Rahul was 12 years old when he was referred for bed wetting (enuresis) and passing stools (encopresis). He was referred by the family doctor who found a non medication approach to his bedwetting and encopresis a better solution, especially considering the long term side effects of the medicines and the fact that there were no physiological causes to his problem.
His problem had escalated soon after they had shifted into this new house. Parents didn’t think that shifting house could have been the reason for the same as he always wanted to shift back to this house. In fact he had many friends here and would initially quickly finish off his homework to go down to play. But soon he started wetting his bed in the night more often and the ‘accidents’ at school too increased.
By the time he started with play therapy, he was regularly wetting his bed in the night and the soiling his pants at least once a month. Rahul was so unsure of his own bowel movements that he refused to go for school trips or for a sleep over at his friends or cousins house. Off late he was fearful of going to school too, as he was now teased for being a sissy boy. At home too, he would play with his play station for hours on end and would be generally. His parents had tried every thing from making him visit the toilet at bed time and before going to school to more frequent visits when outside, but to no vain. Normally an active boy was now unsure and irritated most of the times.
During the case history on enquiring about any traumatic history the parents recalled that just before they had shifted the house he lost his grand mother and around that time the van in which the school children traveled had met with an accident. Although no one was injured Rahul had recounted the incident in great detail. They found it difficult to believe that these could again be the reasons as it was not the first time he was dealing with a loss of a grand parent or meeting with an accident. In fact he had lost his grand father the previous year, to whom he was more attached. Since his grandmother suffered from Alzheimer he hardly ever interacted with her over the years.
Bedwetting is considered to be problematic for children only above 6 years of age. Till about 5 it is considered normal if the child occasionally wets the bed. Usually children have considerable bowel control by the age of 4 and do not soil their clothes. Enuresis can be primary (the child did not grow out of using diapers) or secondary (child stopped wetting beds but suddenly after a period of time started wetting them again, as in Rahul’s case).
It is often connected to psychological issues of emotional stress / anxiety. Often the causes remain unknown to both the child and the therapist. Therefore using cognitive or reasoning approach is difficult with these children and it is not in their awareness or consciousness. Also emotions of shame and guilt are quite complex for the children to express verbally. This coupled with threats or punishment from parents (who feel an extreme sense of concern and frustration dealing with this problem) can become quite traumatic for the child. Play therapy, being dynamic, non directive and symbolic allows the child to reenact and work out his emotional issues leading to the problem in a safe and trusting environment without having to get into verbal communication. This is further supported by some parenting sessions where parents are usually asked to bring about certain changes in the child’s routine to support the sessions proves extremely effective.
The following are some of the changes that parents are requested to introduce:
• Having liquids at least 4 – 5 hours before the bed time.
• Setting up alarms at regular intervals and encouraging Rahul to visit the toilet.
• Keeping an extra pair of clothes and bed sheets so that Rahul need not wake his parents every time he had an accident.
• Not humiliating / threatening / asking too many questions to the child to rectify his behaviours .
Rahul began his play sessions. Initially he found it quite boring to play with toys that were around and often asked if he could carry his video games or whether there was access to computers. But slowly as the sessions progressed he started playing with animals, clay and balls. The therapist noticed that in most of his sessions he would give instructions to the therapist to follow. He would make loud noises and fight with the wild animals. With the clay he would often make snakes and then turn them into turbans which the therapist was instructed to wear and become the care taker of the animals. Some times he used the ball to knock down the animals. After many such sessions, he moved on to drawing. He initially drew only symmetric drawings but soon moved on to draw themes. Most of the themes again reflected anger, punishment and morality issues.
Around the 8th session, the mother mentioned that Rahul had wetted his bed only once and had soon woken up to change his clothes and the bedsheet. The therapist had given a list of instructions to the parents to follow. Soon after that Rahul showed greater interest in his play and also in the sessions.
After his summer break when he returned for the first session, he sent a message containing smiley face and to inform the therapist that they were on their way to the clinic. He seemed to have settled down with not a single mishap of soiling his clothes or wetting the bed. He had returned to his original confident self and seemed less tentative about things. Although he was apprehensive on the first day of school, he settled into his new routine pretty soon. On the follow up terminating sessions, the bedwetting and soiling behaviours had consistently shown improvement with no further accidents. His academic marks also returned to their earlier levels.