Ericksonian hypnotherapy for selective mutism: a single-case study

Abstract

Background and aim of the work:

Children affected by selective mutism don’t speak in contexts that are unfamiliar to them or in which speaking is expected or required (e.g. school, kindergarten…). Such disorder interferes with the child’s normal activities, may have invalidating consequences in the long run if left untreated, is associated to anxious conditions and is considered hard to treat. Contemporary research is still in need of methodologically rigorous outcome studies and the results described in the small number of published randomized controlled trials and retrospective studies indicate cognitive-behavioral interventions lasting 20-24 sessions as the best therapeutic option. This case study, involving a 7-year-old girl, aims at providing preliminary evidence on the effectiveness of Ericksonian hypnosis in the treatment of this condition. A brief review of current evidence is provided.

Methods:

The case was treated by a licensed hypnotherapist, specialized in family therapy, in 5 sessions during the course of 3 months.

Results:

After 3 months the symptoms of the client were resolved and the diagnosis was no longer applicable. Other improvements regarded her mood, social skills and school performance.

Conclusions:

Ericksonian Hypnotherapy lead to the remission of the disorder and to the improvement of the general well being of the client in 5 sessions, a much briefer time span compared to what is reported in current literature. This paper represents the first step in the elaboration of replicable and reliable intervention principles. (www.actabiomedica.it)

Introduction

Selective mutism (SM) is a disorder that usually onsets during childhood and the children who are affected by it, while being able to produce language, don’t speak in contexts in which they are expected to do so (e.g. school, kindergarten). They remain able to communicate verbally in familiar environments (e.g. home).

The prevalence of the disorder ranges between 0.7% and 2% of the population and is more frequent in girls than in boys (1). The disorder typically appears during early childhood and, despite the age of onset ranges between 2 and 5 years of age, symptoms can become evident only when children start going to school. Long term studies showed that the mean duration of the disorder is around 8 years and that, even once the main symptom is resolved, individuals who were affected by SM keep showing impairments in communication skills, school achievement, family and social relationships and are more at risk of developing psychiatric conditions compared to general population (2).

While in the DSM IV SM is listed in a miscellaneous category (3), in the light of the review of recent literature, it was included in the anxiety disorders of the DSM-5 (1). Research indicates that such condition is strongly associated to other anxiety disorders and comorbidity with social anxiety disorder (65%-100%), separation anxiety disorder (17%-32%), specific phobias (30%-50%) was frequently observed (4-7). These data, along with the observation that SM is more frequently associated with internalizing rather than externalizing conditions, contributed to refute the belief that SM is an oppositional disorder (5, 8).

The disorder seems to run in families. Relatives of children affected by SM often suffer from anxiety disorders and show a general tendency toward shyness (9-13). Belonging to an immigrant family or to a family in which some of its members are affected by mental disorders seems to be a predictive factor of the severity of the condition (14). Outcomes seem to be better when treatment is provided early (15).

Treatment of selective mutism

As of today, SM is considered a hard disorder to treat with consequences that also affect adult life and in time several therapeutic approaches have been experimented.

From a pharmacological point of view, interventions with both fluoxetine and SSRIs lead to similar results: despite some improvements, patients remained strongly symptomatic (16, 17).

Regarding psychosocial treatments, rigorous empirical research is still underrepresented and mostly populated by cognitive-behavioral interventions focusing on 1-2 subjects or by retrospective studies that didn’t use standard outcome assessment strategies. Two reviews published on the topic support the effectiveness of cognitive-behavioral therapy (18, 19) and other studies (20,21) show that this approach has lead to improvement in 20-24 sessions. As a result these interventions, which often include activities addressed the child, the family and the school personnel, the SM diagnosis resulted inapplicable to a percentage of children ranging between 50% and 86%. In some cases authors reported improvements in the comorbid anxious conditions.

In light of what we wrote above, we intend to present a case study on a children affected by SM in which Ericksonian Hypnotherapy was used as main treatment modality. We specify that being this a single case study, generalizability of results to other patients is extremely limited and therefore the effectiveness of the intervention must be tested in more methodologically sound studies.

Hypnosis

According to the Society of Psychological Hypnosis (APA div. 30), hypnosis is a procedure in which an operator uses suggestions to modify sensations, perception or behaviors (22). Such suggestions are administered in a specific state of consciousness known as hypnotic trance. Hypnosis is gaining increasing attention in the international scientific community because it is a low cost, relatively simple to use, side effects-free technique (23).

Hypnosis has been effectively used to treat several kinds of anxiety disorders (24), even severe ones such as acute stress disorder (25) and post-traumatic stress disorder (26). Hypnosis has proved itself a promising technique in treating conditions related to childhood anxiety (14, 27-29).

Hypnotherapy has been successfully used to manage and treat other childhood disorders involving speech such as stuttering (30,31). This condition, just as SM, is associated in the vast majority of cases with a specific form of social anxiety that manifests itself in situations in which public speaking, meeting new people, talking to superiors or even answering the phone is required (32).

Studies published in this field show good results in several areas concerning the management and treatment of stuttering. Some focused mostly on strengthening the sense of self (33), increasing self-esteem and reducing anxiety (34-36).

Other studies focusing on the use of hypnosis in the treatment of psychogenic dysphonia exist (37,38). More specifically, Heap (pp.450-451) mentions an unpublished study comparing results of two treatment groups: one received standard linguistic/vocal training with adjunctive hypnotherapy and the other received the same training without hypnotherapy. The first group showed better improvements on both the linguistic/vocal scales and on the quality of life scales compared with the results achieved by the standard treatment group. Building on these encouraging preliminary results, the two authors advocate for the use of hypnosis in the treatment of speech disorders.

Ericksonian hypnosis

There are two fundamental approaches to hypnosis: a direct (or classical) one that conceptualized the hypnotic state as a phenomenon produced by the hypnotist on the subjects, and the Ericksonian (or indirect) one, in which hypnotic trance is described as a physiological state of consciousness in which attention is extremely focused and that tends to spontaneously emerge when individuals are involved in a cooperative, respectful and welcoming interaction called rapport.

This way of using hypnosis allowed to utilize the trance states that spontaneously develop during sessions (39), turning it into a versatile tool that can be used to support other psychotherapeutic models.

Foreword

The therapist who carried out the intervention (N.G.) is systemic-relational psychotherapist, director of an Institute of Ericksonian Clinical hypnosis.

In the following case, she chose to adopt the most indirect hypnotic approach possible, aiming at intertwining it with the playful interaction with the child.

More specifically, games and activities that will be described here are conceived to produce a focusing of the patient’s attention in order to promote access to the common everyday trance as Erickson defined it (40).

During the whole treatment the therapist aims at leading the patient into a state of consciousness in which interspersed suggestions can be received.

The therapist, having formulated a clinical hypothesis, utilizes any occasion to introduce suggestions aiming at promoting change in the form of self-talk, questions, metaphors and stories.

This style is especially suitable to children, as they are naturally talented at quickly entering and exiting trance states even when not formally exposed to induction procedures (41).

Stella

Stella is a 7-year-old girl who was referred to therapy because she didn’t speak to anyone outside her immediate family circle. She was diagnosed with SM.

Medical history

Stella was born without complications, at 2 years-old she was diagnosed with an innocent systolic heart murmur. Since she was 3, she has also been suffering from episodes of paroxysmal supraventricular tachycardia that required hospital stays. She received an anti-arrhythmic treatment with propafenone. The dosage was increased progressively until the disappearance of the crises. Concerning SM, Stella had already been seen by a speech and language therapist and by a child and adolescent psychiatrist. No observable improvements were reported.

Stella is still in kindergarten. Teachers, because of her mutism and attitude, suggested her parents to wait another year before letting her enter primary school. Stella doesn’t socialize, she simply waits on a chair for the moment in which she will finally be allowed to return home. At home she is constantly close to her mother, she follows her from room to room and doesn’t communicate with her mother’s partner with whom they have been living since a couple of months.

Presently, the only people to which Stella speaks are her mother and her grandparents with whom she grew up. Her mother tells me that Stella’s father lives outside Europe. I inform her that we can schedule an appointment with her to gather information but that I will be able to treat Stella only after receiving the consent of both parents.

Preliminary session with Stella’s mother

Stella’s mother is a well dressed and energetic woman, I sense her courage in facing hardships.

She came with her new partner but enters alone into the therapy room. He chose to be there in case I would have wanted to know him. Stella’s father has been having problems with justice since many years, he was arrested for the first time when she was expecting Stella and during the first years of life of the baby he kept getting in and out of prison. While free, he occasionally contacted her.

As of today, Stella, who met him only once, doesn’t consider him a key figure in her life.

Stella’s mother is the daughter of a couple from Eastern Europe. They moved to Italy when she was still very young. They are present, helpful and are described as very respectful of the daughter’s and nephew’s boundaries. Stella and her mother lived with them until a couple of months ago, and the child loves her grandparents very much. They all are workers in factories located in the region where they live.

Two weeks later, Stella’s mother succeeds in obtaining the father’s signed consent and therefore we schedule a session with little Stella. I ask the mother to use a rather unspecific style to tell the child about the session: ‘We will go to a doctor who will help you solve your problem.’ I choose this kind of open invitation because I hypothesize that Stella may be aware to some extent of having some kind of problem and I want her to be the one figuring out what we will be facing together. I also decide not to make a formal agreement concerning whether the mother would remain in the room in order to be able to observe the mother-daughter relationship in the most natural setting possible.

First Session

Stella is a beautiful child, tall and slim. She wears jeans and a pink shirt with small ribbons. She has two pigtails and carries a small bag. Her lively eyes are moody today. She enters the office looking very angry and she obstinately looks down. It is clear that she doesn’t want to be there with me. She tries to hang on to her mother, but she orders her to enter the room and to sit down. Her mother hands me the report of a pedagogist and some of Stella’s drawings. She then leaves towards the waiting room in a mixed state of hope and exasperation.

I remain alone with Stella, it is clear to both of us that she would rather be anywhere else but where she is. She doesn’t know whether to express hate or breaking into tears.

I am holding the report and her drawings. The first introductory lines inform me about the emotional color of the document: Stella expresses no emotions, as if she couldn’t feel any. Remarkable intelligence and commitment; firm and controlled character; she doesn’t accept the new situation: she considers her mother and her grandparents, with whom she lived until some time ago, as her only family. Stella doesn’t even answer to gestures, she doesn’t draw, she doesn’t show interest toward anything, she doesn’t even like puppets or other games.

Coherently with Ericksonian methods I think about the utilization principle: how to turn what is happening during the session as a tool to support therapeutic work? While right now Stella can’t speak she can definitely listen. I decide to comment her drawings with her. I want to give her the possibility to judge me, to put her in an up position in our relationship, to start making her feel more comfortable.

The first drawing depicts Stella in the garden. ‘This sun has very big eyes. He controls everything from up there, uh?’ The the second one portrays a policeman (control again?). In another drawing, in which her family is depicted, Stella drew herself, her mother and her grandparents. ‘Is it you? Your family? Your grandparents? What a beautiful drawing!’

In another one she is with her mother, both big and close together. Her mother’s partner is far, small, on the right side of the sheet. Finally a drawing of Ariel. ‘If Ariel were able to speak everything would have been easier for her.’

I aim at evoking her desire to talk, to answer me and I start asking a lot of questions, alternated by truisms and suggestions to help her accomplish the developmental task she has to face. I know she will not answer, I know that I have to keep the fast pace that children usually like.

‘Mommy brought you here to help you and then chose to go in the other room. Are you angry? Are you angry just at her or at me too? Is there anyone else at whom you are angry?’

She starts answering non verbally, nodding or shaking her head, but she does it only at times.

My questions are pressing, fast, I know how easy it is to lose children’s attention – to become uninteresting for them. I keep asking questions about the future. ‘What would you like now? What would you like to be different?’

I think that letting her know me, be authentic with her and show my difficulty is important.

‘It is so hard for me… I want to help you, but it is very hard, I want to but I am not succeeding as much as I would like, do you feel the same way?’

I think that she may be feeling like having to face an insurmountable task, a mountain that can’t be climbed, and I let her keep listening to me. ‘…things can be done little by little… They become less frightening… In some occasions, things that once scared me a lot, then didn’t scare me at all!’

Children like stories of other children: I tell her about another case I treated. A child couldn’t move his arm because he was hurt, so he started to move it little by little, really tiny movements, very tiny movements! Her mother didn’t even notice that he started to move it. He kept moving it this way and others didn’t even notice it. Sometimes, when he was in bed or when he didn’t know what to think about, he imagined to move it, just as if he was watching a cartoon and he was the hero who could move the arm. In the cartoon he could move it a little or even a bit more, without any effort, it was one of his abilities and he could watch that cartoon anytime he wanted to.

I wonder how would it feel to be at the recreation ground or in a square crowded with people and to start talking in your head at first and then to start whispering, but it would be amusing to speak so softly that no one could hear you… just you… Really fun!’

I imagine this little girl sitting on a bench at the kindergarten, all alone. ‘It must feel really good to be able to do the things I want to do, being free to do whatever I want… You, for example, what would you like to do?’

I imagine how loud the inner noise must be, how many startles during the course of a single day, how many frightening things. ‘Is it possible to feel relaxed and calm with others? It may be fun!’

I think that she is lucky to have her grandparents but she may have grown up in a very serious environment, with a great sense of responsibility and many ideas on how things should be done.

I think that her family may not be very well integrated, that it may not be connected to a large social network. I feel the need to convey lightness, to unburden her, to help her have fun. I playfully try to make her laugh even if I don’t succeed as much as I would like.

At the end of the session Stella achieves her first result, she moves her head, which remained the whole time low and slightly turned towards me. It’s a very minimal movement, a small thing. A beginning.

That’s how our first session ends, I ask her mother to bring Stella’s toys in the next session, I think that they may be useful to use a non verbal expressive channel. On the doorstep, while saying goodbye to her, I tell her that, sometimes, things just can’t be held, like when one has to pee.

I think that social relationships in her city are important and that we will need to work to increase the family’s connections. Stella’s knot is not easy to unravel, but she can count on a family that loves her very much and that really wants to help her.

A phone call

During the two weeks between the first and the second session, I receive a phone call from Stella’s mother who tells me that the child started to speak with Dario, her partner.

I choose not to emphasize this achievement and take the opportunity to utilize this moment: I ask her to ask little Stella whether she would like to talk to me too next time.

Pre-session

For the second session I aim at helping Stella in some specific areas.

First of all, I think it is important for her to begin feeling more at ease even outside the house, in order to establish relationships with others, both peers and adults. Words will come later, but, in the meantime, we must shift from trying to be invisible to expressing emotions that could involve others, allowing for her to be included in social interactions.

It is important, in the context of the constitution process of a new family, that the relationship with Dario keeps improving.

I think that to reach the objectives that I have in mind, Stella should experience physical contact not just with mom and her grandparents, that she should start to experience her body as a tool for playing and communicating.

Furthermore, since she often opposes to simple and reasonable requests made by relevant adults (ex. teachers), I think that I should begin working on developing appropriate behaviors that may help her feeling more at ease in collective contexts.

Last but not least, I plan to help mother and child to be increasingly independent from one another. Stella must become able to remain in a room on her own without feeling the need to constantly follow her mom. It would promote development for both of them.

To work on these objectives, I decide to prepare a series of games with increasing pace. Each one of them will work on one or more of the aforementioned areas. All games are playable without requiring spoken language. I want to build each session by activating emotional experiences that could enrich and widen her possibilities to act in the world. I want Stella to have fun. I want her to step on a merry-go-round.

Second session (15 days after)

Stella arrives in my office with her mother and Dario. On the doorstep she looks into my eyes for the first time and shows a shy smile. Her mother tells me that Stella told her that she wants to speak to me and she asks her to do so.

Hello, she says.

According to Erickson’s teachings, I choose to use the setting in a flexible way. During each session I will see Stella, Stella with her mom, her mom alone (if necessary and feasible) in order to be as free as possible to appropriately orient the intervention. I will find the way to speak in the presence of Dario, whom I consider a valuable resource for the family.

For this reason I scheduled sessions in moments where the office is completely free from other therapists and patients, in a setting in which it’s only us and no one else. Moving between the waiting room and the therapy room will be as moving through the rooms of the house, an intimate space where the only characters will be the protagonists of this story.

I choose to read Stella a story (42) about a duckling that doesn’t want to bathe in the pond. Several animals, each one with its own style, try to push her into the water, but she really doesn’t feel like bathing. Even when the wolf comes, she confronts him because she doesn’t see a wolf, but just someone else trying to force her to do what she doesn’t want to: dive into the water. The story ends with the duckling alone on the pond banks. All characters left, the day is really beautiful and ‘nothing seems more natural than taking a bath’ (ibid.).

With children I often use short stories. I find this to be a very useful tool because while the child is immersed in the story and she shifts her attention towards the inside, I can use suggestions to elicit question, doubts, different ways to look at things.

Sometimes I use stories to tell children that I perfectly understand how they feel, reframing the problem they present. In this specific case in which the duckling doesn’t want to bathe, the indirect communication revolves around the fact that she can do it, that she has the power to change the present situation whenever she wants.

To introduce the stories that I choose to read or tell, I usually tell another story, I create an expectation to make what will follow more precious and significant. In this case, I decide to stimulate Stella’s curiosity with a small video that I did with the collaboration of a little child that I know, Alessandra, who is the same age as Stella. With the consent of her parents, I asked Alessandra to introduce the story of the duckling to Stella, to tell her that she liked it very much (it is true, Alessandra knows and likes the story) and that she was waiting for a response video to know if Stella liked it too.

A task inside a task.

This allows me to have Stella’s complete attention and it is as if Alessandra herself entered the therapy room. I created a communication process between them: Stella is involved and wants to answer to the message. I play with my voice, each animal has its call, I characterize them to stimulate the desire to hear them again and again. She laughs, she is having fun.

At the end of the story, as often occurs with children, she asks me to read the story again and I ask her if she wants to do the animals’ calls together (a small task demanded by an adult). She accepts.

We get closer, I ask her to play pretty hands with me, an old game with a nursery rhyme in which I touch each of her fingers sequentially and at the end I suddenly tickle her. She keeps having fun and we established physical contact.

Children often want to experience several different things and I would love for Stella to open up to novelty, I think it is exactly what she needs. The backbone of my intervention was conceived by building upon an idea: you can do many different things that can be pleasant and interesting. I want to nourish the desire for novelty.

I then decide to use a puzzle that depicts the characters of Frozen, a cartoon about two princesses who live in a land covered by ice.

One of them risks death because of the ice that took hold of her and at a certain point she will become an ice statue. Fortunately, an external intervention will bring warmth once again in her little body.

I choose this cartoon for many different reasons, among these, the fact that the central theme is about trust, the possibility to tell others about oneself and forgiveness. It will be useful later in therapy.

The puzzle is missing a piece that corresponds to the princess’ chest, her heart.

‘A piece is missing!’ Stella shouts out.

This event allows me to ask her about her heart ‘Sometimes it rushes and it scares me.’ From this point, asking what frightens her just feels natural:

‘First of all older children! But adults too and people with loud voices!’ Stella is talking to me. No more monosyllables and tight smiles but a conversation.

I keep working with conversational hypnosis. Children have the natural tendency to be carried away by their fantasies, to shift attention toward the inside. They enter and exit hypnotic trance very quickly, therefore it is very important to maintain a certain pace.

I ask her what makes her feel safe and calm.

‘Being with mom and with my grandparents.’

‘If you always had that calmness inside of you, would you be less scared to meet older children and adults with loud voices?’

‘Yes.’

‘Would you like to have a magic bubble containing all that confidence and calmness that you can use whenever you need it?’

‘Yes.’

‘Ok then. Put yourself inside the bubble and let’s go meet an older child who scares you. What’s his name?’

‘Paolo.’

‘How does he look?’

‘He has black hair, a red shirt and he is frightening.’

‘And are you calm inside your bubble now?’

‘Yes.’

‘Can you feel calm while close to him?’

‘Yes.’

‘And how do you know that you are calm?’

‘My heart is slow and I can look wherever I want.’

I tell Stella that she was really good and that I brought a present for her. She is curious: when she sees a picture of Ariel that can be colored her eyes shine.

‘Do you want to surprise mommy by showing her this picture already colored? In the meantime I will go to the other room to talk with her a little – we are in the other room and you can come whenever you like but if you come with the drawing already colored your mother will be really happy!’

This allows me to speak with her mother about topics related to the construction of a social network around Stella and, more generally, around the family. I emphasize that it is very important for Stella to see other children. The time that I spend talking with her is also an occasion to verify if Stella can remain far from her mother, if she can now carry out independent activities. It is the first step to allow her to build relationships with her peers.

Once the conversation with her mother is over, I go back to Stella and I ask her if she wants to play with me at recognizing facial expressions. I want her to know that there are many ways to communicate and that she is free to choose how to do it in any given occasion.

We close the session by playing Jenga®, a game in which players must build a tower with wooden bricks that must be then taken out of the structure itself to make the tower even higher until its inevitable collapse. During this experience I emphasize how fun it is to destroy the tower, what seems like a catastrophe, if intentional, can be real fun! Facing things can be easier. Stella intercepts my peculiar way of communicating: she jokes with me and tells me that anyway she will not use the bubble we build together. She is playing.

‘Do you want to record a video for Alessandra to tell her if you liked the book?’

‘Yes.’

Once the recording is done, I ask her if next time she would like to bring one of the books she likes in session. By doing so we could record another message to Alessandra in which she suggests her to read it. Stella agrees.

I want to make her feel connected to a child who thinks about her, even if today she isn’t here.

At the end of the session, Stella takes the games that she brought from home and chooses to give one of their favorite ones to me: a small figure shaped as an egg. It is still in my office. I ask the mother to read her the book about the duckling every night. I choose to do so to keep her connected with the therapy context and because I know that repeating certain steps that have been made can reactivate the entirety of the intervention. On the doorstep she greets me with a kiss and I say goodbye to the family repeating to her mother how important it is to build a social network.

Third session (after 16 days)

Stella arrives with her mother, Dario, his son and Hero, their dog. When children feel better they often bring their pets to me – especially dogs – and I like it very much. I consider them part of the family and I think of these behaviors as a deep and delicate way to welcome me into their world. Today even Bruno is here, the son of Dario, who is the same age as Stella and who lives with her mother and who is coming at Stella’s house increasingly often.

The office is quite crowded now, and I think that Erickson, in his house, worked in an apparently chaotic and unpredictable setting in which his wife and numerous children often appeared along with his dogs and eventually other patients. I think that he chose a very comfortable setting. He could count on a multiplicity of hints to build therapeutic interventions.

Stella tells me that Hero has the name of a cartoon character that always stays with girls.

Her mother tells me that the child now speaks to many adults, appears more relaxed, remains alone in her room and doesn’t follow her around anymore. In several occasions she accepted to pay the check in cafes and restaurants.

Now I am updated on recent developments and Stella asks me to read the tale we read in the last session, we play for some time at making the calls of the animals.

Stella proudly tells me that her mother bought the book and read it to her every night.

I show her another one (43). This one contains stories in which the moon, through her big ears, spends her time listening the needs of men and, sometimes, grants their wishes by realizing the changes they need to be happy.

For instance, there is the story of a sad teacher who always had the sides of her mouth pointing downwards; one night the moon intervenes and the morning after she wakes up with the sides of her mouth pointing upwards.

‘Can people change quickly? Can many changes occur in a teeny tiny time?’

Stella nods thoughtfully.

We play pretty hand again but this time I ask her to lead the game. She sits on my lap, she feels good with me, she is happy of working on herself. This task allows me to target relational aspects and to assess Stella’s memory and attention skills. They are excellent.

I often have the clear sensation that children have an immediate ability to notice essential aspects of things, during these kinds of intervention their ability to take care of themselves always grows. This means learning to enter an effective emotional disposition to face troubles, to see them as events that can be managed.

We play again at recognizing emotions but this time I choose to work on subtler emotional states, less obvious ones, that can widen the array of her expressive possibilities.

I still think about Stella alone in the kindergarten waiting for the moment to return home. Surely someone may have joked about her behaving so or worse. I am certain that – inside of her – she may have someone to forgive.

‘Was Anna right in forgiving Elsa?’ (the princesses on the Frozen cartoon).

She thinks about it for some time before answering, we both know what we are talking about.

‘Yes.’

I introduce a new game with magnets and I utilize the natural trance that Stella produces while playing to intersperse suggestions related to attraction; to the fact that, once forgiven, people can come close to one another, just like these magnets.

‘Did you see how many forms you can create with these magnets? Can you build many different things with the same possibilities? You have many little pieces and you can decide what to do.’

I leave Stella and Dario’s son to play together with the magnets and I spend some time with the mother and his partner. Dario highlights all the changes occurred in the child in relating with neighbors, other children and some adults. Her mother tells me that, as a child, while she was never mute, she was very shy. Until 7-8 years old she slept with her parents.

I keep working on making the mother-daughter dyad more independent and suggest that Stella could improve by sleeping on her own. It could be another piece of this work that we are doing together.

‘Did you bring a message with a book that you like that I can show Alessandra? Yesterday she asked me about it!’

‘Yes.’

It is marvelous! Stella, emotionally involved, and tells a story about children becoming friends.

Before leaving the study Stella says goodbye to me, kisses me and hugs me. A really nice change. Now some of the things that we started together will proceed on their own.

Fourth session (one month after)

In the fourth session Stella’s mother tells me that now she is all right and plays with everyone except her teachers and Michela, a school mate.

They are preparing for her birthday party and they decided to invite other children.

Stella stays in the rooms of the house by herself, she sleeps on her own in her new room.

Her mother repeats that until 7-8 years of age she slept with her parents and I tell her that the fact that the child sleeps alone is an improvement for the whole family.

Stella brought me a video in which she dances and a drawing in which both me and Alessandra are depicted. The way in which she behaves now at home, with me, with peers, according to what her mother says, is really different. I realize that it’s all downhill from now, the hardest part is behind us.

Right now we must focus on consolidating the results we obtained so that in September she will be able to speak freely at school.

While we play with the tangram, small geometric tiles that can be used to form images, I keep interspersing suggestions related to the fact that changes can happen quickly.

Still another part on forgiveness.

‘In the end Anna didn’t imprison the prince who behaved badly! She just punched him and tossed him in the water.’ While playing, I intersperse suggestions about the possibility to choose friends, she can choose who will receive her affection.

Stella’s mother is moved and thanks me. She sees these improvements as miracles.

Her Child, and the entire family, have extraordinary resources.

I schedule a follow-up session.

Fifth session (after two months and a half)

In the fifth session Stella’s mother tells me that now she speaks with everyone, teachers and Michela included. The atmosphere at home is even better and the changes we achieved are stabilizing.

Dario couldn’t come, I hear with pleasure that for the first time Stella calls him by his first name. He is not mom’s boyfriend anymore. It is a significant person with whom she has a good relationship.

Stella brings some drawings depicting houses. Now the scenes are not anymore taking place only outside, like the first drawings. Stella draws the interior of the house and she does so in detail. It seems to me that she is now able to look inside herself, to show herself. While being with her I have the sensation, just as when she showed me the video of her dancing, that she wants to show me her world, with all her toys, all the things that are important to her. Like these drawings.

I ask her mother to call me for a last follow up talk after the first 2 weeks of school.

Follow-up phone call

Stella’s mother tells me that the child began school, she is relaxed and smiles to everyone. She feels ok with her teachers and has integrated herself with her schoolmates.

She says that she would like to come see me. She made me a drawing.

Discussion

The subject of this therapy shows typical characteristics of patients affected by SM. More specifically, Stella’s parents come from immigrant families and she has a mother who, while not having apparently suffered from any anxiety disorder, described herself as a shy child.

The case we presented shows that by integrating intervention principles extrapolated by modern research (not forcing the child to speak, not emphasizing the child’s verbalizations, using playful settings, involving families and peers) to Ericksonian methods, a quick resolution of a highly invalidating – for both the child and the family – SM case can be achieved. The use of utilization and interspersal techniques elaborated for the first time by Milton H. Erickson (39) allowed for fluid sessions in which contact with the child was maintained by playful activities that naturally attracted the attention of the little patient.

The relative brevity of the treatment constitutes a potential advantage for both patients and their families since it would reduce the emotional, economic and time burden of the therapeutic program.

In conclusion, this study is the first step in the search for effective and sustainable intervention models that can be replicated by other operators in other contexts. Future studies will investigate such potential with more rigorous methodologies.

Limitations

Being this a single case study, the general conclusions that can be drawn are very limited and to confirm the therapeutic potential of this type of intervention a larger sample study is required.

The intervention principles, while having been codified, as of today, are far from the levels of standardization of other therapeutic modalities and still need a great deal of theoretical and technical work to be clarified and, eventually, generalized.