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cognitive therapy & practical advice

1 Understand the evolutionary reason why lock up is normal physiologically – as a response to a potential threat. e.g. deer, when they sense a threat, freeze to be less noticeable; urination is disabled, because a flow would generate noise, smell and movement, all of which could attract the attention of a predator.

So its not the inability to pee but the anxiety that needs to be addressed so that, when reduced, the body can go ahead and do what comes naturally.

Transfer of blood from inessential organs to the muscles explains shrinkage – sometimes a cause of disquiet.

2 Physical relaxation, including anal sphincter relaxation. Breathing, shoulders, buttocks, abdomen, sphincter. Being physically tense makes it more difficult to pee. This is one reason why it can be more difficult in a rocking train carriage.

Ensure you routinely breathe slowly and deeply; ensure you breathe out fully and relax your abdomen. APs tend to either get panicky, resulting in rapid shallow breathing, or to tense up and not breathe at all! Deep slow breathing will calm you down. Use the Phobease method: breathe in deeply and slowly thru the nostrils, hold for count of four seconds, breathe out slowly & completely through pursed lips.

For your legs, lean forward and back, to find the centre point where the thigh muscles do not tense up. Sag slightly at the knees.

Similarly let your shoulders drop. Hunch them and drop them.

Relax your stomach muscles – it is very common for anxious people to tighten the abdomen below the belly button, so putting pressure on the bladder and creating an urge to pee when the bladder is not yet full enough. Relaxing those muscles can postpone this urge.

Re the sphincter, we cannot consciously relax the urethral sphincter, but we can relax the anal sphincter. To experience the sensation of the opposite of relaxing it, stand up and do whatever you need to do the “stop the flow”. Notice that this has the effect of clenching the anal sphincter. Physiologically there is a link between both sphincters. So to relax the urethral sphincter, consciously clench and then relax the anal sphincter. And then relax it some more, till you feel like your insides could drop down between your legs. This will not necessarily make you pee, but if it is clenched you definitely will not! So…

Flop the bot

People who find public speaking a challenge (itself a social anxiety) are advised to steady themselves, by holding onto something like a lectern. The same applies to us – i.e. touch the wall, bowl or partition to steady yourself.

3 Understand that hesitancy is normal. (Hesitancy is the delay between being ready to pee, and the flow actually starting).

Hesitancy is a range – some men have a hesitancy of milliseconds (!), and the rest exist on a range upward from there. For the author it is 6 – 8 secs. Now this can seem a long time standing there. However if you know that is your normal hesitancy, you can stand there with no fear. The trouble is we only notice the millisecond guys and so believe we are abnormal. We are not.

Hesitancy is situational (external challenge, internal mood – tired, stressed).

Again this is normal. People who do not have a shy bladder experience this – to the extent that at times they cannot go at all. The difference is that they do not see it as a problem, only an inconvenience (!). They just wait till they do pee, or leave and try again later. (see cartoon)

Hesitancy is not a problem; the problem lies in what you think about hesitancy.

Time your shortest hesitancy (say at home). That is your starting point. Most APs panic after what seems a long time, but is only 10 secs. Accept that at first you will wait 20, 40, 60 secs – if not more.

Recognise that being with an authority figure affects you e.g. your boss. Matt Damon once locked up because he found himself in the presence of President Clinton; he moved to a cubicle and was still unable to go.

Any bloke can get lock up – viz the Big Issue cartoon.

4 Thought stoppage: this is where you take control of your negative thoughts. The moment a negative thought pops up, whether in anticipation or at the time, say “stop” to yourself i.e. stop the thought. Do a deep slow breath in though your nose, hold it for 4 seconds, and do a long slow release through pursed lips. Then look at the thought dispassionately and recognise it as an anxiety thought, and say to yourself that it is not based in reality. (In Phobease speak, it is the Boo Monster trying to frighten you.) Then deal with the thought by giving a positive response e.g.

So what, he’s got more interesting things than me on his mind.

So what, I’ll wait her out – I’m not in a hurry.

So what if I can’t pee, I can always try again later.

What if I can pee?

The main thing is to stop any further negative thoughts from getting a look-in, and so increasing the adrenalin in your system. By using Thought Stoppage, you have only a little bit of adrenalin to deal with, and that little bit will fade away if you wait a while. Also avoid drinks that create adrenaline, like coffee and coke.

Remember: other people are not appraising you, judging you, finding you wanting; instead they are not in the least bit interested in you; they are more interested in football, what to wear, sex, work, worries etc.

5 Anchoring. Build up a routine of things you do to help you to pee. Choose a cue word or action that starts off your routine e.g. Johnny Wilkinson’s hands together and shuffling.

6 Wait other people out. If inhibited by the presence of someone else, just wait patiently knowing they will eventually leave. No-one notices or cares. Paradoxically, the busier the place, the easier it is to wait it out. The record is 20 minutes – no-one noticed or cared.

Wait it out, no-one’ll shout

7 Get used to the range of urgency 1 – 10 where 1 = no urgency and 10 = bursting. Most APs are so used to going too early, so as not to get caught out later, that they have forgotten what the full range of urgency is. Experiment at home with this by fluid loading. Drink at least 1 litre and as much as 2 litres: after an hour you will be getting the strong urge to pee. Aim for the 7 – 8 level: a good strong full feeling where you know you need to go within 5 minutes.

Go only when the urge is right for you, not too high, not too low (i.e. not a twinge).

Go as soon as you can when the urgency is right, i.e. before you have time to start worrying.

You will need to practice this, because it takes several sessions to get used to it.

Wait for the urge, then let it surge

8 Understanding how past experience (of failure) and anticipation of the future (of failure) affects how you deal with the present.

In contrast, a non-ap person in a challenging situation will draw on a past experience (of success) and an anticipation of the future (of success) to say to himself “come old man, get on with it”.

When you have a success during desensing, treat that as a memory to revisit time and again as a positive experience. This will help to drive out the negative memory. When you move up your hierarchy, build up these memories of positive experiences and practice them in your mind.

9 The need to develop a Positive Mental Attitude. See the glass as half-full rather than half-empty.

Use positive body language to get a feeling of power.

Be proud of your achievements – walk tall.

The F**k Everyone Else attitude, they can get lost.

Is my glass half full, or half empty?

10 Misfires happen…but so what?! Count your successes, throw away your misfires.

If you do misfire, leave and return a few minutes later. Non-ap peopledo this so you can too.

11 Keep a diary of your successes: time and again APs say that they found their diary surprising, because they had forgotten how many successes they had had; this realisation boosted their confidence.

12 Urinal etiquette. Men avoid standing next to someone unless there is no choice. In such situation, a good proportion of men prefer to use a cubicle and that is OK.

A good proportion of men dislike cramped facilities, busy facilities and troughs. They may even exit and wait to go elsewhere.

It’s OK to want your personal space

Play the urinal etiquette game at:

Note that this is NOT a paruresis game; it is evidence of normal behaviour.

so what can you do practically:

13 Tell trusted people, father, mother, sister, brother, partner, best mates. Be matter of fact about the condition – it is a social anxiety. But ensure you emphasise how it messes up your life and your peace of mind.

Don’t down play it.

If they ask how they can help, say that just them knowing takes pressure off you, but they could help by taking your needs into account e.g. about where to go out, how long to stay, or by covering for you when you take a long time.

Pay your friend a compliment, trust him/her by telling him.

14 Visit a well designed installation to see what it is like, and learn that such places exist.

Some of the newer JD Wetherspoon pubs have good ones, but not always. Use these to desense in, once you’ve mastered the home environment.

15 Most APS do not know what passes for routine behaviour in a public WC because they either do not go to them, or are so freaked out while they are there, that they do not notice. It is necessary to find out what goes on there so…

desense to the environment, and experience normal conditions.

Do this by experiencing the threatening situation with no intention to perform, just to get used to the environment, and to realise that no-one cares. Do this repeatedly, until it becomes a bore.

People who do this find that eventually they get so “bored” with the situation that they start to pee even when they did not plan to.

Fake it till you make it

16 Learn to inconvenience others. APs often freeze because they feel under time pressure – there is a queue, or your group is waiting for you.

You must learn that you have a right to the time you need to perform without being rushed. To practice this, do as above i.e. when you do not need to pee. Take your time when friends are waiting. If anyone comments “you took your time” just brush it off saying “Did I? Sorry” or “It takes as long as it takes” etc. and change the subject.

This toilet is mine and only mine till I have no more need of it

17 Socially anxious people use evidence of what they can see/hear as evidence for what they cannot see/hear.

e.g. if someone happens to glance in your direction, an AP will use that as proof that the person is actually thinking negatively about him/her. But what evidence is there of what is going through the other person’s mind? None!

If you walk past someone standing at a urinal, he may glance up; that is just to check that you have gone past; it is an automatic reaction due to the dislike of the feeling that there is someone out of sight behind him; it is not a judging “look”.

18 Gradual desensitisation. To desense, it is necessary to start with a situation you can cope with. Only when you can perform successfully at that level, do you move up a level. These levels must be small increments of change; see the examples at the end of this document.

You will need to load with fluid (say 1 – 2 litres) till you have a good urge say 7 – 8. Then when you do manage to pee, do so for 3 secs and stop, so as maintain a reservoir for further trials. This is very well explained in Steve Soifer’s book Shy Bladder Syndrome available via Amazon.

If you cannot pee, check your anxiety. If it is climbing rapidly, leave the toilet – you do not want to reinforce the anxiety. If it is manageable, give it some time to settle down, but no longer than 2 minutes – it is better to leave, calm down elsewhere, and reconsider the level you are attempting.

Note that you can do a lot at home with a partner.

19 The spit and stroke technique for men. There seems to be a nerve which, when stimulated, increases the urge to pee substantially. It is located in the bit of penis skin which "anchors" the shaft skin to the underneath tip of the penis. If you are uncircumcised, it means retracting the foreskin partway to do it. Just a light touch and a slight urge can ensue.

Both men and women report that tickling the base of the spine, just above the coccyx, also stimulates flow.

20 Virtual desensitisation. Practice visualising a calming place, till you can go there at will.

Then visualise the anxiety provoking situation to desense to it in the mind, switching to the calm place and back again as necessary.

Practice this virtual desensitisation regularly.

21 Laughter therapy…


…ho, ho, ho

Laughter relaxes the body – you cannot be tense and laugh properly at the same time. Think of something that makes you chuckle or smile while you are there. Imagine that person coming in as having a big red clowns nose, and flappy clown’s feet; the internal chuckle will relax you a bit.

There is a Sufi saying:

Faeces are the excrement of the body
Dreams are the excrement of the mind
Laughter is the excrement of the soul

So take up opportunities in your life to laugh: whether film, show, social occasions, books etc. Then learn to laugh on your own as an exercise.

22 Break the silence. For many, it is the unnatural silence that is unnerving. If you can break the silence it breaks the ice. Additionally, if you can talk about something, it switches the focus of the brain from the right side (the emotional side) to the left side (the rational side that is used for speech). This reduces the control that your emotion has over you.

If with a friend or colleague, get them talking. If with strangers, a non-committal remark can break the ice “better out than in”, “bloody cold isn’t it?”, “brilliant penalty that eh?” .

23 Focus. People with AP tend to go into a toilet like an aircraft carrier, with their ‘radar’ scanning 360 degrees, taking note of everyone and everything around. Non-APs’ are like a fighter plane, with their ‘radar’ focused on the bowl or urinal they are heading for, and stays locked in to the spot they are aiming at, so leaving them unaware of anything around them. Discipline yourself to focus narrowly like that from the moment you go through the door. Deliberately ignore everyone and everything else.

sample desensitisation hierarchies

Start at 1 and move up to 10. Vary the criteria depending on personal requirement (where X is the buddy): Distance, Sitting v standing, Making a noise, X in sight but not watching v X watching (difficult), X silent v X talking.

Distance location is a hotel room with an en-suite bathroom.

10 You and X are “side on” but X is in open doorway.
9 X is in sight in open doorway.
8 X is by bathroom door but out of sight. Bathroom door wide open.
7 X is by bathroom door but out of sight. Bathroom door cracked open.
6 X is half way across the room. Bathroom door cracked open.
5 X is in the room as far from the bathroom as possible. Bathroom door cracked open.
4 X is by bathroom door. Bathroom door shut.
3 X is half way across the room. Bathroom door shut.
2 X is in the room as far from the bathroom as possible. Bathroom door shut.
1 X is out in the corridor.

sitting down

10 You are standing up. X is half way across the room. Bathroom door cracked open.
9 You are standing up. X is in the room as far from the bathroom as possible. Bathroom door cracked open.
8 You are standing up. X is by bathroom door. Bathroom door shut.
7 You are standing up. X is half way across the room. Bathroom door shut.
6 You are standing up. X is in the room as far from the bathroom as possible. Bathroom door shut.
5 You are standing up. X is out in the corridor.
4 You are sitting down. X is by bathroom door. Bathroom door shut.
3 You are sitting down. X is half way across the room. Bathroom door shut.
2 You are sitting down. X is in the room as far from the bathroom as possible. Bathroom door shut.
1 You are sitting down. X is out in the corridor.

A worksheet is available to download.

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