Selective Mutism

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Selective Mutism

Postby messymind » Wed Jun 27, 2012 2:37 pm

Hello,

I'm about to start working with an adult who has been referred with 'Selective Mutism'. The person's diagnosis info is a little sketchy and I'm new to this area. I have found some info about working with children with SM but does anyone know whwere to find any info on adults? Also I would love to hear from anyone who has expereince of working in this area, even just for ideas of how to assess properly! I will continue my literature trawl! :) Thanks
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Re: Selective Mutism

Postby baa » Wed Jun 27, 2012 3:55 pm

It might be worth looking into social phobia related material, that can be helpful, particularly by formulating their view of their voice in the 'viewing self as a social object' part.

That's nice and vague, I'm on my phone, sorry!
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Re: Selective Mutism

Postby messymind » Thu Jun 28, 2012 10:42 am

Thank you! Will look that up. :D
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Re: Selective Mutism

Postby eponymous85 » Thu Jun 28, 2012 11:07 am

sorry to 'broken record' this, but of course you will also want to start with your supervisor (which of course you may have done already)
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Re: Selective Mutism

Postby Laura86 » Thu Jun 28, 2012 11:41 am

Hi Messymind,

I haven't worked with this before, and as Eponymous85 stated your supervisor would be first port of call. I am really interested in this though, and I've worked a lot with anxiety problems which I think it may be related to? If it was me, I'd probably integrate CBT and Narrative ideas - CBT for some of the practical techniques such as experiental work, and Narrative to trace the history of the problem, when it first entered the person's life, how the problem effects them and those around them and the consequences of this, and how the person affects the problem and times when the problem hasn't been around or they've overcome it and what was different then etc. It may also be worthwhile considering Mindfulness-based CBT, or some systemic work with their support network? Let us know how you get on!

Laura
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Re: Selective Mutism

Postby Ruthie » Thu Jun 28, 2012 1:07 pm

Laura86 wrote:Hi Messymind,

I haven't worked with this before, and as Eponymous85 stated your supervisor would be first port of call. I am really interested in this though, and I've worked a lot with anxiety problems which I think it may be related to? If it was me, I'd probably integrate CBT and Narrative ideas - CBT for some of the practical techniques such as experiental work, and Narrative to trace the history of the problem, when it first entered the person's life, how the problem effects them and those around them and the consequences of this, and how the person affects the problem and times when the problem hasn't been around or they've overcome it and what was different then etc. It may also be worthwhile considering Mindfulness-based CBT, or some systemic work with their support network? Let us know how you get on!

Laura


I'm going to be grouchy about this and say that as a qualified CP this is not what I would recommend because basically you've suggested to use narrative to formulate the problem and CBT to treat it (see also: how to fail a case report). It would be better to have an overarching formulation based on a sound coherent theoretical model and a treatment plan based on that.

So in CBT I may formulate how this person's life experiences have led them to hold certain beliefs about themselves (e.g. I'm not acceptable to others, people will be critical/mocking of me), leading to high levels of anxiety and to the development of compensatory strategies to avoid/reduce the threat (e.g. not speaking so as to avoid being criticised or laughed at). Then the treatment plan can be ways to test the belief that people are critical or the person is unacceptable and more importantly develop new beliefs that the person is acceptable/can cope with criticism/ that most people are not punitive/ that criticism says more about the very critical person than the person being criticised etc.

Obviously the above may or may not be part of the formulation for the particular individual Messymind is working with and it would have to be developed collaboratively with that person and under supervision from a suitably qualified person. Perhaps other people can suggest ways of working with this within other models.

This isn't meant to come across as critical - but being a CP is all about being able to make sense of problems using psychological theory and to use this understanding to inform suitable interventions. It is really important to be coherent about how you do this, especially imho with more complex cases where it is so easy to become muddled. Having a formulation and treatment plan based on one sound theoretical model is very steadying for the therapist, the client and also anyone else involved (e.g. client's family, other MDT members etc).

Hope this helps.

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Re: Selective Mutism

Postby Laura86 » Thu Jun 28, 2012 1:37 pm

Good points Ruthie, I wasn’t very clear in what I wrote and I was jumbling things together – I would integrate a narrative and CBT approach to begin with by:

Co-constructing a CBT-based formulation with the client and possibly some of the key workers (including core beliefs, schemas and rules for living etc) in order to gain a shared understanding of the problem, but assisting this process with the narrative questions I posed above (when it first entered the person's life, how the problem effects them and those around them and the consequences of this, and how the person affects the problem and times when the problem hasn't been around or they've overcome it and what was different then etc) which I have found helpful in the past as it also highlights the protective factors and informs the recommendations for points of intervention at the same time as boosting the person's confidence in creating a new narrative where they feel more competent and confident and hence feeling more able to go about experientially disproving some of the old narratives/core beliefs (I’ve done this under supervision – there’s a great book on this as well: http://www.amazon.com/Narrative-CBT-Psy ... 15475724#_ ).

This isn't meant to come across as critical - but being a CP is all about being able to make sense of problems using psychological theory and to use this understanding to inform suitable interventions. It is really important to be coherent about how you do this, especially imho with more complex cases where it is so easy to become muddled.


I completely agree and I don't take this as critical - I sometimes need reminding that whats rattling about it my head may not come out coherently in sentences lol!

Having a formulation and treatment plan based on one sound theoretical model is very steadying for the therapist, the client and also anyone else involved (e.g. client's family, other MDT members etc).


I actually find it more steadying to integrate theroies as I don't feel as constricted (as long as this is backed up by the evidence-base of course and makes sense in terms of theroy-practice links) - but this may come from having two supervisors with different ways of working (one of which often combines CBT and Narrative).

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Re: Selective Mutism

Postby sally » Fri Jun 29, 2012 4:42 pm

A brilliant resource is The Selective Mutism Resource Manual by Johnson and Wintgens - from memory it's all aimed at children but the underlying principles are well explained and should be easy to adapt to an adult setting. Useful reading to inform a discussion with a supervisor.
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Re: Selective Mutism

Postby Borrowed Cone » Fri Jun 29, 2012 10:41 pm

Laura86 wrote:
I actually find it more steadying to integrate theroies as I don't feel as constricted (as long as this is backed up by the evidence-base of course and makes sense in terms of theroy-practice links) - but this may come from having two supervisors with different ways of working (one of which often combines CBT and Narrative).


I must say Laura, that from what you have described, it just sounds like CBT. Narrative therapy includes a lot more that what you have described, such as witnessing, which is imho one of the most important aspects of narrative work. It sounds like you have fallen into the trap of assuming you are doing narrative therapy if you are getting the client to tell and re-tell stories about themselves - which is essentially what all therapy is about.

I'm sure you mean well, and perhaps I have also misunderstood; but I think you are over-complicating things by trying to describe what you would do as narrative therapy combined with CBT. As Ruthie has observed, it sounds like a sure-fire way to fail a case report.

I realise this will come across as slightly attacking, but rest assured it is nothing personal, just a critique of approaches to theory-based formulation.

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Re: Selective Mutism

Postby Laura86 » Sun Jul 01, 2012 2:42 pm

Hi Cone,

I don’t take your comments as attacking (a little patronising maybe but I’m aware you don’t know me or my level of experience to gauge your comments by so all is forgiven :wink: ) and I’m more than happy to provide a rationale behind my thinking.

I agree that what I described was not a fully integrative approach – that’s why I said “I’d begin by” – there’s obviously a lot more involved in the process of working psychologically with someone. To give an example (which hopefully covers a bit more of what I would go on to do) I’m working quite closely with a client at the moment who is affected by anxiety and depression. In brief, we co-constructed a shared formulation as outlined above – the rest of our work has also included some CBT such as thought record sheets, SMART goal setting, relapse prevention planning etc; and also narrative, for example, I wrote a narrative letter to the client after every session, and arranged a meeting after significant goals were achieved for the witnessing aspect, involving key member of the MDT and family members where appropriate, in order to thicken the preferred story for the client and to support the witnesses to see the client on a new light and keep the new narrative growing. There were also various other narrative aspects but I won’t go into too much detail due to confidentiality.

I haven’t started training yet (not until September) so I’m curious as to what is meant by failing a case report, i.e. how do you mean I would have failed? As in my brief responses on this forum I haven’t included anywhere near the detail and rationale I would include in a report (I haven’t even touched on some of the areas of assessment, formulation, intervention and evaluation).

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Re: Selective Mutism

Postby Borrowed Cone » Sun Jul 01, 2012 5:30 pm

Laura86 wrote:Hi Cone,

In brief, we co-constructed a shared formulation as outlined above – the rest of our work has also included some CBT such as thought record sheets, SMART goal setting, relapse prevention planning etc; and also narrative, for example, I wrote a narrative letter to the client after every session, and arranged a meeting after significant goals were achieved for the witnessing aspect, involving key member of the MDT and family members where appropriate, in order to thicken the preferred story for the client and to support the witnesses to see the client on a new light and keep the new narrative growing.


Sounds suspiciously like Nylund to me... :wink:
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Re: Selective Mutism

Postby Laura86 » Sun Jul 01, 2012 9:12 pm

Ooh this book looks right up my street! I've requested for my first placement to be with children & young people, I'm thinking this might come in handy - have you read it? Wondering if it's worth buying or not?

:)
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Re: Selective Mutism

Postby sally » Mon Jul 02, 2012 4:36 pm

Laura86 wrote:Ooh this book looks right up my street! I've requested for my first placement to be with children & young people, I'm thinking this might come in handy - have you read it? Wondering if it's worth buying or not?

:)

Did you mean the selective mutism book that I recommended? I've read it and used it and think it's a brilliant resource. I think there's a second edition being prepared, so it might be worth waiting for that to appear, although I'm not sure of the timescales involved.
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Re: Selective Mutism

Postby jane doe » Mon Jul 02, 2012 6:04 pm

Lindsey Hampson wrote an excellent article in Context magazine on integrating CBT and narrative therapy - I agree with Ruthie that it is important to have a coherent theoretical framework, but if one takes the view that theories, concepts and knowledges (including cognitive ones) are socially constructed rather than objective truths, then that opens up the space for possibilities in your integrative formulation. However, I wouldn't come up with a CBT-informed formulation and then use narrative/SFBT interventions - that *would* be how to fail a case report.
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Re: Selective Mutism

Postby Laura86 » Mon Jul 02, 2012 6:46 pm

jane doe wrote:However, I wouldn't come up with a CBT-informed formulation and then use narrative/SFBT interventions - that *would* be how to fail a case report.


But would it be ok to do as I have done (under supervision) and use a cbt informed formulation, and integrate cbt & narrative interventions? As I said, I don't start training until September so I may be getting this all mixed up. I haven't written a case report for the course, but I have written reports of work like I have outlined above and these have been signed off by my supervisor.

I'll have a look for that article, sounds interesting.

And thanks for the book recommendation Sally, I'll look into it.

Laura

Edit: this paper is interesting: http://www.anzjft.com/pages/articles/445.pdf
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