Talking to Teens - Lecture Notes

Lecture Format

  • The lecture will cover:
    • The purpose of doctor-patient consultations.
    • The HEADSS approach.
    • Recognizing transference and countertransference.
    • Questions.

Why Take Patient Histories?

  • To make a diagnosis.
  • To understand the whole patient.
  • To formulate a treatment plan.
  • To individualize the management plan.
  • To empower the patient to undergo treatment.
  • To build the therapeutic relationship.

Taking Histories

  • Introduction
    • Identification and demographics.
    • Asking for chief complaint.
    • Explore the main problem.
    • Example questions:
      • "Francine, hello…"
      • "What can I do for you today?"
      • "Can you tell me a bit more about what you mean?"
  • Components of a Patient History
    • History of presenting illness.
    • Past medical history.
    • Systems review.
    • Medications.
    • Allergies.
    • Family history.
    • Social history.
    • Conclusion summary.
    • Etc.

HEADSS Assessment

  • HEADSS is an approach used with teenagers.
  • It covers:
    • Home.
    • Education/employment.
    • Activities.
    • Drugs and alcohol.
    • Sexuality.
    • Suicide and depression.
  • It progresses from least to most threatening topics.

HEADSS Questions

  • Home
    • Where do you live?
    • How long have you lived there?
    • Who lives in your home?
    • Relationships within the home.
    • Roles - who are you in your family?
    • Favorite things about home.
    • Things you’d like to change about home.
  • Education
    • Do you attend school?
    • Name of school, Year.
    • What do you enjoy the most about school?
    • Why?
    • What do you enjoy the least?
    • Friends at school.
    • What type of student are you?
    • Any difficulties in school?
  • Activities
    • Follow up on things they have said that they like.
    • What else do you like doing?
    • Who do you hang out with?
    • What do you do for fun?
    • What do weekends look like in your house?
  • Drugs and Alcohol
    • When was the first time you tried… [specific drug]?
    • I am going to ask you the same questions about all these drugs…
    • First time you tried it, how much, how, last time you used.
    • What is the best thing about being high?
    • What are some of the problems with it for you/ your friends / your family?
  • Sexuality
    • How old were you when you attained puberty?
    • Are you in a relationship?
    • For how long, nature of the relationship.
    • Are you attracted to boys, girls, both, neither?
    • Do you have any concerns or worries…pregnancy, STDs?
    • Do you ever feel pressured to do things in relationships or when you are out that you don’t feel comfortable with?
    • What are the most important things for you in a good relationship?
  • Suicide and Self Harm
    • Sadness.
    • Amotivation/Loss of interest.
    • Sleep.
    • Stressors.
    • Other symptoms- psychosis, anxiety, trauma etc.
    • Thoughts of self-harm, suicide- details.

Case Example

  • Consider how Sarah is feeling.
  • Consider what you are feeling (as the interviewer).

Therapeutic Relationship

  • Definitions, examples, implications/relevance are important to consider.

Therapeutic Alliance

  • A cornerstone of treatment in medicine is the therapeutic alliance, whereby patient and doctor establish a rational agreement or contract which supports the treatment (Greenson, 1985).
  • There are three parts to the therapeutic relationship: the therapeutic alliance, the transference and the countertransference.
  • The therapeutic alliance is the rational (implicit) contract between doctor and patient.
  • The contract may be straightforward with mutual cooperation.
  • The contract may be complicated by a covert agenda: the patient's unconscious and unspoken wishes and needs (the transference).

Transference

  • Transference is the phenomenon whereby we unconsciously transfer feelings and attitudes from a person or situation in the past on to a person or situation in the present.
  • The process is at least partly inappropriate to the present.

Countertransference

  • Countertransference is the response that is elicited in the recipient (therapist) by the other's (patient's) unconscious transference communications.
  • Includes the feelings evoked in the doctor by the patient's transference projections.
  • These can be a useful guide to the patient's expectations of relationships.
  • They are easier to identify if they are not congruent with the doctor's personality and expectation of his or her role.
  • Awareness of the transference–countertransference relationship allows reflection and thoughtful response rather than unthinking reaction from the doctor.

Relevance or Implications of Understanding Transference and Countertransference

  • Supports staff by helping them understand what is going on in the relationship with the patients, so reducing anxiety and over-responsibility.
  • Improves patient management by recognising wishes that are not clearly articulated.
  • Anticipates problem areas for patients and so more appropriate therapeutic provision.
  • Helps avoid staff acting-out and improves boundary maintenance.

Tips for Engagement

  • The note an interviewer strikes at the outset may affect the entire outcome.
  • Introduce yourself to the young person first.
  • Ask the young person to introduce you to others who may be present.
  • This gives the young person a clear message that you are interested in him/her.
  • Don't begin the interview by asking 'why are you here?'
  • Chat with the young person about lighter, non-threatening topics.
  • Provide an outline of what's going to happen, including an idea of the range of questions.
  • Prepare them for the sensitive nature of some of the questions.
  • Let the young person know they can choose not to answer any questions.
  • Create an empathetic stance by acknowledging they may feel uncomfortable at times.
  • Build rapport so that the young person feels their concerns have been heard.
  • The young person should come away feeling that someone cares and that it might be useful to return.
  • Ask open-ended questions so that there is opportunity for rapport building and engagement.
  • The goal isn't just to elicit information about what might be 'wrong' with the young person.
  • Spend time during the interview asking for feedback.
  • Check that you understand the young person's main concerns and difficulties.
  • Clarify the young person's goal in coming to the assessment.
  • Before concluding, ask if they have any questions or anything more to add.
  • Parents, family members, or other adults should not be present during the interview unless the young person specifically gives permission, or requests it.
  • The amount of time you spend with the young person alone will depend on his/her developmental age.