Techniques for the Adolescent Patient*

Techniques for the Adolescent Patient^*

Don’t laugh at a youth for his affectations; he is only trying on one face after another to find his own.

–Logan Pearsall Smith

There are three reasons to include a chapter on adolescents in a book otherwise devoted to adult psychopathology: (a) Child and adolescent treatment is a part of most general training programs; (b) many primarily “adult” clinicians are called on to evaluate adolescents; and (c) many “adult” patients are still struggling through late adolescence, which begins during the later teen years and extends to the early 20s. If you can master the techniques of evaluating adolescents, you will find yourself using these same techniques for many of your adult patients, of any age.

THE FAMILY INTERVIEW

Your initial interview with an adolescent will usually include family members for at least part of, and sometimes all of, the session. Adolescents are great minimizers and deniers, and you often will need to interview the family separately to ascertain the presence of any problem at all. In addition, many psychiatric disorders in adolescents are strongly related to family issues, with family dynamics sometimes contributing significantly to them (e.g., oppositional defiant disorder, depression) and at other times being the cause of family strife (e.g., attention-deficit hyperactivity disorder [ADHD]). Finally, treatment can rarely happen without the consent and cooperation of family members.

Thus, for the first appointment, plan to invite the entire family into your office. Usually, I walk out to the waiting room and greet the patient with an introduction and handshake, then face the family, saying, “Why don’t we all go in for the first part of the hour, then maybe I can have some time to chat with____________________ afterward.”

Once in the office, allow the family to decide where to sit, and then shut up and listen for a while, just as you would with your adult patients. If there is some initial silence, you can get things going with questions such as

What brings us all together today?

What sort of issues have been coming up?

or, more simply,

Okay, who wants to do the talking?

A parent usually begins, and it is important that you listen closely, because a family’s desires may be quite different from what you suspected or from what you can provide.

CLINICAL VIGNETTE

Two parents brought in their 17-year-old son for an evaluation. Once in the office, the mother’s first words were, “I want you to commit my son for his drug addiction.”

The son, taken aback, turned to her and said, “Are you crazy?”

What developed was that the parents had suspected the son of drug use but had told him that this was a family therapy meeting to “work out some family issues.” The mother’s expectation was that the clinician would immediately have a police officer escort the patient from the office to a substance abuse treatment facility. The clinician explained that this was not possible and went on to explain the state’s legal criteria for involuntary commitment. Eventually, the adolescent agreed to outpatient treatment of substance abuse and depression.

Allow at least 5 minutes of free speech, in which you simply listen to family members discussing the perceived problem. Aside from clueing you into diagnostic possibilities, this will allow you to understand the communication style and family dynamics. After listening for a few minutes, you will want to jump in with various questions to ascertain elements
of the psychiatric and social history. It is important to adopt a neutral attitude so as not to appear that you are taking the parents’ side. If the parents constantly speak over the patient (or vice versa), make a corrective comment, such as

Everyone obviously has a lot of feelings about this issue, but it is important that I get a chance to hear everyone’s viewpoint without too much interrupting.

After a period of time, you will want to talk to the adolescent alone.

I enjoyed meeting you, and now I’d like to talk about some things with Matthew. Afterward we’ll get back together and discuss what we’ve talked about.

THE INDIVIDUAL INTERVIEW

Initial Questions and Strategies

How much time should you devote to the individual interview? There are no hard-and-fast rules. A full hour of individual discussion may be appropriate for a sensitive and sophisticated 14-year-old adolescent with depression, whereas an angry and involuntary 17-year-old adolescent with conduct disorder may be able to tolerate no more than 5 minutes alone with you. The more verbal and engaged the patient seems, the more time you will want to allot for your individual interview with her.

So there you are, in the room alone with your adolescent patient. Clinicians who spend most of their time with adults often freeze at this point. What do you say to a 15-year-old, who may feel quite awkward and embarrassed, especially now that his parents have left the room?

You want to avoid awkward gaps in the conversation as much as possible, which may involve doing more talking than you normally do. Some degree of self-disclosure may be acceptable too, to build rapport. You can start with some tension-relieving statements such as

Okay. Now I get to hear your side of the story.

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