Interviewing the Adolescent: Strategies that Promote Communication and Foster Resilience
Oana Tomescu
Kenneth R. Ginsburg
Providing care to adolescents with gynecologic conditions is enhanced by a comprehensive history and psychosocial assessment. When adolescents visit health care settings, they may not think about discussing sensitive topics. Providers often need to focus on breaking down communication barriers and establishing open, honest dialogue with adolescent patients. The traditional medical interview, which stresses identifying harmful behaviors and advising cessation, can stifle honest dialogue. In this chapter, we discuss strategies that not only optimize honest communication, but also facilitate positive behavioral counseling with teens. Most critically, we highlight the need to approach youth in a way that does not view them merely in context of their risk behaviors, but rather reinforces their strengths and capabilities, with the goal of helping them become active participants in their own health.
Talking with Teens: Adopting A Strength-Based Approach
Clinicians are often trained to assess a teen’s risk behaviors and then educate her of the dangers the behaviors pose to her health. This approach may work for some highly motivated youth, but it fails to inspire behavioral change in many adolescents. Some teens may experience frustration because this approach leaves them without the tools or resources to initiate change. Other youth may feel offended, shamed, and judged to be conceptualized only in terms of risk and could be left feeling alienated.
A more promising approach to adolescent health care acknowledges the problems these youth face but interprets difficulties as opportunities that can challenge youth and promote positive change (1,2). Using this bio-psychosocial approach, youth are helped to recognize the unique strengths they possess in having rebounded from hardships, instead of succumbing to them. Clinicians still acknowledge risk, but they share the belief that a more resilient youth is better suited to overcome adversity, and thus focus most of their energy on building youth protective factors and resilience (3,4,5). Intrinsically a more patient-centered model, this strength-based philosophy helps adolescents learn to make less dangerous choices through positive behavioral change. When teens are seen in the context of what they are doing right in their lives, they are more likely to develop confidence and a sense of competency to achieve positive outcomes for themselves (6). This approach also helps clinicians advocate for positive change, rather than focus only on negative behaviors.
Strategies That Optimize Communication with Adolescents
The foundation of trusting relationships with teens is open, honest communication. Patient-centered communication skills are the essential tools for facilitating these sensitive assessments.
Embracing a Patient-Centered Approach to Communication
Patient-centered communication can facilitate trust formation and improve patient satisfaction and overall health status (7,8,9) and may even reduce diagnostic testing and referrals (10). Instead of merely focusing on the medical details of the presenting symptom, the clinician achieves a better understanding of the patient as a whole person as well as her illness and life perspective (11,12,13). Active listening skills, such as responding to patients’ cues and using reflection and summary statements, are central to this type of interviewing and demonstrate to the patient that the provider is fully present in the conversation (14,15).
Provider interpersonal style is a critical part of patient-centered communication. Adolescents have offered their view on which characteristics of doctors and nurses they find engaging and which hinder honest communication. Youth are more likely to trust providers who honor their privacy; who are honest, respectful, nonjudgmental, and caring; and who communicate in a non-condescending style (16,17,18,19). In fact, homeless youth describe utilizing a step-wise process in which they observe and evaluate a provider’s reactions to mildly sensitive information before deciding to trust the adult with very personal matters (20). Even, the initial introduction is also critical to trust-formation and providers need to communicate clearly about their role on the patient’s team (21).
Paying Attention to Body Language
Body language of providers can convey positive or negative messages. Shaking hands warmly, sitting at eye level, making good eye contact and leaning slightly forward are all techniques that convey the willingness and intent to listen actively (13,14). Clinicians should inform patients if they need to take notes or type, trying to avoid this activity when discussing personal information with a teen.
Learning to read a teen’s body language is also an important skill. A teen who is avoiding eye contact, mumbling words, or giving one-word answers may be struggling with something, and
providers can often help teens open up by acknowledging this discomfort. Furthermore, youth may use toughness and “attitude” as a defensive posture when they feel intimidated or vulnerable. Providers should understand that the teen is a stranger to the medical setting and may feel intimidated by the inherent power dynamic of the doctor–patient relationship. Acknowledging the discomfort will make the teen feel more at ease.
providers can often help teens open up by acknowledging this discomfort. Furthermore, youth may use toughness and “attitude” as a defensive posture when they feel intimidated or vulnerable. Providers should understand that the teen is a stranger to the medical setting and may feel intimidated by the inherent power dynamic of the doctor–patient relationship. Acknowledging the discomfort will make the teen feel more at ease.
“Setting the Stage” for Honest Communication
The typical adolescent in the ambulatory healthcare setting may not expect to be asked sensitive questions about depression, drug use, or sexual activity; she is there for a check-up and shots and to have her forms completed. Clinicians need to prepare patients for this portion of the assessment. However, adolescents may be hesitant to disclose personal information without first having a sense of the answers to the following questions: (a) Why is the clinician asking me personal questions? (b) What if I don’t want to discuss this information now? (c) Is it worth my time sharing private information; can this person even help me if I ever need it? (d) What will he or she do with the answers? Will I be judged or have my business spread around? Addressing these four concerns, a strategy we call “Setting the Stage,” before commencing the medical interview can help facilitate honest dialogue throughout the remainder of the visit.
“Why is the clinician asking me personal questions?” Youth are more likely to share personal information with clinicians who provide context to their questions (17). Therefore, teens should be told that the practitioner cares about all aspects of their lives and that the provider is going to ask about more personal topics during the visit. Later in the visit, providing context can also be helpful. A question such as “Are you having sex?” may not be as effective in eliciting an honest answer as “I need to know if you’re having sex because I’m worried that your pain may be due to infections people get from having sex.”
“What if I don’t want to talk about this information now?” Youth may not always want to discuss everything going on in their lives, especially if they have just met the provider. Acknowledging that teens have a choice about how much they choose to discuss with their doctors not only shows respect but also gives the provider an opportunity to stress the importance of honesty.
“Is it worth sharing private information? Can this person even help me?” This concern is common to anyone deciding whether to trust another person with a difficult matter, and providers can reassure the teen that doctors can help their patients in many ways. Even if the teen does not have any current needs, this statement provides the teen with future reference in case of crisis.
“What will the doctor do with the answers? Will I be judged or have my business spread around?” This may be the most critical barrier to open communication with teens. All youth have concerns about how much doctors can tell their parents. Additionally, youth are also concerned about confidentiality within the office, as some of the office staff live in the patient’s community (17). Many adolescents are not aware of the concepts and legal protections that protect their right to privacy and benefit from being guided to understand the nuances of doctor–patient confidentiality (22,23,24).
The provider needs to be specific about what is meant by confidential care and under what circumstances confidentially may need to be broken. A phrase such as “I will keep your information secret (or confidential) unless I am worried you will hurt yourself, hurt someone else, or if an adult is hurting you” can be misconstrued. The word “hurt” instead of “kill” may lead adolescents to think the clinician will report smoking, drugs, and sex, all of which they expect doctors think “hurt” them. Terms such as “secret,” which may denote shame, as well as “confidential” which, to a teen, may mean “confidence,” could backfire. Use the word “privacy” instead, and when discussing the limits of confidentiality, state them clearly. It is especially crucial to communicate with the teen that in the case of a crisis when confidentiality needs to be broken, she will be involved in strategizing how to best deal with the safety concern. See Box 2-1 for a sample “Setting the Stage” dialogue.
Box 2-1 “Setting the Stage”
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Box 2-2 “Setting the Stage” with the Parent
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“Setting the Stage” with the Teen’s Parents
Parents often accompany adolescents to their appointments and should be viewed as a resource and an educator of their teen. It is best for the clinician to try to partner with both teen and parent so that team-based interventions can be more easily coordinated in the event of a future crisis (25
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