ACQ_Vol_11_no_3_2009

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ACQ Volume 11, Number 3 2009 141
Mental health
Debbie Plastow
This article
has been
peer-
reviewed
Keywords
CHILD
SELECTIVE
MUTISM
SPEECH
PATHOLOGY
PSYCHOANALYSIS
Kratochwill, Sladezcek, & Serlin, 2002). However, according
to Paul (2007, p. 427), “the most convincing literature pertains
to behavioural modification approaches”. Stone et al. (2002)
conducted a meta-analysis of the four most common
approaches used in the treatment of selective mutism. It was
concluded that behavioural approaches appeared to be
effective in treating selective mutism, however further
findings were limited due to insufficient quantifiable data in
most of the studies. The authors recommended that future
researchers adopt standardised measures and use a
manualised treatment for consistency of approach.
In their meta-analysis, Stone et al. (2002) noted that there
was a paucity of information on family pathology in the children
receiving behavioural interventions, suggesting that such
frameworks do not give great significance to the family situation.
Verhaeghe (2007) questioned the validity of such evidence-
based methodologies in assessing the efficacy of most psycho-
therapeutic treatments, and stated: “Instead of concluding
that [evidence-based] methodology is too limited to [determine
the effectiveness of psychotherapeutic treatments], the
message is that those therapies that cannot be tested … are
simply not scientific nor effective” (p. 5). Verhaeghe argued
that the insistence on manualised or standardised
approaches does not take into account the individual client
or their social situation, including the place of the family.
In this paper I would like to put forward that in a treatment
that focuses predominantly on the behaviour of the child, the
therapist unwittingly becomes aligned with the parents’ and
teachers’ demand for the child to speak. In such approaches
there may be the potential to bypass what lies behind the
child’s silence, and the place of the parents in this. In other
words, such treatments may overlook the particularity of
the child and the family context. Family pathology is one
aspect, but perhaps more important is the child’s symptom
in relation to the family.
What place, then, is there for the child to speak in his or
her voice? In The Child, his “Illness” and the Others (1987),
Maud Mannoni, French child psychoanalyst, wrote: “We find
ourselves grappling with the history of a family … The child
who is brought to us does not come alone, for he occupies
a definite place in the fantasy of both parents” (p. 60). The
history referred to concerns the spoken account that each of
the parents gives of themselves and their child. Through this,
the manner in which the child is caught up in the parents’
own wishes, aspirations, and ideals, becomes articulated.
Consequently, the work undertaken with the parents can
allow them to hear where they place the child in their own
accounts. In this paper, a description will be given of my
Contemporary approaches to the
management of children with selective mutism
generally recommend various forms of
behavioural intervention. Such approaches
focus predominantly on the child’s symptom
of not speaking. Nonetheless, the child does
not exist in isolation. It is proposed in this paper
that the child’s inability to speak in certain
situations may be co-extensive with the
difficulty of being heard by others. This may
include the child’s family, teachers and even
mental health professionals. An alternative
treatment approach using psychoanalytic
principles will be described in which the
child’s symptom is considered in relation to
the history of the family. The objective of this
paper is to elaborate these notions through
reference to a clinical case study.
T he expertise of the speech pathologist in the
assessment and treatment of children with selective
mutism is becoming increasingly recognised in the
psychiatric literature (Paul, 2007). The Diagnostic & Statistical
Manual of Mental Disorders (4th ed.) [DSM-IV] criteria for
diagnosis of selective mutism exclude a communication
disorder (American Psychiatric Association, 2000), yet
these children have an increased incidence of speech and
language problems (Gidden, Ross, Sechler, & Becker, 1997).
The speech pathologist therefore has a significant role in
assisting with differential diagnosis, as well as in providing
treatment in collaboration with mental health professionals
(Gidden et al., 1997; Paul, 2007). In the field of speech
pathology, most current approaches to the treatment
of children with selective mutism advocate behavioural
strategies, with specific goals outlined in graded stages
with rewards for speaking (Gidden et al., 1997; Johnson &
Wintgens, 2001). In such approaches, although the parents
may be involved in aspects of the treatment, the focus is
generally on the child’s symptom, that of not speaking. This
paper will describe an alternative approach to the treatment
of selective mutism, one which considers the child’s
symptom in relation to the context of the family.
Various treatments for selective mutism have been reported
in the literature, including family systems, psychodynamic,
pharmacological, and behavioural approaches (Stone,
Selective mutism or
selective deafness?
Debbie Plastow