Revista Puertorriqueña de Psicología

ISSN: 1946-2026
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Asociación de Psicología de Puerto Rico
Puerto Rico

Jiménez Chafey, María I.; Duarté Vélez, Yovanska M.; Bernal, Guillermo
Mother-daughter interactions among depressed Puerto Rican adolescents: Two case studies in CBT
Revista Puertorriqueña de Psicología, vol. 22, 2011, pp. 46-71
Asociación de Psicología de Puerto Rico
San Juan, Puerto Rico

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Revista Puertorriqueña de Psicología COPYRIGHT © Asociación de
Vol. 22, 2011 Psicología de Puerto Rico

Mother-daughter interactions among

depressed Puerto Rican adolescents:
Two case studies in CBT1
2
María I. Jiménez Chafey
Yovanska M. Duarté Vélez
Guillermo Bernal
University of Puerto Rico, Río Piedras Campus

Abstract
This article presents two case studies of adolescents receiving
cognitive-behavioral therapy (CBT) for depression to illustrate how
family patterns, particularly mother-daughter interactions, contribute
to the perpetuation of depressive symptoms and to treatment response.
Participants were two adolescent girls selected for this case study from
a larger sample of adolescents participating in a randomized clinical
trial on therapy for depression. Both cases required additional therapy
sessions to reduce depressive symptoms. The first case presented no
depressive symptoms at therapy termination and the second continued
to present mild symptoms although neither met criteria for Major
Depressive Disorder (MDD). During the last follow up assessment one
case presented a relapse of MDD. However, when calculating the
reliable change index individually, both cases presented significant
clinical changes.

Keywords: Adolescent, cognitive behavioral therapy, depression

1
!ote: This article was submitted for evaluation on September 2010 and accepted
for publication on January 2011.
2
Send all correspondence to: UPRRP - DCODE P.O. Box 23137, San Juan, Puerto
Rico 00931-3137. Email: [email protected].
MOTHER-DAUGHTER INTERACTION AND DEPRESSION

Resumen
Este artículo presenta dos estudios de caso de adolescentes recibiendo
Terapia Cognitivo Conductual (TCC) para la depresión para ilustrar
cómo los patrones de interacción familiar, particularmente aquellos
entre madre e hijas, contribuyen al mantenimiento de la depresión y la
respuesta a terapia. Las adolescentes fueron seleccionadas de una
muestra mayor de un ensayo clínico de TCC para la depresión en
adolescentes. Ambos casos requirieron sesiones adicionales para
reducir la sintomatología depresiva. Un caso no presentó síntomas
depresivos al terminar la terapia, mientras que el otro continuó
presentando síntomas a nivel moderado, aunque ambas estaban en
remisión de acuerdo con los criterios diagnósticos del Trastorno de
Depresión Mayor (TDM). Durante la última evaluación de
seguimiento uno de los casos presentó un episodio recurrente de TDM.
Sin embargo, al calcular el índice de cambio confiable a nivel
individual, ambos casos presentaron cambios clínicos significativos.

Palabras claves: Adolescente, terapia cognitivo conductual,

depresión

Family factors are particularly relevant for depression in

Latino/a adolescents. They have been found to be significantly related
to depressive symptoms in Puerto Rican adolescents. Particularly
variables such as: family dysfunction, perceived criticism and
perceived acceptance have been found to influence treatment response
(Sáez-Santiago & Rosselló, 2001; Sáez-Santiago & Rosselló, 1997).
Other studies have found that depressive symptoms significantly
correlate with deficiencies in the following areas of family functioning:
roles, communication, expression of affect, affective involvement, and
norms and values (Arzola-Colón, González-Vilanova, & Rosselló,
2000; Martínez & Rosselló, 1995). Forty percent of Puerto Rican
adolescents in a clinical trial of treatment for depression considered
their most frequent problem a family problem (Padilla, Dávila, &
Rosselló, 2002) and 70% considered their most frequent interpersonal
problem was with one or both parents (Rosselló & Bernal, 1999).
Most studies on family factors in adolescent depression have
focused on the impact of parental marital status, parental conflict and
family functioning, while fewer have addressed parent-adolescent
interactions, particularly by gender and ethnicity (Corona, Lefkowitz,
Sigman, & Romo, 2005; Sheeber, Hops, & Davis, 2001). Gender
 MOTHER-DAUGHTER INTERACTION AND DEPRESSION

differences in the prevalence of depression generally appear by early

adolescence, with most studies reporting approximately twice as many
girls presenting depression than boys (Hart & Thompson, 1996;
Powers & Welsh, 1999). These gender differences in depression have
also been observed in samples of Latino youth (Canino et al., 2004;
Siegel, Aneshensel, Taub, Cantwell, & Driscoll, 1998). Most
explanations for this difference revolve around differing cultural
expectations and developmental processes for males and females (Hart
& Thompson, 1996; Powers & Welsh, 1999; Sheeber et al., 2001).
Since familismo is such an important cultural value for
Latinos/as, and Latino parents often adopt cultural values of absolute
parental authority and respect and family unity, the task of
individuation for Latino/a adolescents tends to take place later in
adolescence as compared to mainstream Anglo American culture
(Corona et al., 2005; Rosselló & Bernal, 2005). For Latina girls, the
task of individuation can be more difficult and conflicted due to
differences in gender roles and expectations for females – girls are
provided less autonomy and are expected to stay closer to the family
until later in adolescence (Zayas & Palleja, 1988).
Gender and ethnicity (female and Latino culture) appear to be
risk factors for depression in adolescents, and family variables seem to
contribute significantly to the course of depression and response to
treatment in Latino population (Bernal, Cumba-Avilés, & Sáez
Santiago, 2006; Duarte-Vélez & Bernal, 2007). Few studies on
variables associated with treatment response in adolescent depression
have focused on specific ethnic minority groups or included a
significant number of ethnic minority subjects in their samples.
Preliminary data from a small qualitative study on response to
treatment in Puerto Rican adolescents receiving psychotherapy for
depression suggests that some factors associated with partial or limited
response to treatment for depression are: being female, presenting
multiple co-morbid diagnosis and significant family conflict,
particularly conflict in the mother-daughter relationship (Jiménez,
Rosselló, & Bernal, 2006).
The purpose of this article is to present two case studies of
Puerto Rican adolescents receiving cognitive-behavioral therapy
(CBT) for depression to illustrate how family patterns, particularly
mother-daughter interactions, contribute to the perpetuation of
depressive symptoms and to treatment response.
MOTHER-DAUGHTER INTERACTION AND DEPRESSION

Method
Procedure
Two patients were selected after obtaining informed consent
from a larger sample of adolescents participating in a randomized
clinical trial on therapy for clinical depression which included two
treatment conditions: 12 sessions of CBT and a CBT plus a group
psycho-educational parent intervention (PPI). As part of a
supplemental research project to the clinical trial, additional sessions
(up to a maximum of 12) were offered to adolescents whose depression
did not remit at post-treatment to examine the optimal dose needed for
complete remission as well as characteristics associated with partial or
limited response to therapy. The patients selected were chosen because
they presented partial or limited response to therapy and there were
significant mother-daughter issues that appeared to be contributing to
the adolescent’s depression and response to therapy. Both patients were
selected from the CBT only condition to examine parent participation
in treatment without the structured PPI component.
For the purposes of this study, partial or limited response was
defined as presenting elevated symptoms of depression after a standard
12 session dose of CBT according either to self-report instruments or
clinical interviews assessing depression. Elevated depressive
symptoms were defined as scores above 19 on the Children’s
Depression Inventory which reflect depressive symptoms of moderate
severity or greater and/or reporting five or more depressive symptoms
on the Diagnostic Interview Schedule for Children-VI. Therapists were
doctoral level students in clinical psychology supervised by licensed
clinical psychologists. Both quantitative data from self-report
assessments and qualitative data from videotaped sessions and
progress notes were analyzed to obtain data for this study.
All patients in the project were treated using a manual-based
CBT which has demonstrated efficacy in treating depression in Puerto
Rican adolescents (Rosselló & Bernal, 1996; Rosselló & Bernal, 1999,
2005). The CBT manual sessions are divided into three major modules:
how thoughts influence mood (sessions 1-4); how daily activities
influence mood (sessions 5-8); and how interactions with other people
influence mood (sessions 9-12) (see Rosselló & Bernal, 2005).
Additional continuation sessions for adolescents with partial or limited
response to therapy were planned according to each adolescent’s needs
 MOTHER-DAUGHTER INTERACTION AND DEPRESSION

by reinforcing the selected themes of CBT manual.

Measures
Diagnostic Interview Schedule for Children (DISC-IV) (Shaffer,
Fisher, Lucas, Dulcan, & Schwab-Stone, 2000). Diagnoses were
established using DISC-IV which is based on criteria from the
Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It is
the most recent revision of a structured interview for youth developed
initially by NIMH for epidemiological studies involving children and
adolescents. The use of the Spanish version of the DISC-IV with
clinical samples establishes it is a reliable instrument for children and
parents (Canino et al., 2004). The DISC-IV was administered pre and
post treatment, and at 3, 6, 9 and 12 month follow up assessments.
Children’s Depression Inventory (CDI) (Kovacs, 1992). The
CDI is a 27 item self-report symptom-oriented scale suitable for
children and adolescents that has been translated and adapted for use
with Puerto Rican youth. The CDI is able to differentiate mild and
severe depression (cutoffs values of 12 and 19, respectively) and its use
in Puerto Rican samples suggests high internal consistency (alpha =
0.83) and acceptable concurrent validity (Rosselló, Guisasola, Ralat,
Martínez, & Nieves, 1992). The CDI was administered at the following
times: pre-treatment, at the 3rd, 5th and, 9th session, post treatment every
two sessions of the additional treatment sessions, and at all follow up
assessments (months 3, 6, 9 and 12).
The following measures were administered pre and post
treatment, and at six and 12 month follow up assessments:
Dysfunctional Attitude Scale (DAS) (Weissman, 1979). This
scale measures dysfunctional cognitions and thought patterns of
depressed persons, elevated scores indicate greater dysfunction.
Reliability indices have ranged form 0.71 to 0.84 in U.S. samples. It
was translated and adapted for use with Puerto Rican youth yielding
reliability indices ranging between 0.80 to 0.87 (Scharron del Río &
Rosselló, 1996). A short version of 14 items that has demonstrated
adequate psychometric properties was used in this study.
Piers-Harris Children’s Self-Concept Scale (PHCSCS). The
PHCSC is a self-report instrument consisting of 80 items designed to
assess what children and adolescents think about themselves, higher
scores indicate better self-concept (Piers & Harris, 1984). The scale has
MOTHER-DAUGHTER INTERACTION AND DEPRESSION

a reliability coefficient of .94 and adequate validity. The PHCSCS was

translated and adapted for use with Puerto Rican youth demonstrating
high internal consistency (α = .94) (Ramos, 1984). A short 25-item
version with demonstrated adequate psychometric properties was used
in the present study.
Suicide Ideation Questionnaire (SIQ-Jr) (Reynolds, 1998). The
SIQ-Jr is a 15-item self-report scale that measures severity of suicide
ideation. The SIQ-Jr has an internal consistency of .94. The Spanish
version was translated and adapted in Puerto Rico (Miller, Warner,
Wickramaratne, & Weissman, 1999) and was accepted by both the
author and the publisher (Duarte-Vélez, Lázaro, & Rosselló, 2002).
Brief Family Assessment Measure (BFAM) (Skinner,
Steinhauer, & Santa-Barbara, 1995). The Brief FAM is a short version
of each of the three FAM-III versions (General, Self and Dyadic)
designed to measure family functioning in which higher scores
indicate greater dysfunction. It has been translated and adapted for use
with Puerto Rican youth and demonstrates adequate validity and
reliability.
Family Emotional Involvement and Criticism Scale (FEICS)
was designed to measure family expressed emotion (Shields, Franks,
Harp, McDaniel, & Campbell, 1992). The two subscales of 14 items
each measure perceived negative criticism and emotional involvement
in the family. A high score in both sub-scales implies higher criticism
and higher emotional involvement, respectively. The translation and
adaptation carried out in PR has shown reliability coefficients of .54
for Emotional Involvement subscale and of .71 for the Perceived
Criticism subscale (Martínez & Rosselló, 1995).

Participants
The two adolescent girls selected for this case study were both
14 years old, currently in the 9th grade and had been randomized into
the CBT only condition of the clinical trial.
Lisa (a pseudonym) attended a public school and lived with her
mother, a younger brother, her pregnant older sister and husband, and
their young child. Lisa had never met her father. She had no history of
previous mental health treatment and initially presented no medical
conditions. Her psycho-social history revealed that she had spent
several years in her early childhood living with her grandmother, but
 MOTHER-DAUGHTER INTERACTION AND DEPRESSION

for the past few years had been living with her mother. Her older sister,
who had been living with their grandmother, had recently moved back
in with the patient and their mother. During the screening and
assessment phase of the study she met criteria for Major Depressive
Disorder (MDD), Anxiety Disorder NOS, Obsessive Compulsive
Disorder and Conduct Disorder NOS.
Carmen (as pseudonym) attended a private school and lived with
her mother, her stepfather and a younger sibling. She spent two
weekends a month with her father. Carmen had a history of
psychological and psychiatric treatment; she had been diagnosed with
Attention Deficit Disorder (ADD) and was being treated with
medication (amphetamine). Carmen had been on an anti-depressant for
depressive symptoms, but discontinued it several weeks prior to
entering the clinical trial. During the screening and assessment phase
of the study she met criteria for MDD, ADD, Separation Anxiety
Disorder and Specific phobia.

Results
Case 1 – Lisa
Lisa was brought to therapy by her mother who reported that she
was irritable, cried often, frequently lied, slept and ate a lot, was
receiving failing grades and had been disrespectful to her teachers. Lisa
was very dependent on her and refused to do many things if she wasn’t
present (i.e., go to the bathroom outside their home, go into a store,
sleep at night). She admitted to often feeling “suffocated” by Lisa and
having difficulty maintaining relationships with men because Lisa was
jealous and often interfered. She also reported having had to quit a
nighttime job because Lisa’s grades dropped significantly and Lisa
called her often at work. The results of Lisa’s pre-treatment evaluation
revealed that she presented depressive symptoms in the severe range
(Figure 1), as well as high suicidal ideation, dysfunctional attitudes,
and low self-esteem (Table 1). In terms of family functioning, at pre-
treatment Lisa reported low family emotional involvement and high
scores on perceived family criticism.
During the initial session, Lisa complained of irritability which
was causing interpersonal difficulties with her friends and family, and
frequent bouts of crying for no apparent reason. She was cooperative
although very cautious before answering the therapist’s questions, and
MOTHER-DAUGHTER INTERACTION AND DEPRESSION

FIGURE 1
Depressive
symptoms
from pre-
treatment to
follow-up

*Note: Scores from the 3rd to the 12th session were obtained during
the standard 12 manual-based CBT sessions, scores from the 14th to
the 22nd session were obtained during additional CBT sessions, and
scores from 3-12 months represent follow-up assessments.

TABLE 1
Pre, post and follow-up scores on psychological and family variables
Variable Pre Post Follow-up Follow-up
(6 mon.) (12 mon.)
Case 1
Suicidal ideation (SIQ) 77 13 15 13
Self-concept (PHSCS) 6 20 24 22
Dysfunctional attitudes (DAS) 62 14 14 14
Family functioning (BFAM) 25 15 3 12
Perceived criticism (FEICS) 21 12 11 12
Emotional involvement (FEICS) 11 14 15 22
Case 2
Suicidal ideation (SIQ) 15 8 12 8
Self-concept (PHSCS) 17 15 17 16
Family functioning (BFAM) 10 14 12 10
Dysfunctional attitudes (DAS) 19 19 21 57
Perceived criticism (FEICS) 11 9 10 10
Emotional involvement (FEICS) 23 31 24 21
 MOTHER-DAUGHTER INTERACTION AND DEPRESSION

appeared to have difficulty in expressing her feelings. Some psycho-

social stressors identified initially by the therapist were the recent
move of her sister with her family into the patient’s home, failing
grades, and interpersonal difficulties in the relationship with her
mother and her sister.
During the thoughts module, it became apparent that Lisa
presented insecure attachment to her mother which was reflected in her
irrational thought patterns concerning their relationship. She told her
mother she loved her several times a day and became annoyed when
her mother would not say it back. Lisa felt her mother preferred her
boyfriends to her and told her therapist that when she was 11 years old
her mother had to break up with her boyfriend because Lisa’s jealous
behavior drove him away. Lisa’s verbalizations reflect that she feels
unprotected by her mother particularly when she and her older sister
have heated arguments over housecleaning and babysitting duties.
When her mother goes out with her friends, Lisa becomes angry
because she interprets this to mean “she doesn’t care about her
children” and thinks – “she should be, or want to be, with me all the
time.”
During these initial sessions, the therapist worked with
challenging some of Lisa’s irrational thoughts particularly concerning
her relationship with her mother. She used several cognitive techniques
to work with these thoughts. For example, “finding the evidence” is a
technique used to debate an irrational thought by asking the patient to
find evidence that either support or contradict her negative thoughts.
The therapist worked on Lisa’s main cognitive distortion of “my
mother doesn’t love me or she would want to be with me all the time,”
by talking with Lisa about some of her mother’s other behaviors that
demonstrated that she did love her such as doing activities together and
worrying about her health and grades. The therapist also asked Lisa if
her mother ever told her that she did not love her; Lisa admitted that
her mother had told her that she loved her but not as often as she would
like. Cognitive techniques were also used to teach Lisa to challenge
other negative thoughts such as: “I can’t express my feelings, I can’t
make decisions, and I am worthless.” Lisa presented very rigid and
ego-centric thought patterns so these techniques were used often
throughout therapy.
In the activities module the therapist worked with behavioral
strategies to help Lisa set goals and organize her time to improve her
MOTHER-DAUGHTER INTERACTION AND DEPRESSION

grades, increase her pleasant activities and become more independent

in daily activities. Lisa’s fear of using public bathrooms alone was
explored and an in-vivo desensitization exercise was carried out to
work with these fears in the clinic’s bathroom.
At this point in therapy (after 8th session), Lisa had developed
increased trust in the therapist and her depressive symptoms had
decreased somewhat (Figure 1), yet she continued to present fatigue,
sleep problems, and irritability. After a two-week absence from therapy
sessions, Lisa’s mother informed the therapist that Lisa had been
diagnosed with low hemoglobin and was presenting resistance to
taking her medications. She also informed the therapist that Lisa
continued to sleep with her, was resistant to doing her chores at home
and her grades were not improving. The next two sessions focused on
managing symptoms related to her medical condition, improving her
adherence to medical treatment, and setting goals for a joint session
with her mother to work on the difficulties in their relationship.
During sessions in the interpersonal module, Lisa identified her
social support network as consisting entirely of her mother and her best
friend. This module focused on teaching Lisa social skills to expand
her support network. Lisa admitted being distrustful of others and
complained that her irritability and mood swings were affecting her
friendships at school. Assertive communication skills were practiced in
session using role play exercises.
In a joint session with Lisa’s mother, the therapist counseled the
mother on the importance of setting rules and boundaries at home
particularly regarding sleeping arrangements and household chores. It
had become apparent that Lisa didn’t like to be alone in the house in
the afternoons and spent most of the time sleeping. In turn, her mother
complained that household chores were not being completed which left
her little time to devote to Lisa and her siblings. Specific household
chores were assigned for Lisa by her mother with the therapist’s help
to increase Lisa’s self-efficacy and self-esteem as well as decrease
family conflict. The therapist coached the mother on the importance of
verbal positive reinforcement to maintain behavioral changes initiated
by Lisa. Increasing Lisa’s independence was addressed using a
behavioral contract in which an initial short term goal of sleeping by
herself for three nights a week was established and in return, her
mother would take her out Sunday afternoon for a special activity just
the two of them.
 MOTHER-DAUGHTER INTERACTION AND DEPRESSION

Upon termination of the standard 12 session dose of CBT, Lisa

had reached the goal of sleeping alone and was cooperating more in
carrying out her assigned chores. However, she continued to present
depressive symptoms that met criteria for MDD on post-treatment
evaluations using the CDI (Figure 1) and the DISC-IV, so she was
invited to participate in a supplemental study. The goals for the
remaining sessions were to continue working on Lisa’s independent
behavior and interpersonal difficulties with her mother and sister. Lisa
still presented a lot of anger and resentment towards her sister due to
her sister’s frequent criticism and hostility towards her and lack of
involvement in household chores. One of Lisa’s most frequent
thoughts was, “my sister will never change.”
Lisa no longer met criteria for MDD after two additional
sessions so termination was initiated at this point. She was cooperating
more at home after her mother had set rules and boundaries regarding
her sister’s behavior towards her and her responsibilities within the
home. Lisa slept alone most nights of the week and demonstrated
increased confidence and independence in her behavior and her
relationships. Post-treatment evaluations revealed that Lisa no longer
presented depressive symptoms (Figure 1) or suicidal ideation, and her
dysfunctional attitudes decreased. In addition, her self-esteem
improved markedly (Table 1). Although Lisa met criteria for
Obsessive Compulsive Disorder and Conduct Disorder NOS at pre-
treatment, symptoms of these disorders were not apparent in therapy
so they were not addressed. In terms of family variables, Lisa reported
a decrease in perceived family criticism and increased family
emotional involvement, both of which were maintained in follow-up
assessments.

Case 2 – Carmen
Carmen was brought to therapy by her mother presenting the
following as chief complaints: a decrease in grades, feelings of
inadequacy and guilt, rejection by her peers and frequent fights with
mother. Carmen’s mother reported that she presented a lack of interest
in activities, negativism, hopelessness, isolation, sadness and anxiety.
The results of Carmen’s pre-treatment evaluation revealed that she
presented depressive symptoms in the severe range (Figure 1), yet
contrary to her clinical presentation in therapy, she didn’t report
dysfunctional attitudes or family dysfunction on self-report instruments
(Table 1).
MOTHER-DAUGHTER INTERACTION AND DEPRESSION

During the initial sessions, it became apparent that Carmen

presented frequent automatic negative thoughts. She expressed guilt
over being depressed since it affected her mother. Carmen also felt
constant fear that her mother would die or something bad would
happen to her. The relationship with her mother was a significant
source of stress; it was characterized by frequent arguments initiated
by her mother’s constant complaints over Carmen’s grades. Her
mother was very critical of her academic performance and it became
clear that she had very high and unrealistic expectations regarding her
daughter’s academic and social abilities. She expected Carmen to
grasp material quickly without taking into consideration that
forgetfulness and difficulty concentrating were some of the main
symptoms of MDD and ADD that were affecting Carmen.
Socially, Carmen’s mother expected her to fit in and choose the
“right” friends, while Carmen felt rejected by her classmates at her
new school. Carmen reported some instances of physical and verbal
abuse by her mother prior to beginning therapy. Carmen’s reaction to
the abuse was to initially become very submissive and unresponsive,
which her mother interpreted as disrespect. Later Carmen would
present outbursts where she would cry, yell, scratch her nails into her
skin and bite her arms. Her mother felt these outbursts were tantrums
that Carmen displayed to “get attention” and would yell at Carmen to
stop and control her behavior.
The therapeutic work in the thoughts module was directed at
challenging and transforming Carmen’s negative thoughts, while
validating her feelings of sadness over family and academic problems.
Her thinking patterns were characterized by the use of a negative
mental filter through which she evaluated all aspects of her life: her
self-concept, her social and academic experiences and her family.
Some of Carmen’s most frequent thoughts were - “I don’t enjoy
anything”, “Everything is useless”, “Something is wrong with me”,
“I’m ugly” and “I would like to disappear.”
A frequent technique used in CBT for challenging negative
thoughts is identifying an event, thoughts associated with the event,
and the consequences or emotions resulting from those thoughts. Next,
the therapist and the patient work to identify alternate more realistic
and positive thoughts that will in turn, reduce the impact of the event
on the patient’s mood and behavior. The therapist used this technique
often in therapy to work with Carmen’s negative thoughts. For
 MOTHER-DAUGHTER INTERACTION AND DEPRESSION

example, after a heated argument with her mother over her schoolwork,
Carmen’s automatic thought was “My mother doesn’t understand me”,
which led her to feel “down” all day at school where she also had
problems with her classmates. With the therapist’s help she debated her
thoughts by telling herself that her mother was experiencing a lot of
tension at work and with the rest of the family and that her mother was
trying to understand her. She also told herself - “Even though I had an
argument with my mother, I’m not going to let it ruin the rest of my
day.”
The completion of the first module took seven sessions, instead
of the usual four, due to the severity of her negative thought patterns
and problems between Carmen and her mother. It became apparent that
a meeting with her mother was warranted at this point for Carmen to
be able to progress in therapy. During the meeting, Carmen’s mother
expressed worry over Carmen’s schoolwork and accepted that she put
a lot of pressure on Carmen to improve her grades. On a personal level,
Carmen’s mother recognized that she was experiencing a lot of tension
at her work, often felt depressed and unable to understand and manage
her daughter’s depression (Tarullo, DeMulder, Martínez, & Radke-
Yarrow, 1994). She reported having little patience to deal with Carmen
and had been aggressive verbally and on occasion, physically. The
therapist used this meeting to counsel Carmen’s mother on having
more realistic expectations of her daughter’s grades, on how to manage
her depression in a more sensitive manner, and be more accepting of
her strengths and weaknesses. In addition, the therapist identified some
of the mother’s behavior as abusive and worked on providing her
information on Carmen’s emotional needs and more appropriate
alternatives to disciplining Carmen. Also, the therapist recommended
that the mother seek professional help to manage her own depressive
symptoms.
During the following session Carmen reported having a heated
argument with her mother over schoolwork and on this occasion
managed her feelings by writing a letter in which marked feelings of
hopelessness and of wanting to die were apparent. Suicide risk was
assessed and determined to be minimal since she presented no
intention or plan to harm herself. A suicide prevention protocol was
activated and included establishing both a plan of action for times
when she felt very hopeless, and a prevention plan in which her mother
participated. Strategies for communicating Carmen’s need for personal
MOTHER-DAUGHTER INTERACTION AND DEPRESSION

space to relax and distance herself from her mother were mutually
agreed upon. Nonetheless, writing a letter to express her feeling was a
significant accomplishment for Carmen, since she dealt with her
feelings without having an outburst or hurting herself.
In the following activities module, therapy focused on
increasing Carmen’s pleasant activities and helping her organize her
time better, as well as learning to set realistic goals. Carmen’s self-
concept began to improve which became apparent in her personal
grooming and verbalizations during therapy. She increased her
pleasant activities, even including a friend in several activities. In the
interpersonal module, Carmen acquired assertiveness skills that
helped her feel more confident and comfortable with herself,
particularly when interacting with her peers. However, her most
conflicted relationship continued to be with her mother.
Upon termination of the standard 12 sessions of the manual-
based CBT, Carmen continued to present symptoms of depression
(Figure 1) and still met criteria for MDD on post-treatment evaluations
using the DISC-IV so she was invited to participate in the
supplemental study to receive additional sessions. The additional
sessions focused on improving mother-daughter interactions using
skills acquired during therapy, particularly by focusing on Carmen’s
thoughts and behaviors during these interactions.
During negative interactions with her mother Carmen often
thought, “If I say something, it won’t make a difference”, and her
corresponding behavior would be to remain silent and feel sad which
in turn, would reinforce the cycle of negative interactions with her
mother (Sheeber et al., 2000). Role playing exercises using concrete
examples of interactions with her mother were used to increase
Carmen’s assertive communication skills. Some of the role playing
exercises included identifying pleasant activities Carmen could
participate in with her mother and practice asking her mother to do
them with her.
Carmen had the opportunity to practice assertiveness with her
mother during a joint session. She told her mother how she felt during
their fights and when her mother put her down. Carmen also expressed
her desire to spend more time with her mother and improve their
relationship. These were significant accomplishments for Carmen
given her previous difficulty in expressing her needs and her tendency
to adopt a passive communication style. During the final sessions,
 MOTHER-DAUGHTER INTERACTION AND DEPRESSION

therapy focused on providing Carmen with strategies to prevent future

negative interaction cycles with her mother and manage her mood to
prevent future depressive episodes.
After receiving ten additional CBT sessions to the standard 12-
session dose and a joint session with her mother, Carmen presented
mild depressive symptoms, decreased suicidal ideation and no longer
met criteria for MDD according to the DISC-IV so therapy termination
was initiated at this point. However, contrary to her clinical
presentation and what she expressed in therapy sessions, Carmen’s
self-esteem and dysfunctional attitudes remained essentially
unchanged at post-treatment according to self-report instruments.
There was a slight increase in family emotional involvement (Table 1).
Unfortunately, her depressive symptoms increased at 9 (CDI = 18) and
12 (CDI = 16) month follow-up assessments. She met criteria for MDD
at the 12 month follow up assessment and had a significant increase in
dysfunctional attitudes. The sharp increase in her dysfunctional
attitudes according to the DAS is probably associated with her MDD
relapse.

Discussion
The case studies of two girls in early adolescence receiving
treatment for depression illustrates how mother-daughter interactions
can contribute to the maintenance of depressive symptoms and to
response to therapy. Both cases required additional therapy sessions to
reduce depressive symptoms. The first case presented no depressive
symptoms at therapy termination and the second continued to present
mild symptoms although neither met criteria for MDD according to the
DISC-IV. During the third follow-up assessment (nine months) both
presented an increase in depressive symptoms into the moderate range.
Even though at the final 12 month follow up assessment Carmen’s
depressive symptoms decreased slightly, she still met diagnostic
criteria for MDD. Alternatively, Lisa presented no depressive
symptoms and did not meet criteria for MDD. Further analyses of the
response in both cases was conducted calculating the clinically
significant changes using the mean of the total sample of the clinical
trial from which both adolescents participated and a community
sample of female adolescents; a score of 16 or greater on the CDI was
revealed to represent symptoms in the clinical range (Rivera-Medina &
Bernal, 2008). Thus, Lisa’s scores on the CDI at the last two follow ups
MOTHER-DAUGHTER INTERACTION AND DEPRESSION

were in the non-clinical range and Carmen’s scores were at the clinical
range. However, when calculating the reliable change index
individually, both cases presented significant clinical changes when
their last CDI scores were compared with their pre-treatment scores
(Rivera-Medina & Bernal, 2008). These results suggest that although
Carmen presented depressive symptoms which put her at risk of an
MDD relapse, her symptoms at the end of treatment were markedly
reduced when compared to those at pre-treatment. Overall, the results
suggest that CBT provided the adolescents with strategies to manage
their moods and improve interactions with their mothers. However, it
appears that mother-daughter interactions could have continued to
exert a significant influence on their mood even after therapy which
suggests that additional or alternate interventions should be
considered.
Booster sessions have been found to accelerate the recovery of
non-responders to CBT (Clarke, Rohde, Lewinsohn, Hops, & Seeley,
1999) and might have helped improve response in these cases after
therapy termination. Also, the use of antidepressants for adolescent
depression is being extensively researched during the last decade and
appears to be an effective alternative for improving treatment
outcomes (TADS Team, 2004). Studies have found that the
combination of antidepressant medication and CBT has been shown to
have greater effect sizes on treatment outcome than therapy alone
(Hollon, Stewart, & Strunk, 2006; TADS Team, 2004). However, there
are mixed results regarding the efficacy of antidepressants versus CBT
on treatment outcome for depression (Butler, Chapman, Forman, &
Beck, 2006; Melvin, Tonge, King, Heyne, Gordon, & Klimkeit, 2006)
but most studies suggest that for moderate to severe depression usually
a combination of both is the best treatment to prevent relapses (Hollon
et al, 2006; Hollon et al., 2005).
In Lisa’s case, it appears that her difficulty in managing the
central developmental task of adolescence of individuation contributed
to the development of depressive symptoms possibly by way of low
self-esteem and dysfunctional thoughts (Allen et al., 2006). In turn, her
mother’s reaction to her depression (distancing herself, decreasing
emotional support), reinforced Lisa’s negative thoughts. Her
depressive symptoms would then worsened causing her to display even
more dependent and attention seeking behaviors which made her
mother further distance herself, thus, creating a negative interaction
 MOTHER-DAUGHTER INTERACTION AND DEPRESSION

cycle (Pineda, Cole, & Bruce, 2007). Therapy appeared helpful in

breaking the cycle by helping Lisa decrease dysfunctional thoughts
that led her to be overly dependent on her mother and increase
autonomous behaviors. Also, providing the mother with educational
information on appropriate family rules, boundaries, structure and how
to use positive reinforcement further supported Lisa’s efforts at
individuation.
In both cases family interaction was characterized by the mother
emotionally distancing herself and withdrawing support. Carmen’s
mother was actively critical and occasionally abusive which reinforced
Carmen’s negative thoughts about herself and worsened her
depression. In turn, Carmen’s mother would interpret Carmen’s
symptoms as attention seeking behavior and would reprimand her for
it, again reinforcing Carmen’s negative thoughts and depressive
symptoms. Carmen’s behavior would escalate into tantrums, and her
mother’s reaction escalated into verbal abuse.
Treatment response could have been affected by the complexity
of the cases. Both presented severe depressive symptoms at pre-
treatment as well as multiple co-morbid diagnosis and significant
negative family interactions. Interestingly, in both cases the fathers
were absent so the mothers were overburdened with being the sole
primary caretakers for their daughters. Mothers’ assuming the role of
primary caretaker is a common occurrence in Latino cultures when
parents separate. Flexibility in the use of the CBT treatment manual
was essential; a significant portion of therapy was devoted to working
with family interaction patterns and additional joint mother-daughter
and individual parent sessions were incorporated. It would have been
interesting to see whether treatment outcomes would have changed if
these adolescents had had received the CBT plus parent psycho-
educational intervention condition of the trial.
Cases such as these, with partial response and significant family
stressors, will often need additional sessions as well as modifications
in the treatment manual to specifically address these issues to achieve
complete remission. Some alternatives can be dismantling treatment to
address the patients’ particular needs and strengths by increasing the
dose of certain treatment components (e.g. interpersonal skills,
behavioral activation), and adding specific family and/or parent-child
modules to address conflict and communication. Also, identifying the
characteristics associated with treatment response in the initial stages
MOTHER-DAUGHTER INTERACTION AND DEPRESSION

of treatment can help inform treatment planning in terms of selection

of treatment format, components, and number of sessions (dosage) to
maximize positive outcomes. Antidepressant medication should also
be considered as an addition to CBT to enhance outcomes for moderate
to severe persistent symptoms of depression.
Studies have found that depression in mothers is associated with
an increased risk for depression in their offspring (Beardslee, Versage,
& Gladstone, 1998; Connell & Goodman, 2002), which could have
contributed to the negative mother-daughter interaction cycle in
Carmen’s case. When working with adolescents, assessing family
functioning as well as parental psychological status can be important,
particularly due to the impact that psychological disorders in parents
can have on family functioning, and thus, adolescent mental health. In
Carmen’s case therapy was recommended for her mother. The fact that
Carmen’s mother failed to follow the therapist’s recommendation to
seek psychological help could have also contributed to the increase in
Carmen’s dysfunctional thoughts and depressive symptoms during the
follow-up assessment phase.
While this case study illustrates that CBT can help adolescents
manage dysfunctional thoughts and increase positive behaviors to
improve their mood, the results also suggest that alternate or
complementary therapies should be considered in cases where there is
significant mother-daughter conflict contributing to depressive
symptoms. The use of family therapy might help achieve and maintain
remission of MDD in adolescents. Family therapy has been found to be
efficacious with Latino youth presenting externalizing disorders (Muir,
Schwartz, & Szapocznik, 2004), however no studies on family therapy
for depression in Latino youth have been identified. Family therapy
has recently begun to be studied as an intervention for depressed youth
demonstrating preliminary positive results (Diamond & Lebow, 2005;
Sander & McCarty, 2005). The challenge for the field is to identify
early on those cases that require an intervention that focuses parent-
child interactions and design flexible evidence-based treatments that
can be accommodated to the particular needs of particular cases.
The main limitation of this study is that case studies results
cannot be generalized to the general population. Nonetheless, it
illustrates patterns in mother-daughter interactions that can have an
effect on girls’ depression. The use of self-report instruments can also
be a limitation given that not all cases, such as Carmen, are good
 MOTHER-DAUGHTER INTERACTION AND DEPRESSION

informants of their own symptoms. Having multiple sources of

information, in addition to self-report measures and structured
interviews, on family functioning and parent-child interaction could
have strengthened this study. Other studies have used measures of in
vivo family interaction or problem solving tasks (Allen et al., 2006;
Pineda et al., 2007; Slesnick & Waldron, 1997) or behavioral coding
systems, such as the Living in Family Environments Coding (LIFE)
system (Sheeber et al., 2000; Sheeber, Hops, Andrews, Alpert, &
Davis, 1998), which can provide a more objective measure of family
dynamics and how they might have changed pre-post treatment.
Early adolescence in Latina girls is a high risk time in which
mother’s play a significant role in supporting or hindering healthy
psychological development and adjustment (Duarte-Vélez & Bernal,
2007). It is important to stress that the father’s role probably had a
significant impact on patterns of mother-daughter interactions in terms
of the additional burden the father’s absence placed on the mothers
regarding childrearing and the indirect effect this absence of support
can have on the family system. Most studies on how family
interactions affect adolescents’ depressive symptoms focus primarily
on the mother. Further studies are needed on the effect father-daughter
interactions can have on Latina adolescents’ symptoms. It can be
challenging for therapists who work with Latina adolescents and their
families to encourage healthy autonomy and individuation while
preserving important cultural values of familismo (Halgunseth, Ispa, &
Rudy, 2006). For example, in Lisa’s case some of her dependent
behaviors, such as sleeping in her mother’s bed although she had a
room of her own (a common occurrence in some Latino cultures) were
understood by the family as behavior that fostered family unity and
affection. However in this case, this behavior hindered the
development of healthy autonomy expected at her developmental
stage.
In Carmen’s case, her mother regarded Carmen’s verbal
responses during their arguments as disrespect for parental authority
(an important value in Latino culture). It was challenging to promote
assertiveness skills in Carmen without her mother interpreting
Carmen’s assertiveness as disrespect for her authority. The therapist
had to counsel Carmen’s mother on the importance of fostering
assertive communication skills, which are essential for the
development of self-confidence and autonomy. Cultural competency is
MOTHER-DAUGHTER INTERACTION AND DEPRESSION

very important for therapists who work with ethnic minority youth in
order to respect cultural family values and foster healthy child
development without compromising one or the other (Bernal et al.,
2006; Cardemil & Battle, 2003; Domenech-Rodríguez & Weiling,
2004)
In light of the higher prevalence of depression in Latina
adolescents (Eaton et al., 2006) it is important to further examine
variables related to treatment response, as well as risk and protective
factors of depression, particularly family factors which the literature
has suggested are particularly relevant with this population. In both
cases in this study, the interaction between the adolescent’s thoughts,
behaviors and feelings is clearly illustrated and improvements in
mood were observed with CBT. Prior to therapy initiation, both cases
presented negative family interactions, particularly with in the mother-
daughter relationship. For both adolescents, CBT appeared to help
achieve substantial therapeutic gains on an individual level. However
in terms of the family system, in Lisa’s case the family was more able
to make and maintain changes than that of Carmen. Assessing family
functioning and values is essential when designing treatment plans
with adolescents, particularly for Latino/a adolescents. Interventions
that target the family system can improve outcomes and prevent
relapses with this population.

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