I used psychoeducation to help the patient understand that avoiding feared situations maintains anxiety. We constructed a fear hierarchy for food contaminated with bugs and used imaginal exposures in session. The imaginal exposures allowed the patient to confront her fear of eating food contaminated with bugs safely and easily. In addition, I could quickly modify the imaginal situations depending on the patient's reactions. To supplement the exposures conducted within session, the patient's homework between sessions focused on reestablishing her normal eating habits by ascending her fear hierarchy through in vivo exposures.

We spent the majority of our time during sessions, therefore, conducting imaginal exposures. During the first phase of each exposure, I asked the patient to vividly imagine the situation I elaborated and to record her level of anxiety (0 - 10) at each step of the situation. This took approximately five minutes. In the second phase, I reviewed the steps of the imaginal exposure and reminded the patient of her level of anxiety at each step. During this phase, I asked the patient to recall the automatic thoughts she experienced during each step of the exposure. Third, the patient and therapist took turns evaluating and disputing the automatic thoughts. Fourth, the patient wrote out responses for each thought based on our discussion. Fifth, the patient generated coping statements summarizing what she learned from the exposure.

I deliberately constructed the situations encountered in these imaginal exposures so that they were more anxiety arousing than ones encountered in the patient's everyday life. Like a sprinter who trains for races wearing heavy boots so that the final race will seem easy, I designed these exposures to make overcoming anxiety-arousing situations in her everyday life seem easier. Thus, developing an ability to cope with extremely stressful imaginal situations should make it easier to cope with moderately stressful real situations.

During our fourth session, therefore, we conducted an exposure in which the patient imagined eating chocolate covered ants. Specifically, she imagined herself at a party where she sees a bowl of chocolate covered ants (anxiety = 3). She then decides to eat some of the ants and walks toward the bowl (anxiety = 8). She puts her hand in the bowl (anxiety = 9), puts the ant in her mouth (anxiety = 10), chews the ant (anxiety = 10), and tastes something other than chocolate (anxiety = 10). Finally, she swallows the ant and feels it land in her stomach (anxiety = 10) and eats some more ants (anxiety 10). I then asked the patient to imagine herself five and ten minutes after having finished eating the ants and to report her anxiety level at each point (anxiety = 9 and 7, respectively). Following this, she generated automatic thoughts associated with each step of the exposure. These thoughts included, "I'm going to be sick" and "My stomach is going to explode." By the end of the exposure, however, she had an adaptive thought: "Well, I ate it, nothing happened, so I guess I'll be OK." In responding to the first thought, the patient said, "I'm not really going to be sick; my mind is playing tricks on me." In responding to the second thought, she said, "It's unlikely [that my stomach will explode] or others' stomachs would have exploded already."

By the fourth session, the patient had resumed her normal eating habits. She only experienced anxiety eating the specific brand of food in which she had originally found the grasshopper. Because we had agreed at the start of therapy to have only four sessions, we could not address the patient's fear of bugs more generally. However, I reminded the patient of how she had overcome her fear of eating and encouraged her to use the same strategy to reduce her fear of bugs.

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