The research is about: in our M1 year we get taught the whole Morrison Intake. We have to gather this whole psychological history and in that history we have to ask questions around sexual history and sexual functioning. So it’s [about] how was that experience for us and do we feel that we were adequately prepared. Was it uncomfortable and did it change the working alliance? This is a semi structured interview so I’ve got some questions to guide me. Anything you want to add or was interesting or your experience please let me know - this is what I’m trying to understand, what makes it easy for us what makes it difficult for us.
So the first thing is that if we look at the knowledge and the interview process and content - what was your experience when conducting your first interview with a new client? So just in general what was your experience with a new client?
Participant 5:
My first word would be a bit of anxiety. I was anxious because you get this Morrison structure and you feel that you have to stick that structure and you have to collect as much information as possible. So it created that barrier between me and the client because I felt that I had to get as much information as possible. You keep checking that: do I have this, should I ask that? So it really puts you on edge for a first interview.
Interviewer:
Did you go through a process of orienting your client to the therapy process if you did, did it help and if you didn’t what did you do?
Participant 5:
Well one of the things I did correctly was orientation. I did orientate my client saying this is what we are going to do today. In a way I felt it put me at ease as well as the client so he knew exactly what we were going to do because sometimes the assumption is they are going to come to the session and we will sort out the problem then and there. But if you orientate them saying this is what we are going to do:
gathering information, you then give them the knowledge of what to expect.
Interviewer:
Were you able to orientate around sensitive topics, did you say that we might talk about things that might be difficult or not, or was it a general orientation?
Participant 5:
To be honest it was just a general orientation not specific issues. But there again it might have been because of my anxiety as well. I didn’t want to go down that road.
Interviewer:
Tell me about that - you didn’t want to go down that road, what road was that?
Participant 5:
When you are going to speak about those sensitive issues it’s going to be uncomfortable so I’m not going to talk about this until we get there. I don’t want to anticipate that bridge until we get there, it’s not the entire session[discussing sexual health].
Interviewer:
Why is that difficult? Why is it an uncomfortable subject?
Participant 5:
180 One of the sensitive topics, just to go there first, the sexual part and the presenting topic, when I was doing M1 I feared I was not going to be able to contain this person, am I going to be able to help them?
Am I going to be able to contain them? And the sexual part is a whole different avenue. The cultural perspective, the gender perspective, all of my clients were female, so being male and asking a female about her sexual functioning would be uncomfortable. And cultural wise they were all black clients as well so it’s something that is frowned upon nobody wants to talk about it so that terrain is: don’t talk don’t tell.
Interviewer:
So in the initial interview when you know you have to go through all this stuff is this in the back of your mind that you are now going to have to ask these questions?
Participant 5:
Yes I think it is in the back of your mind, it just makes you feel a bit anxious. I would try if that question was asked.
Interviewer:
So if you could avoid it you would?
Participant 5:
Definitely I would, personally I would feel uncomfortable especially older clients - it just makes it difficult.
Interviewer:
So do you think you were adequately prepared for the process of conducting this initial interview with acquiring a whole overview of a person’s psychological functioning?
Participant 5:
I think we were prepared. When it comes to the sexual history that is the main portion that I felt wasn’t really targeted. I wasn’t really happy with that. For example from my side the gender the culture, the age - so looking at that I feel I wasn’t adequately prepared.
Interviewer:
The general process you felt you were adequately prepared for just not really around gathering sexual history sexual functioning?
Participant 5:
General process I was prepared but that section… no.
Interviewer:
So for you there was a familiarity with the process, you understood what the process was and you understood why you had to ask all these questions?
Participant 5:
Yes, I felt I had to ask these questions. On some aspects I didn’t really know how these questions would relate but never the less I had to ask them.
Interviewer :
So you didn’t know the relevance?
Participant 5:
Some sections had relevance, some sections didn’t have much bearing on what we were discussing.
Interviewer:
So for you personally, your own challenges, your thoughts around sexuality, sexual health, sexual functioning - do think that hindered or assisted in the process? Your own personal feelings about it?
Participant 5:
181 I would say for the clients I saw it didn’t assist in the process at all because there was discomfort on both sides. From my side and the clients’ side as well and again it felt like there was not much relevance. So I wouldn’t say it hindered but it didn’t really assist in the process as a whole.
Interviewer:
If you did and perhaps with subsequent clients, how did you introduce your client to the topic?
Participant 5:
That’s a difficult one because I think I never really introduced them to the topic I just went straight to the question.
Interviewer:
You’re not alone in this by the way, it’s a very common response.
Participant 5:
I didn’t really know how to introduce the topic and why I was introducing the topic. It felt much easier just to ask.
Interviewer:
Ok, then what did you ask?
Participant 5:
Your first sexual experience - which I felt was intrusive. How many partners, your sexual functions - the clients felt uncomfortable. I felt bad at that moment. It’s really hard for me, I skip the question.
Interviewer:
That’s interesting. Your responses are pretty much was everyone is saying [all the participants].
So do we adequately understand the importance of information around sexuality?
Participant 5:
I think not entirely. If you’re asking about sexual functioning … In my intake I don’t go back to that - asking about sexual experiences. I don’t know what I’m going to do with that, what information do I need and what am I going to do with that? Why am I asking you that? What bearing does it have on the intake?
Interviewer:
Would it be useful to your client if you say: the reason why I’m asking you this is that it gives me an indication about how you … Does that make it easier?
Participant 5:
It certainly makes it easier for me, the first step is to know why I’m asking this.
Interviewer:
Like why do we ask around suicide? We need to have an understanding as why is it on the list, why are we asking this?
So can you describe then the moments that initiated any discomforts in you or in your client when you had to start asking anything around sexuality?
Participant 5:
For me it was a problem I finally had to ask: do you feel like having sex? I immediately felt what did you ask that for? I’m a male you’re a female so do you feel like having sex? For me this was not the right way to ask. For me I have not found the correct why to ask about that especially about the sexual functioning, the number of sexual partners…
Interviewer:
What is your concern about your client? What are your concerned about? What they are going to think or feel?
Participant 5:
182 If you think of it from a cultural perspective and the clients we see, there are cultural intricacies. If you’re seeing a black guy there a lot of things on sexual stuff so how are they going to interpret all this stuff? How comfortable are they? Most people are not really open for that and being a male asking a female it just makes it uncomfortable.
Interviewer:
So it would be easier to talk to a male?
Participant 5:
The males I have spoken to it has been easier, there are factors involved. For instance age - age is a critical factor.
Interviewer:
Your discomfort, how did you perceive that? Did you feel anxious, did you rush through it? Did you ignore it, avoid it?
Participant 5:
I think that I just breeze through it I never dwell on a question and move on to the next question.
Interviewer:
And in your client, when you’ve brought this topic up what do you perceive in your client that there is discomfort there, is it facial expression, what do you pick up from you clients?
Participant 5:
I think facial expression and response time. They don’t respond as with other questions - they pause, and it’s like, why are you asking me that question?
Interviewer:
So when you see that you think: ok back off a bit?
So in relation to the effects of culture, you’ve mentioned this before, culture, gender and language differences and working alliance and disclosure how are they present in the room?
Participant 5:
They are very prominent especially when you speak about language, when you’re working with a client that can speak English very well it becomes a less anxious process to speak about sexual functioning. If you speaking to a client that speaks Zulu it becomes a really different process.
Interviewer:
Tell me about that.
Participant 5:
The words…you can’t find the right words to ask about sexual performance.
Interviewer:
Why is that?
Participant 5:
Because the words we have in a way are very direct there’s no sugar coating. So using English is much better, using Zulu words will be quite difficult.
Interviewer:
Gender? You said you feel that gender it is also more difficult speaking to a female client?
Participant 5:
Yes I find it more difficult. I have my own anxiety and they have their own anxiety. In all cultures even speaking to a male about sexual things is anxiety invoking.
Interviewer:
183 Again what is your concern when talking to a female client about sex, what is the discomfort there? I’m interested in what’s deeper there? Why is it easier to speak to a person of the same gender, what is it that makes it difficult?
Participant 5:
Well I think when you look at it, it shouldn’t be difficult but for me I can relate to a male there is less discomfort. I think it’s just cross gender followed by society but it shouldn’t. There are things that you shouldn’t discuss with females and things you can discuss with males.
Interviewer:
And do you think that is quite tied to culture as well?
Participant 5:
I think so in most conservative cultures the whole sexual matter is not spoken about. It’s something you don’t speak about at home, you just don’t talk about it so it becomes a huge difficulty to talk about this to a stranger. So in my social circles I am taught not to speak about it and my client also is taught not to speak about it socially. So it’s two different people who socialise in the same way not to speak about that, they are now forced to speak about that, so when it comes to asking the question we are at a bit of a loss.
Interviewer:
So in your own home was sex not discussed.
Participant 5:
OMG no never, absolutely not there is no discussion around that. No one talks about that even with your older brothers and older sister there is just no discussion.
Interviewer:
So how did you find out about sex?
Participant 5:
Through kids and friends at school, primary school, high school, kids talk, even at school nobody would speak about sex. At high school I had a very liberal teacher so she introduced sex but all the other teachers, no. I come from a very small conservative Christian background so sexual things are not discussed.
Interviewer:
So then do you think religion also plays a part in this?
Participant 5:
Absolutely! I think the discomfort there, being a Christian myself, I have my own convictions around sex and sexual intimacy so when you look at discussing issues with a person who’s married and having sexual intercourse, it becomes difficult because you have your own judgement about premarital sex or marital sex, so you have all this discomfort in yourself as well.
Interviewer:
So religion is also in the room?
Participant 5:
Yes, so for me religion is a huge factor, I see myself as a devout Christian. I have confidence within myself, so I wish I would like to deal with it but they come with their own issues.
Interviewer:
So the conflict is specifically around sex? So that’s your own conflict and things that you are working on, and now you have to ask this and don’t really have a good understanding of why I’m asking this? So a lot of anxiety just in that, and then you’ve got culture and gender and age.
Participant 5:
Absolutely!
184 Interviewer:
Tell me about age.
Participant 5:
If I see a 24 or 25 year old male it will be very much easier to discuss this, we are more or less the same age we do the same things we share the same preferences mostly. But if I see a 78 year old this is a problem. When you see this client, asking them about sexual intercourse, again culture and age, they say I don’t have sexual dysfunction, and I don’t do sex [because of age].
Interviewer:
How do you know a 78 year old is not having sex?
Participant 5:
Yes this is very true because we have a huge belief when you get older sex is something you don’t have any more, it shouldn’t happen, older people shouldn’t have sex, even if they’re married, it’s nasty.
Interviewer:
This is very interesting. This is what we bring into the room.
Participant 5:
In our community you see these older couples but you never think they are engaging in sex, only for young married couples not for old people.
Interviewer:
So when you’re older sex is not appropriate? What about when you’re young, not young in your twenties, younger.
Participant 5:
When you’re young you shouldn’t have that, when you’re older you shouldn’t have that. So there are only a few years you can enjoy sex. When you look at the younger generation this is where religion comes in, not so much culture because in this modern age culture does not play a huge role, so you can’t have premarital sex it’s wrong - it’s a sin only young people that are married should have sex.
Interviewer:
If you had an adolescent client, how do you deal with this topic with a 15 or 16 year old ? Participant 5:
There again I have my own convictions of saying you shouldn’t be having sex. You ask the questions but at the back of your mind you have your own judgements: you shouldn’t be having sex, you’re too young, it really becomes an uncomfortable topic. Even with married couples it is uncomfortable - you have your own judgements.
Interviewer:
So if you have an adolescent client are you able to ask them that? What is the level of discomfort for you in comparison to a 78 year old to now say a 16 year old?
Participant 5:
I think it was more comfortable to have this power over a younger client. For the older client it’s like ok you’re not a child so they have more power but if you’re dealing with a young child you have more power over them. I can ask this any way I like so with a child you have more power.
Interviewer:
So do you think then, your client’s ability to disclose, do you think it’s an invasion of privacy? Their presenting reason for coming to therapy, do you think that plays a part if you had to ask your client about sexual history, sexual functioning?
Participant 5:
I think how I feel, in a way it’s an invasion of privacy, personally I wouldn’t feel comfortable in being asked about sexual things. But if it’s directly related to that, if a person is coming in because of sexual
185 dysfunctioning then I become anxious but if it is not really tied to the presenting problem… this is not why I am here. So depending on the presenting problem determines the anxiety levels in asking around those questions.
Interviewer:
So were you aware at all with the working alliance being affected or was it a concern of yours when asking around sexual health, sexual history and sexual functioning?
Participant 5:
I think it was a concern because for me it was a bit of a break when you ask that. It’s breaking the communication which I found it was better in subsequent sessions marking that so just asking that then and forgetting that I asked that and never going back to that again. It becomes a forgotten rupture, so to say.
Interviewer:
Ok, it’s difficult because we have to ask this question in an intake where we have only just met this person. So do you think it’s easier, should there be a working alliance and good rapport to be able to ask these kind of questions or do you think it’s easier to do it in the beginning?
Participant 5:
Certainly, there has to be a good rapport because it affects their ability to answer. Their number of partners they have had in the past- it’s quite embarrassing. It could be 10 partners so it labels you as this loose person and if I had to disclose this to you I stand the chance of being judged. So I think a good working relationship, trust, comfort is essential.
Interviewer:
That’s interesting- judgement. Is judgement tied to the question around sex?
Participant 5:
I think the response from the client as well there is that thing about judgement. Everyone feels judgement whether I’m 10 years old or 60 years old. So it would be easier to say I only had sex when I got married so there wouldn’t be any judgement but if I was younger I stand a change of being judged.
A good rapport in a critical relationship will make way for an honest answer because a person will be at ease and feels: I won’t be judged by whatever I say to you. But initially the client is still testing the waters: should I trust this person. You’re really disclosing all these sexual matters which is a hugely sensitive topic.
Interviewer:
So tell me then, talking about sensitive topics- how were you talking around suicide, alcohol abuse, drug use? Were you able to ask around those sensitive topics?
Participant 5:
With those sensitive topics I was able to ask about them. I didn’t feel so anxious. Drugs are a social problem, alcohol and smoking doesn’t have much stigma but when it comes to using drugs it becomes uncomfortable because you have your own prejudices and society says using drugs is not a good thing, it’s a forbidden thing. So that section with drug use itself, maybe it shouldn't be anxiety provoking but your own conviction and beliefs of what is right and wrong makes you feel anxious about asking these questions.
Interviewer:
If we had to put sex, drug use, alcohol use, over counter medicine, suicidality, if we had to put all those next to each other which would you say on a ranking scale, which is the easiest one to deal with and which is the most difficult one to deal with?
Participant 5: