Crisis services play an essential role in suicide prevention. When help is as close as your phone, it can be the difference between life and death. But what can you expect when you contact a suicide prevention or crisis text line?
The National Suicide Prevention Lifeline (NSPL) ((800) 273–8255 (TALK)) and the Crisis Text Line (CTL) (Text "HELLO" to 741741) are the two most established national and credible crisis resources in the United States. Both are accessible 24/7 and offer free access to crisis intervention, an indispensable resource, particularly for people in rural areas who may not live anywhere close to a mental health or counseling facility. The goal for these crisis services is to provide emotional support and to work collaboratively to build safety precautions. Any emergency intervention that is not consensual or collaborative must be undertaken as a last resort and use the least invasive approach to keep the person in crisis safe for now.
Research shows that most suicide crises are time-limited and result in impaired problem-solving. For these reasons, people in crisis are often more open to outside intervention. These crisis services options remove the barriers of cost, travel, and waitlists to provide people in crisis an immediate response.
Another huge benefit is that both the NSPL and CTL are also anonymous. When people are struggling with suicidal thoughts and don't want to burden their loved ones, crisis services like these serve as safe places to process their suicidal intensity. Suicidal callers are often wrestling with psychological ambivalence, and talking to an objective third-party can help them weigh their reasons for living and their reasons for dying and receive feedback that will build on their strengths and coping.
The people who answer the crisis texts and calls provide empathy, validation, and accurate information and referrals so that the situation deescalates, and callers are connected to additional helping resources as soon as possible. All call takers receive substantial training and professional supervision before they are qualified to work on their own.
The majority of people who call crisis services are not at high risk of suicide. They seek support for emotional or practical life concerns. The most common nonsuicidal calls focus on relationship issues or general mental health concerns.1 Nevertheless, at least 31 percent of callers express suicidal thoughts or feelings, and about 2 percent of calls occur while a suicide is in process.2
What Do the Crisis Support Teams Do?
Every day, thousands of people answer crisis calls and texts to help hold the pain of people on the other side. They do this not because they get paid well—in fact, most of them are volunteers—but because they have the confidence and competence to have the conversations that others cannot. They offer empathy, connection, and hope to those in despair. They are our unsung heroes.
Their goal is to empower people to move from a "hot moment" to a "cool calm." Many emphasize that people don't have to be in acute crisis to call. They prefer to preempt a crisis by developing a plan to manage it and, in some cases, by providing peer support. In fact, many people responding to the crisis calls and texts have "lived experience" with suicide or other mental health challenges. By this, we mean they have often "walked in the shoes" of the person who is calling and can provide a shared perspective.
Effective crisis services are intentionally client-centered with "no wrong door" to immediate access. In other words, when a person in need seeks help, the last thing they should hear is, "Sorry, we can't address your problem—you need to fill out this paperwork and go to this other resource." Whatever way they get to crisis services, they need to receive a prompt and appropriate response.
Crisis support people listen deeply to the person in crisis and guide them in developing a crisis response plan. They know they are not a replacement for professional services. During the call or the text conversation, they work hard to build rapport (also known as a harmonious connection), reflect and validate feelings, offer support, assess for safety, develop a safety plan, and do a warm handoff to services.
What Happens When the Situation Is Life and Death?
For callers who are in an acute life-threatening situation (e.g., they have already taken a bottle of pills or have a gun in hand), crisis support teams can engage in more aggressive interventions such as tracing calls and sending emergency personnel. Sending emergency services without consent should only occur when, despite extensive efforts to collaborate, the caller is clearly unwilling or unable to work to secure their own safety. For instance, if the individual has already taken action that could result in their death, that would result in an immediate involuntary intervention. However, before this step is taken, all other avenues must be explored.
Why are crisis counselors so cautious about using involuntary emergency interventions? Because possible unintended and dangerous consequences can result when a "rescue" is sent to a caller without their consent. For most parts of the United States, this nonconsensual response is a 911 call. Police are dispatched to the location of the caller, and when police are not adequately trained to help people in a suicide crisis, what follows can be traumatizing. For communities of color and many LGBTQ+ populations, having the police intervene increases their risk of arrest and violence, even death.
In these more intense crises, responders look for an open bed at a local hospital. Police will often then transfer the person in crisis—sometimes handcuffed—to this hospital. If beds are not available, people are sometimes transferred to jail. Many hospitals are not adequately prepared to provide dignified, compassionate, and evidence-based treatment for their suicidal patients, and so this experience can leave people feeling worse when they are discharged. In fact, suicide rates remain high for 3 months after discharge.3
For these reasons, calling 911 is the last resort.
Do Crisis Services Work?
Two landmark publications in the journal Suicide and Life-Threatening Behavior support the value of hotlines. One study looked at the effect of hotline callers not feeling imminently threatened by suicidal thoughts, and the other looked at the effect on callers who were.
For less-at-risk callers, researchers found significant decreases in confusion, depression, anger, anxiety, hopelessness, and distress by the time the call ended. At a follow-up call, the reduction in caller distress and hopelessness remained. But researchers discovered another important detail: 11 percent of their sample deemed less at risk were indeed struggling with suicidal intensity as well. The majority of them simply didn't disclose this information during the call. Almost a quarter of this group of callers had contacted the center again during the interim.
Similar findings were observed during a study on callers at imminent risk of suicide. Researchers noticed "significant decreases in suicidality, specifically, intent to die, hopelessness, and psychological pain" during the course of the telephone session.1 While hopelessness and psychological pain continued to lessen in the weeks following the call, the intent to die did not. The authors suggested that follow-up calls are probably warranted for those with a high level of "intent to die," and the referral process could be improved to better serve this very risky population.
Another important finding of this study busted a widely held misperception: that telephone crisis centers do not reach those at heightened risk for suicide. Instead, these researchers found that over half of the callers dealing with suicidal intensity had active plans to harm themselves, and 10 percent had already taken some action to hurt or kill themselves immediately before placing the call.1
The research concluded that 90 percent of NSPL callers who were at risk of suicide when they called stated that their call to NSPL made a difference in increasing their safety from suicide, with 70 percent stating that their conversation with an NSPL counselor kept them from killing themselves.
Choice, Collaboration, and Consent in a Successful Crisis Intervention
When people are experiencing suicidal intensity, they often feel they have lost total control in their lives—except for the fact that they can still kill themselves. Thus, empowering people to reclaim self-agency is a critical step in the crisis response process. Few like to be forced into a situation against their will, and when it comes to suicide, nonconsensual interventions can be harmful.
Training for crisis supporters not only helps them improve active engagement skills and safety planning, but they are also trained on the many ways nonconsensual and noncollaborative emergency intervention can have negative outcomes on the callers' lives, including the following.
Physical dangers and active discrimination associated with law enforcement may result in disproportionate incarceration and physical harm, including death.
Emotional trauma and shame of involuntary intervention may make people less likely to reach out for help in the future.
Financial burdens may result from costs associated with ambulance and hospital charges.
In addition, the crisis supporters learn that the language we use in crisis response matters. Terms like "active rescue" and "wellness check" may glorify what is often experienced as traumatic to the person in crisis. Rather, the emphasis of the language should be reflective of the ethical weight of the circumstances—"nonconsensual" and "noncollaborative" interventions.
Who Should Use Crisis Services?
People who are in crisis can benefit from these services, but sometimes people are unsure what exactly is "a crisis." Some think that maybe their crisis isn't as serious as someone else's, so they become reluctant to engage for fear they may take a resource away from someone else "more deserving." The guideline is, if you think it's a crisis, then it's a crisis, and you are deserving of services.
People in crisis are obvious candidates, but they are not the only ones. As mentioned earlier, people who are having a hard time but not in crisis are also encouraged to reach out to circumvent a potential crisis. People who are worried about friends, family, or others can call to check in on how they can best respond to the person they are concerned about. People who are bereaved by suicide can use these resources for trauma or grief support. Even people who are curious about what happens when you contact crisis services and want to understand the experience can call so that they become better-informed referral sources for others in the future.
Thus, there are many reasons people seek these life-saving resources. They are incredibly effective and accessible—truly one of the most important links in the chain of survival for suicide prevention.
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