Joanna (not her real name) is a 22-year-old brunette with an intense look in her eyes. She suffers from a fear so pervasive that, in her words, she "wants to die."
Joanna's fear is called emetophobia, the fear of vomit. Few of us enjoy the concept of throwing up. But she is paralyzed by it, forcing her to avoid potential encounters that include holding babies, getting on boats or taking amusement park rides.
Joanna, who asked that her real name not be used to avoid ridicule, had searched for help, but was either laughed off by friends and family or told to "get over it." Finally, she found a possible answer: exposure therapy. In the course of three days, Joanna would go through the process with Mark Pfeffer, the director of the Panic and Anxiety Center in Chicago. The concept is literally to face your worst fears, whether it be spiders, elevators or cocktail parties, guided by a trained therapist.
Pfeffer sees it this way: "Exposure therapy is more of an art form than a science. It's a technique for people to learn to be unafraid, but it's not as simple as throwing someone into a snake pit. "
Edna B. Foa, professor of clinical psychology at the University of Pennsylvania in Philadelphia and one of Time magazine's 100 most influential thinkers in 2010, is a leading figure in the use of exposure therapy. "For the exposure to work," she cautions, "it needs to be done systematically and repeatedly until the anxiety reduces. Exposure therapy is not for every anxiety. It is for people who are anxious about a particular issue."
Although the use of it is expanding, Pfeffer says, "It is the best-kept secret in the psychological world."
In the weeks before the exposures began last year, Pfeffer worked with Joanna to help her understand her triggers. "We teach clients the physiology and the mechanics of their natural fear response," Pfeffer says. "Severe anxiety or panic is a very primitive response to a perceived threat. That's healthy if the threat is real, but it's incapacitating in those with severe anxiety disorders."
Joann, who has since moved from Chicago to Indiana, did her written homework, but soon enough she would have to face situations designed to bring up the sheer panic she went to great lengths to avoid every day of her life.
"It's the anticipatory anxiety that gets in people's way," Pfeffer says. "We teach people how to identify irrational thoughts like, 'If that elevator is stuck not only will I have the biggest panic attack ever, but no one will find me and somehow I'll die in that elevator. ' Anxiety sufferers go to catastrophic thinking very quickly."
Worry is a self-defeating mechanism that tricks people into feeling better, for the moment. "We try to head off the terrible consequence of what we fear by thinking about that very thing," Pfeffer says. "And we do get that momentary sense of being in control. I have a client who's going to have to take the bar exam in nine months and he said to me, 'I'm going to have to start worrying about that right now.'"
When fear or worry is excessive, it infects a person's entire life. Joanna rarely left her apartment and was afraid to move forward in a serious relationship because she feared becoming pregnant. Public transportation was out of the question so the only jobs she could take were those to which she could walk. Socializing was impossible.
"To do exposure therapy the right way requires surrendering", Pfeffer says. "It's letting the symptoms come. It's saying, 'OK, I don't have to do this, but I'm going to choose to face my fear on my terms."
Pfeffer and Joanna had worked out a hierarchy of triggers for her emetophobia, from lowest to highest. He would be asking her to face them one by one on a graduated scale.
When Anxiety Becomes Debilitating
The moment Joanna walked into the office to begin, she looked wild eyed. She started crying almost as soon as Pfeffer began to talk to her, readying her to take the first small step. After some comforting words and asking her to try to think logically about the worst thing that could happen, Pfeffer asked Joanna whether she was ready to look at some pictures and video of people vomiting. She took a deep breath.
There is often confusion for patients about how the therapy works, Pfeffer says, explaining that "they think they're supposed to go into exposure therapy and start feeling better. People look for a quick fix."
But exposure therapy is volunteering to feel bad and it sometimes has to continue for weeks and months.
Asking people to expose themselves to situations that are going to set off panic is just the beginning. The trick is to get them to manage through it and not run. If they do, an amazing thing happens to most people: Their anxiety begins to subside.
And that's what began to happen to Joanna. Within an hour or two, Pfeffer had her holding onto jars of vomit (faked but realistic). She already seemed calmer. He took her emotional temperature often by asking her what her panic level was on a scale of one to 10. She was typically at a four or five. But now, he was going to up the ante.
Pfeffer told Joanna he wanted to take her to Chicago's Navy Pier, filled with fast food, children and one of her major triggers, amusement park rides. For Joanna, it would be a universe of potential disaster.
When they arrived, Joanna was pale. She scanned her surroundings almost constantly, looking for situations where people might become nauseous. Pfeffer kept at it, asking her to welcome in the anxiety and directing her attention to the rides.
He continued to measure her level of panic and, as she accepted the situation, her terror receded. The day culminated with a nervous but game Joanna going on a ride by herself. It had been an exhausting afternoon, but she was beginning to see that there was hope.
The next day she would have even bigger challenges to confront: a boat ride on Lake Michigan and a visit to a café where moms and kids play games and can get a bite to eat. All potentially vomit inducing.
In the morning, Joanna met Pfeffer at the dock and, reluctantly, Joanna boarded, with Pfeffer following. The water was choppy and the boat was small.
They headed off and within a few minutes, Joanna was experiencing a full blown panic attack. She was screaming, crying, and begging to go back. She was at a "10," she said, the worst she had ever experienced.
Pfeffer pointed out calmly that she was surviving and asked her to try her best to remain in the situation, while reassuring her that they would indeed get off the boat, just not yet. When they returned to the pier, Joanna was shaky, but when Pfeffer asked her how she was doing, she brightened and expressed pride rather than panic. She had made it through.
Pfeffer was impressed, noting that Joanna "was more than I could ask for in her willingness to participate but as with most people, sometimes there is an afterglow of treatment. Some people would describe it as a placebo effect, this euphoria of having faced your fear. People almost feel invincible."
So was Joanna really overcoming her fear or was this just a contact high? The next and last exposure was constructed to help her with her dire fear of children. She and her boyfriend wanted to get married and have babies, but her emetophobia made that an impossibility.
Exposure Therapy Has Patients Facing Fears
When Pfeffer and Joanna arrived at the café filled with young moms and their kids, Joanna returned to a distracted, almost disconnected state. She was hypervigilant and tense.
Pfeffer wasted little time and as soon as he found a willing mom, he asked Joanna when was the last time she had held a child. "Never," she replied.
Pfeffer suggested that now might be a good time to start. Joanna nodded slightly, eyeing the tiny little girl whose mother was holding her in outstretched arms, beaming at Joanna. She carefully placed the baby in her lap. Silence.
Pfeffer asked Joanna how it was. She looked closely at the child, held her a tiny bit tighter, and after a moment, smiled. Another door was opening.
Although exposure therapy is dramatic, the effect tends to diminish without follow through.
It's like taking your medication when you have a virus. You may start to feel better halfway through but if you don't finish, you may get sick again," Pfeffer says. "The brain needs sufficient time for that memory to take hold. The analogy is playing a sport or learning a musical instrument. If you don't practice, you will know the basics but you'll get rusty and lose your touch.
"When it comes to facing your fear, though there's so much on the line, it's almost a life or death matter. It's easy to default back to the old way unless you have what I call a good program."
Immediately after therapy, Joanna began practicing her own exposures, but she was inconsistent. In the months since, she has had her ups and downs. She relies heavily on her boyfriend and keeps a restricted daily routine.
But, she says, "I think I am about 50 percent better than I was."
She also believes the time is right for her to tackle the rest of her phobia.
Clinical psychologist Foa says, "Exposure therapy is the way we teach our children not to be afraid. It's the normal way we get over fears in everyday life. If you see a child afraid of going into the water, you say, 'Go with mommy, and we will go to the edge of the water, mommy will hold you.' And that's exposure."