September 2003

Highlights
Creating a Women’s Workshop, “A Woman's Guide on How to Pee Standing”
Working on graduated exposure vs. avoidance
Articles written about female paruretics by 2 woman reporters

1. New “News” Section

(a) Creating an all-women's workshop:

Dr. Steve Soifer, IPA President, writes: 2004 Women's Workshop - A Commitment Steven Soifer ssoifer@ssw.umaryland.edu Dear Friends: Assuming a minimum of five registrants, I want to see an all women's workshop next spring, probably somewhere in the Midwest.
At this point in time, if you are interested, please email me at the above email address. Feel free to respond to the idea on the board, especially regarding location.
Best Regards,
Steve Soifer
IPA Executive Director

Please write to me or directly to Steve if you are interested in attending. It is well worth it (see Sharon’s post below).

(b) Interesting reading.

“A Woman's Guide on How to Pee Standing”.
Go to http://www.restrooms.org and look under “Personal Hygiene Secrets and Solutions”.

(c) A Pee Success Story (and what it’s like to participate in an IPA Workshop from a women’s point of view.)

I attended a workshop given by Steve Soifer in Portland in June, and I had an amazing experience. I attended the Portland workshop on June 13-15, and I had an amazing experience. I am the only woman in the Portland support group, so I was very excited to hear that another woman had signed up for the workshop (and she came all the way from St. Louis to attend!). Everyone who attended the workshop was friendly, and we spent Friday evening just sharing our stories with paruresis.

My paruresis is pretty severe: I can use public restrooms when they are empty, or very large airport-type restrooms when they are busy, but in small or one-on-one situations I have not been able to go (and going around people who know me is especially hard). So in the first practice session (which was Saturday morning) I started at zero on my hierarchy, with my pee buddy all the way at the end of the hall outside the hotel room. We progressed quickly to her being inside the room with the TV on. I then turned the TV off but ran the water. That was also fine. This is where a pivotal moment occurred in the workshop: My buddy had given me a magazine to read while I was waiting for her during her turn. And when it was my turn, I gave her the magazine to read, because I felt that I would be less pressured if I knew she was doing something, rather than just standing there waiting (and listening?!) for me. I also asked her to sit in a chair with her back to the door. Again, less threatening than if she were standing up outside the door. With those two elements in place, I was able to go, with only a little hesitation, without any background masking sounds at all! I wondered if she could hear me, but I knew she wasn’t concentrating on that because she was reading. (Plus, my buddy has a great personality – she was understanding, low key, and more relaxed about the situation than I was, which made her an excellent person to practice with. And helping her practice made me feel more relaxed too.)

This victory gave me the confidence to “graduate” to a public restroom off the hotel lobby in the afternoon session. Since it had helped earlier, I brought along my buddy’s magazine and she brought her book. This helped tremendously in the public restroom too. First I had to run the water while I went (with my buddy in the furthest stall), but knowing she was reading her book helped keep the pressure off me. Then I had another moment of inspiration: I turned the water off, but I asked my buddy to read OUT LOUD to me! This way, I knew that she was focused on something else besides my peeing (since I was convinced that she would be listening for me to start going), and she wouldn’t be able to hear me very well because of the sound of her voice. It was kind of like listening to a book on tape; plus there is something kind of comforting about being read to. I was thrilled when, after her just reading a few sentences, I was able to start to go. Feeling very successful, that’s where I ended on Saturday.

Sunday morning I was ready for The Big Step: No background noise. To build confidence, I started with repeating a step from the day before: having the water on, with my buddy in the furthest stall. Then I decided to try complete quiet. I asked my buddy to simply read her book, in the furthest stall from me. She reassured me that she would not be thinking about me or listening for me to start peeing. I also had my magazine to look at, to take my own mind off my anxiety. I felt trepidation, and I must admit when my stream started I did feel embarrassed that she could hear me – but I kept it going. And nothing terrible happened! The roof did not cave in, my buddy did not suddenly scream, “That’s great!!! You’re going!!!!” – and I did not die of embarrassment. I simply – went. It was a timid little tinkling sound, but it was music to my ears. I went a little more and then stopped. I left the stall and my buddy came out and we hugged. Major victory!!!

I know that what helped was that I had progressive success at each step of my hierarchy, and each time I was successful, my confidence grew. I also felt more relaxed about the practicing process and even looked forward to the next challenge – it was almost becoming like a game. I practiced again when our group went out to lunch, and was pleasantly surprised that I was able to go in a quite busy restroom. (There was also a woman in there nagging at her little girl to hurry up and go, which stressed me since I think my mom rushing me is what caused my paruresis in the first place – but, I just had to take care of me and leave.) I was pleased to have success and reinforce what I’d learned at the workshop.

If you have a chance to get to a workshop, I highly recommend it. There is something very special about working with a group of people who share this common problem and are all understanding, for an entire weekend. It was also a huge relief to spend a whole weekend knowing that, any time I needed to go, I didn’t have to make up some excuse to go find an empty bathroom; folks would let me “escape” if I needed to or would be there to help me, whichever I wanted. I felt very bonded with the group by Sunday and in fact wished the workshop was continuing for another couple days!

It has been a few months now since the workshop, and I wish I could say I have miraculously recovered. I haven’t, but I do feel that the breakthrough at the workshop gave me new confidence, and can remember that I DID manage to pee with another woman in the room with complete silence, which was like a miracle for me. I know that the key to beating this thing is practice, practice, practice, so I’m going to keep doing that and if I can afford it, will try to take another workshop in the future. I also keep hoping that another woman in the Portland area will contact our group leader so I can have someone to practice with. If you’d like to know anything more about the workshop or would like to correspond with me directly and offer mutual email support, please feel free to contact me! Thanks and good luck to you all with recovery.

(d) A Good Discussion about Working on graduated exposure vs. avoidance
by Chris from the Paruresis Discussion forum

Periodically I send messages out to our local support group on topics that come up in meetings. This was one that people suggested would be a good posting:

An important distinction useful in recovery work is understanding the two major components of "avoidant paruresis". The avoidance is one component, the paruresis (inability to urinate) is a separate one. The two can be worked on independently or together. Successful recovery means making progress in both of these areas. One alone is not sufficient.

Typical graduated exposure work focuses on the actual time spent at the urinal or inside a stall, and is closely associated with the urinary system itself, because at that time those muscles and nerves are involved.

Avoidance, however, is something that usually happens outside the restroom and long before urination. It's important to realize that avoidance is a separate thing, happens at a different time, and therefore can be attacked separately to great advantage. Avoidance is that little pain in the pit of the stomach when we see another person walk in the door ahead of us while approaching the restroom, and the voice that says "Oh no, now I can't go in there!" It's also the part that says "I don't need to do any practice today, I can wait until tomorrow." But tomorrow never comes, and we quickly give up regular, frequent practice, a cornerstone of recovery.

While it's not possible to directly control the muscles and nerves associated with urination, it is much easier to control the muscles associated with avoidance, because they are voluntary. We can make our legs move and walk into that restroom, even with the voice screaming, our stomachs tightening, and the list of excuses in our heads growing longer. It is a very important step to take, as it gives us more control and allows us to begin questioning the voice of avoidance. When we start to question and challenge that voice, it loses the power it had over us and we will gain more confidence and be more relaxed.

Many people stop practicing exposure exercises because of the avoidance part of their paruresis. One useful technique if the avoidance seems to be strong is to only work on that (not on the exposure therapy.) Deliberately entering crowded restrooms, even if not using the urinal or stall, is still a helpful step. It's also valuable to do this with
an empty or near-empty bladder, because then one knows they will not be able to go. This removes a lot of the stress associated with possible failure, because now it's a certainty. After spending a number of days working on reducing avoidance, then return to the paruresis side and deal with those urinals or stalls, and the other people using them as well.

2.  Articles written about female paruretics by 2 woman reporters. Here are two of them.

(a) The Boston Globe Online, 7/29/03 About a women attending an IPA Workshop (I contributed to this article)
YOUR HEALTH Helping unlock the bathroom 'stall' Research, seminars can cure shy-bladder phobia

By Kathleen Nelson, Globe Correspondent, 7/29/2003

The urinals at Fenway Park may beckon during the seventh-inning stretch,
but it's a sure thing that some people won't be able to answer nature's
call when beer- and soda-satiated fans line up behind them. Others
freeze up at mall bathrooms or highway rest stops. Or, for those like
Nancy K., perhaps urinating in restrooms on airplanes, at work, or even
when visiting friends' homes seems impossible.

Nancy, who asked that her last name not be used, has paruresis, or fear
of urinating in public, also called shy bladder syndrome. Paruretics
worry someone will see them, hear them, or is waiting for them to urinate.

''Almost every person has a problem going for some reason, at some
time,'' says Dr. Steven Soifer, an associate professor at the University
of Maryland School of Social Work, who has written a book on the subject
and leads seminars to treat the condition.

Based on a 1997 Harvard Medical School study, 17 million people have
difficulty using the bathroom away from home. Soifer estimates that
perhaps a million of those people have full-blown paruresis, a social
phobia that interferes with their travel, work, and relationships.

Social phobias are a medical condition. ''Most individuals with social
phobia start off as shy children and some develop social anxiety
disorders, like paruresis,'' says Dr. Eric Hollander, professor of
psychiatry at Mount Sinai School of Medicine in New York, and director
of the Compulsive, Impulsive, and Anxiety Disorders Program there.

Paruresis's cause isn't exactly clear, adds Dr. Michael Chancellor, a
urologist at the University of Pittsburgh School of Medicine. ''It's
probably a combination of physical factors such as tight pelvic muscles,
and psychological ones, like a traumatic incident.''

Regardless, Chancellor says, ''once the inability to relax the sphincter
valve becomes hardwired into the brain circuitry, it has to be unlearned.''

For Nancy, who is 47, shy bladder began when she was 16. She and a
friend went to the movies and drank alcohol. When they went to the
restroom, Nancy couldn't urinate.

''I remember my friend's curiosity about my trouble,'' says Nancy. ''I
was mortified.'' Afterward she avoided any situation where she could be
embarrassed again.

''The bad news is that social phobias like paruresis are common. The
good news is that they're very treatable. If people have generalized
social anxiety the standard treatment often includes antidepressant
medication,'' says Hollander. In addition, ''facing your fears''
strategies learned through cognitive behavioral therapy help people
confront the feared situation and change their negative thoughts. ''They
see nothing terrible is going to happen,'' Hollander says.

Several weeks ago, Nancy, who is married and has three children, signed
up online for a $395 weekend seminar that Soifer taught in Boston. She
took a day off from the animal hospital where she works and traveled
from Long Island, N.Y., hoping for a breakthrough for a condition that
kept her from attending college away from home (dorm bathrooms were too
intimidating) and that she kept secret, even from her husband, for many
years.

At Soifer's workshops, participants share common stories, and then take
action. They ''fluid load'' by drinking lots of water, coffee, or soda
to nurture the urge. They then team up with a ''pee buddy,'' who starts
a comfortable distance away and gradually moves closer while the
participant tries to urinate.

''At first, I was in the bathroom in my hotel room with the door locked,
and my buddy was downstairs in the lobby,'' says Nancy. Nancy tried to
go. Then her buddy moved into the room, closer to the bathroom door.
Nancy was able to urinate a little bit, but didn't make as much progress
as she hoped. ''I'm planning to try medications and another seminar,''
she says.

Paruresis may be worse for men because urinals are so very public. At
the workshop, male buddies eventually stand directly behind their
partners, maybe even harrumphing or pacing impatiently to replicate
real-life circumstances. If this sounds intimidating, it is. Most make
progress, but need to reinforce lessons learned by continuing to
practice at public restrooms or with a support group. Soifer estimates
that there are about 40 support groups in the United States.

Reinforcement is the key, says Hollander. ''People have to face their
fears on a regular basis. When they're uncomfortable about something,
rather than avoid it, they should seek it out over and over again until
they've mastered it,'' he says.

For rare severe cases, Chancellor teaches patients who absolutely cannot
go in public how to use a catheter. ''Four times a day they push the
catheter past the tight sphincter to let all the urine out,'' says
Chancellor. ''It puts paruretics at more risk of infection, but if they
can't go, their urine is stagnant and their risk of infection goes up
even more,'' he says.

Nancy recently told a coworker at the animal hospital about her problem.
The other day, she helped restrain a frightened dog, which urinated all
over her. The co-worker looked at Nancy. ''Jealous?'' she asked. They
both laughed. ''It felt good to confide in someone,'' Nancy says.

This story ran on page C3 of the Boston Globe on 7/29/2003.
(c) Copyright </globe/search/copyright.html> 2003 Globe Newspaper Company.

(b) The Toronto Star Life Section – About Bathroom Boundaries & Habits Melissa Aronczyk, a Toronto native, is a freelance writer living in New
York.

May. 23, 2003

Our bathroom habits and rituals reveal a lot perhaps a little too much
about who we really are In a world of diminishing privacy, many of us
look to the loo as the last refuge.

Birds do it. Bees do it. Celebrities do it, even though we never see it
happen. It's an act that is at once banal and absolutely necessary. And
it's a biological fact of life: all of us have to go to the bathroom.

But while most of our daily habits have become part of public
conversation, what we actually do in the loo is still a very personal
concern.

Once upon a time, the bedroom was the taboo zone. Parents struggled to
explain to their children what went on behind closed doors. Now that
everyone from Masters and Johnson and Dr. Ruth to Sarah Jessica Parker
has told us in graphic detail, there isn't much we don't know.

But though the doors of the bedroom have been thrown open, most of us
prefer to keep the bathroom door locked. It's where we go to have a
moment to ourselves, a place of quiet contemplation. For some, it may be
the only time they get any reading done.

According to the Canadian decorating magazine, Style At Home, the
bathroom of today is "a haven, a sanctuary, a place for spiritual
rejuvenation."

When you think about how strongly we feel about our own ? and others' ?
bathroom habits, it makes sense. After all, bathroom rituals are sacred.

That wasn't always the case, says Heather George, 30, a University of
Toronto graduate who has conducted extensive research into the social
history of bathrooms. Her term paper, "From Hygiene-Machine to Home Spa:
The Western Bathroom Through Eight Decades," explores how the bathroom's
role has changed over the years.

"Now, bathrooms are about getting away from the world," says George.
"But before, they were about getting ready for the world."

In the 1920s, when indoor plumbing was a novelty, the bathroom was
simply a place to get clean. But by the 1930s, it had already taken on a
social stigma. Ads of the time referred to the bathroom as a potential
source of embarrassment if the fixtures were visible or the toilet not
quiet enough.

It became a room to show off to guests and to be judged by. "It was a
status thing," says George.

Over time, bathrooms got bigger and more luxurious. And there was a lot
more to do in there besides use the loo.

Plants appeared. Carpeting. Wallpaper. By the 1980s, whirlpools, washing
machines and even exercise bikes were part of the environment. To
accommodate the new double-income family, fixtures started to come in
twos -- sinks, shower heads -- to speed up the morning routine.

The more amenities the bathroom accumulated, George notes, the more it
became a place to spend time in, its utilitarian functions usurped by
its increasingly civilized nature.

Now, the bathroom is a place to escape to, a port of privacy in our
often too-public lifestyles. It's not surprising, then, that personal
space is an issue.

Mini-wars are waged daily in the bathroom, won or lost when the seat is
left up or down, the shower curtain open or closed, the toilet paper
unrolling over or under. It's a battle of boundaries. It defines us. And
it humbles us.

From the moment the person we love steps into the bathroom, the mystique
disappears. Nothing brings you off a pedestal faster than emerging with
toilet paper on your heel.

In films and on TV, the bathroom is never a neutral zone. It's usually a
hot spot of discomfort or embarrassment, ripe with metaphor and meaning.

Think of Peter Sellers, wandering into hilariously devastating
situations while looking for a bathroom in The Party, or Ben Stiller's
painful wrestle with his fly in There's Something About Mary. On Ally
MacBeal, the office bathroom was a meeting room, confessional, scene of
confrontation and hiding place. It was also unisex, which makes the
toilet talk even more titillating.

The motel bathroom symbolizes transformation, where you go to change the
colour of your hair, your clothes and your identity. Bathrooms in a
roadside diner are the surest place to lose your lover, who will
inevitably be five kilometres along the highway by the time you come
out. Your date's bathroom is where you discover an awful secret, or try
to hide one of your own.

On one Seinfeld episode, Jerry discovers anti-fungal cream in his new
girlfriend's medicine cabinet and decides he has to break up with her
... until he learns it's for her cat.

A Web site devoted to "plumbing in the movies" (cinepad.com/bathroom)
observes that the first filmmaker to actually show a toilet in the
cinema was Alfred Hitchcock, a master at stripping away illusion and
leaving us bare. After witnessing the bathroom scenes in Psycho, no one
can look at a bathroom the same way again. As Stephen Rebello points out
in his book, Alfred Hitchcock And The Making Of Psycho, "The script is
shot through with obvious delight in skewering America's sacred cows ?
virginity, cleanliness, privacy, masculinity, sex, mother love,
marriage, the reliance on pills, the sanctity of the family ... and the
bathroom."

From the time we're toddlers, we relate to the bathroom in unique and
personal ways. We're fascinated by what goes on in there and
instinctively sense that it is not part of polite conversation.
According to Freud, the character we form during toilet training
accompanies us into adulthood.

Our bathroom boundaries reveal our true nature, perhaps in ways most of
us would rather keep to ourselves.

So, if we don't want to be public about our bathroom habits, what do we
do when we're actually in public?

"Everyone has some hesitancy the closer a person gets to them in terms
of bodily functions," says Steven Soifer, an associate professor of
social work at the University of Maryland.

"There's a fear of proximity. They feel embarrassed about their personal
space being invaded."

For some, the need for personal space makes going to the bathroom in
public not just embarrassing ? it's impossible.

Called Bashful Bladder Syndrome, Pee-Shy and Shy Bladder in clinical
terms, paruresis the fear of peeing in public is an anxiety-related
social phobia. For about 7 per cent of Canadians, it's a source of
potential humiliation, not to mention physical discomfort.

For one woman, it ruined her marriage.

"She couldn't bear to tell her husband that she couldn't pee when
someone else was there, not just in the bathroom but anywhere in the
apartment," says a Toronto columnist of her friend. "She had to get up
two hours before he did and take a taxi uptown to her mother's place.
Then she'd come back and crawl into bed all dewy and perfumed, like
those Rock Hudson movies." The marriage lasted a matter of weeks. "She
just couldn't do it anymore. Nobody could be there when she peed. She
had to be by herself."

When asked if the sufferer wanted to tell her story first-hand, the
columnist replied, "Oh god, she'd kill me if she knew I told you this."

That's one of the problems with this phobia, says Soifer. Most people
don't want to reveal that they can't pee in public. And lack of funding
makes it hard to pursue research. "There's been one journal article in
the last five years," he says.

Soifer's interest in paruresis isn't just professional. "At first, I
thought I was the only one who had this problem," he says. Now, as
president of the International Paruresis Association, he holds several
workshops a year to help people come to terms with their bathroom issues.

He also wrote a book, The Shy Bladder Syndrome: Your Step-By-Step Guide
To Overcoming Paruresis, which has brought considerable relief ? in more
ways than one ? to medical professionals and sufferers alike. It looks
at causes, coping methods and self-treatment, including a 10-step
approach for Graduated Exposure Therapy.

"It involves the individual gradually attempting to urinate in more and
more difficult locations," says Soifer.

So, how does a bathroom phobia come to be?

"The fears people have are lodged somewhere," he says. "For some, it's
the larynx; for others the sphincter muscle. An incident happens that
triggers it."

For Dr. Don Woodside, 61, a child psychiatrist in Hamilton, it was
summer camp. "I was 12 or so, and I dreaded being around the campfire,"
he recalls. "I would run to the woods to pee." Another incident happened
when he was 14. "I was at a Boy Scout jamboree at Niagara-on-the-Lake,"
he says. With thousands of kids camping in a field, there wasn't much
room for privacy. "In one tent, there was a funnel on a pipe where we
were supposed to pee." The weekend was a disaster.

Not being able to produce urine during a medical test, or a difficult
childhood experience like pants-wetting, can also set off the problem.
But the symptoms can sometimes appear without warning. And since
performance anxiety tends to be cumulative, the problem grows each time
the performer has to, uh, perform. Lights, camera, but no action.

Three years ago, while attending a conference in Toronto of the American
Association of Behaviour Therapists, Woodside heard about Soifer's
workshops. It took him six months to get up the nerve to call Soifer and
arrange to show up.

"It was mostly men," Woodside recalls. "Some people had huge problems.
They wouldn't change jobs because of the bathroom. People had never had
dates; there were several single people with an almost complete lack of
social life. They wouldn't go to a movie, wouldn't go to a ball game."

Woodside now runs the Toronto Paruresis Support Group, where members can
meet once a month "to practise with others in a safe and empathetic
environment," according to their Web site.

"It isn't rocket science," says Woodside. "But it's hard to do by
yourself. A large part of the power involves a circle of support."

Paruresis may be a case of bathroom boundaries in the extreme. But in
less clinical forms, many of us have some kind of issue around the time
we spend in the bathroom.

Germs, for instance. To some, long hairs in the drain are the bathroom
equivalent of fingernails screeching on a blackboard. And who hasn't
ferociously scrubbed the soap in the shower to remove a guest's curly
unmentionables?

Matters of hygiene may be the ultimate test of our personal boundaries.
"When I leave a public bathroom, I always use my sleeve to open the
door," says Lois Charters, a Toronto-based yoga instructor. "Doesn't
everyone?" Another woman won't use a toothbrush unless it's made of
clear plastic ? the coloured ones don't seem as clean, somehow.

When Sandra Kolker (not her real name), a financial analyst, moved from
Toronto to New York, she became highly conscious of bathroom germs. If a
public restroom didn't have automatic flush, faucet and hand dryer, she
was unable to use it. "Public bathrooms in New York are disgusting," she
says. "Who knows what people do in there?"

Maybe it's more about what we don't do. According to a 1995 study by
microbiology professor Dr. Charles Gerba at the University of Arizona,
close to half of all Americans do not wash their hands when they use the
bathroom. As many as 25 per cent leave the bathroom with fecal coliform
-- otherwise known as E. coli -- on their hands.

A 2001 study of hand-washing by Dr. Michael John, head of infection
control at St. Joseph's Health Care in London, Ont., found that washing
hands for 15 or 30 seconds considerably reduces microbe transfer. But
most of us wash our hands for 10 seconds or less. And to add to the
microbe count, we don't always dry our hands properly, preferring
instead a quick wipe across our clothes or a fast shake to get the water
off.

And hand dryers, which may seem sanitary, actually increase the amount
of bacteria in the room. When you rub your hands together under the hot
air jet, bacteria from the dryers and from your hands blow throughout
the restroom.

The Gerba study found four "hot zones" in public restrooms, places where
microbes are most likely found: the toilet , the floor around the
toilet, the counter area and door and flush handles. So to add to our
issues of personal space, there's also the physical space to contend with.

And that really only scratches the porcelain surface. Bathrooms are the
final frontier. . Now that sex, family secrets and therapy are cocktail
party conversation, we may finally dare to bare it all.

3. Question of the Season
(Remember, in order to respond to everyone, just click "reply all").

What questions would you like to see posted on this Forum? Also, what can be done to improve greater communication amongst us?