September is Suicide Prevention Month: Crisis Hot Lines

September is Suicide Prevention Month and I’ve been particularly more appreciative of psychiatry residents and crisis telephone hot line volunteers. When I was a resident I took calls from suicidal patients via the hospital operator and, as faculty, I still get the occasional call on the general hospital psychiatry consultation service when I carry the resident’s pager for the times when he or she must attend didactic classes, be absent for some reason, or uncomfortable about taking such calls (understandably more frequent with trainees rotating through the service from non-psychiatric specialties).

The conversations are often lengthy, intense and may end abruptly, leading to hurried phone calls to local police in order to request emergency welfare checks. Sometimes I never learn the the outcome.

I wondered about the research evidence supporting the crisis hot line, given that I was never specifically trained for interacting with suicidal callers and I’m not aware that there is any sort of practical clinical training exercise for teaching this skill to psychiatry residents. Naturally I wondered what’s considered to be the most helpful factors leading to desirable outcomes, how they could be measured if at all, how callers feel about the person they’re talking to on the other end of the line, and whether there’s anyone doing any specific training for this kind of intervention.

The first thing I learned about the evidence-base and research in this area is that it’s difficult to conduct. Authors from one study remarked that “The belief in the relationship between the short-term effects we observed and long-term benefits requires a leap of faith since little empirical proof exists that positive changes at the end of a call are related to long-term positive outcomes [1].” Predictably, empathy and respect are what were found to predict positive outcomes at least in the short term.

Suicide Risk Assessment Standards

Joiner, T., et al. (2007). “Establishing Standards for the Assessment of Suicide Risk Among Callers to the National Suicide Prevention Lifeline.” Suicide and Life-Threatening Behavior 37(3): 353-365.

The lack of empirical proof notwithstanding, there are standards for conducting hot line calls which were developed, in part, because of the observation that even some professional mental health providers were incompetent at this essential skill [2]. This empirical basis for the standards can be summarized in the mnemonic: “IS PATH WARM?”

I=Ideation

S=Substance abuse

P= Purposelessness

A=Anxiety

T=Trapped

H=Hopeless

W=Withdrawal

A=Anger

R=Recklessness

M=Mood changes

I discovered a study which found that suicidality, hopelessness, and psychological pain decreased in callers during the telephone call [3]. Most people appreciate the hot line service [4]. There’s even a training program for learning helper skills, although they tend to be located in Canada and in the eastern or western United States [5]. One volunteer’s testimonial on Vimeo can be seen on the web site here. I wonder if there’s a place in psychiatric residency training for something like it.

Anyway, that’s a quick summary of what my thoughts are on the topic. How about yours?

References:

1. Mishara, B. L., et al. (2007). “Which Helper Behaviors and Intervention Styles are Related to Better Short-Term Outcomes in Telephone Crisis Intervention? Results from a Silent Monitoring Study of Calls to the U.S. 1-800-SUICIDE Network.” Suicide and Life-Threatening Behavior 37(3): 308-321.
Abstract A total of 2,611 calls to 14 helplines were monitored to observe helper behaviors and caller characteristics and changes during the calls. The relationship between intervention characteristics and call outcomes are reported for 1,431 crisis calls. Empathy and respect, as well as factor-analytically derived scales of supportive approach and good contact and collaborative problem solving were significantly related to positive outcomes, but not active listening. We recommend recruitment of helpers with these characteristics, development of standardized training in those methods that are empirically shown to be effective, and the need for research relating short-term outcomes to long-term effects.
A total of 2,611 calls to 14 helplines were monitored to observe helper behaviors and caller characteristics and changes during the calls. The relationship between intervention characteristics and call outcomes are reported for 1,431 crisis calls. Empathy and respect, as well as factor-analytically derived scales of supportive approach and good contact and collaborative problem solving were significantly related to positive outcomes, but not active listening. We recommend recruitment of helpers with these characteristics, development of standardized training in those methods that are empirically shown to be effective, and the need for research relating short-term outcomes to long-term effects.

2. Joiner, T., et al. (2007). “Establishing Standards for the Assessment of Suicide Risk Among Callers to the National Suicide Prevention Lifeline.” Suicide and Life-Threatening Behavior 37(3): 353-365.
Abstract The National Suicide Prevention Lifeline was launched in January 2005. Lifeline, supported by a federal grant from the Substance Abuse and Mental Health Services Administration, consists of a network of more than 120 crisis centers located in communities across the country that are committed to suicide prevention. Lifeline’s Certification and Training Subcommittee conducted an extensive review of research and field practices that yielded the Lifeline’s Suicide Risk Assessment Standards. The authors of the current paper provide the background on the need for these standards; describe the process that produced them; summarize the research and rationale supporting the standards; review how these standard assessment principles and their subcomponents can be weighted in relation to one another so as to effectively guide crisis hotline workers in their everyday assessments of callers to Lifeline; and discuss the implementation process that will be provided by Lifeline.
The National Suicide Prevention Lifeline was launched in January 2005. Lifeline, supported by a federal grant from the Substance Abuse and Mental Health Services Administration, consists of a network of more than 120 crisis centers located in communities across the country that are committed to suicide prevention. Lifeline’s Certification and Training Subcommittee conducted an extensive review of research and field practices that yielded the Lifeline’s Suicide Risk Assessment Standards. The authors of the current paper provide the background on the need for these standards; describe the process that produced them; summarize the research and rationale supporting the standards; review how these standard assessment principles and their subcomponents can be weighted in relation to one another so as to effectively guide crisis hotline workers in their everyday assessments of callers to Lifeline; and discuss the implementation process that will be provided by Lifeline.

3. Gould, M. S., et al. (2007). “An Evaluation of Crisis Hotline Outcomes. Part 2: Suicidal Callers.” Suicide and Life-Threatening Behavior 37(3): 338-352.
Abstract In this study we evaluated the effectiveness of telephone crisis services/hotlines, examining proximal outcomes as measured by changes in callers’ suicide state from the beginning to the end of their calls to eight centers in the U.S. and again within 3 weeks of their calls. Between March 2003 and July 2004, 1,085 suicide callers were assessed during their calls and 380 (35.0%) participated in the follow-up assessment. Several key findings emerged. Seriously suicidal individuals reached out to telephone crisis services. Significant decreases in suicidality were found during the course of the telephone session, with continuing decreases in hopelessness and psychological pain in the following weeks. A caller’s intent to die at the end of the call was the most potent predictor of subsequent suicidality. The need to heighten outreach strategies and improve referrals is highlighted.
In this study we evaluated the effectiveness of telephone crisis services/hotlines, examining proximal outcomes as measured by changes in callers’ suicide state from the beginning to the end of their calls to eight centers in the U.S. and again within 3 weeks of their calls. Between March 2003 and July 2004, 1,085 suicide callers were assessed during their calls and 380 (35.0%) participated in the follow-up assessment. Several key findings emerged. Seriously suicidal individuals reached out to telephone crisis services. Significant decreases in suicidality were found during the course of the telephone session, with continuing decreases in hopelessness and psychological pain in the following weeks. A caller’s intent to die at the end of the call was the most potent predictor of subsequent suicidality. The need to heighten outreach strategies and improve referrals is highlighted.

4. Coveney, C. M., et al. (2012). “Callers’ experiences of contacting a national suicide prevention helpline: report of an online survey.” Crisis 33(6): 313-324.
BACKGROUND: Helplines are a significant phenomenon in the mixed economy of health and social care. Given the often anonymous and fleeting nature of caller contact, it is difficult to obtain data about their impact and how users perceive their value. This paper reports findings from an online survey of callers contacting Samaritans emotional support services. AIMS: To explore the (self-reported) characteristics of callers using a national suicide prevention helpline and their reasons given for contacting the service, and to present the users’ evaluations of the service they received. METHODS: Online survey of a self-selected sample of callers. RESULTS: 1,309 responses were received between May 2008 and May 2009. There were high incidences of expressed suicidality and mental health issues. Regular and ongoing use of the service was common. Respondents used the service for complex and varied reasons and often as part of a network of support. CONCLUSIONS: Respondents reported high levels of satisfaction with the service and perceived contact to be helpful. Although Samaritans aims to provide a crisis service, many callers do not access this in isolation or as a last resort, instead contacting the organization selectively and often in tandem with other types of support.

5. Gould, M. S., et al. (2013). “Impact of Applied Suicide Intervention Skills Training on the National Suicide Prevention Lifeline.” Suicide and Life-Threatening Behavior 43(6): 676-691.
We examined the impact of the implementation of Applied Suicide Intervention Skills Training (ASIST) across the National Suicide Prevention Lifeline’s national network of crisis hotlines. Data were derived from 1,507 monitored calls from 1,410 suicidal individuals to 17 Lifeline centers in 2008–2009. Callers were significantly more likely to feel less depressed, less suicidal, less overwhelmed, and more hopeful by the end of calls handled by ASIST-trained counselors. Few significant changes in ASIST-trained counselors’ interventions emerged; however, improvements in callers’ outcomes were linked to ASIST-related counselor interventions, including exploring reasons for living and informal support contacts. ASIST training did not yield more comprehensive suicide risk assessments.

 

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Comments

  1. kenyatta2009 says:

    Reblogged this on A Little Local Color.

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