# A Study of Suicide Hotlines



## David Baxter PhD (Sep 9, 2007)

A Study of Suicide Hotlines
By John M. Grohol
September 9, 2007

You know they?re there if you need one, but like most people, you?re probably not really sure how they work, or if they even work at all. Suicide hotlines have been around since the 1960s, but were mostly locally-based and locally-run. 

But how do they work? And do they work at all in reducing suicidal thoughts and behaviors?

That was the focus of a series of studies in a journal called Suicide and Life-Threatening Behavior. Today?s _Boston Globe_ has the story, called Wrong Answer, written by Christopher Shea. 

The results were mixed.

According to two articles by lead author Brian L. Mishara [?], 15.5 percent of the 1,431 calls his research assistants listened in on ? at 14 crisis centers ? failed to meet minimal standards for evaluating suicide risk and providing counseling.​The article focuses on what the studies found that cast the suicide call centers in a poor light:

Mishara did find that the helpers who mixed the two approaches ? mostly empathetic, with a dash of problem-solving ? had the best results, and that strategy can be taught, he says.

What stands out, though, is just how often the [suicide hotline] helpers failed to meet the basic standards for either approach. In 723 of 1,431 calls, for example, the helper never got around to asking whether the caller was feeling suicidal.

And when suicidal thoughts were identified, the helpers asked about available means less than half the time. There were more egregious lapses, too: in 72 cases a caller was actually put on hold until he or she hung up. Seventy-six times the helper screamed at, or was rude to, the caller. Four were told they might as well kill themselves. (In one such case, the caller had admitted to compulsively molesting a child.)​So naturally my question is, are the helpers just being poorly trained (doubtful) or is it more likely they suffer from burnout? The research doesn?t say, but it would be the most interesting question to me, because it would point to the need for constant re-training of helpers, and support and reward systems for maintaining empathy and problem-solving skills.

Do suicide helplines help?

In follow-up appointments with some 380 callers, 12 percent said the call had kept them from harming themselves; roughly a third reported having made and kept an appointment with a mental-health professional. On the other hand, 43 percent reported having felt suicidal since the call, and 3 percent had made a suicide attempt.​Again, the results appear decidedly mixed. If only 43% felt suicidal since the call, that leaves over 50% who do not. To me, that?s a pretty good number. You can?t say it?s the call that?s making the difference or not, but it seems like it?s helping at least a third of the people to seek out further mental health services. 

The study, however, hardly represents a condemnation of the centers, [the researcher] Mishara insists. On balance, callers were less hopeless, apprehensive, and generally depressed by the end of calls. ?The good centers are doing an excellent job,? he says, though research ethics forbid him from identifying either the good or bad ones.​Really now? I suppose that in order to get permission to listen in on the calls, he had to guarantee anonymity for the actual call centers, in case they turned out to be one of the ?bad? call centers.

But that seems to put public health and safety at risk, unless the researcher did identify the bad call centers to the centers themselves, in order to help them improve. Without constant, empirically-based feedback, how we know we?re doing a good or bad job?

Interesting ? and badly needed ? studies nonetheless that will hopefully provide some future improvement roadmaps for call centers nationwide.


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## Retired (Sep 9, 2007)

My experience with suicide hotlines is limited to the course I took in Ottawa which provides training for people  interested in suicide intervention.

The course is provided by The Centre For Suicide Prevention:

http://www.suicideinfo.ca/csp/go.aspx?tabid=2

The purpose of the course is to teach a framework or model to use when performing an intervention.  

The ASIST course is available worldwide and one wonders if the hotline staff on which this article is based received adequate training.


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## David Baxter PhD (Sep 9, 2007)

*Wrong answer*

Here's the _Boston Globe_ article referred to in the original post.

Wrong answer
By Christopher Shea  
September 9, 2007

_New research finds surprising errors at suicide hot lines. Like putting people on hold_

THE PERSON MANNING the suicide hot line should have asked a follow-up question about the gun. Yes, the caller had said, he was despondent, and, yes, he mentioned he had considered using a gun to end his life. But that's where that line of conversation ended - until the phone receiver exploded with the sound of a gunshot.

The caller had a rifle with a string tied to the trigger, rigged to point at his head. The bullet went wide, sparing the man, but a question or two more from the crisis-center representative - such as, do you have a gun with you now? - might have changed the course of events.

The journal _Suicide and Life-Threatening Behavior_ has published a remarkable series of articles on the effectiveness of suicide hot lines, opening a window into the world of desperate people and the volunteers who try to help them get through the night. Two of the unprecedented studies involved eavesdropping on suicide hot-line calls - in which the researchers heard things like that terrifying rifle shot - and two main conclusions came out of the work: One, many crisis-line callers are indeed in suicidal distress (and not just lonely or sad) and they are helped by talking to an empathetic fellow human being. And two, the call centers fail, with alarming regularity, to ask some very basic questions: Are you suicidal? Do you have a plan? Do you have the tools at hand to carry it off? Are you alone and drinking?

The studies are part of an effort to bring scientific rigor and a higher degree of standardized quality control to the 120-plus centers affiliated with a federal network of suicide hot lines, and holds the promise of saving lives. Under the network system, people who call 1-800-SUICIDE or 1-800-273-TALK get linked to a federally approved center near where they live. The network directs some 9,000 to 10,000 callers a month to local centers, and the hope is that an effective network might bring down the rate of suicide, which claims 30,000 lives annually in the United States and is the 11th leading cause of death. A study released last week by the Centers for Disease Control and Prevention found a striking 8 percent increase in suicide rates for Americans ages 10 to 24, from 2003 to 2004.

The new research, the most sweeping of its kind ever conducted, has already spurred a revamping of the training given to hot-line volunteers, effective this month.

"This is truly groundbreaking research," says John Draper, director of the National Suicide Prevention Lifeline, whose offices are in New York. "It's a beacon telling us not only what we are doing right but what we could be doing better."

According to two articles by lead author Brian L. Mishara, a professor of psychology at the University of Quebec at Montreal and president of the International Association for Suicide Prevention, 15.5 percent of the 1,431 calls his research assistants listened in on - at 14 crisis centers - failed to meet minimal standards for evaluating suicide risk and providing counseling. An additional 1,200 calls were monitored but deemed purely information-seeking, too short, or otherwise impossible to evaluate.

The study, however, hardly represents a condemnation of the centers, Mishara insists. On balance, callers were less hopeless, apprehensive, and generally depressed by the end of calls. "The good centers are doing an excellent job," he says, though research ethics forbid him from identifying either the good or bad ones.

The studies, and the hot-line network itself, are part of what some might call a belated effort by the US government to treat suicide as a significant health problem. Many people trace official interest in the subject to a Senate resolution, introduced in 1997 by Senator Harry Reid, Democrat of Nevada, whose father killed himself, which proclaimed reducing suicide a national priority. A major surgeon general's report followed two years later. The Department of Health and Human Services introduced the first federal 1-800 suicide-crisis line in 2001 and the Mental Health Association of New York City took over administration of it in 2005.

With the federal money to link up the centers - $2.6 million this year - came the requirement of rigorous evaluation. (In Boston, the federally affiliated center is Samaritans Inc., which has an office in Framingham as well. Its director, Roberta Hurtig, says neither center was evaluated in the recent studies.)

The two articles by Mishara and his eight co-authors focused on the demeanor of people answering phones, and how callers responded. Most centers, the researchers explained, claimed to adhere to one of two styles of counseling: nonjudgmental "active listening" and a more aggressive, problem-solving approach.

One problem: There was no correlation between a center's philosophy, as eloquently described by its director, and what the people answering the phones said and did. Mishara did find that the helpers who mixed the two approaches - mostly empathetic, with a dash of problem-solving - had the best results, and that strategy can be taught, he says.

What stands out, though, is just how often the helpers failed to meet the basic standards for either approach. In 723 of 1,431 calls, for example, the helper never got around to asking whether the caller was feeling suicidal.

And when suicidal thoughts were identified, the helpers asked about available means less than half the time. There were more egregious lapses, too: in 72 cases a caller was actually put on hold until he or she hung up. Seventy-six times the helper screamed at, or was rude to, the caller. Four were told they might as well kill themselves. (In one such case, the caller had admitted to compulsively molesting a child.)

There were 33 evident on-line suicide attempts, yet only six rescue efforts, sometimes because the caller ended the communication. In one case, a caller who'd overdosed passed out, yet the helper hung up.

In addition to the new training, Mishara would like to make call-monitoring a standard feature of crisis hot lines. So far that's optional, although some centers embrace the move. Michael Mitchell, clinical director of the Crisis and Counseling Centers Inc. in Augusta, Maine, has asked that supervisors listen in to about one in 10 crisis calls.

"There's a push-back from some of the more senior crisis workers," he concedes. "They see it as Orwellian." Still, he argues that monitoring is "absolutely" a good idea: After all, if credit-card companies do it, why not call centers, where the lives of "customers" are at stake?

A deeper question lurks behind the studies: Do suicide hot lines reduce suicide rates? Researchers have come to conflicting conclusions.

"They help people in a crisis," says J. John Mann, a psychiatrist at Columbia and a skeptic, "but whether those people would have gone on to kill themselves is unclear."

But another new study in _Suicide and Life-Threatening Behavior_, by researchers at Columbia, Rutgers, and the New York State Psychiatric Institute, suggests that many of the people calling in are, indeed, in extremely dire straits. This team of researchers had counselors at eight centers in 2003 and 2004 ask thorough questions of 1,085 callers who identified themselves as suicidal. Some were too distressed even for questioning: 88 had begun some sort of suicide attempt before making the call, and 136 times the helper ordered some kind of rescue. Overall, 58 percent of the callers had made a previous suicide attempt, striking evidence that they were in peril.

And these people seem to find solace in their phone calls. In follow-up appointments with some 380 callers, 12 percent said the call had kept them from harming themselves; roughly a third reported having made and kept an appointment with a mental-health professional. On the other hand, 43 percent reported having felt suicidal since the call, and 3 percent had made a suicide attempt.

Mann has not read the new studies, but he says that the most productive antisuicide measure he has identified would be to better train primary-care physicians to spot depression. They are notably bad at this: The majority of Americans who commit suicide saw their doctor within a month of their act.

The other antisuicide measure that Mann's research has found to be highly promising is a nonstarter, at least in the United States: "restriction of means." That's a bit of medical jargon that means eliminating guns from homes.


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## Retired (Sep 9, 2007)

> And these people seem to find solace in their phone calls. In follow-up appointments with some 380 callers, 12 percent said the call had kept them from harming themselves; roughly a third reported having made and kept an appointment with a mental-health professional.
> 
> On the other hand, 43 percent reported having felt suicidal since the call, and 3 percent had made a suicide attempt.



I don't know what the expectation of the professionals might be, but I don't find these statistics overly alarming.

The purpose of a suicide hotline is to intervene, gain an agreement the caller will remain safe and to point the person to a resource that can help them resolve the issue that is making them suicidal.

I am troubled by the reports of incompetence that were discovered during the research.  

Hopefully the agencies operating the hotlines will see this as an opportunity to improve their screening and training of their interveners.


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## Daniel (Sep 9, 2007)

Ideally, of course, unpaid volunteers would only serve as backup to a room full of night-shift therapists.


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## Retired (Sep 9, 2007)

> unpaid volunteers would only serve as backup to a room full of night-shift therapists



I couldn't imagine therapists being available across the Country to staff hotlines!   Even if some were available, the funding for such a project would likely be impossible to get.

My limited understanding of hotline service is to help the person get to a resource where they can get help, the local ER, the family doctor, a therapist of even a spiritual advisor.   

A hotline cannot provide therapy, plus it is my further understanding that many therapists are not trained in suicide intervention.

The best scenario, and I stand to be corrected, is a well trained force of competent volunteers, who are adequately supervised and not allowed to overwork themselves to the point of burn out.  

The unfortunate and tragic comments reported in the article from the Boston Globe seem to point to a possible burn out situation, would you not agree?


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## David Baxter PhD (Sep 9, 2007)

Burn out may well be a factor - that has got to be very stressful work. Then again, training ideally would include training on how to recognize and deal with burnout.

I don't see this as a condemnation of crisis lines in general or suicide crisis lines in particular, but I agree with you, Steve - one would hope that this would serve as a flag to take a close look at how volunteers are trained (and updated in their training periodically?).


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## Daniel (Sep 9, 2007)

Regarding volunteer burnout, one issue is that volunteers who can empathize the most with suicidal callers are those who may be more likely to suffer from stress and anxiety:



> Stepwise multiple regression analysis indicated that only one variable, the amount of experience in telephone intervention with suicidal persons, predicted stress level before the shift; volunteers with more experience tended to be less stressed. Stress during the most urgent call was related first to the level of urgency of the call, then to the total length of all calls received, followed by the coping mechanisms of magical thinking, detachment, and feeling personally responsible. Stress after the shift was related first to the total amount of time spent on calls, then to the number of other persons present during the shift. Stress after the shift was also negatively related to amount of education and having realistic expectations about interventions. Magical thinking was positively related to stress, and the mechanism of positive thinking was negatively related. *A high proportion of volunteers had attempted suicide, had previous thoughts about suicide, and had known persons who attempted or died by suicide. *These findings are discussed as to their implications for the selection and training of volunteers in suicide prevention.
> 
> http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum (1993)


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## Mari (Sep 9, 2007)

> Ideally, of course, unpaid volunteers would only serve as backup to a room full of night-shift therapists.



Thank-you for that comment Daniel, I think it is ingenious. 'Suicide is the sometime unfortunate result of an underlying illness'. Do we not usually send critically ill people to the hospital? If someone thought that I was close to death from heart failure would they tell me to call a hotline? I think that it is more likely that they would recommend immediate medical intervention - maybe even call an ambulance. I realize that is an oversimplification of the problem but teens are not going for the help they need. I would really like to see mental health on par with physical health and not something left for trained volunteers to deal with.  I had to look up the spelling of ingenious and noticed that it is one letter away from ingenuous. :dimples: That is very interesting to me for personal reasons. :heart: Thank-you again. Mari


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## Retired (Sep 9, 2007)

> If someone thought that I was close to death from heart failure would they tell me to call a hotline?



Obviously not, because what you describe is a physiological crisis which requires immediate physiological medical intervention.

A person who is suicidal may or may not be ready to carry out their plan.  Through conversation, a skilled intervention worker can determine the level of risk, and present options to the person to keep them safe until they can get qualified help.

However a skilled intervention worker worker is trained to recognize the signs of a suicidal person close to carrying out their plan, in which case they would immediately call 911 to dispatch help.



> I would really like to see mental health on par with physical health and not something left for trained volunteers to deal with.



Trained volunteers are not expected nor can they provide any form of therapy; they are like St. John's Ambulance volunteers ie trained to deal with an emergency, to stabilize the situation and to get the person to the proper qualified help resource.


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## Halo (Sep 9, 2007)

I thought that this was one of the best suggestions of the article:



> Mann has not read the new studies, but he says that the most productive antisuicide measure he has identified would be to better train primary-care physicians to spot depression. They are notably bad at this: The majority of Americans who commit suicide saw their doctor within a month of their act


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## Retired (Sep 10, 2007)

Good point, Halo!  I don't believe _all_ general practitioners lack the skills to notice when a person is suicidal, but in addition to having the skills, the physician needs the time.

This brings us to the state of the medical system, overloaded physicians work schedule combined with lack of training.

It is not an easy problem to solve, so improvements have to be made within the framework already in place.


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