Treatment Plan: Eliza Petrova

This initial phase focuses on building a strong therapeutic alliance with Eliza and her family. Key activities include:

• Building Rapport: Creating a safe, trusting, and collaborative environment for Eliza to feel comfortable. Utilizing her interests (reading, drawing) to engage her.
• Comprehensive Assessment: Gathering detailed information about the onset, triggers, intensity, and specific nature of the emetophobia. Confirming diagnoses and ruling out/characterizing comorbidities (GAD, OCD features, etc.) based on the initial report and direct assessment.
• Psychoeducation (Child-Friendly): Explaining anxiety and phobias in an age-appropriate way (e.g., the "false alarm" system). Introducing the concept of avoidance cycles and how facing fears gently can help.
• Psychoeducation (Parents): Educating Elena and Ivan about emetophobia, the CBT/ERP model, the role of avoidance and safety behaviors (like reassurance), and the rationale for exposure therapy. Addressing parental concerns and disagreements early.
• Collaborative Goal Setting: Working with Eliza and her parents to define specific, measurable, achievable, relevant, and time-bound (SMART) goals for therapy (e.g., "Eat a new food," "Stay in the cafeteria for 10 minutes").
• Introducing Monitoring: Teaching Eliza and parents how to track anxiety levels (e.g., using a SUDS - Subjective Units of Distress Scale from 0-10), triggers, and avoidance behaviors.

This phase prepares Eliza and her family for active exposure work by developing essential tools and understanding:

• Fear Hierarchy Development: Collaboratively creating a detailed list of feared situations, sensations, foods, places, and thoughts related to emetophobia. Ranking these items from least to most anxiety-provoking using the SUDS scale.
• Understanding Avoidance & Safety Behaviors: Identifying Eliza's specific avoidance patterns (food restriction, social avoidance) and safety behaviors (handwashing, checking, reassurance seeking). Discussing how these maintain the fear in the long run.
• Introduction to Exposure Concepts: Explaining the rationale for gradual exposure – learning through experience that feared outcomes are unlikely or manageable, and that anxiety naturally decreases over time (habituation).
• Interoceptive Exposure Introduction: Beginning gentle exercises to purposefully induce mild physical sensations associated with anxiety or nausea (e.g., spinning briefly, breathing through a straw) in a safe environment to help Eliza learn they are not dangerous.
• Imaginal Exposure Introduction: Starting to work with feared thoughts or scenarios through guided imagination or writing/drawing, processing the associated anxiety without avoidance.
• Parent Coaching: Training parents on how to act as "exposure coaches" – providing support without excessive reassurance, reinforcing brave behavior, and managing their own anxiety during challenging moments. Setting clear expectations for parental roles in ERP homework.

This is the core treatment phase, involving systematic confrontation of feared stimuli while resisting safety behaviors:

• Systematic Exposure (In-Session & Homework): Gradually working through the fear hierarchy, starting with lower-rated items and progressing as Eliza gains confidence. Exposures can include:
  • *Interoceptive:* More intensive practice with inducing feared physical sensations.
  • *Imaginal:* Vividly imagining feared scenarios (e.g., feeling nauseous at school, seeing someone cough).
  • *In Vivo:* Engaging in real-life feared situations (e.g., eating slightly 'risky' foods, touching surfaces in public restrooms then eating, watching videos involving simulated vomit sounds/scenes, visiting the doctor's office without excessive reassurance seeking, sitting near someone coughing, eating in the school cafeteria).
• Response Prevention: Actively coaching and encouraging Eliza to resist engaging in safety behaviors during and after exposures (e.g., limiting handwashing, not asking for reassurance, staying in the feared situation, not discarding food unnecessarily).
• Processing Exposures: Discussing what Eliza learned during each exposure – Did the feared outcome happen? Was the anxiety manageable? Did it decrease over time? Correcting anxious predictions with real experience.
• Therapist Modeling & Support: The therapist may model exposure tasks and provide encouragement and guidance throughout the process.
• Parent Involvement in Homework: Parents actively support planned exposure homework between sessions, acting as coaches based on the agreed-upon plan. Regular communication between therapist and parents is key.
• Troubleshooting & Flexibility: Adjusting the pace and specific exposures based on Eliza's progress and reactions, ensuring challenges are manageable but push her boundaries appropriately.

As Eliza makes significant progress, the focus shifts to maintaining gains and preparing for the future:

• Generalization: Practicing exposures and coping strategies in a wider variety of settings and situations to ensure skills are robust.
• Reviewing Progress & Successes: Acknowledging and celebrating the hard work and achievements made throughout therapy. Reviewing goals and assessing progress using rating scales and functional improvements.
• Developing a Relapse Prevention Plan: Identifying potential future triggers or high-risk situations. Creating a specific plan for how Eliza and her parents will manage setbacks or returning anxiety using the skills learned in therapy (e.g., planning mini-exposures if avoidance creeps back in).
• Addressing Residual Symptoms: Targeting any remaining, less severe fears or related anxieties (e.g., mild GAD symptoms, social concerns) if necessary.
• Planning for Session Fading: Gradually reducing the frequency of sessions (e.g., bi-weekly, monthly) as Eliza maintains her progress independently.
• Booster Session Planning: Discussing the option of scheduling future check-in or "booster" sessions as needed, particularly during times of transition or increased stress.
• Continued Parent Support: Ensuring parents feel confident in continuing to support Eliza's progress and utilize effective parenting strategies long-term.