ENURESIS, EARLY ATTACHMENT AND INTIMACY

Samuel M. Stein
ABSTRACT Enuresis is a common childhood problem which, although it causes considerable
distress to both children and parents, nearly always responds to at least one of the available treatment
modalities. These treatment options include behavioural techniques, cognitive therapy, medication
and psychotherapeutic interventions. However, both behavioural treatment and pharmacotherapy
have high relapse rates. In spite of the general acknowledgement that enuresis (especially secondary
enuresis) indicates underlying psychological problems, few cases are described in the literature where
a psychodynamic approach was used successfully. This is especially noticeable given the growing
acceptance that enuresis is related to sub-optimal parenting, poor child-rearing practices and
disruption of maternal care. The clinical vignette described is a case of secondary enuresis in a 10year-old boy which responded favourably to psychodynamic input after behavioural, cognitive and
family therapies failed to resolve the problem. The dynamic formulation postulated a desire for
intimacy, following failed mother-infant bonding due to maternal depression, which was obtained
through enuretic symptoms and interpersonal conflict. This quest for intimacy through replication of
early pleasurable somatic sensations and the utilization of conflict for attention-seeking may rapidly
develop into a repetitive cycle involving delinquency, crime and sexual perversions later in life. In
such cases, a psychodynamic understanding is most likely to succeed as the enuresis represents an
ego-syntonic solution to possible ego-fragmentation, or an attempt at preventing pending
psychological breakdown.

Introduction
Enuresis is a common childhood problem which is frequently seen in child and adolescent
psychiatry practice (Edwards & van der Spuy 1985; Reiner 1995). It is considered as one of
the most frequent behavioural problems among children and, although the condition is largely
self-limiting in nature, it causes considerable distress to both parents and children (Foxman et
al. 1986). The frequency of enuretic children in the population and the drop in prevalence
with increased age imply a problem of gaps between chronological, cognitive and emotional
maturational levels. As such, enuresis can be conceptualized as a physical problem with
behavioural and psychological causes and consequences (Ronen et al. 1995).
Enuresis is defined as bed-wetting after bladder control should have been achieved. At all
ages the enuretic population comprises a mixture of children who have always been wet (
primary enuresis) and children who started to wet after a period of continence (secondary
enuresis). Secondary enuresis has its onset most often between the ages of 5 and 7 years, and
is uncommon after age 11. Boys are also more likely to develop secondary enuresis than girls.
Children who go on to develop secondary enuresis have more psychiatric symptoms before
the onset of the enuresis than children of the same

DR SAMUEL M. STEIN is a Consultant in Child, Adolescent and Family Psychiatry in South

Bedfordshire. Address for correspondence: Family Consultation Clinic, Child and Adolescent Mental
health Service, Dunstable Health Centre, Priory Gardens, Dunstable LU6 3SU.
British Journal of Psychotherapy, Vol 15(2), 1998
The author

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age who never become wet, and day-wetting alone or in combination with nightwetting is
associated with higher rates of psychiatric disturbance (Shaffer 1994).
About half of day-wetters are also enuretic at night, and nocturnal enuresis is defined as
repeated involuntary passage of urine during sleep in the absence of any identified physical
abnormality in children aged above 5 years. In operational terms, between one and three wet
nights per month would classify as enuresis (Kales et al. 1987; Shaffer 1994). Nocturnal
enuresis has an incidence of approximately 15% at age 5 years. However, most enuretic
children spontaneously cease wetting by age 7 years. Between 10 and 12 years of age, only
5% of boys and 4% of girls wet their beds monthly. By 14 years of age, only 3% of boys and
1.7% of girls present with enuresis, and by 15 years of age 99% of children are dry at night.
Boys are significantly more likely to experience enuresis than girls and outnumber girls in
regard to nocturnal enuresis at all ages (Edwards & van der Spuy 1985; Foxman et al. 1986;
Reiner 1995).
Children most commonly desire treatment for their enuresis, with more than 50% of
children being distressed by their bed-wetting. However, parental levels of concern and the
propensity to seek medical treatment are less certain. According to Foxman et al. (1986),
whilst two-thirds of parents expressed concern in regard to their child's enuresis, few parents
actively sought medical treatment for the affected child. Reiner (1995) concurred that parents
were frequently reluctant to seek treatment, and Shaffer (1985) demonstrated that fewer than
30% of 11-year-old enuretics had ever been assessed or treated for their enuresis. This
contrasts sharply with the general consensus that enuresis nearly always responds to at least
one of the available treatment modalities (Reiner 1995). To date, there has been no research
on why parents are reluctant to seek treatment for their enuretic children (Shaffer 1985).
Treatment options must be tailored to clinical and social circumstances. These options
include: fluid-restriction, night-waking, retention-control training, pharmacotherapy,
conditioning approaches, cognitive skills training, behavioural treatments, bladder exercises,
psychotherapy and token economies. The non-pharmacological treatment of enuresis is
preferred, especially in young children, and medication should not be the therapy of first
choice for bed-wetting (Ronen et al. 1995; Kales et al. 1987; Foxman et al. 1986). According
to Reiner (1995), more than 50% of enuretic children will have improvement or resolution of
their enuresis with a conservative initial approach. In this regard behaviourally-oriented,
short-term interventions with a clear focus have been shown to be more effective than longterm, broad-band interventions (van der Boom 1995).
Nocturnal enuresis most commonly responds to conditioning approaches, of which the
pad-and-buzzer is the most popular. The initial success rate of the pad-and-buzzer is 75%,
and it has been shown to be more effective than medication. However the relapse rate is
high, up to 40% (Reiner 1995; Foxman et al. 1986; Kales et al. 1987). In contrast, the
cognitive model focuses on acquisition of self-control skills rather than on conditioning, as
acquisition of self-control skills will lead to spontaneous recovery of the enuresis. An
increase in cognitive skills results in decreased bedwetting, and also shows prolonged
treatment effects. Therefore, according to Ronen et al. (1995), enuresis is a behavioural skill
deficit which necessitates training. They utilized learned resourcefulness in pinpointing the
child's ability to overcome disturbing feelings by modification, imagination, selfreinforcement and selfevaluation. In this way, elimination of enuresis can be directly related
to cognitive skills and one's belief systems and expectations. Hypnotherapy has also been
used for many years in the treatment of nocturnal enuresis, and has been associated with a

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169

significant and sustained effect on follow-up (Edwards & van der Spuy 1985). In terms of
pharmacotherapy, enuresis has been treated for over three decades with Imipramine at doses
of 10-75mg daily. Tofranil was the physician's treatment of choice, but limited to older
children and adolescents. Desmopressin, an antidiuretic hormone analogue, has been used
successfully in doses of 20-40 micrograms daily. Amphetamines and anticholinergic drugs
have also been prescribed (Reiner 1995; Foxman et al. 1986; Kales et al. 1987; Shaffer 1985)
.
Unfortunately, relapse rates following treatment are high and recurrence of enuretic
symptoms is not uncommon. Relapse occurs most frequently after conditioning (padandbuzzer) treatments and after pharmacotherapy. The rate of relapse appears to be lower if slow
taper of medication is used rather than sudden withdrawal of the treatment (Edwards & van
der Spuy 1985; Kales et al. 1987; Reiner 1995). However, cognitive interventions fare better
than do conditioning approaches such as token economies or the pad-and-buzzer. Cognitive
approaches are not subjected to the same extinction processes as conditioned responses, and
internal attributions for success reduce the likelihood of relapse (Ronen et al. 1995; Butler
1993). According to Edwards & van der Spuy (1985), secondary enuretics are more likely to
relapse after treatment than children with primary enuresis.
Whilst it is well established that enuresis can indicate underlying psychiatric problems
and is associated with adverse psychological states, there are few published accounts of
psychodynamic approaches in the treatment of enuresis (Reiner 1995; Edwards & van der
Spuy 1985). A literature search spanning 1983-1995 yielded only eight references which
included both `enuresis' and 'psychotherapy'. Textbooks and recent publications on enuresis
acknowledge the applicability of psychotherapeutic treatments but provide few practical or
helpful details in this regard (Kales et al. 1987; Shaffer 1985). In a similar vein counselling,
reassurance of parents and family therapy are advocated without elaboration. Both Kales et al.
(1987) and Edwards and van der Spuy (1985) suggest that psychological difficulties are more
likely to underlie secondary enuresis, and that psychotherapeutic treatments are therefore
indicated. However, Edwards and van der Spuy (1985) then go on to describe how
psychotherapy has not been found to be significantly more effective in treating enuresis than
spontaneous remission. Whilst concepts such as 'repressed sexual drive being satisfied
through wetting', 'primitive sexual love connected with urethral eroticism' and 'a pregenitally
expressed love affair with her mother' are mentioned, the generally negative attitude to such
conceptualizations are self-evident (Shaffer 1985; Edwards & van der Spuy 1985). This
pessimistic view of dynamic approaches to enuresis is surprising given the increasing
emphasis being placed on the fact that parents of bedwetters are less concerned with the
physical and mental health of their children, that child-rearing practices are conducive to the
persistence of bed-wetting, and that enuresis occurs more commonly if there are repeated
disruptions of maternal care (Shaffer 1985).
Clinical Case
These features were very prominent in a boy whom I treated for secondary enuresis over a
period of 10 months.
John was a 10-year-old boy who was referred to the local child psychiatry service by his general
practitioner because of ongoing enuresis. His enuresis started at the age of 6 years, John having
previously been dry by 21/2 years of age. Paediatric assessment and investigation had

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demonstrated no overt organic cause for his bed-wetting. The onset of the enuresis coincided with
the birth of his younger brother and John's entry into primary school. The school were also
expressing concern regarding his aggression, mood-swings and limited attainment in spite of being
a `bright' and `sensitive' child. Intervention by the enuresis nurse was initially helpful and John
responded to conditioning techniques with pad-and-buzzer. However, over time, the problems
slowly recurred. At the time of assessment, John was wetting the bed several times each week.
John's father is a 45-year-old journalist and his mother is a 33-year-old nurse. The general
practitioner's referral hinted at tensions within the marriage. His father also had a childhood history
of bed-wetting. John has a younger brother, a full sibling, who is 4 years old. His younger brother
nearly died at birth following an emergency Caesarean section, and is subsequently seen as `special'
by his mother. This leads to sibling rivalry and John often teases his younger sibling.
John was born at 42 weeks gestation. After his birth, which was difficult and traumatic, John's
mother suffered from postnatal depression for a period of nearly two years which she described as '
two years of Hell'. During this time, according to her husband, she was angry, paranoid, hostile and
aggressive. John's mother found the early attachment between herself and John difficult, and she
described John as a difficult infant and as a confrontational child. Whilst depressed, John's mother
said that she often came close to hitting him, and would leave him in the room and walk away when
she was angry with him. She also described how she had struggled to come to terms with her
negative feelings towards him.
John's mother said that she 'didn't like' John and found him difficult, aggressive and unhelpful.
However, John's father described him as pleasant and helpful. He confirmed that his wife overtly
disliked John. He felt that she was too hard on John, and that John often did not warrant the
negative and hostile responses which he elicited from her. John's mother also spoke about John's
attempts to get close to her, and about how difficult she found this. The problems were exacerbated
by both parents' work commitments and their return in the evenings tired and worn out. Rather than
his mother comforting John according to his needs, he only received physical cuddles and contact
when she was in need of the interaction. In contrast, she was very close to John's younger brother
whom she loved, liked and gave a great deal of warmth, time and attention. John was described as
having low self-esteem and a tendency to become rapidly very angry over minor incidents. He was
also said to have always been 'unhappy with both the world and with himself.
In the course of the family sessions undertaken, the failure of fundamental bonding and
attachment between John and his mother became increasingly evident. Simple behavioural
interventions designed to increase the time John and his mother spent together were singularly
unsuccessful. Similarly, systemic family interventions aimed at reversing parental roles and having
the father play a greater role in facilitating contact between John and his mother were equally
unsuccessful. In spite of our efforts, it was clear that John's mother was afraid of spending time
alone with him and that she blurred the differences between him and his much younger brother to
facilitate this process. For example, they both went to bed at the same time despite the six year age
difference.
Gradually a pattern began to emerge which informed a more psychodynamic understanding of
John's behaviour. His desperate need for his mother's love and attention was slowly crystallizing what he wanted most was a close relationship with, his mother, characterized by physical and
emotional intimacy. He simply wanted to feel loved and secure. Whilst he most wanted 'cuddles'
from her, he was equally content with mutually aggressive outbursts or states of friction and tension
between himself and his mother. John did not believe that he occupied a permanent space in his
mother's mind, and felt that without his adverse behaviours she would readily forget him. These
behaviours were interspersed with periods of enuretic symptoms. It soon became clear that all three
presentations served the same purpose - they created for John a sense of intimacy with his mother.
Physical contact and cuddles with his mother led to feelings of warmth, contentment and security.
Equally, states of friction and tension allowed John to feel connected to his mother, and very much
held in mind. Likewise, the enuresis served the same purpose. This could be viewed from an
infantile vertex in which early recollections of urinating were accompanied by feelings of warmth,
contentment,

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satisfaction and maternal ministrations. Equally, it could be said that the ongoing enuresis earned
John more attention from his mother in the present and again established an overt contact between
them in an otherwise barren relationship. Only one symptom was ever needed to create a sense of
intimacy and, when one behavioural pattern was overt, the remaining two were quiescent.
This pattern of shifting, intimacy-seeking behaviours was interpreted to the family based on
John's early experiences with a postnatally depressed mother and the failure of bonding and
attachment. They were initially sceptical, especially John's mother who was wary of any
interventions which aimed to increase the intimacy between herself and John. However, they agreed
to keep a diary monitoring the sequence and prevalence of these three different behavioural patterns.
By the next session, changes were already evident. John's parents, monitoring the three alternative
intimacy-creating options, observed that when John received physical and emotional intimacy from
his mother, the aggressive behaviour and enuresis decreased noticeably. For example, on nights
when John was allowed to stay up later than his brother, was given individual time by his mother and
provided with evidence that he was very much being kept in mind, no bed-wetting occurred.
Likewise, conflict between John and his mother (when physical intimacy was absent) reduced the
enuretic episodes rather than increasing them. In the absence of both physical intimacy and conflict,
enuresis inevitably occurred.
Thereafter, each follow-up session brought reports of decreasing aggression and decreasing
episodes of enuresis. John was initially bed-wetting two or three times a week, which then decreased
to once or twice a week. Soon he was hardly wetting his bed at all, and by discharge he was dry for
sustained periods which exceeded four weeks in duration. This improvement, in my opinion, was the
result of changes in his mother's attitude and behaviour towards him. She was being more available
to him, placing his needs first when appropriate, differentiating between himself and his brother,
providing him with more physical contact and giving him more time. John described how his mother
now 'understood' him better and how she now 'noticed' him more. In response, he felt calmer and less
angry which was confirmed by his parents. A similar response occurred between John's parents who
said there was less marital tension at home and that they were able to work together in a more unified
manner. They were also making more time available for each other.
Whilst John's mother initially accepted the need to change on a cognitive level, realizing that
intimacy was less destructive than either conflict or enuresis, she slowly adopted these behaviours in
a more affective manner with John having to initiate the intimate contacts less often.

Discussion
The aim of the discussion, as highlighted by the clinical vignette, is to demonstrate the link
between insecure mother-child attachment, the early failure of intimacy and enuretic
symptoms.
The importance of secure early attachment is well-documented in the literature,
especially the role of maternal sensitivity and maternal attunement to the infant. This
attachment can be operationalized, reframed or observed in a more user-friendly form as the
development of intimacy between mother and child. Disruptions of early maternal care, such
as post-partum depression, may interfere with the bondingattachment-intimacy process with
traumatic consequences for the infant. In order to cope with these traumata, the infant or
child develops defensive manoeuvres or behaviours to replace or represent the experience of
intimacy. Enuresis may act as such a defence mechanism.
Attachment
The attachment of infants to their parents is recognized across the social science
disciplines as a fundamental psychological process affecting human development

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throughout the lifespan. According to Seifer and Schiller (1995), all children will develop
some degree of secure-base behaviour with one or more attachment figures within the first
year of life. The quality of this attachment between infant and parent will influence
subsequent social, cognitive and emotional developments. Secure, safe and stable attachment
has been identified as a primary influence upon the child's evolving adaptation to the
environment, and a secure base also enhances the infant's opportunities to engage in a variety
of adult-supervised learning experiences and exploratory activities (Fonagy et al. 1993a;
Seifer & Schiller 1995). Thus secure attachment experiences create a favourable context for
the acquisition of a `theory of mind', the socio-cognitive capacity which underpins reflective
self-function. In contrast, insecure attachment is a defensive compromise.
Maternal sensitivity is crucial to the development of attachment. The mother's state of
mind regarding attachment, and maternal behaviour towards the infant, may have a
significant impact on the organization of the infant's attachment behaviour (Ward & Carlson
1995; Lowinger et al. 1995). Infants seek to `teach' their parents about the specific
behaviours which they require to establish a secure base. Parents must therefore be able to
correctly read the signals generated by their infant and provide appropriate reinforcement in
the form of adequate stimulation, arousal, feedback and predictability (Seifer & Schiller
1995; Field 1996). Attunement or synchronicity in the parent-child interaction requires an
awareness of the infant as a psychological entity with mental experiences, and the parental
capacity to accurately identify these psychological states appears to play a critical role in the
child's development. Thus finely-tuned nuances and rhythms of affect-laden, preverbal
communications characterize well-functioning mother-infant couples (Fonagy et al. 1993a).
If his mental state is anticipated and acted on, the infant will be secure in his attachment.
To attain secure attachment to the caregiver, the infant thus requires parental sensitivity to,
and understanding of, his mental world. Parents high in reflective function will be able to
provide better containment of the child's affect, create a more stable basis for development of
the child's mentalizing function, and promote a more secure attachment with the child (
Fonagy et al. 1993a, 1993b). This secure attachment relationship will then provide a
congenial context and 'secure base' from which the child can explore and develop (Bowlby
1969). Repeated encounters with a mother capable of reflecting, containing and alleviating
distress will therefore strengthen the child's capacity to tolerate negative affect and increase
his selfconfidence (Seifer & Schiller 1995). Secure attachment is thus the outcome of
successful containment in which the parent appropriately senses and responds to the child's
rudimentary attempts to formulate and express his current mental state, intentions and wishes
(Fonagy et al. 1993a, 1993b).
Intimacy
According to Ainsworth (quoted in Seifer & Schiller 1995), the parenting sensitivity
which underpins mother-infant bonding includes: alertness to infant signals, appropriate
interpretation of responses, promptness of responses, flexibility of attention and behaviour,
appropriate levels of control and negotiation of conflicting goals. Ainsworth's description of
attachment behaviour corresponds very closely with Dignam's (1995) description of intimacy.
According to Dignam, the characteristics of intimacy include: joy and mutual delight,
reciprocal dialogue, openness, contact, union, receptivity, perceived harmony, concern for
other's well-being, surrender of

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manipulative control and desire to master in relating to the other, trust, closeness and being in
an encounter rather than striving or doing in the encounter. This intimacy is an essential
aspect of human development and is important to individual identity.
Bodily contact with the mother provides an essential source of comfort, security and
worth for the infant. Intimacy is part of a successful breast-feeding experience, and a
significant link was found between maternal physical contact at four months of age and the
infant's attachment behaviour with `touch of skin' as an especially vital characteristic and
component of intimacy (Dignam 1995; Lowinger et al. 1995). The interaction between
mother and infant is therefore characteristic of intimacy, described as an exchange in which
the discloser must feel understood, validated and cared for by the listener. Intimacy can also
be more theoretically defined as the quality of a relationship in which the individuals must
have reciprocal feelings of trust and emotional closeness towards each other and are able to
openly communicate thoughts and feelings with each other (Dignam 1995). Thus the
association between maternal sensitivity, intimacy and later infant attachment organization
can be clearly seen.
Failure of Intimacy or Attachment
Unfortunately the attachment system is readily influenced by stress or danger, and
modified by contextual events such as family difficulties and deprivation. Single parent
families, life-threatening illness, parental criminality and prolonged separation from parents
increase the probability of insecure infant attachment (Seifer & Schiller 1995; Fonagy et al.
1993b). A family where children lack an intimate relationship with at least one parent is also
a powerful predictor of serious maladjustment (Braithwaite & Devine 1993). Thus parental
psychiatric illness will increase the likelihood of insecure infant attachment as the mother's
internal psychological state may preclude adequately attuned emotional responsiveness with
the infant (Fonagy et al. 1993b). Not surprisingly there is a confirmed connection between
parental depression and disordered parent-child attachment, and children of depressed
mothers are at risk for low self-esteem. Maternal depression may also contribute to children's
insecure attachment through its influence on broader aspects of the child-rearing
environment. The infant will be vulnerable to inconsistency in caregiver's behaviour and is
more likely to respond with defensive behavioural strategies in the face of a caregiver who is
incapable of responding accurately to his affective signals. As his mental state is not
anticipated and acted on, the infant will be forced to rely upon such defensive behaviours to
maintain his psychic equilibrium (Fonagy 1993a, 1993b). Thus the postpartum period is a
sensitive period for the establishment of bonding between mother and child, which will affect
their long-term attachment and have extended consequences for their emotional well-being (
Crouch & Mauderson 1995).
If the child cannot rely on his mother to respond to signals of negative affective states,
and thereby to reduce them, he must find alternative ways to diminish them (Fonagy et al.
1993b). Because of his immature and yet unconstructed psychic apparatus, the infant has no
recourse to regression and a behavioural strategy must be revoked. The infant's defensive
efforts will therefore be restricted to removing the affective state signalling unpleasure rather
than its cause. Because the infant is habitually forced to employ defensive behaviours to
afford himself protection from a caregiver with insufficient grasp of his mental state, an
insecure attachment is formed. These children grow up over-burdened with the responsibility
of caring for themselves which may ultimately cripple their emotional and social
development.

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However positive life experiences, if sufficiently intense, are likely to be able to reverse
this developmental anomaly in late childhood and probably even in adulthood (Fonagy et al.
1993b). According to van der Boom (1995), intervention promoted a sustained improvement
in mother-child relationships. Thus mothers may require help to learn how to respond in a
sensitive manner to their infants as, by intervening at the point in development when mothers
lose confidence in their mothering, it is possible to prevent negative cycles of interaction
from developing. Parents should be urged to avoid harsh and punitive reactions towards the
child which would only serve to increase anxiety, guilt and anger (Kales et al. 1987).
The Defensive Function of Enuresis
It is evident that early mother-child interactions, attachment and intimacy are integral to
children's mental health. Where intimacy is absent, children are forced to seek alternative
behaviours which, for them, serve the same psychic function. States of unbearable tension
and over-stimulation in infancy which are not resolved by maternal reverie will thus need to
find an alternative outlet. This is in keeping with the suggestion by Freud in 1953 and by
Storr in 1972 (both quoted in Babbage and Valentine 1995) that a blocked capacity for
intimacy may allow other behaviours to serve as alternative means of resolving the emotional
need for attachment. In the clinical vignette, John found three possible outlets for his need
for intimacy reflected in the ever-changing cycle of physical intimacy, conflict and enuresis.
In keeping with Bion's (1961) postulate of `basic assumptions', these fundamental defensive
manoeuvres were interchangeable and alternated with one another according to need, with
only one behaviour required to maintain psychological equilibrium at any given time.
As early as 1929, Ferenczi wrote of the sudden relief (relative pleasure) derived from
urination by a frightened child, and how it stops the child's crying. According to Greenacre (
1953), urination is one of the readiest outlets of anxious tension and may serve a tension
discharging function. Stoller (1979) described a similar case in which his patient experienced
early buttock sensations which, although erotic, did not require a conclusion or orgasm: `
they were simply warm, pleasant and without much build-up; she would have liked them to
persist indefinitely'. These pleasurable early sensual experiences provide the child with a
sense of control over their own body, as well as a sense of achievement and mastery. It also
provides pleasurable relief, perhaps equated with a diminishing sense of persecution. It is
therefore not surprising that the child, at times of stress and humiliation, resorts to these
early psychosomatic pleasures as a way of coping with the negative situation. One of John's
intimacy seeking solutions was the development of secondary enuresis, in spite of previously
being clean and dry. The regressive act of bedwetting proved ego-syntonic and reparative
with echoes of infantile intimacy.
John's other alternative to intimacy was conflict between himself and his mother. After
all, according to Stoller (1979), `any attention, even if painful, is better than none' and `
harassment certainly proves that you are not unnoticed or abandoned'. However, Stoller also
warned that this hungry search for skin. and mucous membrane stimulation, in people who
got too little in infancy, could result in a perversion. Whilst John was able to rekindle a sense
of intimacy with his mother through enuresis and conflict, its ongoing absence as he moved
into adolescence may well have found an alternative outlet through delinquent peer group
activities. John may have sought to

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obtain the intimacy he so desperately wanted through a close-knit peer group, or through
intimacy-evoking activities such as substance misuse and crime.
These activities may replicate the cycle of infant experience where pleasurable sensations
are associated with external persecuting figures who represent the distant, depressed,
unsympathetic and unavailable mother. In this way painful reality is converted into
excitement, and the alternation of pleasure and pain results in an addictive increase in the
need for intimacy (Stoller 1979). By intervening in the child's quest for intimacy through
replication of early pleasurable somatic sensations and the utilization of conflict for attentionseeking, the development of a repetitive cycle involving delinquency, crime and sexual
perversions later in life may be impeded.
Conclusion
In such cases where enuresis replicates, creates or acts as a substitute for a state of
intimacy behavioural techniques, cognitive strategies or pharmacotherapy will not bring
about a sustained improvement. The star-chart approach may help to mimic intimacy to some
degree by virtue of the increased attention and praise involved. The pad-and-buzzer may
allow the intimate sensation of urination but, by waking the child, prevent the onset of
subsequent persecutory enuretic experiences and parental responses. Medication may assist
in lowering states of anxiety created by the absence of maternal intimacy but they would not
serve to re-create the sense of attachment and security which lead to the anxiety in the first
instance. Even family work may achieve little more than persuading the mother to go through
the motions of intimate behaviour with the father providing whatever degree of
compensation possible.
In children like John, a psychodynamic understanding of the ego-syntonic nature and
purpose of the symptom is essential in order to facilitate appropriate treatment. These
symptoms serve to prevent the still immature personality from fragmentation, and play the
vital role of an auxiliary external ego which supplements the deficits of good-enough
parenting experienced in infancy. Without this more analytic insight into the child's enuresis
behavioural, cognitive and family interventions are unlikely to succeed. However, in addition
to the psychotherapeutic approach, treatment may need to promote a corrective emotional
experience which facilitates improved attachment and intimacy between parent and child.
This may be necessary before the child can make adequate use of more sophisticated
therapeutic interventions.
When dealing with enuresis, different types of intervention should be negotiated which
enable the patient to explore different possibilities without pressure to fulfil or comply with
certain therapeutic expectations. In the words of Reiner (1995), 'consideration of the
circumstances surrounding enuresis would seem more important for determining the need for
diagnostic evaluation and treatment'. Therefore treatment of enuresis must always be tailored
to the patient's specific emotional, clinical and social circumstances.
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