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components of a CBT based approach

The Basics of Graduated Exposure

1. Get used to the range of urgency 0 – 10 where 0 = no urgency and 10 = bursting. Most APs 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. They have forgotten (or have never known) what the intermediate levels of urgency feel like. 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, 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.
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 practise this, because it takes several sessions to get used to it.
“Wait for the urge, then let it surge”

2. Hierarchies of challenge

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

1. Proximity of the other person
2. Being heard
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 “that passes in the night”, a trusted friend, an acquaintance or work colleague, a friend
8. The level of urgency: the lower, the harder
9. Surrounding activity: quiet, some people, busy, crowded
10. Time pressure

If all these factors are at the low end of challenge, performance is eased; if all are at the high end, performance is difficult.

To start the graduated exposure, it is necessary to choose a scenario where you are sure you will be able to perform.

You will then increase the level of challenge of one of these factors by a small increment. When you can perform reliably in that scenario, you increase the level of challenge of one or other of these factors by a small increment.

When changing one factor significantly because there is no way to make a small incremental change e.g. 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 perform 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.

3. Procedure

To do graduated exposure, 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.
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 seconds and stop, so as maintain a reservoir for further trials. Leave the toilet and wait three minutes, then repeat the exercise. Do this till you are comfortable with peeing in that situation. Then move up a level on your hierarchy. The process depends on a long series of tiny steps. The process depends on 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.

Topics to Cover Before Your First Graduated Exposure Session

4. Lockup is a natural phenomenon
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 by 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

The nervous system comprises one part that looks after voluntary actions e.g. raising your arm, and a second part (the autonomic nervous system) that looks after actions you do not consciously control e.g. breathing when you are asleep, the body's preparation for fleeing danger etc.

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 is supposed to happen 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; hence nothing will happen.

This is in contrast to a non-paruretic who, say, is trying to avoid giving a 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.


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

Part of the threat response is to shift blood from inessential organs to the muscles to get ready for fight or flight. This explains genital shrinkage, sometimes a great cause of disquiet. The process is similar to the body’s reaction to cold.

5. 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 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 social phobia) 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.

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

Hesitancy is normal. 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. 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. (see cartoon)

Hesitancy is not the 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.

Normal blokes can get lock up – viz the Big Issue cartoon.

7. 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 anxious thought, and not a reflection of reality. 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 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, 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.

So 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 positive response. It can be helpful to dissociate these negative thoughts from yourself, by attributing them to an outside agency (e.g. little devil) that is trying to startle you.

As a result aim to get in your own “zone” viz
“One thing that I took away from one of the workshops was that it's important to get into a 'zone' where you're in your own space, nice and relaxed, taking your time. (Cathy 31/12/05)”

8. Cockpit drill
A pilot goes through a cockpit drill every time before take off. Do the 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 e.g. physical relaxation, switching off negative thoughts, a slight smile, feeling good, clench/unclench etc etc.

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

9. Anchoring

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, 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 yo to concentrate.

You can probably think of sportsmen who do this: Tiger Woods, Jonny Wilkinson.

10. Misfires happen.. but so what!

A misfire is when you do not pee. An AP sees this as a failure, and beats himself up about it. But “normal” guys 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 hierarchy, and went in too high up.


11. The need to develop a Positive Mental Attitude.
See a 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 “to hell with everyone else” attitude, they can get lost.
Everytime you think negatively about something, stop yourself and see it in a positive way.

Is your glass half full, or half empty?

12. Body language
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 a depressive looking 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.
By consciously adopting such a positive posture, you can make yourself feel better.
You will also “own” more space”.

13. Understand how past experience, and anticipation of the future, affects how you deal with the future event when it comes about.

So past experience (of failure) and anticipation of the future (of failure) inevitably makes it more likely that you will fail when the event comes about.

In contrast, a “normal” person will draw on past experience (of success) and an anticipation of the future (of success); this makes it more likely that he will succeed.

In a challenging situation, a “normal” person will draw on 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. This way you build up a history of success. Allied to positive thinking, which helps you to anticipate success, you will improve your chances of performing successfully.

14. Diary
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.
By diary we do not mean an essay: instead a simple coding system that you can read to show how you had many successes in the past.

15. Laughter
“……………… 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.

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

Think of ways of making the other person seem ridiculous.

16. At bedtime

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

Do this regularly each day.

The Location

17. 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.

See the web arcade game on this subject and realise that this is NOT an AP site:

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

18. 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 to wait it out. The record is 20 minutes – no-one noticed or cared.
“Wait it out, no-one’ll shout”

19. Faking it

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; similarly with urinals. Yes urinals – see next bit.
2. 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

20. Visit a well designed installation to see what it is like, and that such places exist.
Some of the newer JDWetherspoon pubs have good ones, but not always. Use these to desense 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, get used to being there, get used to what goes on.

21. 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.

22. Routine behaviour
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 rush in and out and so 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 faking it (see above).

23. Take your time

Dont rush in and out. 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.

24. 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?”.

25. Categories of location

All 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; so you imagine that this will always be the case. However as you gain more experience, you will come to see them as being in a category e.g. a 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.

Guys without AP 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.

26. The nerve stimulation technique.

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

The first affects both men and women: both 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.


27. Tell on a need to know basis
Tell trusted people, father, brother, partner, best mates, on a need to know basis.

Use our script (see hand out or website). On the workshop, the two leaders can role play it.

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.

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 fact 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 t easier to tell as 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?”

You will often find that the listener is affected occasionally, or knows someone who is.

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

Self-consciousness, focus and attention

28. Misused evidence

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”.

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.

29. 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” focussed 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.

30. Attention

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.
e.g. 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; cant describe him though, or
b) anger; what the hell do you think I am? or
c) you get punched!

31. The composite punter
Cleaners and attendants see so many people everyday, that the punter ends up losing identity and becomes a composite punter.

32. 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

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.

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