Suicide Prevention: 5 Key Clinical Strategies for Engaging At-Risk Individuals in Mental Health Treatment

by Dana Alonzo, Ph.D.

(Editor's Note: This article is part of our Suicide Prevention Month series.)

     Research has demonstrated that up to 84% of adults aged 25–64 years who completed suicide saw a health/mental health provider at least once in the year prior to death (Morrison & Laing, 2011), while approximately 65% of adult suicide attempters saw a healthcare professional in the month prior to the attempt (Ahmedani et al., 2015). However, suicide attempters and completers often have difficulty engaging in and adhering to recommended outpatient mental health treatment and often drop out prematurely and/or very quickly after initiating treatment (Alonzo et al., 2016; Lizardi & Stanley, 2010; Stanley & Brown, 2012).

     When considering the factors related to the low treatment utilization rates of individuals at risk for suicide, more often than not the focus is on the characteristics of suicidal individuals that contribute to their poor engagement. However, it is crucial to consider the role of clinicians and how they may inadvertently contribute to the low rate of treatment engagement of suicidal individuals.

     Clinicians are often hesitant to engage with suicidal individuals. They report fear, disc

omfort, a lack of confidence, and feeling ill-prepared to work with suicidal clients (Feldman & Freedenthal, 2006; Jacobson et al., 2004; Ting, Jacobson, & Sanders, 2011; Singer & Slovack, 2011). In addition, they often use negative non-verbal behavior and judgments when working with this population (Pompili et al., 2005; Sethi & Shipra, 2006, Tapola et al., 2016). From the client perspective, many report feeling judged and blamed by mental health professionals and express distrust in healthcare professionals (Goldsmith et al., 2002; Tapola et al., 2016). The fear, hesitancy, and discomfort of the treating clinician have a clear and direct impact on the therapeutic relationship and the suicidal client’s experience of mental health treatment.

     Key clinical strategies to counter a potentially negative interaction with a client experiencing suicidal thoughts and/or feelings that may serve to facilitate treatment engagement and adherence include:

1. Creating an accepting, safe, non-judgmental space for the client to disclose his/her suicidal thoughts. For example, a statement such as, “Help me to understand what got you to the point that you believe suicide is your only option,” is a judgment-free way to engage clients in a conversation about their suicidality.
2. Maintaining a transparent, neutral stance throughout the interview. This may serve to facilitate more honest, open responses on the part of the client.
3. Careful consideration of the number and timing of questions. Although it is necessary to ask the core suicide risk assessment questions (i.e., questions about active ideation, plan, intent, and so forth), avoiding an interrogational style is essential. If the client is openly talking, do not interrupt to cover the default assessment questions. Rather, encourage the natural conversation that the client seems comfortable with, and the client may end up answering many of these questions, even if it is out of order or sequence. Should important questions remain unanswered and there is a need to backtrack to address them, do so when there is a natural break in the conversation.
4. Conveying to the client that alternatives to suicide exist, even though they may be hard to identify at this time. The clinician’s confidence that finding a solution will be possible is an important factor in engaging the at-risk client in treatment.
5. Personalizing treatment. Eliciting the client’s goals for treatment and personalizing reasons for why treatment is important and how it can be helpful will help to maximize the likelihood that the client will continue to attend treatment.

     Treatment engagement is an important yet often overlooked issue in suicide prevention efforts. Individuals at risk for suicide are hesitant to engage in treatment and often expect to be met with discomfort and negative judgments, affecting the likelihood of their initiating and remaining in treatment. Making an active, focused effort to engage at-risk clients in treatment and creating an accepting space to disclose suicidal thoughts may have life-saving consequences.

References

Ahmedani, B. K., Stewart, C., Simon, G. E., Lynch, F., Lu, C. Y., Waitzfelder, B. E., & Hunkeler, E. M. (2015). Racial/ethnic differences in healthcare visits made prior to suicide attempt across the United States. Medical Care, 53(5), 430.

Alonzo, D., Moravec, C., & Kaufman, B. (2016). Individuals at risk for suicide: Mental health clinicians' perspectives on barriers to and facilitators of treatment engagement. Crisis, 38, 158-167.

Feldman, B. N., & Freedenthal, S. (2006). Social work education in suicide intervention and prevention: An unmet need? Suicide and Life-Threatening Behavior, 36, 467–480.

Goldsmith, S.K., Pellmar, T.C., Kleinman, A.M., & Bunney, W.E. (2002). Reducing suicide: A national imperative. Institute of Medicine (U.S.), Committee on Pathophysiology & Prevention of Adolescent & Adult Suicide. Washington, DC: National Academies Press.

Jacobson, J. M., Ting, L., Sanders, S., & Harrington, D. (2004). Prevalence of and reactions to fatal and nonfatal client suicidal behavior: A national study of mental health social workers. Omega: Journal of Death and Dying, 49, 237–248.

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Morrison, K. B., & Laing, L. (2011). Adults’ use of health services in the year before death by suicide in Alberta. Health Reports, 22(3), 1–8.


Pompili M., Girardi P., Ruberto A., Kotzalidis G. & Tatarelli R. (2005) Emergency staff reactions to suicidal and self‐harming patients. European Journal of Emergency Medicine 12(4), 169–178.

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Singer, J. B., & Slovak, K. (2011). School social workers’ experiences with youth suicidal behavior: An exploratory study. Children & School, 33, 215–228.


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Ting, L., Jacobson, J. M., & Sanders, S. (2011). Current levels of perceived stress among mental health social workers who work with suicidal clients. Social Work, 56, 327–336.

Dr. Dana Alonzo received her Ph.D. from Fordham University’s Graduate School of Social Service, where she was awarded a National Institute of Mental Heath Research Training Fellowship. As a co-investigator at the Developing Centers for Interventions for the Prevention of Suicide (DCIPS) at New York State Psychiatric Institute, she conducted studies examining risk and protective factors across cultures related to mood disorders and suicidal behavior. With funding from the American Foundation for Suicide Prevention (AFSP), the National Alliance for Research on Schizophrenia and Depression (NARSAD), the Mental Health Association of New York State (MHANYS), and the Office of Mental Health of New York State (OMHNYS), 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.

If you or someone you know are experiencing a crisis or thinking about suicide, call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255), or text HOME to 741741 in the U.S. to reach a Crisis Text Line counselor.