Mitya and his “secret box.” Psychoanalytic thinking in integrative therapy for selective mutism.

Annotation

This article presents a clinical case of psychotherapy for an eight-year-old boy with selective mutism. The work began with child-centered play therapy, subsequently moving to a psychoanalytic understanding through an analysis of transference-countertransference dynamics. It demonstrates how, through play and symbolization, the child was able to express his feelings and acquire language. The symptom did not recur after completion of therapy. The role of the family system and the importance of family therapy are also discussed. The findings are compared with the work of Yangerman, Berko, and Vasilyeva.

Key words: selective mutism, child-centered play therapy, psychoanalytic thinking, transference, countertransference, containment, family dynamics, symbolization.

Introduction

This article presents a clinical case of psychotherapy for an eight-year-old boy with selective mutism, implemented within an integrative approach. The work began with child-centered play therapy (CCPT), which enabled initial contact and the creation of a safe space for the expression of emotions in a situation unusual for psychoanalysis: the child’s complete silence. Subsequently, the emphasis shifted to a psychoanalytic understanding of the therapy, including an analysis of transference-countertransference dynamics. It is shown how, through play and symbolism, the child gained the opportunity to express feelings and develop speech. The work was terminated early at the initiative of the parents; however, two to three months after the completion of therapy, the child began to speak, and the mutism symptom has not recurred since. At the time of writing, the patient has successfully adapted, speaks several languages, and demonstrates a high level of academic and social integration. The influence of the family system on the maintenance of the symptom and the need for family therapy are discussed. The findings are compared with the results of case analysis in the psychoanalytic works of Yangerman, Berko, and Vasilyeva.

Clinical case: psychotherapeutic work with a child with a symptom of selective mutism

Mitya’s story

Mitya is eight years old and doesn’t speak in certain circumstances: with peers and with insignificant adults. Anna and Sergey, Mitya’s parents, had been living together for quite some time, even before their child’s birth. Anna, unlike Sergey, didn’t want children. When she became pregnant, they married. The pregnancy proceeded well, allowing Anna to work until her final months. But around her seventh month, she was in a serious accident in which the car flipped over, landing Anna in the hospital. She was unharmed and was hospitalized briefly, but she remembers the experience as very stressful. When the time came to give birth, Anna wanted a cesarean section because she was afraid of labor and the pain, but she ultimately gave in to the doctors’ persuasion and delivered the baby naturally. Sergey was by his wife’s side during the birth and subsequently played an active role in her care and upbringing. Mitya was born a healthy baby, but he was very restless. Until he was five, he slept poorly, both day and night. Anna breastfed Mitya for eight months, but since she found this process unpleasant and the milk supply insufficient, Mitya was switched to formula. Around the same time, the parents decided to hire a nanny for the eight-month-old, exhausted by sleepless nights. The nanny stayed with the family for three years, until they moved to Moscow and Mitya entered kindergarten. Anna, when her son turned one, entered medical school and soon returned to work. The boy spent all his time with the nanny, becoming attached to her and loving her dearly. When Mitya turned three, the family moved to Moscow and had to part with the nanny. Mitya was sent to kindergarten. The nanny visited him a few more times. The parents noted that Mitya got used to his new place of residence and kindergarten quite quickly, and it seemed to them that he did not attach much importance to the absence of a nanny.

Mitya’s failure to respond to adults’ greetings and farewells, pretending not to hear, was noticed even when he had a nanny. His parents, when he was 3 or 4 years old, interpreted this behavior as stubbornness and rebellion. Later, at 5 or 6 years old, when the child began avoiding interactions with peers, ignoring their attention and words addressed to him, Anna and Sergey dismissed this as shyness. Before seeking help, they concluded that Mitya was unable to overcome his inhibitions, that this was a “stupor.” It became known that during potty training, Mitya had problems with defecation, and until age 2, he could only go to the toilet in the shower, accompanied by the sound of running water.

We consulted a speech therapist when he was 5 years old – he couldn’t pronounce the letter “R.” The problem was quickly resolved. The speech therapist assessed his speech development as age-appropriate.

They’d never consulted a neurologist, nor a psychotherapist. They brought him to me for a consultation, immediately citing the problem with Mitya’s silence, but with the caveat that they simply wanted to try play therapy.

Parents and their view of Mitya

Anna and Sergey are both educated. Anna has a medical degree and is continuing her education. Sergey, a programmer, has a job that allows him to stay home and spend time with Mitya. Anna works a lot, and Sergey has taken on Mitya’s responsibilities: taking him to and from school, accompanying him to extracurricular activities, preparing meals, and taking care of his clothes. Anna says Sergey has a better rapport with Mitya, understanding him better and finding a way to connect with him. Anna, on the other hand, quickly becomes nervous and loses her temper. The parents seem very anxious, believing Mitya shouldn’t have any secrets from them, because if they don’t know, they’ll miss something bad in Mitya’s life and won’t be able to help. Success in life is very important to them, and they worry about Mitya’s level of education, the prestige of his school, extracurricular activities, and his academic performance. They are very proud of his excellent academic performance and try to fill his time with activities as much as possible. Sergey usually brings Mitya to therapy once a week, picking him up early from school because he doesn’t have any other free time. On weekends, he’s sent to his grandmother’s place outside the city to get some fresh air.

At the first meeting, Mitya’s mother described him as follows: he’s very meticulous, he values ​​routine, he needs to know what’s happening and when, he always wants to do his homework, and he wants to eat what he’s supposed to for breakfast. Anna defined this as a “convenient child.” Interestingly, at the next meeting with both parents, Mitya’s image changed dramatically. Mitya’s father, Sergey, spoke, and in his account, Mitya emerged as a very unpleasant, intrusive, annoying, controlling, stubborn, capricious, lazy, and a nuisance to everyone. Anna supported him in this. The parents explained that Mitya’s interests are focused on reading and playing on his tablet. Mitya doesn’t play at home. Mitya doesn’t express his desires. His mother is surprised, saying that he doesn’t seem to need anything (although he loves chocolate, he never asks for it!), but can become aggressive if something doesn’t go his way. And aggression can escalate, from words to aggressive actions, if he’s not agreed with. However, this may only manifest itself toward, say, a less significant grandmother, and not toward his parents. If Mitya’s parents deprive him of something for educational reasons, he initially throws a tantrum, but then always thanks them. They also said he doesn’t like doing his homework, procrastinating until the last minute, and there’s no way to resolve the issue except through force and coercion. Mitya also “hates time” and doesn’t want to accept time constraints. This adds to the problem. Since Mitya has ritualized many aspects of his life, for example, if he wakes up late and needs to get ready for school quickly, he simply can’t leave until he’s done everything he’s used to in the morning. This leads to arguments.

Mitya is afraid of the dark, frightened by the images he sees in it. He sleeps restlessly, unable to fall asleep for long periods. Once a week, on weekends, he comes to sleep with his parents, forcing his father to move elsewhere. Anna doesn’t like sleeping with Mitya, as he tries to take up all the space, and it’s impossible to get enough sleep with him, but she and Sergei have been unable to stop this. Sergei explained that he himself slept with his mother for long periods, so he doesn’t see anything special about it. Thus, in their family, this situation is institutionalized. Mitya may be kept in the dark about a variety of matters, fearing the disclosure of “family secrets.” However, according to his parents, they have no secrets from Mitya. They have the impression that Mitya doesn’t need them, that he only needs them when he needs something from them. Mitya is very sensitive to his parents’ lack of attention, becoming capricious if he isn’t pitied or if something isn’t addressed. He takes criticism seriously, disagreeing, arguing, and denying the obvious. He only talks to significant adults (parents, grandparents) or when necessary (school teachers, doctors). Mitya doesn’t speak to other adults or children, but always tries to be close to adults (parents or teachers), explaining that he’s afraid of getting lost. At school, everyone knows about Mitya’s quirks and, according to his parents, is understanding.

At my first consultation with Mitya, I saw a silent 8-year-old boy, avoiding direct eye contact, and giving the painful impression of a child in a “stupor.”

Getting Started: Using Child-Centered Play Therapy

When Mitya’s parents brought him in for a consultation, I had a tool called ICTRT at my disposal. Wanting to test it out, I began working with Mitya using this approach. Carl Rogers (1994) and Virginia Exelin (2007) pioneered non-directive play therapy, the basic principles of which are as follows:

– each person is unique and can reach their full potential;

– people strive for self-actualization;

– trust, acceptance, spontaneity – this is what is important for building relationships between a psychologist and a client;

– ensuring a positive attitude in any case, empathic understanding – ensures positive growth of the client;

The primary focus of therapy is the client’s exploration of their feelings. Therefore, I began working with Mitya under the supervision of play therapists working in this approach, drawing on the principles of ICR and Rogers’ Triad: congruence, unconditional positive regard, and acceptance. Looking back on the beginning of this work, I realize that ICR gave me the tools that allowed me to quickly establish rapport with Mitya, engage with him, and build the basic trust necessary for the work.[1]

After conducting a few initial sessions, I began to realize that I couldn’t adhere strictly to this approach, that I lacked a psychodynamic perspective and an analysis of what was happening in therapy from the perspective of transference and countertransference. Therefore, I decided to seek supervision from a child psychoanalyst. When studying the work of psychoanalytic therapists, one can note that the first thing psychotherapists encounter is aggression, hidden behind a child’s passivity and uncooperativeness. Before a child begins to express aggression, the psychotherapist must do a great deal of work to gain trust and create a safe space. In Mitya’s case, the ICTCR allowed this to be accomplished quite quickly. The first four sessions were devoted to establishing rapport, trust, and creating a safe space. This was facilitated by comments given in the style of this approach. Given that Mitya had no previous experience with play, these comments helped Mitya feel less anxious, connected his actions with words, and subsequently allowed him to begin playing. Before this, it felt like Mitya’s actions were paralyzed by fear of harming himself and the therapist. We know that play is for children what free association is for adults. And free association is a connection between the inner and outer worlds through words. It took Mitya time to connect his inner world with the play through my words. Before the play, Mitya’s activity resembled a chaotic pacing around the room, trying to understand what he could and couldn’t do here, my relationship with him, and the degree of his safety in this space. By the fifth session, basic trust and safety had apparently been established. This allowed for a very strong aggression to erupt, provoked by replacing a leaky inflatable boxing toy with a larger one. From this point on, the sessions were devoted to reactive aggression and attempts to protect himself from his own aggression (Mitya tried to wear several masks and helmets at once). Mitya’s fear of punishment for displaying aggression began to manifest itself, and this was evident in his cautious attempts to attack me (bullets and grenades flew in my direction, as if by accident) and his careful monitoring of my reaction to these attempts. To reduce this fear, it was necessary to set limits in a restless and kind manner. Having assured himself that it was safe to express aggression in this space, Mitya gave free rein to it. During the fifth, sixth, and seventh sessions, Mitya furiously beat an inflatable toy and smashed everything on the shelves. It looked like a natural disaster; the aggression was undifferentiated. I made attempts to repel it, but they elicited nothing in Mitya’s response except, as it seemed to me, a “sadistic” grin. At the same time, something new appeared in our interaction. Mitya began to communicate with me through drawings. Mitya began to try to symbolize his aggression. But at the same time, the cancellation of aggression revealed his reluctance to acknowledge it. Countertransference feelings, however, told me that all of this was accompanied by intense anxiety and fear. The child began tracing various objects on the board, from a machine gun to a tank and grenades, which he then crossed out with pink chalk. Then Mitya began drawing something and marking it with a green checkmark. This reminded me of the airport instructions regarding prohibited items and substances. I told Mitya that he was drawing and crossing out prohibited items, while things marked with a green checkmark were permitted. My remark provoked a strong reaction from Mitya. He burst out laughing and began drawing more and more objects on the large board, crossing them out and then marking them with a checkmark. Then Mitya returned to Bobo (an inflatable boxing toy) and began beating him so hard that everything around him fell off the shelves. This clearly frightened him, and he put on a helmet and mask. When I said our time was up, Mitya left Bobo, nodded, ran to the board, and began furiously, loudly banging his chalk, crossing out and shading in the areas he’d marked with an X. Having displayed such aggression, symbolized in the pictures by a machine gun, a tank, and a grenade, he couldn’t walk away acknowledging it. It was as if something so dangerous demanded annulment. After this session, I had a meeting with Mitya’s parents. They told me that two small events had recently occurred that they couldn’t help but notice: Mitya asked a classmate for a pen and greeted a stranger at his father’s request. It’s safe to assume this was an attempt at the next step in symbolization, after Mitya had successfully expressed his aggression through actions in the sessions and then through drawing. During this meeting, some established patterns of behavior in the family and how they might affect all members became clear. My countertransference feelings also became much clearer during the sessions. Both parents had difficulty establishing direct contact, directly expressing their disagreements or desires, and expressing their feelings. They both avoid this, especially in situations of separation, but they don’t admit it. In such a situation, discussing conflicts and experiences becomes very difficult. It seemed that the internal boundaries in the family were very blurred, leading to a confusion of parental figures. Both Sergei and Anna were extremely anxious about their parental responsibilities and tried to ensure that everything was done correctly, demanding the same from Mitya. This led to Mitya feeling helpless in the face of demands that could not be met. The difficulty expressing feelings in the family added to his sense of helplessness and meaninglessness, forcing Mitya to resort to defenses such as infantile omnipotence and symptom-based control. At the very beginning of our work, it was very difficult to set limits for Mitya, and it seemed to me that the limits should be as gentle as possible. At first, I had the impression…I realized that Mitya’s parents set very strict boundaries for him. But then came the conviction that Mitya really values ​​these boundaries, that he’s grateful for them, and that they calm him. From what his parents told me, it was clear that they do indeed have many external demands on Mitya. But at the same time, they have a very difficult time setting internal limits, and they give in when they’re truly necessary. For example, with Mitya’s visits to his parents’ bed. Countertransference feelings that accompanied my work with Mitya and intensified during the meeting with his parents—boredom, guilt over it, a sense of inadequacy, and helplessness—which manifested themselves in my hesitant speech and in my attempts to devalue myself, my time, and my work—allowed me to consider that Mitya probably felt the same way with his parents. He tried to fit in, to be the best, but when he failed, he felt helpless. And his parents felt helpless and inadequate, which caused them to feel a strong sense of guilt. At this same meeting with the parents, something that would subsequently become a constant issue became apparent: sudden interruptions in work without the opportunity to discuss it or express the sadness of separation, just as with his beloved nanny. This manifested itself in the fact that, when discussing how to structure our work and interactions going forward, with summer vacation approaching, the parents expressed a willingness to bring Mitya to sessions during the summer. We had tentatively agreed on eight sessions before the vacation, but it turned out that the eighth session might not happen, as they had decided to leave. The seventh session was the last before the vacation. During it, events occurred that allowed us to understand the peculiarities of the mother-child interaction. Mitya’s strong dependence on his mother and extreme separation anxiety emerged. A hypothesis arose that this fear could hinder the child’s emergence from symbiosis and inhibit his further development, influencing the development of the symptom of selective mutism (SM). At the same time, Mitya demonstrated a strong need for a good attachment, one that allows for the safe placement of feelings. Also, during this session, it became clear to me that at this stage in my work with Mitya, changing his behavior is difficult, as his conflicts have deeper roots that require psychodynamic understanding.The feelings that accompanied my work with Mitya and intensified during the meeting with his parents—boredom, guilt about it, a sense of inadequacy, and helplessness—which manifested themselves in my hesitant speech and attempts to devalue myself, my time, and my work—allowed me to reflect on how Mitya likely felt the same way with his parents. He tried to fit in, to be the best, but when he failed, he felt helpless. And his parents felt helpless and inadequate, which evoked a strong sense of guilt. At this same meeting with his parents, something that would subsequently become a constant problem surfaced for the first time: sudden interruptions in work without the opportunity to discuss it and express the sadness of separation, just as with his beloved nanny. This manifested itself in the fact that, when discussing how to structure our work and interactions in the future, with summer vacation approaching, his parents expressed a willingness to bring Mitya to sessions during the summer. We had a preliminary agreement for eight sessions before the holidays, but it turned out that the eighth session might not happen because they had decided to leave. The seventh session was the last one before the holidays. During it, events occurred that allowed us to understand the peculiarities of the mother-child interaction. Mitya’s strong dependence on his mother and extreme separation anxiety became apparent. A hypothesis arose that this fear could hinder the child’s emergence from symbiosis and inhibit his further development, influencing the development of the symptom of selective mutism (SM). At the same time, Mitya demonstrated a strong need for a good attachment, one that allows for the placement of feelings in a safe environment. Also, during this session, it became clear to me that at this stage of working with Mitya, it was difficult to change his behavior, as his conflicts had deeper causes that required psychodynamic understanding.The feelings that accompanied my work with Mitya and intensified during the meeting with his parents—boredom, guilt about it, a sense of inadequacy, and helplessness—which manifested themselves in my hesitant speech and attempts to devalue myself, my time, and my work—allowed me to reflect on how Mitya likely felt the same way with his parents. He tried to fit in, to be the best, but when he failed, he felt helpless. And his parents felt helpless and inadequate, which evoked a strong sense of guilt. At this same meeting with his parents, something that would subsequently become a constant problem surfaced for the first time: sudden interruptions in work without the opportunity to discuss it and express the sadness of separation, just as with his beloved nanny. This manifested itself in the fact that, when discussing how to structure our work and interactions in the future, with summer vacation approaching, his parents expressed a willingness to bring Mitya to sessions during the summer. We had a preliminary agreement for eight sessions before the holidays, but it turned out that the eighth session might not happen because they had decided to leave. The seventh session was the last one before the holidays. During it, events occurred that allowed us to understand the peculiarities of the mother-child interaction. Mitya’s strong dependence on his mother and extreme separation anxiety became apparent. A hypothesis arose that this fear could hinder the child’s emergence from symbiosis and inhibit his further development, influencing the development of the symptom of selective mutism (SM). At the same time, Mitya demonstrated a strong need for a good attachment, one that allows for the placement of feelings in a safe environment. Also, during this session, it became clear to me that at this stage of working with Mitya, it was difficult to change his behavior, as his conflicts had deeper causes that required psychodynamic understanding.The seventh session was the last before the holidays. Events occurred during it that revealed the peculiarities of the mother-child interaction. Mitya’s strong dependence on his mother and extreme separation anxiety emerged. A hypothesis arose that this fear could be hindering the child’s emergence from symbiosis and inhibiting his further development, influencing the development of the symptom of selective mutism (SM). At the same time, Mitya demonstrated a strong need for a good attachment, one that allows for the placement of feelings in a safe environment. Also, during this session, it became clear to me that at this stage of my work with Mitya, it was difficult to change his behavior, as his conflicts had deeper causes that required psychodynamic understanding.The seventh session was the last before the holidays. Events occurred during it that revealed the peculiarities of the mother-child interaction. Mitya’s strong dependence on his mother and extreme separation anxiety emerged. A hypothesis arose that this fear could be hindering the child’s emergence from symbiosis and inhibiting his further development, influencing the development of the symptom of selective mutism (SM). At the same time, Mitya demonstrated a strong need for a good attachment, one that allows for the placement of feelings in a safe environment. Also, during this session, it became clear to me that at this stage of my work with Mitya, it was difficult to change his behavior, as his conflicts had deeper causes that required psychodynamic understanding.

By this time, I had attended a seminar by a world-renowned play therapist working in this approach, a student of the founder of the ITCR, G. Landrett, professor and chairman of the Israeli Association for Child-Centered Play Therapy. One of the topics of her seminar was working with children with selective mutism. She emphasized the importance of a multimodal approach in this work. In particular, she emphasized the importance of fostering motivation by giving the child the choice of remaining with the parent outside the office or going into the room with the therapist—that is, using behavioral therapy techniques alongside ITCR. This was important because by making this choice, the child learns to overcome internal barriers that may be the cause of their silence. I decided to use this approach in my work with Mitya. The results presented me with a choice: adhere to the principles of ITCR in my work with Mitya, incorporating techniques from other methods considered effective for treating selective mutism, or try psychodynamically oriented therapy. What happened was this: that day, I met Anna and Mitya in the hallway. We talked about the meeting with his parents and how today was the last meeting before the holidays. Then I offered Mitya a choice between playing in the classroom and talking in the hallway. Mitya seemed very confused. I commented on what was happening, and Anna remained silent at my request. Mitya became stupefied, turned to the window, and remained silent. Anna couldn’t bear it any longer and asked him to make a decision. Mitya replied that he didn’t like choosing and looked at her hopefully. I tried a few more times, but seeing that Mitya couldn’t make a decision right then, I made one myself. We went to the playroom. Mitya was clearly relieved, but upon entering the playroom, he displayed extreme anger. He attacked Bobo with a fury he’d never seen before. Finally, kicking him toward the door, he picked up the balls and began smashing the dollhouse with them. Having expressed his anger in this way, Mitya calmed down a bit and began drawing. Mitya spent the rest of the session reconnecting with me. I felt the loss and restoration of this connection as the loss of the ability to understand what Mitya was trying to tell me through his drawings, and the return of that understanding. Mitya was busy drawing for quite a while, diligently drawing circles on the board and connecting them with lines, filling them with sand, and also joining together Kinder Surprise egg halves. It was clear he was pleased with his work. And I felt calm after the horror I’d experienced in the hallway, forcing Mitya to make an impossible choice between the therapist and his mother. At that moment, I had a fantasy of a powerful force of nature, before which a small person was helpless and pitiful. And pitting a child against this force of nature seemed like violence. I felt I couldn’t use such methods on a child. At the ITCR, I began to lack the tools to work with a silent child. My need to think in a psychodynamic way became decisive in my decision to have the work I’d done supervised by a child psychoanalyst and to adjust my future work within this framework. And Mitya, having reestablished contact with me, made clear signs that he wanted to leave his drawings with me, vigorously confirming my assumption that he was leaving them so I wouldn’t forget about him during the holidays.

The seventh session turned out to be the last one before the summer holidays. I had to decide how to structure my future work. My parents expressed their willingness to continue working during the summer. I, too, was interested in continuing without interruption. But what would be best for Mitya? Would working during the holidays be stable enough? What would be less traumatic for Mitya? A long separation with the opportunity to internally process the new relationship experience, or additional experience with potential relationship breakdowns? At the time, the first option seemed more acceptable, and we said goodbye to Mitya for the entire summer holidays.

During the break, I discussed this work with a child psychoanalyst during supervision. As a result, several conclusions and hypotheses were drawn. Mitya’s story reveals that difficulties in mother-child interactions were present from birth. Anna’s ambivalent feelings about her pregnancy, the birth, and breastfeeding influenced the formation of attachment. Difficulties in mutual adjustment influenced Mitya’s development from the earliest stages. This influence was also evident in problems with toileting (first using a gas tube, then defecating only in the shower to the sound of running water). Aversion to innovation, a strong dependence on established rules, pedantry, and difficulty establishing trusting relationships (manifested in Mitya’s reticence to reveal the content of his fears, which haunt him in the dark) indicate a high level of anxiety. Difficulties in asking for help and expressing desires may also indicate an intense anxiety burdening the parental figures. As is well known, aggression is associated with the anal stage of development. Mitya suppresses aggression, fearing to express it, and the resulting separation anxiety hinders his exit from symbiosis (heavy dependence on significant adults). Problems at the anal stage lead to all parental figures taking on a maternal aspect, which further complicates separation from the mother and further development. Mitya’s separation anxiety is clearly evident in all separation situations. It can be assumed that the intensity of this fear influenced the development of a defense mechanism called affective isolation. This is clearly illustrated by the example of his beloved nanny, whose separation did not elicit an emotional reaction in Mitya.

 Our interactions were also fraught with anxiety. During the first few sessions, Mitya left behind a perfect room, as if he hadn’t even been there. He followed all the rules I outlined, ending his activities as soon as the time was up, on demand. He felt the need to mix regular sand with kinetic sand, bury aggressive objects, and wipe the board clean after drawing. My comments about his feelings were accompanied by a chuckle, leaving a sense of their inappropriateness and futility. The boredom that periodically arose in my sessions evoked feelings of guilt and fear. It seemed as if Mitya wouldn’t want to come. This suggested strong, repressed feelings, both in Mitya’s and his parents’. Aggression, as mentioned above, was experienced from the very beginning as intense anxiety and fear. Mitya also attempted to defend himself, particularly with the aid of several masks and helmets, which he donned after a timid attempt to punch an inflatable boxing toy. The intensity of Mitya’s aggression is demonstrated by the fact that over time, in a safe environment, it developed into a rage that swept away everything in its path. And, of course, it was impossible not to notice that a similar way of dealing with aggression and anxiety existed in the family system. For both parents, aggression was unacceptable and caused resentment. In the countertransference, high levels of anxiety and aggression were felt, emanating from both parents. But these feelings were not acknowledged and remained unavailable for discussion.

From silence to word and back to silence again

After the holidays, I saw a different Mitya. Entering the office, he spoke to me as if nothing had happened. I felt delight and gratitude towards him. For me, this was a sign of trust. And while outside the office door, when parting with his parents, he was still the same hesitant boy, needing their approval to enter the office. Once inside, Mitya became an active, calm child, knowing exactly what he was doing. One might think that suppressed aggression and the opportunity to express it were the main factors in the development of his selective mutism. But further developments led me to believe that aggression was only one of these factors. The next few sessions once again demonstrated Mitya’s strong need for a good attachment. And even the very beginning of such a relationship allowed him to use his aggression and demonstrate his ability to develop. And the opportunity to place his feelings in a safe environment helped Mitya discover his inner space and begin to explore it. As a result, he began to express his aggression verbally. Mitya was very sensitive to the needs of those important to him. This was evident in how Mitya chose only those new toys that he considered important to me: he chose crayons in response to my remark that he’d drawn a lot with them before the holidays; he agreed to my suggestion that I add other drawing supplies to his box. He chose nothing else, as if preventing the emergence of anything of his own, something disapproved of by his “therapist mom.” Here, one might assume that Mitya was holding back aggression, which was not considered acceptable in his family but was also a source of growth. Despite this, Mitya eagerly embraced the new toys that were now available to everyone. He rejected the familiar inflatable boxing toy, which was likely laden with past undifferentiated aggression. But now he began mastering the technique of shooting a new slingshot, which required from him not just aggression, but perseverance and the ability to develop. Mitya also developed a new game, which continued throughout subsequent sessions in various variations. He discovered a space in an unexpected place. There, Mitya began placing carefully selected objects, first sketching them on the board and then on a piece of paper. It looked like a list of the contents of his “secret box,” only written not in words but in schematic images. It reminded me of the cave paintings of primitive people, before writing, and perhaps even words. Perhaps this was a demonstration of the foreignness of words for Mitya, the impossibility and meaninglessness of conveying meaning through words. But even though Mitya seemed calmer and more confident than he had been before the holidays, countertransference feelings awakened in me a desire to care for him, to create a safe environment for him, like in a womb. At the same time, his helplessness and indecisiveness (for example, when choosing new toys) irritated and frustrated me. This would then trigger feelings of guilt, awkwardness, and a desire to please. It seemed Mitya really wanted to live up to his parents’ expectations. This was evident when he stuck all the darts in the center of the dartboard and looked at me proudly. He needed every dart to hit the bull’s eye. The reality is that he can develop and be as persistent as a slingshot only with kind support, but not under coercion or suppression. This was vividly illustrated by one moment in the session when Mitya needed to go to the bathroom but remained silent. Something compelled me to ask him directly about it. I could see how angry he became with me, rushing for the weapon and starting to beat up the inflatable boxing toy, which he hadn’t used in a while, but refused to admit. Having expressed his anger in this way, Mitya was able to show independence and express his desire to go to the restroom. After spending about 10 minutes there, he emerged with a mature idea, which he immediately began to implement. He began mixing multicolored kinetic sand using various tools. The tools weren’t satisfying, and after some thought, Mitya turned to his list diagram for help. Finding the hammer he needed, Mitya quickly found it and was delighted. It looked, and then sounded, like a major discovery: “I tried to figure it out! And I got it! I figured out where that hammer is!”

Mitya confidently and joyfully continued his research, mixing, shaping, and breaking kinetic sand with the hammer. In my countertransference, I felt disappointed at that moment, as if I’d been expecting a brilliant discovery and my anticipation had been dashed. One might imagine Mitya’s parents might feel the same way, frustrated by his silence and the difficulties and inconveniences that came with it.

Countertransference feelings that periodically arose in me, when at certain times I couldn’t utter a word, feeling stupid, yet yearning to say something. Mitya can also be “paralyzed” and silent because he feels stupid and inadequate to expectations and demands. But in this session, he was able to make a discovery and formulate it in words, taking advantage of his independence and the space afforded for that independence. Metaphorically, one could say that this trip to the toilet symbolized liberation from verbal constipation. The blockage, the channel of communication between the inner and the outer, was cleared!

And for me, this was a very important moment, because I suddenly saw very clearly in front of me a child, with his values ​​and discoveries, which may not correspond to my values ​​and expectations, but deserve deep respect.

In subsequent sessions, Mitya discovered the potential for independence and activity in the office space. He began to actively explore this space, build connections, and then find ways to protect it. In the office, this manifested itself as an extension of his game with the “secret box.” Mitya filled it with objects important to him, attempted to establish connections between this “secret box” and other objects in the room using wires and radios, and sketched these connections first on the board and then on a piece of paper. It was noticeable, especially in the drawings, that the more immersed he became in his “secret box,” the further he became from concrete, material objects, the more confused his inner world became, and the more intermittent his connection.

This game continued with the construction of a fortress, which included his “secret box.” Here, for the first time, Mitya was able to verbalize his negativity, anger, and aggression toward the outside world, which he perceived as hostile and dangerous, requiring either defense or attack. This was clearly evident when Mitya fired at everything from the fortress he had built and invented other methods of defense, accompanying these with the words, “You could pour ketchup on top of it. You could also pour mayonnaise in there and throw a banana peel. No one would even get close. They’d slip and fall!” But he took the radio and microphone with him to his fortress. He still needed communication, and now he had someone to establish it with in the outside world! During the work with Mitya, another meeting with his parents took place after a long break. It demonstrated the increased tension in the family system due to Mitya’s changes. The parents’ ambivalent feelings toward therapy intensified, causing them to rejoice at the changes on the one hand, and feel unwanted and abandoned on the other. This led to increased anxiety, guilt, helplessness, and despair, which, in turn, led to increased control. This suggests that Mitya’s silence was maintained by the symbiotic family system, which felt the need for this symptom for its own stability.

At this meeting, the parents shared details of how Mitya had begun to speak. They explained that after moving to the countryside to visit relatives, Mitya began communicating freely with the entire family and all the children in the area. However, Anna and Sergei recounted this in a way that cast doubt on the value of this experience. Perhaps this was a manifestation of the parents’, especially his mother’s, jealousy toward Mitya’s therapy. It can be assumed that Mitya’s new experience in therapy, the opportunity to express his aggressive feelings in a safe environment, coupled with Mitya’s placement in an extended family environment different from his usual one, where he was forced to communicate extensively, allowed Mitya to acquire the “gift of speech.”

Mitya’s parents were very disappointed that Mitya had gone silent as soon as he returned from vacation and found himself in a familiar environment. Sensing their disappointment, I quickly announced that Mitya was talking to me and that this was a very important event. At that moment, in my countertransference, I felt regret for saying it. It was as if I’d revealed a secret from our parents, as if they didn’t want him to talk to anyone else. Could this mean there was a danger that Mitya would fall silent again, resolving the loyalty conflict in his parents’ favor? At this meeting, the blurred boundaries in this family system were once again evident (sleeping in his parents’ bedroom is fine, but there are no secrets from each other). Mitya’s attempts to leave this relationship were met with intense anxiety, guilt (“What have we done wrong that Mitya is keeping secrets from us?”), and increased control (“If we don’t know everything about Mitya, how can we help him if something goes wrong?”).

Unexpectedly, they shared with me their thoughts about sending Mitya to a boarding school attached to a military academy after fourth grade. It was as if there was no longer any way to maintain the connection (“He doesn’t need us; he only turns to us when he needs something from us”). It was clear that within this family system, there were ideas about how things should be, how things should be (ideas about how Mitya should be, among others), to which the child’s parents held dearly. And there were difficulties in verbally communicating their desires and feelings to each other. Each parent, expressing their opinion, spread it to the entire family, unaware that it might conflict with the opinion of another family member. Mitya’s parents’ attitude toward the outside world, from which the family system shuts itself off, unwilling to “air its dirty linen in public,” also became apparent. And Mitya’s silence seemed necessary so that he wouldn’t “blab to anyone” about undesirable family events.

In this conversation, it became clear that Mitya’s parents had a highly ambivalent attitude toward Mitya and his symptoms. On the one hand, they wanted him to speak, as it conflicted with their ideas of what was right and how things should be, while on the other hand, they wanted him to remain silent about things considered unacceptable in the family. Starting with the next session, Mitya began to curtail his verbal communication. This could be attributed both to the influence of the family system and to the fact that, gradually moving away from the ICR technique, I began to remain silent more, giving Mitya more space. Our verbal communication largely depended on my active participation. Mitya responded only to my comments, not being as active himself, so I often encountered feelings of guilt about this. This feeling of guilt led me to believe that Mitya’s silence might also be due to his own feelings of guilt when he was unable to say or do anything useful in line with adults’ expectations. As I became more silent, he gradually became silent too, but he began making various sounds during play, sometimes resembling the grunts of a toddler sitting on a potty. And in this silence, powerful feelings began to emerge very clearly.

The fight for the “secret box.”

At this stage of therapy, the process of containment became very evident. Safe conditions were created for Mitya to express his intolerable feelings: hopelessness, helplessness, loneliness, intense anger, disappointment, and the futility of words. Projective identification allowed the therapist to contain these feelings, process them with his more mature mental functions, and return them to Mitya in a more acceptable form. This allowed Mitya to discover his inner space, begin to explore it, utilize it, and establish internal boundaries. It became clear that for Mitya, words were, on the one hand, imbued with aggressive, threatening connotations, and on the other, meaningless, since expressing one’s desires with blurred boundaries was pointless. Internal resistance to verbalization emerged, partly due to a conflict within the family system between the conscious desire for Mitya to speak and the unconscious desire for him to speak only to his parents.

During the next session, Mitya discovered the ransacked “hiding place” and began frantically rebuilding its contents, then burying the grenades in the sand, as if frightened by the intense anger that had flared up within him. In the countertransference, I experienced feelings of hopelessness and futility, as if I needed to say something but couldn’t; words seemed meaningless. I was overcome by boredom, which was likely also a sign of very strong feelings being suppressed. But at the same time, I became confident in the importance of this relationship and that if I couldn’t process and experience this with Mitya, then Mitya wouldn’t be able to overcome his selective mutism. Containing Mitya’s disappointment and anger, including at me for failing to preserve the “hiding place” (the office is used by many therapists) for him and supporting his interests, allowed him to advance in his game and begin to seek ways to protect his “secret box.” This search continued for several sessions and consisted of building a fortress around the hiding place, shooting at it, and throwing grenades at everything outside the fortress, including attempts to shoot at me. He did this in complete silence, which can be explained by the importance of words for Mitya, which was revealed in my fear of the inappropriateness of words when I spoke of his anger and set limits on shooting at me (“You hit me; you’re probably very unhappy with me, but you shouldn’t shoot me; it’s better to say it in words”). It seems that one of the reasons Mitya withholds words is that he imbues them with a threatening, destructive force. The actions with which Mitya is accustomed to expressing himself are less threatening than words.

These sessions took place against a backdrop of hopelessness. The inability to establish and maintain a “hiding place” (discovering it as being emptied session after session) and to protect its boundaries may be linked to Mitya’s maintenance of his symptom, which now, for him, is a “hiding place” that no one can penetrate. Therefore, it seemed to me that the task of therapy at this stage was to create conditions in which the therapist would become an object that does not intrude into the “hiding place,” into Mitya’s inner space, treat it with respect, and experience Mitya’s sorrows and joys with him. This is an undoubted prerequisite for any psychotherapeutic work, but for Mitya, it could become the very condition that would help him build a “hiding place” in his inner world and protect it, renouncing the symptom. These thoughts of mine were also confirmed by the countertransference feelings that arose during this period of work. Mitya had been doing something in his fortress for quite a long time. I could only guess at what he was doing. Sometimes I wanted to get closer, to take a closer look, sometimes to say something about it. But I remained silent, feeling relieved by the feeling of separateness and the opportunity to give Mitya freedom and space. At the same time, an opposite feeling arose. I felt bitter resentment at the fact that he was hiding from me, unwilling to share with me, and untrusting of me. It seemed to me that he was retreating into a shell, like behind this screen, but I had to respect his wishes, his inner space, which he didn’t want to let me into. Apparently, this indicated that his silence and desire to hide were connected to his parents, to the impossibility of having a secret place that was constantly being raided. And the reward for non-intrusion and respect was the warm feeling of openness that came at the end of the sessions.

Another raid on Mitya’s “hiding place” led to the development of this game. Mitya transferred the “hiding place” to a box, which he could fill with important items and carry around while building his fort. This brought Mitya satisfaction, who devoted extended periods of time to exploring his inner space, relying on respect and the opportunity provided. The clicking and clucking sounds of his tongue, and, in moments of particular intensity, the sounds of the baby grunting on the potty, suggested the possibility of speech development under the protection of this relationship.

The discovery of a damaged boxing toy by one of the children visiting the office during one of the sessions, followed by its replacement with a new one, exacerbated feelings of insecurity, loneliness, and devastation. The unexpected two-week break that we were about to take further contributed to the sense of disconnection. This latter circumstance confirmed the difficulty of verbalizing the family system, and the blurring of internal boundaries prevented Mitya from being seen as an individual with the right to self-determination and his own desires, which could be expressed verbally.

As I’ve already written, Mitya’s symptom could have been caused by a conflict within his family system between his parents’ conscious desire for Mitya to speak and his unconscious desire for him to speak only to them. Under these circumstances, the conflict of loyalties cannot go unresolved. To feel safe, Mitya needs to trust his parents and distrust the outside world. The development of this game, involving exploration of his inner space and attempts to find ways to protect it, with respectful provision of this exploration, shared experience of difficult feelings, the therapist’s processing of these feelings, and attempts to return them in a form accessible to the client, led to Mitya finding a way to protect his “secret box” by fortifying it, placing it in its previous secret place, and booby-trapping its door. Mitya was satisfied with the work accomplished, and we both experienced the joy of the security of protection, despite the unsafe surrounding world. The game moved to the next stage. And the influence of the family system became even more pronounced.

The importance of working with parents in child psychotherapy

Projective identification is the earliest form of communication between mother and child, when the child invests their unbearable feelings in the mother, who then mentally processes them and returns them to the child in a more acceptable form. This process of containment largely determines the child’s favorable development, including their thinking and symbolization. To address developmental gaps, therapy must first establish this process, which it did. This allowed Mitya to express his feelings first through actions and then through words, thereby reducing anxiety and separation anxiety. But it became clear that creating a container in therapy was not enough; it was necessary to help establish the process of containment between the child and parental figures, primarily the mother. In our case, this was complicated by the pattern of relationship breakdown that was evident in this family system. Our work with Mitya progressed dynamically, gradually weakening defense mechanisms such as affect isolation, infantile omnipotence, and control. This allowed him to attempt to integrate the good and bad objects, thereby reducing the splitting and, perhaps, taking a step toward the depressive position and the Oedipus complex. However, the “sword of Damocles” of constant ruptures threatened this work throughout. At the same time, the parents’ denial of their feelings and the inability to discuss them also created difficulties in establishing contact with them, to begin establishing the process of containment between them and Mitya.

Mitya’s play shifted to a sandbox with kinetic sand, where he continued to build fortifications and role-play the destruction and restoration of these fortifications. He painstakingly and slowly constructed a world within the sandbox, strengthening the fortress wall and then destroying it with the help of two shells, seemingly symbolic of his parents (one long and sharp, the other rounded with a longitudinal hole). The entire game took on a more symbolic meaning, as if it had reached a second level, like Mitya’s drawings, which required first sketching on the board what was being played with the toys and then more symbolically depicting them on paper. I imagined that the next, third level would be conversation and expressing one’s experiences in words.

But for now, Mitya was mastering the second level, playing out brutal battles in the sandbox, involving aggression, invasion, destruction, helplessness, and hopelessness. This period of work was accompanied by strong countertransference feelings: helplessness, hopelessness, loneliness, a breakdown in connection, and the impossibility of establishing continuous contact. Mitya’s parents’ fear of interrupting therapy and a sense of increasing aggression and jealousy, despite Mitya regularly attending sessions, indicated increasing tension in the family system. This parental ambivalence was also clearly evident in reality. Mitya’s parents took breaks, informing me at the last minute. At first, they readily agreed, but then refused to attend parent-teacher meetings, citing work commitments and the fact that they were studying “literature, dissertations, and foreign publications” on the topic of SM and had a host of questions. After the break, I forgot to talk to Mitya about this, even though it had always been a very important topic for me, one that couldn’t be ignored. Thus, Mitya found himself in a very difficult situation. On the one hand, he sensed his parents’ resistance to something new and valuable emerging in therapy, something that posed a threat to his symptom, which ensured his complete dependence on them, but he couldn’t resist this resistance. On the other hand, our relationship was becoming increasingly important to Mitya. Mitya would come after the break and pick up where he’d left off in the session before the break, over and over again, tearing down and rebuilding his fortress, playing out feelings of anger, hopelessness, and loneliness, and rebuilding broken connections. One day, after a fierce fight in the sandbox, Mitya spent a long time crafting a flag, which he proudly hoisted over the ruins of the fortress. He then wanted to keep it, which we did, placing it in Mitya’s box. Finally, Mitya was able to ask for help. We know that he always had difficulty asking for help and expressing his wishes.

It can be assumed that the symptom became an expression of his infantile omnipotence and control, which helps the child cope with severe anxiety. The symptom became a kind of “omnipotent silence,” the silence of a child who needs nothing, yet desperately needs it.

After a dramatic situation in which he needed his flag, he tried his best to retrieve it, but couldn’t get it from the box high on the shelf. At that moment, I was able to connect his sandbox play with the overturned, helpless ambulances with my countertransference feelings of helplessness, despair, and desire to help. This allowed me to interpret that it seemed as if no one around him could help. And Mitya immediately took advantage of this and spoke. And his words were completely different from before. They were spoken in a whisper, as if apprehensively, as if testing their effect. But these were words that Mitya wanted to say himself, wanted to ask for help. And he received that help.

From that moment on, a change occurred that I couldn’t help but notice. Specifically, our communication with Mitya, as well as with his father, became more open and warm. I felt it in the joy of meeting, in the open gaze of Mitya and his father. I felt it in the warmth of the sessions and the opportunity to silently share both the shared space, preserving our inner space, and difficult feelings. These difficult feelings, such as anger, impotence, helplessness, and even terror, were connected to the upcoming separation for the winter holidays, with all the previous sudden separations. I began talking about the holiday separation a few sessions before the incident with the inflatable boxing toy, which was repaired and returned to the office. During this period, the fear of a sudden breakup intensified, which in fact happened when the second-to-last session, which ultimately turned out to be the last, was almost canceled. During this session, Mitya took out all his anger on the boxing toy for the previous breakups and for the breakup for the holidays and pierced it with a plastic dagger.

In the countertransference, this hurricane of emotions felt like freely flowing energy for the first time! And suddenly it ends in catastrophe and horror! A rupture that seemed irreparable! I managed to cope with my feelings and suggested to Mitya, reflecting all these feelings, that we repair the toy together. Horror experienced in isolation differs from horror experienced with someone supportive. A hurricane of emotions doesn’t feel like the end of the world, and a situation of hopelessness turns out to be fixable. And this torn inflatable toy became a metaphor for our entire work. With this, Mitya left for winter break, having already started a new game in the sand during the last session, burying shiny pebbles, which he left for me to keep, perhaps for safekeeping, or perhaps as a New Year’s gift or as a thread connecting the old and the new. I developed and remained afraid that Mitya’s parents would take him out of therapy. Although Sergey became calmer and more open, I sensed increasing resistance from Anna and growing tension within the family system. And although we were unable to meet with Mitya’s parents for parental counseling, I hope that in the New Year we will be able to take a step toward better communication.

Discussion

In her work, M. Klein places great importance on the first object relationships, namely, the relationship with the mother’s breast, which forms the basis for the favorable development of mental functions. The development of a stable projective-introjective process in the infant’s psyche is influenced by their innate characteristics, the mother’s mental structure, and the external environment. “A good breast is accepted internally and becomes part of the ego, and the infant, who was initially inside the mother, now accepts the mother internally. Klein believes that a favorable “romance with the breast” is also influenced by the infant’s well-being in the prenatal period, which is directly related to the mother’s psychological and physical state during this period, the processes of birth, feeding, and the external environment of the dyad. “During further development, it is important whether the mother enjoys caring for her child or is anxious and experiences psychological problems related to feeding—all these factors influence the child’s ability to accept milk with pleasure and internalize a good breast” (Klein, 2010). Klein believes that a child’s capacity for love and hate is innate, although the degree to which they are expressed depends on external factors. “The struggle between the life and death instincts and the resulting fear of self- and object-destruction through one’s own destructive impulses are fundamental factors in the infant’s initial relationship to the mother” (Klein, 2010). From Mitya’s story, we learn of her mother’s intense ambivalence regarding the unplanned pregnancy. Her anxieties and doubts persisted throughout the pregnancy, leading to the idea of ​​a cesarean section in the absence of medical indications and the pronounced hostile experiences that accompany breastfeeding. These facts suggest a complex internalization of the healthy breast, difficulties in experiencing the primary Oedipal situation, and a transition to a depressive position. Mitya’s psychological characteristics, such as a high sensitivity to the needs of his mother-therapist (fulfilling the mother-therapist’s wishes, but not his own), severe anxiety (poor sleep, fears), and low frustration tolerance (avoidance behavior, denial of desires), can be linked to Mitya’s early development. The characteristics of Mitya’s family environment, where all aggressive and destructive behaviors are suppressed, where a pattern of silence is pronounced, and there is a prohibition on discussing difficult and unpleasant aspects of life, especially outside the family (“not airing dirty linen in public”), lead to his overflowing with destructive feelings and the need to maintain a symbiotic fusion with the maternal object, leading to the emergence of the symptom of SM.

Containment became the primary goal of therapeutic intervention. The process of containment is based on projective identification, as described by Klein. D. Riveri writes that projective identification “is the fantasy of introducing all or part of the self into an object to gain power and control over it, either through love or hate” (Riveri, 2001). Klein herself, in her work “Notes on Some Schizoid Mechanisms,” describes this process as follows: “Along with… the harmful excrements, the hated, split-off parts of the infant’s self are also rejected and projected onto the mother, or, I would rather say, into the mother. These excrements and bad parts symbolize not only damage to the object, but also possession and control over the object. … This leads to the emergence of specific forms of identification that form the prototype of an aggressive object relationship. I propose to use the term “projective identification” to describe these processes (Rivery, 2001). A little later, Klein clarifies that not only bad but also good parts of the self can be projected, which, however, is not always beneficial for the infant’s psyche, as it leads to ego depletion. Nevertheless, she emphasizes, “the process of splitting off parts of the self and projecting them onto other objects… is a vital component of normal development, just as it is important for the formation of pathological object relations.”

W. Bion expanded the concept of “projective identification” and began to view it as a primitive form of communication between mother and child (therapist and patient), when the child places unacceptable parts of themselves into the mother, simultaneously forcing her to experience these parts as her own. Bion called this process “containment” and believed that it directly influences the development of thinking and speech, since the development of the ability to symbolize depends on the mother’s containment of the child’s anxieties, her processing of these anxieties through her more mature mental functions, and their return to the child, processed in the form of feeding, rocking, words, and intonations. Bion believed that the failure of containment is due to both an unfavorable innate predisposition of the child and an unfavorable environment. An unfavorable innate predisposition is characterized by such characteristics as high anxiety, poor tolerance of frustration, a predominance of destructive impulses, and an insurmountable conflict between the drives for life and death. By “unfavorable environment,” they meant an object inaccessible to projection. Such an object is experienced by the infant as an additional source of disruption to connections.

If an infant is endowed with such innate characteristics as intolerance of frustration and heightened anxiety, and their environment is unable to contain their projections, their anxieties escalate to the point of terror, and the infant’s ability to utilize the rudiments of thinking to reduce these anxieties is lost. As a result, splitting and projective identification are overused, while the processes of linking, processing, and modification are inhibited or do not occur at all. In Mitya’s case, we can assume that a dysfunctional family situation before his birth and his prenatal history may have predetermined this innate predisposition, while a maternal figure was also difficult to access for his projections. Favorable circumstances in Mitya’s history included the presence of a father who was somewhat receptive to Mitya’s projections, as well as a nanny who, according to his parents, was loving, warm, and attentive to Mitya. I think that, despite the problems with containment at the earliest stages of development, these became the factors that allowed Mitya to develop thinking and speech, albeit with some impairments.

Speech provides the opportunity to symbolize and express fears, anxieties, and desires, which proved difficult for Mitya, as disruptions in his thought processes meant that words, for Mitya, were imbued with a destructive object, an aggressive meaning that was dangerous to Mitya himself. In our work with Mitya, containment became the basis of therapeutic communication. If containment is inadequate, when the object fails to process intense feelings through its more developed mental functions, the infant’s ability to develop his own container capable of such processing is inhibited.

The case description clearly demonstrates how Mitya was constantly busy constructing his container, which initially had no place at all. It needed to be reclaimed and defended, filled and emptied, tested for strength, and new connections forged. Mitya’s play and drawings clearly demonstrated the difficulties of the thought and symbolization processes, as well as the intensity of the splitting into good and bad objects. The good object was represented by the merged parental figure, while the bad object was projected externally. It represented danger and was the target of aggression, so there was no point in talking to it. The therapist periodically became the representative of this bad object during therapy. However, the atmosphere of acceptance and satisfactory containment allowed Mitya to attempt, in the final sessions, to integrate the good and bad objects, reduce the splitting, and perhaps take a step toward a depressive position.

The transition to a depressive position can be considered, according to Klein and Bion, a condition for the development of thinking and symbolization, resulting from the development of types of identification—that is, types of experiential processing in which internal space acquires an additional dimension, time, and thus the possibility of separation, the possibility of psychic representation and symbolization of the absence of a real object, and the recognition of the limitations of one’s omnipotence and dependence on reality. Initially, Mitya used his silence both as an omnipotent control and as a refusal to accept reality and acknowledge his dependence on it and on time, and thus the awareness of his separateness. During therapy, the “toilet” theme became a vivid illustration when Mitya managed to overcome his “verbal constipation” and, for the first time, was able to articulate the connection he had made (“I tried to understand. And finally I understood! I understood where that hammer was!”).

Thinking is a creative process, and problems with vital functions such as feeding, elimination, and breathing can adversely affect the creative process of thought and symbolization. In Mitya’s case, the elimination problems he had had since birth, possibly also a consequence of his mother’s poor attunement to the infant, led to a disruption in the transformation of his experiences into thoughts and, subsequently, into words.

Meltzer D., developing Bion’s theory of thinking, identified five aspects of mental life as necessary conditions for the development of language:

Desire to exchange ways of thinking and information;

The need to have an object with a non-illusory mental reality towards which language can be directed;

Introjection of the object of speech, based on which, through identification, the grammatical music of linguistic sentences can be mastered;

Mastering vocabulary through the use of masterfully repetitive babble to put dream thoughts into words, accessible for use both internally for thinking and externally for communication.

Sufficient mental apparatus for the generation of dream thoughts acceptable for thinking and memory (Meltzer, 1974).

Observations during therapeutic work suggest that Mitya has developed a sufficient mental apparatus as a basis for thinking and symbolization, and has mastered a vocabulary that can be used both internally and externally for communication. However, disturbances in projective-introjective interactions with the primary object complicated introjection and identification with the object of speech, which turned out to be excessively fragmented, leading to difficulty in developing inner speech and a lack of desire to exchange thought patterns and information.

From all of the above, we can attempt to formulate the factors influencing the formation of the symptom of selective mutism in the clinical case under consideration:

Mitya’s unfavorable prenatal history led to a high level of anxiety, poor tolerance of frustration, and a predominance of destructive impulses.

The mother’s inadequate containment, which could have led to a disruption of Mitya’s vital functions of nutrition and excretion, disrupted the processes of splitting and normal projective identification, and as a result, led to some disturbances in the process of thinking and symbolization, expressed in the endowment of words with frightening meanings, such as murderous, destructive force, omnipotent control;

Symbiotic fusion with the object represented by the merged parental figure, the intensity of separation fears, which complicate the transition to a depressive position, and the possibility of working through the Oedipal situation.

Mitya’s clinical case allows us to consider selective mutism not only as a communicative disorder, but primarily as a defense against intolerable affects associated with early object relations. Psychoanalytic authors (M. Klein, W. Bion, D. Meltzer) emphasize the role of early interactions with the maternal object in the development of the ability to symbolize, think, and speak. In Mitya’s case, difficulties with containment, expressed in the inability to process his anxieties, were particularly significant. This, apparently, led to the child’s use of silence as a form of control and defense against the destruction of internal boundaries.

As demonstrated in this study, the initial phase of therapy, implemented within the framework of the ICTCR, enabled the establishment of basic trust in conditions of complete verbal isolation. This highlights the potential of humanistic methods in overcoming initial mistrust and creating the conditions for subsequent psychoanalytic work. However, manifestations of intense aggression, anxiety, guilt, and dependence on parental objects became evident even in the early stages. A shift in therapeutic focus to psychoanalytic isolation, with an emphasis on transference and countertransference, revealed that the symptom of silence is maintained not only by individual defenses but also by the entire family system. Emotional fusion, undeveloped boundaries, the inability to express feelings, and the presence of an ambivalent “tell/don’t tell” message led to the symptom fulfilling an important adaptive function, maintaining the child’s loyalty to the parents.

These observations are consistent with the conclusions reached in previous theoretical analyses of the psychoanalytic understanding of selective mutism (Vasilieva, Yangerman, Berko). In each of the cases examined, the symptom was viewed as the result of complex interactions between parental projections, separation fears, and the inability to integrate affects. As in Yangerman’s observations, the therapeutic movement from action to symbol, from silence to speech, was accompanied by intense emotional experience—for both the child and the therapist. In Mitya’s case, these experiences were reflected in play, drawing, bodily reactions, and a shift in focus from expressive activity to selective contact and verbalization.

The gradual formation of a “secret box” as an image of inner space observed during therapy, the experience of its destruction and restoration, and the transfer of these experiences to the relationship with the therapist indicate the development of the ability to symbolize and create one’s own “container”—an inner space capable of holding and processing emotional experience. This suggests a genuine psychological transformation occurring within a stable, accepting, and non-intrusive relationship.

Despite the family’s interruption of therapy, the case can be considered a success: several months after the end of the therapy, the child began speaking, the symptom did not recur, and subsequent adaptation was successful. In this context, working with parents and recognizing unconscious processes in the family system and parental figures became particularly important.

Conclusion

Working with Mitya confirmed that the symptom of silence is not only a denial of speech but also a way to exist in relationships, maintain intimacy, and express hidden aggression and vulnerability. Silence became a language through which the child could be heard—before he could freely and safely speak verbally. Thus, Mitya’s clinical case demonstrates the potential of psychoanalytic thinking within the framework of integrative therapy, in which the symptom is not suppressed but becomes a guide to restoring development.

Today’s understanding of selective mutism has been shaped by research in fields such as psychiatry, neurology, and cognitive behavioral approaches. Researchers and clinicians have done extensive work classifying mutism and SM, identifying diagnostic criteria, and identifying its causes. However, diagnostic criteria are still being refined, and the causes of SM are so broad and diverse that the etiology of this disorder remains unclear. SM has a detrimental impact on a child’s development and emotional life, so developing effective treatment is crucial. However, since SM is a relatively uncommon disorder (1%), this negatively impacts research in this area.

Research on the psychodynamic approach is currently very limited, and it consists of case reports. This is because formulating a unified psychodynamic hypothesis is difficult, and creating a unified treatment algorithm is impossible, as it is not the symptom that is being treated, but the child’s specific personality within their family environment. Despite this, a psychodynamic understanding of SM can be very useful in understanding its nature and causes.

Based on the above and summarizing the conclusions drawn from the examination of the case descriptions of three psychoanalytic therapists – N. Vasilyeva, who proposed a view from the point of view of the classical theory of drives, Z. Berko – from the position of the theory of M. Mahler and D. Yangerman (1979), – in line with the ideas of D. Winnicott, as well as our own clinical material, examined through the prism of M. Klein’s theory of object relations and W. Bion’s theory of thinking, we can come to conclusions about the main factors in the emergence of the symptom of SM, namely:

– Difficulties in the early stages of interaction between mother and baby, which are accompanied by disturbances in the processes of feeding and elimination;

– Aggressive and destructive impulses, unsuccessfully contained by the primary object, remain unprocessed in the infant’s psyche and, subsequently, receive maladaptive forms of expression;

– A symbiotic relationship with the mother, and the associated infantile omnipotence and intense separation fear, which prevent the transition to the next stage of development;

– The influence of an unfavorable environment that unconsciously supports a symbiotic relationship and the suppression of aggressive impulses, as well as a family system in which there is a problem in expressing feelings in words.

– An unfavorable prenatal history contributing to a high level of anxiety, low frustration tolerance, and a possible innate predominance of destructive impulses.

The fifth and final point is not clearly outlined in the studies reviewed, but it seems important to highlight it separately, since, in the author’s opinion, without innate predispositions, along with fairly specific external conditions influencing the child’s development and interactions with caregivers, the development of the SM symptom is not obvious. Therefore, the author believes that when working with children with SM, it is necessary to pay attention to all of the above-mentioned aspects together. This can be proposed as a practical application of the findings obtained in this study. Also, in practical work with children with SM, attention should be paid to the importance of interaction with parents. Since this interaction can present a significant challenge during the process of working with a child, as clearly demonstrated by Mitya’s clinical case, it is important to pay attention to the contract with parents, negotiated at the beginning of the work. Specifically, it is necessary to stipulate the expected duration of the work, the frequency and importance of adhering to session timeframes, payment, vacations, absences, and conditions for ending therapy, as well as regular meetings with parents. An important condition for psychotherapy for a child with SM is the support of parents throughout the process, including both individual therapy (especially for the child’s mother) and family therapy. This is because the SM symptom is closely linked to processes occurring within the family system, which maintains homeostasis and requires the symptom to maintain its stability.

This clinical case illustrates the potential of an integrative approach to treating a child with selective mutism, where a combination of ICT methods and psychoanalytic thinking played a key role. The use of ICT methods at the initial stage allowed for the establishment of initial contact under conditions of complete verbal isolation, which formed the basis for further analytic work. A shift to a psychoanalytic understanding of the situation, including through transference and countertransference analysis, allowed for the identification of the unconscious mechanisms underlying the symptom: fear of separation, unintegrated aggression, the inability to symbolize, and pressure from the family system.

Of particular importance in the work was the gradual development of the child’s inner space and the ability to create a “container” for affective experiences. The symptom of silence was viewed as a form of defense and an expression of loyalty to the parental system, which did not allow for the expression of feelings and autonomy. Despite the premature termination of therapy, the result was sustainable: the child began speaking after several months, the symptom did not recur, and the level of adaptation increased significantly. This case highlights the importance of building a trusting relationship, the ability to withstand stress, and the importance of psychoanalytic interpretation of symptoms, even in conditions of limited therapeutic contact.

Thus, the author’s experience is consistent with the observations of other researchers who have described successful cases of integrative therapy for children with selective mutism. Several publications (Fernandez & Sugay, 2016; Un, 2010; Gulesen et al., 2022; Ale et al., 2013) emphasize the combination of play, behavioral, and supportive techniques with attention to the child’s inner world, their anxiety, and their need for symbolization.

Mitya and his “Secret Box”. Psychoanalytic Thinking in the Integrative Therapy of Selective Mutism

Annotation

The article presents the clinical case of psychotherapy for an eight-year-old boy with symptoms of selective mutism, conducted within an integrative framework. The therapy began with child-centered play therapy, which allowed for the establishment of initial contact and the creation of a safe space for affect expression. As the relationship developed, the focus shifted to psychoanalytic understanding, including the analysis of transference and countertransference dynamics. It is shown how, through play and symbolization, the child was gradually able to express emotions and regain speech. The article also discusses the role of the family system in maintaining the symptom and the importance of family therapy. The conclusions are compared with the findings from psychoanalytic studies by Jungerman, Berko, and Vasilieva.

Keywords: selective mutism, child-centered play therapy, psychoanalytic thinking, transference, countertransference, containment, family dynamics, symbolization.

[1] From the works of psychoanalytic therapists that I later studied, it is clear that in each specific case, psychotherapists had to find a way to communicate with silent children, which took quite a long time and required ingenuity from them.