How to Practice Exposure Therapy for Paruresis

Paruresis is also known as shy bladder. This condition refers to difficulty and/or inability and fear of urinating in public restrooms or when other people are nearby. It is related to social anxiety disorder (SAD) in that it is a type of performance phobia that is specific to using public restrooms.

Signs of Paruresis

Paruresis can range from mild to severe. Symptoms of paruresis include the following:

• Needing complete privacy when using a restroom
• Fear that other people will hear you when using the restroom
• Complete inability to use toilets other than at home
• Feeling anxious about needing to use a toilet
• Not drinking so that you won't have to use the restroom
• Avoiding events because of the need to use the public restroom
• Negative thoughts about yourself when using the restroom

Impact of Paruresis

In a survey conducted with 63 patients affiliated with the International Paruresis Association (IPA), it was shown that paruresis had been a problem for an average of a couple of decades for patients.

It had also significantly affected their lives, such that one-third avoided parties, sporting events, and dating, while half were limited in their choice of job.

In terms of social anxiety in general, patients were more likely to say that they experienced problems in performance rather than social interaction settings.

Treatment of Paruresis

The most common treatment for paruresis is graduated exposure therapy, which research has shown can be successful.

"Exposure therapy is an evidence-based treatment for anxiety and can be a helpful treatment for people struggling with paruresis. The key is to slowly 

Rachel Goldman, PhD, explains, "Exposure therapy is an evidence-based treatment for anxiety and can be a helpful treatment for people struggling with paruresis. The key is to slowly start exposing yourself to anxiety-provoking situations, situations that you fear, or that you are avoiding. When putting yourself in these situations, it's also helpful to couple it with a relaxation technique, so in the moment when it feels particularly scary, you can counter it with something like a breathing exercise to help make it feel more manageable."

In the context of paruresis, graduated exposure therapy involves gradually using restrooms in increasingly difficult circumstances and is usually performed under the supervision of a trained behavioral therapist.

However, if you have a willing partner, there are steps you can take to attempt graduated exposure on your own. Before starting exposure therapy, have a doctor rule out medical causes.

You will need the following: 

• A trusted friend or relative to help you with exposures
• At least one hour twice per week to practice
• Paper and pen to write out a hierarchy
• Access to locations to practice exposures

Steps to Overcoming Paruresis On Your Own

1. Enlist the help of a trusted friend or relative.

This person will be present during early exposures to mimic the situations that you would experience in public. If you are unable to find a partner, it is possible to follow the steps by utilizing naturally occurring public locations.

2. Learn whether urgency to urinate makes it more or less difficult for you to perform.

If having to urinate urgently makes the process easier, be sure to drink lots of fluids prior to each exposure session. If the need becomes very urgent and you are still unable to urinate, consult a doctor or urologist.

3. Construct a behavioral hierarchy scale.

Make a list of locations or situations in which you find it difficult to use restrooms. For each item on the list, assign it a value from 0 to 10, with 0 being very easy (e.g., your home) and 10 being the most difficult (e.g., a busy public restroom).

4. Begin with an item rated 0, such as urinating at home while a guest is present.

Have your partner remain in your home in another room while you attempt to urinate. If possible, allow urine to flow for 3 seconds before stopping.

5. Meet your partner for a 3-minute break.

6. Once again, attempt to urinate.

Do not use coping strategies such as running a faucet or trying not to make noise. This will only extend the time needed for exposure as you will later need to learn how to perform without coping techniques.

7. Continue in this fashion, alternating exposures and breaks for up to an hour.

8. If the session has been successful, move on to the next easiest item on your hierarchy and practice this exposure in your next session.

Have a goal of working on exposures at least twice per week—several times per week being even better.

9. After 8 to 12 sessions, you should find your ability to urinate freely greatly improved.

Completing 15 to 20 sessions is the ideal goal.

If all of the above sounds too daunting or too much to start with, consider joining a paruresis support group. There you will meet other people who are struggling with the same problems and who will be able to give you support as you work on overcoming this difficulty.

Conclusion

If you continue to struggle with this problem, consider consulting a mental health professional for treatment. Methods of treatment other than graduated exposure may be helpful, such as relaxation techniques, psychotherapy, and cognitive-behavioral therapy (CBT).