toilet-di-fernandes
May I use your toilet?
A CBT treatment manual for clients that suffer from toilet phobia (Parcopresis)


By
Mario Dieter Schmidt
Post Graduate Certificate in Health Sciences [Eastern Institute Of Technology Hawke’s Bay
Napier New Zealand], 2015

Author Note

Mario Schmidt, Department of Health Sciences, Eastern Institute Of Technology Hawke’s Bay Napier.
Mario Schmidt is now a post-graduate student at EIT Hawke’ Bay
This manual fulfills the critical writing component of the course MN8.414 Cognitive Behaviour Therapy (Assessment 7 Manual). Word count: 12,000
Correspondence concerning this manual should be addressed to Mario Schmidt,
lighthouseman@orcon.net.nz.
Table of Contents

Abstract................................................................................................................3
Introduction…………………………………………………………………….3
Cultural, social, familial & socio-economic factors…………………………….4
Notes on causation from a cognitive-behavioural perspective………………….5
Engagement and assessment ..............................................................................7
Irrational thinking...............................................................................................10
Interventions & Techniques ………………………………………………….12
Rational analysis technique...............................................................................13
Inference chaining.............................................................................................14
Disputing techniques ........................................................................................17
Creative disputation...........................................................................................18
Catastrophe scale technique…………………………………………………..20
The empty chair technique................................................................................22
Benefit calculations ..........................................................................................23
Exaggeration technique ....................................................................................23
Role-playing .....................................................................................................24
Pragmatic disputation .......................................................................................25
Logical disputation ...........................................................................................25
Empirical disputation.........................................................................................26
Developing rational alternatives........................................................................26
Exposure ...........................................................................................................28
Behavioural change ..........................................................................................29
Homework.......................................................................................................29
Evaluation, ending therapy and follow-up........................................................31
Using different modalities CBT/Gestalt............................................................31
Summary of strategies and techniques..............................................................32
Limitations……………………………………………………………………4
Final thoughts…………………………………………………………………35

Ancillary "clinical commentary"……………………………………………...37
References .........................................................................................................39

Abstract

In 2013 I had a woman referred to me by a local doctor. The women suffered from a toilet phobia, which is recognised as a form of social anxiety. Before that, I had not heard of such a phobia. Back then; I had been a psychotherapist trainee who had not worked with anxieties and I had only been trained in Gestalt therapy, but not in CBT. Sometime later, it became clear that Gestalt therapy was not effective at all. This led me to refer the client to a CBT therapist, which the client declined because of financial reasons. Following this, I did not hear from this client for about six months. My failure to help this client motivated me to sign up for a postgraduate CBT diploma at a local university. A few months later, the client agreed to work with me again, this time using the CBT modality. I found the use of CBT extremely effective when dealing with toilet anxiety. After the experience of working with such a client, I decided to share my firsthand knowledge by writing this toilet phobia manual. I hope that this CBT manual will help other therapists, or even clients who suffer from a toilet phobia to understand and treat the problem of toilet phobia.

Introduction

Toilet anxiety is a term used to identify a condition that affects people that have problems and issues with using toilets. Symptoms may include extreme fear of using a public toilet, having an accident such as defecating themselves in public or being far away from a toilet at any time. Symptoms can also include worry about their smell when using a toilet. People who suffer from this anxiety may also avoid using public toilets. They often don’t like to be seen using a toilet either. One of the main unhealthy emotions evoked are anxiety and shame. Currently, there is very little research on this type of anxiety disorder or phobia. There has not been a book written on this subject and except for a couple of websites dedicated to this subject, even a Google search is fruitless. It is a form a social-phobia, also called ‘Shy Bowel' and 'Parcopresis'. People who suffer from this anxiety usually suffer in silence and they are ashamed of having the issue. Eventually, the problem can worsen over the years after the onset of the phobia and clients may give up the hope of full recovery. They may accept the condition as normal and sometimes somatic symptoms start to appear. Somatic symptoms related to this phobia are irritable bowel syndrome, constant diarrhea, and a possible development of eating disorders. The constant elevated levels of adrenaline and cortisol levels may upset and disrupt bodily functions and physical health gets affected in many ways because of the irregular fluid or food intake. Irrational thinking increases and cognitive errors become ingrained, e.g. ‘I am disgusting’, ‘everyone is looking at me’, and ‘people don’t really use public toilets’. Or, ‘you do only number two’s at home’ or ‘nobody goes to the toilet at the movies’. Behavioural changes develop, and clients start to plan outings and travel, or escape routes are explored. The client may wait for people to leave a toilet and observes other people using toilets. Clients may even create anxiety through imagining fearful situations, in an attempt to empty bowels before leaving home, and routines are developed such as stopping to eat before going out. OCD behavior may develop because the client is trying to control situations and the anxiety. Avoidance of appointments, excuses and escape routes are considered, if a meeting cannot be avoided. Intimacy with partners may also be affected. Eventually, people may become isolated and they end up avoiding social interactions or friendships and usually the whole day is dedicated to the planning of when to eat or drink, or when or how to use a toilet. The main fear associated with this is always the possibility of defecating oneself in public or using public transport and meeting people.

Cultural, social, familial & socio-economic factors

The client was a middle-aged European female that was married and had one child. During this case study and manual, this client will be called Susan. This was not her real name. The client had this phobia for 14 years before she was referred to counselli0ng. The onset for such a phobia seems to be in adulthood, and it does not seem to affect any particular culture or socio-economic class. The client came from a typical middle-class family. The phobia clearly had affected the client’s marriage as well as her social life. Eventually, the client had difficulties holding down a regular job because of the phobia. This created some considerable financial issues for the family as well. The client had lost all hope of recovery because she had tried so many other treatment options before. These included yoga, meditation, holistic approaches and dietary changes. She was convinced that even CBT would not help her condition, but she was desperate to try something else one last time.

Notes on causation from a cognitive-behavioural perspective

The first thing that a therapist might notice during an initial assessment is the client’s cognition errors of how he/she perceives the imagined threat of defecating him/herself in public. One might wonder where such a dysfunctional cognition error could originate. “A central tenet of the cognitive theory of anxiety is that abnormal fear and anxiety derive from a false assumption involving an erroneous danger appraisal of a situation that is not confirmed by direct observation” (Clark & Beck, 2010, p. 6). Susan clearly was imagining a danger that was not real because it had never actually happened during the last 14 years; however, she believed that it could happen to her. “The activation of dysfunctional beliefs (schemas) about threat and associated cognitive-processing errors leads to marked and excessive fear that is inconsistent with the objective reality of the situation” (Clark & Beck, 2010, p. 6). This may explain such a cognitive error, but CBT also proposes a biopsychosocial explanation. Susan reported that her mother also had the same problem. Maybe there had been some biological or psychological inheritances here, or maybe the client observed this behavior with her mother. These possibilities had been discussed during Susan’s therapy, so there could also have been some environmental factors at play here. Susan also mentioned that she had an accident in school as a child. Susan needed to use the toilet, and she went to the teacher to ask, if she could do so, she was told that she could not. Susan then defecated in her pants during the class. This may explain at least the origin of such a phobia, however, knowing or being able to explain where this phobia originated from, did not help the client to get over it. The ABC Model helped Susan to put the causation process of such irrational thinking into perspective for her, this model is also used in this manual, which was developed by Albert Ellis the founder of Rational Emotive Behavioural Therapy (REBT) (David, D. (2010). Below is a typical ABC sequence example that a therapist might work with during a session.

  • Activating event: Phone call invitation to a birthday party.
  • Beliefs about A: Automatic thinking of “Oh my God, there will be many people there and I will shit myself”. Or the core belief of “I am not worthy of being invited to a party because there is something wrong with me.”
  • Reaction: Emotion: Anxiety
Behaviour: avoiding situation (saying no, I am busy that day, sorry). Cancelling or turning down the invitation relieves the anxiety again (short-term reward). Long-term consequence: social isolation and depression.
This emotional episode for example, clearly demonstrated to Susan that it was not (A) that caused (C), but that it was (B) (irrational thinking and core belief) that caused (C). CBT and REBT argue that almost all human emotions and behaviors are caused by what people think or how people perceive any particular situation. Almost all people will think irrationally at times as well as rational (Dryden, Neenan, 2004). Humans may have a biological tendency to do both, and it might even have an evolutionary advantage or some adaptive value for our ancestors. REBT theory suggests that the tendency to think irrationally (anxiety or phobias) could be passed on genetically through chemical changes in DNA. If irrational thinking increases through anxiety or stress it is the therapist’s job is to demonstrate to the client that she has a choice of how to respond by becoming aware of irrational thinking and behavior (David, 2010). It is important for clients to learn the ABC model so thoughts can be tracked.

Engagement and assessment

One important component of any therapeutic endeavour is the relationship and the therapeutic alliance between the therapist and the client (Dryden, Neenan, 2004). When Susan first came to therapy in 2013, it became clear that Gestalt therapy was not effective. Susan’s therapy was eventually terminated because it was not helping Susan with her phobia. When therapy was continued in 2014 using the CBT modality, a relationship had already been established. Susan’s history, life story, the problem and how it was managed was already known and talked about in the previous year. Nothing had changed for Susan during the 12 months after her therapy was discontinued. The importance of the relationship and therapeutic alliance between the client and the therapist when working with toilet phobia is vital because of the emotional shame that is evoked. Clients with this phobia are very ashamed, and it requires a ‘high’ level of intimate sharing on the client’s part during sessions. Clients talk a lot about defecating, stool, and toilet behaviour during sessions. Relationships develop with trust and safety. If the client feels safe, intimate sharing becomes easier. This takes time to develop in therapy. Although CBT theory does not emphasise the importance of a therapeutic relationship or trust and safety as much as other humanistic counseling models (Dryden, Neenan, 2004), more humanistic counseling models propose that it is of high importance because it speeds up the therapy process. The use of basic counselling skills such as empathy, positive regard, and genuine respect are of high importance (Feltham, 1999). During Susan’s therapy a combination of CBT, Client-Centered and Gestalt were used. The first thing that was observed when Susan talked about her phobia was that she was not hopeful of ever becoming ‘normal’ again, as she described it. A priority for a CBT therapist is to restore faith and hope again. Without the hope of recovery, it would be hard to engage any client in therapy (Frank, 2012).
The assessment started from the first day of therapy. Susan’s treatment goals and her motivation for change were talked about. The CBT modality was briefly explained to Susan and how CBT works and the ABC model was also introduced during the early stages of Susan’s therapy. A verbal contract was negotiated with Susan that established how her therapy would proceed and what was expected from Susan and the therapist. The problem was discussed in detail and how long it might take to see results using CBT techniques. Also discussed was a therapist’s need to write a case conceptualisation as well as the treatment strategy, and that this would be shared with Susan. Sharing a case conceptualisation with a client is a departure from other psychotherapy models where clients may not get included in this. CBT theory suggests that it helps the client understand and articulate the problem, make sense of it from a psychotherapeutic view “and how this integrated perspective will inform treatment” (Ledley, Marx, 2005, p. 84). CBT theory also suggest that the client is the expert of the problem and that the inclusion and sharing of a treatment plan and case conceptualisation helps clients to understand the causation and underlying mechanism of the problem, and how it can be tackled. Clients know best about the problem and difficulties they experience and if it does not match, a therapist can always make changes to such a case conceptualisation because any case conceptualisation is an ongoing process (Ledley, Marx, 2005). The inclusion of Susan into the case conceptualisation also made it a collaborative effort, which is the foundation of the CBT modality (Froggatt, 2012). It also helped Susan to discover the underlying mechanism of her phobia and how the cognitive dysfunction was maintained. Susan had learned a very dysfunctional behaviour and therefore developed a very rigid belief system that had also resulted in the use of some major cognitive errors. Susan used all 11 dysfunctional irrational inferences and evaluations (discussed shortly), and sadly she was unaware of that. She believed her inferences and evaluations. Her thinking errors contributed to her anxiety and therefore temporarily gave her the short-term illusion, or reward of relieving her self-created anxiety by trying to control situations with OCD type behaviours. This reinforced her cognitive errors, but kept the cycle of anxiety going.
The long-term damage or the result was her social isolation, dysfunctional family life, and bad physical health (somatic symptoms) as well as feeling hopeless, sad, and frustrated. Susan’s dysfunctional cycle of anxiety had been going on for 14 years now, and she adapted by trying to avoid the imagined feared situation. Susan would then excuse herself or decide not to go out. She avoided movies, dinner invitations, and appointments. Her behaviour also included trying to empty her bowels and stopping eating before outings. Once she felt locked into a meeting, she created and felt anxiety to stimulate bodily functions. She then would not leave the house before she was satisfied that her bowels were completely emptied. She would go through her routines of planning, rehearsing, toileting, and other OCD behaviours. After Susan's return, she usually ate badly by rewarding herself with junk food. Her constant elevated cortisol and adrenaline levels resulted in continuous health issues and somatic symptoms for Susan. The reason for this is that cortisol and adrenaline are triggered simultaneously and ‘hand in hand’ with each other, when such fear is imagined or real. When cortisol and adrenalin get released into the system, it releases sugar from fat to help respond to the fight-flight response. When cortisol levels drop again, cravings for carbohydrates return (Hart, 1999). The constant elevated ‘Dance of the Hormones’ (Hart, 1999) in Susan’s body made her very unhappy. The cortisol and adrenaline that get constantly activated by the imagined threat disrupt the hormonal balance, and the “happy messengers” are prevented communicating these messages to the brain. The result is depression and more anxiety or even panic attacks (Hart, 1999). The treatment recommendations planned for Susan’s phobia had been to dismantle Susan’s rigid and dysfunctional belief system she had about herself and the way she managed her anxiety. The intention had been to change her core belief system through CBT and REBT disputation techniques, raising awareness about the ABC sequence, exposure techniques and exploring rational alternative thinking and behaviour options. It was anticipated that by the end of the year her anxiety levels would slow down, and her somatic symptoms also would have reduced if the bodily functions have had a chance to normalise again. Susan was made aware from the first day of the start of her CBT sessions that these sessions would be very different from the approach that was taken when the Gestalt modality was used, and that CBT was a more directive counseling approach (Froggatt, 2012). Susan regained some enthusiasm, understanding and hope again that CBT might be more helpful in treating her phobia after her first two CBT sessions. Progress was made.

Irrational thinking

One of the main objectives in CBT and REBT is to increase rational thinking and decrease irrational thinking (Dryden, Neenan, 2004). Clients with a toilet phobia constantly perceive situations as threatening or shaming when using toilets out in public therefore irrational thinking is constant. Reality is distorted, and it is a misinterpretation of what is really happening. The client can’t support the evidence of a possible threat, but holds and even clings onto the cognitive error regardless. Certain styles of irrational thinking develop in response to that. In CBT theory all humans think both rationally and irrationally, but in times of stress, irrational thinking can increase (Dryden, Neenan, 2004). CBT and REBT also divide these thinking styles into automatic thoughts (conscious) and core beliefs (unconscious). Automatic thoughts are also divided into two sub groups, which are called inferences and evaluations. When Susan started her CBT sessions, it was observed that she had high levels of irrational automatic thinking through both her inferences and evaluations she expressed when Susan’s phobia was discussed during her therapy. There are seven inferential distortions and four evaluations or automatic thinking styles that people generally use when they think irrational. Wayne Froggatt (Froggatt, 2012) calls these:

Seven Inferential distortions:

Negative Filtering (My situation is hopeless)
Overgeneralising (People don’t use public toilets)
Fortune-telling (My anxiety will never get better)
Emotional reasoning (I am sad and angry and the reason is you because….)
Black & White thinking (If you don’t accept my anxiety you must hate me)
Mind-reading (They think that I am a disgusting)
Personalising (Everyone notices me when I use the toilet, they criticize me for using the toilet at the movies).

Four Evaluation styles

Demandingness (I cannot get up in front of everyone to use the toilet at the movies; I must endure waiting to end of the movie. Demands can be about the self, others or the world)
Awfulising or Catastrophising (It’s going to be a disaster when I go to the party)
Discomfort-intolerance (I can’t stand it at this party because everyone is so boring)
Self/other-rating (I am not good enough, they are much more educated than me or I am disgusting because I have this problem).
Susan was observed using all the above cognitive distortions during her therapy. The 11 distortions above also represent the 11 irrational beliefs of REBT as proposed by Albert Ellis in his book “Reason and Emotion in Psychotherapy” (Ellis, 1962). Ellis’s old version of these 11 irrational beliefs are far too long for clients to make sense off these days, but Froggatt's simpler format helps clients to remember these automatic thinking styles better than the beliefs Ellis proposed in his book. Clients usually adapt to the above concept quite fast and before they know it, they start using the same terms. A drawing of the ABC model, and the 11 distortions of thinking on a whiteboard during Susan’s therapy sessions helped because Susan was able to refer to these every time she came for therapy. REBT suggest that clients disturb themselves in two ways “(1) Holding irrational beliefs about their ‘self’ (ego disturbance) or (2) by holding irrational beliefs about their emotional or physical comfort (discomfort disturbance)” (Froggatt, 2012, p. 9). Some clients also disturb themselves with both of the above disturbances. Susan had issues with both of the above concepts because Susan had a very bad self-image and she was very uncomfortable in many situations when she engaged with people because she was not able to relax anywhere but at home.

Interventions & techniques

During the first two sessions when Susan was assessed and a working relationship was established through gaining trust, it was observed that Susan was awfulising and catastrophising a lot as well as rating herself and others. These evaluations also stood out every time when such distorted cognitions had been analysed during the following sessions. Susan’s main inferences used had been mindreading, fortune telling, and overgeneralising. Sometimes it was attempted to discover underlying core beliefs, and sometimes the focus was on disputing her inferences or evaluations. During most sessions, the main technique used was when Susan was asked to discuss an actual episode of irrational thinking. Susan was questioned early on during a session if she could remember an activating event. This could have been a simple appointment she had avoided or an outing she had to do for example. The ABC model was used for this. Mini analyses such as these are explored on episodes that have already happened. It is always best to explore recent events instead of episodes that occurred a long time ago (Froggatt, 2012). It is easier to get the exact automatic thoughts at the time simply because it was easier for Susan to remember recent episodes. Other techniques used to attain an ABC sequence were visualisation and imaginary techniques. Here, Susan was invited to remember details of an event such as the time, where it happened, or what was happening, at the time. This could include information about the surroundings, smells, who was there, and what else was happening. Eventually, Susan would be able to describe a particular situation in detail and what her automatic thoughts had been and what her behaviour was at the time. Then, a correct ABC sequence could be established and analysed. Below are the interventions and techniques that worked and had been used during Susan’s six months CBT therapy process. The main technique used:

Rational Analysis Technique (as in REBT) (Froggatt, 2012)

Susan would be asked to remember a specific occasion when she became anxious. Then, the (A) Activating event was identified: Appointment with someone. Then, it was established how Susan reacted to (A) getting her to imagine (A) at the time during the session, trying to discover (C) Consequence. Usually, this would lead to the exact emotion and behaviour Susan might have felt at the time. She might have felt anxious and tried to relieve anxiety by planning, controlling, or avoiding the feared event. This was then explored further. A whiteboard was used to establish the exact ABC sequence for the chosen episode. Once the episode was established with (A) and (C) Susan’s thinking was explored (B) automatic thoughts (inferences and evaluations). During this process, it is vital that a therapist makes sure that the client understands that it was not (A) that caused (C) but that it was (B) the automatic thoughts or core beliefs that caused (C) the emotions and behaviour. Sometimes a therapist can try to get to core beliefs by using the technique of inference chaining, which will be explained shortly. Then, the analysis would go on to clarify a new desired affect (E). Or sometimes more time was spent staying and working with the inferences or evaluations that Susan revealed, so they could be disputed (D) so Susan could develop a rational alternative to her irrational thinking or beliefs (Froggatt, 2012). Over time, clients will become used to such a ‘rational’ analysis during a session. The idea is to get the client used to the ABC sequence so clients can do these for themselves one day when they leave therapy. Clients eventually learn to observe their own behaviour and emotions, link these to an activating event and become aware of irrational thinking (inferences/evaluations). These repeated so-called rational analyses with the use of a whiteboard also teach the client the ABC connection (Froggatt, 2012). Such a rational analysis would take about 45 minutes. Then, homework options would be discussed (F), as well as any new learning Susan made and this would be processed on the end of each therapy session with Susan so she could reflect on any new learning she became aware of during her session. Summary:
A. Ask for an Activating Event
C. Assess the Consequences (Emotions/Behaviors)
B1 Identify the automatic thoughts
B2 Identify the core belief(s)
E. Clarify the desired new Effect
D1. Dispute the beliefs
D2. Replace the old belief with a new rational one.
F. Develop action (Froggatt, 2012)

Inference Chaining Technique (REBT Theory)

Inference chaining is also called the ‘Downward Arrow Technique ‘in CBT theory (Beck & Beck, 2011). It usually leads to an unconscious core belief if that technique was executed well. First, the therapist selects inferences from the client and the emotions that had been triggered at the time of the activating event. When the therapist has selected the relevant key inference that matches the strongest emotion triggered at the time of the activating event, the therapist starts chaining from there. Here is a verbatim of a real time session with Susan.
Therapist: Tell me about a recent episode when something like this happened.
Susan: Just last week when I was asked to get into a car with a friend. (A)
Therapist: What was the emotion at the time?
Susan: I was terrified at the time and I could hardly control myself. (C)
Therapist: So this event triggered your anxiety again? (C) Emotion
Susan: Yes (Blushing in the face/ heavy breathing) (C) Behaviour
Therapist: What did you tell yourself at the time? (Collecting inferences)
Susan: That I am going to defecate myself in the car. (Fortune telling)
Therapist: OK, let us assume you do in fact, defecate yourself in the car. (Inference chaining attempt)
Susan: Oh my God, I can’t imagine that! I literally would reach into my handbag and shoot myself in the head.
Therapist: OK, we both know that this would be irrational (laughing) but what is anxiety provoking if you happen to have an accident in the car?
Susan: It would mean that there is something seriously wrong with me because people just don’t do things like that!
Therapist: OK, let us assume that the people in the car in fact think that there is something wrong with you, what would that mean to you?
Susan: It would prove that I am in fact, disgusting and not worth having as a friend.
Therapist: What core belief do you think you might be holding here about yourself?
Susan: There is something seriously wrong with me, and that I am disgusting and worthless.
Therapist: OK, you believe that you are disgusting and worthless? Let us try disputing this!
This identified (B) Core belief, will lead to Ego disturbance. Once you arrive at an evaluation or a core belief you cannot chain further. The next step would be to clarify or confirm the core belief which usually is a dogmatic must/demand on others, the self or the world and then dispute the core belief (D) find a preferred new desired effect (E) and replace the belief with a more rational alternative (Neenan & Dryden, 1999). Inference chaining summary: Establish or identify (A) the activating event. Collect the inferences and get the client to choose the key inference and then start chaining down from there, always relating it back to the chosen unhealthy emotion or behaviour the client wants to change (C). Sample: “Let’s assume they really don’t like you, what is ‘anxiety’ provoking about that?” for example. Always look for an evaluative belief such as demanding, awfulising, discomfort intolerance and especially people-rating evaluation. Eventually, a therapist may discover what disturbance is predominant in this situation. Is it more about ego disturbance or is it about discomfort intolerance? When the core belief (B) has been identified, it will be time to dispute this belief (Froggatt, 2012). Disputing core beliefs is an important part of CBT.
For this to eventuate, the therapist has to establish with the client what the client actually wants to change or what a preferred alternative behaviour or emotion could be (E) ‘Desired new Effect’. Susan for example would say that she would have liked to spend less time planning outings or wanting to be more spontaneous for example. She also wanted to feel less anxious about going out. Susan was becoming aware that her anxiety was not good for her well-being and that she was creating this anxiety in her head. Susan also did not want to feel shameful about using a toilet. Susan’s main unhealthy emotions she experienced were shame and anxiety, and a considerable amount of time was spent working on these two unhealthy emotions. When inference chaining is used, it is vital to always look for unhealthy emotions, not healthy emotions
(Froggatt, 2012). For example: “Let’s assume they really don’t like it when you ask someone to stop the car, what is anxiety provoking about that?”
Dysfunctional Emotions Functional Emotions (New ‘E’s)
Excessive anxiety Concern
Depression Sadness
Damning anger Constructive Anger
Hostility Annoyed
Guilt Remorse/Regret
Hurt Disappointment or constructive anger
Jealousy Concern or Disappointment
Shame Regret or Concern
(Froggatt, 2012)
Once the client understands the connection of (B) and (C) therapy proceeds to changing the dysfunctional or unhelpful (B) and (C) by using disputation techniques (D). The disputation process is vital in CBT. The techniques that have been used with Susan are described below.

Disputing techniques

When Susan first arrived for therapy her irrational beliefs started to reveal themselves every time Susan made some sort of the fleeting comment of what she was thinking about a day-to-day situation and when an inquiry was made, she immediately replied with defensive responses. For example, she might say, “Normal people don’t use public toilets” and when questioned, “Oh, they don’t?” she would smile and reply, “No; of course, not, certainly not for number two’s.” This would lead into an argument or struggle with her of why ‘Normal’ people don’t do number two’s on public toilets. Susan would cling onto her irrational beliefs, defend these with passion and there was no way she would consider another point of view. She truly believed her inferences or cognitive errors. Early on in therapy disputation with Susan would have gone nowhere so getting into the disputation process with Susan was avoided at this stage. A more ‘Out of the box’ thinking was required and options had been explored of how one could penetrate through such a strong dysfunctional belief system.

Creative disputation

When Susan was sitting in an office at a local doctor practice where she had her regular Gestalt therapy in the first year of her therapy, a particular situation was discussed which was about what other people think when they see Susan using a public toilet. In response to that an experiment was suggested to Susan and she was invited to participate. After contracting with her, getting her corporation and setting out or planning the experiment, Susan was invited to leave the room and walk past the young receptionist to the toilet, wash her hands and come back. With some slight resistance Susan agreed and after she returned she was asked again to walk past the reception and come back. Susan did so and after her return she was asked of what she made of it so far. Susan immediately talked about what the young receptionist would have thought of her using the toilet. After Susan’s assumptions had been collected the receptionist was asked to enter the room, the situation was briefly explained beforehand (doing an experiment with a client, etc.) and she was invited into the therapy room. In the room, the receptionist was introduced to Susan and the receptionist was questioned if she had noticed Susan walking past the reception. The receptionist replied that she did see her walking past at some stage. When the receptionist was asked what she thought when Susan walked past her, the innocent receptionist had no idea, and she replied in a naïve manner that she wasn’t thinking anything when she noticed Susan walking past because there is a lot going on in reception. Then, the receptionist left the room again. As soon as the receptionist had left, Susan started to cry. She suddenly realised that all the assumption she made about what the receptionist was thinking when she walked past reception had been wrong. The experiment worked. Susan could no longer hang on to her assumptions; Susan’s assumptions had successfully been disputed by doing this experiment. After this experiment was processed on the end of Susan’s session, Susan went home again with more awareness around her tendencies to irrational thinking. These sorts of experiments come from ideas during a session, they are spontaneous and usually they happen without planning. Sometimes they work, sometimes they don’t. In this instance, it worked. This was the first time during therapy when Susan realised that some of her beliefs are not true, and that she had made a cognitive error. Although this was done during Gestalt therapy, it can be done doing CBT.
For the third CBT session a few months later, another experiment was tried. One of the main problems that had been encountered with Susan during the first few CBT sessions was that she had little hope of recovery, and that the imagined feared situations she always anticipated had simply been out of context to reality. Susan anticipated an event that actually had not happened for 14 years. Susan's biggest fear was that she would one day have an accident and defecate herself in public, yet it actually had never happened. She spent huge energies on something that might happen to Susan and huge energies planning and avoiding such imagined situations. For this third CBT session a specific movie scene was prepared so it could be shown to Susan. The movie was called ‘Backcountry’ and it was about a couple camping in the Canadian mountains. In that movie scene, a large grizzly bear attacks the couple and the bear eats the man during a seven-minute scene. The scene was absolutely horrific, possibly ‘the most horrific’ movie scene one can imagine. The plan had been to show this scene to Susan during her session. The idea was to get Susan to realise that her fear of defecating herself in public was out of context to real fear and danger. The plan was to write down a ‘Catastrophe scale’ on the whiteboard first with Susan. Then, the movie scene was to be shown to Susan and maybe this scale could be adjusted after that. The result of the experiment was a breakthrough. It happened in the third session, and this was also the day when Susan finally asked if she could use the bathroom. This change in behavior was new because Susan never ever asked anyone before if she could use the toilet in someone’s home.

Catastrophe scale technique

Susan was invited to reveal situations that raised anxiety for her in her every day life and these events were rated on a scale between one and 10. After that, these anxiety provoking day-to-day situations were put on the whiteboard. The idea was that this might lead to a reevaluation of the recorded ratings (Dryden, 2012), after she had seen the movie clip. Below are the anxiety provoking rating scale that Susan established with the therapist.
Defecating in public 100% anxiety
Getting a lift in a friend’s car 100% anxiety

Getting on public transport 90% anxiety
Using a public toilet 80% anxiety
Going to movies 70% anxiety
Going to supermarket 60% anxiety
Walking the dog 50% anxiety
Meeting people in the street 40% anxiety
Going to friend’s house 30% anxiety
Going to see a therapist 20% anxiety
Visitor at home 10% anxiety
Staying home 0% anxiety
The usual contracting and talking about the experiment and what the purpose or intentions had been for this experiment, were explored and talked about. One has to get agreement and cooperation from the client for such experiments to work. It would also be unethical to rush the client or not to explain the experiment’s purpose or process. Sometimes you get to an impasse during the preparation of such an experiment, and if the client is hesitant to participate in the suggested experiment, a therapist can always explore or work with the impasse instead. Anything can be ‘grain for the mill’ in therapy (Clarkson, 1994).
The setup of such an experiment takes about five to 10 minutes. After Susan watched the movie scene, Susan’s experience was processed and the focus went back to the whiteboard. When Susan was asked if anything had changed with her perception regarding the rating scale that had been established earlier, before she had seen the movie, Susan started to laugh. She replied that nothing was even remotely comparable, to that, which was written on the whiteboard. She replied that in light to what she had just seen on the screen, the movie made her fear look ridiculous and completely out of context. After Susan was invited to rate the scene in the movie, she replied that this situation would obviously create 100% anxiety. When she was asked again how the other ratings would now rate she started to look confused. Following that, Susan was asked ‘what is the worst thing was that could happen?’ if she really defecated herself in someone’s car. She replied that she might lose a couple of friends, but that it was not life-threatening. When Susan was pressed again to go back to the scale so the scale could be adjusted accordingly, Susan conceded and she reflected back talking about shame and how all the things she had imagined are just created in her mind. She realised that the fear she dreaded was just created and not real. After Susan was made aware that it only took 30 minutes of therapy, to come to this new awareness, she became quiet. When Susan was asked if her fear of defecating herself in public was possibly even reduced to about 50% considering the movie situation, she reluctantly agreed. When Susan was then told that it was even possible to reduce this fear further if she would continue with therapy Susan suddenly started to cry. After Susan was questioned of what she was feeling during this moment, she replied that she had found 'hope' again. Susan reflected back on the session, and the session was processed so her new awareness could be integrated. This time Susan went home with some newly found hope for recovery. This session was a breakthrough and a major milestone during Susan’s therapy and Susan talked about this session for weeks to come.

The empty chair technique

This technique is also one taken from the Gestalt theory. A gestalt therapy experiment is an intentionally designed experience to bring up unconscious material. This material can be used to facilitate change and increased awareness for clients (Brownell, 2010). Two voices Susan had internalised through years of self-talk were externailised during one of her session. One voice was the critique that was constantly at work, and Susan gave it the name “Meanie”. Meanie’s job had been to tell Susan what she had to do and what she couldn’t do. Meanie was running Susan’s life. Meanie also was the one that was looking out for Susan’s safety. Meanie was doing all the planning and catastrophising and was the one that constantly put her down and told her that she was disgusting and useless. The other voice was the little girl, who was told what to do, and how to behave. She even named it the little girl. The little girl had not much to say at all in Susan’s life. Now and then a chair technique was used to create a dialogue between the two voices. Sometimes the anxiety even got a name because Susan called it ‘IT’ continuously. ‘IT’ was put into the chair opposite to Susan, and a dialogue was created between Susan and the ‘IT’ (Anxiety). Sometimes other imagined people were put into the chair and Susan was invited to give people names, or use metaphors, again externalising feelings. This technique enabled Susan to have a dialog with her anxiety. Through these sorts of experiment’s clients can express and experience emotions and behaviours that promote catharsis, but this is not always the intention. Experiments also provide new information a therapist can discover and work with (Brownell, 2010).

Benefit calculations (Froggatt, 2012)

Sometimes benefit calculations were used. The pros were recorded about Susan’s planning around toilet issues on one side of the whiteboard. On the other side, the cons or disadvantages about her planning and what it did in the long-term were recorded. Planning outings had been very time-consuming for Susan; therefore a simple benefit calculation made it obvious to her that it was in her interest to reduce her behavior of continually planning outings. After such a benefit calculation, Susan was invited to come to therapy without planning it, to make a start in changing this behavior. Eventually, Susan could stop planning before therapy. Benefit calculations are very effective in disputing irrational thinking and core beliefs as well as changing unwanted behaviours. These calculations can be used for many scenarios or problems that arise during therapy. Benefit calculations such as this also were used if Susan wanted to solve a particular problem.

Exaggeration technique (Brownell, 2010)

Sometimes Susan was asked to exaggerate her controlling behaviour. Once Susan was encouraged if she could pretend to go to a toilet and act out using a toilet out in a counselling room. The thought alone of doing something like that created anxiety so eventually the experiment was modeled to Susan (Modeling) because she just wasn’t able to do it. It was very funny at times, and the whole episode ended in bursts and fits of laughter. Humour was also used a lot in Susan’s therapy to normalise the shame that came up now and then. Susan once said during therapy that nobody in a restaurant goes to the toilet to have a ‘Shit’. Susan was absolutely positive that she was right. When she was asked to repeat the irrational statement she had just made in a really loud exaggerated voice, she realised how irrational her statement actually was. When Susan repeated her belief it sounded like this; “Even though this restaurant has toilets, nobody is allowed to use these because that is not what people do.” Such experiments can be done with humour in mind and techniques such as this can be very effective, but they also raise awareness to how serious some of the cognitive errors can be and are not even noticed anymore. It helped Susan to become aware of how irrational and dogmatic some of her thoughts or rules/demands had really been. Creative disputation techniques work very well, and new ideas can be continually explored when working with such clients. There are many more techniques such as coping rehearsals, the worst-case technique, the blow-up technique, time projection techniques, visualisation techniques, the use of mindfulness humour and metaphors (Froggatt, 2012). Another form of creative disputing is the Role-Play technique that was used with Susan as well. The role-Play technique requires a strong counseling relationship because they can get awkward for clients.

Role-Playing

Role-Plays can help uncover automatic thoughts and core beliefs from the unconscious. The client can respond by modifying these newly discovered beliefs through role-playing. Clients learn through role-play new social skills; they can practice also new beahviour (Beck & Beck). One day Susan was asked why it is so hard for her to tell people or even her best friend about her anxiety, obviously she had some shame around it. A simple role-play enabled Susan to explore that during therapy. In such a case the therapist would role-play to be Susan’s friend and he would respond with maybe three different responses back to Susan what her friend might say after she had told her friend about her anxiety. A Role-Play can also be a good rehearsal exercise. The client can practice talking about the issue. It normalises talking about difficult issues. The Role-Play provided a safe environment for Susan to practice talking about a problem that she might not be able to discuss otherwise. It can be very useful, but used mostly in CBT are the three basic disputation styles below.

Pragmatic disputation

This Socratic disputation style has worked really well with Susan. Pragmatic disputation is a form of gentle persuasion. It works by asking the client questions rather than making suggestions. It helps clients to uncover, reevaluate, and deal with situations realistically based on their own considerations. (DiGiuseppe, Doyle, Dryden & Backx, 2013). It helped Susan to admit that the way she had adapted to the anxiety had only short-term rewards, but long-term her health was getting worse. Questions like: (See below).
Is this way of looking at the situation working for you?
How does this point of view affect how you feel and behave?
What are the consequences if you continue to do this?
Is this a useful strategy? Does this belief work for you?
Is this strategy working for you? What would you like to change if you could?
Could you imagine giving up this belief, what would it be like?
What are the pros and cons if you gave up this belief?

Logical disputation

This sort of questioning is useful to challenge a client on his/her logic and if the irrational beliefs are clearly not logical and inconsistent with the clients reasoning. (DiGiuseppe et al., 2013). This style of disputing or reasoning was used with Susan; however, logic disputation was not working as well as pragmatic disputation techniques with Susan. It was very likely that one found oneself drawn into a logic tussle about what is logical and what was not with Susan, so this was less useful at times. Questions like:
Is it logical to continue with this, even though this strategy makes you ill?
You say that people don’t use public toilets even though they are there for people to use, is that a logical conclusion?
Is it logical to stop eating before you leave the house and start purging later?
Does it make sense not to tell people about your anxiety even though you say that telling people about it would reduce your anxiety?
Why do you feel you “must” plan ahead before you leave the house, although you haven’t had an accident for 14 years?
You say you don’t want to inconvenience people, yet you expect your own family to put up with your inconvenient planning behaviour, what is the difference? Does that make sense?
How does getting up to go to the toilet in the movies make it unreasonable?

Empirical disputation

This style of disputing worked much better, however. Most of Susan’s cognitive errors had absolutely no empirical evidence because Susan used to overgeneralise a lot. “The cognitive errors will likely involve errors of induction, in which clients make overgeneralized conclusions based on insufficient data” (DiGiuseppe et al., 2013, p. 162). Questions such as:
Where does it say that people don’t go to the toilet at the Movies?
Where does it say that people don’t use public toilets for number two’s.
Where is your evidence that people think that?
How do you know that the receptionist thinks that when you walk past?
Where is the evidence that if you stop planning outings, there will be an accident?
How do you know that it is not acceptable to ask someone to stop the car?
Is there a law that stipulates that people are not allowed to have an accident?

Developing rational alternatives

Part of the disputing process is the development of a rational alternative, which is a statement, or a sentence the client creates for himself. The therapist needs to assist the client to construct a new rational belief, which is an improved new perception of the situation; ideally it is also a compromise from the rigid inflexible position the client took, before the disputation stage was worked through (Dryden & Branch, 2008). Susan for example came eventually to the conclusion that her irrational belief that nobody should be getting up during the movies to go to the toilet was not useful. With this irrational belief, Susan only ever used seats on the edge of a row, next to an entrance (the worst seat in the house), although the theatre had much better seats with better views available. The reason for this was, so Susan was able to sneak out to the toilet without anybody noticing her, or that she would not be an inconvenience to anybody, although it was OK for her to inconvenience her own husband with this behaviour. Eventually, Susan conceded that her belief was irrational. “A non-dogmatic preference has two components: (i) An ‘asserted preference’ component and (ii) a ‘negated demand’ component” (Dryden & Branch, 2008, p. 161). Disputing evaluation:
Demand: ‘Nobody should be getting up during the movies to go to the toilet’
‘Asserted preference’ component: It’s annoying when people get out of their seats at the movies, it is not normal and it drives me crazy!
‘Negated demand’ component: but I can tolerate it if that happens to me.’
Non-dogmatic preference: It’s annoying when people get out of their seats at the movies, but I can tolerate it if it happens to me’ (Dryden & Branch, 2008). Part of successful disputing is the development of a rational alternative. “In conclusion, the purpose of disputing your client’s irrational beliefs is to help her to gain intellectual insight into the fact that her irrational beliefs are inconsistent with reality, illogical and lead to poor psychological results as well as impede goal achievement, whereas rational beliefs are empirically based, logical and constructive” (Dryden & Branch, 2008, p. 168). Only replace beliefs that have been disputed enough and the client conceded that the old belief is no longer useful and irrational. The new belief also needs to clearly contradict the old belief. The client needs to believe this new perception and she needs to embrace it, so old core beliefs can be replaced successfully.

Exposure

While Susan was in therapy, most of the work was around working with cognition and behaviours, but that was not the only way her anxiety was reduced. Eventually, it became clear that Susan also needed to be exposed to real situations in her life out of the counseling room. The problem was that Susan avoided situations that even remotely could be scary or would expose her to her imagined fearful situations. The problem with doing that (avoiding fears) was that Susan never got a chance to overcome her fears. Also, over the past 14 years Susan avoided her fears and it made them even stronger, although she believed her avoidance strategy was actually helping her. The only way Susan would be able to accomplish this was by systematic desensitisation. Susan had to learn to push her own boundaries, and force herself to make behavioural changes in her life. Usually, the subject of exposure was discussed before the end of therapy sessions and most of Susan’s homework was centered on exposure and behavioural changes out of therapy. This was done by creating lists and possible goals such as going to a movie, not planning coming to therapy or reducing her usual time of planning at home before she would leave the house. There is much empirical evidence that supports the notion that CBT is best used with exposure therapy when dealing with anxiety disorders. A treatment package combining both, CBT and exposure therapy, would therefore be more efficient and effective in treating various anxiety disorders (Abramowitz & Deacon, 2011). The step-by-step exposure achieved through behavioural changes with the combination of CBT therapy sessions, and interventions were vital to help Susan to recover. Another way of exposure to fears had been techniques that used imaginary feared situations during therapy. Here, Susan was invited to imagine feared situations using a mindfulness introduction. Once the fear was triggered, it could be explored and disputed.

Behavioural change

The client behavioural change can only be achieved if the client concedes that the current strategies don’t work. The behaviour needs to be scrutinised for this to eventuate. After that process, the client will be more motivated to change his behaviour and strategies. (Hughes & Herron, 2014). Susan positively agreed that her strategies had not been working out for her in the long-term so it was agreed to work on behavioural change, exposure, and CBT to target the problem with interventions from all three angles at the same time. Also, this approach gave Susan the confidence back, the hope and the courage to try new behaviour for the first time in 14 years. With new behavioural strategies, the client will be doing something different or trying a new way. Susan needed to confront her fears for the first time, rather than avoiding them. “Behavioural strategies involve deliberately acting in new ways: confronting fears to discover one can cope with them; raising tolerance for discomfort by deliberate exposure; opposing old beliefs to prove that they are invalid; reinforcing new beliefs by acting on them; and experimenting with new ways to handle problematic situations” (Froggatt, 2012, p. 71). Most of this was achieved through homework assignments, agreed on at the end of therapy sessions. Susan then reported back her own progress during the following sessions. The collaborative nature of this strategy assured Susan’s willingness to trying and testing out new behaviors.

Homework

Homework helped Susan because it kept her busy between sessions to think about why she is in therapy. It also kept her engaged with trying to change her emotions, behaviors, and beliefs. Homework also prepared her for the next sessions, and it kept her focused. Most of the homework was behavioral because that was something she could not do much in therapy. Following sessions continued by talking about the changes she had made during the week or if she were successful or not with something she wanted to try. Below is a list Susan of goals Susan compiled as part of one of her homework assignment. The list represents all the areas Susan had been working on. Some are behavioral changes, some are about exposure and some are cognitive changes Susan worked on out of therapy.
Not turning down opportunities
Stop purging and eat more healthily
Open to having friends
Encourage sociability
Work on relationship changes
Have empathy for others and myself
Learn to do less planning
Less catastrophising
Work on my positive Self-image
Working on not acting inferior
Working on not feeling disgusting
Be kind and be less demanding on myself
Grieve for lost time and have regrets
Put things into perspective
Be more creative
Entertain the idea of sharing the anxiety with other people
Practice mindfulness
Work on improved bowel health and movements
Work on NOT hanging on to old core beliefs
Believe that it will change in time eventually
Reality of dreams/ Make plans for the future without anxiety
Become aware of rational thought processing
Reduce my irrational thinking
Increase my rational thinking
Track the ABC sequences when anxiety is triggered

Evaluation, ending therapy and follow-up

To date, Susan had 12 CBT sessions, and it has been agreed that there has been some considerable change. Susan is still working on the above list of goals; however, CBT still needs to be continued to prevent relapse. Susan is aware that the use of regular CBT techniques is vital to prevent relapse. CBT does not cure people, it only works in the long-term if clients continue to adapt to a CBT lifestyle (Witkiewitz, 2007). As part of Susan’s recovery this manual was offered to Susan to help her integrate her CBT experience and to have something tangible she can hold on to after therapy ends. She was pleased that she could take this manual away with her. Susan anticipates leaving therapy soon when she feels that she is ready to continue on her own. Susan symptoms have improved and that was acknowledged in one of her last sessions. Dependency issues had also been talked about as well as the option of coming back to therapy at any time if Susan started to struggle on her own. Susan knows that this door is always open to her in the future.

Using different modalities: CBT/Gestalt

During Susan therapy, the CBT and the Gestalt modality has been used interchangeable and it worked. Gestalt works with defensive functions and strategies, which also include much irrational thinking. This irrational thinking style in CBT theory, or the activation of defensive functions in the Gestalt theory is a similar concept. Both take into account past negative experience (schemas). “Schemas are organizing principles or meaning structures, which—when activated— establish a perceptual and experiential filter in the individual’s relation to the environment” (Tønnesvang, Sommer, Hammink, & Sonne, 2010, p. 592). Schemas develop in early age and once they are established and the experiential and perceptual filter was created in dysfunctional and stressful environmental settings they become rigid and the affected person finds it difficult to adjust to changing circumstances. CBT theory suggests that schemas get adjusted throughout life if family of origin circumstances had been favourable; however, if dysfunction occurred, modification of schemas will not happen. “Once schemas have been established, the individual will typically try to confirm and maintain them, also in the face of disconfirming data in the environment. It happens partly through cognitive distortions, and partly through the behavioral patterns that are developed to cope with schemas” (Tønnesvang, et. al., 2010, p. 592).
In CBT theory, a therapist usually works with a client to adjust these core beliefs and rigid schemas or cognitive errors (inferences & evaluations) with disputation techniques. Rational alternatives will be explored. In Gestalt theory, the therapist tries to bring awareness to defensive functions (or cognitive errors as in CBT) and the Gestalt formation process by deepening the client’s experience. Unconscious processes become conscious, and this is done through the ‘Experiment’ that is set up in collaboration during the session. (Wheeler, 2013). These experiments also can be used in the CBT modality, just as this was done with Susan. Both modalities also work in the here and now although Gestalt does explore the past more often than CBT. However, both modalities look for change in behavior.


Summary of strategies and techniques discussed

This model was mainly used during sessions with Susan. There is a sequence that was followed during most of the sessions with Susan.
A. Ask for an Activating Event
C. Assess the Consequences (Emotions/Behaviours)
B1 Identify the automatic thoughts
B2 Identify the core belief(s)
E. Clarify the desired new Effect
D 1. Dispute the beliefs
D 2. Replace the old belief with a new rational one.
F. Develop action/Homework, etc.
(Froggatt, 2012, p. 32).
The above summary of the ABC model, also called a ‘Rational Analysis’, is something that was used as a template for most sessions with Susan. The process or sequence usually takes an hour. If possible the technique of Inference Chaining was used to get to (B). A therapist must always focus and relate back to the unhealthy emotions such as shame, guilt, anxiety, rage, hurt or depression.
Identify from the seven Inferential distortions: (Froggatt, 2012)
Negative Filtering Black & White thinking Emotional reasoning
Overgeneralising Mind reading
Fortune-telling Personalising
Identify from the four Evaluation styles (Froggatt, 2012)
Demandingness Awfulising & Catastrophising
Discomfort-intolerance Self/other-rating
Also discussed has been the use of creative disputation techniques such as the Catastrophe scale, benefit calculations, empty chair technique, exaggeration technique, and role-play.
Also discussed was the importance use of the three basic disputation skills: Pragmatic, logical, and empirical disputation techniques and the concepts of:
Developing rational alternatives
Exposure (gradual desensitization)
Behavioural change
Homework.
Limitations of CBT
The client needs to be motivated and committed to get better or for CBT to work. The client needs to be fairly intelligent to grasp CBT to understand the connection of thoughts and how they influence emotions. CBT only works if the client continues to practice CBT after treatment educates him/herself further about the CBT modality and adopts CBT as a lifestyle. This is because relapse is likely if the client does not continue with the use of CBT techniques to deal with this phobia. The building of a strong working relationship is particular important because the client will be sharing a lot of intimate details about toilet use and behaviour. The client group (In this case female client/male therapist dynamic) may also influence the therapy outcome. Safety concerns need to be addressed during session. Safety concerns also need to be addressed when the client starts actual exposure experiments in the outside world of therapy. CBT exposure techniques during therapy have limits. The phobia also has a strong biological inheritance factor to be considered so this may also have limitations as to how much the client can actually change. There is also very limited research out there relating to toilet phobia and clients find it difficult to find information or books that deal with such a phobia. To deal with this issue it has been decided to publish this manual on a website to improve access to information and how it is treated within mainstream society.
Toilet phobia is still a subject that people rarely discuss therefore treatment has limitations. Most clients find it difficult to discuss their phobia; therefore they hide this phobia and become isolated. Certain populations and those dealing with health inequalities might find it difficult to get access to treatment if they have to pay for therapy. Susan’s therapy was without charge. When working within interdisciplinary health settings, the limitations of working with this phobia are to be considered. Group work may suit this phobia; however, it is likely that there are not many other clients around with the same phobia because the phobia is so rare. Also, not many clinicians know about this phobia and in my experience CBT is the only treatment option that actually works. Ethical factors need to be considered when working with this phobia using other modalities, as I found it necessary to consider. It is not ethical to work with such a client group using another modality (just as I did, using Gestalt) not knowing anything about the phobia and then referring or terminating therapy too late.

Final thoughts

Although some of the content in this manual talks a lot about techniques and procedures at times, it is not always exactly like that during a CBT session when I am with a client. As I am trained in Gestalt therapy, I like to give the client some room and I don’t always follow the CBT structure of how a CBT session should proceed as I sometimes compromise. I believe that clients come to therapy because they want and need to talk, and I like to allow the client to do this in therapy for some time. Sometimes I plan a session, but most of the time I don’t plan ahead. I also keep an eye on talking times, and I like to see an equal share of talking time in therapy. I like to think that there would be a 50/50 share of talking time between the client and me. If the client spends too much time talking, I would make an intervention, but I also would make sure that I don’t talk most of the time either because CBT can be very directive. My therapy sessions have more structure since I studied CBT and REBT. Before I studied these modalities, I made an assumption that they are not proper psychotherapy. I called CBT a plaster because I thought that clients would not deal with their underlying issues. However, I was wrong. During my work with Susan I realised that CBT is a very powerful tool when I work with anxiety, depression, and addictions. As I said before, when I worked with Susan using only Gestalt therapy, progress was not happening and Susan was not improving, but when I adapted using CBT as well, Susan did improve. Since discovering this, I have adapted to using both modalities utilising both CBT and Gestalt when required. In my view CBT lends itself to using it with other modalities.
During my work with Susan, I had supervision with five different psychotherapists and none of the supervisors had ever heard about toilet phobia. During our work, I consulted with each of them and the feedback I got helped me stay on track with Susan. I questioned at the start of therapy if a client with such a phobia should be on anxiety medication, and we considered that. Each of the supervisors had differing views on that. In the end, Susan decided not to take any medication during our work. In my view, the client worked better without anxiety medications and it was a good call. I would like to thank Susan for being my practice psychotherapy client for this manual because without her I would not be able to write this manual. It is a simple manual written for people that also suffer from this anxiety and other counsellors or psychotherapists. I can only conclude that CBT works as a treatment for toilet phobia. We had results after about 12 hours of CBT. If Susan continues her work, I am sure that eventually, the phobia can be overcome. I am confident that Susan has enough skills now to observe her automatic thoughts, track them back to triggers and emotions so she can regulate her emotions better, as well as her behaviour by using the ABC model at home or anywhere else she might be after therapy ended. Thank you for being my client Susan, I enjoyed you as a client and it was a privilege working with you. I learned a lot about CBT during our work together. This manual is for you so you always remember your psychotherapy journey. You are now officially an acceptable member of society again!
“Rules governing defecation, hygiene and pollution exist in every culture at every period in history. It may in fact be the foundation of civilization: What is toilet training if not the first attempt to turn a child into an acceptable member of society? “ -Rose George

figure_toilet
Ancillary "clinical commentary"

As I already mentioned, Susan and I had 30 hours of therapy using the Gestalt therapy model before I eventually trained in CBT so I could help Susan and start using CBT. Gestalt therapy had some real limitation in helping Susan, but I am sure that the relationship we had already developed, helped when we started eventually using CBT. I think that is an important fact to consider. I was really surprised to see the difference of speed in Susan’s recovery, once we started using CBT. CBT clearly has its place in psychotherapy now and I can only recommend using CBT when working with depression and anxiety. I am sure it works for many other issues such as addictions or eating disorders and even schizophrenia. CBT has become a powerful tool in my arsenal of psychotherapy skills and I am grateful for Susan finding her way to me. Susan motivated me to study CBT, because she was the one that turned up one day with a CBT book in her hand, asking me if I could try this on her. One other thing that is worth mentioning here is that Susan was not charged for any of her sessions because I had been in training during the time we worked together. I would estimate that the same treatment with a professional CBT therapist would take about 20 hours. Considering that it costs about $150 per hour these days, the same treatment would cost around $3000. This is a lot of money and time for people to invest into their mental health and not many people can actually afford such treatment. No wonder many people with this phobia go on without treatment, just as Susan had done for 14 years. I recommend to anybody out there that has this phobia to give CBT a try. Nobody needs to suffer from such a debilitating anxiety when it can be overcome by using CBT psychotherapy. There is hope of real recovery for any person that suffers from this anxiety. It can be treated, trust me because I have observed it myself. Susan’s story is a testament to this and that it can be done as long as a client is committed to the treatment and wants to change.
The other point I like to make again is that CBT needs to be continued after therapy ends. It has to become a lifestyle. CBT is not a cure and if ignored or neglected after treatment symptoms are likely to return. In my view CBT has a strong biological inheritance factor that has to be considered. Some anxieties and phobias or other issues like alcoholism and drug abuse, etc. may even be passed on through genetic changes in DNA. This makes some clients more vulnerable than other more resilient people. CBT is designed to be adapted by clients that have had CBT treatment. Clients that leave therapy should be familiar with the ABC model and carry on using the model, long after they have ended therapy. I am sure Susan will continue to work on her quest to overcome this phobia. The end!
"Keep your thoughts positive because your thoughts become your words. Keep your words positive because your words become your behaviors. Keep your behaviors positive because your behaviors become your habits. Keep your habits positive because your habits become your values. Keep your values positive because your values become your destiny."--Mohandas K. Gandhi

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