Can Three Numbers Stem the Tide of American Suicides?

Suicide hotlines are based on the simple idea that a conversation with a sympathetic stranger can save a life. Historically, most suicide hotlines have been run by volunteers without advanced degrees in counseling or related fields, and there’s research to suggest that nonexperts are at least as effective, if not more so, than professionals at helping suicidal callers.

Today, volunteers are an integral part of the National Suicide Prevention Lifeline, the free 24/7 hotline available throughout the United States at 1-800-273-TALK (8255).* More than half of the roughly 170 crisis call centers that make up the Lifeline recruit volunteers from the general public and train them to handle calls. Those volunteers work at the front lines of one of the nation’s most vexing public-health crises, a suicide rate that has risen steadily in the past 20 years, in defiance of a global downward trend. More than 47,000 people died by suicide in the U.S. in 2017, according to the Centers for Disease Control and Prevention.

Read: The Silicon Valley suicides

Calls to the Lifeline have risen in parallel. This year, it expects to receive 2.5 million calls, an all-time high. But that might represent only a small fraction of Americans at risk. For every person who dies by suicide, 280 people seriously consider it, according to estimates by the CDC and the federal Substance Abuse and Mental Health Services Administration, or SAMHSA. In the U.S., that translates to roughly 13 million people.

“The hurdle we’ve always had is getting people to know how to find us,” says Dwight Holton, the CEO of Lines for Life, a Lifeline call center based in Portland, Oregon.

That might soon change. The Federal Communications Commission recently recommended making it easier to reach the Lifeline, by dialing 988 instead of the more cumbersome current 10-digit number. The thinking is that someone in the midst of a crisis is more likely to remember—and dial—a shorter number.

For those involved in the Lifeline, the proposed change presents both a major challenge and a validation of a strategy they’ve long believed in. The new number would require the local call centers—many of which are already strapped for staff and funding—to handle a projected deluge of additional calls. But it also would be an opportunity to put into practice on a much grander scale the notion that anyone with the right training can make all the difference for someone in distress.

Suicide hotlines have been around since the 1950s, but only more recently have researchers attempted to study their effectiveness. The field is fraught with challenges. The gold standard for clinical research, the randomized trial, is a nonstarter, because randomly putting half the callers on hold is clearly out of the question. Meanwhile, studies comparing the suicide rates in populations of people who do or don’t have access to a crisis line are complicated by demographic, economic, and other factors that might account for any differences.

In the mid-2000s, a series of studies began to build a compelling case that crisis calls do work—and revealed some insights into why. One 2007 study led by Madelyn Gould, a psychiatric epidemiologist at Columbia University, had the staff at eight U.S. crisis centers ask callers specific questions at the beginning and end of conversations to assess their suicidality. Evaluating nearly 1,100 of these conversations, the researchers concluded that callers’ intent to die had decreased by the end of the call, as had their feelings of hopelessness and psychological pain. Some of these benefits persisted when the researchers interviewed a sample of the same callers a week or two later.

In the same journal issue, another research team, led by the psychologist Brian Mishara at the University of Quebec, reported findings on which aspects of the interaction between caller and counselor make the most difference, based on listening in on more than 1,400 calls in real time (a recorded message announced that calls may be monitored). Respect and empathy topped the list. Counselors who were able to quickly establish a rapport with callers and work with them to explore solutions—asking, for example, how they’d resolved a previous crisis, or who in their lives might be able to help—achieved the best outcomes.

As these and other research findings have come out, they’ve been used to standardize and improve the training and practices of Lifeline counselors. Mishara’s research, for example, suggested that simply listening is not enough to help distressed callers, so training guidelines were revised to teach more collaborative problem solving. “It takes a certain kind of person to not be judgmental and to be in a moment with someone who is talking about life and death,” says Shari Sinwelski, the associate director of the Lifeline and a former director of three crisis call centers. “But if they have that natural ability to listen and put themselves in that person’s shoes, then the communication skills can be taught.” Volunteers typically undergo 80 to 100 hours of training before they start answering calls.

According to Mishara, research dating back to the 1960s suggests that people without advanced degrees in psychology, social work, or related fields are better than professionals at helping suicidal callers. “The skills that people learn to be a therapist are different from the skills you need to help someone in a suicidal crisis over the phone,” he says. “Psychotherapy involves an established relationship in which you see the person for many weeks or months, and the focus is often on diagnosis and long-term treatment.” Quickly finding common ground with a stranger in distress seems to be a different skill entirely.

That’s not to discount the importance of long-term care. Gould’s research suggests that despite some lasting benefits for suicidal callers, nearly half later experience a recurrence of suicidal thoughts. As a result, the majority of Lifeline call centers now make follow-up calls to people deemed to be at risk. But even that’s not always enough. Ideally, Gould says, the Lifeline would act like air-traffic control for people in crisis, not only averting the immediate danger, but also connecting them to resources in their area that could put them on a more permanent path to safety.

Before the newly recommended phone number can become a reality, the FCC needs to complete its formal review, a months-long process that will include soliciting and reviewing public comments if the plan keeps moving forward. If the number does go into effect, Lifeline administrators predict that calls could double to 5 million in the first year and keep growing to 12 million to 16 million by the fifth. Meeting that need will require more funding and staff for the local call centers, many of which are already struggling to meet the demand for their services, says John Draper, the Lifeline’s director.

The Lifeline currently receives $6 million a year from SAMHSA in the form of a grant to Vibrant Emotional Health, the New York City nonprofit that administers the Lifeline (and employs Draper and Sinwelski). This money covers administrative and operational costs for networking the individual call centers around the country so that each call gets routed to the nearest available one. (Veterans who dial the Lifeline can opt to be routed to a dedicated line run by the Department of Veterans Affairs.) The SAMHSA grant does not cover the operations of the local call centers themselves, which mostly rely on funding from state and local governments. Some receive additional money from foundations or from contracts to answer calls for insurance companies or health-care systems.

“We’re doing our very best to answer as many calls as we can right now,” says Wendy Martinez Farmer, the CEO of Behavioral Health Link, a crisis call center in Atlanta. “But with the more accessible number, we certainly expect many more calls, and the funding is going to have to match the charge.” Farmer’s center is funded by the state of Georgia to run the state’s own crisis line. It receives no funding to answer Lifeline calls, but does so anyway when it has enough staff to handle the work, Farmer says.

In a report to the FCC filed earlier this year, SAMHSA estimated that $50 million would be required to handle the anticipated influx of calls to the Lifeline, but it did not elaborate on where that money might come from. In a statement, the agency said only that it “supports this proposal to make it easier to connect people in crisis to 24/7 support—with the understanding we would need to have the sustained resources to make this update a reality.”

The SAMHSA report projects that an additional $50 million investment in the Lifeline would more than pay for itself in reduced ER visits and hospitalization costs. Farmer and Holton say their experience bears that out. According to Holton, his call center, Lines for Life, de-escalates more than 95 percent of calls without having to contact emergency services. Every averted ambulance trip saves thousands of dollars, he says, and frees up resources for other emergencies.

In addition to expanding the Lifeline, Draper would like to see some of the skills used by crisis counselors filter into the general population, analogous to people learning to perform CPR or the Heimlich maneuver. “There’s a lot people can do for themselves and others to prevent suicide that we haven’t been telling them as clearly and loudly as we should,” he says. These are the same relatively simple things that suicide-hotline volunteers have been doing for years. In 2016, the Lifeline launched a website that outlines several steps people can take if they believe someone they know might be at risk of suicide.

That’s important, Draper says, because even with expanded access to the Lifeline, not everyone who’s at risk will make the call. “We’re not very good at predicting who will attempt suicide,” he says. “But we’re much better at helping to keep people safe.”

* This article previously included incorrect digits in the Lifeline’s phone number. We regret the error.