The YCBT Services Blog

As noted in a very helpful past article you can find here, a lot of hope can be found if you are struggling with shy bladder through Cognitive-Behavioral Therapy (CBT). As noted, CBT will help through graduated exposures to be able to reduce anxiety and create a learning process that allows one to urinate in public more freely over time. Additionally, through my experience working with many people living with shy bladder (you are not alone), I have found the below steps to be vital in creating an effective exposure plan and overcoming shy bladder syndrome.

SPEND TIME TO IDENTIFY YOUR SAFETY BEHAVIORS

All too often when I meet with individuals living with paruresis they are eagerly and courageously wanting to make progress and jump into an exposure. Or perhaps one has already attempted graduated exposures with great effort, but progress stalled without knowing why. One of the most important aspects of effective exposures is to spend time to become aware of all of the habits used to feel less anxious in the moment when attempting to urinate in public…these habits are also known as safety behaviors. While wanting to avoid the fear of not being able to void or being judged by others, safety behaviors unfortunately can reinforce the process of anxiety and get in the way of long-term progress. A few very common examples of safety behaviors with shy bladder include:

1. Restricting liquid intake while out in public
2. Only attempting to urinate in “safe” feeling restrooms
3. Researching restroom environments before visiting a place
4. Checking in and around the restroom for others present before trying to go
5. Checking internally for signs of anxiety or urgency before trying to go
6. Scanning for noise or checking others behavior for threat before trying to go

These are just a few examples of the habits that develop to try to avoid a negative outcome and get through a situation but wind up building apprehension and can get in the way of making progress. A vital step is to become aware of all the nuances of safety behaviors present so that strategies can be developed to practice graduated exposures without them getting in the way.

FRAME A NEW GOAL

A lot of times the worry regarding being able to void or not builds up into a pressure-packed goal of being able to pee or not…as if an audience is there waiting to throw tomatoes or cheer if “pass” or “fail.” When starting graduated exposures, it very helpful to reappraise the goal to focus on something else. For example, many people I’ve worked with find an initial goal of just attempting to go and waiting for two minutes no matter what as a much more helpful starting place. This allows one to take the focus off of the pressure to go or not, have the opportunity to become aware of and get better at tolerating the thoughts and feelings that arise in the two minutes, and test out any predictions present of what will happen if they wait the two minutes even if voiding doesn’t happen.

SLOW DOWN

The habitual focus on performance and the feared / expected outcome of not being able to go can often lead to a rushed process attempting to void that is cut short at the peak of anxiety. With a new goal of just a set time or otherwise in mind, allowing oneself to slow down, breathe deeply, and let be…accepting uncertainty as part of the process…will help to create new associations with the process of voiding, and might just create some positive surprises along the way.

MAKE SPACE AND CARRY ON

Finally, another common barrier to progress I’ve noticed is the tendency to scan for any anxiety present before trying to urinate and to automatically see that as a threat or problem in and of itself that needs to be solved first. Instead of trying to combat, push away, or avoid trying to go in response to anxiety present, shift your response to just acknowledging that anxiety is present, remembering that it is just a feeling that can be there (not a threat or predictor of outcome), and carrying on with your goal of giving oneself the deserved opportunity to try to void can be a more helpful way through the process.

I hope the steps described above can be helpful in making progress and providing hope that effective help is available. Clinicians well-trained in CBT and with experience working with paruresis can help provide the structure and support needed to help overcome shy bladder. Additionally, the International Paruresis Association provides a wealth of resources and workshops to help those afflicted by shy bladder.

Robert Yeilding, PsyD, A-CBT

NSAC – San Clemente / Orange County