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Overcoming Vomiting Issues: A Comprehensive Case Study in Psychotherapy

The problem of vomiting

Table of Contents

I recently received a call from Himani (name changed), a highly driven 20-year-old college student who excels in her studies. However, she has been facing a distressing issue—unexplained episodes of vomiting. Despite undergoing comprehensive medical tests, no physical ailments have been identified as the cause for her condition. Consequently, her doctor has recommended that she seek the guidance of a psychologist .

Overcoming Vomiting Issues Case Study – Complete Session Flow

Initial Consultation/ Pre-Therapy Session

A women seeking help for overcoming vomiting issues

During our initial session, Himani shared in detail the issue she had mentioned during our phone call. She opened up about her experiences, starting from when she was in 9th grade. At that time, she struggled with her weight and faced constant teasing from her peers. As she progressed to the 11th grade, she began experiencing bouts of vomiting, sometimes occurring up to four times a day. This led to significant weight loss.

Despite performing well academically in 12th grade, her interest in studies gradually waned due to the overwhelming nature of her vomiting episodes. Consequently, she now finds herself under immense pressure regarding her studies, as her father has high expectations of her. Unfortunately, she is unable to dedicate sufficient time to her studies and finds herself sleeping excessively.

Deeply concerned about her health and studies, Himani’s father took her to numerous doctors and hospitals for consultation and treatment. However, no medical condition was identified as the cause of her symptoms.

While she did appreciate the positive aspect of her weight loss and the way she looked, she also experienced weakness and the distressing feeling of being misunderstood by her family. Some family members even suspected that she was intentionally inducing vomiting to gain attention, criticizing her for burdening her father with this issue.

In the course of our conversation, Himani wanted to emphasize that a year ago, she had been in a romantic relationship that her parents disapproved of. Despite their initial reservations, her parents showed remarkable understanding and supported her when faced with criticism from other relatives. This experience left her feeling guilty for causing her loved ones pain. Additionally, she expressed that she finds herself emotionally fragile, often bursting into tears over seemingly small incidents, such as her mother’s refusal to purchase something she desires.

After listening to Himani’s challenges, I began by providing her with psycho-education, explaining the fundamental concepts behind my therapeutic approach. I introduced her to Cognitive Hypnotic Psychotherapy for overcoming vomiting issues, which encompasses various techniques and methodologies. Following that, I guided her through the pre-coaching process, helping her understand the steps we would take together.

Moving forward, I explained to Himani that in her case, once we have clearly defined the current problem and identified the desired outcome, I will assist her in:

  1. Defining the existing problem with precision.
  2. Clearly outlining the expected outcome of our sessions.
  3. Understanding the type of future she envisions for herself.
  4. Evaluating the tasks she currently needs to perform and how they relate to her desired future.
  5. Identifying the triggers that precipitate her vomiting episodes.
  6. Guiding her through a step-by-step process of managing these triggers.
  7. Identifying any underlying core issues associated with her vomiting problem.
  8. Restructuring her thoughts and reconditioning her emotions, thereby addressing any barriers preventing her from effectively performing required tasks.

By addressing these aspects of her situation, we can work towards alleviating Himani’s challenges and facilitating her personal growth and well-being thereby helping her in overcoming vomiting issues.

Session 1: Defining Challenge and Desired Outcome

Defining challenges

During our first session, I utilised the SOFT SEA Coaching Framework in conjunction with the Meta Model Questioning technique to assist Himani in defining her current situation, desired outcome, and envisioned future.

To begin, I asked Himani to summarize the specific challenge she was facing and wished to address through therapy, encouraging her to express it in her own words using the following format:

S – Situation: “I feel depressed about my vomiting issues when no doctor is able to rectify my problem, and everyone (including my younger brother, paternal uncle, grandmother, aunt, and their families) insists that I am intentionally causing it.”

O – Outcome: “I aspire to eliminate my vomiting and perform well academically, securing a good job. Currently in my final year of BSc, I have plans to pursue an MSc and then a PhD. Additionally, I am interested in taking the NET exams or obtaining a Junior Research Fellowship (JRF). Ultimately, my goal is to become a professor or researcher.”

However, as Himani did not encounter any issues with studying, aside from experiencing low energy levels due to her vomiting, she refined her desired outcome statement as follows:

“I wish to be free from my vomiting.”

Next, I prompted Himani to describe her ideal future, allowing her to envision the possibilities she would love to work towards. She shared the following points:

  1. Regaining a sense of normalcy.
  2. No longer being subjected to accusations of causing her health issues.
  3. Attaining overall physical well-being.
  4. Escaping the criticism aimed at her for supposedly damaging her health.

As part of her homework assignment, I instructed Himani to continue outlining her envisioned future. Additionally, I advised her to pay close attention to the triggers that initiate her vomiting episodes, as she had been struggling to pinpoint specific triggers and often mentioned that the vomiting could occur at any time, even after consuming water. 

Session 2: Trigger Identification and Future Elicitation

In our second session, which took place the following week, I began by inquiring about any changes Himani had observed in her behaviors, thoughts, or emotions throughout the week. Here are her observations:

Observation 1: Himani noticed that she vomited when experiencing stress or when she had a headache.

Trigger 1: A couple of days ago, Himani was thinking about her father’s health, and this caused her to vomit. She was worried that her father would be upset if her health issues persisted. She had a conversation with her father in the morning and vomited after lunch.

Trigger 2: When Himani returned to the hostel from home on the 31st, she experienced a severe headache and had a lot of vomiting. This condition prevented her from studying for two days, leading her to feel guilty.

Trigger 3: Himani’s brother told her that she was causing trouble for their father, and this thought continued to play on her mind, resulting in vomiting.

To address these triggers, I employed the technique of Thought Restructuring with Himani, helping her change her thought patterns associated with the identified triggers. To illustrate how new thoughts become more automatic, I offered an example:

I asked her, “What comes to your mind immediately when you hear ‘Jai’?” She responded, “Hind.”

Next, I asked, “What comes to your mind immediately when you hear ‘Mera Bharat’?” She replied, “Mahan.”

I explained that this is precisely how the new automatic thoughts would work. Then, I guided her through the thought restructuring process, teaching her the following framework:

When = Trigger ,Then = New Thought

For example: When I get stressed and vomit, thinking about my father’s health, then I know the sessions I am having with Kiran Mam are going to help me stop vomiting. When I get tired and have a bad headache, then I know I will be able to take care of myself by eating healthy. When my brother tells me that I am troubling our father, then I realize that it is not true as I love my father and cannot trouble him.

To explore her future further, I asked Himani the “miracle question” to prompt her to envision her desired future. Additionally, I assigned her homework, which involved practicing the thought restructuring technique daily to internalise the new thoughts and make them more automatic. I also requested her to complete her future vision and instructed her to document the emotions she experienced just before vomiting during the week, noting any changes she noticed.

By engaging in these exercises and techniques, Himani would gradually work towards overcoming her challenges and cultivating a healthier mindset.

Session 3: Working with Secondary Gains

During this session, we began by reviewing the events of the past week. Himani had written her future vision, and we went through it together, refining it to be more sensory-specific. To aid her in moving towards her envisioned future, we utilised a transformation metaphor and created a task list.

Himani encountered difficulties in completing the tasks outlined in the transformation metaphor, which left her feeling frustrated. To address this, we employed the N-step reframing process. This process allowed us to identify any secondary gains that might have been impeding her progress towards achieving the goals set within the transformation metaphor. We then worked together to explore alternative ways through which she could attain those secondary gains.

Following the reframing process, Himani experienced a transformative shift and successfully transformed the old garden into a new one within the metaphor. However, after the session, she displayed some confusion and mentioned that she didn’t fully grasp the concept of the alternate ways. I reassured her that it was a normal response and explained that her unconscious mind had already initiated the process of change. Over the next few days, she could expect to witness changes in her behaviour and mindset.

For her homework, I instructed Himani to complete her future vision and task list. I also encouraged her to pay close attention to any triggers she might encounter and practice the “when then” technique we had previously discussed.

By actively engaging in these assignments and strategies, Himani would be able to further progress towards her desired future and gain a better understanding of how to manage and respond to triggering situations.

Session 4: Re-framing via Inner child healing

Despite our efforts, Himani continued to experience vomiting episodes at least four times a week, particularly when she felt tired. To address this issue, we implemented an inner child reframing technique. However, we encountered resistance during the process. The first inner child who emerged was a 9th-grade student who did not reveal any positive intentions. The second inner child, a year younger than Himani, also struggled to articulate a positive intention and appeared confused.

To overcome this impasse, I encouraged Himani to inquire about the positive intention underlying this confusion. Initially, she responded with “don’t know, don’t know.” Eventually, she suggested that the intention might be related to weight loss, although she repeatedly emphasized that she did not vomit intentionally for that purpose. However, she did acknowledge feeling good after losing weight.

We then engaged in a creative exercise where we called forth an alternative behaviour. Himani listed the following behaviours:

  1. Exercise
  2. Eat healthy
  3. Avoid junk food

Although Himani insisted that weight loss was not her primary motive, she consciously believed that vomiting occurred due to stress and tiredness.

Next, we invoked the presence of the third inner child, who was in the 11th grade and overweight (prior to the onset of vomiting). Himani was instructed to visualise her slimmer self and observe the differences in body shape. She was then prompted to create a task list outlining the necessary actions to achieve her current desired weight size.

The tasks identified were as follows:

  1. Think positively – avoid overthinking and overreacting.
  2. Enjoy favourite foods – release happy hormones and reduce irritability.
  3. Ensure adequate rest to manage fatigue.
  4. Focus on studies to minimize stress-induced headaches and prevent vomiting episodes.

For her homework, Himani was assigned to work on her task list. By implementing these strategies and actively working towards her goals, she would be able to address the challenges associated with vomiting and make progress towards a healthier and more fulfilling future.

Session 5: Additional Task List

This session revolved around helping Himani further fine tune her task list and add additional tasks that she wanted to include as a part of her routine. With the help of the Meta Model Questions, I was able to help her get more clarity about these tasks.

  1. Morning Yoga: Set the alarm to wake up at 6:15 a.m. and dedicate a minimum of 15 minutes to practicing yoga.
  2. Barefoot Walk: Spend 10 minutes walking on the morning wet grass without wearing slippers, allowing the refreshing sensation to invigorate her senses.
  3. Regulate Rice Intake: Reduce daily consumption of rice, as Himani believes that excessive rice consumption contributes to her vomiting. She aims to incorporate a balanced and diverse diet.
  4. Self-Love: Cultivate a sense of self-acceptance and acknowledge her inherent perfection in her unique way, fostering a positive mindset.
  5. Evening Shower: Prioritize taking a shower before bedtime to promote relaxation and ensure cleanliness.
  6. Post-Dinner Walk: Engage in a leisurely walk after dinner, benefiting digestion and providing a refreshing break from study or daily routines.
  7. Indulge in Moderation: Enjoy an ice cream treat every other day, savouring it mindfully and without guilt, as a way to experience simple pleasures in moderation.
  8. Dance Routine: Dedicate a joyful 10-minute session each day to dancing, boosting both physical activity and emotional well-being. 

By incorporating these additional tasks into her routine, Himani will enhance her overall well-being and make progress towards achieving her desired weight and energy levels. H.W. Implement the newly added tasks from the task list consistently to support your journey towards improved health and well-being.

Session 6: Future Pacing

During the sixth session, Himani shared that she had started experiencing a sense of improved health as she engaged in the assigned tasks. She diligently performed all the tasks except for morning yoga.

To address this, we worked together to create a “When… Then…” statement specifically for her morning yoga routine. 

The statement we developed was: “When the alarm rings at 6:15 in the morning for my yoga time, then I realize that doing yoga will enhance my health and promote proper digestion.” 

At this point, I had confidence that Himani could effectively handle any hindrances that arose by using these personalized “When… Then…” statements, as she had become proficient in creating them independently.

To deepen her understanding of how the activities she was undertaking would contribute to her desired future, I facilitated a hypnotic process. Guiding Himani into a deep state of relaxation, I encouraged her to imagine how the current activities she engaged in were ultimately helping her create the future she desired. 

During this session, I also incorporated an anchor technique to reinforce her desired emotions, particularly confidence. This anchor would serve as a powerful reminder of her capabilities and help her maintain a sense of control over her life. 

Over the course of seven sessions of overcoming vomiting issues, Himani made notable progress, feeling more in control of her life and confident in managing the assigned activities. She maintained contact with me through phone conversations for an additional four weeks, during which she shared her feelings and reported her ongoing progress.

My Observations

Throughout this case study, which deals with the problem of vomiting, I have observed the significant role that imagination can play in therapy, provided that the counsellor possesses the necessary skills to apply appropriate imagination processes in the relevant context.

Utilizing reframing techniques has proven to be a powerful tool when clients find themselves stuck in certain patterns or behaviors. It enables them to uncover the positive intentions behind their actions and facilitates the reframing process, leading to positive outcomes.

Another valuable tool is the use of “WHEN THEN” statements, which allows clients to affirm and actively change their thought processes. This technique empowers clients to take ownership of their own cognitive transformation.

References of techniques used

The techniques employed in this case study dealing with the problem of vomiting draws from various methodologies, including:

These approaches have been integrated to create a comprehensive and effective therapeutic process. The concepts and techniques discussed during this case study are based on the topics covered during the Cognitive Hypnotic Coaching® Diploma and the Cognitive Hypnotic Psychotherapy™ Diploma

By applying these evidence-based techniques and building upon a solid theoretical framework, counsellors can effectively support their clients’ progress and help them achieve their desired outcomes.