Ultimate Guide to Starting a Crisis Line

Introduction

Following up on my previous post Starting a Crisis Line or Hotline, I had some reader commentary asking about some more specific nuts and bolts for someone who is passionate and interested in starting a crisis line, hotline or helpline but doesn’t really know where to begin. Obviously, while it is best to bring in experienced individuals sometimes they simply aren’t available. For the purpose of this guide, I will describe the steps to create a fictional crisis line, the Southeast Iowa Crisis Center (SEICC), or “Seek.”

Throughout this article, I use “crisis line”, “helpline” and other terms interchangeably, except in the section “Deciding on Type of Service Provided” where I distinguish between the two.

Staffing a Steering Committee

The first step will be to decide on and form a Steering Committee. This will be a group of individuals who will be responsible for helping to bring your vision of a crisis line to life. Too few people and you may feel overwhelmed. Too many and you risk decision paralysis – not being able to make decisions because of too many disagreements. Perhaps 4-6 people is the optimal size for a Steering Committee.

If (or when) you form a nonprofit, you’ll need a Board of Directors. The members of your Steering Committee often make a suitable Board. Their tasks will include all of the items discussed below.

Choosing a Population and Coverage Area

You likely know this information before you begin, but it’s important to clearly define your population and coverage (or catchment) area as you work on your crisis line. You might choose to create your crisis line based on a specific age range (such as the Kids Help Phone for those 0-25), subject area (like the Rape, Abuse and Incest National Network [RAINN]), geographic region (like Tennessee Statewide Mental Health Crisis Line) or job status such as the Veterans Crisis Line.

Some funders will only fund certain populations or programs but it’s important that you not get into the business of chasing funding by going against your mission – this could lead to you losing your nonprofit status or losing trust among your supporters.

Identifying Mission and Vision

The next step to starting a nonprofit or a new product is to define what you wish to create. An organization’s mission statement is short and punchy, describing what they do. This can be a tagline or slogan, but doesn’t have to be. Distress Centre Durham‘s mission statement is “Helping people in distress to cope.”

Vision is more long-term and describes an outcome. An example vision statement for Habitat for Humanity is “A world where everyone has a decent place to live.” You don’t necessarily have to publicize your visioning statement but your mission and vision will determine whether activities that you pursue are within your organization’s purview.

SEICC’s mission will be “Keeping Iowans safe with 24/7 emotional support”, while the vision will be “Nobody suffers alone.”

Parkinson’s Law of Triviality

There is a concept in management called Parkinson’s Law of Triviality. Essentially it states that organizations spend disproportionate amounts of time on easy-to-grasp issues while neglecting more important but more difficult ones. This is an important trap to avoid when considering things like your organization’s logo, or other elements that are pretty minor in the grand scheme of things.

Picking a Staffing Model

At this stage, you have identified a group of individuals that are going to help you build your crisis line. You’ve also decided on a mission and a vision. You need to decide whether you will use a model of volunteers supported by paid staff, a blended model, or all paid staff. There are pros and cons to each approach.

Volunteers, Staff Supported

Advantages of the volunteers-supported-by-staff model include it is easy to start and individuals can self-select as one or the other (either applying for a staff position in administration or a volunteer position providing direct service.) One downside to this model is that initially your administrative staff will probably have to cover shifts on the helpline until you all get experienced, and that it can be hard to ensure 100% coverage if your service gets popular.

Blended Model

A blended model involves a mix of paid staff and volunteers. This is a more common model in the United States than in Canada, which tends to use purely volunteers. The advantages are that you can attract a more credentialed staff who might hold multiple roles (e.g. a helpline manager might be responsible for 20 hours of helpline work and 20 hours of administration.)

The downsides are that this can make your volunteers uncomfortable, and increase the expenses you need to get your crisis line off the ground.

All Paid Staff

Using all paid staff is an emerging crisis line model. Some helplines like the Veteran’s Crisis Line have used this model for many years. With this model, you can ensure 100% coverage (because your staff are paid to be in the chair), but this will be very expensive. Although research shows that paying crisis line workers does not diminish their importance, it may make it harder for your callers to trust that they’re really interested in listening.

This can also increase the rate of burnout because paid workers are providing many more hours of support each week or month versus a volunteer.

Deciding on Type of Support Provided

It’s important to decide if you’re going to be a distress line, a crisis line, or both. Some organizations will break their services into two distinct phone numbers and lines, with specific caller concerns, while many others (like Distress Centre Durham) will provide all forms of support.

Despite the use of the name “distress line” or “crisis line”, an organization may take all types of calls. You’ll need to read the explanation of the service provided before making a decision about whether or not an agency really does limit or parcel out their support.

Distress Line

A distress line focuses on individuals who are struggling and need to talk to someone but who can still cope. Someone in distress can still think about potential solutions to their problem, is not struggling with high-risk suicide thoughts, and does not need safety planning.

Crisis Line

A crisis line provides support to individuals who are struggling with high-risk suicide, crisis situations (where they can’t think of what to do), or who are otherwise unsafe. Many crisis lines have access to mobile crisis units, may call ambulances to take callers to hospitals or otherwise access more intensive support.

Hours of Operation

Deciding on the hours of operations for a crisis line is an important element. Many crisis lines started as 4-hours a day, 7 days a week operations before moving to 12 or 24 hours. Other organizations started immediately with 24 hours.

Staffing Volume

You’ll need to calculate the amount of staff you need for your crisis line (whether paid or unpaid) once you’ve decided on your hours of operation. One way to do this is the Erlang C formulas that are used to staff call centres (which you can fill with dummy data based on crisis lines in other regions.)

If you’re paying your staff, this will be easier. It might be easier to start small and then build up as your service gets more well known and well supported.

Choosing a Location

Choosing a location for a new crisis line (or any nonprofit really) will depend most commonly on your finances. Many organizations get cheap or free space in an organization like a church starting off, before moving to an office. If you’re really tight on space you might even be able to set up in a large office in someone’s home.

The keys to choosing a location will include availability, security, convenience, and price. While price is obvious, I’ll speak about the others.

One advantage of a stand-alone building is you have 24/7 access to it. If you’re in another type of location you may find it difficult or impossible to access after-hours, which can complicate things. Security is also a factor, in that if you’re not advertising your crisis line location it shouldn’t be obvious where you’re located. While a far-away location might seem to be ideal for security, it complicates accessibility (distance travelled) for your volunteers and limits convenience.

Forming a Nonprofit (or not)

Choosing whether to incorporate is a challenging decision to make. Incorporation provides you with benefits like protection of your assets, tax exempt status (once you’re registered as a charity) and the ability to pursue formal funding. The downsides are that it takes work to form and maintain the nonprofit status.

Finding Sources of Funding

Initial sources of funding may come from your Steering Committee but eventually you’ll need to explore outside sources. When your crisis line has operated for 1-2 years you’ll likely be eligible to apply for formal funding grants such as those at the local, state and federal levels.

Other sources include corporate sponsorship, fundraising events and direct donations.

Developing Policies and Procedures

Policies and procedures are important for ensuring that your volunteers respond in a consistent way. Examples of policies and procedures that you may wish to develop:

  • Call Trace and Intervention
  • Callers as Volunteers
  • Confidentiality
  • Recruitment (Criminal Record Check)
  • Victims of Abuse (Reporting Child Abuse)

Call Trace and Intervention

A Call Trace and Intervention policy will describe under what circumstances you will initiate call trace (to try and find an individual’s address or other identifying information) and under what circumstances you will call police/911 for Active Rescue. Some crisis lines will never initiate Active Rescue, for instance the UK Samaritans, unless the caller requests it. Many crisis lines will always err on the side of caution.

Call Trace will depend on the technology available to your crisis line but may include use of 411 (for non-blocked numbers) or contacting 911 directly to pass available information to them.

Helplines will often describe their intervention policy on the lines as something to the effect of, “We only intervene in cases of imminent homicide, suicide, or disclose of child abuse.”

Callers as Volunteers

Callers to your helpline will usually result in the creation of a call report or other record of that conversation. If you recruit volunteers from the same area that you take calls from, it’s possible that someone who has previously called your line may become a volunteer – and therefore be able to read their call report.

For that reason, you may require that volunteers to your helpline must have not used your service in the amount of time that records are retained. For instance, at Distress Centre Durham call reports are retained for one year so volunteers must not have used the service in that time in order to be eligible.

Confidentiality

Confidentiality is at the core of emotional support. Creating a safe environment is key to helping callers discuss their issues openly. Confidentiality means that volunteers who disclose information about callers outside of the crisis line or make contact with them outside of the line can be dismissed.

Examples of violations of confidentiality:

  • Talking about callers to your friends or family
  • Posting information about callers on social media
  • Giving information from the crisis line to another agency without that caller’s permission

It’s important to establish a very high degree of confidentiality or else callers will quickly lose trust in the helpline.

Data Destruction

A data destruction policy includes information on when and how you’ll destroy data that you’ve collected, such as via call reports or caller profiles. The most important element is to include a timeline for how frequently you’ll destroy data – such as on a quarterly basis for data that is more than 12 months old.

Recruitment (Criminal Record Check)

A Criminal Record Check (CRC), known by other names like a Police Record Check (PRC) or a Disclosure and Barring Service (DBS) Check describes a person’s record of criminal offenses. Many jursidictions include an option specifically for crimes against vulnerable individuals like children or seniors.

Many crisis lines will limit their volunteers only to those who have no criminal record, while some will allow – with approval – individuals who have certain types of non-violent offenses from many years ago.

Victims of Abuse

Nonprofit organizations are often legally required to report abuse, like child abuse or elder abuse. A policy explaining this will help callers better understand when they disclose child abuse, what the volunteer will do. In many crisis lines this means calling Child Protective Services (CPS) or a similar agency (like Children’s Aid Society in Ontario.)

You may also wish to include a statement about how your helpline takes a non-judgemental stance on abuse – not encouraging individuals to leave unless they’re ready to leave on their own.

Volunteers in Counselling or Therapy

Helpline work can be demanding and burnout can be a challenge. For this reason, it’s important to know when your volunteers are undergoing counselling or therapy. One way in which to do this is to have volunteers self-identify if they are receiving counselling or therapy and then giving them a letter to give to their therapist. That clinician will simply sign asserting that the work will not be harmful, and that can be filed away.

Volunteer Recruitment

Recruiting volunteers will depend on your local community. In some communities, United Way may operate a volunteer board online that you can submit your crisis line to. Universities or colleges may allow you to post flyers or distribute information to the students.

A good training class will be between 5 and 20 individuals, but recruiting throughout the year will be important for ensuring consistent service delivery.

Volunteer Screening

Screening involves determining if individuals possess the appropriate attitudes to be successful in helpline training. The American Association of Suicidology Crisis Center Certification identifies these attitudinal outcomes that individuals should experience by the conclusion of training:

  • Acceptance of persons different from oneself, and a non-judgmental response toward sensitive issues (e.g. not discussing suicidal ideation or abortion with a client in terms of its moral rightness or wrongness)
  • Balanced and realistic attitude toward self in the helper role (e.g. not expecting to “save” all potential suicides by one’s own single effort, or to solve all the problems of the distressed person)
  • A realistic and humane approach to death, dying, self-destructive behavior and other human issues
  • Coming to terms with one’s own feelings about death and dying insofar as these feelings might deter one from helping others.

Volunteer screening may include an application form that asks questions about the caller like:

  • Are there situations or topics (such as abuse or abortion) that may place you in a moral or ethical dillema?
  • What are your beliefs on suicide?
  • How do you feel you would talk to someone who is different from yourself?

The screening process does not have to rule out anyone yet, but may be helpful for prepping you on the interview.

Volunteer Interviewing

See also: Interviewing on a Suicide Hotline

The process of the volunteer interview will be to collect more information on the potential volunteer to make sure there is compatibility with your service. For instance, some individuals may only want to work with children or may not want to work with suicide – and your desires for your line may not align with that.

The interview is also an opportunity to see how someone is on the phone, and to help answer more of their questions about what the process looks like.

Volunteer Training

See also: Crisis Hotline Training Curriculum

Volunteer training is the process of teaching a volunteer the core skills that they need to be prepared for the helpline. Rather than reproducing material I’ve written about elsewhere, see the link above. From there you can find posts across my blog that will be useful for building a training program.

Training should run approximately 40 hours, with at least 24 hours of classroom training and 16 hours of supervised “on the phone” training being mentored by a shift supervisor or experienced volunteer before the newly trained volunteer is able to take shifts on their own.

You may find it helpful to bring on a therapist or counsellor to help you develop your initial helpline curriculum, or use a crisis line trainer from an area near you that doesn’t overlap with your catchment area.

Identifying Caller Issues

Caller Issues are the specific issues prevalent in your community that may lead you to develop training modules on them to prepare your volunteers. One example is in college towns where concerns over sexual assault or alcohol and drug abuse may be more prevalent.

The easiest way to do this is with effective helpline management software (see the next section.) With a detailed call report you will be able to pull statistics on exactly what your callers are discussing and this will help you fine-tune your training. Generally, the core elements of emotional support and crisis intervention will be exactly the same.

Helpline Management Software

In order to run a helpline you’ll need some form of helpline management software. I recommend iCarol, which my crisis line has used for several years. iCarol provides all the features you’d expect online helpline software to provide:

  • Shift Calendar so volunteers can sign up for shifts
  • Call Reports so volunteers can record details about their conversations
  • Chatboard for facilitating communication between staff and volunteers
  • Events Calendar
  • News

And a variety of other features, all designed with confidential helplines in mind.

Outcomes Measurement and Evaluation

See also: Methods of Evaluating Helplines and Hotlines

Outcomes Measurement and Evaluation describes the things that you will need to do in order to prove that your helpline is effective. One way in which to do this starts with your Basic Training program. Have your volunteers complete a pre and post training survey that includes questions about the perceived value of the training, their ability to display empathy and their understanding of crisis and suicide risk assessment. You’ll see their scores increase, demonstrating the knowledge transfer.

Another way to evaluate a Basic Training program is with a tool like the Suicide Intervention Response Inventory, which has volunteers rate how effective a series of statements are in providing emotional support. Their scores will change throughout training, indicating their increased skill.

On the phone calls themselves, your call reports can include space for Outcomes Measurement. This can include things like, “Callers says they feel better”, “Decreased distress and anxiety”, “Reduced isolation and loneliness.” These outcomes can be used to show what changes your callers experience throughout the call.

Joining Professional Associations

Finally you may wish to join professional associations like the Association of Crisis Workers or Crisis Lines in your area, or other professional groups that provide support to nonprofits. This will help you network, fundraise and attract volunteers to your organization.

Conclusion

As you can see, a lot goes into developing a crisis line – but it is not unmanageable. If you’ve decided to launch a crisis line, let me know in the comments! And please continue to ask questions if you’d like.

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Building a Suicide Prevention Group

Introduction

I’ve had the pleasure of serving on the Durham Region Youth Suicide Prevention (YSP) Action Group since February 2016. The goal of the YSP is to address the rising youth suicide rates in Durham Region in Ontario. This group was financially supported by a 3-year grant from the Ministry of Children and Youth Services.

For other regions interested in implementing similar suicide prevention groups (whether to address youth, elderly, military, or other targeted group suicide rates or others) the following may be helpful. Because my group was focused on youth suicide prevention, more of the resources below apply to that but the concepts are equally applicable to others.

Building Capacity

The first step is for your suicide prevention group to learn about suicide in your targeted population. Academic journals can be helpful in this way, as can other resources depending on the group you are looking for. I’ve linked some examples below, including a number of blog articles.

Learning About Adult Suicide

Learning About Elder Suicide

Learning About Law Enforcement Suicide

Learning About Male Suicide

Learning About Military Suicide

Learning About Youth Suicide

Choosing Your Suicide Prevention Group Members

In order to develop a suicide prevention group, you must identify individuals in the community who can participate. In order to be most effective, a suicide group should be cross-sectorial – that is, it should include individuals from a variety of stakeholders that are affected by that demographic. Examples of sectors and include:

  • Criminal Justice
  • Education
  • Faith / Religion
  • Hospital / Medical
  • Mental Health
  • Substance Abuse

It is important to recognize that regardless of the group you target, many of these stakeholders will be relevant. For instance, in an elderly suicide prevention group, organizations that work with seniors directly (such as seniors centres, long-term care facilities and hospices) will be important, but faith-based organizations, substance abuse workers and criminal justice may provide valuable insight based on their work with elderly clients.

Conducting A Needs Assessment

Once you’ve identified the group of individuals who will make a part of your suicide prevention group, the next step is to conduct a needs assessment. Needs assessments are formal explorations of what exists in your community, and what does not. This allows you to identify the gaps and make a formal plan for eliminating those gaps.

Examples of completed needs assessment for suicide prevention include Shasta County, California and Juneau, Alaska.

This strategic planning tool from TogetherToLive can help you start your needs assessment process. This process should also include community consultation via surveys, focus groups or other methods to collect information from individuals who have lived experience with suicide in your community, especially in your target demographic.

Choosing Interventions

Now that you’ve conducted a needs assessment, you have an idea what elements are lacking in your community. Interventions fall into one of three categories:

  1. Universal Interventions apply to everyone in a particular area. For instance, all individuals who present to an emergency room are administered a suicide screening measure; this is a universal intervention
  2. Indicated Interventions apply to individuals who are identified as high-risk for suicide. For instance, students who appear to be experiencing emotional health issues are referred to school mental health counselling
  3. Selected Interventions apply to individuals who present with suicide risk factors or warning signs. These can include referrals to therapists, crisis lines or transportation to the hospital for emergency mental health treatment.

There are a variety of interventions that your suicide prevention group can choose, targeting four different categories. These categories are Life Promotion (or Primary Prevention), Suicide Prevention, and Postvention.

Life Promotion Interventions

Life promotion interventions are those that focus on “build[ing] their resilience through their personal strengths, available resources and relationships with those around them.” These interventions focus on individuals who haven’t yet experienced suicidality. For youth, this will involve programs about self-esteem, healthy relationships and problem-solving, while for soldiers this might include PTSD awareness, managing combat stress and accessing physical and mental health resources as needed.

Suicide Prevention Interventions

Suicide prevention interventions are those that focus on individuals who have expressed suicidal ideation or at risk for suicide. This is the most common category for intervention because these individuals have begun to slide down the river towards suicide.

  • Restricting Access to Means – Restricting access to lethal means involves training individuals to assess and remove lethal means like firearms or lethal quantities from suicidal individuals so that they are able to stay safer. (Johnson, et. al., 2011)
  • Web-Based Suicide Prevention/Support Services – These include online discussion boards and other resources that provide platforms for suicidal people to discuss their issues, crisis chat services and other web-based programs. The Best Practices for Online Technologies (Reidenberg, Wolens, & James, 2013) can help with this.
  • Suicide Prevention Training for Primary Care Physicians – Primary care physicians represent an important point of contact for suicidal individuals. Primary care physicians often report feeling undertrained to adequately respond to suicide (McDowell, Lineberry & Bostwick, 2011).
  • Suicide Screening – Suicide screening involves administering a tool to individuals without necessarily having identified suicide risk yet. This can be a universal or indicated method. The ED-SAFE study (discussed more under “Emergency Department and Follow-Up Care” explains the advantages of universal screening. Troister et. al. (2015) discusses three screening tools: the Beck Depression Inventory II (BDI-II), the Beck Hopelessness Scale (BHS) and the Psychache Scale.
  • Gatekeeper Training – Gatekeeeper Training equips laypersons with the tools to recognize suicide risk and to connect with medium and long-term resources like crisis lines and therapy. Popular (and validated) crisis lines include ASIST (Applied Suicide Intervention Skills Training; Rogers, 2010) and QPR (Question, Persuade, Refer; Quinnett, 2012).
  • Suicide Hotlines and Crisis Lines – Suicide hotlines and crisis lines provide immediate emotional support, suicide risk assessment, crisis intervention and safety planning. They are an important element in the suicide prevention framework by catching individuals who may be very close to suicide. Crisis line outcomes have been studied (Kalafat, 2007; Gould, et. al., 2007) and found to have a range of benefits to callers.
  • Psychological Treatment / Psychiatric Treatment – Psychological and psychiatric treatment includes therapy, counselling, medication and a range of other treatments that are available and provided by mental health clinicians. The availability of mental health treatment can have an impact on the suicide rate. (Jagodic, 2013; Kapusta, et. al., 2010)
  • Emergency Department and Follow-Up Care – Emergency departments represent an important access point for mental health care. Universal screening with the ED-SAFE Tool has been shown to double the rate of detected suicide versus a control population. (Boudreaux, et. al., 2015) Additionally follow up has been shown to reduce the rate of re-admission. (Harrison, et. al., 2011)
  • Reducing the Harmful Use of Alcohol – Substance abuse is significantly related to suicidal behaviour. (Wilcox, Conner, & Caine, 2004) By assessing the risk of substance abuse and putting in place treatment options for the targeted population, the impact of addiction or harmful use of substances, including alcohol can be reduced.

Postvention Interventions

Postvention interventions refer to those items that are implemented in the aftermath of a suicide death. A number of interventions are listed on the TogetherToLive Postvention section. Some of these resources are explored below:

  • Provide immediate debriefing and information to survivors helps reduce the impact of the loss (Cox et. al., 2012; Parsons, 1996; Celotta, 1995; King, 1999) This debriefing should provide psychoeducation on grieving, depression and potential post-traumatic stress disorder (PTSD) while also emphasizing the importance of grieving.
  • Identify individuals at high risk and reach out to them (Celotta, 1995; Carter & Brooks, 1990). How this occurs will differ depending on the targeted population but it is important that a system is in place to refer individuals for support (an indicated risk strategy) and ensure that all those affected know how to reach out.
  • Ensure the media provides a respectful response to the suicide that acknowledges its impact without glorifying it (Bohanna & Wang, 2012; MediaWise, 2003) Safe messaging strategies can be implemented to reduce the risk of suicide contagion

Implementing Your Interventions

Once you’ve determined the interventions you would like to choose, you must begin to implement them. This can be accomplished by breaking your suicide group into sub-teams that focus on specific interventions. This allows you to begin to tweak your approach by seeing your chosen interventions applied in actual practice. Examples of implementations for some of the above interventions could include:

  • Providing ASIST gatekeeper training to local community members
  • Arranging for training of primary care physicians in suicide risk assessment
  • Distributing posters with information on local crisis lines in schools
  • Working with the hospital to deliver follow-up calls to patients seen in the Emergency Department for mental health issues

This effort usually requires support from the agencies involved (such as the hospital, the school, etc.) and therefore it is helpful if these individuals are present on your suicide prevention group.

Evaluating Your Suicide Prevention Group

Once you’ve implemented your interventions, evaluation will help you see the impact of your suicide prevention group activities. The exact method in which you measure your impact will differ depending on the interventions you choose, but could include things like:

  • Tracking the number of calls to local crisis lines or admissions to hospital for suicide-related behaviours
  • Counting the number of people you delivered gateekeeper training to
  • Providing pre and post-assessment surveys to gauge learning by people attending trainings
  • Measuring the suicide rate in your community or in your demographic

Ensuring that you have an evaluation plan designed before you implement your interventions will prevent you from forgetting to collect data or collecting the wrong data. Your suicide prevention group can then review this information and tweak your strategy as time goes on, altering the strategy or focusing on new interventions and goals.

References

Bohanna, I., & Wang, X. (2012). Media guidelines for the responsible reporting of suicide: A review of effectiveness. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 33(4), 190-198. doi:10.1027/0227-5910/a000137

Boudreaux, E., Allen, M., Goldstein, A.B., Manton, A., Espinola, J., Miller, I. (2015) Improving Screening and Detection of Suicide Risk: Results from the Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) Effectiveness Trial. Society for Prevention Research 23rd Annual Meeting. Accessed Jun 28 2015 from https://spr.confex.com/spr/spr2015/webprogram/Paper23206.html

Carter, B.F., Brooks, A. (1990) Suicide postvention: Crisis or opportunity?. School Counselor. 37(5)

Celotta, B. (1995) The aftermath of suicide: Postvention in a school setting. Journal of Mental Health Counseling. 17(4)

Cox, G.R., Robinson, J., Williamson, M., Lockley, A., Cheung, Y.T.D., Pirkis, J.  (2012) Suicide Clusters in Young People Evidence for the Effectiveness of Postvention. Crisis. 33(4) 208-214 doi: : 10.1027/0227-5910/a000144

Gould, M. S., Kalafat, J., HarrisMunfakh, J. L., & Kleinman, M. (2007). An evaluation of crisis hotline outcomes part 2: suicidal callers. Suicide And Life-Threatening Behavior, (3), 338.

Harrison, P. L., Hara, P. A., Pope, J. E., Young, M. C., & Rula, E. Y. (2011). The impact of postdischarge telephonic follow-up on hospital readmissions. Population Health Management, 14(1), 27-32. doi:10.1089/pop.2009.0076

Jagodic, H. K., Rokavec, T., Agius, M., & Pregelj, P. (2013). Availability of mental health service providers and suicide rates in Slovenia: a nationwide ecological study. Croatian Medical Journal, (5), 444. doi:10.3325/cmj.2013.54.444

Johnson, R. M., Frank, E. M., Ciocca, M., & Barber, C. W. (2011). Training Mental Healthcare Providers to Reduce At-Risk Patients’ Access to Lethal Means of Suicide: Evaluation of the CALM Project. Archives Of Suicide Research, 15(3), 259-264. doi:10.1080/13811118.2011.589727

Kalafat, J., Gould, M. S., Harris Munfakh, J. L., & Kleinman, M. (2007). An evaluation of crisis hotline outcomes part 1: nonsuicidal crisis callers. Suicide And Life-Threatening Behavior, (3), 322.

Kapusta, N. D., Posch, M., Niederkrotenthaler, T., Fischer-Kern, M., Etzersdorfer, E., & Sonneck, G. (2010). Availability of mental health service providers and suicide rates in Austria: a nationwide study. Psychiatric Services, 61(12), 1198-1203. doi:10.1176/appi.ps.61.12.1198

King, K. (1999) High School Suicide Suicide Postvention: Recommendations For an Effective Program. American Journal of Health Studies. 15(4).

Lapierre, S., Erlangsen, A., Waern, M., De Leo, D., Oyama, H., Scocco, P., & … Quinnett, P. (2011). A systematic review of elderly suicide prevention programs. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 32(2), 88-98. doi:10.1027/0227-5910/a000076

McDowell, A. K., Lineberry, T. W., & Bostwick, J. M. (2011). Practical suicide-risk management for the busy primary care physician. Mayo Clinic Proceedings, (8), 792.

MediaWise. (2003) The Media and Suicide. Accessed electronically from http://www.mediawise.org.uk/wp-content/uploads/2011/03/The-Media-and-Suicide-.pdf on November 26, 2016.

Parsons, R.D. (1996) Student suicide: The counselor’s postvention role. Elementary School Guidance & Counseling, 31(1)

Reidenberg, D., Wolens, F. & James, C. (2013). Responding to a cry for help: Best practices for online technologies. Retrieved on November 26, 2016 from http://www.sprc.org/resources-programs/responding-cry-help-best-practices-online-technologies

Rogers, P. (2010) Review of the Applied Suicide Intervention Skills Training Program (ASIST). LivingWorks. Retrieved on November 26, 2016 from https://www.livingworks.net/dmsdocument/274.

Troister, T., D’Agata, M. T., & Holden, R. R. (2015). Suicide risk screening: Comparing the Beck Depression Inventory-II, Beck Hopelessness Scale, and Psychache Scale in undergraduates. Psychological Assessment, 27(4), 1500-1506. doi:10.1037/pas0000126

Quinnett, P. (2012) QPR Gatekeeper Training for Suicide Prevention The Model, Theory and Research. QPR Institute. Retrieved on November 26, 2016 from https://www.qprinstitute.com/uploads/QPR%20Theory%20Paper.pdf.

Wilcox, H. C., Conner, K. R., & Caine, E. D. (2004). Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies. Drug And Alcohol Dependence, 76(Supplement), S11-S19. doi:10.1016/j.drugalcdep.2004.08.003

Cite this article as: MacDonald, D.K., (2016), "Building a Suicide Prevention Group," retrieved on June 25, 2017 from http://dustinkmacdonald.com/building-suicide-prevention-group/.

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How to Perform Social Return on Investment

Introduction

Social Return on Investment (SROI) is a way of measuring the impact of projects or programs that is especially suited to the work that non-profits do. To see the difference, let’s move from a for-profit to a non-profit mindset. A for-profit’s return on investment (ROI) focuses on money only: for instance, $25,000 investment in supply chain management results in an additional $75,000 in revenue; this means the ROI is 3:1, or $50,000.

Because non-profits don’t often generate revenue, this measure is less useful. Instead, non-profits often track outcomes like the number of clients served. At the Distress Centre, we receive over 7500 calls a year and save approximately 35 lives through emergency intervention. These numbers are useful, but they don’t translate well into a per-dollar figure. For instance, on a budget of $260,000 (a rough estimate), we pay $35 per call, or $7,429 per emergency intervention.

Is $35 per call reasonable? It may appear to be too expensive. What about when we divert an individual from hospital, or prevent a suicide attempt in progress? We have no way to track the monetary benefits of these, until we use SROI.

How SROI Works

SROI works by assigning a monetary value to activities that until now could not be monetized. Some of these are easier to calculate because real dollars are involved (for instance, when you de-escalate someone and they don’t need to go to the hospital, you’ve saved the cost of the police/ambulance and the emergency room service), while some are more difficult (the increased quality of life that one gets from a conversation on a crisis line.)

Value is assigned by a variety of methods that try best to approximate the costs involved. These items that are used to approximate value are called “proxies”, and lists of proxies are available on SROI-related websites.

Performing SROI

SROI has six major steps:

  1. Establish the scope and identify stakeholders
  2. Mapping outcomes
  3. Demonstrating outcomes and giving them a value
  4. Establishing impact
  5. Calculating the SROI
  6. Reporting, using and embedding

These are reviewed in more detail below. The data (charts, financial proxies, explanations, etc.) is reproduced from an unpublished SROI analysis conducted by myself, of the ONTX Chat and Text Program at Distress Centre Durham.

Establish the Scope and Identify Stakeholders

Establishing the scope for an SROI analysis involves identifying the purpose, audience and focus of the analysis. 

The audience for this analysis includes the four pilot Centres, our funding partners (Trillium, United Way and Greenshield Canada) and other services interested in producing a similar analysis of their service. The focus will be on one year of outcomes data collected in the operation of the ONTX project.

Stakeholders, in the SROI methodology, are individuals who experience gains as a result of the service provided. These can be direct gains (such as the reduction in distress experienced by a visitor to the crisis chat service or the savings experienced by not having to use EMS resources transporting a suicidal person to hospital) or indirect gains (such as the career benefits experienced by a responder who delivers the service or the of improved relationships with friends and family visitors may experience.)

In order for stakeholders to be included in the analysis, they must be material – that is, they must experience a benefit as a result of the service.

Mapping Outcomes / The Theory of Change

A theory of change, also known as a logic model, is a cornerstone of the SROI methodology that describes how inputs (the funds and people used in direct service delivery) result in changes (outcomes) that can be quantified to value the service. An example logic model for the ONTX Chat and Text Program is listed below:

Stakeholder Intermediate Outcomes Final Outcome
Visitors
  • Decreased harmful intentions
  • Immediate crisis diffused
  • Decreased suicidal intent
Reduced likelihood of visitor attempting suicide
  • Improved self-esteem, self-control or confidence
  • Less distressed or anxious
  • Options explored
  • Action plan explored
Improved visitor coping skills
  • Decreased isolation and loneliness
  • Improved connectedness
  • Knowing a responder is there for them
Enhanced visitor belonging
Police / EMS
  • Less likely to require ambulance or police service because of a high-risk suicidal caller
Reduced use of 911
  • Fewer responses to suicide deaths because of Responder intervention
Reduced cost to 911/EMS
Medical System
  • Less instances of hospital admission because of self-harm/suicide attempts
Reduced use of public health system

Demonstrating Outcomes and Giving Them a Value

Each of the final outcomes from the chart above needs to be operationalized, which involves identifying concrete elements to suggest an outcome has or will occur. This allows an assignment of financial value to those outcomes in determining the SROI.

Each of the above outcomes requires a financial proxy, or a method of quantifying its value. Some financial proxies are simple unit costs, like the cost of deploying police and an ambulance to respond to a suicidal crisis, while others are more difficult to quantify.

In consultation with stakeholders, a review of the SROI literature (including with other crisis chat services), the following financial proxies were decided upon:

Final Outcome Financial Proxy Calculation (all figures in dollars unless noted) Value per Instance
Reduced Likelihood of Visitors Attempting Suicide One month of life, adjusted with the disability weight assigned to Suicide and Self Harm (Value of a Statistical Life Year (VSLY) / 12 months) x 0.64 weighting $6,900.49
Improved Visitors Coping Skills Cost of two visits to a family doctor/general practitioner 40 per visit x 2 $80
Enhanced Visitor Belonging One week of leisure for the median Canadian income 3922 (yearly leisure expenses) / 52 $75.42
Reduced Cost of 911/EMS Cost of ambulance response for a suicide attempt 600 $600
Reduced Cost of Police Response to Suicide Death Unit cost of two police officers and two paramedics responding for total of 5 hours at median wage 36.53 x 2 x 2 (Police)

25.81 x 2 x 1 (Paramedic)

$249.36
Reduced Use of Public Health System Cost of hospitalization for suicide attempt minus the average cost of an ED visit (998 x 7.74) – 267 – 249.36 $7,208.16

Establishing Impact

The SROI methodology involves totaling the number of outcomes (now quantified as dollar values) against the total cost of inputs required to operate the service. Inputs can include direct service, such as employees, technology costs, advertising and so on.

Because three of the four Centres did not receive funding to hire an independent staff person, a value of 25% on a salary of $40,000 was used. This provides an estimation of the dollar value.

Input Description Value ($)
Distress Centre Durham Staff (prorated to 8 mos.) $15,000 x 0.8333 = $12,500
ONTX Grant (pro-rated to 6 mos.) $257,700 / 4 = $64,425
Community Torchlight Staff (est.) $10,000
Distress Centre Toronto Staff (est.) $10,000
Spectra Helpline (est.) $10,000
Total Inputs $106,925

Number and Dollar Value of Final Outcomes

Based on one year of data (June 29 2015 to June 29 2016), we can see the following outcomes. Only the items directly from the call reports are reported below for this sample analysis. The other intermediate outcomes (such as Less likely to require ambulance or police service because of a high-risk suicidal caller) have been operationalized in the report but are not listed here for space and complexity reasons.

Reduced Likelihood of Visitor Attempting Suicide ($6900.49 x 1,190)

Decreased harmful intentions – 522
Immediate crisis diffused – 301
Decreased suicidal intent – 367

Improved Visitor Coping Skills ($80 x 3,794)

Improved self-esteem, self-control or confidence – 796
Less distressed or anxious – 1831
Action plan explored – 1167

Enhanced Visitor Belonging ($75.42 x 1473)

Decreased isolation and loneliness – 1473

Total

$6900.49 x 1,190
$80 x 3,794
$75.42 x 1473
= $8,626,196.76

Deadweight and Attribution

Next, we have to estimate deadweight and attribution. Deadweight is the percentage of the outcome that would have happened regardless of our involvement. For instance, if a visitor told us that if they couldn’t reach our service, they knew five others they could, it is unlikely that much of the outcome would be lost if they could not access the ONTX pilot.

We have decided to calculate deadweight as a 15% reduction in overall value for every resource a visitor could identify as an alternative to our service. Since the average was 2, we assume 30% in deadweight.

Attribution is the amount of the benefit that is attributed to other persons. Because our service is often the primary intervention we have limited attribution, so for this analysis we will not note any attribution.

This takes our benefit value of $8,626,196,76 and reduces it to $6,038,337.732.

Finishing our Calculation

We take our total benefits generated, divide them by the total cost of the input to find the SROI ratio.

$6,038,337.732 Total Benefit / $106,925 Total Inputs = SROI Ratio of $56.47

For every one dollar invested in the ONTX pilot there is a social benefit of $56.47.

Sensitivity Analysis

Sensitivity analysis is a way of repeating calculations to take into account higher or lower than expected figures. See the table below:

Final Outcome Low Financial Proxy Original Financial Proxy High Financial Proxy Low Value Moderate Value (used for analysis) High Value
Reduced Likelihood of Visitors Attempting Suicide One week of life, adjusted with the disability weight assigned to Suicide and Self Harm One month of life, adjusted with the disability weight assigned to Suicide and Self Harm Two months of life, adjusted with the disability weight assigned to Suicide and Self Harm 1,592.42 6,900.49 13,800.98
Improved Visitors Coping Skills Cost of one visits to a family doctor/general practitioner Cost of two visits to a family doctor/general practitioner Cost of four visits to a family doctor/general practitioner 40 80 160
Enhanced Visitor Belonging One day of leisure for the median Canadian income One week of leisure for the median Canadian income One month of leisure for the median Canadian income 10.75 75.42 301.68
Reduced Cost of 911/EMS N/A Cost of ambulance response for a suicide attempt N/A 600 600 600
Reduced Cost of Police Response to Suicide Death Unit cost of two police officers and two paramedics responding for total of 2 hours at median wage Unit cost of two police officers and two paramedics responding for total of 5 hours at median wage Unit cost of two police officers and two paramedics responding for total of 7 hours at median wage 99.74 249.36 349.10
Reduced Use of Public Health System Cost of hospitalization for 3 days minus the average cost of an ED visit Cost of hospitalization for suicide attempt minus the average cost of an ED visit Cost of hospitalization for 12 days minus the average cost of an ED visit 2,477.64 7,208.16 11,339.64

Based on the low and high values specified we have benefits as follows. The reason we multiply by 0.7 is our deadweight, estimated earlier.

Low
1,894,978.8 + 3200 + 15834.75 = 1,914,013.55 x 0.70 = 1,339,809.485

High
16,423,166.2 + 607,040 + 444,374.64 = 17,474,580.84 x 0.70 = 12,232,206.588

Returning to our original formula:

  • Low $1,339,809.485 Total Benefit / $106,925 Total Inputs = SROI Ratio of $12.53
  • Moderate (already calculated) $6,038,337.732 / $106,925 Total Inputs = SROI Ratio of $56.47
  • High $12,232,206.588 Total Benefit / $106,925 Total Inputs = SROI Ratio of $114.40

Therefore our SROI analysis ranges from $12.53 – 114.40. Given this wide range, it may be safer to use a value of +/- 15% of our middle value, or to explore more carefully the value of the Final Outcome Reduced Likelihood of Visitors Attempting Suicide (which is currently calculated in terms of months of life, adjusted with the disability weight assigned to Suicide and Self Harm.)

Cite this article as: MacDonald, D.K., (2016), "How to Perform Social Return on Investment," retrieved on June 25, 2017 from http://dustinkmacdonald.com/perform-social-return-investment/.
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Spousal Assault Risk Assessment (SARA)

Introduction to Spousal Assault Risk Assessment

The Spousal Assault Risk Assessment (SARA) by Kropp, Hart, Webster & Eaves (1995) is used to assess the risk of intimate partner violence. Their tool recognizes that intimate partner violence may occur without regard to gender (male on female, female on male, female on female, male on male, and any other combination including trans and non-binary individuals), marital status (married and commonlaw individuals may engage in intimate partner violence), and does not necessarily require physical injury.

What follows is a brief summary of how to administer and score the SARA. More comprehensive information can be found in the manual itself. The SARA may be administered by minimally trained individuals up to Forensic Psychologists and Psychiatrists.

The SARA is comprised of 20 items that to provide a framework of historic, static and dynamic risk factors that have been shown to increase risk.

Information Required Prior to Assessment

All available sources of information should be consulted before completing the SARA.  This should include:

  • Interviews with both the accused/perpetrator and the victim/survivor(s) with a goal of collecting the SARA items
  • Standard measures for substance abuse (drugs and alcohol), personality, and IQ if available; the SARA manual recommends the Michigan Alcoholism Screening Test (MAST) by Seltzer (1971) for alcohol, and the Drug Abuse Screening Test (Skinner, 1982) for drugs, and the Personality Assessment Inventory by Morey (1991) for personality
  • Police reports, court documents, criminal records, etc.
  • Interviews with relatives or children who may have been exposed to abuse
  • Interview with probation officers

Coding

All items in the SARA are scored based on a 3-point scale:

  • 0 = Absent
  • 1 = Subthreshold
  • 2 = Present

If there is not enough to code an item, it should be excluded, not coded as absent. For instance, if there is no information to confirm or deny a current substance abuse issue, this should be left blank and noted, not assumed to be absent.

Critical Items

Some items are considered critical items – if these are present then it is enough to assume that potential/actual victims are at risk. These items are coded on a 2-point scale:

  • 0 = Absent
  • 1 = Present

These items are chosen as critical items based on the evaluator’s judgement.

Summarizing Risk

The result of a risk assessment will usually address two issues:

  1. Is there risk to the partner?
  2. Is there risk to children/non-spouse/others?

This summary is coded on a 3-point scale,

  • 1 = Low
  • 2 = Moderate
  • 3 = High

Communicating Risk

Writing a risk assessment is outside the scope of this article but you may see the original guide for more detailed information or my blog post about documenting suicide risk assessments for more information.

Assessment Items and Risk Management

For more detailed rating criteria please consult the original guide. The coding has been omitted from this table in appreciation for the original author’s copyright.

Item Name Coding Risk Management Strategies
1 – Past Assault of Family Members Intensive supervision or monitoring
2 – Past Assault of Strangers or Acquaintances Intensive supervision or monitoring
3 – Past Violation of Conditional Release or Community Supervision Intensive supervision or monitoring
4 – Recent Relationship Problems Interpersonal treatment (individual or group)

Legal advice or dispute resolution

Vocational counselling

5 – Recent Employment Problems Interpersonal treatment (individual or group)

Vocational counselling

6 – Victim of and/or Witness to Family Violence as a Child or Adolescent None given in guide;Interpersonal treatment (individual or group)
7 – Recent Substance Abuse/Dependence  Court-ordered abstinence, drug testing

Alcohol/drug treatment

8 – Recent Suicidal or Homicidal Ideation/Intent Crisis counselling

Hospitalization

Psychotropic medication

Court-ordered weapons restrictions

9 – Recent Psychotic or Manic Symptoms Crisis counselling

Hospitalization

Psychotropic medication

Court-ordered weapons restrictions

10 – Personality Disorder with Anger, Impulsivity or Behavioural Instability Intensive supervision

Long-term individual therapy

Group treatment

Psycho-education

11 – Past Physical Assault None given in guide;

Intensive supervision or monitoring

12 – Past Sexual Assaut/Sexual Jealousy None given in guide;

Intensive supervision or monitoring

Long-term individual therapy

13 – Past Use of Weapons and/or Credible Threats of Death None given in guide;

Court-ordered weapons restrictions

14 – Recent Escalation in Frequency or Severity of Assault None given in guide;
15 – Past Violations of “No Contact” Orders Intensive supervision or monitoring
16 – Extreme Minimization or Denial of Spousal Assault History Intensive supervision

Long-term individual therapy

Group treatment

Psycho-education

17 – Attitudes That Condone or Support Spousal Assault Intensive supervision

Long-term individual therapy

Group treatment

Psycho-education

18 – Severe and/or Sexual Assault None given in guide; long-term individual therapy
19 – Use of Weapons and/or Credible Threats of Death None given in guide; long-term individual therapy

Court-ordered weapons restrictions

 

20 – Violation of “No Contact” order Intensive supervision or monitoring

Other Considerations

The SARA manual indicates a number of other risk factors which may be factored into the assessment at the expert judgement of the evaluator. Examples of these include:

  • Current emotional crisis
  • History of torturing or disfiguring intimate partners
  • Victim or witness of political persecution, torture, or violence
  • Sexual sadism
  • Easy access to firearms
  • Stalking
  • Recent loss of social support network

Bibliography

Kropp, PR., Hart, S.D., Webster, C.D. & Eaves, D. (1995) Manual for the Spousal Assault Risk Assessment Guide, 2nd ed., The British Columbia Institute Against Family Violence.

Morey, L.C. (1991) Personality Assessment Inventory Professional Manual. Odessa, FL: Psychological Assessment Resources, Inc.

Selzer, M. (1971) The Michigan Alcoholism Screening Test: The quest for a new diagnostic instrument. American Journal of Psychiatry, 127. 1653-1658.

Skinner, H.A. (1982) The Drug Abuse Screening Test. Addictive Behaviour. 7, 363-371.



Cite this article as: MacDonald, D.K., (2016), "Spousal Assault Risk Assessment (SARA)," retrieved on June 25, 2017 from http://dustinkmacdonald.com/spousal-assault-risk-assessment-sara-guide/.

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Starting a Crisis Line or Hotline

Introduction

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.)

Helpline Evaluation

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.

Cite this article as: MacDonald, D.K., (2016), "Starting a Crisis Line or Hotline," retrieved on June 25, 2017 from http://dustinkmacdonald.com/starting-crisis-line-hotline/.

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