Journal of Clinical Child Psychology

ISSN: 0047-228X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/hcap19

Treating noctural enuresis in one session of family

therapy a case study

Andrew Lee Selig

To cite this article: Andrew Lee Selig (1982) Treating noctural enuresis in one session
of family therapy a case study, Journal of Clinical Child Psychology, 11:3, 234-237, DOI:
10.1080/15374418209533093

To link to this article: http://dx.doi.org/10.1080/15374418209533093

Published online: 20 Oct 2009.

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 Journal of Clinical Child Psychology Copyright 1982 by the Section on
1982, Vol. 11, No. 3, 234-237 Clinical Child Psychology, Division 12,
American Psychological Association, Inc.

Treating Noctural Enuresis in One Session of Family Therapy

A Case Study

Andrew Lee Selig

University of Colorado Health Sciences Center

Nocturnal enuresis can be a significant symptom, occurring in as many as

20% of all children. A number of etiological theories have been proposed to
explain the symptom, very few of which include family dynamics. Likewise, a
number of treatment approaches have been advocated and evaluated with
most reporting limited successes. This paper is a case study of a 6½-year-old
identified patient, who was enuretic for three years. Various treatments had
been tried but without success. The child was referred and the family was ask-
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ed to come for the initial interview. A family assessment was conducted, based
on principles of brief, symptom-focused family systems psychotherapy. Direc-
tives were given to the family and the symptom was eliminated. Follow-up at
one year indicated no recurrence of the symptom and positive changes in other
areas of the family. The treatment rationale and effectiveness are discussed.

Enuresis presents a challenge to psychologists, dynamics.1 Psychodynamic theories view enuresis

physicians, family, educators, and mental health
professionals. Epidemiological studies suggest
that the frequency of bedwetting is as high as 20%
at the age of 7 years (Rutter, Yule, & Graham,
1973), and that it is more prevalent and severe in
boys than in girls after the age of 5 (Oppel,
Harper, & Rowland, 1968 and Rutter, Yule, &
Graham, 1973).
A number of etiological theories have been pro-
posed to explain enuresis. The most common
theories generally fall into two categories: psycho-
dynamic and physiological-behavioristic (Lovi-
bond & Coote, 1969). There are also a limited
number of references on the role of family
Andrew L. Selig is currently associate professor of psy-
chiatry, University of Colorado Medical School, John F. Ken-
nedy Child Development Center. He received his doctorate
from Harvard University and has held academic positions at
Harvard University and the University of British Columbia. He
has held positions at different levels in mental health centers,
consultant to the Massachusetts Department of Mental Health,
and director of several training programs in family therapy. He
has published numerous articles and a book, all of which deal
with the application of systems theory to change and program
development with families and organizations. He has done
training on family assessment, family treatment, and develop-
ing family approaches in organizations in the United States and
Canada.
Requests for reprints should be addressed to Andrew Lee
Selig, Sc.D., John F. Kennedy Child Development Center,
4200 E. Ninth Avenue, Box C 234, Denver, Colorado 80262.
as a symptom of a more pervasive emotional dis-
turbance. Physiological-behavioristic theories
view enuresis as a failure to develop cortical con-
trol over the mechanism of bladder release. There
are several references for the role family dynamics
plays in enuresis; however, they tend to view
families by characterizing individual personalities
in the family rather than interactional processes
(Stockert, 1971; Bindelglas, Dee, & Enos, 1968).
A number of treatments have been proposed,
each with somewhat discouraging results, and very
few that propose a family therapy orientation. For
example, psychodynamic psychotherapy has been
used (Werry & Cohrssen, 1965, and DeLeon &
Mandell, 1966); drug treatment (Poussaint & Dit-
man, 1965); conditioning with a bed buzzer
(Werry & Cohrssen, 1965); and bladder training
(Muellner, 1960) have been used. Quay & Werry
(1979, p. 164) state that "the most effective treat-
ment is a bed-buzzer, but, even with it, execution
can be difficult, failures are common, and relapse
is high."
There are limited reports on the use of family
therapy in treating enuretic symptoms, and they
report only on successful cases (Erickson, 1954;
Minuchin, 1974; Madanes, 1981).
The purpose of this case study is to illustrate the
powerful impact that family therapy can have over
1
Based on literature review from Psychological Abstracts
back to 1974.

234
 NOCTURNAL ENURESIS
a very short period of time in eliminating long-
standing enuresis and doing so after other, more
traditional interventions have been tried and have
failed.
Identification of the Problem:
Brian was a 6½ -year-old kindergarten boy who
was brought to a Child Development Center be-
cause of bedwetting for the past 3 years. Brian's
parents separated before he was born. Until ap-
proximately three years of age Brian lived with his
mother and sister, 2Vt years his senior. He was
toilet trained without any bed-wetting by the time
he was three years of age. When Brian was about
three and one-half years, his mother began living
with her boyfriend. Since that time Brian became
increasingly enuretic, to the point of wetting his
bed on a nightly basis.
At the Child Development Center, mother stat-
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ed that Brian had been examined on numerous oc-
casions by pediatricians and that numerous forms
of therapy had been unsuccessfully tried. These in-
cluded fluid restrictions prior to bedtime, waking
Brian several hours after going to sleep, a short
trial of medications, and hypnosis.
On examination, Brian was found not to have
other signs, symptoms or complaints. A Slossen
Intelligence Test revealed an I.Q. of 115. The
Draw-A-Person Test was within normal limits.
The Draw-A-Family Test included figures of the
children, mother and boyfriend. Mother and
child's interaction in the play environment seemed
very appropriate.
Treatment:
Brian, his mother, sister, and mother's boy-
friend were all asked to come for a Family Assess-
ment Interview. The rationale given was that in
order to best understand Brian, it was crucial to
understand his family. The family agreed and
came for the first interview.
During the interview, it was determined that
mother had become underinvolved and almost re-
moved herself from parenting either of her chil-
dren, especially Brian. Since beginning to live with
her boyfriend she had felt unsuccessful in disci-
plining her children. She viewed herself as being
unable to control or encourage them particularly
when she compared herself to the way her boy-
friend positioned himself with the children. The
boyfriend, believing mother to be unable to han-
dle the children, had assumed almost complete re-
sponsibility for their discipline. He acknowledged
that his methods and approach to discipline were
sometimes rather harsh as a compensation for
mother's leniency. Both mother and boyfriend
agreed that mother was too soft and lenient with
her children and that Brian tended to cling to her
Journal of Clinical Child Psychology, Volume 11, Winter, 1982 • 235
more than they would like. Brian would become
particularly clinging after being punished by the
boyfriend. Mother and boyfriend were both con-
cerned that Brian was too dependent on mother.
Toward the end of the first family meeting the
family was asked if they would cooperate with a
specific task. They were told that the task would
help verify how the family was working together
and provide data for future sessions. The family
agreed to work on the task. Specifically, the boy-
friend was to stay completely out of disciplinary
actions when and mother were with the children at
the same time; mother was instructed to handle all
the disciplinary actions. At first mother and boy-
friend hesitated to accept the task, feeling that she
would not be able to adequately handle it. They
were told that this was part of the task; that
mother probably would be able to find some way
to handle the situation, based on her own re-
sources. Furthermore, this disciplining arrange-
ment was to take place for six consecutive days
before the next family meeting that was then
scheduled two weeks later.
Treatment Rationale:
The treatment described here is based on four
principles: 1) altering interactional patterns, 2)
giving clients homework and directives, 3) brief,
symptom focused psychotherapy, and 4) accentu-
ating the positive in individuals and their inter-
actions.
Changing interactional relationships is assumed
basic to altering internal feelings and self-esteem
(Haley, 1963). Altering interactional patterns can
more easily be accomplished by accentuating the
positive aspects of those interactions and giving
directives or homework that will increase the pro-
bability for a change in the interactions. The focus
is on specific symptomatic behavior, and altera-
tions of the interactional processes which can be
accomplished in brief time periods.
As has been pointed out, the solutions families
utilize to deal with problems often become central
to the perpetuation of the very problem interac-
tion or behavior they were intended to stop
(Watzlawick, Weakland, Fisch, & Bodin, 1974;
and Sluzki, 1981). Based on these premises, inter-
ventions need to break these repetitive circular
processes. Successful interventions will lead the
system to different interactional sequences that
cannot be predicted and which are not prescriptive
of what "should be" (Dell, 1982).
The enuresis began after the boyfriend moved
into the home, and therefore it was assumed this
change in the family was the primary precipitant
for the symptom. Brian's behavior and statements
during the interview suggested he was afraid of the
 SELIO
boyfriend and wanted a closer more positive rela-
tionship with him. Simultaneously, Brian wanted
more attention from his mother and was accom-
plishing this goal by clinging to her and receiving
negative attention for his bedwetting.
The mother and boyfriend both agreed that
something needed to be done with Brian and were
both worried about his dependence on mother.
They expressed no obvious discomfort with their
own relationship. The boyfriend indicated want-
ing some help in his role of disciplinarian, which
had gradually become his complete responsibility.
Simultaneously, mother indicated she would feel
better about herself if she could find ways to deal
with Brian and undertake, herself, a larger role in
parenting.
Second Interview:
Two weeks after the initial assessment inter-
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view, the family came for the second session. They
reported that they had followed the task complete-
ly, beginning the day after the first family meet-
ing. Brian was dry the next night, and had con-
tinued to be dry for the entire two weeks. The boy-
friend reported that he and Brian had gotten along
better than they ever had previously, and that they
had talked together more intimately than ever
before. The boyfriend felt very relieved that he
was no longer "always the heavy hand" in the
family. Mother reported, much to her surprise,
that she had found ways to better handle the chil-
dren. She also reported that she was more asser-
tive with her boyfriend, and that their relationship
seemed to be getting stronger. During the inter-
vening two weeks they made the decision to get
married, a decision which they had been hesitant
to make for the past several years.
During this second and final family session,
mother's tendency to be underinvolved in parent-
ing while undervaluing her own abilities as a
parent and the boyfriend's tendency to take over
the parenting role in order to compensate for
mother's underinvolvement and leniency were dis-
cussed. It was agreed by all that there was no need
for further treatment at that time.
Effectiveness of Intervention:
In reality, it is probably impossible to ascertain
why specific psychotherapeutic intervention
works. My analysis in this case is that the directive
given to the family fit with felt needs shared by all.
The boyfriend was not completely comfortable
assuming ail the responsibility for disciplining,
and mother, likewise wanted to find ways she
could become more involved with her parenting
responsibilities.
Brian wanted to please boyfriend and mother.
He no longer needed bedwetting as a means to
236 • Journal of Clinical Child Psychology, Volume 11, Winter, 1982
move closer to mother and distance from boy-
friend. As the mother assumed more responsibility
for disciplining her son, the boyfriend no longer
had to be the "tough" disciplinarian.
In this case, a direct intervention apparently was
the appropriate choice, since the family responded
well to it. In other cases, more indirect interven-
tions, or paradoxical interventions are indicated
(Minuchin, 1981). Perhaps the most interesting as-
pect of this case is that the intervention, which wa,s
aimed at changing interactional patterns primarily
within the parental subsystem, not only eliminated
the symptomatology in the child but also affected
the couple's decision to solidify their relationship
through marriage. This outcome is supported by
theoretical notions regarding system functioning
which, in general, postulate that systemic change
has the potential for large ripple effects beyond
the specific subsystem of focus.
Outcome:
One year after the second family interview,
Brian continued to be dry most of the time.
Mother also reported that she was much less wor-
ried about his bedwetting. Mother and her boy-
friend reported that their relationship had con-
tinued to strengthen and they had set a date to be
married.
Cautions Regarding Generalizations:
Family therapy is not always successful. When
family therapy is successful in resolving problems
and enhancing strengths it is not always accom-
plished in one meeting or with one set of detailed
tasks. However, viewing a child's difficulties as an
exorable part and process of interactions within
the family can open alternative ways of interven-
tion. This case study described a successful treat-
ment of enuresis in which the focus of the in-
tervention was on the child's caretakers, rather
than on the child or his symptoms.
References
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chosocial factors in enuretic children treated with imipra-
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DeLeon, G., & Mandell, W. A comparison of conditioning and
psychotherapy in the treatment of functional enuresis.
Journal of Clinical Psychology, 1966, 22, 326-330.
Dell, P.F. Beyond homeostasis: Toward a concept of coher-
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Erickson, M.H. Indirect hypnotic therapy of a bedwetting
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1954, 2, 171-174.
Haley, J. Strategies of psychotherapy. New York: Grune and
Stratton, Inc., 1963.
Loviband, S., & Coote, M. Enuresis, in C. Costello (Ed.),
Symptoms of psychopathology, New York: Wiley, 1969.
 NOCTUNRAL ENURESIS

Madanes, C. Strategic family therapy, Jossey-Bass, San Sluzki, C. Process of symptom production and patterns of
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Journal of Clinical Child Psychology, Volume 11, Winter, 1982 • 237