Consider this situation from one of my sessions this past week:
Kimberly is a 12 year old girl who is in treatment for depression and severe anxiety. She lives in a lower socio-economic neighborhood that consists of crime and drug abuse. Her mother is an alcoholic who binge drinks every weekend with her new boyfriend of 4wks. Every weekend Kimberly’s mother struggles to stay away from the alcohol. Her mother has been on disability for 15yr for bipolar disorder and for a heart condition. Kimberly’s mom doesn’t have transportation to take her to school each day so she is stuck walking to school with kids who are either bullying her, threatening to bully her, or pressuring her to try drugs with them after school. Kimberly is feeling overwhelmed by her own mental health problems and environmental stressors. Once in school, she finds herself struggling with anxiety and asks her teacher to allow her to sit in the back of the class alone. Her teacher, who has been in the army for years, tells her to “suck it up” and “hang in there with the other students.” She tries to explain that her anxiety and depression have worsened due to changes in her home life and that she needs a little flexibility. She tries to convince her teacher that she will complete her work but just cannot participate actively in class at this time. Her teacher sends her to the Principals office and she gets a rating on her report card of “failing to participate.” Her mother begins to yell at her and sends her to her room. Kimberly sits in her room, having already been in crisis state, and contemplates suicide. She grabs a pocket knife and begins to cut her arms and legs. Her mother just happens to walk into her room and see blood. Mother calls 911 and reports that her daughter needs psychiatric treatment. The police call an ambulance that eventually takes Kimberly to the nearest psychiatric hospital for evaluation. The attending psychiatrist diagnosed Kimberly with major depressive disorder, severe, single episode. She is then held in the hospital for 48-72hrs before obtaining an appointment with an outpatient therapist. Her therapist further evaluates her, designs a crisis plan with Kimberly, and begins to discuss problem-solving skills. Kimberly explains that she does not have control over her situation because her mother “does what she wants to do and I am just a kid.” Her therapist explains that while she may not have complete control over her circumstances, she can use problem-solving skills that can help her cope in the meantime. The therapist explains that instead of engaging in self-injury as a coping skill, she can turn to self-soothing to calm down (listening to music, exercising, talking to a friend, dancing, etc.) and then walk through the problem-solving stages:
- Identify the problem: too many changes in the home, declining mental health, lack of understanding teachers
- Past responses that didn’t work: cutting, thinking about suicide (which resulted in being hospitalized and medicated)
- Develop a different plan: use coping skills first, reach out to someone for help that might understand you better such as a school counselor or Principal.
- Find ways to take baby-steps in implementing this solution: each time Kimberly feels overwhelmed, she is to try one coping skills per day and then increase the amount of coping skills she uses each week.
- Consider what can or who can support you in trying this new solution or different response: talking to a school counselor or the Principal about the coping skills you need to use in order to stay on track in school. Kimberly asked me to write a note to her school’s Principal and teacher so they could better understand the situation.
- Ask for feedback once you have tried the different response (asking others if they think your approach was better): after a week of trying her new skills, Kimberly is to ask her teachers if they saw a difference in her.
- Trying it all out: Kimberly set her mind on giving this process a try without fighting it or making excuses for why it won’t work.
- Evaluating it (determining if it actually worked): Kimberly will write in her journal or talk with her teacher about how these skills help or do not help.