In This Issue
Ed Shneidman leads off this issue with an essay advancing the concept of “a good death.” He offers ten specific criteria for a good death, and proposes a simple golden rule for optimal dying. As always, Ed's contributions to this journal are stimulating, thought-provoking, and challenging. I look forward to a lively debate in response to his most recent musings on death and dying.
Morton Silverman et al., present a revision of O'Carroll et al.'s “Tower of Babel” nomenclature, as well as the background, rationale, and methodology associated with these deliberations over the past 8 years. As they observe, the Tower of Babel nomenclature paper (O'Carroll et al., 1996) refocused international attention on the critical importance of developing a uniform set of terms and definitions for our field. Over the last decade, the exponential increase in the number of research projects, clinical and scientific publications, international symposia, as well as governmental and nongovernmental organizations, attest to the public and academic attention being paid to suicide-related ideations, communications, and behaviors. Slowly, but surely, talking in public about suicide-related phenomena and its aftermath is becoming more commonplace. Nevertheless, confusing terminologies and inconsistent definitions abound at all levels of discourse. Silverman et al. offer a set of terms and definitions that reflect efforts to bring clarity, precision, and uniformity to our work.
The study by Jane Pirkis et al. provides further evidence for our ongoing need to educate the media about their role in preventing suicide. As they point out, there are times when it may be appropriate for a suicide to be reported, providing this is done accurately, responsibly, and ethically. They acknowledge that the news media may be an important player in raising awareness about suicide, increasing understanding of depression and related issues, and providing information about sources of help for vulnerable individuals. They observe that no studies have systematically examined the proportion of suicides that are actually reported in the media. Furthermore, they consider what makes a suicide newsworthy. By combining data on media reports of individuals’ suicides with routinely collected suicide data, it was found that 1% of Australian suicides were reported over a 1-year period. Reported suicides fell into three groups: suicides reported in a broader context; suicides by celebrities; and suicides involving unusual circumstances/methods. They conclude that the data suggest a need for media professionals and suicide experts to work together to balance newsworthiness against the risk of copycat behavior.
Lars Hansen et al. examine whether cognitive behavioral therapy (CBT) changes the level of suicidal ideation in patients with schizophrenia compared to a control group. In their study they identified 90 individuals with chronic schizophrenia who had positive symptoms and were resistant to medication. They found that CBT provided significant reductions in suicidal ideation at the end of therapy, and was sustained at a 9-month follow-up.
I am very pleased to present a special section on research investigating the effectiveness and utility of suicide prevention crisis telephone counseling. There has not been sufficient research looking at the role of crisis counseling in preventing suicides. On the positive side, some recent research has looked at teenagers’ attitudes about seeking help from telephone crisis services (Gould, Greenberg, Munfakh, Kleinman, & Lubell, 2006), while other studies have shown the effectiveness of telephone counseling for youth (King, Nurcombe, Bickman, Hides, & Reid, 2003) and the elderly (De Leo, Dello Buono, & Dwyer, 2002). In addition, researchers have looked at telephone contact after suicide attempts (Cedereke, Monti, & Ojehagen, 2002) and re-attempts (Vaiva et al., 2006), as well as the research efficacy, utility, and validity of silent monitoring of crisis calls (Mishara & Daigle, 1997).
Crisis hotlines are a recommended suicide prevention strategy based on the rationale that suicidal behavior is often associated with a crisis, and telephone crisis services can provide the opportunity for immediate support at these critical times by offering services that are convenient, accessible, and available 24/7. One measure of the effectiveness of telephone crisis services has been the assessment of suicide rates in communities served by the centers. These ecological assessments have provided either equivocal conclusions or positive, but weak, evidence of a preventive impact of suicide prevention centers; however, it is difficult to draw conclusions from these studies in the absence of data on whom the crisis centers reach or an evaluation of proximal outcomes, such as changes in suicidality during and shortly after the calls. Some of the obstacles in doing quality research on telephone crisis hotlines are: (1) maintaining confidentiality and anonymity of the caller; (2) coordinating research that extends beyond one hotline, or one geographical area; (3) lack of personnel and monitoring resources necessary to produce significant research findings; (4) accounting for staffing differences, in that some hotlines work with volunteers while others are working with paid mental health professionals; (5) valid techniques to monitor calls and assess the quality of the intervention provided as well as the effect it has on the caller; and (6) lack of a community control group.
With the establishment of the National Suicide Prevention Lifeline (1–800-SUICIDE) on January 1, 2005, and the increase in AAS certification and networking of crisis centers, came the opportunity to conduct research studies to evaluate (1) theoretical models of helper behavior and actual practice; (2) the impact of crisis intervention techniques; and (3) changes during the course of the crisis call (with follow-up weeks later) for those identified as crisis callers as well as those identified as suicidal crisis callers. The research team of Brian Mishara et al. silently monitored 2,611 calls received by 782 helpline workers at 14 telephone crisis hotlines networked through the toll-free 1–800-SUICIDE national number. They observed helper behaviors during the call, rated helper characteristics at the end of the call, and observed crisis caller characteristics and behaviors during the call. They investigated whether helpers used a more directive problem-solving model or a more nondirective active listening model.
Their first paper compares models of helper behavior to actual practice in telephone crisis intervention. This study helps to establish a common and acceptable vocabulary among hotline administration and volunteers. Recommendations include the need for quality assurance, development of standardized practice, and research relating intervention processes to outcomes (see Kalafat et al., Gould et al., and Mishara et al. in this issue).
In the second part of their study, Mishara et al. look at which helper behaviors and intervention styles are related to better short-term outcomes in telephone crisis intervention, based on monitoring 1,431 crisis calls to 14 centers. This study is a major contribution to our understanding of the necessity of required training of staff and volunteers to adequately serve the callers (see Joiner et al., this issue). The authors found that empathy and respect, as well as factor-analytically derived scales of supportive approaches and good contact, and collaborative problem solving were significantly related to positive outcomes. Of note was their findings that a large proportion of calls involved a crisis (65%), and a large proportion of the crises involved suicide (40%). A disturbing finding was that in only 346 of the 1,431 (24%) crisis related calls, the caller was asked if he or she was considering suicide, but in another 349 calls the caller said they were thinking of killing themselves without being asked. Of the 723 who were never asked, 22 of the callers later indicated that they were in the process of a suicide attempt during the call. Of the 472 callers who said that they were considering suicide, 179 were then asked if they had a plan, 71 told of a plan without being asked, and 219 were not asked anything at all about their suicidal intentions. Mishara et al. recommend that: (1) there is a need for continued quality control monitoring to ensure that calls are handled in the way centers desire and to improve the quality of help provided; (2) training curriculum should include practice in intervention methods that are related to positive outcomes, including the importance of establishing good initial contact, showing respect for callers, validating callers’ feelings, and taking a more directive problem solving approach; and (3) risk assessment needs to be improved by better training and supervision, not just whether or not an assessment is made, but also to ensure that when a caller expresses suicidal ideation, a complete assessment is conducted.
In related research, the team of John Kalafat et al. evaluated eight telephone crisis services located in six states, with 240 counselors participating. In total, the team completed baseline assessments on 1,617 crisis callers with follow-up assessments on 801 callers. Additionally, they completed baseline assessments on 1,085 suicidal crisis callers with follow-up assessments on 380 suicidal callers.
The goal of both studies was (1) to assess the immediate impact of a single telephone contact (that is, the attenuation of callers’ crisis state and the development of a coping plan and/or a referral for additional services or supports); (2) to assess callers’ crisis state 2 to 3 weeks after the call; and (3) to assess the recollection of and follow through of plans or referrals. In the first study, outcomes for general crisis callers were evaluated, while the second study focused on suicidal callers. In the first study, Mishara et al. found that callers’ distress was significantly reduced from the beginning of the call to the end of the call and up to 3 weeks later. At follow-up, the most frequent comments described empathic helpers who listened and allowed the callers to talk about their concerns, helped them to calm down and think more clearly, and provided options for dealing with their concerns. The services were described as readily available with helpers willing to stay on the line as long as needed. However, the lack of a control condition makes it difficult to definitively attribute the improvements in crisis state to the crisis intervention. Of note is the finding that at follow-up, 94 (11.7% of 801 crisis callers followed up) reported that they had suicidal thoughts since their original calls to the centers, that 52 of these individuals were having these thoughts when they called the center, and 17 said they told the counselor about these thoughts. This has two implications for crisis services: (1) policies and procedures must be developed regarding assessment of suicidal risk for all crisis callers or for a clearly specified type of crisis caller; and (2) training must be developed that enhances the ability and inclination of call handlers to systematically assess for suicide risk (see Joiner et al., this issue). The need to systematically conduct evidence-based risk assessments is attested to by the finding that the cohort of crisis callers in the present study who had suicidal thoughts did not improve over the course of the call or at follow-up to the same extent as other crisis callers.
Kalafat et al. focused their study on evaluating crisis hotline outcomes for suicidal callers. Proximal client outcomes were measured by changes in callers’ suicidal state from the beginning to the end of their calls and again within 3 weeks of their calls. They found that over half of the 1,085 suicidal callers (53.9%) had a suicide plan when they called the crisis center, 8.1% had taken some action to harm or kill themselves immediately before calling, and more than half (57.5%) had a history of prior suicide attempts. Rescue procedures were initiated for 37.9% of the callers who had taken some action to harm or kill themselves, 19.2% of those who had a current plan to hurt/kill themselves, and 15.2% of callers who had a history of previous suicide attempts. There was a significant reduction in suicide status from the beginning of the call to the end of the call on intent to die, hopelessness, and psychological pain. Notably, 11.6% (n = 44) of suicide callers at follow-up said that the call had prevented them from killing or harming themselves. The most frequent negative feedback concerned problems with referrals. Of the 151 follow-up suicidal callers who were given a new mental health referral, only 35% had kept or made an appointment in the period between the initial call to the center and the follow-up assessment. The researchers concluded that seriously suicidal individuals are reaching out to crisis services. The clinical efficacy of the crisis intervention is consistent with the significant decreases in suicidality found during the course of the telephone session, and the continuing decrease in callers’ hopelessness and psychological pain in the weeks subsequent to the crisis intervention. Their findings also suggest that follow-up outreach strategies may need to be heightened. It appears that steps to address the factors that would improve referrals to mental health services, including increasing their knowledge of community resources, matching callers’ needs with appropriate services, and fostering connectedness to support services, need to be taken.
Thomas Joiner et al. have furthered the results and recommendations of these two studies by developing standards for the assessment of suicide risk among callers to the National Suicide Prevention Lifeline, which was established through a federal grant from the Substance Abuse and Mental Health Services Administration. Joiner et al. provide the background on the need for these standards; describe the process that produced them; summarize the research and rationale supporting the standards; review how these standard assessment principles and their subcomponents can be weighted in relation to one another so as to effectively guide crisis hotline workers in their everyday assessments of callers to the Lifeline; and discuss the implementation process that will be provided by the Lifeline.
In summary, I hope that this special section will be widely read and discussed, and that its research findings and recommendations will become the foundation for a renewed investment and appreciation of the role of telephone crisis hotlines in the prevention of suicide and suicidal behaviors.
