EMDR and the Treatment of Paruresis
EMDR and the Treatment of Paruresis
Paruresis comes with complications that can have a very real effect on the afflicted person’s day-to-day life. Imagine missing the train to work because you had to hunt for an empty bathroom at the station. Imagine losing a new job because you couldn’t “perform” for the required physical. Imagine the humiliation and pain of an incontinent episode when your body can’t hold onto it for another minute, when there was a bathroom – a public bathroom – there the entire time.
Phobias are not created equally, and individuals that suffer with paruresis are acutely aware that others may not take a “shy bladder” seriously. Paruresis may be a funny prop for weeknight sitcoms, but the effects of this condition on the people who have it are no laughing matter. That’s because the condition is more than just feeling a little weird about using the bathroom when others are nearby.
While the general public may not have much knowledge of paruresis, therapists have been making great strides in treatment through a process known as Eye Movement Desensitization and Reprocessing, or EMDR.
The Theory Behind EMDR
EMDR was developed in the late 1980s by American psychologist Francine Shapiro as a therapeutic treatment for Posttraumatic Stress Disorder, or PTSD. In 2004, Shapiro’s treatment was included in the 2004 American Psychiatric Association’s Practice Guideline for the Treatment of Clients with Acute Stress Disorder and Posttraumatic Stress Disorder.
Therapists treating clients suffering from paruresis recognized the acute stress associated with the condition and began successfully applying the principles of EMDR to the treatment of “bashful bladder.”
The theory behind her method is that sensory stimuli – particularly eye movement, tactile stimulation, or bilateral sound – can help those that suffer from traumatic memories process them more completely. The idea is that once these memories are fully processed, the mind is able to heal the trauma and move on to a healthier way of thinking.
The 8 Phases of EMDR Therapy
EMDR is not a “quick fix” solution to a client’s bathroom anxieties, and can take many weeks of therapy to overcome. According to Shapiro’s EMDR: Eye Movement Desensitization of Reprocessing: Basic Principles, Protocols and Procedures, 2nd ed. (2001), Phase I can be summed up as follows:
“In the first sessions, the client’s history and an overall treatment plan are discussed. During this process the therapist identifies and clarifies potential targets for EMDR. Target refers to a disturbing issue, event, feeling, or memory for use as an initial focus for EMDR. Maladaptive beliefs are also identified.”
Phase II follows these sessions, though eye movement therapy doesn’t begin in earnest until Phase IV. The second phase instructs clients to “identify a safe place, an image or memory that elicits comfortable feelings and a positive sense of self. This safe place can be used later to bring closure to an incomplete session or help a client tolerate a particularly upsetting session.”
Phase III is much the opposite. Rather than developing a “safe place,” it requires the client to create a “snapshot image” that represents the stressor in his or her life; in the case of paruresis, this could be an image of a public urinal or a line of people standing outside the bathroom door. Shapiro says, “Using that image is a way to help the client focus on the target, a negative cognition (NC) is identified – a negative statement about the self that feels especially true when the client focuses on the target image. A positive cognition (PC) is also identified – a positive self-statement that is preferable to the negative cognition.”
In Phase IV, the desensitization phase, the client is asked to focus on the image, the NC and the emotional stress they cause. The therapist then asks him or her to visually track an object moving from side to side. After this brief exercise, the client is asked to reveal any feelings, sensations or images that have emerged. Now focusing on this thought or image, the exercise begins again with a new set of eye movements. The therapist tracks the emotional disturbance of the client throughout the exercise, which ends when the distress has diminished to 1 or 0 on the Subjective Units of Disturbance Scale (SUDS.)
Shapiro describes Phase V as the installation phase, wherein the therapist takes stock of the client’s feelings about the PC and helps the client choose a new one if necessary. The negative snapshot and the PC are then “held together” while the eye movements begin again, with the therapist checking in to determine how valid the PC now feels to the client.
Phase VI involves a body scan wherein the therapist asks the client to identify any stress, pain, or discomfort manifesting in his or her body. If this has occurred, the client focuses on the sensation and new sets of eye movements will begin. If no discomfort is noted by the client, treatment moves to Phase VII, which is simply a debriefing on the treatment process.
Phase VIII begins with a re-evaluation session where the client discusses any changes in physical sensations or emotional disturbances, and culminates in the client’s assurances that any events relevant to the problem have been processed.
The Element of Exposure in Treatment of Paruresis
Clients using EMDR as a treatment for paruresis may find that because the memories that made it difficult to use the bathroom when others are around have been fully processed and new thought patterns have been installed, they no longer suffer the crippling anxiety of “bashful bladder syndrome.”
Critics of EMDR state that it’s really just the exposure and desensitization to the negative “snapshot” that accounts for the method’s success, and that eye movement has little to do with the actual processing. Regardless of how the treatment works, the fact remains that more than a dozen clinical trials have proven the method’s usefulness in treating debilitating anxieties. And when removing those anxieties from your life means being able to live without paruresis, does it really matter how it works?
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