Exposure Hierarchy – Adults

If you were used to our old site, this hierarchy is essentially the same – I just used my powerpoint slides to display all the words and pictures. The words are a little better organized, I think, and I moved the silhouette of a woman vomiting farther along as it seemed to upset clients in the “cartoon” stage of their exposure work.

If you’re sharing your screen you can make the slides larger or smaller by zooming in or out manually.

Imaginal Exercises

These may be done at the beginning, middle or end of the exposure work. Scroll to the bottom of this page for imaginal exercises.

Words and Sentences

Cartoons & Drawings

People before Vomiting (Nauseous People)

People After Vomiting

Vomit only (no people)

People Vomiting

In Vivo: Safety Behaviours

Before you begin working with videos it’s a good time to give the client a bit of a break and have a session discussing their ongoing in vivo work. Specifically, this means the giving up of their safety and avoidance behaviours. I (Anna) usually have clients fill out a checklist of safety and avoidance behaviours on intake such as the one here. I then have them create an in vivo hierarchy numbering each behaviour from easiest to most difficult to give up. I go through the checklist with them at this point in the exposure work. I then suggest that they take two or three blank calendars (such as the one here) and fill in the dates on which they will give up the behaviour. I also ask that they take a picture of their calendars and send them to me so that I can check in with how they’re doing, briefly, at the start of each session.

Videos

The set of videos I’ve put together for you begin again with very simple ones such as cartoons, babies, etc. and progress to a man vomiting on a plane. They can all be found in a playlist on our YouTube Channel here. I share my screen with online clients and watch along with them. I also assign what we’ve done in session as homework for the week. The client should watch the video until it causes them no anxiety.

Sounds

Interoceptive Exercises

Interoceptive exposure is something that involves the whole body. Each of these exercises could theoretically lead to vomiting. The point is that you don’t know. At this stage of recovery, the rubber meets the road. You need to be willing to vomit now. This is not the same as forcing yourself to vomit. If you want to do that you may certainly go for it, but do it after you’ve done these interoceptive exercises AND the “Deepened Extinction” exercises.

The question to ask oneself is: “Am I willing to accept ANY outcome?” It’s usually not a “yes” or “no” answer. Willingness can be expressed in terms of a percentage. I ask my clients how willing they are to accept any outcome when doing a given exercise. 50% willing? 75%? only 10%? Any percentage above zero is good! Anyone who is 50% willing, in my opinion, is willing. They won’t like it but they can probably do it with some support and incouragement.

These interoceptive exercises also teach clients that it’s not that easy to vomit, and that all the things they thought would make them vomit for sure don’t after all.

1. Spin around in an office chair, or just spin in the center of the room until you feel very dizzy.
2. Eat a big meal, more than you would normally eat.
3. Smell a vomit mixture. If you can find butyric acid, add a few drops to a can of vegetable soup (don’t add water). DO THIS OUTSIDE as the smell sometimes permeates the whole house. If you can’t find butyric acid, then use a lot of cheap parmesan cheese. Add it to the soup mixture until it smells like vomit.
4. Clean up a mess. Take some vegetable soup or tinned chili or spaghetti and throw it wherever you’re afraid someone will vomit. Practice cleaning it up. If your child thinks it’s a fun exercise, throw some on them. Practice getting their clothes off, putting them in the shower, etc. Launder the clothing and bedding. Rent a steam cleaner for your carpets. It’s all a pain in the butt, but totally do-able! The exercise will teach you that it’s not a catastrophe or a disaster or your worst nightmare. It’s just a situation. A few hours ago our built-in vacuum cleaner bag exploded all over our garage. Dust, hair, spiders and tiny Lego everywhere. It took 2 hours for him to clean up. A situation, that’s all.
5. Practice vomiting by putting oatmeal in your mouth and spitting it into a toilet, especially if you don’t like toilets! You may need to start with water if this really makes you queasy. After oatmeal you can try spitting that horrible mixture in point 3.
6. Have someone else fake-vomit and make horrible noises when they do. Most husbands are totally down for this. They can also make a mess by missing the toilet, and you can go in and clean it up.
7. Order the game Beanboozled from Amazon or some Harry Potter “every flavour bean” and try your luck. They all taste disgusting. I found the canned dog food flavour much worse than the vomit flavour.
8. Gag yourself with a popsicle stick or a toothbrush. Try this a number of times and in a few locations.

Deepened Extinction

Deepened extinction, a phrase coined by researcher and clinical psychologist Michelle Craske, is the level of exposure you’ll want to do in order to really and finally know that you’re completely recovered. It is not easy to do, but is very easy to explain.

Deepened extinction is simply combining two or more exposure exercises.

In the table below, you can see the numbers 1-34. These are 34 SEPARATE EXPOSURE EXERCISES. (Scroll right on a mobile phone to see the whole chart.) Begin with #1 – do both the vertical and horizontal exercise at the same time (eat a big meal/when not feeling well). Then go on to #2 and so on to #34. Try to do these exercises in about two months (one every second day).

These exercises serve two purposes:

1. Each exercise will make vomiting much more likely. They will prove that you are willing to vomit, but the goal is not to make you vomit on purpose.
2. You will learn after doing them all that it’s not nearly as easy to vomit as you previously thought.

	Eat a big meal	Listen to sounds	Watch a vomit video	Smell vomit mixture	Fake vomiting	Spin around	Taste vomit beans	Gag yourself
After eating a big meal	——–	—–	14		—–	——	30	31
When not feeling well	1	8	15	21	26	28	31	32
While listening to sounds	2	—-	—-	—–	——	—–	——-	——-
While watching a vomit video	3	—–	——	——-	——–	——	——–	———
While smelling vomit mixture	4	9	16	——-	——–	—–	———	———
While fake vomiting in a toilet	5	10	17	22	——–	——	———-	———-
While spinning around	6	11	18	23	———	——-	———-	after spinning – 33
While tasting vomit beans	7	12	19	24	27	29	———-	after tasting – 34
While gagging yourself	——-	13	20	25	——-	——–	———-	————

Once you’ve mastered all these, try combining THREE things such as smelling vomit, tasting a vomit-flavoured jellybean all when you’re not feeling well or after a big meal.

Next try doing other things when you’re not feeling well such as going out to a movie or, if you’re not feeling too bad, a restaurant or dinner party. You can put a plastic bag in your pocket or purse so you don’t have to worry about embarrassing yourself in public, but don’t use any other safety behaviors – particularly NO MEDS!

TIME FOR A CAR RIDE?

The car can be challenging because most people with emetophobia believe they get carsick. There’s a simple test for this: ask your parents if you vomited in the car when you were a child. If the answer is yes, then you legitimately get carsick. Dramamine in the US or Gravol in Canada is therefore your best friend. If you have Zofran (Ondansetron) note that it is not as effective as Dramamine/Gravol for motion sickness.

But let’s go with you DON’T get carsick, you just get anxious and feel nauseous. The answer to this is to practice riding in the car, preferably as a passenger. You can make a list of all the things you’d rather avoid: riding with a less-known driver, riding in the back, riding with others, riding with kids. Like everything else, make a list or hierarchy and try each thing. For DEEPENED EXTINCTION you want to ride in the car when you’re already feeling nauseous, after you’ve had a meal, while tasting vomit jellybeans, while smelling vomit, etc. By this stage, we’re sure you can figure it out.

Working in Imagination

There are several ways to do imaginal exercises with Exposure and Response Prevention. Here we outline two of them which we employ in our practice with adults.

1. Brief imagination exercise.

This exercise would more than likely be used near the beginning of exposure treatment. The clinician asks the patient to imagine a vomiting scene, beginning with the least frightening such as an animal vomiting, or a person who is not contagious vomiting. We would ask for an SUD level before and during this exercise. As with all exercises, if the patient’s SUD level is below 8 then we would ask “can you tolerate this anxiety without doing anything to try to control it or lower it?” Normally the patient answers in the affirmative. Sometimes level 8 is tolerable. 9 or 10 probably is not (but we would still ask). If the SUD level goes to 9 or 10 (a panic attack), then slow breathing, relaxation of muscles, and a calm steady voice of the clinician may be warranted.

Sometimes this imaginal exercise works well and sometimes it is not the least bit frightening to the patient.

2. Visualization writing exercise.

This exercise would likely be employed nearer the end of ERP. The clinician asks the patient to write out their absolute “worst nightmare” scenario. It can be typed. The patient then reads the scenario aloud. It can be done for homework, not necessarily in session. Again, SUDs are tracked. If the number is not tolerable then slow breathing, relaxing or even distraction may be used. However, the patient must go back and read the scenario again until it does not illicit any feelings of fear. Once the patient is literally bored with reading the scenario they may be asked to visualize themselves being very calm and acting in a “normal” way during the scene. This follows the principles of sports psychology where one envisions the perfect play, hit or shot. It is done over and over again until it becomes an automatic thought in the patient’s mind.

3. Best Case Story

I (Anna) usually do the “worst case scenario” writing exercise about ⅓ of the way in to exposure work, and then near the end I ask the patient to write out a “best case scenario” story where they are acting calm and peaceful during an episode of vomiting.

4. Just for Fun

Patients may play a game of “Mad Libs” where the words inserted into the story MUST be “vomit” and/or any words for vomit such as “puke” etc. These games may be played as homework with one’s family or friends to help patients get used to the sound of the words.