Termination Phase

At the beginning of Session 10, the therapist reminded Mariana that only three sessions remained and that their focus would shift to reviewing the course of therapy while continuing to work on communication and problem-solving skills. Mariana reported consistent improvement in her depressive symptoms. She felt happier and less irritable, and was eating and sleeping well. She had not experienced suicidal ideation or self-harm urges since her admission to the psychiatric ER over six weeks earlier. Her average mood rating for the week was 2/10; at its worst, after disagreeing with her father about TV watching, it increased to 3/10. The therapist and Mariana compared her current symptoms to those she had reported when treatment began and linked her work in therapy to her mood improvement. They reviewed her disputes with family members, which had decreased in frequency and intensity, to examine the new repertoire of communication and negotiation skills learned over the course of treatment. Mariana recalled her progress with using “I” statements to communicate her feelings and needs to her family members. She acknowledged greater awareness of the nonverbal messages she relayed through facial expressions and stance, and the impact these messages had on others’ moods. They reviewed her use of such strategies as “striking while the iron is cold” and “give to get,” which helped Mariana recognize the importance of timing in interpersonal interactions and the role of perspective taking in positive social interactions. She was becoming better versed in problem solving and the need to compromise at times. As a result of this new approach to relationships, Mariana felt closer to her family and was cultivating a growing network of school friends with similar ethnic and linguistic backgrounds. These positive changes helped her feel more “content” about her life in the United States.

Mariana’s mother joined the session for the remaining fifteen minutes to allow the therapist to check in on the parents’ perception of Mariana’s depression and to help plan for the termination phase. Most of Mariana’s treatment had been individual therapy, but her mother had joined parts of sessions both to support Mariana’s efforts and to address specific parent-child conflicts that were contributing to the depression. Parental involvement in IPT-A varies according to the identified problem area as well as the safety concerns related to the adolescent’s depression. Mariana’s mother participated both to support Mariana and to learn better ways to communicate and negotiate with her. Her mother listed the improvements in Mariana’s behavior, communication style, and mood at home. The quality of family relationships had improved, ameliorating everyone’s mood. The therapist encouraged the mother to commend Mariana for her progress during their joint time together, which she later did. The therapist communicated empathy with Mariana’s struggles at home, and identified the strategies that Mariana had used to manage the recent transitions in her family, social, and school life more effectively.

When considering future roadblocks to adaptive interpersonal functioning, Mariana reflected upon her avoidant style in overwhelming situations. She recognized her tendency to withdraw and isolate herself when she felt bad or confused about how to negotiate problems. Mariana recently had begun to notice a similar avoidant pattern in her approach to school. She admitted that excessive television watching after school was one way to avoid feeling helpless, frustrated, and sad about her declining academic performance and continuing struggles in a monolingual English-language classroom. Mariana had begun to arrive late to school three or four times per week over the past 2 weeks. She agreed that deterioration in her school functioning could worsen her depression. She and the therapist role-played how to speak with her teachers and guidance counselor about her academic difficulties and the possibility of switching school programs.

In Session 11 Mariana rated her average mood 2/10. She and the therapist reviewed her discussions with school personnel, about which Mariana felt good. She and her mother worked with the guidance counselor to enroll her in an after-school homework program for Spanish-speaking students at her school. She had arrived on time for school every day this past week. This, coupled with renewed efforts to complete as much of her homework as possible on time, resulted in a positive mood. She also had fewer disputes with her father over the television because she was more engaged in completing her schoolwork.

Mariana and the therapist spent the session focusing on possible challenging future situations and interpersonal strategies she could use in these situations. They identified a potential upcoming stressor in her probable change of school setting from a monolingual English program to a bilingual program. Feeling comfortable in her peer group and now adjusted to the rhythms and structure of her current school, Mariana was saddened to make yet another life change, although she could list the benefits of making this change. They discussed the importance of communicating her feelings and needs to her parents and appropriate school personnel as soon as they arose. They reviewed the strategies she had used to ease her transition into her current school setting, such as “conversation starters” and proactive involvement in extracurricular activities, highlighting how these could be useful in any new setting.

Mariana and the therapist addressed another upcoming transition: her movement out of weekly therapy and how that might feel for her. Mariana expressed pride about her progress in therapy and confidence in her developing abilities to communicate and solve problems more effectively. The therapist emphasized that Mariana’s progress resulted from her regular attendance at sessions, her efforts to express her feelings more directly, and her willingness to learn new strategies through activities such as role-plays and interpersonal experiments. Mariana acknowledged sadness about leaving the therapist. The therapist modeled the expression of affect by affirming Mariana’s feelings and acknowledging that she would miss Mariana.

Mariana’s mother accompanied her to the final weekly session, Session 12, to join its latter part. Mariana and the therapist met alone first to highlight her accomplishments in treatment, review her feelings about terminating, and decide what would be discussed with her mother. The therapist helped Mariana to consider the distinction between sadness about saying goodbye to the therapist and a relapse of her depression. Mariana’s mother joined the session and attested to Mariana’s progress in communicating more directly and respectfully, complying with parental demands at home, and improving relationships with all family members, all of which coincided with the improvement in Mariana’s mood. The therapist felt rewarded to see how playfully and lovingly Mariana acted towards her brothers while her mother spoke. She pointed this out to Mariana and her mother as another of her accomplishments in therapy.

Mariana’s final CDS score of 4 indicated that presence of depression was “very unlikely.” A C-GAS of 75 also reflected Mariana’s improvement while accommodating some remaining school difficulties. Together, Mariana, her mother, and the therapist examined a graph of Mariana’s mood ratings since the start of her treatment, and celebrated its downward trend. The therapist praised Mariana for her hard work in therapy and also congratulated Mariana’s mother for supporting Mariana’s treatment. The mother joked about learning useful communication skills such as “I” statements and “striking while the iron is cold” from Mariana.

Her mother’s remaining concern was about Mariana’s school functioning. She noted Mariana’s recent efforts to improve in this area but still worried about the effect of Mariana’s inappropriate school placement on her motivation and mood. This provided an opportunity to review the warning signs of depression with both the mother and Mariana, including sustained increases in irritability, sad mood, social withdrawal, appetite changes, and any passive suicidal ideation and urges for self-harm. Mariana and her mother agreed to monitor these depressive symptoms. Given Mariana’s unstable school situation and her mother’s need for additional support in negotiating the school system, they agreed that Mariana would continue to come for post-treatment follow-up sessions every other week for 8 weeks to see if the therapist could help them change the school placement.

Follow-up

Mariana and her mother attended four more sessions on an every-other-week basis. Mariana continued to report improved mood and maintained gains in family and social functioning. With the therapist’s help, Mariana’s mother reinforced Mariana’s positive gains through praise and modeling effective communication strategies learned in treatment. During this time Mariana faced another new but exciting transition: the family planned to move to a new, larger apartment. Mariana’s school placement and academic struggles unfortunately continued. The follow-up sessions focused on assisting Mariana’s mother in negotiating with the Board of Education. After the two months, Mariana and her mother agreed that they felt stable and could proceed independently with managing Mariana’s school placement. Both felt comfortable returning to treatment or contacting the therapist in the future as needed.

 
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