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Giving voice to a voiceless child – Active music therapy with a girl
who has Selective Mutism
Dorit Amir
Introduction
The main part of my presentation is focused on describing and analyzing
my work with Shiran, a 6- year-old girl who suffers from Selective
Mutism. I will start with talking about selective mutism – history,
definition, etiology, phenomenology and treatment approaches. I will
then talk about the essence of music therapy in working with a child who
suffers from SM, the role of the music-therapist and the place of
improvisation in working with SM clients.
About Selective Mutism
1. History and definition
Selective Mutism is a psychiatric disorder most commonly found in
children, characterized by a persistent failure to speak in selected settings
that continues for a reasonable period of time, usually a month or two.
It was first discovered and described by Kussmaul, (1877 in Dow, Sonies,
Scheib, Moss and Leonard, 1996) in the latter part of the 19th century.
Selective Mutism is a rare disorder that is said to affect less than 1% of
school-aged children (Dow et al, 1996). It is slightly more common in
girls than in boys. Formerly called Elective Mutism (it is still called
Elective Mutism in some areas of the world), it was changed in
recognition of the fact that a child does not choose, or elect, to be
selectively mute.
The term Selective Mutism describes the behavior of children who are
able to speak but remain silent with certain people or in certain settings. It
is most commonly noticed when a child joins a school.
According to the DSM-IV, Selective Mutism is in the miscellaneous
section under "Other disorders of childhood and adolescence". The key
indicators of selective mutism are:
 Consistent failure to speak in specific social situations where
speech is expected (e.g. school) despite speaking in other situations
(e.g. home).
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 Duration is more than a month (not limited to the first month at
school).
 The failure to speak is not due to a lack of knowledge of, or
comfort with, the spoken language in the social situation.
 The disturbance is not caused by a communications disorder (e.g.
stuttering) and does not occur exclusively during the cause of a
pervasive development disorder, autism, schizophrenia or mental
retardation.
 The disturbance must interfere with education, occupation or social
communication.
The onset is usually before age 5, although the disturbance may not come
to clinical attention until entry into school (Kolvin & Fundudis, 1981;
Sluckin, 1977; Sluzki, 1983). The disturbance usually lasts for only a few
months, but in some cases, may persist for several years.
Selective Mutism is a complicated phenomenon to understand and to treat
due to unclear cause, confusion in determining the essence of the
phenomenon and as a result, difficulty in determining the best treatment
approaches.
2. Etiology
The cause is not known and there are many speculations as to what causes
it. SM may be associated to a variety of things, and there may be different
causes for different individuals: extreme shyness or self-consciousness,
physical or sexual abuse, neglect, other types of psychological trauma,
and dysfunctional family relationships have all been proposed in the past
as possible causes of selective mutism. In a review of the literature
associated with Selective Mutism (Hesselman, 1983; Kolvin & Fundudis,
1981; Leonard & Topol, 1993), theories of causation include immigrant
family background, significant early childhood trauma, injury that affects
the mouth, and possible family secrets. Anxiety is presumed to be an
underlying feature (Lesser-Katz, 1986; Black & Uhde, 1992, 1995).
Children who have developmental language or articulation problems and
children who are quiet because of concerns about accents and limited
fluency can also suffer from Selective Mutism.
Most children with this disorder are very shy and anxious when
interacting with unfamiliar persons, or in any situation where they feel
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that they are the center of attention or are being observed or evaluated.
As they become more accustomed to and comfortable in a particular
social situation, they are more likely to talk. It seems likely that this
extreme shyness or self-consciousness (or “social anxiety” as it is referred
to by psychiatrists) is the central cause of the disorder. In fact, it seems
likely that in many cases Selective Mutism is no more than an extreme
shyness or an early childhood form of “public speaking anxiety.” Indeed,
in the literature of the last 10 years authors have been talking about
resemblance between children suffering from selective mutism and adults
suffering from social phobia (Dow et al, 1996).
Heredity has also become a possibility. Many of the children have parents
or siblings who have suffered from selective mutism or from extreme
shyness - mothers and sometimes fathers remember that they had the
same difficulties when they were young. At those years this phenomenon
wasn’t known and was generally excused as being overly shy. This
observation, as well as what we know about the hereditary basis of
extreme shyness, suggests that a vulnerability or tendency to develop the
disorder is passed on genetically, just as a tendency to develop diabetes or
heart disease may be passed on (Giddan & Ross, 1996).
3. The essence of the phenomenon
The unknown cause leads to a confusion and a disagreement concerning
the understanding of the phenomenon – is it an anxiety disorder? A social
phobia? A language or communication disorder?
There are studies that indicate that selective mutism may be a symptom of
social anxiety, rather than a distinct diagnostic syndrome. There is a wide
variation in these children’s social actions. Some children enjoy contact
with others and play easily, but remain silent. Some have a close friend
who often speaks for them by interpreting gestures. Others find all
aspects of social situations uncomfortable and do not participate at all.
There are children in the 2nd, 3rd, and 4th grades that have never spoken
in school. There are students in high school who have not uttered any or
no more than a few words in a school setting. The condition can have
dramatically negative effects on social functioning (Gallagher, 2002).
Currently, SM is seen as a condition of severe anxiety or phobia
(Anstendig, 1999).
4. Treatment approaches
As a result of the above-mentioned uncertainty, there is a big confusion as
of how to treat children with this phenomenon. Treatment strategies are
varied. An inventory of published case material (Wright, Holmes,
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Cuccaro, & Leonhardt, 1994; Dow et al, 1996) reveals that a systematic
approach to treatment has not yet been developed.
The effective treatment of selective mutism consists of steps to
address three basic problems:
 The child's high level of anxiety in social situations.
 The limited experience the child has had in speaking with people
other than family members.
 The high level of support that is present for nonverbal
communication.
Supportive or exploratory psychotherapy has not proven very successful.
Although individual psychotherapy, play therapy, psychoanalysis, and
family therapy have frequently been recommended for children with
Selective Mutism, and although these approaches may be important in
building greater confidence and a more relaxed orientation in life, there is
no evidence to date that these types of treatment are likely to be of
substantial benefit. Therefore, professionals have turned to methods
helpful in anxiety reduction and skill building. Behavioral therapy with
family Interventions; psychoeducational program and the use of
medications, alone or in combination have been described most recently
(Gallagher, 2002). Treatment with certain medications like Fluoxetine –
Prozac (Dummit, Klein, Tancer, & Asche, 1996) or Phenelzine (Golwyn
& Sevlie (1999) has been shown to be safe and very helpful for some
children. A specific type of psychotherapy known as cognitive-behavioral
therapy (or CBT) is often helpful, when provided by a therapist who has
had intensive training and experience in using this method of treatment.
The CBT therapist works with the child and her teacher and parents to
develop a plan to assist the child in very slowly increasing her
vocalization, with frequent praise and encouragement, and working at a
pace that the child is comfortable with (Anstendig, 1998; Blum, Kell,
Starr, Lender, Bradley-Klug, Osborne, & Dworick, 1998). In case of a
childhood trauma, this plan does not take care of the emotional aspects of
the child who has been experiencing trauma.
A major question is not what treatment helps these children, but if to treat
them at all. Some children seem to improve over time without any
specific treatment and simply "grow out of it". The younger the child and
the shorter the interval of time that the child has been in school without
talking, the more likely it seems to be that the child will start talking
without any treatment. However, some children may continue to have
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significant problems with extreme shyness, even after they start talking in
school.
As a result, the process of deciding when and how to treat a child with
Selective Mutism is a complex one. Multiple factors must be considered,
including: how severe is the selective mutism, and how much it interferes
with the child’s academic, [and I add emotional] and social development?
Does the child seem to be improving without treatment? What are the
relative risks and side effects of different types of treatment? How do the
parents and the child feel about treatment, including treatment with
medication? (Giddan & Ross, 1996). In any case, one has to remember
that intervention requires patience and time and that the involvement of
the parents is critical (Gallagher, 2002).
I would like to suggest that music therapy could help children who suffer
from Selective Mutism.
The essence of the music therapy in working with a child with SM
The child who suffers from SM and people in his immediate surroundings
like teachers and parents can experience high levels of frustration and
even anger when it persists. Forcing a child to speak does not help. As
suggested in the literature, approaches of intervention tend to work best
when they occur in the places where the child does not speak. However,
sometimes the child needs to be treated in a place that is outside of her
regular and familiar environment, a place where she gets full attention
and does not have to worry about not talking.
Music therapy can provide a safe environment for a child with Selective
Mutism due to its nonverbal nature. It is a place where the child does not
have to talk and can express herself via non-verbal means. Since the child
does not need to talk, she can communicate and build up the relationship
with the therapist via music. In this way (not being forced to talk) the
child feels less anxious and starts trusting the adult therapist and slowly
can open herself towards her.
The role of the therapist
The therapist’s job is to be fully there for her client and to share her
client's journey by providing musical means of expression and
communication. She has to be very gentle and careful in her interventions
in order to honor her client's pace and respect her client’s decision not to
talk. In this way the client will be able to trust the therapist and start
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building up a relationship with her. The therapist has to make some
decisions as to what clinical activities might be suggested. At the
beginning stage of therapy, for example, when the child does not talk, the
therapist should not expect or ask the child to sing or to fill up words in
songs. She can, however, suggest activities such as “music minus one”
when sounds of various instruments fill up the spaces that are being
created in the music (Levin, Levin & Safer, 1975).
Observing the child and listening to the way the child presents herself in
the room can teach the therapist something about the child’s present
emotional state and the possible cause for the disorder. Working with a
client who suffers from selective mutism, only by listening and observing
what the client does when she is involved in a musical act of some sort,
can the therapist understand the nature of her musical act and also her
relationships with herself and with others in the here and now and in the
past. Does the child sit in one place or run around? Is she active or
passive? What instruments does the child choose – small or big, metal or
wood, wind or percussion? How does she play with them (i.e. with one or
both hands? with the therapist or only alone?) Does she make an eye
contact with the therapist? In what way does she respond to the
therapist’s singing or playing? How does she use the musical elements?
(i.e. does she play loud or soft, does she change the dynamics, does she
play fast or slow, etc.); Does she use her voice – when and in what way?
What quality does her voice have? Listening to the child’s music as well
as to the therapist’s own inner world can give the therapist an
understanding of what is going on in her client's inner world (Amir,
1995).
The importance of improvisation
I see the musical improvisation that is created by client and therapist as a
musical act that serves as a vehicle to evoke emotions, ideas, images,
fantasies, memories, events and situations that are connected to the
client's intra and interpersonal relationships. When working with non
verbal children, the assumption is that the client’s problems and conflicts
are being expressed and processed musically and not verbally. Every
sound that the client produces in improvisation expresses something
about her. The improvisation mirrors who the client is, how does he
organize his external and internal worlds (Stephans, 1981). Any musical
structure that the client presents in an improvisation can serve as a mirror
of the client's psychological organization and dominant function
(Scheiby, 1991).
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In 1998 Christopher Small introduced the term “Musicking” in his book
Musicking – The Meanings of Performing and Listening (1998). Small
believes that music is an activity, something that people do. Musicking
covers all participation in a musical performance, whether it is active or
passive, sympathetic or antipathetic, constructive or destructive,
interesting or boring (Small 1998:9). There is no question in Small’s
mind that taking part in a musical act is of central importance to our
humanness.
He believes that only by understanding what people do when they are
involved in a musical act we can understand the nature and role the
musical act fulfils in human life. Small claims that understanding
musicking is part of understanding ourselves and our relationships with
other people. Through musicking we can bring into existence
relationships in our world as we experienced them in the past, and as we
wish them to be.
A musical improvisation contains aspects of emotional, psychological
and creative expression in a rich kaleidoscope that are built from intra and
inter-personal patterns and that are expressed in the “here and now”. At
the same time, musical improvisation can reach the unconscious and can
be seen as a symbol of unconscious material. We get the meaning not
only from the connections within the music itself, but also from the
connection between the music and extra-musical events.
During the second stage of therapy, when the child trusts her therapist
and is being more open, the therapist can encourage the client to go to
unconscious areas and explore them through the use of vocal and musical
improvisations. Playing, humming, vocalizing and singing existing and
improvised songs, all of these are ways of investigating the inner world of
the client, exposing unresolved issues and releasing blocked emotions.
Now I would like to describe to you my work with Shiran.
Family and historical background
Shiran is the oldest daughter in a family of parents and two children.
Bruce, her brother, is 4 years younger than her. Her father is an engineer
and her mother is a housewife. The family lives in a small house (two
bedrooms and a living room) in a small city.
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Ruth, Shiran’s mother, reported that the pregnancy and Shiran’s birth
were quite normal, and Shiran’s early development was also a normal
one, without any special problems that she can remember.
When Shiran was 3 years old she started going to a kindergarten with a
group of eight children and she adjusted quite quickly and liked going
there. When she turned 4 her brother was born and at the same time she
started going to a new kindergarten with a group of 35 kids. At this time
she had problems staying in the kindergarten. Separations in the mornings
were very difficult – the father brought her to kindergarten and she was
crying hard, didn’t want him to leave. After a while she calmed down but
remained quiet.
For the first three months Bruce, her brother, was in her parents’
bedroom, but then he was put in Shiran’s room. At nights Shiran refused
to stay in her bed and she fell asleep in her parents’ bed. After she finally
fell asleep, they carried her to her bed, but in the middle of the night she
woke up and went to her parents’ bed for the rest of the night.
When Shiran was 4 years and two months old, she stopped talking in
kindergarten. She became extremely shy, her self-confidence was low and
she cried very frequently at home and at kindergarten. She participated in
all the activities but in a passive way. The teacher reported that she feels
that Shiran is a sad girl, with no joy.
The move to elementary school was very difficult. For many weeks
Shiran refused going to school and staying there without her mother. She
knew some of the kids who were in kindergarten with her, but continued
to be mute. She talked only at home.
According to the mother, even though they love each other, the
relationship with her husband has never been good. The parents didn’t
communicate well with each other and fought quite frequently. After
Bruce’s birth, the tension between the parents got worse and they fought
more frequently. Shiran’s mutism made the tension worse.
Reasons for referral
Psychological tests suggested that Shiran has above average
intelligence and suffers from high level of anxiety. Shiran was sent to do
a psychiatric evaluation that suggested that she was suffering from SM
syndrome. Her selective mutism was seen as a condition of severe anxiety
or phobia. It was also suggested that Shiran’s syndrome is there
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unconsciously in order to direct all the attention to herself so that her
parents will solve (or forget) their problems and stay together. Both nonverbal form of therapy and family therapy were recommended.
Since one of her ways to connect with the world was listening to musical
records and videotapes, the school psychologist thought that music
therapy is the right treatment modality for her and referred her to me. She
hoped that Shiran (and her parents) would be able to make a good
connection with me and trust me. Shiran started music therapy when she
was 6 ½. At the same time, a social worker started to work with the
parents.
Description of the therapeutic process
Sessions 1-3 – initial impression and evaluation
When Shiran comes to me for the first time, I see a beautiful little girl
who is holding her mother’s dress and refuses to come with me to my
room. She stays near the entrance door, hardly moves and does not say a
word. I take the Autoharp out of my room, go to the outside door and
start strumming very gentle strums in d minor. After app. 20 minutes she
is willing to let go of her mother’s hand and very hesitantly walks with
me to my room. The door is open and the mother stays outside the room
but can be seen by Shiran, who stands by the door. I go to the far corner
of the room (it is a small room) and keep strumming the Autoharp the
same way I did before. Now Shiran sits near the door, looking at the
floor. From time to time she looks up and makes a very brief eye contact
with the Autoharp. She stays in the room 15 minutes and walks back to
her mother. That concludes our first session.
More or less the same happens during our second session. The
Autoharp becomes the instrument I use. In the third session, she sits near
the door as usual, looking at the Autoharp that I have on my knees in the
far corner of the room. While I am playing the Autoharp and vocalizing
very gently ohu and aha sounds, she crawls and sits next to me.
Something within me tells me to stop playing. After a few quiet moments,
she puts her hand on the Autoharp and strums it once. She looks at me
and smiles. I smile back to her.
A music therapy session can be a microcosm of the client’s life. The way
Shiran behaves inside and outside the room tells me about her inner
being: for a long time she doesn’t let go of her mother’s hand and stays
next to the door. The careful and slow way she moves towards my room,
the place where she finally sits next to the door and looking at the floor;
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the way she does not look or relate to anything that is in the room, all of
these give me the impression that Shiran is an extremely shy and
frightened little girl. During my playing the Autoharp I have an image of
a small bird being in a cage with her wings broken. Every time Shiran
lifts her head and looks at the Autoharp I feel as if she is trying to lift up
her wings, but fails. I believe that all of that mirrors the way she
experiences herself and her surroundings. Her way of dealing with new
and scary places and people is by shutting herself down.
My first interaction with her is created outside of the therapy room
through the Autoharp. The sounds create potential playful space that
according to Winnicott (1971) exists in the inner being and the outside of
the client’s being. I am responsible for the sounds; they reach Shiran’s
ears and hopefully reach her inner being. If the client is passive or
resistant, we can create contact through playing for the client. I welcome
Shiran to my home with playing sounds that mirror her being: very
gentle, delicate and somewhat sad sounds, created on a gentle instrument
- the Autoharp. The way Shiran is attached to her mother in this
beginning stage shows her level of anxiety while being in a new place and
meeting a new person. If I succeed to be a “good enough mother”
(Winnicott, 1971), maybe she will be able to trust me.
In the first stage Shiran limits her space to the closest way out - the
door. That shows me that she is scared and might suggest how much she
is afraid of the world. The tension in her home, her parent’s constant
fighting and the birth of her brother made her feel threatened and insecure
in her most intimate environment, an environment that fails to give her
the basic feeling of warmth and security in order to create the basic first
trust in the world. At this initial stage of the therapy process, I accept her
completely the way she is, and don’t put any pressure on her to come
closer or be more active. I give her the message that she can take as much
time as she needs in order to feel more comfortable. The sounds of the
Autoharp form the first connection between us. She looks like she is
listening to the sounds and every once in a while she makes an eye
contact with me. I am encouraged by her little smile
At this time, my goal is to make it a safe place for her and reduce her
level of anxiety. In order to make a connection between Shiran and me,
between Shiran and the music, I use the Autoharp: it is a harmonic
instrument that I can carry with me outside the room and can produce
very gentle sounds.
My assumption is that a very short time after her brother was born, she
started to feel unsafe and stopped trusting the world around her. She talks
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at home, but stop talking outside. Maybe this is her way to punish her
parents. Maybe it is her way to draw the attention to herself and become
the IP (identified patient) of the family in order to solve her parents’
problems and resolve the tension between them.
Sessions 4-25
In the next sessions Shiran starts to be more active. She notices
some of the musical instruments I have in my room and starts making
sounds. She chooses the small hand bells, little cymbals and wind chimes.
At first she plays them very carefully: she takes the hand bells, shakes
them two three times and puts them back. She takes the little cymbals,
tries to put them around her fingers on both hands and hit them softly
together. When she plays the wind chimes she uses a mallet at the
beginning and plays extremely gently, it is very hard to hear the sound.
After a few sessions, she starts using her hands when playing the wind
chimes – she moves her fingers slowly over the chimes. Later on she
plays them a little faster, louder, in a less gentle way.
The way a client plays and the choice of instruments she makes
show her way of dealing with the world around her: playing the same
way and not experimenting with dynamics and tempo can say something
about being scared (stephens, 1981). Shiran picks up small instruments
and plays them very carefully. At this stage her music making is hesitant,
soft and gentle. I am listening to her sound making, accompany her with
melodic instruments like the recorder, bells and Autoharp. The Autoharp
starts and ends our sessions. At the end of the session, we sit next to each
other and I sing the good-bye song. Occasionally Shiran joins me in
strumming the strings. I feel that we are starting to connect in a more
intimate way. From time to time she smiles at me and at the instruments.
The way the client plays in relation to the therapist shows her way
of relating to another human being. At this time Shiran leaves her familiar
place near the door and comes to sit next to me at the end of the session.
The room starts to be more familiar to her and she starts to feel safe in it.
It is manifested when she adds more instruments to her musical
experiments. Later on, she is willing to experiment with various dynamics
and bigger movements.
As her trust grows the client feels more comfortable and can be
encouraged to play together with the therapist. Playing together can be
experienced as an intimate connection, and therefore, the client needs to
be ready for it. At the very beginning Shiran only listens to me playing
the Autoharp. Then she explores the instruments by herself while I listen,
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but also strums the Autoharp that is on my lap. Later on she allows me to
come sit next to her and share her physical and musical space – I join herwe sit and play together.
Sessions 26-39
After 6 months of sessions (once a week, 45 minutes session),
Shiran feels very free in the room. She still does not talk. At this time she
discovers the bongos and starts to check them out. She is drumming very
lightly with her fingers. She starts exploring them with both hands, trying
many different ways of drumming, with and without mallets, inside and
outside, in various dynamics and tempo. The bongos turn to be the center
of the sessions. I accompany her on another set of bongos, basically
giving her a rhythmic support – playing basic beat and variations on the
basic beat. We play games of taking turns in imitating and adding
rhythmic patterns. She is leading: inventing a new rhythmic pattern on the
bongos and I follow her, and then we switch turns: I am leading and she
follows me. Sometimes we beat together for 2-3 minutes.
At this point I open the piano. The piano is the biggest instrument
in the room, and can be experienced as threatening. So far she hasn’t even
looked at it and I chose not to play it, but to play other instruments with
her. I sit next to it and improvise soft melodies, and every once in a while
she comes and sits next to me on the piano’s bench.
She discovers the slide whistle and the kazoo. She improvises with
the slide whistle in her mouth and at one point plays the whistle and the
piano at the same time.
Her confidence grows and it seems that she feels more secure. She
listens and occasionally plays some notes on the treble. From now on the
piano takes the place of the Autoharp – it is the instrument we play at the
beginning and at the end of our sessions, playing the opening and the
good-bye songs. During the session I introduce various melodic,
harmonic and dynamic elements. Shiran starts playing the whole
keyboard with one finger on the white keys only, and then plays clusters
all over the piano with each hand separately and both hands together. She
gradually starts to use the black keys also.
Sessions 40-60
In the 40th session she discovers the big drum that has always been
in the room. She starts drumming it very gently, with one finger, and
gradually puts more intensity into her drumming. In one session she starts
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drumming very quietly, and gradually her beating becomes faster and
louder. She uses both hands and looks totally involved in her drumming
that becomes very loud and aggressive. I drum together with her
simultaneously on the same drum and all of a sudden Shiran screams,
comes to me and cries. I open my arms and hug her.
This is a turning point. She lets herself loose control and all of a
sudden there is a voice – a vocal scream. I feel that in her scream and
crying she re-finds her voice - she gives voice and lets herself express and
release anger and frustration. For me it is a moment of insight and awe
(Amir, 1992, 1993, 1996).
Since this session, we are drumming together many times: we start
with basic beat, slow and soft, and gradually increase the tempo and
doing crescendo, until we come to a peak and sometimes let out vocal
sounds. As the beating go faster and faster, there is a moment of
excitation that brings release. The expression is purely musical, very
intense. We don’t talk about any of it, since her symptom is selective
mutism and she doesn’t talk with me, but I have no doubt that Shiran is
giving expression to intense feelings of anger that she has towards her
parents and her little brother. I feel that she allows herself to give
expression to her feelings of anger, frustration and pain. At the same time,
there is an inner opening - she discovers her inner strength and experience
power.
The second year
We start the second year of our work after a 6 weeks vacation with
a total regression. She refuses to come to the room and stands by the
entrance door. When she finally comes she sits next to the door exactly
like as it was at the beginning of our work. I feel terrible. I feel that by
taking such a long vacation I betrayed her trust and deserted her. I share
with her my feelings. It does not take long before she starts being more
active and plays the instruments she used to play. She starts to hum very
quietly while being busy playing instruments and it feels like she tries to
cover up her voice by making noise. I accompany her humming on the
Autoharp, which turns again to be an integral part of our sessions like at
the beginning of the process. Shiran starts improvising vocally. At one
point she improvises a song about “a mom and her baby” and we can hear
how much tension and anger there is in her tone of voice.
Singing becomes a dominant activity. She improvises freely and
sings parts of familiar children songs. I don’t make any verbal comment
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but acknowledge it through my accompaniment. Later in the year she
starts talking sporadically and then in full, regular manner. She tells
stories and sings songs. We continue to work mostly musically. I talk
more freely, making verbal suggestions and comments, and she talks
freely by making up stories. We improvise, invent songs on specific
themes and create musical accompaniments to her stories. Later on she
starts talking and expressing herself in a more free and spontaneous
manner through the use of music and words.
The work on the piano continues. It turns out to be the main
instrument we use. My harmonies encourage Shiran to express feelings
that were denied and are difficult for her to contain. We work on
opposites such as fast and slow, loud and soft, long and short. I am strong
- I am week; I am scared, I am secure, I am mad, I am sad, I am close, I
am distanced. Shiran expresses these feelings in her music, and gives
them expression in her stories. We integrate the polarities through
improvisations and musical games. The work on polarities in music
therapy gives possibility for greater inner freedom and openness to the
experience in its fullest. From being frozen and resistant Shiran moves to
being more creative and takes initiative, leadership and responsibility.
She feels stronger and discovers her creative abilities. She initiates more
and needs less support. She takes responsibility on the therapeutic process
and enlarges her repertoire of behaviors and experiences.
The therapeutic process continues for two years. Shiran starts to
feel more confident in the world. She tries out new things and experiences
successes. Her playing becomes more assertive, with louder dynamics
and clearer organization. She starts talking outside as well. There are
moments of regression when Shiran wants to be a baby again. At times
she lies on the floor in a fetus position, does not talk and only listens to
my playing. At other times she is painting on the floor while I play the
piano and hum.
The teacher tells me that she sees a very big change in Shiran. She
feels that Shiran is more focused on her studies. She also participates
more in social games with other children and forms friendships with a
few of her classmates. She starts talking more but not with everyone. She
appears to be more playful and less tense.
It is important to state that the parents have been in couple-family
therapy, and improved their relationship. It certainly played an important
role in Shiran’s growth. Without the parents taking responsibility on their
15
issues and working them through it would have been very difficult to
achieve what we achieved in music therapy.
Summary
Shiran, selectively mute, came to me when she was 6 ½. I think
that Shiran, being a sensitive and extremely shy child, suffered from SE
due to a psychological trauma that she experienced when her brother was
born, and due to tense family relationships. It might very well be that she
got mute in order to unconsciously punish her parents and at the same
time to draw the attention to herself and to act as the IP (Identified
Patient) in her family. SM in Shiran’s case was also a symptom of social
anxiety that Shiran suffered from due to the above causes.
The music therapy room provided a safe place for Shiran. The musical
instruments functioned as Shiran’s voice and gave her various messages
loud and clear. At the beginning the message was: “I am a little girl who
is frightened and is not ready to deal with the threatening world both
outside and inside me. I am not sure I can trust anybody.” As the
therapeutic process continued, Shiran’s started to use the instruments in a
different way. By choosing bigger instruments and playing them louder
her message was: “I am gaining more confidence and allow myself to feel
more secure in the world”. Later on, when she gained more trust in me
and felt freer and more secure in the room, she used the instruments in
order to deal with the trauma - to process unresolved issues and conflicts
and to release blocked emotions concerning her parents and the birth of
her brother.
We can say that Shiran’s use of the music mirrored both physical and
mainly emotional developmental steps and strengthened her true self.
At first she chose small instruments (that she didn’t have to put in her
mouth) in order to produce small, gentle sounds. Later, she chose wind
instrument and used them, but still did not talk. The possibility and the
permission to “talk without talking” paved the way to humming,
vocalizing, singing and finally talking. She found her voice.
Bibliography
American Psychiatric Association. (1994). Diagnostic and statistical
manual of mental disorders (4th ed.). Washington, DC: Author.
Amir, D. (1992). Awakening and Expanding the Self: Meaningful
Moments in the Music Therapy Process as Experienced and Described
16
by Music Therapists and Music Therapy Clients. New York University
Doctoral Dissertation, UMI Order Number: 9237730
Amir, D. (1993). Moments of Insight in the Music Therapy Experience.
Music Therapy 12(1). 85-100.
Amir, D. (1995). On Sound, Music, Listening, and Music Therapy. In
Carolyn B. Kenny (Ed.) Listening, Playing, Creating: Essays on the
Power of Sound. NY: SUNY Press. pp 51-57.
Amir, D. (1996). Experiencing Music Therapy: Meaningful Moments in
the Music Therapy Process. In Mechtild Langenberg, Kenneth Aigen,
Jorg Fromer, (eds.) Qualitative Music Therapy Research, Beginning
Dialogues. Gilsum, NH: Barcelona Publishers. pp 109-130.
Anstendig, K. D. (1999) Is selective mutism an anxiety disorder?
Journal of Anxiety Disorders, 13, 417-434.
Anstendig, K. D. (1998) Selective mutism: A review of the treatment
literature by modality from 1980-1996. Psychotherapy, 35, 381-391.
Black, B. & Uhde, T. W. (1992). Elective mutism as a variant of social
phobia. J Am Acad Child Adolesc Psychiatry, 31(6). 1090-1094
Black B., & Uhde T.W.(1995). Psychiatric characteristics of children
with selective mutism: A pilot study. J Am Acad Child Adolesc
Psychiatry, 34(7). 847-856
Blum, NJ, Kell, RS, Starr, HL, Lender, WL, Bradley-Klug, KL,
Osborne, ML, & Dworick, PW )1998( Case study: Audio feedforward
treatment of selective mutism. Journal of the American Academy of
Child and Adolescent Psychiatry, 37, 40-43.
Dow, S. P., Sonies, B.C., Scheib, D., Moss, C. & Leonard, L. H. (1996).
Practical Guidelines for the Assessment and Treatment of Selective
Mutism. Annual Progress in Child Psychiatry and Child Development,
452-472.
Dummit, ES, Klein, RG, Tancer, N, Asche, B, et al. (1997) Systematic
assessment of 50 children with selective mutism. Journal of the American
Academy of Child and Adolescent Psychiatry, 36, 653-660.
17
Dummit, E. S, Klein, R. G, Tancer, N. K. & Asche, B. (1996) Fluxoetine
treatment of children with selective mutism: An open trial. Journal of the
American Academy of Child and Adolescent Psychiatry, 35, 615-621.
Gallagher, R. About Selective Mutism. Profiles of silence
http://www.aboutourkids.org/articles/about_mutism.html
Giddan, Jane J. & Ross, Gloria J. (1996). Selective Mutism in Elementary
School: Multidisciplinary Interventions. Toledo, Ohio: National College
of Ohio, Toledo
Golwyn, D.H & Sevlie, C. (1999) Phenelzine treatment of selective
mutism in four prepubertal children. Journal of Child and Adolescent
Psychopharmacology, 9, 109-113.
Hesselman, S. (1983). Elective mutism in children 1977-1981. A literary
summary. Acta Paedopsychiatrica, 49, 297-310.
Kolvin, I., & Fundudis, T. (1981). Elective mute children: Psychological
development and background factors. Journal of Child Psychology and
Psychiatry, 22, 219-232.
Leonard, H. L., & Topol, D. A. (1993). Elective mutism. In H. L.
Leonard (Ed.). Child and adolescent psychiatric clinics of North America.
Anriery disorders. Philadelphia, PA: Saunders. pp. 695-708
Lesser-Katz, M. (1986). Stranger reaction and elective mutism in young
children. American Journal of Orthopsychiatry, 56, 458-469.
Levin, H. D.; Levin, G. M.; & Safer, N. D. (1975). Learning Through
Music. Boston, MA: Teaching Resources Corporation.
Scheiby, B. (1991). Mia’s Fourteenth - The Symphony of Fate:
Psychodynamic Improvisation Therapy with a Music Therapy Student in
Training. In Ken Bruscia (ed.). Case Studies in Music Therapy.
Phoenixville, PA: Barcelona Publishers. pp 271-290.
Sluckin, S. (1977). Children who do not talk at school. Child: Care,
Health and Development, 3, 69-79.
Sluzki, C. F. (1983). The sounds of silence: Two cases of elective mutism
in bilingual families. Family Therapy Collections, 6, 68-77.
18
Small, C. (1998). Musicking – The Meanings of Performing and
Listening. Hanover NH: Wesleyan University Press.
Stephens, G. (1981). Adele: A Study in Silence. Music Therapy 1(1),
25-32.
Winnicott, D. (1971). Playing and Reality. London and NY: Routledge.
Wright, H. H., Holmes, G. R., Cuccaro, M. L., & Leonhardt, T.V. (1994).
A guided bibliography of the selective mutism (elective mutism)
literature. Psychological Reports, 74, 995-1007.
Special needs of children with elective mutism
(www.essexcc.gov.uk/Educat/Parents/SpecialEdNeeds/ElectiveMutism.asp)