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Establishing Standards for the Assessment of Suicide Risk Among Callers to the National Suicide Prevention Lifeline

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Establishing Standards for the Assessment of Suicide Risk Among Callers to the National Suicide Prevention Lifeline Suicide and Life-Threatening Behavior 37(3) June 2007 353 2007 The American Association of Suicidology Establishing Standards for the Assessment of Suicide Risk Among Callers to the National Suicide Prevention Lifeline Thomas Joiner, PhD, John Kalafat, PhD, John Draper, PhD, Heather Stokes, LCSW, Marshall Knudson, PhD, Alan L. Berman, PhD, and Richard McKeon, PhD The National Suicide Prevention Lifeline was launched in January 2005. Lifeline, supported by a federal grant from the Substance Abuse and Mental Health Services Administration, consists of a network of more than 120 crisis centers located in communities across the country that are committed to suicide prevention. Lifeline’s Certification and Training Subcommittee conducted an ex- tensive review of research and field practices that yielded the Lifeline’s Suicide Risk Assessment Standards. The authors of the current paper provide the back- ground 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 rela- tion to one another so as to effectively guide crisis hotline workers in their every- day assessments of callers to Lifeline; and discuss the implementation process that will be provided by Lifeline. On January 1, 2005, the National Suicide anytime from anywhere in the nation and are Prevention Lifeline (1-800-273-TALK) was routed to the nearest networked crisis center. launched. Lifeline, supported by a federal Callers are then connected with a trained grant from the Substance Abuse and Mental telephone worker who can provide emotional Health Services Administration (SAMHSA), support, assessment, crisis intervention, and/ consists of a network of more than 120 crisis or linkages to local treatment and support re- centers located in communities across the sources, including emergency services. country that are committed to suicide pre- Two major goals of Lifeline are to pro- vention. Persons in emotional distress or in mote efficient access to this service so it will suicidal crisis can call the toll-free number at reach more people nationwide at risk of sui- Thomas Joiner is Distinguished Research Professor and the Bright-Burton Professor of Psychol- ogy at Florida State University; John Kalafat is Professor, Rutgers Graduate School of Applied and Professional Psychology; John Draper is the Director of the National Suicide Prevention Lifeline pro- gram and Heather Stokes is the Director of Certification & Training of the National Suicide Preven- tion Lifeline program at Link2Health Solutions, Inc., New York City, operated through a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA); Marshall Knudson is Director, Alachua County Crisis Center, Gainesville, FL; Alan Berman is Executive Director, American Association of Suicidology; and Richard McKeon, Center for Mental Health Services, SAMHSA. This project is supported by a grant to Link2Health Solutions, Inc., from SAMHSA. Address correspondence to Thomas Joiner, FSU Psychology, Tallahassee, FL 32306-1270; E-mail: [email protected] 354 NSPL Risk Assessment cide, and to ensure high quality of services to risk assessments. Kalafat, Gould, Munfakh, its callers so as to more effectively prevent and Kleinman (this issue) studied 1,085 sui- suicide. Lifeline established a subcommittee cidal and 1,617 nonsuicidal crisis callers to of American and Canadian suicide preven- eight crisis hotlines. The hotlines had agreed tion experts in March 2005 to consult on de- to use standardized, evidence-based suicide veloping standards and recommended prac- risk assessments and measures of crisis states, tices for its network of crisis centers. Lifeline’s assessed near the start and at the end of their Certification and Training Subcommittee’s calls; and, for those who consented, at a fol- (CTS) extensive review of research and field low-up call approximately 3 weeks after the practices yielded recommendations that are original call. Significant reductions in crisis embodied in Lifeline’s Suicide Risk Assess- and suicide status occurred during the calls ment Standards, which were phased in for and continued to the follow-up. Notably, in implementation beginning in January 2007, response to an open-ended question at fol- with the expectation of network-wide adher- low-up as to what was helpful about the call, ence by September 2007. 11.6% (n = 44) of suicidal callers said that the In this article, we provide the back- call prevented them from killing or harming ground on the need for these standards; de- themselves. scribe the process that produced them; sum- Follow-up assessments were conducted marize the research and rationale supporting with 801 of the 1,617 callers who had been the standards; review how these standard as- categorized by centers as nonsuicidal crisis sessment principles and their subcomponents callers. At follow-up, 52 (6.5%) reported hav- can be weighted in relation to one another so ing suicidal thoughts when they had origi- as to effectively guide crisis hotline workers nally called the centers, and 27 of these said in their everyday assessments of callers to they had told the crisis worker of these Lifeline; and discuss the implementation pro- thoughts. Crisis centers had not conducted cess that will be provided by Lifeline. risk assessments for these callers, and these callers were more distressed than callers who did not report suicidal thoughts. This study THE NEED FOR EVIDENCE- highlighted the need to inquire about suicide BASED RISK ASSESSMENT on crisis calls, particularly with more dis- STANDARDS tressed callers (see Gould, Kalafat, Munfakh, & Kleinman, this issue; Kalafat et al., this Because of their accessibility, crisis issue). hotlines are in a unique position to intervene In another study Mishara and col- with individuals at various points along the leagues (this issue) silently monitored 1,431 pathway to suicidal behavior, including the calls to 14 centers. Overall, when emotional moments or hours prior to fateful decisions. or cognitive changes occurred from the be- This special contribution to suicide preven- ginning to the end of the calls, such changes tion is undermined if staff members are un- were positive. Their report concluded that able, unwilling, or reluctant to persistently the centers had helped a significant number inquire about and explore suicidal thoughts of callers and may have saved some lives. For and feelings with callers. example, at the end of the calls, 52.3% of Recently completed SAMHSA-spon- callers were less confused and more decided sored evaluations of crisis hotlines’ processes about next steps, 48.7% were less helpless and outcomes employed monitoring of hot- and more resourceful, and 40% were more lines and follow-up of callers to hotlines. hopeful. These studies provided overall evidence in Of the 1,431 callers, 723 were not support of crisis hotlines’ role in responding asked about suicidality. Of the 474 who were to crisis and suicidal callers, while raising asked or who reported suicidal thoughts, no some concerns about the quality of suicide questions about the means were asked on Joiner et al. 355 46% of the calls. In 159 instances when the that persistent assessment of suicidal thoughts, helper was aware that the caller was consider- feelings, and plans, as well as of alternatives ing suicide and had determined what means and inhibitors, is the most effective way to to use, the helper asked only 30 of those call- reduce callers’ isolation, anxiety, and despair, ers if an attempt was in progress. Questions and to begin the exploration of alternative about prior attempts were asked of only 104 ways of addressing their problems. callers. The study characterized these risk as- sessments as not following the accreditation guidelines of the American Association of THE PROCESS OF DEVELOPING Suicidology or procedures mandated by their SUICIDE RISK ASSESSMENT own center directors. STANDARDS FOR It should be noted that failure to con- NETWORK CENTERS duct appropriate suicide risk assessments or to pursue clients’ suicidal communications is Establishing Expert Consensus not unique to crisis hotline staff, as this has on Standards been found also among professional mental health providers (Bongar, Maris, Berman, & In order to meet the goals of reaching Litman, 1998; Coombs et al., 1992) and more people nationwide at risk of suicide and among primary care physicians (Williams et serving them more effectively, Lifeline has al., 1999). Nevertheless, this finding for orga- engaged national and international experts nizations, many of which include suicide in- and stakeholders in suicide prevention who tervention as a primary part of their mission, provide ongoing consultation and advisement prompted the CTS of the Lifeline Network to the project. The CTS is comprised of ex- to make the development of standards for ev- perts in the field of suicide prevention re- idence-based risk assessment a first priority. search, training, crisis center evaluation, and Primarily due to their accessibility to administration. In order to better ensure the callers in immediate suicidal crisis, crisis hot- application of crisis center research findings lines must engage in the assessment of immi- into field practices, the CTS has strong rep- nent risk. As telephone services, crisis hot- resentation of crisis center directors as well. lines face unique challenges in conducting In addition to the research findings suicide risk assessments and intervening with from the Mishara et al. (this issue) and Kala- suicidal persons. Crisis workers must estab- fat et al. (this issue) studies indicating a need lish and maintain rapport with callers with for more consistent, thorough assessment of whom there is less control than in face-to- caller risk by telephone crisis workers, the face situations, who may be using a phone absence of evidenced-based suicide risk as- service primarily because they wish to retain sessment standards for crisis centers further this control, and/or may be reluctant to com- underscores the need to address this issue mit to face-to-face contact or ongoing treat- immediately.
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