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Learning about Paruresis with Dan Rocker
558 Plays2 years ago
In this episode, Fara and Grant are joined by Dan Rocker, the President of the International Paruresis Association, and the Co-Director of the Shy Bladder Center. Dan Rocker is an expert on Paruresis (significant urinary hesitation and inhibition) and breaks down some myths and misconceptions about the social phobia. We hope you enjoy!
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Transcript
Common Fears vs. Private Issues
00:00:00
Speaker
You know, I mean, if you're afraid of heights, if you're afraid of dogs, if you're afraid of the dark. I mean, you know, these things people tend not to be as ashamed of, but things that deal with, as you point out, private issues, they're more adjacent to shame. Hello,
Meet the Experts: Dr. White and Dr. Brenner
00:00:16
Speaker
I'm Dr. Farah White. And I'm Dr. Grant Brenner.
00:00:19
Speaker
We're psychiatrists and therapists in private practice in New York. We started
The 'Doorknob Comments' Concept
00:00:24
Speaker
this podcast in 2019 to draw attention to a phenomenon called the door knob comment. Door knob comments are important things we all say from time to time, just as we're leaving the office, sometimes literally hand on the door knob.
00:00:36
Speaker
Doorknob comments happen not only during therapy, but also in everyday life. The
Why Avoid Deep Discussions?
00:00:41
Speaker
point is that sometimes we aren't sure how to express the deeply meaningful things we're feeling, thinking, and experiencing. Maybe we're afraid to bring certain things out into the open or are on the fence about wanting to discuss them. Sometimes we know we've got something we're unsure about sharing and are keeping it to ourselves. And sometimes we surprise ourselves by what comes out.
00:01:04
Speaker
Okay, welcome to the doorknob comments podcast.
Focus on Paruresis: An Introduction
00:01:08
Speaker
Today we're going to be talking about an important and sometimes lesser known phenomenon that clinicians may or may not notice called paruresis, also bashful bladder. We're joined by guest
Meet Dan Rocker: A Personal and Professional Journey
00:01:21
Speaker
Dan Rocker.
00:01:22
Speaker
licensed clinical social worker who's a psychotherapist in private practice in New York City working with individuals, couples, and groups. Dan graduated with a BA from Wesleyan University and an MSW from New York University's Silver School of Social Work. He was psychodynamically trained at the Psychoanalytic Training Institute of New York Counseling and Guidance Service. He is a graduate of the Clinical Externship Training Program at the Ackerman Institute and was a member of Ackerman's board of directors from 2015 to 2019.
00:01:51
Speaker
Prior to his career as a therapist, Dan worked as a trader at Jefferies and Company and as the head of trading for investment firms, Rocker Partners and Zimmer Partners. Dan has been an active volunteer in and supporter of the doula to a company and comfort program.
00:02:07
Speaker
providing visits to palliative care patients since 2004. Most importantly for today, he is the president of the International Pariuresis Association, an organization that provides advocacy and treatment for individuals who suffer with the social anxiety disorder of shy bladder. He is also the co-director of the clinical arm of the IPA, the shy bladder center, and has generally been involved with leadership of the IPA for over 15 years.
00:02:32
Speaker
Dan, welcome. It's a particular pleasure having you join Doorknob Commons today as we've known each other since we were teenagers. Yes, I guess about 40 years at this point, Grant. So it's a pleasure to come onto your show and it's a pleasure to meet you as well, Farrah.
00:02:48
Speaker
Thanks so much for being here. Yeah, so I'm sure we'll have time for some banter and repartee later, but let's jump in on paryuresis. What is paryuresis and what might the causes of paryuresis be?
Understanding Paruresis: Causes and Symptoms
00:03:03
Speaker
So, paruresis is a diagnostic feature of social anxiety disorder, and I imagine a bunch of the people who listen to this podcast might have a DSM handy or a diagnostic and statistical manual. You might be surprised to learn that paruresis is mentioned in the DSM by name, and it is really
00:03:22
Speaker
defined as an inhibition or significant delay in initiating a stream of urine when one is in either public restrooms or commonly in even private restrooms when one is under the impression that one could be
00:03:38
Speaker
heard to be urinating or very saliently heard to not be urinating. And also a very significant trigger is the sense of time pressure that someone's waiting for you, that someone saw you enter the restroom and might be wondering why you've been in there for so long. You know, think of it as a spectrum kind of disorder where at its most mild presentation,
00:04:00
Speaker
It could be viewed as a very strong preference for privacy when urinating. At the more extreme reaches, it comes to resemble agoraphobia where the symptomatic client is functionally unable to urinate outside of what they consider to be the safe toilet. The safe toilet is inevitably in their home. And so they abjure the kind of activities that tend to make a life good and whole. They tend to not date.
00:04:28
Speaker
they tend to not work outside of the home and they tend to stay away from leisure activities that would have them away for say more than two hours at a time. So in other words, it seems like something that could be very niggling and shy and kind of inconsequential, but it can have very dramatic impact on the quality of life of the affected individual. It can cause profound suffering. If there are any thoughts?
00:04:53
Speaker
Wow. Wow. Well, yes, I have a lot of thoughts. You know, one is how you sort of got interested and active in this area. And then the other is sort of how much is known about the physiology and like the mechanics of it maybe, you know, and also how it's treated really.
00:05:16
Speaker
Sure.
Dan's Story: Seeking Help After 9/11
00:05:18
Speaker
Let's see. So in terms of the physiology, it's pretty important. I'm going to recommend when people come in to me initially for treatment that they have a urologic workup, particularly if they're older. I mean, if they're teenagers, perhaps it's less likely that there's some interference from lower urinary tract symptoms. But if
00:05:40
Speaker
You know someone my age and i'm fifty four shows up and they've got this problem i'm gonna make sure that they get your logic work out of work up to make certain that there is you know nothing physically wrong i've had clients come in if we know that they have interstitial status or they have bph or something of that nature that will make things difficult for them even if they didn't have any kind of psychological hang up about it. And to get your first question actually,
00:06:10
Speaker
Your question about my involvement. I'm an individual with lived experience of paruresis I've had paruresis for as long as I can remember Certainly back when I first met Grand High School. I had paruresis and I did not Know that it was that I wasn't the only person in the world with paruresis very frequently when people come in to see me for the first time they are certain that they are uniquely disabled and they they don't even
00:06:38
Speaker
they didn't even think in fact in my case i did not think it was i had no reason to believe it was a psychological prom i just i just knew that very. More often than not that when i endeavor to use a public restroom i wasn't gonna be successful and so i went my affiliation with the ipa began in the year two thousand and one.
00:06:58
Speaker
In the aftermath of 9-11, I was working right across the street from the towers, and I had lost a lot of friends that day. It was a terrible day for me, for everyone in the city. And it just kind of strengthened a resolve in my mind like, oh, gee whiz, I'm not going to die with this ridiculous disorder or problem. I've got to aggressively go out and try to get out of my own head and figure out what to do about this.
00:07:27
Speaker
And so i found this organization online the international party recess of which i'm now president and they were sponsoring workshops weekend workshops i want to one in new york new jersey in november of two thousand one and that started my recovery and so i have been associated. With the ipa in some capacity ever since whether i was first leading
00:07:54
Speaker
as a layperson leading support groups here in New York City with no training. But then after I became a clinical social worker assisting at some of the workshops and ultimately then kind of taking over and leading all of the virtual workshops myself,
00:08:13
Speaker
And you know probably doing about ten of the in real life workshop so far and i'll be doing another one in vienna in september another one in baltimore i think in october so we kinda get around both domestically and internationally.
00:08:29
Speaker
You know, I'm conscious as we're talking, the subject, you know, I would imagine often draws discomfort and some humor. You know, I want to be sensitive though. And so the next question I was curious about is what are the common myths and misconceptions about paryuresis?
Paruresis Myths and Misconceptions
00:08:50
Speaker
Oh, okay. There are a lot of myths and misconceptions. Some of them are very anodyne and straightforward, like you would assume, or I would think most people would assume,
00:08:59
Speaker
that the key trigger for paruresis is someone looking at you or like watching, you know, just seeing you while you're urinating and that that would become morbid with body shyness.
00:09:08
Speaker
One of the things that is so vexing and mystifying about paruresis to we individuals who have it is, you know, it doesn't seem to, you know, have, uh, you know, I am not a shy person. I don't have body shyness and I don't care if people are watching while I walk around at the YMCA prior to, uh, we're working out, uh, if I'm in the altogether.
00:09:34
Speaker
Um, so I think people don't understand it's really, uh, it really has much more to do with hearing and specifically, and this is an interesting distinction that Carl Robbins, the co-founder of the IPA and a behavioral therapist down in Baltimore mentioned to me. It's not so much with the hearing that it's the people are afraid of being heard to have a weak stream or a stop start stream like Morse code or something like that. It's more that they're afraid of the accumulating silence that indicates that nothing's happening.
00:10:03
Speaker
And if nothing's happening, what's the matter with that guy? There is also questions people ask me frequently, does this mean I'm if they're male? Actually, yeah, only males have asked me this question, does this mean I'm gay? I have not found it to be correlated with either sexual orientation. Another question that is very frequent is it associated with sexual dysfunction? It does not seem to be associated with sexual dysfunction either.
00:10:31
Speaker
And, you know, what's, what's really mystifying is that this is one of the social anxiety symptoms that doesn't hang together with many of the other social anxiety symptoms. So for example, on Reddit, there is a social anxiety subreddit that at the last time I checked had probably 350,000 members. Every time I post something in that subreddit about paruresis, it seems like a stone. No one, no one comments, no one, you know,
00:11:00
Speaker
People just don't, I get no traction there. Parurisis has a subreddit that has about 1% of that membership, about 3,000 people. They all get what I'm talking about. And so what's really, as I said, mystifying is I have clients
00:11:18
Speaker
who are the chief executive officers of publicly traded companies. They have to speak a lot. They're at the center. They make decisions. They're very public facing people. I've had clients who've been main stage at Coachella. I have, and in fact, I may have time to discuss it a little later, but very recently,
00:11:38
Speaker
You know, my, my work with one of my clients was featured in a book that he wrote about part of the New Yorker author, Adam Gopnik. His book is behind me. It's, it's called the real work on the mystery of mastery. And, you know, someone like Adam who can speak to thousands of people without notes, uh, doesn't seem like an individual, uh, who would be particularly socially anxious.
00:12:01
Speaker
And yet, and perhaps grand, you could comment about whether I seem to be particularly socially anxious. It also tends not to be related to introversion. A lot of people would think, well, this person must be shy, they must be introverted. There are many of us who are in fact extroverts, but who also have poreuresis. And I'll give you this last one, which almost everyone asks is, is there a shy, defecating syndrome as well?
00:12:29
Speaker
And do people with paryuresis have that? And that is another kind of red herring or misconception. And another thing that is frankly mystifying and bedeviling is that most of us who have paryuresis have no battle shyness, which is something that the general population tends to have.
00:12:51
Speaker
I think I've read somewhere that up to 50% of the population would really reserve their bowel maintenance routines for their home. They wouldn't even think of doing it in public. I think it's physiologically a much different operation.
00:13:08
Speaker
I guess we're more able to defecate while under sympathetic nervous system activation than we are able to urinate under sympathetic nervous system activation. And actually that might be putting the card a little bit before the horse because since we tend not to be anxious about defecating,
00:13:27
Speaker
We don't get sympathetic activation when we go to defecate that we do get when we are urinating under one of those circumstances that i outlined earlier where you sense that someone's waiting on you or that there is someone who can hear that you're trying and nothing is coming forth.
00:13:46
Speaker
Yeah, it makes me wonder a little bit about the neurology and the physiology of it. As you said, it's quite different, even though they happen in the same general geographical area. And, you know, one question I have, and then Farrah, I'm really curious where you are. Actually, yeah, I'm interested in what some of the misconceptions that therapists may have and what your recommendations are, but I'm also curious whether for you or for people you've worked with, with a part of Uresis,
00:14:11
Speaker
Is there like an index case, like a first time they remember it happening?
Onset and Reinforcement of Paruresis
00:14:16
Speaker
And is there kind of a kindling effect, the way sometimes people who have a panic attack will then have that amp up? And this may speak to treatment later on as well. So that's a good question. About the index case, many people come in and they will say, I know exactly when this started. This started on this class trip when I was in sixth grade and they wouldn't let me use the bathroom at the Morristown Museum. I don't know.
00:14:39
Speaker
Um, but, um, more often than not, um, and, you know, and some people, uh, will actually, they'll attribute it to child rearing to the, you know, the, what their parental expectations around your, you know, here, take this mayonnaise car in the back, uh, in the back seat on the drive to Lake Winnipesaukee and just use this. Um, and if they couldn't do that, you know, the, the attendant ire from the parent.
00:15:02
Speaker
In most cases, some people do have trauma. I have worked with many people who have had some bullying trauma most commonly and some boundary crossings, boundary violations, and sexual trauma. That tends to be in the minority rather than the majority of cases. In the majority of the cases that I see, people aren't really sure. They know plus or minus when it started
00:15:30
Speaker
And it tends to be, since it's a condition that tends to be operantly, negatively reinforced by avoidance, what happens is, you know, at first you have an uncomfortable situation, and then you figure out that avoiding actually made you feel better, pantomiming that you are urinating, washing your hands, leaving the bathroom. Okay, that satisfies everyone else. And, you know, now we can get back to the road trip. I mean, you continue to suffer.
00:15:58
Speaker
But then you get that idea in your mind. Oh, I felt better when I left. So that becomes your go to defense. And you deploy it more readily every time you feel anxious in the bathroom. And so it tends to be the treatment tends to be very paradoxical in nature, where we have to explain to the clients up front, oh, everything that you thought that you were doing that was defensive and protective.
00:16:24
Speaker
was in fact damaging and in the service of making the symptom worse. So if everything that periuresis, I'm using air quotes here, tells you to do, you do 180 degrees the opposite.
Treatment and Hope for Paruresis
00:16:40
Speaker
And so I think you had asked a little bit about what the treatment looks like. The first, right out of the gate, you want to start with a strong dose of hope.
00:16:51
Speaker
And it's a very self-disclosure treatment on my end. Everyone who comes to see me has looked at my website. They know I have lived experience. They've probably seen videos that I've made on YouTube describing it, describing poreuresis in my recovery. And so they have a good sense of like, oh, okay, well, this guy seems to have made a good recovery. And the way he's describing his early symptoms sounded a lot like the way I am now.
00:17:18
Speaker
And then I basically, you know, there's a psychoeducation piece. There's just a straight up bladder management education piece about, you know, when you drink and how high your urinary urgency should be on a Likert scale when you actually decide that it's time to go and urinate. Meaning not to urinate too often or too small stimulus. Exactly. And in fact, you know, years ago I went to see a urologist
00:17:48
Speaker
of Grant, you actually referred me to this gentleman. And, you know, this urologist did, I didn't derive a tremendous amount of benefit from whatever he was trying to treat me. Still feeling guilty. No, no, no. I'm going to absolve and get rid of that. Because what that doctor did is a great expense, but he illustrated something that I use all the time with my clients. And so I have amortized in that expense.
00:18:16
Speaker
And he gave me this beautiful these hands and he would describe like a globe like a water balloon and he'd say your bladder is like a water balloon and the more full it is imagine a full water balloon and just throwing it on the exam table this nice arcing loop of water will come shooting out of it and said but imagine if you got a balloon that's only a third full and you just drop it on the table.
00:18:38
Speaker
glug glug and then a lot of residual is like that's why you really wanna have a nice full bladder to facilitate urination. And he then further said trying to urinate without having a full bladder is like trying to throw a baseball without moving your hand behind your shoulder.
00:18:58
Speaker
you can do it but it's not going to be a nice forceful strong throw it's gonna be an anemic uh attenuated throw and so i tell my clients you know perhaps there was this revolutionary war general general i remember hearing the instructions was like don't fire till you see the whites of their eyes you know that's the message uh implicit in what i'm talking about in terms of bladder management go when you are absolutely sure that you have to go
00:19:26
Speaker
do not go when you don't have to go. Because then you get this track record of going and you can't go and there's a very small volume or it's very hard for you to go. But if you go when you're highly urgent only, you're really maximizing your chances of urinating. It ties in with self-esteem and muscle fibers are strongest when they're stretched moderately. And I would imagine, you know,
00:19:49
Speaker
There's all kinds of thoughts I have about self-esteem and masculinity, but Farrah, I'm wondering because I think a lot of people might think this is sort of a male problem and women also have pariuresis, but what kind of thoughts are you having? Oh,
Paruresis and Gender Differences
00:20:04
Speaker
sorry. I'm missing small parts here and there, but no, I definitely think women
00:20:11
Speaker
obviously share some of the same anatomy. It can be complicated with women, I think, by the fact that there may be other things going on. Women commonly get UTIs or have other issues associated with pelvic floor dysfunction and pain.
00:20:37
Speaker
Um, so I do think that your advice about first, you know, ruling things out, maybe seeing a Euro gynecologist, um, would, is a really great first step, uh, for most women who are struggling with something like this along with, and I was actually going to ask you, you know, in terms of, you know, your practice, what are the, what is the split? I mean, do you see evenly men and women or more men than women or
00:21:07
Speaker
the occurrence rate for something like this. So I would say that the prevalence rate for poruresis is, people ask me this all the time and I don't have a good answer.
00:21:17
Speaker
My organization uses the same prevalence rate as social anxiety, which I think is a mistake because of, as I mentioned before, there are lots of people with social anxiety who get all cross-eyed and have no idea what I'm talking about when I mentioned far ureasis. So we use 7% as a number. I think the truth is about maybe half of that. Even at half of that, we're talking about 10 million Americans.
00:21:42
Speaker
I think that as many women as men have poruresis, but they deal with it very differently. As you point out, and Grant, you pointed this out.
00:21:55
Speaker
dual function of the penis, there tends to be a strong association with masculinity and having problems with your penis is going to lead men to question their masculinity. Even something as minor as some men prefer to sit down to urinate because it's physiologically easier for them.
00:22:15
Speaker
There's an insult for that in lots of cultures and german that says it's pinkler and you know i remember seeing i remember at some point seeing a t-shirt said tony romo p is like a girl i mean to be tired
Cultural Views on Masculinity and Urination
00:22:31
Speaker
with anything feminine when someone is describing a masculine activity for you is a problem now i have had women in my workshops.
00:22:41
Speaker
and typically the way they describe it their experience of your recess is that it is physically grossly uncomfortable that it is embarrassing to them.
00:22:51
Speaker
but that it does not hit their femininity at all. In fact, I remember very vividly when I was leading a workshop four years ago in Philadelphia, a woman of late middle age, after hearing the men go around the table and talk about how it was like a hit to ground zero of their masculinity, she looked very perplexed and she said, well, I'll tell you what,
00:23:16
Speaker
I've had three children and raised them to adulthood. I don't know how I could be any more feminine. This is just really embarrassing and really uncomfortable. And, you know, actually there was a question in here about rule out. I have, you know, the one question rule in so that therapists might want to know about this.
00:23:40
Speaker
I'll ask my clients hey do you have this problem when you're at home and you're alone and you don't have any time pressure and if the answer is yes. I say will get the to a urologist because you're having this problem when you're at home and you're alone and you know there's no waiting on you i don't think it's part of your recess.
00:23:59
Speaker
But if the answer is, oh no, I mean at home alone under no time pressure, then it's like, okay, you're in the right place because it is definitively a psychological phenomenon. And I think it is, you know, for years I had trouble getting my head around the fact that it was listed as a social anxiety when I felt that that felt so alien in my experience and in other respects.
00:24:24
Speaker
But I've come around and I think, listen, what's the difference between being in Yankee Stadium and being at home alone and under no time pressure? Society.
00:24:34
Speaker
It is mediated by other people being around. Even the perception that other people might be around is enough to tighten people up and make them misfire is the term of art we use for not urinating. You either urinate or you misfire. We don't go for the language of success or failure because we think that just working on the problem is a success in and of itself because you spend all this time
00:25:01
Speaker
running from the problem, being ashamed of the problem, not wanting to discuss the problem, not working on the problem. And it gets worse and worse and worse. So I would imagine sort of stress and perfectionism can exacerbate that as well. Oh, totally. I would say that perfectionism is a trait that is very high in the population that I see for poreuresis. And
00:25:23
Speaker
And that's one of the fun things. I mean, you had asked a little bit about analysis earlier. I was thinking about the sort of psychoanalysis, I think is a very exceptionally useful treatment approach and way of viewing the world for a lot of people, but just for listeners to have some context,
00:25:46
Speaker
There have been times where psychoanalysis has done more harm than good. And oftentimes that happens through ascribing a hidden or unconscious person.
00:25:57
Speaker
usually somewhat negative or nefarious motivation to some symptom. And then insisting that the person must have some underlying psychological problem that's causing it. As you mentioned, Dan, a stereotypical one for a man with part uresis might be, oh, you're a repressed homosexual. And people who know the history of psychoanalysis
00:26:22
Speaker
will know that one of the less proud moments that the field has had, and in psychiatry as well, is it's like the homosexuality was viewed as a pathology for many, many years. And so anything to do with male behavior could be ascribed to kind of
00:26:43
Speaker
this underlying problem, but there may be other motivations like a wish for attention or something like that. And I would think that all of these misconceptions that even well-intentioned therapists might imagine, and that's part of the reason why we want to have you on as a guest, we'll make it harder for someone part of your recess to recover. So what were you going to bring up having given that context? Well, I was actually going to bring up something that I remembered from the work of Carl
00:27:10
Speaker
This is pronounced Abraham or Abraham, one of the early analysts in one of the essays that he had written, I think on anal character. He talked about these characteristics.
00:27:22
Speaker
you know, which of course Freud had outlined as well about, you know, parsimony and- You know, retentive versus impulsive, like personality traits that were tied to early pre-sexual or pre-edible function development and often related to sort of like experiences, as you alluded to earlier, being humiliated by parents during toileting training.
00:27:48
Speaker
Right. So in one of the things, and I like to use a strengths perspective, you know, it's the way I was trained as a social worker. And so I tend to
00:28:00
Speaker
call attention to the character cluster that tends to coincide with paruresis, this kind of anal detail oriented character. And I say, you know, what's really difficult about this is that there are so many attributes of this character cluster that are valorized in other areas of our lives.
00:28:20
Speaker
you know um it is good to be punctual it is good to be good and thrifty and good with money uh it is good to in a limited sense to have high standards i wouldn't go as far as perfectionism but to have high standards and all of these things that help us in our careers and in our relationships come out to come back to bite us in the tuchas uh when there is a bathroom because
00:28:44
Speaker
you know, we're overly solicitous to other people. We want to get out of the way. We don't want to, you know, be in the way. And so that does, in fact, tie back to some of the esteem issues that you have. Some underlying insecurity, like I'm inconveniencing people. These are the types of intrusive thoughts that people might have. I would imagine if you go through like a cognitive behavioral approach, you're going to ask the people, what are their automatic thoughts around going to urinate?
Cognitive Exercises for Paruresis
00:29:13
Speaker
And then they may have some of these cognitions that are maladaptive. Yeah. Right. And then we try to do like the rational, emotional, behavioral approach of, of just kind of disputing those, you know, are you sure that this is what this means? Is there no other way of looking at this? Uh, I also have worksheets, you know, that kind of flip the script and say, okay, uh, you know, you're not telling all your friends about paryuresis. What is it to the thing? Why do you think your friends are your friends? Um, and oh, by the way,
00:29:43
Speaker
What if your friends told you that they had a problem like this? And ostensibly the idea of- Perspective taking. Exactly, looking at things from more than one perspective. Now, what would you say if someone liked making people wait for them in the bathroom and they took some sort of pleasure from that or felt powerful knowing that people were being inconvenienced?
00:30:08
Speaker
I don't see that, so I haven't seen that. How would I address that if someone came in? I want to know what that's doing for them, what that makes them feel, what that reminds them of, that feeling of power that they get from knowing that others are standing cross-legged outside waiting for them to only get relief at their whim.
00:30:32
Speaker
That might actually, now that I'm describing it out loud, that sounds like it's got a kind of masochistic, no, I'm sorry, sadistic rather, sexual component to it. But again, it's not something that I see. So I haven't really prepared what my answer would be. People are going to seek, not likely to seek treatment for that. No, because it would be egosyntonic. You know, the,
00:30:58
Speaker
And then, you know, to speak of the anal character, you know, there's the difference between, say, obsessive compulsive disorder and obsessive compulsive personality disorder. I think a lot of my clients, you know, find their being hyper scrupulous to be rewarded in other areas of their life. And so, you know, the idea that they would stop accommodating others and ask others to accommodate to them is very alien to their way of thinking.
00:31:28
Speaker
Yeah, actually Farah, I was thinking of presentation of females. Oh, and also how to incorporate, I think that...
00:31:38
Speaker
I had asked before we went on air today, how often you ask toileting questions about your clients. And that wasn't because I meant to ask you specifically. I'm a member of a supervision group where I'm the youngest guy by about 30 years. And so some of the other members of this group cumulatively have 200 years of family therapy experience between them.
00:32:05
Speaker
And when I presented to be admitted to the group, they made the comment to me, wow, this is fascinating. We have never seen anyone with this problem. And my comment to them was actually, you probably each individually seen dozens of people with this problem. You just weren't interviewing around it. And so to, you know, to give an example of that, when I was doing my training, uh, at Ackerman, I was working with a couple.
00:32:30
Speaker
The presenting problem had absolutely nothing to do with paryuresis. One of the values at Ackerman is to be very self-disclosure-y appropriately, to let people know who it is that they're talking with. When I introduced myself to them, I mentioned that I am here at Ackerman.
00:32:50
Speaker
I also have a private practice on the Upper West Side, and I'm the president of this association that deals with shy bladder. And the husband, without missing a beat, just said, oh, I have that. And the wife, just kind of her neck just turned as if she couldn't believe what she was hearing. And she just said, oh, I just thought you had an iron bladder. And he was like, no, I have that.
00:33:16
Speaker
And it did not become part of the treatment. It was evidentiary to me of how seldom people bring it up in treatment. So when the women in my supervision group said, we haven't seen this, it's like, well, have you asked? And so to the name of your show, it's like a doorknob comment. I think about, I guess, Columbo, the old detective show from the 70s with, who was it, not Peter. Peter Falk.
00:33:44
Speaker
You know, rumpled raincoat. Oh, one last question for you. You could always, when you're doing an assessment around anxiety, and particularly if that anxiety has a bit of an agoraphobic flavor to it, you might finish whatever questioning you're doing and just throw in a question at the end. Oh, by the way, I almost forgot to ask, you got any problems with public restrooms?
00:34:08
Speaker
And someone without part of your recess will just be like no like you know next but someone with part of your recess is likely to stop you and be like what do you mean or ask for more and then you've got the entree to ask a little bit about their toy learning behavior i mean i you know to tie this back to your question for about females.
Identifying Paruresis in Clients
00:34:30
Speaker
I remember talking to a woman about 10 years ago, the presenting problem again had absolutely nothing to do with poruresis. And at one point she told me that her routine for dating was that she would, if it was blind date, she'd use these apps, she'd show up at a bar that they were gonna meet and she would prepay for two drinks and close out her tab. That struck me as somewhat idiosyncratic. And so I just kind of asked her, I was like, well,
00:34:59
Speaker
Why do you think, given any thought as to why you do that every time you go for one of these dates? And is it, what emerged was that she was very scared of being trapped, of having had a second drink and then having urinary urgency and then having to try to flag down the bartender and not having him or her show up in time and having the urgency rise and then know that she can't use the public restroom.
00:35:26
Speaker
And so, you know, it shows up in these very odd ways. So you mentioned the woman in the bar. You talked about feeling trapped. I thought, I learned this word recently, clithrophobia is a fear of being trapped. And so maybe that's a component. And yeah, there's a lot of stigma and embarrassment around periuresis and anything to do with these types of habits as well as sexuality. You know, there's a reason that we call that part of the body.
00:35:54
Speaker
private, you know, part of the body. And so if you don't ask, people may not say anything. And then the couple you described, I guess they've been married quite a while and wife had no idea that that her husband had this issue.
The Core Fear: Public Embarrassment
00:36:04
Speaker
I wondered specifically, and maybe this is a misconception, if people with Pariuresis are afraid of wetting themselves or being incontinent. Oh, excellent question. I think that is the core fear.
00:36:17
Speaker
And I don't think that there's anything about urinating on oneself that is truly threatening individuals with poreuresis. It's adding the social component again. I think that like, for example, I would say the majority of people, I shouldn't say the majority, but a very common presenting problem is people come in and they say, I got a flight in 10 days to Europe. The last time I went was an absolute disaster. I had a panic attack on the plane. What can I do? And I think, well, I wish you would contact me a little.
00:36:48
Speaker
But I think the core fear is I will go to the lavatory, I will misfire, I will return to my seat, I will have escalating anxieties, sweaty armpits, and cruelly, an increased desire to urinate because of the anxiety. Then I'll go back to the lavatory. Everyone will notice that I've gone back to the lavatory, as if people are noticing this all the time. And I will be unable again, I will return to my seat, and after a certain number of iterations of this drill,
00:37:16
Speaker
I'm going to have a panic attack in my seat, urinate on myself. Everyone will see. They'll know there's a crazy person on the plane and it will be so humiliating. People will take videos. I'll never live it down. I think that's the core fear. And nowadays that'll be on TikTok or social media. I think most people, I mean, if you're
00:37:37
Speaker
afraid of heights, if you're afraid of dogs, if you're afraid of the dark. I mean, you know, these things, people tend not to be as ashamed of, but things that deal with, as you point out, private issues, they're more adjacent to shame. Great. And so what I, you know, what's very, what's very frequent for me to ask people is, what was the last time that happened? You know, and I'll pull out my
00:38:01
Speaker
10 is if I got to take copious notes, tell me all about the urinated all over yourself on the plane problem. And so far, no one has been able to furnish an example. It's a catastrophic thought. It's the most common catastrophic thought that tends not to be realized. Yeah, and it's very painful not to be able to go to the bathroom, of course.
Call to Action: Seek Help for Paruresis
00:38:20
Speaker
And, you know, incontinence of stool would probably be more embarrassing. And if we had more time, we could talk more. Any thoughts before we ask folks where they can find you, Dan?
00:38:31
Speaker
Well, I want to thank you first of all for coming on. I feel like I learned a lot today. I hope that this reaches a lot of people because like you were describing feeling very alone with this. I think that is something that we don't want anyone to feel. It's part of why we do what we do and bearing witness and being there for people and letting them know that they're not alone.
00:38:55
Speaker
is I think one of the goals of this podcast. So, you know, thank you for sort of keeping the conversation true to that spirit and for sharing your own story. Thank you. Don't be ashamed if you have these types of feelings around urinating in public restrooms.
00:39:13
Speaker
Bring it up with someone. The treatment is available. You're not alone. Lots of people have this problem. Millions of people in the US. You don't need to stay silent. Help is available. Dan, where can people find you?
00:39:27
Speaker
Oh, I can be found at my website, which is danrocker.com. I also have a peruresis specific website, which is it's a restroom.com. That can be because I want people to know it's a restroom. It's for your rest. It's a comfort station for your comfort relief station for your relief. I mean, it's not like the proving grounds.
00:39:46
Speaker
The International Paruresis Association can be located on the web at paruresis.org. Yeah, I think that's the best way to reach out to me or for anyone with paruresis, if they'd rather talk to someone else, you could talk to Tim Pyle, our executive director, par excellence. Excellent. Paruresis excellence, par excellence. Dan, thanks for being on the program.
00:40:12
Speaker
You're welcome. Thank you for giving me the opportunity to speak a little with a little bit of a louder microphone. Yeah, definitely. Loud leadership. I'm Grant Brenner. I'm here with my co-host. I'm Farah White. We are the Doorknob Comments podcast. And you can find us at doorknobcomments.com. We appreciate positive ratings. And we're also on Instagram and TikTok and stuff like that. Have a good one. Thanks, guys.
00:40:39
Speaker
Remember, the Doorknob Comments podcast is not medical advice. If you may be in need of professional assistance, please seek consultation without delay.