Diagnosis and Treatment Planning
The therapist informed Mariana and her mother that Mariana met DSM-IV criteria for a major depressive disorder and presented evidence-based treatment options of IPT-A, cognitive-behavioral therapy, and pharmacotherapy. Mariana’s mother expressed reluctance to proceed with psychotropic medication but said she would reconsider if Mariana’s symptoms did not improve. The therapist recommended IPT-A due to the interpersonal aspects of Mariana’s depression. Because of Mariana’s history of passive suicidal ideation and self-injurious behavior, the evaluating therapist, Mariana’s mother, and Mariana collaborated on a safety plan that included giving the family the hospital’s emergency phone number in case symptoms worsened, clearing the home of potential threats to Mariana’s safety such as pills or razors, and agreeing that Mariana would tell her mother if she began to feel worse.
The first goal for Session 1 was to reevaluate Mariana’s symptoms and confirm the diagnosis of a depressive disorder to establish her appropriateness for IPT-A treatment. Mariana continued to endorse the same symptoms of depression as at intake, including passive suicidal ideation. She denied active suicidal ideation, plan, and intent. She added that she now felt sleepy throughout the day. The therapist introduced Mariana to the mood rating by asking her to rate her average mood during the past week on a scale of 1 to 10, with 10 representing the most negative and 1 the most positive. Mariana endorsed an average mood rating of 7/10. The therapist also asked her to provide mood ratings for the times during the week when she had felt the worst and when she felt the best, and to describe the events associated with her moods. She reported an 8/10 in response to negative interactions with her mother and brother, and a 4/10 following a positive outing with her sister. The therapist explained that they would review Mariana’s depression symptoms and mood rating at the start of each session to understand how positive and negative changes in her mood related to interpersonal events and to track her progress in therapy.
A second goal of the session was to provide psychoeducation to Mariana and her mother about depression and its impact on psychosocial and behavioral functioning. The therapist introduced them to the idea of the limited sick role, which conceptualized Mariana’s depressive illness as akin to a medical illness: “Just as a medical illness or physical impairment can result in limited functioning and the need to make adjustments, so can depression." The therapist explained that Mariana should be encouraged to do as many of her normal activities as possible, including schoolwork and household chores. However, she might not do them as well as prior to her depression. The family was told that as Mariana’s symptoms improved, she would begin to perform better, emphasizing the time-limited nature of the situation.
At first, Mariana’s mother was reluctant to consider that Mariana might not be capable of meeting expectations in completing household chores due to her depression. She became more amenable once it was clarified that the goal of treatment, and an essential ingredient in recovery, was reengagement in daily activities, and that this was a treatable aspect of the depression illness. Since parents of depressed children are often depressed themselves, the therapist reviewed the mother’s symptoms to determine whether she needed adjunctive treatment to be able to support Mariana’s recovery. Mariana’s mother did not meet current criteria for a depressive disorder. However, during the discussion, the mother did recall past experiences of depression and its concomitant difficulties. This enabled her to empathize more with Mariana’s condition.
The third goal of the session was to describe the IPT-A approach to treating depression, focusing on understanding the link between depressive symptoms and current difficulties in significant relationships. The therapist indicated they would together identify the interpersonal difficulties most closely related to Mariana’s depression and then identify and practice skills to improve her relationships and ultimately improve her mood. By the end of the session, Mariana’s affect was brighter, and she expressed relief in feeling understood and supported by the therapist: “So, I’m not crazy" Still, she expressed skepticism that things could actually change at home. Mariana’s generally positive response to the initial session and treatment plan outline made the therapist hopeful about her capacity to engage in and benefit from treatment. Mariana’s mother’s level of engagement with the treatment plan was also heartening.
Session 2 began as did most sessions, with the therapist asking: “How have things been since we last met?" This question gives the therapist a snapshot of problems from the past week and gives the adolescent a chance to talk about what is on her mind so that she can then focus on depression-related events. Mariana reported no overall change in depressive symptoms since the previous session, and rated her average mood for the week 7/10. She observed that her mood declines mostly related to disagreements with her mother about household chores and caretaking responsibilities for her younger siblings.
Mariana and the therapist initiated the interpersonal inventory by completing the closeness circle (see Fig. 12.1). The therapist explained that because Mariana’s closeness circle included so many people, they would not be able to discuss each relationship but would focus on those Mariana considered most important and most related to her mood in either positive or negative ways. She gave Mariana the choice to select whom she wanted to discuss first. For each relationship, the therapist asked about the frequency and content of Mariana’s interactions with the person, the relationship’s terms and expectations, positive and negative aspects, how the relationship had changed since Mariana became depressed, and changes Mariana would like to make in the relationship.
Mariana chose to discuss her relationship with her mother first, as it affected her the most. She described her sense of loss when her mother emigrated, and her feelings of longing for their reunification. She recounted frustration, disappointment, and betrayal upon seeing her mother again after their years of separation, only to learn about her mother’s other children and ongoing relationship with Mariana’s father. Although Mariana had attempted to express her feelings to her mother, she felt that her mother did not listen to her and was routinely distracted by the demands of her other children and by household responsibilities. She reported feeling easily angered and irritated by her mother’s requests, which mostly concerned the need to complete household chores.
Discussing her brother, Juan, she described resenting having to help take care of him and her other younger brother when she essentially felt uncared for herself. These feelings were now exacerbated by Mariana’s mother’s recent medical complications from a gallstone. She hesitantly, albeit honestly, admitted to behaving aggressively on occasion towards Juan but denied an active intent to harm him. Nonetheless, she was reluctant to assume responsibility for these behaviors, instead blaming her brother for being bothersome. When discussing the sister who remained in her home country, Mariana said she attempted to maintain regular contact, but cost and her sister’s irregular access to telephones and computers made communication challenging. Mariana reported struggling with guilt over having left her behind.
At the end of the session, the therapist talked with Mariana’s mother about her medical status and resultant greater need to rely on Mariana for household and caretaking responsibilities. The therapist validated the mother’s situation, but questioned whether Mariana could meet these expectations given her depression and need to focus on her own well-being, and whether other children could also help out. They generated strategies to adjust these expectations and make alternate child care and household chore arrangements for consideration, and devised an alternate plan. Mariana was given an opportunity to select three chores (making her bed every morning, folding and putting away her clothes, and washing and putting away her own dishes after meals) that seemed to be reasonable expectations for an adolescent. Mariana’s mother recruited her sister to equitably share a greater portion of the child care responsibility to the extent the sister’s own busy work schedule permitted, but Mariana found even this limited assistance was an improvement.
During Sessions 3 and 4, Mariana continued to experience depressive symptoms, including sadness, depressed mood, increased tearfulness, irritability, disturbed appetite and sleep, feelings of guilt, gastrointestinal discomfort, attention and concentration difficulties, loneliness, “boredom,” “laziness,” “loneliness,” and feeling hopeless regarding her family’s poverty and unstable immigrant status. She denied suicidal ideation and self-injurious behaviors. Mariana’s moods at the start of Sessions 3 and 4 were 5/10 and 6/10 respectively. When asked to rate her lowest mood since the previous session, Mariana both times reported a 9/10, linking the worsening mood to a dispute with her mother. She reported increasing anxiety and uncertainty about an upcoming change in school at the start of the new school year, in conjunction with difficulty in learning English.
These sessions focused on completing Mariana’s interpersonal inventory. Mariana had greater difficulty discussing her father, who had recently reentered her life after a prolonged separation. Unlike her relationship with her mother, Mariana did not long for closeness with him. Rather, she wished to maintain physical and emotional distance, as she doubted his intentions and ability to remain a positive, stable presence in the family’s life. Furthermore, she was confused about the nature of her parents’ relationship, and had trouble accepting that her mother had hidden their history over the years prior to Mariana’s arrival in the United States. That her father lived in another city but consistently visited the family every month, often under the influence of substances, reinforced Mariana’s feelings of instability, and made it difficult for them to form a close attachment.
The friends Mariana placed on her closeness circle came from her hometown. She spoke about how much she missed them, and how difficult it had been to make close friends since moving to the States.
The initial treatment phase concluded with the therapist presenting the proposed problem area formulation to Mariana. Based on the interpersonal inventory, both a role transition and a role dispute seemed appropriate formulations. Because the conflict with her mother occurred in the context of several life transitions, the therapist decided to formulate the case as primarily a role transition, with disputes as a secondary problem arising from transition difficulties. The therapist told Mariana that after reviewing her important relationships, Mariana’s depression seemed linked with multiple transitions, including Mariana’s move to the United States, which involved adjusting to a new country, school, culture, language, and siblings, and more generally, her father’s inconsistent involvement and role in the family.
The therapist also highlighted past stressful transitions that likely increased Mariana’s vulnerability to depression, such as her mother’s departure for the United States and the subsequent changes in her living situation years before. She noted Mariana’s great difficulty in communicating her feelings and needs directly and appropriately within relationships, particularly with her mother. As a result, the therapist explained, “You tend act out your feelings through your behavior: for example, the times when you have hit your brother instead of expressing them through your words" This pattern further alienated others and isolated Mariana, which compounded her depression. Her current communication difficulty was hurting her ability to adaptively manage her multiple transitions, increasing her conflict with her mother, and exacerbating Mariana’s depressed mood.
To ensure that Mariana understood the formulation, the therapist asked her to explain it using her own words, which Mariana was able to do. Mariana agreed with these observations and expressed relief at the recognition of these challenges she had experienced. She liked that the next phase of treatment would focus on practical ways to manage these transitions and interpersonal disputes by discussing situations that might occur between sessions. At the end of Session 4, Mariana’s mother informed the therapist that she would be having gallbladder surgery. She anticipated a long recovery and could not confirm when she would again be able to accompany Mariana to session. She and the therapist agreed to maintain contact by phone.