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Article Excerpt
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.
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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...
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