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Tuesday, October 27, 2009

Treatment Tuesday - Enuresis, Phobias, and PTSD

This week’s assessment comes courtesy of Lynn. She’s writing a historical based on the Kindertransport (evacuation of Jewish children prior to WWII; read more about it here). Her MC is 8-year-old Halina* who goes to live with a Quaker family in London. Her 13-year-old brother is left behind due to no room on the train. Halina maintains contact with her parents until they are sent to Auchwitz. Halina eventually moves to the United States. In 1950, when Halina is 20, she marries and two years later gives birth to a daughter.

* Names have been changed to protect the fictional.

Lynn wants to know how someone would help Halina through her multiple issues, which she listed for me:

1) Survivor guilt – she’s not sure what happened to her brother; friends and family were exterminated
2) Insecurity – how could her parents leave her? Did they not love her? Issues with bedwetting
3) Ostracism – hard time fitting in with British children (different language, culture, religion)
4) Phobias – train stations/suitcases
5) Re-evacuation adjustment to the England countryside when war is declared
6) Flashbacks to the burning of the Berlin synagogue during the bombing of London and burning of St. Paul’s Cathedral
7) Repressing memories as a grown woman; not wanting to share it with family
8) PTSD – depending on when this term was named

Can I just say that Lynn has got her ducks in a row? KUDOS! This was such a fantastic rundown of everything you want Halina to experience and work through. You’ve obviously thought this out and it shows. You practically have your own assessment, which is fantastic!

I think I can help by shedding some additional light on some of the “heavy hitters” you put poor Halina through (meanie!). :)

You have her wetting the bed (called enuresis), which is a realistic response for an 8-year-old who has been forced to leave her parents and brother and essentially moved into foster care. Most likely, she’d have secondary enuresis, which is when a child is dry for at least 6 months and then starts to wet the bed, indicating a more emotional reason, but it could be physical or a change in sleep patterns. If Halina never was consistently dry at night, then she has primary enuresis, and her brain just needs to learn to wake her up when her bladder signals it is full.

Enuresis is typically something children grow out of, but there are practical things her British family could do to try to help her.

• Reduce amount of liquid drunk a few hours before bed
• Reward child for dry nights
• Have them change their own sheets when wet
• Bladder training during the day where Halina would be asked to “hold” her urine when she needs to go so that she stretches the bladder to hold more urine (also called retention control, although probably not back then!)

If I did my math right, Halina would be 8 in 1938. This just happens to be the year that bedwetting alarms came out. Now, I have no idea how expensive they were, but the idea is that the alarm goes off as the child is voiding, and this wakes them up and they can either go to the bathroom or hold the urine until later (negative reinforcement). It’s very effective, but the alarms have a high drop-out rate. Back then there was no medicine for this problem as there is now, so these are your options.

Her specific phobia of train stations and suitcases is appropriate and can be easily done in fiction. Obviously, these things remind her of being taken away from her family, and who she left behind. In particular, I’d think the train station would just be an awful place for her to revisit, since your sketch seemed to indicate her brother was at the train station with her, but unable to accompany her because of a lack of room. So that would be extremely traumatic for an 8-year-old to witness and then being left alone on the train. Halina would stop at nothing to avoid train stations and suitcases. Phobias were known to the mental health field in the 30s, but I couldn’t find out much about treatment. You can see my post here regarding phobia treatment (the part you want is about half-way down). Back then, they might have just given in to her anxiety and made it where she never had to visit those places much. There are perfectly “normal” adults who die with phobias still in tact.

Survivor guilt, which first was diagnosed around the 60s, was removed from the Diagnostic and Statistical Manual of Mental Disorders IV in 1994 and redefined as a significant symptom of Post-Traumatic Stress Disorder. So you won’t be able to mention that until quite some time after she’s married, if you decide to. Her flashbacks would be incorporated into this diagnosis, as would the repressing memories (which is an avoidant response common in PTSD…people don’t want to think about things that give them anxiety).

As to how her husband might could help her through these issues, I’d make him an extremely strong male lead. Halina will need some security after such a traumatic past. You mentioned her husband would be a Holocaust survivor. This could be really good, if you write it in such a way that they bond through a sort of mutual experience (even though Halina escaped the Holocaust, she was terribly affected by it). If you make husband’s issues too strong, then it’ll lose feasibility (in my opinion). Halina has so much on her plate to deal with that I’d think it unlikely for her to fall for someone in worse shape than she’s in. Does that make sense? Might just be a personal thought, but it seems she just needs a strong man.

People with survivor syndrome have to learn that they are suffers, too. They take on an unnecessary amount of guilt, almost like the tragedy was their fault. Maybe Halina’s husband could be this huge Jewish nationalist who really sees this fact as it is: the Jews were victims. Halina could learn to accept that she wasn’t in any way responsible and this will enable her to move on with her life and grieve the losses she has suffered. When you’re stuck with survivor guilt, the grieving process gets stuck, too. Her husband would need to be persistent, really drawing out her memories and encouraging her to talk about things rather than stuff them inside, which enabling her to come to terms with what really happened. He’ll have to get past her repression some how. A person can convince herself something didn’t happen if they are good enough as repression and denial. Her husband (maybe when he’s a fiancé?) might have to really put some faces to the horrific event by showing her pictures of the camps or some awful scar he has a result…to really bring home that it did happen. Halina has to face it and grieve it.

Okay. This has been a really meaty assessment, but that’s mainly because you gave me SO much to work with, which is great. I wish I could have done a little more research about treatment for some of these things back in the 30s, but maybe you can do some Googling on your own.

Thanks for writing in…really enjoyed this assessment.

This service is for fictional characters only, so any resemblance to real life examples is entirely coincidental. Any other fictional character assessment questions can be directed to

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Jennifer Shirk said...

I enjoyed the assessment, too! I think I'd like to use "Survivor's Guilt" for a new character. I think it would fit with my storyline. If I have questions, I'm e-mailing you. :)

Eileen Astels Watson said...

Wow, that will be one novel full of conflict! My friend could have used this information on bed wetting years ago, she had such difficulty with her son with this. His was primary enuresis (man what technically sounding terms) since he just always did it, there was not emotional instigation.

Boy do I learn a lot from these, right to dates when the mental specialists start changing the terms. Amazing!!!

Angie Ledbetter said...

Cool. Linking to your couch in tomorrows Wednesday Writing post. :)

Jessica Nelson said...

That sounds like a great story, though sad. Nice assessment!

Tamika: said...

This is definitely couch material. Deep.

I love the angle it would bring to a story. Thanks for the assessment.

Roni Loren said...

Great assessment. That character definitely has a lot going on!

Story and Logic Media Group said...

I was a bedwetter when the machines came out. My parents could not afford to buy one so my father examined it and made one. Two sheets of mesh with a sheet between and on the top. As soon as water hit the mesh was connected and set of a light and sound. Mine probably just had light or sound. That was a long time ago folks!

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Both comments and questions are welcome. I hope you enjoyed your time on the couch today.