How Technology Has Influenced Suicide Assessment

At one time, the prevailing opinion among many mental health professionals was that suicide hotlines wouldn’t be effective. As late as 2009, four clinicians, writing jointly in the journal Suicide and Life-Threatening Behavior, said, “Assessing and diagnosing patients without seeing them in person deprives the clinician of important clinical information such as body language, eye contact, appearance, posture, and grooming. In addition, it is difficult to manage a crisis when large distances separate clinician and caller.” [1]

That pervasive view didn’t stop a group of clinicians from starting a suicide hotline in Los Angeles in 1962, or a onetime priest and longtime San Francisco radio correspondent for the BBC from starting a suicide hotline in San Francisco the same year. The L.A. hotline was launched, in part, because of the attention around Marilyn Monroe’s death, and was answered by professionals.

The S.F. hotline, in contrast, started as a one-person affair. Bernard Mayes placed ads on Muni buses in San Francisco saying, “Thinking of ending it all? Call Bruce,” with his phone number. Then, working under the pseudonym of Bruce, Mayes answered calls on a couch in his basement. In the beginning, he had no idea whether the phone would ring, but it did—once the first night, 10 times the first week, and 200 times the first month.

From the National Suicide Prevention Lifeline to 988

In 2005, the National Suicide Prevention Lifeline was born with funding from the federal Substance Abuse and Mental Health Services Administration. Today, it’s the country’s primary suicide hotline. Anyone who is suicidal or worried about someone who is suicidal can contact the Lifeline 24 hours per day, 365 days per year for free, confidential counseling and emotional support.

Calls are routed to several hundred crisis centers that are accredited by the American Association of Suicidology, generally to the center that is closest to the caller. Active-duty service members, veterans, and their families can press “1” to be connected to a center that has special expertise in military issues.

In 2022, a three-digit phone number—988—replaced the former 800 number for suicide prevention, and the Lifeline rebranded itself as 988 Suicide and Crisis Lifeline. Federal funding increased, and the call volume exploded.

How Over-the-Phone Suicide Assessment Works

There are three questions that the Lifeline recommends counselors ask: “Are you thinking of suicide?’ “Have you thought about suicide in the past two months? “Have you ever attempted to kill yourself?”

Follow-up questions include: “Will you talk to your therapist about this?” “If not, will you let me talk to him or her?” “Have you considered changing therapists?” “Will you promise to call this number again if you’re feeling down?”

Counseling someone over the phone might not be as desirable as meeting with them in person, but it’s effective nonetheless. Moreover, in one way, it’s more effective because clients have greater control. They don’t have to worry about offending anyone if they walk out of a session; they can simply hang up.

The physical separation also makes some clients more willing to share their troubles. In addition, clients can talk in the comfort and convenience of their home or office, so counseling is more accessible.

Can Suicide Assessment Work Over Text?

In recent years, crisis centers began offering text and chat services as well, often in collaboration with Crisis Text Line, an independent agency that started in 2013. The same concerns were raised initially—that by not being able to hear someone’s voice, counseling would be ineffective.

This, too, has proven to be untrue. While a written conversation is less desirable from a counselor’s point of view than a phone conversation, which in turn is less desirable than talking to someone in person, it’s better than nothing. Moreover, since texting is the preferred means of communication for many people, particularly youths, it makes sense for counseling to be available in this way. Teens might be resistant to talking, but chatty when texting.

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Texting also has a major benefit for clients: “Tears go undetected by the person you’ve reached out to,” Alice Gregory noted in her New Yorker article on the Crisis Text Line. Moreover, “You don’t have to hear yourself say aloud your most shameful secrets.” [2] As a result, people may disclose sensitive information about themselves in a text that they wouldn’t in a phone call.

Hotlines and text services aren’t meant to replace face-to-face counseling. Rather, they are ways to connect with individuals who are contemplating suicide and might be unreachable otherwise.

For immediate help in the U.S., 24/7: Call 988 or go to 988lifeline.org. Outside of the U.S., visit the International Resources page for suicide hotlines in your country. To find a therapist near you, see the Psychology Today Therapy Directory.