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.

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.