In Vivo Exposure Exercises

Anna S. Christie

When I first meet a new patient I have them fill out an intake form which includes checking off which of a long list of safety and avoidance behaviours they have. I mention briefly upon intake that one of our short-term goals will be to give up all of them, and try to approach as many things on the avoidance list as possible. I just ask them to think about it.

Sometimes patients take a look at the list themselves and begin to give some things up such as asking for reassurance or Googling symptoms or norovirus outbreaks. I don’t usually mention it further until after we have finished looking at words, drawings, and many, many pictures ranging from slightly nauseous-looking people to people vomiting. The next step on the hierarchy I employ with everyone is videos and then sounds. But before we start those I bring back the list of safety behaviours. I like to talk about each one, so that the patient can spend some time thinking about them at this point. Then, for homework that week, I ask them to put the list of safety and avoidance behaviours into order from the least to the most scary to give up. Giving up each one is considered an in vivo (“in real life”) exposure exercise.

Once the patient has a list or hierarchy, I ask them to print out 2 or 3 blank calendars and enter into the next 2 or 3 months each safety or avoidance behaviour in order so that giving each one up happens on a specific day. I ask them to take a picture of the calendars with their phone and send the pictures to me for their file. Before we watch videos or listen to sounds each session I ask how they did with giving up the safety behaviour that they would have recorded on the calendar since the previous session.

The in vivo exposures are an important part of the recovery process with emetophobia. I remind patients that folks who don’t have emetophobia (let’s call them “normal” for the sake of this exercise) don’t practice any of the things on their list. Most adults who don’t vomit often go for 10 or 20 years without vomiting, so people generally don’t think about doing something to prevent it. We all learned with Covid that washing hands, and not touching your face or wearing a mask went a long way in preventing it, as well as preventing colds, flu, noroviruses and so forth. If you didn’t get Covid you were probably the healthiest you’ve ever been during that time.

It sometimes surprises patients that giving up a safety behaviour on a certain date means giving it up forever from that date forward. Sometimes we have to discuss that a bit, and how backsliding back into the phobia often comes from picking up safety behaviours again.

I find in hearing stories from patients, that sometimes a therapist will pick a safety behaviour almost at random and ask the patient to give it up. Usually, it’s the thing that’s bothering their family the most such as asking for reassurance. However, often the patient is unable to give such a thing up at this time because it doesn’t fit into the hierarchy as the first step. If patients can rank the safety behaviours themselves and give them up in order of easiest to most difficult, it gives them a measure of confidence and control rather than beginning therapy feeling helpless or worse, a failure.