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Critical Faculties

Wrong answer

New research finds surprising errors at suicide hot lines. Like putting people on hold.

A suicide callbox on the Golden Gate Bridge in San Francisco.
A suicide callbox on the Golden Gate Bridge in San Francisco. (Jim Wilson / The New York Times Photo)
Email|Print| Text size + By Christopher Shea
September 9, 2007

THE PERSON MANNING the suicide hot line should have asked a follow-up question about the gun. Yes, the caller had said, he was despondent, and, yes, he mentioned he had considered using a gun to end his life. But that's where that line of conversation ended - until the phone receiver exploded with the sound of a gunshot.

The caller had a rifle with a string tied to the trigger, rigged to point at his head. The bullet went wide, sparing the man, but a question or two more from the crisis-center representative - such as, do you have a gun with you now? - might have changed the course of events.

The journal Suicide and Life-Threatening Behavior has published a remarkable series of articles on the effectiveness of suicide hot lines, opening a window into the world of desperate people and the volunteers who try to help them get through the night. Two of the unprecedented studies involved eavesdropping on suicide hot-line calls - in which the researchers heard things like that terrifying rifle shot - and two main conclusions came out of the work: One, many crisis-line callers are indeed in suicidal distress (and not just lonely or sad) and they are helped by talking to an empathetic fellow human being. And two, the call centers fail, with alarming regularity, to ask some very basic questions: Are you suicidal? Do you have a plan? Do you have the tools at hand to carry it off? Are you alone and drinking?

The studies are part of an effort to bring scientific rigor and a higher degree of standardized quality control to the 120-plus centers affiliated with a federal network of suicide hot lines, and holds the promise of saving lives. Under the network system, people who call 1-800-SUICIDE or 1-800-273-TALK get linked to a federally approved center near where they live. The network directs some 9,000 to 10,000 callers a month to local centers, and the hope is that an effective network might bring down the rate of suicide, which claims 30,000 lives annually in the United States and is the 11th leading cause of death. A study released last week by the Centers for Disease Control and Prevention found a striking 8 percent increase in suicide rates for Americans ages 10 to 24, from 2003 to 2004.

The new research, the most sweeping of its kind ever conducted, has already spurred a revamping of the training given to hot-line volunteers, effective this month.

"This is truly groundbreaking research," says John Draper, director of the National Suicide Prevention Lifeline, whose offices are in New York. "It's a beacon telling us not only what we are doing right but what we could be doing better."

According to two articles by lead author Brian L. Mishara, a professor of psychology at the University of Quebec at Montreal and president of the International Association for Suicide Prevention, 15.5 percent of the 1,431 calls his research assistants listened in on - at 14 crisis centers - failed to meet minimal standards for evaluating suicide risk and providing counseling. An additional 1,200 calls were monitored but deemed purely information-seeking, too short, or otherwise impossible to evaluate.

The study, however, hardly represents a condemnation of the centers, Mishara insists. On balance, callers were less hopeless, apprehensive, and generally depressed by the end of calls. "The good centers are doing an excellent job," he says, though research ethics forbid him from identifying either the good or bad ones.

The studies, and the hot-line network itself, are part of what some might call a belated effort by the US government to treat suicide as a significant health problem. Many people trace official interest in the subject to a Senate resolution, introduced in 1997 by Senator Harry Reid, Democrat of Nevada, whose father killed himself, which proclaimed reducing suicide a national priority. A major surgeon general's report followed two years later. The Department of Health and Human Services introduced the first federal 1-800 suicide-crisis line in 2001 and the Mental Health Association of New York City took over administration of it in 2005.

With the federal money to link up the centers - $2.6 million this year - came the requirement of rigorous evaluation. (In Boston, the federally affiliated center is Samaritans Inc., which has an office in Framingham as well. Its director, Roberta Hurtig, says neither center was evaluated in the recent studies.)

The two articles by Mishara and his eight co-authors focused on the demeanor of people answering phones, and how callers responded. Most centers, the researchers explained, claimed to adhere to one of two styles of counseling: nonjudgmental "active listening" and a more aggressive, problem-solving approach.

One problem: There was no correlation between a center's philosophy, as eloquently described by its director, and what the people answering the phones said and did. Mishara did find that the helpers who mixed the two approaches - mostly empathetic, with a dash of problem-solving - had the best results, and that strategy can be taught, he says.

What stands out, though, is just how often the helpers failed to meet the basic standards for either approach. In 723 of 1,431 calls, for example, the helper never got around to asking whether the caller was feeling suicidal.

And when suicidal thoughts were identified, the helpers asked about available means less than half the time. There were more egregious lapses, too: in 72 cases a caller was actually put on hold until he or she hung up. Seventy-six times the helper screamed at, or was rude to, the caller. Four were told they might as well kill themselves. (In one such case, the caller had admitted to compulsively molesting a child.)

There were 33 evident on-line suicide attempts, yet only six rescue efforts, sometimes because the caller ended the communication. In one case, a caller who'd overdosed passed out, yet the helper hung up.

In addition to the new training, Mishara would like to make call-monitoring a standard feature of crisis hot lines. So far that's optional, although some centers embrace the move. Michael Mitchell, clinical director of the Crisis and Counseling Centers Inc. in Augusta, Maine, has asked that supervisors listen in to about one in 10 crisis calls.

"There's a push-back from some of the more senior crisis workers," he concedes. "They see it as Orwellian." Still, he argues that monitoring is "absolutely" a good idea: After all, if credit-card companies do it, why not call centers, where the lives of "customers" are at stake?

A deeper question lurks behind the studies: Do suicide hot lines reduce suicide rates? Researchers have come to conflicting conclusions.

"They help people in a crisis," says J. John Mann, a psychiatrist at Columbia and a skeptic, "but whether those people would have gone on to kill themselves is unclear."

But another new study in Suicide and Life-Threatening Behavior, by researchers at Columbia, Rutgers, and the New York State Psychiatric Institute, suggests that many of the people calling in are, indeed, in extremely dire straits. This team of researchers had counselors at eight centers in 2003 and 2004 ask thorough questions of 1,085 callers who identified themselves as suicidal. Some were too distressed even for questioning: 88 had begun some sort of suicide attempt before making the call, and 136 times the helper ordered some kind of rescue. Overall, 58 percent of the callers had made a previous suicide attempt, striking evidence that they were in peril.

And these people seem to find solace in their phone calls. In follow-up appointments with some 380 callers, 12 percent said the call had kept them from harming themselves; roughly a third reported having made and kept an appointment with a mental-health professional. On the other hand, 43 percent reported having felt suicidal since the call, and 3 percent had made a suicide attempt.

Mann has not read the new studies, but he says that the most productive antisuicide measure he has identified would be to better train primary-care physicians to spot depression. They are notably bad at this: The majority of Americans who commit suicide saw their doctor within a month of their act.

The other antisuicide measure that Mann's research has found to be highly promising is a nonstarter, at least in the United States: "restriction of means." That's a bit of medical jargon that means eliminating guns from homes.

Christopher Shea's column appears regularly in Ideas. E-mail criticalfaculties@verizon.net.

(Correction: Because of a reporting error, a story in the Ideas section on suicide prevention ("Wrong Answer," Sept. 9) misstated the number of calls answered by the federal network of suicide hotlines. The network takes between 36,000 and 37,000 calls per month, on average.)

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