has been able to demonstrate experimentally that certain 'task motivational' ... Tlie Eiim of this study was to assess the effectiveness of hypnotherapy with ...
J. CkmpychaL Pjychul. Vol. 26, No. 1, pp. 161-170, 1985. Primed in Great Briuun.
0021-9630/85 >3.00 + 0.00 Pcrgamon Prew Ltd. © 1985 Aisociation for Child Piycholo^ and Psychiatry.
HYPNOTHERAPY AS A TREATMENT FOR ENURESIS S. D. EDWARDS* andH. I. J.
VANDERSPUY^ •Department of Psychology, University of Zululand, South Africa and •f Department of Psychiatry, McMaster University, Ontario, Canada INTRODUCTION
enuresis, or bedwetting, is a common childhood problem. It is more common in boys than girls after the age of five (Oppel et aL, 1968). Approximately 5% of all children wet their beds three or more times a month at the age of 10 yr (De Jong, 1973). While it is seldom that precise etiology can be identified in any individual child, a number of associations have been noted which have led to various theories: genetic, genito-urinary abnormality or malfunction, deep sleep, coercive or early toilet training, stressful life events during a critical phase of development and adverse psychosocial or psychological states (Shaffer, 1977, 1980). There is evidence for some association between enuresis and psychiatric disturbance, although only a minority of enuretics are found to be psychiatrically disturbed (Rutter et at., 1973; Kolvin and Taunch, 1973; Shaffer, 1977, 1980). While there is no definitive evidence that the association is a causal one, the association between enuresis and psychiatric disturbance probably operates in different directions in different children (Shaffer, 1977. 1980). A distinction is commonly made between primary and secondary enuresis (Kolvin and Taunch, 1973). The first refers to persistent wetting from birth, the second to the reappearance of enuresis after a period of continence (MacKeith, 1968). There is consistent evidence that stressful events and psychiatric disturbance precede the onset of secondary enuresis (Werry and Cohrssen, 1965; Rutter et aL, 1973) and that secondary enuretics respond better to treatment of a more psychological nature yet relapse more than primary enuretics after treatment (Novick, 1966; Shaffer etaL, 1968; MacKeith, 1968, 1972, 1973). There are various methods of treatment for nocturnal enuresis, all of which seem to have limitations. Psychotherapy has not been found to be significantly more effective than spontaneous remission (Werry and Cohrssen, 1965; De Leon and Mandell, 1966). Both psychopharmacological and conditioning treatment have high relapse rates (Turner, 1973; Blackwell and Currah, 1973). Some or other form of hypo therapy has been used for many years in the treatment of nocturnal enuresis (Wolberg, 1948; Ambrose and Newbold, 1968). There is evidence for its utility and efficacy (Lazorovici, 1970; Hartland, 1971), but there has been no adequately controlled experimental research in the area. NOCTURNAL
Requests for reprints to: Prof. S. D. Edwards, University of Zululand, Private Bag XlOOl, KwaDlangezwa 3886, South Africa. Accepted manuscript received 3 June 1983
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S. D. EDWARDS AND H. I. J. VAN DER SPUY
There are two distinct paradigms in hypnosis research (Spanos and Chaves, 1970). The traditional trance paradigm typically involves a ^hypnotic induction', i.e. suggestions of eye heaviness, eye closure, relaxation, drowsiness, sleep and a unique state of deep trance. Research pioneered by Barber (1965; Barber and De Moor, 1972), who advocates an alternative paradigm, has been instrumental in delineating critical antecedent induction variables to hypnotic behaviours. Barber has been able to demonstrate experimentally that certain 'task motivational' instructions aimed at enhancing expectancies, attitudes and motivations, administered in the waking state, had as significant an effectiveness on responsiveness to test suggestions as the traditional hypnotic induction. Tlie Eiim of this study was to assess the effectiveness of hypnotherapy with nocturnal enuretic boys. METHOD Forty-eight nocturnal enuretic boys between the ages of 8 and 13 yr (mean age 10!4 yr) were included in the study: 24 primary and 24 secondary enuretics. To qualify as secondary enuretics subjects had to have had at least one period of 3 months of dryness or at least three separate dry periods of 1 or 2 months after initial toilet training. With the approval of the Education Department and schools concerned, subjects were recruited from the 12 largest boys' schools in the Cape Peninsula by some 4478 letters offering treatment for enuresis. They were all medically examined to rule out organic pathology cuid they had to be free of diurnal enuresis. The sample was fairly homogeneous for social class, with a slight upper middle class bias. There were no significant differences in social class between the primary and secondary enuretic gixaups. Seven primary and 8 secondary enuretics were classified as upper middle class, while 17 primzuy and 16 secondary enuretics were classified as middle class in a 6 category social class scale. (See Appendix for social distribution.) The 48 primary and secondary enuretics were matched for age and randomly assigned to the following four treatment conditions (the 2 x 4 factorial design thus involved 12 enuretics per treatment condition: 6 primary and 6 secondary). 1. Trance plus suggestions (H+) A trance was induced in a special relaxing chair. Pre-recorded suggestions were provided in a standardized manner through headphones. The tape recorder was initially used as an amplifying system for the hypnotic induction through the headphones before the taped suggestions were given. The hypnotic induction consisted of suggestions of relaxation, eye heaviness, eye closure, drowsiness, sleep and suggestions to subjects that they were entering a unique state in which they would have interesting emd unusuail experiences. A counting technique in conjunction with suggestions of deepening sleep was also used. The tape-recorded suggestions were directed at: (i) general tension reduction and enhancement of general self-confidence. These suggestions were geared towards the reinforcement of dry nights and the positive cumulative behavioural changes associated with dry nights; and (ii) suggestions specifically aimed at the enuresis. They included suggestions to cover the following areas: (a) increased bladder capacity, amongst others by holding on as long as possible before going to the toilet during the day; (b) reduction of fluids before bedtime; (c) a visit to the toilet before going to bed at night; and (d) waking up at night to go to the toilet on experiencing a full bladder. (The full text of these suggestions is available from the authors.) 2. Suggestions without trance (IV+ ) The same procedure as in (I) (H + ), but with no attempt to induce a trance first. This treatment condition was based on Barber's (1965; Barber and De Moor, 1972) theory and findings that the same results can be obtained through a state of heightened suggestibility without trance induction, following such necessary antecedents as enhanced rapport and positive expectancies, attitudes and motivations.
HYPNOTHERAPY AS A TREATMENT FOR ENURESIS Standardized 'task motivational instructions' were administered to this group, prior to the taperecorded programmes of suggestions. 3. Trance alone (H) The original idea was to only induce a trance and then to wake them up again. As moral objections were raised against this, minimal suggestions were given before trance induction. They were told that the hypnosis would help them to become dry and to become more confident and independent. This was, however, done briefly in an informal manner and not through the headphones. The trance was induced afterwards and after a few minutes they were woken up. 4. No-treatment controls {NT) Enuresis records were obtained on these subjects throughout. They were offered treatment after the 6-month follow-up period. Before treatment started subjects and their parents were first seen for an initi2Ll interview, where full details were tciken and the program was explained. Parents were requested to take baseline enuresis records before treatment commenced. Baseline records ranging from 11 to 21 weeks were obtained. Detailed enuresis records were kept throughout the treatment and the 6-month foUow-up periods. Communication with parents was standardized with special forms on their involvement in the record keeping and rewarding of dry nights. Treatment consisted of six standardized weekly sessions, lasting an hour each. During the first two session rapport was established and three hypnosis scales administered: the Children's Hypnotic Susceptibility Scale (London, 1963), the Barber Suggestibility Scale (Barber, 1965) and Diagnostic Ratings of Hypnotizability (Ome and O'Connell, 1967). These scales were administered to all treatment subjects, following either a hypnotic induction (groups H+ and H) or task motivational instructions (Croup W+ ). There were no significant differences between the three treatment conditions with regard to suggestibility or hypnotic susceptibility. Some response to the hypnosis scades was obtained in all subjects. For example, all subjects responded with a level of subjective involvement, or attained a rating level of at least 3 on the Orne and O'Connell (1967) diagnostic scaJe. During the remaining four sessions treatment conditions described under Method were administered. Statistical analysis Data was analyzed by a three-way analysis of variance with repeated measures on factor C, which refers to the same subject at different times. The other two factors were (a) the primary/secondary enuretic distinction and (b) the four treatment conditions. RESULTS
Improvement over baseline
The reduction of number of wet nights per week was significant over the baseline at the 1 % level for all three treatment conditions combined, i.e. n = 36 {Fratio = 11.8) but not for the no-treatment controls (F ratio = 0.027). Analyzed separately, this was also significant at the 1 % level for trance plus suggestions {F ratio = 9.04), for suggestions alone (i^ratio = 14.27) and for trance alone (F ratio = 5.67) (see Fig. 1). These results refer to improvement over the 6-month follow-up period. Two treatment conditions, namely trance plus suggestions and suggestions alone, resulted in a significant improvement (P ^ 0.01) in number of wet nights over baseline during the treatment period itself (F ratio for trance plus suggestions = 4.07 and F ratio for suggestions alone = 7.56). The trance alone and the controls showed no significant differences over the treatment period. Comparison with no-treatment controls
The data were transformed into Z scores for comparisons between the four treatment conditions {n = 48). It is clear from Fig. 2 that the group who received suggestions in the waking state did better than the other groups when Z scores were used, and
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S. D. EDWARDS AND H. I. J. VAN DER SPUY
ex (A
o
3
6 o «
2
EO
El
E2
E3
E4
E5
Six -week intervals
FIG. 1. Enuresis records in dry nights for the four treatment conditions, H+ , W+ , H and NT, from baseline, EO, over treatment. El, until the 6-month follow-up, E5.
El
E2
E3
E4
E6
Weekly intervals
FIG. 2. Enuresis records in Zscores for the four treatment conditions, H + , W+ , H and NT, over the 6-week treatment period, El-6.
this was the only group which reached significance at the 5% level over the 6-month follow-up period (F ratio = 2.849) when compared to the no-treatment controls. Differences between the four treatment conditions only beccime apparent during the third week of treatment, at which time the tape-recorded suggestions aimed at decreasing enuresis were introduced in treatment conditions H + and W-t- (weekly
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HYPNOTHERAPY AS A TREATMENT FOR ENURESIS
/^ratios for the 6-week treatment period: 1.2, N.S.; 1.6, N.S.; 3.2, P< 0.05; 3.8, P< 0.05; 4.9, P< 0.01; 6.9, P< 0.01). Only treatment conditions H-f and W-»- were significantly more effective than no treatment (NT) over the treatment period [F ratio for W-t- v s N T = 5.5, P < 0.001; Tukey Ratio for H + v s N T = 3.8, P < 0.05; Kirk (1968)]. While this does not deny the operation of other non-specific variables, e.g. the growing therapeutic relationship, the above provided consistent evidence that the effectiveness of hypnotherapy was primarily due to the program of suggestions, whether preceded by a hypnotic induction or not. Comparisons with otherforms of treatment
As full enuresis records were obtained for all 48 subjects over an extended period of time, direct comparisons could be made with the outcomes of other studies. For the purpose of these comparisons the subjects of our three treatment regimes were collapsed into one group to obtain an adequate sample size (i.e. n = 36). {Werry and Cohrssen, 1965) Briefpsychotherapy and bedbuzzer. In this study the number
of wet beds in the fourth month of therapy was expressed as a percentage of the pretrial monthly frequency and five outcome levels were differentiated: (a) cure—0%: no wet beds during the fourth month; (b) greatly improved: 1-35%; (c) moderately improved: 36-69%; (d) unchanged: 70-100%; (e) worse: over 100%. Our data was converted to make a direct comparison possible. Five subjects were excluded from the hypnotherapy group as they did not meet the pretreatment criteria of Werry and Cohrssen. The results of the comparison are reported in Table 1. It is clear from Table 1 that hypnotherapy had significantly better results than brief psychotherapy but no significant difference in comparison with the bedbuzzer. {Kolvin et al., 1972) Placebo, bedbuzzer and imipramine. In this study treatment lasted
for 2 months, with a follow-up in the fourth month after treatment. Outcome was expressed as a percentage of improvement in the wetting per month before treatment, compared to after treatment. Cut-off points were established at 40 and 80% levels of improvement. Improvement of 80% or better was regarded as a cure or near cure. TABLE 1. COMPARISON OF HYPNOTHERAPY WITH BRIEF PSYCHOTHERAPY AND BEDBUZZER (WERRY AND COHRSSEN, 1965)
Treatment groups No treatment (n = 27) Brief psychotherapy (n = 21) Bedbuzzer (n = 22) Hypnotherapy (n = 31)
Therapeutic response Greatly improved Improved
Cure 1 2 7 6
(3.7%) (9.5%) (31.8%) (19.4%)
2 2 6 11
Comparison No treatment vs hypnotherapy Brief psychotherapy vs hypnotherapy Bedbuzzer vs hypnotherapy
(7.4%) (9.5%) (27.3%) (35.5%)
5 3 4 6 d.f
12.214 6.660 1.145
1 1 3
(18.5%) (14.3%) (18.2%) (19.4%)
Unchanged or worse 19 14 5 8
(70.3%) (66.7%) (22.7%) (25.8%)
Significance P
