Role Structure and Subculture in Families of Elective Mutists^†

My Case Records

Elective mutism is a rather rare symptom, and I have worked personally with only four of these children, three from Jutland and one from Greenland. Two of these children were total mutists at the time of first contact. The four families are here named A, B, C, and D, and it seems to me they all show the characteristic traits delineated in the above hypothesis.

Family A. The mother's family of origin was dominated by the grandmother, and the mother seemed to have followed suit in her own family. She was a stubborn person and in disagreements would not give in, even in the face of clear evidence; she was able to get her own way regardless of the rest of the family. One of her methods was stubborn silence. The family replied to this with tolerant recognition. She was the MM. There were also signs of symbiotic patronizing and spoiling. The child, EM, ruled the family, especially the parents, with obstinate refractoriness. In spite of his 7 years, he insisted on being held like a baby when answering the calls of nature. He would not take off his clothes at bedtime, and the parents yielded to the boy, reporting (with a proud undertone) that he had slept with his clothes on. The mother, in particular, accepted this and was very protective. She continually reproached herself that an older brother of the EM had died in a traffic accident “because she didn't look after him properly.” Although both parents had a somewhat symbiotic partnership with the EM, it is easy to point out the mother as the SP. One also had the impression of being confronted with a ghetto feeling in the family, both parents expressing their doubts about the skill of the child psychiatrists, psychologists, and teachers they were in touch with through the boy.

The boy was of course influenced by this view, and an educator reports a game with a doll put into “hospital” by the boy. When asked if the doll would be all right, the boy answered with conviction that the doll could get well only if it was allowed to return home. There is reason to believe that the ghetto effect in this family came from pronounced solidarity in both parents' families of origin. The mother had the leader role in the family and was able to laugh in her husband's face, to his obvious discomfiture.

After putting the boy in several institutions, the family finally left him in an institution for maladjusted boys. He stayed there from his ninth to his thirteenth year without saying more than five or six words in all, despite the good reputation of the place. The boy was now referred to the psychiatric hospital in which I was working. At the start a colleague tried narcoanalysis; it was in vain. The family was more uncooperative than ever before, pointing to the bad results as reason to let the boy come home. Educators, psychiatrsits, nurses, etc., understood the parents' frustration very well but also thought they heard an undertone of triumph.

Family B. Anna was a girl of almost 15. She had not talked outside her home at any time and had been silent at home also when strangers were present. At age 7 she was placed in an institution. She did not talk there, and visits home grew more and more infrequent, clearly increasingly avoided by Anna. At last she was a total mutist.

Her father was a skillful sealhunter who had always been a good provider for his big family; Anna had fifteen siblings. A Danish film company once hired him to play a role as a sealhunter in a motion picture. During the shooting, a well-known and popular Danish star was very angry with him and called him a “typical Greenlander” adding some disparaging adjectives. The father became mute for three months, and the filming was abandoned. Anna's mother rarely said anything when strangers were around (both parents were MM).

The family's lifestyle was rather retiring and isolated from the rest of the community. The children seldom appeared outside the house; one brother did not talk during the first months in school (another MM). Anna's father felt like an outsider as a sealhunter; the rest of the population in the little town had turned to more modern ways of earning a living. Further, the little community was intermixed with Danish “colonists,” whose status might have seemed totally unattainable to most people living there. But Anna's father didn't give in. He continued to perform his old role, and everybody wondered a little that he was able to return home every day with food enough to satisfy his big family (GL).

Her first day in kindergarten, 6-year-old Anna sat passively staring with a blank expression on her face. The school's Greenlandish teachers had to lead her to her place in the classroom. She didn't take her things out of her bag, she didn't take off her coat. They gave her a pencil; she sat for hours, stiff, with the pencil in her hand just as it had been put there. She stood up and urinated without showing any reaction. She did not dare to make contact with her schoolmates. After three months the teachers gave up helping Anna. She was sent home, having withdrawn from a natural step in her development, which, until her first day in kindergarten, had been rather normal. (She had been able to sit up at the age of six months and walk alone before she was one year old, but started to talk only at 4 years of age).

Soon Anna was placed in a children's home. Her new therapist, who was also the director, worked closely with the family, especially the father. She was Danish but had a great interest in the old Eskimo culture. She learned from him how to control a dog team, an art only rarely mastered by a Dane.

In the house of this energetic and warmhearted woman, Anna arrived as a totally passive girl who could neither eat nor dress nor go to the toilet by herself. For many months she moved around by crawling on the floor, able to talk only when she had a person to hold on to. When she was 9 ½ years old, she still did not talk and was referred to a child psychiatric facility in Denmark. Here she worked well at school but remained passive and mute. She was still so after returning to Greenland. From 10 to 12 years, Anna's movements and gestures became more normal, and she functioned socially in a normal way, only lacking language. (At home, with her parents, Anna's motor functions had appeared normal when she was playing with her siblings.)

During these years she had an unusual relationship with her father (SP), writing letters to him, telling him about her love for him, but also threatening suicide to “help him get rid of her.” The father played three roles in the system (SP, MM, and GP).

This was the situation when Anna at 14 came to Denmark for the second time along with her therapist (or rather foster mother), who again tried to contact a child psychiatric department. Anna was admitted and started school in the hospital. One has the impression that her therapist from Greenland did not trust this school, and perhaps the staff did not see the therapist in a positive light either. At any rate, contact between the two sides never really developed, and Anna did not start to talk.

Family C. Here we have a long, drawn-out story of a mutist who had been silent for about ten years — throughout her school education. She was able to speak a few words now and then when alone with the family, but in class she hardly talked at all. Her mother had not talked to her father, probably because of anger against him that she was not able to express openly; their marriage ended in divorce. Further, the mother had been a mutist as a child until 17 years of age (MM), at which time she had had to shift for herself. Today the mother says she is glad that she started to talk, but she is not sure that her daughter is sufficiently resistant to stand such a drastic move. And the mother adds that she herself still does not feel safe enough among people to be convinced that it really is an advantage for her daughter not to be a mutist (GL). She does not want to put any pressure on her daughter because she sympathizes with her and is afraid of forcing her into a world where she might be destroyed. (SP).

Family D. In this family we have the most well-established people in the whole series. The father and the mother helped each other in their small factory. They were fortunate and possessed many material status symbols. They felt that their only problem was the youngest son, 5 years old. But under the surface the tensions were apparent. The family did not feel accepted in the village, where most people were small shopkeepers, farmers, and craftsmen. The family felt that the others thought the family was rolling in money without being compelled to work. The mother did not feel accepted by her husband (GL), who wanted her to have an abortion at the time she was pregnant with the boy, now the patient (EM). She supposed that her husband wanted a smart lady to represent the factory at sales exhibitions. Perhaps she was right to a certain extent. She felt responsible for the boy, and she wanted to protect him against an evil world onto which she seemed to project most of the anger she felt against her husband but did not give voice to. She was the SP and the MM as well, having been a rather silent person in the first years of their marriage, and even more so as a small girl.

The boy was sent to the children's ward of a general hospital. There he stopped talking even with his parents, except for whispering a word now and then. He was then referred to a child psychiatrist, who asked me to contact the family.

Case Records from O. Rold Jensen

O. Rold Jensen, working at an institution for children with speech defects, has collected seven case records,¹ which means every elective mutist child coming to the institute between the years 1969–1973. The institution serves Nordjyllands amt (council), but it is well known that not every elective mutist living in a given area attends an institution like that.

These files contain every note about contacts with the family, the school, and the kindergarten and statements from psychologists, psychiatrists, and other professionals as well. I have looked for the hypothesized roles of EM, MM, SP, and GL and for evidence of an existing family ghetto and unhappy interaction with the community.

Family E. Mother seemed shy, modest, and almost hid herself behind her husband at the first home visit (MM). She could not see any problem in mutism, as her two brothers (MM's) did not talk to strangers before they were 8 and 10 years old. The patient, EM, who was 6 years old, sat on his mother's lap, sucking his thumb and whispering with his mother. After an operation for adenoids, he would not leave the home for a couple of months. The boy was admitted to the institution, but as soon as he got a little better, the mother (SP) wanted him home on some transparent pretext. She didn't get her way at first, but the boy showed decreasing interest in school work and the teachers at the institution felt forced to let him go. The psychologists reported three drawings: one with a huge person, representing himself; another with a smaller person, representing his mother; and still another with a small father. The father (GL) supported the mother and son about leaving the institution.

Family F. Both parents seemed to be self-conscious (MM). Every sibling, four in all, had been shy when younger, (MM). Mother was described as unhappy, inhibited, and embarrassed when confronted with personal questions. She answered quietly and after a pause. By letter she expressed herself brilliantly in a sort of cry for help. The father became more open after some conversations, but for the most part used empty phrases. Mother (SP) wrote, “L. is like me, she needs help.” Mother was afraid that the child, L. (EM), would experience the same difficulties as she herself already had. This family was an interesting example of “family ghetto.” EM did not speak in kindergarten except on rare occasions, when she uttered a single word. But one day, relatives from Canada came to visit in Denmark, and the girl (EM) spoke and entertained by singing! The father (GL) then saw treatment as unnecessary, and the mother sided with him verbally (but not by letter).

Family G. Mother didn't speak to strangers as a small girl, but this was never recognized as a serious symptom; eventually she started to speak spontaneously. Mother (MM) identified with her daughter (EM) and admitted that she overprotected her. Mother was SP too. The family was primitive but warm, and functioned well internally; confronted with the outer world (and its therapists), the father was uncooperative (GL). A family session was planned but never carried out. The picture of the family is rather negative; they remained mostly unknown territory, and the case was considered a failure.

Family H. The father was inclined to depressions and isolation from both family and society; he was the MM. When a loan was refused in a bank, he reacted for weeks with silent, depressed withdrawal. We found only vague signs of symbiosis, but the child (EM) was cross and childish when parents and staff were present at the same time. Her behavior was similar upon arriving home from kindergarten, perhaps a reaction against symbiosis with the mother (SP?). Mother was the GL, having not sent the child to kindergarten for the dubious reason that “it would never help the child.”

Family I. The symptoms began while the child (EM) lived with her grandparents in her mother's original home. EM and grandmother (SP) slept in the same bed. This family, especially the grandfather (GL), saw kindergartens as “new-fangled nonsense” and were cool to the suggestion that the child be placed in one. The mother had been silent in the presence of strangers (MM) and still did not express her feelings and wishes. She felt indebted to her parents for helping her when she was unmarried and pregnant and when later she had no home for the child. During a conjoint family therapy session, however, it came out that the wanted her daughter (EM) to live with her. The grandmother (SP) reacted strongly against letting the girl do this. After therapy, the girl was able to solve the problem herself. She told the family that she wanted to live with her mother and her mother's new lover. After that, the symptoms vanished.

Family J. The father was very shy, especially when younger. At the time of his engagement to the mother, he did not dare to speak when they were together with strangers (MM). He admitted that he was not satisfied with himself and his achievements. EM, a girl, never asked for anything in the kindergarten. She expected to be served and remained seated, or even walked away, if not satisfied. Sometimes she cried in such a situation. The father had the best contact with the girl, who seemed to feel rejected ever since the birth of her little brother. Her mother (SP) let the girl dominate the family in a passive, stubborn fashion.

This family is interesting, because there was no ghetto effect, and of course, no ghetto leader. The mother was trustful and cooperative, and the child soon started to speak, probably because the mother began to visit the kindergarten, showing the girl that she felt the personnel were trustworthy.

Families A-J. Seven of the EM roles were played by girls, three by boys. In seven of the families, mother had a similar role (MM). Indication or evidence of symbiosis was found in each family — the mother was SP in seven, the father in only one family, the mother's mother in one, and in one we have no evidence of a special SP role player. Signs of “family ghetto” were found in nine families, with strong evidence in six of these.

Two families were easy to help (I and J). In family I, the roles MM, SP, and GL were played by three different family members; in family J, the roles MM and SP were played by different persons and that of the GL was not played at all.

Two families were very difficult cases (A and B). The interaction between society and those families was highly disturbed, and the roles MM, SP, and GL were played by the same member of the family.

My Experience

I have seen four families — two were cases of total mutism, derived from elective mutism, (family A and B), and two of elective mutism that in family D threatened to become total mutism. The total mutism seems in families A, B, and D to be the result of aggressive feelings against the biological family, leaving the EM role player to therapists or institutions, which were looked upon by both the patient and his family as strange and potentially dangerous.

In family A, the classic form of conjoint family therapy had already been tried, including family sessions in the home with as many members present as possible. The treatment had been without success, probably because the therapists did not concentrate on the relation between society (culture) and family (ghetto, subculture). Instead the therapy dealt mostly with internal communication in the family. This is an excellent model when the ghetto effect is not too distinct. Perhaps one's professional conscience does not really allow it, but at the start of therapy there is more to be gained by having a meal with the family or drinking a beer with the father (often GL). In such situations, it is possible to study the family's sense of humor, interests, emotional language, etc. The therapist learns to express himself more or less in the family's own style in order to seem less alien and threatening. In this phase it is important to confront the family with the therapist's own positive and negative feelings as provoked by the family. Unless this is done, the therapist cannot be accepted as anything other than a polite representative of a patronizing institution. The therapist risks being rejected one day with precisely the same politeness with which he introduced himself. For further enlightenment, see Kempler, (9).

After having tried to establish good contact with family A by more conventional methods, I became frustrated by their litany of complaints about the institution's neglect that they had uncovered during the boy's visits home on weekends. The list was long and tedious consisting mostly of small spots on the boy's clothes and the like. I felt completely sure that my anger was provoked by the fact that the family was preventing me from taking up more serious subjects. Then I told family A that it was the most difficult and uncooperative family I had met for a whole year. It was true. After this the ice was broken.

Even this would not have been enough in the case of family A. After seven years of elective mutism, the boy had developed total mutism, and he was now so socially underdeveloped that his skills were only a parody of the accomplishments of most boys at the age of 14. His self-esteem suffered greatly. For many years people around the boy unconsciously considered him less than human, unable to think, because he never uttered a word. He escaped responsibility for the daily household tasks as a sort of secondary gain. All facial expression was extinct, apart from a pleading look in his eyes that provoked people to help him into helplessness. At first glance one really got the impression that this boy was subnormal with a low IQ.

Taking this boy in as a foster child, our first goal was to reinforce his self-esteem by teaching him new skills. We found inspiration in Glasser's book Reality Therapy (4). The boy was confronted with his new family's disapproval when he refused to eat with us, to wash regularly, and to help in the kitchen as our own children did. He learned how to paint a door. We demanded these achievements of him, and in this way we showed him indirectly that we took it for granted that he was able to manage the duties required of him. During this period, the boy's facial expression became more open and his chewing muscles less tense — they were not visible though his cheeks any more. But after five and a half months he still did not speak to us. Every week his presence grew more and more unbearable. We could not help interpreting his silence as triumphant stubbornness, probably because in every other field we were successful by maintaining a policy of firmness, warmth, and unrelenting demands. But of course he was not really triumphing. The problem was that we were unable to feel his desire for help, probably because he was afraid to even think of speaking.

Then one day an amateur hypnotist dropped in. He is an engineer and a good friend of our family. As everything else had been tried, I said, partly for fun, that he, J. Kristensen, was the man to cure this “hopeless” boy. And so he was. After a few sessions, the boy began to whisper to his new therapist. Combined relaxation and suggestion, together with patience and sympathy, gave good results. Each session lasted about twenty minutes and was held in private. On the first occasion he opened his mouth and took a deep breath, and later he dared to expire through his mouth. After four to five sessions he dared to read aloud an easy text. Then came the day when I was allowed to listen. To make the boy read, my friend put me in the corner. Later he was able to read when we were alone. Then came the moment when the next person was invited to listen, and, after having read for every person in the family, he started to read aloud for one of his schoolteachers, and so on. Fourteen months later the boy was able to contact people himself, using the spoken word. He now goes to an ordinary school.

Of course we considered it of the greatest importance to keep in touch with the biological family of our foster child. The work with his social development has continued mostly in cooperation with his schoolteachers. After twenty months in our family, his willingness to speak became pretty normal, but it was quite clear that our foster child had certain speech defects that did not seem to disappear with time. A speech therapist is now working on this. As to the boy's IQ, we are still uncertain. We seem to see him waking up gradually, from month to month. About two years ago he tested at an IQ under 70, but this no longer is accurate.

We must not forget a special problem that showed up during treatment. It was when speech development started. We became jealous of the friend who gave us a hand but simultaneously provoked our anger against the boy and himself. After all we had been through, we found it unjust that we were not allowed to hear him speak. We had to discuss this problem with the therapist before further treatment in order to calm down both ourselves and our foster son. From that moment the therapy continued with success.

The biological family's distrust faded, but now and then the mother still asks anxiously if her son is ill. His progress in school interests her, but not as much as his imagined weakness. Perhaps it is no wonder that his brother, two years younger, suffers from encopresis. He still lives with his parents.

In family B, the EM was a 15-year-old Eskimo girl from Greenland. She was referred to the same hypnotist as our foster son, and the same procedure was used, this time with quicker results even though she too had been a total mutist for many years. There is no doubt that her Danish foster mother, a kindergarten teacher, had done two things already: (a) established good relations with the father, who was both the GL and the SP, by inducing him to teach her how to drive a dog sledge, thus encouraging him to feel safe and at ease with her; (b) began social training of the girl in the home of the foster mother (this was easier than before because of the good contact with the biological parents).

It is astonishing that a few hours' work was enough in this case to break the silence. Two hospitalizations in child psychiatric wards had been tried without improvement. As I see it, the hospitals started out with an enormous handicap because of the foster mother's half-unconscious negative feelings about institutions owing to some school problems in her own childhood. Furthermore, a change of milieu was not what this EM needed. All that could have been achieved by this had already been achieved. The girl said subsequently that for a long time (several years ?) she had thought that she was able to speak if she really wanted to. Later she really wanted to speak but became scared when she realized that it was impossible for her to do so. (Perhaps this change in self-perception marked the point where the milieu therapy was complete.)

This girl spoke Danish from the beginning in spite of the fact that Greenlandic was the language she spoke before she became totally mute many years earlier. No speech therapist was needed.

In family C, a family therapy session was held with the 17-year-old EM, her mother, a girlfriend, some teachers, and, last but not least, her father, who had left the family many years ago after a divorce. The father trusted the outside world in a natural way and showed the girl how to do so too; the mother had not been able to do that. Half a year later the former EM's new school reported that the result was lasting. The patient was reported to be talking “like a waterfall.”

In family D, the author has tried to carry through the therapy according to theory from the very beginning. First on the program have been home visits and the removal of the child to a new kindergarten of the SP's (mother's) own choice. The father became interested in the social training of the boy, who had been kept at the level of a 3-year-old, though his real age is 5. After four months, the boy began to speak aloud — at home. In the same period, the boy has been treated by a “zone therapist” found by the parents who have great confidence in her. According to their reports, the therapy includes painful massage of the feet followed by massage of tense muscles anywhere in the body. In this female therapist's office, the boy, perhaps for the first time in his life, has encountered his mother's acceptance of his ability and power to endure pain and thus indirectly a demonstration of her confidence in him. Week by week the boy is putting on weight, after having showed signs of light anorexia. He is also more free in his behavior in the kindergarten.

I had hoped to get further with the parent's interactional problems before working directly with their boy's elective mutism, but their impatience showed me that it was time for results. My cotherapist, J. Kristensen, did not obtain the same quick result he obtained in families A and B. The therapy was completed after a year and a half.