Middle Phase

Mariana appeared sad and withdrawn when she arrived for Session 5. She stated that she was “bad" with a current mood of 7/10, and an average of “9 or 9.9/10" for the week. She endorsed sadness, irritability, lethargy, decreased appetite, and feelings of worthlessness and guilt. Mariana also reported increased daily thoughts of wanting to die in order to escape current stressors. On three occasions she had thought about throwing herself into oncoming traffic. She denied current active ideation. Mariana explained that her father had arrived in town about five days prior for a ten-day family visit and was staying in Mariana’s family’s apartment. Two days after his arrival, he and Mariana argued about Mariana’s treatment of Juan. Mariana reported he screamed at her, calling her a “bad girl," “ungrateful," and “disrespectful." Her father prohibited further interactions with her brother. She admitted to yelling back at him in anger and walking away in the middle of the argument. Mariana and her father had not spoken since. Mariana felt hurt and angry at him, as well as abandoned by her mother, who had not intervened. Furthermore, she was feeling apprehensive about starting the school year in a new school the next week.

Asked which event of the past week had most upset her, Mariana cited her difficulties with her father. The therapist emphasized the link between the events surrounding her father—his arrival and their fight—and her mood. It was important to help Mariana articulate her feelings about her father and his past and current role in her life so that she could understand how these feelings were currently affecting their relationship. She described her anger at his verbal abuse of her and her mother in the past, and now again towards her. She expressed ambivalence about his presence in her life: she wanted a father, but was disappointed by his inability to be a stable emotional, physical, and financial presence. On some level, she blamed him for her mother’s departure to the United States. Mariana was confused about his current role in her family’s life, as the status of her parents’ relationship remained unclear. The therapist asked M ariana: “What would it be like to communicate your feelings about the current situation directly to your parents—to tell them that you are sad or angry or confused, for example—instead of refusing to speak to your father?” Mariana predicted they would not listen to what she had to say. The therapist asked whether she was willing to experiment with different approaches to communicating her feelings to see if they could understand her, which might help her to feel better. Mariana thought nothing would help, and grew more sullen and withdrawn.

The therapist pointed out how Mariana’s mood deteriorated when discussing her relationship with her father. She appeared sad, angry, helpless, and hopeless about her ability to change her family situation. Mariana nodded in agreement but remained quiet. The therapist asked Mariana to rate her mood again, which had worsened to a “9 or 10/10.” On reassessment, Mariana endorsed active thoughts of wanting to die. She did not state a specific plan to harm herself, but could not contract for safety. The therapist called Mariana’s mother, informed her of Mariana’s status, and asked her to come to the hospital to meet them. Mariana’s mother arrived and corroborated Mariana’s report of the week’s events. Mariana continued to endorse active suicidal ideation and remained unable to contract for safety. She was admitted to the Children’s Comprehensive Psychiatry Emergency Program (CPEP), where she remained overnight for monitoring and evaluation.

The therapist met with Mariana and her mother and father in a crisis session the next day, immediately upon her discharge from the Children’s CPEP, where she had been evaluated and deemed stable. Mariana reported an overall mood of 4/10. The session began by revisiting the precipitants of Mariana’s ER admission. Mariana expressed feeling “bad” about the argument with her father, while her parents articulated frustration with Mariana’s irritability, defiance, and impatient behavior towards her younger brother. Mariana and her parents recognized how their feelings, and their difficulty communicating these feelings appropriately, led to an escalation in conflict.

The therapist provided the family with additional psychoeducation about depression, explaining, “Mariana is depressed. A central feature of adolescent depression is irritability. It is important to encourage her direct communication of feelings and respectful behavior while also recognizing how her depressed feelings are currently influencing how she behaves. The goal of therapy is to help Mariana feel and behave better. Given the many changes you have experienced as individuals and as a family these past few years, I imagine that you both can relate to the many life changes that Mariana has experienced, and is now experiencing. She feels sadness, confusion, and anger about these changes. She also feels hopeless and helpless about making things better, which is part of what led her to feel she did not want to live.” Mariana’s parents said they understood, and her father commented on everyone’s need to “do their part” in improving relationships within the family.

An additional therapeutic goal was short-term problem solving in potential areas for dispute over the next few days so as to avoid exacerbating the crisis. The first area of conflict was Mariana’s behavior towards her brother. She found him “hyperactive” and annoying. Her parents explained that he just wanted to play with her. The therapist asked if it was possible to schedule short periods of supervised playtime for Mariana and Juan to give him the positive attention he wanted while also allowing her longer “break” periods from interacting with him. They agreed to experiment with this plan. The second conflict concerned Mariana’s free time. She loved to watch television and did not like sharing the TV with other family members. Mariana and her parents devised a TV schedule to which all members would adhere. They also brainstormed positive activities they could engage in together such as watching movies, shopping, and playing games so that Mariana would remain supervised and her time would be structured. When an adolescent presents with safety concerns, parental involvement is increased temporarily to enlist them to help ensure their child’s safety and to make changes to decrease immediate triggers in the child’s environment.

At the end of the session, the therapist, Mariana, and her parents reviewed safetyplanning procedures. Mariana understood that she should tell her parents if she had suicidal thoughts. Her parents knew to call 911 or proceed to the ER with any significant concerns about Mariana’s safety.

Afterwards, the therapist briefly met individually with Mariana to assess her reaction to the session and to reaffirm their alliance. She reminded Mariana of their earlier discussion of the boundaries of confidentiality and how her safety concerns had warranted sharing some of this information with her parents. The therapist reminded her that they would be resuming individual sessions with the hope that Mariana would begin to work with her parents at home between sessions. Mariana expressed comfort with the session’s process and outcome, and understood the therapist’s involving her parents more actively in treatment to help ensure Mariana’s physical safety and emotional stability, as well as to address family interactions contributing to her deteriorating mood. She expressed surprise and relief at how both parents responded to her distress, and especially appreciated her father’s acknowledgment of shared responsibility for her difficulties. She agreed to return for another session two days later.

In the second crisis session, Mariana’s mood was brighter: she reported feeling “fine,” 3 or 4/10. She denied self-harming thoughts or actions. The therapist encouraged Mariana to connect interpersonal interactions to her improved mood. She had been heartened by the previous session’s outcome and was enjoying spending time with both parents in structured, “fun” activities. The therapist praised Mariana’s willingness to communicate her feelings to her parents in the prior session and her collaboration with them in planning for the weekend. She encouraged Mariana to maintain open communication with her parents by talking to them about her feelings about their relationship and changes she was experiencing as they arose. She and Mariana practiced what Mariana could say to her parents if things did not go according to plan over the weekend, and how Mariana could share any feelings or thoughts of wanting to hurt herself.

The therapist addressed how Mariana was feeling about starting school in a few days. Mariana was still nervous. She expressed anxiety about meeting new people and apprehension about her ability to manage English classes. Mariana and the therapist revisited how Mariana had managed previous school transitions. Mariana recalled how her initial awkwardness faded over time as she began to talk to other kids in classes and to build friendships through involvement in after-school activities. Mariana and the therapist used these past experiences to brainstorm a list of “conversation starters” through which to engage others. Mariana and the therapist discussed ways she could seek help within the school for any academic difficulties if she was struggling with English language problems. They agreed that the first few days might be challenging as she adjusted to new demands, and that she could “forgive” herself accordingly.

The therapist then met briefly with Mariana’s father, who had accompanied her to the session. He noted improvements in Mariana’s mood and behavior. The therapist highlighted the positive impact of his participation in Mariana’s treatment on her mood and functioning. This facilitated discussion about his role in Mariana’s and the family’s life. He explained that he and Mariana’s mother were working towards reconciliation, with plans for him to visit for longer periods of time. He also reported no longer using substances. He and the therapist discussed ways to clearly communicate these plans to Mariana, and to discuss feelings associated with these changes. They reviewed recommendations for safety and activity planning for the coming weekend, and scheduled a session with Mariana for the following week.

In Session 6, Mariana rated her average mood for the week 2/10. She attributed her improvement to positive interactions with family members as well as a successful first day of school. She liked the idea of scheduling family and individual activities, and practiced expressing this to her parents so that they could continue to do this together. At school, she had used a few “conversation starters” to talk to two other Spanishspeaking classmates. They teamed up to help one another navigate their new school building, figure out their schedules, and eat lunch together. Mariana’s worst mood for the week was 8/10 following a dispute with her mother over watching television. The therapist and Mariana conducted a communication analysis to dissect this.

therapist: What do you think led up to the argument?

mariana: I was watching my favorite soap opera, and my mother interrupted me like she always does to ask if I could wash dishes. There were only fifteen minutes left and she couldn’t wait. I hate it when she does that! therapist: What did you say to her then?

mariana: I told her to wait until my show was over to talk to me. therapist: How exactly did you do that? Like, what words did you use and in what tone of voice did you speak to her?

mariana: I said something like: “Leave me alone and don’t come until my show is over in fifteen minutes.” therapist: Okay. What happened next?

mariana: She walked away, but then came back five minutes later and yelled at me for not doing the dishes. therapist: What did you do then?

mariana: I screamed back at her: “Why can’t you just wait until my soap opera is over?!”

therapist: And then?

mariana: My mother lectured me about how I need to respect authority, and that I need to do what I am asked to do around the house without questions. She then told me I watched television too much and turned off the TV. therapist: And what did you do?

mariana: I screamed back at her that I was not going to do the dishes.

The therapist encouraged Mariana to name the specific feelings—sadness, anger, helplessness, and frustration—she had in response to the interaction. Mariana explained that watching soap operas was important to her because they reconnected her to her home country, language, and culture. She felt that her mother did not understand this. They then focused on how Mariana communicated her feelings and needs. Based on her observations of Mariana during interactions with her parents, the therapist pointed out the nonverbal means through which Mariana “talked” to her parents when upset. Through crossed arms or waving hands, indirect eye contact, shrugs of her shoulders, and a sucking of her teeth, Mariana expressed a dismissive, “I don’t care” attitude. Mariana also admitted to using a whiny or aggressive tone of voice that was likely to aggravate her mother. The therapist encouraged Mariana to consider from her mother’s perspective why she might have gotten upset with Mariana. Mariana began to recognize the numerous responsibilities her mother juggled, that her mother’s expectations for assistance were realistic, and that her communication style might be affecting the way her mother and other family members responded to her.

For the remainder of the session, Mariana and the therapist role-played using communication strategies to improve her interactions with her mother, such as “I” statements (e.g., “Mom, I feel annoyed when you interrupt me during my special TV time”); communicating an understanding of her mother’s perspective, or “give to get” (e.g., “Mom, I understand that you are feeling stressed and need help around the house and the dishes needed to be cleaned; I just would like to do them after my soap opera is finished”), and finding the right time to have a conversation. (See Appendix 1). She also practiced making these statements with a more relaxed, open, and direct nonverbal stance.

After role-playing different scenarios, Mariana felt comfortable approaching her mother later that evening before going to bed and saying: “I felt sad and frustrated about what happened between us this week, and I know that you did too. I understand that you need me to help, and I would like to. Watching my soap operas is important to me because it’s one way I feel connected to home. Can we agree upon a set time when I do the dishes every day as long as you agree not to interrupt me when I am watching my soap opera?” She and the therapist practiced how to respond if Mariana’s mother reacted poorly, with a focus on considering each other’s perspectives. Mariana agreed to report on the outcome of her interpersonal experiment during the coming week.

In Session 7, Mariana continued to report an average mood of 2/10. She remained less irritable and sad, more socially engaged and energetic, with more stable eating and sleeping habits. At her worst during the week, 5/10, Mariana attributed her mood decrease to feeling uncomfortable in hot weather rather than as a result of a negative interpersonal interaction. Mariana and the therapist reviewed the outcome of the week’s interpersonal experiment. She and her mother agreed upon a time for her to complete daily chores that did not interfere with Mariana’s television watching. Mariana felt empowered and recognized how the new communication strategies she was beginning to use yielded more positive interpersonal interactions with family members, thereby improving her mood. Mariana and the therapist used the session practicing how to communicate her appreciation of recent positive interactions to her mother and father, and identifying other interpersonal situations in which she could use similar communication strategies. At the session’s end, the therapist reminded Mariana that there would be two more middle-phase sessions before proceeding to the termination phase of treatment.

In Session 8, Mariana endorsed a mood rating of 4/10 for the week. Her mother had been unable to accompany her to the session as planned due to protracted recovery from the gallbladder surgery. Consequently, Mariana’s mother had again increased demands on Mariana to assume more housekeeping and child care activities, and they had to curtail their recreational time together. The therapist asked how Mariana felt about this most recent life change. They discussed Mariana’s ambivalent feelings: she was worried about her mother’s health, and sad that they could not spend more time together after a period of increased closeness. She was also angry and frustrated at having to increase her responsibilities around the house, and felt guilty about these feelings given her mother’s condition. Furthermore, she resented that her older sister, who worked evenings, seemed to get away with doing less than Mariana to help out at home.

The therapist validated Mariana’s feelings. They also considered Mariana’s mother’s perspective given the unexpected complication of her current illness, which helped Mariana to differentiate the current circumstances surrounding her mother’s illness from past situations when she had felt abandoned by her mother. The therapist highlighted Mariana’s recent interpersonal experiment, which demonstrated that Mariana felt better when she expressed her feelings and needs directly to her mother along with problem-solving. Mariana agreed that she felt worse when she assumed a passive, helpless approach to managing conflict with her parents. They considered a goal for Mariana to speak with her mother and sister to determine a more equitable plan for dealing with the present situation.

Using a decision analysis, the therapist and Mariana took turns brainstorming possible alternatives. Next, the therapist helped Mariana to evaluate the options and to choose the option to try first: Mariana proposing to her mother and sister a list of chores and child care responsibilities, with a schedule of who was responsible for what and when based on each sister’s schedule. The family’s positive response thus far to structuring activities made this seem viable. They role-played a conversation in which Mariana used “I” statements to articulate her feelings and “give to get” statements to communicate understanding of her mother’s situation. Mariana anticipated that her sister might argue that her work schedule was too variable to commit to a set timetable. Mariana employed the “give to get” strategy in deciding to offer to be on “standby” for last-minute changes in her sister’s schedule as long as her sister would pay Mariana back with an equal amount of time spent on household responsibilities at another point. She departed the session motivated by her plan.

In Session 9 Mariana reported an average mood of 5/10. She endorsed slight increases in sleepiness, anergia, irritability, decreased appetite, and feelings of boredom. She denied thoughts and behaviors of self-harm. At its worst this past week, Mariana’s mood was a 6/10 following a disagreement with her father and maternal uncles about TV use. She described a positive outcome to the conversation with her mother and sister as practiced during the previous session, but complained that her father’s return to the household, along with visits by her maternal uncles, complicated their ability to implement their plan as originally designed. Her parents’ announcement that her father was moving back to live with them permanently also affected her mood rating. Mariana felt conflicted about this change. Adding another person to the family’s small, already crowded apartment made her feel she had no privacy or control over her favored leisure activity of watching television.

She conceded that one positive aspect of her father’s return was adding someone else to share household chore and child care responsibilities.

The therapist reviewed successful strategies that Mariana had been using in previous weeks and her improved communication, and helped Mariana work on negotiating a revised television-watching plan. She also encouraged Mariana to expand her use of free time through involvement in a local basketball program. This would allow Mariana to reengage in a sport she had enjoyed in her home country and to spend less time in her house. It would increase her socialization with Spanish-speaking peers in her neighborhood, as most of her school friends lived far from her. Mariana recognized the potentially positive impact on her mood, and role-played calling the director of the basketball program to ask about registering.

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