by Lynda Hudson, FBSCH
Since nocturnal enuresis is one of the most frequently encountered problems in my work with children, and therefore one most likely to be encountered by hypnotherapists beginning to work with children for the first time, it seems useful to consider possible approaches in some depth. Olness,1977b, states that: ‘Through the ages, nocturnal enuresis has been the most common chronic behavioural problem faced by the paediatrician’.
Let us consider the history taking; normally we are advised to take a case history at the first appointment but I would suggest that taking the history on the phone from the parent(s) before seeing the child is an important first step. Alternatively, one could set up the first appointment for the parent alone, although against this idea is the impression that could be given to the child that, firstly, the issue is to be dealt with by adults and, secondly, that negative things are being said about him / her in secret. I prefer to speak to the parent in the evening when the child is probably in bed but where the call is on an apparently casual basis. I do not want the child to hear chapter and verse of their shortcomings (which frequently occurs even in these so-called enlightened times), nor do I want them to feel that they are being talked about rather than talked to.
It is important to discover whether the problem is ongoing and possibly developmental in origin (primary enuresis), whether it is a case of sudden onset (secondary enuresis) and whether there are times when the problem does not manifest at all. If the latter, what makes it worse and what makes it better? Does the problem exist only at night or is there also a problem of any kind during the day? The latter might be an indicator of organic causes that need investigation. It is important to check for the existence of chronic constipation, which can be a common cause of urinary incontinence. Children should be advised to cut down on caffeine drinks if they consume large amounts of them since there is a possible association between caffeine and enuresis.
You may like to use a formal questionnaire such as the one in the Appendix C of ‘Hypnotherapy with Children’, Olness and Kohen, but I prefer to take a more relaxed approach and ask questions in words selected to suit the individual client.
The parents’ attitude towards the problem is important and may be significant either in cause or treatment; parents who have another child that was dry at three or earlier may have unrealistic expectations of the child. Unconsciously, this can put emotional pressure on the child who may merely be neuro-physiologically less mature at the same age as their sibling. The parents’ attitude during treatment needs to be supportive or the careful work of the therapist may easily be undone. This needs to be discussed before treatment begins and expectations of the parents should be made explicit and their agreement sought. I explain that it is important for the child not to use any kind of incontinence protection, however inconvenient that may be regarding sheet washing, since it is vital that the child learns to distinguish feelings of being wet and being dry. Parents should, of course, use protection for the mattress but be prepared to continue washing sheets. Even where the child is quite young I always encourage them to be involved to some degree in the business of sheet changing which of course may slow down the process; thus it becomes clear why the parents’ co-operation is so important. I also expect parents to accommodate my ideas concerning drinks and bedtime routines referred to below.
Where it is a case of sudden onset, it is critical to discover, where possible, what was going on in the child’s life during and before that time; a death of a person or pet, a birth, a move, a change of mood within the family or even a seemingly minor quarrel with a friend or being embarrassed or being told off can all play a major part in enuresis.
Frequently, upsets at school or nursery school are not known about or seem unremarkable and insignificant to the parent and you only get to find out almost by chance from the child at a later date, or, truth to tell, you may never find out. This may hamper treatment and be responsible for an unsatisfactory outcome or, on the other hand, the child may sail through the treatment benefiting enormously from the ego strengthening; there can be no certain prediction.
I also believe, from personal experience, that it is important to discover as soon as possible the state of the parents’ relationship. Where parents are getting on badly, whether or not they are living together, I have frequently found that this is either causally connected or concomitant with the child’s enuresis. Obviously this is a sensitive area, nevertheless it can prove to be vital information. I had been working with a child for several weeks who was very up and down in her progress; I had tried all sorts of ways to find out factors that were making a difference, for example she was more likely to be dry if her father put her to bed than if her mother did so. I finally found out purely through a chance remark of the child that her parents had always had an explosive relationship and had split up during the weeks of my seeing her. Neither the child, nor the mother, nor the father had volunteered this information despite the fact that we had a seemingly very good and honest relationship. Somehow it did not seem relevant to them in relation to the child and her bedwetting! One day as they arrived, I was seeing out an adult patient and the child was astounded to know that adults as well as children came to see me. She asked me if I could help her Daddy get happier, and then the story came out; it turned out to be a crucial factor in her gaining control of her bladder at night.
On the first appointment with the child I spend time eliciting how it will make a difference when they are able to have more dry beds (notice the presupposition of the word when rather than if). I get them to imagine they can see a video of the morning when they have the first dry bed and answer my questions. (At this point I am not even trying to put them into a formal trance state but the child will usually ‘see’ the events easily since they are well used to using their imaginations actively). What will be the first thing that is noticed? How do they feel when they notice the bed is dry? What do they do then? Can you see your face? Can you see the big smile on it? How does that affect Mummy / Daddy/ the cat, etc.? What differences does it make during the day, the next night? What can they do now that is different from how it was before? In other words I get them to build the solution for me in great detail so that later I can feed it back to them in trance as a pseudo orientation in time. In point of fact this is the first part of the treatment because their brain is already visualizing the treatment and feeling more confident about it. Ensure the use of the present tense and confidence of voice tone as you speak.
At this point I will talk about the relationship of the brain and the bladder, often making use of a flip chart to draw a cartoon style bladder and brain. (There is a version on P141 of ‘Hypnotherapy with Children’.) The child is involved in this process and encouraged to colour in and be creative as the drawing progresses; I get them to imagine a big door, with a strong lock and key which holds the urine, wee, pee etc. in the bladder. They post sentries, or even whole armies, at the door with mobile phones to contact the brain to wake them up when it is time to wake up and walk to the toilet. (Notice the deliberate use of the word walk because sometimes go to the toilet is understood by children merely as a command to empty the bladder). Sometimes the signal from the bladder is weak and all that is necessary is for the sentries to check the lock and turn the key again.
Elaborate with colours, feelings, voices and sounds so that once again you have your own script which has been at least half elicited from the child to feed back strongly to the child once they are in trance. In fact, my belief is that the child is already in an altered state at this point, (a state of strong internal focus) and this is the first run through of your therapy.
Go through the routine that you expect them to keep to, always eliciting and gaining agreement as you go along, eg Drink a lot of water during the day, go to the toilet and practise stopping and starting the flow, cut down on caffeine drinks, and make the last drink in the evening around teatime (obviously this depends on the age and the child’s bedtime, but discourage drinks just before bed.) As long as the child is drinking plenty of water during the day it will not hurt them at all. Before they go to bed each night, I ask them to run through a private video in their heads seeing themselves locking up the bladder door, getting the sentries in place etc. either sleeping through the night or having the sentries calling up the brain on their mobiles. If they use their mobiles they get the child to wake up and go to the toilet to unlock the bladder gate and empty the wee into the toilet where it belongs. They see themselves going back to bed and waking in the morning with a dry bed, big smile etc. (in other words feeding back everything that has previously been elicited from the child him or herself). Since the child will do this in one or two minutes or less, it is no hardship and the vast majority keep to doing it each night with no problem at all.
At last comes the time for a bit of overt trance work; choose whichever method you think fit, remembering that children often wriggle around and sometimes act out the movements as you talk. This is not always so, however, and sometimes they go into very deep and still trance states and display the signs you normally see in adults. At this point you more or less repeat everything you have already done getting them to watch the ‘Kieran’ channel on TV and intersperse indirect and direct suggestions. Although in general I agree with keeping the focus on beds being dry, I have also achieved good results at times from using the direct suggestion to ‘stop wetting the bed’, particularly where this is the stated aim of the child him or herself.
I talk about the different ways that children respond to the treatment; how some just decide to have all dry beds from now on; some decide to do it in a few days from now, and some do it gradually, a little by a little by a lot. I will do this both in and out of trance; the presupposition is always certainty that they will achieve their aim but there is leeway in the period of time taken to achieve it. In this way, disappointment is avoided without loss of confidence if they do not respond immediately. On subsequent visits, I check on how well they have been doing, always remembering to credit them with success where there has been even the smallest amount of positive response. If the response has been positive, I build on what has been done before with basically more of the same, plus lots of ego strengthening and congratulations. If there has been no response, I will ask questions to check what has been going on for them at school / at home during the week, whether they went through their private video routine each night (I get them to re-run it for me at the time so I can check that they were not giving themselves negative programming by mistake), whether they stuck to the no drinks at bedtime routine. I will then choose some variation on one of the following:
Always include some kind of ego strengthening and give as much credit as possible for any small amount of progress, even if that is being able to stay confident and in a good mood while he is doing things more slowly. Self-esteem always needs boosting;
More formal hypnosis using a ‘convincer’ coupled with strong direct suggestions;
New visualizations of different desired outcomes, eg. always being woken up by the sentries to go to the toilet rather than sleeping through the night. Little girls may prefer fairy godmothers, fairy princesses, etc., watching over them when they sleep, sprinkling magic dust or magic spells;
Dreams where they speak to someone who looks just like them who has found a way to get over the problem;
Where there is sudden onset, there is an obvious need to uncover the cause and help the child deal with the feelings; expressing and acknowledging their feelings may be sufficient in itself, dispelling fears, reassurance that a previous negative experience is unlikely to happen again, allowing the expression of anger, encouraging the child to grieve the loss of a person / animal / home / friend / role in the family, explaining that some events which have occurred must be told to an adult and that they themselves are not to blame. There are so many ways of dealing with the above that they require a separate article and will not be dealt with in more detail here. It is important to be aware that there are cases where there is no progress and it is vital for the child to understand that for some reason this may not be the right time for it to happen, but they should be reassured that their inner mind is working on the solution and will surprise them by sorting out the problem in its own time, in its own way. This is clearly of the greatest importance because otherwise there is a danger that an already low self-esteem can plummet even further. They can be told about other clients who have responded in the same way so they are reassured that they are not the only one. Of course there may be many reasons, only a few of which are listed below, for lack of progress:
We may never know exactly why any one individual fails to respond and I believe it is important to accept from the outset that in some cases hypnotherapy is not the treatment of choice for an individual client. It may be that they should be referred to somebody with more experience, referred for further medical investigation or for psychotherapeutic help or it may be that they merely need more time to develop. The latter can often be the case with nocturnal enuresis. Having said that, most children respond easily, get excellent results and are a delight to work with.