The effective way to help kids afraid of throwing up is two-fold. First, face the fear. That part of the treatment is called exposure. (Just so you know, contact with actual vomit or the act of vomiting is not a necessary part of exposure.) Second, don’t play it safe. That is called response prevention (preventing the usual response). Kids come up with all kinds of ways to stay “safe.” These are steps 4 & 5 in my previous post. In this post I will only cover exposure. In my next post I will cover response prevention. For kids with anxiety both of these are incredibly difficult so it is important to understand how this works.
What is Exposure?
Exposure is doing something deliberately that will evoke the distress normally avoided. Don’t miss this. Exposure is being anxious on purpose. You are not doing exposure if you are trying to not be anxious or if you are not anxious at all. This is hard to get because it is so counter-intuitive. For example, let’s say the exposure is looking at a picture of person who appears sick. Most kids will try to come up with a story about the person in their mind so it is not so scary. They might think the person may be sick but not in a way that would lead to vomiting. This might seem good, right? Wrong, that is NOT the way to do the exposure. The goal is to feel the fear and think the scary thoughts and do it for an extended amount of time. (**Please keep reading, this can be done with only moderate discomfort so don’t dismiss this because you think your child will NOT do it.)
I will address why exposure works in later posts but if you are interested, here is an article about it. Briefly, here are some of the reasons:
- Learning that you can tolerate the discomfort is contrary to the old fear beliefs. It becomes less threatening.
- If you stay in something long enough your body gets used to it. Think about a concert. The sound hurts at first but you get used to it.
- If you do it on purpose you are choosing it and that gives you some control back.
- The feeling makes you think something bad will happen. If you do it enough your brain realizes the feeling doesn’t lead to the feared outcome and reduces the feeling.
- Anxiety problems are a result of mistaken ideas. Exposure leads to disproving these mistaken beliefs.
The fact is that kids with fear are already thinking about it all the time. I am not asking anyone to do anything they are not ALREADY doing. We are just going to do what their brain is doing with a plan to make it less scary. Their nervous system is already creating exposure in an attempt to overcome the fear. I tell kids we are just going to help their brain finish what it is trying to do and stop the things that are keeping that from working.
Exposures can be all sorts of things. You can imagine, observe, watch through media or actually experience that situation that triggers distress. In this series of posts I give an overview of the steps I typically use with kids and layout the principles so you can apply it to all sorts of fears. For more detail, we have developed a supplement to Turnaround that will give you the step-by-step process. Following are the steps necessary for successful exposures.
Exposure should be organized and planned
When I explain exposure to adult clients they tend to give it a try without a plan. They are in the moment and so they try to do some exposure on the fly. Sometimes they can see the benefit but often they don’t make much headway because they bite off more than they can chew or don’t do it enough. It is important to lay out a “map” and follow it step-by-step, especially with kids. This is, of course, easy for some people and hard for others. I am personally not very structured. If there were a way to wing it, I would have found it. So when I say follow the map, I mean follow the map. So here are the steps to make the map.
1) Make a list of triggers to face
You will make out a list of things that would evoke anxiety or distress. Then order them from easy to hard. You will probably change it a bit as you go but make your best guess. Exposures can be imaginary, virtual, situational and interoceptive. Here are some examples:
Think about the fear. You can use words, stories or other means to help focus on what is feared.
You can use pictures or videos that trigger the fear. You can find nearly anything on youtube. It is an exposure wonderland!
Where are the situations that trigger the fear. Arrange to go to those. Are there restaurants or places that trigger fear? Are there items or actions that trigger fear?
This means creating sensations in the body. Lots of kids with this phobia are scared of getting hot so the exposure would be to get hot.
The detailed steps we use for emetophobia are part of our supplement.
2) Track the distress
This procedure is called a SUD score (Subjective Units of Distress score). With older kids I use a scale of 1 – 10. You can use 1 – 100 also. If numbers don’t work there are plenty of visual examples online like thermometers you can use. I print a card to use and here is what it looks like. You can change the words to best fit your child’s descriptions of the distress if you want.
For younger kids I have a white board and have them draw a line. The top of the line is “freaked out” and the bottom is “doesn’t bother me at all.” Here is a picture of the board after a session. We were doing exposures on words. You can see the distress wasn’t too bad. Particularly at the beginning I try to keep the exposure mild to moderate. This is important to clearly show the effect of the exposure. Kids’ memories of this are not very good. It is biased toward the distressed feelings so an “objective” measurement is extremely important. It is very motivating to see progress. I have them mark or give me a score at the initial exposure, during the exposure and then at the end of the exposure. Periodically, I will go back to previous exposures and most of the time it will have dropped even further. Once you do the harder exposures the first ones seem very easy.
3) Do Exposure gradually
When you do this you will run into resistance. Who wants to feel anxious? If an exposure is too hard don’t force it but don’t give up. Just break it into a smaller step. Finding a beginning point is often a surprise. A client and I will come up with an exposure plan and sitting in my office they are sure they they can do it. However, they are frequently surprised that it is WAY more difficult than they imagined. Therefore, start slow and easy. Better it is too easy rather than too hard. Do NOT worry about what your child WON’T do, help him or her figure out what they CAN do.
Parents, remember while helping your child that what they fear is not actually dangerous or threatening. You will hate to see them scared and will want to comfort them. Encourage but don’t rescue. The purpose of exposure is for your child to eventually see that it is not dangerous. Then the anxiety will go down. Don’t try to remove the anxiety first and then face it. That is backwards. You can adjust the difficulty but don’t remove it.
4) Prepare your child that it WILL be difficult
Make sure your child is prepared to feel anxious. I emphasize this over and over. However, I tell kids it is my job to figure out how to make an exposure kind of hard but not too much. I want them to tell me if it is too much. More than likely your child will feel comfortable telling you it is too hard so, if possible, don’t get into a power struggle. I will tell kids they are the experts of their anxiety. The more information they can give the more I can help them. Tell your child it is normal to feel uncomfortable when doing exposures. I tell kids, everyone and I mean everyone, feels uncomfortable. It is a fact that exposure tasks must evoke discomfort to be successful. In other words, you are doing it right if it is distressing. This discomfort is temporary and it will subside as you remain in the task and as you repeat the task. You can probably think of a time your child did something or learned something that was hard at first but is now pretty easy. Remind them of this.
Motivation is crucial for this. It is hard and so a child will want a good reason to do this. We spend a lot of time working on motivation in the Turnaround program and if you have it already you may want to go back through parts of it, especially days 8 and 9 where we cover exposure.
I tell kids to try to not fight the anxiety or fear. They will not benefit from exposure if they fight the anxiety. Instead, they need to just let themselves feel the discomfort. Don’t do anything about it, just let it be there. You may have to encourage them that it is something they already feel and it will just be uncomfortable, not dangerous. Throughout this process, ask your child what they think about what you are saying. They may have concerns and being able to address those are really important.
I have few responses to help with this. I may ask or say some of these. 1) Do you think you could do an exposure if we keep it really easy? Sort of like a hungry feeling? 2) Do you think you could hear me say or just look at a word about this? 3) If you think it might be too much let me know and we will stop right then. This gives a sense of control. 4) You are probably going to feel bad anyway, wouldn’t it be better to get to be in charge of it? 5) You have been really good at not throwing up, right? You can probably handle a small worry, right? Just do what you normally do when it is not too hard. Ask them if they have ideas that might help them face it.
5) Do the exposure long enough for it to work
How long will it take? I so wish I had known the answer to that when my daughter was struggling. I tried an exposure with her and when she got anxious we all freaked out and quit. That may be worse than not trying an exposure. It just makes you more afraid. Your child will need to stay in the anxiety until it starts to subside on its own or at least until you child reports they are doing better tolerating it. It doesn’t have to be gone completely, just lower.
Keep doing the exposure until the distress comes down. This is important because this will be the experience to support that exposure works. Believe me, they will want proof. I usually make note of the time. I can then say, “Okay, now we have some kind of idea about how long an exposure will take.” I always qualify this by expressing some uncertainty but it helps kids know it is uncomfortable but it will pass and about how long. Then I can say, “Do you think you can stand being uncomfortable for about X amount of time?” This really helps with some of the initial fears kids have about the process. Just as a rule of thumb, in my experience, it takes 15 to 30 minutes when you are first starting. You just have to accept it takes as long as it takes. Nothing is wrong if it takes a while or even goes up at first.
I have found that specific questions about the distress can be helpful. I will ask, “Can you tell in your body where you feel the worry?” Usually it is the tummy or throat. With one young client, I don’t remember how we got to this analogy but we started to describe the uncomfortable feeling in her tummy as a potato. I would ask her, “How big is the potato?” It disarmed the feeling by calling it something silly but also became another way to measure the exposure. I could use the metaphor to ask her if she would be willing to feel the potato for a bit while we did the exposure.
A counseling session is usually around an hour. That seems about the right amount of time for the initial exposures. I wouldn’t go longer than that at home. I check in a lot to see if they are okay to keep going or if it is time to end. As you go along the exposures may not take that long. Pay more attention to the process of anxiety decreasing and less about the clock. If it is clear a child is worn out or feeling a bit overwhelmed then I don’t mind ending sooner. You will have to figure out that with your child. Also, counseling is usually once a week. So I send a child home with homework to practice the same exposure we did in session as many days as they can before next appointment. (I have varying degrees of compliance with that but don’t make a big fuss if not much happened at home. I just tell them it will take longer to get through this and they can decide.) I won’t move to the next exposure in the hierarchy until the current exposure is pretty low like a 3 on the SUDs.
So the rhythm is do the exposure during the session. Homework is to repeat it as many days as they can. Then the next session we take the next step up the hierarchy, then home to practice, and so on. You will have to find the right speed for the process at your home. Remove all the distractions you can during the exposures and plan enough time. In the next post I will address response prevention. This whole process may seem a bit overwhelming at first. That is why Dr. McCarthy and I have created supplemental product for this to go with the Turnaround program. We cover all this in detail and provide the materials you will need.
Much of this article was adapted from this superb book and his steps for successful exposures: Abramowitz, Jonathan S. (2012-06-25). Obsessive Compulsive Disorder (Advances in Psychotherapy; Evidence-Based Practice) (Kindle Locations 2630-2652). Hogrefe Publishing (com). Kindle Edition.
There is a marvelous website by Anna Christie, BA, M.Div, RCC, devoted to emetophobia that helped us developing this for children. The site is for adults but you can see the principles and examples of the hierarchy clearly laid out. It is outstanding. Here is the link.