CBT For Paruresis: A Useful Therapy

Start by scoring your urgency where 0 = no urgency and 10 = bursting. Most people with Paruresis are familiar only with the extremes: They either go too soon, when on a 2 or 3; or they are caught out and are on a 10 for ages. Learning what the intermediate levels of urgency feel like will help with pee shyness over time. 

Try this CBT experiment at home 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, that is not uncomfortable, and where you know you need to go within 5 – 10 minutes.

Pee for about 3 seconds and stop; difficult but you can do it. Then wait a few minutes. Repeat this, topping up with water, for 45 mins, then drain off. This allows you to start getting accustomed to distinguishing various levels of urgency, and how long you can last. 

To overcome the social anxiety of this kind of toilet phobia, it is necessary to go only when the urge is right for you: not too high, not too low (i.e. not a twinge). In other words go as soon as you can when the urgency is right, i.e. before you have time to start worrying. You will need to practise this, because it takes several sessions to get used to it.

“Wait for the urge, then let it surge”

Performance is inhibited by one or more of the following factors. Each factor has its own challenges.

1. Proximity of other people

2. Toilet sounds

3. Being able to hear other people around

4. If in a cubicle/bathroom, the door being locked, shut, cracked open, ajar, fully open

5. Being in line of sight of someone else

6. Sitting or standing

7. Other person being a buddy, a stranger, a trusted friend, an acquaintance or work colleague, a friend 

8. The level of urgency: the lower, the harder 

9. How many other people are nearby

10. Time pressure

The more of these challenges that exist the more difficult the ability to urinate in the presence of other people.

The process is to deal with these triggers one at a time using graduated exposure. Graduated means in very small steps.

To use Graduated Exposure, first write down a sequence of scenarios. The examples below are based on a hotel room but can apply to a domestic bathroom too.

Start at 1 and move up to 10. Level 1 is the base position where you are pretty sure you can pee. When you can perform reliably in that scenario, you can increase the challenge of any of the above factors (proximity, door position, TV sound, talking/not talking by small amounts.

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.

Notice the very small steps.

Distance  

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.

Go into the situation; remember your routine. When you achieve a steady flow, let the flow of urine run for three seconds and then stop it, to conserve fluid for the next go. Exit. Wait a couple of minutes and repeat. Repeat till you are comfortable with the situation. Then move up a step. The process is slow and steady.

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.

If you have to alter one factor significantly because there is no way to make a small incremental change, for instance moving from a private bathroom to a public facility, reduce one or more of the other factors in order to compensate. Another example of this is when you need to use a public toilet but the urgency is low or there is a significant time pressure, reduce the level of challenge of one or more of the other factors to compensate.

Note that you can do a lot at home with a partner by trying some of these therapeutic techniques for Paruresis.

Lock up is normal in nature as a response to a potential threat. For example deer, when they sense a threat, freeze to be less noticeable. Urination is disabled by the subconscious (the autonomic nervous system), because a flow would generate noise, smell and movement, all of which could attract the attention of a predator. This system is NOT under your control.

Simplified description of the bladder

One part of our nervous system looks after voluntary actions (e.g. raising your arm). A second part (the autonomic nervous system) looks after actions you do not consciously control, like breathing when you are asleep, and the body’s preparation for fleeing danger.

The bladder is surrounded by muscle fibre called the detrusor. The tube that empties the bladder is called the urethra and it exits via the internal sphincter (think of a tap). The detrusor and the internal sphincter are not under your voluntary control, but under “subconscious” control.

The urethra then goes through the external sphincter, which IS under your voluntary control.

What happens is that the bladder fills up and at a certain point sends a signal to say “time to empty”. The subconscious mechanism triggers the detrusor muscle to squeeze the bladder in order to force out the urine – think of compressing a small balloon in your hands. At the same time the internal sphincter opens. The only thing stopping you from wetting your pants is your voluntary control of the external sphincter which you keep closed. When conditions are right, you consciously “let go” which opens the external sphincter and you pee.

With paruresis, the environment you are in causes your brain to go into an alert state i.e. it thinks there is a danger somewhere. The brain’s action is to trigger the “freeze” response whereby the unconscious mechanism (the sympathetic system within the autonomic nervous system) relaxes the detrusor muscle, and closes the internal sphincter. Hence even if you voluntarily want to pee, the unconscious is saying “wait, there’s something wrong”.

So it does not help to be made to drink more and more in an attempt to force you to pee. The subconscious has shut the internal sphincter, the detrusor is not squeezing the bladder so nothing will happen.

This is in contrast to someone with no pee shyness who is trying to avoid giving a urine sample. In that case the detrusor is squeezing, the internal sphincter is open, and it is only the conscious desire to not pee that is keeping the external sphincter closed. Being forced to drink more and more increases the pressure of the urine against the external sphincter and eventually the person will be unable to hold it back.

Conclusion

So what needs to be addressed is not the inability to pee; it is the need to reduce the feeling of being under threat. Once that is achieved the autonomic nervous system will not kick in, the urinary system will not be shut down, and the body can do what comes naturally.

Being physically relaxed is hugely important. Focussing on relaxed breathing, shoulders, buttocks, abdomen, and anal sphincter, will help because being physically tense makes it more difficult to pee. This is one reason why it can be more difficult in a rocking train carriage.

Paruresis sufferers 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. Breathe in deeply and slowly through the nostrils, hold for count of up to four seconds, breathe out slowly & completely through pursed lips. Let your abdomen relax so that you feel like a deflating balloon. 

For your legs, lean forward till your thighs tense up and your toes press against the floor. Then lean back until your thighs tense up and your toes curl up. Having done that, identify the neutral point where your thighs do not tense up. Then sag slightly at the knees. 

Similarly let your shoulders hunch then drop. Shake them up and down to loosen then. Notice how they up lower than before.

Relax your stomach muscles – it is very common for anxious people to tighten the abdomen below the belly button. This puts pressure on the bladder and creates the urge to pee when the bladder is not yet full enough. Pull your belly in, and then let it out like a beer belly. Relaxing those muscles can postpone this urge.

You cannot consciously relax your urethral sphincter, only your 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 and lifting your genitals.

Physiologically there is a link between both sphincters. So to relax the urethral sphincter, consciously clench and then relax the anal sphincter. Clenching this is the action you make to stop yourself farting. And then relax it some more, till you feel like your insides could drops 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 specific social anxiety) are advised to steady themselves by holding on to something like a lectern. If you are working to overcome shy bladder syndrome, touch the wall, bowl or partition to steady yourself.

(Latency is the delay between being ready to pee, and the flow starting).

Latency is normal. Latency is a range – some men have a latency of milliseconds (!), and the rest exist on a range upward from there. Now it can seem a long time standing there not peeing. However if you know that is your normal latency, 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.

Latency is situational. An external challenge, or your mood – tired or stressed) causes the latency to increase. Again this is normal. Men 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. Latency is not the problem; the problem lies in what you think about latency.

Time your average latency in a safe place (say at home). That is your starting point. Most people with paruresis panic after what seems a long time, but is only 2-3 secs. Accept that at first you will wait 20, 40, 60 secs if not more.

Thought stoppage is a key CBT technique for dealing with anxiety issues like paruresis. In this case you take control of your negative thoughts. You can’t prevent a negative though from popping up in your mind. But the moment a negative thought does pops up, whether in anticipation or at the time, say “STOP” to yourself and stop the thought.

Take a deep slow breath in through 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 anxious thought, and not a reflection of reality. Say to yourself that it is not based in reality. Then deal with the thought, say “there’s a guy there wondering why I am not peeing”, by giving a positive response such as:

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

• So what, I’ll wait him 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: each negative thought produces some adrenaline. So the more negative thoughts, the more adrenaline in your system, resulting in rapid heartbeat, sweating and rapid or no breathing. 

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. Peeing to them is totally uninteresting; akin to blowing one’s nose.

Write down all your anxious thoughts. A cognitive therapist would then talk you through each of these, asking you for evidence that each one reflects reality, and offering factual reasons why your fears are unfounded. By talking through this you develop a new way of seeing things, and you have to practice responding to these negative thoughts with a realistic and positive response. 

It can be helpful to dissociate these negative thoughts from yourself, by attributing them to an outside agency (e.g. little devil) sitting on your shoulder, that is trying to startle you so as to feed off your fear. Visualising this little devil can help you to answer back to it using an internal dialogue.

same. Build up a routine of things to do as you prepare to go for a pee, and to do when you are in place such as physical relaxation, switching off negative thoughts, a slight smile, feeling good, and clench/unclench.

It is important to use this drill every time you pee, even in a safe place, so that it does become routine.

There is a classic experiment where a bell was rung every time food was given to a dog. Quite quickly the dog came to associate the bell with food. Then when the bell was rung in the absence of food, the dog would salivate in anticipation. 

So after a successful pee, do something to represent that success; hitting the air is a bit obvious, but a slap of the thigh, a click of the fingers, clicking teeth, pulling an earlobe, that sort of thing.

Then do that same action as you go in for a pee. As you get more and more successes, so the action will be linked with success; using it on “entry” will put you in the right frame of mind and help you to concentrate.

H3: 10: Misfires happen.. but so what!

A misfire is when you do not pee. Don’t see this as a failure but as “normal”. People have misfires occasionally. They just walk out and try again later; they do not see it as an issue. So count your successes, and throw away your misfires. In fact treat them as a learning opportunity; you will mainly find it was because you forgot your position on your hierarchy, and went in too high up.

Is your glass half full, or half empty?

Be proud of your successes and walk tall.

Adopt a “to hell with everyone else” attitude. And focus on your successes in public toilet situations.

Every time you think negatively about something, stop yourself and see it in a positive way.

We know the mind can affect the body; what is less well known is that the body can affect the mind.

A depressed mind will show itself in body language – slumped shoulders, downcast face, head-down posture, rapid walk with short steps. Conversely adopting such a body posture can make one feel “down”.

Contented people are head up, shoulders relaxed and back, neutral or slightly smiling face, relaxed slower pace of walking, and defocused eyes looking at infirnity.

Cognitive Behavioural Therapy for sufferers of Paruresis suggests that by consciously adopting such a positive posture, you can make yourself feel better.

You will also “own more space”. 

Understand how past experience, and anticipation of the future, affects how you deal with the future event when it comes about. CBT states that anticipating future failure inevitably makes it more likely that you will fail when the event comes about. CBT encourages pee shyness sufferers to use past success to help you anticipate future success which makes it more likely to happen.

When you have a success during de-sensing, 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 Graduated Exposure hierarchy, build up these memories of positive experiences and practice them in your mind. This way you build up a history of success and you will improve your chances of performing successfully in the future. 

Keep a diary of your successes. Paruresis sufferers who have used a diary say that they found re-reading it surprising, because they had forgotten how many successes they had had, which boosted their confidence. A diary doesn’t need to be an essay, just a simple coding system that you can read to show how many successes you have had in the past.

Find a way of turning a stressful situation into a comical one. This helps to trivialise the threat.

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 trying to pee. Imagine the person coming into the public toilet as having a big red clown’s nose, and flappy clown’s feet; the internal chuckle will relax you a bit.

Prior to going to bed, write down a couple of positive things that have happened to you that day. Experiments show that this feeds into a better sleep pattern, and feelings of well-being the following day, and on to better health.

Do this regularly each day.

Many men dislike cramped or busy facilities and troughs. They may even exit and wait to go elsewhere. They often avoid standing next to someone unless there is no choice. In such situations use a cubicle instead.

Small toilets with two cramped urinals and one cubicle are a common example. A good half of men who do not have paruresis prefer not to use the second urinal and will opt for the cubicle instead. So you can too!

See the web arcade game on this subject.

“It’s OK to want your personal space”.

If inhibited by the presence of someone else, just wait patiently knowing they will eventually leave. The average time to complete a pee is 21 seconds: it’s not too long to wait. No-one notices or cares. The busier the place, the easier it is to wait it out.

“Wait it out, no-one’ll shout”

This is a very powerful tool: it comprises going to the toilet when you do NOT need to go, and going through the motions. Why? Several reasons:

1. It will help you to learn to manage the anxiety caused by being in that specific location, without adding all the extra anxiety due to the need to have to pee. So if you have got used to peeing at home with a buddy nearby, but are very worried about using a cubicle, go and fake it in cubicles as many times as necessary until you feel more comfortable there.

2. This works in urinals too. It will make you realise that you CAN wait other people out: after all faking is not peeing, and so is waiting others out; if you can do one, you can do the other.

3. It is handy to do it while you are fluid loading, rather than wasting time waiting for the urge to build up. Guys who do this are always taken by surprise when they pee even though they had not planned to.

4. It gives you a way to visit lots of installations, to get used to the whole range that exist.

“Fake it till you make it”

Visit a well-designed public toilet installation to see what it is like, and that such places exist.

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

You can go in to wash your hands, comb your hair, get some tissue to blow your nose. While doing this in a relaxed way you’ll get used to being there and get used to what goes on.

People with shy bladder syndrome often freeze because they feel under time pressure – there is a queue, or your group is waiting for you.

One of the techniques CBT therapists have developed for Paruresis is to learn that you have a right to the time you need to perform without being rushed. To practice this try the techniques in 19 and 20 above 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 until I have no more need of it.

If you have paruresis you may have spent little or no time in public toilets, and so do not know what passes for normal behaviour in one. Cognitive Behavioural Therapy for Paruresis can enable you to learn this through ‘Faking it’ (see 19 above) in public toilets. If you know what passes for routine behaviour in a public toilet you can desensitise to the environment, and get used to normal conditions

Don’t rush in and out of the toilet. When you have finished relieving yourself, take your time to wash and dry your hands, and comb your hair. So long as it is a clean toilet, it is an opportunity to sort yourself out

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. In fact you were probably talking before going to the toilet, so carry the conversation on in there. If with strangers, a non-committal remark can break the ice “better out than in”, “bloody cold isn’t it” “brilliant penalty that eh?”. 

Toilet scenarios come into one of several categories. At first, every toilet may seem unique to you, and you feel you can perform only when you have got used to it. However, as you gain more experience, you will come to see them as being in a category e.g. spacious services with strangers, or a cramped pub with mates. If you have got used to the services with strangers, going to another one like that will feel OK.

This is where it ties up with the topic: how past experience, and anticipation of the future, affects how you deal with the future event when it comes about.

People without Paruresis have performed in so many situations that anywhere they go is similar to where they have been before, and so they can draw on past performance. You just need to allow time to build up a similar experience.

There seem to be two nerves which, when stimulated, increases the urge to pee substantially.

The first affects both men and women: both genders report that tickling the base of the spine, just above the coccyx, stimulates flow.

For men only: another nerve is located in the bit of penis skin which “anchors” the shaft skin to the underneath tip of the penis; the medical term is the frenulum; the slang term is the banjo string. If you are uncircumcised, it may mean retracting the foreskin partway to do it. Just a light touch and a slight urge can ensue.

Tell people only if they need to know AND you trust them. If they don’t need to know, why tell them. If you don’t trust them, then certainly don’t tell them.

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. Make sure you explain the subconscious control of the process i.e. it is out of your conscious control. There is a helpful and concise script on the website.

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.

The first time is hard; but when you see how little the listener reacts, it will help to de-dramatise the condition for you. In half the cases the listener will know someone affected to some degree, sometimes him/herself. The other person may react with a “is that all?” and ask whose turn it is to “buy a round”. It is also common for the listener to forget you told him or her, because it is no big deal to them.

That makes it easier to tell the second person who needs to know, and you can get to a point where you are reasonably comfortable to assert your needs when the situation requires it: “I need my space, my time, OK?”

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

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, a Paruresis sufferer will use that as proof that the person is actually thinking negatively about him/her. But is there really evidence of what is going through the other person’s mind?

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”. This looking is often an automatic response to a movement in the edge of the field of vision. Like lock-up, it is an evolutionary defence mechanism. It is not looking, but just a reflex glance.

The cognitive behavioural therapy approach to situations that make bashful bladder sufferers uncomfortable, is to learn to focus narrowly on just the chosen urinal (or cubicle), not the whole room, from the moment you go through the door of the public toilet. Deliberately ignore everyone and everything else. Behave like a fighter pilot focussing on a target, and not like a radar operative in an aircraft carrier, checking everything around 360 degrees for friend or foe.

Other people in a public toilet are unlikely to even notice you. The brain can pay attention to only one thing at a time. As other people are paying attention to themselves, they cannot be paying attention to you. See ‘the black gorilla experiment’.

Imagine you were set up with a clipboard and badge to do a survey. You are to stand outside a public toilet, and ask every man coming out “Excuse me, sir, could you just describe the people who were in there with you please.” Can you guess the likely responses?

a) bafflement: yea there was a bloke on my right I think; can’t describe him though, or

b) anger; what the hell do you think I am? or

c) you get punched!

Cleaners and attendants see so many people everyday, that the punter ends up losing identity and becomes a composite punter so they don’t notice you either. 

A CBT technique useful for Paruresis sufferers is to practice visualising a calming place, until you can go there at will. 

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

Practice this virtual desensitisation regularly.

Another visualisation technique is, in advance, to visualise a successful pee: walking in, standing or sitting there, the flow starting and completing, and you leaving calmly. Repeat that several times before you go into the toilet. This puts you into a performing frame of mind.