Journal ofFamzly Therapy (1983) 5: 189 - 198

Success after failure: the reassignment of responsibility in an integrated approach to a family with an adolescent bedwetter

Harry Wright,* John Wilkinsont and Angela Proud$

In this paper we review the development of our team’s thinking and demonstrate it through our approach to a particular family. This approach integrates theoretical models, the resources of the team members and the family’s belief system. Analytic and structural models give an understanding of the family’s problems. A behavioural intervention, integrated with this understanding, enabled us to circumvent the family’s investment in failure and to negotiate avoided developmental tasks.

Introduction

The Hazel Clinic is located in the county town of a very rural area. The authors were pleased to find like-minded professionals in each other. With the support of the Consultant Psychiatrist and Nursing Officer, a weekly Family Therapy Clinic was established. Initially, weekly seminars were necessary to integrate the diverse personalities and backgrounds. Experience ranged from psychoanalytically based work in therapeutic communities through behavioural psychotherapy to medicine. Thinking styles varied from intuitive and accurate perceptiveness to theoretically based conceptualization. The continuing integration and development of our team was spurred on by our treatment of a family presenting with an enuretic son.

Enuresis

Before we could tackle the problem of nocturnal enuresis as a team, we needed to reconcile our apparently opposed approaches.

The analytic model is very rich in the understandings it offers. Develop- mentally, enuresis can be seen as a retreat from the resolution of the

Received 2 March 1981: revised version received 7 August 1982. * Community Psychiatric Nurse, The Hazel Clinic, Llandrindod Wells, Powys. t Senior Clinical Psychologist, The Hazel Clinic. $ Clinical Assistant, The Hazel Clinic.

189 0163-4445/83/030189 + 10$03.00/0 0 1983 The Association for Family l‘herapy

190 H . Wright et al.

Oedipal conflict (sublimation of libidinal feelings for the opposite-sex parent and identification with same-sex parent) to an earlier stage of development characterized by issues of control. Thus enuresis is a regres- sive phenomenon produced by intense anxiety following repression and this anxiety has its source in tabooed impulses of a sexual or aggressive nature (Mowrer, 1950). Parents share these developmental tasks with the child. Uncertainty and insecurity on their part will intensify the anxiety inherent in the task. Regression to an earlier stage results in the child feeling more secure in an apparently more dependent r61e. So, whilst enuresis is maladaptive behaviour it has the function of fulfilling the child’s need for containment through control of his parents.

The behavioural model would see enuresis, in a child of normal physical and intellectual development, as a failure of conditioning. In normal acquisition of bladder control, correct toileting is rewarded by the parents. Primary enuresis is, therefore, the result of inappropriate con- ditioning by the parents. This may be either the failure to reward correct toileting or rewarding of incorrect toileting behaviour. Where a child was previously dry, the recurrence of repeated bedwetting (from whatever initial cause) is maintained by the parents’ behaviour which the child finds rewarding. We infer from this that it is the parents’ behaviour which must be changed along with the child’s.

Both models share a developmental view of the task faced by the child which is strongly influenced by interaction with the parents. A later recurrence is seen by both models to gratify the child’s needs. At the simplistic level, both the analytic and behavioural models could focus individually on the child. However, in the context of a family the parents and child interact with one another. Thus the problem is in the inter- action. Consequently it is necessary to view the family as a system. Both the analytic and behavioural frameworks acknowledge this and have developed theory and practice to accommodate it (Box and Thomas, 1979; Cooklin, 1979; Dare, 1979; Douglas, 1979). However, some practi- tioners would seem to involve parents in behavioural interventions as surrogate therapists. That is, the parents are invited to apply and maintain a behavioural task, prescribed to produce change in the child. This excludes elements of both linear and circular causality, unless the parents’ involvement in the problem is acknowledged implicitly in the design of the behavioural task. A thorough behavioural analysis would acknowledge the parents’rde in maintaining the behaviour and lead to an intervention aimed at changing both the parents and the child.

The integration of team members and their theoretical models is essen- tial to a balanced approach. In discussing the analytic and behavioural

Integrated approach to enuresis 191

models of enuresis we have suggested how differing theories overlap. However, having achieved this level of integration the most important step remains; the family’s view of the problem must be accommodated. If the therapist fails to achieve this the family may feel unacknowledged and will not engage in treatment or may project their own sense of failure into the person of the therapist. That is, the enuretic child, through a process of mutual projection, holds the family’s sense of failure. The family, as a system, in an amoeba-like way, engulfs the therapist so that he then becomes included in a larger system. Subsequently failure of therapy, with continuing wet beds, becomes his responsibility in much the same way as the enuresis was the responsibility of the child. This analogy fits well as the therapists career with the family is similar to that of the food engulfed by the amoeba, used to satisfy its needs and then expelled, never having been truly integrated in the body of the organism.

It is important, when considering the family’s view, to take account of their position as a family in relation to the immediate society. When families present for treatment they carry with them their own feeling of having failed in some respect as parents. This view is endorsed by society and the agents of society, friends, relations, family practitioners and health visitors, who may offer advice on how to deal with the problem. Thus society at large implies, or the family are able to infer, that the parents have failed to succeed in full with their child and the child has failed as he is acting beyond the norms of accepted behaviour. The thera- pist’s offer to see the family implies that he too believes the family are in need of help and, therefore, must be failing. Success in therapy would confirm previous failure. Consequently such families may perceive them- selves as being under siege from any attempt to change the status quo. Thus a defensive spiral develops where more rigid structures are estab- lished to protect the family from perceived and actual criticism and increasingly powerful interventions.

The paradoxical success (of the child’s failure to control his bladder at night) is to control his parents by making them meet his dependency needs. The parents reflect this paradox in repeatedly seeking help which they cause to fail. The therapist’s task is to reverse the process. The following account demonstrates the development of this thinking from our work with one particular family.

Case illustration

The family consisted of Father (forty-nine), a local businessman;

192 H. Wright et al.

Mother (forty-seven), working part-time in a local shop; Tom (sixteen), the index patient, an unemployed school-leaver; Cynthia (fourteen), an adopted child, attending residential school for the mentally handicapped: Phillip (eight), a quiet, shy boy.

The family had been referred to our family therapy clinic by their family doctor. The nominated patient was Tom, their sixteen-year-old son. He had never been dry for more than two or three nights since birth. He had been seen in the past by many professionals (psychologists, child psychiatrists, family practi- tioners and a health visitor), who had apparently been unable to help, there being no improvement in Tom’s bedwetting.

We offered an early appointment, inviting all the family to attend. Only mother, father and Tom arrived. The appointment clashed with an annual school event for the youngest child and the parents had decided not to involve the middle child, an adopted daughter of fourteen. She was, they informed us, resident in a special school some distance away, and they could not see how the problem involved her. It was Tom’s problem.

This was their firm opinion throughout the treatment. They left us with the feeling that they were affronted by our agreement to see them.

This first session was spent in information-gathering. We ( A . P . and H.W.) were interested to see that Tom and Mother sat on the settee, at opposite ends, and that Father sat on the other side of Tom in a separate chair.

Father said that Tom should talk to us as it was because of him that the family was there. Tom remained silent. His father then monopolized the greater part of the session in a long explanation of Tom’s bedwetting, his failure to achieve at school and his failure to be able to find any employment. He explained, too, how awkward and embarrassing Tom’s problem was to himself and to his wife because she was always washing Tom’s sheets and everyone noticed, particularly as he was a local businessman and they had many callers at the house. He repeatedly stressed how much they wanted to help their son. He had tried to find out what it was that troubled his son but could elicit no cause. He hoped that the boy would be able to speak to us and that we would be able to do something for him. Tom had failed in his studies despite his ‘uninfluenced’ desire to join the business or to train as a social worker.

For some time during this session we had felt that Father was defining our r6le for us and for the rest of the family. He had told us what to think and do, how todo it and to whom. His strong reassurance that Tom had made an uninfluenced decision to follow in Father’s footsteps clarified the feeling for us. We were sceptical of Father’s opinion but could see how Tom may have come to make this statement under the accumulated weight of Father’s covert expectations. Father was displaying his concern for his child to us through his attempt to influence us to his view of the problem, and to his view of our r61e in which we would become safe to him. His attempts to influence us may illustrate the way in which his son was influenced by him to make an apparently free choice to fulfil Father’s wishes.

Integrated approach to enuresis 193

That is, he was demonstrating to us how he had persuaded his son to choose the business or social work through his attempts to persuade us to his point of view in this session.

He also told us in this session where the problem lay in the family. He had talked of his wife’s embarrassment over cleaning dirty sheets daily and went on to describe how Tom would not help himself. Father told us of an episode when he was busy ironing Tom’s freshly laundered sheets late one evening. Tom was watching the TV and Father asked him to start gettingsupper ready. Tom’s reply was to say, ‘You do i t , you do nothing all day-you’re only a figurehead.’ Tom’s enuresis can, therefore, be seen as a focus for tensions between the primary triad of Father, Mother and first-born.

The above was also indicative of the reciprocity of the situation in that both he and his wife were actively supporting their son’s bedwetting through their collusion with this regressive behaviour. We took this up with them and dis- covered that neither would Tom change his bed, nor would he wash or iron the soiled linen, so they were ‘forced’ to do it themselves. We observed that all three were involved and that it was a problem they shared. We pointed out that they regularly accepted responsibility for their son’s wet bed by washing the dirty sheets for him.

The parents responded to this in a very indignant way. What did we expect them to do with people in and out of the place all day? I t would get to smell like a urinal. At this time and throughout our sessions with them, they always denied that they were involved in any way in Tom’s problem. If we attempted any observation or interpretation the parents would spring to their own defence, re- sponding with disbelief and incomprehension. Despite our attempts to involve him, Tom remained uncommunicative.

Our intention in giving an account of the initial interview is firstly to demon- strate the family’s inability to move from the status quo or to share our under- standing of the nature of the problem, and secondly to give the basis from which we made our formulation and developed a treatment plan.

Our initial formulation was that Tom and Father had been unable to resolve the Oedipal conflict, or rather that this was an issue which it had never become safe to face. Consequently Tom’s bedwetting was a statement of his continuing infantile need for Mother in the absence of any secure boundaries within which to come to terms with his rivalrous feelings towards Father. Tom’s repression of Oedipal feelings produced anxiety and the symbolic communication of enuresis to his parents who also indicated that the problem lay within the triad by excluding the two other children from the first session. This was not to say that the other children were not influenced or involved in any way, but that this was where they felt that help was needed. (We felt that it was highly significant that the middle child, the daughter, was adopted the day after Tom’s fourth birthday.) The family had illustrated the nature of the difficulty within the triad by choosing to sit where they had at the beginning of this first session. Tom and Mother were seated at a distance on opposite sides of the settee and Father to one side in another chair. He was closer to Tom than his wife but none of them were touching or close

194 H. Wright et al.

to each other. In supervision, the implications of our dynamic formulation were discussed. As the family appeared so entrenched in denial and repression we felt interpretation was inappropriate. The Dry Bed Technique (see Appendix), in a modified form, was chosen as a way of clarifying the parents’ collusion in Tom’s bedwetting. As a strategy we chose to demonstrate their failure as behaviour therapists rather than as parents. To have confronted them about their parenting would have resulted in a defensive strengthening of the homeostasis (as we knew from the first session). We perceived them as an embattled family which had failed in treatment many times in order to preserve their own integrity and belief in themselves as a good family. Once they had made treatment fail we expected the details of their account to demonstrate the parents’undeniable responsibility. T o maintain their view of themselves as good parents they then had to make the technique succeed. Implicit in the successful application of the technique is the requirement that the parents be firm and consistent. This would provide a structure for the resolution of Oedipal conflict and would be modelled by the therapists’ handling of the parents when discussing their failure. This session ended with the therapists feeling excited by the glimpse they had of where help could be given, but frustrated by the family homeostasis.

During the next session three weeks later, we described the technique and dis- cussed its application. We dispensed with the bell and pad as we wanted to be as clear as possible that this part of the programme was a contract between Father and his son. That is, it was imperative that nothing became interposed in the interraction between them. We also omitted the positive practice element as we considered this inappropriate for a reasonably intelligent teenager. We placed particular emphasis on the hourly checks by father, disapproval for wet beds and approval for dry beds, correct toileting and cleanliness-training.

We gave Father the task of ensuring that Tom followed the modified technique and invited Mother to support her husband. We said that Tom should be made to wash and iron his own soiled linen. We stress that we felt quite timid in the face of their protests about odour and so on, but firmly left it to them.

Here it must be stated that both the therapists were acutely sensitive to the possibility of alienating both parents, particularly Father. I t seemed at the time that they experienced our seeing them together as a statement of their culpability. Father made us very aware of his exposed position in the local community as a businessman and consequently we became anxious that there be no breach ofcon- fidentiality. This is illustrated by our decision not to use video with them, despite their having already agreed to its use.

When they returned for the next session, the technique had failed. Tom had finally refused to get up and Father had eventually found it impossible to stay awake or to respond to the alarm clock. We took this opportunity to point out how they had failed to fulfil their obligations within the programme. They pleaded that it was an unreasonable programme.

At this point the therapists withdrew to discuss the situation with their super- vising colleague. We understood our decision not to use video and our timidity as responses to family pressure to become impotent therapists, perhaps in the same

Integrated approach to enures23 195

way that Mother and Father were impotent parents. (Later, we learned from the parents that they were worried about being perceived as nasty; to them being firm meant to be unlikeable.) Consequently, the family would have been able to iden- tify their failure to change as a fault of the therapists or of the treatment, as they had with all the previous interventions. This confirmed our belief that we needed to be in control of this family, that is, to take a firm line and to make our demands and expectations absolutely clear. We returned to them and used the re- mainder of the session to acknowledge their continued, active support of Tom’s bedwetting by not completing the programme. We also felt that father needed permission to confront his son. We attempted to give this in the session by con- fronting them, thus providing a r d e model whilst concurrently identifying the lack of success as father’s failure to be firm with his son within the programme. They left, agreeing to give i t one more try.

As they were unable to attend for the next session, it was six weeks before we saw them again. In this session we were pleased to hear that they had completed the programme and had found it successful. On the night of the programme Tom had been awkward and resistant, but Father had met this with resolve and deter- mination. Mother had helped Father to get out of bed each hour throughout the night. Following this, Tom had been dry for six weeks with only two wet beds in that time. However, they had left the bed-changing, sheet-washing and ironing to Tom. In the six weeks since we had seen them, Tom had also bought a small motorbike and found himself a job in a local hotel. Significantly in this session Tom was no longer seated between his parents; his father was seated in a chair beside his wife and closer to her than was Tom.

Discussion

In our account of the treatment of this family we acknowledge that be- havioural techniques had failed in the past and that we reached an impasse when attempting interpretive work. We also point out the useful- ness of an analytic formulation in guidingour adaptation of a behavioural technique. We recognize that our use of this technique altered the structure of the family in such a way as to free the family to face and begin to resolve Oedipal conflicts which had hitherto been avoided. (Adherents of any particular model may interpret our success in terms of their own model.) As mentioned in the introduction Mower (1950) also views enuresis as a regressive phenomenon produced by intense anxiety following repression and that this anxiety has its source in tabooed impulses of a sexual or aggressive nature. We submit that our account of the process of integration as discussed in the introduction and illustrated in the treatment section, enabled us to work successfully with this family.

In the treatment section we briefly referred to the adoption of a sister to Tom when he was four years old. In fact the child was collected on the day

196 H. Wrcqht et al.

after Tom’s fourth birthday. The parents must have been negotiating the adoption for a considerable time, thus compounding their difficulties in helping Tom negotiate the Oedipal stage of his development. Anna Freud (1947) notes that a new child, who takes the toddler’s place, may be bitterly resented. The older child may feel betrayed, cheated, pushed out and deserted. He may feel extremely jealous and hateful of the newcomer, even to the point of wishing the newcomer’s death or disappearance. He sometimes competes with the baby by wanting to drink from the bottle or the breast and by becoming wet and dirty again. Wolberg (1977) also suggests that enuresis is an appeal to return to an earlier, more dependent, stage of development by becoming childish, passive and helpless. He goes on to interpret enuresis as a symbolic castration. That Tom bought a motorbike upon successful completion of treatment may be seen as the realization of male potency and a more adult level of independence.

The process of therapy was to move the parents closer together. We would suggest that this was our primary aim in using the Foxx and Azrin technique. It was essential, too, that the father was granted permission to confront his son. However, this was impossible without the support of mother. In Tom’s case, both parents associated firmness with being ‘bad’ or unlikeable. They both needed help in providing firmness and support. They needed validating in the r6le of parent.

In this family, the enuresis seemed to highlight an uncomfortable distance between the parents. In this context it is possible to see enuresis, in some dysfunctional families, as an attempt to avoid the parental close- ness which effective individuation would produce.

We feel that the thinking illustrated in this paper has implications for therapy, theory and training. In therapy we have argued the need to integrate the family’s belief system and differing therapeutic approaches with the theoretical models from which they evolve. Any one approach, whilst succeeding with some clients, fails with others. This implies that an integrated approach makes it possible to treat a broader spectrum of the client population. The integration of the clients’ model is essential in engaging them and establishing a working alliance. Alternative approaches are thus necessary to meet this model. In our introduction we mention how this can be aided by an integration of different professional experience into a supervision group.

An openness to the shared understanding between different theoretical models is essential to this process. This paper does not claim to promote a new theory of eclecticism, nor merely to restate the obvious. It stresses the need for eclecticism which is not based empirically on trial and error but arises from the integration of client and therapist theories.

Integrated approach to enuresis 197

The implications for training, which arise from this paper, are that theories should not be taught in isolation from each other, trainees must learn to elicit and negotiate with the clients’ model and similarly there should be negotiation rather than prescription between supervisor and trainee.

References

BOX, S. and THOMAS, J. (1979) Working with families: a psychoanalytic approach.

COOKLIN, A. (1979) A psychoanalytic framework for a systemic approach to family

DARE, C . (1979) Psychoanalysis and systems in family therapy.~o~rnalofFa~zz~y Therapy,

DOUGLAS, J. (1979) Behavioural work with families. Journal of Family Therapy, 1:

FOXX, R. M. and AZRIN, N. H. (1973) Toilet TrainingtheRetarded. Illinois. ResearchCo.

FREUD, A. (1947) Emotional and instinctive development. In: R. W. D. Ellis (Ed.), Child

MOWRER, 0. H. (1950) Leamzng Theory and Personality Dynamics. New York. Ronald

WOLBERG, L. R. (1977) The Technique of Psychotherapy--Enureszj, pp. 932-933.

Thoughts on the Conference Workshop. Journul ofFamily Therapy, 1: 177-182.

therapy. Journal ofFamily Therapy, 1: 153-~165.

1: 137-151.

371-382.

Press.

Health and Development. London. Churchill.

Press.

New York. Grune and Stratton.

Appendix. The Foxx and Azrin (1973) Dry Bed Technique

The Dry Bed routine contains the following components: Increased fluid intake-increases the probability of bladder voiding leading to

increased learning through reward or disapproval. Immediate detection of accidents -bell and pad used to alert both trainer and subject

immediately accidents occur. Disapproval and night-time cleanliness training- disapproval is given immediately

the alarm signals enuresis and trainee is required to remake bed, change clothing and dispose of wet bedding and clothing.

Rewards for correct toileting- approval is given for dry bed and rewards (usually food) and approval given for correct toileting (use of toilet).

Positive practice of correct toileting- before going to sleep and whenever an accident occurs the trainee has to practice going from the bed to the toilet to familiarize himself/ herself with what has been an unusual event for them.

Self-initiation training. The trainer reduces the degree to which he prompts the trainee to get up. The procedure is usually carried out on one night only, with the urine alarm remaining in

The procedure is explained to all involved and then the first training night proceeds as the bed until there have been seven consecutive dry nights following this.

follows:

198 H. Wrzght et al.

The trainee and trainer go over the procedure before bedtime. All necessary equipment is made ready.

The trainee lies down on the bed and carries out Positive Practice. closes eves. counts to twenty and then gets up, walks to the toilet, sidstands as if to void for thirty seconds and then returns to bed. Repeated ten times.

(4) As much fluid as trainee will accept is given and trainee then goes to bed to sleep. (5) One hour later trainee is awakened. ( 6 ) Reward for dry bed. (7) Trainee takeddirected to toilet. (8) Stays at toilet until either urine voided or five minutes are up. (9) Voiding rewarded: trainee directed to flush toilet.

(10) Returns to bed. (1 1) Trainee given fluids.

(12) Awaken trainee. (13) Inform him that he has wet bed and show displeasure. (14) Turn off alarm and send trainee to toilet. (1 5) Clean urine alarm. (16) Cleanliness traznznggc (a) Trainee changes soiled clothing: (b) Changes pad: (c) Dispose of soiled garments: (d) Urine alarm replaced. (17) Positive Practice carried out as step (3). (18) Repeat procedure from step (5) every hour throughout the night. On the second night, if accident occurred during the first night, positive practice is

The urine alarm remains in the bed until scven consecutive dry nights have been

If the alarm goes off duringsucceeding nights, cleanliness trainingand positive practice

The whole procedure is vigorously documented and recorded. For the purposes of the treatment of this in family therapy, several modifications were

(1 ) No urine alarm. (2) Positive Practice excluded. (3) On second attempt, wife was made responsible for rousing husband.

If alarm goes off (or bed found wet):

carried out before sleep.

recorded

are carried out.

made: