Engaging People At Risk for Suicide: Interview with Dana Alonzo, Ph.D.

[Episode 111] Today's episode of the Social Work Podcast is about engaging people who are suicidal into professional mental health services. I spoke with Dr. Dana Alonzo from Fordham University. We talked about some of the reasons why people might not want to seek professional mental health services when they are suicidal, and some of the things that mental health professionals do to make it hard for folks to want to stay in treatment. Dana sees this as a problem of engagement. She described the process of how she developed her intervention and what it entails. She ends with some tips on how to improve engagement in treatment for anyone, regardless of suicide risk.



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If you’re feeling suicidal, please talk to somebody. You can reach the National Suicide Prevention Lifeline at 1-800-273-8255; the Trans Lifeline at 877-565-8860; or the Trevor Project at 866-488- 7386. Text “START” to Crisis Text Line at 741-741. If you don’t like the phone, consider using the Lifeline Crisis Chat at www.crisischat.org.

Transcript

Introduction
Jonathan Singer: Hey there podcast listeners, Jonathan here.  I am so excited about today’s episode,  you know, one of the things that is most challenging in the world of mental health services (that includes talk therapy and case management and medication and all sorts of things that we have out there to help folks do better in their lives, one of the biggest challenges is engagement.  The modal number of sessions that somebody attends is one. That means if you look at all the sessions that people attend and all the people that attend sessions that the most number of people only attend one session. Now, one session might be great if you have a very discreet, slight problem that you need a little bit of help with to keep going.  One session is really problematic if you’ve got some deep-seated issues that have been problematic in your life for a long time, or, if they’re life-threatening, such as in the case of folks who are suicidal.

I’m really excited about today’s guest, Dr. Dana Alonzo, because treatment engagement for folks who are suicidal, that’s her wheelhouse; this is her area of expertise.  One of the things that she learned in her research is that clinicians saw that success in treatment was because of what they were doing, but if the treatment wasn’t successful, they blamed it on their clients. Now, this is a huge problem.  This means that clinicians (not all clinicians—obviously I’m not talking about you, but, you know, maybe your colleagues), that instead of thinking about what they can do to engage this person in treatment, to keep the treatment going, there is this attitude that, ‘well, if treatment goes well, it’s because I’m doing well’ [the therapist] and ‘if it doesn’t go well, it’s because my client did something wrong.’  Now, if you’re suicidal, you’re already thinking that you’re doing things wrong. You’re already thinking that life isn’t working well for you.  And if you have a clinician that thinks, ‘Well, if they don’t want to come back, that’s their deal’ then that is problematic for the client and their likelihood of living, on multiple levels.

So, I wanted to talk with Dana about her work in treatment engagement.  Now, Dana Alonzo received her Ph.D. from Fordham University’s Graduate School of Social Service, where she was awarded a National Institute of Mental Health Research Training Fellowship.  As the Co-Investigator at the Developing Centers for Interventions for the Prevention of Suicide at New York State Psychiatric Institute she conducted studies examining risk and protective factors across cultures related to mood disorders and suicidal behavior. She’s been funded by the American Foundation for Suicide Prevention, the National Alliance for Research on Schizophrenia and Depression, and a couple of organizations in New York State. Her research has focused on the development of novel interventions aimed at improving treatment engagement and adherence among suicide attempters. Dr. Alonzo founded the Suicide Prevention Research Program at Fordham University’s Graduate School of Social Service. Dana is the co-author, along with Robin Gearing of the Springer text, Suicide assessment and treatment: Empirical and evidence-based practices.  You can find that on our website or just Google Dana Alonzo and Suicide and I’m sure you will find it.

In today’s episode, Dana and I talk about engaging folks at risk for suicide in mental health services. She starts out by explaining kind of a classic cognitive behavioral perspective for why folks in a suicidal crisis might find it challenging to seek help.  We then sort of flip that around and we talk about some of barriers, the systemic barriers to help-seeking.  This includes clinicians’ attitudes towards clients who are suicidal, availability of treatments, training of graduate level professionals, and we go on to talk about some of the things that people can do to engage folks who are suicidal (or really anyone who is seeking mental health services).  So, I hope that you really enjoy this episode and that you get something out of it, whether you’re working with a suicidal client right now, or not, because, one of the things that is true about mental health is that you’ve either worked with folks who are suicidal or you’ve not yet worked with folks who are suicidal. Now the links to some of the things we talk about in the show are on socialworkpodcast.com.  If you want to follow social work podcast on Twitter,  just go to @socworkpodcast or the facebook page where you can connect with a community of folks over 14,000 strong at facebook.com/swpodcast. One of the ways you can support the podcast is by filling out our survey.  If you are on iTunes, go on iTunes and give us a 5-star rating and tell us what you think about the podcast (I mean, hopefully good stuff). The more 5-star ratings and the more reviews,  the easier it is for folks that have never heard of the podcast, to hear it, and hear what we do.

And now, without further ado, on to Episode 111 of the Social Work Podcast. Engaging people at risk for suicide: Interview with Dr. Dana Alanzo.

Interview

[05:56]
Jonathan Singer: Alright. Dana, thank you so much for being here on the Social Work Podcast and talking with us about engagement and folks at risk for suicide.

Dana Alonzo: Thanks for having me.

[06:06]
Jonathan Singer: So, you and I both do suicide prevention research, that’s our area. One of the great things about the last twenty years is seeing that there are all of these treatments that have been developed that have actually been shown to reduce suicide risk for folks. But you, it’s so interesting; you focus on this thing that happens right before, right? It addresses this issue of engagement. Can you talk about that?

Dana Alonzo: Right, so one of the things we know is that an Evidence Based Practice can only be as effective as the patients who are there to receive it. And unfortunately for this very highly vulnerable group of individuals at risk for suicide we know that they just don’t go to mental health treatment at the rate that would be helpful to mitigate their risk. And I think there are a number of reasons why that is and I think one thing that research has shown us so far is that individuals at risk for suicide tend to engage in a series of cognitive distortions that impact the way that they experience themselves in relationship to others and the world. And they tend to interpret experiences in a negative way. And these kinds of repeated negative experiences over time can lead to difficulty with managing emotion, with maintaining interpersonal relationships and tend to lead to a lack of expectation for positive experiences in the future. We also know that these kinds of cognitive distortions impact the way individuals at risk for suicide engage in decision making processes. So, there are several different stages that are involved in making a decision, coming up with an effective solution and individuals at risk for suicide tend to get stuck in that process at a bunch of different points. The first is that it is really hard for them to identify an accurate trigger for their distress. So they’re searching for cues in the environment. And because they tend to engage in these cognitive distortions that I mentioned earlier, they have a very hard time figuring out what the correct trigger is. Alright, so if they can overcome that hurdle and actually identify the correct problem they can move along, and then they tend to get stuck with identifying a possible solution. They get overwhelmed in that process and either have trouble generating any kind of solution at all or generate a bunch of solutions and then get stuck trying to figure out which one is the best. Or they come up with a great solution and they try to put that into action and because they’ve identified the wrong trigger, what they find is their attempt is unsuccessful and they can’t resolve their problems and this feeds into that whole lack of positive expectations about the future.

[08:46]
Jonathan Singer: So there all these ways of thinking about what’s going on with them and the people around them that doesn’t match reality. And then there’s this process about like “What’s the problem and how can I solve it?” and it’s really complicated.

Dana Alonzo: That’s absolutely correct.

[09:04]
Jonathan Singer: So this sounds like this is all on the suicidal person that it’s not about our system of care which we know is really problematic. Where does that all tie into this?

Dana Alonzo: Right, Absolutely, so assuming that an individual is able to overcome all of those hurdles we just talked about and actually decide that treatment might be an option for them and in the face of really low expectations for success, they still say, I’m going to give it a try.

[09:33]
Jonathan Singer: Which is amazing! [chuckles]

Dana Alonzo: Right, Absolutely, right, and it happens! Right? And it’s important to recognize that it’s a really important strength in this group of individuals. That they risk, putting themselves out there and making themselves vulnerable for something that they really think isn’t going to help anyway. But, once they get to treatment what we know is that providers/clinicians, tend to have a really strong reaction to individuals presenting with suicidal ideation and what research shows is that clinicians tend to experience a greater level of fear working with clients who have suicidality as part of their presenting problem. They tend to use their nonverbal behavior in a more negative and judgmental way. So even when they’re able to contain themselves from making judgmental statements about ‘Why would you do that? This is, there are other ways, we’re going to work on this and figure out better ways’ Which they think might be supportive, what their nonverbal behavior is expressing is judgment in some way or dislike or disapproval. Research has shown us that clinicians tend to view clients who experience suicidality as less likable and more blameworthy for their problems. So, combined when you think about the individuals struggling with these problems, they’ve overcome the hurdle of identifying the right trigger. They’ve figured out a bunch of solutions, they’ve tried and it didn’t work. They still manage to get themselves to treatment and then they present for treatment and then they find a clinician who is judging them at best and fearful of them at worst.

[11:10]
Jonathan Singer: [Chuckles] That sounds awful.

Dana Alonzo: Right, absolutely. And then the expectation is that they’ll say “Oh but that’s okay, I’ll keep going.”

[11:19]
Jonathan Singer: After all of these things, the person who maybe even like four hours earlier was thinking ‘I’m going to kill myself’ and is now in front of a clinician, has to then overcome all of the clinicians' issues, as well as their own. [chuckles]

Dana Alonzo: Absolutely. And it’s reasonable, actually, that the clinician might feel fearful or might not know what to do when the client presents this way because the majority of direct practitioners are social workers, like over 65% at this point. So, most likely when someone who is suicidal goes for outpatient treatment they’re going to see a social worker. And most social work programs don’t provide training in suicide assessment and treatment and when training is provided, the average amount is two hours.

[12:04]
Jonathan Singer: Right, which is terrible. So, you’re saying it’s reasonable to expect not because it’s actually okay…

Dana Alonzo: Acceptable, no.

[05:56]
Jonathan Singer: But it’s given that the poor level of training in social work, as well as psychology and other programs, that’s kind of where we are, which is problematic. And I know that you teach a class, we won’t get into all of that, but you’re doing something actively to address that and there are some other folks around the country.

Dana Alonzo: Right, what’s not reasonable is that we expect that the client says, “Oh well I know that the person might not have received much training in this and so I’ll bear with it and see if it gets better, right, like that’s ridiculous.

[12:40]
Jonathan Singer: [chuckles] Yeah, yeah. That is. Okay so, given that there’s not the level of education and training that there needs to be, what do we do?

Dana Alonzo: So, I mean, a couple of things. I think one of the things that I’ve tried to spend time understanding is from the client’s perspective, what is it that makes a difficult for them to engage in treatment. So, we’ve heard this kind of stuff, “It’s difficult to form a trusting relationship with my clinician because I feel like they’re judging me or I feel like they just don’t understand how I arrived at the point where this was my option.” But I’ve also spent some time talking to clinicians who work with high-risk clients and identifying from the clinicians perspective, what are the barriers to and facilitators of treatment engagement of suicidal clients, to see, and one of the things that’s important to know, is do our perceptions match what our clients’ perceptions are. And often times we find that they don’t, and we’re making a lot of assumptions. What was most surprising to me about this study that I conducted doing in-depth focus groups with clinicians who are in New York City and the Tri State area, working with in and outpatient (large outpatient) mental health centers and identified as working with high-risk clients, was that if they felt engaged in the process, then, by default the client would. It did not acknowledge what the client’s experience might be at all. But when it came to identifying barriers to treatment, client insight into their illness was the number one barrier identified. Right, so clients are fully responsible for why they don’t engage and clinicians are fully responsible when it’s going well.

[14:15]
Jonathan Singer: So, wait; is it reasonable to say that that’s very much like a ‘Pass the Buck’ response on the part of the clinicians?

Dana Alonzo: Well, to me it certainly feels that way. It feels like the suggestion is that I do everything I can and should and when it doesn’t go right I don’t need to look at myself and say do I really do everything I can and should. Right, because instead, I say, “Well, obviously it’s because the client isn’t doing their part.”

[14:39]
Jonathan Singer: Which is particularly problematic when you’re talking with folks who are ambivalent about living in the first place. [laughter]

Dana Alonzo: Absolutely.

[14:48]
Jonathan Singer: So when you said that the social workers felt engaged, what did you mean? What do you mean by engagement?

Dana Alonzo: So I think that’s actually a really interesting question and it was the question that I had for those clinicians. So, ‘Define what it means when you engaged with these clients.’ And what I hear varies certainly across clinicians, but I get a lot of ‘I feel connected to them emotionally in some way. I feel like I can understand their experience in some way. I feel like we have a connection that’s based on trust where the client tells me things that they might not feel comfortable telling someone else.’

[15:26]
Jonathan Singer: It sounds a lot like therapeutic alliance, rapport, and those sorts of things. Is that right?

Dana Alonzo: Absolutely. When I think of engagement, and I think of my work I’ve done in interventions and how I measure engagement. I’m interested in more than just the kind of physical presence in the room. Right, that’s one piece, is you have to be there to be engaged. So, ‘Do you show up for your first session? How many sessions do you show up for afterwards?’ But the psychological component as well. Right, and so ‘How connected to your worker do you feel?’ on the flipside. ‘How satisfied are you with the care that you’re receiving?’ ‘How well do you feel like the care that you’re getting is moving you towards your goals?’

[16:01]
Jonathan Singer: Okay so you’ve developed an intervention that addresses this issue of engagement. So, what do you do in the intervention?

Dana Alonzo: Let me first tell you a little bit about where the intervention came from. And one of things you can imagine is that often times the clinicians’ perceptions about the level of engagement vary greatly from the clients, right? And this is something that I looked at early on, and did some research in a large urban psychiatric emergency room in New York City. And spoke with people who were presenting at the Emergency Room for either severe suicidal ideation or post-suicide attempt. And we talked about issues related to mental health treatment utilization and their experience in the emergency room and the likelihood that they were going to follow up with the treatment that had been recommended. One of the things that I would hear time and time again from patients is that, how depersonalized the experience of seeking help was for them and that while clinicians might think that they’re doing a really good job with asking all of the questions they need to ask to do an accurate risk assessment, right like, ‘Are you having suicidal thoughts; Do you have a plan? How often do you have these thoughts? How long do they last?’ right and the whole checklist of things so that they can walk away feeling like ‘Great, we had a great conversation, I have a clear sense that this person is at risk or not at risk and my job here, my work here is done.’ What clients were feeling, at least in the emergency room was ‘They’re just asking me the same questions they ask everybody else and I am not a person to this worker.”

[17:35]
Jonathan Singer: Right, the worker is trying to check off boxes and say, ‘We’ve established a level of risk, now we can sort of pass along this person to the next person or something like that.’

Dana Alonzo: Exactly. And then not only did the doctor do that, but then the nurse did that, and then the resident did that and then the resident came back with their attending and they did that again together and so right? Multiple interactions that were never meaningful as far as the client was concerned. [These findings] were the most important thing from the clinicians’ perspective. So, there’s this mismatch here. The other thing that learned from the emergency room when I was doing the study, is that there is this perception that, at least when I was doing the study, that ER’s tend to be the first point of contact for individuals at risk of suicide. That they tend to be out in the community, not utilizing services and they end up in a suicidal crisis and go to an emergency room and finally get help that way. The majority of individuals in my study had actually attempted to start outpatient treatment in the year prior to the ER visit. Something happened in that outpatient experience that was not satisfying for them or didn’t work for them and they dropped out. Then they were in the community, struggling, not knowing what to do. Having all those things in the beginning, having a hard time figuring out what their trigger is. ‘What else should I do? I’ve already tried treatment and of course it doesn’t work for me’ and these lack of positive expectations and so they don’t’ go back, right, and now they end up in the community and really do have nowhere else to go, and then they end up in the ER.

[19:05]
Jonathan Singer: Got it, so they went through that problem-solving thing you were talking about in the beginning.

Dana Alonzo: Exactly.

[19:09]
Jonathan Singer: And they couldn’t successfully resolve it and so then they found themselves in the ER.

Dana Alonzo: Exactly, and so one of the things we realized was we have an opportunity to not only reduce the over-reliance on emergency rooms which we had been seeing increasing in this population, but also unnecessary inpatient psychiatric hospitalizations, which tend to be the default discharge mode from an emergency room as soon as the word ‘suicide’ is said. Right so ‘Oh, they’re here for suicide, we’ll just send them to the inpatient psych unit’ and inpatient psychiatric hospital stays are not only financially burdensome but can be psychologically burdensome and can be extremely distressing and when risk is not at a level that actually needs that, what it does is send a message to the client ‘Don’t tell anyone you’re having these thoughts because you’re going to have to end up admitted to the hospital,’ right?

[20:02]
Jonathan Singer: Yeah and I know that in my research with kids, one of the things that’s come up is that kids who were really at low risk and maybe hadn’t really thought a lot about suicide found themselves in a closed environment with kids that knew a lot about suicide.

Dana Alonzo: Right.

[20:19]
Jonathan Singer: And so there was really this transition of knowledge around suicide risk that put these low-risk kids at higher risk.

Dana Alonzo: Right, absolutely. And then you find that the rate of engagement in treatment following discharge from an inpatient unit for suicidality is extremely low. Right, not surprisingly, right? Oftentimes that inpatient hospitalization could have been avoided and people were just sent that message, ‘Don’t talk about this, right, you’re just going to end up right back there.’ So research shows something like within 3 months of an inpatient hospital stay for suicidality, 38 percent of individuals will no longer be in treatment. Right, and three months is the highest risk period for repeat attempts, so most people who are at great risk are not getting the needed treatment and that’s a problem, right? So, from that study I developed an intervention during intake appointments at an outpatient mental health clinic to help bolster the engagement in treatment in outpatient mental health services.

[21:18]
Jonathan Singer: As you’re talking about this, I’m getting this picture of a bunch of little circles and like an arrow, right? It’s this idea, okay so you have one circle is folks in the community, right, folks who are suicidal. And then you’ve got the providers in the community, there’s this interaction with them that doesn’t work. And then time goes on and the suicidal client moves out of the outpatient circle, and then they’re just kind of floating and then there’s the inpatient circle. ER/inpatient, they float into that and it’s all along this timeline, and I know that this stuff isn’t linear, it makes it easier to draw but it’s not exactly linear. Is that your conceptualization of how this works? And if so, where does your intervention come in?

Dana Alonzo: So, I’ve spent a lot of time trying to understand the suicide prevention process as it looks currently, or has looked traditionally rather. What you tend to see is a lot of research in the area of risk assessment. We’ve developed a lot of standardized measures that have now shown to be valid and reliable for assessing for various characteristics of suicide risk, like either degree of ideation, or degree of intent, or even reasons for living, or wish to live, wish to die. A lot of research around this. We also have seen as you mentioned earlier on, the development of evidence-based practices to address suicidal behavior and so there’s a big chunk of research in the field of suicidology focused on intervention development for addressing suicidal behavior. And then there’s a lot of research that looks at disposition planning, things we can do when people are being discharged from care to equip them with skills to help them reduce risk of suicide, like safety planning, for example. Like a concrete tool that we can provide to help the client conceptualize what they can do when they’re in a crisis to avoid acting on suicidal behavior. But nowhere in that process is there a real recognition of the fact that clients are not utilizing services. And so if they don’t go, you can’t do a great risk assessment and you can’t provide an evidence-based practice. Or if they show up in the emergency room you can do a great risk assessment and then you lose them on the treatment end and you can’t provide the practice. So somewhere they’re getting lost and that’s where I ended up with the treatment engagement piece, because what I recognize is that despite advancements in psychopharmacological treatments for the disorders most often associated with suicide like depression and bipolar disorder; despite the development of all these new EBPs to address suicidal behavior and lots of money being poured into public awareness campaigns to bring the issue of suicide out to the public and try to reduce stigma. In NY for example, in Washington Heights, on the sides of busses you’ll see in Spanish you’ll see ‘Estás deprimido?” Right “Are you Depressed? Are you having thoughts of suicide.” [There are] Lots of things to bring awareness of suicide to the community. And we’ve had very little success in reducing the suicide rate in the United States, in fact it’s increased now. So we’ve had all these great advancements and no impact and for me the answer is we’re not getting the people who need the results of our gained knowledge to the treatments, right, so that’s where my focus on treatment engagement comes in. And it kind of shifts the suicide prevention process a little bit to pay attention to this earlier stage.

[24:48]
Jonathan Singer: So tell us about this engagement intervention. What are you doing to address this huge gap in the prevention timeline research framework?

Dana Alonzo: Sure. In the intervention, there’s a combination of brief motivational interviewing and personalized feedback on an individualized risk assessment that was developed for the intervention that consists of evidence-based risk and protective factors for suicide.

[25:18]
Jonathan Singer: Okay so brief motivational interviewing and personalized feedback, what does that actually look like in the room?

Dana Alonzo: Right, absolutely. So, if you imagine our suicidal client coming in with that combination of cognitive distortions, and low expectations and low motivation and uncertain about whether this is really going to actually be effective for them, one of the first things that the intervention does is engage the client in a conversation about what have prior treatment experiences been like for you. Right? That way I have a sense as the clinician, of what works for this person and what didn’t work. Because I want to certainly make sure that I don’t do those things again, right? We then talk about ‘What are your expectations for treatment this time? You’ve had these experiences in the past. They weren’t so great for you or they worked then but now whatever you learned then is no longer helpful. What are you hoping to get out of treatment now?’ And then, we move to the personalized risk assessment portion of the intervention and the suicide risk profile is, as I mentioned, a list of known risk factors and protective factors related to suicidal behavior. And the clinician and the client engage in a conversation about which of these factors are present in the client’s life. Right, it really individualizes the process of risk assessment because no one, no two people are going to have the same risk profile. And, even if the same factors are present, they’re not going to be affecting the individual in the same way. So the individual really has the opportunity to tell their story. You know, this really resonates with me, this idea of social isolation and here’s why and they have their opportunity to explain their situation to the clinician. And the risk factors are presented not in the way that, ‘Wow, you meet thirteen of seventeen risk factors, you’re doomed to engage in suicide.’

[27:02]
Jonathan Singer: That’s really bad! [Chuckles]

Dana Alonzo: Right, exactly! The conversation is always linked to and how treatment can mitigate that risk. Right, so ‘here’s something you’ve been struggling with. You’ve tried on your own to figure out what to do about it and it hasn’t worked so well. Let’s talk about how treatment can help you address this factor. So, if you were to actually go to your appointments, this is the way that this risk factor would be addressed.’ And then at the end of the risk profile, the client and the clinician would engage in a conversation about ‘So what are your thoughts about treatment now? Has it changed it all now that you’ve thought about, you’ve seen the constellation of risk factors that are present and have thought and have had a chance to hear how treatment can be helpful at addressing these issues that you’re struggling with? Does it change at all your ideas about how important treatment is for you and how likely you are to attend your sessions?’ Right, and then they discuss ‘When would be a good time to take this risk profile out? Alright, you’re going to get a copy of it moving forward, when might you take it out?’ And during those times when you feel like ‘I just don’t want to go to session today, I just can’t get it together’ or ‘You know my clinician did something last week that I really didn’t appreciate, said something that was hurtful or didn’t seem to get what I was trying to say and it was really frustrating. I’m not going to bother.’ Those are the times that you’re going to want to take out the risk profile and remember how important treatment was for you in this moment and use it to at least call your clinician and say, ‘This is what I’m feeling and I’m not even wanting to come in today,’ and give them an opportunity to talk about that with you.

[28:34]
Jonathan Singer: So, it’s interesting because you’re talking about the risk profile which I think most of us think about really as this should I hospitalize, you know all that sort of stuff, but you’re actually talking about it as a tool for motivating the person to engage, re-engage, address this to stay participating in this process.

Dana Alonzo: Right, and so it’s not a tool for assessing the level of risk, low/moderate/severe. It’s not the standard, you know, ‘How often do you think about it and for how long,’ and does this person have the capacity to act. It’s really an assessment of---the individuals's-if you think about it from a social work perspective and doing an ecomap---what are the resources that the client has both internal and external to help get them through a suicidal crisis and does the individual see how treatment can be helpful at addressing each of those things. And the goal is not to end up with an idea of how strong their risk is but how important treatment is.

[29:37]
Jonathan Singer: I love the visual of an ecomap because you have the client, and you have these, and again I love circles, clearly. You have all these circles surrounding the client and it’s like, ‘So this is your connection to this system or this system, you know work and treatment and medication and whatever it all is. It’s like what is your relationship to those, and instead of being like, ‘Well that’s not going to happen’ it’s like, ‘Let’s talk about what you would benefit from, how could you do this again?’

Dana Alonzo: Or what systems are missing, or which are underutilized or which are not even recognized as important or as a resource that could actually be utilized. And then the last piece of the intervention taking from what we learned about what seemed to possibly be effective in prior studies is there’s a follow-up phone contact with the client. Very brief, maintaining the spirit of motivational interviewing again, to ask the client ‘Are you attending your sessions?’ If yes, ‘How’d you do that, do more of it.’ Right? And if you do that, and if not, it’s not a call where you’re going to problem solve barriers and solve these problems with the client but ‘Do you think you can call your clinician and let them know what’s been getting in the way and give them an opportunity to help talk you through that and get you back in treatment.’ Because the goal, again, is not to reduce the suicidal behavior, it’s to get the client to the treatment that will do that. So it’s constantly making that connection to the importance of treatment and trying to support the engagement in services.

[31:04]
Jonathan Singer: I appreciate you talking about this with regards to suicidal folks and where all this fits into the suicide prevention framework. In your research and in your clinical experience are there things that you have learned about engagement in general and engaging clients that you think are just good general tips for folks to take away, whether or not their client is suicidal?

Dana Alonzo: Yeah, absolutely, I think first and foremost, the idea of the check in with your client is something that I think often forgotten. I think there’s an assumption that if I feel like this is working, then it’s probably working and often times that’s not true.

[31:46] Jonathan Singer: And so what does a check in look like? If I’m a client, what would you do to check in with me?

Dana Alonzo: I think actually session by session feedback is extremely important. I wouldn’t let a week go by without saying to my client at the end of the session: ‘How was this for you? What stands out for you today? Is there anything on your mind that I didn’t get to? Is there anything you feel like you’re being left with that we need to address before you leave today?’ It can be as simple as that.

[32:13]
Jonathan Singer: I think session by session is great, absolutely. Is there anything else?

Dana Alonzo: I think that it’s really important to acknowledge when the client has shared with you something that isn’t working for them or hasn’t worked with them that you’re mindful of that and attentive to it. Right? Because there’s a reason and if the client has taken the risk to share with you that this hasn’t worked and this isn’t working and then it’s important to understand why and make sure you don’t keep doing that. So, using that feedback in a meaningful way.

[32:46]
Jonathan Singer: There have been times where I’ve been in therapy, as the client, and I’ve said ‘You know it doesn’t really work for me when people agree with me a lot. I get, a lot of people agree with me in my life. I need somebody to challenge me or to call bullshit on what I’m doing, right? And then the therapist just continues to agree with me. It’s so disconnecting, right?

Dana Alonzo: Absolutely, it’s not feedback for the sake of feedback. It’s not ‘I now give you the opportunity’ and so you’ve shared so I’ve done my job, but what do you do with what you hear? And you really have to be willing to hear it and then do something about it.

[33:27]
Jonathan Singer: Yeah

Dana Alonzo: Yeah

[33:29]
Jonathan Singer: So these all sound like things that are pretty accessible, right, so if you’ve been trained and lots of folks have been trained in motivational interviewing, they know the basic concepts, right? And even if folks haven’t gotten a lot of great training on suicide risk assessment—this idea of risk and protective factors is something that we talk about. And so if people wanted to get trained in your specific intervention, where would they go? How would they do that?

Dana Alonzo: The intervention has been manualized and we have some great data in terms of feasibility and acceptability and are working on effectiveness research right now. So anyone interested can contact me for more information.

[34:10]
Jonathan Singer: That’s great. Dana, thank you so much for sharing with us about your research and about the thoughts about engagement, particularly with folks who are suicidal, I really appreciate you taking the time.

Dana Alonzo: Well, this is absolutely terrible. Jonathan Singer: [Laughter]

Dana Alonzo: [Laughter]

[34:25]
Jonathan Singer: That was totally disconnecting and I feel unengaged completely.

Dana Alonzo: [Laughter]

Jonathan Singer: [Laughter]

Dana Alonzo: And cut? What?

[34:35]
Jonathan Singer: And…cut.

Transcription generously donated by: Kendra Wagener, MSW,  AAS Certified Crisis Counselor, Forensic Specialist

References and Resources

• Alonzo, D., & Gearing, R. E. (2017). Suicide assessment and treatment, second edition: Empirical and evidence-based practices (2 edition). New York, NY: Springer Publishing Company.
• Alonzo, D., Stanley, B. (2013). A novel intervention for treatment of suicidal individuals. Psychiatric Services. 64, 494. doi: 10.1176/appi.ps.640105
• Suicide Prevention Resource Program: https://www.fordham.edu/info/24281/full-time_faculty_profiles/8748/suicide_prevention_research_program

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APA (6th ed) citation for this podcast: Singer, J. B. (Producer). (2017, September 10). #111 - Engaging People At Risk for Suicide: Interview with Dana Alonzo, Ph.D. [Audio Podcast]. Social Work Podcast. Retrieved from http://www.socialworkpodcast.com/2017/09/engagement.html