The worn page features 13 easy tasks for most teens: eat out, walk the dog, go a day without a panic attack — among 10 others. For Clark Topjon, they were unfathomable.
The 16-year-old jotted them down two years ago before beginning exposure therapy for an emetophobia, or severe fear of vomiting. Countless vomit videos, puke-flavored jellybeans and handfuls of fake throw-up later, Topjon just smiles at his shaky, ninth-grade handwriting.
The goal list, now more like a certificate, bears 13 checkmarks. Every last task is now habitual.
Exposure therapy took only two months and seven sessions to help Clark. Before that, his emetophobia worsened over three years, despite medical, homeopathic and talk treatments.
Roughly 15 percent of Americans develop phobias, said Thomas Wise, American Psychiatric Association co-chair of the Committee on Adult Psychology. If unaddressed, they can worsen over time and turn serious, even life-threatening.
In the United States, exposure treatment — facing fears — has steadily gained acceptance in the last couple of decades, Wise said. For phobias, exposure therapy is the sole proven cure. But still, many people with phobias are slow to seek, and find, it.
"It's great that it turned out this way," said Greg Topjon, Clark's father. "The only regret is the poor kid lost three years of really neat time."
By definition, phobias are any anxieties that limit life, like a fear of cars too intense to drive to work or a fear of dogs that keeps someone from walking outdoors. Ashley Smith, psychologist for the Kansas City Center for Anxiety Treatment, likened them to fire alarms that sound with the simple lighting of a candle or stovetop.
"Until you realize it's a false alarm," she said, "you'd be running out of the house all the time."
In Topjon's case, this meant hours on end in the bathroom, afraid he might vomit. He also started phoning his parents incessantly and skipping breakfast for fear the hungry feeling meant he might get sick.
For Wendy Erickson, of Overland Park, Kan., the limit from her phobia was simply a flat refusal to fly.
Earlier in life, Erickson loved plane trips. She flew for family vacations. She flew to Florida on frequent ocean visits to see her grandparents.
"I was a person who flew all the time and loved it," Erickson said.
But all her infatuation with flying ended with one broken elevator in 1987, which sparked a case of claustrophobia. She sat, trapped and alone, for 45 minutes, before a fireman eventually pried it open and pulled her free. When she emerged, she wouldn't visit her grandparents — or the ocean — for 23 years.
"I looked at (flying) as being up in the air 30,000 feet in a tube," Erickson said.
Erickson's phobia lasted longer than Topjon's because, for decades, she didn't see it as a treatable illness. She and her family just accepted that every family trip would be by car. The times her two daughters, Libby and Annie, or her husband, David, did fly, she simply stayed home.
In the end, Erickson only changed her attitude toward treatment because her eldest daughter moved to Chicago last spring. With Libby in a medical residency there, she couldn't bear not visiting.
Libby suggested exposure therapy at the Kansas City Center for Anxiety treatment as her top choice.
A graduated approach
The Kansas City Center for Anxiety Treatment keeps an assortment of potentially fearful sights. The ones prescribed commonly include clown figures, hypodermic needles, fake blood and cages of spiders and snakes.
The staff also takes patients with embarrassment fears to supermarkets to have them clap in public. For a fear of speeches, the staff poses as inattentive students, throwing paper planes and talking as the patients present a topic.
Amy Jacobson resorted to vomit-flavored jellybeans and home-cooked fake vomit — favorites for emetophobia — to treat Topjon. She flew on a plane with Erickson to St. Louis.
But she saved all this at the start. Most professionals, Smith said, use a "graduated" approach which, albeit slower than "flooding," is milder and less traumatic.
So, at first, Topjon merely thought of vomiting, then looked at pictures and watched movies of people throwing up. Only later did he eat the jellybeans; hold a hand in fake vomit, which he then thought was real; and gag himself — all with Jacobson telling him he was going to vomit.
Erickson, for a long time, just watched movie after movie of planes — inside and outside the cabin — taking off and landing.
Not until May 9, more than a month after beginning, did Erickson board a St. Louis-bound plane with her doctor.
Smith compared the gradual approach in exposure therapy to acclimating to a cold pool by entering one limb at a time.
But even gradual exposure with phobias — spread over four to 10 sessions instead of just one or a few — isn't easy. The Kansas City Center for Anxiety Treatment uses a stress scale from one to 10, with level 10 being total panic, for patients to self-monitor their anxiety.
"The first couple of times, I was 9, 10 the whole time," Topjon said.
The anxiety often weighs on the therapists, too.
"The hardest part is tolerating their distress," Smith said, of her patients. "I certainly would do it a different way if other ways worked."