TPC-Journal-V1-Issue1

50 The Professional Counselor \ Volume 1, Issue 1 While psychodynamic approaches were formally the treatment of choice by many counselors and researchers, behavioral interventions are currently included in most treatment programs for selective mutism. This type of treatment provides a step-by-step approach that can be easily modified to fit the changing needs of the child. Behavioral techniques, such as shaping and self-modeling, are rarely used in isolation so it is difficult to assess the effectiveness of any single strategy. As a complete entity, behavioral treatment has been carefully researched and numerous studies have shown efficacious outcomes of this type of treatment (e.g., Gray et al., 2002; Kehle & Owen, 1990; Lescano, 2008). Cognitive-Behavioral Approach While the success of behavioral interventions is rarely disputed, the behavioral approach to therapy does not place emphasis on an individual’s anxious thoughts. Some researchers consider this a major flaw and stress the importance of restructuring thought processes. The cognitive-behavioral approach to treatment, or CBT, is a practical, action-based treatment program that incorporates many of the aforementioned behavioral techniques such as systematic desensitization and stimulus fading. However, CBT is different from behavioral approaches because it has an additional dimension that stresses anxiety management education (Chansky, 2004). Chansky (2004) explains that during CBT, both children and parents develop “a specific set of skills to address the thoughts, physiological responses, and behaviors associated with anxiety” (p. 47). Treatment also requires children to use problem-solving and employ self-talk (McHolm et al., 2005). The ultimate goal of CBT is to help children modify their behavior by assisting them in redirecting their anxious fears and worries in healthy ways (Shipon-Blum, 2007). Cognitive-behavioral treatment includes several components in addition to behavioral techniques. An important aspect of CBT is assessment. Many early sessions are solely dedicated to identifying factors that contribute to the child’s anxiety (Chansky, 2004). The information obtained in these interviews guides treatment and provides a foundation when planning therapeutic activities. Shipon-Blum (2002), for example, has developed a continuum for ongoing assessment that ranges from non-communicative to initiating verbal communication, with many stages of nonverbal and verbal communication in between. This continuum is used to assess a child’s level of anxiety within different settings as well as to set and modify goals for treatment. Since levels of anxiety are likely to elevate during behavioral interventions, particularly systematic desensitization and stimulus fading, children are taught relaxation skills in order to manage anxiety before applying such techniques (Cohan et al., 2006). These skills may include breathing techniques, muscle relaxation, or story telling (Sharkey & McNicholas, 2008). Once research linked selective mutism to anxiety, evidence-based CBT interventions that were previously used to treat other anxiety disorders in children and adolescents were commonly incorporated in the treatment of selective mutism (Mendlowitz & Monga, 2007). One of these interventions, cognitive restructuring, has been utilized to call attention to and minimize negative or anxiety-producing automatic thoughts (Chansky, 2004). In its conventional form, this type of intervention requires the client to share and express feelings to the counselor. This clearly presents an obstacle when working with children who are selectively mute and are not comfortable talking in certain situations, such as a counselor’s office (McHolm et al., 2005). If a child can be expressive using nonverbal means, or if a child is comfortable enough to speak to the counselor, cognitive restructuring can assist a child in learning to cope by thinking realistically. It is important to mention that a child’s cognitive development dictates how well this intervention may work. Therefore, this intervention may be most effective with older children having average to above-average intelligence and the ability to think flexibly and in abstract ways. Despite these limitations, cognitive restructuring is an important element in the treatment process for some children. Cognitive-behavioral treatment has gained attention from researchers of this disorder. Recent case studies and reviews (e.g., Cohan et al., 2006; Mendlowitz & Monga, 2007; Schwartz et al., 2006; Woodcock, Milic, & Johnson, 2007) have demonstrated the success of CBT in treating children suffering from selective mutism. Additionally, the safe nature of this type of treatment along with its high success rates, make it popular. Perhaps its most significant drawback is the amount of time and patience required of the counselor. Mendlowitz and Monga (2007) estimated that children suffering from selective mutism require five to six times more CBT intervention sessions than children suffering from generalized anxiety or separation anxiety.