Clinician perspectives of the therapeutic use of the self-confrontation procedure with suicidal clients.This research investigated clinician perspectives of the therapeutic use of the self-confrontation procedure with suicidal clients. The self-confrontation procedure, which involves the use of video playback of interviews with clients who have experienced suicidal ideation and attempts, has previously been used for research purposes. The current research sought to build on the use of the self-confrontation procedure by asking mental health clinicians how they might use the method in a therapeutic context. These professionals developed an understanding of the procedure through experiential activities, practice, readings, and discussion. They first identified the challenges in working with suicidal clients, and then developed ideas about how the self-confrontation method could be useful in overcoming these challenges.
This research has been motivated by recognizing two important problems in suicide prevention counseling. First, it has been suggested that the initial meeting with suicide attempters is an important and special window of opportunity that should be used carefully (Michel, Maltsberger, Jobes, Leenars, Orbach et al., 2002). However, counselors and clinicians are often under pressure to collect copious amounts of biographical and personal data, to administer and interpret tests and measures on suicidality and associated mental disorders, and to conduct in-depth, thorough suicide risk assessments (e.g. Stellrecht, Gordon, van Orden, Witte, Wingate et al., 2006; Bryan & Rudd, 2006). Despite the good intentions and evidence backing a thorough assessment, clients can unfortunately experience this process as impersonal, overwhelming, and even coercive at times (Jobes, 2000; Valach, Young, & Lynam, 2002).
As salient as this initial information may be, it is important to understand that the encounter of the suicidal person and the counselor or clinician is not just a frame or vehicle in which this information is shared and collected. Rather, it is a pivotal, agentic relational process that research shows may be one of the most important interventions when working with persons who are suicidal (e.g., Bostick & Everall, 2007; Jobes, Wong, Conrad, Drozd, & Neal-Walden, 2005; Michel et al., 2002). Indeed, the primacy of the therapeutic alliance from the outset of the initial encounter has long been recognized as fundamental to successful therapeutic outcomes (Grencavach & Norcross, 1990; Horvath & Luborsky, 1993). Therefore, in our research, we sought to equip clinician/participants with the means to facilitate a more holistic and existential approach to working with suicidal clients (Cutcliffe, 2005) by breaking with traditional conceptualizations and approaches to psychotherapy (Popadiuk & Arthur, 2004).
The second problem often addressed in the suicide prevention literature is the discrepancy between research and practice. Even well-researched suicide risk assessment models, epidemiologically based suicidality monitoring instruments, and evidence-based clinical interventions have not been proven to reduce suicide rates or non-fatal suicide attempts (Rogers & Soyka, 2004). This breach may be, in part, a product of a serious gap that exists in the knowledge transfer process between research and the subsequent lack of uptake in clinical practice (Cleary, Walter, Luscombe, 2007; Waddell, 2001). These authors argue that the disconnection between research and practice can be linked to two problems: (a) most researchers neglect disseminating research findings beyond academic journals and conferences, and (b) research is often incomprehensible and inaccessible to a clinical audience. In our study, therefore, we attempted to bridge this gap by directly engaging clinicians in the research process.
The Self-Confrontation Method & Suicide Prevention
This study on clinician perspectives of the therapeutic use of the self-confrontation procedure with suicidal clients was designed with two purposes. First, we were interested in the perspectives of counselors regarding the potential use of an innovative therapeutic procedure with clients who had suicidal thoughts or had attempted suicide. Second, we wanted to investigate the process of introducing a new therapeutic procedure to counselors previously only used for research purposes.
With regard to our first purpose, counseling clients who have recently attempted suicide can be challenging for counselors (Bongar, 1991; Oordt, Rudd, Jobes, Fonseca, Runyan et al., 2005). Clients may be experiencing hopelessness, depression, or guilt that robs them of energy and motivation to engage in the counseling process. They may feel further alienated from professional helpers if they have already experienced clinicians at the hospital emergency or psychiatric wards who have used a standardized suicide risk assessment to ask a wide range of questions in a way that can be experienced as overly clinical, intrusive, and diminishing (Jobes, 2000; Michel et al., 2002; Valach, Young, & Lynam, 2002). At the same time, when a client comes to an agency for counseling after making a suicide attempt, counselors may approach the recent attempter with ambivalence about exploring the attempt fully due to a lack of knowledge about how to assess and treat suicidal clients, a fear of precipitating a subsequent attempt, or frustration about the perceived intention of the attempt, among other concerns (Bongar, 2001). In fact, Pope and Tabachnick (1993) reported that working with suicidal clients and their suicidal behaviors was the most stressful clinical scenario for counselors working in the field.
Unfortunately, clinical practice with suicidal clients has not successfully addressed these issues. Indeed, some practices and approaches seem to exacerbate or even create resistance in clients (Michel et al., 2002). They are, in a sense, iatrogenic. To address a number of the difficulties identified above, we propose the use of the self-confrontation procedure (Valach, Michel, Dey, & Young, 2002) as a therapeutic intervention with this client population. This procedure is based on an action theoretical understanding of suicide, but its use is not limited to that conceptual framework (Valach, Michel, Young, & Dey, 2002). To date, this particular procedure has only been used for research purposes (Michel et al., 2002; Valach, Michel, Dey, & Young, 2002; Valach, Michel, Young, & Dey, 2002). This innovative procedure involves the use of video playback of interviews with clients who have experienced suicidal ideation and attempts and invites the client's recollection of thoughts and feelings from the therapy on seeing short segments of the video. A review of Valach and his associates' research study by an international group of mental heath professionals has resulted in the identification of the procedure as having potential useful outcomes when used in counseling and other psychological and psychiatric interventions with suicidal clients (Michel et al., 2000).
The self-confrontation procedure that was introduced to counselors and clinicians as part of our study is consistent with narrative and constructivist theories and methodologies that encourage the development of client narratives (Josselson, 2004; Mahoney, 2004; Neimeyer & Stewart, 2000; Popadiuk, in press). In her work on narrative research, Josselson (2006) poignantly describes the strength and richness of narrative when she states that it "strives to preserve the complexity of what it means to be human and to locate its observations of people and phenomenon in society, history, and time" (p. 3). Haverkamp and Young (2007) further outline some of the major tenets of constructivist approaches, including (a) a relativist ontology that supports multiple valid perspectives, (b) that knowledge or meaning is co-constructed through the interaction between the researcher and the participant, and (c) that the researchers values, beliefs, and characteristics are acknowledged in the research process. Other researchers have provided rich examples of client narratives in their research projects, such as suicide and adolescents (Bostick & Everall, 2007), non-marital break-ups in college students (Hebert & Popadiuk, in press) and women international students in difficult relationships (Popadiuk, 2004).
Based upon constructivist, narrative underpinnings, the self-confrontation method becomes a vehicle for researchers to explore and expand upon client narratives and their meanings. Videotaping the client allows for an uninterrupted flow of the narrative and gives the counselor the possibility to clarify the underlying meanings once the client has finished telling his or her story. This intervention may also have the potential to address the multiple challenges counselors face related to working with a client's suicidality (Bongar, 1991). In particular, the self-confrontation procedure has been successfully used with clients who have experienced suicidal ideation and attempts (Michel et al., 2000; Valach, Michel, Dey, & Young, 2002). The procedure involves the use of the following steps: (a) a videotape is made of the therapy session, (b) the videotape is played back with the client immediately following the session and stopped every 1 to 2 minutes (meaningful units), and (c) the counselor asks the client to recall thoughts and feelings at the time of the initial conversation with the counselor. For example, the following transcript illustrates the client's narrative in the initial interview with the counselor and the subsequent counselor/client responses during the self-confrontation interview.
Client in Initial Interview with Counselor:
Th: Perhaps it would be the easiest if you start by briefly describing what happened or how it came about that you cut your wrist
Cl: My mother dropped in. It was a Sunday and I was depressed for several months over the break-up with my boyfriend. My mother appeared unannounced, which felt like she was supervising me 24 hours a day. And she told me that worrying about me was a heavy burden for her, which I knew. We had a big argument which was not really about the break-up or how I was feeling about the break-up, but it was about me feeling supervised by her. I said things which I don't think I should have said, but it just came out like I was a pressure cooker.
Self-Confrontation Interview Conducted After Initial Narrative
Th: Can you tell me what you were thinking and feeling during that moment in the videotape when you described the argument with your mother?
Cl: I was feeling good. I expected this question, so it was not surprising [that you asked]. I was wondering if should I mention this thing with my mother to you or not ... it's a bit difficult to explain, the thing about criticizing her and so on. I don't want to blame my mother. She really tried her best. It was necessary to tell you this story, because the situation was unusual. I was arguing with my mother, but it wasn't the usual kind of fight that we would have. I wanted to say it without making it too negative. Because you didn't ask anything further about it, I thought I had given a good explanation of it. (Adapted from Valach, Michel et al., 2002).
In practice, about 15-20 minutes of a counseling session in which the client discusses his or her suicide attempt would be used for the self-confrontation playback. After the initial narrative is told to an active, empathic, and caring listener, the session has the potential to take another direction as the example above illustrates. The counselor rewinds the tape and begins to play 1 to 2 minute sections or a brief, meaningful unit of the narrative until the counselor and client review about 15 minutes of the counseling session. After each brief section of tape, the counselor asks the client, "As you watch our previous dialogue together, can you tell me what you were thinking and feeling as you were telling this part of the story?" The client proceeds to provide additional information about the internal processes that were occurring during those few moments, which often, but not always, results in new, more meaningful, and deeper disclosures. What we see in the example is that in the self-confrontation, the client provides additional information about how she felt that her mother was trying her best, and that the argument with her mother was unusual, which speaks to a change in their relationship. Furthermore, the client demonstrates her awareness of the counseling process by stating that she had expected the counselor's question, as well as indicated her awareness of the counselor's reaction to how she told her story.
Notwithstanding the possible merits of the self-confrontation procedure in both research and counseling, mental health professionals working with suicidal clients may avoid using it for a variety of reasons. First, there is little systematic clinical evidence for its use or the outcomes that can be expected from its use. Second, the use of video in therapeutic situations may appear unnecessarily intrusive and cumbersome. Third, there has been no systematic identification when and for whom the procedure is indicated or contraindicated.
Thus, our research purpose was addressed by the following questions:
1. What are the challenges and difficulties that counselors face in counseling clients who have attempted suicide or have significant suicidal ideation?
2. How do mental health professionals respond to the possibility of using the self-confrontation procedure to address these challenges or other aspects of counseling with this population?
3. What advantages do counselors see in its use? What limitations do they see in preventing them from using it? In what context and under what circumstances would they use it?
Focus group methodology informed the design and implementation of this study (Morgan, 1998). This method allowed us to recognize the expertise of counselors involved in the field and to use their expertise in identifying the challenges in working with suicidal clients in determining the potential uses for the self-confrontation procedure. The focus groups facilitated access to the opinions and experiences of practitioners on the complex and sensitive issues of suicide and its treatment. This method also had the benefit of allowing the possibility to develop consensus and support if a new practice was to be implemented. The follow-up strategy undertaken after the initial focus groups with some participants was interviewing, "one of the most common and most powerful ways we use to try to understand our fellow human beings" (Fontana & James, 1994, p. 361). Although a qualitative research interview closely resembles a regular conversation, it involves specific questioning techniques and particular approaches by utilizing a semi-structured interview format (Kvale, 1996). Both the focus group and individual interview procedures used in this study were approved by the Human Subjects Ethical Review Board at the University of British Columbia.
The five male and three female participants (N = 8) in this study currently worked with suicidal clients in counseling or mental health settings, including an employee assistance program, a day program for clients with schizophrenia, and a community mental health team. Professional credentials included four master's-level clinical social workers, two occupational therapists, a master's level psychiatric nurse, and a bachelor-level psychiatric nurse. Each of the clinicians was highly experienced in providing support or counseling to clients, had a minimum of three years experience working with clients, and had previously worked in other counseling, hospital, or mental health settings. The dominant ethnicity represented was Canadian-born Caucasian of various ethnic and national heritages (e.g., English, Egyptian/English), and one participant had immigrated from Mexico. The participants were recruited to this study through snowball sampling within a network of counseling and health care agencies and hospitals.
A two-stage process was used to implement this study. Initially, the first and second authors, aided by a graduate student assistant, led a focus group of about a three-hour duration for each of two groups of participants. The discussion portions of the focus groups were videotaped, as well as some of the self-confrontation procedures conducted with participants. In addition to transcribing portions of the tape, detailed notes were taken during sessions by the research assistant. The purpose of these focus groups was twofold. First, we wanted the participants to identify challenges and difficulties in working with suicidal clients. Second, we introduced and practiced the self-confrontation procedure in an experiential format. We began the focus group by asking participants to identify and discuss the challenges they faced in working with suicidal clients. This discussion served as a scaffold to introduce, demonstrate, and practice the self-confrontation procedure. Specifically, in each focus group, the participants had the opportunity to see the self-confrontation demonstrated with at least two of them in the role of a client presenting the narrative of how they came to work with suicidal clients. These participants subsequently engaged in the self-confrontation procedure regarding the narrative they had presented. This experiential part of the focus group provided participants with first-hand familiarity of the self-confrontation which they subsequently used as a basis for judging its use with suicidal clients. At the end of the focus group the participants were provided with two readings on the self-confrontation procedure (Michel et al., 2002; Valach et al., 2002) and its use in suicidal research and asked to consider its use over the following month.
The second stage of the research was to follow up with the participants based on their first focus group experience in either a second focus group or individual interview. Five clinicians choose the individual interview to accommodate scheduling and other issues. The purpose of this second follow-up interaction was to have the participants assess the use of the self-confrontation procedure in counseling suicidal clients. The questions that were used to stimulate the focus group discussion or feedback in the individual interviews included "What seems important and useful in what you observed in the self-confrontation procedure?" How could this procedure be used with suicidal clients?" "With what clients and in what contexts would you use this procedure?" "In what contexts would its use not be appropriate?"
The analysis of the data, undertaken jointly by the first and second author, Popadiuk and Young, was based on a close review of the videotapes, as well as verbatim quotations and notes taken during the workshops, follow-up sessions, and from the telephone interviews. We looked for specific answers to the research questions, that is, what were the challenges in working with suicidal clients, how do counselors respond to the use of this procedure, and what were the specific potential uses of the self-confrontation procedure. We organized the responses into categories, which were subsequently further delineated as major themes and subthemes.
Firstly, we (Popadiuk and Young) read through the transcripts, interview notes, and watched the videotapes of the focus group discussions. We discussed the information and how we understood its context and meaning. Then we manually prepared discrete quotations that represented a single narrative idea and broadly sorted these quotations to construct three overriding categories from the data (e.g., Client Issues, Counselor Issues, and Process Issues). Next, we worked together on the first category to develop themes and subthemes. A consensus model of decision making regarding this process was used in this analysis. Finally, we each took one of the two remaining categories and individually developed the themes and subthemes. Upon completion of this analysis, we reviewed each other's categories, and discussed and resolved through consensus any parts of the analysis that were problematic.
The follow-up focus group, along with individual interviews provided an opportunity to validate the participants' initial perceptions of the self-confrontation method, and to explore their reactions about the initial focus group demonstrations of the self-confrontation. In addition, the third author (Valach) reviewed the categories, themes, and subthemes, along with the selected participant quotations that were used to highlight the nature of these themes for a final review, discussion, and validation of the findings. These various steps reflect common thematic analysis procedures, as well as the validation process utilized in judging the soundness of findings in qualitative studies (Fischer, 2006; McLeod, 1994; Parker, 2005).
One of the first tasks in this research was to ask participants to identify some of the common challenges in working with suicidal clients. This interactive and lively discussion resulted in contributions addressing topics in three categories, client issues, counselor issues, and process issues.
In the first category, client issues, four interrelated themes were constructed. First, the focus group participants identified psychological or physical aspects that are brought into the counseling office by clients. The first theme that emerged around this issue centered on the client belief that suicide action is the only viable option to deal with psychological pain. One participant in the group explained:
Some clients can't see a way out of their chronic and debilitating depression or psychotic illness, except for suicide. They are tired of the pain, and they understand that there may be little hope for life to get better, especially after many years of struggling.
Another participant added a different perspective: "Suicide seems to be a choice rather than a symptom of pathology, which I've seen when schizophrenic clients are clear, and not psychotic, when they make a suicide attempt."
The second theme that emerged from the data addressed the issue of agency and described how some clients come to professional helpers with distorted, negative cognitions. These included things such as self-devaluation, which made their desire to destroy themselves through suicide somehow more cognitively acceptable. A participant explained, "Depression and anxiety lead to perpetual negative thinking and feeling bad about themselves. It is challenging to work with a client who is depressed and only sees a distorted image of themselves and the world." Clients who have a psychotic illness, like schizophrenia, similarly struggle with problematic cognitions and suffer under the disability to distinguish between their personal intentions and the thoughts generated by their illness: "A client dealing with hallucinations has significant problems managing their hallucinations around their suicidality because of the distorted thought processes."
The third theme that developed from the participant discussion on client issues focused on the wide range of suicidal intentions across clients. One participant who had many years of experience working in a variety of counseling settings related, "Sometimes clients want to punish someone rather than it being the case of not wanting to live life." Another participant talked about his frustration, "Work with trauma survivors and personality disordered clients is difficult," while yet another reflected on the fragility found in many clients. Other participants suggested that clients' intentions about suicide differed depending on whether they were primarily depressed, abused drugs and alcohol, had few problem-solving skills, wanted revenge on a loved one, or possessed an external locus of control, to name only a few. The participants noted that a client's intentions were a key factor in determining how to treat the client therapeutically, since different suicidal intentions called for different kinds of interventions. This fact also recognized the relational issues connected with suicidality, and the importance of a strong therapeutic alliance, in which the client felt safe to honestly disclose their potentially shame-inducing intentions.
The fourth and final theme related to client issues examined the multiple social and health problems of many suicidal clients. One participant highlighted the difficulty working with youth and young adults when they experience multiple losses, especially when faced with a mental illness. She described one adolescent client and his family:
The client had no insight and did not want help even after surviving a very serious and disabling suicide attempt. The client had many problems--multiple mental disorders, family difficulties, failing school, and now a permanent physical disability--but he kept refusing to come in to see me once he was released from the hospital. Then there was denial from the family of the seriousness of all the problems. The parents completely denied the severity of the act itself, that he could attempt it again, and his level of impulsivity.
Overall, the focus group participants identified a wide variety of client issues that proved to be challenging to them. The discussion provided an examination of the complexity, depth, and variety of psychological, personal, and family issues related to working with many suicidal clients. In our engagement with participants, we sometimes noted the frustration that they expressed, as well as a sense of being overwhelmed by the kinds of issues that clients presented to them. At the same time, we also experienced the passion, care, and commitment that these professionals held for the clients with whom they worked.
The second category developed from the data, counselor issues, focused on a wide variety of complications that impacted the counseling process due to attitudes and behaviors that many counselors brought to the work. One of the predominant themes related to the high levels of anxiety felt by the clinician regarding suicide assessment. A participant discussed how professionals carry all the responsibility if a client makes an attempt or dies by suicide: "We are worried that someone will make a suicide attempt or die, which creates more anxiety when working with suicidal people." An exploration of counselor anxiety led some counselors to examine their own experience more closely: "If a client is at high risk for suicide, I can worry about it day and night until I see the client again. It is exhausting to be worried about someone so much, even thought you know in your mind that there is not much you can do in between sessions."
A related theme had to do with counselors actively avoiding suicidal discussions with clients. Participants discussed how they often felt helplessness in working with the issue of suicide, and so found ways to avoid asking the important questions. In this regard, one participant stated, "Many clinicians have the attitude 'don't ask, don't tell,'" a sentiment that many others acknowledged seeing in themselves and other counselors at times. One participant asserted that "sometimes I actively have tried to avoid a suicidal discussion if at all possible." Often, the avoidance was linked with feeling exhausted and overwhelmed by the client workload, or the anxiety of figuring out what to do with the client once they found out they were suicidal. These disclosures seemed to break the silence about a practice sometimes done, but rarely discussed. Further, these comments loop back to the first theme in that avoiding the discussion also served to lessen the anxiety, especially with clients who were chronically suicidal or did not appear to be at high risk based on other markers that came out in the interview.
The fourth theme highlighted by participants was blame and guilt in the face of a suicide attempt or death. One clinician stated, "There is worry about blame, guilt," while another talked about the pressure to blame someone in the team, because "someone had to be responsible for the treatment." There was a sense in the group that although being blamed by others or self was not helpful, knowing that someone else was responsible or that another clinician made a mistake could bring some relief to the team. One person stated, "You can tell yourself that you would have done things differently. There is a sense of control in that."
Another theme that arose under the category of counselor issues reflected the participants' sense of inadequate levels of suicide intervention training. One participant stated, "Counselors are uneasy, anxious with attention-seeking behavior in clients, because the clinicians don't think that they have a skill set to deal with this kind of situation." Another added, "even though I have some experience with Dialectical Behavioral Therapy and the Dawson approach, I am concerned that I have inadequate levels of suicide intervention training as a clinician." Another participant bemoaned the fact that "there is insufficient training to deal with trauma survivors and personality disordered clients." Yet, another said that "systematically some staff have more training, so the question arises as to who should work with these [borderline] clients, and so these staff have to work with these high risk clients more often than others." This pointed to a strong reason why a clinician would not want to receive more in-depth training in working with suicidal clients. A slightly different perspective on training issues was related to supervised practice: "It's one thing to go to a two day workshop; it's a totally different thing to have someone supervise your counselling in the new things you've just learned so you can make sure you're doing it right." Additionally, these discussions touched upon systemic and structural inequalities regarding who sees what kinds of clients. This theme engendered heated discussion in the groups.
The third and final category arising from the data focused on process issues that were embedded within the therapeutic context or relational interaction of counseling. This category contained more thematic strands than the first two categories, indicating the salience of the interpersonal aspects of therapy. The first theme in this category focused on the problem of helping clients with particular diagnoses to develop insight about their issues. A frustrated participant talked about the difficulty of working with suicidal clients when the person cannot or will not work with the clinician to see how their diagnosed mental health issues are seriously negatively impacting their life. On the other hand, a participant saw a different problem in relation to diagnoses: "I see clients coming in and clinicians trying to fit a client into a label when they did not necessarily fit. I don't think that labeling helped in these situations."
The next theme that emerged from the data centered on engaging clients in the therapeutic relationship. The idea of maintaining honesty and being direct in the therapeutic relationship was part of this theme. Participants discussed the importance of quickly establishing rapport and developing the therapeutic relationship. Everyone agreed that this was of critical importance, but how to do this was a topic for discussion. One participant noted that sometimes two intentions can be in conflict when working with suicidal clients: "I want to remain honest with what I am saying to a client, but wanting to maintain rapport." When developing relationships with suicidal clients, the participants saw that it was a delicate balance of asking questions, mutual honesty, and engaging the client enough so that he or she would return. Clinical experience proved to be important in being able to quickly determine the right mixture of authenticity, assessment, and engagement with any given client so that mutual honesty and respect could emerge and lay a foundation for future work together.
The third theme explored the idea of assessing level of suicidal risk. This theme appeared to be related to the previous theme of engaging the client in an honest dialogue, but it went beyond rapport building and clinician directness to include the specific relational dynamics of a suicide assessment, and focused more on the client's side of the interaction in the relationship. For example, participants wondered, "Are the clients being truthful about how suicidal they are?" and "How much does the client really want to be engaged in the therapeutic relationship? Are they being honest with themselves and with me?" Discussions ensued about the need to balance probing about the client's safety with accepting the client's narrative about his or her current status. Again, strong clinical judgment backed by sufficient training, experience, and supervision helped counselors in answering these difficult questions for themselves.
Fourth, participants identified an important theme about how clinicians need to instill hope, especially when the client has experienced multiple losses. Some participants admitted to feeling hopeless when working with some clients, which made it more difficult to instill hope in their clients. This theme also links back to the ideas of honesty in the relationship and the difficulty in negotiating conflicting feelings within the relationship. Participants discussed how hope was involved in the transference/countertransference process, which led them to offer suggestions about ways of instilling hope in their clients. For example, when participants felt hopeful about a client's situation, they could often see the immediate impact of their expressed hope on the client: "It is amazing when I tell a client that there is hope for something else, something different, a brighter future. Sometimes clients need to hear that if they stick with it, they will get past the roadblock." Participants discussed the joy in seeing how clients can light up, if only for a moment, when asked about something they hoped for in the future. Participants also agreed that both the client and the clinician are impacted by the reciprocal nature of giving and receiving of both hope and hopelessness in sessions. In other words, when a client held even a glimmer of hope for his or her situation, the counselor could more easily internalize it and present it back to the client. Likewise, feelings of hopelessness could move back and forth between the counselor and client in a downward spiral of despair if left unchecked.
Fifth, a theme more salient to participants working with clients in rehabilitation settings focused on how in-depth functional and cognitive assessments often contribute to sense of loss, especially in someone who has made a suicide attempt with injuries. A participant reflected on a client who was relieved that he had not died during the attempt, but once the full assessment had been completed, he suddenly had to deal with the fact that he had sustained a serious brain injury that would never get better. The participant explained, "This client felt so bad after learning about all his new problems, especially his brain injury, that he became even more depressed than before." Participants agreed that clinicians need to be careful on how much information to give to clients all at once, and the manner in which the information is conveyed.
The sixth and final theme in this category highlighted the difficulty in shifting clients from an external to internal locus of control. One participant asserted that "these clients were having an external experience of control and they needed to establish an internal locus of control" in order to make a real difference in their lives. Other participants echoed this sentiment noting that the counselling process can be difficult when the person is completely focused outside of himself or herself. "Creating therapeutic change with the client is relational," stated one participant, "it is something that happens together within the therapeutic relationship. That's how it happens."
Perspectives on the Use the Self-confrontation Procedure
During the first focus group, the participants had learned about, observed, participated in, and practiced the self-confrontation procedure. Subsequent to this focus group they had the opportunity to read about the procedure and consider its use in practice. The participants' perspectives on the use of this procedure can be presented in two parts. First, their experience of their observation of, participation in, and understanding of the procedure, and second, the implications they drew for its use with suicidal clients based on their experience and understanding.
Participant experiences of the self-confrontation procedure. For the most part, the participants experienced the self-confrontation procedure positively. One participant acknowledged that the immediacy of viewing himself right after being taped was both powerful and unnerving. The participants experienced the self-confrontation as a process through which one could work with a person's emotions and cognitions. But this working on thoughts and feelings was contextualized by the participant's narrative and self. To paraphrase one participant who experienced the procedure, "it was a good process, reflecting on myself and working with my emotions and thoughts." It provided the participants an opportunity to visualize the past and uncover new aspects of their experiences.
The participants seemed surprised by the intensity of the procedure and its facility to bring layered inner experience to the surface quickly. One participant stated, "I saw my layers of defense," which she had not expected to see. "It's intense," said another participant, "I see using it on myself." As more of the videotape was played, the intensity increased for one participant in the self-confrontation procedure. This individual saw the procedure as a means to honor and deal with this inner experience. This inner experience was also addressed sometime after the procedure itself. One participant said, "It had a huge effect on me driving home. The process was freeing for me." Another said that it had helped her with her inner work. The counselor leading the self-confrontation was seen as being "on the same side as the client." For the participants in the focus groups, the self-confrontation procedure demanded a modicum of self-reflection and self-esteem. Their experience also seemed to demand an ability to concentrate on, and have access to, feelings and metacognitions. Further, the participants debated whether the focus should be on the present experience during the self-confrontation or exclusively on their experience as recorded on the videotape. One participant suggested that by focusing on the here-and-now during the self-confrontation, he could have "gone deeper" into the work.
Implications for using the self-confrontation in practice. The participants addressed the strengths of the self-confrontation procedure and identified ways in which it could be used in counseling with suicidal clients. They also addressed the limitations of this procedure. Among the strengths of the procedure was its use in counselor training and professional development workshops, which could be simple to implement since videotaping practice was already in place. Participants noted that the manner in conducting the self-confrontation procedure was different than the standard method of using videotape in training. The participants saw its potential to address issues other than suicidality and that it could be used as a preventative measure with high risk clients. They also suggested that the procedure helps to identify recurrent themes and provides a way of connecting therapy and assessment. The therapeutic processes addressed and enhanced by the self-confrontation procedure included allowing clients more time for reflection, "making the subjective objective," and they thought that "the narrative focus is useful."
Additionally, the self-confrontation was seen as particularly relevant for clients who wanted the opportunity to tell their story, particularly in the case of a person who is "coming back" from an attempted suicide. Related, a point raised from the readings that some participants thought interesting was how the self-confrontation procedure could be conducted by two different clinicians. Instead of the client simply re-telling the story to the next professional in the team or on the ward, the self-confrontation could be utilized to continue to deepen the narrative. Furthermore, the self-confrontation procedure was seen as honoring inner experience and moving the experience of a suicide attempt beyond the physical, which they reported as the focus of the response in some hospital emergency rooms. The possible ranges of outcomes that these clinicians identified for the self-confrontation procedure included encouraging self-efficacy, building insight, increasing information exponentially, and identifying suicidal triggers.
The participants also identified what they perceived as limitations of the self-confrontation procedure. One limitation was its use with clients who had schizophrenia. One participant commented: "They [clients with schizophrenia] don't necessarily have access to feelings and are unable to have metacognitions." Thus, the power of the self-confrontation seemed to suggest limiting it use to clients who are able to deal with a high level of intensity effectively. As another limitation, the procedure was seen as too much of an "in your face" approach for clients who have untreated psychotic disorders. In addition, the self-confrontation procedure was seen as having limited use for clients with attachment disorders who would have difficulty talking about feelings, clients with drug induced psychosis, and clients with borderline personality disorders. One clinician commented, "A client with abuse or attachment disorder; he would not talk about feelings. It would be threatening 'you're trying to pierce my armor.'" Client readiness for using the self-confrontation was an issue that was repeated by the participants; "the patient needs to be ready," one participant commented. Another caution that was addressed was its use with clients whose suicidal attempt may have caused apparent physical disfigurement. Rather than a stand alone therapeutic procedure, the participants suggested that the self-confrontation procedure would work well as a complement to narrative therapy, dialectic behavior therapy, solution-focused, and Satir systemic approaches.
Several questions about the self-confrontation procedure remained for these counselors following this experientially-oriented research study. These included: Where does the method lead the counselor? What about the extra time it seems to take? When would this be used? How would counselors deal with issues related to videotaping, permission and equipment? What is the theory of change?
In summary, the findings indicate that the participants in this study had significant concerns about working with suicidal clients. Moreover, these concerns are related. The risk involved in counseling clients who are suicidal is challenging because some types of suicidal clients themselves are difficult and present a range of problems both personal and contextual. Thus, engaging them in a therapeutic process demands a wide range of significant therapeutic skills as well as training and direct supervision to keep those skills fresh. However, even with the best of skills, the complex nature of suicide and the threat of losing a client to suicide induces significant personal reactions from counselors. While the participants found the potential of the self-confrontation procedure generally helpful, the complexity of their concerns made it easy for them to identify specific limitations.
Our findings in this study clearly indicate that counselors have a range of significant concerns about working with suicidal clients. They also seem open to investigating new approaches. However, the incorporation of the self-confrontation procedure explored in this study seemed contingent on the pragmatics of work environment and agency expectations, and to some extent on characteristics of the client group. The participants in this research raised a number of questions about the self-confrontation procedure and its use. The nature of the questions indicated that counselors are concerned about a range of issues when being introduced to new methods that include its conceptual fit with a theory of change and its complementarity with other approaches that are outside of what are viewed as "normal" or traditional ways of working with clients. Their concerns with practical issues such as amount of time and the use of videotapes may indicate that the pragmatics of counseling agencies and service providers may inhibit the development of therapeutically useful approaches. Among these pragmatic concerns, the counselors seemed particularly concerned about the use of video with particular client populations. It was clear that the video recording of client-counselor sessions was not the norm in the agencies that these clinicians worked in. Moreover, they expressed concern about heightened possibility of legal challenges in work with this more vulnerable clinical population.
Irrespective of the findings themselves, the research method, which involved an experiential use of focus groups and interviews, points to a heuristic approach for introducing new therapeutic interventions to counselors. It recognizes and respects their expertise and uses experience for the basis of and motivation for learning. In particular in this research, by beginning with the challenges to counseling suicidal clients, the participants were able to relate the procedure to their own practice.
This study is limited by the amount of time devoted to the protocol, that is, one three-hour workshop and one follow-up group discussion or individual interview. According to the counselors, the pragmatic difficulties of implementing videotaping would inhibit their adoption of the procedure being studied in this research. Thus, the research method used in this study may be more suitable for introducing a procedure that has less perceived practical impediments to practitioners.
It is worthwhile noting that the most highly endorsed use of the self-confrontation procedure by these participants was in supervision and training of counselors. In essence, they were able to imagine and support its use in the area in which they had had direct experience. They were also able to clearly differentiate between the traditional uses of video feedback in supervision as compared to the self-confrontation procedure. For further use of the research method used in this study, researchers may find it helpful to augment the experiential part of the process with examples closer to the domain of actual use. In this case, for example, it may have been helpful to demonstrate the use of the self-confrontation procedure with suicidal clients rather than with the counselors themselves.
Acknowledgement: This research was supported by the University of British Columbia's Humanities and Social Sciences, Small Grant Program.
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Natalee Popadiuk is affiliated with the Counseling Psychology Program in the Faculty of Education at Simon Fraser University. Richard A. Young is affiliated with the Department of Educational and Counselling Psychology, and Special Education The University of British Columbia in Canada. Ladislav Valach is affiliated with the University of Zurich in Switzerland Correspondence regarding this article should be directed to Natalee Popadiuk. E-mail: firstname.lastname@example.org.