Asking Questions I: How to Approach Threatening Topics

Always the beautiful answer who asks a more beautiful question.

–e. e. cummings

Over the course of the diagnostic interview, many of your questions will be threatening to your patient. The simple admission of psychiatric symptoms is humiliating for many people, as is the admission of behaviors considered by society to be either undesirable or abnormal. Such behaviors include drug and alcohol abuse, violence, and homosexuality. Beyond this, there are other behaviors that your patients may not want to admit, because they may think you will disapprove of them personally. These might include a history of noncompliance with mental health treatment, a checkered work history, or a deficient social life.

To maintain a healthy self-image, patients may lie when asked what they perceive to be threatening questions. This has been a significant problem among both clinicians and professional surveyors for years, and a repertoire of interviewing techniques has been developed to increase the validity of responses to threatening questions (Payne 1951; Shea 1988; Sudman and Bradburn 1987). Good clinicians instinctively
use many of these techniques, having found through trial and error that they improve the validity of the interview.

NORMALIZATION

Normalization is the most common and useful technique for eliciting sensitive or embarrassing material. The technique involves introducing your question with some type of normalizing statement. There are two principal ways to do this:

1. Start the question by implying that the behavior is a normal or understandable response to a mood or situation: With all the stress you’ve been under, I wonder if you’ve been drinking more lately?

Sometimes when people are very depressed, they think of hurting themselves. Has this been true for you?

Sometimes when people are under stress or are feeling lonely, they binge on large amounts of food to make themselves feel better. Is this true for you?

2. Begin by describing another patient (or patients) who has engaged in the behavior, showing your patient that she is not alone:

I’ve seen a number of patients who’ve told me that their anxiety causes them to avoid doing things, like driving on the highway or going to the grocery store. Has that been true for you?

I’ve talked to several patients who’ve said that their depression causes them to have strange experiences, like hearing voices or thinking that strangers are laughing at them. Has that been happening to you?

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