# 90 August 2007

"There is no end. There is no beginning. There is only the infinite passion of life."

Federico Fellini
Film Director

(continues below)

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# 90 August 2007

"Easing the Patient's Pain When Sharing Embarrassing Material with Both Adults and Children"

TISA Description of the Problem: This is certainly not the first time that we have addressed this problem in the Tip of the Month Feature (See Tip #7 "Asking Asian Americans about a Family History of Mental Illness: Some Cross Cultural Tips", Tip #76 "Raising the Topic of Physical Fighting", and Tip #88 "Helping Patients to Share Missed Medication Doses with Minimal Shame") but the methods for transforming this type of pain are many. Here are yet two more very nice tools, provided by Bill Snyder, M.D., who I had the pleasure of meeting at the Milton S. Hershey Medical Center.

Tip: It is intuitive that many patients are not forthcoming with information or minimize symptom severity during evaluations due to embarrassment or fear of disapproval by the interviewer. Additionally, many patients harbor a sense of inherent defectiveness, thereby precluding their hope of recovery and investment in the treatment process. I've found the following statements, introduced early in the evaluation, facilitate a decrease in self-perceived stigmatization. A slight modification has proven especially effective during child and adolescent interviewing:

Adults - "I'm sorry things aren't going well in your life right now, and I'd like to help you with that. I've found that many times unfair things happen to people that cause them to feel or act in ways they normally wouldn't."

Children/Adolescents - "I'm sorry things aren't going well in your life right now, and I'd like to help you with that. Many kids have told me bad or unfair things have happened to them that cause them to feel really bad,
really mad or really worried. This makes them feel and act in ways they normally wouldn't, and this causes problems for them. I think you and I can figure this out so you can be happier."

TISA Follow-up: The tips above are examples of a more generic validity technique called "normalization." In normalization the clinician does not focus on the client's pain or defenses specifically, but, instead, normalizes to other people, in essence decreasing shame by noting that other people have experienced the same thing (note the words, "Many kids have told me bad or unfair things have happened to them that causes them . . . " in the second example above).

For instance, when raising the potentially shame producing topic of suicide, a clinician might gently say, "Some of my patients, who are feeling very depressed like you are, tell me that thoughts of killing themselves sometimes crosses their minds. Have thoughts of suicide crossed your mind?" If you are interested in learning more about normalization and some of the other validity techniques (there are around ten of them), you might enjoy my book "Psychiatric Interviewing: the Art of
Understanding, 2nd Edition" which describes and illustrates them in detail.

Tip provided by:

Bill Snyder, MD
The Milton S. Hershey Medical Center