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In this case, when I'm active at night, my formal name is Nocturnal Enuresis. Because of the ways I was responded to, because of shame and blame, some children were made to feel really bad about themselves. For more information see: www.dulwichcentre.com.au/dulwich-centre-foundation.html Further resources and references This handbook has aimed to offer some hopeful and creative ways to engage with children who are experiencing bedwetting in times of trouble.
Introduction
Dulwich Centre Foundation is involved in projects aiming to assist children living in vulnerable circumstances, including children who have experienced or witnessed violence. During these projects we hear about how children and young people in such distressing circumstances are increasingly vulnerable to experiencing bedwetting. We particularly hear about children in immigration detention centres, children who are living with their mothers in domestic violence shelters, and children in contexts of war or natural disaster, who are having to deal with wet beds in times of trouble.
We also hear about the effects of this bedwetting on the children's sense of identity, on relationships within the family, and on the relationships children have with other children. We found that bedwetting can also impact on family members, especially if the family is dealing with a lot, like coming to a new country.
While wetting the bed can be a completely normal part of growing up, and is often experienced without any influence of distress or trauma, this handbook aims to offer hopeful and creative ways of responding to children who have experienced trauma and/or witnessed violence and in the midst of dealing with these tough experiences are also finding themselves in wet beds. We hope this resource will be helpful for workers and for parents/carers. Down the track we are also hoping to produce a storybook that children and young people can read.
Keywords: enuresis, trauma, narrative therapy, fears, children
A conversation with Enuresis
Enuresis is a character known to many children and families here in Australia and around the world. Known also by the more common name of Bedwetting, Enuresis agreed to participate in a conversation to introduce this publication. 'I'm not talked about nearly as much as I would like', claimed Enuresis, 'there can be misunderstandings, it's time to open things up a little; get to know me better'. The conversation commenced with an exploration of the rather exotic sounding name; Enuresis.
My name Enuresis comes from the Greek. I enjoy my name actually, it reminds me of my long and rich heritage, I have been around for centuries. There is even mention of me in ancient Egyptian medical texts as early as 1550 BC. Of course there are other names for me, bedwetting most commonly. In this case, when I'm active at night, my formal name is Nocturnal Enuresis. Less often I'm active in the daytime, then I'm known as Diurnal Enuresis. But really I'm most busy at night. Some children have called me by nicknames such as The Night Wetter, Sneaky Wee, Annoying Accidents, The Worry Waterfall, Leaky Wee, or The Trickling Terror, among other things.
How do you feel about these other names?
Well, they're okay, not as grand as Enuresis of course. But I don't mind children coming up with a name for me that makes sense to them. Something nice and familiar, you know, my relationship with each child can be quite particular. And it is mostly children who know me well. I am most busy for younger children. For children around four years old, I am there for about one in three. As children grow, I don't hang around with as many. For six year olds, it's about one in ten, and by the time children are 10 years old, I'm only interested in about one in twenty. Generally, I tend to favour boys; just a little more than girls. All in all, it's quite a lot of children that I know, don't you think?
Yes, that is quite a lot of children. How do you choose who to get familiar with?
Well, for many children it's a simple issue of biology. You see, as children grow past the toddler years, there's a hormone that the body produces, called anti-diuretic hormone or ADH, this reduces the amount of urine produced at night so that they can start sleeping through the night without a need to empty the bladder. It is thought that for some children this gets produced later in life than others. The system hasn't fully kicked in, so urine continues to be produced at night, more than the bladder can hold. Another idea is that for some, messages to the brain that the bladder is full are not being sent efficiently yet. For these sorts of issues, genetics seems to play an important role. Most, about 85%, of children who know me, have relatives who knew me too. I tend to stick to particular families. Other children simply might take longer to learn how to hold on throughout the night. Very occasionally, there might be an infection that invites me along, but this can be determined pretty easily by a doctor*.
Well, that all sounds quite straightforward. Why is it do you think that you're, as you said, not talked about so much ... even kept secret or hidden? Is it fair to say that you often team up with embarrassment or even blame, or shame?
There are a couple of things to say here. In the greater scheme of things, these biological understandings of me are relatively new. Years gone by, I wasn't understood in these ways. In the absence of other explanations, blame might have been invited by my existence, or shame. It was thought that I was something the child could control easily. There were days when some children were punished, humiliated. I never enjoyed these times; times of 'hanging out the stained sheets' I call them. Because of the ways I was responded to, because of shame and blame, some children were made to feel really bad about themselves. I still see this happening sometimes and really, I don't like it. Embarrassment, shame, stigma and blame are not my friends and they are not in my team, but they can hang around me.
The second point to make here is that, despite my intentions, without any fault on my part, I can lead to some messy experiences. Unfortunately, urine can leave a less than favourable odour, especially if I am around a lot - nightly for example, or more than once a night. People can be a bit prudish about what comes out of the body; they don't like it when urine goes all over children's pajamas or bedding. Some families find it harder to talk about bodies and body functions than other families.
Sometimes I am seen as a sign that a child is immature, a baby, or unclean, or not capable. I can get in the way of children doing things they would like to do, like sleep over at friends' houses or go on school camps. I also might interfere with the sleep for everyone in the house, and I create quite a workload of washing for people. This can all get very wearying I suppose. Sometimes I become the only story about a child, other stories, like things they are good at or care about, become obscured by me. The complication here is that when a child is made to feel at fault somehow, embarrassed or ashamed, this can make it harder for children to say goodbye to me. When there are worries around for a child, or fears, sometimes I become more and more of a problem.
So, there are the physical issues you mentioned above, but there are also other factors, like worry?
Let's be clear. For some children it's simply a matter of biology. And these days, lots of people are onto these issues and a child is simply supported to manage with me in their lives. Some children take a form of anti-diuretic hormone (ADH), especially when they want to sleep over at a friend's house or go on a school camp. Other children use an alarm mat on their bed that teaches them to wake up when their bladder starts to empty in the night. There is lots of information about these things on the World Wide Web. Doctors know about these things too.*
But these things don't work for everyone, it's not so straightforward for some children, it's a little more complicated, there may be worries or fears in their lives. There might be difficult things going on for them, distressing things. Some children are responding to upheavals, families moving about, changing formations ... or there might be scary things going on around them, or hurtful things, violence for example. Sometimes, for children who are managing hard things, when there is trouble around, I might be part of the picture. I am pretty busy around the world in places of war, where there's lots of fighting and shootings. I'm also busy in places like women's refuges and immigration detention centres where people have fled violence. I am sure you have heard of stories when even big people are really scared, then they have urine coming out, I cannot be controlled by them because their bodies are terrified.
But surely children who are managing worries or fears have enough on their plate without having to deal with you as well? Why do you hang around for these children?
Well, fear and worry do affect children's bodies you know. Look, I've been around a long time. I've known lots of children ... all over the world. I actually think it should be said that children do a great job managing hard times, responding to difficult things going on around them. Even when things are tough, I see them carrying on. Some kids keep a lookout for others they care about, despite what's happening to them, they might keep going to school, keep thinking about their future, they find ways to avoid scary things or even make the trouble less. But when there's ongoing distress, continuous fear or worries, their bodies can be in a state that's ready for action, that's ready to deal with any dangers. They are super alert. This hyper-aroused state can involve all sorts of changes, involving lots of hormones and chemicals.
Kidneys and bladders can be affected, and that's where I come in. And often scary things have happened at night, and that's when I'm most active.
In these situations then, in times of troubles, what do you recommend?
Well, I think it might be helpful to realise that a child has so much going on; I'm not all there is. If a child gets called names, if shame or blame are around, this makes it all more difficult. I'm pretty busy, as I said before. I don't actually like it when a child starts to think of himself or herself as 'Bedwetter' or 'Unclean' or that they are somehow undeveloped or incapable. Where children are supported to remember other things about themselves, who they are outside of me, I think this is better. It goes without saying that if it is at all possible, getting the worries or fear to be less is important. Also understanding that children are doing their best in the face of the fears or the worries, understanding how they are responding, this can be good too.
Enuresis, I think we are all surprised to hear of your sentiments of care for the children you know.
Well, yes, I've had a bad rap in the past. But this is changing and will continue to change I hope. It's because of this hope that I agreed to do this interview. And I'm getting tired, I would like to be less busy.
Is there anything else you would like to clarify?
Yes I'd like to say something more about the importance of consulting with children about me. I see children do all kinds of things to cope with me in their lives, or make me less of a problem. Some kids put themselves on schedules to regularly empty their bladders, some even set alarm clocks in the night to get to the toilet before their bladder overflows. Some children pray, some write wish lists. Some work hard to make their bedroom a comforting and safe place. Sometimes they tell trusted friends about me and work out strategies together, like putting plastic garbage bags under the sheet so the bed doesn't get wet. Some kids stop drinking fluids from the afternoon on - actually I don't recommend this, unless it's about stopping all those drinks with caffeine in them like tea or cola.
For those children with worries or fear, some kids have ways of calming their bodies, reducing the hyper-arousal, like certain games, or thinking up good stories about themselves or others. Some kids choose trusted people to talk to before they go to bed, even people who are not physically there, to help them feel safe, or move their beds to places they feel safer. Some have special things, like treasured softtoys, that they keep close at night. I reckon kids could share these things that they know; all sorts of things they do to try to minimise my impact. These things say something to me about what kids want for their lives, what is important to them. Having me around isn't something they want!
As I've said, I am getting tired; I would like to be less busy. When family members or trusted people get involved, they can all work on problems together. This is helpful I think. A child dealing with worries or fear and then me as well, if a child has to do it alone, it's really much harder.
Enuresis thank you for your insights. I think we all share in your hope that the 'bad rap' you have received in the past will continue to reduce and that you will, as you have said you would like to, become 'less busy'.
Useful ways of talking about bedwetting: Externalishing conversations
Nicholas Harris, aged 11 years, was brought to see me by his parents over their concerns about bedwetting. This bedwetting had resisted many, many attempts to resolve it, and it was becoming increasingly embarrassing for Nicholas, and, as well, more significantly constraining of his life. Not only did it make it impossible for him to sleep over with friends, but it was preventing him from stepping into many of the activities that were available to his peers - for example, going away on camp. It was also clear to me that this problem was now having a demoralising effect on Nicholas's parents. They despaired of this problem ever being resolved.
I asked Nicholas what the bedwetting was talking him into about the sort of person he was. Was it convincing him of positive things about who he was as a person, or was it convincing him of negative things about who he was as a person? Questions of this sort introduce externalising conversations that accomplish several objectives. They provide the opportunity for people to make public their private stories of identity, and to step into a position that is once removed from these stories. From this position people begin to experience a degree of alienation from these private stories of identity, and to break from the negative 'truths' about who they are that are borne by these stories - negative 'truths' that have been so capturing of them in the past.
In response to these questions, and with the assistance of his parents, I learned from Nicholas that the bedwetting problem was talking him into the idea that he was 'incompetent'.
Michael White (1995, p.201-202)
A useful starting place for talking with children about bedwetting is to position the problem as the problem rather than the child as the problem. Taking an investigative stance, the therapist or worker can consult the child in regard to the operations of the bedwetting, what might be contributing to its existence, what its effects are on the child's life, what it might be signalling to the child, how the child currently responds to its operations and ideas the child might have for its management. These sorts of investigations serve to externalise the bedwetting and give the child a place to stand in relation to bedwetting. As described in the example conversation above, the impact of the problem on a child's conclusions about who they are can be explored. Importantly, separating the child from the problem can open the way to considerations of whether these conclusions are satisfactory or warranted.
Children might be asked to nominate their preferred name for the bedwetting. Some names used by other children include Sneaky Wee, The Night Wetter, The Worry Waterfall, Annoying Accidents, Leaky Wee, or The Trickling Terror. Children can be invited to draw or sculpt their particular bedwetting character to help the process of externalising. Conversations can continue while the drawing or sculpting is taking place.
Useful questions might include:
* How often does IT visit?
* Does IT visit others in your family? Has IT ever?
* Who else knows about IT?
* What does it make those people who know about IT feel do you think?
* Does it affect your relationships with people you care about?
* Do you know what might invite IT or support IT to visit?
* Is there anything good about IT?
* When is IT strongest, when does IT do the most trouble?
* Are there times when IT is less troublesome or stays away?
* What does IT make you feel about yourself?
* Does it talk you into believing negative things about yourself, or positive things?
* If IT makes you feel bad, what helps you feel better again?
* Is there anything you do once IT has visited? Does this help?
* Do you have ideas about what you would like to do to help IT stay away?
* How would you describe your relationship with IT?
* What thoughts do you have about the future of your relationship with IT?
* Does IT fit in with any hopes or dreams you have about your life?
This way of talking about the bedwetting can be shared by family members or others who know about IT. IT can become a shared problem that everyone is working on, rather than the problem being the sole responsibility of the child. In this way, any shame or self-blame might be reduced. Rather than seeing themselves as defined by the bedwetting, children can be supported to see other, more preferred stories, of who they are. These preferred stories can then be supported and grown. The following excerpt continues the story of Nicholas:
Further questions established that, for Nicholas, not only did incompetence represent one of his negative 'truths' of identity, but that in a more general sense, it represented a 'dominant plot' in his life, it had been quite influential in shaping his life ...
... However, in working to identify contradictions to the dominant plot, rather than seeking contradictions to the problem, we find a broad field of enquiry opening before us. In stepping into this field, Nicholas, his parents and I, discovered an abundance of contradictions to the dominant plot of 'incompetence'.
Michael White (1995, p. 202)
Externalising bedwetting or other problems might offer a useful way of talking with children that enables the problem to be explored in its own right rather than a child being seen as the problem. Also, it offers ways of opening conversations about other stories of identity that are preferred or fit more closely with a child's sense of who they are. In the following example given by Australian therapist Radhika Santhanam- Martin, it was discovered that Bedwetting had convinced Selvan that he was weak and not clever. But this story was soon dislodged, and replaced by understandings of Selvan as strong, clever and capable.
Selvan's Story
Selvan was about seven years old when we began meeting. I found out that in his early life in Sri Lanka, Selvan had met all the usual milestones including bladder control at night. When he was about four and a half years old, he was unwell with a high fever. For the first time, bedwetting made an appearance. His family told him that this was no problem, nothing to worry about. The understanding was that when the body becomes weak, then this, bedwetting, is what happens. Not long after this time, the situation in Sri Lanka became very difficult for Selvan and his family. After his father was taken prisoner, Selvan and his mother fled to Malaysia where they were admitted to a detention centre for asylum seekers. Here the bedwetting reappeared. Again, Selvan was told that the bedwetting was related to his weak body. This was a time of uncertainty and fear, of questioning; 'Will we ever be safe?', the food was insufficient also. Selvan's mother reassured him that these circumstances made the body weak. And this was why the bedwetting was back.
Later, Selvan and his mother travelled by boat to Australia. In Australia, they stayed in two different detention centres. Now seven years old, Selvan again experienced a fever and then again, along came the bedwetting. Selvan and his mother met a pediatrician who mentioned to Selvan that fever and bedwetting do not usually go together. And the pediatrician asked his mother whether she would consider discussing this with a psychologist. That is how they met me.
I asked Selvan what name he might give to the bedwetting problem. I asked how he understood it. He explained the story he had always been told that it was because of his weak body. But he said that in his thinking, a weak body also meant a weak mind. His understanding was that a weak mind means you are not clever. Thus, bedwetting made him feel less clever.
I wanted to see if we could find other stories about Selvan, stories different to the one that he was not clever. I asked whether there were stories about him, known to other people, that contradict this idea that he is not clever. I encouraged them to consult the family back home to gather special stories of cleverness. There were many stories. One story was told by Selvan's mother. She told how after Selavn's father had been taken prisoner, Selvan was such an important helper for her. She said that Selvan kept her alert, safe, that she it would have been really difficult to leave Sri Lank and seek refuge abroad if it were not for Selvan. At the time of leaving Sri Lanka, Selvan's uncles had told Selvan that they considered him such a strong, sensible boy. His uncles were sure that Selvan would be a good support for his mother. Selvan also remembered how he spoke no English when he leftSri Lanka. He had tried to learn as much as possible since leaving Sri Lanka and learnt right through his journey across Malaysia and while on Christmas Island. His mother taught him to spell, read and write. When the time was ready and he was assessed while they were on community detention, they were told that his English language skills are age appropriate, even slightly above average.
And he was admitted to mainstream school. One further story was from school where Selvan was asked to sing in a performance because, said his teacher, his pronunciation in Tamil was so good. All these stories were very different to the story of Selvan having a weak body and a weak mind.
The next time we met, Selvan told me 'Actually, I discovered that I have a very strong body. I was speaking with my grandmother in Sri Lanka, on Skype. She told me that she considers me very clever, that I have a strong mind and a strong body. She said that I was the one to learn bladder control very early ... at 11 months old! I'm the first one in the family to have bladder control so early.'
It turns out that the bedwetting did not persist. For Selvan's mother it was never a problem ... she had said that the bedwetting comes and goes and is 'only a little problem'. She said to Selvan; 'If you stopped having a wee at all, now that would be a problem! A healthy body must wee!' Selvan understands now that the bedwetting might come when he's feeling tired or fragile. So now he looks out for signals such as getting upset or afraid ... He gets afraid sometimes in the night thinking about 'what if the army comes to get his mother and him'; 'what if his father is not able to see him'. He feels tired thinking about these things. At these times Selvan knows to look after his body - to rest, talk to his mother, drink water, eat good food or talk to his grandparents or uncles in Sri Lanka.
Responding to troubled times
For many children, the bedwetting comes at a time of particular worries or frightening experiences. It might be when parents have separated, when they have moved house, or moved from another country. It might be that violence has been witnessed or experienced. Frightening or traumatic experience might serve to separate, or cut children off, from what they once knew to be true and predictable about life. Ideas about safety can be powerfully disrupted. A sense of agency over one's life might be shaken. When this is the case, it is helpful to support children back to 'firmer ground'.
When it is known that distress, worry or fear are significant, these might be externalised rather than, or in addition to, the bedwetting. Children can be consulted about what they consider to be the dominant problems in their lives and conversations can be guided accordingly. For example, in speaking with Canadian based therapist, Angel Yuen, Jack named 'The Big Nerves' as the main problem in his life. In response to questions about how The Big Nerves were impacting on Jack's life, Jack revealed to Angel that:
* They make my body feel weird
* The Big Nerves are in my stomach
* They make me throw up
* I can't focus in school - harder to do my math & writing
* I can't read
* Make me feel scared
Although children may not be able to control the circumstances of their lives, it can be useful to uncover the ways, however small, that they are responding to the circumstances of their lives. Rather than considering children as passive recipients of traumatic or worrying events, thoughts and actions initiated by children hint at a continued agency. These thoughts and actions might be signalling a protest about what is occurring or a commitment to maintain something known or cherished about life. In the presence of trauma, fear or worry, children might be unaware of their responding thoughts and actions and may feel quite powerless. Investigating and making visible what children are in fact doing to mediate the trauma, fear or worry, can help to restore a sense of agency and consequently safety to a child's life.
For Jack, investigative questions revealed that he was in fact finding ways to mediate the impact of The Big Nerves:
* When The Big Nerves make me scared I pretend I'm a Pokeman and that I have all these powers
* Some can put you to sleep. So I use those to put The Big Nerves to sleep.
* One is a telepathic mutant and he will know when The Big Nerves are coming.
* One has a dark wand night laser.
By establishing that children do in fact have ways of responding to traumatic events in their lives, it is possible to begin to restore and/or develop personal agency, a sense that it is possible to be influential in your own life. It becomes possible to make children's skills in responding more accessible to them, more known. Further questions revealed that Jack had the following ideas about what helped him 'Beat The Big Nerves':
* Jumping on the trampoline
* Going in the pool
* Playing music
* Going for bike rides and gelatos
* Cuddling
* Thinking of my little sister giggling
Following the series of conversations with Angel, Jack said that he very much hoped to share his skills and knowledges of 'Beating the Big Nerves' to help other children facing scary times.
Significantly, skills in living and knowledges about life can then be linked to children's values, beliefs, hopes and commitments in life, to preferred ways of being. In this way, children can be engaged with stories of identity that are preferred, that move away from stories that are dominated by the problem, such as 'bedwetter' or 'incompetent'.
One of the key components in these types of conversations is being aware at the outset of the shaky ground on which children experiencing trauma may be standing. The emphasis is on assisting passage to 'firmer ground' rather than inviting conversations that repeat or magnify the trauma story. In summary, from Michael White (2006):
When meeting with children about experiences of trauma, the story of this trauma and the effects that this has had on the child's life is often the first story that is brought to our attention. This story requires recognition.
But there is also a second story of how the child has responded to these experiences of trauma, and this second story is often overlooked. No-one is a passive recipient of trauma. Even children respond in ways to lessen the effects of the trauma, to seek comfort, to try to preserve what is precious to them, and so on. This second story is very important. The ways in which children respond to trauma are based on certain skills. These skills reflect what the child gives value to. And what the child gives value to is linked to the child's history, to their family, to their community and their culture.
These responses to trauma are not solely individual. They are not formed independently of the contribution of others. In these responses, children are linked to key figures in their lives. In narrative practice we are very interested in developing rich accounts of this second story. By developing rich accounts of this second story we reconnect children to culture, to family, to community and to history. (pp. 87-88)
The following section explores ways to make and support these reconnections.
Creating a support team
Distress or traumatic experiences, as well as enuresis, are often accompanied by secrecy and may invite also a sense of isolation. Conversations that serve to join therapists and carers in collaboration with children against problems can begin to diminish isolation. However, finding ways to engage other cherished figures with the child can be even more powerful in reducing isolation. and furthermore serve to build upon other preferred stories of children's identity.
This was true in relation to Prince and his father in the following story, Prince and Salem the Stream, told by Karen Treisman a therapist from the UK.
Prince and Salem the Stream
Prince was a bright, engaging, and imaginative 7-year-old boy. He was originally from the Congo and had arrived in the UK about a year previous to meeting with me. Prince had been accompanied to the UK by his mother. His father reportedly was kidnapped from the family home, and to date his whereabouts remain unknown. Prince's mother, Grace, reported that Prince had been exposed to numerous stories of trauma and loss, as well as first-hand experiences of physical and sexual violence.
When we first met, Prince was doing well at school and had made several friends. He enjoyed drumming, singing, and art. Grace's main concern was that Prince was experiencing headaches, stomachaches, and wetting the bed on a nightly basis. She had visited the local enuresis clinic who, following thorough checks, had advised that strategies to support Prince around anxiety would be optimal. Grace herself was reluctant to engage in therapy and reflected on how back home she would have visited a sangoma (traditional healer). We explored various cultural discourses around bedwetting, therapy, and help-seeking which supported Grace in giving therapy a try.
During the sessions, Prince was supported in using narrative techniques to externalise the enuresis. He aptly named the enuresis Salem the Stream. Prince was supported in drawing and painting Salem the Stream. We then discussed questions such as, 'What makes Salem the Stream stronger/weaker/dryer', 'What tools and skills do you have to shrink Salem the Stream', 'Are there times when Salem the Stream stays away or is scared to come too close?', and 'who else is helping or fighting Salem the Stream?' Following this, Prince selected a few methods of responding to Salem the Stream. He shouted at the poster he had made of Salem the Stream and then tore the paper up and threw it away in the dustbin. Prince also found an instrument which represented Salem the Stream (a wind chime) and then Prince would play loudly with a drum to counteract and drown out the noise of Salem the Stream. Finally, Prince made an elaborate mould of Salem the Stream using clay and then took great pleasure in jumping and squashing him!
Alongside the above, we transformed Prince's room into a safer more comforting place with glow in the dark stars, a stress ball, worry dolls, a worry box, a safe place poster, and a night lamp. Prince also called on his creative and artistic talents to decorate a super safe and comforting blanket with fabric pens. Grace, myself, and many more people on Prince's team, wrote supportive messages on this blanket!
We also recruited Grace to be on board as part of the team keeping Salem the Stream away! Before he would go to sleep, Grace would wrap Prince up in his safety shield and magic blanket, as well as reminding Prince of all the challenges he had overcome in the past, and of all his special unique skills, qualities, and talents which he had up his sleeve. Grace practised relaxation techniques with Prince, and even went one step further and got her own fairy dust, dream catcher, and worry box!
When I asked Prince 'Is there anyone in your life who might have understood how you are feeling?' Prince identified his father. And so we engaged in some re-membering conversations (Morgan, 2000; White, 2007), through which Prince reconnected with some of his father's strengths and skills which remained in his heart and in his head.
I asked Prince questions such as, 'What was it that your father brought to your life?', 'What did he help you with?' and 'How did he influence what you thought or felt about yourself?'
I also asked, 'What skills and strengths did you notice and appreciate in your father?' and 'What skills and strengths do you think he appreciated about you?'
We then went on to discuss how like Simba in the Lion King (a favourite cartoon) his father, like Mufasa, remained in his heart, head, blood, and reflection. We then made a key ring and filled it with different colours of sand. Each colour represented a different special person/animal in his life. The largest section/colour represented his father. Prince would keep this key ring with him at all times.
Prince also decided to write a letter to his father to ask him join his team to assist in reducing the influence of Salem the Stream. In this letter, Prince wrote what he missed about his father, the things he appreciated about his father, and the things he wanted to share with his father about his life and concerns. He used pictures to explain himself. Prince also requested support from his father and he likened him to a star in the sky watching over him and a guardian angel cradling him. Prince kept this letter in a safe place and he also chose to place a photocopy of the letter in a bottle (as if it was a 'message in a bottle').
Towards the end of therapy, Prince was no longer wetting the bed and described Salem the Stream as a 'faraway ghost'. Prince also reported that, should Salem the Stream visit again, he would be okay as he knew how to 'squash' him. Grace concluded that now Salem the Stream is yet another challenge that Prince can add to his long list of things he has overcome!
In another story, as told by Australian based Sue Mitchell while working with Palestinian families in the Gaza Strip, Tarek was able to remember some things he had forgotten about himself with the assistance of his cherished uncle Ab.
Tarek's mum, Amina had invited me to meet with her and Tarek because of concerns about Tarek's isolation from his siblings and other children, his poor school performance and in particular, nightly bedwetting. I asked Tarek what he thought about his mum's concerns and told me, very quietly, that things were not right for him. He told me that he was teased by his older siblings and other children for wetting the bed, and for being small and weak (he was smaller than average for his age). He told me they called him names. Because of this, he didn't like going to school and found it difficult to concentrate when he was there. One of the things that distressed him most he said, was that he wasn't able to go to the Mosque on account of being 'unclean'. His mother complained of the constant washing of bed sheets. The mattress he slept on was ruined and smelled bad. The family had a very small income and replacing the mattress was difficult. Amina said it was difficult to provide enough food, which was the priority. Tarek told me he felt lonely, that he was causing his mum lots of trouble, and that there was something wrong with him.
I asked Tarek if there was anyone he could think of in his life who might know another story about him. Tarek thought for a while and then mentioned his uncle Ab who used to live upstairs from Tarek. Living in a place of armed conflict, Ab had been shot by sniper fire while standing by his living room window. Ab's body had been carried down the cement stairs and Tarek had been given the job of cleaning the blood from the stairs. He spoke of the image of his uncle's blood on the stairs and how difficult it was to remove the blood. As he spoke tears fell from his eyes.
I asked him about Ab, what kind of relationship he shared with Tarek. Tarek said that they were very close. He said that he loved his uncle dearly and that his uncle really 'understood him'. I asked some more questions about Ab and what he contributed to Tarek's life. Tarek said that Ab always had time for him, that when he came to visit he would sit Tarek on his lap and talk with him. Tarek said that Ab made him feel special. Now that Ab was gone there was no-one who made him feel this way. I asked Tarek what Ab might want to tell me about Tarek, if it were possible to ask. This was difficult for Tarek to answer but he said that he would say good things about Tarek, that he was responsible and kind. And also that he was funny. These were very different understandings of Tarek than those most dominantly available to him now. We spoke some more about why Ab would say that Tarek was responsible and kind and funny. I was trying to get as many examples of these ideas of Tarek as possible. I then asked Tarek what he thought he might have meant to his uncle. Tarek said he hadn't thought about this before but, in thinking about it, he thought that he was probably important to his uncle. His uncle didn't have any sons and seemed to enjoy spending time with Tarek. I asked whether their relationship might have taught something to Ab, about what kind of man he was. Tarek thought that their relationship might have taught Ab that he would be a good father to a son, or that he was a good uncle to his nephew. Tarek usually sat with his shoulders slumped and his face turned to the ground. But as he spoke of these things he sat more upright and began to look me in the face. I asked him what it was like to be talking about this and it said that it made him feel 'safe'. I asked him what his uncle might say to him, if he were able to speak directly to him. Tarek said he didn't know but he agreed to think about it.
When we returned the following week, Tarek met us at the door with his mother close behind. Amina was smiling and said that Tarek had some good news for us. Once we sat down Tarek told us, smiling but with humility, that he had been to the Mosque that week. He had been waking in the morning after not wetting the bed at all. I asked Tarek what he thought had contributed to this development. He said that at night, before going to sleep, he had been having small conversations in his mind with his uncle. He would say goodnight to Ab and listen for Ab's words in return. He said these words he heard in his mind were comforting and helped him feel safe.
In this example, Tarek can be seen to have been re-engaged with a cherished uncle who was able to assist in generating stories of Tarek other than those of him being 'unclean' and 'having something wrong with him'. Uncle Ab was invited onto Tarek's support team. Cherished others do not have to be people. They may be characters in books or cartoons, superheroes, pets or imagined friends. Importantly, these re-membering conversations (Morgan, 2000; White, 2007) invites more than a passive remembering.
One of the key aspects of re-membering conversations is that they generate two-way accounts of relationships. They create stories about relationships that emphasise the mutuality of these relationships, that emphasise the two-way exchange that is involved in these. In the first stage of re-membering conversations, the counsellor asks questions that seek stories about what the significant figure contributed to the child's life, and about what this suggests the figure appreciated about the child. But in the second stage of re-membering conversations, the counsellor asks questions that bring forth the second aspect of these relationships. These questions seek stories about the child's contribution to the life of the figure, and about how this was confirming of, or might have been confirming of, what life was all about for this figure.
Through these conversations, children come to witness their identity through the eyes of the re-membered figure and give expression to how they might have touched the figure's sense of identity. This enables the child to draw new conclusions about their own worth and value.
Michael White (2006, pp. 94-95)
Using Documents & Certificates
Conversations can be wonderful in uncovering different ways children are responding to problems in their lives, their skills and knowledges about living and also what it is children value, are committed to and dream about. One of the ways to honour these discoveries, and to have them accessible once the conversation has concluded, is to create documents.
Here is an example of a document that Michael White wrote using the words of Robert, who was six years old at the time. Robert and his parents were at their wits' end at trying to cope with persistent soiling (not wetting the bed, but pooing in the pants). Robert externalised the problem as Mr Mischief, and the following letter was created:
How Mr Mischief messes up Robert's Life
1. He gets me into trouble with Mum and Dad. I don't like this.
2. He dirties my pants. I don't like this. This is uncomfortable.
3. He makes other children want to go away from me. I am unhappy about this.
This could make me lonely.
4. He takes away my fun. I don't like this because I like having fun.
5. He is making me less grown up. I am upset about this, because he will make me younger than my younger sisters.
6. He is making me a follower. I don't like this because I would like to be a leader.
7. He is stopping me from doing things. I'm cross about this, because I like doing lots of things, and I'd like to run faster.
8. He is becoming a habit. I wouldn't like this because habits are hard to get away from. I wouldn't want a habit to rule my life.
9. He could make me into a slave. I wouldn't want this, because I want better things for my life.
10. He is starting to make the decisions in my life. I'm not happy about this because I should be making more decisions in my life.
I would like to get my life back from Mr Mischief. It is my life, it belongs to me. It will be difficult, but I know how to do difficult things. When I was learning to ride a bike, this was difficult. But I didn't let this push me back. I kept trying and I got the hang of it. I didn't surrender and in the end I was successful. If I keep trying to get my life back from Mr Mischief, I will get the hang of it. (White, 1995, pp. 207-208)
The externalisation of the problem and this document proved to be a turning point for Robert and his parents, as Michael (2004) described:
At the second interview, I discovered that the soiling had decreased by 50 per cent, and was no longer a daily occurrence. I also learned that, for the very first time in his life, on the occasions upon which Robert had soiled his pants, he was acknowledging this to others instead of denying it. Of course, this wasn't the end of the story, because, as one might expect, Mr Mischief turned out to be a very slippery character. I met with this family on several more occasions, identifying the skills that Robert was using to out-trick Mr Mischief, and those aspects of the parent-child team work that seemed to be working best. Before long, Robert had sealed Mr Mischief's fate - and it was apparent that Mr Mischief had become resigned to this - and he received a Certificate of Achievement. (p. 208)
Certificates
Certificates can elevate and honour efforts children have made to manage the difficulties in their lives. Here is an example of a certificate that could be awarded to Jack for managing The Big Nerves:
IT IS HEREBY CERTIFIED THAT
Jack
HAS PARTICULAR SKILLS IN MANAGING THE BIG NERVES
THESE SKILLS INCLUDE:
* Pretending he's a Pokeman
* Using Pokeman powers to put the big nerves to sleep
* Using the dark wand night laser
* Jumping on the trampoline
* Going in the pool
* Using telepathic mutant powers to know when The Big Nerves are coming
* Going for bike rides and gelatos
* Thinking of my sister giggling
* Cuddling
* Playing music
THIS CERTIFICATE HAS BEEN AWARDED IN FRONT OF JACK'S FAMILY AND 'WHISKERS' THE CAT
SIGNED BY ANGEL YUEN
TORONTO, CANADA
Formal certificates can be placed in prominent places and might be used to encourage caregivers to ask further questions about how they have made such achievements and the meaning of this in their lives.
Unexpected outcomes: Alyssa and the Nightwetter
When problems are externalised and children are invited to use their ideas, skills and imagination, the outcomes can sometimes be unexpected. This is perhaps best described through the following story told by Peter Fraenkel, a therapist in New York City.
Alyssa and the Nightwetter
By Peter Fraenkel, Ackerman Institute, New York City.
Alyssa was a 9-year-old, white middle-class Jewish girl living with her parents and younger sister in New York City when I met her. She had been toilet trained at age 3, but had never fully achieved regular night-time dryness. She generally wet the bed every night. Her pediatrician determined that she had no physical problems contributing to her bedwetting, and recommended psychotherapy. She was in psychoanalytic play therapy for two years, which she enjoyed due to her capacity for imaginative play, but this therapy had no effect on her bedwetting. Her parents then placed her in behaviour therapy, which involved utilising the bell and pad (a pad placed under the bedsheet that, with the slightest drop of urine, set offan alarm bell). She slept through this alarm, and her parents, under instruction from the therapist, would wake her up, have her go to the toilet (an aversive/punitive technique called 'positive practice') and take offthe bedsheets in the morning. This, too, had no effect on the frequency of her bedwetting, but did lead her to feel more shame about the problem, amplified by the negative interaction with her parents, and their frustration. The behaviour therapist recommended family therapy, which is how I came to meet them.
In the first session with the parents, I learned that Alyssa was doing well in school, had a number of friends, had no developmental issues from birth onwards, and had not experienced trauma. The parents' relationship was strong, but they were understandably frustrated by the tenacity of and lack of explanation for Alyssa's bedwetting. In a first session with the parents and Alyssa, I found her to be a cheerful, bright girl who was also frustrated with her problem. The main negative effects of the problem on her life was the tension it caused between her and her parents, and that it kept her from going on sleepovers with her friends.
Building on my sense of her creativeness, and in particular her love of drawing, I suggested that problems sometimes appear and take over our lives for mysterious reasons, and that sometimes it's better just to do some things to try to solve the problem, without getting too much into figuring out why we have them. I also explained that sometimes we end up thinking of ourselves as mostly being about the problem, so that we and the problem become the same. And I noted that she clearly had many wonderful qualities that had nothing to do with this bedwetting problem. Alyssa responded enthusiastically to these ideas; her parents, especially her father, were a bit more circumspect (having spent many hours bringing her to unsuccessful therapies, and spending a fair amount of money for these therapies). I emphasised with their frustration and doubt about the usefulness of therapy, and said that we'd only know if this approach worked if it worked, and that I thought it was worth a try, and that in my experience, the key thing that made therapy work is if we can get excited about taking on a problem - rather than just wanting it to stop or go away. With this frame, they were willing to try.
I went to on suggest to them we give the problem a name different from 'Alyssa's bedwetting' - 'almost like it is a creature or being or something that gets you to wet the bed'. I explained that, in ways we don't quite yet understand, sometimes giving a problem a name separate from the person who has it allows a bit of distance and separation from the problem that then allows us to take it on. This made sense to everyone. I also noted that some research had found that some kids who wet the bed are extremely sound sleepers, and that they sleep so soundly that they don't feel the pressure from the bladder telling them that they need to go to the toilet. The parents affirmed that Alyssa was indeed an extremely sound sleeper, and that they had equipped the pad with several bells, quite loud ones, and that she slept through them all. She also slept through the ringing of alarm clocks.
Quite quickly, Alyssa named the problem Nightwetter'. I then suggested that each night, before bed, she do a drawing of Nightwetter, and put it in a box and put the box in her closet, where it would be far from her bed and less likely to lead her to wet the bed. I also explained that by doing a drawing at night just before bed, she might prepare her sleeping mind to pay more attention to the pressure in her bladder and that might lead her to wake up before wetting. She readily agreed to the plan of drawing Nightwetter and putting Nightwetter in a box. I suggested that the parents' role would be to be her cheerleader, congratulating her on dry nights and encouraging her to try again after a wet night.
The next morning she awoke to find that she had not wet the bed, for the first time in many months. She and her parents were ecstatic. Losing power from his defeat the night before, Alyssa renamed him Stupid Elderly Nightwetter, and his defeat was front page news in the New York Times (See drawing above. Note that Nightwetter holds a can of P8 juice - a play on V8 Juice, a popular eight-ingredient juice)
The next morning, she was again dry.
That night, Alyssa renamed him Stupid Very Elderly Nightwetter (and as the drawing shows, he began losing pee, and therefore, strength), and she was again dry.
Although the next night Alyssa drew him with a caption indicating that he was losing more pee and more strength, in fact, she drew him quite large, and that morning, she was wet.
The next night, Nightwetter appears happy about his victory over Alyssa, but she inventively draws herself in a "security bubble" designed to protect herself.
That morning, she was wet. However, determined to defeat Nightwetter, Alyssa then draws Nightwetter on a desert island in the Bahamas surrounded by sharks, with Alyssa above him in her security bubble, and the sun shining brightly (to dry him out).
That morning, Alyssa was dry. She presented all of these pictures to me with her parents present that day.
Her father impatiently commented, 'Why don't you just kill him offalready?' Alyssa paused, and looking thoughtful, said, 'Because I don't believe in killing anything'. That evening, her relationship to Nightwetter shifted.
Nightwetter is crying, and cries, 'Someone please help me! I'm going to die!' In her thought bubble, within her security bubble, she notes, 'I think I should help him'. That morning, she was wet, but just a little.
The following evening she drew what she called the 'resolve picture', and gave Nightwetter some wings so that he could fly offthe island.
Smiling, he says to her, 'Hey thanks for the wings. What can I do for you?' Alyssa says, 'No problem. Just bother someone else'.
The next evening, Nightwetter gets married (to Ms. Lips), and Alyssa is dry the following morning.
They quickly produce two children (procreation among Nightwetters and their partners is apparently a more rapid affair than in the human species), and being the responsible, involved father that he is, Nightwetter finds himself with work-family balance issues - needing to go to work, but committed to take care of the kids. Ms. Lips suggests he resolve this dilemma by retiring from the Nightwetting business. Alyssa named this the 'decision picture'.
Clearly, Nightwetter (who, notably, for the first time in the series, is not named), now has other things to focus on than making kids wet their beds.
Alyssa is dry that morning. The next evening, Nightwetter announces he's decided to retire, and seems quite happy about it, as does Ms. Lips. The kids are too busy bumping into each other to make a statement, but they are smiling.
Alyssa is dry that morning, as she is the next morning. That evening, the family is depicted on vacation. Alyssa is dry that morning as well.
That evening, Nightwetter states that he wants to go back to work, but he has hives, and his kids note that he doesn't look too good.
Nevertheless, Alyssa is wet that morning. The following evening, Nightwetter tells Ms. Lips that they will move the next day to Australia, and she is pleased.
Alyssa is dry that morning. I saw her and her parents that evening, and noted that it was a good coincidence that Nightwetter had decided to take his family to Australia, because there were some really good therapists there who work with kids and their problems the way I do. The problem essentially solved, Alyssa lost interest in drawing Nightwetter, and had her first ever sleepover with a friend, and did not wet the bed. A week later, she showed me a letter she'd received from 'Nightwetter Lips' from Australia (being a feminist kind of guy, he'd taken Ms. Lips name), in which he wrote an apology to her, and gave her an update on his life, now that he'd given up his job making kids wet their beds. He wrote:
Dear girl,
I'm sorry that I always bothered you at night. You know, I've decided to stop! My wife ain't too thrilled though (I don't recall if we explored this surprising development in Ms. Lips' attitude towards his career). But my kids on the other hand are thrilled to have their papa home for good. It's nice here in Australia, lots of kanaroo (sic) waste, but otherwise, me my wife (sic) and my children are happy. We've adopted a baby Kangaroo. And how is life in the city? Please write back.
Yours truly,
Nightwetter Lips
Interestingly, Nightwetter has grown a beard (perhaps suggesting that he's more relaxed now that he's retired), and is wearing a Jewish star. Also, please note that his can of P8 juice is now labeled V8, suggesting that he's just a regular guy, no longer in the business of bothering kids by making them pee at night. Unfortunately, to my memory (and by the absence of anything to the contrary in my notes), I did not suggest that Alyssa write him back. But by that time, everyone felt that the problem was gone, and we'd all gotten healthily bored with it, and the therapy ended soon after.
An invitation
This handbook is part of a continuing project to assist children who are experiencing hardship and facing wet beds as a result. We would welcome your reflections on this publication and your participation in the development of further resources.
If you try out the ideas in this publication please let us know, as we will find ways to share stories of practice between families and workers. As mentioned earlier, we are also in the process of producing a children's story book that externalises enuresis. If you are interested in trying this out, please let us know. Thank you.
Please forward your comments to:
Dulwich Centre Foundation
Hutt St P.O. Box 7192
Adelaide, South Australia, 5000
Email: [email protected]
Acknowledgement
Dulwich Centre Foundation has links with practitioners in different parts of Australia and different parts of the world who are involved in creative and hopeful narrative responses to bedwetting. We have included hopeful examples and stories of these here and express our appreciation to the many therapists, children and families who have contributed to this project.
Special thanks to Peter Fraenkel, Angel Yuen, Radhika Santhanam-Martin, Karen Treisman and Sue Mitchell.
Sue Mitchell wrote the conversation with Enuresis that appears in the first section of this handbook and played an influential role in putting this handbook together.
We are also grateful to Julienne Beasley for her beautiful illustrations. Julienne's work can be further explored at www.jbart.com.au
David Denborough was involved in conceptualising and editing this resource. The project was envisaged by Cheryl White.
Significant feedback was offered by Dr Shanti Raman, Belinda Mawhinney, Maree Bargar, David Epston, and Dr Ken Jureidini.
Nihaya Abu-Rayyan, Caleb Wakhungu, Ncazelo Ncube, Megan McGrath, Hannah Jensen, Alison Schafer, Rania Aiash, and Ershad Fawcett have all made meaningful contributions to this project.
This handbook was funded by the Collier Charitable Fund. We are profoundly appreciative of their support.
About Dulwich Centre Foundation
Dulwich Centre Foundation is a not-for-profit charitable institution. We are involved in direct counselling and community work with individuals, groups, and communities; developing respectful, effective, and culturally-appropriate methodologies to respond to community mental health issues and collective trauma; working in partnership with local communities to engage with children, young people, and adults using these methodologies; and building the capacity of local mental health workers/community members to address mental health issues in a range of contexts. The Dulwich Centre has a 30-year history of providing counselling, community work, training, conferences and publishing. We have worked extensively both within Australia and in a range of countries with vulnerable children.
For more information see: www.dulwichcentre.com.au/dulwich-centre-foundation.html
Further resources and references
This handbook has aimed to offer some hopeful and creative ways to engage with children who are experiencing bedwetting in times of trouble. It is by no means exhaustive! There are a whole range of other narrative practices that are often used with children who have experienced hardship.
These include methods like the Tree of Life and Team of Life that use metaphors to engage children in the development of rich stories about their lives that acknowledge their unique skills, knowledge, values, intentions, commitments, hopes and dreams. These practices honour the contributions of others met along the way, the impact of heritage and culture and children's responses to difficult experiences. These methodologies have been used in many contexts around the world where children are living with fear, sadness, worries and other difficult experiences. We have included resources on these practices below.
Team of Life
The Team of Life uses sporting metaphors to assist children to address the difficulties in their lives without having to speak directly about them. For more information, see Denborough (2008, 2010), and www.dulwichcentre.com.au/team-of-life.html
Tree of Life
This methodology uses the metaphor of a tree to assist children to tell their stories in ways that make them stronger. For more information, see Ncube (2006), Denborough (2008) and www.dulwichcentre. com.au/tree-of-life.html
Web resources include:
Dulwich Centre website: www.dulwichcentre.com.au
Narrative therapy online: www.narrativetherapyonline.com
* Where a child is having significant troubles with bedwetting, it can be important for a doctor to check whether there is a physical explanation, including whether there is anything wrong with the child's kidneys.
* The use of an anti-diuretic drug treatment and the use of alarm mats are currently the two most common responses to bedwetting by pediatricians (see Walle, et.al, 2012). Where bedwetting is occurring in a context of broader experiences of trauma and fear, however, responding primarily with the use of medication or the use of alarms can be complex. Additionally, in some contexts of social hardship, such medications and alarms are not available. The ideas and practices offered in this handbook can be seen as complementary approaches to bedwetting when children are living in contexts of fear or worry.
References and suggested readings
Denborough, D. (Ed.). (2006). Trauma: Narrative responses to traumatic experience. Adelaide, Australia: Dulwich Centre Publications.
Denborough, D. (2008). Collective narrative practice: Responding to individuals, groups, and communities who have experienced trauma. Adelaide, Australia: Dulwich Centre Publications.
Mitchell, S. (2005). Debriefing after traumatic situations- using narrative ideas in the Gaza Strip. International Journal of Narrative Therapy and Community Work, 2:23-28. Reprinted in Denborough, D. (ed) Trauma: Narrative responses to traumatic experience. Adelaide: Dulwich Centre Publications
Morgan, A. (2000). What is narrative therapy? An easy-to-read introduction. Adelaide: Dulwich Centre Publications.
Ncube, N. (2006). The Tree of Life Project: Using narrative ideas in work with vulnerable children in Southern Africa. International Journal of Narrative Therapy and Community Work, (1), 3-16.
Ncube, N. (2010). The Journey of healing: Using narrative therapy and map-making to respond to child abuse in South Africa. International Journal of Narrative Therapy and Community Work, (1), 3-12.
Shalif, Y. & Paran, R. (2008). Learning from children and adults in times of war: Stories from the bomb shelters in the north of Israel. International Journal of Narrative Therapy and Community Work (2), 4-16.
Walle, J.V., Rittig, S. Bauer, S., Eggert, P., Marscahll-Kehrel, D., & Tekgul, S. (2012). Practical consensus guidelines for the management of enuresis. European Journal of Pediatrics 171:971-983. DOI 10.1007/s00431-012-1687-7
White, M., 1995. Re-Authoring lives: Interviews and essays, Adelaide, Dulwich Centre Publications.
White, M. (1985). Fear busting & monster taming: An approach to the fears of young children. Dulwich Centre Review, (pp. 29-34). Reprinted in M. White, (1989), Selected Papers (pp. 107-113). Adelaide, Australia: Dulwich Centre Publications.
White, M. (1995). Therapeutic documents revisited. In M. White, Re-authoring lives: Interviews and essays (pp. 199- 213). Adelaide, Australia: Dulwich Centre Publications.
White, M. (2004). Working with people who are suffering the consequences of multiple trauma: A narrative perspective. International Journal of Narrative Therapy and Community Work, (1), 45-76. Reprinted in D. Denborough, (Ed.), (2006).Trauma: Narrative responses to traumatic experience (pp. 25-85). Adelaide: Dulwich Centre Publications.
White, M. (2006). Responding to children who have experienced significant trauma: A narrative perspective. In M. White, & A. Morgan, Narrative therapy with children and their families (pp. 85-97). Adelaide, Australia: Dulwich Centre Publications.
White, M. (2007). Maps of narrative practice. New York, NY: W. W. Norton.
White, M & Morgan, A (2006). Narrative therapy with children and their families. Adelaide: Dulwich Centre Publications
Yuen, A. (2009). Less pain, more gain: Explorations of responses versus effects when working with the consequences of trauma. Explorations: An E-Journal of Narrative Practice, (1), 6-16. Retrieved from http://www.dulwichcentre.com. au/explorations-2009-1-angel-yuen.pdf
Copyright Dulwich Centre 2013