- Existing research on crisis lines is weak, mostly focusing on short-term improvements.
- The rise of technology-based crisis support systems beg for additional research and ethical use of private information.
- A push for culturally-informed training and evaluation for volunteers is needed.
- State and federal-level planning, in addition to all-inclusive crisis systems, are vital to successful 988 implementation.
By Sasha Zabelski, MS, Ph.D. student, University of North Carolina, Charlotte, Public Health Sciences; Robert J. Cramer, Ph.D., Associate Professor & Irwin Belk Distinguished Scholar in Health Research, University of North Carolina, Charlotte, Public Health Sciences
Suicide is still a leading cause of death worldwide. Thankfully, the U.S. is finally trying to tackle the problem from a policy perspective. The 2020 National Suicide Hotline Designation Act sets up our nationwide transition to 988—the mental health equivalent of 911. This type of crisis line is a key part of suicide prevention.
My research team at UNC Charlotte reviewed the current status of crisis lines. We did so to provide education for the public and better inform training and practice. Here’s what we found:
What Do We Know About the Mental Health Impacts During and After a Crisis Call?
While there is limited research on the immediate and long-term outcomes for those that call the crisis lines, existing research shows that overall distress and suicidal thoughts tend to decrease both during and right after the phone call. Overall, those who call say they feel 43 percent less distressed by the time they finish their call. There have also been some promising long-term outcomes for those who call the National Suicide Prevention Lifeline including a reduction in hopelessness, psychache, depression, and anxiety.
However, despite every caller being provided with referrals to follow up with after their call, only 33 to 42 percent report contacting a referral that was provided for them. One current helpful practice implemented by the National Suicide Prevention Lifeline has included a follow-up call, which happens within days after an initial call. Eighty percent of people said that this call stopped them from killing themselves, and 90 percent stated that the call kept them safe from engaging in any other self-harm.
Chat and Text Lines: New Ways of Tackling Mental Health Crises
One branch of the National Suicide Prevention Lifeline is the Lifeline Chat. Studies conducted on the effectiveness of the chat line have been minimal so far. Research examining the Lifeline chat services indicates that most individuals find the chat services helpful, but 50 percent of people still felt suicidal after being in contact with the chat line.
The Crisis Text Line is also widely available; however, it is not affiliated with the National Suicide Prevention Lifeline. Data gathered by the Crisis Text Line suggests that contacts are mostly comprised of texters under the age of 25. The Crisis Text Line data indicates a high number of contacts coming from low-income urban neighborhoods, leaving a large gap in individuals contacting the text line from rural areas. The COVID-19 pandemic led to an increase in crisis texts, with the biggest increases occurring among children, specifically lesbian, gay, bisexual, transgender, queer, and other (LGBTQ+) youth.
What Resources Exist for Persons with Higher Suicide Risk?
The National Suicide Prevention Lifeline has expanded to include options for Spanish speakers and individuals who are deaf or hard-of-hearing. Beyond the National Suicide Prevention Lifeline, other non-profit organizations have created hotlines for populations at high risk of suicide. These hotlines may lead certain populations to be more likely to access crisis care; for example, nearly half of callers to an LGBTQ+ youth crisis hotline stated that they would not have contacted a non-LGBTQ+ hotline and that they felt more comfortable speaking to counselors that were trained in affirming sexual and gender minority individuals.
Another high-risk population with its own hotline is The Veterans Crisis Line (VCL). This crisis line was established in 2007 and has completed over one million referrals to Veterans Affairs Suicide Prevention Coordinators. A high number (80 percent) of veterans that call the line stated that calling the hotline stopped them from killing themselves. Additionally, it has been shown that the veterans crisis chat line was used as the first contact with mental health services for many veterans receiving referrals and following up with services post-call.
Where Do Crisis Support Lines Go From Here?
Recommendation 1: Improve the multicultural aspects of crisis lines.
All research conducted on crisis support lines in the United States so far gives us limited knowledge of how these lines operate, who they serve, and how effective they are. There has been almost no research showing how much volunteer training affects mental health and suicidal outcomes in the long term for callers. One study indicated that the referrals offered during the call were not appropriate due to not having insurance or the right type of insurance to access the service.
Research has shown that in order for individuals to have relevant skills for intervention, updated, frequent suicide prevention training should be provided. Therefore, hotline volunteers should have required follow-up or refresher training to keep their knowledge fresh and to have a better understanding of the caller’s specific needs, including any barriers they made be facing in accessing services (e.g., transportation, therapists accepting Medicaid).
Several high-risk groups (e.g., American Indians, Alaska Natives, and people struggling with suicide loss) have not been mentioned in the crisis support line literature. Although there are currently individual crisis lines that serve veterans, LGBTQ+, Spanish speakers, and hard of hearing individuals, we could not find any research evaluating how culturally sensitive and non-discriminatory volunteers are when speaking with marginalized populations. We recommend developing staff training and evaluation that targets cultural humility, racism, and discrimination. It has previously been shown that culturally informed suicide prevention trainings have been effective and are needed by communities at risk.
Recommendation 2: We need more research on newer approaches to crisis support.
Newer branches of crisis support lines—including chat and text—have shown some promise though research is still limited in understanding how effective they are in preventing suicide. The new 988 number will also be offered as a text line option, likely leading to an increase in individuals using the text service.
Unfortunately, due to the limited studies, we are not yet sure whether people will find this type of line helpful. We should continue studying how chat and text lines affect suicide and mental health outcomes during and after contact. Additionally, chat and text lines should work to understand whether other high-risk populations are contacting their lines and, if not, how they can make the lines accessible for all.
The introduction of various forms of crisis services such as technology-based options had many wondering about the handling of sensitive caller/texter/chatter data. A Politico story published earlier this year raised ethical concerns about the Crisis Text Line and found that anonymized texter data was being shared with a partner for-profit company with acknowledgment of these practices only being found behind a consent link containing a lengthy disclosure.
With the sensitive information shared on these lines, it is important to keep crisis lines accountable. One way to ensure this is by clearly informing the user before they begin a conversation on the ways in which their data is being handled and allowing those that use these lines to delete their data after contacting the organization. All crisis lines can work towards providing a more comprehensive and transparent conversation with callers, texters, and chat users about privacy, data, and trust.
Recommendation 4: Devote more funding to crisis lines.
Funding the overall crisis system can help provide resources to call centers, volunteers, and other issues mentioned above. Transitioning to 988 will likely lead to an increase in calls, and crisis lines may be unprepared to handle the subsequent issues.
With this in mind, we hope that all states adopt funding measures that will cover the cost of sustaining call centers and create a robust system for all. Funding will help train volunteers in providing culturally competent services, data privacy, and enhanced de-escalation skills.
Finally, funding can be provided to researchers who can continue to study the effectiveness and helpfulness of crisis support lines. The current gaps in practice and research that have been identified are strongly the result of underfunding evidence-based practices and systems as a whole.
Britton, P. C., Bossarte, R. M., Thompson, C., Kemp, J., & Conner, K. R. (2013). Influences on call outcomes among veteran callers to the National Veterans Crisis Line. Suicide & Life-Threatening Behavior, 43(5), 494–502. https://doi.org/10.1111/sltb.12033
Crisis Text Line. (n.d.). Crisis Text Line. Crisis Text Line. https://www.crisistextline.org/
Federal Communications Commission (2021). Implementation of the National Suicide Hotline Improvement Act of 2018 (Report No FCC 21-119). Website: https://www.fcc.gov/document/fcc-approves-text-988-access-suicide-prevention-lifeline-0#:~:text=Description%3A,Hotline%20by%20July%2016%2C%202022.
Fildes, D., Williams, K., Bradford, S., Grootemaat, P., Kobel, C., & Gordon, R. (2022). Implementation of a pilot SMS-based crisis support service in Australia: Staff experiences of supporting help-seekers via text. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 43(1), 46–52. https://doi.org/10.1027/0227-5910/a000758
Goldbach, J. T., Rhoades, H., Green, D., Fulginiti, A., & Marshal, M. P. (2019). Is there a need for LGBT-specific suicide crisis services?. Crisis, 40(3), 203–208. https://doi.org/10.1027/0227-5910/a000542
Gould, M. S., Kalafat, J., Harrismunfakh, J. L., & Kleinman, M. (2007). An evaluation of crisis hotline outcomes. Part 2: Suicidal callers. Suicide & Life-Threatening Behavior, 37(3), 338–352. https://doi.org/10.1521/suli.2007.37.3.338
Gould, M. S., Munfakh, J., Kleinman, M., & Lake, A. M. (2012). National suicide prevention lifeline: Enhancing mental health care for suicidal individuals and other people in crisis. Suicide & Life-Threatening Behavior, 42(1), 22–35.
Gould, M. S., Lake, A. M., Galfalvy, H., Kleinman, M., Munfakh, J. L., Wright, J., & McKeon, R. (2018). Follow-up with callers to the National Suicide Prevention Lifeline: Evaluation of callers' perceptions of care. Suicide & Life-Threatening Behavior, 48(1), 75–86. https://doi.org/10.1111/sltb.12339
Gould, M. S., Chowdhury, S., Lake, A. M., Galfalvy, H., Kleinman, M., Kuchuk, M., & McKeon, R. (2021). National Suicide Prevention Lifeline crisis chat interventions: Evaluation of chatters' perceptions of effectiveness. Suicide & Life-Threatening Behavior, 51(6), 1126–1137. https://doi.org/10.1111/sltb.12795
Hedegaard, H., Curtin, S.C., & Warner, M. (2020). Increase in suicide mortality in the United States, 1999–2018. NCHS Data Brief, no 362. National Center for Health Statistics. https://www.cdc.gov/nchs/products/databriefs/db362.htm
Hoffberg, A. S., Stearns-Yoder, K. A., & Brenner, L. A. (2020). The effectiveness of crisis line services: A systematic review. Frontiers in Public Health, 7, 399. https://doi.org/10.3389/fpubh.2019.00399
Internet Society. (2019). Policy Brief: Principles for Responsible Data Handling. Internet Society. https://www.internetsociety.org/policybriefs/responsible-data-handling/
Johnson, L. L., Muehler, T., & Stacy, M. A. (2021). Veterans' satisfaction and perspectives on helpfulness of the Veterans Crisis Line. Suicide & Life-Threatening Behavior, 51(2), 263–273. https://doi.org/10.1111/sltb.12702
Kalafat, J., Gould, M. S., Munfakh, J. L., & Kleinman, M. (2007). An evaluation of crisis hotline outcomes. Part 1: Nonsuicidal crisis callers. Suicide & Life-Threatening Behavior, 37(3), 322–337. https://doi.org/10.1521/suli.2007.37.3.322
Levine, A. S. (2022). Suicide hotline shares data with for-profit spinoff, raising ethical questions. POLITICO. https://www.politico.com/news/2022/01/28/suicide-hotline-silicon-valley-privacy-debates-00002617
National Suicide Prevention Lifeline. (n.d.). FAQ. https://suicidepreventionlifeline.org/faq/
National Suicide Prevention Lifeline [NSPL]. (n.d.). Lifeline Chat. https://suicidepreventionlifeline.org/chat/
Ramchand, R., Jaycox, L., Ebener, P., Gilbert, M. L., Barnes-Proby, D., & Goutam, P. (2017). Characteristics and proximal outcomes of calls made to suicide crisis hotlines in California. Crisis, 38(1), 26–35. https://doi.org/10.1027/0227-5910/a000401
Runkle, J. D., Yadav, S., Michael, K., Green, S., Weiser, J., & Sugg, M. M. (2022). Crisis response and suicidal patterns in U.S. youth before and during COVID-19: A latent class analysis. The Journal of Adolescent Health, 70(1), 48–56. https://doi.org/10.1016/j.jadohealth.2021.10.003
SAMHSA. (2021). People at Greater Risk of Suicide. https://www.samhsa.gov/suicide/at-risk
Shtivelband, A., Aloise-Young, P. A., & Chen, P. Y. (2015). Sustaining the effects of gatekeeper suicide prevention training. Crisis, 36(2), 102–109. https://doi.org/10.1027/0227-5910/a000304
Stewart, R. E., Mandell, D. S., & Beidas, R. S. (2021). Lessons From Maslow: Prioritizing Funding to Improve the Quality of Community Mental Health and Substance Use Services. Psychiatric Services, 72(10), 1219–1221. https://doi.org/10.1176/appi.ps.202000209
Teo, A. R., Andrea, S. B., Sakakibara, R., Motohara, S., Matthieu, M. M., & Fetters, M. D. (2016). Brief gatekeeper training for suicide prevention in an ethnic minority population: A controlled intervention. BMC Psychiatry, 16, Article 211. https://doi.org/10.1186/s12888-016-0924-4
Thompson, L. K., Sugg, M. M., & Runkle, J. R. (2018). Adolescents in crisis: A geographic exploration of help-seeking behavior using data from Crisis Text Line. Social Science & Medicine (1982), 215, 69–79. https://doi.org/10.1016/j.socscimed.2018.08.025
Veterans Crisis Life. (2021). About us. www.veteranscrisisline.net/about/about-us/
Vibrant Emotional Health. (2020). 988 Serviceable Populations and Contact Volume Projections. https://www.vibrant.org/wp-content/uploads/2020/12/Vibrant-988-Projections-Report.pdf?_ga=2.62739180.1718066263.1611784352-1951259024.1604696443
Williams, K., Fildes, D., Kobel, C., Grootemaat, P., Bradford, S., & Gordon, R. (2021). Evaluation of Outcomes for Help Seekers Accessing a Pilot SMS-Based Crisis Intervention Service in Australia. Crisis, 42(1), 32–39. https://doi.org/10.1027/0227-5910/a000681