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Shy Bladder Components of a CBT Based Approach 1

Shy Bladder Components of a CBT Based Approach 1

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Shy Bladder Components of a CBT Based Approach 1
Shy Bladder Components of a CBT Based Approach 1

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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.

Only when you can perform successfully at that level. the body's preparation for fleeing danger etc. When conditions are right. What is supposed to happen is that the bladder fills up and at a certain point sends a signal to say "time to empty". check your anxiety. Topics to Cover Before Your First Graduated Exposure Session 4. which IS under your voluntary control. it thinks there is a danger somewhere. smell and movement. and reconsider the level you are attempting. Then when you do manage to pee. leave the toilet – you do not want to reinforce the anxiety.think of compressing a small balloon in your hands. the unconscious is saying "wait. Procedure To do graduated exposure. The subconscious mechanism triggers the detrusor muscle to squeeze the bladder in order to force out the urine . Do this till you are comfortable with peeing in that situation. but no longer than 2 minutes – it is better to leave.g. The detrusor and the internal sphincter are not under your voluntary control.g. it is necessary to start with a situation you can cope with. The only thing stopping you from wetting your pants is your voluntary control of the external sphincter which you keep closed. If it is climbing rapidly. 3. and a second part (the autonomic nervous system) that looks after actions you do not consciously control e. do you move up a level. 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. or there is a significant time pressure: reduce the level of challenge of one or more of the other factors to compensate. You will need to load with fluid (say 1 – 2 litres) till you have a good urge say 7 – 8. you consciously "let go" which opens the external sphincter and you pee. do so for 3 seconds and stop. Then move up a level on your hierarchy. Note that you can do a lot at home with a partner. urination is disabled by the autonomic nervous system. the environment you are in causes your brain to go into an alert state i. calm down elsewhere. then repeat the exercise. all of which could attract the attention of a predator. The urethra then goes through the external sphincter. Lockup is a natural phenomenon Understand the evolutionary reason why lock up is normal physiologically . there's something wrong". raising your arm. Hence even if you voluntarily want to pee. give it some time to settle down. . The bladder is surrounded by muscle fibre called the detrusor.e. At the same time the internal sphincter opens. deer. because a flow would generate noise. freeze to be less noticeable. The tube that empties the bladder is called the urethra and it exits via the internal sphincter (think of a tap). If you cannot pee. e. breathing when you are asleep.g. but under "subconscious" control. Simplified description of the bladder The nervous system comprises one part that looks after voluntary actions e. With paruresis. when they sense a threat.as a response to a potential threat. The process depends on This is very well explained in Steve Soifer’s book Shy Bladder Syndrome available via Amazon.Another example of this is when you need to perform but the urgency is low. Leave the toilet and wait three minutes. so as maintain a reservoir for further trials. The process depends on a long series of tiny steps. If it is manageable. This system is NOT under your control.

breathe out slowly & completely through pursed lips. Physiologically there is a link between both sphincters. APs tend to either get panicky. is trying to avoid giving a sample. This explains genital shrinkage. 6. lean forward and back. This is in contrast to a non-paruretic who. For your legs. say. Ensure you routinely breathe slowly and deeply. Re the sphincter. and the rest exist on a range upward from there. To experience the sensation of the opposite of relaxing it. hence nothing will happen. the internal sphincter is open. Sag slightly at the knees. Hunch them and drop them. and it is only the conscious desire to not pee that is keeping the external sphincter closed. resulting in rapid shallow breathing.e. or to tense up and not breathe at all! Deep slow breathing will calm you down. consciously clench and then relax the anal sphincter. abdomen. Being physically tense makes it more difficult to pee.So it does not help to be made to drink more and more in an attempt to force you to pee. till you feel like your insides could drops down between your legs. Notice that this has the effect of clenching the anal sphincter. once that is done sufficiently. And then relax it some more. The subconscious has shut the internal sphincter. to find the centre point where the thigh muscles do not tense up. Hesitancy is a range – some men have a hesitancy of milliseconds (!). Conclusion So it not the inability to pee that needs to be addressed. This will not necessarily make you pee. Use the Phobease method: breathe in deeply and slowly thru the nostrils. Part of the threat response is to shift blood from inessential organs to the muscles to get ready for fight or flight. 5. The same applies to us i. 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. Physical relaxation. sphincter. the urinary system will not be shut down. the autonomic nervous system will not kick in. instead. shoulders. and the flow starting). including anal sphincter relaxation. For the author it is 6 –8 secs. 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. In that case the detrusor is squeezing. Similarly let your shoulders drop. the detrusor is not squeezing the bladder. it is necessary to reduce the feeling of being under threat. and the body can do what comes naturally. bowl or partition to steady yourself. hold for count of four seconds. sometimes a great cause of disquiet. but we can relax the anal sphincter. buttocks. This is one reason why it can be more difficult in a rocking train carriage. The process is similar to the body’s reaction to cold. touch the wall. Breathing. we cannot consciously relax the urethral sphincter. So to relax the urethral sphincter. Relax your stomach muscles – it is very common for anxious people to tighten the abdomen below the belly button. Relaxing those muscles can postpone this urge. by holding onto something like a lectern. Now this can . ensure you breathe out fully and relax your abdomen. so putting pressure on the bladder and creating an urge to pee when the bladder is not yet full enough. Hesitancy (Hesitancy is the delay between being ready to pee. stand up and do whatever you need to do the “stop the flow”. Hesitancy is normal.

he’s got more interesting things than me on his mind.g.g. I can always try again later. (In Phobease speak. 7. (see cartoon) Hesitancy is not the problem. instead they are not in the least bit interested in you. Normal blokes can get lock up – viz the Big Issue cartoon.g. Remember: other people are not appraising you. So what. nice and relaxed. By talking through this you develop a new way of seeing things. he moved to a cubicle and was still unable to go. and do a long slow release through pursed lips. your boss. That is your starting point. It is important to use this drill every time you pee. Recognise that being with an authority figure affects you e. Then look at the thought dispassionately and recognise it as an anxious thought. Also avoid drinks that create adrenaline. However if you know that is your normal hesitancy. hold it for 4 seconds. By using Thought Stoppage. and not a reflection of reality. Say to yourself that it is not based in reality. . We are not. Men who do not have a shy bladder experience this – to the extent that at times they cannot go at all. It can be helpful to dissociate these negative thoughts from yourself. Again this is normal. What if I CAN pee? The main thing is to stop any further negative thoughts from getting a look-in. Build up a routine of things to do as you prepare to go for a pee.seem a long time standing there. and you have to practice responding to these negative thoughts with a positive response. you can stand there with no fear. 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. clench/unclench etc etc. work. the problem lies in what you think about hesitancy. Do the same. stop the thought. 60 secs if not more. Do a deep slow breath in though your nose. Accept that at first you will wait 20. asking you for evidence that each one reflects reality. A cognitive therapist would then talk you through each of these. Most APs panic after what seems a long time. sex. So write down all your anxious thoughts. switching off negative thoughts. whether in anticipation or at the time. worries etc. and to do when you are in place e.) Then deal with the thought by giving a positive response e. (Cathy 31/12/05)” 8. Time your shortest hesitancy (say at home). The moment a negative thought pops up. by attributing them to an outside agency (e. a slight smile. say “STOP” to yourself i. like coffee and coke. or leave and try again later. Cockpit drill A pilot goes through a cockpit drill every time before take off. Matt Damon once locked up because he found himself in the presence of President Clinton. stressed). and offering factual reasons why your fears are unfounded. The trouble is we only notice the millisecond guys and so believe we are abnormal. Hesitancy is situational (external challenge. taking your time. physical relaxation. you have only a little bit of adrenalin to deal with. 40. They just wait till they do pee. internal mood – tired. only an inconvenience (!).e. Thought stoppage: this is where you take control of your negative thoughts.g. even in a safe place. but is only 10 secs. and so increasing the adrenalin in your system. it is the Boo Monster trying to frighten you. The difference is that they do not see it as a problem. so that it does become routine. I’ll wait him out – I’m not in a hurry. judging you. little devil) that is trying to startle you. what to wear. they are more interested in football. feeling good. finding you wanting. So what. and that little bit will fade away if you wait a while. So what if I can’t pee.

You will also “own” more space”. Conversely. But “normal” guys have misfires occasionally. treat that as a memory to revisit time and again as a positive experience. affects how you deal with the future event when it comes about. using it on “entry” will put you in the right frame of mind and help yo to concentrate. . Then do that same action as you go in for a pee. Misfires happen. what is less well known is that the body can affect the mind. and anticipation of the future. A depressed mind will show itself in a depressive looking body language. 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. downcast face. rapid walk with short steps. or half empty? 12. you can make yourself feel better. get on with it”. So count your successes. Anchoring After a successful pee. Body language We know the mind can affect the body. that sort of thing. In fact treat them as a learning opportunity. neutral or slightly smiling face. This will help to drive out the negative memory. 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. An AP sees this as a failure. relaxed slower pace of walking. Allied to positive thinking. but a slap of the thigh. As you get more and more successes. a “normal” person will draw on past experience (of success) and an anticipation of the future (of success). The “to hell with everyone else” attitude. See a glass as half-full rather than half-empty. do something to represent that success. a click of the fingers. In a challenging situation. Be proud of your achievements . shoulders relaxed and back. build up these memories of positive experiences and practice them in your mind..9. they can get lost. When you have a success during desensing. and throw away your misfires. hitting the air is a bit obvious. this makes it more likely that he will succeed. slumped shoulders. Everytime you think negatively about something. you will improve your chances of performing successfully. and beats himself up about it. Understand how past experience. they do not see it as an issue. stop yourself and see it in a positive way. 10. Positivism 11. This way you build up a history of success. When you move up your hierarchy. but so what! A misfire is when you do not pee. Contented people are head up. The need to develop a Positive Mental Attitude. You can probably think of sportsmen who do this: Tiger Woods. Jonny Wilkinson. head-down posture. By consciously adopting such a positive posture. They just walk out and try again later. adopting such a body posture can make one feel “down”. you will mainly find it was because you forgot your hierarchy. 13. so the action will be linked with success. clicking teeth. Use positive body language to get a feeling of power.walk tall. which helps you to anticipate success. In contrast. Is your glass half full. and went in too high up.

This helps to trivialise the threat. Why? Several reasons. In such situation. 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. 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. no-one’ll shout” 19. books etc. and flappy clown’s feet. 15. 18.14. social occasions. it will help you to learn to manage the anxiety caused by being in that specific location.com/The_Urinal_Game.html “It’s OK to want your personal space”. Experiments show that this feeds into sleep patterns. Paradoxically. Wait other people out. and on to better health. the internal chuckle will relax you a bit. show. the easier to wait it out. and feelings of well being the following day. because they had forgotten how many successes they had had. No-one notices or cares. Diary Keep a diary of your successes: time and again APs say that they found their diary surprising. Imagine that person coming in as having a big red clowns nose. Faking it This is a very powerful tool: it comprises going to the toilet when you do NOT need to go. this realisation boosted their confidence. See the web arcade game on this subject and realise that this is NOT an AP site: http://gamescene. Find a way of turning a situation into a comical one. 16. The Location 17. A good proportion of men dislike cramped facilities. “Wait it out. Think of ways of making the other person seem ridiculous. If inhibited by the presence of someone else. a good proportion of men prefer to use a cubicle and that is OK. Laughter “……………… ho ho” Laughter relaxes the body – you cannot be tense and laugh properly at the same time. 1. Do this regularly each day. At bedtime Prior to going to bed. They may even exit and wait to go elsewhere. and going through the motions. Think of something that makes you chuckle or smile while you are there. the busier the place. So take up opportunities in your life to laugh: whether film. just wait patiently knowing they will eventually leave. Urinal etiquette Men avoid standing next to someone unless there is no choice. . busy facilities and troughs. Then learn to laugh on your own as an exercise. write down five positive things that have happened to you that day. The record is 20 minutes – no-one noticed or cared.

affects how you deal with the future event when it comes about. a spacious services with strangers. you will come to see them as being in a category e. rather than wasting time waiting for the urge to build up. Categories of location All toilet scenarios come into one of several categories. get them talking. When you have finished relieving yourself. or your group is waiting for you. it is the unnatural silence that is unnerving. but not always. However as you gain more experience. that they rush in and out and so do not notice. every toilet may seem unique to you. At first. and anticipation of the future. 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. get some tissue to blow your nose. but are very worried about using a cubicle. similarly with urinals. go and fake it in cubicles as many times as necessary until you feel more comfortable there. You can go in to wash your hands. Visit a well designed installation to see what it is like. This toilet is mine and only mine till I have no more need of it. 2. Routine behaviour Most APS do not know what passes for routine behaviour in a public WC because they either do not go to them. going to another one like that will feel OK.without adding all the extra anxiety due to the need to have to pee. Break the silence. if you can talk about something. when you do not need to pee. you can do the other 3. or are so freaked out while they are there. Guys who do this are always taken by surprise when they pee even though they had not planned to. 21. get used to what goes on. get used to being there. take your time to wash and dry your hands. once you’ve mastered the home environment. if you can do one. Use these to desense in. So long as it is a clean toilet. a non-committal remark can break the ice “better out than in”. do as above i. “bloody cold isn’t it” “brilliant penalty that eh?”. To practice this. and you feel you can perform only when you have got used to it. Yes urinals – see next bit. comb your hair.g. . and so is waiting others out. Take your time Dont rush in and out. Take your time when friends are waiting. Fake it till you make it 20. it is handy to do it while you are fluid loading. If with strangers. If you have got used to the services with strangers. to get used to the whole range that exist. This is where it ties up with the topic: how past experience. 24. it is an opportunity to sort yourself out.e. and that such places exist. Do this by faking it (see above). Learn to inconvenience others APs often freeze because they feel under time pressure – there is a queue. You must learn that you have a right to the time you need to perform without being rushed. If with a friend or colleague. or a cramped pub with mates. 22. while doing this in a relaxed way. and comb your hair. Some of the newer JDWetherspoon pubs have good ones. 23. If you can break the silence it breaks the ice. and experience normal conditions. it gives you a way to visit lots of installations. 4. For many. So if you have got used to peeing at home with a buddy nearby. so you imagine that this will always be the case. This reduces the control that your emotion has over you. It will make you realise that you CAN wait other people out: after all faking is not peeing. 25. 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). Additionally. It is necessary to find out what goes on there so… desense to the environment.

if someone happens to glance in your direction. But what evidence is there of what is going through the other person’s mind? None. The nerve stimulation technique. but they could help by taking your needs into account e. The first time is hard. it may mean retracting the foreskin partway to do it. it is an automatic reaction due to the dislike of the feeling that there is someone out of sight behind him.g. stimulates flow. on a need to know basis. an AP will use that as proof that the person is actually thinking negatively about him/her. brother.Guys without AP have performed in so many situations that anywhere they go is similar to where they have been before.g. Trust 27. father. On the workshop. focus and attention 28. say that just them knowing takes pressure off you. it is not a judging “look”. or by covering for you when you take a long time. because it is no big deal to them. Tell on a need to know basis Tell trusted people. The first affects both men and women: both report that tickling the base of the spine. Don’t down play it. help to dedramatise the condition for you. Use our script (see hand out or website). my time. or knows someone who is. Just a light touch and a slight urge can ensue. If they ask how they can help. increases the urge to pee substantially. You just need to allow time to build up a similar experience. It is also common for the listener to forget you told him or her. and so they can draw on past performance. the two leaders can role play it. Pay your friend a compliment. he may glance up. but when you see how little the listener reacts. There seems to be two nerves which. trust him/her by telling him. when stimulated. e. 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. just above the coccyx. it will. . If you are uncircumcised. how long to stay. Misused evidence Socially anxious people use evidence of what they can see/hear as evidence for what they cannot see/hear. But ensure you emphasise how it messes up your life and your peace of mind. that is just to check that you have gone past. If you walk past someone standing at a urinal. Be matter of fact about the condition .it is a social anxiety. about where to go out. the medical term is the frenulum. OK?” You will often find that the listener is affected occasionally. That makes t easier to tell as second person who needs to know. partner. 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. Self-consciousness. In fact the other person may react with a “is that all?” and ask whose turn it is to “buy a round”. 26. best mates. the slang term is the banjo string.

e. Deliberately ignore everyone and everything else. Virtual desensitisation Practice visualising a calming place. Non-APs’ are like a fighter plane. The composite punter Cleaners and attendants see so many people everyday. it is an evolutionary defence mechanism. Imagine you were set up with a clipboard and badge to do a survey. . 29. so leaving them unaware of anything around them. that the punter ends up losing identity and becomes a composite punter. X silent v X talking. Bathroom door shut. and ask every man coming out “Excuse me. what the hell do you think I am? or c) you get punched! 31. As other people are paying attention to themselves. X is in the room as far from the bathroom as possible. X is by bathroom door but out of sight. with their “radar” scanning 360 degrees. or b) anger. X in sight but not watching v X watching (difficult). X is half way across the room. Attention The brain can pay attention to only one thing at a time. Practice this virtual desensitisation regularly Sample Desensitisation hierarchies Start at 1 and move up to 10. 32. Bathroom door cracked open. and stays locked in to the spot they are aiming at. they cannot be paying attention to you. Bathroom door wide open. but just a reflex glance. Vary the criteria depending on personal requirement (where X is the buddy): Distance. could you just describe the people who were in there with you please. taking note of everyone and everything around.” Can you guess the likely responses? a) bafflement: yea there was a bloke on my right I think. till you can go there at will.This looking is often an automatic response to a movement in the edge of the field of vision. 30. cant describe him though. Bathroom door cracked open. X is by bathroom door but out of sight. X is in sight in open doorway. Distance location is a hotel room with an en-suite bathroom. It is not looking. 10 9 8 7 6 5 4 You and X are “side on” but X is in open doorway. switching to the calm place and back again as necessary. Sitting v standing. You are to stand outside a public toilet. sir. Then visualise the anxiety provoking situation to desense to it in the mind. Focus People with AP tend to go into a toilet like an aircraft carrier. Discipline yourself to focus narrowly like that from the moment you go through the door. Bathroom door cracked open. the black gorilla experiment. with their “radar” focussed on the bowl or urinal they are heading for. Making a noise.g. X is by bathroom door. Like lock-up.

then our email address is displayed on the contact page here. X is in the room as far from the bathroom as possible. You are standing up. united kingdom paruresis trust P. X is in the room as far from the bathroom as possible. sitting down 10 9 8 7 6 5 4 3 2 1 You are standing up. You are sitting down. You are standing up. X is half way across the room. X is by bathroom door.3 2 1 X is half way across the room.org. X is out in the corridor. X is in the room as far from the bathroom as possible.O. X is by bathroom door. Cumbria. Kendal. You are standing up. Bathroom door shut. Bathroom door shut. You are sitting down. . Bathroom door cracked open. Bathroom door shut. You are sitting down. Bathroom door shut. X is half way across the room. You are standing up. X is in the room as far from the bathroom as possible. Bathroom door shut. X is out in the corridor. X is out in the corridor. Bathroom door shut. Box 182. X is half way across the room. Bathroom door cracked open. You are standing up. LA9 9AE email support@ukpt. You are sitting down. Bathroom door shut.uk If your browser does not display an email link. Bathroom door shut.

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