Components of a CBT based approach

The Basics of Graduated Exposure

1: Get used to the range of urgency
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
3: Procedure

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
6: Hesitancy
7: Thought stoppage
8: Cockpit drill
9: Anchoring
10: Misfires happen.. but so what!


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
13: Learn from the past
14: Diary
15: Laughter
16: At bedtime

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.

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

18: Wait other people out
19: Faking it
20: Visit a well designed installation
21: Learn to inconvenience others
22: Routine behaviour
23: Take your time
24: Break the silence
25: Categories of location
26: The nerve stimulation technique


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
30: Attention
31: The composite punter
32: Virtual desensitisation

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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