Selective Mutism (Psychology Revivals)

Implications for Research and Treatment

Thomas R. Kratochwill

• Publisher: Psychology Press
• Year: 2015
• ISBN:
  9781317532705
• Edition: 1
• Topic: Psicologia
• Subtopic: Storia e teoria della psicologia

Originally published in 1981, this title was designed to present a comprehensive review of research on, and treatment of selective mutism. It represents the only systematic overview of research and treatment procedures on this behavioral problem at the time. In many respects the literature on selective mutism clearly presents the differences in assessment and treatment between the intrapsychic (or psychodynamic) and behavioral approaches to deviant behaviour. The title presents an overview of the two major therapeutic approaches of human behaviour within the context of treating selective mutism.

1 Selective Mutism: Issues in Diagnosis and Classification

Anyone who has been engaged in treating children's behavior disorders will appreciate the diversity of influences that are related to maladaptive functioning. Deviant behavior during childhood represents a composite of environmental, genetic, and social-cultural influences. With such potential diverse influences, it is no wonder that there are literally thousands of books dealing with different aspects and perspectives on normal and abnormal functioning in children. Certain theoretical and philosophical perspectives on human functioning largely determine specific definitions of deviant behavior, as well as normative standards, and ultimately influence how such problems are treated.

Presented in this book is an examination of different approaches to the research and treatment of children commonly labeled "electively" or "selectively" mute. Salient characteristics of this population of children and the active processes in treatment and research that result in labeling them as deviant are discussed, as well as methods for improving this process. Methods of treatment and research are discussed from two different approaches that reflect the predominant orientations of published studies involved with treating childhood selective mutism. These approaches include the intrapsychic, or psychodynamic, and behavior modification, or behavior therapy, models of human functioning. Because the intrapsychic and behavioral models represent different conceptual and methodological approaches to deviant behavior, both approaches present sometimes diverse assessment and treatment strategies.

In this volume, the term behavior modification and behavior therapy are used synonymously. Although some writers have attempted to distinguish the terms, contemporary arguments suggest that there has been no consistent usage, and generally there is little to be gained by making distinctions (see Kazdin & Wilson, 1978; Wilson, 1978). My approach in the present volume is primarily behavioral in that recommendations for future treatment and research are based on behavioral procedures. Some of the characteristics of the behavioral approach toward assessment and treatment are detailed in Chapter 3. The interested reader should also consult several primary sources for an extensive overview of behavior modification (e.g., Bandura, 1969; Kazdin, 1975, 1978a; Kazdin & Wilson, 1978; O'Leary & Wilson, 1975; Ross, 1974; Sulzer-Azaroff & Mayer, 1977).

Before embarking on an overview of the intrapsychic and behavioral appraoches to treatment and research on selective mutism, some issues relevant to diagnosis and classification are presented. Of necessity, this involves a brief overview of some of the major issues raised in diagnosis and classification of behavior disorders. The present discussion is not intended to be comprehensive, for this would involve a major work in its own right. Indeed, there have recently been major texts devoted to the topic of psychiatric diagnosis (Rakoff, Stancer, & Kedward, 1977; Spitzer & Klein, 1978), and chapters and journal articles have proliferated. The interested reader is referred to these sources as well as to several major publications that provide a detailed discussion of this area (Adams, Doster, & Calhoun, 1977; Begelman, 1976;Cromwell, Blashfield, & Strauss, 1975; Phillips, Draguns, & Bartlett, 1975; Quay, 1979; Ullmann & Krasner, 1969).

Diagnosis and Classification

Throughout the history of psychology and psychiatry, individuals have endeavored to differentiate various types of behavior disorders and to describe their unique features. An important step in the study of behavior, and particularly deviant behavior such as mutism, involves grouping observations into an organized scheme. Classification has provided a process of identification of phenomena, so that events may be measured and communicated among professionals. In medicine, the search for disease entities proved valuable because advances made in diagnosis were related directly to treatment and specific understanding of etiology. Unfortunately, at this time, psychology and psychiatry have failed to provide a comprehensive system of classification that unifies and transcends specialty areas (cf. Adams et al., 1977).

Over the past 100 years, various mental health professionals have been engaged in description, treatment, and research on a child behavior disorder that is characterized in its behavioral manifestations by a lack of functional speech in all but a few select situations and/or with certain individuals. Both intrapsychic and behavioral researchers have tended to label the problem in similar ways. That is, both groups have tended to use a common term to describe this problem. This might be regarded as a major problem for the behavioral approach, which typically has not held labels and traditional diagnosis in high regard. For example, Phillips et al (1975) were critical of the behavior modification approach for using conventional classification schemes. They suggest that behavior modification has not yet succeeded in completely eschewing classifying entities. They further point to the fact that some behavior modification texts (e.g.,Ullmann& Krasner, 1969; Yates, 1970) still divide the subject matter into chapters corresponding to traditional diagnostic units. It might be added that this is true of many recent texts examining various aspects of behavioral treatment and assessments (e.g., Hersen & Bellack, 1976; Kazdin & Wilson, 1978). Of course, the focus of this book is on a deviant behavior that has been labeled "elective" or "selective mutism," and so such a criticism might apply here as well.

However, the argument against behavior therapists for their use of conventional classification schemes is not substantive. Defining a particular behavior disorder is a hazardous task, particularly when one considers the field of abnormal psychology and the problems that have accompanied diagnosis. Indeed, the very task of defining is complex and multifaceted. Begelman (1976) suggested that there are at least 11 distinguishable activities in the clinical literature that have been identified as defining: namely, categorizing, stipulating, substituting, abstracting, disturbing, operationalizing, verifying, mapping, theorizing, judging, and pointing.

In the case of mutism, stipulatory definitions have been a common form of defining this problem used by behavioral researchers. Stipulatory definitions involve a speech convention. Thus, with regard to the problem of mutism,

TABLE 1.1
The Various Terms Used to Describe Children Who Speak Only in Select Settings and/or Only to Certain Individuals

Label		Author(s)
1.	Elective mutism	Elson, Pearson, Jones, & Schumacher, 1965; Wulbert, Nyman, Snow, & Owen, 1973
2.	Functional mutism	Amman, 1958
3.	Reluctant speech	Williamson, Sewell, Sanders, Haney, & White, 1977b
4.	Selective mutism	Kass, Gillman, Mattis, Klugman, & Jacobson, 1967; Kratochwill, Brody, & Piersel, 1979; Piersel & Kratochwill, in press
5.	Speech avoidance	Lerea & Ward, 1965
6.	Speech inhibition	Treuper, 1897
7.	Speech phobia	Mora, Devault, & Schopler, 1962
8.	Speech shyness	Nadoleczng, 1926; Rothe, 1928; Spieler, 1941
9.	Suppressed speech	Sanok & Striefel, 1979
10.	Thymogenic mutism	Watemik & Vedder, 1936
11.	Voluntary mutism	Kussmaul, 1885
12.	Hearing mute	Adams, 1970
13.	Temporary mutism	Kanner, 1975
14.	Negatism	Bakwin & Bakwin, 1972; Rigby, 1929

various writers have established, through convention, that the term elective or selective mutism will be used as the name (label) for a particular pattern of behavior. Of course, one problem with this approach is that different researchers have used quite different labels to refer to the same or similar behavioral patterns. Whereas Tramer (1934) is commonly credited with lauching the term elective mutism in the clinical literature, the German physician Kussmal described "voluntary" mutism in association with insanity as early as 1877 (cf. Von Misch, 1952). But these are only a few of the terms that have been used to describe a pattern of behavior in which a child does not speak in certain situations and/or to certain people. Table 1.1 shows the various labels that have been used to describe this behavior pattern. Nevertheless, the vast majority of these terms deviate little from Tramer's (1934) original portrayal, in which the behavioral manifestation was exhibiting abnormally silent behavior outside all but a small group of intimate relatives or peers.

The point is that both behavioral and intrapsychic writers have used similar terms, but the approach toward assessment, diagnosis, and treatment differ markedly between the two. This is best reflected in a brief overview of the two contrasting approaches to diagnosis of deviant behavior in general.

Traditional Diagnosis

A traditional view of mental disorder has been conceptualized within medical concepts of the nature of illness. Within this framework, the individual exhibiting disturbed or deviant behavior is considered sick and is suffering from an illness that prevents normal adjustment to society (Phillips et al., 1975). The medical model has expanded in recent years (Spitzer & Klein, 1978). One of the major problems with past attempts to classify deviant behavior is that a disease model from medicine has been applied to behavior. The application of a disease model (either in its literal or metaphorical sense) to abnormal psychological behavior has led to attempts to identify specific disease entities or processes. In the case of its literal application, seven or more decades of biological, biomedical, and genetic research have isolated remarkably few physical bases for recognized forms of psychopathology (Phillips et al., 1975). Of course, the application of the medical model to physical disease remains one of the most remarkable features of contemporary science.

When used in its metaphorical sense (as in psychoanalysis, where symptoms are considered an expression of a clash among incompatible processes within the personality that can be traced to early childhood experiences), it has not fared well either. Present-day diagnostic schemes can be traced to the German psychiatrist Emil Kraepelin (1856-1926), who developed a diagnostic system that exerted a major influence on psychiatry (cf. Kazdin, 1978a). The major features of Kraepelin's system and his basic approach toward mental deviance have been largely retained. The past, current, and future editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I, DSM-II, and DSM-III [see American Psychiatric Association, 1968, for DSM II] demonstrate their Kraepelinian heritage, as do many textbooks in abnormal psychology (e.g., Cole, 1970; Coleman & Broen, 1972; London & Rosenhan, 1969; Suinn, 1970; Ullmann& Krasner,1969) and psychiatry (e.g., Arieti, 1959; Freedman & Kaplan, 1967; Mayer-Gross, Slater, & Roth, 1969). Spitzer and Endicott (1978) make the cogent point that classifications of mental and other medical disorders have existed for decades despite the lack of any agreed-on definition of what constitutes a medical disorder in the first place. Even official classification schemes of the. World Health Organization (The International Classification of Diseases) and the American Psychiatric Association (the first and second editions of DSM) made no attempt to address the issue.¹ Although a dissatisfaction with DSM-II has led to the development of DSM-III, the new DSM reflects a close affiliation with the medical model and has retained many of the problems of DSM-II (cf. Schacht & Nathan, 1977).

What is involved in the new American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (third edition), or DSM-III? The DSM-III is undergoing field trials and by the end of 1981 will likely be in general use.² Generally, DSM-III provides for the diagnosis of mental, medical, and psychosocial conditions presented by clients within several diagnostic "axes." A number of recent works have reviewed various issues in the conception and use of DSM-III (cf. McReynolds, 1978; Quay, 1972; Schacht & Nathan, 1977; Spitzer, Sheehy, & Endicott, 1977; Spitzer & Williams, 1980; Zubin, 1978). The DSM-III adheres to a multiaxial diagnostic system in which five axes will be referenced in diagnosis of an individual—namely: (1) clinical psychiatric syndromes and other conditions; (2) personality disorders (adults) and specific developmental disorders (children and adolescents); (3) nonmental medical disorders; (4) severity of psychosocial stresses; and (5) highest level of adaptive functioning in the past year (McLemore & Benjamin, 1979). In the area of mental disorders (axes I and II), there are over 230 separate categories of disturbance, representing a 60% increase in the total number of psychiatric disorders contained in DSM-II and a 280% increase over DSM-I (McReynolds, 1978).

Like its predecessors, DSM-III adheres to a categorical, disease-entity conception of behavioral disturbance. Spitzer et al. (1977) defend this position:

The justification for using a categorical approach in DSM-III which treats psychiatric conditions as separate entities connotating entity status if not denoting it lies in the practical utility of such topology for communication, treatment, and research, despite theoretical limitations. Furthermore, the history of medicine attests to the value of categorical subdivision in the discovery of specific etiology and treatment [p. 6].

Thus, we have a new DSM that is based on the medical model and that describes many new instances of "psychiatric" disturbance.

Over the past few years, a considerable amount of debate has occurred in the area of diagnosis and the use of traditional classification schemes, especially DSM-I and II. Begelman (1976, pp. 23-24) summarized nine somewhat overlapping criticisms of the DSM system. One has been added to his list (see 10). Generally, the problems can be summarized from several perspectives (cf. Adams et al., 1977; Begelman, 1976; Hersen, 1976; Marholin & Bijou, 1978; McLemore & Benjamin, 1979; Phillips & Draguns, 1971; Rhodes & Paul, 1978; Spitzer & Klein, 1978; Spitzer & Wilson, 1975): (1) excessive reliance on the medical model of abnormal behavior (e.g., Adams, 1964; Albee, 1968; Begelman, 1971; McReynolds, 1978; Szasz, 1960;UUmann& Krasner, 1969); (2) facilitating the stigmatization of individuals (e.g., Farina & Ring, 1965; Goffman, 1973; Laing, 1967; Millon & Millon, 1974; Rosenthal & Jacobsen, 1968; Sarbin & Mancuso, 1970; Scheff, 1973; Stuart, 1970); (3) employing debatable theoretical notions (e.g., Cautela & Upper, 1973; Panzetta, 1974); (4) poor or low reliability a...