4. FINDINGS
4.2. The Working Alliance
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.
68 which may cause discomfort often leave the trainee psychologist concerned about the impact that such enquiries may have on the working alliance and whether to pursue this line of enquiry.
Participant 4 (female): … 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 and I think as a therapist you make a judgment 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.
Semi-structured interviewing seems pivotal in managing the content in a dynamic way rather than using straight forward questions and answers. Dynamic interviewing requires the trainee psychologist to determine whether certain questions will risk the working alliance or if the working alliance is able to cope with sensitive topics being discussed. According to Markovic (2013) it is useful to be able to make suggestions while at the same time allowing space for the client to freely express her opinions and ideas. One participant was very conscious of what the client would think of him if he raised the topic of sexual health.
Participant 2 (male): … whether they can trust me to be judgment free and also about my reaction
Another participant was too overwhelmed with his own perception of how the client would view him.
Participant 10 (male): …even in therapy I sit there and think they will perceive me as being forward.
4.2.2. The perception of the working alliance
The trainee psychologist seems to feel the need to ascertain how good the working alliance is at the time of enquiries regarding sensitive questions and whether this may risk that alliance.
Participant 6 (female):… yes I think that's very important to get that information, however, I don’t think it’s useful in the intake, as I said neither party knows each other, they are less likely to be honest particularly if they pick up that I’m anxious about asking about it.
69 There appeared to be a difference in understanding the type of information that one is looking for and this would be informed by the working alliance regarding the timing of questions around sexual health.
Participant 4 (female): Well what are you really asking, are you sexually active? Yes or no. I think that those ones [questions] 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.
One participant felt that it was important to have established a solid working alliance in order to ask personal information about sexual health.
Participant 9 (female): I honestly don’t know why, I’m very open, I can talk about anything, I just think it’s talking to a random person about their sexual history so yes it can get a bit awkward.
Echoing similar sentiments another participant felt there needed to be a good working alliance and rapport before asking questions around a sensitive topic such as sexual health.
Participant 5 (male): …there has to be a good rapport because it affects their [the client's]
ability to answer.
An interesting comment highlighted the balancing act that a trainee psychologist is often faced with, which is when to follow the client's lead and when to follow the process and structure of the interview. It seems to be an ongoing challenge to balance the task of building the working alliance and gathering a full history and when one is perceived as being more important than the other.
Participant 7 (female): I think it’s relevant always and I think rapport is really important in questioning, however, when it comes to certain presentations in front of you, you have a certain obligation as to whether this person is able to provide you with truthful and responsible account of what it is that you want to know and not just something that is going to end it, the topic.
70 Participant 10 (male): Yes there has to be a sense of trust and comfort they can then speak to me, they don’t judge me they don’t perceive me as anything different, but until you’ve reached that point it’s very hard, there are risks.
The quote below is indicative of how aware the trainee psychologist is of the working alliance and that it is the relationship between client and clinician that influences disclosure, not the topic itself.
Participant 10 (male): It depends on the client, some clients are comfortable to speak about it some clients are not, I think it’s more something I need to deal with than the clients, if the client wants to speak about anything irrespective of those aspects, they will speak about it even if there’s a difference in age, gender, they have to trust you otherwise they just shut down.
4.2.1. Impact on the working alliance Perception of self
Initially when developing this research project it was anticipated that the working alliance would be affected in some way during this section of the interview due to task related anxiety that trainees experience during the initial interview. However the emergent conversations seemed to indicate that there was a minimal impact on the working alliance and any discomfort experienced was the subjective experience of the trainee.
Participant 4 (female): For me now it [the discomfort] was the assumptions that I had, cultural and religious….
Participant 6 (female): I didn’t notice anything again because I didn’t ask it direct enough so there wasn’t really an impact on the outcome except for creating a little bit of discomfort in the room and then quickly moving on.
Participant 8 (female): How would he view me in that moment, would he also feel why am I asking that? Why is that relevant? You’re so young.
One participant felt that it is never an appropriate topic to inquire about as it is too personal.
71 Participant 1 (female): For me I’m a very closed person, it’s not something I will talk about to anybody so for me it is a bit of a challenge. So I don’t want to talk about it so how can I expect someone else to talk about it, but I know it is something that has to be done ...
Perception of the process
Most participants felt that there had not been an impact on the working alliance which highlighted the fact that the discomfort and anxiety is an internal experience of the trainee psychologists. During the course of the semi-structured interview with the researcher some participants came to the realisation that their own anxiety and discomfort were the underlying obstacles to this segment of the interview with their client.
Participant 1 (female): I think it made it awkward and tense [the working alliance] for that moment but after that he was open to answering things. I think it was just to get over that bump and carry on and then it was fine.
The participant expressed the sense that it was a task that she needed to get through and cover the areas of inquiry that were necessary.
Participant 8 (female): You just want to get that interview done, get all the information, your supervisor needs to see it, quickly talk about it and move on.
One participant expressed some uncertainty about covering the topic of sexual health. Although he was familiar with what to expect from the process of the interview, the inquiries around sexual health were daunting.
Participant 10 (male): Looking at the list was fine but that question was like red!!! You’re prepared for every other question except that one, everything just falls flat…very challenging. . Personal Reflections: Initially many of the research participants felt uncomfortable with the topic of sexual health. They were all familiar with the process and what was required from the interview. The content and managing the topic of sexual health was what I perceived as causing some discomfort. However, I framed the topic as being another interesting area of enquiry and attempted to chat about the topic in a conversational manner which seemed to put most of the participants at ease. Due to my own perception and understanding of the relevance of sexual
72 health I am at ease with managing the topic and did not feel uncomfortable during the interviews. It is my sense that me being at ease with sexual health vocabulary and content assisted most of the participants to experience this ease of the conversation and by the end of the interviews many were using terminology more easily than they had in the beginning of the interview. This confirms much of what the participants commented on that it was their own discomfort that affected the process and their clients. The more relaxed and comfortable the participant was with the topic the less perceived discomfort in the client.
4.3. Obstacles to emerge: Contextual factors