Susan, a 14-year-old Caucasian female foster child was referred to my mental health agency by a Cabinet social worker after she had told her current foster family that she wants to kill herself. It was reported that Susan had been removed from her home at age 5 and had been in foster care since that time. She was removed from her home after being found to be living in horrendous conditions. Susan was physically abused and had been born with fetal alcohol syndrome. It was also reported that Susan had been sexually abused by her maternal grandfather and maternal uncle prior to the removal. Susan had been diagnosed with oppositional defiant disorder and bipolar disorder. Susan was also reported to have a slight learning disability. Mental health treatment history was provided by the social worker including medication list and past treatment approaches with the child.
The social work file revealed that once the child and her siblings were removed from their mother, they were initially placed together, however, due to her brother having severe mental health issues, he was placed in a more therapeutic setting and they were not placed back in the same home. Since her removal, several of Susan’s placements disrupted and she had been in more than 10 placements. Susan had received mental health treatment in the past, but it was not reported to have been effective. Susan has been defiant in her foster homes and has been physically aggressive toward other children in the homes. The file indicated that Susan’s maternal grandmother had attempted suicidal by shooting herself, however, survived and is now permanently disabled. Susan’s mother also has an extensive history of mental health issues and has been hospitalized in the past in a state mental health hospital for treatment.
Although there have been issues in the past, this is the first time that Susan has talked about taking her own life. Susan’s foster mother reported that she has difficulty communicating with the child and Susan becomes upset very easily. She stated that Susan is worse on days that she has to go to court in regard to her case and her parents fail to attend. She stated that she would like to keep Susan in her home, but Susan’s behavior has been worse lately. Last week, Susan told her foster mother that she wanted to die and told her that she should just “slit her wrists” because no one loves her. This concerned her foster mother and prompted her to contact the social worker for services for the child. Susan reported that she does feel like she wants to die sometimes and that no one loves her. She stated that her family doesn’t care about her and she doesn’t really get along well with other kids. Susan reported that all of her foster parents just “try to get rid” of her and that her mom has moved on and is now married and doesn’t visit with her anymore. She reported that she sometimes feels like it would be easier to die than to “deal with all of it”.
The Problem- Suicidal Ideation
The term suicidal ideation is referred to when an individual has intent to commit suicide and a plan of how to do so. Suicide is the third leading cause of death among children and adolescents ages 10-24 year old and most of these individuals have at least one psychiatric disorder (Karaman & Durukan, 2013). Physical, emotional, and sexual abuse are associated with an increase in mental health issues, suicidal ideation being one of these (Leenarts, Diehle, Doreleijers, Jansma, & Lindauer, 2012). Disruptions of relationships and bonds as well as household dysfunction are also factors that can increase that likelihood that a child would have suicidal thoughts/ideations (Sheftall, Mathias, Furr, & Dougherty, 2012). Depression and family history of suicide are also factors that are significant to suicidal risks. Depression is the most common form of mental health diagnosis found among suicide attempters and teens that had committed suicide (Karaman & Durukan, 2013).
Assessments
In order to gain insight into the significance of Susan’s suicidal risks, assessments were completed during the initial phase of treatment. It was reported that Susan had been diagnosed with depression in the past and has a family history of depression as well. Due to these factors, she was given the Kutcher Adolescent Depression Scale (KADS) and was scored according to her answers. The KADS-11 is an 11-item questionnaire in which the client rates the frequency of certain thoughts within a timeframe (“Psychology Tools”). The scale has been proven to be effective in the indication of changes in children diagnosed with major depressive disorder (Brooks, Krulewicz, & Kutcher, 2003). The screening tool is scored from 0-33 with higher scores indicating more severe depression. Based on her answers, Susan scored a 22 out of 33. Susan indicated on the scale that she feels sad most of the time, and is easily agitated all of the time. She indicated that she has had suicidal thoughts in the last week, but denied having a plan. It was also indicated on the scale that she has feelings of worthlessness and displeasure most of the time as well.
Engagement Strategy
Due to Susan’s past history of abuse and feelings of distrust of adults, the engagement process was imperative in order to build rapport with Susan and formulate effective treatment strategies. Engagement was difficult with Susan, as it appeared that she was typically very defensive and had a very negative outlook on treatment and mental health professionals in general. She seemed to see all social workers as bad, rather than as helpers. The clinician utilized motivational interviewing and active listening skills in order to engage Susan in the initial meeting. Motivational interviewing allowed the clinician to place initial focus on the clients strengths, and display empathy and emphasis on the partnership between Susan and the clinician (Walsh, 2013, pg. 274) Susan initially began answering questions with very brief answers or simply with “yes” or “no”. When asked to explain or elaborate, she would sigh and appear to become agitated. The clinician took her time with Susan and would use brief pauses in order to allow Susan to collect her thoughts and settle down before asking further questions. Motivational interviewing techniques allowed the clinician to approach the client in a non-confrontational manner, while helping to elicit change.
Due to Susan’s extensive history of abuse and multiple placements, the goal of the first session was to just talk and get to know the client, allowing her to begin to feel more comfortable with the clinician. Susan was asked to talk about things that make her happy and likes and dislikes as an activity to make her more relaxed in speaking with the clinician. The clinician explained to Susan that in working together, they will get to know one another and be able to work together on goals in order to help her feel better. Susan agreed to do so with very little ambivalence at the end of the meeting. Before leaving the meeting, the clinician formulated a safety plan with Susan’s foster mother and Susan as she had made a statement about committing suicide. The plan is as follows:
1. Susan will be open and honest with her foster mother and will tell her immediately should she have any thoughts of harming herself.
2. Susan will contact the crisis center immediately should she have thoughts of suicide.
3. Clinician will be notified of any thoughts of suicide or worsening depression.
Supports and Obstacles to Change
Susan’s main forms of support were identified as her state social worker and her current foster mother. Susan had no other family involvement and had moved schools several times, therefore, had not really formed bonds with other peers or staff members at her schools. It appeared that Susan’s depression was directly linked to her history of abuse and the lack of familial involvement. Susan had mental health diagnoses that may also be contributing. Aside from receiving mental health treatment through the IHOP program, Susan was seen by a psychiatrist for medication management. The psychiatrist was also listed as a support for the child in regard to her treatment.
Susan’s foster mother was involved in Susan’s treatment and willing to participate in in-home therapy as well. She reported that she wanted to make all efforts to help Susan remain in her home and not have to be placed in a facility or another foster home. She reported that she would ensure that Susan attends sessions with the worker. Susan’s state social worker reported that she too would attend sessions as needed in order to provide support to the child.
Treatment Plan
A treatment plan was established between Susan and the clinician. In the plan, Susan would meet privately with the clinician one time weekly at the office and once every other week in her home with her foster mother. The meetings in the office would be 60-90 minuets for 8 weeks and would consists of therapy and activities in order to assist Susan in minimizing her feelings of depression and any thoughts of suicide. Engagement was difficult with Susan due to her past, however, the clinician focused on rapport building and activities to obtain information in regard to the severity of Susan’s depression in order to measure the effectiveness of treatment later. Family meetings in the home were included due to Susan’s feelings of worthlessness and the fact that she had relayed that no one cares for her. During these sessions, the foster mother could meet with the clinician and Susan in order for Susan to see that she is supportive of Susan’s treatment as well as her remaining in her home.
During sessions, times of anger, anxiety, depression and other negative feelings were discussed in order for Susan to be able to identify specific triggers for her feelings and behaviors. Susan was asked to discuss her reaction to different situations and to then discuss alternative methods that could have been utilized in order to prevent negative thoughts and feelings. The clinician used the time for reflection in order to assist Susan in realizing her own potential and praising her for making decisions that were beneficial to her, such as pausing to think before reacting to someone who she felt insulted her. Aside from working on her temperament, Susan was asked to focus on the positive aspects of her life as well. Negative thoughts and feelings were initially discussed, however, through treatment, Susan was able to begin to focus on positive aspects of her life. It was apparent that many of Susan’s thoughts and behaviors fueled from feelings of rejection by adults in her life. Activities were planned for Susan to spend time with her foster mother for bonding, and Susan was asked to reflect on these times as well in therapy.
Goals were set between the clinician and Susan to work toward in treatment. Goals were as follows: 1. Reduce feelings of sadness/depression. 2. Actively participate in relationship building activities with her foster mother, 3. To prevent any thoughts of suicide or suicide attempts, 4. Participate in a regular activity of her choice either at school or in the community (youth group, sports, clubs, etc.).
Intervention
Problem solving and coping skills deficits is a factor in adolescents with suicidal ideation (Hetrick et al, 2013). Cognitive Behavioral Therapy is based on the cognitive model, and elements of behavioral change. Individuals in distress tend to have negative perceptions of situation; therefore CBT is aimed at assisting the client in identifying which of these perceptions are distorted. Adolescents who attempt suicide are also found to have poor solution choice and do not consider long-term effects of their actions (Hetrick et al, 2013). CBT is an approach aimed at assisting the client in changing perceptions of situations in order to make more rational decisions. Behavioral changes are also a focus of CBT and responses to situations are a goal of therapy. CBT can be used to assist adolescents in improving social skills, problem solving, and ultimately cognitive restructuring (Phillips, Corcoran, & Grossman, 2003). Trauma focused CBT has been proven to be effective with children who have suffered abuse or neglect as well (Lenarts, Diehle, Doreieijers, & Jansma, 2012).
During the weekly meetings with Susan, she and the clinician discussed how to use problem solving in order to overcome her feelings of rejection from her family. They discussed how to substitute positive thoughts for negative thoughts and how this would change the way Susan feels overall. Susan was able to list positive aspects of her life and things that make her happy and focus on those things when she begins to feel sad or depressed. Coping skills were formulated and Susan was educated on specific coping skills that may assist her negative thoughts and behaviors. The ABC method was used during sessions in order to assist Susan in gaining more insight into how her automatic thoughts may be replaced with an alternative thought. During family sessions, the family was encouraged to speak openly about thoughts and concerns and much of the time was spent to facilitate bonding between Susan and her foster mother in order to prompt the sense of attachment and belonging that Susan appeared to be lacking.
Evaluate Goal Achievement/Termination
At the end of the 8-week period, Susan completed the KADS to determine if her feelings of depression were reduced. Susan scored a 15/33 indicating that treatment had been effective in reducing her feelings of depression. Susan self-reported that she had not had any thoughts of suicide in 4 weeks and appeared to be more comfortable with her foster mother. Susan had joined the youth group at her foster mother’s church and had made a friend while there. Her foster mother reported that Susan’s outbursts of anger had been significantly reduced and they plan to continue their bonding activities after termination of services.
During the final session, the clinician ensured Susan that she had the tools to continue to make progress toward her goals even after treatment. Susan appeared to be much more comfortable talking about her feelings and stated that she has been feeling better recently. She reported that she plans to continue to use her coping skills and wants to remain in her current foster home. She stated that she has not had thoughts of suicide, but has had bouts of sadness. The clinician explained that Susan may continue to have times of sadness, but if she continues to use coping skills and tools acquired during treatment, she will overcome these feelings and replace them with positive thoughts. Susan left the session with a feeling of acceptance and understanding of her own worth, which was a goal of the clinician. Susan’s self confidence was increased and she was able to see her own ability to make positive decisions and have control of the outcomes of many situations.
Resources
Brooks, S., Krulewicz, S., & Kutcher, S. (2003). The Kutcher Adolescent Depression Scale: Assessment of Its Evaluative Properties over the Course of an 8-Week Pediatric Pharmacotherapy Trial. Journal of Child and Adolescent Psychopharmacology, 13(3), 337-349.
Hetrick, S., Yuen, H., Cox, G., Bendall, S., Yung, A., Pirkis, J., & Robinson, J. (2014). Does cognitive behavioural therapy have a role in improving problem solving and coping in adolescents with suicidal ideation? The Cognitive Behaviour Therapist TCBT, 7. doi:10.1017/si754470x14000129
Karaman, D., & Durakan, I. (2013). Suicide in children and adolescents. 5(1), 30-47.
Leenarts, L., Diehle, J., Doreleijers, T., Jansma, E., & Lindauer, R. (2012). Evidence-based treatments for children with trauma-related psychopathology as a result of childhood maltreatment: A systematic review. European Child & Adolescent Psychiatry, 22, 269-283.
Phillips, J., Corcoran, J., & Grossman, C. (2003). Implementing a Cognitive-Behavioral Curriculum for Adolescents with Depression in the School Setting. Children & Schools, 147-158.
Psychology Tools. (2015). Retrieved November 8, 2015.
Sheftall, A., Mathias, C., Furr, R., & Dougherty, D. (2013). Adolescent attachment security, family functioning, and suicide attempts. Attachment & Human Development, 15(4), 368-383.
Walsh, J. (2013). Motivational Interviewing and Enhancement Therapy. In Theories for direct social work practice. Belmont, CA: Thomson Brooks/Cole.