Fear of Incontinence
Case Study
John, age 22, came to me because he is suffering fear of incontinence. He avoids driving on a highway where the exits are too far apart. He avoids completely public transportation. He avoids driving in a car in company of others. He is afraid of soiling himself. The fear of loss of control over his bodily needs causes him much anxiety. Last year as he was leaving his friend's house he felt the need to go to the bathroom to relief himself. But since he preferred to do it at home he decided to hold on till he arrived at his home. Alas he could not hold out and ended up relieving himself uncontrollably in his pants while driving. This shamed traumatized him and ever since he is afraid he will lose control again.
"What is the worst thing that will happen if you lose control?" I asked John.
"If I am alone in the car I will despise myself for I will feel like a little child who is incapable of self control. If other people are
around, they will laugh at me and this will be a very shameful and humiliating experience." Answered John and continued "I am aware that I am not the only person this has happened to. When I shared my fears with two of my good friends, they confessed that they too had had similar experiences at different times in their lives. Well, maybe they have a stronger character than me. Maybe they are less fearful of being mocked." He ended painfully.
John told me that since childhood he is weary of social criticism. He avoided raising his hand in class and refused to participate in class shows. He said that his older brother is like their Mom. He has "Thick Skin." In company, he has no inhibitions about voicing his opinion even if it's contrary to the majority. He has no problem expressing anger towards people who hurt him. In contrast, John and his father
are characterized as having "Thin Skin." They are both very sensitive, tend to refrain from expressing emotions overtly and both are intimidated by social criticism.
Since I was convinced that John's fears of incontinence stem from his heightened sensitivity to social criticism and not from a childhood trauma, I decided on a short term therapy that will guide him into developing a "Thicker Skin." My assumption was that a thicker skin will help him to worry less about social criticism in case he soils himself in public. And when he can experience that, his various fears will diminish and his life will return to normal.
I opened our second session with an explanation of the evolutionary reason for his social fear, which causes him to avoid situations that appear dangerous. After I told John about our ancestors who lived in the prehistoric jungle and about the struggle for social status in modern society, I related it to his personal issue. "You are treating the risk of incontinence in a similar way that an ancient man responded to a situation endangering his social status." I explained. "When pre historic man found himself in a power struggle for social status he was facing with two options: to take the risk and attack his opponent or to avoid conflict and retreat to his cave. I assume that if you were that
ancient man, you would have elected to avoid confrontation. Since you worry about being ridiculed and humiliated if you do not control yourself, you tend to confine yourself to home and not take risks. On the other hand, the fact that you did seek help shows that you are aware that your fears are exaggerated and you would like to overcome them. I will help you develop a "thicker skin."
"You are right, I came for a treatment to overcome my fears but the thought that I may lose control in the presence of my friends scares me to death." Said John in a trembling voice as his body shriveled like a scared child.
"We will do it gradually, similar to a system used by a circus clown, learning to control his balance while walking on a tight rope. At the beginning he practiced without any audience with the rope hanging low and a safety net underneath. Only at the end he can walk high
without a net, in front of an audience. You will start training to control the fear of soiling yourself by acquiring a safety net and second aid."
"I don't quite understand what you mean," said
John with quizzing eyes. "I know what a "safety net" is and what "first aid" is but what is "second aid"?"
"Safety net" as I define it, is adult diapers which prevent messing your pants and exposing the incident. "Second aid" is cleaning aids like moist wipes. I suggest that for our next meeting you will bring a box of adult diapers and a box of moist wipes. Next meeting I will explain what you need to do.
John looked shocked at my request. He must have thought that his psychologist went mad. During the week I had a passing thought that maybe I was mistaken in my approach regarding John. I was concerned that he may drop the therapy since his basic approach was avoidance of fear invoking situations. To my delight, John arrived on time. He declared right away that he did not purchase the items. He shared a difficult
experience. After much deliberation he went to the pharmacy to purchase said items but behind the counter was an attractive young lady. He was too ashamed to continue with the purchase and left the store.
I felt relieved. He found a way of not accepting my suggestion. He was not forceful enough to confront me out right by saying something like: "I will not buy these thing... I am not a baby... Diapers are not a safety net... Find a more normal way to deal with my problem..." Instead he used his usual mode of operation: emotional suppression and avoidance of scary situations. I decided to keep my thoughts to myself and pursue the original course of action.
"I am proud of you for overcoming your hesitation and going to the pharmacy. I am convinced that the next time when you will go to buy
diapers and moist wipers, you will be less tensed. I suggest that you tell the sales lady that it is for your Grandpa and ask for the size that fits you.
"Let's assume I will purchase these items, what am I supposed to do with them?" He asked.
The way he presented the question hinted that he was willing to take the risk and continue the treatment. I suggested to John to first war the
diaper for a few hours only at home. The aim was to get him used to them physically and mentally. When he will feel comfortable wearing them and stop being conscious about them, he is to move to the next phase i.e. wearing them outside the home in his neighborhood. In the third phase I expect him to drive to work & back home wearing the diaper and he may take it off at work if he so inclines.
"That seems easier than I expected." John said with a light smile. "But why do I need the Second Aid and what is the next step?"
"I suggest that we postpone this discussion for the next meetings" I replied. In my heart I worried that if I tell him what I have planned for him, he will skip the treatment.
In our next meeting, Moses shared his week's experiences. He sounded excited about his achievements. He said that in the first hour of walking around the house wearing the diapers, he felt very uncomfortable. He thought the diaper was rustling. Never the less he dared to walk outside the house warring that people walking behind him may notice he was wearing a diaper. After a few test runs he relaxed and started to feel comfortable with the diapers. He was very proud to share that during the week he dared to drive longer distances than any time in the past two years.
I decided it was time to move to the next phase, overcoming the fear of losing control.
"I am very proud of you for getting used to the diaper that easily. The safety net enabled you to venture to placed you were afraid to go to before. Now we are moving to the next level which is to be less sensitive to the fact that till the age of 99 you may lose control at lease another three and a half times. Since there is little chance that I will be around to help when you reach this ripe old age, I have to prepare you emotionally to the possibility that it may happen to you just like it may happen to anyone."
Since Moses nodded his head in agreement, I continued: "I am going to ask you to do something that will be very difficult for you to do. I believe however that after you do it you will realize it is not that bad and it will help you overcome the fear that something may happen in the future. When you are alone at home I want you to wear the diapers and do your business in the diapers. Then go to the bathroom and clean yourself with the moist wipes. Remember that while people are disgusted with other people's feces it's much less with your own. I expect that after a few test runs you will learn to clean yourself quickly and efficiently. When you discover that the devil is not that bad, you can join your friends to longer trips. You will take with you your kit of safety net and second aid in reasonable quantity. If it so happens that you soiled yourself on rout, you will ask to stop at the nearest bathroom and go clean yourself. From my experience this exercise can rid you of your phobia."
To my surprise and delight, John deemed less shaken then I expected. During our next five sessions, progress was slow and suffered some setbacks as well. John understood, logically, that good friends will not ridicule him and not abandon him on the road. But the fear of the risk was strong. During these meetings, I incorporated several time the method of "Future Projection." Accordingly, I asked John to imagine his worst-case scenario: soiling himself in different situations but instead of feeling humiliated and helpless as he feared would happen, he was to imagine that he is dealing with it successfully, with ease and dignity. Sometimes he imagined that nobody actually sensed that he soiled
himself and he was able to clean himself in a public bathroom. Another time he imagined that it happened on the highway and the distance to the next rest station was too long. He imagined asking the driver to stop by the side on the road and he cleaned himself in the bushes. At the end of every session, John declared that he will join one of his friends to a long-distance trip, but he did not. He used different excuses that helped him with his avoidance behavior.
The breakthrough happened when one of his friends, how was aware of John's situation, pressured him into joining him to a football game. John raised many excuses trying to avoid the trip but the friend did not give up and they took the trip. John told me the next session that till the minute he reached the car he was trembling all over his body. The instant the car moved he relaxed and during the trip there were even times he forgot completely about his problem. As a result of his positive experience he contacted other
friends and asked to join them on their trips. With each trip his self confidence grew.
The treatment ended and while Moses was not completely rid of his fears, he was able to cope and function without resorting to his old negative pattern of avoiding any situation that invokes fear. When he had to drive to a new place or a distant place he would wear his diaper. When a trip invoked only minor fears he would carry with him his kit of diapers and wipes. To short and familiar destinations, he even traveled without his safety net and free of fear.
Children and adults, who suffer from fear of loss of bladder control, generally tend to have a cautious personality more than their peers. Since “knowledge is power”, it eases for self-acceptance and for positive coping with fear of losing bladder control, reading of the chapter "Cautious vs. Daring" is recommended.