Emetophobia: Exposure therapy not working for you? Try the alternative! Behavioural experiments.
Exposure therapy (also known as exposure and response prevention - ERP) is often the first go to treatment for emetophobia. And as a therapist I have seen it do wonders.
However, just because it works, doesn’t mean it is the best or only tool you can use. Often, exposure therapy is difficult to do yourself, and if not set up properly can make you feel worse, out of control or panicked. It has the potential to set you back. So, it’s good to have more than one tool.
So why does exposure not always work?
Exposure is designed to teach us something about our feared situation indirectly. Ideally, you learn that your fear is not likely to occur and that you can cope with feelings of anxiety. However, depending on how exposure was set up you might not learn this, be able to apply it to other situations, or potentially learn the opposite lesson.
In my experience as a therapist, exposure works best to words, images, sounds or videos associated with vomiting. As these are easy to set up and people often quickly learn they can cope. But exposure can be hard to set up to feared situations, illness, or dropping some types of unhelpful behaviours.
So, what’s the alternative? Behavioural experiments.
So, the aim of exposure is to teach you something indirectly. Well “behavioural experiments” are a tool which is designed to directly teach you something through testing out your beliefs and thoughts directly.
This works amazingly well for overcoming unhelpful behaviours (i.e. safety behaviours). CBT therapists consider behavioural experiments as the most powerful way of helping a client and are considered the gold standard in therapy tools (even over exposure).
Setting up an experiment is easy and follows 5 simple steps:
1) Find out the belief you want to test.
The first step in a behavioural experiment is selecting a belief or idea to test. These beliefs are often related to thinking vomiting is likely if you don’t do something to prevent it.
This is why those with emetophobia tend to:
· Avoid situations.
· Engage in reassurance seeking.
· Use checking behaviour (e.g. checking each piece of food is cooked enough).
· Use a range of “safety behaviours” designed to reduce the chance of vomiting (e.g. Over cooking food, excessive washing or cleaning).
· Worry.
· Mentally plan.
· Use positive affirmations.
· Body scan for symptoms.
· Be hyper vigilant for signs of illness.
Examine one of these behaviours at a time and ask yourself: “What is this behaviour trying to achieve?” or “what do I think will happen if I don’t do this?”
Once you know your answer I would advise trying to phrase your answer/thought in a testable way. When testing a belief, it is advised to phrase it as an “if X then Y” statement as this provides a good hypothesis to test. A good way to identify these statements is to ask yourself what your feared outcome is if a certain behaviour is not done.
For example:
· “If I use a microwave, I will get food poisoning”.
· “If I visit my friend who was recently ill, then I will also get sick”.
· “If I don’t worry about it, I might miss something”.
· “If I don’t know where the toilets are, if I was to vomit, I wouldn’t know where to go”.
2) Design a way of testing out this idea:
We need to test the accuracy of these beliefs. Anxiety often makes us believe things which are not true. If you have used an “if X then Y” statement, then often designing an experiment is easy. Do or don't do X and see if Y happens.
A second option is something called an “A/B A/B experiment”. This is an experiment where you alternate days by increasing the level of the behaviour one day, then reducing it the next day. This helps you see if the behaviour is helpful or unhelpful.
This is useful for:
Reassurance seeking.
Body scanning.
Worrying.
Mental planning.
For the example used in the last step, an experiment might be:
· “If I use a microwave, I will get food poisoning” – I will try cooking a meal in the microwave and see what happens.
· “If I visit my friend who was recently ill, then I will also get sick” – I will visit my friend and act normal (no excessive hand washing etc) and see what happens.
· “If I don’t worry about it, I might miss something” – I will worry a lot one day and then stop the second day and see which one is better for my anxiety and see if anything bad happens.
· “If I don’t know where the toilets are, if I was to vomit, I wouldn’t know where to go” – I will go to a new restaurant and not try to find out where the toilets are and see what happens.
3) Predict an outcome:
The next step is to predict an outcome of the experiment. This is a crucial step so don’t miss it out!. Write down what you think will happen. This allows you to reflect on this prediction after you have done the experiment.
4) Test out the idea:
Once you know how to test out your idea and have made your predictions. It’s about having some courage. Go and do it.
5) Outcome:
After your experiment you need to record the outcome. Write it down and reflect on it.
· Did anything bad happen? If not, why?
· Compare the outcome to your prediction.
· If something bad did occur, how well did you cope with it?
· What does this say about your original belief?
· What have you learnt about handling anxiety?
· What have you learnt from this and how are you going to act in the future?
If nothing bad occurs but you convince yourself you “got lucky”, you can repeat experiments as many times as needed.
These 5 steps can be easily seen in this table. Feel free to draw out your own.
1) Belief or idea to test.
2) How to test it.
3) Predictions.
4) Outcome.
5) Learning.
Therapy:
Emetophobia is treatable. I recommend reaching out to a BABCP accredited CBT therapist or self-referring yourself to the NHS talking therapies services which can offer Emetophobia support.
Written by David Kaneria - CBT Therapist