Update: May 22, 2017 Please see Ultimate Guide to Starting a Crisis Line for a much more comprehensive treatment of this same topic!
Do you want to start your own suicide hotline, crisis line or helpline? This is an extremely ambitious and admirable goal and I admire you for thinking about your community! Thousands of suicide lines listen to millions of people across the globe every year, preventing thousands of suicides and making the world a better place.
While some areas have lots of crisis lines and supports in place, other communities have a complete lack of them. Especially outside of North America, crisis lines can cost money to call, or may not even exist at all.
Most crisis lines are started by volunteers like yourself, who took the task upon them for the good of their communities. Eventually most lines receive some form of funding, but in the beginning they’re often run out of churches and with volunteer labour.
A few of the things you’ll need to start your own crisis line include:
- Office space
- Phone Service
- Helpline Software / Computers
- Crisis Line Training
- Hotline Evaluation
Office Space / Phone Service
These may seem daunting, but they’re not as complicated as they may initially seem. Office space, for instance, is often donated by churches or other community groups for fledgling non-profits. All you really need is an area for taking calls, and an area for performing administrative work. This can be in a single room to start, and could be someone’s house.
Phone service can be expensive, but using VoIP services can help reduce the cost and improve the accessibility to your volunteers. Something to keep in mind is the possibility of doing call forwarding. What this means is that if your volunteers are at home, the calls can be forward to their home or cell phone and they can answer them from there.
Helpline Software / Computers
Initially your helplines can use paper call reports to record information, later switching to a database, or if you can afford it you can subscribe to an online web-based software like iCarol that will give you much more freedom and flexibility.
It may be helpful to get in touch with local crisis lines in your area (or in larger cities) to learn about the way they code calls. This will help you to understand the basics, before you create your own call report that uniquely captures your population.
Crisis Line Training
Crisis line training is probably the most difficult element to starting a crisis line. Working with a neighbouring crisis line to undergo their training is helpful. Additionally, a lot of crisis lines have local mental health professionals work as clinical supervisors until the organization has enough institutional expertise to provide their own.
Tools that can be used to assess crisis line volunteers include the Suicide Intervention Response Inventory (SIRI) or the Crisis Center Discrimination Index (CIDI). Suicide risk assessments are also an important element of starting a crisis line because you’ll need to respond in an effective and reliable method for determining a caller’s suicide risk.
Some suicide risk assessment tools. include the CPR Model (Current Risk, Previous Exposure, Resources), the DCIB (Desire, Capability, Intent, Buffers) Model and the NGASR (Nurse’s Global Assessment of Suicide Risk.)
Evaluating your hotline is an important element of operating it. If you ever want to receive funding, you need to show that your line is actually beneficial.
This can be as simple as establishing standards for your volunteers (e.g. all volunteers will undertake a 40 hour training session, all volunteers will fill out detailed call reports with outcomes measures, etc.) or as complex as having a silent monitoring system to allow supervisors to listen to calls or research where callers are contacted afterwards to find out their experiences.
The core of emotional support, which is the service provided on crisis lines, is called active listening. Active listening is a special type of listening, distinct from the regular listening we do everyday.
Active listening should also be separated from the work that counsellors and therapists do, which is called professional listening. While therapists and counsellors certainly use active listening, they also use additional advanced skills not covered here (such as interpretation and challenging.)
Active listening is made up of a number of individual skills that include:
- Demonstrating attending behaviour
- Using empathy statements
These are reviewed below.
Although active listening skills may seem like common sense, it takes conscious practice to develop use of these skills to be second nature. As is often said about this topic, it’s common for people to “wait to talk” instead of truly listening. They’re not hearing the emotions under the content, they’re just waiting for a pause to jump in with their next sentence.
Attending behaviour refers to your non-verbal behaviours used to show that you’re listening. This includes things like eye contact, where your body is pointed, your posture, and so on. The acronym SOLER is one that is used to summarize attending behaviour. It is important to keep in mind that attending behaviour is culture-specific, and this is written with Western cultures in mind.
Other cultures may have different standards for what is considered attending behaviour. For instance, eye contact is often rude and intrusive in Asian cultures, while in North America it is rude to not maintain eye contact.
SOLER is not relevant to crisis lines (because you’re working over the telephone) but is still covered here because occasional in-person clients may occur in some organizations.
- S – Sit Squarely
- O – Open Posture
- L – Learn Towards the Client
- E – Eye Contact
- R – Relax
Sit squarely refers to your body positioning, which is to point your body towards client so that they know you’re listening, rather than pointing your body away from the person you’re speaking to.
Open posture refers to keeping your arms and legs open. Crossed arms or legs put together are considered closed body language and are off-putting to clients. Instead, keep your legs apart (though not enough that it could appear unprofessional) and keep your arms at your sides or in your lap rather than closed.
Lean towards the client sounds like what it says – to show interest when a client is speaking, lean towards them rather than leaning back which communicates disinterest.
Eye contact, as well, is important for showing interest and building rapport in western cultures. Keep in mind that some other cultures may place different value on eye contact and so it’s important to know the culture you’re working with.
Relax – Relax! No need to be tense, your discomfort may be interpreted by your client as disliking them, so make sure to take a deep breath, be honest with your client if something bothers you, and always keep the lines of communication open.
Empathy statements are the core of emotional support. These are feeling words that allow you to communicate that you have an idea what another person is going through. Empathy is defined as “the ability to understand and share the feelings of another”, which is different from sympathy, which is “feelings of pity and sorrow for someone else’s misfortune.”
With empathy, you are highlighting feelings as if you are experiencing them yourself. Examples of empathy statements are:
- That sounds really scary
- You must be feeling so frustrated
- If I were you in shoes I would be devastated
Empathy statements may initially sound un-genuine or forced, but with practice they will get second nature. You may find it helpful to look at a list of feeling words to develop your skills. For additional practice please see my article Empathy Statements in Helpline Work.
Paraphrasing is defined as “express[ing] the meaning of (the writer or speaker or something written or spoken) using different words, especially to achieve greater clarity.” In the emotional support context, paraphrasing means to restate the content that a person has said.
An example of this would be, if someone tells you that their dog died. An example of a paraphrase would be “You lost your pet.” Paraphrasing is used to ensure you’ve heard the content that a person has said while they speak to you.
Reflection is similar to paraphrasing but the goal is to reflect the emotion underlining the statement that a person has said. This is quite a bit different than paraphrasing. For instance, if we return to our example of someone telling you that their dog died, the paraphrase was “You lost your pet.” The reflection would be, “You’re feeling really alone right now.”
A reflection highlights an emotion, and is used frequently to check in to make sure that your empathy statements are on point.
Summarizing is similar to paraphrasing or reflecting but it is a longer statement used to sum up several minutes of conversation. Many counsellors use summaries to open their sessions by reviewing the previous week’s conversations, and periodically throughout their sessions.
An example of a summarize that could apply to our dog-grief conversation would be like follows: “So, from what we’ve been discussing, you lost your dog last month and it’s weighing really heavily on you. You feel alone because your house is empty and you don’t know how to cope.” This highlights some emotional items (feeling alone, weighing really heavily on them) and some content items (dog lost last month, empty house.)
Silence is an important element in active listening and is often overlooked. Silence can be used to help a person process what has just been discussed – it is not necessary, nor desirable to fill every moment of a conversation with words. Sometimes just sitting with someone and being witness to their pain is helpful.
Advanced Active Listening Training
If you’re interested in developing your active listening skills you may want to join a crisis line, or consider taking an Introduction to Counselling course at a local college or university to build your theoretical skills and practice roleplaying with others.
As well, please my article on Building Communication Skills and on Improving Your Helpline Work.
Suicide prevention is a significant issue in the US military, with the loss of current service members and veterans a significant public and social health cost. There have been a variety of theories on the causes of the increase in military suicides, which has been termed an “epidemic.” (Pilkington, 2013)
Model of Suicidal Behaviour
A model of suicide behaviour is used to understand the factors that may lead to suicide for a specific population. One model that applies well to explaining military suicides is called the Interpersonal Theory of Suicide (van Orden et al., 2010). This model states that three elements need to be present for a person to become suicidal:
- Thwarted belongingness
- Perceived burdensome
- Acquired capability
Thwarted belonging can occur when a returning service member loses the esprit de corps that characterized their military service, and a large part of their social support. This is especially true if a veteran is disabled.
Perceived burdensomeness can occur when a service member with a disability or mental health issues finds themselves unable to function independently. This may be a particularly difficult adjustment for someone who was used to feeling in control and being independent.
Finally, acquired capability involves fearlessness and experience with physical injury that reduces a suicidal person’s ability to resist suicide. Military members have virtually all acquired the capability for suicide via combat experience and other exposure in their careers.
Prevalence of Suicide in Servicemembers and Veterans
For many years, the military had a comparable or slightly lower rate of suicide than the general population (Armed Forces Health Surveillance Center, 2012) but recent trends have had suicide rates increase significantly (Department of Veterans Affairs, 2010).
Kaplan, McFarland, Huguet & Newsom (2012) note that while the existing research has been mixed on the exact nature of the suicide rate increase, it is definitely elevated. Further research will need to be conducted to determine the exact causes.
Causes of Military Suicide
There are a number of suspected causes of the increase in suicidal behaviour in soldiers since 2006 identified by Hyman, Ireland, Frost & Cottrell (2012) include:
- Presence of a mental health diagnosis
- Having been on deployment
- Taking anti-depressants
- Taking sleep medications (which were associated with more deployments)
They note that the impact of these on the suicide rate was strongest in National Guard and Army Reserve members and interestingly, quite weak in the Marine Corps. This suggests that perhaps the esprit de corps that is present in the Marines helps to buffer against the negative elements of mental health issues. The lowered suicide rate in Marine Corps members was present despite the fact that Marines were less likely to have protective factors like spouses and children.
As well, Alexander, Reger, Smolenski & Fullerton (2014) in their pilot study using the Department of Defense Suicide Event Report (DoDSER) to collect data on suicide deaths (and matched “control” soldiers who did not die by suicide) found events like “recent failed intimate relationships, outpatient mental health history, mood disorder diagnosis, substance abuse history, and prior self-injury” linked to suicide, all of which fit in one of the three categories of the Interpersonal Theory of Suicide.
Suicide Awareness in the Marine Corps
MCRP611C Combat Stress, the 2000 Marine Corps combat stress control manual includes a section on suicide awareness. In addition to listing common signs of suicide and preparatory behaviour such as:
- Believes he or she is in a hopeless situation
- Appears depressed, sad, tearful; may have changes in patterns of sleep and/or appetite
- May talk about or actually threaten suicide, or may talk about death and dying in a way that strikes the listener as odd
- May give away possessions
It also includes the acronym AID LIFE:
- Ask: “Are you thinking about hurting yourself?”
- I Intervene immediately.
- D Do not keep a secret concerning a person at risk.
- L Locate help (NCO, chaplain, corpsman, doctor, nurse, friend, family, crisis line, hospital emergency room).
- I Inform your chain of command of the situation.
- F Find someone to say with the person. Do not leave the person alone.
- E Expedite! Get help immediately. A suicidal person needs the immediate attention of helpers.
Role of Chaplains in Army Suicide Prevention
Army Chaplains provide primary spiritual care to soldiers (Zeiger, 2009) but are also considered the “gatekeepers” who most non-commissioned officers, enlisted leaders in the military, refer soldiers to when they find out they’re suicidal. (Ramchand, Ayer, Geyer & Kofner, 2015) Chaplains are afforded confidentiality like attorneys or therapists and this makes them attractive as first-level referrals.
Ramchand et. al. (2012) also found that a majority (54%) of Chaplains and Chaplain’s Assistants had received some kind of mental health training, but that they their suicide prevention knowledge was lacking and had difficulty intervening because of the stigma of mental health treatment.
Counselling on access to lethal means (CALM) is one approach that has been proven to reduce suicide rates in the civilian population. CALM refers to the techniques used to limit or disable access to suicide plans, such as removing firearms from the home or locking up prescription medication that a person could use to suicide with.
Hoyt & Duffy (2015) provide a number of approaches for limiting means, including providing space on base for a soldier’s private weapons during a suicidal crisis, emphasize weapon safety (e.g. locking up of firearms) to reduce impulsive use, and engaging the entire chain of command on when means restriction is necessary.
Post Traumatic Stress Disorder
Much has been made of the influence of post-traumatic stress disorder on the suicide rate. Research indicates that both PTSD and traumatic brain injury independently increase the suicide rate. (Barnes, Walter & Chard, 2012) however virtually all mental health issues increase the suicide rate (Harris & Barraclough, 1997) with depression being more important than PTSD in the suicide rate.
Interventions to Reduce Military Suicide
Zamorski (2011) reviews a variety of interventions that have shown evidence or potential in reducing suicide risk in soldiers, though from a Canadian context. Some of these are listed below:
- Treatment of underlying mental health issues
- Screening for depression
- Training of gatekeepers to ask about suicide
- Systematic followup for suicide attempters and high risk patients
- Counselling and restriction of access to lethal means
- Resilience training
- Systematic monitoring and quality improvement of mental health
Zamorski notes Knox et. al.’s (2003) study of a comprehensive suicide prevention program that included many of the above interventions. Over a 6 year span, the suicide rate declined 33% as a result of the implementation of these techniques.
Alexander, C.L., Reger, M.A., Smolenski, D.J. & Fullerton, N.R. (2014) Comparing U.S. Army Suicide Cases to a Control Sample: Initial Data and Methodological Lessons. Military Medicine. 179. 10:1062
Armed Forces Health Surveillance Center. (2012) Deaths by Suicide While on Active Duty, Active and Reserve Components, U.S. Armed Forces, 1998-2011. Medical Surveillance Monthly Report. 19(6)
Barnes, S. M., Walter, K. H., & Chard, K. M. (2012). Does a history of mild traumatic brain injury increase suicide risk in veterans with PTSD?. Rehabilitation Psychology, 57(1), 18-26. doi:10.1037/a0027007
Department of Veteran Affairs. (2012) Suicide Data Report. Kemp, J., Bossarte, R.
Harris, E.C., Barraclough, B. (1997) Suicide as an outcome for mental disorders. A meta-analysis. British Journal of Psychiatry. 170:205-28
Hoyt, T. & Duffy, V. (2015) Implementing Firearms Restriction for Preventing U.S. Army Suicide. Military Psychology. 27(6) 384-390 DOI: 10.1037/mil0000093
Hyman, J., Ireland, R., Frost, L., & Cottrell, L. (2012). Suicide Incidence and Risk Factors in an Active Duty US Military Population. American Journal Of Public Health, 102(S1), S138-S146. doi:10.2105/AJPH.2011.300484
Kaplan, M.S., McFarland, H., Huguet, N. & Newsom, J.T. (2012) Estimating the Risk of Suicide Among US Veterans: How Should We Proceed From Here?. American Journal of Public Health. 102(S1)
Knox, K.L., Litts, D.A., Talcott, G.W., Feig, J.C. & Caine, E.D. (2003). Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: Cohort study. British Medical Journal, 327, 1376.
Pilkington, E. (2012) “US military struggling to stop suicide epidemic among war veterans”. The Guardian. Accessed electronically on Dec 27 2015 from http://www.theguardian.com/world/2013/feb/01/us-military-suicide-epidemic-veteran
Ramchand, R., Ayer, L., Geyer, L., & Kofner A. (2015) Army Chaplains’ Perceptions About Identifying, Intervening, and Referring Soldiers at Risk of Suicide. Spirituality in Clinical Practice. 2(1) 36-47
United States Marine Corps. (2000) MCRP611C Combat Stress. Accessed electronically on Dec 27 2015 from http://www.au.af.mil/au/awc/awcgate/usmc/mcrp611c.pdf
Van Orden, K.A., Witte, T.K., Cukrowicz, K.C., Braithwaite, S., Selby, E.A., & Joiner, T.E. (2010) The Interpersonal Theory of Suicide. Psychology Review. 117(2)575-600 doi: 10.1037/a0018697
Zamorski, M.A. (2011) Suicide prevention in military organizations. International Review of Psychiatry. (23)173-180
Zeiger, H. (2009) Why Does the U.S. Military Have Chaplains?. Pepperdine Policy Review. Accessed electronically on Dec 27 2015 from http://publicpolicy.pepperdine.edu/academics/research/policy-review/2009v2/why-does-us-military-have-chaplains.htm