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COUNSELOR PERSPECTIVES ON SUICIDE AND SUICIDAL IDEATION:
A QUALITATIVE STUDY
STEPHEN GERARD LUSSIER
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
TABLE OF CONTENTS
L IST O F T A B L E S .................................... ........................................ .. .v
LIST OF FIGURES ..................................... vi
ABSTRAC T ............. ............ ............................... viii
1 INTRODUCTION ................... .................. .............. .... ......... .......
Purpose of the Study ................... ............................ ................ .. ......... ..2
Im portance of Suicide.........................................................................2
Reactions to Suicide ............... ...... .. ..................................4
The Importance of Counselor Beliefs and Attitudes ....................................... .6
Summary...................................... .................. .............. ........9
2 REVIEW OF LITERA TURE .............................................................................. ......12
American Attitudes Related to Death and Dying .....................................................12
American Attitudes Related to Suicide............................... ...............28
Counselor Attitudes Related to Suicide...............................................31
Similar Counselor Attitudes and Personal Experience.............. ...33
Fragmented Counselor Attitudes and More Cognitive Considerations.............34
D efinitional Issues ................... .... ............................. .................. 36
Suicide ............... ................... .............. .36
Suicidal ideation............. ... .............. 40
Theoretical Grounding.......................... ....... ............. 41
Theoretical Grounding for the Research Question............................................41
Cognitive Consonance and Dissonance......................................43
Ethical D ecision-M aking...................................... ................... ............... 51
Theoretical Grounding for the Research M ethod..............................................56
Credibility and trustw orthiness .............................................. ......58
Methods used to establish trustworthiness............... ...............59
Triangulation ........................................ ...... ...... 62
Theoretical Grounding for the Interview Process .......................................... 64
General issues of reflexivity........................... ................... 65
Purpose and Relevance to Practice ............... ........................ 68
R elevance to Practice ................................................. ............... 68
3 M ATERIALS AND M ETHODS ........................................................ 76
Research M ethod .......................................... .. ...............76
Grounded Theory................ ................. 78
D ata C collection ................... ........ ............ .... ..... .......... ........ 79
Sam ple questions ....................................... ........ ........ ................ 8 1
Participants .............................. ............................... .......82
Interview logistics .............................. .............. .............. 85
Data Analysis................................ ........86
Pilot Study ................................................88
Interview ..................... ............ ..................89
Field Notes ................................. ....... ...............90
Transcription and Software ........................................ .................90
Themes ...................... ... ................................ 90
Relevance to Research Proposal ........... ............................. ........90
Summary ........................ .............................. ..........91
Researcher Bias Statement ............................................... ........93
4 DATA ANALYSIS ........................................ ........96
Answering the Question .................................................. ........96
Developing Thematic Patterns................................................... 100
Counselor Beliefs ................................................. .........102
Feelings of hopelessness ................................................102
Suicide as an option.................. ........ ....................................103
Counselors' own personal suicide ideations ........................................106
Appropriate action........................ .....................106
Theme: Human worth....................................... .........109
Theme: The ripple effect........................... ........................... 110
Theme: Religious beliefs .................. ............... ..............111
Counselor Emotions ................................ .................113
Theme: Feelings of professional failure and self-doubt...........................113
Theme: Feelings of responsibility ..............................................................114
Themes: Feelings of responsibility and counselor age................ ....1.........115
Unfettered feelings ........................... ........................ 116
Steps in Developing a Data-Analysis Model ......................... ...............117
Explanation of the Data-Analysis Model ..................... ..............123
Interpretation of the Data-Analysis Model....................... ............124
Perceived role of counselor............. ... ... .............125
Willingness to hospitalize against client's will ............... ...........126
Perceived responsibility ........................................ ..... ........ 127
Counselor emotional response ....................................... .. ......129
Counselor religious identification ............ ..................................... ......130
Counselor's age / experience......... ...........................................131
Counselor's personal suicide history........... ................. .... ......... 133
Ancillary Them es .................. ............... ................... 133
Disability and illness factors ......................................... 134
Suicide vs. other forms of death....... .............................................134
Issues of counselor training ................................................................... 135
Saturation .............................................................................................. 135
5 DISCUSSION ............... .... ........................... 137
Study Findings and the Previous Literature...... ............... .....................137
Suicide as a Possible Alternative.................................... ........ 138
Suicide as an Option (But Not For My Client)............... .... ...............139
Conditions of Cognitive Consonance and Dissonance...............................141
Condition of Cognitive Consonance .....................................141
Conditions of Cognitive Dissonance.......................................143
Six Possible Scenarios of Cognitive Dissonance ....................... 144
Legal or professional sanctions ................. ........ .. .................... ......... 144
Com peting ethical principals.............................. ..... ......... 145
Limited client numbers....... ......... ............. ............ 148
Special conditions of hospice............. ..................................... ......... 149
Personal experience ......... ........ ...... .. ....... .............. 151
R ole of the counselor.................................................. 153
False disclosure.......................... ........................157
Study Themes and the Previous Literature...................................159
Themes ......................... .............................. 160
Perceived role of counselor....................... .................. 160
Willingness to hospitalize against a client's will to prevent suicide.......... 162
Perceived responsibility for client suicide ..................................... 165
Counselor emotional response ...........................................167
Counselor religious identification .............. ........... ...... ......... 168
Counselor's age / experience............................. ........ 169
Counselor's personal suicide history......... ................... 171
Implications for Training, Clinical Practice, and Future Research ........................172
Counselor Training ................. .... ..............................................172
Clinical Practice......................................... .........174
Future R research ................... .................................. ...... .. ........ .......... .... 176
A m multicultural approach................................ ................... 177
INFORMED CONSENT FORM ........................................................179
LIST OF REFEREN CES ..................................... ................... .....185
BIOGRAPHICAL SKETCH ................................................ ............... 202
LIST OF TABLES
4-1. Participant D em graphic Profiles............................................................... .....96
4-2. Hopelessness............................ .......... ......... 99
4-3. Did the participant ever share in this sense of hopelessness with client?..............1...00
4-4. Over-all sim ilarities and differences........................ .........................................113
4-5. Suicide as a Possible Alternative: Final Table of Possible Connections...............1.19
LIST OF FIGURES
2-1. Stages of Dying. .............................. .......................... ........ 25
2-2. Integrative Decision-Making Model of Ethical Behavior. ............... ...............53
4-1. Data-Analysis Model: Possible Connections ................. ................. ...........120
4-1. Continued......................................... ........ 121
4-1. Continued......................................... ........ 122
4-2. Data Analysis Model: Suicide As A Possible Alternative Step 1 .......................123
4-3. Data Analysis Model: Suicide As A Possible Alternative Step 2 ......................124
4-4. Perceived Role of Counselor ...................... ......................125
4-5. Willingness to Hospitalize............................... .........126
4-6. P perceived R responsibility ..................................................................................... 128
4-7. Counselor Emotional Response....... ......... ...................129
4-8. Counselor Religious Identification.................. ......................... .. .......... 130
4-9. Counselor's Age/Experience .................. ......... ..............132
4-10. Counselor's Personal History of Suicide..... ................ ......... 133
5-1. Suicide as a Possible A lternative................................................ 138
5-2. Counselor Having Such a Client ................................... ...... ............... 140
5-3. Perceived Role of Counselor ............................... .............161
5-4. Willingness to Hospitalize.................... ......... ....... .........162
5-5. P erceiv ed R espon sibility ..................................................................................... 165
5-6. Counselor Em otional R esponse.......................................................... ......................167
5-7. Counselor Religious Identification................ ............................ ........ 169
5-8. Counselor's Age ...................... ......... ........ ... ...............170
5-9. Counselors Personal History ................. ........... ...................171
Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
COUNSELOR PERSPECTIVES ON SUICIDE AND SUICIDAL IDEATION:
A QUALITATIVE STUDY
Stephen Gerard Lussier
Chair: Linda Shaw
Major Department: Rehabilitation Science
Suicide has long been a significant concern for the counseling profession. Suicidal
clients are likely to present a myriad of ethically challenging issues ranging from suicide
prevention through considerations of suicide as a rational therapeutic option. This
qualitative study approaches these challenges to the counseling profession by
investigating the relationship between a counselor's personal beliefs about suicide and his
or her attitudes toward clients expressing suicidal ideations.
Grounded Theory was the research method used to conduct this study. Data were
collected through individual interviews, coded for thematic patterns, and analyzed by the
process of constant comparison. All participants were professional counselors.
From the data, two basic and conflicting beliefs emerged, seemingly rooted in
convictions about suicide. Participants were divided into two discrete camps contingent
on the belief that either (a) suicide might be appropriate for some people, or (b) suicide is
never appropriate for anyone. Numerous counselor attitudes toward clients expressing
suicidal ideations surfaced, each appearing contingent on this basic belief dichotomy. A
data-analysis model is presented, detailing possible connections among these mutually
exclusive beliefs, and such attitudes as a counselor's perceived role toward a suicidal
client, willingness to involuntarily hospitalize a potentially suicidal client, perceived
responsibility for client suicide, level of emotional response associated with client
suicide, identification with a religion or religious belief system, age and professional
experience, and personal suicide history.
Perhaps the most intriguing finding was that no counselor reported ever having
treated a client for whom he or she deemed suicide to be an appropriate alternative.
Discovering this to be the case for participants believing that suicide might be appropriate
for some people, this attitude was labeled suicide as an option (but not for my client).
Cognitive dissonance theory was used to explore this and all other combinations of
attitudes and beliefs, to help understand the relationship between a counselor's personal
beliefs about suicide, and his or her attitudes toward clients expressing suicidal ideations.
Finally, implications for counselor training, clinical practice, and future research were
A vast body of literature addresses suicide as an important issue for the counseling
profession. During the course of their careers, most counselors will encounter at least one
consumer with suicidal ideations (Carney & Hazler, 1998; McAdams & Foster, 2000;
Rogers, 2001). These counselors potentially confront a myriad of ethically challenging
suicide-related issues ranging from suicide prevention (Davidson, Wagner, & Range,
1995) through considerations of suicide as a rational option in therapy (Werth &
Holdwick, 2000). Many counselors lack the knowledge and information required for the
competent assessment of a potentially suicidal client (Carney & Hazler, 1998); and even
those possessing this knowledge often find themselves in profound ethical conflict
regarding treatment options (Lester & Leenaars, 1996; Corey, Cory & Callanan, 1998;
This conflict appears to represent a considerable diversity of counselor attitudes
toward suicide. Some counselors advocate suicide prevention in all cases (Richman,
1992) while others sometimes view suicide as a viable option (Rogers, Guiulette, Abbey-
Hines, Carney & Werth, 2001). Even counselors in the same professional organization
hold differing attitudes toward suicide, as evidenced by member reactions to an amicus
curiae [friend of the court] brief filed by the American Counseling Association (ACA)
(Werth & Gordon, 2002) in favor of Oregon's Death With Dignity Act (1997). These and
other examples of counselor attitudinal diversity toward suicide are discussed later.
Developing a better understanding of beliefs underlying the diversity of counselor
attitudes toward suicide is at the core of much of the counseling literature on this topic
(Neimeyer & Neimeyer, 1984; Moritz, Van Nes & Brouwer, 1989; Lester & Leenaars,
1996). Part of the motivation behind this professional interest may be the high level of
importance associated with counselor beliefs and attitudes in the context of counselor
competence. Knowledge of counselors' beliefs and attitudes is said to augment counselor
competence in a variety of ways, from enhancing counselor education (Westefeld, Range,
Rogers, Maples, Bromley & Alcorn, 2000), to ethical decision-making (Laux, 2002).
Specific research exists pertaining either to counselors' individual personal beliefs about
suicide, or to their attitudes toward clients expressing suicidal ideation. Yet little
research indicates what, if any, relationship exists between a counselor's personal beliefs
about suicide and his or her attitudes toward clients expressing suicidal ideations. This
study aimed to help fill this information gap by answering the following research
question. What is the relationship between a counselor's personal beliefs about suicide
and his or her attitudes toward clients expressing suicidal ideations?
Purpose of the Study
Importance of Suicide
It has been argued that the greatest influence on culture is death and dying (Aries,
1974; Glaser & Strauss, 1965, 1967; Kubler-Ross, 1969, 1975). Suicide is now the eighth
leading cause of death in the United States (Centers for Disease Control, 2002) and
would likely be ranked even higher were it not for societal attitudes heavily biased
against declaring suicide as the cause of death (Fulton & Metress, 1995). Death by
suicide differs from most other forms of death (e.g., heart disease, cancer, accidents) in
that suicide carries with it a powerful social stigma, a particular type of disgrace (Moller,
1990) not present with most other deaths (Lester, 1993; Ingram & Ellis, 1995). Moller,
Lester, and Ingram and Ellis assert that the stigma associated with suicide reflects on the
suicidal person as being a weak, cowardly, and immoral individual. The relatives of a
suicidal person (especially the parents) often find themselves cast within a similar
penumbra of stigma and blame (Lester, 1990). According to Lester (1990, 1997),
survivors of suicide are often treated unsympathetically by society and sometimes blame
themselves for the suicide of a loved one. Other studies show that counselors of clients
who have committed suicide are also prone to self-blame and recrimination (Chemtob,
Hamada, Bauer, Kinney & ToriGoe, 1988; Moritz et al., 1989; Menninger, 1991; Little,
1992; McAdams & Foster, 2000). Yet between 66 and 80% of those who do commit
suicide tell someone, often their counselor, of their intent (Grollman, 1988; Brems,
2000). Studies show that most counselors will encounter at least one consumer with
suicidal ideations (Carney & Hazler, 1998; McAdams & Foster, 2000; Rogers, 2001), and
that there is a 20% chance that a client will be successful in a suicide attempt (Bongar,
Considering the significant effect of death on culture, the high prevalence of
suicide as a particularly stigmatizing form of death in the United States, and the
likelihood of counselors encountering potentially suicidal consumers, it is not surprising
that a vast body of research attests to the importance of suicide to the counseling
profession (Lester & Leenaars, 1996; Neimeyer, 2000; McAdams & Foster, 2000; Rogers
et al., 2001; Laux, 2002). In their article, The ci/i \% of suicide and suicide prevention,
Lester and Leenaars (1996) debate and disagree on numerous ethical issues related to this
topic. Neimeyer (2000) illustrates the importance of such ethical dilemmas to the
counseling profession with specific attention to counselor training. He points out that the
current state of inadequate counselor training in the areas of suicide and suicide
prevention "leaves trainees substantially unprepared for managing the complexity of
actual suicidal crisis" (Neimeyer, 2000, p. 551). McAdams and Foster (2000) further
underscore the severity of this problem. The study by Rogers, Guiulette, Abbey-Hines,
Carney & Werth (2001) found that practicing counselors disagree with one another and
sometimes with their own professional codes of ethics, about issues related to suicide and
its prevention. Laux (2002) outlined the need for counselors to improve their
understanding of suicide in such areas as theory, risk assessment, intervention,
prevention, postvention, and training. As recently as April of 2003, the ACA Ethics
Committee published an outline of procedures to help members interpret the ACA Code
of Ethics concerning end-of-life issues (Hubert, 2003).
Much of the existing research pertaining to counseling and suicide seems to
indicate an unclear connection, and perhaps inconsistent relationship, between
counselors' personal reactions to their own consumers expressing suicidal ideations, and
counselors' reactions to the more abstract concept of death by suicide. This is of
particular significance because of the impact such inconsistencies may have on counselor
behaviors in the client-counselor relationship. The following is a description of this
uncertain connection, its influence in the client-counselor relationship, and a discussion
of why such an influence is important to the counseling profession.
Reactions to Suicide
Studies on the personal reactions of counselors to their own consumers expressing
suicidal ideations find significant uniformity of reactions. A number of similar studies
(Chemtob, Hamada, Bauer, Kinney & ToriGoe, 1988; Moritz, Van Nes & Brouwer,
1989; Menninger, 1991; Little, 1992; McAdams & Foster, 2000) found client suicide to
be the therapist's most frequently named cause of anxiety. According to these studies,
many therapists viewed the suicide of a client as a professional failure on their part. In
addition to questioning their own professional competency, the most common emotional
responses to such an event included feelings of guilt, anger, and sadness.
Counselor reactions to the more abstract concept of death by suicide are more
fragmented. Two clear examples of this may be found in the current counselor debate
over rational suicide (Richman, 1988; Albright & Hazler, 1992; Rogers et al., 2001), and
counselors' reactions to the recent Supreme Court battle over Oregon's Death with
Dignity Act (1997).
Briefly, rational suicide is a term used to describe the conditions under which
suicide would be considered by both the counselor and consumer to be a rational choice
(Rogers et al., 2001). Proponents believe that some cases exist in which suicide is a
rational alternative. This greatly concerns others who argue against even the concept that
suicide could ever be a rational act (Richman, 1992), or that it is the moral duty of all
healthcare professionals to prevent suicide (Elitzur, 1995).
Oregon's Death with Dignity Act (1997) was contested before the United States
Supreme Court in the 1996 case of Quill v. Vacco. Several Amicus curiae [friend of the
court] briefs were filed both for and against implementation of the Act. Prominent
professional counseling organizations joined both sides (Werth & Gordon, 2002). Further
demonstrating the lack of consensus on this issue were clear signs of dissension among
the ranks of the organizations themselves. The debate over the decision by the ACA to
join the brief in favor of the Death with Dignity Act continues today (Donaldson, Patton
& Wood, 2002; Bennett, 2002).
The Importance of Counselor Beliefs and Attitudes
This uncertainty in the relationship of beliefs and attitudes held by counselors about
suicide as a general construct, and toward those individuals expressing thoughts of
suicide is at the core of this research question. The relationship between a counselor's
own personal beliefs, and his or her attitudes toward suicidal consumers is important to
understand, because of the impact it may have on counselor behaviors in the client-
The quality of the counseling relationship, sometimes called the therapeutic
relationship or working alliance, is generally considered to be the most important factor
contributing to consumer growth and well-being in the context of professional counseling
(Goldstein, 1962; Gladding, 1996; Walborn, 1996). "The successful outcome of any
counseling effort depends on a working alliance between counselor and client"
(Gladding, 1996, p. 142). Goldstein (1962) states, "There can no longer be any doubt as
to the primary status which must be accorded the therapeutic transaction" (p. 105).
Walborn (1996) asserts that possibly all schools of therapy recognize the primacy of the
The general link between personal beliefs and behavior has been firmly established.
Virtually all personality theorists recognize that a connection between the two exists.
Albert Ellis, founder of the theory of Rational-Emotive Therapy (RET) (Ellis & Grieger,
1977), later to become REBT with the addition of "Behavior" to the title, states:
We largely (though not exclusively) control our own destinies, and particularly our
emotional destinies. And we do so by our basic values or beliefs by the way that
we interpret or look at the events that occur in our lives and by the actions we
choose to take about these occurrences (p. 5).
Similar views, regarding the link between personal beliefs and behavior, are found
throughout the literature related to counseling and consumer suicide. For example, in
their discussions of euthanasia, Albright & Hazler (1995) argue that beliefs and attitudes
are cultural derivatives that eventually determine individual behavior. Werth & Holdwick
(2000) consider the debate over rational suicide and, citing the work of Fenn & Ganzini
(1999) and Ganzini et al. (1996), state, "Professionals who believe that a person should
not be allowed to have aid-in-dying may try to use their role as an individual's therapist
(or the evaluator of whether the person has impaired judgment) to try to prevent the client
from hastening death" (p. 526).
Viewed from the perspective of cognitive dissonance theory, the attitude of the
counselor toward the consumer may be seen as a bridge between belief and behavior.
Both beliefs and attitudes are, in essence, cognitions. These two cognitive elements will
either concur or conflict (Festinger, 1957). According to the theory of cognitive
dissonance, this concurrence or the resolution of this conflict is the major determinant of
a person's behavior.
Since there is a strong likelihood that counselors will encounter consumers
expressing suicidal ideations, a counselor's own personal beliefs and attitudes toward
such a consumer are, therefore, subject to concurrence or conflict as represented in
cognitive dissonance theory. Two possible kinds of cognitive relationships may exist.
These two cognitive elements will either concur or conflict. Either of these situations,
concurrence or conflict among beliefs and attitudes, may or may not be cognitively
problematic for the counselor.
One possible cognitive relationship would be that a counselor's beliefs and
attitudes are in congruence. Using the language of cognitive dissonance theory, these two
cognitions are considered to be consonant. Consonant cognitions psychologically
presuppose one another (Festinger, 1957). According to cognitive dissonance theory,
consonance is not an impetus for behavioral change. The counselor is likely to continue
the current therapeutic course. For example, believing suicide to be immoral would
reflect an attitude of consonance when using no-suicide agreements with suicidal clients.
Since consonance is not an impetus for behavioral change, the counselor is likely to
continue using no-suicide agreements with his or her clients. Ethical problems related to
consumer autonomy are possible in such a situation. The counselor, being without
motivation in this circumstance, is unlikely to seek out potential ethical dilemmas.
The other possible cognitive relationship would be that a counselor's beliefs and
attitudes conflict with one another. Using the language of cognitive dissonance theory,
the counselor is experiencing cognitive dissonance (Festinger, 1957). Cognitive
dissonance occurs "whenever a person has two or more cognitions that are dissonant
[having an obverse relationship] with regard to each other" (Wicklund & Brehm, 1976,
p. 2). According to cognitive dissonance theory, dissonance is an impetus for behavioral
change. The counselor is likely to alter the current therapeutic course. For example,
believing suicide to be a matter of personal ethical autonomy might reflect an attitude of
dissonance when feeling duty-bound to use no-suicide agreements with suicidal clients.
Since dissonance is an impetus for behavioral change, the counselor might choose to
discontinue using no-suicide agreements with his or her clients.
In either case, the relationship between a counselor's own personal beliefs and his
or her attitude toward a client expressing suicidal ideations is important to understand,
since this relationship influences the therapeutic alliance. According to the theory of
cognitive dissonance, the tendencies of belief and attitude to either concur or conflict is
the major determinant of a person's behavior. Since the person's (in this case the
counselor's) behavior is of the utmost importance to the therapeutic relationship, the
determinants of this behavior must also be of vital importance. In the case of a suicidal
consumer, these vitally important behavioral determinants are the counselor's own
personal beliefs about suicide and his or her attitudes toward a consumer expressing
suicidal ideations. Even more specifically, the counselor's behavior in the therapeutic
alliance is governed by the relationship that exists among these beliefs and attitudes.
Uncovering the nature of this relationship is the goal of this research question.
Death and dying are arguably two of the greatest influences on human culture.
Suicide, a particularly stigmatized form of death and dying, is now the eighth leading
cause of death in the United States. Between 66 and 80% of those who do commit suicide
tell someone, often their counselor, of their intentions. Studies have shown that most
counselors will encounter at least one consumer with suicidal ideations, and that there is a
20% chance that a client will be successful in a suicide attempt.
Considering the significant effect of death on culture, the high prevalence of
suicide as a particularly stigmatizing form of death in the United States, and the
likelihood of counselors to encounter potentially suicidal consumers, it is not surprising
that a vast body of research attests to the importance of suicide to the counseling
profession. However, debate and disagreement currently exist on numerous points of
ethics related to this topic. Literature suggests that a current state of inadequate counselor
training in the areas of suicide and suicide prevention "leaves trainees substantially
unprepared for managing the complexity of actual suicidal crisis" (Neimeyer, 2000, p.
551). Practicing counselors often disagree with one another and sometimes with their
own professional codes of ethics about issues of suicide and its prevention (Albright, &
Hazler, 1992; Bongar, 1992; Davidson, Wagner & Range, 1995; Battersby, 1997).
Much of the existing research pertaining to counseling and suicide indicates a
complex and unclear relationship among counselors' personal reactions to their own
consumers expressing suicidal ideations, and counselors' reactions to the more abstract
concept of death by suicide. This is of particular relevance because of the impact of
counselor beliefs and values on counselor behaviors in the client-counselor relationship.
Nearly all schools of therapy agree on the primacy of the therapeutic relationship to a
positive therapeutic outcome, and virtually all personality theorists recognize a link
among personal beliefs and counselor behaviors that result in the development of a strong
therapeutic alliance. The perspective of cognitive dissonance theory, when applied to the
attitude of the counselor toward the consumer, may be seen as a bridge between belief
Therefore, it is the intent of this study to help answer the question: What is the
relationship among a counselor's personal beliefs about suicide and his or her attitudes
toward clients expressing suicidal ideations?
* Attitude: individuals' affective perspective or disposition, reflecting their general
expectancy of a situation, based on their underlying beliefs. Attitude is the
component of communication that is an affective perspective based on cognitive
beliefs (Long, 1996, p. 110). "An idea charged with emotion which predisposes a
class of actions to a particular class of social situations" (Triandis, 1971, p. 2)
* Belief: "A mental state as in when one accepts a proposition as true (judges it to be
true) and is prepared to act (mentally or physically) on this basis" (Aydede, 2003.
* Physician-assisted suicide: "The process by which "the physician provides a
patient with the medical means and/or medical knowledge to commit suicide"
Glasson, 1994, p. 92).
* Rational suicide: "Following a sound decision-making process, a person has
decided, without being coerced by others, to end his or her life because of
unbearable suffering associated with terminal illness" (Werth & Holdwick, 2000, p.
* Suicide: "Death from injury, poisoning, or suffocation where there is evidence
(either explicit or implicit) that the injury was self-inflicted and that the decedent
intended to kill himself/herself' (O'Carroll et al., 1996, pp. 246-247).
* Suicidal ideation: literally refers to thought, or ideas, about suicide. However,
since such ideations are so inherently private, this study uses this term to describe
"Any self-reported thoughts of engaging in suicide-related behavior" (O'Carroll
et al., 1996, p. 247).
* Suicide-related behavior: Potentially self-injurious behavior for which there is
explicit or implicit evidence either that (a) the person intended at some (nonzero)
level to kill himself/herself, or (b) the person wished to use the appearance of
intending to kill himself/herself in order to attain some other end (O'Carroll et al.,
1996, p. 247).
REVIEW OF LITERATURE
This literature review concerns the following research question. What is the
relationship between a counselor's personal beliefs about suicide and his or her attitudes
toward clients expressing suicidal ideations? Comprising five sections, this review asserts
the importance and shows the relevance of this study. "Section One: American Attitudes
Related to Death and Dying" discusses American attitudes related to the experience of
death and dying. "Section Two: American Attitudes Related to Suicide" narrows that
focus to suicide and the attitudinal ramifications of that particular manner of dying.
"Section Three: Counselor Attitudes Related to Suicide" concentrates on suicide as it
relates to the counseling profession. "Section Four: Theory" is a theoretical discussion of
the positive correlation among human beliefs and actions. Section Four also sets forth the
theory underlying the interview process. "Section Five, Conclusions" is a statement of
tentative conclusions asserting the research question's relevance to counseling research
and practice based on the information presented in the previous sections.
American Attitudes Related to Death and Dying
It has been argued that the greatest influence on culture is death and dying (Aries,
1974; Glaser & Strauss, 1965, 1967; Kubler-Ross, 1969, 1975). It is likely the one
experience shared by every human being who has ever lived. The following is an
examination of that experience and its influence on American culture.
It would be a mistake to assume the existence of a homogenous American attitude
toward death and dying. American societal attitudes toward death are as mixed and varied
as its citizenry. Our own personal experiences of death are far from universal. While
humans may share some commonalities of experience and attitude, Corr (1979) notes
"this sharing takes place in different and often distinctive ways from society to society
and from individual to individual" (p. 8). As discussed below, in such a heterogeneous
society as the United States, any attempt at defining an "American" societal attitude
toward death and dying is fraught with difficulty.
Subcultures exist for many reasons. Some are the result of immigrant Americans
bringing with them the culture of their country of origin. Others are religiously defined.
Still others are formed on the basis of age or gender. Since subcultures often have
subcultures in themselves, there is frequent overlapping among groups (Rubin &
Roessler, 2001). Not only is the United States culturally heterogeneous, it is also
geographically heterogeneous, as attitudes about death and dying often vary by region
(Lester, 1998). Finally, socio-economic status (SES) is often the influence that
overshadows and either accents or diminishes the effects of other cultural influences
(Rubin & Roessler, 2001). Each of these impediments to a unified definition of a single
American societal attitude on death and dying is examined.
Attitudes about death vary by cultural background (Lester, 1994; Levy, Ashman
& Dror, 1999; Mishara, 1996). Consider the differences between the dominant White
American culture that generally considers death a topic to avoid (Glaser & Strauss,
1965), and Mexican-Americans of the southwest who hold the annual holiday The Day of
the Dead. The Day of the Dead is a time for singing, dancing, and celebration, all the
while dressed in skeleton costumes (Green, 1980; Moore, 1980). Different cultural
attitudes about death might contribute to the fact that Caucasians also account for over
90% of all American suicides (Centers for Disease Control, 2002).
"Hispanos(as) in northern New Mexico remember the death of a loved one by a
type of written narrative referred to as a recuerdo, a remembrance" (Korte, 1995; p. 245).
According to Korte, the recuerdo is "recounting a person's life in an epic, lyrical, and
heroic manner" (p. 146). Cultures that have a special day to celebrate the dead, or honor
the dead in song and dance, appear to be demonstrating a different attitude toward death
than cultures opting to avoid that same subject matter. The United States is home to
dozens of dramatically different ethnic backgrounds.
Attitudes about death vary by religious belief (Levy et al., 1999; Rasmussen &
Johnson, 1994; Walker, 2000). While ethnicity and religion are often conterminous, they
are here treated as conceptually discrete.
Nearly every religious belief system shares two common themes, some notion of an
afterlife, and a "code of conduct" to be followed in this life so as to attain a desired
afterlife situation (Walker, 2000). As shown next, an individual's concept of these two
themes affects (and is affected by) his or her attitude toward death. Some of the most
prevalent approaches to eschatology in the United States may be found in the
philosophies of extinctionism, existentialism, Shamanism, the Hebrew Torah, the Judeo-
Christian bible, the Islamic Qur'an, Eastern beliefs in reincarnation, and various secular
alternatives to (and/or combinations of) the above.
Extinctionism and Existentialism postulate that death is most likely the end of a
person's being, since no evidence exists to the contrary (DeSpelder & Strickland, 1996;
Schrader, 1967). This view is common to Freudian thought (Freud, 1957), Confucianism
(Toynbee, 1973), Marxism, and humanitarism (Walker, 2000). Existentialist thinkers
include Kierkergaard, Sartre, Camus, Marcel (Schrader, 1967), and Becker (1973).
Shamanism, still practiced by many Native American tribes, may have been the
world's first religion to have a concept of spiritual immortality after death (Walker,
2000). According to Walker, Shamanism is thought to be the basis of all modem religions
adhering to belief in an afterlife. The Hebrew Torah, also the Old Testament of the
Christian Bible, may be two of the first incarnations of Shamanism into modern religious
The Torah, while including the idea of an afterlife, does not include the notion of
personal immortality or the soul (Plaut, 1981). The Torah and Old Testament view of the
afterlife is that of .\/tv,/, "the ancient Hebrew conception of death as a place of peace and
repose" (Walker, 2000). Around the time of Jesus, the Hebrew view of the afterlife was
beginning to change, as evidenced by the differing views of the Sadducees and the
Pharisees. The Sadducees represented the Sheol view of the afterlife. The Pharisees
taught that the Hebrews would be resurrected from the grave to help God recreate the
earth or "New Jerusalem" (Plaut, 1981). According to Plaut, both believed in the
necessity of a behavioral code of conduct, but for different reasons. The Sadducees taught
that the code was necessary for an orderly civilization. The Pharisees believed that only
those who followed the code would be resurrected at the end of time. This was
envisioned as a corporal resurrection, reuniting the body and soul.
The Christian Bible, or the New Testament, has its roots in the beliefs of the
Pharisees; and developed the idea that dead people's souls could go to be with God in
heaven until the time of the resurrection (Plaut, 1981). This belief is reflected in the
Islamic Qur'an (Walker, 2000; Esposito et al., 2002). For both Islam and Christianity,
adherence to a proper code of conduct is a prerequisite for being with God and for
resurrection. Also significant to the Islamic tradition are various forms of death
(including suicide in the service of God) to be discussed later. Islam contends that "the
moment of death is foreordained and suffering should not be avoided because it serves
for expiation of sins" (Smith & Perlin, 1979, p. 655).
Atheistic extinctionists, the agnostic existentialists, the animism of Shamanism, and
the monotheisms of the Hebrews, Christians, and Muslims differ from the polytheisms of
Hinduism and Buddhism. The eschatology of both Hinduism and Buddhism includes the
concept of reincarnation, the belief that a person lived and died before this life, and will
continue to be reborn after his or her death (Long, 1975). Hinduism teaches that, "no
human life can be filled with a sense of meaning and efficacious action unless it is lived
in full acceptance of the fact of death" (Long, 1975, p. 65). As stated by Hopfe (1987),
"The basic world view of Hinduism is that life is an endless cycle of birth, life, death and
rebirth and the goal of religion is to cease living" (p. 104). Buddhism, currently the
world's largest religion (Esposito et al., 2002) teaches that the characteristics of one's
reincarnation are dependent on the quality of one's karma (Smith & Perlin, 1979;
Esposito et al., 2002). According to Smith and Perlin, in the Buddhist view, suffering
Each belief system suggests significant attitudinal variability. The United States is
home to dozens of similar dramatically different religious backgrounds (Esposito et al.,
2002) and to a great number of persons who "combine these belief systems, effectively
fusing religious faith with empirical knowledge and humanitarian codes of conduct"
Basic differences in attitudes about death are also found by gender (Canetto &
Feldman, 1993; Canetto, 1992; Humphrey & Palmer, 1990; Moremen & Cradduck,
1998). One measure of this difference is evidenced by findings that females are more
likely than males to attempt suicide (Canetto & Lester, 1995; Range & Leach, 1998;
Westefeld et al., 2000; Laux, 2002). While female attempts far outnumber those of males,
men are far four times more likely to be successful (and account for 72% of all suicides)
(Centers for Disease Control, 2001).
In 1991, Canetto notes a stronger relationship for women than for men between
level of dependence and suicidal behavior. That is, those exhibiting a greater level of
dependence are more likely to engage in suicidal behaviors. However, her studies do not
find this dependence to be related to a "love object," as is the case in traditional
psychodynamic theory (Canetto, 1992; Canetto & Feldman, 1993). This dependence is
usually associated with nonfatal suicide attempts and suicidal ideation (Canetto &
Feldman, 1993). Beck et al. (1973) found women more likely than men to cite
interpersonal problems as the cause of their suicide attempt or ideation. Stillion et al.
(1989) and Canetto (1992) attribute these gender-related differences to socialization.
Stillion et al. found that surviving a suicide attempt carried with it much harsher negative
social criticism for men than it did for women. Canetto (1992) points to considerable
variation even within the sexes, stating that "suicidal behavior may be mediated by the
person's sensitivity to gender conventions" (p. 13).
While men are more likely to kill themselves than are women, 72% of
Dr. Kevorkian's assisted suicides were women (Canetto & Hollenshead, 1999). In their
study of the Kevorkian cases, Canetto and Hollenshead cite such perceptions of gender
differences as possible reasons for this blatant gender discrimination. These include (but
are not limited to) "pragmatism about one's death, a diminished sense of entitlement,
social and economic disadvantage, and cultural definitions of the full life" (p. 183).
Gender differences regarding social attitudes about death are also reflected in
newspaper obituaries (Moremen & Cradduck, 1998). "Despite women's inroads into paid
labor, they continue to receive less recognition for their accomplishments after death"
(Moremen & Cradduck, 1998; p. 248). According to Moremen and Cradduck, women's
obituaries tend to be shorter, less likely to include a photograph, and are published nearly
eight times less frequently than men's. Finally, a specific study of death anxiety by
Rasmussen and Johnson (1994) found higher levels of death anxiety among female
participants than among males.
Death-related attitudinal differences are also found by age (Davis-Berman, 1998;
Levy et al., 1999). Various cultures often respond differently to the impending death of
an elder as opposed to the same condition in a youth. For example, Euro-Americans are
generally more accepting of the death of an elder, whereas Asian-Americans tend to
acknowledge the deaths more equally (Wass, 1979; Weaver & Koenig, 1996). Levy et al.
(1999) found that "societally-transmitted negative stereotypes of aging can weaken
elderly people's will to live" (p. 409). They further state that such negative
Euro-American stereotypes dominate both the young and old, affecting individual and
family decisions on end-of-life care. In her study of aging in relation to fear of death
among college students, Davis-Berman (1998) found such fears to be a factor in why
some students balk at taking courses on aging. Davis-Berman notes that even students
who do take such courses often retain their negative stereotypes toward aging.
Attitudes on death vary by region (Moreman & Cradduck, 1998; Reid & Reid,
1999). One example is how the inhabitants of different regions choose to memorialize the
death of a loved one. In such states as Texas and Oklahoma, it is commonplace to find
roadside death memorials erected by family members on the site of a fatal automobile
accident (Reid & Reid, 1999). These descansos [resting places] had their origin as grave
markers of the early Spanish Conquistadors. Later, they became signs of those who died
while traveling (OPB, 2002). Reid and Reid note that this particular outward sign of
internal beliefs and attitudes toward the death of a loved one is much less prevalent in
states such as Maine and Vermont. In their study on obituaries, Moreman and Cradduck
(1998) discovered regional differences in how women are remembered after their deaths
as opposed to men. They found significant anti-female bias to exist in New York, but it
was expressed less intensely in Miami.
Additional evidence may be reflected by regional suicide rates. "Suicide rates are
generally higher than the national average in the western states and lower in the eastern
and midwestern states" (Centers for Disease Control, 2002). Should such behaviors be
indicative of internal attitudes, it would appear that regional attitudinal differences do
Finally, SES may be the most influential of all (Rubin & Roessler, 2001). Corr
further notes that the United States, the world leader in medical technology, does not lead
the world's mortality or even infant mortality rates. Many other countries have lower
rates of both general and infant mortality. Achieving notably better rates are Australia,
New Zealand, and the Scandinavian countries (Corr, 1979). Corr points out that large
heterogeneous countries, such as the United States cannot compete with smaller
homogeneous countries and considers this to be largely a function of SES. Native
Americans, perhaps the nation's lowest ethnic SES group, have a significantly higher
mortality rate than the rest of American society (Corr, 1979). Regardless of an
individual's ethnic, religious, or regional background, regardless of a person's gender or
age, the level of his or her access to the healthcare system is greatly determined by his or
her SES (Rubin & Roessler, 2001). It is, therefore, reasonable to postulate that, in
addition to the other variables addressed above, a person's SES is a dramatic influence on
his or her attitudes on death and dying. This conclusion is a direct derivative of SES as a
determinant of an individual's access to healthcare. As Rubin and Roessler point out, the
greater a person's healthcare access, the more options he or she has for end-of-life care.
End-of-life care options have considerable variability from dying alone in a hospital (with
or without palliative care), to dying in the company of friends and loved ones (as pain-
free as possible) in a hospice situation (Beauchamp & Veatch, 1996). It may be
reasonable to conclude that an individual's expectation of his or her own kind of death,
which is influenced by SES, might help shape that person's attitudes about death. A
country with such vast SES differences as the United States is unlikely to produce a
common national attitude toward death and dying. Therefore, a discussion about societal
attitudes toward death in the United States must be predicated on the existence of such
To make such a diverse topic somewhat more manageable, the remainder of this
section concentrates on the dominant White American culture of European ancestry. This
segment of society is chosen for the following reasons. White Euro-American attitudes
are manifest in laws passed and court cases heard. This provides a basis for empirical
observation of behavior related to attitude. Secondly, the major social and psychological
theories on death and dying in America have been written by and about this group. It
would be remiss to omit these theoretical perspectives in a discussion of death and dying
in America. Thirdly, the majority of counselors are members of this group. Lastly, this
group is human and, therefore, bound to die. Aside from being American, this is certainly
a point of commonality between this social segment and all others.
Death may well be the one experience that all humans have in common. Not every
person who has been born will grow old, but all people will surely die. Yet many seem to
find death difficult to accept (Datson & Marwit, 1997; Neimeyer & Neimeyer, 1984).
Perhaps this is because the reality of dying seems so dissonant with the continuity of
daily life (Vickio, 2000). Whatever the reason, dialogue about death is not an easy
subject for many Americans (Glaser & Strauss, 1965; Kubler-Ross, 1975). Witness the
attitudinal cacophony surrounding the issues of abortion [legalized in all states in 1973
(Planned Parenthood, 2002)], the death penalty [legal in 38 states (MSNBC, 2002)], and
physician-assisted suicide [legalized in Oregon only (Oregon Death with Dignity Act,
While some people have learned to embrace death, as exemplified in the literary
work Tuesdays iilh Morrie (Albom, 1997), one seemingly overriding American response
to death is avoidance (Glaser & Strauss, 1965). The medical model of healthcare views
the death of a patient as failure (Simpson, 1979). Simpson postulates this view may be
linked to the psychology of physicians themselves. Perhaps individuals choosing the
profession do so partly due to a higher than average fear of death. "The intensity with
which the physician experiences the fear of personal death has been associated with a
variety of factors, including the choice of specialization, the ability to successfully
repress their death anxiety, and demographic factors" (Hamama-Raz et al., 2000, p. 140).
For example, Glaser and Strauss (1965) found surgeons to be generally better able than
psychiatrists at dealing with their own death anxiety. Possibly indicative of these
tendencies is the statistical finding that the suicide rate among physicians is twice that of
the general American population. For psychiatrists, the occurrence of suicide is four
times the national average (Grollman, 1988). The very words dead and death have been
supplanted by the use of such tropes as deceased, no longer i/ ith us, orpassed away. For
many Americans death has become a forbidden, even shameful, subject (Aries, 1974).
Aries (1974) notes this was not always the case. Since the beginning of
colonization, Americans had died in their homes surrounded by their children, family,
and friends (Aries, 1974). Death was a socially accepted fact of life. All this changed in
the mid 20th Century when Americans began to die in hospitals (Glaser & Strauss, 1965;
This change can largely be attributed to technological advances in medicine
(Beuchamp & Veatch, 1996). Prior to this time, death was a simpler matter. When a
person's heart and respiration stopped, everyone agreed that he or she was dead. In
America today, there is no such consensus. Each state decides for itself the conditions)
that constitute death. For some it remains the cardio-pulmonary definition of old, a
position supported by many Orthodox Jewish Americans, Japanese-Americans, and
Native Americans (Beuchamp & Veatch, 1996). Other states take into consideration a
condition identified as 'brain death' (Veatch, 1979; Fulton & Metress, 1995). Yet, as
Fulton and Metress report, an exact definition of 'brain death' remains controversial and
the subject of considerable debate.
Perhaps the most poignant death-related result of medical technology is the manner
of death. People used to die relatively quickly (Aries, 1974). Technology has not only set
people to debating the definition of death, but has caused them to die much more slowly,
painfully, and expensively. The advent of the hospice movement, discussed later in more
detail, is helping to change this end of life experience (Davidson, 1979).
As Americans began to die in hospitals, their children were among the first to be
excluded from this experience (Aries, 1974). Gradually, all involved began to shield even
the dying individual from the knowledge of his or her impending death. Family, friends,
and healthcare professionals joined the dying patient in what Glaser & Strauss (1965)
named, "The ritual drama of mutual pretense" (p.64). This drama is played out when all
involved, including the patient, know that death is imminent yet pretend to lack such
knowledge. The frequency with which this ritual is enacted illustrates the extent of
American death avoidance behavior. The British anthropologist Gorer (1967) wrote in his
essay The Pornography ofDeath, "We have come to view the subject as inherently
abhorrent, one which can never be mentioned openly or discussed directly. Like all
disgusting subjects, death can only be introduced into polite conversation obliquely or
As mentioned earlier, children, previously included at the bedside of a dying family
member, have become increasingly shielded from the event of death (Aries, 1974;
Kubler-Ross, 1975). The shielding of children from the death experience is perhaps the
most damaging since it is considered by many to negatively affect their personality
development (Stillion & Wass, 1979). In Erik Erikson's theory of human development
(1950), infancy, early childhood, and adolescence are associated with the development of
trust or mistrust, autonomy or shame and doubt, and initiative or guilt respectively. At
each of these childhood developmental stages protecting the child from the experience of
death is likely to engender psychological distress later in life (Kubler-Ross, 1975; Stillion
& Wass, 1979). These children soon become society's next generation of adults.
According to this perspective, their negative attitudes on death and dying were shaped by
the exclusion of the death experience. The essence of this situation is elegantly stated by
Jocelyn Evans (1971) in her book, Living n i/i/ a man who is dying. "We have created
systems which protect us in the aggregate from facing up to the very things that as
individuals we most need to know" (p. 83).
Yet, at the same time, there exists what Aries (1974) termed a "Cult of the Dead"
(p. 74). Shrouded in patriotism and nationalism, Americans honor certain types of death
with grand and massive memorials such as Arlington Cemetery and the Tomb of the
Unknown Soldier. Glaser & Strauss (1965) state that Americans appear more comfortable
with these particular socially accepted forms of death than with death in the abstract. "We
engage in very little abstract or philosophical discussion of death. Americans are
characteristically unwilling to talk openly about the process of dying itself' (Glaser &
Strauss, 1965; p. 3).
For many, the premier theorist on the subject of death and dying in America is
Elizabeth Kubler-Ross. Her theory on the Stages of Dying (Kubler-Ross, 1969) continues
to guide end-of-life care today. Though vastly oversimplified, her theory is summarized
here. Once a person becomes aware of his or her impending death, he or she experiences
(to varying degrees) the following stages.
1. The first stage is one of denial and isolation. The dying person feels alone and
indicates the belief that the diagnosis must be a mistake.
2. The second stage is one of anger. The individual often feels that he or she is being
treated unfairly. This anger may be directed toward family, medical staff, or even
3. Stage three is the bargaining stage. The person may try to strike a deal with God in
return for his or her life.
4. This failing, the dying man or woman usually enters stage four, depression.
5. Should the individual survive long enough to come to terms with depression, he or
she may finally accept the situation, which is stage five.
1 2 3 4 5
A Awareness of 4 4 4 Time Death A
Figure 2-1. Stages of Dying. From Kubler-Ross, E. (1969). On death and dying. New
York: Macmillan. Scribner p. 265. PG = Preparatory Grief. PD = Partial
All these stages are defense or coping mechanisms for dying. Kubler-Ross insists
the one condition that persists throughout all the stages is hope. Without hope, transition
from one stage to another would not be possible.
When Elizabeth Kubler-Ross began her death studies in the mid 1960s, there was
very little literature available on the subject (Kubler-Ross, 1975). This is no longer the
case. Today there are major professional journals dedicated to the study of death and
dying including Death Studies (formerly Death Education), Omega: Journal of Death
and Dying, and Suicide and Life-Threatening Behavior.
American attitudes have changed dramatically since 1975 and in no small part due
to the efforts of Elizabeth Kubler-Ross (Fulton & Metress, 1995; Beauchamp & Veatch,
1996). In 1973 the United States Supreme Court ruled that a woman's right to an abortion
is protected under the 14th Amendment in the Constitution that protects the concept of
personal liberty (Roe v. Wade, 1973). In 1980 Derek Humphry formed the Hemlock
Society after assisting his wife to commit suicide. The Hemlock Society has its main
office in Eugene, Oregon and is dedicated to the right of an individual to end his or her
own life (Humphry, 1991). In 1986 the Supreme Judicial Court of Massachusetts ruled
that Paul Brophy could became the first permanently unconscious patient kept alive by a
feeding tube to be allowed to legally die by the removal of said tubes. Four years later the
Supreme Court denied Nancy Cruzan same option. The court did, however, not only hear
the case, but also set the precedent for physicians to respect a Living Will, which Ms.
Cruzan did not have (Cruzan v. Director, Missouri Department of Health, 1990).
Since 1990 the news media has brought numerous death-related issues to the
attention of the American public. Throughout the 1990s, physician Jack Kevorkian
continually made headlines with his Mercitron or "suicide machine" (Fulton & Metress,
1995). Derek Humphry published his book, Final Exit about the mission of the Hemlock
Society (Humphry, 1991). It became an immediate New York Times best seller. In 1997,
as mentioned earlier, the state of Oregon passed its own Death with Dignity Act.
Perhaps most indicative of a nation-wide attitudinal shift is the hospice movement,
which has also been largely credited to the efforts of Elizabeth Kubler-Ross (Fulton &
Metress, 1995; Beauchamp & Veatch, 1996). Davidson (1979) explains the origin of the
word as follows.
Hospice is a medieval term that refers to the wayside inns for pilgrims and other
travelers, particularly at those places of the greatest vulnerability and hardship. The
hospice movement represents the development of a variety of programs designed to
better assist terminally ill patients for whom aggressive medical treatment is no
longer deemed appropriate in travel through life (p.158).
Hospice care began, and largely remains, a grass-roots movement that arose in
response to the conditions surrounding death and dying documented in the 1960s and
1970s by Aries (1974), Glaser & Strauss (1965, 1967) and Kubler-Ross (1969, 1975).
While the hospice movement does not advocate suicide, assisted or otherwise, it does
support a dying individual's right to refuse further medical treatment beyond palliative
care (Sendor & O'Connor, 1997).
Another movement, which does advocate for an individual's right to die by means
of suicide and assisted suicide, is Death with Dignity (Quill, 1991; Albright & Hazler,
1992). It's members use the term voluntary euthanasia. Euthanasia, from the Greek,
literally means "the good death" as opposed to d1yi\u/iuiai\ or "the bad death" (Fulton &
Metress, 1995). A bad death is considered to be long, painful and without dignity. The
good death refers to dying without pain and with dignity.
At the fringe of this movement are dozens of nonphysician-assisted suicide activist
groups. These groups, from around the world and from in the United States, are part of
what Ogden (2000) terms, the Deathing Counterculture. While certainly not
representative, the Deathing Counterculture in the United States is comprised
predominantly by White Euro-Americans. Their goal is to provide all Americans the
technological ability to end their own lives (Ogden, 2000).
American Attitudes Related to Suicide
In 1999, there were 29,199 reported cases of suicides in the United States, which
translates to about 12 suicides per 100,000 Americans (Centers for Disease Control,
2002). The number of suicides that year was 1.7 times higher than the number of
homicides. The Centers for Disease Control (2002) ranks suicide as the ninth leading
cause of death overall and third for people between the ages of 15 and 24. While these
numbers may seem high, Blumenthal (1988) (as cited in Fulton & Metress, 1995)
suggests the actual number of suicides is likely two to three time higher. While the
reasons for this disparity in numbers range from lack of death certificate uniformity to
insufficient information as to the cause of death, Fulton and Metress (1995) note stigma
as a significant factor contributing to the official underreporting of suicide.
The term stigma is perhaps most closely related to the term disgrace (Moller,
1990). A person with a stigma is perceived as somehow negatively outside the norm of
society. He or she is unusual, and in possession of qualities considered by the general
public as undesirable. Moller writes, "Every society sets forth a range of qualities and
behaviors which it prescribes as being desirable and an additional complex of attributes
and behaviors which it proscribes as undesirable" (p. 67). Attached to those proscribed
negative qualities is the notion of stigma.
Death and dying has certainly been awarded the social stigma of undesirability. The
stigma associated with suicide is reflected as being, weak, cowardly, and immoral
(Lester, 1993; Ingram & Ellis, 1995). Interestingly, American society has generally come
to accept certain kinds of suicide, or rather, suicide by certain kinds of people. The
suicide of the very old, the very sick, and the very disabled, has tended to meet with
general societal approval (Beauchamp & Veatch, 1996; Canetto & Lester, 1995; Ellis &
Hirsch, 2000). Survivors of suicide victims from these groups are similarly judged as
being less "responsible" for the suicide than are survivors of young and healthy suicide
victims Range & Martin, 1990). This suggests the question, why. Why these groups and
not others such as the young and healthy?
The answer may be found in the similarities among these three groups and an
understanding of the stigma attached to disability. In a very real way, the elderly and the
very ill may be perceived as being disabled. They are disabled by their age, their illness,
or a combination of the two. Social attitudes are often sympathetic, sometimes even
encouraging, of an individual with a severe disability who wishes to end his or her own
life (Rubin & Roessler, 2001). This may be the result of the general social attitude that all
persons with disabilities would choose to be rid of their disability if that choice were
possible (Hahn, 1991). Martin and Range (1990) note, preexistingg prejudices and
paranoias can affect social reactions to suicide" (p. 189).
Disability, in a society that caters to the youth culture of vigor and vitality (Corr,
1979), is stigmatized as representative of polar opposite qualities. The stigma of disability
may accurately be viewed in the light of the stigma of death and dying, and the stigma of
suicide. The beginning of this section discussed stigma as described by Moller (1990).
The following are two lines from that description, but in the place of the word "stigma" is
the word "disability." The reader is invited to mentally substitute, for "disability," the
words "very old" or "very ill." A person with a disability is perceived as somehow
negatively outside the norm of society (Rubin & Roessler, 2001). He or she is unusual,
and in possession of qualities considered by the general public as undesirable. Some
members of society might regard the suicide of such individuals as helping rid
undesirable elements from the general public.
Physician Jack Kevorkian assisted 100 persons to die and, although tried several
times, was never convicted for assisted suicide (PBS, 2000). The disability advocacy
group "Not Dead Yet" lists, on its web site (Not Dead Yet, 2002), all those deaths
assisted by Dr. Kevorkian. The group makes the case that these individuals were largely
not immediately terminal and were allowed to die based solely on their disability.
According to a study by Canetto and Hollenshead (1999) on those assisted by
Dr. Kevorkian between 1990 and 1997, the foremost reason stated by the patients and
their families for the suicide assistance was having a disability.
Dr. Kevorkian was convicted of murder in 1999 for administering a lethal injection
to Thomas Youk, age 52. Mr. Youk had late-stage Amyotrophic Lateral Sclerosis and
requested the injection (PBS, 2000).
In the case of Quill v. Vacco (1996), the Supreme Court heard arguments for and
against the Oregon Death With Dignity Act (1997). As part of this hearing, the disability
advocacy group Not Dead Yet entered an amicus curiae [friend of the court] brief (Not
Dead Yet, 1996) in opposition to the Oregon law. Joining Not Dead Yet in the brief were
several other disability rights groups also in opposition to physician-assisted suicide.
These groups included, the American Disabled for Attendant Physician-assisted Suicide,
the American Disabled for Attendant Programs Today, the Association of Programs for
Rural Independent Living, the Disability Rights Education and Defense Fund, Justice For
All, the National Council on Disability, the National Council on Independent Living, the
National Spinal Cord Injury Association, the World Association of Persons with
Disabilities, and the World Institute on Disability (Not Dead Yet, 2001). Indicative of
mixed attitudes among the health professions, the American Psychological Association
(APA) signed on to an amicus curiae brief presented by the American Medical
Association in opposition to the Oregon law (Werth & Gordon, 2002), while the
American Counseling Association (ACA), the Association for Gay, Lesbian, and
Bisexual Issues in Counseling; and an ad hoc Coalition of Mental Health Professionals
Supporting Individual Self-Determination in Decisions to Hasten Death all signed on to
another amicus curiae brief sponsored by the Washington State Psychological
Association (WSPA) in support of the Oregon law (Werth & Holdwick, 2000; Werth &
Gordon, 2002). The debate over the ACA decision to join the WSPA brief continued with
individual letters in Counseling Today (Donaldson, Patton & Wood, 2002; Bennett,
Counselor Attitudes Related to Suicide
American counselors are predominantly of European ancestry (Rubin & Roessler,
2001) and individual counselors are subject to generally the same social influences as the
rest of the population. A counselor's attitude is, therefore, greatly influenced by the
American culture of which he or she is a member.
Client, counselor, and third-party attitudes toward life and death are culturally
driven, thereby making the recognition of cultural differences critical to
understanding the vastly different decisions that can be made. These cultural value
judgments help determine one's thoughts, beliefs, and, eventually, actions (Albright
& Hazler, 1995, p. 179).
As previously stated, suicide is now the ninth leading cause of death in the United
States, the third leading cause for people between the ages of 15 and 24 (Centers for
Disease Control, 2002), and would likely be ranked even higher were it not for social
attitudes heavily biased against declaring suicide as the cause of death (Fulton & Metress,
1995). Westefeld et al. (2000) estimates that approximately one American in every 60 has
encountered the death of a loved one via suicide. The magnitude of suicide in America
creates an important counseling concern, the importance of which is evident in the
counseling research literature. Studies, such as those by Carney and Hazler (1998),
McAdams and Foster (2000), and Rogers (2001) indicate that a majority of counselors
will experience at least one consumer with suicidal ideations. Of that group there is a
twenty percent chance that a counselor will have a consumer successfully commit suicide
(Bongar, 1992). This is because between 66 and 80% of individuals, who actually do
commit suicide, tell at least one other person of their intentions. One of the people in
whom they confide is often their counselor (Grollman, 1988; Brems, 2000).
The literature addressing counselor attitudes toward clients expressing suicidal
ideations appears simultaneously to be both cohesive and fragmented. Studies on
counselor's personal experiences with suicidal clients tend to show counselor attitudes to
be quite similar. More abstract, cognitively oriented, studies that consider moral, ethical,
and logistical aspects of suicidal clients in general, depict counselor attitudes as more
disparate. The following is an examination of each, beginning with the more cohesive of
Similar Counselor Attitudes and Personal Experience
Chemtob et al. (1988), Moritz et al. (1989), Menninger (1991), Little (1992), and
McAdams and Foster (2000) conducted studies in which therapists most frequently
named client suicide as a cause of anxiety. These authors discovered that many therapists
viewed the suicide of a client as a professional failure. Feelings of guilt, anger, and
sadness were documented as a counselor's most common emotional responses to the
suicide of a consumer. Ensuing malpractice liability and legal repercussions often
augment such feelings of self-recrimination (Bongar, 1991). Counselors are not alone in
the self-blaming process. Studying individuals who had survived the suicide of a family
member or close friend, Lester (1991) observed a great deal of perceived responsibility
on the part of noncounselors. He also notes that survivors are routinely blamed by others
in society, and that the degree of blame to a large degree hinges on how responsible
society perceived the survivor to be for the life of the suicide victim while he or she was
living. For example, a parent may be blamed more for the suicide of a child than for the
suicide of a friend.
Several researchers report the development of counselor attitudes toward suicidal
clients appears distinctive in that these attitudes are not seen as entirely the result of past
experiences. Rather, as described below, this is in part due to the way in which the
suicide-ideator client presents a special set of circumstances for the relationship with his
or her therapist.
Suicidal clients tend to rely heavily on a process of communication termed
projective identification (Malin & Grotstein, 1966). This process involves a continuous
attempt at manipulating the counselor into validating the client's own internal perceptions
(Sandler, 1988). This kind of communication tends to evoke powerful emotions on the
part of the therapist (Maltsberger, 1985).
Richards (2000) examined that relationship in the context of transference and
countertransference. She found the counselor to be at significant risk of developing
unconscious responses to the client expressing suicidal ideations. The suicidal client often
projects intense emotions via the previously described process of projective
identification. The counselor through the process of countertransference then acts on this
emotional transference. The Richards (2000) study yielded results consistent with earlier
studies on counselor attitudes toward clients who either expressed suicidal ideations or
who actually committed suicide. The following statements by counselor study
participants are descriptive of its findings.
* "I just felt very angry that she didn't give me a chance" (p. 331).
* "The way the [suicide] attempt was announced to me was sadistic" (p. 331).
* "Her mother said, 'I thought you may like to know that (name) killed herself.'And
the implication was that I had failed her" (p. 331).
* "I felt at times completely useless, hopeless as a therapist and a human being,
always doing and saying the wrong thing" (p. 332).
* "I experienced something of his depression and feelings of helplessness and
hopelessness" (p. 334).
* "I was initially angry with him, then sad. In subsequent months I experienced a loss
of confidence as a therapist" (p. 334).
Fragmented Counselor Attitudes and More Cognitive Considerations
Counselor attitudes toward clients expressing suicidal ideations remain fragmented
on the more cognitive level. This is not surprising when considered in light of the current
counselor debate over rational suicide (Richman, 1988; Albright & Hazler, 1992; Rogers
et al., 2001). Briefly, rational suicide is a term used to describe the conditions under
which it would be considered by both the counselor and consumer to be a rational choice.
Rogers et al. (2001) considers suicide to be rational when the following conditions are
* (1) The person considering suicide has an unremitting hopeless condition. Hopeless
conditions include, but are not necessarily limited to, terminal illnesses, severe
physical pain, and/or psychological pain, physically or mentally debilitating and/or
deteriorating conditions, or quality of life no longer acceptable to the individual.
* (2) The person makes the decision as a free choice (i.e., is not pressured by others
to choose suicide).
* (3) The person has engaged in a sound decision-making process. This process
should include the following:
o Consultation with a mental health professional who can make an
assessment of psychological competence.
o Nonimpulsive consideration of all of the alternatives.
o Consideration of the congruence of the act with one's personal values.
o Consultation with objective others (e.g., medical and religious
professionals) and with significant others (p. 238).
Proponents believe that there exist some cases in which suicide is a rational
alternative. Proponents include 81% of psychotherapists (Werth & Liddle, 1994) and
76% of counselors (Rogers et al., 2001) "indicating some level of acceptance of the
concept of rational suicide in working with an individual in a professional context"
(Rogers et al., 2001, p. 370). This greatly concerns many people, including the members
of Not Dead Yet (2002), who fear that counselors, as members of American society, may
be predisposed to view suicide as obviously rational for persons with disabilities. This
fear may be justifiable based on an understanding of stigma in American society.
As early as 1988, Richman (1988) leveled his challenge to the concept of rational
suicide in, The Case Against Rational Suicide. Richman (1992) restated his position
against the very notion of dichotomizing suicide into the rational and irrational. "To
imply that there are no cognitive errors behind rational suicide that it is always the free
choice of an individual, that there need be no contact with a counselor, no exploration of
the decision, and no bringing in of the family or other support systems is neither
rational nor irrational; it reflects ignorance" (Richman, 1992, p. 130).
Rogers and Britton (1994) described rational suicide as a slippery slope in their
discussion of its application to persons with AIDS. Firstly, note that the suicide rate of
AIDS patients is much higher than that of the general public. Secondly, that studies such
as those by Werth (1992) and Domino, Gibson, Poling, and Westlake (1980) indicate that
the general public seems increasingly approving of suicide as an option for individuals
with AIDS. The concern of Rogers and Britton (1994) is over the possibility that suicide
is being considered as a rational choice for an ever-widening scope of individuals and
groups. The attitude in opposition to the idea of rational suicide is expressed in the words
of Corr, (1979).
Many people who threaten to commit suicide are really crying out for help. In
response, we often ignore their real needs and sometimes we actually encourage
their self-destructive tendencies. That is, we sometimes employ our freedom to
convey to suicidal persons our agreement that their lives are without worth, when
what is really called for is an effort to aid them to identify and to promote the
values inherent in their lives (p. 39).
This attitude, predating the current debate concerning rational suicide, an
individual's right to die, and voluntary euthanasia, remains relevant today.
In light of the controversy surrounding suicide, rational suicide, euthanasia,
physician-assisted suicide, an individual's right to die, and views that suicide is actually a
cry for help, a closer examination of the definition of suicide would appear pertinent. As
is the case with so many other features of suicide, there exists little definitional
homogeneity. Webster (1986) defines suicide as, "The act of killing oneself
intentionally" (p. 1424). However, such a prosaic description of such a complex behavior
proves inadequate. Numerous attempts to improve on this definition have been made over
the years by researchers in the domains of sociology, psychology, philosophy and
Sociologist Emile Durkheim (1951) viewed suicide in terms of an individual's
degree of social interaction or social relatedness. He believed people who committed
suicide to be socially isolated and unable to identify with other members of the social
group to which he or she belonged.
The Existentialist philosopher Jean Baechler (1979) defines suicide in terms of an
individual's quest for a solution to his or her own existence. "Suicide denotes all behavior
that seeks and finds the solution to an existential problem by making an attempt on the
life of the subject" (p. 11).
Psychologist Edwin Shneidman (2001) defines suicide as a reaction to what he
I believe that suicide is essentially a drama in the mind, where the suicidal drama is
almost always driven by psychological pain, the pain of the negative emotions -
what I call psychache. Psychache is at the dark heart of suicide; no psychache, no
suicide (Shneidman, 2001, p. 200).
Williams (1997), believes the feeling of entrapment to be a necessary condition of
suicidal behavior. He describes the suicidal individual as someone who feels trapped by
life's circumstances, and yielding to suicide being the sole option.
Roy, Nielsen, Rylander, & Sarchiapone (2000) point to evidence indicative of
suicide having a genetic component stating, "The importance of psychiatric, social, and
biological factors, psychodynamics and physical illness as determinants of suicide is well
established. However, increasing data suggest that genetic factors may also play a part in
suicidal behavior" (p. 210). The descriptions of Shneidman, Williams and Roy et al.
(2000) afford but a glimpse into the complexity of suicide. While not all researchers
subscribe to the notions of psychache or entrapment, and relatively few have examined
the genetic factors, there does appear to be consensus about the multidimensionality and
multideterminality of the suicidal act.
In 1985, Shneidman published a book dedicated entirely to the task of defining
suicide. What follows is the culmination of that endeavor, "Currently in the Western
world, suicide is a conscious act of self-induced annihilation, best understood as a
multidimensional malaise in a needful individual who defines an issue for which the
suicide is perceived as the best solution" (p. 203). There are two points of this broad
definition that are most universally accepted. First, that it acknowledges that any
definition of suicide must be understood relative to the time at which it is used, and the
society in which it is used. Second, it describes suicide as being both a conscious decision
and a self-induced action. Stillion & McDowell (1996) point out that not all suicidal
individuals exhibit "multidimensional malaise", one example being a person with a
terminal illness who may try quite vigorously to end his or her own life. Another example
of a lack or malaise is active euthanasia. While active euthanasia is generally considered
to be suicide, passive euthanasia is not.
The definition used for this study is as follows. "Death from injury, poisoning, or
suffocation where there is evidence (either explicit or implicit) that the injury was self-
inflicted and that the decedent intended to kill himself/herself' (O'Carroll Berman,
Maris, Moscicki, Tanney & Silverman, 1996, pp. 246-247). This definition reflects a
broad understanding of the phenomenon including the two most common conditions
found in the literature, intention and outcome. A majority of authors agree that, "To be
classed as a suicide, a person must intend to kill himself, and he must actually do so"
(Farber, 1968, p. 5).
While both conditions are necessary, this definition still remains open to a variety
of individual interpretations. This is the case because although outcome is obvious (the
individual is dead), intention is more problematic. The suicide victim is unavailable to
explain his or her intentions. "Outcomes are clearer than intentions: The subject survives
or he dies. But we cannot infer intention from outcome; outcome is determined by a
number of contingencies" (Farber, 1968). Not every person who dies while engaging in
self-destructive behavior intended to die. Conversely, not every person who attempts to
kill him or herself succeeds. However, it would be incorrect to infer that one could learn
about the intentions of successful suicide victims from the testimony of suicide
attempters. Data confirming these constitute two distinctly different groups of individuals
(and the information gleaned from one cannot be presupposed of the other) is so
prevalent that some authors now use the word parasuicide. Parasuicide is a term used to
describe intentional, but nonfatal, self-injurious behavior (Linehan, 2000; Maris, Berman,
& Silverman, 2000).
"In all but the most impulsive suicides there is a period of suicidal ideation"
(Stillion & McDowell 1996, p. 27). Suicidal ideation refers to ideas about suicide or
suicidal thoughts (Farber, 1968; Battin, 1982; Webster, 1986; Stillion & McDowell,
1996; Rudd, 2000). "Suicide ideators are individuals who think about or form an intent to
suicide of varying degrees of seriousness but do not make an explicit suicide attempt or
complete suicide" (Maris, Berman & Silverman, 2000, p. 20).
According to Kolko (1990), these ideations range from vague thoughts of suicide to
specific ideas about one's own suicide. They may or may not involve personal notions of
intent, and may or may not include an actual suicide plan. While it is suspected that all
those who suicide had been suicide ideators, relatively few suicide ideators actually
follow through and commit suicide (Linehan, 1982; Maris, Berman & Silverman, 2000).
However, of those who do, between 66 and 80% tell someone of their suicidal ideas
(Grollman, 1988; Brems, 2000). Often, in addition to being nearly ubiquitous, suicidal
ideations become compulsive. Thoughts of suicide intrude with increasing frequency
until the individual feels unable not to think about suicide (Stillion & McDowell, 1996).
This study uses the following definition of suicidal ideation as "any self-reported
thoughts of engaging in suicide-related behavior" (O'Carroll et al., 1996, p. 247). This
definition takes into account the principal characteristic of suicidal ideation being the
process of engaging in suicide-related thoughts, but specifically covers only those
thoughts about which the client tells the counselor. By doing so, this definition rules out
hearsay evidence of suicidal thoughts, and disallows the counselor attributing assumed
thoughts to the client.
The first two sections of this literature review provided an appreciation for the
issues of death, dying, and suicide. The third section illustrated the importance of these
issues to counseling. This section provides a theoretical underpinning for three questions
of why. Why is the relationship between a counselor's personal beliefs about suicide and
his or her attitudes toward clients expressing suicidal ideations important to understand?
Why is qualitative research an appropriate method with which to analyze the research
question? Why is the interview an appropriate qualitative technique with which to study
the research question?
Theoretical Grounding for the Research Question
Why is the relationship between a counselor's personal beliefs about suicide and
his or her attitudes toward clients expressing suicidal ideations important to understand?
The answer is behavior, or more specifically, the behavior of a counselor toward a
client expressing suicidal ideations. The quality of the counseling relationship, sometimes
called the therapeutic relationship or working alliance, is generally considered to be the
most important contributing factor to consumer growth and well-being in the context of
professional counseling (Goldstein, 1962; Gladding, 1996; Walborn, 1996). "The
successful outcome of any counseling effort depends on a working alliance between
counselor and client" (Gladding, 1996, p. 142). Goldstein (1962) states, "There can no
longer be any doubt as to the primary status which must be accorded the therapeutic
transaction" (p. 105). Walbom (1996) asserts that possibly all schools of therapy agree
with the primacy of the therapeutic relationship.
This therapeutic relationship, or alliance, has two major components: trust and
collaboration (Walborn, 1996). While the consumer certainly comprises half this
relationship, the behavior of the counselor may be the most influential factor contributing
to the nature of the therapeutic alliance. Counselor education stresses the importance of
counselor behavior (both verbal and nonverbal) as evidenced by such techniques as
mirroring, active listening, responding, expressing positive regard, using silence, and
empathic statements. The fact that a counselor is listening, feels positive regard, or
empathizes with a client is meaningless in a therapeutic relationship unless the client is
aware of these thoughts and feelings (Long, 1996). It would seem a reasonable deduction
that counselor behavior is necessary for the establishment of trust or collaboration, and an
indispensable component of the therapeutic alliance.
Therefore, understanding why a counselor acts as he or she does must be
considered important. Most personality theorists suggest a positive correlation among
human beliefs and actions. Many contend that a person's beliefs are a primary cause of
his or her behavior. Albert Ellis, founder of the theory of Rational-Emotive Therapy
(RET) (Ellis & Grieger, 1977), later to become REBT with the addition of "Behavior" to
the title, states
We largely (though not exclusively) control our own destinies, and particularly our
emotional destinies. And we do so by our basic values or beliefs by the way that
we interpret or look at the events that occur in our lives and by the actions we
choose to take about these occurrences (p. 5).
Viktor Frankl (1965), founder of Logotherapy, asserts that these personal values
and beliefs are of ultimate importance because it is in these that a person finds the
meaning necessary for life, and it is for these that he or she will live or die. Both Frankl
and Ellis espouse the view that beliefs cause behaviors. Similar views are apparent
throughout the literature related to counseling and hastened forms of death. For example,
Albright and Hazler (1995) state, "These beliefs [about death and dying] result in
actions" (p. 179). Werth and Holdwick (2000), considered by many to be leading
researchers in the field of suicide research, state that "it is apparent that personal values
can and do affect professional actions" (p. 526). An alternative view, that behaviors
cause beliefs, is found in behaviorist theory (Skinner, 1938). Assuming a causal
relationship, regardless of direction, between beliefs and behavior, it would be reasonable
to expect the knowledge of a person's beliefs might provide valuable insight into his or
Cognitive Consonance and Dissonance
The research question examines two kinds of cognitions, counselors' personal
beliefs about suicide, and counselors' attitudes toward clients expressing suicidal
ideations. Therefore, two possible kinds of cognitive relationships may exist. These two
cognitive elements will either concur or conflict. For example, a counselor might believe
that suicide is morally wrong and his or her attitude toward clients expressing suicidal
ideations may reflect this belief. Such a counselor might attempt to dissuade the client
from committing suicide. On the other hand, a counselor might believe that suicide is
morally wrong, but his or her attitude toward clients expressing suicidal ideations may
not reflect this belief. Such a counselor may opt to set aside this particular personal belief
in favor of the ethical principal of autonomy, thereby accommodating the client's right to
self-determination. A variation on this second possibility could be a counselor who
believes that suicide is a personal choice, but his or her employer requires employees to
counsel clients against taking their own lives. For each of these situations, the
relationship between a counselor's personal beliefs about suicide and his or her attitudes
toward clients expressing suicidal ideations are examined in the context of cognitive
dissonance theory (Festinger, 1957).
Either of these situations, concurrence or conflict among beliefs and attitudes, may
or may not be cognitively problematic for the counselor. Suppose the counselor believes
suicide to be morally wrong and his or her attitude toward the client reflects this belief. In
turn, the counselor argues against committing suicide based on that moral conviction. In
the absence of any strong competing beliefs, using the language of cognitive dissonance
theory, these two cognitions are considered to be consonant. Consonant cognitions
psychologically presuppose one another (Festinger, 1957). According to cognitive
dissonance theory, consonance is not an impetus for behavioral change. The counselor is
likely to continue the current therapeutic course.
Now suppose that same counselor also believes in the ethical principal of
autonomy. Autonomy, the right of self-determination, is one of the four ethical principles
stated by Stadler (1986) to be of utmost importance for counselors. In this case, the
counselor may experience difficulty with his or her attitude toward the client. The
counselor might think that he or she is violating a valued ethical principal by imposing
his or her own beliefs and ignoring those of the client. Using the language of cognitive
dissonance theory, the counselor is experiencing cognitive dissonance (Festinger, 1957).
Cognitive dissonance occurs "whenever a person has two or more cognitions that are
dissonant [having an obverse relationship] with regard to each other" (Wicklund &
Brehm, 1976, p. 2). In this case, the dissonance arises from two competing beliefs, the
immorality of suicide, and the necessity of client autonomy.
According to cognitive dissonance theory, a dissonant cognitive relationship
creates an unpleasant tension that motivates the individual to act in some manner so as to
alleviate that tension (Festinger, 1957). Cognitive dissonance theory does not predict how
a person will act to diminish the tension, only that he or she will act to do so. In other
words, cognitive dissonance is a stimulus to behavior. The ultimate importance of
counselor behavior toward his or her client has been previously established. While
cognitive dissonance theory does not predict how a person will act to diminish tension; it
does suggest a variety of possibilities. These possibilities are germane to the research
question since they may be a part of the relationship between a counselor's personal
beliefs about suicide and his or her attitudes toward clients expressing suicidal ideations.
There are two methods by which cognitive tension may be reduced or alleviated.
One is for the counselor to attempt to reduce the importance of, or eliminate entirely, the
dissonant cognition. The other is for the counselor to find additional supporting
consonant cognitions or work to increase the importance of the existing consonant
cognition (Festinger, 1957). Discerning which cognition is dissonant and which is
consonant is a highly subjective process based on the relative importance of these
cognitions to the counselor, and each cognition's individual resistance to change
(Wicklund & Brehm, 1976). This choice among competing cognitions is an implicit
statement of personal values. "Choices are mirrors of values" (Salladay, 1986, p. 20).
Should the counselor decide that his or her own personal moral beliefs are of
paramount importance, he or she could attempt to reduce the importance of client
autonomy, or declare it to be of no value whatsoever. For a member of the counseling
profession, this would be a complex endeavor. Counselors are bound by specific ethical
mandates and the fostering of client autonomy is one of those mandates (Kentsmith,
Salladay & Miya, 1986; Cory, Cory & Callanan, 1998). According to Kentsmith et al.,
"Autonomy includes the freedom to make an irrational, harmful, or even stupid decision"
(p. 9). Even the ethical principal of nonmaleficence, which is generally considered
paramount, might not trump autonomy when understood in this light. Therefore, should
the counselor decide that such reduction is not an option; he or she might seek out new
information to bolster the morality argument. For example, the counselor might look for
alternative ethical positions more supportive of an antisuicide moral position and more
imperious than his or her professional ethics. One such absolutist ethic, popular in the
United States, is the Christian ethic (Salladay, 1986). According to Salladay, the
Christian ethic locates the standard for right and wrong in God rather than in individual
circumstances. Such a standard is absolute, unchanging, and not subject to the relativistic
ethics of a profession.
The degree to which a cognition is resistant to change is more complex than the
relative importance of various competing cognitions. Cognitive resistance to change is
predicated on two conditions; the level of ambiguity associated with the cognition and the
degree of difficulty involved in changing the cognition (Festinger, 1957). For some
counselors there might exist no moral ambiguity. The counselor not questioning his or
her moral certitude would view any competing cognition as dissonant and in need of
change. Other counselors might not view their personal morals as unquestionable but
may find the degree of difficulty involved in changing their position overly demanding.
Such a counselor may have recently made a behavioral commitment to his or her
religious organization such as enrolling a child in a parochial school. Cognitions based on
behavioral commitment are highly resistant to change (Festinger, 1957). In both
situations, that of moral certitude and recent behavioral commitment, the counselor is
much more likely to act against client autonomy than against his or her personal moral
beliefs. He or she is likely to seek out information in support of the moral belief and, at
the same time, actively avoid contact with any information that might call that belief into
question (Festinger, 1957).
Two final issues for consideration areforeseeability and responsibility (Wicklund
& Brehm, 1976). Forseeability refers to whether or not the counselor was able to
anticipate the cognitive conflict before it occurred. The counselor acting in accordance
with his or her moral beliefs, but foreseeing the ethical challenge of addressing autonomy
issues, will likely experience less motivational tension than the counselor who did not
foresee the cognitive conflict. This is considered to be the case for two reasons.
One reason is because "Commitment is a necessary condition for the arousal of
dissonance" (Wicklund & Brehm, 1976). According to Wicklund and Brehm, an
individual committing to a belief entailing foreseen cognitive conflict is likely to make
such a commitment in one of two ways. He or she may, in anticipation of the future
conflict, commit less fervently to that belief thereby reducing the level of motivational
tension experienced when faced with the conflict. Another tack is for the individual to
commit to the belief with that belief carrying the caveat of future cognitive conflict.
Hence, when the belief is challenged, the challenge is part and parcel of the belief itself.
This being the case, the cognitive conflict produces less motivational tension than if it
had not been foreseen and incorporated into the belief.
A second reason why forseeability might reduce motivational tension may be found
in the relationship between expectations and motivation. Aronson (1960) theorized that
the confirmation of a person's expectations is a major factor for the motivation of
behavior. According to this component of cognitive dissonance theory, a person
expecting future cognitive conflict will view such conflict as confirmation of his or her
expectations. Conversely, the absence of future conflict would be viewed as
disconfirmation and produce greater levels of motivational tension. Therefore, while the
person who does not encounter the expected conflict avoids experiencing the unpleasant
emotions associated with such conflict (e.g., disappointment, frustration, and
embarrassment) he or she will instead experience dissonance in the form of motivational
tension. Such a person can be expected to actively seek out cognitive conflict, even at the
cost of the above-mentioned negative emotions, to minimize dissonance.
Responsibility refers to the degree to which the counselor perceives that he or she
is acting freely. Consider the previous example of the counselor who believes that suicide
is a personal choice, but his or her employer requires employees to counsel clients against
taking their own lives. Such coercion, formerly calledforced compliance (Festinger,
1957), is now termed induced-compliance (Harmon-Jones & Mills, 1999). The counselor
who believes that his or her behavior is the result of induced-compliance will likely
experience less motivational tension than if the behavior is seen as the result of free
choice. However induced the compliance, the resulting cognitive dissonance may still
affect the counselor's self-concept (Aronson, 1999). This is in part because of the
personal regret generated by an individual's actions, which are not in accord with that
individual's beliefs or personal orientation (Seta, McElroy & Seta, 2001). Regret is an
emotion owing to the cognitive dissonance theory assertion of the human desire for
cognitive consistency (Festinger, 1957). According to Aronson (1999), such an individual
might come to view him or herself as a hypocrite thereby experiencing "dissonance in the
absence of aversive consequences" (p. 119).
Another issue, related to self-concept and lending support for the need to better
understand the role of cognitive dissonance when researching the relationship between a
counselor's personal beliefs and attitudes, is counselor happiness. Happiness has been
found to benefit not only the happy individual, but also those with whom that individual
interacts (Myers, 1992). In the case of a counselor, this may be translated into benefits for
clients and increased job satisfaction. According to Lyubomirsky (2001), personal
happiness is more a matter of subjective cognition(s) than of "objective variables" such
as personal wealth and possessions. In support of this conclusion, Myers (2000) points to
the relative stability of personal happiness levels in the United States over the past fifty
years in spite of a near tripling in income. Lyubomirsky further proposes happiness to be
largely the result of "cognitive and motivational processes" (p. 240). Cognitive
dissonance theory would seem a sound theoretical foundation on which to examine such
cognitive and motivational processes. While it is obviously an oversimplification to
conclude that a happy counselor is a good counselor, the literature on counselor
"burnout" points to a counselor's personal level of unhappiness as having a profoundly
negative affect on his or her counseling proficiency.
Burnout is a term encompassing a myriad of unpleasant job-related feelings. People
experiencing burnout are "experiencing dissatisfaction with their jobs, boredom, physical
and mental exhaustion, frustration, low self-esteem" (Combs & Avila, 1985, p. 192).
Edelwich and Brodsky (1980) define the term "to refer to a progressive loss of idealism,
energy, and purpose experienced by people in the helping professions as a result of the
conditions of their work" (p. 14). A counselor suffering from burnout is a counselor
impaired (Brems, 2000). Such impairment manifests itself in the counseling relationship
as "the interference in ability to practice therapy" and "results in a decline in therapeutic
effectiveness" (Sherman & Thelen, 1998, p. 79).
Burnout is widespread among counselors (Combs & Avila, 1985; Cory, 1986) who
are, as a group, especially susceptible (Edelwich & Brodsky, 1980; Vacc and Loesch,
1994; Brems, 2000). According to Brems (2000), there are two chief reasons for this
being the case. The first is directly related to counselor personality traits. The "traits that
have guided them into their chosen profession" are also "traits that tend to be highly
correlated with burnout" (p. 263). Burnout-related personality traits include paternalism
for the feelings and actions of others, perfectionism about personal competence, self-
doubt, and above average sensitivity to the feelings and reactions of others (Glickauf-
Hughes & Mehlman, 1995). The second reason for counselor susceptibility to burnout
relates to the contingencies of the counseling work environment. Among these
contingencies are client behaviors, unpleasant working conditions, emotional isolation,
and the counseling relationship itself (Bayne, 1997). One specifically identified client
behavior contributing to counselor burnout is suicide.
The suicide of a client "can leave a clinician shaken and self-doubting for quite
some time" (Brems, 2000, p. 275). Self-doubt, as earlier mentioned, is one of the
counselors' burnout-related personality traits. Brems (2000) further notes that self-doubt
often leads to emotional isolation, another burnout-related personality trait. Finally, client
suicide can contribute to burnout by casting doubt on a counselor's self-perceived
competency. Many therapists view the suicide of a client as a professional failure on their
part, resulting in questioning their own professional competency (Chemtob, Hamada,
Bauer, Kinney & ToriGoe, 1988; Moritz, Van Nes & Brouwer, 1989; Menninger, 1991;
Little, 1992; McAdams & Foster, 2000). Perfectionism about personal competence is a
third counselor burnout-related personality trait (Glickauf-Hughes & Mehlman, 1995).
Client suicide could therefore be considered a major contributor to counselor burnout.
It is anticipated that issues, (such as counselor burn-out) and considerations
relevant to cognitive consonance and dissonance will provide a theoretic framework for
the interviews, the analyses, and the conclusions reflected in generation of the final
research report. The question of the relationship between a counselor's personal beliefs
about suicide and his or her attitudes toward clients expressing suicidal ideations is
theoretically anchored in cognitive dissonance theory.
The following is a brief discussion of counseling ethics and the ethical decision-
making process. The role of ethical decision-making is pertinent to the research question
because it offers a systematized and thoroughly researched method for coping with the
cognitive dissonance inherent in many ethical dilemmas. The ethical decision making
process may be employed whenever the counselor experiences an ethical dilemma, a
situation involving two or more competing ethical principles (Kentsmith et al., 1986).
Kentsmith et al. (1986) assert that "reasoning and logic" should be used in the process
"based on values, attitudes, personal beliefs, duties, and obligations" (p. 6). Logic is
necessary, according to Kentsmith et al. (1986), to combat the emotional distortion of
A number of different models have been proposed to guide the ethical decision
making process. For example, Kentsmith et al. (1996) suggest a six-step model to
"Determine the facts. Analyze the ethical aspects. Outline options. Make a decision. Take
action. Evaluate the decision" (pp. 7-8). One year earlier, Hill, Glaser, and Harden had
introduced a similar seven-step model that stressed collaboration with the client as an
essential component of the counselor ethical decision-making process.
Another model is the Tarvydas's Integrative Decision-Making Model of Ethical
Behavior (Cottone & Tarvydas, 2003). This model is particularly relevant to the research
question of this study. Its contextual elements add "the realization that many additional
forces may affect the counselor" (Cottone & Tarvydas, 2003, p. 93).
Stage III, of the Tarvydas Model, identifies these additional forces as competing,
nonmoral values, personal blind spots, or prejudices. "Nonmoral values involve anything
that the counselor may prize or desire that is not, in and of itself, a moral value, such as
justice, valuing social harmony, spending time with friends or working on one's hobby,
or having personal wealth" (Cottone & Tarvydas, 2003, p. 93). Tarvydas points out
counselor cultural encapsulation as one possible source of personal blind spots, or
prejudices. She stresses the need for counselors to understand themselves, to be aware of
the ways in which their own backgrounds and values may influence their ethical
Regardless of the model being employed to define the problem or analyze the
ethical aspects, the counselor must understand the six underlying ethical principles of the
Tarvydas's Integrative Decision-Making Model of Ethical Behavior (Figure 2-2).
(1) autonomy (self-determination), (2) nonmaleficence (doing no harm), (3) beneficence
(doing good), (4) justice (fairness or equal treatment), (5) fidelity (honoring one's
commitments), and (6) veracity (honesty) (Kitchener, 1984; Corey et al., 1998). These
principles refer to the counselor's responsibilities to his or her client.
Themes or Attitudes in the Integrative Model
Maintain an attitude of reflection.
Address balance between issues and parties to the ethical dilemma.
Pay close attention to the context(s) of the situation.
Utilize a process of collaboration with all rightful parties to the situation.
Stage I. Interpreting the Situation through Awareness of Fact Finding
Component 1 Enhance sensitivity and awareness
Component 2 Determine the major stakeholders and their ethical claims in
Component 3 Engage in the fact-finding process
Stage II. Formulating and Ethical Decision
Component 1 Review the problem or dilemma
Component 2 Determine what ethical codes, laws, ethical principles, and
institutional policies and procedures exist that apply to the
Component 3 Generate possible and probable courses of action
Component 4 Consider potential positive and negative consequences or each
course of action
Component 5 Consult with supervisors and other knowledgeable
Component 6 Select the best ethical course of action.
Stage III. Selecting an Action by Weighing Competing, Nonmoral Values, Personal
Blind Spots, or Prejudices
Component 1 Engage in reflective recognition and analysis of personal
competing nonmoral values, personal blind spots, or prejudices
Component 2 Consider contextual influences on values selection at the
collegial, team, institutional, and societal levels
Component 3 Select the preferred course of action
Stage IV. Planning and Execution the Selected Course of Action
Component 1 Figure out a reasonable sequence of concrete actions to be
Component 2 Anticipate and work out personal and contextual barriers to
effective execution of the plan of action, and effective counter-
measures for them
Component 3 Carry out, document, and evaluate the course of action as
Figure 2-2. Integrative Decision-Making Model of Ethical Behavior. From Cottone, R.
R., & Tarvydas, V. M. (2003). Ethical and professional issues in counseling
(2nd Ed.). Columbus, Ohio: Merrill Prentice Hall.
An ethical dilemma is often the result of two or more competing ethical principles.
It is the duty of every counselor to evaluate each principle involved in a dilemma to act in
the best interest of the client (ACA, 2002, A.1.a; Corey et al., 1998). Corey et al. (1998)
also recommend that the counselor spend the time, including continuing personal therapy,
necessary to understand him or herself in relation to one's stand on each ethical principal.
This is another example of the previously mentioned need, "counselor, know thyself."
"Without a high level of self-awareness, counselors will most likely obstruct the progress
of their clients" (Corey et al., 1998, p. 34). Laux (2002) suggests that counselor ethical
training should speak specifically to the ethical decision-making processes connected
with work involving clients expressing suicidal ideation. The suggestions made by each
of the aforementioned authors that counselors should strive for self-awareness may be
understood in terms offoreseeability in the conceptual context of cognitive dissonance
Foreseeability, as stated earlier, refers to whether or not the counselor is able to
anticipate a cognitive conflict before it occurs (Wicklund & Brehm, 1976). Counselor
training pertaining to the possible ethical dilemmas involved with the treatment of a
suicidal client might increase a counselor's ability to anticipate various future cognitive
conflicts. According to cognitive dissonance theory, foreseen ethical challenges are cause
for less motivational tension than those that are unforeseen. Similarly, a counselor's own
continuing personal therapy might reasonably be expected to lessen possible future
cognitive dissonance since, as stated by Corey et al. (1998), such counseling will assist
the counselor to better understand his or her ethical viewpoints. Counselor self-
knowledge (whether via training, personal therapy, or experience) could directly affect
the foreseeablity of possible future ethical issues related to the treatment of consumers
expressing suicidal ideations.
Many authors also consider it crucial that the counselor involve the client
throughout the decision-making process (Hill, Glaser & Harden, 1995; Walden, 1997;
Corey et al., 1998). Reasons for such involvement include, client empowerment (Walden,
1997), and the counselor's ethical duty to "encourage client growth and development in
ways that foster the clients' interest and welfare" and to "avoid fostering dependent
counseling relationships" (ACA, 2002, A. 1.b.). Avoiding the fostering of dependence is
in keeping with the ethical principle of autonomy. The code of professional ethics for
rehabilitation counselors specifically cites the counselor's duty to respect client autonomy
in section A. 1.d. including cases where "involuntary commitment or initiation of
guardianship are taken that diminish client autonomy" (CRCC, 2002, p. 1).
Professional ethics codes are the formally expressed responsibilities that counselors
have to their clients, peers, and the public (Bersoff, 1999). These codes are used by
counselors to guide their professional behavior and by Ethics Committees to investigate
and resolve accusations of unethical behavior (AAMFT, 2001; APA, 1992; ACA, 2002;
CRCC, 2002). According to the American Psychological Association (APA, 1992), the
ethics code "is intended to provide both general principles and the decision rules to cover
most situations encountered by psychologists" (p. 9). The Commission on Rehabilitation
Counselor Certification (CRCC, 2002) states, "The basic objective of the Code
[of Ethics] is to promote public welfare by specifying ethical behavior expected of
rehabilitation counselors" (p. 4). The American Counseling Association states that its
ethics code, "establishes principles that define the ethical behavior of Association
members" (ACA, 2002, p. 1).
While these codes are helpful, they often provide little specific direction (Bersoff,
1999) and, therefore, are not a substitute for the ethical decision-making process. "When
psychologists [and counselors] cannot refer to a specific standard, they must rely more
heavily on their own value systems and on their own interpretations of the "spirit" of the
APA [and other professional ethics codes] standards" (Tymchuk, Drapkin, Major-
Kingsley, Ackerman, Coffman & Baum, 1982, p. 94). Without firm grounding in the
theory and practice of ethical decision making, reliance on one's own values may prove
problematic since, as Kitcherer (1984) observes, "In some cases, however, one's ordinary
moral sense may be misleading or inadequate" (p. 134). The earlier mentioned Tarvydas
ethical decision-making model specifically warns of the problematic, misleading, or
inadequate nature of one's own values or moral sense. "It is important that counselors
allow themselves to become aware of the strength and attractiveness of other values they
hold" (Cottone & Tarvydas, 2003, p. 93).
Theoretical Grounding for the Research Method
Why is qualitative research an appropriate method with which to analyze the
research question? Miles and Huberman (1994) consider a qualitative approach as most
conducive for achieving a holistic understanding and to possible serendipitous discovery.
These two research qualities are especially important when the phenomena under
consideration are not clearly understood or lack sufficient previous research analysis
(Glaser & Strauss, 1967; Miles & Huberman, 1994). Both of these preconditions exist for
this research question. Little is known about the relationship between a counselor's
personal beliefs about suicide and his or her attitudes toward clients expressing suicidal
As mentioned previously, research on this topic is limited for both psychiatrists
(Werth, 1992; Werth & Cobia, 1995; Werth & Holdwick, 2000) and counselors (Rogers
et al., 2001) and has been largely quantitative. The qualitative aspects of those studies are
limited to attitudes related to the concept of rational suicide, which is a narrow subset of a
much broader and larger unexamined issue. The grounded research methodology for this
study is designed to allow the data to speak, as much as possible, for itself. Therefore any
preestablished position as to the viability of suicide is unnecessary and could even prove
As explained below, grounded theory is the term used to describe the inductive use
of data to generate a substantive theory concerning the phenomena from which that
produced. Glaser and Strauss (1967) explain that their inductive methodology is
predicated on the absence of a priori assumptions necessary for hypothesis testing. A
more complete accounting of triangulation methods for this study is in the next section on
credibility and ti n\vm thine,\
Three major theorists in the area of death and dying (Glaser & Strauss, 1965;
Kubler-Ross, 1969) employed qualitative methods in their studies, gathering data through
individual interviews using open-ended questions. Extrapolating from their own
qualitative methods, Glaser and Straus (1967) went on to create Grounded Theory.
Grounded theory is used in answering this research question.
Grounded Theory is a qualitative research methodology designed for the
development of substantive theory. Its basis is "the systematic generation of theory from
data, that is itself systematically obtained from social research" (Glaser, 1978, p. 2).
Theory development is also appropriate when the phenomena under consideration are not
clearly understood or lack sufficient previous research analysis (Glaser & Strauss, 1967).
Additionally, theory development is specifically recommended by Laux (2002), in his
recent article entitled, A primer on suicidology: Implicationsfor counselors. This study is
intended to develop a substantive (as opposed to formal) theory. Grounded Theory, its
tenets, and relevance to the research question are discussed in detail in chapter three.
Credibility and trustworthiness
Qualitative research is sometimes criticized as being too subjective. "Subjectivity
has long been considered something to keep out of one's research, something to, at least,
control against through a variety of methods to establish validity. It has had a negative
connotation in the research world" (Glesne, 1998, p. 105). However, this notion is now
being challenged (Olsen, 1994; Glesne, 1998; Denzin & Lincoln, 2000). These authors
argue a case for what Peshkin (1985) calls "virtuous subjectivity." Virtuous subjectivity
is a concept recognizing that subjectivity is present in all research. This being the case, it
is incumbent on the researcher to recognize said subjectivity. Subjectivity, recognized
and properly monitored, can actually contribute to the trustworthiness of the research
(Peshkin, 1985; Olsen, 1994; Glesne, 1998; Denzin & Lincoln, 2000).
Establishing trustworthiness is essential to the credibility of the qualitative research
findings (Glesne, 1998). While quantitative experimental research relies on realist
concepts for verification and validity, qualitative research consists largely of verbal
description having data that does not fit the paradigm of realism. In the realist paradigm,
research has the supposed ability "to represent social phenomena in some literal fashion:
to document their features and explain their occurrence" (Hammersley & Atkinsion,
1995). However, "A personal narrative is not meant to be read as an exact record of what
happened nor is it a mirror of a world (out there)" (Riessman, 1993, p. 64). Instead,
qualitative studies rely on the concept of ti /uni. /ill /iew According to Riessman (1993)
ti n\,vi i /, /iuei is not the same as 1/il /i Whereas 1/il l/ is a realist concept presupposing
the existence of objective reality, tlini, w/1 iline,, is a social constructivist concept
holding that reality is itself a subjective matter. "The issue, then, is not really about
objectivity. The issue is about researcher credibility and trustworthiness, about fairness
and balance" (Patton, 1990, p. 481). It is the responsibility of each person to judge
whether or not he or she "trusts" the study's findings.
Methods used to establish trustworthiness
Essential to the validation of trustworthiness is an adequate demonstration, on the
part of the researcher, of the study's limitations (Glesne, 1998). Glesne believes that the
better a reader understands the details of the research; the better he or she is able to judge
the trustworthiness of that research. "Limitations are consistent with the always partial
state of knowing in social research, and elucidating your limitations helps readers know
how they should read and interpret your work" (Glesne, 1998). This study thoroughly
describes every aspect of the research process paying close attention to study limitations.
A second method for the enhancement of trustworthiness, according to Lincoln &
Guba (1985), is for the primary investigators) to make use of an outside auditor for the
purposes of developing and apply codes, and to assist with the interpretation of field
notes. This study used an outside auditor, who also assisted the principal investigator
with a third method for strengthening the study's trustworthiness: bias recognition. Bias
recognition is necessary for the researcher to effectively scrutinize his or her own
personal subjectivity (Peshkin, 1988; Olsen, 1994; Glesne, 1998; Denzin & Lincoln,
2000). As previously mentioned, subjectivity is not necessarily a research flaw, however,
if left unchecked or unrecognized it can seriously jeopardize the trustworthiness of the
According to Riessman (1993), there are at least four additional methods to
enhance the trustworthiness of research data: persuasiveness, correspondence, coherence,
and pragmatic use. The first of these, persuasiveness, is closely related to the concept of
plausibility. Are the research finding plausible? Is the researcher's interpretation of the
data reasonable? And finally, is the reader of the research convinced of its plausibility
and reasonability? The researcher alone, therefore, cannot achieve persuasiveness.
"Persuasiveness ultimately rests on the rhetoric of writing on literary practices and
reader response" (Riessman, 1993, pp. 65-66).
The second of Riessman's (1993) additional methods, correspondence, is not used
in this study. Correspondence entails the researcher bringing the research findings back to
its participants for the purpose of obtaining their input. This study intends no further
contact with study participants beyond the interview.
Coherence, proposed by Hobbs (1985) is a criterion with three categories: global,
local, and themal. According to Hobbs, the interpretation of study data gains plausibility
when in the context of, and applicable to, these three categories of coherence. Global
coherence pertains to the broad goals of the research, of which the researcher is writing.
The overall goal of this study is to better understand the relationship between a
counselor's personal beliefs about suicide and his or her attitudes toward clients
expressing suicidal ideations. To enhance trustworthiness, the data of this study are
interpreted in terms of this global goal.
Local coherence pertains to the "linguistic devices" employed in the research report
itself, intended to promote reader understanding of the research and the subsequent
interpretation of its data (Hobbs, 1985). Local coherence is obtained in this study through
a research report detailing the use of comparative analysis. As mentioned previously,
Glaser and Strauss (1967) suggest a method of comparative analysis for the discovery of
the conceptual categories necessary in the paradigm of grounded theory. This written
description will guide the reader through the ongoing process of comparative analysis,
which takes place throughout the coding process wherein the conceptual categories
emerge. The comparative analysis in the report assists the reader to understand just how
the researcher interpreted the data.
Themal coherence concerns content, in the case of this study, interview content.
According to Hobbs (1985), trustworthiness is enhanced when the study data, the
interview content, is shown to have a coherent theme. Such themal coherence may be
demonstrated by highlighting the recurrent themes in the interview text. Riessman (1993)
warns that the interview is not the best format for use of the themal coherence criterion.
This is because the interviewer potentially holds such powerful sway over the direction of
the interview and could, therefore, artificially control its thematic content. This study
proposes to circumvent such an objection by using the earlier outlined technique of the
active interview described by Holstein & Gubrium (1995).
The last of the Hobbs (1985) coherence criterion to enhance trustworthiness is
pragmatic use. This criterion cannot be determined before or during the time in which the
study is conducted. Pragmatic use refers to "the extent to which a particular study
becomes the basis for others' work. In contrast to other validation criteria, this one is
future oriented, collective, and assumes the socially constructed nature of science"
(Riessman, 1993, p. 68). This study is intended specifically as a springboard for future
research. It is a preliminary step in the direction to better understanding the relationship
between a counselor's personal beliefs about suicide and his or her attitudes toward
clients expressing suicidal ideations.
In addition to trustworthiness, another technique to strengthen qualitative research
credibility is triangulation. Triangulation is a method by which the same phenomena are
studied using a combination of methodologies (Patton, 1990). Denzin (1978) explains the
logic underlying the concept of triangulation is that "no single method ever adequately
solves the problem of rival causal factors" and because "each method reveals different
aspects of empirical reality" (p. 28). Patton (1990) adds "Triangulation is a powerful
solution to the problem of relying too much on any single data source or method, thereby
undermining the validity and credibility of findings because of the weaknesses of any
single method" (p. 193). Triangulation, therefore, is a strategy by which the researcher
attempts to minimize the weaknesses inherent in any single approach by adding the
support of the strengths inherent in various other approaches. The four basic types of
triangulation are: data triangulation, investigator triangulation, theory triangulation, and
methodological triangulation (Denzin, 1978).
Data triangulation refers to using more than one source of data in the same study
and then drawing comparisons. Comparing the interview accounts of a variety of
participants, each with different perspectives of the same phenomenon, is one way of
triangulating research data. This study triangulates in this manner by purposefully
selecting participants from a variety of counseling settings (e.g., rehabilitation counselors,
mental health counselors, marriage counselors, etc.). There is evidence that strongly
suggests that counselors from differing settings are likely to have different perspectives
on the suicide phenomenon. One example is that counselors from differing settings
become members of different professional accrediting organizations.
Rehabilitation counselors usually receive certification from the Commission on
Rehabilitation Counselor Certification (CRCC). Mental health counselors are often
members of the American Counseling Association (ACA). Marriage counselors are most
often members of the American Association for Marriage and Family Therapy
(AAMFT). Evidence exists demonstrating that different professional counseling
organizations have different perspectives on at least some aspects of suicide. Some of
these differing perspectives were mentioned in Chapter 1 pertaining to physician-assisted
suicide as established by counselors' reactions to the recent Supreme Court battle over
Oregon's Death with Dignity Act (1997). During this contest, amicus curiae [friend of
the court] briefs were filed both for and against implementation of the Act. Prominent
professional counseling organizations joined both sides (Werth & Gordon, 2002).
Investigator triangulation refers to using different investigators or evaluators in the
same study. This study intends to employ this method of triangulation by adding an
outside auditor for the purposes of developing and applying codes, and to assist with the
interpretation of field notes.
Theory triangulation refers to using competing theoretical models to interpret the
data of a single study. Until the onset of data analysis, the appropriateness of this mode of
triangulation remains unknown.
Methodological triangulation refers to using more than one method to study a
single phenomena or group of phenomenon. This study does not use this triangulation
technique. Rather, it relies on the integrity of a single evaluation method. The rationale
underlying this choice is based on the arguments of Guba and Lincoln (1988). They note
that qualitative research designs possess their own internal consistency and logic, and
state that the use of one internally consistent and logical approach is preferable to the
mixing of methodologies. The caution is specifically aimed against the mixing of
qualitative and quantitative methodologies in the same study. The argument is that a
researcher cannot be simultaneously inductive and deductive. In other words, it is not
possible to carry out hypothesis testing while concurrently remaining open to emergent
data (Guba & Lincoln, 1988). This study uses grounded theory. As mentioned previously,
grounded theory is the term used to describe the inductive use of data to generate a theory
concerning the phenomena from which that data were produced. Glaser and Strauss
(1967) explain that their inductive methodology is predicated on the absence of a priori
assumptions necessary for hypothesis testing.
Patton (1990) asserts, "Triangulation is ideal. It can also be very expensive. An
evaluation's limited budget, short time frame, and political constraints will affect the
amount of triangulation that is practical" (p. 187).
Theoretical Grounding for the Interview Process
Why is the interview an appropriate qualitative technique with which to study the
research question? "Preconceived ideas are pernicious in any scientific work, but
foreshadowed problems are the main endowment of a scientific thinker, and these
problems are first revealed to the observer by his theoretical studies" (Malinowski, 1922,
This study rests on the social constructionist approach wherein all interviews are
active (Holstein & Gubrium, 1995), in the sense that, "Respondents are not so much
repositories of knowledge treasuries of information awaiting excavation as they are
constructors of knowledge in collaboration with interviewers" (p. 4). From this point of
view any data gathered by means of an interview is collaborative. Therefore, this study
project makes no attempt to sterilize the interview process or to downplay its reflexive
nature. Instead, this study not only acknowledges the interview's active nature as a
feature of the research, but also capitalizes on what Douglas (1985) refers to as the
creative interview. Douglas urges the interviewer, "Always be poised to pounce on any
phenomenon that shines with the promise of a new truth discovery" (p. 69).
Accompanying the creative or active interviewing process is the question of
reflexivity. How much of the interviewee's response is the result of the interviewer's
behavior? Since the interviewer/researcher is intimately and reflexively involved in all
aspects of the research from the inception of the research question through the writing of
the report, this question might be considered more broadly.
General issues of reflexivity
Reflexivity has been said to be a part of all research (Hammersly & Atkinson,
1995). It is that part of research on which the influence of the researcher is exerted,
sometimes referred to as researcher effect. "Researchers are part of the social world they
study" (Hammersly & Atkinson, 1995, p. 16). Hence researcher effect burgeons from the
researcher's own socio-historical background, from which arises his or her personal
system of values, beliefs, and over-all point of view. It is "the impact of the researcher's
position and perspective" on the research and its results (Finlay, 2002, p. 537).
Researcher effect begins in the preresearch stage and continues through the writing of the
research report. Prior to the study the researcher must have some relationship to the study
subject matter that prompted the formulation of the research question. Throughout the
research process, Finlay (2002) advises researchers to "examine their motivations,
assumptions, and interests in the research as a precursor to identifying forces that might
skew the research in particular directions" (p. 536).
Researchers, especially quantitative researchers, have long striven to minimize or
eliminate these effects. Numerous qualitative researchers are of the opinion that the
elimination of researcher effect is impossible, even dangerous, since its consequence may
go unnoticed (Douglas, 1985; Hammersly & Atkinson, 1995; Plummer, 2001). The
results of researcher effect, when erroneously considered eliminated or marginalized, are
likely to be attributed to subject variables. The source of the problem, according to van
Manen (1990), is human commonsense. All researchers approach their research replete
with an entire set of presuppositions and assumptions regarding the topic to be studied.
These, along with the knowledge acquired throughout the literature review process,
"predispose us to interpret the nature of the phenomenon before we have even come to
grips with the significance of the phenomenological question" (Manen, 1990, p. 46).
According to Riessman (1993), in an interview situation, the interviewee is telling a
story. He or she must construct past events and actions into a personal narrative.
Regardless of the role played by the interviewer, the information contained in such a
narrative may be incomplete, historically incorrect and/or an intentional falsehood
(Riessman, 1993; Stivers, 1993).
Additionally, since the respondent is not conducting the research, the interview
narrative must be interpreted. The words of a participant do not "speak for themselves" or
"provide direct access to other times, places or cultures" (Riessman, 1993, p. 261), as
alternative interpretations are always possible (Stivers, 1993). Readers of research reports
will interpret these words a third time. Still, these interview narratives do represent in ti/th,
the truths of personal experience (Stivers, 1993).
The interview is an attempt to acquire data about the attitudes of counselors from
their point of view. Aware of this medium's reflexive nature, the interviewer made every
effort at bracketing (Miles & Huberman, 1984; Holstein & Gubrium, 1995) personal
preconceptions, putting them on hold for the duration of the interview. This bracketing is
part of distinguishing the presuppositions and assumptions of the participant from those
of the researcher. Finlay (2002) points out that this is especially important when the
researcher and participant share similar professional backgrounds; in this case both are
counselors. She states, "I had to guard against assuming that we shared the same
language and saw the job in the same way; if I failed to do so, I might have missed the
point that there were differences" (p. 537).
At the same time, "One of the most important elements of context is the audience
to which the actions, in the accounts, were directed" (Hammersly & Atkinson, 1995,
p. 218). The participant knew that the interview was intended for research purposes. He
or she was made aware of the research topic. It is then reasonable to assume that the
interview context was constructed for the interviewer with the idea that, though
anonymous, it was still a public rather than private exchange. Considering the relative
sophistication of the interviewee there may be a commingling of description and analysis.
Purpose and Relevance to Practice
The goal of this study is to explore the relationship between counselors' own
personal beliefs about suicide and counselors' attitudes toward clients expressing suicidal
ideations. Since these two types of cognitions may be either congruent or discrepant,
cognitive dissonance theory (Festinger, 1957) provides a useful theoretical context for the
investigation of this relationship.
Relevance to Practice
The possible benefits resulting from such knowledge are considerable not only to
the counseling profession, but also to the consumers they serve. As previously noted,
congruence of thoughts, actions, and feelings is considered necessary for the essential
counselor trait of genuineness (Cormier & Cormier, 1991; Long, 1996). According to
these authors, the development of this same type of congruence for the client is often a
goal of the counseling relationship.
Enhanced understanding could benefit counselors themselves. An educational
outcome, stressed by most counselor education programs, may be represented by the
phrase "Counselor know thyself' (Meier & Davis, 1993). "You [the counselor] should be
aware of your own feelings, attitudes, values, and motivations for working with others"
(Doyle, 1998, p. 6). Many counseling theorists deem this necessity for counselor self-
awareness to be crucial to counselor competence (Cormier, 1986; Doyle, 1998; Egan,
1990). "Therapists must be able to look at their clients with objectivity and not become
entangled in their personal dynamics" (Phares, 1992, p. 320). "If they [counselors] are
self-aware, they may more effectively and honestly compensate for their conflicted
impulses" (Cottone & Tarvydas, 2003, p. 93). Since the majority of counselors have
experienced at least one client expressing suicidal ideations (Rogers et al., 2001), a
counselor might be well advised to know him or herself intimately in this area. Individual
counselors may choose to carry out self-examinations of a kind similar to that which they
read in this study.
Other benefits for counselors could be in the area of counselor training. Counselor
education programs are largely research based (Neimeyer, 2000). If it is reasonable to
assume that many counselor attitudes toward suicide are influenced by their training, then
understanding the attitudes of current practicing counselors may lend insight into the end
results of such training. Just as individual counselors may benefit from the knowledge of
their peers attitudes and actions, counselor educators might choose to amend or bolster
their current programs. Authors such as Westefeld et al. (2000) recommend that
suicidology should be considered a necessary and integral part of counselor education.
They suggest the study of suicide begin as early as possible in the counselor's academic
program and continue throughout his or her field placements. The need for counselor
training in the area of suicide and intervention is further indicated and supported by the
research of Bascue (1977), and Foster and McAdams (1999).
The area of counselor training most often neglected, when training on suicide is
offered at all, is the effect of a suicidal client on the counselor. "In spite of the fact that
dealing with suicidal clients is threatening to most therapists, very little training in coping
with the suicidal death of a client is included in graduate programs for therapists"
(Stillion & McDowell, 1996, p. 242). Stillion and McDowell (1996) note that counselors
are faced with a myriad of emotional, ethical, and legal issues after the suicide or even
attempted suicide of a client. They urge counselor education programs to prepare
therapists for the likelihood of experiencing a grief reaction, calling into question their
own professional competence, and the possibility of legal liability.
The need for enhanced counselor training is underpinned by the cognitive
dissonance theory concept offoreseeability (Wicklund & Brehm, 1976). As stated earlier,
forseeability refers to whether or not the counselor was able to anticipate the cognitive
conflict before it occurred. A counselor who is able to anticipate the myriad of emotional,
ethical, and legal issues is likely to experience less cognitive dissonance associated with
these issues than is a counselor lacking such foreseeability.
Relevance to counselor supervision may also be indicated. Counselors experiencing
the suicide death of a client may feel overly responsible and need supervision to clarify
their own role in the occurrence. For this reason, debriefing and perhaps even personal
therapy have been suggested for therapists after the suicide of a client (Lavin, Roy,
Dunne-Maxim & Slaby, 1994).
It is an increasingly common practice for counselors to seek regular supervision
(Bernard & Goodyear, 1998). Since, as previously mentioned, most counselors will
experience at least one client expressing suicidal ideations it is likely that such an
experience might become a topic of supervision. Counselor supervisors are obliged, as
are all practicing counselors, to keep abreast of current research literature (Bernard &
Goodyear, 1998). The results of this study might help them to better address such issues.
Enhanced understanding in this area could be of great use to Counselor
Professional Ethics Review Boards, or Ethics Committees. As part of their duty to protect
the public, these groups are responsible for examining alleged counselor misconduct and
for administering corrective measures (Walzer & Miltimore, 1993; Cobia & Pipes, 2002).
While research has generated a great deal of information about the specific ethical
dilemmas facing therapists today, "relatively little is known about the nature of the actual
situations that practitioners find ethically, legally, or professionally problematic" (Haas,
et al., 1986, p. 99). Greater knowledge of counselor beliefs and attitudes about suicide
and suicidal ideation might be of assistance in both tasks. They might more readily
comprehend an accused counselor's stated motives when determining guilt or innocence.
Greater insight into counselor thinking might also enrich the creative thinking necessary
for the design of remedial action and preventive education.
The conclusions sections of many research articles often include a plea for
continued research in the area under study. Researchers appear overwhelmingly
cognizant of their own incremental role in developing a deeper understanding of their
subject matter. Often illuminated are the study's own weaknesses and/or limitations as
suggested topics for continued research. This is also the case in the area of counselor
attitudes toward suicide and suicidal ideation. Relevance of this issue for
psychotherapists has been previously documented (Werth & Holdwick, 2000). In so
doing, the case was made for expanding exploration of this issue to other health
professionals including counselors. Since those recommendations, this researcher is
aware of only one study with counselor participants, that of Rogers et al. (2001). The
following are five practice-related issues considered by Werth and Holdwick (2000) to
have shared relevance with counselors.
The first issue is that of population diversity. As is the case with psychotherapists,
counselors are apt to work with clients of diverse populations. Werth and Holdwick
(2000) note that demographic diversity appears to significantly affect how clients view
issues of suicide. For example, they found African Americans and Latinos far less likely
to accept hastened forms of death than White European Americans. Westefeld et al.
(2000) recently reported similar findings in their compilation of suicide literature from
across several diverse disciplines. Counseling practitioners "must be aware of how
cultural diversity may affect end-of-life decisions, especially those related to hastening
death in some way" (Werth & Holdwick, 2000, p. 525-526). Laux (2002) reminds
counselors that when considering cultural diversity "it is vital to recognize that within-
group differences often exceed between-group differences" and warns that "group
comparisons may lead to overgeneralizations at the individual level" (p. 381).
The second issue concerns value conflicts. Werth and Holdwick (2000) further
support the importance for mental health workers' [including counselors] awareness of
the personal value conflicts possible in the treatment of clients expressing suicidal
ideations. They warn "it is apparent that personal values can and do affect professional
actions" (p. 526).
The third issue is that of the "ethical and legal issues and the standard of care"
(Werth & Holdwick, 2000, p. 526). According to Werth and Holdwick a pervasive ethical
and legal misconception surrounds the treatment of clients expressing the desire to end
their own lives. This misconception is the popular belief in the therapist's duty to try to
prevent suicide. Werth and Holdwick note that such intervention has neither a legal nor
professionally ethical mandate.
The fourth issue relevant to practice is that of assessments. Werth and Holdwick
(2000) note that therapists called on to assess client decisions about suicide should be
aware of the aforementioned issues of population diversity, value conflicts, and the
ethical and legal aspects of standards of care. They are particularly interested in
practitioner knowledge of depression, terminal illness, suicidal ideation, and rational
suicide and comment on the general failure of professional training programs to educate
on the topic of suicide.
Werth and Holdwick's (2000) fifth issue considered as relevant to counseling
practice is that of professional training. They state the imperative of education and
continued education as follows. "Counseling psychologists are normally not trained (a) to
consider the possibility that a person's decision to hasten death may be rational or (b) to
work with terminally ill individuals who are considering hastened death" (p. 530).
While rational suicide is not the sole focus of this study, it may be the most closely
associated research spotlighting counselor attitudes toward suicide and suicidal ideation
to date. The Rogers et al. (2001), Werth (1992), Werth & Cobia (1995), and Werth &
Holdwick (2000) studies of rational suicide focus on the previously delineated definition
as an accepted concept and examine subjects' attitudes toward this concept. This study
does not limit itself to any particular paradigm or line of inquiry. Certainly, some
participants may be familiar with the rational suicide literature, but this study is interested
in any and all counselor attitudes toward suicide and suicidal ideation.
Further supporting this issue's relevance for counselors is the previously discussed
ACA support for the legalization of physician-assisted suicide expressed by signing on to
the amicus curiae ("friend of the court") brief submitted to the Supreme Court by WSPA
in the case of Quill v. Vacco (Werth & Gordon, 2001). Apparently, understandings of
counselor attitudes and beliefs regarding suicide are inconsistent and far more complex
than was initially imagined. Opposition to this position by so many disability advocate
groups lends the topic special relevance to counselors working in the rehabilitation fields.
Considering (1) the position of the ACA, (2) the reaction by some of its' members and
several disability advocate groups, (3) the absence of any knowledge base about
counselor attitudes toward rational suicide, (4) the Supreme Court's decision to allow
individual states to make laws regarding physician assisted suicide, and (5) the
recommendation by previous rational suicide researchers that further research is
necessary, the issue of relevance for this pilot investigation of counselor attitudes toward
suicide and suicidal ideation appears well grounded.
Counseling is a discrete profession stipulating a specific educational study required
to achieve a master's or doctorate degree (Gladding, 1996). Such training is deemed
indispensable by most professional organizations responsible for counselor certification
(APA, 1996; CRCC, 2001; ACA, 2002b). The logic underlying this training is meant to
"assure the public that the counselor meets minimal educational and professional
standards" (Gladding, 1996, p. 7). Therefore it is the public, the potential consumers of
counseling services, who are the primary intended beneficiaries of counselor training. As
previously described, this study may be expected to benefit counselor training thereby
providing benefit to consumers of counseling services.
The supervision of counselors is intended as an intervention supported by
empirically based theories grounded in scientific research (Bernard & Goodyear, 1998).
According to Bernard and Goodyear, one of the three chief purposes of counselor
supervision is to protect the consumers of these services. It is therefore reasonable to
assert that the efficacy of this protection is largely dependent on the theories supporting
the supervisory intervention, which are in turn grounded in research. This study is
intended to help generate a substantive theory related to suicide. As previously described,
such theory may benefit counselor supervision thus providing benefit to consumers.
While it is ethically permissible to expect fair compensation and professional
gratification for their efforts, a counselor's primary duty and responsibility is to the
consumer of his or her services (ACA, 2002; CRCC, 2002). Consumers are the ultimate
beneficiaries of counseling research that may impact counselor training, supervision, or
the remedial actions taken by Counselor Ethics Review Boards.
MATERIALS AND METHODS
The following methodology was used to answer the research question: What is the
relationship between a counselor's personal beliefs about suicide and his or her attitudes
toward clients expressing suicidal ideations? What follows is a presentation of the
research method, characteristics of the study participants, and procedures for obtaining
participants, procedures for data collection and analysis, and a pilot study synopsis.
The paradigm of this study is qualitative. This approach was used, for three
reasons, each based on the nature of the research question: What is the relationship
between a counselor's personal beliefs about suicide and his or her attitudes toward
clients expressing suicidal ideations?
The first reason for proposing the use of a qualitative method is the current level of
understanding concerning the relationship between a counselor's personal beliefs about
suicide and his or her attitudes toward clients expressing suicidal ideations. A thorough
literature search suggests that, at present, little is known about the nature of this
relationship. Qualitative analysis is appropriate when the phenomena under consideration
are not clearly understood or lack sufficient previous research analysis (Glaser & Strauss,
1967; Miles & Huberman, 1994). In such a situation, Glaser and Strauss recommend
qualitative research for the generation of theory, called the "grounded theory" method.
They suggest a method of comparative analysis to discover the conceptual categories
necessary for theory generation. "In discovering theory, one generates conceptual
categories or their properties from evidence; then the evidence from which the category
emerged is used to illustrate the concept" (Glaser & Strauss, 1967, p. 23). The details of
this method are outlined later in the discussion of grounded theory.
The second reason for proposing the use of a qualitative method is rooted in the
current state of the research most closely related to the research question. As mentioned
in Chapter One, the existing research examines attitudes related to the concept of rational
suicide. The focus is on the counselor's attitudes related to the concept of suicide as being
a rational choice for certain individuals under specific circumstances (Rogers et al.,
2001). This research to date is largely qualitative. For example, Rogers et al. (2001)
randomly sampled 1,000 members of the American Mental Health Counselors
Association using a mailed survey. They received 241 usable responses. The survey,
adapted from that of Werth and Liddle (1994), included a case vignette "describing the
context and condition of an individual who has made a decision to commit suicide"
(Rogers et al., 2001, p. 367). Based on that vignette, participants answered three
quantitative questions and three open-ended qualitative questions. Two researchers,
working toward consensus, coded the qualitative data. Responses for which category
coding consensus could not be attained were dropped from the study.
The third reason for using a qualitative method is historically grounded. Glaser and
Strauss (1965, 1967), who developed the qualitative method of grounded theory, did so
through their research on death and dying. Elizabeth Kubler-Ross (1969, 1975), another
preeminent researcher in the area of death and dying, also employed qualitative methods
in her studies. The methodologies used by these researchers are summarized in Chapter
Two: Literature Review. Proposing the use of a qualitative approach in this study is to
follow a well-established tradition to research phenomena related to death and dying.
The essence of qualitative research is an attempt to make sense of, and extract
patterns from, personal stories (Glesne, 1999). The above-mentioned method of grounded
theory of Glaser and Strauss (1967) was the qualitative method employed for this study.
Grounded theory is the term used to describe the inductive use of data to generate a
theory concerning the phenomena from which that data were produced. Grounded theory
"provides us with relevant predictions, explanations, interpretations and applications"
(Glaser & Strauss, 1967, p. 1) appropriate to empirical situations. Hence a theory derived
in this manner is inseparably linked to, or grounded by, the data from which it is
Grounded theory provides a framework in which the researcher may move
methodically from data collection, through data analysis, to writing the research report
and the subsequent generation of theory (Glaser, 1978). This inductive process stands in
contrast with most quantitative research, which according to Glaser and Strauss (1967)
generally includes an "explanation [of the study's findings] taken from a logically
deduced theory" (p. 4). Whereas deductive methods attempt to confirm facts or interpret
data relative to preexisting theory, Glaser and Strauss explain that their inductive
methodology operates with the absence of a priori assumptions. Various contemporary
authors stress the need for theory development related to suicide and counseling.
Westefled, Range, Rogers, Maples, Bromley, and Alcorn (2000) assert that counselors
presently function theoretically in the areas of suicide prevention and suicidology.
According to Laux (2002), "There is a great need for the development of a priori theories
that would lead to testable hypotheses" (p. 382).
According to Glaser (1978), a properly generated grounded theory possesses the
characteristics offit, relevance, and modifiability. Fit refers to the criterion that its
categories must fit the data. Theoretical categories, or themes, must emerge from the
data. They should not be preconceived, or preceded, from some preexisting theory before
the data are collected. Relevance refers to the relationship between the data and the
theory grounded in that data. A grounded theory has the ability "to explain what
happened, predict what will happen and interpret what is happening in an area of
substantive or formal inquiry (p. 4)" because the relevance of that theory is derived from
the data from which it emerged. Modifiability indicates that a grounded theory is never
considered to be a fact. It is never completely finished. A grounded theory is inseparable
from the data. As the data changes and new data become available the theory must
remain open to modification.
As was the case for the death and dying research conducted by Glaser & Strauss,
and Kubler-Ross, the interview is the method for gathering the data for this study. There
exist criticisms of the interview as being a limited data source. This is because the
participant-interviewee is capable of relating only his or her own perceptions from his or
her own point of view (Patton, 1990). Patton notes that interview data are, therefore,
subject to the distortions of subjective personal bias, emotions, and even the participant's
own lack of observational skills. "Interview data are also subject to recall error, reactivity
of the interviewee to the interviewer, and self-serving responses" (Patton, 1990, p. 245).
Aware of these potential difficulties, this study proposes using a particular form of
interview described as an active interview by Holstein & Gubrium (1995) or as a creative
interview by Douglas (1985).
The active, or creative, interview is a collaborative process undertaken by the
researcher-interviewer and the participant-interviewee. The reflexive nature of the
interview is acknowledged and capitalized on. The interview data was, therefore,
analyzed with the knowledge that it is not an exact representation of the participant's
activities, beliefs and attitudes, but rather a co-constituted accounting. The dynamics of
the interview relationship itself influences research results. According to Gergen and
Gergen (1991) different researchers present themselves differently, respond to
participants differently, and trigger different responses.
Reflexivity applies to that part of research on which the influence of the researcher
is exerted, sometimes referred to as researcher effect. "Researchers are part of the social
world they study" (Hammersly & Atkinson, 1995, p. 16). Hence researcher effect
burgeons from the researcher's own socio-historical background, from which arises his or
her personal system of values, beliefs, and overall point of view. It is "the impact of the
researcher's position and perspective" on the research and its results (Finlay, 2002,
p. 537). Researcher effect begins in the preresearch stage and continues through the
writing of the research report. Prior to the study the researcher must have some
relationship to the study subject matter that prompted the formulation of the research
question. Throughout the research process, Finlay (2002) advises researchers to "examine
their motivations, assumptions, and interests in the research as a precursor to identifying
forces that might skew the research in particular directions" (p. 536).
This study adopts a social constructionist point of view and does not attempt to
minimize or eliminate these effects. The logic underlying this approach is the
understanding that reflexivity is a part of all research (Hammersly & Atkinson, 1995).
Failure to acknowledge this, including researcher attempts to minimize or eliminate its
effect, is likely to result in the effects of reflexivity being erroneously attributed to
subject variables (Douglas, 1985; Hammersly & Atkinson, 1995; Plummer, 2001).
Therefore, for this study, the construction of the interview is conversational in
nature directed by the interviewer in ways designed to stimulate discussion about the
relationship between the interviewee's personal beliefs about suicide and his or her
attitudes toward clients expressing suicidal ideations. To this end, the interviewer
prepared several open-ended questions prior to the interview. These questions were
designed to elicit two types of information. First, information invested in the
participant's memories about incidents involving client suicidal ideation and second,
information regarding the participant's own beliefs about suicide. The questions possess
the qualities of being both straightforward and respectful of the participant's beliefs and
experiences. They are also adaptable to the changing conditions of the interview process,
meaning that their exact wording was sometimes altered, some questions were not used,
and other questions were added extemporaneously. The questions are listed below.
* What does "committing suicide," mean to you?
* Please articulate your own personal views on committing suicide.
* Have you ever considered ending your own life?
* Do you have any advanced directives (e.g., Do Not Resuscitate) concerning your
* Describe your own feelings relating to client suicide in your role as counselor.
* Take me through an experience of yours involving a client with suicidal ideations.
* Have you ever had a client successfully end his or her own life?
* If yes, can you describe how that experience affected you?
Supporting questions, drawn from the interviewer's experience as a counselor, are
spontaneously dispersed throughout the interview. These are intended to encourage
elaboration, build confidence (both in the participant's stories and the interview process
itself), and show that the interviewer has understood what was being related. The
remainder of the interviewer's contribution is non-verbal body language (such as
mirroring the participant's posture) or simple reflections of the participant's
communication. Such actions serve purposes akin to the supporting questions.
The method for study participant selection is purposeful sampling. Purposeful
sampling (Patton, 1990; Glesne, 1999) is appropriate as the purpose of the study is not
wide generalizability to a larger population (Glesne, 1999). Each participant is selected
for a purpose specific to a better understanding of the research question. "The logic and
power of purposeful sampling lies in selecting information-rich cases for study in-depth.
Information-rich cases are those from which one can learn a great deal about issues of
central importance to the purpose of the research, thus the term purposeful sampling"
(Patton, 1990, p. 169).
Of the various strategies for purposeful sampling, the method for this study is
maximum variation sampling (Patton, 1990). According to Patton, the goal of maximum
variation sampling is to allow for the description of themes arising from a wide variety of
participants while employing a relatively small sample. This is accomplished by choosing
participants using such criteria as to maximize the variation within that sample. The
rationale underlying maximum variation sampling is that "Any common patterns that
emerge from great variation are of particular interest and value in capturing the core
experiences and central, shared aspects or impacts" (Patton, 1990, p. 172). The following
participant selection criteria are based on information culled from the literature review
coupled with the requirements of the research question.
Each participant is a practicing counselor having experienced at least one client
exhibiting suicidal ideation(s). The basic criterion is two fold. First, the research question
requires that the investigation be limited to counselors. Second, the research question
includes the components of counselor beliefs about suicide and counselor attitudes
toward clients) expressing suicidal ideation(s). This second component necessitates that
the counselor participant actually possess such an attitude, not mere speculation as to
what that attitude might be.
Geographically, recruitment took place within a one-hour drive radius of the
University of Florida. This was an economically imposed study limitation. The research
was not funded.
Study participants were recruited from a variety of counseling settings. The
literature indicates possible attitudinal differences among counselors affiliated with
varied professional organizations. For example, in the Supreme Court case of Quill v.
Vacco (1996) involving physician-assisted suicide, amicus curiae briefs were presented
both for and against the Oregon Death With Dignity Act (1997) by various organizations
representing mental health practitioners. Additional attempts were made to recruit an
equal number of males and females as the literature indicates possible attitudinal
differences between the sexes regarding death, dying, and suicide (Moremen &
The number of participants was methodologically driven and included eight
individuals. In accordance with grounded theory, "Beyond the decisions concerning
initial collection of data, further collection cannot be planned in advance of the emerging
theory (as is done so carefully in research designed for verification and description)"
(Glaser & Strauss, 1967, p. 47). Glaser (1978) asserts that the emerging theory controls
the data collection process. Therefore, the exact number of participants was not known
before hand. With the collection of initial data came the development of cognitive themes
such as belief structures, or ways in which individual participants view the suicide-related
material discussed in the interviews. The process of interviewing new participants
continued until it became evident that no new themes were forthcoming within the
sample parameters. Glaser and Strauss (1967) refer to this condition as theoretical
saturation. The final number of participants was established when the last new interviews
produced only data repetitious of the previous interviews (Miles & Huberman, 1984).
This represents one of the major differences between qualitative and quantitative
sampling methods. Quantitative research uses the logic of probability sampling. It derives
its power from selecting a sample group of subjects from, and statistically representative
of, a predetermined larger population. The goal is the ability to generalize from the
sample to the population (Gravetter & Wallnau, 1999). Qualitative research uses the logic
of purposeful sampling. It derives its power from the selection and in depth study of
information-rich cases. "Information-rich cases are those from which one can learn a
great deal about issues of central importance to the purpose of the research, thus the term
purposeful sampling" (Patton, 1990, p. 169). The technique of purposeful sampling
operates in tandem with the sample size criterion of saturation. "In purposeful sampling
the size of the sample is determined by informational considerations. If the purpose is to
maximize information, the sampling is terminated when no new information is
forthcoming from new sampled units; thus redundancy is the primary criterion" (Lincoln
& Guba, 1985, p. 202).
The researcher interviewed each participant once. The interviews were audiotaped.
The average duration of each interview was 45 minutes and took place at a site mutually
agreed on by both interviewer and interviewee. The site was private to allow for
Preceding any participant contact, the Institutional Review Board (IRB) of the
University of Florida approved the research. The IRB provided the researcher with
approved Informed Consent forms, which were presented to each participant prior to the
interview. The researcher thoroughly explained the content of the form to each
participant and each participant signed an Informed Consent form (Appendix) before
commencing with the interview. The forms are the only study record identifying the
individuals by name and are stored in a locked file cabinet.
The audiotapes of each individual interview, also stored in a locked file cabinet, are
identified numerically and sequentially in the order in which the interviews occurred. The
name of the participant does not appear on the audiotape cassette. All attempts were
made to avoid using the participant's name during the taping of the interview. In the
event his or her name was spoken while taping, that name does not appear in the tape's
transcription. A professional transcriber, familiar with the rules of research
confidentiality, transcribed the audiotapes verbatim. This study did strictly adhere to all
professional and university guidelines to assure participant confidentiality.
No field notes were taken during the interviews. The researcher wrote field notes
both before and after each interview. The preinterview notes were of an organizational
nature. The postinterview notes were for the purpose of organizing the researcher's
thoughts prior to the transcription of the audiotape and capturing immediate impressions
and reflections of the researcher. Field notes were hand written, then later computer typed
by the researcher for use with the NVivo program. Original hand-written notes are stored
in a locked file cabinet.
The data for this study was analyzed by means of comparative analysis.
Comparative analysis, in the context of grounded theory, is part of a system of discovery
appropriate for use with a participant pool of any size (Glaser & Strauss, 1967). This
study used a comparative analysis of the information presented by each study participant
during his or her interview. Each individual interview produced a number of conceptual
themes or categories. These themes or categories were analyzed, by means of comparison
across interviews, for the purpose of generating a theory based entirely on that data. "In
discovering theory, one generates conceptual categories on their properties from
evidence; then the evidence from which the category emerged is used to illustrate the
concept" (Glaser & Strauss, 1967, p. 23). Comparative analysis can then be used to detect
commonalities and differences among participant themes. "Qualitative researchers seek
to make sense of personal stories and the ways in which they intersect" (Glesne, 1999,
p. 1). The underlying logic is to ascertain the generality of specific themes and concepts,
to establish boundaries for the newly generated theory. The specific method this study
uses to accomplish this goal is termed constant comparison.
Constant comparison, according to Glaser and Strauss (1967), is a method
consisting of four stages: "(1) comparing incidents applicable to each category, (2)
integrating categories and their properties, (3) delimiting the theory, and (4) writing the
theory" (p. 105). While each stage does lead to the next, previous stages remain
operational and continue to function through the completion of the fourth stage.
Beginning with the first interview, Glaser and Strauss (1967) explain, the data are coded
"into as many categories of analysis as possible," then subsequent interview data are
added and constantly compared to the existing codes "as categories emerge or as data
emerge that fit an existing category" (p. 105). This method of constantly comparing new
data to old requires that categories and codes be continually integrated, updated, and
revised (as dictated by the data) until the final research report is completed.
Constant comparison has become a staple of modern qualitative research analysis
in area of death and dying studies (Leichtentritt & Rettig, 1999; Trainor & Ezer, 2000;
Chochinov, Hack, McClement, Kristjanson & Harlos, 2002; Lyons, Orozovic, Davis &
Newman, 2002). Numerous authors recommend its use with the grounded theory method
(Strauss & Corbin, 1990; Bogdan & Biklen, 1998; Silverman, 2001; Camic, Rhodes &
Dr. Mary Ellen Young, Ph.D. acted as the outside auditor for this study. In this
capacity, she assisted the primary investigator with coding, constant comparison, and
identification of researcher bias. Dr. Young is a seasoned qualitative researcher, well
acquainted with the goals, methodology, and theoretical orientation of this study.
QSR NVivo computer assisted data analysis software was used for storing,
cataloguing, searching, and coding the interview and fieldnote data. QSR (Qualitative
Solutions and Research) has a 20-year history beginning with a program known as
NUD*IST(Non-numerical Unstructured Data Indexing, Searching, and Theorizing). QSR
NVivo is specifically designed for qualitative data analysis "to integrate coding with
qualitative linking, shaping and modeling" (QSR, 2003, p. 1). This is particularly
appropriate for the research question concerning counselor's beliefs and attitudes and for
the interview research methodology, which includes much inquiry into the counselor's
QSR NVivo allows for the flexibility required by qualitative research. "Qualitative
research is a constant process of idea-generation and idea-development" (Richards, 2000,
p. 30). The necessity to update and continually reinterpret the data of a qualitative inquiry
is reiterated by many qualitative research authors (Glaser & Strauss, 1967; Miles &
Huberman, 1984; Patton, 1990; Glesne, 1999).
A pilot study was conducted using the above research method and procedures for
data collection and analysis. The study consisted of a single interview. The participant
was a counselor having personal experiences with clients expressing suicidal ideations.
The purpose was to explore the relationship between the counselor's own personal beliefs
about suicide and her attitudes toward clients expressing suicidal ideations. Analysis of
the results included several themes, subthemes, and interviewer reactions both during and
after the interview. Each was examined individually and contextually.
The interview took place on a screened-in porch at the home of the participant. No
one but the interviewer and participant were present and the interview was audiotaped for
later transcription. Prior to the interview, the participant was made fully aware of the
topic and its future uses. The length of the interview was preordained to be no more than
one hour but would be allowed to conclude before that time if deemed appropriate by
either the participant or interviewer.
The interviewer utilized the several open-ended questions listed above as the
questions in the Data Collection section. The design of these questions was to elicit three
types of information. First, was information about the participant's memories involving
incidents involving suicidal ideation. Second, was information regarding the participant's
own beliefs about suicide. Third, was information on the participant's view of her own
cognitive processes that resulted in the way in which she responded to her client's
expressions of suicidal ideations. To achieve this, the questions possessed the qualities of
being both straightforward and respectful of the participant's beliefs and experiences.
They were also designed to be adaptable to the changing conditions of the interview
Supporting questions were also dispersed throughout the interview. While some
were preplanned, most were spontaneous and drawn from the interviewer's experience as
a counselor. These questions served the purposes of encouraging elaboration, building
confidence (both in the participant's stories and the interview process itself), and
demonstrating that the interviewer understood what was being related. The remainder of
the interviewer's contributions was largely non-verbal or simple reflections of the
participant's speech. These actions served purposes akin to the supporting questions.
While no field notes were taken during the interview, several pages were produced
both before and after. The pre-interview notes served an organizational function. The
post-interview notes were for the purpose of organizing thoughts prior to the
Transcription and Software
A professional transcriber transcribed the audiotape, used to record the interview.
The verbatim transcript was 13 pages in length, single-spaced, and with number 10 New
Courier font. The tape itself was easy to hear and understand. The form of the
transcription was designed to accommodate the N5 software program used to analyze the
Two main themes emerged during the interview. Associated with each of these
were several sub-themes. Each sub-theme carried a number of ancillary themes, all of
which were identified, categorized, and analyzed using the N5 program and grounded in
the data of the actual words of the interview.
Relevance to Research Proposal
The pilot study served the purpose of discerning the plausibility of technique and
the appropriateness of applying grounded theory to this research question. Discerning the
plausibility of technique included logistical concerns and the researcher's ability to carry
out an interview appropriate to both the research question and the methodology of
grounded theory. The pilot study revealed that the technique of conducting a one-on-one
interview at a location chosen by the participant, and using a combination of both
preconceived and extemporaneous questions, was indeed effective. The interview
proceeded smoothly producing a plethora of information, which proved useful in later
data analysis. The audiotape was easily understood and transcribed. This professional
transcriber also transcribed the tapes of the current study.
The process of data analysis employed for the pilot study established the
appropriateness of applying grounded theory to this research question. Several themes
and sub-themes were generated, grounded in the participant's actual words, and relevant
to both the participant's beliefs about suicide and attitudes toward clients expressing
suicidal intentions. An example of this was the theme Consumer Type.
The participant had experience with two types of consumers, adolescent
"Anywhere from 17, probably the youngest I have ever had that threatened [suicide] was
eight," and geriatric "I dealt with it also in the nursing home that I worked in with older
patients who were very ill." During the interview it became apparent that the participant
regarded these groups quite differently. "Interviewer: When you are counseling and you
have a client who has suicidal ideations, how do you deal or how have you dealt with the
client?" "Participant: It depends on the age." Behaviors and attitudes related by the
participant about counseling stratagems and opinions varied greatly between the two.
They came to be the major sub-themes associated with the major theme of Consumer
The preceding methodology was used to answer the research question: What is the
relationship between a counselor's personal beliefs about suicide and his or her attitudes
toward clients expressing suicidal ideations? The importance of this research question
stems from the knowledge that suicide is the ninth leading cause of death in the United
States. Between 66 and 80% of those who do commit suicide tell someone, often their