Workshop Presentations

‘Psychological Issues in Teenage pregnancy’  Diana ML Birch

A.  Teenage sexual belief systems.

That old black magic ...    The challenge of developing sexual feelings and urges strikes at the core of our beliefs about the world, who we are and the meaning of our lives. How can we understand this challenge and the sexual belief systems of young people? Any assessment is inevitably influenced by our own beliefs and we must take care to retain objectivity, listening to our young patients rather than imposing our own interpretations on their situations.

Where do these belief systems stem from?   Parental, cultural and religious beliefs and myths form a basis upon which the more contemporary  ‘up market’ beliefs are built - for instance the current peer group stance or the ‘dish of the day' in terms of the media 'hero'.  The immediate message can be as evanescent as the foibles of the pop charts - as professionals, we need to keep abreast of what the latest ‘no 1’ is teaching our youth. These belief systems, however bizarre and contrary to our own personal beliefs are at least tangible. We can understand where they stem from and we can to some extent modify them with appropriate input in the style of cognitive therapy, sex education etc.

In psychotherapeutic terms we can say that they are messages from the internalised Parental ego state (Transactional analysis), in simple terms the parental 'do this' 'don't do that' voices we carry around in our heads like a nagging conscience. Freudians would call this the superego.  The intensity of these messages can be modified by educating or activating the Adult ego state (ego), the 'thinking' part of our inner selves which deals with factual knowledge.  For instance group beliefs such as "You can't get pregnant the first time" or "It's OK if you do it standing up" can be confronted with factual knowledge such as '1 in 20 pregnant schoolgirls got pregnant as a result of the first time they had sex' and 'sperm can swim up hill'!

But at a deeper level, we have beliefs that are out of reach of direct social pressures. At this deeper level are what I would describe as 'magical beliefs'. Intrinsic ideas with a high emotional content, a feeling of instinct and intuition and which may have no perceivable basis in current reality.   These 'magical beliefs' acquired at an early stage of development may be ascribed to the Child ego state (TA) or perhaps the Id (Freud). They are very firmly adhered to largely out of awareness and profoundly affect the individual's sexual and reproductive practices. Failure to understand such beliefs can entirely sabotage a treatment or contraceptive programme. 'Magical beliefs' centre on fundamental concepts such as feelings about self, body and control and on the nature of life itself.

The adolescent during psychological development is much preoccupied with the question "Who am I?" confusion inevitably arises when "Who am I?" becomes "Who are we?".   Establishing a personal identity can be an almost impossible task for a pregnant adolescent who suddenly finds that her identity is changing beyond her control, she is no longer a 'little girl', she is a fertile woman. The role of mother is thrust upon her before she has established her own identity, hence the belief that she cannot get pregnant and the frequent denial of pregnancy.

"I knew about sex and how girls could get pregnant, but I never thought it would happen to me."  Many girls deny they can become pregnant. They believe that they are too young. Belief in the impossibility of pregnancy can become almost a 'magical protection' like a lucky charm used against the evil eye 'well it won't happen to me'. These teenagers are still at the stage of concrete reasoning and cannot identify with the experiences of others. They believe fervently in the invincibility of youth. This explains why health education methods based on 'shock tactics' do not work with this age group.

"My grandad smoked and he got cancer. I've been smoking since I was thirteen but I'm OK".

"You hear about things happening to other people but you never think it will happen to you. When my friend got pregnant, I sort of thought she must have been a bit stupid but then I realised that I hadn't come on (with a period) and I realised that I had been doing the same as her."

Operating at this basic level and being unable to identify with the experiences of others means that young people (or adults who have not 'matured' psychologically) at this stage cannot learn from others mistakes, and perhaps can only learn from their own.

Teenage sexuality is profoundly affected by beliefs about control. A feature of adolescent development is an internalising of the 'locus of control' ie an assumption of responsibility for one's actions and one's body. Many do not reach this stage, remain with an external locus of control and believe that they have no control over their bodies or actions. They are not in control of when they have sex and they are unable to control whether they get pregnant. They are not responsible. Pregnancy is something which 'happens' to them. It is a matter of fate.   Many girls said that they hoped they would not get pregnant but never considered doing anything to prevent it. Such girls are accustomed to having little control over their circumstances. They live in poor housing, have little money, do badly at school and are unable to change their environment.   When an unplanned pregnancy occurs this represents the ultimate loss of control, even their bodies are acting independently of their wishes.

In fact, within this belief system there appears to be an element of belief in the 'autonomous womb'.   It is as if the teenager believes that the body consists of three areas; the non sexual body over which one can exert some control in, for instance running, walking; the sexual erotic areas which are under less control but can be fun to use such as the penis, breasts and vagina; and the third area over which there is no control, the womb.  The belief in the autonomous womb explains why teenagers do not believe that sex will result in pregnancy. It also explains some of the denial.

"Well, I knew someone was pregnant, but I didn't know it was me."

Missed periods, feeling ill and tired, putting on weight and feeling the baby move all add evidence to bring home to a girl the realisation that she is pregnant. Despite this one fifth of schoolgirls do not face up to the situation until a third person, their mothers or sisters tell them that they are pregnant. Girls seem to be spurred into taking action by missing further periods, and lull themselves into a false sense of security in the middle of the month.  It is as if each expected, but missed period reminds them that they could be pregnant and should be doing something about it, whereas as this danger time passes they can deny it again with another 'magical belief'  - “Well, perhaps I was only a little bit pregnant."

Lack of control is at the basis of the teenagers notoriously poor use of contraception. Only 7% of London pregnant schoolgirls have ever used contraception. Young girls deny to themselves that they are having sex and convince themselves that if they do end up in bed with a boy, this is a 'once off' and not a regular happening. This denial is a protective mechanism. They are conditioned into believing that girls who have sex or want sex are 'sluts' so they must convince themselves that they are 'not like that'.    The belief is that unplanned sex is an accident. Nobody can be blamed for the occasional slip, for 'getting carried away', 'swept off her feet' ... the cliches are endless. However premeditated sex is inexcusable.     "I never thought I'd be doing anything like that. I went to a party and I suppose I got a bit carried away, you know how it is."

B. The Self Esteem Study

In order to explore the relationship between ideas of self and sexuality, a research model compared a control group (secondary school age girls) a group of pregnant schoolgirls (aged 13-15) and a group of schoolgirl mothers with children at least 2yrs old. The groups were investigated by - A self esteem measure, A 'deprivation score'  looking at life experiences; A 'sexual' scale estimating degree of sexual experience or sexual trauma.

Girls who were more deprived, had lower self esteem but those who were pregnant were less affected by these adverse factors. Similarly those with adverse sexual experiences were generally more deprived and had lower self esteem measures. Again the pregnant girls were less affected.  It would seem that pregnancy partially protects the individual from threats to self worth but the effect is temporary. By the time the child is two the harsh realities of life take their toll once more. The temporary nature of this boost to self esteem may account for repeat pregnancy, in an attempt to re-establish identity with the counter culture and redefine alternative dimensions of value.  Why does it seem that pregnancy is such a potent source of self value?  " ... Seen from the young girl's viewpoint, pregnancy may not be so undesirable. Certainly it brings heartache and hardship, the extent of which should not be underestimated, but for underpriviledged girls with little education and non existent job prospects, motherhood is a fulfilment. With the birth of her baby a 'failed' school drop out, an unemployable misfit, becomes an acceptable member of society with a valued role - that of a mother. She is successful and out of her loveless world she has created her own baby who will love her."

In pregnancy, a girl identifies with the ideal mother which she never had and can never be. We need to help her to identify instead with the ideal woman who has no need to be pregnant in order to achieve self value. Pregnancy can be used by some deprived girls as a source of self worth and as a false solution to their problems. That being so, an alternative solution must be offered. They must be given a different way of valuing themselves in order to ensure that, when they become pregnant, this is because they desire parenthood with all its responsibilities, hardships and joys and  not merely as the only perceived escape from a catalogue of problems.

C. Repetitive Patterns -

Why do girls ‘repeat’ their pregnancy experiences?    Girls with multiple relationships can progress from one relationship to another and repeat the experience without seeming to ‘learn’ from the previous situation. A  high level of emotional  flexibility and a kind of resilience can protect them from some of the knocks while ‘enabling’ further continuance of this inherently damaging pattern.  The same could be said of repeating the experience of pregnancy and childbirth.  If bringing up a child is hard and girls are just coping with a baby - or two, or  three - why  have another? Why repeat the experience? - particularly if it is not an entirely ‘wanted’ event.  It is interesting  to look at this repetition in terms of failure to ‘work through’ a painful experience.   The girl enters into - ‘falls into’ - the next scenario while she is still reeling from the first.  She has no time in which to ‘lick her wounds’, take in the experience, learn from it and so modify her future reactions.  In general a traumatic event is followed by a reaction which gradually dampens with the passage of time and settles in resolution. That initial impact could be a conception, a pregnancy, childbirth, or a partner leaving. 

Let us consider the stages of ‘recovery’ from such a ‘trauma’.  The initial strong reaction - the ‘outcry’ - is followed by a period of denial when we don’t really want to deal with the situation and we would rather it ‘went away’. As the denial period progresses, the ‘victim’ is confronted by reminders which nudge reality back into the scene ... intrusive thoughts and memories of what has really happened stop us from continuing in the denial process.  Constant reminders and confrontation of denial allow a period of ‘working through’ to be entered into when we can come to terms with what has happened and this results in completion and acceptance of our situation. It is only by working through all these stages and arriving at understanding, accepting and fully realising our situation that we can stop it happening again.

So how is the process applicable to repetition of pregnancy? At each stage we could see how a girl could either ‘work through’ to the next stage or be blocked in the process. The ‘blocks’ can be derived from her social circumstances, by the presence of other types of emotional assaults or other traumas in her life or by the too rapid arrival of another man on the scene or another pregnancy. Basically she may not get time to deal with one stage and move on to the next before another ‘trauma’ raises it’s head. Any of such influences will arrest the recovery process and in fact send her ‘back to square one’. Each time she is sent back to ‘Go’ she will find it that much harder to stay on the path and will experience repeated re-experiences of the same harmful route - she is as if trapped in a mad game of ‘Monopoly’ never able to throw the right dice to get her ‘out of jail’.

D. Pregnancy as a Maturation Experience.

Leading on from our discussion of self worth and the manner in which young women with unfulfilling life experiences,   with abusive childhoods and with  poor future prospects can ‘use’ their pregnancies as a source of self worth .. it is worthwhile considering what else a pregnancy could contribute to the emotional changes and developments going on for that young woman in adolescence.

The pregnant girl can identify with the foetus and concretise her experience of the ‘inner child’ in her developing baby; this allows her another chance to be ‘loved this time’ by  the ‘ideal’ mother.  It also results in a confusion between container and contained and thus confusion of the boundaries between  the mother’s  ‘self’  and the baby’s ‘self’  - preparing the ground for an overly symbiotic attachment and problems in separation and individuation. Many of the theories and factors put forward above could be said to be negative and perhaps interfering with ‘normal’ maturation and development but are there aspects of childbearing for the young women that could be described as positive and beneficial?

If in pregnancy a young woman is identifying with - and almost becoming - the ‘inner baby’  - will the development of this inner baby allow for the re-experiencing of the same stages of development by the young mother? Just as she can be loved and wanted again as a ‘new baby’  - looking at the experience from a rather psychoanalytical point of view - can  she have another chance at ‘getting it right’ for other emotional  or ‘psychic’ aspects of  her  development?   “ ... It  is striking that despite advances in contraception and the easy availability of  termination of pregnancy,  a considerable number of teenage girls still become pregnant and some become mothers. For many  the normal developmental crises of puberty and adolescence,  followed by that of first pregnancy and motherhood, facilitated further psychic growth ....”

Certainly there are situations where pregnancy does seem to afford an opportunity for ‘psychic growth’ , for maturation and personal development. There are also unfortunately times where the ‘traumatic nature’ of the pregnancy and birth experience afford the opposite  - where the experience can seem to  “... revive primitive anxieties and conflicts  ... which cause them to regress” (Pines 1988) and where the  “... birth of a real baby may prove disastrous”.  That is ‘real’  baby as opposed to ‘fantasy’ baby or ‘ideal’ baby.

So what makes the difference?  What turns the potentially positive experience of pregnancy and childbirth into a negative and vice versa? The key to the question lies in the girl’s ‘object relations’ - in other words how she sees her self and the world around her - how she experienced her world and thus herself as a child.

To very much  oversimplify for the sake of this current discussion - Just as the young mother experiences some of her world as ‘good’ and some as ‘bad’ - she has in childhood internalised a view of  her mother as the ‘good mother’ or the ‘bad mother’ and thus also a ‘good internal object’ and ‘bad internal object’.  If we develop the premise that the foetus is the ‘child within’ with which the mother identifies  -  then that inner child can be also be seen as  ‘bad’ or ‘good’ depending on the expectant woman’s previous life experience. The baby is an embodiment of the girl’s ‘object relations’ and the conception can thus be the stage upon which the early drama which defined the nature of the ‘internal objects’ can be replayed .. and hopefully altered for the better.

If, as is hopefully most usual, the child represents the idealised mother - the child is the ‘good object’ ... but if the child represents the hated mother - the child becomes the ‘bad object’.  In other words if the ‘action replay’ that we are allowed in identification with  this developing ‘new baby’ evokes feelings of the existence of a perfect ‘idealised mother’  - then this experience will be positive and lead to growth and positive maturation and change.

If however the ‘action replay’ evokes the revival of memories of the neglectful and rejecting mother of say an abused girl - then the baby will be perceived as an unloving rejecting being who becomes unwanted, unlovable and rejected  - the experience leads to regression and is more likely to lead to a need for further repetition ... another try .. another hope that it might be different .. might be better.

The way the pregnancy / birth experience is perceived will very much depend on how the mother herself is cared for during the pregnancy.   If the young mother is being ‘held’ and cared for and nurtured during the pregnancy , the outcome is likely to be positive  - if not  - if the mother is not ‘held’ and cared for herself  - perhaps boyfriend has left and she has no support - the outcome is likely to be negative.  A vulnerable or fragile personality could break down completely under the ‘assault’ of a pregnancy experience.

Hence the experience might be summarised thus :-

+ ve - Brings identification with unspoilt self / child  ... care for neglected child -> Love and caring for baby.

- ve - Brings identification with the ‘unlovable’ child  -> projection of negative hostile feelings. - > Rage and jealousy of baby.

Throughout this discussion  - we must maintain the concept in our minds that the vision of ‘self’ as experienced by the mother is completely wound up and inextricably linked with the vision of ‘the object’. In other words the ‘object’ which is the mother and at the same time is the child is also the ‘self’.

“The special task that has to be solved by pregnancy and becoming a mother lies within the sphere of distribution and shifts between the cathexis of self representation and object representation”.

Those mothers who are not ‘held’ during their pregnancies and who thus re-experience their childhood rejection through rejection of their pregnancies - may to some extent find that a therapy experience can put right some of those wrongs - In therapy for these girls - they need to find their ‘ideal mothers’ in the professional setting - in the transference - otherwise they will attempt to ‘do it again’ in a slightly different situation, with a different partner , with a different baby - in the hope that this will ‘make them good’.  Hence the ‘repeaters’.     Perfect mothers are hard to find!

Special Seminar     Communicating with Adolescents

Improving Health Professionals Communication Skills With Adolescents  Daniel Hardoff

A role play project with teenage actors

Prepared by - Daniel Hardoff MD, and Shifra Schonmann PhD. Division of adolescent medicine, Bnai Zion Medical Centre, the faculty of medicine, Technion, and the laboratory for research in theatre/drama education, the faculty of education, Haifa University.

Trustful doctor-patient relationships are essential for efficient health care. Physicians frequently feel uneasy when confronting adolescents who seek advice in their clinics. This may result from the difficulties of adolescents to clearly express their health concerns, as well as from their reluctance to share their feelings with adults. The establishment of communication skills with patients is required at all levels of training in medicine, and various methods have been developed to improve these skills, including the use of actors as role models. Only few reports describe this method with regard to adolescent patients, but none of them used actors who are adolescents themselves.

In this workshop we describe a two years project that has been developed in collaboration with WIZO secondary school for arts at Haifa, in which eight 17 years old pupils of the theatre department were trained by a theatre specialist and an adolescent medicine physician to role play 20 different medical situations in front of groups of paediatricians and family practitioners. Various issues regarding chronic illness, sexuality and eating disorders were included in these role play situations. Emphasis was given to the fact that frequently adolescents do not bring up their main concern in the presenting complaint. The physicians were asked to adhere to a physical as well as psychosocial system review in order to reach sensitive issues within the unique world of adolescents. Participants will have an opportunity to experience this training method with several of the adolescent actors, and to discuss its value in obtaining communication skills with adolescent patients.

The title of this session is on improving health professionals communication skills with adolescents. And we are going to do that or to demonstrate it using role-play techniques with teenage actors. We have here three already at the end of their teenage years actors with whom I work for two years and I will present them when we start doing the role-play. I have just a brief introduction that I would like to read to you, so it will be short enough and then we’ll proceed with the workshop itself.

While medicine has improved in various technological dimensions doctor /patient relationships remain at the core of medicine. Obtaining an appropriate history is still the basis for evaluation of any patient. The more skilled health professional will arrive sooner at the correct diagnosis with minimum further additional tests, Creating a trustful and confidential atmosphere between the doctor and the patient will enhance compliance for therapy and reduce unnecessary tensions. These statements are true for patient of all ages and for doctors of every speciality in medicine. Adolescents are placed at the unique developmental stage where officially they are considered as minors but gradually become capable to make their own decisions and take responsibility. In their striving for independence adolescents frequently refrain from listening and following adults’ advice. Health professional who work with adolescents usually feel as adolescent’s advocates however they are frequently faced with rejection and even hostility. Therefore their ability to be trusted and authoritative and at the same time to succeed in obtaining maximum information from a teenage patient requires special communication skills.

While experience is a major factor in this respect technical guidelines and history taking are helpful. One method is a system review both medical and psyco-social which enable the doctor to address issues which have not been presented in the chief complaint and in the past medical history. Teenagers came to present their complaints, frequently hiding the main problems and the review of system may reveal that. There are several methods that have been developed to train professionals in history-taking and in communicating with patients and role-play is a common technique to exercise doctor /patient relationship. The use of actors for role-play has been proved to be effective.

Our project in unique since the actors who train us doctors for communication skills are themselves teenagers. Thus a more authentic clinical experience is created enabling the trainees, the doctor, to receive feedback from the adolescent actors about their feeling during the interaction. In this presentation we will focus on the methodology and not on the training itself aiming to create in this audience a brief image of what is happening during the training session. We hope this presentation will serve as a stimulus to use this educational tool in your settings.

I will not elaborate on the technique itself at the beginning, what we would like to do is to present you how it is done, but will do it briefly. Every case that we develop takes about an hour discussion. They are set up in a group of physicians, nurses, other practitioners, social workers it does not matter, they sit in the hall and a case is presented by the adolescent actor, where a volunteer is sitting in front of the audience is taking the history and after some time we stop the scene to get some response from the physician, we are doing the exercise, the actor himself or herself and audience and then we continue. We will not do full exercise of each case, just demonstrate the method.

There are three actors here and I would like to ask the physicians in this audience to volunteer here not to test their ability in history taking, but to demonstrate how it works, we will not elaborate on each case we’ll just go from one case to another because we are now very short in time and as I said usually when we do this session it is one and a half hours and we present two cases only. So, we will start now and we will stop many times and I will ask Michelle Shapiro who is an actress this time she will be a 14-year old girl who comes to the doctor. Would you like to be a doctor, school doctor, it’s OK. She comes to school maybe.

Doctor: How are you doing, Michelle?

School-girl: OK. I just feel sick, I’ve been feeling sick a lot lately, I didn’t really want to come here, my mum made me.

Doctor: Can you tell me a bit more about how you feel sick?

Girl: I feel nauseous, I feel like throwing up sometimes, and tired and stuff.

D: And did you have this other times before or do you think it is a bit unusual for you to feel like that?

G: Oh, I don’t remember, but I don’t think I ever felt this way.

D: And what are your ideas about it, feeling like this?

G: I don’t know, that’s why I came to you.

D: Right, good. But you didn’t want to come to me.

G: Well, I guess I did, I mean it’s not fun to feel this way all the time, so ...

D: That’s right. And how long have you been going on for now?

G: Oh, two or three weeks now.

D: And I’ve got a few ideas about it and shall I tell you what the possible things are that can make you feel like that?

G: I don’t care, do I really want?

D: The first thing that comes to mind that it could be symptoms of early pregnancy, does that shock you completely?

G: Well, I did not plan on getting pregnant right now or anything, I mean it’s not like what I want to do with my life right now.

D: Are you going to school?

G: Yeah.

D: How it’s been at school?

G: OK.

D: have you got a boyfriend or something?

G: My boyfriend does not go to school, he is much older.

D: Oh, right. How old is he?

G: Twenty.

D: Twenty, yeah, and have you been together for a while?

G: What does that have to do with it?

D: Well, we can leave that if you want. Have you had any close relationship with him?

G: Well, we are going out, what do you mean close, I mean...

D: Have you made love together?

G: You mean sex?

D: Sex.

G: Of course.

D: Yes, and about contraception?

G: Well, we are careful.

D; What does that mean, how are you careful?

G: Well, we are just careful, I mean, we make sure that you know that nothing happens and stuff...

D: Aha, how can you do that?

G: We just don’t, I mean...

D: Do you choose a certain time when you have sex or you don’t have sex?

G: Ah, no. I just do whenever I feel like it.

D: Right, does your boyfriend withdraw maybe before you come?

G: Oh, well you put it that way, yeah, I guess.

D: Right. So that’s the only way you are careful at the moment. You think you could become pregnant by being careful like this or is it not possible?

G: No.

D: You don’t think you could get pregnant. Well,

Hardoff.    We’ll cut here, OK, applause to the doctor. Of course thing might do on and what we are doing in a session with a group of physicians, this case, I mean you came right to the point.

D: What would you say, was it actually good or

Hardoff: We do not say whether it was good or not good. But this is the time to stop and get the audience response of they thought about what you were doing, but before usually what we do and we are not doing now is that we cut the thing we ask first the doctor who’s doing it to tell the audience how he or she felt but this is an awkward situation, this is not a clinical situation, it is in front of an audience and you had first to express how you felt, then we ask the adolescents how she felt and then we ask the audience to comment whether they thought it was an appropriate or inappropriate way to get some suggestions. Then we’ll ask someone else to continue, but you were very good, you came straight to the point, we have exercised this many times with general practitioners in the community where they see many other people and from time to time they see a teenager and when a teenage girl comes to them saying that she is feeling sick, they think of all kinds of things like viral diseases, gastro-intestinal problems and you name it and they forget that they have to do a system review and to go over the system, sometimes they get sucked into  how they vomit and how what the colour of the vomit was. OK, is it green, do you ever have eat, you know they go and do what doctors should do, right and then they forget sometimes that they have to go over the system to ask about gastro-intestinal, urinal and so on and also ask about the period. If they ask about the period then we will reach the diagnosis maybe a little later than you did because you just went straight to the point quickly in fact immediately. Of course, you might get something else.

Doctor:  I just came from a workshop about teenage pregnancy, so...

Hardoff: But we have experience a difference response from different doctors in different groups because not all of them oriented to think this way and what we wanted to demonstrate right now is not to see how quickly you got to the diagnosis but to show you how it works in this situation. We will move on because we could dwell on it quite a while, because then we could discuss contraception, termination of pregnancy, whether she wants to carry the baby and I mean there is a lot more to discuss and this is at least an hour of exercise with a group of doctors, but for the purpose of this demonstration I will leave it here and we’ll go to the next case and we’ll se how it goes, OK?

There is no reason to be under stress because I am not examining the people, I just want to show, to demonstrate the method, OK? This young gentlemen, his name is Gull and I‘ll give you just a brief past medical history so that things will go straight to the point. Gull is an asthmatic and from early childhood. And he used to be OK for many years by taking some preventive therapy with inhalation and from time to time he had asthmatic use venti-inhalation and he was quite all right for many years and just recently he suffers more from asthma, he’s been twice in hospital, he had urgent therapy and he’s now coming back to you as his practitioner, his doctor because he is now back from the hospital and want to consult with you or maybe he does not want really but he was brought to you. OK  so this is the situation. Now we’ll let it go.

Doctor: Hi, Gull, how are you, I haven’t seen you for some time, what happened, I heard that you have been to a hospital, what happened there?

Boy: I just had more asthma that’s all, I just had one attack, nothing serious.

D: You were in the ward for  couple of days? Were you in the ward?

B: Ah, yeah, never mind, it wasn’t like two days, more like one day.

D: How did it go, was it a very bad experience or did you have a good time?

B: No just, you know, I pass along, it’s not something serious, I think.

D: But you think maybe you so ill just like that and then went to hospital because you are very good when I saw you in the past.

B: I don’t know, it’s kind of this period, I don’t know. Nothing serious, I don’t know what causes it, I don’t think there is any special reason.

D: OK. Because you’ve been taking your medication regularly in the past, has anything happened that you’ve been not using them regularly?

B: Yes, last couple of months I’ve reducing things because I want to try and get along without. I think it will do me good, I think it’s a bit hard at the moment but I think I can take it.

D: OK, are you now at the college, what are you doing now, can you tell me what is happening to your life in general?

B: I am just in school, that’s all.

D: How is it, are doing well or having some...

B: yeah, sure.

D: That’s good. You have a lot of friends?

B: Well...

D: Do you go out and have fun? You seem it’s important to have a good time and when you meet your friends, do they know that you are taking medication for asthma?

B: Some of them know, I don’t go showing that, that’s stupid, you know...

D: yes, that’s right, so have you had opportunity to meet anyone else who has asthma like you?

B: I’ve met a few downtown, in the community, yeah, I know some people.

D: And it’s not nice to be taking medication when you are going out, so it can be difficult.

B: well, I think I am going to be good without it,  soon I’ll leave it, I think it’ll be fine.

D: How are your mum and dad feel about it, your life and taking medication, do they nag you?

B: Yes, of course.

D: That’s the pain, isn’t it.

B: yeah, they wanted me to come here.

D: I can understand you grow up and you want to distance yourself, you want to be independent, because a lot of youngsters feel like you when you talk to people, maybe a lot feel like that, you are absolutely right. Having been to hospital and come out do you feel you need to do something else about the medication?

B: I don’t think so, it wasn’t so bad, I can get over it and I am sure it’s soon will not bother me again.

The workshop continued with further discussion …