Abstract
Selective mutism is a childhood disorder involving a lack of speech in certain situations often due to traumatic or embarrassing social encounters (Viana et al., 2009). Treating selective mutism primarily entails exposure therapy and behavioral experiments, which capitalize on encouraging the clients to speak in feared social situations as a way to reduce anxiety (Catchpole et al., 2019; Furr et al., 2020; Valaparla et al., 2018). Given the social nature of selective mutism, its treatment must involve a social psychiatric perspective, which highlights the social precipitants of mental disorders, the social effects of mental disorders, and the social approach to prevention and treatment (Krupinski, 1992). However, the restrictions brought about by the COVID-19 pandemic have resulted in limited opportunities for socialization and posed several challenges in treating clients with selective mutism. Deriving from practice and evidence, I outline insights and recommendations for clinicians working with children and adolescents with selective mutism during the pandemic, with practical applications of the social psychiatric perspective.
Contextualized strategies during COVID-19
Many clinicians utilize new and adaptive ways of conducting therapy sessions (e.g. video conferencing) amid the pandemic. As the COVID-19 pandemic is causing restrictions in mobility and face-to-face interactions, creative approaches based on social psychiatric perspectives during virtual therapy sessions are available to clinicians working with selective mutism cases. During online therapy sessions, for instance, asking a client to present or talk about their interests (live or recorded) can be a helpful “warm-up” social strategy. Once rapport is established, clinicians must identify the social situations where the client selects to mute and rank the situations based on associated anxiety or fear. This should serve as a guide in the incremental progression (i.e., from least anxiety-provoking to most anxiety-provoking situations) of exposure and behavioral techniques. Moreover, bringing in another clinician in the virtual session to practice exposure through speaking and social interaction can be beneficial.
As parents and other family members serve as the primary (or sometimes the only) socialization agents of children, especially during the pandemic, treating selective mutism requires active collaboration between the clinicians, parents, and family members (Catchpole et al., 2019). Such collaboration includes determining manageable and attainable treatment goals in collaboration with parents. Clinicians can encourage parents to involve the client and the family in fun games at home to serve as social warm-ups and interaction (Catchpole et al., 2019). Actual exposure and behavioral techniques such as assigning children with selective mutism to home-based tasks (e.g. phone calls to order food) that require talking in the client’s feared situations could provide opportunities to challenge their fears (Østergaard, 2018). Exposure techniques based on virtual reality were also found to assist children with selective mutism in facing their anxiety to socialize (Tan et al., 2022). Occasional virtual socialization meetings with relatives and peers are recommended, while face-to-face meet-ups can be done in consideration of the existing COVID-19 protocols.
As home and school-based interventions are known to address selective mutism (Oerbeck et al., 2014), clinicians and parents can also collaborate with teachers in helping children with selective mutism amid the restrictions brought about by the pandemic. While it is generally not advisable to force children with selective mutism to speak, teachers can utilize strategies that encourage speech and socialization. For instance, children who are mute in the classroom can benefit from a “buddy system” which involves placing the child with his or her “buddy” classmate/s in group activities. A gradual increase in exposure to classroom socialization (e.g. presenting through a recorded presentation at first, and real-time presentation next) can help the client in navigating social situations (Kovac & Furr, 2019; Williams et al., 2021). Regular progress monitoring is necessary to determine effective and ineffective psychotherapeutic strategies in every client as different people may respond to treatments in varying ways (Furr et al., 2020).
In summary, while the COVID-19 pandemic has posed several obstacles in the treatment of mental disorders, clinicians must find creative and collaborative ways to help clients including children and adolescents with selective mutism. The social psychiatric perspective can be adapted into new and creative ways of treating psychosocial illnesses such as selective mutism during the mobility restrictions caused by the COVID-19 crisis. The current pandemic shows us a glimpse of what the future of psychotherapy would look like, and that mental health professionals would always find ways to adapt to any changes.
