PCIT-SM is a behavioral treatment approach that uses positive reinforcement to help children increase their brave talking while decreasing the negative reinforcement cycle that is maintaining their anxious avoidance of speaking. Positive reinforcement of brave talking involves rewarding the desired behavior of talking. The negative reinforcement cycle that maintains SM involves children being self-rewarded by avoiding talking because avoiding talking is the quickest way they know to decrease their own anxiety.
Before focusing on brave talking PCIT-SM devotes time to building a relationship between the therapist and the child without prompting for speech. Activities that the child is interested in are completed together. This phase of treatment is called the Child Directed Interaction (CDI). This phase is essential for building comfort in treatment for the child before tackling the challenge of working on their anxiety. CDI is used to help a child warm-up at the start of each session. CDI is usually done in the presence of an adult such as a parent that the child already talks to. CDI is also used as a warm-up when a new person is introduced or another variable is changed. The concept of contamination plays a role throughout PCIT-SM.
- Contamination is the phenomenon of a child or teen with SM already having experience not speaking to a person, in a place, or in a situation. Children or teens with SM will be unable to speak with any contaminated subject without intensive practice and support. We avoid contamination by completely avoiding questions and heavily relying on the use of CDI skills from PCIT-SM. We also work to un-contaminate previously contaminated individuals in VDI by thoughtfully fading in people who are contaminated and/or working in places or situations that are contaminated.
When the therapist is ready to have the child work on their brave talking the Verbal Directed Interaction (VDI) phase of treatment is begun. Here are some key terms that will come into play during VDI: fade-ins, rehearsal, shaping, living and exposure lifestyle.
- Fade-ins are the process of helping a child with SM talk to a new person. It involves slowly getting a child or teen comfortable speaking in front of and eventually to a new person, scaffolded by gradually moving the person being “faded in” closer to the child to encouraging interaction, and then passing the talking baton from the familiar person to the new person.
- Shaping is used to establish a behavior that does not currently get performed. It involves breaking the ultimate goal down into smaller steps to take toward that goal. Shaping is a process of taking small steps starting with a lower difficulty action and gradually increasing the difficulty working progressively toward the ultimate goal. You want to wait until your child has more confidence with the step they are working on before increasing the difficulty. If you take things a step harder and your child is completely unable to do it then you probably need to break the steps down into smaller steps toward their goal. In PCIT-SM the therapist will support you in pacing the shaping steps. We think of it as taking steps up a ladder with each step or rung on the ladder being slightly harder than the last.
- Rehearsal means practice! If you want your child with SM to order their own donut, they will need to practice first. If nonverbal greetings are also hard and you want your child to wave at their friend as they walk up to the school building, they will need to practice first. They will likely need to practice many times and in a variety of settings. Practice will happen in session but practice outside of session is essential for progress to generalize to your real life. Do not underestimate the power of practice in getting your child ready to face a new challenge with their brave talking or participating. Rehearsal could mean practicing with you multiple times, it could mean practicing with a bunch of different people, it could mean practicing in a bunch of different places. We call looking for any opportunity to practice “living an exposure lifestyle.” Pretty much anywhere you find people is a chance to practice and live that exposure lifestyle.
There are different intensities of treatment available for children with Selective Mutism. PCIT-SM can be delivered individually or in group. Generally children begin with individual therapy and after making progress may be referred for a weekly SM group. Sometimes children with SM take a good amount of time to warm up, making a traditional hour a week therapy model not the most effective approach. In these cases more intensive individual treatment may be recommended first. Intensive treatment could be a few longer sessions each week for a period of time or could be as much as full days of treatment spanning an entire week either in the office or in your home/school/community. Weekly SM groups are allow children to work on talking with adults and other children in activities that simulate things that happen in a classroom. Groups are a great opportunity to work on higher level goals. Some children also benefit from a more intensive group treatment approach. The SM camp models are known as Intensive Group Behavioral Treatments (IGBTs). Our practice will be offering an SM camp this coming summer 2023 called Mighty Mouth Kids Sarasota based on the MMK model developed by Dr. Steven Kurtz.
Your therapist in PCIT-SM will guide you every step of the way in using the strategies discussed here in and out of session to help your child succeed and will help guide you in the intensity of treatment your child needs to succeed!
The treatment principles and terms in this Blog are drawn from PCIT-SM developed by Dr. Steven Kurtz of Kurtz Psychology Consulting.