Reassure patients that vomiting is not part of exposure therapy. This is because the problem is not vomiting; it is anxiety. Treatment with exposures will focus on slowly raising their anxiety to about mid-level and learning to recognize, assess and tolerate the feeling without using a safety behavior or any attempt to calm down.
Most patients are terrified of “Exposure therapy” for a variety of reasons, the first being that they often believe it means they have to vomit.
Explain that exposure therapy means beginning with very simple, easy things like words or phrases, followed by drawings, cartoons, pictures of nauseous people, and so on. The idea is that they will allow their anxiety to rise, but never to the level of panic, and they will do nothing to try to control or lower their anxiety. Things like breathing slowly or relaxing muscles or telling yourself things like “I won’t vomit” are actually safety behaviors when used in this context and they will not be needed because we will not show them anything that makes them panic.
The idea of not controlling anxiety may be foreign to your patients who have read of desensitization online or had other clinicians coach them to do so. You can remind them that despite trying to breathe and relax, their phobia remains, or they wouldn’t be here.
Remind patients that they are already thinking and feeling distress about what they fear all the time.
Although current research encourages exposure to have surprises, in that they suggest you don’t put the list of triggering or distressing things into a hierarchy anymore, but only a random list, THIS WILL SEND EMETOPHOBICS RUNNING. Don’t surprise them. Let them know this.
The first step in exposure therapy is getting used to the word “vomit.” Have patients say it, write it, and hear it. (Note we work differently with children). In that way, you can actually talk with them about it!
The Patient is in the driver’s seat.
They are in control, and they decide whether and when to go to the next item on the list.
The Importance of Homework
Homework is perhaps the most important part of CBT. If your patient doesn’t want to do any homework on their own, let them know that the treatment process will take about 10 times longer. (3 years as opposed to 4 months.)
The S.U.D. Scale
On the scale, 0 means no anxiety at all, and 10 means the worst panic possible. If you describe the scale to the patient in this manner, then they cannot give you a number like 11 or 1000, no matter how anxious they feel. We still will use SUD scores even though there is evidence that decreased anxiety isn’t always the best framework. It just works clinically. SUD scores are practical.
The Brain Made Easy
Anna has all of her patients listen to one of her podcasts called “The Brain Made Easy.” This helps educate patients about how the brain works in relation to anxiety and panic. The podcast is Season 1, Episode 11.