I feel the case I have choosen, of Zak, a four-year-old boy, is representative of my ability to apply psychotherapeutic techniques both with the identified patient and with families: history-taking, knowledge of and training in interviewing, assessment, prognosis, and treatment of psychological dysfunctions. I also demonstrated my understanding of a multi-axial diagnosis, meeting the criteria of an elective mutism disorder (DSM III, 313.23). These axes are:
|4||psycho-social stresses (mother’s constant anxiety about Zak)|
Based on information from Zak’s pediatrician and nursery school teaches, we ruled out organic speech and hearing disorders as the causes of Zak’s elective mutism. We also found he had normal fine and gross motor skills. Finally, Zak displayed no severe intrapsychic pathology, as he did not demonstrate any unusual fears or abnormal anxiety, and he was appropriately oriented to time and space.
Instead, our assessment of Zak’s problem centered on two major perpetuating issues: 1) The family system. The mother anticipated Zak’s every need and spoke for him most of the time. The father lacked involvement with Zak, and deferred to his wife in decisions about the child; and 2) The school made very few demands on Zak to speak.
In my clinical experience, the prognosis is very good for disorders primarily perpetuated by the adult’s behavior, as this one was. Most often, you see excellent results when you change the social system in which the child is involved, which in this case was the family, extended relatives, and school system. Also, as you help a child feel more autonomous and appropriately powerful, his self-esteem increases and the need to gain control by withholding speech decreases. The treatment approach in this type of case is both behavioral and system-oriented.
This is the case of Zak, age four, a caucasian boy, his mother, Jane, age 27, and his father, Bob, age 35. They were referred to the clinic because Zak had been in a pre-school for one year, and had refused to talk to anyone during that period of time. When his mother would pick him up at school, he would say, in a very low voice, “Hi.” This was the only word the school ever heard Zak say during his enrollment. The school had tried many ways of getting Zak to speak, but had been unsuccessful. Both the mother and father reported that Zak speaks to them at home very openly. However, they indicated he will not speak to relatives or to new people he meets. The mother presented herself as an anxious, worried woman who was overly close to Zak, and who had difficulty separating from him. The father had a limited and passive role in the raising of Zak. Zak was diagnosed as having an elective mutism disorder by the Julia Ann Singer Center. DSM III describes this disorder as having the following characteristics:
- refusal to talk in all situations outside of the immediate family, including school
- has the ability to use and comprehend speech and language
- has no physical disorder
I will describe three excerpts that were part of the nine month treatment in changing the family pattern that were perpetuating this disorder. The clinical characteristics that I will demonstrate in my learning are:
- Family therapy techniques
- behavior techniques
- clinical process
- clinical self-awareness
- counter transference
Prior to the first excerpt, we had five sessions during which we established a relationship with this family, helping the family become more trusting of the therapeutic team. Up to this point we had not confronted the problem of the mother’s separation issue with Zak, or the father’s passive role in the family.
The mother continued to explain all of Zak’s non-verbal behavior. I asked her if she noticed that she seemed to anticipate every look and gesture her son made and then explain it to us. The mother said, “That’s because Zak won’t say anything.” Dr. Fleming said in a light but firm way, “Boy, it would be nice to have someone like you around.” Turning to the child, he said, “You’re not ever going to need to talk if mom keeps talking for you.” Zak looked at his mother with a surprized reaction.
I told Zak that we were going to make a new rule in these sessions: from that point on, mom could not answer for him. He looked at his mother in a mildly upset manner. I said to him, “You don’t look as if you like my rule.” The mother also appeared a little uncomfortable at what I was requesting of her. I said to the mother in a firm and empathetic way, “I can see this is hard on you, but Zak needs to find out he is a big boy and does not need help from his mom all of the time.”
I started feeling irritated with the mother’s continuing interpretations of Zak’s non-verbal behavior, even though I did not show in my tone or attitude I was feeling this way. These feelings made me examine my counter-transference feelings. I realized my mother always explained everyone’s behavior, and was excessive in dominating conversations. In some ways this mother reminded me of my mother. I also recognised another part of this irritation centered with the father because of my feelings with his lack of assertiveness with the family. I think I always had wanted my father to be more assertive with my mother, because I felt unprotected by my father. If I had allowed these feelings to get in the way, I either could have been inappropriate in my response to the mother, or tried to compete with the mother to protect the child.
I showed my clinical self-awareness with my observation of Dr. Fleming’s paradoxical strategy with the mother.
I demonstrated my ability to confront this mother in a supportive and empathetic manner in pointing out to her that Zak needed to grow up, and did not need her help all the time. This also demonstrated my clinical self-awareness of the separation issue. Zak was going to have to separate before he could form his own identity within — yet apart from — the family.
By confronting the mother about not talking for Zak, I demonstrated my awareness of the importance of the separation issue between Zak and his mother.
In this excerpt I will demonstrate how we began to alter the family systems, affect the separation issue, and encourage the father to develop a more active role with his child.
Zak came into the session and sat next to his mother as he had in previous sessions. The father sat in the chair opposite Zak and his wife. I asked, “Where does Zak sit at the dinner table?” Mom said, “Always next to me.” I said, “Dad, I think you should ask Zak to sit next to you.” I asked the mom how she felt about that and she said she thought it was a good idea. I said to Zak, “I think it would be a good idea now to practice sitting next to your dad.” Zak had a scowl on his face. I said to him, “You look like you don’t like this idea, but mommy and daddy are going to make the rules and you will learn how to follow them and have fun with dad, too.” I asked the dad to tell Zak that he wanted his son to come over and sit next to him, and I asked the mother to encourage Zak to do so. Zak refused to move. I told the dad to get up and get Zak and walk him over to the chair.
Zak seemed a little sad being separated from his mother. I asked the mother how she felt, and she said it was hard to watch Zak look unhappy. I turned to Zak and said, “Mommy’s got to learn not to worry, even if you get a little upset, because you’re going to be okay, and you can be just as happy with your daddy.” The dad said that he was pleased that Zak was sitting next to him, and that he had expected it to be more of a struggle.
In this excerpt, I was able to demonstrate my use of a combination of behavioral strategy and family strategy techniques to begin to re-align the family system. These techniques helped Zak separate from his mother, and begin to feel safe enough to develop an alliance with his father. At the same time, we began to form an alliance between the mother and the father. Then when I cued the mother to reinforce the father, Zak began to see his father’s importance as part of the family. This was the beginning of enhancing the father/son alliance. We made use of negative feedback to restore the equilibrium in the family by seating Zak next to his father. I also used clinical process when I supported the mother’s feelings, while still being firm in giving her the message of how she needed to separate from the child.
I had previously talked to the parents, so when they came into the session they were prepared to explain some new rules to Zak about his refusal to talk to Dr. Fleming and myself. They then told Zak that neither of them would get him a game or play with him unless he used words, and that he would sit away from both of his parents until he verbalized what he wanted. If he did not say what he wanted within ten minutes, he would have to go sit in the corner facing the wall, and he would stay there until he spoke. Zak looked very surprised. He sat in the chair and refused to talk. You could see at this time he was visibly upset, and he kept looking to his mother for cueing. By this time his mother had been taught to turn away. After ten minutes, the father said, “I guess we’ll have to put Zak in the corner.” Zak still refused to talk, so the father led him to the chair.
Zak sat in the corner for about thirty minutes, during which time we played one of his favorite games. The strategy was to make him feel that, by not talking, he was losing something else that was very important to him. Zak was starting to cry, but he finally whispered that he wanted to get up. The parents turned to him and were very happy. I said to him empathetically, “I always knew you could talk in front of people. And I think mom and dad now know that you can learn to talk more and more when other people are around. I’m very proud of you; I know how hard that was.” I turned to the parents, “I think Zak needs some homework.” The parents turned to Zak and said, “We’re very proud of you, but from now on you are going to learn to use words a little at a time, and if you don’t there will be rules and consequences like you had today in this session. But we really know you can do it.”
This excerpt demonstrated how I was able to educate these parents in communicating in a different way, making their expectations clear with their child using behavioral strategies, family alliances, and establishing expectations for him. Seating Zak in the corner was an example of a strategic intervention that I used to change his behavior pattern. I also demonstrated my ability to help Zak confront his omnipotent behavior and learn to listen to the expectations of his parents and talk in front of people other than his family.
In these excerpts, I helped this couple see that this was a family problem, by showing them how they perpetuated their son’s refusal to talk. First, I helped the mother see her part in sabotaging her husband’s relationship with their son. Second, I was able to help the mother see that the boundaries with her son were inappropriate in that she was enmeshed with his feelings.
I used a combination of behavioral and family strategies to help change the child’s symptomatic behavior. By facing the child toward the wall, I prevented the child from having any visual contact with his mother, because even visually she could cue the child that she was worried about him and felt badly for him.
The therapeutic team’s major alliance was with the father, because the imbalance in the family system was the child’s overattachment with the mother.
Dr. Fleming’s point about Zak not having to talk while his mom was available was an example of a paradoxical technique we used to help Zak’s mother see the irony of her behavior.
I used clinical process and a paradoxical sense to help the mother and father see the irony in their behavior. Other clinical processes that were used with this family were support and empathy (to establish rapport with them).
In spite of the demands I was making, I was able to relate to this child in an effective manner, without hurting the therapeutic relationship, by being very supportive and accepting of him while he was struggling at giving up control of his words.
The clinical characteristics demonstrated in these excerpts were family therapy techniques, behavioral techniques, counter-transference, and clinical process.
I would like to comment on our use of the network approach in this case. In this type of problem, using a network approach is critical to gain improvements of this disorder. It takes into consideration all of the major systems that are part of the child’s life; the family system, the extended family system (including relatives), and the pre-school system. The network approach uses a psychotherapeutic intervention that focusses on changing the social environment of the individual family or larger group in distress. The social network mediates between the individual or family and society interaction with this complex reticulum of ties contributing to the development of one’s sense of psychological self (Wellman, 1980).
In this case, with Dr. Fleming’s consultation, I visited the pre-school, and consulted with them to reinforce the behavioral strategies we were teaching the parents. These strategies included:
- Zak was not allowed to play with his favorite activities unless he verbally requested them.
- Zak was also not allowed to be just around the adults in school.
- We increased the number of times Zak could not play with his favorite activities if he would not use speech.
- We helped the teachers see how they were perpetuating the problem by talking for Zak.
After three months of these interventions, Zak slowly began to use words in front of the staff. We also invited all significant relatives to come in to a session and we strategized how they should relate to Zak from that point on. The use of this approach, in my opinion, expands my understanding of how one must intervene in certain types of psychological dysfunctions. I found it extremely helpful to use the network approach to solve a problem of this nature.