Trigger Warning

TW: mental health, hospitalization, emetophobia, general scary shit

In early 2020, before everyone in the US started freaking out about the pandemic, I was freaking out all by myself. After three visits to the ER for continuous panic attacks, I spent six days in the hospital on the mental health floor adjusting to new medicines and experiencing all kinds of group classes and activity therapy. Following the week of inpatient services, I was discharged and placed in an Intensive Outpatient Program or IOP.

My first day of IOP was the Wednesday after President’s Day weekend. The program ran from 10 am to 2 pm on Mondays, Wednesdays, and Thursdays. Each day as a participant you signed in, picked up your clipboard and name tag, and proceeded to go through three classes/group therapy sessions with a short lunch break in the middle. The classes and therapy sessions varied each day. Classes ranged from Med Ed (medication education, my least favorite) to learning about the signs and symptoms of depression and how it is diagnosed (the most enlightening). They would teach us coping skills, stress management, and all about unhelpful thinking patterns: how to recognize them and how to stop them in their tracks.

Activity therapy was more fun. One day it was art therapy where my drawing of a series of blue and orange triangles led to a deep discussion about the resemblance to shark’s teeth and how the drawing represented either my anxiety biting into all areas of my life or, alternatively, me biting back at my anxiety and depression. We also experienced music therapy, guided meditation, and chair yoga.

The one session that never varied day to day was check in. While two of our three sessions were different every day, no matter what you were also going to check in. Check in was pretty much what it sounds like: a group of us patients sat around in a circle with a social worker, intern, or counselor as a facilitator. For forty-five minutes we took turns going around the group and everyone had a few minutes to share how they were doing.

Sharing started with going through the daily checklist on your clipboard. Each day upon arrival when we picked up our clipboards we had to fill in a column of questions, the same questions every day. When it was our turn to check in, the first think we did was run down the check list. Here is a sample of what my checklist typically looked like:

Rate how you’re feeling on a scale of 1 to 10: 4

List two feelings you are experiencing: anxious, worried

Thoughts of hurting yourself or others? No

Taking meds as prescribed? Yes

Alcohol and drug free? Yes

Urging to drink, drug? No

Other destructive behaviors? No

Eating behaviors yesterday: 3 meals

Sleeping behaviors last night: 8 hours, continuous

Hygiene: Took shower? Yes. Brushed teeth? Yes. Clean clothes? Yes.

IOP Goal? manage anxiety to feel better & live life

Obstacles to achieving your goal? intrusive & automatic thinking, ruminating

Plan - 3 behaviors that will help you reach your goal: 1) positive self talk/STOPP technique, 2) grounding myself/mindfulness, 3) keeping myself busy

Affirmation (a positive statement about you, even if you do not believe it): I can do this!

(Sidebar: I recognize my answers on this list makes me seem like a functional human, but trust that the normal amount of sleep was due to the medication and the fact that I wasn’t working meant I had nothing else to do but take care of myself. Often when deep in a mental illness hole it is hard to even brush one’s teeth, hence the above questions.)

After running down the check list, the facilitator of the group would ask us questions. Sometimes they would be in response to something we said in the check list. For example, if my sleep was disrupted they would ask why and what happened? What did I do to try to get back to sleep? We would talk about that for a few minutes, address any other topic that came up, and then it would be on to the next person.

During check in on my first day at IOP the intern running our group asked me how I was feeling given that it was my first day. I said I was nervous and unsure of what to expect. She reassured me that in this space they did everything they could to be supportive of everyone, to address everyone’s needs, and to avoid the use of triggering language in group so that everyone could feel safe. Then she turned to the rest of the group and asked them to share their experiences on their first days at IOP. A young woman sitting next to me spoke up.

“I felt the same way on my first day,” she said. “I was so nervous I felt like I was gonna throw up the whole time.”

The intern running the group thanked her for sharing and moved on to the next person. Meanwhile my blood pressure was spiking, I was lightheaded, and my palms were sweating into my pants as I clutched my thighs to stay calm.

Because, you see, I have what is called emetophobia: the fear of throwing up. On that first day I was very nervous, a feeling which I always feel in my stomach. Feeling nervous in my stomach makes me anxious that I might throw up, which means I then begin to feel nauseous, making me feel even more nervous. You can see how this becomes a terrible cycle of nerves and nausea, which serves to distract me from anything else going on around me. For all the good that young woman was trying to do by making me feel more comfortable, what actually happened was my anxiety was triggered by her mention of throwing up.

Even in my state of anxiety I immediately saw the humor in this situation. Not one minute after the intern assured me that there would be no triggering language used, I was triggered by someone’s language choice. I chose not to say anything about it for a couple of reasons. First, I didn’t want to have to explain how I was terrified of throwing up and even the mention of it freaked me out. It’s an embarrassing thing to admit. And second, I was used to it. I have spent most of my life being freaked out at any mention or hint of nausea or throwing up, so I was very used to hiding that fear and dealing with it in my own way until I felt better.

Identifying and understanding my triggers has been important in caring for my mental health. It helps me to not put myself in situations where I know I’m going to be triggered. Like I don’t go on roller coasters because of the risk of motion sickness for myself as well as those around me. I’m not a doctor because I know that certain bodily functions really freak me out (plus I’m too dumb to be a doctor). And I avoid little children like the literal plague during flu season because chances are pretty good that if you’re around them long enough one of them is going to barf. No, thank you.

Here’s the problem, though. This thing that I am afraid of is part of regular life. It is also not one of those globally accepted triggering things such as violence, gore, rape, fireworks, car accidents, et cetera. This trigger of mine is not socially acceptable as a trigger. Even though the fear of throwing up is more common than you’d think (Google it), it feels like a shameful secret that I get to enjoy all by myself. There is no one out there advocating for me and my fear even though it is very real and can easily send me into a tailspin at any given moment.

I just finished watching Breaking Bad for the first time. The show is about the cooking and selling of meth and the violence surrounding drug dealing, manufacturing, and cartels. (Actually, the show is about the people involved in such things, but you get what I mean.) Every episode begins with a little line in the top left hand corner warning the viewer of things that might be troubling: violence, gore, substance abuse. Even smoking gets a mention in the warning. There is no mention, though, of the fact that the main character receives a diagnosis of cancer and goes through chemotherapy treatment which leads to, you guessed it, lots of barfing. I’m not talking a little bit, I’m not talking just the sounds, I’m talking full on shots of barfing. It is disgusting.

I spent much of the time watching this show ready to throw my arm across my eyes so I wouldn’t have to see the disgustingness in action. Ten or fifteen years ago I would have needed to plug my ears too, but as a seasoned emetophobe I have grown used to the fake sounds of tv barfing. I recognize it for what it is and dismiss it as fake. But I still don’t want to see it. And if caught on the wrong day with my anxiety higher than usual, the sight of fake tv barf can still send me over the edge.

Yet still there is no trigger warning for me and those like me. For awhile I used to be annoyed by this. I used to wish that the MPAA would include warnings of throwing up in their movie ratings so that I could be prepared. But the truth is that wouldn’t make a difference. If I really wanted to see a movie but I knew there was barfing in it, I’d still watch it. But I would enjoy the experience less because I’d be constantly on my guard for when the barfing would occur. I have found it better to be surprised in my disgust and fear and deal with it in the moment rather than anticipate it and be nervous for hours.

Trigger warnings are important and have their place. I am all for anything we can do to help people manage whatever it is they’re dealing with. But for all the times that we successfully help someone avoid being triggered, there will be just as many times that someone is triggered by something that doesn’t seem scary to the rest of us. It isn’t possible to stop every single trigger because the simple truth is that everyday life is triggering. There is no changing that. If even the people providing mental health care cannot stop or do not recognize every trigger, what can we honestly expect from the rest of the world?

I recognize now that I will spend the rest of my life being triggered: by this fear of throwing up and by the other things that tend to set off my anxiety. There is no avoiding the trigger: I have accepted this. But sometimes guns misfire. Sometimes bombs don’t go off even though the button is pressed. Being triggered doesn’t necessarily mean you have to explode; there is opportunity between the trigger and the reaction to put a stop to it all, or at least to lessen the effects. And that, my friends, is the trick. Learn how to stop the explosion before it stops you, even if it comes on without a warning.