School Avoidance. A Solution-Focused Therapeutic Approach

Transcription

1 School Avoidance A Solution-Focused Therapeutic Approach

2 Solution-Focused Strategies for Addressing School Avoidance I. Phenomenology and Mechanics of School Avoidance Review psychological mechanics that result in school avoidance Describe Neuro-Developmental (NDIT) informed Therapy model or intervention II. Elements of a Successful Solution Focused Strategy Student Centered Reduce student's sense of vulnerability Reduce student's level of self-consciousness Reduce student's level of isolation Reduce student's level of passive avoidance.

3 Strategies Continued Family Centered Intervention Address the problem of obsessive rumination and compulsive fixation Reduce (Hostile) dependency Restore parental hierarchy Develop crisis management strategies School Centered Intervention Accommodations and interventions that work III. Problem Solving Exercise Participants should be prepared to discuss problematic situations to which concepts and strategies presented in the workshop can be applied.

4 Differential Diagnosis of School Avoidance

5 I can't go to school because... "I can't get up in the morning." Sleep - wake disorders "I feel sick" Mental disorder due to another medical condition Somatic symptoms and related disorders. "Something is happening at school" Trauma and Stressors, related disorders Neurodevelopmental disorders ADHD, Learning disorders, Intellectual disabilities

6 I can't go to school because... "I just can't go!" Obsessive Compulsive and related disorders "I don't feel like myself." Schizophrenia Spectrum and other Psychotic disorders Dissacociative Disorder "I'm too stoned to go..." Substance-related and Addictive disorders.

7 I can't go to school because... "I'm just not going!" Disruptive, impulse control and conduct disorders. "I feel anxious." Anxiety disorders, separation anxiety disorder "I feel depressed." Bipolar and related disorders Depressive disorders, Disruptive Mood Dysregulation Disorder

8 "I can't get up in the morning..." Incomplete arousal (partial wakefulness) results in a lack of clarity, focus, and salience Subjective sense of vulnerability Heightened Anxiety Conflict between parents and student's brain that seeks a return to sleep

9 "I feel sick!" Agitation and Anxiety increases physiological stress Physiological stress intensifies the experience of latent physical conditions Hyperfocus on latent physical conditions produce a fear of losing control, becoming ill or embarrassing oneself in a perceived hostile and unsupportive environment. As a result, the student experiences a feeling of vulnerability and exaggerated need to be in control

10 "Something is happening at school..." Student feels a heightened sense of negative self-consciousness, a sense of inadequacy and a sense of alienation This results in a decreased sense of control and an increased sense of vulnerability Heightened anxiety, agitation and physiological arousal

11 "I feel anxious!" Fear of loss of control Dependency, i.e. "you make me feel safe" Anxiety creates fear of losing control in what is perceived as a hostile and threatening environment Intense avoidance

12 "I just can't go!" Anxiety and hyperarousal, generate the development of an obsession about not going to school The obsessional thought attached to a behavior i.e. the compulsion not to go to school The frustration of this compulsion produce desperation, agitation, and aggression

13 "I'm just not going!" Increased anxiety, sense of vulnerability Excessive compensation for sense of vulnerability, increased anger and belligerence Anger and belligerence create conflict and suppress Executive Functioning Creating a heightened sense of dyscontrol

14 "I don't feel myself!" The student feels strange, disoriented, confused, out of touch with reality These symptoms produce intense fear Fear produces isolative withdrawal and regression into a an internal reality

15 "I'm too stoned to go..." Chronic use and dependency on mind altering substances Psychiatric symptoms, amotivational, and preoccupation with substance use or sale Legal problems, addiction

16 Manifestation and Phenomenology of School Avoidance Triggering Events + Disposition to Anxiety Break in Routine Vacation, prolonged illness, etc. Physical Distress Stomach problems, headaches, etc. Not being prepared Interpersonal Conflicts Threat to reputation Loss Family Conflict Spontaneous Development of Obsession Thought "I can't go to school" + Negative Obsession Anxiety "I can't go to school"

17 Where Does Anxiety Come From? Post Traumatic Anxiety Psychiatric (Clinical Anxiety) Developmental Immaturity or Neuropsychological Process Genetics Clinical Anxiety Unresolved Dependency

18 The Birth of the Negative Compulsion Motivation Commitment Arousal Leads to: Need to Avoid Negative Compulsion

19 Developmental Issues Affecting Anxiety Academics Family Social Relationships Obsessional Rumination Rigid Expectations Negative Visualizations Executive Functioning Arousal Emotional Self-Regulation Activation of Tasks Organization of Processing Information

20 Developmental Issues Affecting Anxiety Cont. Processing Needs Processing Capacity Incomplete Development of P.F.C. % of Overload "Who am I?" or ADHD Passive Avoidance Shutdown Emotional Dysregulation Anger Acting Out Negative Personal Narrative Shame Resentment Helplessness Despair

21 Ceilings and Spikes Activity Thought of Activity Anxiety Arousal Frustration of Obsession Expectation Reality = % of Anxiety

22 Passive Avoidance - Mental Paralysis Noise Low Dopamine Doing Weak Signal Low Norepinephrine

23 Modes and Transitions Wake Up Leave for School School House H.W. Bed Altered mood states produce a discontinuity within the student's sense of self

24 Suicidal Ideation Emotionality Acting Out Belligerence Argumentative Hyperemotionality Executive Functioning Avoidance The Crisis

25 What does intervention look like? Anxiety - "In a box" or trapped Opening the box

26 Neuro-Developmentally Informed Psychotherapy - NDIP Neurological + Developmental + Experiential = Sense of Self Psychotherapy produces: Understanding/clarity regarding the mechanisms which produce the problem to be treated Formulations which are nonjudgmental and facilitate solutions A collaborative problem solving model that reduces conflict between those working to resolve the problem Facilitates a more hopeful and integrated perspective

27 Confusion Anxiety Anger Conflict? Conflict leads to Fragmentation Therapist Community Support Family School Fragmentation intensifies the Problem

28 What are we looking for? Too much information Don't bury families in referrals Residential Treatment Inpatient Partial Hospitalization Community Supports Pediatric Consultation School Counseling Psychotherapy/ Family Therapy School Based supports CSE Home Instruction IDT Psychiatric evaluation/ Medication Other medical evaluations Gastrointestinal Neurological SPOA PIN Diversion

29 Effective Advocacy should focus on developing a collaborative solution-focused effort. Family Therapist Child Community Support School

30 Manifestations of Acute Anxiety Student Centered Intervention Anxiety Feelings of Vulnerability Self-Consciousness Isolation and Alienation Irritability Distractibility/Lack of Focus Passive Avoidance Rigid and Obsessive Psychological Processing Emotional & Behavioral Dysregulation

31 Elements of a Successful Solution Focused Strategy

32 Student Centered Intervention The problem of feeling vulnerable The problem of feeling self-conscious The problem of feeling isolated and alienated The problem of being dependent The problem of passive avoidance

33 The Problem of Vulnerability Avoidance Escalation

34 The Solution of the Problem of Vulnerability Make Friends Pass Courses Reduce backlog of work Reduce Emotional Instability Create an Expectation Build confidence and mastery by facilitating momentum of observable achievement Mastery GOOD JOB Anxiety

35 The Problem of Self- Consciousness

36 The Solution to the Problem of Self- Consciousness Student Don't Stand Out! Be Prepared Don't Miss Days Create a Herd

37 The Problem of Isolation & Alienation

38 The Solution to the Problems of Isolation & Alienation Peer Peer Peer Student Develop a herd

39 The Problem of Passive Avoidance Intention Positive Stimulation Favored Activities (games, seeing friends) High Salience Activity Intention Mundane/Repetitive Non-Favored activities (homework, chores, etc.) Low Salience Noise/Weak Signal Strength Activity

40 The Solution to the Problem of Passive Avoidance Signal Strength by creating consequential salience Create Habits (Habits require less processing) Facilitate Autonomy (Eliminate confusion regarding who is flying the plane) Intention Activity

41 Solutions Cont. Enhance P.F.C. Predominance Provide Clarity and Insight Instruct the Student on how to label and differentiate natural and purposeful thought from obsessive rumination Teach the student to isolate and contain obsessive-rumination and to become inattentive to these thoughts.

42 Family Centered Intervention The problem of obsessive rumination and compulsive fixation The problem of hostile dependency The problem of an inverted parental hierarchy The problem of spikes and crisises

43 The Problem of Obsessive Rumination and Compulsive Fixation Anxiety Seeks Discharge Through Behavior (the Compulsion) NO NO NO NO NO NO NO Arousal When compulsion is frustrated, anxiety increases to desperation

44 The Solution to the Problem of Obsessive Rumination and Compulsive Fixation

45 The Problem of Dependency Well Being Security Separation Student Parent Anxiety Outsourcing of Well Being and Security

46 The Solution to the Problem of Dependency Go to Sleep Independently

47 Dependency Field is Strong Child Hostility Negativity Diminished Functionality Parent Improved Mood Autonomy Confidence Mastery

48 The Problem of an Inverted Parental Hierarchy Parent 1 Parent 2 Parent 1 Parent 2 Child 1 Child 2 Child 1 Child 2 Skewed Schismatic Child Parent 1 Parent 2 Child Inverted Parental Hierarchy

49 The Solution to an Inverted Hierarchy Create an understanding of the problem that is accurate, solution focused and non-judgmental Provide measured and consistent limit setting Consequences are provided in a respectful, non-reactive and authoritative manner. As formal authority becomes accepted levels of conflict, diminish and relatedness improves. This facilitates parental influence over the student's decision making process Develop communication and collaboration within the parental diad

50 Goals of Counter Intuitive Practices 1. Contain aggression, tantrums and emotional Dysregulation 2. Enhance compliance, cooperation, tolerance for transitions, and tolerance for the mundane and repetitive 3. Create an expectation of negative consequences which is consistent and predictable C = "I didn't like what you did" "We're in Charge" Consequences are non-verbal, i.e. non-triggering communication of the above concepts

51 Frequency and Consistency Immediacy and Intensity Perspective Defensive Vulnerability T 1 T 2 T 3 T 4 This allows for information to be processed, recalled and consequently leads to the generation of more consistent mindfulness and learning.

52 Managing Crises Triggering Event A Help! I'm falling! B E F Consequence Three Minute Rule Keep Student Safe Keep Others Safe Keep Yourself Safe C D

53 School Centered Intervention

54 Accommodations and Interventions that Help Devise a specific plan to address areas of vulnerability Establish a trusted point person to manage episodes of acute anxiety Desensitize students to being in their classes Shorten the day

55 Avoid having the student return to class when they are far behind the rest of the class or have a backlog of incomplete assignments Prepare an explanatory statement that the student feels comfortable with to explain their absence from school

56 Enhance peer relatedness and sense of connection Eliminate ambiguity about expectations Present an emotionally neutral but appropriate attitude toward returning to school Be realistic about the societal and legal expectation of school attendance

57 Continue to refine and troubleshoot the strategy as changes occur Reinforce students sense of mastery, don't provide positive feedback which is unrelated to achievement Be proactive, try to anticipate and manage potential points of regression Don't overreact to regression, stay neutral and positive

58 Contact Information Hudson Valley Cerebral Palsy Association (845) Find me on therapists.psychologytoday.com