Clinical Challenges in Psychiatric Rehabilitation Research: A View from Field Researchers

The Research Department of Thresholds, one of the nation’s largest and premier mental health social service agencies, is an exciting and unique workplace for two recent graduates of clinical master’s programs. As young mental health professionals in training, we have the opportunity to contribute to the development of cutting edge interventions while also building a clinical toolbox consisting of strong assessment and diagnostic skills as part of regular research program interviews. As a microcosm of the overall process, the research interview’s primary purpose is to gather information that may influence recommendations for intervention, clinical best practices, and treatment techniques. Before those conclusions are drawn, research participants volunteer vulnerable, intimate information that contributes to the collective findings. At times it is easy to forget these individual stories when the published papers we read speak of the collective outcome. As research assistants in the field, we are enveloped in those personal stories daily. 

Collecting Sensitive Information
Most research projects require collecting major study outcomes, like employment, but also include other factors and variables that are evaluated as well. As researchers, we regularly collect sensitive information from study participants, such as substance use, violence exposure, personal trauma, and suicidality generally for the purposes of diagnosis or symptom ratings. Most assessments are self-report, so participants are often asked to describe distressing symptoms in detail and discuss traumatic events. Thus, the assessments may leave participants feeling raw and vulnerable. As a result, researchers must be skilled at addressing the consequences of asking such direct questions about often horrific experiences as part of data collection, necessitating more “clinical” responses and skills. For example, in an interview for a research project a participant disclosed having witnessed the violent death of his close friend and became visibly upset – tearful, tense, and short-tempered. In this kind of situation, assessment must take a backseat to compassion. The assessor provided a safe space where the participant could take a break, relax, and was free to process his experience as needed. After determining that he was comfortable proceeding, the assessment continued. The validation and support assessors can provide to individuals in these intense moments makes all the difference in whether participants leave feeling secure and safe, and ultimately willing to continue in the research as well as return for follow up interviews.

Role of the Researcher
During these extensive and intimate interviews in which participants discuss complex situations, other areas of concern often can arise organically. As researchers, we can be placed in a dual role; our job is to collect evaluation data, but we also have responsibilities as mandated reporters. For example, in responding to items that assess home life, participants have alluded to or directly disclosed aggressive behaviors toward children or minors. This is a difficult position for researchers, since any suggestion of child abuse warrants thorough follow up, and does occasionally result in placing a call to the local authority for children and family services. The ability to recognize situations in which to alert local authorities, following through with the reporting process, and communicating with the participant’s primary staff are vital to conducting ethical and responsible assessments. Another sensitive topic that arises is suicidality. If a participant discloses any thoughts of self-harm, we are required to conduct a thorough risk assessment to ensure safety and continuity of care. We would not say this is switching our hats from a researcher to a clinician; the clinical skills we use determine the quality of research collected because we are addressing the safety and wellbeing of participants. At the Thresholds Research Department, we have developed a comprehensive suicide assessment protocol to ensure participants are safe and researchers are prepared to ask the necessary questions. 

Evaluating Risk
The Suicide Assessment, Action, and Documentation Plan was developed to ensure safety of the participant and provide a clinically sound template for the researcher to follow if crisis arises during a research evaluation. The safety protocol assesses for low, moderate, or high risk, followed by detailed procedures for each level of risk. Some examples of initial questions to assess for suicide risk level include:

•    “Have you ever attempted suicide in the past? How many times?”
•    “How intense are the thoughts you have been experiencing on a scale from 1-10?”
•    “Have you been thinking about how you would kill/harm yourself? Have you worked out the details of how you would do this?” 
•    “How do you keep yourself safe when you are having these thoughts? What has kept you from killing/harming yourself?”

The plan has examples of low, moderate, and high risk responses. Response examples are put in place to help the researcher understand a participant’s suicide risk level. Once level of risk is determined, a support plan is initiated to match the risk level. These steps range from contacting a participant’s clinician (low risk), putting together a safety plan (moderate risk), or dialing 911 together if a participant cannot guarantee his or her own safety for the next twenty-four hours (high risk). All steps are documented and developed in collaboration with the research participant. In addition, all steps require contact with the participant’s clinical team to ensure continuity of care and consultation to determine a) what is in the best interest for the participant and b) allows the researcher critical support in making sensitive and timely decisions.  

Overall, we cannot underestimate the value of research regarding psychiatric rehabilitation and other mental health services in promoting recovery. However, researchers also have the duty to protect study participants and ensure that they are safe and secure in addition to ensuring the confidentiality of their data and other personal information disclosed in research interviews. As such, research staff must be prepared to address these issues, and to have well-developed plans and resources available to support these efforts.