Bath Spa University
Bath Spa University, Avon, England United Kingdom:
PR4103: Research & the Professional – Masters Programme in Psychotherapy
The PR4103 Assignment: By Russ Henderson M.N.C.P. (Snr Accred)
A Critique of a piece of published research
The hardest words: “exploring the dialogue of suicide in the counselling process – a discourse analysis”
Research Authors: Andrew Reeves, Ric Bowl, Sue Wheeler, Elspeth Guthrie
(Counselling and Psychotherapy Research Magazine: 2004, vol.4, no1)
The Dialogue of Suicide
The particular theme of this piece of research was to analyse the therapeutic dialogue between the counsellor and a group of clients presenting with amongst other problems, suicidal thought.
The research sought to deepen existing knowledge from previous studies into the area of risk assessment. The main aspects under observation were the efficacy of such risk analysis given counsellors and clients work under firmly established contracts of confidentiality, the effect of suicidal disclosure upon the counsellor, and to also look at how and what more the health system can do generally in improving the services counsellors can offer to people presenting with such catastrophic frames of reference. The aims and purposes of this piece of research very clearly outlined the author’s focus of intent into two specific avenues.
Firstly, how do counsellors deal with disclosures of suicidal intent? Secondly once such a disclosure has been made what then are the implications for the client? The backdrop to this was whether there were aspects of the therapeutic dialogue that might either inhibit or facilitate an exploration and assessment of risk.
The research paradigm set out to conduct the counselling work to be undertaken with standardised client actors as opposed to authentic clients. The rationale offered for this was clear in identifying the needs of the client who is presenting with varying degrees of suicidal intention, had to be ethically considered and safely managed in the first instance. The intended research as valuable as it may prove to be did not outweigh the primary needs of the client. Fears and concerns surrounding the amplification of the clients distress if permission was sought for purposes that did not directly attribute to the clients narrative were reasonable obstructions to the use of authentic clients.
This ethical rationale was backed by the success of previous research studies, which used data collated from studies using standardised actors to simulate suicidal themed disclosure. (Scott et al, 1976).
This current research programme used 20 counsellors who were qualified and experienced primary health care intervention workers, all who had been trained inside of psychodynamic and interpersonal therapeutic approaches. All counsellors had given their permission for the videos taken from the simulated sessions to be used for this research project. The actors had been briefed to present with a range of symptoms such as depressive mood, somatised pathology and suicidal thinking.
The clarity of the research aims were straight forward, looking at how counsellors deal with risk along with the ensuing implications for the client and how this process might affect the assessment of risk inside of the therapeutic relationship.
The author’s main research thrust, was the notion of harm and how counsellors effectively assess that harm. This area of concern was directed to both client and counsellor.
The ethical dimensions of directly becoming involved in what is ultimately the existential decision of the client, with the juxtaposition of the counsellor’s common humanity to intervene when suffering is deemed to be overwhelming, was plainly evident.
Concern was also raised by the authors, that risk assessment tools currently used within the formal settings inside of our health care system are not readily transferable into the dynamics of the Person Centred Counselling domain. Issues of “power sharing” with the client may hinder therapeutic work inside of a Rogerian based counselling forum. However this generalised perspective is coming to be viewed as an outdated notion given that all health care professionals across the U.K. should work to common assessment frameworks when dealing with issues of destructive mental health. (Kindon S. 2002).
The researchers put much focus upon commonly accepted thinking paradigms such as how counsellors approach their work, contracting issues and confidentiality, awareness of ethical boundaries etc.
The altruism of the therapist in tandem with their momentum of practical benevolence contrasting alongside the clinical assessment process clearly highlighted the empasse counsellors in this predicament faced. This complex landscape of opposition evoking a polarity of moral versus clinical was cleanly dealt with by the authors.
However the empasse was clearly evident. The critical interplay of both objectivity and subjectivity was undoubtedly animated by the research topic, on the one side was the person who had lost the will to survive yet in accordance with our cultural values and beliefs has the right to choice, sat opposite a member of the comminuty attempting to elevate the informed nature of the clients choice.
The authors opted for “discourse analysis” not a specific methodology of research enquiry in itself, yet quite similar in concept to that of “Interpretive Phenomenological Analysis”, a process of exploring in detail the participants view of the topic under investigation” (Smith J. Jarman M. & Osborn M.1996).
Another strand of the rationale to use this method of data collection was so that the focus of the research could reflect back into the direct experiences of those involved to heighten and deepen their own ontological and epistemological views of themselves and their worlds. The authors placed much emphasis for their choice of discourse analysis upon the citations of Palmquist 2004, Stubbs 1983 and Mcleod 2001, discourse analysis supposedly reducing the possibility of duplication when anaylising complex data, and also amongst other elements would give the authors greater dimension to really see what is making the difference within the therapeutic dialogue.
Stemming from discursive psychology (Willig C 2001) discourse analysis would give the authors the freedom to explore the dynamic interactions between the observer and the observed. The focus on critically analysing the discourse, it was hoped, would elicit a greater understanding of what actually works when accessing risk, complemented by what may be the inhibiting componentry.
The authors detailed some background as to why they had chosen discourse analysis as a mechanism for the methodological acquisition of their data. Discursive psychology has clinical background expertise in working with Male issues of crisis, low affect, understandings of bulimia and Female depression (Margison et al 2000). Given that the discourse of suicide was always going to be a subjective and contentious arena for the researchers to deliberate their findings inside of, the rationale for discourse analysis as a chosen method of examining the subsequent data appeared appropriate and proportionate for the task.
The data from the sessions between the counsellors and the clients were primarily recorded onto video tape, and then typed verbatim into transcripts. These transcripts “included pauses, hesitations, interruptions, and some non verbal-communication such as sighs”. The authors took in total 16 transcripts which were completed, 4 other transcripts were omitted because of corrupted soundtracks. During the process of transcribing, “response notes” were taken to record the researchers responses and thinking strategies.
The authors attempting to gain an “insiders perspective” of their subjects worlds. (Conrad P. 1987) When the actual discourse came to be evaluated, these notes then gave access to a re-enhanced understanding of the therapeutic dialogue.
The notes also assisted in identifying the researcher’s ontological and epistemological views of hers / his internal worlds thus reducing the altitude of hypothetically themed analysis.
However the intensity as to how the counsellor can identify and differentiate just what is risk and what is fantasy thus supporting the client in a more cohesive manner, is likely to reveal that there will inevitably be doubt and uncertainty. (West W. 2002)
The amount of information alluding to suicidal preoccupation would be the deciding influential factor to which counselling approach seemed to be the most effective. The therapeutic strategy had decided upon using a psychodynamic approach therefore the process of eliciting information from the client in order to assess the amount of risk the client was facing would be the reflective or the explorative approach, and obviously counsellors adopt a combination of both.
Brief reference was made to research per se showing psycho-social difficulties such as relationship breakdown, alcohol / substance misuse etc. as contributory factors which might give rise to suicidal preoccupation, conversely this piece of research made no mention whatsoever of the clients social status, gender, ethnicity, age, occupation, existing pathology, previous mental health, medication, etc.
Research over recent years focussing upon troops returning from combat inside of Iraq clearly shows distinct correlates between co-morbidity and suicidality. (Andrade J & Feinstein D 2004) None of this crucial information was made available for the reader, therefore the subject of suicide stood in total isolation. (Tyrer P. & Casey P. 1993)
Such crucial data would aslo determine the modality of the counselling approach to be used. Clients presenting with acute stress disorders, or post traumatic stress related symptoms would be unlikely candidates for a psychodynamic approach. The option of suicide would likely become amplified and more entrenched under deep scrutiny by the counsellor. (Koss M. & Shiang J. 1994)
The researchers then went onto evaluate the discourse between the counsellor and the clients.
This evaluation looked at the transcripts taken from video recordings of the sessions also using “response notes” taken during the pieces of work to identify the observer’s assumptions and reflections during the transcript scrutiny. The counsellors appeared to be adopting a reflective approach, indicating that the counsellor’s domain of influence may on some level be defined by the position taken by the client.
There were 2 tables in the published article. The first table exampled some of the transcripts of the clients “discursive object of suicide” which gave only very brief sentences of what the client was to have said such as “Might get away – do myself in”, which was complemented in the table by a brief forwarding paraphrase “Do myself in”.
To give a further flavour of the transcripts from the clients perspective, sentences such as “It’s useless, just a waste – there’s no point” and “Yeah I feel like I’m er – I don’t belong anywhere in life” were included.
The second table gave examples of counsellor responses to the “discursive object of suicide” for example “I’m getting the impression” and “So I think I’m hearing” also “Is that something you could tell (share with) me”?. The research did conclude that the counsellors who used a predominantly reflective approach seemed to glean less insight into the world of their client; therefore an ability to heighten the analysis of risk factors became somewhat diminished.
This became an area of concern for the authors, as notions of collusiveness and preoccupations relating to the counsellors own ontological assumptions of her / his worldly thinking were possibly contaminating the work.
Given that this was a “staged” experiment, and that the clients were indeed actors, also in the absence of very salient information for the reader to see such as client histories etc., just by reading the very brief glimpses of the sentences from the transcripts, which was the living testimony of some of what was said, it seemed impossible to substantiate actually what had happened, plus also what might have made the research more thorough in it’s presentation, this is not a criticism, merely an observation.
The major ethical issue became very apparent at the beginning of the research, by the decision to use actors as opposed to “real clients”.
The research authors made it clear that it was not in their opinion ethically viable to request permission from a client presenting with suicidal intent, as this would likely to be a distraction from their client’s narrative of pain, possibly increase suicidal thinking, and likely to reduce any disclosure in the first instance. Few counsellors in this study, did not use the word suicide, neither did their clients. The presence of collusion did not seem in isolation to any transcript. Perhaps this was an effect the counsellor may have had on the client, it is however a possibility that the counsellor whereby using a predominantly reflective approach, never gave explicit permission for the client to break through the surface to what they were so obviously alluding to, again in the absence of further information it is difficult to ascertain what was going on.
An awareness and sensitivity towards the ambivalence of the client towards suicide as a possible viable alternative to their distress was noted in their conclusion. As stated earlier the ethical dilemmas weathering the counsellor is an extreme dynamic which will rely heavily upon the science of supervision for future clarity and expanded thinking. The article transcripts did not appear to raise the issue of “affective expression”, the process whereby the counsellor seeks to gauge the emotional literacy of the client, an area which would be so vital inside of the topic concerned. (Worden J. 1983)
It was clear that risk assessment inside of the counselling environment for clients presenting with harmful preoccupations was very different to that of other health care personnel working inside of other mental health settings. The counsellor works very much in isolation, the therapeutic alliance or the contract is very different.
Using the methodology of discourse analysis proved to be interesting, it certainly provided information which could be critically examined for observer effects, successful therapeutic interventions, and educating the counsellor as to how they may improve their style of interaction.
The research did not mention transference and counter transference. This would undoubtedly be a major impact contributing to both the observer and observed communication styles and presentations. Given the complexities of discourse around suicide, each person would become more individual in their quest for recognition. (Berne E. 1964)
The challenge for counsellors is to acknowledge the propensity the dynamic of projection has for affecting the communication patterns inside of the counselling forum.( Margison et al 2000) We are also reminded that uncovering defensive strategies of clients, assists them in identifying their unconscious “phantasies” inside of their relationships. (Clulow C et al 2002)
Researcher effects when working with suicidality, such as passivity, being stuck, out of depth, becoming angry, isolated etc. were identified as major counter transferential components by the Psychoanalyst Paula Heimann back in 1950, where she observed many “candidates” becoming afraid and guilty when they become aware of their feelings towards their patients. (Heimann P. 1950)
The research appeared well planned and clearly presented, void of complexity, and written in a style readily available for most. The authors ideas and focus were succinctly interpolated with avenues of research clarity. The final collation regarding the gradual unfolding of the research was done with fluidity and sensitivity.
This has been an interesting piece of research to critique, as there are numerous opportunities to search for material that would corroborate and or challenge the notions presented in the authors work. The researcher effects and ethical dimensions were of interest; however the absence of crucial information as to the clients mental health was a major omission as the subject matter stood alone. A definite sense of “gravitas” underpinned the work; the sheer finality of which the counsellor is facing heightened the enormity of the problems the research was attempting to unravel. Virtually nothing was mentioned as to the significance of the therapeutic relationship itself regardless of the therapeutic modality being used.
An important conclusion was that counselling as a treatment option for members of the community presenting with mental health distress cannot be overstated. (May T 1993) Aside from the ethical dilemnas inherent inside of the counselling discourse of suicide, the research did for me highlight the possibility that the counsellor may actually confirm to the client that the isolation in which they live at that moment in time is to great to endure and the final solution of suicide is indeed a viable means to an end. As a therapist who has lost a young client to suicide this is indeed a harsh landscape to walk.
Berne, E. (1964). Games people play. Penguin press. (p.14)
Andrade, J. & Feinstein, D. (2004). Energy psychology. Theory, indications, evidence. Appendix, pp 199 – 214, Ashland, Or, Innersource
Clulow, C. Shmueli, A. Vincent, C. Evans, C. (2002). Is empirical research compatible with clinical practice? British journal of psychotherapy Vol. 19 (p. 1)
Conrad, P. (1987).The experience of illness: recent and new directions. Research in the Sociology of Health Care.6: (p.1-31)
Heimann, P. (1950). On counter transference. International journal of psychoanalysis. 31. (p.81 – 84)
Kindon, S. (2002). Common ground for common assessment. Strategy publications. (p. 14)
Klamen, DL. Yudowsky, R. (2002). Using standardised patients for formative feedback in an introduction to psychotherapy Course. Academic Psychiatry. 26 (3): (168-72)
Koss, M. Shiang, J (1994). Research on brief psychotherapy. In A, Bergin, & S. Garfield, (Eds). Handbook of psychotherapy and behaviour change. (pp 664 – 700), New York: Wiley
May, T. (1993). Values and ethics in the research process. Social research magazine. Oxford University Press (p.33)
Margison, FR. Barkham, M. Evans C. Mcgrath, G. Clark, J. Audin, K. Connel, J. (2000). Measurement and psychotherapy. Evidence based practised and practise based evidence. British journal of psychiatry 177 August (p.123 – 130)
Mcleod, J. (2001). Qualitative research in counselling and psychotherapy. London: Sage Publications.
Palmquist RA. (2004). Discourse Analysis. The university of Texas graduate school of library and information Science. www.glis.utexas.edu/-palmquis/course/discourse.htm [accessed 18.4. 2008]
Scott, N. Donnelly, M. Hess J.(1976) Longitudinal investigation of changes in interviewing performance of medical students. Journal of clinical psychology. 32: (p.424 – 31)
Smith, A. Jarman, A. Osborn, M (1996) Doing interpretive phenomenological analysis. Quality health psychology ch. 14. (p. 218)
Tyrer, P. Casey, P. (1993) Social function in psychiatry. ch.5. (p. 78)
West, W. (2002) Some ethical dilemmas in counselling and counselling research. British journal of guidance and counselling. Vol. 30. No. 3
Willig, C. (2001) Introducing qualitative research in psychology. Adventures in theory and method. Buckingham Press
Worden, J. (1983) Grief counselling and grief therapy. Third edition. Brunner – Routledge. c. 7. (p.152)