A short post today; while considering embarking on a side project to develop an iOS or Android application it occurred to me that suicide prevention and crisis intervention are areas where mobile applications could certainly come in handy (as well as case management.)
I downloaded an Android emulator and several free apps to prevent suicide:
- HELP Prevent Suicide
- R U Suicidal
- Safety Plan
- Suicide? HELP
- Suicide Test
None of them were particularly useful, they all seem to follow a similar layout.
Android Suicide Prevention Applications
HELP Prevent Suicide
This application includes a link to the National Suicide Prevention Lifeline, the NSPL phone number, warning signs, some strategies for laypeople to help (asking about suicidal thoughts, listening and connecting to others) and a list of helplines. Most of the apps tended to follow this model.
R U Suicidal?
This application was unique in that it focuses on a series of videos. (There’s another version of this app for your spouse or significant other.) Recorded by a Psychologist, the intent is that you’ll watch the video, and then it pauses at points to allow you writing space for your feelings.
I found the videos un-engaging and the lack of a seek bar to move through the video or any text accompaniment means if I were in a crisis I likely wouldn’t sit through them.
Safety Plan App
This app, like the name says, just does safety plans. It gives some prompts and allows you to write information on warning signs that trigger suicidal or self-injurious thoughts, coping strategies, contacts, and so on. Because there are no defaults or examples you’d likely need a second person to help you bounce ideas off of.
Suicide Test App
The most interesting app of all was simply called Suicide Test. It had 20 yes/no questions, and then scored them to tell you your suicide risk. The font was terrible and some of the questions nearly unreadable but I liked the idea and the simple interface.
Building a New Suicide Risk Assessment Application
If I were to design a new suicide risk assessment application (and it’s on my to-do list), it would feature the following:
A comprehensive suicide risk assessment tool that meets the NSPL standards
- A layman’s quiz to help them flesh out their own suicide risk
- A support network/safety planning document with suggestions to help stimulate filling it out
- Links to helplines
- Information for both the suicidal person and the third-parties who may be viewing the app on how to reach out for help and to be non-judgemental
No application currently on the market meets these requirements, which is a real shame. Before the end of the summer I hope to have a prototype with which to begin usability testing. Watch out for it!
Yesterday I had the opportunity to complete training on effective use of the Structured Assessment of Violence Risk in Youth (SAVRY) tool. This tool, designed for children 12-18 (and used up until 21) has shown moderate validity in predicting adolescent violence.
I just finished reading Youth Violence: Theory, Prevention and Intervention, and the SAVRY was one of the tools covered. It’s performed very well.
The tool focuses on Structured Professional Judgement (SPJ), which is an alternative to two other approaches, Unstructured Clinical Judgement (where the clinician makes their gut impression after an interview, weighing whatever factors they care about in their head) and actuarial approaches (where factors that have been predicted to increase violence risk from a statistical perspective are weighted as present.)
SPJ is a combination of these two approaches; in the case of the SAVRY, it combined static (unlikely to change) risk factors common in actuarial approaches, with dynamic ones that are more likely to be found in clinical judgement assessment.
The elements of the SAVRY are below:
Historical risk factors
1. History of Violence
2. History of Non-Violent Offending
3. Early Initiation of Violence
4. Past Supervision/Intervention Failures
5. History of Self-Harm or Suicide Attempts
6. Exposure to Violence at Home
7. Childhood History of Maltreatment
8. Parental/Caregiver Criminality
9. Early Caregiver Disruption
10. Poor School Achievement
Social/Contextual risk factors
11. Peer Delinquency
12. Peer Rejection
13. Stress and Poor Coping
14. Poor Parental Management
15. Lack of Personal/Social Support
16. Community Disorganization
Individual risk factors
17. Negative Attitudes
18. Risk Taking/Impulsivity
19. Substance Use Difficulties
20. Anger Management Problems
21. Low Empathy/Remorse
22. Attention Deficit/Hyperactivity Difficulties
23. Poor Compliance
24. Low Interest/Commitment to School
P1. Prosocial Involvement
P2. Strong Social Support
P3. Strong Attachments and Bonds
P4. Positive Attitude Towards Intervention and Authority
P5. Strong Commitment to School
P6. Resilient Personality Traits
Importance of Helpline Risk Management
Risk management is the process of assessing and taking steps to mitigate areas where things that might go wrong in your organization. While we all hope that nothing would ever go wrong, it’s important that we are not caught blindsided. Some of these issues are within our control (e.g. helpline quality issues) while others, like natural disasters are not.
A helpful way to look at this, which came up at a conference that I attended recently, was to imagine you are being interviewed by the media because something has gone wrong. What would you tell the journalist that you currently do to avoid this problem? If the answer isn’t good enough, perhaps looking at where you can improve.
Failures in Risk Management
Failures in risk management can have wide-ranging impacts. They include a drop in morale of your volunteers, financial penalties resulting from lawsuits, a reputation hit among the community, even loss of funding and closure of your helpline.
Probability/Impact Heat Map
An interesting concept I learned in a conference was the idea of a “Probability/Impact” heat map. This was a simple way to envision the various issues that could affect your helpline. Here is an example of a simple heat map with two items, Natural Disaster and Helpline Quality Issue.
The Natural Disaster (let’s say, a hurricane) would have an extremely large impact on the helpline’s ability to operate, however hurricanes (at least here in southern Ontario) are extremely rare so their probability is low. While it might be helpful to write policies in case of a potential natural disaster (some of which are detailed in the below sections) they can likely safely be reviewed on a yearly-basis, perhaps at a Board Meeting – unless a hurricane is imminent.
On the other hand, while helpline quality issues do not have as big an impact on the helpline’s ability to operate (although still substantial, if they are widespread), they are much more common than hurricanes.
For that reason, you will likely spend more time in your day-to-day implementing policies, regular supervision and monitoring, and (ideally) having a detailed performance improvement program for volunteers identified as falling below standard. This, combined with a strong training program and an awareness in the volunteers of what is expected of them should help to mitigate issues resulting from poor quality volunteers.
As you proceed through each section, keep in mind what elements you already implement to mitigate risk and where you can improve.
Recruitment and Screening
Recruitment and screening is your first opportunity to meet potential volunteers and learn about issues that may present themselves later in their volunteerism. By taking a keen interest in the volunteers you are recruiting now, you can be better prepared for issues later.
Almost all helplines involve some kind of interview process for potential volunteers. Do you use a structured interview process, or wing it? If a potential applicant feels discriminated against during your interview process you can open yourself up to legal or public relations issues.
Risk Management for Interviewing:
- Create a structured interview with specific questions asked of every candidate
- When conducting interviews, write down notes for each response and store them in the volunteer’s file
- Write a protocol explaining in what interview responses (if any) lead to supervisor review or automatic discontinuation of their application
- Include questions on areas such as sexual assault, self-injurious behaviour, suicidal thoughts – ask volunteers if they have any exposure to these potentially “triggering” topics and discuss with applicants how they will be impacted
Police checks are the most obvious form of screening for helpline volunteers. In Canada, a Vulnerable Sector (VS) Check provides both a regular criminal record check, as well as information on sex crimes and other records relevant to working with vulnerable clients, even if they have received a pardon or they were not convicted.
In the UK, this is known as a DBS (Disclosure and Barring Service) check, and it works in a similar way, showing crimes that would be excluded from a normal criminal record check.
It’s important to remember that a criminal record check is not a guarantee against crime, because volunteers may become involved in the criminal justice system after the start of their volunteerism, or may have committed crimes for which they were not caught or convicted.
Risk Management for Police Checks:
- Require police record checks for all volunteers
- Require an updated criminal record check every several years (covered by the helpline if within your budget) or as a low-cost alternative, have volunteers sign an attestation that they have not been arrested in the previous year
- Create a protocol for what offences you will allow on the helpline and when; for instance, you may be okay with offences that occurred more than 10 years ago, or you may only allow crimes that were not “moral turpitude” offences (drunk and disorderly may be okay, theft or assault may not be.)
- If you allow volunteers on the lines with these crimes, document your decision to do so and have them sign a document certifying their requirement to stay “crime free” in order to continue being involved with your line
Reference checks, like police checks, are common for both employees and volunteers on helplines. References allow us to learn more about a person from their peers and previous supervisors. This can be illuminating.
Reference checks should be conducted with a standardized form and specific questions looking at a potential volunteer’s interpersonal skills and how they work under stress. Examples of questions can include, “How does this person interact with other people in their life?” and “Have you ever seen this person react under stress? How did they perform?”
One misconception about references in Canada is that if an employee gives a poor reference about a colleague they are opening themselves up to legal liability. This is untrue; in fact, reference checks are considered qualified privilege (Dunlop, n.d.)
Risk Management for Reference Checks:
- Use a standardized reference check form and record the answers; make sure to document the method of communication, the date, and the title and name of the person you spoke to
- Ask volunteers for a minimum of two references. This shields you against problems if one reference has been “coached” to only speak positively about volunteers
- Create a policy regarding how you will proceed if references are inaccessible; will you allow volunteers to continue during the process with only one submitted reference, will you ask them for another reference or discontinue their application?
Training is arguably the most important element to protecting callers and clients from poor quality volunteers. By providing a strong training system, volunteers are able to provide consistent service to all callers.
Emotional Reaction of Volunteers
While everyone thinks about the service to the callers, there are also risks of harming potential volunteers during training. It is important to recognize that they may be impacted or triggered by roleplays, by discussion around topics like suicide, abuse (including self-abuse) and sexual assault.
There are a number of steps you can take to protect the emotional health of your potential applicants.
Risk Management for Volunteers during Training
- Ask volunteers who identified as undergoing counselling or therapy to provide your helpline with a letter confirming their suitability for volunteering. At Distress Centre Durham, volunteers are provided with a letter that lists the potential impacts of volunteering and clinicians are simply asked to sign the document certifying that volunteer work will pose no harm
- Have volunteers or staff ready during the training to debrief in private with volunteers who are negatively impacted participating in roleplays
- Closely monitoring the non-verbal signs of volunteers during discussions and documenting the results of those observations. Document everything! This way if you need to later release a volunteer from their commitment, you have evidence to support your decision
Security (Physical and Electronic)
Physical and electronic security is an important element of risk management. Many helplines are in spartan circumstances, in industrial parks or the basements of churches where there is not a lot of vehicle or person traffic. Additionally, late night shifts can have volunteers leaving at midnight, 2am, 4, 6, etc., where they could be in danger.
Risk Management for Physical Safety
- Ensure a floodlight is available for the front door and parking lot; a peephole allowing volunteers to see out the main door will allow them to ensure the area is clear before departing to their vehicles
- Having two volunteers on staff. By making sure that (where available) two volunteers leave and enter the building at a time, you can ensure they feel safe
- Installing cameras or other surveillance equipment can be both a deterrent and helpful in the aftermath of a physical safety incident.
- Multi-layered alarm systems allow you additional forms of protection. For instance, in addition to having a front door with a master key, you can install an alarm system with a code. This mean that even if your keys are compromised or the lock is picked, individuals are not able to enter your building without tripping the alarm system.
- Establishing protocols for locking doors help volunteers ensure that they know something is amiss. For instance, if the front door is to be locked at all times, except for 5 minutes before and after a shift, a volunteer who enters the building and finds the door open at an irregular time knows to be on alert.
As more and more information is stored digitally, the impact of “hacking” and data theft becomes bigger and bigger. Crisis lines in particular may store a lot of information on their callers and this may be vulnerable to theft.
Risk Management for Information Security
- Encrypt information on hard drives, using a tool like Microsoft’s free Bitlocker, so that if the hard drive or computer is stolen the information will be inaccessible without the password
- Disconnect computers where helpline work occurs from the internet, or use a web blocker to prevent access to all non-essential websites
- Develop information protection policies, such as locking all volunteer and caller files in keyed cabinets (and limiting access to who has the keys)
- Consider using an online helpline management software like iCarol; all information transmitted with them is encrypted at both ends and stored offsite in secure data warehouses where security is the priority. This can help both your funders and callers feel more secure.
Natural disasters are also a concern depending on where your helpline is located. It’s important that you put in place policies to help mitigate data loss and allow your helpline to function in times of disaster, when you may find yourself a crucial source of information, emotional support and crisis intervention in the aftermath.
Risk Management for Natural Disasters
- Develop policies on how your helpline will respond during disasters; will you forward your lines to cell phones so volunteers can take calls off-site, or will you shut down for safety?
- Backup information on to external hard-drives or other external data sources that can be removed, or completely outsource back up to an offsite data provider so you are protected even in case of sudden disasters
- Keep physical copies of information such as volunteer and staff contact information securely stored for emergencies
Direct Service (On the Helpline)
Sometimes risks occur from the work that your helpline workers are actually performing on the phone. These are the most worrying to volunteers, callers and managers because of their contact with often vulnerable clients.
There are a number of risk management techniques that can be put in place to help mitigate the risk poor delivery of helpline service has on your line.
Risk Management for Helpline Service Quality
- Perform regular supervision of volunteers; this can include reading their written call reports, randomly listening to their calls live, meeting with them for weekly or monthly supervision meetings and ad hoc meetings if callers report concerns with specific volunteers
- Establishing very clear standards and protocols around breaches of confidentiality, meeting callers offsite, giving advice, or other concerns that your helpline may face. Explain the behaviour, give examples of behaviour that falls below the standard, and explain the consequences, up to and including being released from their volunteering duties
- Conduct regular surveys with callers. For instance, a yearly or semi-annual survey with callers can help you identify issues that may slip through the cracks if you don’t perform live call monitoring because of budgetary or ethical concerns
- Using a tool like Chronicall can help you see patterns in call data that you may not have been aware of before. For instance, I developed a tool that allows me to input shift coverage data from iCarol and call data from Chronicall, and identify areas with high rates of shift coverage and a large numbers of missed calls. This could mean that some volunteers missed that shift, were ignoring calls or were dealing with crisis calls that required them to not answer incoming calls.
Hopefully some of these risk management techniques will have been new to your crisis line; implementation of a comprehensive risk management process in cooperation with your administration and Board of Directors is essential in mitigating potential disasters before they happen.
Do you have any recommendations for risk management methods I may not have thought of? Suggest in the comments.
Dunlop, C. (n.d.), Edmond Harden. “Qualified privilege protects comments made during reference check from defamation action”, accessed electronically from http://www.ehlaw.ca/publications/mar03/millerbns.pdf on Mar 30, 2015