take over the lead.

The thing is, sometimes you just think you’re headed for Niagara Falls and you’re terrified so you take over when you don’t need to. We phobics can be like that sometimes. But don’t let anyone tell you that you’re a freak.

Emetophobia and the fear of sound

Emetophobia is not just the fear of vomiting. It is also the fear of anything to do with vomiting. The sight, the smell, the sound, the contagions. Most of my clients are more afraid of being sick themselves than they are of seeing or hearing other people. But yet, whenever someone in their own house is sick, they’re usually terrified that the family member has somehow contracted Norovirus and that they’re contagious.

I believe my phobia began sometime before I can really remember, but it was made a thousand times worse between the ages of eight and nine when my dad was sick with colon cancer. He was vomiting often, and it sounded like death. Sadly, he did die when I was nine so that probably reinforced the phobia for me. To this day no one has sounded as horrible or as unique as my dad when he was sick. I thought in later years that perhaps I was imagining it, or at least embellishing the memory. Until one day when I was in my forties I heard my aunt (dad’s sister) talking to another sister about how awful my dad sounded when he was sick. She recounted visiting him in the hospital once after he’d had surgery as a young man. In those days anesthetic was ether, and it made people terribly sick. The funny part about the story is that she went to the nurse’s station to ask his room number, but then heard him vomiting at the end of the hall in his room and knew right away by the sound that it was him.

As time went on, I married and had three children. My husband did not vomit for 32 years, even though he’s not the least bit afraid of it. I could not have chosen a more appropriate mate. But then there were the kids. When we had a young family we were pretty cash-poor, so there was no way I could go to a hotel room. After my successful emetophobia treatment we were a bit better off, but I no longer needed the hotel! Back when the kids were young if I heard anything that remotely resembled them being sick in the night I would race down to our basement rec room, curl up on a most uncomfortable couch and plug my ears tightly with my fingers. And cry. There was lots of crying back then. My kids would cry for me, and I would cry for myself and my husband was probably crying that he had to deal with it all. Those kids are 44, 37 and 35 now and I have seven grandchildren. They’re all very well-adjusted, educated and productive members of society with no phobias of their own and I have a great relationship with each of them. I share that not to brag, but to reassure you that if you’re doing what I did your kids can still turn out ok.

I’ve had clients who book a hotel room, who sleep in their cars, who go to their mother’s, who camp out downstairs or in the attic. One client insisted that their “mortgage helper” suite be left empty so she could move into it every time someone in the family was ill.

The treatment for emetophobia involves, among other things, desensitization to the sounds of vomiting. Most people with emetophobia are afraid of being sick themselves, while some are just triggered by the sight or sound. Either way, nobody likes to hear it. I used to have three or four sounds that I found on the internet which I went to great length to find, and used those in my emetophobia treatment program. But then I found this great website that has 88 sounds of vomiting, and it’s free for anyone to use! Here’s the link if you’re interested: https://www.soundsnap.com/tags/vomit You can begin by having your volume very very low, and then slowly increase it. Try all 88! The great thing is that it will desensitize you to the sound if you work on it, so you can be in a hospital ward with the curtain drawn, be a couple rows behind someone on a bus or plane, or be in your own house minding your own business and listen to someone vomit. It’s all the same. Good luck!

B.R.I.T. – A Way to calm anxiety

According to the experts – scientists who study anxiety and treatments – the best way to deal with an anxiety or panic attack is to do nothing. Just let it be. Don’t run away from what triggered it, don’t use a safety behaviour so you’re not sick, don’t even think about it, which means don’t battle it in your mind and try to stop it. If you can do that, then the anxiety will come to a peak and then slowly dissipate on its own, all within 15-20 minutes. EASY FOR THEM TO SAY, EH?

There – you got my little bit of Canadian for today! The formula, according to said experts is:

Notice it

Acknowledge it

Don’t engage with it

“Just notice it” my therapist used to say. It made me so mad. How the H-E-double-hockey-sticks could I NOT notice it? (I’m on a Canadian roll now, eh? Go Canucks!) But seriously, I used to go from 0-10 in 1/5000th of a second. I wondered if anyone who came up with these ideas had ever actually had a panic attack. It troubled me deeply as I sought to help others with their emetophobia because I assumed that everyone was like I used to be.

As the years and the clients clicked by I started to notice a pattern with them. They were not like me. In fact, I have met or talked online to very few people who reacted as I did to the triggers. I basically felt well and healthy every day of my life. I never felt nauseous, icky or “off.” So I’d be going along minding my own business when one of my three kids would come up to me and say, “Mom, my tummy hurts.” ZAPPO! 10/10. I had no time to “notice it” or “acknowledge it” – that was just crazy talk. Ironically, once I was successfully treated for the phobia and wasn’t afraid of vomiting anymore, I started to notice that I got anxious about other things. It’s like before – if everyone was feeling good – I didn’t care what else happened to me or anyone else in the world. No one was going to vomit, so everything was great! Once I got over the emetophobia I realized that I was still an anxious person, because I was born that way (and so were you). NOW, when the grandkids go to the playground I’m the one thinking OMG HE’S ONLY 2 AND HE’S AT THE TOP OF THE SLIDE!!!! My point? It’s not 10/10 – it’s maybe 4 or 5, and then the more I watch him the more it creeps up and up and up. I just let it be, and eventually it goes away on its own.

Many of my clients are like that with emetophobia. They wake up feeling “off,” so they’re a little nervous – maybe 3/10. Then they eat breakfast and start to feel icky – 4-5/10. Then as the day wears on icky turns to worried which makes the icky worse and the numbers creep up. Now, I understand that your experience may also be different than that, but the point is that if your anxiety moves up slowly, then the experts are correct: do absolutely nothing about it.

Today’s little acronym is “B.R.I.T.” (How do you like that, peeps in the UK? eh? eh?) BRIT is not for the slow climb – just notice, acknowledge, and don’t engage those. BRIT is for the times when it goes HIGH QUICKLY. Or when you just can’t “do nothing” about your anxiety, and so it continues to rise. BRIT are the ACTIONS (Remember last week’s “A” in the STAR plan?) needed to calm down. They’re all tools you carry with you every single day. You don’t need a safety kit in your purse. You just need BRIT. So let’s go through them one by one.

Breathe

Your breath is your salvation! Learn to breathe slowly and evenly, deep into your abdomen. Let the out-breath be longer than the in-breath. Try “7-11 breaths” – breathe in for 7 counts, out for 11. Check out my YouTube Video on how to breathe properly to help bring anxiety down: https://youtu.be/PPkUWoloQog

Relax

“Relax” means to relax, soften and drop the large muscle groups in your body starting from your forehead and eyes, and extending down to your toes. In order to do this effectively you have to practice it. I give all my clients a sheet of paper with the numbers 1-90 on it so they can check off the number of times they listened to a 20-minute recording teaching progressive muscle relaxation. Just putting on a recording when you’re anxious will not help you very much. You need to learn the technique much like learning a piano concerto or an entire hip hop routine. You can’t just tell someone to do either of these – they have to learn the notes/steps and practice until it’s just “body memory.” It’s the same thing with this. Your body has to know where to go. Here’s a link to one of my progressive muscle relaxation recordings. There are many more on YouTube: https://youtu.be/XfF5Srxtj9M

Shout out to PianistMiri who improvised on harp with me to make these! https://www.youtube.com/user/pianistmiri She does WICKED piano covers of popular songs!

Imagine

Studies have been done on the brain where a person was shown an object such as a cabbage in an fMRI machine. The next day the person was put in the MRI machine again and told to remember the object from the day before. The cool thing is that the brain lit up exactly the same way. Like, exactly. So of course the “logic” part of the brain knew the cabbage wasn’t there – that the subject was just imagining it on the second day. But the rest of the brain did not know. Psychologists got hold of this and used it for anxiety recovery. Imagine you are in the most peaceful, tranquil, calm and beautiful place in the universe. Really imagine it. Your brain won’t know you aren’t actually there.

Using the “imagine” tool may be helpful when sitting on in an airplane, but not as helpful if you’re at the front of the room giving a presentation. It’s ok – you have three other tools.

Think

Sometimes when we’re busy emoting (aka freaking out) we fail to THINK. Thinking can calm the troubled mind and body. Use positive, calm and rational thoughts. I used to write mine down on a business card and carry it with me all the time when I was working on my emetophobia. I volunteered at the hospital, and one day I walked into a patient’s room and she was very nauseous, holding one of those cardboard bowl things under her chin. I could not take the card out and read it, but I reached into my pocket with my hand and just felt it. That really helped. Here are some positive thoughts (“positive cognitions”) that have helped me, and many of my clients. In fact, my clients came up with most of them:

  • You’re not in any danger
  • It feels dangerous but it isn’t
  • Usually the worst doesn’t happen
  • If it really happens, your anxiety will go down.
  • Vomiting isn’t dangerous or harmful. It can’t hurt me, so I don’t need to be afraid of it
  • There’s no point being afraid all of the time for something that happens so little of the time/rarely
  • It doesn’t matter if I vomit
  • Even if I get sick, I will be ok.
  • I’m perfectly safe
  • It doesn’t matter
  • I can cope with vomiting

Coping With Emetophobia – The S.T.A.R. Plan

Often before people with a fear of vomiting can get help they are left alone, terrified and feeling hopeless. They might not even know that being afraid of vomiting has a name: emetophobia. Some academics refer to it as “Specific Phobia of Vomiting” or SPOV. The treatment for emetophobia involves making a list of all the things that you avoid because you’re afraid, and all the safety measures you employ so you don’t get sick. This website has a “Resources” section that thousands of therapists already use for gradual exposure to some of those things. You start with the easiest thing on the list and work your way to the most difficult. You’ll normally need the help of a qualified therapist with experience treating emetophobia.

The goal in treating emetophobia is to have you come to the realization that vomiting isn’t the problem – anxiety is the problem. Once you get there, you’ll be able to tolerate your anxiety and do nothing to stop it. And once that happens, you will stop getting anxious in the first place. For some of you reading this, that may seem like a long way off. Others of you may think (as I once did) “I’ll never be able to tolerate that much anxiety! It’s terrifying and horrible!” It’s true that tolerating anxiety that goes immediately from 0/10 to 8, 9, or 10/10 is probably not possible. If it’s a slow rise, however, you may be able to avert it from getting to those high numbers, but if you’re like I was, it was usually zero to 10 in a millesecond.

So I came up with a plan that I call the S.T.A.R. Plan©. My S.T.A.R. Plan was inspired by the writers of “Coping Cat” and “The Cat Project” who came up with a “F.E.A.R.” plan for anxious children. It wasn’t quite right for emetophobia, but I loved the idea of a plan.

If you find yourself in a situation that triggers your emetophobia, it’s always good to have a plan. If you’re anything like I once was, your plan would be to get triggered, freak out and run. If you are triggered by your own nausea, however, it’s impossible to run, so you apply safety behaviours like asking for reassurance online or at home, or taking some stomach medication. This may help calm you down in the short-term, but as far as helping to treat your emetophobia for good, ass Dr. Phil might say, “How’s that workin’ for ya?”

S stands for “Scale” which refers to the 11-point scale that therapists use to determine how anxious you are. Zero means no anxiety at all, and 10 is the worst panic possible. When your emetophobia gets triggered, your anxiety will go up to one of the numbers on the scale. If you want to get better, it’s important for you to know what number you’re at. Sometimes you may become so anxious that you forget the S.T.A.R. plan, so it’s good to have a support person remind you by asking “what number are you at?”

T stands for “Tolerate.” The best way to get over a phobia is to stay in the situation and tolerate the anxiety without doing anything or thinking anything to make it go away. Different people are able to tolerate different levels (0-10) of anxiety. Your ability to tolerate the anxiety may also be dependent upon how quickly the number went up. If you can tolerate it, great. If not – move on to the “A.”

A stands for “Action.” If you can’t tolerate the anxiety, you can ask yourself “what actions could I take to bring down my anxiety?” These actions require learning and practice, which is the topic of another blog, but basically here are four actions that should help (They spell “BRIT”):

  • Breathe slowly and deeply. Slow is more important than deep.
  • Relax the major muscle groups in your body, head to toe. Relax your body. Try doubling your relaxation, then doubling again.
  • Imagine yourself in a safe, peaceful place if you can.
  • Think. I teach my clients to come up with a “mantra” of sorts to say to themselves. Mine was “You’re not in any danger,” but there are many more that my clients have come up with over the years. My favourite is “Vomiting is not dangerous or harmful. It can’t hurt me, so I don’t need to be afraid of it.”

R stands for “Repeat.” So all you have to do is go back to the beginning (the “S”) and ask yourself what number on the Scale of 0-10 are you at now? Most of the time you’ll find that your anxiety has gone down a point or two. So maybe you can Tolerate it now. If not, keep going through the S.T.A.R. plan until your anxiety is low enough to tolerate. Good luck!

Sex and emetophobia

It wasn’t until a client once asked me if it were ok to talk about sex that I started to think about sex and emetophobia. I reassured them that they can talk to me about absolutely anything. One might think that we 60-something grandmas don’t know much about the subject except for the missionary position in a long flannel nightie, but let me revamp our image for you: we went to college in the 70s. THE SEVENTIES. All the girls were on birth control pills, and there wasn’t any disease you could catch from a partner except gonorrhoea, which if you were so unfortunate, could be cleared up with one dose of penicillin. The good old days before herpes and HIV. Imagine it.

My first counselling gig was at the University of Waterloo “Peer Counselling Centre” in 1976. With some good, solid training, we volunteered a few hours a week talking to our peers about sex, birth control, abortion, being gay, being born in the wrong gender. Yes, 44 YEARS later we’re still talking about that.

But I digress. Emetophobics actually have a few things to worry about when it comes to sex, especially with some of the latest activities that many couples enjoy. What’s worse is that they’re often afraid to share these fears with their sexual partner.

I’ll try to be crystal clear, so you may want to read this blog in private.

Oral sex

Oral sex can present a problem to either male or female emetophobes. For the (straight) female or gay male the possibility of gagging on either the penis or the ejaculate can be terrifying. Men can become equally terrified of their partner gagging and even vomiting during oral sex. There are some emetophobic queer women who are quite reluctant to perform oral sex on another woman.

anal sex

Considering that Norovirus particles are contained in fecal matter, anal sex can be daunting whether one is the giver or the receiver. The problem is that the penis (or sex toy) is removed, theoretically contaminated. And then what do you/they do with it? We all know it’s not getting near your mouth anytime this century. But does he know that?

anilingus

Yep. I had to look that one up. Thanks to a comedy routine by Chris Rock, I heard it was called “tossing his salad.” Apparently there are a plethora of other terms. Suffice it to say that your average emetophobic would not be caught dead doing this one, which involves your tongue and your partner’s anus.

anal-digital stimulation

What’s he going to do with that hand now?

the solution

This may seem ridiculously simple, but you have to talk to your partner about the kind of things you like to do, and what you feel uncomfortable with. If you’re afraid to do just about everything, and your partner really wants to be adventurous then perhaps they aren’t the right partner for you. But if you’re already married to them, then there needs to be some give and take. Explain what frightens you. It’s easy enough for him not to push his penis too far into your mouth, and to let you know when he’s about to ejaculate. If they want anal sex, you might have to negotiate a shower afterward before doing anything else. You get the idea. Talk. If you can’t talk to someone with whom you’ve taken off all your clothes, then who can you talk to?

The other, perhaps more obvious solution, is to get treatment for your emetophobia. It really is treatable, and you don’t need to be afraid of the many things in life that non-emetophobics enjoy forever.

Best of luck, and remember that you can discuss anything with your therapist if need be.