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class 9_the adolescent interview_2

class 9_the adolescent interview_2 - CHAPTER 8 The...

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Unformatted text preview: CHAPTER 8 The Adolescent interview An adolescent is neither a smaii aduit nor a large child. By this age, toys and games have usualiy outlived their useful— ness in an interview situation; however, an initiai game of checkers or chess may help get some younger adolescents started. A snack or drink may also help facilitate dialogue (remember to ask parental permission first). Depending on an adolescent’s degree of maturity, most of the interview techniques that are used with adults can be applied to the adolescent inter~ view. Regardless of age, an informant can heip set the stage for the evaluation of a hospitalized patient. However, as with an adult outpatient, an adolescent office patient should usually be interviewed before information is obtained from the parents. At some point, you may want to follow up the individuai interviews of adolescent and parents with a family interview to learn how the parents and their chiid interact. As you will. note in. the interview presented in this chapter, the clinician spends much time trying to deveiop rapport. This is not unusual for an adoles- cent patient, who wili not uncommonly require more time to deveiop trust in the clinician than will typically be necessary for either an adult or a younger child. To conserve space, we have summarized some passages of dialogue. This interview takes place on an adolescent inpatient unit. (It is safe to assume that in this case it is not the patient who has initiated the evaluationm an issue that should be clarified at the beginning of any adolescent interview.) The interviewer has never met the patient before and does not have access to his prior history. Casey is dressed somewhat sioppiiy in baggy jeans, sweatshirt, and baseball cap turned backward. He lounges in his chair and pays as iittle attention as possible to the interviewer. 722 8. The Adolescent Interview 723 INTERVIEWER: Hello, my name is Mr. W I want to thank you for agreeing to be interviewed today Did your doctor tell you Why I wanted to meet with you? Ibis rather formal introduction may seem foreign to some Clinicians who treat adolescents. We feel it is important to find a middle ground between excessive formality and inappropriate familiarity. Adolescents need to feel that the adults in their world have the maturity and experience to handle their problems and to ensure their safety. Seductiveness, rampant informal ity, or attempts (usually unsuccessful) to dress or talle [the teenagers can repel an adolescent patient as surely as condescension or lacle of engagement can. CASEY: Yeah . . . INTERWEWER: And why was that? CASEY: I don’t remember. INTERVEEWER: Well, that’s OK. Let me try and explain. 1 work with Dr. 2., and I would like to get to know you a little better so i can help Dr. understand your problems better. is that all right with you? CASEY: [Long pause} Yeahhh . . . INTER‘V‘IEWER: Could you tell me why you came here? CASEY: idunno. [Silence] INTERVIE‘WER: What sort of problems were you having? CASEY: Nuthin’ . . . INTE‘RVIEWER: It sounds like you’re not too keen to talk. CASEY: [Frolonged silence} The interviewer 's good attempt at an open~enaea beginning has been consis~ tently rebufletl by a patient who is at best uninterested in talking If possible, the interview must now he salvaged by closed~enaetl questions, with careful attention to opportunities to form some sort of relationship with Casey. First, the interviewer presents some ground rules. INTERV’IEWER: Let’s talk a little bit about What we’re trying to do here. You’re here in the hospital when you don’t want to be, and we’re trying to learn what it Will take to get you out. Dr. Z. has already heard something from your folks about why you’re here; now we want to hear your side of it. 724 I. INTERVIEWING CHILDREN AND ADOLESCENTS Anything you say that will help us may get you out of here more quickly. Do you understand? CASEY: [Nods his head and steals a glance at the interviewer.] Uh-huh. INTERVIEWER: We also need to agree on this: i’m going to try to be sensitive to your feelings, but i will have to ask a lot of questions. lfI ask a question that you don’t feel you can answer truthfully, just ask me to talk about something else. But don’t just make something up. Any time you don’t tell the truth, it will confuse us. And you could be here longer. OK? CASEY: {Nodal INTERVIEWER: Still another thing: What you tell me I will treat as confidential. That means i won’t tell anyone, Without your permission. The only possi- ble exception, I think you’ll understand, is if you’re planning to harm yourself or someone else. Then I’d have to make sure you and others are protected. OK? CASEY: Sure. With these statements, the interviewer has emphasized three important points.- (I) a philosophy that the patient is not the entire problem, (2) the need for truth, and (3) the need for safety. These are fundamental to every adolescent interview,- they may have to he stated more than once. In addi- tion, the interviewer has addressed the adolescent’s need for assurance that his possibly embarrassing thoughts and feelings will not he divulged without his express consent. INTERWEWER: How old are you? CASEY: Fourteen. INTERWEWER: How long have you been in the hospital? CASEY: This is my second week, I think. INTERVEEWER: And you were an inpatient before at another hospital? CASEY: Yeah. INTERWEWER: HOW long were you an inpatient? CASEY: Nine days. Sofai; the interviewer has been asking simple questions that this recalcitrant patient can answer in a word or two. Ihe patient’s sloucheal posture, brief answers, and initial refusal to cooperate all signal the absence of rapport. 8. The Adolescent Interview 3'25 INTERVIEWR: Was it helpful to you? CASEY: No. I didn’t like it. E thought it was just torture. _ iNTERWEWER: Torture? By repeating a word oflered by the patient, the interviewer encourages an open-ended response. This technique is one of tine most useful for guiding the direction of an interview while encouraging verbal output. CASEY: Yeah. They treated me like a criminal. Almost exactly the same as in juveu nile hall. INTERVIEWiiR: Have you been to juvenile hall? A lapse: Instead of saying, “Tell me more, ” which wonld leeep the dialogue open—ended, the interviewer asks a yes-«no question. CASEY: I’ve seen it. Yes. IN'FBRVIEWER: From inside or outside? CASEY: From inside. INTERVIEWER: Boy, you’ve seen a lot of things? But you look kind of sad today. The interviewer focuses on affect by making a statement (“You look sad”) rather than by asking a question ("Do you feel sad?) The statement avoids argument and reinforces the use of words to communicate (especially appro priate for younger children). CASEY: wen . . . yeah‘ Just today. l’m getting into trouble with Cherub. She is just provoking me until I say something to her, and she doesn’t get into any trouble. They even notice it. I mean, she’s calling me all these names. INTERVIEW'ER: Do you feel they’re picking on you? CASEY: No, it‘s just really Cherub, and Johnny has done some stuff, too. He’s thrown my dominoes out the Window. I’ve seen him do that, and then he lies to me. And that makes me mad. ENTERVIEWER: I can understand that. Let me ask you this: Have you ever been in this place before? ' The interviewer wants to move ahead, but an abrupt subject change may not be the best way to proceed, especially with a yes—no question. CASEY: NO. INTERVIEVVER: How many times were you in juvenile hall? T25 25. h '. E. $1 ‘S s l. INTERVIE'WING CHILDREN AND ADOLESCENT§MM_ CASEY: i wasn’t in there. INTERWEW'ER: I thought you said you were? CASEY: i saw it. IN’i‘iaRmswaR: From the outside? CASEY: No, I was inside for a probation hearing. Interviewer and patient are sparring, testing each other’s veracity and trust— worthiness. The patient continues to he guarded, hut the interviewer responds with another attempt at open—ended questioning. INTERVIEWER: What were you doing on probation? CASEY: I robbed this lady’s house a couple of times. lwent with someone the first timeman older guy. We. took some Cigarettes and some iiquor and money. ENTERWEWER: Uh—huh. A barely uttered encouragement leeeps the ball rolling without getting in the way of the patient ’3 stream of thought. Adolescents often handle negative mood states (anger; anxiety, depression, guilt) through counterphohie acting out. Clinicians, like this interviewer; must be careful to responar with accep~ tance without appearing to condone the behavior in question. At the same time, they must dig beneath the behavior to search for its psychological underpinnings. CASEY: Well, it wasn’t much. She lives a few biocks away from me, and we just walked in. The back door was open. INTERVIEWde {Waits in siience for many seconds until the patient, feeling the need to fill the void, begins to speak again] CASEY: He . . . he was my homeboy, and {just went aiong. It was a couple of months ago, beginning of the sehooi year. He stole a car. I didn’t steal the car, but I was in it. Now he’s on probation. Hem— INTERWEWER: And when do you get ofl probation? To keep the focus on the patient, the interviewer interrupts, but uses the patient’s own word to make the transition. CASEY: I think it’s going to he 5 years. INTERVIEWER: And since then, have you been going to school regularly? CASEY: Yes. Sometimes I ditch, but I‘ve been going. Even if it’s a iot of buiishit. 8. The Adolescent Interview I _ ' T27 INTERVIEvnaR: Look, let’s change our focus a bit. Tell me if there was ever a time in your life when you weren’t getting into trouble. Were there happy times in “your life, or has your life been kind of shitty all along? This interviewer has obtained some information concerning Casey’s relation ship with his peersman important topic for any evaluation of a teenager. The interviewer next tries to ioole for any past history of untrouhled, positive family experiences. Although this transition is abrupt, it is announced (“let’s change ourfocns’i) to let the patient know that they will he pursuing a differ- ent coarse and that the interviewer is assuming more control of the process. The mild vulgarity (“shitty’Q may he an attempt to use language the patient will relate to. Of course, it is important to speak so that the teen will under- stand, hui an adult who tries to imitate teenager-5’ language too closely risks rejection. Clinicians sometimes feel that they must choose between relating to an adolescent patient as a peer and sounding like a censorious parent. In reality, a middle ground is almost always possible. CASEY: Depressing, because of what happened at school. It was really one teacher, one bad teacher who started the whole thing. INTERVIEWER: {Eh-huh. CASEY: This teacher—it was first gradcwpicked. on me, and I had her all the way through sixth grade. She was a jerk. She’d pick three people out of each class, all these people she didn’t like. Every time she came in, she’d. make them sit outside just because she didn’t like them. I was one of them. INTERWEWER: So it started in first grade, and it followed you because of that one teacher? CASEY: Yeah. ENTERVIEWER: And you couldn’t break the habit or change their minds? Several summary statements verifi) that the interviewer understands. CASEY: It wasn’t that. It was the teacher. She was real mean. I accidentally broke a pencil once, and she got real mad at me and sent the down to the office. She says, “The school pays good money for these pencils, and you go around breaking them. You’ve got to go to the office.” They did this stuff all the way through sixth grade. INTERWEW'ER: And then what happened? 728 I. [NTERVIEWING CHILDREN AND ADOLESCENTS Now the interview is moving along well, but the clinician'is still concerned at the relative lack of aflective material. I t is fairly usual for an adolescent topor- tray all the problems as emanating from without. Denial of responsibility sug— gests character. pathology in an adult, but may he normal for an adolescent. [The patient relates more material about his progress through school.] INTERWEWER: When you started thinking about grade school, it seemed to me that you started to cry a little bit. Was it a hard time for you? CASEY: I started to cry? What do you mean? I’m crying because of What’s going on in that other room. [tie gestures next door, Where loud voices can be heard] Some facts have emerged about Casey’s long-standing difiiculties in school, but only a little rapport has developed. When the interviewer attempts to focus on aflect, the patient shies away and returns to the present. INT‘ERVIEWER: You keep thinking about Cherub? Cassy: And how I’m getting in trouble for things that she did. INTERWEWER: That’s a pattern. People sort of pick on you, and you get into trou- ble. How come that happens to you? Here the interviewer attempts an interpretation in the form of a question. In general, we agree with the conventional wisdom that it is best to avoid early interpretations. Ihey are often wrong, and even when correct, they may pre- vent the revelation of more intimate material. In this case, however, the patient responds positively. CASEY: It‘s because they know I’ll get angry at them if they set me off, so they do. INT‘ERVIEWER: They try to set you off? ' CASEY: They get me in trouble by doing that. JN‘mRVIEWER: So when you get angry, what happens? Do you hit them? CASEY: No. Well, sometimes, but usually I start cussing at them and stuff. I did with Cherub and I got in troubie for it, even though Cherub was saying really disrespectful things, like “Oh, you have no friends." Stuff like that. She wasn’t getting into trouble with that, and I’m really angry because I got in trouble. INTERWEWERt You get into trouble; she didn’t. She got off free? 8. The Adolescent Interview The interviewer is still trying to establish rapport with statements and ques- tions that empathize with the patient’s feelings of being scapegoated. This is a strategy that can backfire in the long run, because the patient surely under— stands on some level that he contributes to his own troublesome interactions. However, in this diagnostic interview, the interviewer still wants to develop reliable, diagnostically useful information. The information needs to include not only the symptoms of the illness and the facts of thepast history, but also data about the patient’s capacity for insight and for forming therapeutic relationships. CASEY: Yeah. And she gets to leave the program today, and She barely goes to any of the groups. I go to the groups. 1 don‘t stay in my room and refuse to go to them. INTERWEWER: And she doesn’t have to? CASEY: No. Some meaningful facts have been obtained, and some degree of understand- ing of this adolescent boy’s minimal insight into his problems has been observed. The interview is proceeding smoothly, and much more information has been obtained from a reluctant patient than might be expected. By this time, the bridge to a dififerent subject has been reduced to a single word, “Now.” INTERWEWER: Now, how did you get yourself into the hospital here? CASEY: I got really angry at school and spit at one of the teachers, and they sus- pended me, and my mom said, “That’s it. You’re going to a hospital.” INTERVIEWER: Do you think it’s been helpful? CASEY: I don’t knew, really. I’m saying it’s been helpful because I want to get out of here, but I think it’s just been torture. INTERWEWER: Do you have to take any medicine? CASEY: 1 take lithium and Zoloft. INTERVIEW'ER: How do they make you feel? CASEY: Lithium makes me shake a lot, and Zoloft, i don’t know. INTERVIEWER: Do they help you control your temper? CASEY: Sometimes, yeah, but when Cherub does that kind of stufic to me, i still get angry. ' 7'29 130 I: I‘NTERVIEWING CHILDREN AND ADOLESCENTS INTERV’IEWER: When you’re mad and get into fights, have you ever hurt anybody? CASEY: Yeah. I don’t fist-fight or anything too often, though. INTERVIEWER: Give me an exampie of someone you hurt. CASEY: This one kid at school, 1' whacked him across the face and hurt him realky bad. I think I gave him a bioody nose, but that was all. INTERWEWER: Do you have friends in schooi? CASEY: At B—w High 1 was reaily popuiar, and I was hanging out with the popu— lar students there. Then I got put in Cm High, and 1' don‘t even know any— one there. INTERVIEWR: What’s (2— High? is that where the prohiem kids are? CASEY: No. It’s a really preppy school. INTERWEWER: is it a private schooi? CASEY: No. It seems really preppy, and I don’t reaiiy like it. INTERVEEWER: Why did you get put there? Because my mom felt that I was getting in too much trouble at B— High. IN'TERVIEWER: Tel}. me about your family—your mom and dad, Using a bridge supplied by the patient, the interviewer moves to another area. CASEY: They‘re OK, I guess. INTERWEWER: Do they work? CASEY: My dad does. He’s an. engineer. INTERVIEWER: And your mom. stays home? CASEY: Yeah. INTERWEWER: Have you ever heard them fight? CASEY: Yeah, I have, but they don’t do it too often. INTERVIEWR: So they get aiong pretty weii? CASEY: "Yeah. INTERWEWER: Any brothers and sisters? CASEY: I got a sister. 8. The Adolescent interview INTERWEWER: Tell me about her. CASEY: She’s 12. ENTERVIEWER: Does she look up to you—mtry to do What you do? CASEY: Not all the time. She doesn’t smoke or anything, and if I smoke, she doesn’t. I hope she doesn’t copy me. When talking about his sister and bisfamz'ly, Casey seems to soften, and even expresses the hope that the sister will not tales afi‘er him. This may be evi- dence of a capacity for empathy—a subject that is very important to evalw ate in any adolescent patient. INTERVIEWER: When did you start smoking? CASEY: This past summer. iN’I‘ERVIEWER: Did you start drinking then, too? CASEY: I drank a little bit. I drank a lot of wine and stuff below that, but that’s when I started drinking hard alcohol. lNTERViEWER: Did you ever have any problems from drinking? CASEY: What kind? [After further questioning about possible academic, medical, and personal problems from smoking and drinking, followed by some questions about street drugs, the interviewer learns where Casey was born and why the family moved to the current location. Casey also discloses some facts about his grandparents. ] INTERWEWER: Did you ever think about going back to D—m to live? CASEY: Yeah, i really want to go back to D—, but my mom says no. INTERVEBWER: [Softly] It could be like a new start. CASEY: Yeah. Everybody in my familywants to go back to 13— except for my dad. Ibis has been Casey’s first really enthusiastic response in the interview, anal the interviewer builds on it. It is especially vital with an adolescent patient to project the clinician is genuine fondness for the patient. Because of Casey’s initial hostility and resentment at hospitalization, it has taken much of the interview to get to this point. INTERWEWER: When your mom said no, did she mean she didn’t want to, or she didn’t want to because of your dad’s job? 737 732 I. WTERVIEWING CHILDREN AND ADOLESCENTS CASEY: She told me she did. She told me She’d like to move back to D”, but Dad’s got a good job. INTERWEWER: So when you were 5, your family moved to this area, or did you move around a iittle bit? CASEY: We moved here. INTERVIEWER: You’ve had the same house that you’ve always had Since you were 5? CASEY: Yeah. INTERVIEWER: Do you have any pets? CASEY: Yeah, I have two cats. INTERVIEWER: No dogs? CASEY: I want a dog. This is the second positive statement of the interview The interviewer uses it as a springboard to the discussion of other positive feelings. INTERVIEWER: You do? A dog would be good for you. What kind of dog would you have? ' CASEY: A golden retriever. INTEIWIEWER: Yeah, they’re great. Say, do you think things are better between you and your mom and dad since you’ve been in the hospital? CASEY: Yeah, and 1 haven’t gotten yelled at by my dad. INTERWEWER: Are you mad at your dad? CASEY: I get mad at him ...
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