Sensitive subjects - summary of chapter 9 of the first interview

The first interview
Chapter 9
Sensitive subjects

Introduction

If your patient doesn’t mention sensitive topics spontaneously, you should bring them up. Don’t wait until the very end of the interview to do this.

Suicidal behaviour

Delving into suicidal behaviour is a must. Nearly every mental health diagnosis confers some degree of suicide risk beyond what is found in the general population.

If the patient raises the topic, you can pursue it with a degree of comfort. Unless your patient seems unusually uncomfortable, you don’t need to apologise if you ask this question yourself.

If the patient says he hasn’t had any suicidal thoughts, and this seems to jibe with the patient’s mood and recent behaviour, you can accept this as a simple fact and move on. If the response is equivocal or delivered with telltale body language you must pursue the matter.

If your questioning seems to cause discomfort, you may need to comment on the distress.

If actual attempts occurred prior to this episode, memories may be dim. You should learn as much as you can about previous attempts. This can help you 1) predict what your patient might do next 2) assess what actions you should take.

Get answers to these questions about previous attempts 1) how many have there been 2) when did they occur 3) where was the patient at the time? 4) what was the patients mood at the time? 5) what methods were used? 6) was the attempt under influence of drugs or alcohol? 7) did the patient have other mental disorders at the time? 8) what were the stressors that preceded the suicidal behaviour? 9) how serious were the attempts?

Physical and psychological seriousness

The seriousness of a suicide attempt is judged in two ways 1) how physically harmful it was. An attempt is serious when it results in significant bodily harm 2) how strong the patient’s intent to die was.

Some attempts are highly unlikely to cause any serious harm. These gestures suggest that the patient had in mind some purpose other than dying. You must learn what intention lays behind it.    For some, your best course of obtaining information could be to infer intention from behaviour. Planning and preparation are usually associated with more serious attempts. Inaction after an attempt should ring an alarm. Feelings after being rescued are informative.

You must correlate whatever you learn about previous suicide ideas and attempts with your patient’s current thinking on the subject. It is vital to learn whether your patient has ideas or plans that could prove lethal, especially within the next few hours or days.

Any current ideas or plans that could prove harmful require rapid action.

Violence and its prevention

A history of violent behaviour can have serious implications for patients as well as for intended victims.

If your patients admits to legal difficulties, you will have natural lead-in to questions about violence. Much violence is domestic.

If no lead-in occurs, you will have to ask. You can work up the subject gradually.

Throughout, try to understand what lies behind your patient’s violent ideas or behaviour, and what might be causing these feelings.

Personal safety should always be a principal. 1) ensure that you have an unimpeded exit rout form the room where you are working 2) make sure that someone is within earshot or can instantly answer a warning buzzer or other alarm 3) be especially alert when your patient has a prior history of violence 4) keep alert to the nuances of voice, words, and body language that can indicate a need for action 5) as soon as you sense danger, act. Announce calmly what you’re about to do. 6) once you are out of the room, get help from anyone who is available

Substance misuse

Substance use must be covered in the initial interview of every mental health patient.

Alcohol

Many people still view substance misuse as a disorder of morals. Patients find this difficult to discuss.

If the patient doesn’t raise the subject of drug and alcohol use, you will have to create your own opportunity.

Find out how often and how much your patients drinks. Ask precise answers, this discourages vague or evasive answers.

Even if the patient denies current heavy drinking, learn how much drinking there has been in the past.

Unless your patient denies ever having a problem with drinking, you will need to ask questions about several categories of consequences.

Street drugs

With street drugs, the procedure is similar as to alcohol. Learn when the use began, when it ended, the type of drug, the frequencies and the effect on the patient.

If you don’t understand a term, just ask.

Prescribed or over-the-counter medications

Don’t forget to inquire into overuse of medicines.

Sexual life

Discuss the sexual life openly, without showing disapproval or censure.

You may already learned something about the relationship between the patient and partner that provides a natural introduction to the subject of sex. If not, you can ask an open-ended question. ‘I would like you to tell me about your sexual functioning’.

Sexual preference

It may be wise to start with asking about sexual preference. This can avoid the possibility of misunderstandings.

Sexual practices

When there is a history of sexual difficulty, a great many questions should be asked that you wouldn’t delve into routinely. When these questions must be broached, they are often better left until a subsequent interview.

Common sexual issues

Common sexual issues are: impotence, inability to achieve or maintain erection, dyspareunia (pain with intercourse), premature ejaculation, retarded ejaculation, concerns about possible homosexuality or bisexuality.

When you are learning about the patient’s sexual life, ask for specific instances in which the problem arose. Find out when it began, how often and under what circumstances it occurs, how severe it is, what has been done about it, and what seems to help.

Paraphilias

Specific paraphilias are exhibitionism, fetishism, frotteurism, pedophilia, sexual masochism, sexual sadism, transvetic fetishism, voyeurism, other paraphilias.

Sexually transmitted diseases

For all patients, be alert for a history of sexually transmitted diseases.

Sexual abuse

Childhood molestation

Childhood sexual experiences have been linked to many adult disorders.

If you have reason to suspect childhood molestation, return to the subject in a later interview, when your relationship is on solid ground.

Rape and spouse abuse

Usually the preferred first approach is a sympathetic, unstructured invitation to describe the events and their consequences.