Anxiety and School Refusal: A Case Study

Presenting problem/request of each party

Mother- for Mac to be supported in addressing his anxiety at school and grief at the death of his God-mother

School – for Mac to attend regularly and mother to stop blaming school for Mac’s problems

Mac- same as Mum

Social system presenting to session

Mum and Mac

Ecogram

Analysis using Bower Place Model

Politics

Authority and Responsibility: Ownership of the problem was a central issue in this matter. Mac’s mother put full responsibility for Mac’s difficulties on two sources. His grief at the death of his God-mother who had lived in the family and the school. Mac’s mother believed he had been very close to his great aunt and her death a major source of distress which resulted in his inability to sleep in his own bed, engage in age appropriate self-care and attend school. When Mac did attend and teachers required, he co-operate, obey ordinary rules, and participate in learning activities he would be distressed and share this with his mother. She would support his perception and frame this as bullying, keep him home from school and become angry with the teachers for causing distress. Over time the teachers had become increasingly accommodating to her for fear of her anger.

Space

Mac and his mother were very close to the extent that they  shared a bed as Mac refused to sleep in his own room as he had told his mother he believed it was haunted, a view with which she sympathised. He was alienated form school yet managed to maintain friendship through on-line interactions. At times he and his mother would conflict and he would be physically abusive of her.

Time

Time past was ever present in this family and Mac and his mother’s interaction, which babied him kept them both living in a time before his great aunt died. Neither were able to conceptualise a time future, Mac through school attendance or his mother by forming relationships outside the family.

Development

Both Mac and his mother lived as if Mac were a much younger child. He continued to sleep in his mother’s bed and relied on her for basic physical self-care.  At school he would soil and wert himself and be so distressed that he would be sent  home. This severely compromised the productive identity of both mother and son, the sexual identity of his mother and while Mac had some on-line friendships, both peer identities. Their family identity was excessively emphasised for both.

Constraints

Mother’s distress and guilt about her relationship with her great aunt who had both raised her and been abusive. This did two things;

1. 1. Protect Mac from all responsibility including age appropriate self-care which meant he did not manage toileting at school making school attendance humiliating and more difficult for him
   2. Framed all Mac’s difficulties as grief and loss following the death of his God mother

• The isolation of the family which meant Mac’s mother sought emotional closeness from Mac who felt responsible for her
• Mac’s school refusal which allowed his mother to avoid her own distress, loneliness and the risk associated with seeking adult company

Advice

Mac’s mother and his school were both given the same explanation; that time was running out for Mac to learn age appropriate behaviour and that the current adults who cared for him would be kinder and more supportive than his peers and others as he entered high school.

That Mac required all the key adults in his world to be supportive of his learning and to not allow him to avoid this necessary task. He needed to experience his world as coherent and in agreement so he could be brave enough to step outside his current level of comfort.

Two separate forms of explanation were given, one to Mac and his mother and one to Mac’s mother and school.

1. The therapist agreed that Mac was anxious and that his mother was the best person to help and support him learn to be brave. Her belief that it was possible for Mac was the most important ingredient. A plan to help him sleep in his own bed with the help of his dog was devised which required his mother to alter the pattern of accommodation to Mac’s protest.
2. In a meeting with the school it was suggested that time was running out for Mac to learn the skill of managing himself at school and that both his mother and teachers needed to co-operate in helping him take proper authority over his soiling in a way that did not humiliate him and allowed him to remain at school. It was noted that the older he got the harder it would be for those who cared for him to help and that other people may be less kind. A strategy was devised between Mac’s mother and teachers which all agreed to support, which was then explained to Mac. This addressed the fracture between Mac’s mother and the school and the coalition between mother and son against the school.

Unique theoretical analysis of key presenting issue

A number of lines of explanation were used in understanding this situation.

1. Mac’s mother had been abused and neglected by her Godmother. She wished to believe that a powerful connection had existed between her son and Godmother which would demonstrate that she had really loved her.
2. Mac’s mother had grown up in a small world as her father had left her mother when she was young. Her mother had subsequently died leaving her in the care of her God mother who lived alone and drank excessively
3. Mac’s mother was excessively caring and attentive of her son, giving him the attention, she had lacked and protecting him from responsibility which had burdened her childhood.
4. Both Mac and his mother were frightened by the world outside the family. Mac was falling behind in his learning and Mac’s mother feared both loneliness and the risks of relationships
5. The pattern of accommodation between mother and son was replicated between the school and Mac’s mother whereby they would excessively accede to her demands as a way of ‘keeping the peace’
6. Time future needed to be invented for both and excessive accommodation removed
7. The inequality between mother and child and school and family needed to be remediated
8. The inequality of infantilising and pathologizing Mac needed to be addressed