emetophobia treatment plan / exposure

I wanted to share this article, which outlines a treatment plan that was successful in curing a 12 year old girl's emetophobia.

Worrywise Kids In Session: Case Conference on Vomit Phobias and OCD

Some thoughts I have after reading it:

1) I'm pretty fascinated by the idea of a fake vomit mixture. I remember reading about the idea somewhere else a few years ago, and I thought about doing it, but I decided it would be gross and that the idea really didn't bring up that much anxiety for me. However, in this scenario they add in the elements of urgency (by running to the toilets with the mixture in their mouths) and messiness (getting some of it on the toilet seat). That makes me feel more anxious when I think about doing it, which is surprising to me.

2) Since this treatment plan is for a 12 year old, I wonder if a similar plan would be as successful for an adult. I've often wondered if I could have gotten past all this if I had just gotten therapy for it when I was really young. I'm guessing age 11 would have been the prime time for me to go into extensive phobia counseling. But maybe the only reason it's easier for a child is because they have more motivation and are more willing to take risks. She mentions at one point that other patients resist the exposure exercises more. I found myself resisting a LOT of them even though I was only thinking about them, not even being asked to do them.

I am resistant to the idea of hanging out in a nurse's (or doctor's) office with sick people, to the idea of having a normal conversation with someone who was just sick, and to the idea of going on nauseating rides like roller coasters. When I think about exposure, I think "sure, I have no problem with it, as long as I'm not doing something that legitimately makes it likely I will end up vomiting." Things like going out to restaurants, eating "high-risk" foods, and taking trips involve a certain degree of risk, obviously, but in the logical part of my mind I know it's a very small risk. Actually forcing myself to ride a roller coaster or have a conversation with a sick person seems like a very big risk.

Either I'm being irrational by thinking that it's a big risk, OR that's the idea, to take a big risk and not care. I'm not sure which it is, but I'm guessing probably the second one. I know part of exposure therapy involves going to extremes, doing things that not even a normal person would do. For example, in a book I read about OCD (Freedom from Obsessive-Compulsive Disorder, by Jonathan Grayson), part of an exposure hierarchy for someone afraid of germs was to touch the inside of a dumpster. Why? For one thing, although a normal person would not just go up to a dumpster and touch the inside (and would feel grossed out by the thought), they might take out the garbage before going out to eat without thinking about it, which is essentially the same thing. Also, going to extremes takes you even further in your recovery. Doing something as extreme as touching the inside of a dumpster makes you even more aware of how low-risk other (less extreme) activities are.

3) This particular therapist mentions that the main reason she did not have the 12 year old girl induce vomiting as part of the exposure hierarchy was because young girls have body image issues and are at risk for eating disorders. I'm assuming this means that if she was working with an adult, she would include this step.

I have mixed feelings about this. I think self-induced vomiting is dangerous. This is probably due to more irrationality on my part (my general health anxiety), since I think manipulating your body in any way, even by taking a painkiller, is dangerous. This is why I hate medication so much. Of course, I still take it, as sometimes it's necessary, but very rarely. I have read that taking the recommended dose of Ipecac (the most commonly used emetic) is not dangerous, but I'm not entirely convinced.

Then there's the "evidence" that vomiting (self-induced or not) doesn't cure emetophobia. I put "evidence" in quotes because I'm talking about stories I've read on various websites from people who have either gotten sick with a virus or have self-induced, usually through taking Ipecac. I can't really call this evidence, because I can't say for sure these stories are true, although I'm assuming they are. Most of the people who give these accounts claim that they don't feel that anxious directly following the act of vomiting, but that they are back to their usual phobic state within a day (or a few days).

On the other hand, there is the occasional account where the person says that the act of vomiting did cure them or at least made them feel considerably better. I've given this a lot of thought, wondering why it works for some when it doesn't for (it seems) most. Maybe the phobia is not as severe for these people. Maybe they have some fundamental difference in their personalities or brains that makes them good candidates for this type of treatment. What I tend to lean towards (out of hope, because it's something that I could actually control) is that it has to do with how these people react to the experience in the moment. Some people, after vomiting, are horrified and upset and scared. They are usually writing about how they "ruined their streak" or how their anti-emetics didn't work (or they didn't even have time to take them), how aware they suddenly are of how little control they have over vomiting.

Other people are excited and relieved. They write about how they felt better after vomiting, how proud they are of themselves for getting through it, how it wasn't as bad as they had always thought. I don't think this has to do with the experience itself (as in it was much worse for the people in the first, upset group). These people are making a choice to cast the experience in a positive light. It's not fun or pleasant, but they choose to downplay those parts and emphasize the triumph involved, and the fact that no terrible consequences came from vomiting.

I tend to be a negative/pessimistic person, so I would probably fall into the first group. This gave me the idea of writing a letter to myself, a letter that I would read immediately if/when I ever vomited, to remind myself that I should make every effort to see this experience as okay and even a good thing. I haven't actually written it yet. It's just something I've been mulling over.

4) The imaginal exposure parts bothered me a little, because sometimes it is actually the case that a kid gets teased for vomiting or that a parent reacts badly. I don't have any experience with the teasing, but I remember my parents always being more annoyed than concerned when I got sick (or my sisters did), because they didn't want their carpet (or the car, etc.) to get messed up. It makes me wonder what the point is of convincing yourself this is unlikely to happen, especially if you are still a child. Shouldn't the focus be more on accepting that other people might be inconsiderate/mean and that it's okay (they'll get over it)? Maybe that was part of the focus. I mean, it is a pretty short case study and obviously isn't including every detail.

5) Everything else aside, this little girl is my absolute hero.