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An Evaluation of Crisis Hotline Outcomes Part 1: Nonsuicidal Crisis Callers



The effectiveness of telephone crisis services/hotlines, examining proximal outcomes as measured by changes in callers' crisis state from the beginning to the end of their calls to eight centers in the U.S. and intermediate outcomes within 3 weeks of their calls, was evaluated. Between March 2003 and July 2004, 1,617 crisis callers were assessed during their calls and 801 (49.5%) participated in the followup assessment. Significant decreases in callers' crisis states and hopelessness were found during the course of the telephone session, with continuing decreases in crisis states and hopelessness in the following weeks. A majority of callers were provided with referrals and/or plans of actions for their concerns and approximately one third of those provided with mental health referrals had followed up with the referral by the time of the follow-up assessment. While crisis service staff coded these callers as nonsuicidal, at follow-up nearly 12% of them reported having suicidal thoughts either during or since their call to the center. The need to conduct suicide risk assessments with crisis callers and to identify strategies to improve referral follow-up is highlighted.
322 Suicide and Life-Threatening Behavior 37(3) June 2007
2007 The American Association of Suicidology
An Evaluation of Crisis Hotline Outcomes
Part 1: Nonsuicidal Crisis Callers
John Kalafat, PhD, Madelyn S. Gould, PhD, MPH,
Jimmie Lou Harris Munfakh, BA, and Marjorie Kleinman, MS
The effectiveness of telephone crisis services/hotlines, examining proximal
outcomes as measured by changes in callers’ crisis state from the beginning to the
end of their calls to eight centers in the U.S. and intermediate outcomes within 3
weeks of their calls, was evaluated. Between March 2003 and July 2004, 1,617 crisis
callers were assessed during their calls and 801 (49.5%) participated in the follow-
up assessment. Significant decreases in callers’ crisis states and hopelessness were
found during the course of the telephone session, with continuing decreases in
crisis states and hopelessness in the following weeks. A majority of callers were
provided with referrals and/or plans of actions for their concerns and approxi-
mately one third of those provided with mental health referrals had followed up
with the referral by the time of the follow-up assessment. While crisis service staff
coded these callers as nonsuicidal, at follow-up nearly 12% of them reported hav-
ing suicidal thoughts either during or since their call to the center. The need to
conduct suicide risk assessments with crisis callers and to identify strategies to
improve referral follow-up is highlighted.
Telephone crisis services (TCS) have been many maladaptive behaviors such as alcohol
use, interpersonal violence, or suicidal behav-providing crisis intervention and referral ser-
vices in the United States for over 40 years. ior involve maladaptive responses to crises;
(3) crises are characterized by increases inThe conceptual bases for crisis intervention
include: (1) crises are time limited and pre- anxiety, which produce cognitive constriction
and attenuate problem-solving ability; andsent an opportunity for positive or negative
outcomes, based on the application of effec- (4) due to the failure of the usual coping
mechanisms and heightened vigilance, indi-tive or maladaptive coping, respectively; (2)
Dr. Kalafat is a faculty member of the Rutgers Graduate School of Applied and Professional
Psychology; Dr. Gould is a Professor at Columbia University in the Division of Child and Adolescent
Psychiatry (College of Physicians & Surgeons) and Department of Epidemiology (School of Public
Health), and a Research Scientist at the New York State Psychiatric Institute; and Ms. Munfakh and
Ms. Kleinman are in the Division of Child and Adolescent Psychiatry and New York State Psychiatric
Supported by a cooperative agreement from the Substance Abuse and Mental Health Services
Administra tion (SAMHSA), U79SM54128. We gratefully acknowledge Dr. Rachel Strohl and Ms. Rebe-
cca Brent Weinberg for their assistance in data collection and analysis, respectively. While they must
remain anonymous, we want to thank the participating centers for their dedication and hard work on the
Address correspondence to John Kalafat, PhD, Rutgers Graduate School of Applied and Pro-
fessional Psychology, 152 Frelinghuysen Rd., Piscataway, NJ 08854-8085; E-mail: kalafat@rci.
Kalafat et al. 323
viduals are more open to intervention (Caplan, maladaptive coping, and to help the caller
find a plan for coping with the situation that1964; Rapoport, 1965). The implications of
these concepts for intervention suggest that precipitated the crisis and/or another helping
agency that can provide further assistance.interventions must be readily accessible to
provide adaptive responses to crises to atten- Evaluations of TCS have included
caller feedback/satisfaction, assessments ofuate maladaptive outcomes; due to the reduc-
tion in defenses, a relatively brief interven- helping processes and proximal outcomes
(changes in caller crisis or suicidal status),tion may have a significant impact; and a
collaborative intervention which includes ac- rates of follow-up with referrals, and assess-
ments of distal outcom es consisting of changestive problem solving and mobilization of in-
ternal and external resources is necessary to in community suicide rates. The focus of this
study is outcomes for nonsuicidal crisis call-take advantage of the opportunity for growth
presented by crises (Baldwin, 1979; Brock- ers to TCS. Therefore, studies of crisis and
referral outcomes for these callers are re-opp, 1973).
Based on this rationale, a model of cri- viewed. A companion article addresses TCS
responses to suicidal callers (Gould, Kalafat,sis services has evolved that consists of 24-
hour telephone services (often supplemented Harris Munfakh, & Kleinman, this issue).
Early process evaluations of telephoneby mobile outreach teams) staffed by spe-
cially trained professionals and/or parapro- counseling interventions focused on helper-
offered conditions of empathy, warmth, andfessional volunteers who provide one-time or
time-limited interventions to clients at no genuineness (Rogers, 1957), which are repre-
sentative of helping approaches of many tele-charge. A consensus has evolved around a
four to six step problem-solving intervention phone crisis centers to this day. Studies found
moderate levels of these conditions as ratedmodel first adopted by the Los Angeles Sui-
cide Prevention Center (Farberow, Heilig, & on simulated calls and role-plays, variations
between centers, and increased levels associ-Litman, 1968), consisting of establishing rap-
port; defining the problem(s) (including as- ated with training and experience (Bleach &
Claiborn, 1974; Caruthers & Inslee, 1974;sessing risk for suicide); exploring affect (in-
cluding reducing anxiety and other affects France, 1975; Kalafat, Boroto, & France,
1979; O’Donnell & George, 1977); however,that attenuate problem solving); exploring
callers’ coping repertoires; and developing al- the relationship between these conditions
and call outcomes was not assessed. Otherternatives for addressing the problem (i.e., a
specific plan of action and/or referral to in- studies have assessed the presence and timing
of the components of the helping model andformal or formal resources). In addition to a
variety of crisis situations, TCS provide im- examined their relationships to caller out-
comes through follow-up calls to callersmediate responses to suicidal callers. For
callers in less acute suicidal states who may (Echterling & Hartsough, 1989; Echterling,
Hartsough, & Zarle, 1980; Young, 1989).be at the ideation or planning stage, TCS
aim to identify the precipitants of the suicidal The presence and timing of these compo-
nents were related to positive caller feedbackstate, generate alternative coping strategies,
and mobilize supports for callers. For callers and outcomes such as relief of distress, confi-
dence, and emotional more acute, imminent suicidal states, TCS
may engage in more active interventions such Asessments of callers’ follow through
with referral recommendations have alsoas obtaining the location of callers through
direct request, tracing calls, or employing been conducted (Buchta, Wetzel, Reich, But-
ler, & Fuller, 1973; Paul & Turner, 1976;caller identification; and, sending community
emergency response personnel. The goal of Slaikeu, Tulkin, & Speer, 1975; Slaikeu &
Willis, 1978). In general, studies found fol-telephone crisis intervention, then, is to re-
duce maladaptive cognitive and affective low through rates of approximately 50%.
Two early studies that rated the appropriate-components of the crisis state, to attenuate
324 Nonsuicidal Crisis Caller Outcomes
ness of referrals provided by telephone staff cesses, use of internal call monitoring, and
willingness to adopt agreed upon standard-raised concerns about the accuracy of refer-
rals (Bleach & Claiborn, 1974) and their ap- ization of call record keeping and evaluation
procedures. An additional three centers hadpropriateness for the caller’s problem (Apsler
& Hodas, 1975). Whether or not callers fol- been originally recruited, but dropped out of
the study because one had assumed a newlow through with referrals may also be a
function of such variables as caller motivation service and could not take on additional proj-
ects; another conducted face-to-face outreachand availability of other sources of support
(Slaikeu et al., 1975; Slaikeu & Willis, 1978). with all callers, and thus was not a typical
telephone hotline; and the staff of the thirdAlso, it may be that effective efforts to reduce
callers’ anxiety or resolve their concerns may refused to collect evaluation data. Seven of
the participating centers were members of aattenuate motivation to contact referrals. Fi-
nally, counselor skill may affect referral fol- national 1-800-SUICIDE network. The eight
centers were located in six states (2 midwest,low through; for example, Slaikeu et al.
(1975) found that callers who followed through 4 northeast, 1 south, and 1 west). Telephone
counselors in these centers were either paidrated the counselor who provided the referral
as more helpful than those who did not. In (4), volunteer (3), or a mixture of both paid
and volunteer (1). The annual call volume inaddition, Paul and Turner (1976) found that
provision of incentives for crisis staffs con- these centers ranged from 7,993 to 85,000
calls per year. The method used by crisis cen-scientious provision of referrals increased
rates of follow through. ters to select which counselors would partici-
pate in the project varied. Three crisis cen-To date, there are no studies that eval-
uate a primary aim of crisis servicesto re- ters required all of their counselors to
participate, and in two other centers counse-duce the crisis states of callers from their
presenting levels at the start of the calland lors participated on a volunteer basis. The re-
maining three centers used specific criteria toto provide a specific plan of action or referral
for the caller’s presenting problem. The pur- select only a portion of their counselors: in
one, all but the overnight staff were requiredpose of our study was to evaluate the effec-
tiveness of TCS for achieving positive client to participate; in the second, only paid staff
was selected to participate; and in the thirdoutcomes as indicated by changes in callers’
crisis states from the beginning to the end of center only those with extensive crisis coun-
seling experience were selected. A total oftheir calls to participating centers (immediate
outcomes), and again within 3 weeks of their 240 counselors in the eight centers con-
ducted the baseline assessment with callers.calls (intermediate outcomes). Callers’ recol-
lection of and follow through with plans of The number of counselors participating in
each center ranged from 9 to 70. The averageaction and/or referrals received during their
calls were also evaluated. The companion ar- number of baseline assessments conducted
per counselor in each center ranged from 2ticle (Gould et al., this issue) addresses im-
mediate and intermediate outcomes for sui- to 33.
Baseline Cohort. Adult nonsuicidal in-cidal callers.
dividuals experiencing a crisis who called one
of the eight recruited TCS were the targeted
population for this study. Crises were definedMETHOD
as upset states precipitated by events with
which individuals currently felt unable toSample
cope. Between March 2003 and July 2004,
telephone crisis counselors conducted theTelephone Crisis Services. Eight TCS
were selected on the basis of organizational baseline assessment with 2,702 of the 5,168
eligible callers (52.3% participation rate). Ofstability (in operation at least 5 years), suffi-
cient call volume, quality assurance pro- these, 1,613 were crisis callers (25.9% male
Kalafat et al. 325
and 74.1% female). Gender was not coded at terviewers received passive or active refusals
at follow-up. Common reasons for counse-baseline for four crisis callers. The majority
of assessed crisis callers (90.1%; n = 1,357) lors not asking for consent for the follow-up
call were that the caller had to quickly termi-called the center’s local crisis hotline tele-
phone number and 149 (9.9%) called a na- nate the call, or hung up.
Crisis callers who participated in thetional 1-800 network that connected callers
to local crisis lines. follow-up assessment were similar to nonpar-
ticipants with regard to crisis state at the be-Of the 5,168 eligible callers, 2,466
(47.7%) callers were not assessed for the fol- ginning of the call and to changes in their
crisis state from the beginning to the end oflowing reasons: call volume too high (788),
callers’ suicide risk status too high (654), call- the call. However, crisis callers who were fol-
lowed were significantly more overwhelmeders refused/hung up (648), counselor thought
not appropriate to assess (226), and phone and received significantly more referrals from
counselors than crisis callers who were notproblems (150).
Out of the 87,459 calls received by the followed (Table 1).
participating counselors, 82,291 (94.1%) call-
ers met exclusion criteria and were not as- Measures
sessed. Of the excluded callers, 31,862
(38.7%) individuals called only for informa- An advisory board, consisting of ex-
perts in crisis lines, risk assessments, andtion and referral but were not in crisis;
16,664 (20.3%) were third-party callers also evaluation; and a Crisis Centers Directors
Board, consisting of the directors from sixnot in crisis; 13,986 (17.0%) were intoxicated
and/or belligerent callers; 12,619 (15.3%) telephone crisis services originally recruited
to participate, were created. With the assis-were frequent chronic callers; 2,732 (3.3%)
were minors; 2,381 (2.9%) were non-English tance of these two boards, and SAMHSA
staff, the client-centered outcomes werespeaking; and 2,167(2.6%) callers were not in
a mental state fit to complete the assessment. identified and final drafts of the baseline and
follow-up measures and the implementationFollow-Up Cohort. Between April
2003 and August 2004, of the 1,617 crisis plan were prepared for piloting. The final
baseline assessment also incorporated recom-callers who completed the baseline assess-
ment, follow-up assessments were conducted mendations received from counselors who
piloted the assessment with 103 callers inwith 801 (49.5%) callers (23.6% male and
76.4% female). Follow-up assessments were four centers. Manuals were developed to
train the crisis counselors and the follow-upconducted between 1 and 52 days from the
baseline assessment date, with the average interviewers.
Profile of Mood States: Modified (POMS-being 13.5 days. For these callers, the age
ranged from 1885, and the mean was 37.6 M). Early work in the field of crisis inter-
vention included descriptions of the crisisyears. The ethnic distribution was 57.3%
White, 26.0% African American, 13.1% His- state based on observations of individuals’ re-
sponses to disasters, war, and other situa-panic, 1.4% other, 1.3% Native American,
and 1.0% Asian. Ethnicity was not coded for tional crises (Stein & Lambert, 1984). These
descriptions include cognitive componentsone caller.
For the 816 (50.5%) that did not par- such as confusion, overwhelmed, and con-
stricted problem solving; affective compo-ticipate in the follow-up, the reasons for not
participating were: 470 (57.6%) refused at nents such as anxiety, helplessness, and anger;
and cognitive-affective states such as hope-baseline, 124 (15.2%) gave the crisis counse-
lors invalid contact information, 69 (8.5%) lessness and depression. Halpern (1973) de-
veloped a self-report measure that consistedwere not asked if they wanted to receive a
follow-up call, and 153 (18.7%) gave consent of statements reflecting most of these states
and found that it reliably distinguished be-for follow-up contact but the follow-up in-
326 Nonsuicidal Crisis Caller Outcomes
Crisis Callers: Comparison of Follow-up Participants and Nonparticipants
Followed Not Followed
(n = 801) (n = 816)
Time 1 Mean SD Mean SD
Total POMS-M 33.33 (11.12) 32.03 (11.77) F = 2.16 ns
Confusion 6.83 (3.30) 6.71 (3.34) F = 0.32 ns
Depression 7.74 (3.25) 7.62 (3.39) F = 0.23 ns
Anger 6.09 (3.56) 5.59 (3.62) F = 3.08 ns
Anxiety 7.52 (3.20) 7.35 (3.38) F = 0.96 ns
Helpless 2.42 (1.40) 2.30 (1.41) F = 3.44 ns
Overwhelmed 2.98 (1.19) 2.78 (1.32) F = 6.81**
Hopelessness 2.55 (1.03) 2.48 (1.04) F = 4.81 ns
Initiated Rescue Procedure 2 0.3% 1 0.1% χ
= .00 ns
Referral Given 541 68.0% 428 53.4% χ
= 34.73***
**p < .01; ***p < .001
tween individuals experiencing different types be administered, was also eliminated. This
reduced the number of items to 12. Two ad-of crises (e.g., interpersonal, divorce, be-
reavement) and a non-crisis comparison group. ditional items, helpless and overwhelmed, were
then added to the assessment to capture theFor the purposes of the present study, we
sought an instrument that described compo- words most commonly expressed by crisis
callers to describe how they are feeling. A to-nents of the crisis state and was brief, sensi-
tive to short-term changes, and psychometri- tal score on the POMS-M was the sum of
all 14 items. Callers were asked to rate theircally sound. The POMS-A met these criteria
and an adaptation of it was used to assess call- feelings on a 5-item scale (Not at all, A little,
Moderately, Quite a bit, Extremely) near the be-ers’ crisis state or level of distress. The
POMS has been utilized in hundreds of in- ginning of the call to the center, again at the
end of the call, and at the follow-up inter-vestigations to measure transient mood states
(McNair, Lorr, & Droppleman, 1992). The view.
Hopeles sn ess . Call er s were also assessedshortened version of the POMS-A (24 items)
is suitable for use with adolescents as well as for feelings of hopelessness by two sets of
questions. Callers were first asked, “To whatadults (Terry, Lane, Lane, & Keohane, 1999).
The POMS-A uses a “right now” time frame. degree do you feel that there is no hope for
improvement in your situation in the future?Based on factor analytic studies (McNair et
al., 1992; Norcross, Guadagnoli, & Pro- As you look into the future, do you see things
getting better in your life?” Responses werechaska, 1984; Rhoades, Grabowski, Elk, &
Cowan, 1993; Usala & Hertzog, 1989), six rated from 1 (Nothing will change, things will
stay bad)to5(Sure that the future will be bet-factors have been derived from the POMS
and POMS-A; namely, tension-anxiety, depres- ter). The response codes were recoded so that
higher scores indicated more hopelessness.sion-dejection, anger-hostility, fatigue-inertia,
confusion-bewilderment, and one positive state, The following question was, “To what extent
does the following belief, which I am aboutvigor-activity. To facilitate the use of this as-
sessment during a crisis call, the measure- to say, describe how you are feeling right
now? I don’t think I can go on.” Responsesment was shortened by excluding two factors,
fatigue-inertia and vigor-activity. The lowest were rated on the scale from not at all to ex-
tremely. Hopelessness was the average of theloading item, one for each of the domains to
Kalafat et al. 327
scores from both items. These questions Training Procedures
were asked at the beginning of the call to the
center and repeated at the end of the call and Center Staff. The research team trained
the crisis centers’ staff on the baseline admin-at the follow-up interview.
The remaining measures were asked istration protocols. In five centers, the re-
search team directly trained the counselors.only during the follow-up interview.
Plan of Action Compliance. This set of In the remaining three centers, the research
team trained one or more crisis center mem-questions assessed whether callers agreed
with and followed through with the plans of bers who then trained the centers’ counse-
lors. The suicide risk assessment protocol isaction developed by the crisis counselor with
the caller. Action plans ranged from “looking described in the companion paper (Gould et
al., this issue). For nonsuicide crisis calls,for a new job” to “taking a walk to calm
down.” If callers did not agree with the plan, counselors were instructed to conduct the
POMS and hopelessness assessments on allor if they did not completely follow through
with the plan, then their verbal responses as of the calls. Criteria for excluding calls from
the assessment were developed in collabora-to why they did not agree or follow through
were recorded as text responses. tion with center directors from the advisory
board. These were individuals who calledService Utilization and Compliance.
These questions assessed whether callers only for information and referral but were
not in crisis; third-party callers; intoxicatedagreed with and followed through with refer-
rals given to them. Callers were asked and/or belligerent callers; frequent chronic
callers; minors; non-English speaking callers;whether they remembered receiving refer-
rals, the type of referral(s) received (emer- and callers who were not in a mental state fit
to complete the assessment. Aside from in-gency services, mental health services, social
services, and information and referral ser- clusion of the POMS and hopelessness, we
did not promote any other changes in thevices), the extent of their agreement with the
referral(s), and the extent of follow through. centers’ usual crisis procedures or interven-
tions. Counselors were trained to ask ques-If callers did not agree with the referral, or if
they did not follow through with the referral, tions by incorporating them into their own
centers’ standard assessment and interventionthen their verbal responses as to why they did
not agree or follow through were recorded as procedures and helping styles. This assured
that the call would flow smoothly and nottext responses. These narrative responses
were recoded by two independent raters. Ex- feel like a structured interview. For example,
counselors were encouraged to use their ownamples of codes were, “services too far away,”
and “unable to pay for service.” language and style to ask questions, and to
use common crisis intervention language,Client Feedback on Call. Two open-
ended questions about what was helpful or such as “it sounds as if or “I’m wondering.”
Also, counselors were trained to not asknot helpful about the call initiated the assess-
ment: “Thinking back to the call you placed questions but to just code the responses if a
caller spontaneously provided answers toto the crisis line, can you tell me how the call
was helpful to you?” “Can you tell me what questions. The training included role-playing
and discussions about what was or was notwas not helpful about the call?” Follow-up
interviewers made verbatim notes of callers’ working after each roleplay.
Follow-up Interviewers. To ensure in-responses to these questions. Twenty-one
close-ended questions followed the open- dependent follow-up assessments, these in-
terviewers were paid members of the projectended assessment and provided ratings in
three areas: helper interventions, emotion evaluation staff and not crisis center staff.
They had either telephone crisis counselingregulation, and overall efficacy, but the re-
sponses to the close-ended questions are the experience or equivalent clinical training and
experience. Training of follow-up interview-focus of another paper.
328 Nonsuicidal Crisis Caller Outcomes
ers included instructions on how to maintain between the counselor’s assessment and their
monitoring assessment and provided feed-client confidentiality during follow-up con-
tact; how to obtain informed consent; how to back to the counselor.
Intermediate Outcomes (Follow-up).administer the assessment in a compassionate
manner while retaining control of the inter- Eighteen follow-up interviewers participated
in the follow-up data collection. Interviewersview; and how to conference callers back to
the crisis center when they met criteria for were monitored during their first follow-up
assessment. The Project Coordinator moni-the required conference call as described in
the safety procedures section. Training was tored their audiotaped interviews and assess-
ments, and provided feedback to the inter-conducted through instruction and role-
playing. viewers in order to improve the quality of
their assessments.
Quality Control Procedures
Consent and Safety Procedures
Immediate Outcomes (Baseline). Sti-
pends were provided to each crisis center for Immediate Outcomes (Baseline). The
project was approved for a waiver of consenta staff member to function as a local data co-
ordinator under the supervision of the center for use of de-identified information gathered
during the baseline assessment. The assess-director. The local data coordinators re-
viewed completed assessments, provided on- ment procedures involved no more than min-
imal risk and were routine for telephone cri-going feedback and training to the counse-
lors, and sent de-identified baseline data and sis services. Compensation was not offered to
callers for completing the baseline assess-callers’ contact information to the Project
Coordinator. Local data coordinators were ment because it was included as part of the
intervention normally provided to callersalso responsible for reviewing the centers’
call records and comparing them to com- (such as a risk lethality assessment and asking
callers about their thoughts and feelings).pleted assessments to ensure that all eligible
callers were being assessed. If assessments Using an IRB-approved re-contact
consent script, counselors asked callers withwere not conducted with potentially eligible
callers, the coordinators reviewed the call re- whom they had conducted baseline assess-
ments if they wished to receive a follow-upcords for these callers with the crisis counse-
lors. The local data coordinators and the call from the research team in a week or two
to see if they were interested in participatingProject Coordinator communicated via tele-
phone and e-mail on a weekly basis to discuss in a follow-up assessment. To protect the
confident ial it y of calle rs during the re-contac tthe quality of the data collection and clarify
protocol procedures. efforts, counselors asked callers how and
when they wanted to be contacted, as well asFor additional quality control purposes
and to ensure the reliability of the baseline what type of message (if any) could be left
on an answering machine or with the personassessments, on-site silent monitoring was
conducted on approximately 10% of calls in picking up the telephone.
Intermedi ate Outcomes (Follow-up). Ac-each of the centers. Silent monitoring as-
sessed whether counselors were following the tive consent to participate in the follow-up
telephone survey, and for the research teamproject’s protocol. The monitors, drawn from
the centers’ local communities or from the to access callers’ baseline response and refer-
ral information, was obtained using an ap-centers’ staff, were hired by and reported to
the research team. As the monitor listened to proved telephone consent script at the start
of the follow-up call. A waiver of documenta-a call, s/he completed a baseline assessment
that was later compared to the assessment tion of consent was obtained so that consents
could be audiotaped rather than written. Forcompleted by the counselor. At the end of
the call, the monitor noted any discrepancies quality control purposes, approximately 10%
Kalafat et al. 329
of each follow-up interviewers’ assessments A repeated measures design was em-
ployed to examine changes over time, alwayswere audiotaped with callers’ consent to do
so. Callers participating in the follow-up as- employing center as the between subjects
factor. The measures were assessed at threesessment received a $25 money order.
Safety Procedures. The follow-up as- time points: near the beginning of the call
(Time 1), at the end of the call (Time 2), andsessment included criteria to determine
whether callers needed intervention, which at follow-up (Time 3). The repeated re-
sponse measures for the crisis callers were to-was defined as callers having made plans or
tried to hurt or kill themselves since speaking tal POMS-M score, the four component
scores derived from the POMS-M, andwith the center, or having serious intent to
die. The method for getting help to callers hopelessness.
Chi-square tests comparing males toconsisted of follow-up interviewers re-connect-
ing the caller to their crisis center while the females on problems mentioned at baseline
were performed. Crisis callers who were fol-interviewer remained on the line to ensure
that the caller was in communication with lowed were compared to those who were not
followed on baseline measures at the begin-the center. If callers were unable to partici-
pate in a call with their center immediately ning of the call, by means of univariate analy-
ses of variance. Interactions between follow-after completing their interviews, follow-up
interviewers obtained callers’ consent for the up status and changes from Time 1 to Time
2 were examined using two-way analyses ofcenter to contact them. In this last instance,
the follow-up interviewer contacted the cen- variance.
Immediate outcomes (Time 1 to Timeter and gave them the caller’s contact infor-
mation and details as to why the caller 2) and intermediate outcomes (Time 1 to
Time 2 to Time 3) were assessed by a re-needed intervention.
A confidentiality certificate was ob- peated measures design, including center as
the between subjects factor. Also assessed bytained from SAMHSAs Depart men t of Health
and Human Service. The project’s protocol repeated measures were immediate and inter-
mediate outcomes by type of initial problem.was approved by Rutgers Graduate School of
Applied and Professional Psychology and the The statistical analyses were con-
ducted with SPSS statistical software (versionNew York State Psychiatric Institute/Colum-
bia University’s Institutional Review Boards. 12.0). Given the number of comparisons, re-
sults were considered significant at α<.001,
but results at α<.01 are presented in the ta-Analytic Strategy
The primar y samplin g unit of the study
was crisis center and the secondary sampling
unit was caller within center. Thus, we exam-
ined the extent to which within-center clus-
Presenting Problems
tering existed in order to determine whether
Callers presented at the center with a
this clustering variable needed to be included
variety of problems including abuse/violence
in the analyses. The sample clusters (center)
(10.8%), addictions (13.0%), base needs
had little impact on outcomes (distress [as
(18.7%), interpersonal problems (67.4%),
measured by the POMS-M], intent to die,
mental health (48.2%), physical health
and hopelessness) as indicated by the in-
(13.4%), work (9.9%), and other problems
traclass correlation coefficients, which were
all close to zero (ranging from .004 to .05).
Therefore, the use of mixed-effects linear
Immediate Outcomes
models to account for the clustering variable
of center was unnecessary. Center was in- Callers’ distress, as assessed by the to-
tal score on the POMS-M, was significantlycluded as a covariate in the analyses.
330 Nonsuicidal Crisis Caller Outcomes
reduced from the beginning of the call (Time Suicidal Thoughts at Follow-up. At fol-
low-up, 94 (11.7%) of the 801 crisis callers1) to the end of the call (Time 2) (p < .001)
(see Table 2). There was also a significant re- reported that they had suicidal thoughts since
their call to the crisis center. When theseduction on the domains of the POMS-M as
well: confusion (p < .001), depression (p < callers were asked if they were having these
thoughts when they initially called the center,.001), anger (p < .001), anxiety (p < .001),
helpless (p < .001), and overwhelmed (p < 52 (55.3%) said yes, 35 (37.2%) said no, and
7 (7.4%) callers said they did not remember..001). There was also a significant reduction
in callers’ level of hopelessness (p < .001). Of the 52 callers who said they had suicidal
thoughts at baseline, 27 callers (51.9%) saidCallers with mental health problems were
significantly more depressed and hopeless they told the counselor about their thoughts,
17 (32.7%) said they did not tell the counse-than callers with nonmental health problems
(p < .001) (Table 3); however, there was no lor, and 8 (15.4%) said they did not remem-
ber. Compared to the crisis callers who didsignificant interaction between mental health
status and time. In other words, a mental not report any suicidal thoughts since their
initial call, the 94 crisis callers who reportedhealth problem did not modify the change
from Time 1 to Time 2. suicidal thoughts were significantly more dis-
tressed, as indicated by their total and com-
Intermediate Outcomes
ponent scores on the POMS-M and hope-
lessness scores at follow-up (Time 3) (Table
There was a significant reduction in
5). They were also significantly more de-
callers’ distress levels from the end of the call
pressed at the beginning of the baseline call
(Time 2) to follow-up (Time 3) as measured
(Time 1) and there was a tendency for these
by the total POMS-M score (p < .001) (see
callers to be more helpless and hopeless (p <
Table 4). Each of the individual scales of the
.01) at the baseline (Time 1) and more hope-
POMS-M and callers’ feelings of hopeless-
less (p < .01) at the end of calls (Time 2).
ness also showed significant reductions over
time (p < .001). Mental health problems did
not modify the changes from the end of the
call (Time 2) to follow-up (Time 3), as indi- Out of the 1,617 callers who partici-
pated in the baseline assessment, 969 (59.9%)cated by the nonsignificant interaction effects
of problem by time. were given a new referral, of which 67.9%
Crisis Callers: Immediate Outcomes (n = 1,617)
Main Effect
Mean SD Mean SD of Time
Total POMS-M 32.72 (11.46) 22.98 (12.54) F = 968.47***
Confusion 6.79 (3.31) 4.59 (3.08) F = 618.58***
Depression 7.67 (3.32) 5.54 (3.40) F = 582.55***
Anger 5.87 (3.60) 4.01 (3.36) F = 398.41***
Anxiety 7.44 (3.27) 5.32 (3.23) F = 471.23***
Helpless 2.36 (1.41) 1.55 (1.27) F = 352.74***
Overwhelmed 2.89 (1.26) 2.01 (1.29) F = 494.13***
Hopelessness 2.51 (1.04) 2.08 (0.90) F = 291.72***
Note. Significant differences over time for all measures at p <
***p < .001
Kalafat et al. 331
Crisis Callers: Immediate Outcomes by Initial Problem
Mental Health Non-Mental Health
(n = 771) (n = 826)
Effect of
Time 1 Time 2 Time 1 Time 2
Main Effect Problem
Mean SD Mean SD Mean SD Mean SD of Problem by Time
Total POMS-M 33.70 (11.25) 24.76 (12.79) 31.81 (11.56) 21.21 (12.03) F = 6.52** F = 0.03 ns
Confusion 6.79 (3.39) 4.88 (3.17) 6.80 (3.23) 4.33 (2.94) F = 2.55 ns F = 0.47 ns
Depression 8.18 (3.15) 6.14 (3.42) 7.19 (3.38) 4.97 (3.28) F = 26.12*** F = 2.22 ns
Anger 5.80 (3.59) 4.12 (3.47) 5.90 (3.60) 3.89 (3.26) F = 3.28 ns F = 1.73 ns
Anxiety 7.72 (3.18) 5.86 (3.26) 7.22 (3.33) 4.85 (3.13) F = 9.61** F = 0.07 ns
Helpless 2.44 (1.38) 1.63 (1.26) 2.30 (1.43) 1.48 (1.27) F = 5.07 ns F = 4.56 ns
Overwhelmed 2.97 (1.21) 2.17 (1.30) 2.82 (1.29) 1.87 (1.26) F = 6.40 ns F = 0.23 ns
Hopelessness 2.62 (1.06) 2.20 (0.90) 2.41 (1.01) 1.97 (0.89) F = 16.27*** F = 7.07**
**p < .01; ***p < .001
332 Nonsuicidal Crisis Caller Outcomes
Crisis Callers: Intermediate Outcomes (n = 801)
Time 1 Time 2 Time 3
Main Effect T2T3
Mean SD Mean SD Mean SD of Time Contrast
Total POMS-M 33.37 (11.07) 24.01 (12.67) 17.30 (13.84) F = 258.90*** F = 61.56***
Confusion 6.85 (3.29) 4.76 (3.17) 3.50 (3.23) F = 177.13*** F = 36.60***
Depression 7.69 (3.25) 5.71 (3.46) 3.76 (3.48) F = 222.03*** F = 76.43***
Anger 6.11 (3.56) 4.22 (3.51) 3.02 (3.27) F = 122.69*** F = 25.33***
Anxiety 7.50 (3.19) 5.60 (3.27) 4.45 (3.46) F = 133.12*** F = 25.36***
Helpless 2.43 (1.40) 1.62 (1.30) 1.02 (1.31) F = 151.42*** F = 56.98***
Overwhelmed 2.99 (1.19) 2.13 (1.30) 1.55 (1.49) F = 198.56*** F = 46.33***
Hopelessness 2.55 (1.03) 2.10 (0.88) 1.75 (0.85) F = 214.92*** F = 64.27***
Note. Significant differences over time for all measures at p < .001.
***p < .001
(658) were to mental health resources. An ad- included such strategies as discussing the
problem with a partner, calling a lawyer, orditional 135 (8.3%) callers were referred back
to their current therapist or services. Of the engaging in a relaxing and/or diversionary
activity. Out of the 801 crisis callers who par-801 callers who participated in the follow-up,
541 (67.5%) were given a new referral at ticipated in the follow-up, counselors devel-
oped plans with 464 (57.9%). At follow-up,baseline, of which 72.5% (392) were to men-
tal health resources. An additional 75 (9.4%) 369 (79.5%) callers recalled the plan and of
these, 160 (43.4%) callers completed “all” ofcallers were referred back to their current
therapist or services. The overall referral rate the plan, 47 (12.7%) callers completed
“most”, 54 (14.6%) completed “some,” 72for those who participated in the baseline was
68.3% and the rate of referral for those who (19.5%) said the plan was still “in process,”
and 35 (9.5%) callers had not carried out anyparticipated in the follow-up was 76.9%.
Callers’ type of problem had little im- of the plan. The extent of follow through was
not coded for one caller (.3%).pact on whether or not a new referral was
given. The referral rate by callers’ type of
problem ranged from 53.1% to 69.6%; how- Re-Contact with the Center
ever, callers with mental health problems and
or base needs problems had the highest refer- Of the 801 crisis callers who partici-
pated in the follow-up, 186 (23.2%) callersral rate of 69.6%. Of the 392 follow-up crisis
callers who were given a new mental health had re-contact with the crisis center after
their initial call with the center. Because thereferral, 33.2% had kept or made an appoint-
ment with a mental health service in the pe- centers categorized these as nonsuicide crisis
calls, it is most likely that the callers ratherriod between the initial call to the center and
the follow-up assessment. than the centers initiated the re-contact. Of
those who had re-contact with the center, 96
(51.6%) callers had one additional contact,Plans of Action
32 (17.2%) had two contacts, 27 (14.5%) had
three contacts, 6 (3.2%) had four contacts, 17During the calls, crisis counselors de-
veloped “plans of action” with callers. These (9.1%) had between 5 and 15 contacts, and 8
(4.3%) callers did not remember the numberwere plans that callers agreed to follow
through with to try to help themselves. Plans of times. More callers who had re-contact
Kalafat et al. 333
Crisis Callers Endorsing Suicidal Thoughts at Follow Up, Compared to Crisis Callers Not Endorsing
Suicidal Thoughts at Follow Up
Endorsing Suicidal Not Endorsing Comparison of
Thoughts Suicidal Thoughts Means at
(n = 94) (n = 706) Follow-Up
T1 T2 T3 T1 T2 T3 T1 T2 T3
Total POMS-M
Mean 35.93 25.85 25.41 32.98 23.81 16.16 2.36 ns 1.38 ns 6.22***
(SD) (9.56) (11.33) (15.20) (11.29) (12.89) (13.24)
Mean 7.51 5.07 5.17 6.74 4.69 3.21 2.11 ns 1.05 ns 5.63***
(SD) (2.95) (2.73) (3.72) (3.34) (3.22) (3.08)
Mean 8.88 6.45 5.88 7.58 5.63 3.47 3.66*** 2.14 ns 6.45***
(SD) (2.55) (2.94) (3.76) (3.30) (3.50) (3.34)
Mean 6.13 4.03 4.52 6.10 4.25 2.83 .09 ns .57 ns 4.77***
(SD) (3.51) (3.28) (3.73) (3.56) (3.55) (3.14)
Mean 7.98 6.09 5.76 7.45 5.54 4.25 1.50 ns 1.50 ns 4.00***
(SD) (2.97) (3.14) (3.65) (3.22) (3.28) (3.40)
Mean 2.77 1.72 1.73 2.37 1.62 .93 2.59** .67 ns 5.65***
(SD) (1.18) (1.23) (1.44) (1.43) (1.31) (1.27)
Mean 3.06 2.09 2.34 2.97 2.14 1.45 .75 ns .34 ns 5.52***
(SD) (1.08) (1.20) (1.54) (1.21) (1.31) (1.46)
Mean 2.85 2.34 2.45 2.51 2.07 1.66 3.01** 2.73** 8.74***
(SD) (1.03) (0.93) (0.98) (1.03) (0.88) (0.79)
**p < .01; ***p < .001
with the center had thoughts about killing Caller Feedback
themselves since their initial call to the cen-
ter (18.8%) than those who had not re- At follow-up, 801 crisis callers pro-
vided a total of 1,345 responses to the posi-contacted the center (9.6%; χ
= 10.69, p <
.001). On the POMS at the follow-up call tive question and 145 responses to the nega-
tive question. Fifteen crisis callers said(T
), those who had re-contact with the cen-
ter as compared to those who had not were nothing was helpful about the call.
Two raters, both of whom were experi-significantly more hopeless (t = 3.48, p <
.001), and there were trends toward their be- enced crisis counselors, independently coded
the positive responses into 17 a priori catego-ing more anxious (t = 2.90, p < .004), de-
pressed (t = 3.01, p < .003), confused (t = ries, plus six additional categories that were
developed to account for the responses gen-2.97, p < .003), and overall more distressed as
measured by the total POMS score (t = 3.05, erated through content analysis. Negative
statements were coded into 15 categoriesp < .002).
334 Nonsuicidal Crisis Caller Outcomes
generated from content analysis of the re- the hypothesized role of telephone crisis in-
tervention in attenuating crisis states. Whilesponses. The raters agreed on 86% of their
coding of positive statements and 74% of demand characteristics may play a role in
callers’ reports to helpers at the end of calls,their coding of negative statements. Dis-
agreements, most of which consisted of one the continued or additional reductions in dis-
tress reported by callers to independent eval-of the raters failing to rate a statement, were
resolved through discussion. uators at follow-up attenuates this concern to
a degree. This finding also suggests thatMany categories accounted for a small
percent of the responses. The top six catego- changes occurring during the calls are not
transitory phenomena and may set the stageries of positive responses (>6% of responses)
described empathic helpers (7.8% of re- for improved coping with crises.
Nearly a quarter of callers had re-sponses; 13.1% of callers) who listened and al-
lowed the callers to talk about their concerns contact with the centers for one or more
calls. Multiple contacts by callers to crisis(23.4%; 39.2%), helped them to calm down
(9.2%; 15.4%), think more clearly (6.8%; centers are a complex phenomenon. For
some callers, these may represent a “safety11.4%), and provided options for dealing with
their concerns (15.4%; 25.8%). The services net” when local communities lack sufficient
support resources, or simply indicate that cri-were described as readily available with help-
ers willing to stay on the line as long as sis services may require more than one con-
tact to meet the needs of callers. For otherneeded (available, patient , 6.7%; 11.2%).
The most common problem noted by callers, multiple calls to centers may indicate
inappropriate reliance on the service in placecallers concerned the referrals provided by
crisis staff (23.2% of responses; 5.6% of call- of follow through with other options. Fur-
ther research is necessary to clarify this phe-ers). Some of the referrals were not appro-
priate for the caller’s problem, but most of nomenon, as repeat callers comprise a sub-
stantial proportion of calls to some centers.the difficulties with referrals were due to the
agencies to which callers were referred. The Previous research has provided some
support for the helping model espoused bynature of these difficulties included cost,
waiting lists, and unhelpful responses. The many telephone crisis services (Echterling &
Hartsough, 1989; Echterling et al., 1980;next most frequent concerns were about in-
adequate solutions to problems. The callers Young, 1989), and the caller feedback ob-
tained in this study also conforms to the pro-raised concerns that they weren’t given any
help on how to solve their problem: “they posed elements of telephone intervention.
This feedback described available, empathicjust comforted me” (10.8%; 2.6%); or, were
given unhelpful suggestions/solutions (10.3%; helpers who listened to callers and let them
talk, helped them to calm down, and pro-2.5%) (e.g., “He said things I already know”).
Callers also indicated that crisis staff asked vided options for addressing their concerns.
Reduction in distress is one probabletoo many questions (10.8%; 2.6%); yet the
“calls were too short” (8.3%; 2.0%). Callers mediator of positive resolution of crises. An-
other element of crisis intervention is the de-also identified unhelpful characteristics of
some counselors (e.g., condescending, not velopment of a plan of action for addressing
the caller’s concern and/or the provision of aconcerned, abrupt) (8.8%; 2.1%).
referral to an agency that can further assist
the caller. Of the 801 followed callers, 392
(48.9%) were given mental health referrals atDISCUSSION
baseline, which is the largest category of re-
ferrals given. Of these, 33.2% had made orSignificant changes from the begin-
ning to the end of the calls in desirable direc- kept an appointment since their original call.
This is lower than the modal 50% followtions in affective and cognitive variables that
characterize crisis states are consistent with through rate reported for earlier studies
Kalafat et al. 335
(Stein & Lambert, 1984), although the types Finally, there is concern about the
finding at follow-up that 94 (11.7% of 801of referrals were not specified in these stud-
ies. Reasons for lack of follow through were crisis callers followed up) reported that they
had suicidal thoughts since their original callsnot obtained in the current study, although
some information is available from 45 callers to the centers, that 52 of these individuals
were having these thoughts when they calledwho, in response to the open-ended ques-
tions as to what was not helpful about the the center, and 17 said they had told the
counselor about these thoughts. This has twocall, reported problems with the referrals
provided by crisis services. These included implications for crisis services: first, policies
and procedures must be developed regardingreferrals that were not appropriate for the
callers’ concerns and problems with the assessment of suicidal risk for all crisis callers
or for a clearly specified type of crisis caller;agency to which the caller was referred, such
as cost and long waiting times. At least one and, second, training must be developed that
enhances the ability and inclination to sys-previous study found that referral follow
through can be improved by provision of in- tematically assess for suicide risk. The need
to systematically conduct evidence-based riskcentives for staff for more conscientious re-
ferrals (Paul & Turner, 1976). Thus, training assessments is attested to by the finding that
the suicidality of a substantial number of cri-may ameliorate this problem to some degree.
However, as crisis services expand beyond sis callers was missed during the crisis inter-
vention and that they remained suicidal attheir own communities to statewide or multi-
state service areas, they need to maintain follow-up. It should be noted that failure to
conduct risk assessments or pursue patients’more extensive current and accurate referral
databases as well. It may also be possible that suicidal communications has also been found
among professional mental health providersthe attenuation of crisis states achieved by
crisis workers may have reduced the distress- (Bongar, Maris, Berman, & Litman, 1998;
Coombs et al., 1992) and primary care physi-mediated motivation to seek further help.
Further research is necessary to test this hy- cians (Adamek & Kaplan, 2000; Williams et
al., 1999). These findings for mental healthpothesis of unintended side effects of crisis
intervention. and medical providers have been attributed
to the documented lack of training in suicideCrisis counselors developed plans of
action with 464 (57.9%) callers for address- risk assessment and management for these
professionals (Bongar, 2002; Williams et al.,ing their concerns. Of these, 20.5% did not
recall their plans, 43.4% reporting having 1999). This reinforces the need for training
in this area.completed the entire plan, 46.8% reported
various stages of progress on their plan, and The present study has several advan-
tages for examining the effectiveness of tele-9.4% had not carried out any of the plan.
This is a more encouraging follow through phone crisis services. First, this study pro-
vided an empirical evaluation of crisis hotlinerate than the referral rate. There are several
possible reasons for this, including the possi- services using a broader range of potential
beneficial effects than used in an earlier gen-bility that the plans are more subject to con-
trol by the callers and/or may require less eration of evaluation studies. Conceptually
and/or empirically based variables associatedtravel and cost. Also, plans of action may be
more likely to be developed through a collab- with crisis states of callers were selected as
immediate and intermediate outcomes. Sec-orative process. A study by Echterling and
Hartsough (1989) provides some support for ond, while the inclusion of a control condi-
tion, for example, a placebo call protocol, wasthis. They found a positive relationship be-
tween problem solving involving the develop- unethical, the repeated measures design al-
lowed each caller to act as his/her own con-ment of action plans that occurred near the
end of calls, as opposed to earlier phases of the trol in the assessment of the client-centered
outcomes. Third, the follow-up assessmentcalls, and positive call outcomes at follow-up.
336 Nonsuicidal Crisis Caller Outcomes
provided invaluable information on referral coordinators, who were reimbursed by the
project grant to ensure appropriate data col-follow through and allowed for an evaluation
of the callers by interviewers independent of lection, may also represent an additional re-
source that may not be available in manythe crisis centers. Fourth, in contrast with
most earlier studies, a multisite methodology centers. Third, while selection biases may
also exist with regard to the callers who werewas employed, which may increase the gen-
eralizability of the findings. While not a rep- followed, for crisis callers the concern about
possible positive selection bias among callersresentative sample of U.S. crisis centers, a
geographically diverse set of centers with who consented to follow-up is attenuated by
the finding that there were almost no differ-varied counselor characteristics (e.g., volun-
teer or paid; lay or professional) was em- ences between the baseline sample that was
not followed up and the follow-up sample inployed and yielded the largest sample of call-
ers in nonsuicidal or suicidal crises studies to levels of distress at the beginning of their
calls nor in changes from the beginning todate.
The study has important limitations. end of the calls. The lone exception was that
followed callers were significantly more over-First, the study was uncontrolled, as men-
tioned above, because of ethical concerns whelmed at the start of their calls than non-
followed callers. Fourth, telephone crisis ser-about compromising the clinical services pro-
vided to persons in crisis. Second, selection vices did not routinely collect demographic
information, such as age and ethnicity, onbiases exist with regard to the centers and
counselors who participated. The participat- callers, which precluded our ability to exam-
ine the specificity of the findings for differenting centers and counselors had to be amena-
ble to implementing a series of questions populations of users.
In sum, the information yielded by thisabout the caller’s current emotional state,
which was not compatible with some centers’ study is consistent with the effectiveness of
telephone crisis services in reducing the crisisor counselors’ helping model. Furthermore,
the implementation of the research protocol state of callers. However, the lack of a control
condition makes it difficult to definitively at-may have influenced the nature of the inter-
action between the helper and the caller. An- tribute the improvements in crisis state to the
crisis intervention. Based on the feedbackecdotal reports from crisis staff were mixed
in that some found the questions to be some- provided by callers, as well as the record of
referrals and action plans, these centers ap-what intrusive, while others indicated that it
facilitated their assessment of the caller’s pear to be providing callers with opportuni-
ties to problem solve and identify resourcesstate, helped the callers to clarify their feel-
ings, and helped the callers and crisis workers for addressing their concerns. The results
also highlight the need to systematically em-to see the progress achieved during the call.
In any case, the results can only be general- ploy reliable and valid risk assessments on
crisis calls and to enhance successful referralized to an intervention model that incorpo-
rates some direct assessments of callers’ men- of callers in need to appropriate services.
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... From a policy analysis perspective, there is limited research on the proximal (i.e., during or immediately after the crisis contact) and distal (i.e., long-term postcrisis contact) impacts of the use of crisis lines on outcomes among suicidal patients. Most of the existing research on crisis call outcomes has followed the procedure outlined by Kalafat and colleagues (20). In this procedure, assessments are completed at the beginning and end of the contact by crisis center staff and do not require the consent of the caller. ...
... In terms of long-term outcomes, contact with the NSPL has been associated with reductions in hopelessness, psychological pain, depression, and anxiety in the weeks following a crisis call (20,22). Findings (20,22) indicate that a minority of callers complete follow-up with a mental health care provider, with approximately 33%-42% following through with the crisis hotline referral. ...
... In terms of long-term outcomes, contact with the NSPL has been associated with reductions in hopelessness, psychological pain, depression, and anxiety in the weeks following a crisis call (20,22). Findings (20,22) indicate that a minority of callers complete follow-up with a mental health care provider, with approximately 33%-42% following through with the crisis hotline referral. Research also indicates that continuity of care following NSPL contact, in which a hotline counselor follows up with clients and conducts a brief clinical intervention (e.g., providing coping strategies, social support, and advice on environmental safety), offers additional protection. ...
Objective: The 988 telephone number was established by the National Suicide Hotline Designation Act of 2020 and implemented in July 2022 as a more accessible way to reach the National Suicide Prevention Lifeline. Current financial and training resources, however, are insufficient to ensure effective implementation. Methods: To better understand the state of the literature on crisis support lines in light of the 988 transition, the authors summarized research on suicidal and nonsuicidal outcomes of callers, research on other types of crisis support services, and the benefits of text- and chat-based crisis lines. Results: Overall, existing evidence for the effectiveness of crisis lines has been weak and has primarily focused on short-term improvements in user distress and on user satisfaction. In addition, research on crisis lines specifically targeted to marginalized populations (e.g., sexual minority groups) and on text- or chat-based crisis lines is lacking. Conclusions: The policy-focused recommendations derived from this review include the need for additional research on crisis lines, design and evaluation of culturally tailored training for volunteers and staff, and ethical oversight of private data collected from crisis services. Scaling up state-level planning and comprehensive crisis systems is necessary to successfully implement 988 and to fill current training and research gaps.
... The authors claim that this technique has various advantages over conventional therapeutic intervention methods, including ease and immediacy of access, client confidentiality, cost-effectiveness, and service accessibility to those who are geographically and physically separated. 30 The word ''hotlines'' is used by Kalafat et al. 31 as a synonym for ''Crisis Centers.'' For over 40 years, he has defined telephone crisis services (TCS) as a support for numerous maladaptive behaviors, such as alcohol crisis intervention and referral, interpersonal violence, or suicidal conduct services. ...
... For over 40 years, he has defined telephone crisis services (TCS) as a support for numerous maladaptive behaviors, such as alcohol crisis intervention and referral, interpersonal violence, or suicidal conduct services. 31 Tele-Help/Tele-Check, a telephone service initially developed to help older persons with home support, is also used for crisis management. Tele-Help/Tele-Check employs a portable alarm system and provides clients with active contacts by qualified people who can give information, support, and prompt action in case of medical and psychological problems. ...
... Psychiatrists have been reported as an essential part of the core team of hotlines by some authors, 15,19,20,23,24 as have psychologists, 19,21,24 nurses, 18,20,24 people close to the patient, 21 trained counselors, 14,16,31,33 and trained staff members. 13 One author stated that trained counselors may be used in the Safety Plan. ...
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Background: Crisis hotlines are described as a direct communication system, usually telephone, set up to prevent suicide. However, few studies have evaluated their effectiveness. Objective: The present study aims to perform a systematic review, using PRISMA, on the effectiveness of interventions through direct communication systems to reduce the number of suicides or suicide attempts. Methods: This is a systematic review that searched the following databases: Medline, Cochrane, Scielo, and We used the Oxford 2011 classification to assess the level of evidence. Results: The literature search found 267 studies, of which 35 fulfilled the selection criteria. Although significant heterogeneity was found among studies, there is evidence that direct telephone interventions are effective when included in broader preventive protocols with a trained team. Discussion: Despite the limitations, e.g., heterogeneity of samples, distinctive designs, and different outcomes, it is possible to implement a protocol for the use of remote services to prevent suicide and suicide attempts. Conclusion: A hotline or similar could be an effective intervention for broader suicide prevention programs. However, as the studies are very heterogeneous, it is necessary to specify the main protocols components that enhance effectiveness.
... 8 Available data suggest that crisis lines appear to reduce immediate distress and imminent suicide risk. [8][9][10][11][12][13][14] More broadly, crisis line contacts have been found to decrease depressive symptoms, 15,16 emotional distress, 15,[17][18][19] hopelessness, 8,9 and severity of the presenting problem 20 and to increase hopefulness 17,21 and resourcefulness. 21 Further, many users report that they would use the crisis line service again and recommend it to others. ...
... 8 Available data suggest that crisis lines appear to reduce immediate distress and imminent suicide risk. [8][9][10][11][12][13][14] More broadly, crisis line contacts have been found to decrease depressive symptoms, 15,16 emotional distress, 15,[17][18][19] hopelessness, 8,9 and severity of the presenting problem 20 and to increase hopefulness 17,21 and resourcefulness. 21 Further, many users report that they would use the crisis line service again and recommend it to others. ...
Importance: Since July 2022, calling or texting 988 in the US connects callers to the National Suicide Prevention Lifeline following a law passed by Congress to simplify access to the mental health crisis line in the US. Compared with other areas of suicide research, knowledge regarding how and to what extent crisis lines prevent suicide crises and suicide deaths remains in its infancy. The state of this research is briefly reviewed and critical directions for future research on factors that may influence effectiveness are suggested. Observations: The new 988 line stands to improve access to critical lifesaving measures in the moments of a suicidal crisis. However, urgent questions remain regarding how to improve effectiveness of crisis lines. Available evidence suggests that crisis lines are often effective at reducing immediate distress and reducing suicide risk, but substantial gaps remain in understanding how crisis lines work. Conclusions and relevance: Future research is recommended with suicide prevention crisis lines, such as 988, to identify and test factors influencing effectiveness, including conversation, consumer, dyadic, and structural-level characteristics. Existing research, while minimal, suggests that prescription of 988 to prevent suicide death is clinically warranted, but much more work is needed to optimize care.
... The helplines were also effective in eliminating the intent to harm or kill themselves in a significant number of cases. (Kalafat et al., 2007). Progressively, various stakeholders such as general practitioners, helpline staff, and callers have evaluated helpline services positively (Morgan et al., 2012). ...
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The present paper aims to review the mental health resources currently available in India for individuals seeking online or on-call counseling services during crisis situations. A comparative literature review was used to identify the strengths and limitations of the different helplines currently available in India. A list of helplines and services were reviewed and interviewed to understand their working model and whether they were actively functioning. Findings from this study can help in determining and facilitating the presence of culturally appropriate, easily accessible as well as valid and genuine helpline resources across the country.
... While there is scope to extend research, innovative approaches to conducting research in crisis helplines over the last 2 decades have much improved our understanding of their efficacy. Notable methodologies include analysis of taped calls (King et al., 2003), silent monitoring of calls (Mishara et al., 2007a(Mishara et al., , 2007bRamchand et al., 2016), enlisting crisis supporters to complete reports following calls (Gould et al., 2016), and assessments conducted by crisis supporters at the beginning and end of calls to assess short-term outcomes Kalafat et al., 2007;Tyson et al., 2016). ...
Introduction: Crisis lines are a central component of suicide prevention strategies in the U.S. and for the Department of Veterans Affairs. The purpose of this study is to evaluate the impact of calling the Veterans Crisis Line on treatment contact and utilization. Methods: Call records from 599 veterans who called in 2019 were linked with medical records and analyzed in 2020. Multilevel generalized linear modeling examined pre-post changes in treatment contact (yes/no) and utilization (number of days of care). Results: In the month after the call, 85% of callers made contact with health care, and 79% made contact with behavioral health care. Callers were more likely to make contact with health care in the month after the call than in the preceding month (AOR=6.27, 95% CI=4.22, 9.32) and more likely to make contact with behavioral health care (AOR=10.21, 95% CI=6.66, 15.67). Days of health care nearly doubled to 4.82, and days of behavioral health care more than doubled to 3.52. Conclusions: Among veteran callers who are linked to medical records, calling the Veterans Crisis Line may increase contact and utilization of health care and behavioral health care. These findings support crisis lines that are linked with healthcare systems in public health strategies for suicide prevention.
Objective: This study was the first to examine the characteristics and referral outcomes for veterans calling the National Call Center for Homeless Veterans (NCCHV). Methods: The authors analyzed data from NCCHV and U.S. Department of Veterans Affairs (VA) health care records. Results: Between December 2018 and October 2020, the NCCHV received 266,100 messages, with no major increase in the first 6 months of the COVID-19 pandemic. Of 110,197 veterans who contacted NCCHV, 69.6% were at risk for homelessness, and 20.1% were homeless. Most contacts (90.2%) resulted in a referral or transfer to a local resource. About 59.5% of NCCHV veterans had a medical record in the Veterans Health Administration; their use of homeless programs increased from 25.9% to 81.3%. Uses of mental health services, substance use treatment, and medical services showed small-to-moderate increases after NCCHV contacts. Conclusion: NCCHV is important for linking veterans to health and social care. Additional work is needed to assess veterans' outcomes after an NCCHV contact.
Lifeline Australia aims to prevent suicide and support community members in personal crisis via the provision of free anonymous telephone, online chat and text message services. This study aimed to identify the expectations and outcomes of Lifeline help‐seekers, including whether there are differences between suicide‐related and non‐suicide‐related contacts. Help‐seekers (N = 553) who had previously contacted Lifeline via telephone, online chat, or text message crisis services were recruited via social media and a link provided after Lifeline service use, who completed an online survey about their awareness, expectations and outcomes of Lifeline's services. The responses from help‐seekers who self‐reported suicide‐related and non‐suicide‐related reasons for contact were compared. Participants were highly aware of Lifeline's services, particularly the phone service. The main expectations of all help‐seekers were to feel heard and listened to, feel less upset and feel understood. There were 59.5% of the sample that reported suicidality as a reason for contact. Suicide‐related contacts endorsed more reasons for contact than non‐suicide‐related contacts. Expectations of suicide‐related help‐seekers were greater, but they were less likely to report that their expectations were met. The high expectations and complexity of suicide‐related contacts reveal the challenges in meeting the needs of this high‐priority group, particularly within the context of the multiple demands on crisis support services.
The purpose of this study was to work systematically through all known measures for preventing railway suicides and to consider their suitability for the Finnish railway environment. The research method included a selection and grouping of measures, definition of assessment criteria, a literature review and compilation of assessment forms, and a workshop for experts in the field. We assessed 21 measures based on 12 specified criteria. Specifically, the aim of these criteria was to support the identification and structuring of the available information on each measure to be in easily exploitable format for railway stakeholders. The measures were listed in order of priority in three categories based on final assessments from the workshop. The measures categorised as top priority with the highest potential to reduce suicides on Finnish railways included training of railway personnel to identify suicidal people (also called Gatekeeper training), camera surveillance, detection systems (radar, movement sensors, etc.), collaboration between organisations, learning from international experience, cooperation between railway organisations, police and fire and rescue services, and training of mental health providers. This prioritisation, together with the information included in the assessment forms and expert's views related to each measure, support the Finnish railway stakeholders in selecting measures and defining implementation strategies to prevent railway suicides on Finnish railways. The insights of Finnish experts on the effectiveness and potential implementation of these different measures are valuable information also for railway stakeholders in other countries when selecting appropriate measures to prevent railway suicides. The results of this study support the safe and effective functioning of the railway system by adding knowledge that will help effectively prevent railway suicides and loss of life, delays to train traffic, and work-related stress and trauma to railway staff, rescue personnel and eyewitnesses.
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A high percentage of parasuicides visit professional caregivers prior to the attempted suicide. The content or outcome of these consultations is unknown. We interviewed hospitalized attempters and the professional caregivers they identified as having been consulted prior to their attempts. About half of these patients directly disclosed suicidal symptoms or intentions, especially to mental health professionals. These professionals more often inquired about suicidal ideations than did nonpsychiatric physicians. However, few caregivers noted suicidal thinking or probed suicidal symptoms. The data suggest that professional caregivers and especially nonpsychiatric physicians should be more sensitive and responsive to the signs and symptoms of suicidality.
Evaluated a university-based telephone counseling program through follow-up of 74 callers (18 males and 56 females). Callers reported a significant reduction in the severity of the original problem within the 5-day follow-up period, with "the call" being cited by most as accounting for the change, and "passage of time" as the next most frequent response. Content analysis revealed that most helpful counselor behaviors were giving clear and accurate information, being supportive and reassuring, and providing a new perspective. Implications for telephone counseling services are discussed. It is concluded that this study demonstrates the feasibility of telephone follow-up in evaluation of telephone counseling services. (12 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This book will serve as a first line of defense for the clinician. It provides information which, appropriately applied, can forestall most problems that can arise when a suicidal patient appears in a clinician's practice or in the hospital. The goal is to help the clinician treat a suicidal patient in a reasonable, sound practice with sophisticated management behaviors to optimize clinical care. B. Bongar's aim is not only to help the clinician to meet such problems, but also to point out that adherence to the principles of practice he describes in careful detail will minimize the risk and avoid the duress of legal involvement. More importantly, it will also improve the quality of care provided to patients and thus increase the potential for saving lives, which is the basic reason for the willingness of a mental health clinician to undertake a therapeutic alliance with a deeply troubled, emotionally distressed suicidal patient. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
80 crisis center callers (20 males, 60 females) with interpersonal and emotional problems were interviewed immediately after their calls to examine telephone volunteers' most helpful behaviors and the relationship between these behaviors and caller change. Listening and feedback, understanding and caring, appropriate climate, nonjudgmental support, and directiveness described the "overall most helpful behaviors," with reliable agreement (82%) for 5 judges. Analysis revealed that the category of understanding and caring was reported most frequently (39%). A Duncan multiple range test revealed that directiveness yielded notably more change than nonjudgmental support. Results support the current emphasis on empathy in crisis center practice and training. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Reviews the principles of crisis intervention in theory and practice for the mental health practitioner who has not been exposed in the past; concepts that explain the model are presented. The relationship between homeostatic functioning and coping processes is described, and the distinct phases in the life cycle of an emotional crisis are summarized. Evidence is presented for the generalizability of a crisis state. 10 basic corollaries of crisis theory are noted and are summarized as follows: Crises (a) have no relationship to psychopathology, (b) are self-limiting, (c) cause weakening of defenses, (d) cause increased capacity for learning, (e) can be used to resolve conflicts, (f) allow small influences to produce disproportionally large changes, (g) in resolution are shaped by current influences, (h) always include a real or imagined loss to the individual, (i) are always interpersonal events, and (j) in effective resolution, prevent future similar crises. Types of emotional crises are listed and discussed, and the tasks of the therapist in crisis intervention are reported. (53 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This study tested whether specific phases of helping occur during successful crisis telephone calls. Helper statements made in sampled calls were coded, and the outcomes of the calls were assessed. Systematic changes in assessment, affect integration, and problem-solving behaviors through the beginning, middle, and final thirds of calls were found to predict a successful outcome. A fourth helper category, establishment of a helping relationship, was negatively related to successful outcome. A three-phase model of telephone crisis intervention is offered, and the action orientation of crisis intervention is emphasized.