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.