Crisis Lines: Current Status and Recommendations for Research and Policy

Suicide is a significant public health concern in the United States (1); it is the 11th leading cause of death among adults, with the age-adjusted rate of suicide increasing by 35% in the past 20 years (2). The escalating rate of suicide has brought increasing public attention to this issue. As a result, many experts advocate making suicide a top public health focus. Specifically, there have been initiatives targeting the growing suicide rate, one of which has been led by the U.S. Department of Health and Human Services (3). One such policy initiative funded the National Suicide Prevention Lifeline (NSPL) telephone number, which allows individuals free, confidential access to talk with trained volunteers and to receive referrals to mental health resources in their area. This hotline has evolved to include chat and text formats. In addition, population-specific crisis resources have emerged, such as the Veterans Crisis Line (VCL), the Trevor Project Line, and the Nacional de Prevención del Suicidio (www.thetrevorproject.org/get-help; https://www.apa.org/topics/crisis-hotlines).

The growing movement toward making crisis services more accessible was bolstered by congressional approval of the National Suicide Hotline Designation Act of 2020, which cleared the way for national implementation of the shorter 988 telephone number for NSPL in July 2022 (4). Proponents of the act argued that creating an easy-to-remember three-digit number for the NSPL would help individuals to receive efficient assistance (5). Furthermore, the shortened 988 number would help individuals access local crisis services and mental health resources. Although the NSPL has made strides in addressing inequities in access to mental health services, evidence gaps remain that need to be addressed as more individuals become aware of the new telephone number.

At the same time, the rise of the NSPL and associated crisis resources (discussed below) raises ethical concerns. Confidentiality and privacy concerns may influence whether hotline users are willing to disclose information as well as which kinds of information they share. Research on general acknowledgment of suicidal behavior has supported this idea. For instance, a study (6) of youth disclosure of suicidal and nonsuicidal injurious behaviors found that nonsuicidal behaviors were acknowledged more often than suicidal behaviors. Also, many youths failed to acknowledge their self-injurious (suicidal and nonsuicidal) thoughts and behaviors when asked by a health care provider (e.g., pediatrician or mental health care provider). Common barriers to disclosure included fear that the provider would tell a parent or guardian, fear of worrying their parent or guardian, and fear of being hospitalized. In a military context, confidentiality and privacy concerns can drive concealment of suicidal thoughts and behaviors that could cause harm to one’s career (7). Increasing the confidentiality around asking about suicide has been associated with a slight increase in disclosure of suicidality among a sample of U.S. National Guard service members (7). Confidentiality and privacy will continue to be challenges with the transition to 988.

This policy review examines the research conducted since the introduction of the NSPL on the state of crisis support lines; current efforts to create equity in the help-seeking process, including designating hotlines targeted to historically marginalized populations; and suicidal and nonsuicidal outcomes of callers. We also expanded on the systematic review conducted by Hoffberg and colleagues (8) by highlighting the need for further research and policy changes regarding training for crisis line staff and volunteers, evaluation of caller outcomes, and a focus on specialized populations—all of which can be used to guide research and clinical practice on the 988 crisis line.

Overview of the NSPL

In response to the growing problem of suicide, a number of public health prevention strategies have gained traction. Crisis hotlines are one such community-focused prevention strategy (9). As a federally driven initiative, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and Vibrant Emotional Health, the NSPL was established to create a national crisis line that provides free crisis intervention services and can be accessed by anyone across the United States (https://988lifeline.org/faq). The NSPL was established in 2004 with one dedicated telephone number to enable individuals in crisis to immediately reach someone (10). The NSPL currently consists of 200 local- and state-funded crisis centers across the country, which are operated on a 24/7 basis (https://988lifeline.org/our-crisis-centers). When calling the NSPL, users are connected to their local hotline center, which has a working knowledge of nearby mental health referral sites. If local call centers are not able to answer a call, the call is rerouted to an out-of-state call center or to NSPL’s national backup network (11). Calls to the NSPL have increased exponentially since it first launched, with 3.5 million people reaching out to the NSPL since 2005 (12). Despite the increase in calls, the NSPL has mostly kept up with the demand. Data have shown that 85% of calls were answered on first contact; however, only 56% of texts and 30% of chats have received an immediate response from a staffer (12). The NSPL has struggled to fully staff its call and chat centers and has noted a need for more crisis call centers to keep up with increased demand from the transition to the 988 number (12).

The NSPL is commonly publicized in instances of crisis response and safety planning, research participation documents, and public awareness campaigns (13). The NSPL encourages businesses and individuals to promote the telephone number and provides free materials to advertise the resource (https://988lifeline.org/faq). For instance, the NSPL telephone number is automatically offered when a person types something into the Google search bar that references suicide (14). The NSPL and its local call centers employ a mix of paid staff and volunteers who have qualifications such as education and experience in the mental health field, as well as those who have no experience but have empathy for individuals in crisis.

All NSPL staff are trained through LivingWorks’ Applied Suicide Intervention Skills Training (ASIST), which has been shown to improve caller satisfaction and perceived helpfulness of the responder (15). Research on ASIST (16, 17) has shown the program to be effective in providing skills and training for staffers helping people who express suicidal ideation; however, the impacts of the training on suicidal behavior have not been extensively researched. Certified call centers affiliated with the NSPL are required to provide basic training for call center staff and to participate in quality assurance evaluation, including providing data on caller demographic characteristics and outcomes (e.g., evaluation of call logs) (18). Call center staff are also required to follow a risk assessment protocol with every person who calls or sends a text or chat message (19). The NSPL subsidizes the cost of further training for staff, but no data are available on how many staff pursue further training or on the types of training offered (https://reimaginecrisis.org/988lifeline). In light of the various uses of the NSPL number and the lay community members who help staff the centers, there is need for a review of who reaches out to the hotline during a crisis, how they are being assisted, how effective the assistance is, and areas requiring improvement. Such a review is particularly important to better inform policy decisions as services are expanded to a more comprehensive crisis system with the shift to 988.

Caller Outcomes Associated With the Use of Crisis Lines

From a policy analysis perspective, there is limited research on the proximal (i.e., during or immediately after the crisis contact) and distal (i.e., long-term postcrisis contact) impacts of the use of crisis lines on outcomes among suicidal patients. Most of the existing research on crisis call outcomes has followed the procedure outlined by Kalafat and colleagues (20). In this procedure, assessments are completed at the beginning and end of the contact by crisis center staff and do not require the consent of the caller. At the end of the crisis call, callers can consent to a follow-up assessment and provide details on how to be contacted in order to protect confidentiality. The existing evidence (21) suggests that hotlines reduce caller distress and suicidality during the telephone call and for a short time after the call (e.g., 2–3 weeks). In terms of proximal outcomes, callers to the NSPL tend to report a decrease in intent to die from the beginning to the end of the call (22), with a 43% reduction in distress by the end of the call (23). Importantly, policy evaluation evidence indicates that caller outcomes vary by counselor training and approach during the call. For example, callers who completed calls with hotline counselors trained in the ASIST model had better mental health outcomes at the end of the call, including feeling less depressed, alone, and suicidal, compared with callers whose hotline counselors were not ASIST trained (15).

In terms of long-term outcomes, contact with the NSPL has been associated with reductions in hopelessness, psychological pain, depression, and anxiety in the weeks following a crisis call (20, 22). Findings (20, 22) indicate that a minority of callers complete follow-up with a mental health care provider, with approximately 33%–42% following through with the crisis hotline referral. Research also indicates that continuity of care following NSPL contact, in which a hotline counselor follows up with clients and conducts a brief clinical intervention (e.g., providing coping strategies, social support, and advice on environmental safety), offers additional protection. Nearly 80% of clients who expressed suicidal ideation during their crisis call and received a follow-up call indicated that speaking with the counselor had stopped them from killing themselves, and >90% reported that the follow-up call kept them safe (24). Currently, call centers are encouraged to conduct follow-up calls with callers who are deemed to be at medium or high risk for suicide, if staff resources permit (25).

Text- and Chat-Based Services

Text- and chat-based services have opened doors for a subpopulation of people who are unable or choose not to call the NSPL. Common reasons to use text or chat crisis services instead of the telephone line include not having access to a telephone, having a disability that prevents one from using a telephone, convenience, and increased desire for caller anonymity (26, 27). Crisis text- and chat-based services are fairly new in the field of crisis support; therefore, research on the use and efficacy of these methods has been sparse.

Chat-based crisis services can be accessed through the NSPL chat website (https://suicidepreventionlifeline.org/chat). To access chat services, the user must first fill out a survey of demographic characteristics before being connected with a counselor. Crisis chat services have been found to be as effective as telephone services in reducing user distress and appealing to younger people (28, 29). For instance, a recent study (30) examined the overall effectiveness of the chat service, reporting that two-thirds of chat users found the service to be helpful but that only half felt less suicidal after contacting the chat service. Compared with telephone service users, chat service users may have had greater suicidal ideation at the end of their session because fewer chat service volunteers conduct suicide risk assessments, despite elevated reports of suicidal ideation from chat users (30).

The Crisis Text Line (CTL; https://www.crisistextline.org) is accessed by texting HOME to 741741 via mobile phone, WhatsApp, or Facebook. The CTL is not directly affiliated with the NSPL and is available for users worldwide. Similar to the chat service, the CTL primarily appeals to a younger age group, with 75% of texters being under the age of 25 (https://crisistrends.org/#faq) (31, 32). Despite a disproportionate number of texts from those in low-income neighborhoods, a study by Thompson and colleagues (33) found that adolescents who frequently texted the CTL came from primarily urban settings, leaving a gap in text line access for adolescents from rural areas. Furthermore, the COVID-19 pandemic has prompted increases in text-based crisis line use among youths, specifically among lesbian, gay, bisexual, transgender, and queer (LGBTQ+) youths, highlighting the need for culturally informed training for volunteers and staff interacting with these populations via text (34). Despite the benefits that have come with these new technologies, some concerns have emerged, including data privacy rights and a lack of studies on the efficacy of these modalities (8, 35).

Specialized Hotlines for Minoritized Groups

The NSPL currently provides tailored options for Spanish speakers and for people who are deaf or hearing impaired through its main telephone line (https://988lifeline.org/faq). In addition to the general national crisis hotline, population-specific hotlines exist for groups at increased risk for suicide. These hotlines may increase help-seeking behaviors by providing culturally sensitive care. For example, nearly half of callers to an LGBTQ+ youth crisis hotline indicated that they would not have contacted a non-LGBTQ+ hotline and that they were motivated to use the LGBTQ+ hotline because of the presence of sexual and gender minority–affirming hotline counselors (36). In 2020, the Trevor Project’s crisis services for LGBTQ+ youths (telephone, chat, and text) received >150,000 contacts (37), with callers disclosing concerns such as homelessness, mental health struggles, and suicidality (38). The Trans Lifeline is a crisis support hotline run by transgender individuals for transgender individuals; since its inception in 2014, the hotline has received >100,000 calls (www.translifeline.org/about/#impact). A recent study (39) addressed issues affecting LGBTQ+ youth users of tailored telephone and text services. Several positive outcomes were observed (e.g., high user satisfaction, positive perceptions of the crisis service workers’ warmth and compassion). However, confidentiality and privacy concerns led LGBTQ+ youths to more frequently text rather than call.

The VCL was established in 2007 under the Joshua Omvig Veterans Suicide Prevention Act (40). Since its foundation, the VCL has received nearly 6 million telephone calls and has initiated >1 million referrals to Veterans Affairs suicide prevention coordinators (www.veteranscrisisline.net/about/about-us) as well as to other culturally tailored services (e.g., programs for homeless veterans) (41). In terms of policy outcomes, the VCL is proximally effective, with callers reporting reductions in distress, suicidal ideation, and suicidal urgency over the duration of the call (42). Specifically, >80% of VCL users reported that contacting the VCL was helpful and stopped them from killing themselves (43). However, findings (44) have indicated a lesser impact on long-term suicide outcomes, with risk for suicidal behavior and death by suicide elevated from the point of the initial VCL call for up to a year later, compared with the general veteran population in the Veterans Health Administration (VHA) system. Furthermore, Predmore and colleagues (27) found that veterans used the chat service as a first contact with mental health services; more than half of all VCL contacts ended with a referral (45). Therefore, the VCL is an important first step in accessing services for military veterans.

Recommendations for Crisis Line Policy, Research, and Practice

The state of evidence for crisis support services remains in its infancy. As such, promising opportunities exist to move research, policy, and practice forward as the national 988 implementation takes hold. Table 1 summarizes major gaps and potential future directions in this area. We share the following recommendations.

Enhance Training, Cultural Competence, and Evaluation

Despite some research on the effectiveness of crisis lines, several knowledge gaps remain. There is a distinct lack of literature addressing the effectiveness of training for long-term caller outcomes and for other proximal outcomes. An expanded focus on proximal outcomes is vital and should include how call center staff address lethal means safety and nonsuicidal self-injury. Long-term caller outcomes that may be important for training, research, and evaluation purposes include the seeking of mental health services postcrisis, suicidal ideation over time, and use of crisis lines or services. The literature that does discuss caller outcomes fails to include important factors, such as which training programs the employees and volunteers completed, the number of training programs completed, and the extent of skills used during calls. Although center volunteers provide referrals for callers to use after the call, many individuals have cited that lack of insurance or underinsurance was a primary barrier to seeking services after the call (22). Thus, the referrals provided may not suit the caller’s needs or the referrals may not be up to date (23). Call center employees and volunteers can benefit from training that highlights the referral process and how to tailor it to individual callers. In addition, call center effectiveness can be evaluated by tracking the rate of referrals used (46). Research has shown that effectiveness of gatekeeper training (an intervention for non–mental health specialists to identify and appropriately react to suicidal behavior) (47) can be improved by continued learning, reminders of what was learned, and program updates (48). Therefore, we recommend implementation of repeated training for crisis center staff, with evaluation of the effectiveness of training at several time points. Training should also address callers’ specific requirements, access barriers, and the need to make appropriate local referrals.

Additional aspects of training require attention. Although there is some indication that hotline volunteers receive routine training, there are no specific requirements about training frequency, modality, or evaluation for centers affiliated with the NSPL (15). At minimum, training should be designed to assess important gatekeeper training constructs, such as attitudes about suicide prevention, use of suicide prevention training skills, and intention to use skills in instances outside of training (49). Several areas of training require improvement. First, through policy refinement, the NSPL should be mandated to publicize training information for staff in a transparent manner. Second, from a practice perspective, training needs to better account for attitudes toward suicide and other factors affecting counselor performance. Attitudes toward suicide can be evaluated during the initial training and targeted in subsequent training, because these attitudes can affect clinical decision making (50). Finally, to make direct, geographically helpful referrals that meet callers’ needs, call center leaders should develop relationships with appropriate community resources (51). State-level policy makers can consider NSPL–community agency partnerships that include keeping updated lists of services and providers in the immediate geographic area and furthering understanding of the barriers unique to the community.

Several high-risk groups (e.g., American Indians, Alaska Natives, people struggling with suicide loss) have not been included in targeted suicide prevention measures, such as crisis support lines (https://www.samhsa.gov/suicide/at-risk). Moreover, although individual crisis lines that serve veterans, LGBTQ+ individuals, Spanish speakers, and people with impaired hearing exist, evaluation of crisis line volunteers’ culturally sensitive and nondiscriminatory performance is lacking. We recommend developing culturally responsive staff training and evaluation.

Basic research may be targeted toward assessment of the prevalence of hotline use by specific groups. For example, culturally informed gatekeeper training programs have been developed, have been shown to be effective, and are needed by racial-ethnic communities at risk (52–54). Similar basic research should take place at crisis services targeted to other high-risk groups. Cultural adaptation of training may include population-specific risk or protective factors, cultural beliefs about suicide, and codesign and facilitation of programs by multicultural experts or by members of the minoritized community. Evaluation outcomes for minoritized groups may include how effective hotline workers are in using culturally competent skills (e.g., cultural humility) and whether offered referrals are culturally appropriate. Call center evaluations should also include feedback questions asked of hotline users regarding cultural competency of the counselors. These recommendations align with current Centers for Disease Control and Prevention guidelines (55) for culturally sensitive evaluation for minoritized groups. As the NSPL becomes more accessible through the 988 number, caller diversity will likely increase, and these individuals cannot all be diverted to specialized hotlines (e.g., Trevor Project, VCL). This increased call volume will require all volunteers to be equipped to understand cultural nuances and properly respond in a culturally competent manner.

Expand Research on Telephone-, Text-, and Chat-Based Services

The overall state of the research on crisis services was found to be relatively poor (8). Use of the highest levels of rigor (e.g., randomized controlled trials) (56) may be both impractical and unethical in many circumstances. For example, it would heighten risk to crisis service users to randomly assign them to some type of time delay or pure control condition. Such barriers place clear limitations on the quality of crisis line research. However, it is possible to answer a number of important questions within the bounds of ethical research. For instance, we noted above the need to enhance training for crisis service workers. It would be feasible to compare the impact of different types of training by offering competing training approaches (e.g., ASIST vs. other gatekeeper training), randomly assigning service users to staff members by training type, and comparing the possible association between crisis line workers’ training type and caller outcomes. To bolster the evaluation of such questions, additional information on long-term caller outcomes is needed. Carefully explained collection of information could be added to crisis line protocols during a follow-up contact. Incentivized research participation could be offered to service users after the initial contact to avoid concerns of coercion during a crisis and to enhance the amount of prospective evaluation data.

Text, chat, and other suicide lifelines have received little attention regarding their effects on suicidal and nonsuicidal outcomes. The new 988 number is also offered as a text option (57) and will likely lead to an increase in individuals using the text service, despite the absence of clear research evidence of the efficacy of text crisis services in reducing distress and handling texter volume (58). Future studies can address two areas. First, studies should be aimed at understanding how chat and text services affect user outcomes. Similar to research on crisis telephone lines, the focus should also include long-term outcomes after service use (59). To combat the dearth of research on chat and text services, standardized evaluations of these services should be performed and should include suicidal and nonsuicidal outcomes (60, 61). Second, the accessibility of chat and text services to high-risk populations should be studied. If these services are deemed effective, studies should be conducted to understand the types of populations, beyond adolescent and LGBTQ+ populations, who use these services and to learn how these services can be better promoted among these populations (62).

Provide Ethics Oversight for Crisis Support Services

The introduction of newer crisis service formats, such as technology-based options, has yielded questions about ethical considerations for caller data. One recently publicized concern was raised about the CTL, where caller data were passed to a partner for-profit organization—with acknowledgment to the user about such practices offered through a link to a disclosure composed of many lengthy paragraphs (63). Many crisis hotline users divulge sensitive information during calls. Private-sector disclosure and use of these sensitive data may amplify service users’ pain. Moreover, crisis line user confidentiality and privacy are paramount concerns. At present, crisis line calls are not guaranteed to be confidential or private, although geolocation data are not currently used by the NSPL, and callers have the option to remain anonymous (https://screening.mhanational.org/content/what-happens-if-i-call-suicide-prevention-lifeline). Crisis line workers may call the police for geolocation if the caller is deemed to be an imminent risk to self and requires immediate intervention (https://www.vibrant.org/geolocation-and-988). Police intervention to ensure the caller’s safety occurs for about 2%–3% of calls (roughly 48,000 calls: https://screening.mhanational.org/content/what-happens-if-i-call-suicide-prevention-lifeline; https://www.vibrant.org/geolocation-and-988). How these matters will be addressed as 988 is rolled out in localities remains to be determined. Importantly, mental health policy, such as the National Suicide Hotline Designation Act of 2020, has not caught up to the ethics involved in technology-based services.

We believe policy makers need to address the ethical concerns of how crisis support service information is used. A need exists for caller data to be used for research purposes (e.g., surveys on caller experiences); however, these data must be collected in an ethical, confidential manner. Ethical data practice should clearly inform users, before a conversation is begun, on the ways in which their data will be handled (64). For example, the CTL recently enacted a policy allowing users to delete their data (https://www.crisistextline.org/privacy). This practice lets users decide whether their data can be used. Additional consideration can be given to having comprehensive and transparent conversations with callers, texters, and chat users about their data. These conversations could take place after the crisis situation, and staff should clearly state the option to opt in or out of data use and should avoid legal jargon. For example, the Trans Lifeline is currently working on a policy that would clearly inform callers of the hotline’s use of data storage and call encryption, in layperson language (https://translifeline.org/hotline/#faq). In addition, auditing procedures by a third party (e.g., an accrediting nonprofit body or government organization) could be established to ensure responsible handling of caller data (64). A final consideration for ethical research on caller outcomes could include linkage of caller data to a secured system, as the VCL does through its connection to the VHA (42).

Expand Crisis-Related Resources

Many of the issues outlined above can be partially rectified by providing greater funding to support workers, call centers, and the overall crisis system. Rollout of 988 will increase call volume—leading to worries about inadequate numbers of trained staff to address caller needs (65). We recommend that all states adopt funding measures to cover the cost of creating and sustaining call center operations. This funding priority would also allow for training opportunities beyond the ASIST model to help address the need for culturally competent service provision. The gaps in practice and research that have been identified are largely the result of underfunding of evidence-based practices and systems (66). According to guidelines established by SAMHSA (67), an extensive crisis response system would include a regional crisis call center, a mobile crisis unit, and crisis stabilization facilities in addition to psychiatric inpatient options. Creating a well-managed crisis referral system will support more individuals and divert them from medical emergency services (https://thinkbiggerdogood.org/how-communities-must-use-988-to-improve-care-and-correct-crisis-system-disparities). Funding will also allow further designation of resources for research support for crisis centers to help them better understand and adapt their services to callers, texters, and chat users.

Conclusions

The NSPL is one of many crisis support hotlines offered in the United States. Research into how and for whom the hotlines work has been scarce, including a lack of studies on hotline outcomes, the impact of hotlines on minoritized populations at risk for suicide, and whether volunteer training is effective and culturally competent. Recommendations for policy and research include required training criteria, monitoring of ethical data sharing, and increased funding to create a more sustainable and robust crisis support system.