Now let’s listen to an interaction where Dr. Denke takes a more understanding approach and listens more.
DR. DENKE: I want to remind you, anything you say to me is totally confidential. I won’t tell anyone unless you ask me to. Or unless you or someone else is in danger, okay? (Cody nods) So what can you tell me about the changes in your mood recently?
CODY: I’m fine.
DR. DENKE: Your parents are concerned you’ve been getting angry more easily.
CODY: (slightly annoyed) I get angry because everyone still treats me like a kid.
DR. WORNIK: Dr. Denke hears Cody’s defensiveness and starts by building rapport. He leads with an affirmation of how far Cody has come, and then reflects the positive aspects of Cody’s responses.
DR. DENKE: It’s always hard for parents to recognize their children are becoming adults. But I can definitely see how much you’ve grown.
CODY: I’m making a 3.5 in school, got in early decision to college, and I’m busting my butt at the gym every day. And now they come dragging me out here because I get a little... intense sometimes.
DR. DENKE: You’ve been working really hard. I know when you first started working out, you were worried you wouldn’t stick with it.
CODY: I was such a loser.
DR. DENKE: Why do you say that?
CODY: I mean, you remember. I just sat around like a lump. I was no one. Now, I’m becoming a man.
DR. DENKE: Working out is really important to you. You want to be strong. Push your body to do the most it can for you.
CODY: I’m never going to be that fat little kid again.
DR. DENKE: (guessing, continuing Cody’s thought) You like going to the gym. You’ve worked hard there to reach your goals and that makes you feel better about yourself.
CODY: Yeah, the guys there, they’re men, you know. They’re so past all the high school crap.
DR. DENKE: You’ve made friends there.
CODY: Yeah. I used to hate jocks, but these guys... it’s not about winning. It’s about everyone helping each other become the best you can be.
CODY THOUGHT: They believed in me, even when I was a fat loser. Not like everyone else.
DR. WORNIK: Not only is Dr. Denke building a relationship with Cody, he’s learning valuable information. Many kids who work out at commercial gyms first encounter anabolic steroids when they learn older gym members are “juicing.” To Cody, his relationship with the guys at the gym may seem positive, but Dr. Denke should follow up and see if they have provided more than emotional support. Notice how he leads into asking about steroids with three indirect questions.
DR. DENKE: How do your friends at the gym help you?
CODY: Well, you know, like showing what I’m doing wrong in my workouts. How to get stronger, that kind of thing.
DR. DENKE: They share supplements, stuff like that?
CODY: Sure, I mean if they have something that really works.
DR. DENKE: Right. Because if you find something that works, you’re excited, right? Anyone would be. (Cody nods) Anyone ever say anything about using steroids?
CODY: (taken aback) What? No!
DR. DENKE: (mild) They’re pretty common at a lot of gyms. I wouldn’t be surprised if some of the guys you know have tried them.
CODY: (shrugs, uncomfortable, but not denying it)
CODY THOUGHT: Crap. Everybody said you were gonna ask me…
DR. DENKE: If you see friends using something and getting results, it’s hard not to be curious...
CODY: I guess.
DR. DENKE: Maybe hard not to want to try them yourself.
CODY: What are you saying?
DR. WORNIK: Notice how Dr. Denke took a moment to normalize Cody’s curiosity about steroids. That can help maintain a good relationship, even when dealing with sensitive topics. Cody signaled that he isn’t ready to open up about this topic, so Dr. Denke switches back to indirect questions.
DR. DENKE: (backing off) You know, there are a lot of pro athletes who try to boost their testosterone in different ways, to get stronger or faster. Like taking anabolic steroids. What do you think about that?
CODY: (snorts) If someone was going to pay me 80 million bucks to play baseball, I’d use anything I could to be the best.
DR. DENKE: (reflecting, non-judgmental) It sounds like you feel it’s just part of the game.
CODY: (uncomfortable) I don’t know. I mean, it’s just testosterone, right? We all have it. These guys, they’re pro athletes; they’ve probably got a lot more than someone like me anyway. Why wouldn’t someone try to catch up?
CODY THOUGHT: If I wasn’t such a fat loser, I wouldn’t have to take steroids to keep up.
DR. DENKE: What do you know about testosterone and how your body reacts to it?
CODY: It’s a hormone. It helps you grow muscle, and... have sex and stuff. (looks a little embarrassed)
DR. DENKE: That’s right. Is it okay if I tell you a few more things about it? (Cody shrugs) Well, in a healthy young man like you, we expect to see fairly high levels, which means a lot of space in the testicles to produce it. But what I’m seeing is that your testicles are smaller than I would predict (Cody grimaces), yet your body has a lot of other signs of high testosterone. What do you think of that?
CODY: (defensive) I don’t know.
DR. DENKE: What it suggests to me is that you’ve probably been exposed to an artificial source of testosterone. When that happens, it can stop your body from making its own.
CODY: (long pause - Cody is silent)
DR. WORNIK: Dr. Denke is being very patient about approaching things indirectly and working up to the sensitive topic of steroid use. This will make Cody feel less threatened when Dr. Denke brings it up--let’s see what that looks like. Listen for how Dr. Denke normalizes Cody’s desires, then asks about others’ use rather than his own use.
DR. DENKE: It’s really normal for people to want to feel stronger and look better. Not just athletes; I think we’re all looking for the best way to do that.
CODY: (quiet) Yeah.
DR. DENKE: Do you know anyone who’s tried steroids?
CODY: Yeah. (pause) Yeah, there’s a few guys at the gym who juice. (quickly) Not just the crazy bodybuilder types, good guys who want to get bigger. They’re not what you think.
DR. WORNIK: Because Cody is feeling respected and understood, he answered truthfully. He gave a tacit acknowledgement that he is, at the very least, part of a community where steroid use occurs. Now Dr. Denke shifts to building a case against steroid use, but again, indirectly--he uses Ask-Tell-Ask to respectfully share information.
DR. DENKE: It’s pretty tempting to take a pill that will help you get the body you want. (pause) I’m wondering what you know about the flip side of steroids?
CODY: (testing the waters -- how will the doctor react to this) Uh, I’ve read that they can, uh, give you acne, sometimes make your hair fall out. (peeks at Dr. Denke, who nods) And, um, can make you get angry, but the guys at the gym say some of that’s bull. (Dr. Denke carefully doesn’t look at him, giving him the space to decide how much to say). And something with your liver?
CODY THOUGHT: Is this when the lecture starts?
DR. DENKE: What have your heard about what steroids can do to your liver?
CODY: I mean, I know it can, I don’t know, mess it up somehow. But some of that’s, like, crap isn’t it? You know, real exaggerated?
DR. DENKE: Some of it is uncertain. And there’s some truth, too. Whether or not steroids can cause liver cancer is still unclear, but they definitely do cause non-cancerous tumors that can rupture and bleed. (Cody grimaces) And they can cause a condition where your liver leaks bile into the bloodstream. What do you make of that?
CODY: Ugh.
DR. WORNIK: Ask-Tell-Ask allowed Dr. Denke to find tailor his information to Cody’s needs, and it also engaged Cody in the discussion. Most anabolic steroid users do have some concerns about their health. If you show that you won’t judge them or overreact, they could see you as an answer to some of their concerns. Cody is at the tipping point where his concern is outweighing his distrust.
CODY: So, is there a way to… I don’t know, check for health problems? If someone was using…?
DR. DENKE: We could do a liver panel to see if there’s been any damage to your liver. Maybe monitor your blood pressure and check your growth chart to see whether it’s leveling off. It’s really important to catch this stuff before it can do too much damage.
CODY: (long pause - looks away, then:) Don’t tell my parents.
DR. DENKE: Thank you for being honest with me, Cody. I know it’s not easy. (Cody nods, not quite able to speak yet). I’ll write up the order for those tests right now. But first, I need to know what I’m looking for.
CODY: (deep breath) Anadrol.
DR. DENKE: We'll get blood samples to the lab today. With any luck your liver is still in good shape. But with steroids, it's usually just a matter of time before it gets worse.
DR. WORNIK: In real life, it may take multiple conversations for a patient to reach this point, where they are comfortable enough to share that they are using steroids. The important thing is to be patient and not push them away with too many questions or judgmental statements. Now Dr. Denke moves to a discussion of a change plan. Notice how he uses questions to discuss a change plan collaboratively and non-threateningly.
DR. DENKE: Have you thought about a long-term plan? (Cody looks confused) For coming off the steroids?
CODY: No. I should. I know I should, but I-I can’t.
DR. DENKE: I know you’re concerned about your health, Cody.
CODY: (shouts) I just can’t!
(Cody is surprised by his own anger. Dr. Denke is quiet for a moment, watching him struggle with himself.)
DR. DENKE: Coming off steroids is complicated. Can I tell you a little bit about the process?
CODY: Uh, I guess.
DR. DENKE: There’s a lot of different parts of you involved -- your body, your mind, your emotions. Quitting can cause a lot of tension and doubts, so I’d definitely want you to talk to a therapist, probably an addiction counselor. And an endocrinologist or sports medicine doctor would need to oversee any plan for how to wean you off.
CODY: (long pause - mumbles) My mom’s going to kill me.
DR. DENKE: (very sincere) Your parents brought you here because they were concerned about you. Your mom thought you were having a breakdown. I think she’ll be relieved that it’s something you can quit. (pause) Can I bring them back in?
CODY: (takes a deep breath, then nods)
(The conversation ends.)
DR. WORNIK: In this conversation, Dr. Denke demonstrated different ways to broach the subject of steroids with Cody, a patient who had many clear signs of steroid use. By taking a respectful, supportive tone and patiently using indirect questions, Dr. Denke build a strong relationship with Cody and obtained a tacit admission of steroid use. Cody is trying to quit, though he still has a long road ahead of him. Remember, in real life, this is likely to take much longer -- don’t give up if a patient is reluctant to admit use after one conversation!