Alexa on graduation day with her therapist, Monica Rojas, PsyD.
On June 25, Alexa Salguero-Diaz joined her classmates from her laptop to deliver her valedictorian speech for their virtual high school graduation. “A few years ago, I didn’t think about my future,” she said. “I didn’t even think I had one. But now, I’m actually excited for my future, and the adventures I’m going to have.”
It had been a long and painful journey for her to get to this point.
Alexa didn’t have an ordinary childhood, and she didn’t graduate from an ordinary high school. She graduated from Mount Sinai’s Comprehensive Adolescent Rehabilitation and Education Service (CARES), an integrated program for teens who struggle with mental health and/or substance use that combines a high school education with intensive psychological treatment. Founded in 1990, CARES aims to prevent the effects of mental illness and substance use on adolescents’ brain development, the subsequent decreased academic performance, and the ripple effects on their lives. CARES is the only program of its kind in the country.
When Alexa transferred to CARES, she was 17 and had been hospitalized for the 13th time for self-harm with the intent to commit suicide. The trauma she experienced due to abuse by a family member at a young age resulted in a lifetime of depression, multiple forms of self-harm, anxiety, anorexia, and bulimia, and addiction to multiple substances including Xanax.
After two years at CARES working with her therapist, Monica Rojas, PsyD, and in various targeted therapy groups including dialectical behavioral therapy (DBT), substance abuse, and milieu therapy, Alexa is in a much better place. She hasn’t used substances for three years, and is stable with no self-harm or suicidality. She is also armed with coping mechanisms and resources to get through any lapses that may arise.
“If I feel like I want to hurt myself, I let Monica or someone else know,” she said. “I’m not scared to go back to the hospital if I need to.”
Childhood challenges
Many of Alexa’s mental health problems can be traced back to genetic vulnerabilities, given her family history of depression and trauma, and the fact that she was abused at the age of seven. She never told anyone, and believes she denied and avoided the memories because it didn’t feel safe to talk about them.
In middle school, bullying and sexual harassment became a huge issue, which led to coping through substances and other risky, life-threatening behaviors. Alexa slowly began to realize there were connections between her past and present as she worked with therapists to understand how she was trying to master the traumas by re-enacting them over and over. “That’s when the sadness started coming. I started hurting myself, and I wanted to die every day.”
As a first generation Salvadorian-American, Alexa made brave efforts to share these stressors with family. But given how taboo it is to speak of abuse in so many cultures, she was unable to receive the support and validation needed.
The trauma from her abuse haunted her, and drugs helped her forget—temporarily. “I got addicted to Xanax, molly—whatever was around, but especially Xanax. I skipped school just to do drugs.” Alexa put herself in dangerous situations in order to use substances, which further exacerbated her trauma.
“I wanted to take away all my bad thoughts and go to another world, but in reality, it made things worse. I just wanted to die,” she said.
The abuse also created a sense of worthlessness and disgust. “It all started because of that sexual trauma when I was younger. I just felt so useless and ashamed of myself and disgusted with how I am, how I look.” This led to anorexia and bulimia in her sophomore year, coupled with substance abuse and suicidality.
“When I was in my original high school in the Bronx, that’s where my depression and anxiety got really bad,” she said. “I was actually hospitalized 12 times when I was there.” Alexa’s education was frequently interrupted due to these hospitalizations with an average stay of one month. Additionally, one serious attempt landed her in a coma for a week and subsequently hospitalized for two months. Because of these multiple prolonged hospitalizations, Alexa fell behind in school. At age 17, she was still in need of 22 credits and all five of her Regents exams in order to earn her high school diploma.
The path to recovery
In 2019, Alexa transferred to CARES, on the recommendation of psychiatric hospital staff. “It was really the best choice I made,” she said. “I felt so much support.”
Dr. Rojas believes falling behind in school fed into Alexa’s shame and mental health issues, and that interventions for her mental health needed to be integrated with keeping her education on track.
“CARES is the kind of place where we say ‘You can do this,’ and we will work together as a team to help you reach your academic and mental health goals,” she said. Her steady progress in therapy fostered autonomy and confidence, which influenced her academic achievements.
CARES functions as a “warm handoff,” bridging the gap between inpatient and outpatient therapy. The program’s multidisciplinary team onsite consists of psychologists, psychiatrists, social workers, a psychiatric nurse practitioner, DOE teachers, and guidance counselors, along with trainees in these disciplines.
The CARES treatment team works together to make an individualized treatment plan for each patient that includes individual therapy two times per week, group therapy five times per week, family therapy, and medication management. Additionally, students have access to milieu therapy onsite to support students during the school day. The unique support of milieu, or “therapy on demand,” is to help students cope in vivo by coaching them through crises using effective skills in the moment.
Alexa believes the intimacy of the space itself was helpful for connecting with people. “It’s very easy to socialize because it’s just one floor, in one building. It really helped my social anxiety,” she said. She also used this time to explore several aspects of her cultural and sexual identities. “It wasn’t really a big deal, people weren’t shocked. But it did help me feel more comfortable with who I am.”
Of course, COVID-19 presented problems in providing intensive care. Although CARES offered a blended learning option in the fall of 2020, Alexa attended CARES remotely from March 2020 to March 2021 because of concerns around the pandemic. “It was pretty hard because it made it easier to not go to class and group therapy sessions,” Alexa said. But she persevered with the help of her support network and CARES team.
“Alexa’s capability for deep insight and ability to share is so impressive and constantly inspiring me,” said Dr. Rojas. “Even in the substance group for teens, Alexa told her story and it was so helpful for destigmatizing substance use for the others in the group. To be able to ask for what she needs even when she doesn’t feel like it—after everything she’s been through—is really amazing.”
Graduation and the path forward
The New York City Department of Education and CARES staff unanimously voted Alexa as valedictorian, along with one other student. “I was so confused,” she said. “I really never thought that I would even be considered for that.”
In her speech, Alexa provided sound advice to her peers: “To everyone that is here or still in school, or struggling with mental health, don’t let it get to a point where you regret your choices. Instead, make the choices that will lead you to have a life that you dream of. Whatever advantages or opportunities you get in life, take it, because it could be something wonderful.”
Alexa’s love of animals and art led her to create an Etsy shop: Muffin’s Stickers, named for her dog who passed away in January.
“My life revolves around animals. When Muffin passed, I really fell into a deep void. I wanted to die, and I felt completely empty,” she said. “But once I learned how to deal with it, I realized my dog would want me to continue school.”
Art has always been an escape for Alexa, so she began painting pet portraits, which she converted to stickers based on her art as well as custom commissions. In the beginning her customers were mostly friends and family, then informal marketing via TikTok and at CARES helped her attract more customers.
“It really helps to distract me and keep my days busy,” she said. Down the road, she hopes to earn a pet grooming certification so she can open her own pet shop.
As Alexa joined her family, classmates, and care team in Morningside Park for a graduation celebration, she reflected on the last two years of her life. “I came so close to not achieving any of this,” she said. “I could be under the ground or cremated right now. But I’m glad I didn’t succeed in doing that, because the people I met through CARES are the best people ever. The friends I made in the hospital, and the connections I made with adults really helped me a lot and made me feel less alone. I still feel alone and depressed at times, but then I remember everyone I’ve met and imagine how many more people I can meet.”
Alexa will begin outpatient therapy at Mount Sinai in the coming weeks as part of an individualized continuum of care. In her free time, she stays busy with her Etsy shop and is currently applying to trade school to obtain her pet grooming certification.