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Treating adolescents: Why won't they follow my advice?

Harvey, Michael A. PhD

doi: 10.1097/01.HJ.0000406771.03100.bf
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Michael A. Harvey, PhD, is a clinical psychologist in private practice in Framingham, MA. He provides training and consultation on hearing loss and mental health issues, and is a consultant faculty member at Salus University. Thoughts on something you've read here? Write to us at HJ@wolterskluwer.com.

There's an old saying: “Raising teenagers is like trying to nail Jello to a tree.” I've been told the same is often true when providing them audiologic care. Adolescents assert their need for autonomy while adults assert their need for control. I can imagine many hearing care professionals reading this and thinking, “I schedule adolescents between my easier patients,” “I psych myself up first,” or “It feels like I'm entering a battle zone.” I nod my head in agreement because it's familiar terrain in my psychotherapy practice.

There are strategies for avoiding fruitless power struggles with adolescents and for increasing the likelihood that they will follow your recommendations. Hearing care professionals frequently ask me how psychotherapy techniques can be put to use in audiology. Although I know little about the audiology part, the tasks of managing resistance and other psychological land mines are applicable across disciplines. Plus these tips do not take significant additional time nor do they overstep your area of competence.

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EMOTIONALLY PREPARE YOURSELF

With the onslaught of back-to-back patients and barely enough time to breathe, it can be challenging at best to deal with adolescent posturing and to withstand what can be their irritating active or passive resistance. But for this very reason, it's critical to take a deep breath and conjure up a sense of playfulness and humor. Do an attitude shift, and despite your wish to be helpful, remind yourself not to invest in a power struggle. To do this effectively, we must find some way to have fun.

I recall a time when an adolescent initially entered my office, sat in the chair farthest from me, turned it toward the window, and folded his hands. How was I going to have fun? I asked him if he had the misfortune of watching the Red Sox lose the night before. No response. I continued bemoaning the game, inning by inning. After 30 seconds or so, he interrupted and announced that he was a Yankees fan. “A Yankees fan,” I screamed back. “Oh, my God, and I thought we needed to talk about your depression. This is much more serious. This is terrible! A Yankees fan! In my office!”

I assured him that I might be able to help him by using “Baseball Reassignment Therapy” (changing his alliance from the Yankees to the Sox), that medication may help, maybe eating Boston cream pie or Boston baked beans, etc. I went on and on for well over five minutes, thoroughly enjoying myself. Although later he said to his mother that I was “weird,” he came back for subsequent appointments, positioned his chair to face me, and we began talking about his depression and drug use.

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CONNECT BEYOND THE PROBLEM

Meet 16-year-old Bob. Like many adolescents, his parents “dragged” him to my office because he didn't accept his hearing loss and refused hearing aids. I used my standard opening with him.

“You don't want to be here, do you?”

He shook his head.

“Neither do I” was my reply. “What would you rather be doing?”

“Hanging out,” he grunted.

“Me, too,” I tried to grunt back. “Looks like we're stuck with each other for a while.”

No response.

“Hmm, hanging out is a good thing,” I continued. “For me hanging out would be watching Law and Order, listening to the Grateful Dead, or cooking. The problem with cooking, though, is my wife says I make a mess, but clearly she's wrong—no doubt in my mind.”

Bob remained silent. Nonetheless, I saw a sly smirk that indicated progress.

“How would you hang out if you didn't have to be here?” I asked.

“I hang out in my bedroom, but my mom's always badgering me to clean it up.”

“Like when I'm cooking. But you don't make a mess either, right?”

“You got that right, doc,” he agreed.

“I'll convince your mother if you convince my wife,” I said.

First a smirk, now a nod.

When adolescent patients like Bob feel they are dragged in, it's important to begin the initial meeting with something positive, often with something other than what they expect. It's critical to amplify (pun intended) the human connection—we're in this together, apart from the context of audiologist-patient. In less than three minutes after I introduced myself to Bob, we exchanged a smirk and nod about something other than the loaded presenting problem. And per step one, I was enjoying our interaction. Had I begun with my usual opening questions—What brings you here? How can I help?—I would have set myself up to be viewed by Bob as colluding with his parents and the audiologist who were, in his words, “stupid.”

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ASSESS READINESS FOR CHANGE

“Why do you think your mom dragged you here?” I asked Bob.

With adolescents who come in unwillingly, it is often helpful to begin with why they think they were brought in.

“I dunno.” Shrug.

“I guess your mom also dragged you to see Dr. Smith [the audiologist], huh?”

“Yeah.”

“So I got this report from Dr. Smith. [I look at Bob's audiogram.] It says you have hearing loss that makes it impossible to understand certain conversations, and she recommended hearing aids. Do you agree with that?”

“No. My hearing is fine!” Major sigh.

Bob's presentation is consistent with the stage of change termed the Pre-Contemplation Stage; he denied his hearing loss and the need for accommodations.1 Psychologically, it would have been an error for me or the audiologist to have immediately explained that he had a hearing loss and attempt to persuade him to get treatment. Although factually, the diagnosis and treatment plan would have been be correct, these well-meaning demonstrations of our expertise would have served only to increase his resistance. Consider the old joke, how many psychologists does it take to change a light bulb? Answer: It doesn't matter; the bulb has to be ready to change.

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AFFIRM SELF-DETERMINATION

It is often more difficult to do something good for yourself when so many others are trying to convince you. As one adolescent put it, “When I do things that my parents don't want me to do, at least I know I'm doing it for me, but if everyone is telling me to do something—even if I know it's a good idea—I don't know if I'm doing it for them or for me.” This is a common posture for adolescents, in part because of their tenuous sense of identity. It sets the stage for overt and covert opposition.

In the context of providing audiologic care, it is important to acknowledge adolescents’ authority over themselves, to overtly acknowledge and validate an adolescent's ability to do what he wants to do. Stated differently, you can acknowledge your helplessness to make people do what you think they should, and state openly that you're not going to make that futile attempt. You need not shy away from expressing your professional recommendation, but emphasize that you have no illusions of omnipotence for forcing the adolescent patient to comply with your treatment plan, even though, in your professional opinion, you believe it's correct.

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DISCOVER THE INVISIBLE PEOPLE

I sometimes imagine that patient visits occur in front of an invisible audience of critics who advise him whether he should follow the proposed treatment plan. It's vital to discover who these characters are, and figure out how they may affect whether your audiologic recommendations are followed. For adolescents in particular, that wide network includes critical peer group influences that must be adequately understood and sometimes used in treatment planning.

One effective method of making the relevant characters visible is a family therapy technique called circular questioning.2 Essentially, it's an exploration of who says what to whom about your treatment recommendations.

The following vignette shows my circular questions to Bob and his responses.

“Whose idea was our meeting and why? Do you agree or disagree with that person?”

“This appointment was my mom's dumb idea. There's no way I'm going to wear hearing aids.”

“Who might your parents tell about this appointment, and what would be their response to your parents or you?”

“My mom would tell the whole world about this appointment if she could. My grandparents, Uncle Pete, Aunt Joanne, and her friends [he listed their names]. They would all be on her side.

“Which of those people are most concerned about your hearing loss?”

“After my mother, my grandpa would be the most concerned about my hearing, and want me to use hearing aids because he's always after me to do well in school. Then Aunt Joanne, who has an opinion about everything. Uncle Pete, who's stupid, and then some of my mom's boring friends who are teachers: Diane and Sandy, but maybe not Sis because she's kind of cool and has an open mind.”

“Who might you someday tell about this appointment? What do you think their response would be?

“Maybe I'd tell my best friend, Jack, because I tell him everything. Jack would say that my parents are being jerks, that they treat me like I'm a baby, and he'd say that I do just fine like I am. But he tells me not to yell or swear at them because they're big on respect, and I'll get in more trouble.”

“What would you say back to your friends?”

“I would say to Jack that I agree with him, and he and I would tell my parents and all their friends to mind their own business.”

“If you do get hearing aids, what would these people say to each other? What would they say if you don't get hearing aids?”

“If I get hearing aids, my family and mom's friends would have a celebration, but I wouldn't go. If I don't get hearing aids, maybe my mother's friend, Sis, would understand, and my father would be okay because he doesn't get involved with this stuff like my mom. Jack and I watch sports with my dad.”

Note that Bob's interpersonal landscape around his hearing loss became a rich and complex drama. This activity requires only a few minutes, and can be included in a patient questionnaire to save time during the office visit. The importance of this intervention is clarified in the next step.

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CONNECT WITH THE PROTAGONIST

In literary circles, the term protagonist is defined as the principal character in a piece of literature. Here, the protagonist refers to the person who can exert maximum influence on a patient to follow your recommendations.

Given the cast of characters and the drama elucidated from circular questioning, it is clear that Jack is the protagonist. If the audiologist invites Jack to the office visit with Bob and his mother, there would be an opportunity to connect with him, which is critical for a successful outcome. If Jack were on board with the idea of amplification, it would be a go. Restricting yourself to a traditional meeting with only Bob and his mother would be least likely to result in a successful outcome.

I asked Bob if he would invite Jack to our next meeting. With some coaxing, he agreed. One week later, the two best friends were in my waiting room competing with each other on a handheld computer game. After some initial chitchat with Jack, we agreed that they would interview the audiologist together while his mother stayed in the waiting room. I asked Jack and Bob to prepare a list of questions for the upcoming appointment with the audiologist:

* What do you think Bob misses?

* What would he hear with hearing aids and an FM system?

* Will his hearing get worse without these things?

* How could he hear better without hearing aids?

* What size and color hearing aids do you have?

To the extent that an adolescent's self-identity depends on rebellion, our efforts at control—aka guidance, recommendations, persuasion, behavioral programming, pleading, and threatening—are likely to be as effective as nailing Jello to a tree. The steps outlined here offer another approach: find some way to enjoy and connect with the adolescent in your office. Carefully time the visit when the window of opportunity is open so you can give advice, respect the adolescent's ultimate authority over himself, and expand the locus of treatment to include key persons in the social ecology, particularly influential friends.

Bob and Jack eventually paid a visit to the audiologist. She passed Jack's interview because they were both skiers (she had a photo of her skiing in the office), and Bob has agreed to “sometimes” wear hearing aids. And then there's my other patient, the Yankees fan. I occasionally get emails from him, typically when they beat the Sox, which coincidentally occurred as I was writing this article. It read: “Hi Mike. We kicked your [butt] last night. How does that make you feel?”

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REFERENCES

1. Prochaska JO, Norcross JC, Diclemente CC: Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward. New York: Quill; 1995.
2. Palazzoli MS: The problem of the referring person. J Marital Fam Ther 1980;6(1):3-9.
© 2011 Lippincott Williams & Wilkins, Inc.