Selective mutism and Play Therapy: Searching for expressions as a means of communications

I have had the honour of working with families and children who selective mutism is a reason for consultation. This has led me to learn, reflect and research how Play therapy can be a way to support children who encounter this difficulty. Here I offer my reflections and hope it will be useful to both therapists and carers/schools who are considering how play therapy can support their child.

According to Diagnostic and Statistical Manual of Mental Disorders (DSM-5 2014) the criteria to diagnosis Selective Mutism consist in presenting   (1) the failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school) despite speaking in other situations. (2) The disturbance interferes with educational or occupational achievement or with social communication. (3) The duration of the disturbance is at least 1 month (not limited to the first month of school). (4) The failure to speak is not attributable to a lack of knowledge of, or comfort with the spoken language required in the social situation.

Clients can present symptoms such as they do not initiate speech or reciprocally respond when spoken to by others. The lack of speech occurs in social interactions with children or adults outside his home. This situation can affect their learning due to teachers could not assess them. Some clients can use non-spoken or nonverbal means (e.g., grunting, pointing, writing) to communicate and perform or engage in social encounters when speech is not required.

The National Health Service UK (NHS, 2016) stablishes that children with Selective Mutism does not refuse or choose not to speak, but they are unable to speak. It also is asserted that the expectation to talk to certain people triggers a freeze response and talking will be impossible. This can be observed as “fear” of social interactions, which start when they put a step out the house. Their body language and face expressions can change. The NHS (2016) also stablishes that this symptoms appear in early childhood between ages two to four. It’s often noticed when the child start to interact with people outside his home, such as going to nursery or school. 

The Polyvagal theory approach (Porges, 1995, 2007) provides a theoretical framework in which to examine the relationship between neurophysiology and social behaviour in individuals with SM. According to the polyvagal theory, the ability to shift between behavioral states is dependent on the efficiency of the neural regulation of the autonomic nervous system to shift among physiological states. The ability to efficiently shift among physiological states is essential to human survival, enabling rapid and adaptive changes in behavior as context changes. This ability to rapidly shift physiological state would, in a risk environment, enable a rapid shift back and forth between a physiological state that would promote social communication and proximity to a state that would promote defensive mobilization behaviors such as fight and flight. It is possible, given the clinical features of SM, that individuals with SM have difficulties in reestablishing safe, calm states that would promote social communication even within relatively low-risk environments.

SM and non-directive Play therapy

In the Play therapy process, The therapist will introduced herself to the child in the classroom and in the therapeutic room the therapist explains what is going to happen and how play therapy works. The therapist will accept the silence and the child is welcomed to look at the room and choose what to do. The therapist will notice what the child is looking at, and will give a sense of permission to do what he wants to do. In this process the therapist will not put any pressure on the client to speak. If that would happen it can increase the levels of anxiety in the child. “The therapist accepts the child exactly as she or he is.” (Axline, 1993, p.86) and accepting that the child is the one who will lead the way the therapist just follows (p.119)

During Play Therapy the child can choose from many mediums, such as painting, instruments, symbols. The child can choose instruments for example, and the therapist will mirror those sounds back to the child. If the therapist hear some words or guttural noises coming from the child, the therapist will mirror his noises and sounds. It can be whispers, sighs…any sounds.

The tent can be an important aspect of the play room. Children can go inside the tent, sometimes in the beginning, sometimes in the middle and sometimes in the end. The child inside the tent can invite or not the therapist.

After several sessions the therapist can introduce gently a new sound (or new movement/ or new play ) while he/she plays with the client. By doing this will mean that the therapist will not just mirror the client sound, but also can initiate a different rhythm or instrument. In trying to do so the therapist acknowledge that playing with music was a conversation were one and the other can say different “sound-words”.

This new intervention can gently introduce and provided more playfulness in the interactions, the child can seemed surprised in the beginning when he heard a slightly different sound or play, but afterwards, it can allow the client to be more aware of the present of the therapist in the play.

Play Therapy help to lessen and relieve anxious symptoms (Lawver & Blankenship, 2008 in Fernandez and Sugay, 2016) and studies of play therapy interventions with children with anxiety show that Play therapy provides an environment where children do not feel pressure to speak and were enable them to communicate comfortably in whichever manner they choose (Hultquist, 1995, p. 204 in Fernandez and Sugay, 2016)

If the child present physical defence, such as tent, ear defenders, non-eye contact, or toys against overwhelming communicative intrusions, they are an important protective mechanism that needed to be treated respectfully. Accepting those boundaries, honouring them as  protective mechanism, notice how they can change through the therapeutic process,  are important  not only in helping the client to express and process his anxiety but also as means of making it possible for the child and therapist to grow a trusting relationship that could enable further meaningful communication and change.

How meaningful would be to observe if the child can expand the experience of the tent/blocks/barriers to the whole room? Can the therapeutic room work in the future as the tent itself? Would it be possible for the child and the therapist to build a relationship where the therapeutic space would become the safe space to make sounds or even words?

Sounds and music with SM

If the first interactions were guttural sounds and the Therapist intuitively began to mirror them. It is important to remember that pre verbal exchanges are the early patterns of interactions between infants and adults learned in infancy and it is a period were the exploration of the effects of this vocalizations helps to build confidence to take greater risks in their later expression of tone and vocal release. “Whatever sounds the child creates should be mirrored, […] This reinforces the child’s creation of her own sounds while at the same time allows room for the response, awakening the child’s awareness of the response of another human being”. (Loewy, p. 64)

If there is exploration of music and sounds with instruments,  the musical instruments were the tools that provided the language through with the emotional communication could be listened and responded accordingly.  The child and the therapist can begin to explore this way of communication until they stablished common understanding patterns of interactions.

Bion (1962) developed the concept of “containment” and transformation related to the Melanie Kelin´s original ideas of transference. He states that the mother/therapist receives the infant´s anxiety and then she transforms them in ways that the child can take in. Robarts (2015) suggests that this explanation illuminates the process of the relationship in creative therapy. “Musical aspects of containment and transformation reside in the way the child is heard, listened to, and understood as much as being musically accompanied” (p.72) Jones (2012) states that is the therapist´s responsibility to listen to the emotional communication and respond accordingly. Musical containment provides an acknowledgement of the anxiety without the therapist being overwhelmed by it. “Experiencing this sense of safe and support enables the child to move on in the therapeutic relationship”. (Jones, 2012, p. 25).

 Robarts (2015) and Jones (2012) arguments theoretically how in therapy the child was leading the process and how the therapist by mirroring and reflecting was helping in building a trusting relationship. The therapist is listening, sensing child´s feelings and brought them back to the in the sound conversation in a safe way. Therapist was saying “I am hearing you” “I am here with you”.

With instruments the therapist can invited the child to respond to a new tone or rhythm, and by making this the therapist can focused in the musical communication rather thus taking pressure off the attempts at speech. This new exchanges allowed shifting power in the relationship and the client developed confidence, control, and the child and therapist shared musical making and mutuality.

Introductions of directive approach

On a later stage, more structured or directive approach can be introduced in the process of therapy, especially if the child is ready to use writing as means of expression, or if words appear in the room. I would focus on Interoception, offering "check in" activities with colour, sounds, shapes, lines or symbols. It can also be introduced a small body map to check in how their body feels, where they feel those sensations, naming what is been offered without judgement and gently finding a word, image, shape that would represent it. This will facilitate ways to get in contact with their sensations and feelings as signals sent from their bodies. The aim would be to slowly help children to build a new relationship with their nervous system, noticing how it changes, understanding how their bodies talk, learning how to listen and how make sense of their signals.

Bibliography:

• Newman-Mercado, S. (2004). The SELECTIVE MUTISM FOUNDATION’S Influence over “Selective Mutism” in the Diagnostic and Statistical Manual of Mental Disorders (DSM). [online] Available at: https://www.selectivemutismfoundation.org/knowledge-center/articles/view-selective-mutism-in-the-dsm  [Accessed 11-03-2019].

• NHS (2016) Selective Mutism. [online] available at: https://www.nhs.uk/conditions/selective-mutism/ [accessed 10-04-2019]

• Bion, W (1962) A theory of Thinking. International Journal of PsychoAnalysis, 43, pp.306-310.

• Dieterich- Hartwell, R (2017) The Art of reaching out. American Journal of Dance Therapy. Volume 39, Issue 2, pp 179–188 [online] available at https://link.springer.com/article/10.1007%2Fs10465-017-9257-1 [accessed 10-02-2019]

• Fernandez, K & Sugay, C (2016) Psychodynamic Play Therapy: A case of Selective Mutism. International Journal of Play Therapy, Vol 25, No 4 pp2013-2019. [online] available at http://eds.b.ebscohost.com.ezproxy.leedsbeckett.ac.uk/eds/pdfviewer/pdfviewer?vid=1&sid=1abdfc11-6a03-42e8-b0de-40676642960d%40sessionmgr104

• Freud, S. (1912). The dynamics of transference. Standard Edition (Vol. 12, pp. 99–108). London: Hogarth Press.

• Loewy, J (1995) The Musical stages of speech: a developmental model of Pre verbal Sound Making. Music Therapy. Volume 13, Issue 1, 1995, Pages 47–73, [online] available at:  https://academic.oup.com/musictherapy/article/13/1/47/2757105

• Robarts, J (2015) Music Therapy with Children with Developmental Trauma Disorder. In Malchiodi & Crenshaw (ed.) Creative Arts and Play Therapy for attachment Problems. London: the Guilford Press. Pp. 67-81

• Jones, K (2012) How intense is this silence [online] available at: https://journals.sagepub.com/doi/pdf/10.1177/135945751202600204