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AVERSIVE CONTROL IN THE TREATMENT OF ELECTIVE MUTISM
AVERSIVE CONTROL IN THE TREATMENT OF ELECTIVE MUTISM
William H. Shaw) M.D.) D.C.H.) C.R.C.P. (C)
Elective mutism is a relatively rare childhood behavior pattern for which a variety of explanations have been propounded and treatment methods tried (Pustrom and Speers, 1964; Elson et al., 1965). In recent years, learning theory principles have been applied in the treatment of some cases: these have mostly taken the forms of social reinforcement and nonreinforcement (Reed, 1963; Straughan et al., 1965). In the case to be presented, the systematic use of a noxious stimulus was the essential element in a successful treatment program. This method involved practical, theoretical, and ethical issues. CASE REPORT: WILMA
This girl was born in Holland, the fourth of six children, and the younger of two girls, to a family which valued emotional control and verbal reserve. Her mother was strong, stoical, and quietly authoritative; her father was inadequate, excitable, talkative, and dependent on his wife. Wilma was an attractive but self-contained child, whose speech development in Dutch was quite normal. When she was 2Yz Dr. Shaw is Chief of Psychiatry, York Central Hospital, Richmond Hill, Ontario. This is a modified version of a paper given at the Canadian Psychiatric Association annual meeting in Quebec City in June, 1967. The author is indebted to Dr. H. R. Alderton (Thistletown Hospital) for his valuable advice during the treatment of this patient, and to Dr. C. Netley (Hospital for Sick Children, Toronto) for his critical reading of the manuscript.
572
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years old, the family moved to an English-speaking community in Canada. Her father's dreams of prospering failed repeatedly in the ensuing years, and he blamed this on his difficulty in learning the new language. Unlike her sister and brothers, Wilma did not begin to speak English, although she continued to use Dutch normally. When she was aged 3 to 5 her older sister had a period of elective mutism confined to the school setting; this behavior was forcibly terminated by corporal punishment at school. Wilma was aware of this at the time. She told her brothers that she intended never to speak English, and after starting school herself she made good this undertaking. She also began a progressive reduction in the number of Dutch-speaking people to whom she would use even that language. From age 8 onward, she spoke only to members of her immediate family, and exclusively in Dutch, although by now English was the language generally used in her home. She became increasingly rejecting of her father, while still apparently admiring and identifying with her mother and older sister. Her academic progress over the years was normal, apart from her persistent silence, for which she was physically punished at least twice by school staff members. At age 7 and again at age 9 she was referred to the local mental health clinic, but she and her parents failed to cooperate in outpatient treatment. At age IOY2, following the third such referral, her parents consented to her admission to Thistletown Hospital (Rexdale, Ontario). In the hospital her manner was self-possessed and reserved. Although rather rigid and independent-seeming, Wilma conformed smoothly to most hospital routines and presented no behavior problems. She came to be recognized as an intelligent, capable, self-sufficient girl, and although she was sometimes haughty with the other children, she gained unique prestige and influence among them. Although she refused to cooperate in formal psychological testing, she did do a Metropolitan Achievement Test, on which at age 11 she scored at the grades 9 and 10 level in English language skills. However, despite months of speech therapy, individual psychotherapy, and milieu therapy, Wilma's mutism stubbornly persisted. Meanwhile, a number of tentative inferences had been made regarding intrafamilial factors contributing to the development of her elective mutism. These included: the "strong, silent" mother, the inadequate father blaming his failures on having to learn to speak
574
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English, and the example of her older sister's mutism. While these factors may have been causative originally, it seemed that Wilma's mutism had come to have an independent life of its own, now mainly related to other forces. It was hypothesized that a major current obstacle to her normal use of English speech was the fact that most of her repertoire of social behavior had been built up around the maladaptive practice of mutism, the abandonment of which would therefore be difficult and probably anxiety-provoking for her. More obviously (but ultimately less significantly) passive aggressiveness was also involved. There were on the other hand a number of indications that she had some desire to begin using speech appropriately-to deepen her relationships with a few preferred staff members, to get out of the hospital, and to live as a normal teen-ager in the years to come. At the beginning of her second year in the hospital, Wilma was started on a series of twice-weekly intravenous injections of amobarbital sodium (7Y2 gr.) and methamphetamine hydrochloride (30 mg.), aimed at helping her overcome her presumably strong inhibitions regarding speech (Delay, 1949; Houston, 1952). After four weeks the amobarbital sodium was stopped, but she continued to receive twiceweekly injections of methamphetamine hydrochloride (20 mg. LV.), and showed a consistently intense dislike of these. After three weeks of this treatment Wilma finally whispered her first word since admission. This occurred in a secluded site away from the hospital, when she was alone with her favorite staff member, who was putting great pressure on her to speak as a proof of their friendship; as Wilma spoke a single English word ("yes") in a whisper, her manner was very tense,selfconscious, and furtive. During the next few months further progress was only minimal, confined to single words spoken in private to the same counselor on a few occasions. Even this output ceased entirely when injections were temporarily discontinued, but resumed when injections were resumed. Significantly, it began to appear not only that the small gains were indeed related to the methamphetamine hydrochloride injections, but also that this effect was based on her perceiving them as punishment for nonspeech-punishment which she was trying to avoid by producing this minimal speech. It was decided to try exploiting more systematically this apparent effect of the injections. A formal program was set up in which her
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verbal output was to be expanded gradually toward normal. At the outset of this program her verbal behavior showed the following characteristics: whispered voice, single-word utterances, at a frequency much less than once daily, addressed to a single well-liked adult female without witnesses, in secluded locations. These characteristics represented the extreme ends of a number of continua through which she was expected to move toward the normal use of speech. The program involved specific daily expectations regarding her verbal behavior, with periodic upgradings related to these continua. Each day's minimal speech requirements were made explicit to her, as was the condition that if she did not meet these requirements by bedtime, she would receive an injection (methamphetamine hydrochloride, 20 mg. I.V.) on the following morning. This program was carefully explained to her at the outset. She was subsequently given explicit information regarding each successive expansion in requirements, and her progress was frequently reviewed with her. This program lasted seven months. Wilma's early speech had a definite Dutch accent, which faded only gradually. She continued speaking in a whisper for several months, until a more normal voice was formally required from her. Although she continued to show a consistently strong dislike of the injections, her attitude to the program otherwise seemed more often positive than negative. On most days she spoke first (thereby satisfying the formal requirement of speech at least once daily) during the first half of her waking hours. When by thus speaking as required she won a day's reprieve from injection, her feeling of relief was usually apparent. With each successive expansion in her verbal behavior (whether use of more normal speech, or use ofspeech in more normal situations) she initially showed tension, hesitation, and self-consciousness. These reactions cleared on subsequent repetitions, and the gains were maintained spontaneously thereafter. The threat of injection could thereupon be related to yet a further expansion. Although Wilma was not formally required to speak more than once daily (expansions being instead confined to how, where, and to whom she spoke), she exceeded this required minimal frequency increasingly often as the months passed. At the same time, she was increasingly able to avoid the potentially daily injections-eight injections being needed during the first month, six during the next three months, and
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only two in the last three months. As her conversation expanded and became more spontaneous, she began to give spoken confirmation of a number of the assumptions on which the program was based. She emphatically confirmed that she found the injections noxious, because they made her feel extremely "dizzy." She confirmed that avoidance of these injections was her main immediate motive for each expansion in her verbal behavior, and glumly acknowledged that she felt the injections were necessary for her progress. Regarding her difficulty in expanding her speech, she once exclaimed to her favorite counselor, "You expect too much of me! It's easy for you, but not for me!" Normal social reinforcers appeared to play an increasingly important role in conditioning Wilma's speech as the months passed. Once they saw that she was really able to speak, staff members could more easily make mutism difficult for her by declining to respond to nonverbal communication. However, despite social pressures, her progress lapsed during two periods in which the threat of injections was removed (once on a trial basis, and once when the author was absent on vacation). Wilma's progress in speech was accompanied by an increase in her spontaneous use of vivacious gestures and facial expressions, and by an increasingly outgoing and cooperative attitude. For example, after her previous persistent refusal, she now calmly permitted dental work to be done. She also agreed to a limited amount of psychometric testing, obtaining a full-scale score of 120 (Verba1111, Performance 125) on the WISC, and scoring at the 97th percentile on the Raven Matrices. After seven months, it was possible to remove the threat of injections permanently, and ordinary social reinforcers now proved sufficient to continue shaping her verbal behavior toward normal. On the California Test of Personality, done at this time, the main findings were "a relatively high sense of personal worth and personal freedom." On a visit to her home community a few months later, she used English speech appropriately, and her discharge from the hospital followed soon after. On follow-up one year after discharge Wilma was found to be maintaining normal adjustment in her home, community, and school. She was using speech appropriately in all settings, had closer relationships with other family members and normal relationships with peers, was making very good academic progress, had participated in a public
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spelling contest, and was captain of a baseball team. DISCUSSION
The anxiety Wilma clearly showed with each new expansion in her use of speech confirmed our working hypothesis that a major reason for the persistence of her mutism was that the experience of speech was anxiety-provoking for her. Removing this restraint would not alone have immediately enabled her to start using English speech appropriately. Her history indicated that she had no experience in speaking English, and her initially accented speech confirmed this. She also had to learn to use spoken English (and to rebuild much of her social repertoire accordingly). The formal treatment program consisted of a series of rising expectations in her use of English speech, with failures to meet daily requirements resulting in punishment by injections. What directly promoted her progress was not the injections, however, since these were relatively infrequent (only sixteen in seven months) and delayed so long (until the following morning) as not to have had a direct effect. The function of the injections was essentially an indirect one, that of sustaining the threat of injection. The periodic injections served to establish this threat situation as a conditioned aversive stimulus, and their decreasing frequency over the months presumably reflected at least in part the progressive strengthening of the conditioning. (Other factors contributing to this decreasing frequency probably included: increasing adaptation to the total situation of the program, increasing motivation, and increasing influence of social reinforcement.) This daily renewed threat situation became sufficiently aversive that on a large and increasing majority of days Wilma sought relief by speaking as required, usually early in the day. The anxiety-provoking experience of speaking was thus accompanied virtually daily by the relief associated with the termination of an aversive stimulus, and this event appeared to have two results: the operant of speech was reinforced, and the experience of speaking was paired with "aversion relief," a response incompatible with anxiety (Thorpe et al., 1964; Solyom and Miller, 1967). That operant conditioning occurred, with shaping of her speech in English through successive approximations to normal, is evidenced by the increasing frequency of speech (beyond formal requirements), and by its progressive changes from whispered to
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normal vocal tone, and from single-word utterances to normal sentences. That aversion relief was conditioned to the experience of speaking, progressively replacing anxiety (or in Wolpeian terms reciprocally inhibiting it), is indicated by the increasing spontaneity of her speech, and by her decreasing anxiety with subsequent exposures to each situation, starting with an audience of one favored female adult far from the hospital, and progressing up the stimulus-generalization gradient. In brief, Wilma's speech training involved both classical conditioning (threat situation becoming a conditioned aversive stimulus) and operant conditioning (speech being reinforced by termination of this conditioned aversive stimulus), and it thus exemplified Mowrer's (1950) two-factor learning model. The operant learning component would probably be more precisely described in this case as escape conditioning than as avoidance conditioning (Appel, 1964). This conditioning method partly resembles those reported by Thorpe et al. (1964) and by Solyom and Miller (1967), who used "aversion relief" successfully with phobic patients, and by Lazarus (1959) with a 10-year-old boy afraid to sleep in his own bed. However, these cases differ from the present one, in that these patients' anxieties were associated with stimuli rather than with an operant (except in Solyom and Miller's case of Mr. B. M.), the only aversive stimulus used was an unconditioned one (electric shock), and operant conditioning of skilled behavior was not involved. The use of aversive stimuli is usually held to be unsuitable in dealing with behaviors based on anxiety. Mowrer and Kluckhohn (1944) observed that if a subject has learned to make a particular avoidance act when in a state of anxiety, punishing that act may strengthen it by increasing the anxiety. Wolpe (1958, p. 116) described the imaginary case of a student fearful of speaking out in group discussion being forced to speak by the threat of a beating, but not benefiting because being driven by fear into the feared situation had if anything strengthened his fearful reactivity. For a similar reason, Jones (1961) referred to the punishment of responses mediated by a conditioned avoidance drive (such as anxiety) as being an undesirable technique even if effective. Schmidt (1964) found negative reinforcement to be the least effective method of modifying a highly anxious patient's verbal responses. Beech (1960) reported that the higher the patient's level of anxiety, the worse were the results of avoidance conditioning. Sloane
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et al. (1965) found that their neurotic subjects showed a heightened autonomic arousability and conditionability which seemed to impair their ability to learn volitionally to perform avoidance behavior, and suggested that therapy of the introverted neurotic patient should thus include alleviation of his anxiety or arousability. In Wilma's case anxiety was being offset by aversion relief, which thus tended to exempt her from the above warnings regarding aversive control. According to Holland and Skinner (1961), it is poor technique to employ aversive stimuli in shaping skillful behavior because such stimuli elicit emotional responses which interfere with the development of all but comparatively simple behavior patterns. Presumably this applied less in Wilma's case because her learning of English speech was greatly facilitated by her possession of English language and Dutch speech, and again because her anxiety responses were being counteracted by aversion relief. The outcome of Wilma's treatment was influenced by a variety of other factors less closely related to the formal conditioning program. Confined to the hospital, she was forced for the first time in her life to be dependent on English-speaking people outside her family. Although ambivalent about changing, she was increasingly motivated to secure her discharge by losing her mutism, and to begin life as a normal girl at last. While still in the hospital, she came to realize that only by speech could she deepen her relationships with a few preferred staff members. Pressure from her favorite counselor was probably crucial in her emitting the initial modicum of speech on which the conditioning program was based. Staff members made important contributions by reinforcing mutism less and less, and by encouraging and facilitating her avoidance of punishment, and this probably also strengthened her ties with them, as was observed in the studies of Lovaas et al. (1965, p. 99) : "affectionate and other social behaviors towards adults increased after adults had been associated with shock reduction." However helpful or even necessary all these factors were, they were not sufficient to overcome her mutism without the formal conditioning program, as was clearly shown by the abrupt total standstills while the program was twice temporarily suspended. Only after seven months were these other influences able to sustain her progress. While it has been observed that stimulant drugs tend to facilitate conditioning (Franks, 1961), such an effect must have been
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negligible in this case, since Wilma received methamphetamine hydrochloride injections on only a relatively few occasions. Elective mutism is probably not a single entity, but involves different causes in different cases (Reed, 1963). Apart from original intrafamilial factors, and the continuing influence of her passive aggressiveness, Wilma's case appears to have represented one major cause increasingly over the years: mutism as avoidance behavior when speech is too anxiety-provoking. This cause applied in the second of Reed's two groups of elective mutes, those who may have learned mutism as a "fear-reducing mechanism," and her personality more closely resembled those in that category (more tense and watchful, striving, and concerned about their condition). Her mutism was, however, more fixed and long-standing than in Reed's cases (or the vast majority of other reported cases), and her treatment had to include something in addition to the social reinforcements and nonreinforcements employed by Reed. The decisive additional measure involved physical punishment. It is properly held that punishment has only a very limited role to play in the psychiatric treatment of children (Alderton, 1967). In the circumstances of Wilma's case, however, it was considered to be justified: for years she had spoken only within her family circle, other forms of treatment tried had failed, and with the persistence of her mutism her social adjustment would have surely become increasingly deviant, and fixed as such. Significantly, neither the repeated use of punishment nor the loss of her mutism resulted in adverse emotional reactions or symptom substitutions. SUMMARY
Learning theory principles were decisively involved in the successful treatment of a case of elective mutism, long-standing and resistant to other measures. The patient was a girl, 12 years of age at the time of the formal conditioning program, which lasted seven months and involved progressive expansions in her use of speech, with failure to meet specific daily requirements resulting in an aversive injection the following morning. Her mutism was judged to reflect anxiety about speaking. It appeared that the daily renewed threat situation became a conditioned aversive stimulus, which her speech automatically terminated, resulting in both operant conditioning of her speech and counteraction of the anxiety by aversion relief.
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REFERENCES ALDERTON, H. R. (1967), The role of punishment in the in-patient treatment of psychiatrically disturbed children. Canad. Psy chiat, Assn. J., 12 :17-24. APPEL, 1. B. (1964), Analysis of aversively motivated behavior. Arch. G en. Psychiat., 10:71-83. BEECH, H. R. (1960), The symptomatic treatment of writer's cramp. In: Behaviour Therapy and the Neuroses, ed. H. J. Eysenck , Oxford: Pergamon Press, pp. 349-372. DELAY, J. (1949), Sur les explorations pharmacodynamiques en psy chiatr ie: nar co-analyse et choc amphetaminique , Proc, Roy. Soc. Med., 42:491-496. ELSON, A., PEARSON, C., JONES, C. D., & SCHUMACHER, E. (1965), Follow-up study of childhood elective mutism. Arch. Gen. Psychiat., 13: 182-187. FRANKS, C. M. (1961), Conditioning and abnormal behaviour. In: Handbook of Abnormal Psychology, ed. H. J. Eyserick. New York: Basic Books, pp, 457-487. HOLLAND, J. G. & SKINNER, B. F. (1961), The Analysis of Behavior. New York: McGrawHill. HOUSTON, F. (1952), A preliminary investigation into abreaction comparing methedrine and sodium amytal with other methods. J. Ment, Sci., 98:707-710. JONES, H. G. (1961), Applied abnormal psychology: the experimental approach. In: Handbook of Abnormal Psychology, ed.• H. J. Eysenck, New York: Basic Books, pp, 764-781. LAZARUS, A. A. (1959), The elimination of children's phobias by deconditioning. In: Experiments in Behaviour Therapy, ed. H. 1. Eysen ck. New York: Macmillan, 1964, pp. 467-474. LOV AAS, O. I., SCHAEFFER, B., & SIMMONS, 1. Q. (1965), Building social behavior in autistic children by use of electric shock. J. Exp, Res. Pers., 1:99-109. MOWRER, O. H. (1950), Learning Theory and Personality Dynamics. New York: Ronald Press. - - & KLUCKHOHN, C. (1944), Dynamic theory of personality. In: Personality and the Behavior Disorders, ed, 1. McV. Hunt. New York: Ronald Press, 1:69-135. PUSTROM, E. & SPEERS, R. W. (1964), Elective mutism in children. This Journal, 3:287297. REED, G. F. (1963), Elective mutism in children: a reappraisal. J. Child. Psych ol: Psy chiat., 4:99-107. SCHMIDT, E. (1964), A comparative evaluation of verbal conditioning and behaviour training in an individual case. Behav, Res. Ther., 2: 19-26. SLOANE, R. B., DAVIDSON, P.O., STAPLES, F., & PAYNE, R. W. (1965), Experimental reward and punishment in neurosis. Compreh, Psychiat., 6:388-395. SOLYOM, L. & MILLER, S. B. (1967), Reciprocal inhibition by aversion relief in the treatment of phobias. Behav, Res. Ther., 5 :313-324. STRAUGHAN, 1. H., POTTER, W. K., rr., & HAMILTON, S. H., Jr. (1965), The behavioral treatment of an elective mute. J. Child Psychol. Psychiat., 6: 125-130. THORPE, 1. G., SCHMIDT, E., BROWN, P. T., & CASTELL, D. (1964), Aversion-relief therapy: a new method for general application. Behav, Res. Ther., 2 :71-82. WOLPE, J. (1958), Psychotherapy by Reciprocal Inhibition. Stanford: Stanford University Press.
William H. Shaw) M.D.) D.C.H.) C.R.C.P. (C)
Elective mutism is a relatively rare childhood behavior pattern for which a variety of explanations have been propounded and treatment methods tried (Pustrom and Speers, 1964; Elson et al., 1965). In recent years, learning theory principles have been applied in the treatment of some cases: these have mostly taken the forms of social reinforcement and nonreinforcement (Reed, 1963; Straughan et al., 1965). In the case to be presented, the systematic use of a noxious stimulus was the essential element in a successful treatment program. This method involved practical, theoretical, and ethical issues. CASE REPORT: WILMA
This girl was born in Holland, the fourth of six children, and the younger of two girls, to a family which valued emotional control and verbal reserve. Her mother was strong, stoical, and quietly authoritative; her father was inadequate, excitable, talkative, and dependent on his wife. Wilma was an attractive but self-contained child, whose speech development in Dutch was quite normal. When she was 2Yz Dr. Shaw is Chief of Psychiatry, York Central Hospital, Richmond Hill, Ontario. This is a modified version of a paper given at the Canadian Psychiatric Association annual meeting in Quebec City in June, 1967. The author is indebted to Dr. H. R. Alderton (Thistletown Hospital) for his valuable advice during the treatment of this patient, and to Dr. C. Netley (Hospital for Sick Children, Toronto) for his critical reading of the manuscript.
572
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573
years old, the family moved to an English-speaking community in Canada. Her father's dreams of prospering failed repeatedly in the ensuing years, and he blamed this on his difficulty in learning the new language. Unlike her sister and brothers, Wilma did not begin to speak English, although she continued to use Dutch normally. When she was aged 3 to 5 her older sister had a period of elective mutism confined to the school setting; this behavior was forcibly terminated by corporal punishment at school. Wilma was aware of this at the time. She told her brothers that she intended never to speak English, and after starting school herself she made good this undertaking. She also began a progressive reduction in the number of Dutch-speaking people to whom she would use even that language. From age 8 onward, she spoke only to members of her immediate family, and exclusively in Dutch, although by now English was the language generally used in her home. She became increasingly rejecting of her father, while still apparently admiring and identifying with her mother and older sister. Her academic progress over the years was normal, apart from her persistent silence, for which she was physically punished at least twice by school staff members. At age 7 and again at age 9 she was referred to the local mental health clinic, but she and her parents failed to cooperate in outpatient treatment. At age IOY2, following the third such referral, her parents consented to her admission to Thistletown Hospital (Rexdale, Ontario). In the hospital her manner was self-possessed and reserved. Although rather rigid and independent-seeming, Wilma conformed smoothly to most hospital routines and presented no behavior problems. She came to be recognized as an intelligent, capable, self-sufficient girl, and although she was sometimes haughty with the other children, she gained unique prestige and influence among them. Although she refused to cooperate in formal psychological testing, she did do a Metropolitan Achievement Test, on which at age 11 she scored at the grades 9 and 10 level in English language skills. However, despite months of speech therapy, individual psychotherapy, and milieu therapy, Wilma's mutism stubbornly persisted. Meanwhile, a number of tentative inferences had been made regarding intrafamilial factors contributing to the development of her elective mutism. These included: the "strong, silent" mother, the inadequate father blaming his failures on having to learn to speak
574
William H. Shaw
English, and the example of her older sister's mutism. While these factors may have been causative originally, it seemed that Wilma's mutism had come to have an independent life of its own, now mainly related to other forces. It was hypothesized that a major current obstacle to her normal use of English speech was the fact that most of her repertoire of social behavior had been built up around the maladaptive practice of mutism, the abandonment of which would therefore be difficult and probably anxiety-provoking for her. More obviously (but ultimately less significantly) passive aggressiveness was also involved. There were on the other hand a number of indications that she had some desire to begin using speech appropriately-to deepen her relationships with a few preferred staff members, to get out of the hospital, and to live as a normal teen-ager in the years to come. At the beginning of her second year in the hospital, Wilma was started on a series of twice-weekly intravenous injections of amobarbital sodium (7Y2 gr.) and methamphetamine hydrochloride (30 mg.), aimed at helping her overcome her presumably strong inhibitions regarding speech (Delay, 1949; Houston, 1952). After four weeks the amobarbital sodium was stopped, but she continued to receive twiceweekly injections of methamphetamine hydrochloride (20 mg. LV.), and showed a consistently intense dislike of these. After three weeks of this treatment Wilma finally whispered her first word since admission. This occurred in a secluded site away from the hospital, when she was alone with her favorite staff member, who was putting great pressure on her to speak as a proof of their friendship; as Wilma spoke a single English word ("yes") in a whisper, her manner was very tense,selfconscious, and furtive. During the next few months further progress was only minimal, confined to single words spoken in private to the same counselor on a few occasions. Even this output ceased entirely when injections were temporarily discontinued, but resumed when injections were resumed. Significantly, it began to appear not only that the small gains were indeed related to the methamphetamine hydrochloride injections, but also that this effect was based on her perceiving them as punishment for nonspeech-punishment which she was trying to avoid by producing this minimal speech. It was decided to try exploiting more systematically this apparent effect of the injections. A formal program was set up in which her
The Treatment of Elective Mutism
575
verbal output was to be expanded gradually toward normal. At the outset of this program her verbal behavior showed the following characteristics: whispered voice, single-word utterances, at a frequency much less than once daily, addressed to a single well-liked adult female without witnesses, in secluded locations. These characteristics represented the extreme ends of a number of continua through which she was expected to move toward the normal use of speech. The program involved specific daily expectations regarding her verbal behavior, with periodic upgradings related to these continua. Each day's minimal speech requirements were made explicit to her, as was the condition that if she did not meet these requirements by bedtime, she would receive an injection (methamphetamine hydrochloride, 20 mg. I.V.) on the following morning. This program was carefully explained to her at the outset. She was subsequently given explicit information regarding each successive expansion in requirements, and her progress was frequently reviewed with her. This program lasted seven months. Wilma's early speech had a definite Dutch accent, which faded only gradually. She continued speaking in a whisper for several months, until a more normal voice was formally required from her. Although she continued to show a consistently strong dislike of the injections, her attitude to the program otherwise seemed more often positive than negative. On most days she spoke first (thereby satisfying the formal requirement of speech at least once daily) during the first half of her waking hours. When by thus speaking as required she won a day's reprieve from injection, her feeling of relief was usually apparent. With each successive expansion in her verbal behavior (whether use of more normal speech, or use ofspeech in more normal situations) she initially showed tension, hesitation, and self-consciousness. These reactions cleared on subsequent repetitions, and the gains were maintained spontaneously thereafter. The threat of injection could thereupon be related to yet a further expansion. Although Wilma was not formally required to speak more than once daily (expansions being instead confined to how, where, and to whom she spoke), she exceeded this required minimal frequency increasingly often as the months passed. At the same time, she was increasingly able to avoid the potentially daily injections-eight injections being needed during the first month, six during the next three months, and
576
William H. Shaw
only two in the last three months. As her conversation expanded and became more spontaneous, she began to give spoken confirmation of a number of the assumptions on which the program was based. She emphatically confirmed that she found the injections noxious, because they made her feel extremely "dizzy." She confirmed that avoidance of these injections was her main immediate motive for each expansion in her verbal behavior, and glumly acknowledged that she felt the injections were necessary for her progress. Regarding her difficulty in expanding her speech, she once exclaimed to her favorite counselor, "You expect too much of me! It's easy for you, but not for me!" Normal social reinforcers appeared to play an increasingly important role in conditioning Wilma's speech as the months passed. Once they saw that she was really able to speak, staff members could more easily make mutism difficult for her by declining to respond to nonverbal communication. However, despite social pressures, her progress lapsed during two periods in which the threat of injections was removed (once on a trial basis, and once when the author was absent on vacation). Wilma's progress in speech was accompanied by an increase in her spontaneous use of vivacious gestures and facial expressions, and by an increasingly outgoing and cooperative attitude. For example, after her previous persistent refusal, she now calmly permitted dental work to be done. She also agreed to a limited amount of psychometric testing, obtaining a full-scale score of 120 (Verba1111, Performance 125) on the WISC, and scoring at the 97th percentile on the Raven Matrices. After seven months, it was possible to remove the threat of injections permanently, and ordinary social reinforcers now proved sufficient to continue shaping her verbal behavior toward normal. On the California Test of Personality, done at this time, the main findings were "a relatively high sense of personal worth and personal freedom." On a visit to her home community a few months later, she used English speech appropriately, and her discharge from the hospital followed soon after. On follow-up one year after discharge Wilma was found to be maintaining normal adjustment in her home, community, and school. She was using speech appropriately in all settings, had closer relationships with other family members and normal relationships with peers, was making very good academic progress, had participated in a public
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spelling contest, and was captain of a baseball team. DISCUSSION
The anxiety Wilma clearly showed with each new expansion in her use of speech confirmed our working hypothesis that a major reason for the persistence of her mutism was that the experience of speech was anxiety-provoking for her. Removing this restraint would not alone have immediately enabled her to start using English speech appropriately. Her history indicated that she had no experience in speaking English, and her initially accented speech confirmed this. She also had to learn to use spoken English (and to rebuild much of her social repertoire accordingly). The formal treatment program consisted of a series of rising expectations in her use of English speech, with failures to meet daily requirements resulting in punishment by injections. What directly promoted her progress was not the injections, however, since these were relatively infrequent (only sixteen in seven months) and delayed so long (until the following morning) as not to have had a direct effect. The function of the injections was essentially an indirect one, that of sustaining the threat of injection. The periodic injections served to establish this threat situation as a conditioned aversive stimulus, and their decreasing frequency over the months presumably reflected at least in part the progressive strengthening of the conditioning. (Other factors contributing to this decreasing frequency probably included: increasing adaptation to the total situation of the program, increasing motivation, and increasing influence of social reinforcement.) This daily renewed threat situation became sufficiently aversive that on a large and increasing majority of days Wilma sought relief by speaking as required, usually early in the day. The anxiety-provoking experience of speaking was thus accompanied virtually daily by the relief associated with the termination of an aversive stimulus, and this event appeared to have two results: the operant of speech was reinforced, and the experience of speaking was paired with "aversion relief," a response incompatible with anxiety (Thorpe et al., 1964; Solyom and Miller, 1967). That operant conditioning occurred, with shaping of her speech in English through successive approximations to normal, is evidenced by the increasing frequency of speech (beyond formal requirements), and by its progressive changes from whispered to
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normal vocal tone, and from single-word utterances to normal sentences. That aversion relief was conditioned to the experience of speaking, progressively replacing anxiety (or in Wolpeian terms reciprocally inhibiting it), is indicated by the increasing spontaneity of her speech, and by her decreasing anxiety with subsequent exposures to each situation, starting with an audience of one favored female adult far from the hospital, and progressing up the stimulus-generalization gradient. In brief, Wilma's speech training involved both classical conditioning (threat situation becoming a conditioned aversive stimulus) and operant conditioning (speech being reinforced by termination of this conditioned aversive stimulus), and it thus exemplified Mowrer's (1950) two-factor learning model. The operant learning component would probably be more precisely described in this case as escape conditioning than as avoidance conditioning (Appel, 1964). This conditioning method partly resembles those reported by Thorpe et al. (1964) and by Solyom and Miller (1967), who used "aversion relief" successfully with phobic patients, and by Lazarus (1959) with a 10-year-old boy afraid to sleep in his own bed. However, these cases differ from the present one, in that these patients' anxieties were associated with stimuli rather than with an operant (except in Solyom and Miller's case of Mr. B. M.), the only aversive stimulus used was an unconditioned one (electric shock), and operant conditioning of skilled behavior was not involved. The use of aversive stimuli is usually held to be unsuitable in dealing with behaviors based on anxiety. Mowrer and Kluckhohn (1944) observed that if a subject has learned to make a particular avoidance act when in a state of anxiety, punishing that act may strengthen it by increasing the anxiety. Wolpe (1958, p. 116) described the imaginary case of a student fearful of speaking out in group discussion being forced to speak by the threat of a beating, but not benefiting because being driven by fear into the feared situation had if anything strengthened his fearful reactivity. For a similar reason, Jones (1961) referred to the punishment of responses mediated by a conditioned avoidance drive (such as anxiety) as being an undesirable technique even if effective. Schmidt (1964) found negative reinforcement to be the least effective method of modifying a highly anxious patient's verbal responses. Beech (1960) reported that the higher the patient's level of anxiety, the worse were the results of avoidance conditioning. Sloane
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et al. (1965) found that their neurotic subjects showed a heightened autonomic arousability and conditionability which seemed to impair their ability to learn volitionally to perform avoidance behavior, and suggested that therapy of the introverted neurotic patient should thus include alleviation of his anxiety or arousability. In Wilma's case anxiety was being offset by aversion relief, which thus tended to exempt her from the above warnings regarding aversive control. According to Holland and Skinner (1961), it is poor technique to employ aversive stimuli in shaping skillful behavior because such stimuli elicit emotional responses which interfere with the development of all but comparatively simple behavior patterns. Presumably this applied less in Wilma's case because her learning of English speech was greatly facilitated by her possession of English language and Dutch speech, and again because her anxiety responses were being counteracted by aversion relief. The outcome of Wilma's treatment was influenced by a variety of other factors less closely related to the formal conditioning program. Confined to the hospital, she was forced for the first time in her life to be dependent on English-speaking people outside her family. Although ambivalent about changing, she was increasingly motivated to secure her discharge by losing her mutism, and to begin life as a normal girl at last. While still in the hospital, she came to realize that only by speech could she deepen her relationships with a few preferred staff members. Pressure from her favorite counselor was probably crucial in her emitting the initial modicum of speech on which the conditioning program was based. Staff members made important contributions by reinforcing mutism less and less, and by encouraging and facilitating her avoidance of punishment, and this probably also strengthened her ties with them, as was observed in the studies of Lovaas et al. (1965, p. 99) : "affectionate and other social behaviors towards adults increased after adults had been associated with shock reduction." However helpful or even necessary all these factors were, they were not sufficient to overcome her mutism without the formal conditioning program, as was clearly shown by the abrupt total standstills while the program was twice temporarily suspended. Only after seven months were these other influences able to sustain her progress. While it has been observed that stimulant drugs tend to facilitate conditioning (Franks, 1961), such an effect must have been
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negligible in this case, since Wilma received methamphetamine hydrochloride injections on only a relatively few occasions. Elective mutism is probably not a single entity, but involves different causes in different cases (Reed, 1963). Apart from original intrafamilial factors, and the continuing influence of her passive aggressiveness, Wilma's case appears to have represented one major cause increasingly over the years: mutism as avoidance behavior when speech is too anxiety-provoking. This cause applied in the second of Reed's two groups of elective mutes, those who may have learned mutism as a "fear-reducing mechanism," and her personality more closely resembled those in that category (more tense and watchful, striving, and concerned about their condition). Her mutism was, however, more fixed and long-standing than in Reed's cases (or the vast majority of other reported cases), and her treatment had to include something in addition to the social reinforcements and nonreinforcements employed by Reed. The decisive additional measure involved physical punishment. It is properly held that punishment has only a very limited role to play in the psychiatric treatment of children (Alderton, 1967). In the circumstances of Wilma's case, however, it was considered to be justified: for years she had spoken only within her family circle, other forms of treatment tried had failed, and with the persistence of her mutism her social adjustment would have surely become increasingly deviant, and fixed as such. Significantly, neither the repeated use of punishment nor the loss of her mutism resulted in adverse emotional reactions or symptom substitutions. SUMMARY
Learning theory principles were decisively involved in the successful treatment of a case of elective mutism, long-standing and resistant to other measures. The patient was a girl, 12 years of age at the time of the formal conditioning program, which lasted seven months and involved progressive expansions in her use of speech, with failure to meet specific daily requirements resulting in an aversive injection the following morning. Her mutism was judged to reflect anxiety about speaking. It appeared that the daily renewed threat situation became a conditioned aversive stimulus, which her speech automatically terminated, resulting in both operant conditioning of her speech and counteraction of the anxiety by aversion relief.
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