Self-Reports of Corrective Experiences by Suicide Attempters in a Video Self-Confrontation

Addressing suicide processes in their own rights and not only as a part of another disorder opens a door to new interventions. Thus, any monitoring of and reflecting on suicide processes should be helpful in suicide prevention. Video supported self-confrontation interviewing is a tool that provides such monitoring. However, reports and studies on the effects of video self-confrontation with patients after a suicide attempt are surprisingly rare. The present qualitative study summarizes some of the subjective experiences of patients hospitalized after a suicide attempt. The patients described their experiences of the effects of the self-confrontation interview using video recordings of their suicide action narratives interview with a psychotherapist. The reported changes regarded mostly exposure effects and an increased action awareness exposing the distortions of their suicide actions, such as lack of contextualization of the suicide action in other life pursuits and goals, plans, as well as compromised monitoring and feedback processes during suicide action, dissociation, and discrepancies between emotion and behaviour. We propose that the self-confrontation could be a useful tool in suicide prevention when used appropriately.

Keywords: Suicide; Self-confrontation; Action; Suicide prevention

Suicide is a complex process understood as anchored somewhere on the continuum between a conscious decision, on the one hand, and an illness, on the other [1]. We see action, and thus any suicide actions, as an integrative process of manifest behaviour, internal processes and social meaning thus overcoming the Cartesian dualism [2] of some psychological models that separated cognitive and behavioural, but also individual and social processes [3]. We proposed that suicide should be seen in terms of goal-directed processes as short-term actions, mid-term projects, and long-term pursuits or career [4,5]. In this view the conception of prospective, intentional steering, control, and regulation of suicidal action replaces the mechanistic causal view of suicide.

Further, such goal-directed conceptualization integrates a whole range of processes between conscious steering by goals and unconscious regulation [6]. Suicidal people report and show many faults in their goal-directed processes when engaged in suicidal behaviour. Less in the sense that their suicidal intentions cannot be well executed, but more in the sense that the whole suicidal behaviour mirrors or represents disorganized goal-directed processes. The whole system’s organization of actions and projects involved in suicide can be seen as susceptible to faults and thus result in self-injury or destruction by launching and following self-destructive goals. Following this conceptual approach and the reports of suicidal people we identified suicide action as a distorted goal-directed process [7]. As all action steps, action and project processes can lead to a substantial change of an action and in an action and a project and thus help avoiding suicide, self-injury or destruction it is more than an action selection that has to be scrutinized.

To account for the integrative nature of action while studying goal-directed processes we proposed using a method of monitoring of internal action processes by a video supported recall that is also labelled a self-confrontation interview and which is similar to the interpersonal process recall technique [8-10]. This in addition to the method of systematic and naïve observation. Further, we suggested that a self-confrontation interview is not only important for gaining insight into the narratives of suicidal processes, but it also helps in correcting many action distortions and action faults found in suicide actions [3,12]. What are these faults and distortions? We consider action process in systemic terms, hierarchically and sequentially organized at different levels of systems organization as stipulated in systems theory (i.e. top level: a goal, medium level: functionally defined action steps, lowest level: structurally defined elements of action). Action is embedded in a project or several projects and these are a part of long-term career or life pursuits. Projects and careers are also seen in terms of goal-directed systems. An action distortion would occur if the action-project-career context is not well considered and the action or even action steps obstruct or hinder the achievement of important project goals. The career survival goal is the most important one that the person is unable to consider in suicide. Launching a suicide or self-destructive career, project, action or an action step are complex processes based, as argued in Valach, Michel, & Young (2016), on action distortions. Action steering, controlling, regulating, monitoring, energizing and many other action processes and instances can contain distortions after which a destructive and final suicide action step can follow [7]. Already the lack of unity of an actor in a self-related action, as in a suicide action, that results in a disconnection among the actor, who wants to die, the actor who is killing, and the actor who is experiencing the killing, can serve as a suicide-enabling action distortion. Disconnect between a suicide project and, e.g., a parenting project results in lack of an emotional monitoring feedback that would change the suicide project.

Equally, disabled emotion and pain monitoring during an action is a distortion that facilitates a destructive suicide action step. These are only a few examples of action distortions experienced and reported by suicidal people [7]. A self-confrontation procedure could be seen as an addition to already existing techniques in suicide prevention and treatment of suicidal clients [13,14]. As we proposed that the suicidal behaviour is based on distorted action processes we also suggest that the self-confrontation interview provides a corrective experience leading to changes in the distorted action [7]. It has been shown in a report on a study that integrating the use of the self-confrontation interview in treatment of suicidal people, together with other measures, leads to a substantial reduction in suicide attempts by 80% [15-17]. We assume that some of these changes experienced during the video-self-confrontation could be monitored by patients in the self-confrontation interview while they are occurring. The purpose of this study is to illustrate the changes in the views of suicidal action patients as seen in a self-confrontation interview following their suicide attempt.

The present study is a qualitative analysis of self-confrontation video-recordings from an earlier study with 40 patients on suicide processes as described by them a few days after a suicide attempt [3].

In a general hospital in Switzerland, a head psychiatrist invited patients hospitalized after their suicide attempt to participate in a research study which involved talking to a psychotherapist about their suicide attempt. The rate of patients garnered for the study was high, though a representative sample was not striven for. Patients with a diagnosis of a psychosis or considered as acutely suicidal were not eligible to participate in this study. We conducted interviews with 40 patients.

This study was supported by the Swiss National Research Foundation. The study was approved by the institution where the interviews were conducted (psychiatric out-patients clinic of the University Hospital), as well as by the ethics commission of the Swiss National Research Foundation. In addition, we also received approval of the relevant departments of the University Hospital where these patients were hospitalised.

Prior to participating, the patients were informed about the procedure in detail, including videotaping the narrative and the self-confrontation interviews, and were asked to sign a permission form. They were informed that these videotapes would be seen by project collaborators, as well as being transcribed and analysed for research purposes. They were also asked for permission allowing us to quote substantial parts of these interviews in an anonymous form in professional scientific publications.

The interviews were conducted in an office in the psychiatric out-patient clinic. There were two video cameras, two video recorders, and two large TV monitors in the interview room. In addition, the Skin Conductance Reactivity (SCR) was monitored during the interview using a small electrode on patients and psychotherapists’ palm. Neither the SCR nor the narrative interview data are reported here. Only the self-confrontation interviews data are reported here.

After clearing all the formalities, the patients were asked and encouraged in an open-ended interview to tell the psychotherapist what happened during their suicide attempt. The interviews lasted from 30 to 60 minutes. This initial interview was videotaped. After this narrative interview another project co-worker, a psychologist or a psychotherapist, conducted a self-confrontation interview (a video supported recall) with the patients, stopping the video of the initial interview every few minutes and asking the patients to report on any thoughts, feelings, and sensations occurring during the initial interview, as well as any other thoughts the patients might have. The self-confrontation interviews were also video-recorded. The self-confrontation interview lasted about 50-90 minutes. The interview was conducted in German, therefore the quotes from the interviews presented in this study have been translated into English keeping the wording as close to the original as possible.

The self-confrontation interviews were transcribed and submitted to a qualitative content analysis. The researchers read the transcripts and viewed the video recordings repeatedly in order to obtain a full understanding of the on-going processes during the initial interview and the self-confrontation interview, as well as the stories the patients told and of the suicide events. Based on our experience with the previous analyses of these data, we were able to narrow our focus on utterances containing the action processes indicated above, that is the reports on changes in the patient’s views on their suicide actions [7]. Thus, we were searching for utterances in which the patients indicated an impact of the self-confrontation interview. The appropriate utterances were marked and compared with the utterances of the other 39 narratives and grouped according to their content similarity as far as action processes were concerned. In the analysis presented below the selected key utterances in the self-confrontation interviews referring to changes in regard to suicide behaviour are discussed.

The following quotations indicate the impact of the self-confrontation interview as formulated by the patients.
(A=Interviewer, P=Patient)

(1) (Pat. 8) P: (looking at it now) I’ve realized that these people (a riding couple whom she befriended) are very important for me. I wouldn’t have thought that before.

The increased awareness of the relevance of a relationship described in the interview indicates that during the self-confrontation interview the patient became aware of the interpersonal dynamics relevant for her suicide. This awareness was not available to her during the suicide action. During the self-confrontation the patient was able to appraise her suicide action as inappropriate. By becoming aware of the interpersonal dynamics she had experienced during her suicide project, the patient realized that her situation was not inescapable and that other more mundane actions would be more suitable.

(2) (Pat. 7) P: … Looking at it now I have to say that I am a stupid cow doing something like this…(overdosing) It is important emotionally that I said it, …

The patient negatively evaluates her suicide action and distances herself from it. It contradicts her values and other long-term pursuits. This assessment was not available during the suicide action, as the patient assumed then that her suicide action is a good way of solving her problem. In recognizing that she responded with a dramatic action to a trivial situation the patient was able to regain her action competence. She recognized that she did not act in accordance with her self-projects and life pursuits.

(3) (Pat. 6) P: Surprisingly enough I did not see myself eating and vomiting, but I saw a part of our flat, a window leading to the balcony. I saw it always in front of me.

I never saw the situation with me standing in front of the toilet, crying like a dog and asking myself repeatedly why am I doing it. I did not see this scene then but I can see it now.

The patient indicates that due to the self-confrontation he is able to change his perspective, to observe himself not only during the interview, but also during the suicide action and that helps him in reassessing his suicide action from this changed perspective (i.e. from internal to external, from subjective to social). Engaging in switching between an internal and an external view of his suicide action leads to a more realistic assessment of this action with a possible suicide preventive effect. Thus, the patient was able to correct his action experience, in which he was unable to monitor and reflect his situation and unable to reassess the appropriateness of his action.

(4) (Pat. 40) The patient has difficulties in observing the video recorded interview. He looks away.

P: On the one hand I am shocked (to see) how deep I sank and, on the other hand, I am amazed how many thoughts I had about it. I was aware of it, what a stupidity it was, because one is creating problems for others, makes them feel guilty. I am amazed to see how rational I was at that time, although I did not have any will to live. It was somehow important for me. It was probably the reason why I did not kill myself.

The patient evaluates his behaviour described in the interview and discloses a number of experiential and action discrepancies. He becomes aware of the inappropriateness of his suicide action and of his inconsistent thinking during the suicide action. This change in view due to the self-confrontation interview enables him to reassess his suicide action with possible suicide preventive consequences. The patient realizes in the self-confrontation that his action did not reflect his high standards, his value projects and career. Although his emotional monitoring was somehow limited and too weak to energize an alternative action, his vigorous rational reasoning during the suicide action enabled him to stop the suicide action. The insight gained during the self-confrontation may help in strengthening the patient’s link between his identity standards and projects, and his actions.

(10) (Pat. 27) P: Watching myself now I can’t understand why I did it. I threw everything away without thinking.

The patient expresses his dissatisfaction with his suicide behaviour described in the interview. Thus, the self-confrontation experience led to a realization that his suicide behaviour was not well reasoned and not compatible with his other life-pursuits and project plans. In linking the suicide action to a reason the patient is able to recognize the future thoughtless action as such, reflect upon it, that is, examine its connectedness to higher order projects and careers, and change it into a life-enhancing action.

These first five quotations (1-4, 10) have in common that the patients became aware during the self-confrontation of a connection or a disconnection between their suicide action and superordinate projects or life pursuits which were abandoned during the suicide action. It was either a relationship project (1; Pat 8), or value pursuit (2; Pat 7), or convention pursuit (3; Pat 6), or self and identity pursuits (4; Pat 40), or just realizing the absence of this connection (10; Pat 27). By re-connecting to these superordinate life-enhancing pursuits the suicide action lost some of its urgency and reason.

(5) (Pat. 39) P: It worries me and I am asking myself repeatedly ‘Why and How come’?… It is unusual that I see myself… Internally, I experience everything what I talked about again. If I say ‘unfaithful’ I get shivers. The same happens when I see the video recording now.

This patient indicates two possible mechanisms of change. Asking himself “why and how come” he is able to question his suicide in regard to other long-term pursuits that he was unable to follow during the suicide action. Additionally, he reports experiencing the same feelings and sensations during the narrative interview as during the suicide attempt suggesting a possible exposure effect of the self-confrontation. Thus, the patient indicates improved understanding of his actions and an insight that certain strong emotions and sensations are evoked by verbalizing and remembering his traumatic experience and not by the monitoring of the situation he experiences at the moment. Through this habituation process these emotions became less action relevant.

(6) (Pat. 36) P: … I don’t want to get this thing out again and again and talk about it. It is embarrassing that I attempted suicide. That worries me. And when I have to listen to it again and again... I think that it should be over once. Do you know what I mean?

Let’s get it over with. That is my personal position...

It is easier to talk about it now as I was talking about it already. At first it was very difficult for me to tell my story.

The patient indicates his negative evaluation of his suicide action and his unwillingness to reflect on his suicide, as it is not congruent with his other long-term life pursuits, Further, he reports an exposure effect of the self-confrontation interview. The self-confrontation allows him to reflect on his suicide action again, to accept it and to lessen its motivational power. The narrative interview and, particularly, the self-confrontation interview enables the patient to process his suicide narratives (i.e. the reasons for his suicide action as well as the suicide action itself) with his full action capacities that may protect him from committing a further distorted action such as suicide.

(7) (Pat. 33) A: How did you feel watching yourself?…

P: There are some things, which I could remember better in the second viewing.

The patient indicates the role of the self-confrontation interview as a vehicle to better recollect the suicide action and thus increase the effect of the narrative interview in getting at more of the external and internal details of the suicide action. In enriching the cognitive details the patient is lessening the emotional impact. Being aware of more details of the suicide action and project enables the patient to revise and correct it to a degree that he can respond with a life enhancing action.

(8) (Pat. 30) A: How are you seeing yourself in this moment for the first time on the video?

P: …It occurred to me that it is good to hear everything again, the whole story, the whole video.

The consciousness becomes stronger. One can see what one did. I suppressed everything inside me and tried to cope with it in that way. (Looking at it) it becomes clearer for me, it becomes clear what I did.

The patient appreciates his gaining deeper awareness of his own suicide action described in narratives. He also indicates a contextualization of his suicide action into his other long-term life pursuits. His suicide action becomes available for reflection and correction due to the self-confrontation interview. He gained insights into his suppression of unwanted emotions and into suicide behaviour as a goal-directed action. Ascribing himself agency enables him to generate life-enhancing actions in similar situations.

(9) (Pat. 3) P: Looking at it now (the video) it is as if someone tells a story. It does not touch me, because he said it already, something like this. I listen and wonder how did I deliver it. I brought it in such a way how I felt it and that’s how it was…

But actually, it is my story…

I am distant. In one moment when I was talking to my son, there was a moment in which I was talking about my son, about separation, I had to cry but I did not see it now. This surprised me now.

There are two pieces of knowledge (I gained): I realized that the separation bothers me a lot und it hurts me a lot. Separation is heavy. When I have to say goodbye to someone or someone leaves me. It became very clear.

The patient describes her emotionally-dissociative experience during the self-confrontation. On the other hand, she also indicates her increased awareness of a personal emotional problem that might open a door for therapy to generate suicide preventive changes. Further, she realizes a discrepancy between her feeling and her behaviour, an important step in suicide prevention. The self-confrontation interview helps in dissolving the dissociative stance of the patient and in recognizing an experience as driven by emotional memory and not by her monitoring of the situation. These are substantial corrective changes of action perception and understanding.

(11) (Pat. 18) P: I see myself in a different way. That is interesting.
A: What is different when you see yourself?
P: I feel, I am very jumpy but I can see that I am very peaceful and calm.
A: That is correct.
P: But inside, I am not peaceful and calm… That is what occurs to me. Also the voice is quite calm.
A: And very good as you talk.
P: That surprises me.

The patient expresses being surprised by the discrepancy between what she feels and what is visible. Thus, the self-confrontation may open a door for realizing and reducing the discrepancy between her feelings and her behaviour, a relevant issue in suicide prevention. Recognizing the perspective nature of our actions during the self-confrontation may help in recognizing life-enhancing alternatives to a suicide action.

(12) (Pat. 17) P: I feel peculiar. It is because I have difficulty in expressing my feelings in front of other people. When I see myself now doing it I am embarrassed. I can express my feeling only poorly. Seeing myself it is much worse…

A: What did you feel during this sequence of the interview?
P: I would have loved to cry. But I was not able to. I never can.
A: One realizes that from the interview that you hold back.
P: Yes that is the case.
A: Did you have a thought while describing this?
P: Looking at this now I say always to myself that I have to let my feelings free. But I never manage. I just can’t do that.
A: Is that the goal of the therapy you go to?
P: Yes.
A: Does the therapist know that you hold back?
P: No she doesn’t know.
A: She doesn’t know.
P: But I am determined that I am going to tell her next time.
A: You should do that. You’ve said already before that you have difficulties in telling the therapist everything.
P: I definitely decided to tell her.
A: I believe that it is important.
P: It is a big hurdle in my life but I have to do it otherwise I am not going to get anywhere with my problems.
A: I believe so as well. Then it is a very bad for a therapy if one doesn’t say everything.
P: I know. It is not that I don’t trust her or that I don’t feel good there. I just can’t do it. I can’t even tell my mother. And I have a very good relationship with her. I can’t do it with my sisters. It is my personal problem. I am getting ready for the next psychotherapy session…
P: It is typical for me. I am saying all this as if it wasn’t anything.
A: You are showing to others that you are a strong person.
P: But I would best shoot myself again. No that is too strong. If I let all my feelings free, then I would get a mental breakdown. That is typical for me.
A: You are holding everything back inside you. You want to be strong because you are afraid of feelings.
P: Exactly.

The patient confesses in the self-confrontation interview her strategy of suppressing the expression of her feelings in front of other people, which she even is able to do during her psychotherapy sessions. She expresses her intention to inform her psychotherapist about it and to learn to express her feelings. Considering, that the patient was not able to address this issue in her psychotherapy, but can do it now after one self-confrontation interview session indicates the impact of this procedure. The self-confrontation frees the patient of her fear of facing others to a degree that she can admit her fear of expressing her emotion and talk about it.

(13) (Pat. 15) A: Did you think anything watching yourself on video?
P: I've realized that I am saying everything cooler than I feel about it. But I think that everybody feels that seeing himself afterwards...
P: I am surprized how I am presenting this. Despite the fact that it was very bad (what happened) I am talking about it with humour. I am asking myself where this optimism comes from.

This patient indicates his realisation of discrepancies between his feelings during the narrative interview and his own behaviour, suggesting that he not only holds back with his feelings, but that he communicates a feeling opposite to his experience. This insight is an important prerequisite for suicide prevention, as he is encouraged to relate his emotions and his behaviour.

(14) (Pat. 14) P: To talk about it and to see myself on the video is no fun.

It is very difficult for me. But perhaps it needs something difficult, which one has to overcome oneself...
P: It is very sad to see myself like this. I remember here the times when I had a lot of life satisfaction. I used to enjoy everything. But seeing myself here it shows zero charisma… Hearing myself talking like this, I don’t sound very convincing. I am lifeless. I have to gain what I’ve lost.

I am very dissatisfied with what I hear, with myself. Also the choice of words... Everything is poor…

P: I think that it is good for me to see everything on the screen. One has to put it in front of one’s eyes...

P: It is hard work. I knew what is expecting me. I knew that I am going to be turned inside out. But I thought that it could have a dissolving, cathartic influence.

The patient expresses his negative evaluative feelings about the video. He indicates his readiness to change his life and an expectation of a catharsis effect of the self-confrontation. Furthermore, he indicates that he realizes his lack of feedback in his actions is an important suicide preventive insight, as poor or absent monitoring and feedbacks are important action distortions characterizing suicide action. The patient also realizes and considers a discrepancy between his emotional project goals and his emotional actions.

(15) (Pat. 12)

P: It is difficult to describe. It hurts if one has to talk about it. But it is good if one talks about it. I can always drop some load off my shoulders.

This patient expresses a negative emotion while re-experiencing his suicide action in narrating and in viewing his narrating, but also a relief after the interviews. Thus, the accompanied self-confrontation is an important help, as such an experience is too difficult for the patients to go through on their own. The positive emotion experienced after the self-confrontation may facilitate suicide preventive and life enhancing actions.

(16) (Pat. 11)

P: Listening to me I don’t like my choice of words while talking to the psychotherapist. It disturbs me.
A: And you are realizing it now. You did not realize it during the interview?
P: Yes. I did not realize this while speaking. Perhaps the other person talking to me realizes that. I did not see it and it is quite strong. It is as if one might smack me on the face looking at this video.
A: Is it really that bad?
P: Yes. It really hurts. But it is only what one can see… The thinking goes further. When I stand in front of a client…
A: Do you have the feeling that you’ll be making a bad impression?
P: I did not care. But now I have this feeling. Actually, I don’t care now. I am as a human being as I am. I can’t get out of my skin. One could maximally work on that. One can’t communicate the feelings so simply.

The patient evaluates his own behaviour on video and the behaviour described in the interview, and indicates a process due to the self-confrontation of accepting himself as he is, as well as a readiness to work on his personal problems. He states a dismay of his communicative action that is not congruent with his self-project, accepts this discrepancy, and forms an intention to work on it.

The second group of quotations deals with some problems in emotional monitoring. Pat 30 (8) reports on supressing emotions and becoming aware of them and of the fact of suppression, some others (Pat 39 (5); Pat 36 (6)) describe the exposure process and its consequences, or a dissociative experience (Pat 36 (6)), yet others address their realizing of discrepancies between feelings and manifest actions (Pat 17 (12)). Some do not supress their feelings, but only their manifest expression (Pat 15 (13)). Others become aware of their deep feelings only after seeing themselves in video self-confrontation (Pat 14 (14)), or appreciate the healing effect that the self-confrontation interview has on their emotional state (Pat 12 (15)), resulting in, e.g., self-acceptance (Pat 11 (16)). These problems, revised in the self-confrontation are important action distortions typical for suicide action.

The above utterances explicitly refer to the effects of the self-confrontation interview. There are other utterances implicitly indicating an effect of the self-confrontation interview not quoted here. The majority of the patients found the self-confrontation challenging. One even did not want to continue the self-confrontation interview (P28 (not quoted)). Only a few mentioned having a previous experience of viewing video recordings of themselves and thus being relaxed about the session (P29, P34, both not quoted). The most mentioned impact of the video self-confrontation interview is related to the patients’ evaluation of their appearance on the video.

Patients were also not satisfied with the way they talked (P7, (2); P11, (16)), looked (P30 (8)), they referred to their voice as being different to what they experienced (P23, P24, P37, P38, all not quoted) or the behaviour they exhibited (P37, P38, both not quoted), their interactive behaviour such as not responding to the interviewer’s questions (P35, not quoted) or just expressed how unusual it is seeing themselves (P25, not quoted), or being generally dissatisfied with themselves (P24, not quoted).

The purpose of self-confrontation interviewing as a research tool is to collect additional information mostly on internal processes through the increased awareness impact of this video self-confrontation [8]. This also is an impact with suicide prevention potential, thus making it suitable as a suicide preventing intervention. Some patients even explicitly mentioned their increased awareness, not only in regard to the suicide narrative interview, but to the suicide action (“I could remember better (in viewing the video recording)” (P33, (7)), indicating that the “…consciousness becomes stronger…It becomes clear what I did” (P30, (8)), becoming aware of the emotional anchor of a relationship and thus of its role in the suicide action (P8, (1)), or of an emotional threat by a separation (P3, (9)) relevant for suicide action.

This increased awareness of suicide action often led to the question about possible reasons (“why and how come?” (P39, (5)), realising that the suicide action was far from well-reasoned (“I can’t understand why I did it..” (P27, (10)) and led further to a negative evaluation of the suicide action (“It is embarrassing that I attempted suicide” (P36, (6)), “what a stupidity it was…” (P40, (4)), “…stupid…doing something like this…” (P7, (2)).

Apart from finding the self-confrontation interview challenging patients often expressed a relief after the interview (P12, (15)), e.g., in form of a catharsis (P14, (14)).

Some patients specifically referred to the experience of talking about their suicide and seeing themselves reporting on their suicide action and addressed a discrepancy they realized between what they felt while talking and how they saw themselves on video, i.e. their manifest behaviour. Becoming aware of their emotional arousal, on the one hand, and their controlled and suppressing behaviour, on the other, is an important achievement relevant for further suicide preventive intervention (P18, (11), P15, (13), P17, (12)). One patient verbalized a change in his perspective while looking at his suicide action (from an internal to an external) enabling him to reassess his action (P6, (3)). This is a process often discussed as occurring in self-confrontation. Another patient developed an accepting stance to himself, which is an important prerequisite for further suicide preventive work. He also expressed his readiness to work on his personal problems, thus indicating another important effect of self-confrontation (P11, (16)).

The above utterances and their summaries describe how patients themselves expressed their experience of the effect of the self-confrontation interview of their suicide actions’ narrative. The actual effects of this procedure cannot be limited to these patients’ verbalizations. However, some of the patients indicated the key processes we assume are functional in self-confrontation. We propose that action awareness occurs. This is achieved by presenting short segments of actions (here the narrative of the suicide action), thus turning the attention of the patients to the action process instead of promoting dispositional attribution processes. We consider self-confrontation procedure in its two main effects. Firstly, it provides a means to exposure exercise well known in cognitive-behavioural therapy [18,19]. Such an exposure is particularly important in viewing the existentially threatening emotional memory often described in suicidology as mental pain or psychache [20]. Secondly, the action awareness enables the patient to view their suicide actions in a different action context leading to a number of processes facilitating suicide prevention in revising the distortions of suicide actions, thus changing them into life enhancing processes. Examples of main distortions indicated here were a lack of considering the context of the suicide action in terms of other life pursuits and plans, lack of monitoring and feedback, dissociative processes, compromised action integration.

Some reports on the effects of video self-confrontation underline the enhancement of positive effects targeted in psychotherapy, yet others warn the clinicians because of the detrimental effects of self-confrontation [21,22]. Reports on using self-confrontation in suicide prevention are rare [23]. However, the ways how these effects were studied 40-50 years ago are too unspecific for the current use. The plain self-confrontation cannot be expected to have a focused facilitating effect in psychotherapy, as we cannot maintain that any “talking” would do for qualifying the effects of talking therapy. The exposure effects of confrontation are well known, but require certain procedures and techniques. The increased action awareness is less known, but equally important to consider. In reports on action improvement the effect of video self-confrontation seems to be quite promising and thus helps in introducing a novel view of suicide and suicide prevention [24,25].