169 Participant 3:
No we actually didn’t.
170 Absolutely. So far I’ve pretty much followed Morrison’s, to the tee even to the extent I clock watch - I’ve done my introductions, I’ve spoken about confidentiality, I’ve oriented the person to what we’re doing here today. Our roles, and then I feel we’ve done fifteen minutes so let’s move on to the next thing. So I’ll say we’ve covered this and then so let’s go to the history taking. I keep the structure in mind but able then to not have to follow it like verbatim but the structure is there with the headings in the back of my mind that I’m following.
Interviewer:
So it sounds that it’s very much a comfort and a tool to assist you with how to go forward?
Participant 4:
Absolutely.
Interviewer:
So just for interest do you think that this will always be a way that you would structure first interviews or is this difficult to ask?
Participant 4:
It’s a question I’ve been asking myself quite a bit this last week after attending a marriage workshop, in my mind it’s a very …… dynamic approach, it’s very solid, it’s a very investigative approach as well, you know what you’re going in for. You most likely had a screening down so you have in mind a topic or heading there, other than in this respect I probably would follow the structure. But I hope in the future I won’t, maybe follow the main headings where you basically introduce yourself, cover confidentialities and give the person time to talk but I wouldn’t necessarily label each section.
Interviewer :
In terms of orienting the client around sensitive topics, how do you approach that?
Participant 4:
I didn’t have a specific plan for sensitive topics but I think that for me you can’t really prepare for this.
Probably better if you don’t prepare for it because you’re going to handle it in a more real kind of way.
I guess my plan just to take it and work with each person, so just thinking of a couple of clients when I’ve had very easy going or clients that I’ve had a very good rapport it almost just comes, it doesn’t feel awkward or uncomfortable. I can think of a client that it was very difficult and every session was rigid so when it got to that point, because it was one of my first ones, it took me quite a while to do the first intake and also due to the client with her spouse.
Interviewer:
So with sensitive topics like with that client, you had the Morrison form in front of you and it’s in the back of your mind. How did you feel knowing that this is a part of history taking that you had to get through specifically with sexual history in mind?
Participant 4:
I think I felt anxious just even thinking about the fact that I’m going to have to do it and I knew with this particular client it was going to be difficult. But then again, I don’t know if everyone else does this but I think definitely at that point I hide behind procedures and policies and use that to ease into it. It’s really interesting to note that I do that when I’ve pre-empted some kind of difficulty or some kind of resistance or some kind of guardedness about the topic. If not, if I don’t perceive that about my client, it would almost flow in and I would never feel the need to hide behind it. I think that in the back of my mind that if this turns into a difficult situation I’m going to say: this is a necessary question, rather than just having a conversation about it. But just saying that I think of a specific situation where I was interviewing a client and then mentioned something that I was able to use to lead into that. I was so happy inside so I thought this is a fantastic opportunity so let’s go in now so I didn’t have to have that
171 awkward moment of saying: ok now let’s talk about this. They almost brought up the topic so I was able to go with the flow.
Interviewer:
So do you think you were adequately prepared for conducting the initial interview with acquiring the general overview of a person’s psychological history? Do you think your training adequately prepared you for going through all the areas that you had to ask about?
Participant 4:
I’d say yes it has. It’s really that structure because initially you had that long list of absolutely everything that you need to find out about this person in fifteen minutes and it would almost be impossible to do.
If you would go through that check list verbatim as if you’re almost in hospital you probably won’t get through it in an hour or fifty minutes but when you have a conversation about it, it makes it possible.
Interviewer:
So you did find it helpful and the structure gave you comfort as to where you’re heading?
Participant 4:
Yes, it’s also a base. You know that it’s always there so you can deviate when you need to but you always have the security of coming back to it which is nice.
Interviewer:
So there is a familiarity then with the process once you get with your client, understanding the process.
So personal challenges around sexual health, your personal challenges, did they help or hinder the process? Or any ideas or feelings towards sexual health and understand why you need to question around that, what things could you draw on that were helpful or what were the things you found difficult to get to talking about sexual history, sexual functioning?
Participant 4:
I suppose whether it was a challenge or not is difficult to say. But what I can say in that regard is that sexual health, sexual orientation and sexuality is something I have purposefully tried to become as informed about it as I can possibly be and a lot of it I probably gained working with Childline so getting that experience, exposure and also socially I suppose exposing myself to people and friends with different sexual orientation, participating in the different drives that they’ve got and attending workshops and seminars, so you are exposed to it.
Interviewer:
So in other words things don’t really shock you that much so you’re better prepared?
Participant 4:
Absolutely, so with regard to asking questions about sexual health, sexual orientation all of that it doesn’t feel as awkward. In the back of my mind I almost have every possibility that I know about so if somebody does say something I’m not going to react with shock. So it’s a preparation but like in an inadvertent way.
Interviewer:
It’s not a life skill, it sounds like you’ve been trying to develop a life skill and understand more about sexual health?
Participant 4:
Yes…. and then that almost prepares you for it, I think the challenge with talking about it is not the actual concept or the act of talking. I think it’s the navigating through the murky waters, for some people it may be, because you don’t want to shut that person down. You may be happy and comfortable to talk about any topic but you’re not sure where they are then you have to almost feel and see where they are and try and go in and talk on a level they are comfortable with.
Interviewer:
172 So it sounds like you’re saying that it needs to be broached in a way that it’s normal? So on that Morrison form there’re a whole lot of things you’re asking around and sexual health and sexual functioning and sexual history is part of that so you can approach it in a normal way like you would approach everything else? Is that what I’ve understood what you are saying?
Participant 4:
Absolutely, yes and over this time I think that your research is really interesting and where it’s going to play a really important role. I’m not saying to normalise it but to just make sexuality and sexual health, it’s something everyone has to deal with, something everyone does. It’s still somewhat taboo almost to think about it or even still to talk about it.
Interviewer:
Yes and it does still seem quite a difficult thing for people to get around. So when you introduce your client to sexual health, you say you like to try and ease your way into it. So it doesn’t sound like in the back of your mind you think I’ve got to tick all the boxes, you know that you have to question around that and you wait for an opening to get there? What happens if it doesn’t happen? If it’s quite a guarded person and the opportunity doesn’t arise?
Participant 4:
I’ve had one specific experience, it became a thing in that session. I know I have to get there, I suppose I probably took the route that most people did and did the whole medical history and figured it in from that approach. So it wasn’t more from the interpersonal relationship side of it, it was from more a medical side of it, probably not a good idea to always do that, there should be a good combination of both.
Interviewer:
What was it about that client that made it difficult?
Participant 4:
Culture, religion, I knew it straight away, It was probably bad of me in the beginning, to assume it, I made that assumption, it was an assumption, it was a woman in a patriarchal society. I just could feel it was going to be a wall, so maybe I pre-empted and made that anxiety for myself. I could have possibly created the tension, I was awkward about it but maybe it wouldn’t have been. So a lesson learnt not to go in with assumptions.
Interviewer:
What was the assumption?
Participant 4:
The assumption was that this was going to be difficult because this woman is not going to want to talk about her sex life really with her husband. From the beginning I knew he was very controlling and she didn’t have much say in her day to day life even in terms of her beauty regime, if that’s the right word, and it seemed very controlling. So yes the assumption was that she really doesn’t speak about this at all. I think the assumption was that even if she was going to a GP or a gynaecologist it would be very hush, I’m just trying to remember… in the first interview we spoke about the three kids and she didn’t speak about being pregnant and her birth and all of that in a relaxed open way. And as a side note, whether it was important or not… I was pregnant at the time so I obviously knew and from a personal experience how you have to talk about those things, think about those things, your body is going through all those things. She almost wormed around them, she was pregnant and had three kids, it just happened, the stork dropped them off and that was it, so the approach to having three kids was that the stork dropped them off.
Interviewer:
173 So the assumption is that she probably would not want to talk about that too much, and what was the assumption around religion?
Participant 4:
The assumption with regard to the religion… that it doesn’t encourage or allow for that open conversation.
Interviewer:
So being a woman and as you said being in a patriarchal society, added to religion, there’s this assumption and quite a normal assumption.
Participant 4:
The assumption was that the religion and cultural practice doesn’t allow for that open communication and is something that is kept quiet and behind closed doors, it just happens when people are not around them, I must deal with my assumptions!
Interviewer:
That’s very interesting, we all take assumptions into the room, that’s why I’m so interested why sometimes it’s so easy to talk about it and other times it’s not and some people can just question around it and some people can’t?
Participant 4:
For sure!!! I think having down that narrative workshop it’s so interesting, you’re always bringing yourself into it.
Interviewer:
Yes. So for you, do you feel that you understand, it sounds like this life skill you’ve been working on is a good understanding of why questioning around sexual health is important and relevant. Would that be true? You feel there is relevance around this topic?
Participant 4:
Absolutely, and I think as therapists we should constantly try and improve and develop on those life skills and I think even just now I’m realising that as much as I thought I was doing that. You can still do more of it, you can still prepare yourself more, you can still expose yourself more and learn how to deal with even the difficult or assumed to be difficult situations.
Interviewer:
Well I think sometimes it’s interesting because it’s like we keep sexual health or sexuality as separate to the rest of a person’s functioning. So do we understand that sexual health is part of the complete person?
Participant 4:
I think it should be considered as part of the complete person, because can’t say whether this person is depressed but you not going to talk about their sex life or whether this person has got some other situation happening, or if it’s a trauma? It’s part of life and you need to take that into consideration which includes sexuality and sexual history.
Interviewer:
So if you look back over some of your initial interviews and gathering history can you think of what initiated discomfort, specifically around talking about sexuality, what was perceived? Was it facial expressions? Was it body language? What were those moments that were uncomfortable, for you or the client?
Participant 4:
For me now it was that assumption that I had, cultural and religious that was the one and then with another client it was a completely different scenario where I was working with an adolescent where the adolescent was really used to keeping back information about herself and guarded. And so it was more
174 about, not that we were talking about the subject, it was now getting uncomfortable to trust me, it was that trust issue as well which is important, so in order to talk about it you need to trust that person.
Interviewer:
Yes, so then do you think that there is enough rapport built in the first interview to do that or do think talking about sensitive topics is perhaps for later?
Participant 4:
No…..I said no quickly, very quickly [in responding] but I also think it depends on the person and the reason why they’re coming and I think this will determine whether the first interview is the right place to do it or not. I think as a therapist you make a judgement call that this is not the right time then the second interview will be the better option it’s also something you don’t necessarily want to rush into because you want that person to give you honest information you don’t want just a generic response.
Interviewer:
So were there moments with your clients that you perceived discomfort or maybe slight reservations in needing to respond to questions around sexual health.
Participant 4:
Working with a client, the adolescent, there definitely was a resistance and guardedness for a couple of the sessions whenever I did bring the topic up I almost knew that the information wasn’t real. And that’s interesting because in this respect I was constantly bringing the topic up so it was something that was always on my mind because it was pertinent to the case, and I knew that the information wasn’t true. So that was also different because the other woman I was resistant.
Interviewer:
So then it’s interesting because in an initial interview we have to cover all these topics and that’s one of them but it seems to be very linked to rapport and working alliance, so is it always appropriate to do an initial interview?
Participant 4:
I think we get away with it because we just make it clinical and as an individual person you are most like exposed to a doctor and a GP in a very hospital kind of setting, you just ask a whole bunch of questions and you get a whole bunch of answers and the assumption is that the person will give you the truth and the person will give you the right information or the real information, so I think in that way we get away with it. But if you look at it from a therapeutic side and the fact that they’re coming for therapy, you’re a therapist, you’re not a GP or those nurses in an ER doing triage, it’s not a triage at all, doing temperatures, blood pressures, I think from a therapeutic perspective rapport is necessary.
Interviewer:
That’s interesting because that almost says that in the initial interview you can fall back on that very clinical interview of gathering history and then flag it if maybe it needs to be flagged, was my client resistant about it so perhaps when you move into a more therapeutic level it’s something I need to explore when there’s more rapport?
Participant 4:
Well what are you really asking [the client]: are you sexual active? Yes or no. I think that those ones you can kind of get your answer and then you can get your history as part of your first intake, but if you’re asking deeper more real experiential questions you need rapport.
Interviewer:
That’s very very interesting, that’s a nice breakdown.
What would you have ascribed to having precipitated some of these little moments of discomfort, so assumptions being one of them, you had an assumption before, is there anything else you can add to that?
175 Participant 4:
That led to discomfort either mine or theirs?
Interviewer:
Yes, and adolescent?
Participant 4:
Life stages would follow on the adolescents part because they just naturally keep that side because they not at that stage, they wouldn’t talk about it anyway unless they’re with their peers so I guess it’s building up that rapport to get to that piers level, assumptions is definitely the one.
Interviewer:
Yes we always have assumptions, it’s always our assumption as to how the person’s going to react when we bring up the topic. Do we make it uncomfortable for our clients, or are they uncomfortable? Is it that we bring it into the room? Or are they already uncomfortable?
Participant 4:
There again I take it back to last year with experience, not once did I feel uncomfortable in a hospital setting and I clearly remember working with a really difficult client at Addington and I went through the entire history in about 40 minutes and it was just cold and clinical and to the point: asking are you sexually active, how many sexual partners, did you use protection? I just ticked the box, move onto the next, whereas if I think about in a clinic in a therapeutic setting that when the hesitance comes in.
Interviewer:
That’s really interesting, I like the way you have separated the clinical from the therapeutic. So in relation to culture and gender, language difference and working alliance which of these things do you feel really impact talking around the topic of sexual health?
Participant 4:
For me personally I probably want to say straight away culture and society because I probably personally take the blame of privilege.
Interviewer:
Blaming it to who?
Participant 4:
To culture and society in general and people. I am really generalising at the moment, but people still feel it’s taboo even though they say it’s not I think there’re only a handful of people without even thinking about it will be able to have a conversation about sexuality and sexual health or your own personal sexual experience.
Interviewer:
So you’re saying that culture and society make this topic a taboo topic.
Participant 4:
I think in many situations it still dictates how and when a person talks about it.
Interviewer:
Which is interesting because society at large are throwing sex in our face every day, which is so bizarre, it’s in our face all the time but no one talks about it. So how does culture affect you, when you have sitting across from you, like me and you, if I’m from a different culture how does affect whether you talk about sexual health or not?
Participant 4:
I think it’s probably the same as how you fall back on the clinical perspective, the clinical approach, you can feel comfortable because it’s clinical and medical, I think in the same way you would make an assumption based on a person’s culture or appearance or their background, what you do know about them, whether they will be comfortable or not, some cultures are comfortable some are not.