Depression and Cutting

The First Visit

When Cherie brought 13-year-old Maddy in for her well-child visit, I immediately knew that the appointment was going to be a long one. When I opened the exam room door, I found the mother and daughter fighting. It appeared as though Maddy was winning because her mother was in tears.

“Dr. Meeker” her mother began, “Please do something with Maddy. She’s out of control. She won’t listen to me. I just found out she’s been cutting her arms and her friends are getting her into a whole lot of trouble.”

Maddy piped up, “That’s not true. You just don’t like any of my friends because they don’t get straight A’s and they don’t dress like you think they should. They’re nice! And besides, if I cut, it’s none of your business.”

Fortunately, I knew Maddy, so I skipped the cordial hellos and jumped right into the conversation. “Maddy” I said, “Are you cutting?”

She looked at her mother then down at the floor and responded, “Yes, a little,”

Cherie sat next to her and cried. “I just don’t understand,” she said. “Why would she do something like that??”

“So Maddy, why are you cutting yourself?” I asked her this as I walked to the exam table and patted the top, indicating I wanted her to jump up on the table. She complied and I grabbed her arm and gently rolled up her sleeve. Both of her arms were covered with multiple superficial scars… My heart sank.

“Oh Maddy” I said. “This makes me so sad.” I looked at her and she looked away, not really knowing what to say.

“It just, I guess, kinda makes me feel better. I don’t know. I do it when I’m mad. I get mad at my mom and my dad and I get mad at myself. I’m just stupid, ‘ya know.”

“No, I don’t know,” I said. “I’ve known you for a long time and I know that you’re not stupid. As a matter of fact, I’ve had conversations with you that I often have with adults, so I know that you are very smart. What do you mean by stupid?”

“I just don’t like myself.” Maddy said.

Her mother cried harder.

“How long have you not liked yourself very much?” I asked.

“I dunno…ever since last summer.” Maddy explained, “It got bad when my boyfriend broke up with me.”

“Oh, what a blessing that was!” her mother cheered. “Tell her, Maddy. He is now in prison. He was a terrible influence on you!”

I looked back at Maddy and she was clearly upset at her mother, but couldn’t deny the claim. Her 17-year-old ex-boyfriend was now in prison.

After we all chatted for 45 mins, I learned that Maddy’s father had taken a job overseas working on an electrical plant. He worked for three months, came home for six weeks and then returned again. Maddy said she missed him, but overall was “glad” he was gone because she “didn’t get along with him either.”

I explained to Maddy and her mother that we needed to work hard on some stuff, but before they returned in a week, I needed them to specifically do three things: First, I wanted Maddy to keep a “mad journal.” In the journal, I wanted her to write anything that she wanted when she was angry. She had a real artistic flair, so I told her to draw images and to use color in her writing.

Second, I told her mother that I wanted her to take Maddy out to dinner or to have a special dinner at home with just the two of them every week. During the dinner, they could not argue or talk about anything difficult. It didn’t have to be long, but the purpose of the dinner was to be together… even if they didn’t speak.

Third, I needed Maddy to agree to it.

Fortunately, the two of them complied with my plans. I told them to return in a week.

The Second Visit

When Maddy and her mother came back to see me, it was clear that the two of them were still on rough terms. I could hear them arguing outside the exam room.

“So” I said cheerfully, “How are you two today?”

“Good.” Maddy chirped. She seemed to be in a better mood than her mother.

“Maddy, what do you mean by ‘good? ’” I asked.

“Well, Mom and I didn’t fight as much this week and she left me alone more than she usually does. I mean, she didn’t pick any fights with me.” Maddy reported.

I turned to Cherie. “What do you say, Cherie? Did this week go any better?”

“Ugh. I don’t know. She’s impossible. I ask her friends over, but she complains that I don’t like them. She wants to wear obscene clothes to school and when I tell her ‘no’ she yells at me and slams the door to her room. I can’t seem to do anything that makes her happy.” Cherie said.

“Tell me about dinner. Did you have dinners together?” I asked.

They looked at one another. “Yes” Maddy said. “We did. It was weird. I mean, do we have to keep doing that?”

“I tried Dr. Meeker,” explained Cherie, “I really did. I took Maddy to her favorite restaurant and she spoke three words to me. She hates me. I want to do anything I can for her. I listen. I know she’s smart and I tell her that all the time. I ask her how she’s doing, what she likes at school, what she wants to do when she’s older and she just glares at me like I have three heads. She can’t stand me. I just wish she’d tell me what she wants me to do and I’d do it.”

“Maddy” I started, “Here’s the deal. Your mother loves you a lot. You can see that. The problem is that she can’t see what’s inside your head and she also can’t see the feelings inside your heart. So, can you help her out a little?”

“Well, she should know what I think and feel, after all, she’s my Mom.” Maddy continued, “And she was a kid once, why doesn’t she get it? Why doesn’t she get me? She’s supposed to!”

I explained to Maddy that sometimes parents love their children “sideways.” Meaning that the love doesn’t come out the way children think it should, so they just assume that the parents don’t love them. I asked Maddy to tell her mother what made her feel more loved. Was it not snarling at her friends’ clothes? Was it asking certain questions or was it helping her with homework?

Maddy started to cry. I waited until she settled down and she spoke. “Well” she sniffled, “my Mom tries too hard. She always seems so suspicious of me and that makes me feel like I’m a bad kid.”

“What is your mother suspicious about?” I asked.

“She thinks I’m going to run away or get in trouble or do something bad to myself.” She responded.

“Well” I asked. “Should she worry about those?”

Maddy was startled by my question. She didn’t know what to say because she realized that her mother was right. Her mother did have a right to worry because Maddy was trying to hurt herself.

Over the next few weeks Maddy and her mother came to realize that much of Maddy’s behavior stemmed from two things: missing her father and feeling rejected by her boyfriend.

Her “bad moods” as she described them, began shortly after her father left and her cutting began after her boyfriend broke up with her. So, why did she take everything out on her mother? Because that’s what sad kids do. She couldn’t be angry with her father because she wanted to make sure that her time with him at home was pleasant and she believed that if she were a “better” girlfriend, her boyfriend wouldn’t have broken up with her. When children hurt, they often turn the anger inward on themselves because they believe that they are responsible for many bad events. In short, the breakup triggered her desire to punish herself and this led to her cutting.

“Here’s what I’d like you to do Maddy.” I told her. “I want you to write a letter to your father, but I don’t want you to send it. Tell him why you miss him. Tell him what it feels like to be left behind. If you feel that he should be staying home, tell him that. Write whatever you want because no one, including your mother, can read the letter.

When I was alone with her mother, I said, “Cherie, I want you to do something as well. I want you to stop asking Maddy what you should do. Don’t let her know how much her behavior upsets you. When she sees you tangled in knots over something she says or does, it actually makes her feel frightened. She doesn’t want to feel like she has that much power in your life, because it makes her believe that she’s too much for you to handle. And that makes her feel very insecure. Can you try that?” Cherie agreed to try.

The Third Visit

Over the ensuing weeks, Maddy wrote letters to her father, Cherie made sure that they ate dinner together at least once per week and she tried not to let Maddy see how upset she was.

I asked Cherie to bring Maddy’s father in for a visit the next time that he was home. She did and I saw the two of them together.

We exchanged cordial greetings and then got down to business. “So, Mr. Webber, as you know, Maddy’s really been struggling and we’re trying to get to the bottom of it. She is depressed and as most depressed teens do, she turns her anger in on herself. She’s been cutting, acting out and getting in trouble at school. What are your thoughts about why Maddy could be depressed?”

“Hmm. I don’t really know.” He responded thoughtfully, “We’ve never been close. She and her mother do everything together and I’m always on the outside. Honestly, I have no clue.”

“Before you left for this new job and spent more time at home, did you and Maddy ever do anything together?” I asked.

“Not really. I mean I tried to go to her concerts when I could, but as I said, Maddy and I have never been close. She doesn’t seem to want to do anything with me so I leave her alone. Particularly over the past three years, she’s been closed off to me. I just assumed that she really doesn’t like me, so I leave her alone.” He reported.

“Are you ever affectionate with her?” I asked. Maddy’s father looked at me as if to say “Didn’t you just hear what I said? What kind of question is that?”

“No, not really I guess. I mean, when she was younger, I tried to hug her but she backed away and shuddered so I left her alone. Like I said, she really doesn’t seem to want me to be around her.” I could hear his sadness in the explanation.

I learned during my visit with Maddy’s father that he was a sensitive man who had his feelings hurt by Maddy over the years. She and her mother never included him in what they were doing and Cherie never encouraged him to take Maddy out alone. So, like many fathers who get their feelings hurt, he felt confused. So, he simply backed out of her life. In fact, Maddy confided in me later that this hurt her terribly. She believed that her father didn’t like her or love her. She interpreted his behavior, even his taking a job overseas, as a way to get away from her. This felt devastating to Maddy.

Cherie, in response to the broken relationship, decided to compensate for the fact that her husband was never around and sidled up to Maddy, giving her clothes, letting her date a young man that she never should have dated and basically allowing Maddy do whatever she wanted because she didn’t ever want to make her upset.

Over the next months, I spoke with Cherie and Maddy individually and together. I found them a great therapist who worked with both of them and after 18 months, the two were finally back on track.

The Final Visit (18 Months Later)

“I love, love, love it!” I exclaimed as I walked into the exam room. Maddy had cut her hair and dyed it a beautiful shade of red. Being an artsy type, she was always changing hairstyles with green, pink or other unusual shades. Today, she looked particularly lovely and more grown up.

“Ok. The haircut’s amazing,” I told her. “You look older and more confident. But, can we ditch the tongue bar? I hate those things. You are way too pretty for that and besides, you’re smart and you’re going to want to get a great job one day and some employer’s going to balk at that.”

Maddy smiled. I talked straight to her because over the months, she learned that I really liked her and “had her back.” Both Maddy and her mother sat in the room and reflected on the past two years together. Maddy had turned 15 and was still fairly immature, but her cutting had stopped and she wasn’t running around with a crowd of friends who were trying to get into trouble. She had also put dating on hold.

“So how are you two getting along?” I started.

“Good.” Maddy offered. “I mean, you know, we have our arguments here and there. But, we do have fun together sometimes. My mom’s stricter than she used to be. She still doesn’t trust me but that’s OK. I’m not getting into trouble anyway.” Maddy smiled coyly.

Cherie interrupted, “Hold on. I trust you… most of the time. I mean Maddy, really. You know the rules. If you behave and stay out of trouble I let you do a lot. Give me some credit here.”

We chatted for a while and talked about Maddy’s medication. Along the way, we had tried a low dose of an antidepressant and she responded very well. Cherie asked how long Maddy needed to be on it.

“I’d like to make sure that you’re feeling ‘normal’ for a while Maddy, if you know what I mean. When the medicine’s working, your moods will be more stable and you won’t feel like you’re living with a gray blanket over your head all the time. You won’t feel as down, but you won’t feel giddy either. It’s kind of like treating diabetes. When a diabetic teen has the right amount of insulin in her blood, she feels like she no longer needs it because her blood sugars are normal. Medication for you is like that. It brings the hormone levels in your brain back to normal so you feel like nothing’s wrong. We’ll stay where we are for another year and then see if we can wean you off of it completely. Sound good?” I asked.

“Sure, Dr. Meeker,” she replied, “whatever I need to do. Life is really good now and I don’t want to change anything.”

Family Makeover Conclusions

Maddy is now 16, I am happy to report that she is doing very well and is looking forward to college! Their situation is so common to many teens and parents today. So let’s review some of the issues that got her into trouble and how she, her mother and her father were able to work their way out of this difficult time:

• Maddy’s depression. After puberty began, Maddy became very self-conscious and her self-esteem plummeted. She withdrew from her dad because she was uncomfortable with affection. The more she withdrew, the more he withdrew. Maddy inferred that her father didn’t like her or love her anymore and this hurt her deeply. Then, when he took a job overseas, she was convinced that she drove him to leave. This is irrational, but it is how teens think! So, once we got her to see that she actually desperately wanted her father’s approval, love and affection, her depression began to lift. But we also chose to use medication when her depression wasn’t lifting quickly enough. Often, medication can help patients respond to counseling better.

• Maddy’s bad behavior. Much of her behavior (getting into trouble at school, having the boyfriend, cutting) all stemmed from a subconscious desire to show the world (mother, father, friends) how bad she really thought of herself. Additionally, the bad behavior garnered her a whole lot of attention and brought her mother to her knees. We helped Maddy face her fears, depression, feelings of self-contempt and sadness, and she began to let those feelings out.

• Cherie’s unhealthy response- Cherie, acting as a single parent, felt guilty that her husband wasn’t interested in Maddy. So, she “felt sorry” for Maddy and began letting her do whatever she wanted. In addition, in an effort to keep Maddy “close” to her, she began acting like a sister to her rather than a mother. Cherie was lonely, needed companionship, and she turned to Maddy. This made Maddy feel off balance, frightened and left her with a sense that she could alter her mother’s moods whenever she wanted. At 13, this was terrifying. Cherie learned to stand up for herself and enforce rules in her home. At first, Maddy rebelled, but after a few weeks, relaxed and learned to feel “safe” in her home and around her mother. Cherie also began confiding in friends about her feelings rather than confiding in her daughter.

• Her father’s withdrawal. When her father withdrew, this made things much worse. Once we helped her father realize how hurt Maddy felt by his behavior (and work) he was able to engage her more. He began showing her affection, writing her emails and calling her on the phone. She realized that her father loved her very much, but communicated it in a way that Maddy couldn’t understand. Helping her father communicate his love and affection for Maddy dramatically improved her self-esteem and alleviated her depression.