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Friday, March 31, 2006

How to make a plan for graduated exposure.

In his book, Edmund Bourne explains how to construct a plan for Graduated Exposure Therapy. This is also covered in Steven Soifers book on Shy Bladder. If I put those together with my own experience here's what I think you should do (Remember, I'm not a doctor, this is not medical advice).

Step 1 : Identify Where You Are.

You want to get started on defeating your Shy Bladder symptoms but first it's a good idea to take a hard look at your condition. It might help to answer for yourself some of the following questions and writing down your answers. You can always shred the paper later but writing this down may give you some insight into your particular case.

Questions :
* What was the first time I experienced this problem?
* How has it affected my life?
* Does anyone know that I suffer with this?
* If I have told someone, what was their reaction?
* Does anyone in my family have this condition? (it does seem to run in families)
* What have I already tried to overcome this condition?
* Under what circumstances am I able to go?
* Under what circumstances am I definately unable to go?

Step 2 : Get Physicians advice.

I know, I know. This is the step we all hate and many of us skip. It may be you know that you don't need to see a MD but it's always a good idea to remove any physical problems from the picture. Chances are however that if you can go at home but not in a public restroom the problem isn't an enlarged prostate or other problem, it's Shy Bladder.

Step 3 : Choose your weapons

Another good reason for getting a physicians advice is that you might choose a Selective Serotonin Reuptake Inhibitor (SSRI) drug. It's worth reading the International Paruresis Associations (IPA) drug page for a full treatment of this subject. It may be that not all SSRI's are created equal. The IPA hints at anecdotal evidence that Paxil may actually be useful for Shy Bladder. Again, this is not medical advice, talk to your physician.

Hypnosis? Some have reported that they used Hypnosis in their programs to overcome Shy Bladder.

Cognitive Behavioral Therapy (CBT). This is a form of Psychotherapy that works to "restructure" the negative and unhelpful thoughts that plague Shy Bladder sufferers - you know the ones "Everyone is watching me, they've noticed I can't go" or "Someone is going to come into the bathroom any second..." Normally CBT will be combined with Graduated Exposure Therapy.

Graduated Exposure Therapy. My tool of choice and the one recommended in all the books as a therapy that's simple, cheap and effective (if you're persistent).

You can do graduated exposure therapy yourself and/or you can choose to jump-start your recovery by attending a Graduated Exposure Therapy workshop (run by the IPA), by joining a support group or by finding yourself a Pee-Buddy.

Step 4 : Identify your scale

Maybe you can't go anywhere except at home with the door firmly locked and only when you know there's nobody else in the house or maybe you can go in a public restroom but only in a locked stall. We all have to start somewhere. The important thing is to identify the steps that it will take to reach freedom.

So create a scale, a series of steps 8-20 in all that will act as milestones in your progress. When I started I was unable to use a public restroom except in a locked stall, sitting down to minimize the noise. Here's my scale :

1. Locked stall, standing up.
2. Unlocked stall, standing up.
3. Unlocked stall, door ajar, standing up.
4. Unlocked stall, door wide open, standing up.
5. Unlocked stall nearest the urinals, door wide open, standing up.
6. Urinal #1 (of 3), waiting until someone else comes in.
7. Urinal #2 (of 3), waiting until someone else comes in.
8. Urinal #2 (of 3), waiting until someone stands next to you to initiate flow.
8. Urinal #2 (of 3), in a crowded bathroom.
9. Any urinal at a high-throughput venue such as a stadium, airport or bar.

Since Shy Bladder is a Social Anxiety I ensured that I only practiced when people were around.

I figure once I reach #9 I'll be pretty much free though I may always have a tendency to slip back so I will always have to practice at least a few times a week. I've made it as high as step 8, but right now I'm somewhere around step 6-7. This is a normal pattern of advancement and dropping back slightly.

Step 5 : Have a backout plan

In step 6 you're going to start practicing the graduated exposure therapy but first plan an exit strategy in case you are unable to go. Make sure you have a bathroom identified (at home maybe) that you can reach in case you get into trouble. This might include knowing where the nearest hospital is in case you need to be catheterized to relieve the pressure. I've never needed this safe bathroom in my progress but you might.

Step 6 : Execute the plan.

Now the fight. If you're doing hypnosis, CBT and drugs you have it relatively easy. If you're doing Graduated Exposure Therapy you have to overcome the natural tendency not to drink. You need to drink, a lot, in order to give yourself opportunities to practice and you need to maintain high urgency levels.

Drinking 100+oz's of water a day isn't easy and it can be torture waiting around with very high levels of urgency in order to ensure that there are others around when you go. You'll be sitting in meetings and all you can think about is how bad you need to go. But you can progress this way, rapidly.

Step 7 : Keep a diary

Not really a step this more a peice of advice. I've kept a diary via this weblog and I am always amazed as I read it how often I failed or fell-back. I've also re-experienced the euphoria of a good day - these are all things that I wouldn't remember if I wasn't keeping a detailed diary of what I did, how if felt and what I thought. You're progress won't be linear, you'll jump ahead and fall-back on your steps but keep trying and you'll have a breakthrough day or two as I did when it seemed like you were already free of Shy Bladder and that give you a glimpse of what you're life will be like once you made it through.

Good luck! Post in this blog to let us know how you're doing.

Further reading :

What to do when you fail.
Recovery Stories
My plan to beat Shy Bladder.
Getting help for Shy Bladder


Anonymous said...

I'd say the lack of comments shows the lack of coping with the problem. One thing I can agree with, tell everyone you know about the problem. After telling my roommate, I have no problem peeing around him, it took about a week and I'm pretty comfortable now, I almost feel like I'm in 7th grade again.

I haven't told all my friends yet, but I know when I do, it makes it that much easier to get it done.

Anonymous said...

I just found this site. I've been dealing with this for about as long as I can remember, but it never really occurred to me that I could do something about it.

So thank you. I'm starting from literally the same degree of severity that you were, so your plan of action is exactly applicable for me.

What makes it hard is that I work from home these days, so I have to make sure to go in to town every day to test myself. Anyway, you've given me some hope that I can actually fix this, so thank you for that.

Anonymous said...

Thanks for the article. It would be a good idea to keep a checklist and track your progress. And it is utmost important to share this problem with our close friends.

Anonymous said...

Thanks this article is great I've been dealing with this for as long as I can remember. I actually resorted to pads or thin nappies to deal with the problem as I would have smearing issues or hang on so much that I could no longer hold on