Resolving Adult Enuresis

Introduction

During the course of my work, I have successfully treated a wide array of common problems from simple or complex phobias through to insomnia, anxiety disorders, and depression. I am often consulted by people experiencing problems that typically would be considered too embarrassing to talk about either publicly or even to a doctor or therapist. Unsurprisingly, most of these consultations usually occur via email. Typical of these problems are sexual dysfunctions and anxieties such as impotence and premature ejaculation, odd compulsions and attractions, and the troublesome secret thoughts usually kept very private from any other person.

Adult bedwetting is one such hidden problem and is one that is so rarely discussed in any public domain. As a subject, adult bedwetting is potentially met with derision, sarcasm, and ridicule. And so, as a hidden topic, the personal consequences to an affected person are kept private, and thus it remains a subject about which the majority of people, including some therapists, remain ignorant. The consequences of adult bedwetting to the individual can be huge. Intimate relationships may be avoided (often to the mystification of friends and family), there may be a sense of inadequacy and shame, and low self-esteem is common. The affected person may avoid holidays and also avoid any other overnight stays away from home.

Before I go further into the causes, consequences, and patterns of treatment of adult enuresis, let us first review some statistics regarding children with the condition. Physiological disorders or functional problems with the bladder are often not present in such children; however, they are often found to have what is termed a “functionally small” bladder. This means that the child will get a signal or urge to empty their bladder at far lower volumes of urine than other children. At night, the brain releases quantities of a hormone known as ADH, or anti-diuretic hormone. This hormone reduces the amount of urine the body produces, some studies suggest that enuretic children may produce insufficient amounts of this hormone. About 3/4 of children with enuresis will have a parent who is, or was, a bedwetter themselves. Curiously, the chances of a child having enuresis are 7 times greater if their father currently has, or had, the problem in childhood himself. There is also a correlation in identical twins, and these statistics do strongly suggest a genetic component in the behaviour. However, as is often said, correlation is not proof of causation, and I am yet to find a genetically programmed psychological adult bedwetter beyond skilled clinical help.

Bedwetting is considered normal in children under the age of 5 years old and may appear in older children following a stressful event such as the birth of a younger brother or sister, parental separation or bereavement, moving house, change of schools, serious illness in the child or another close family member, or hospitalisation. In adults, bedwetting may fall into two major categories: it may either be a pattern that has existed since childhood or have developed later on during adulthood. When adult bedwetting has developed when previously it did not present a problem, it is most important for a medical examination to rule out a number of possible physiological causes of the problem, even when the psychological trigger for the problem is believed to have been identified.

Physiological Stuff and Bladder Facts

Common physiological problems and disorders that may precipitate adult bedwetting include diabetes, neurological disorders, bladder infection or other abnormality, medication side effects, and prostate difficulties. Common age-related bladder problems include difficulty in starting to urinate, or poor urine flow (this is most common in men); an urgency to urinate even when the bladder isn’t very full; a “weak” bladder where urine leakage occurs during lifting, sneezing, coughing or laughing; and urine “frequency” where the trips to the toilet are required more than previously. It is worth having any such symptoms investigated by a doctor. Always. Despite common belief, the bladder doesn’t shrink with age. However, the detrusor muscle that controls bladder emptying can alter in function with age, creating a change in bladder function.

Pelvic floor exercises can strengthen this muscle and help tremendously to avoid the problems of urgency. Pelvic floor exercises can also enhance one’s sex life by increasing the strength, control, and duration of orgasmic response.

On average, the adult bladder can comfortably hold about a pint, or 500 ml, of urine before the level of discomfort begins to build, commanding the person to do something about it. Actually, the bladder can hold a far higher quantity quite easily. As a former hospital nurse, I’ve catheterised a number of patients who were experiencing urinary retention, a temporary inability to pass water. The record so far was just over two and a half litres of urine. The sigh of relief was audible from the next building away. Despite the common expression, I’ve never known a bladder to actually burst. Actually, what happens is that when the bladder reaches maximum capacity, a trickle, or overflow incontinence, occurs, relieving the extra pressure. This rarely occurs until the bladder has reached maximum capacity.

Bladder Anxiety

A common psychological condition is that of “bladder anxiety” – where the person reacts to the discomfort signal from the bladder with a degree of anxiety. This person may experience anxiety generally in their life, or it may just be focused on the sensation coming from their bladder. A sense of urgency can ensue, creating considerable stress where the person finds himself or herself unable to locate a toilet in the immediate vicinity. Such anxiety sufferers may adapt their behaviours to accommodate this problem and so will adjust and control their fluid intake and trips out of the house so that their route is determined by the location of accessible toilets. Journeys into unfamiliar territory where toilet access can be uncertain may be avoided altogether.

Clinical treatment involves addressing this anxiety and other underlying anxiety issues, which may arise from unfortunate and embarrassing incidents earlier in life, and also training the client to begin to build up their tolerance to the discomfort signals from the bladder, as well as performing pelvic floor exercises to increase the level of conscious control over urination and bladder response. Bladder anxiety is a good demonstration of a simple problem with a simple solution that can completely take over a person’s life.

Double Bind – Brief Case Study

Dreams and Dreaming

Now, dreams can be interesting things. Start keeping a dream diary. You will find it hard at first to recall the dreams. Do it like this: On waking, quickly write down keywords that will jog your memory later about the dreams. Keep the notebook by your bed or under your pillow. The following evening, review the key words and actively try to recall the dreams and write them down. The jogging of the memory and active recall begin to have two effects:

1. You will find that dream recall becomes much easier and clearer.
2. Your dreams will become increasingly vivid.

Many people find that after about 4-6 weeks, they can do what is known as lucid dreaming. What this means is that they become “awake” during their dreams and so can control and direct them. This can be both fun and exceptionally useful.

One model of dream activity is that REM dream sleep enables the brain to complete sequences of behaviour, activity, or thinking that were otherwise incomplete during the previous day. For example, a man who is shortly to be giving a business presentation that brings him anxiety may find himself worrying about it in the days or weeks preceding the presentation. Typically, in anxiety states such as this, the person with the anxiety won’t actually complete the sequence of their presentation in their thoughts. His imagination or imagined movie of the presentation gets only so far and then tends to loop round again; thus, the person repeats the same anxiety thought over and over, never actually completing the sequence. Think of it like this. You have a clip from a horror film. The clip is 10 minutes long, and about 4 minutes into the film, the horrible thing happens. At about 6 minutes into the film, the hero overcomes the horrible thing, and the movie clip concludes safely for all involved. However, the anxious person never plays the movie clip all the way through. Instead, what tends to occur is that they reach the point of maximum emotional intensity, i.e., about 4 minutes, and then start to replay the clip from the beginning again. And this is repeated over and over. One basis of treatment of such anxiety is to enable the person to actually complete the movie all the way through to the end, rather than aborting it due to anxiety halfway through. The brain is a pattern-oriented machine, and so in his dreams, the businessman with a presentation looming will complete the sequence he was unable to complete in his normal waking consciousness. This will usually occur with the associated fear and anxiety that prevented him from completing his internal movie of the event.

So what the man was unable to do in his waking state, he then completes in his unconscious, dreaming state. In short, dreams can finish the incomplete. In working with a number of adult bedwetters, I have examined their daytime toileting anxieties. Now, this is far more common with men than it is with women. When using public or communal facilities, women tend to have the advantage of cubicles. We, men, have to deal with the prospect of urinating whilst standing about 18 inches from another man. And when there are only three urinals to choose from, no one likes to use the middle one. A recent report by The British Psychological Society suggests that up to four million people in the UK cannot urinate in public. This condition is known as “bashful bladder” and can have far-reaching consequences, including people leaving their jobs, as they are unable to cope with using shared facilities. Such anxiety is common, and one psychological study of dubious research ethics demonstrated that men take significantly longer to pass urine when another man comes and stands close to them or stands by the urinal next to them. The cause is obvious, really, to men at least, even if not the psychologists. Standing in front of other men with your genitals exposed and trying to relax enough in order to urinate just isn’t natural. Men did not evolve to stand next to each other with their genitals in hand and urinate!

Where this is of interest with regard to nocturnal enuresis is that a person may, in the daytime, demonstrate great bladder control in order to avoid exposing themselves to the anxiety connected with peeing in public. However, the thought sequence itself may never get to be completed and so is only completed later on unconsciously when the person is asleep. The unconscious mind takes over and completes the sequence in a dream, thus producing a nocturnal enuresis. Clearing up the daytime urination problems and anxieties in such clients often results in a resolution of the nighttime bedwetting without any need for exposure therapy.

Dreams can be interesting when it comes to nocturnal unconscious behaviours such as enuresis. I can still remember the dreams I had as a young child that always accompanied a wet bed. I used to wake up shivering, usually some time afterwards, when the wetness had lost its warmth and shout for my parents that the bed was wet. I always knew that I was the one who wet the bed, but I could never actually say it. A level of dissociation was present where I said, “The bed is wet” rather than, “I wet the bed.”

This all changed when my father asked me one day, “Well, who wet it?” and I denied that it was me. He gently coaxed me that this wasn’t actually true and that, in fact, I did know. After some persuasion, I admitted that I did know and that it was actually me. I remember feeling a significant level of shame that day, but never again did I wet the bed. Taking ownership of a problem can be a painful moment for many adults, too. The most common method of not taking ownership is to utilise the “illusion of ownership” technique illustrated by the following justifications (or “reasons”, “excuses” or however we would like to view them as):

• “I have a condition.” (i.e., the condition causes the problems).
• “It’s my nerves.” (i.e., the nerves are responsible).
• “It’s a genetic disorder.” (i.e., the genes are responsible).
• “It is because of my childhood.” (i.e., my childhood is responsible).
• “I cannot help it; it is just the way I am made.” (i.e., the way I am made is responsible).
• “It’s because of stress.” (i.e., stress is responsible).
• “I’ve always been this way…” (i.e., the way I have always been is responsible).

After my painful confession and taking ownership of the behaviour, what was most noticeable was the change that occurred in my dreams. You see, in my dreams where I wet the bed, I was always actively urinating in my dream. My young brain and unconscious mind were managing to both protect my need for sleep and respond to my physical need to urinate. Thus, it permitted me a dream. Actually, it created a story whereby urinating was legitimised. For whatever reason, I was always in the garden of “Mary, Mary, Quite Contrary”. Now, I didn’t know who Mary was or why she was quite contrary, but I did know the secret of how her garden grew… I kept peeing into her watering can.

After my forced confession and “day of shame”, my dreams changed. I still dreamed of needing to urinate, but for whatever reason, I couldn’t reach the place to urinate into. As I grew older, I forgot about Contrary Mary, whom I understand now was actually a reference to Mary Queen of Scots, and instead of a royal watering can, I progressed to a variety of other legitimate places for urination. But the thing is, my unconscious brain now had another thing to protect – as well as the need to protect the requirements of sleeping, it needed to respond to my need to urinate and avoid another day of shame.

Another aspect of sleep is that dreams appear to serve a “sleep-protective” and wish-fulfilment function. In that the person who is thirsty dreams of drinking water, the single man who craves a pretty colleague at work dreams of an amorous encounter and so on. The sleep-protective function enables the person to carry on sleeping, undisturbed by their wishes and needs. Thus, I could never actually reach the place I needed to be able to reach in order to legitimately urinate. The toilet was either too far away or it was too high. Or there were monsters in the way or just a monstrous queue, the toilet was too small, or I didn’t have the right entry ticket, or I simply couldn’t find it. Always, despite my urgent need to pee, I could never actually reach the right place. Thus, I would continue sleeping and dreaming of not being able to find or reach the toilet, or the signal would eventually register on the right part of my brain, and I’d wake up and go out to use the bathroom. Curiously, not once have I ever dreamt that I had woken up and used a dream bathroom by mistake, and returning to sleep afterwards has always been a most comfortable and natural experience.

Taking psychological ownership of a problem isn’t easy, but if you are to be the one to take control, it is a vital step towards creating personal change.

More About Dreams…

A colleague once told me about the dream he had that was the trigger for his bedwetting. As a child, he learned the words of the nursery rhyme “Oranges and Lemons”, also known as the “London Bells” nursery rhyme, which ends with that lovable line, “Here comes a candle to light you to bed; here comes a chopper to chop off your head.” Well, the words and verses tend to vary according to geographical region, and when he was aged 7, his family moved, and John was relocated to a different school. On his first day there, the teacher organised a children’s game oriented around the rhyme, which had an extra verse. Unfamiliar with the words, another child joked that that meant that John would have to have his head “cut off” in accordance with the game. For poor John, already worried and disoriented enough as it was, this being his first day at this new school, well, this was almost too much for the poor guy. Later on in the playground, another anxious child confided in John that he knew that bad people hid choppers in the rafters of old houses that would sometimes come down and chop the sleeping person’s head off in the night. By the time he got home that day, poor John was a nervous wreck. From being nocturnally dry from age 4, he went to being a fervent bedwetter for several years, complete with disturbing nightmares. Of course at the time, the bedwetting and nightmares started at exactly the time of a change of house and a change of schools. Therefore, the reason was put down to an understandable stress response resulting from the change. But of course, to every adult, this is exactly what it looks like – but according to 7-year-old John’s reality, he knew there were choppers in the rafters just waiting to chop off his head because he could not remember or did not know the right words to the stupid nursery rhyme. Of course, John quickly settled into the new school and made new friends, but the nocturnal anxiety continued. His parents, of course, asked the obvious questions – maybe he was being bullied or had a problem with his teacher or some other obvious external cause; what they couldn’t have known, though, was the power of childhood imagination and subjective realities. Yet strangely, such children quickly learn not to discuss such fears with adults. I guess they know that adults don’t really understand such things.

Parental Reactions

How the person responds to their bedwetting will have a noticeable impact on their ability to overcome it. A lot of the behavioural and emotional responses to bedwetting are learned from parents, who tend to have a variety of responses. Many parents will consider bedwetting in their children a perfectly normal activity that will eventually grow out of, and thus, they do not draw any particular attention to it. Commonly, parents will begin to tire of the issue and, at a certain stage in the child’s development, may start applying pressure in varying forms in an attempt to discourage the bedwetting behaviour. This can set the child up for failure, where he or she consistently fails to meet the parental expectation. People being as they are tend to generalise failure, and so the child may then begin to generalise the failure at maintaining a dry bed across contexts and thus feel a failure in many other areas of their lives. This can lead to a feedback loop where there is parental and peer group response to the sense of inadequacy, which, all too often, then begins to provide fuel to the issues of low self-esteem. In treating adult nocturnal enuresis, addressing self-esteem issues and responses to failure can be an important therapeutic manoeuvre in overcoming the problem.

Common reactions to bedwetting:

• It is ignored.
• It is punished/ridiculed.
• It is not punished, but attention is drawn to it.
• The child is encouraged to assume responsibility – i.e., by washing the sheets themselves, etc.
• The child is treated as a victim, or as being vulnerable, etc.
• The child is forced into nappies/plastic pants.

Whatever occurred as a child, what is important for the enuretic adult is that you take action. Responding to and adapting to the problem is a useful strategy in the short term but does little to create lasting change. I worked for a short time on a children’s orthopaedic ward. It wasn’t uncommon for children of all ages to wet the bed – this is common with hospitalisation. What was interesting was that often the children didn’t know what to do – after all, at home, they have an expected pattern of how to deal with the wet bed – either by ignoring it, calling for a parent, stripping the wet sheets off or whatever it is. In the hospital, everything is different for the child, and so uncertainty about the correct behaviour is high. The other issue facing any child is that they were usually in a room with other children, also in bed, stuck in traction or whatever it was. Therefore, the risks of peer-group humiliation were potentially quite high, especially if a member of the ward staff would carelessly mention it, thus allowing the other children to know. Actually, what I found was just how invariably sympathetic other children would be to the briefest instruction that “hey, if you wet the bed or mess the sheets, just let one of the nurses know, and we can change that for you.” Saying this as though it were the most normal thing in the world was usually enough to remove the potential fear of embarrassment, and most of all, the potential fear of how the nurses would react to a child who wets the bed.

Name Calling and Internal Self-Talk

In working with adult bedwetters, I have found that they can be tremendously harsh on themselves. Just go inside your own mind for a second and examine some of the things you say to yourself. It is amazing how people tend to give themselves negative suggestions, talk to themselves harshly, call themselves names and cast value judgements upon themselves.

Typical patterns of spoken internal criticism:

• “I am” patterns.
  • “I am such a loser.”
  • “I am such an idiot.”
  • “I am useless.” And so on.
• “You are” patterns, where “you” is addressed to the self.
  • “You are such a loser.”
  • “You are an idiot.”
  • “You will never change.” And so on.
• “I hate” patterns. These set up a negative relationship between the person and their “self” where one part of themselves feels hate and the other feels hated.
  • “I hate myself.”
  • “I hate my problem.”
  • “I hate the way I behave.” And so on.
• Negative programming and auto-suggestion patterns.
  • “I won’t ever change.”
  • “I cannot change.”
  • “This problem will never go away.” And so on.

Now think about it – you wouldn’t talk to anyone else that way, would you? Yet, somehow, people think it is ok to talk to themselves that way. If this is you, then you really should be ashamed of yourself and apologise to yourself immediately. Now do this – be NICE to yourself for a change. You would not bully a child to change his or her behaviour and then expect him or her to be happy with the change, and you don’t shout at someone repeatedly to help build their confidence – so be nice and stop all the negative self-talk.

The Ultimate Cure: Re-Conditioning The Paradoxical Way

Now, one common system for curing bedwetting is the pad and bell method. Simply put, this is a device that, when wet, sets off a loud bell to awaken the sleeper from their deep slumber. It is said to have about a 50%-80% success rate. As a pattern interrupt, this works well, but it is also a great sleep disturber for some people. For those for whom such a device does not work, the problem may lie in the detail that the bell only sounds after the person has started urinating. Another device based on a similar strategy replaces the bell with some electrodes, and instead of a bell ringing, the person wakes up to the sensation of being partially electrocuted. These devices are quite readily available on the Internet and cost around £30 and are well worth a try. However, there is another method that is very successful but that so many therapists are reluctant to suggest and enuretic patients are reluctant to try. It turns all logic on its head and is termed “paradoxical intention.” Developed by psychiatrist and Holocaust survivor Viktor Frankl, paradoxical intention has an astonishing success rate. The essence of the technique is that the person makes a mental shift from trying not to have the problem to actively engaging in doing the problem. So, for example, the panic attack sufferer deliberately practises having panic attacks, the nail-biter deliberately bites their nails, the insomniac is encouraged to lie still and try to stay awake as long as possible, and so on. What begins to occur is that the unconscious impulses that drive the behaviour begin to move into consciousness and thus under conscious control. As a therapist, I have found this especially helpful with problems such as blushing and anxiety.

What this means for the adult bedwetter is that rather than trying to control the problem, they engage in a conscious effort to produce the problem. As unpleasant as it might seem, getting into bed with a full bladder and deliberately urinating into the bed is the first step. When I work with clients, I listen carefully to the objections they raise regarding this; often, useful information arises regarding the unconscious nature of the problem. Take a moment to write down your own objections, if you have them. Now, just deliberately wetting the bed isn’t enough. What you have ahead of you is the uncomfortable experience of deliberately spending the night in a wet bed. You must not change the sheets until morning. As you can imagine, sleep is unlikely to be very easy while doing this experiment. You must carry on with your day’s activities, such as work, etc., as normal. The experiment must be integrated into your normal daily life routine and not sectioned off as a special event that is unconnected. Throughout all of this, carefully track your own thoughts, objections, excuses and so forth and write them down. To my students, I describe the effect as “unconscious material comes gushing out when you engage clients in paradoxical intention; be sure to catch it all.”

Conclusion

It is worth knowing that adult bedwetting is not caused by a particular psychological problem. In fact, whilst the bedwetting itself can lead to particular psychological problems, adult bedwetters are actually no more screwed up than any other portion of the population. Adults have been wetting beds for as long as there have been adults and beds. Searching for a “deep-rooted” psychological problem is undoubtedly unnecessary and is potentially counterproductive. From my experience of listening to clients’ stories, far too many have learned to have new problems whilst in analytical therapy. Despite the frustration of previous failures, the adult bedwetter is not a useless victim of a hopeless condition who must simply learn to live with their problem. Bridging the gap between the unconscious nocturnal activity via the methods outlined and paradoxical intention has been demonstrated to be a most effective technique that is both cheap and easily applied. It does, however, require a degree of gumption to be able to actually do it, as the technique flies in the face of everything the adult bedwetter has been trying to do all those years. In NLP there is a common saying, “If you always do what you’ve always done, you’ll always get what you’ve always got, so do something different!” Do more. Be different!

Postscript

A sultan was on a ship with one of his best servants. The servant who had never taken a voyage – in fact, as a child of the mountains had never even seen the coast – sat in the empty belly of the ship and screamed, cried, trembled, and wailed. All were kind to him and tried to calm his fears, but their kindness reached only his ear, not his fearful heart. The ruler could hardly bear to hear the servant’s cries any more, and the voyage through the blue waters under the blue sky was no longer a pleasure for him. Then the wise hakim, the physician, approached him and said, “Your Highness, with your permission, I can calm him down.” Without a moment’s hesitation, the sultan gave his permission.

The hakim ordered the seamen to throw the servant overboard; the seamen did this to the crybaby only too gladly. The servant thrashed about in the water, grabbed for air, clutched to the side of the ship, and begged that they take him on board again. So they pulled him up by his hair. From then on he sat very quietly in a corner. No one heard another word of fear from his mouth.

The sultan was amazed and asked the hakim, “What wisdom is contained in this action?” The hakim answered, “He’s never tasted the salt of the sea. And he didn’t know how great the danger was in the water. So he couldn’t know how wonderful it is to have the sturdy planks of the ship under him. Only he who has faced danger can know the value of peace and composure. You, who always have enough to eat, do not know the taste of country bread. The girl whom you do not consider pretty is my beloved. There is a difference between a man who has his beloved beside him, and a man who expectantly longs for her arrival.”

From “Oriental Stories as Tools in Psychotherapy” by Nossrat Pesechkian ISBN: 81 207 1071 1