4. FINDINGS
4.1. Conceptual maps
4.1.4. Perceived discomfort
63 It is worth considering that it would be time consuming to have to explain to every client the role of sexual history and broadening the view of the client, and to rationalise any enquiries concerning the subject, in relation to the client's reason for coming to see a psychologist.
However, if the trainee psychologist understands the relevance of this area of enquiry, then this inevitably informs her judgment as to how to proceed with it using dynamic questioning.
Participant 5 (male): 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 [the segment of sexual health] not the entire session.
Participant 6 (female): … I didn’t want to alert them [the client] to the fact that it was sensitive because it makes it more difficult for me to ask. So no I didn’t [orientate about sensitive topics]
Orienting the client seems to be linked with being able to build rapport with a client and is succinctly summarised as follows:
Participant 7 (female): I think orienting them is very very important, each person’s structure is entirely different, through orientation rapport is being built, so although we may end up talking about something sensitive today it is important that they come back and with consistency rapport is being built and assists with sensitive topics.
Personal Reflections: During this part of the interview with some of the participants, I shared some of my understandings of why this information could be useful. As indicated in the literature review there are many factors such as relationships with others, body image and self- esteem issues that may point to this line of questioning as being relevant and useful. This has been an area of personal interest due to the fact that sexuality is often only understood within a medical framework hinging on symptoms and diagnoses. My interest is in seeing the person as a whole, within their context and including all facets of their lived experience.
64 schedule alleviated this to some extent. A pertinent debate seemed to be around the issue of the timing pertaining to when to enquire about sexual health and whether it was appropriate during the first interview or should be raised in subsequent therapy sessions.
Participant 8 (female): One’s not too sure, do you start with it? Or right at the end of the interview? It is quite tricky but I think as you get to know the client you get to almost being able to judge when to talk about a sensitive topic, like tests or trials, see how they respond to that and then ask about it, but you don’t get taught that either.
Participant 9 (female): It was ok, the structure of the forms I don’t like especially with the sexual history it pops up in between the group questions and it is awkward.
Furthermore this participant explained:
Participant 9 (female): Yes I do actually because I think especially for therapy unless it’s an assessment on sexual functioning. But I think for therapy you could bring it up in your third session but we are asked to do it in the first session. You don’t even know the person, they don’t even know you, it’s fifteen or twenty minutes into the session and you ask them are you having sex with your wife or how long is it that you have not been having sex.
One participant perceived that enquiring about sexual health hindered the process of the interview.
Participant 5 (male): …it [asking about sexual health] 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.
There were a few participants who were able to broach the topic of sexual health and prior to this line of questioning did not seem to have as much anxiety linked to the task as the others did. The discomfort appears to have been felt acutely within the trainee and not caused by anything said or done by the client. Following the process of the interview alleviated managing issues with the content, however, as the following comment highlights there are many other factors that may impact the decision to raise certain subjects.
65 Participant 7 (female): It may not be an invasion of privacy but in the process of gathering information that question could be asked at a later stage, if you have someone so severely depressed it could be difficult to ask them that question [about sexual health].
Although the process of the interview seems to be clear for most participants there are instances which confuse the process. An example is when one participant describes her discomfort at conducting a parent intake and being unsure whether the topic of sexual health was relevant to discuss in terms of the relationship between the parents.
Participant 9 (female): Yes and you have to ask them also about their sexual history and how intimate they are and I find that a bit irrelevant, it could be, there may be some issues there but I still think it’s irrelevant.
4.1.4.2. Content and initiating this area of inquiry
During the moments prior to asking about sexual health most of the participants experienced feelings of anxiety that seemed to be linked to the content of the questions. The anticipatory affect related to the task of initiating inquiry into sexual health and appears to have had an impact on whether the trainee was able to ask the questions about sexual health or not. Those who felt they had limited experience in engaging in the topic of sexual health tended to avoid the topic altogether.
Participant 8 (female): I think just asking about their sexual experiences, their sexual libido, personally I didn’t know what to say about that, because I personally was not sexually active while doing this so I felt very inexperienced, I didn’t even understand how was their first time, how frequently…..
Once the topic of sexual health had been raised some of the participants clearly perceived discomfort in their clients due to the content of enquiry.
Participant 3 (female): I think it [the topic of sexual health] was unexpected, then saying that she was taken aback but then she was happy to answer but it did take a moment…not discomfort, just the initial surprise.
66 Participant 8 (female): … she would look down, smile, be quite, I would then comment on her being quite, we may then carry on with that or I would just leave it all together because I’m pushing too much so let me come back to that…
A participant noticed the client's discomfort through facial expressions and a delay in responding to the questions that had been asked.
Participant 5 (male): … 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?
There is awareness in the trainee psychologists that much of the discomfort arose within themselves and their own discomfort may actually create the discomfort experienced by the client.
Participant 8 (female): I felt that when I stumbled or hesitated that caused the client to react, either laugh or look away.
One participant felt acutely aware of the fact that the content of sexual health was difficult to deal with due to the newly formed working alliance between himself and his client .
Participant 2 (male): I know so little about the person on the other side and I am asking incredibly personal questions, which I don’t know how to phrase it right and I don’t want to cause disrespect…
Discomfort in the client fuelled the feelings of discomfort experienced by one of the participants.
Participant 9 (female): Yes he paused as well I could see he felt a bit awkward, he smiled and I think he also wanted me to go over quickly, he didn’t say much either just it was fine it was good so I could tell he felt awkward so that made it more awkward for me.
One participant explains how she does not feel comfortable to raise the topic of sexual health unless there is a clear indication to do so, linked to the referral question.
67 Participant 1 (female): …if it is a presenting problem I don’t have an issue with it, they have brought it forward so I’m going with it, compared to the sexual thing, if I brought it up then I’m uncomfortable.
The complexities related to the topic of sexual health make it difficult to comprehend why it is so challenging and why it ignites such discomfort for the trainee psychologist.
Participant 9 (female): Maybe it’s the difficultness of sex, it’s the physical rather than other things we’re talking about,, stuff that perhaps happened in their childhood, it can be intimate if it happened as a child so long ago but even in the present it’s so physical and it’s something that we all experience. A client can talk to me about being abused or molested as a child and I have never experienced it but I can sit and listen to it but when it comes to sex or sexual history I’m sure we’ve all engaged in some form of sexual activity so I think that it’s more of a reality for you sitting talking to somebody about their sexual history so I think that’s the awkwardness.