First, let’s look at an interaction that goes poorly. Dr. Wornik will appear from time to time with observations and advice.
DR. DENKE: So, I’m going to be asking you some questions that I ask all the teenagers I see with symptoms like the ones you’re describing.
ELLA: Uh, okay.
DR. DENKE: And I want you to know, anything you tell me today stays between you and me unless you say otherwise. Or unless you or someone else is in danger, okay? (Ella nods) But I know there are some things that are easier to talk about when mom is out of the room, right? (smiles)
ELLA: (nervous, talks quickly) I guess. I mean, it was her idea to come here.
DR. DENKE: How’s school going for you generally?
ELLA: I don’t know. My parents are like, crazy. They moved us here just so I could go to this great high school, but... (makes a frustrated noise) It’s really hard… In middle school, they thought I was smart, but maybe I’m really stupid, and my old school just sucked so they couldn’t tell? Because I can’t do anything here, not even the stuff I used to be good at.
DR. DENKE: You’re having a hard time in your classes.
ELLA: And my parents are all, “You’re just not trying hard enough,” but I am. I’m up like all night studying, but when I sit down at a test, I just can’t focus and… (trails off and shifts nervously)
DR. WORNIK: So far, this visit is going well. Dr. Denke asked “How’s school going for you?”, which is an open-ended question, and he also reflected the content of her answer when he said “You’re having a hard time in your classes.” Ella is responding by opening up and sharing useful information. But Dr. Denke is about to slip up.
DR. DENKE: (smiles) You’re not stupid.
ELLA: I am! I can’t get anything right anymore. I mean, I used to be good at math, right? Like 90th percentile on all the bubble tests. But now I’m in Algebra II and they want us to start doing these, like, trig problems and stuff with the quadratic equation, and I just can’t make any sense of it.
DR. DENKE: Math gets harder in high school. Even smart kids have to put in more work than they used to.
ELLA: I am working! I’m up until two, three AM studying and it’s just never enough. It’s like I don’t have time to breathe.
DR. WORNIK: He was trying to reassure Ella, but to her it sounded like he was dismissing her experiences. Telling a patient they shouldn’t feel a particular way usually pushes them to argue more about why they do. Now Dr. Denke is about to slip into an authoritarian tone. Listen to how Ella responds.
DR. DENKE: It sounds like you don’t get much time to sleep.
ELLA: Yeah, well, you can’t exactly put “well rested” on a college application. (Dr. Denke waits) Look, I know I should get more sleep, but it’s… it’s just got to wait, you know? I’ve got stuff to do.
DR. DENKE: Sleep is important, Ella. Your body needs sleep in order to stay healthy.
ELLA: (deflated) I know...
DR. DENKE: Sleep is so important that depriving someone of it is actually considered torture under the Geneva Conventions.
ELLA: (half-hearted) Right. I’ll… I’ll try to sleep more.
DR. WORNIK: “Sleep is important” is almost certainly something Ella has heard before. Hearing it again isn’t likely to change her behavior. Try using Ask-Tell-Ask when you need to share information. By asking questions first to determine what a patient already knows, you can make sure that anything you say will be new information.
Now, let’s listen as Dr. Denke gets the conversation back on track with a good question, then shuts Ella down with an answer that minimizes her concerns.
DR. DENKE: Sounds like you’re under a lot of pressure. How do you handle it?
ELLA: (nervous laugh) I don’t know. Not well. (a pause, Dr. Denke lets her continue) I mean, I just… I have all this stuff to do, (speaking faster and faster) but when I try to sit down and do it I can’t even focus on what’s in front of me because there are too many other things going on in my head and I can’t sort out what to pay attention to.
DR. DENKE: That sounds really difficult.
ELLA: And I have a friend, Dana, she… she takes a medicine that helps with that sort of thing. With ADHD? (slight pause, hopeful) Do you think maybe that would help me?
DR. DENKE: Just because you’re having trouble focusing doesn’t mean you have ADHD.
ELLA: But I do! I mean, I can’t focus on anything any more. I really need something that will help me or I...I just don’t know what I’m going to do.
DR. DENKE: ADHD is a complicated condition. It’s not something that you can self-diagnose. I’d need to get more information from your parents and teachers and probably have you evaluated by a mental health specialist.
ELLA: (crestfallen) Oh. But I think I should at least… try the medicine. You know, because it might help?
DR. WORNIK: Notice how Ella pushed back against Dr. Denke. Disagreeing with a patient can be like tug-of-war. By arguing that Ella might not have ADHD, Dr. Denke made her pull all the harder in the other direction. Taking a patient’s concerns seriously, on the other hand, can help them relax and be less adamant that they already have all the answers.
Now Dr. Denke will ask about stimulant misuse. He’ll take a non-judgmental tone that will encourage Ella to be honest.
DR. DENKE: Have you ever tried ADHD medication?
ELLA: (quickly) No! (pause) No...
DR. DENKE: So, you’re telling me this is something you’ve talked with your friend about a lot. You feel like you’re having many of the same symptoms she did and she told you that she’s had real relief from her medication. (Ella nods) But you’ve never tried any yourself.
ELLA: Well… (squirms uncomfortably)
DR. DENKE: You have tried it.
ELLA: (pause, then admits) Only because I really need it! (defensive, justifying) I’m like a thousand times better when I’m on it. I get all my work done, and I can still go the next morning and be able to get through everything at school.
DR. DENKE: Thank you for telling me. It’s important for me to know anything you’ve tried to help with your symptoms.
ELLA: (hopeful) So, that means I have it, right? ADHD? If the medicine helped so much?
DR. DENKE: How much of your friend’s medication have you tried? Do you know the name and dosage?
ELLA: Uh, Adderall. I only take it if I have a lot of tests or something.
DR. DENKE: So how often is that?
ELLA: Uh, a few times a week, I guess. It depends when Dana brings it in.
DR. WORNIK: That went well. But now Dr. Wornik goes back to the tug-of-war, trying to scare her away from stimulants without speaking to her underlying concerns.
DR. DENKE: ADHD medications are powerful drugs. They can have some very bad side effects. Everything you’ve told me about -- the heart palpitations, the insomnia, even the lack of focus in school -- could all be caused by taking your friend’s medication.
ELLA: No, I took the meds because I was already having problems.
DR. DENKE: Unless you have a formal diagnosis of ADHD, these medications will do you more harm than good.
ELLA: (plaintive) Then I need a diagnosis.
DR. DENKE: You don’t have ADHD.
ELLA: I do! How can you just say that?
DR. DENKE: Your symptoms don’t fit the profile for the disorder.
ELLA: You have no idea how hard this year has been! I’m like, my thoughts just race all over the place and half the time I forget what I was about to say by the time I say it. I’m like a mess.
DR. DENKE: ADHD is a lifelong condition. If you had it, you would have shown signs starting before puberty. It’s not something you suddenly develop at 15.
ELLA: No. I do have it.
DR. DENKE: I’m going to recommend you see a substance abuse counselor.
ELLA: I’m not on drugs!
DR. DENKE: A substance abuse counselor will be able to help you through the withdrawal.
ELLA: I need Adderall. I came here because I thought you would help me, not take away the only thing that’s making my life bearable.
DR. DENKE: You need to talk to someone--
ELLA: Forget it. I’m not doing drug counseling. I don’t have a problem.
DR. WORNIK: This conversation is unlikely to help Ella. She is feeling misunderstood and attacked, and as a result she refuses to listen to Dr. Denke.