The primary purpose of a crisis hotline is to provide timely, empathetic support to callers, identify problems and potential solutions, ensure callers are safe, and connect them with appropriate resources. While crisis hotlines can provide support for a variety of presenting concerns, such as domestic abuse or drug use, they are a promising tool for suicide prevention. When individuals experience a suicidal crisis, hotlines can serve as a “just in time” intervention and provide support to ensure immediate safety and a plan for after the crisis resolves.

In 1958, the first suicide prevention crisis hotline in the USA was established in Los Angeles, California (Office of Surgeon General & National Action Alliance, 2012). The line was staffed by trained, community volunteers (Harding, 2009). In 1963, the line began 24/7 coverage, and staff were trained in an active intervention model that emphasized that crises are often short term. Listeners were coached to ask questions such as “Where does it hurt?” and “How can I help?” (Morris, 2011). Subsequently, suicide prevention crisis centers were established throughout the USA to assist those experiencing acute suicidality or emotional distress. In 2004, the Substance Abuse and Mental Health Services Administration (SAMHSA) created the National Suicide Prevention Lifeline (Lifeline), a national network of 180 crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week. The Lifeline currently answers over 2 million calls per year (National Suicide Prevention Lifeline, 2020), with call volume likely to increase substantially in the coming years. As of July 16, 2022, “988” is designated as the dialing code for the Lifeline allowing everyone in the USA to quickly access the Lifeline as opposed to the longer 1-800-278-8255 which will remain active as well.

Despite the extensive practice of using of crisis hotlines, there are limited data on the prevalence, patterns of use, or overall effectiveness of this type of intervention. Notably, there have been significant challenges in demonstrating the efficacy of crisis hotlines over time, with the most significant being the absence of randomized controlled trials (RCTs) to test effectiveness. However, during the first major expansion of crisis hotlines, a comparison of counties with and without crisis hotlines found evidence that the presence of crisis hotlines was associated with a reduction in suicide rates but only among white women 24 and younger (Miller et al., 1984). Not only is more current effectiveness data needed, but an evaluation of who is willing to access hotlines and who benefits from these interventions is needed.

Crisis hotlines tend to incorporate a similar approach to assisting and managing callers. Generally, an individual experiencing acute distress calls the hotline, and a crisis worker will attempt to de-escalate the situation via phone, create an immediate plan for safety, and, if appropriate, provide referrals to community resources. While this traditional approach has been considered best practice in the field, there are limitations. Prior to the mid-2000s, there was little evidence-based guidance on best practices for suicide prevention and crisis hotline work. For example, “no harm contracts” were considered standard practice at the time despite having no empirical support (Lewis, 2007; see Monahan et al., Chap. 9, this volume).

Although it will be important to augment the research base around crisis hotline interventions over time, we first need to understand the consensus components of best practice in this area. This chapter illustrates innovations in crisis hotline services that can improve the quality of engagement during times when individuals need timely and effective support. Behavioral Health Response (BHR) is a regional crisis hotline located in St. Louis, Missouri. BHR is a member of the National Suicide Lifeline Network and has sought to improve mental health support access for individuals in crisis by adding problem-/demographic-specific hotlines, internet chat links, texting options, telehealth, and mobile outreach responses. This chapter also provides a detailed description of how BHR created and implemented a Youth Connection Helpline system to serve as a model of how to integrate the science of crisis hotline work into a youth-focused community safety net. This chapter emphasizes the importance of integrating crisis hotlines with other community resources and the value of tracking outcomes to achieve intended goals. Guidance on how to implement and evaluate a youth-focused crisis system is provided.

Behavioral Health Response

In 1994, Missouri created a statewide crisis system with 24/7 crisis intervention hotline and mobile outreach services. At the time, Missouri’s crisis system was the first statewide crisis system that guaranteed 24/7 telephonic and mobile outreach services that could directly connect callers to state-funded systems of care. Missouri helped to advance the field by using a crisis hotline service to systemically connect callers to both mobile outreach services and ongoing outpatient services. This also marked the beginning of a transition from crisis hotlines being mostly volunteer, community-initiated efforts to publicly funded statewide efforts. As part of this effort, BHR was created to provide crisis hotline and mobile outreach services to residents of the eastern region of Missouri, encompassing St. Louis City and the surrounding nine counties.

BHR provides a regional crisis hotline for the St. Louis metropolitan area and also answers Lifeline calls that originate from this same region. Only about 8% of callers to BHR’s regional crisis line report suicidal thoughts compared with the more than 20% of Lifeline callers from the same region. Callers to the regional crisis hotline are often motivated to speak to someone in the moment and establish a connection to services. Alternatively, Lifeline callers are often more motivated to engage in a supportive conversation, are already engaged with services, and often call the Lifeline phone number rather than the crisis line number for their treatment agency. Interestingly, some Lifeline callers struggling with thoughts of suicide avoid calling their own treatment agency’s 24/7 crisis line number, as they want to speak to someone outside of their treatment team and want that information kept separate from their ongoing care. It is important to recognize that callers’ wants and needs do not always align with providers’ wants and needs. Notably, calls to BHR’s youth dedicated lines are most often from youth or from a third party (e.g., parent, other concerned adult, peer) trying to obtain help for a youth in crisis.

The BHR Youth Connection Helpline System

The BHR program created the Youth Connection Helpline (YCH) system to better meet the needs of the community. In 2009, only a small percentage of calls, less than 200 callers in all, to BHR were from youth under the age of 18 in a metropolitan area of 2 million people, suggesting limited awareness and/or accessibility. In response, BHR sought and obtained funding to create a youth-focused crisis system in 2010. BHR believed that having a youth-focused line that was dedicated and marketed to youth, with the addition of text and chat access, would increase utilization and lead to more youth in crisis getting services.

In 2010, BHR received a grant from SAMHSA and Lifeline with the aim of adding crisis hotline follow-up services. Prior to receiving this grant, BHR was unable to fund follow-up phone calls. A majority (90%) of crisis calls were resolved via the initial phone call and a referral. The remainder either received a mobile outreach and the case was resolved after completing the mobile outreach. Only callers deemed to require police rescue received follow-up calls and that was to determine outcome of the police response. This grant allowed BHR to make follow-up calls as standard of care for all callers who were experiencing suicide thoughts at the beginning of the call. The results were often dramatic for callers. At first, callers expressed confusion when the option of a follow-up call was offered. However, BHR began reporting deeper and more enriching contact with callers. Because BHR had ongoing contact with an individual after their initial call, BHR was able to better understand how the crisis line had helped them and learn more about the caller’s life and their challenges accessing ongoing services. Additionally, BHR clinicians formed more meaningful connections with callers through consistent follow-up. Some client’s developed deep bonds with their follow-up clinician, and we had to develop transition plans in order to end the follow-up contact. Offering follow-up phone calls also made it easier to de-escalate callers and decreased use of responses by law enforcement. Callers indicated that the opportunity to receive a follow-up call reduced perceptions of loneliness and created a tangible sense of hope. Collection of outcome data also increased, allowing BHR to track how many callers were connected with mental health services, followed their safety plans, required hospitalization after contact, or subsequently engaged in suicidal behavior.

At the end of 2010, BHR expanded services to all youth under the age of 19 in part of their coverage area, which resulted in the creation of the Youth Connection Helpline (YCH) system. BHR committed to follow up every caller on the YCH, whether the caller was a youth or someone calling about a youth. Additionally, follow-up expanded from 2 weeks (the model of care under the Lifeline follow-up grant) to 4 or 6 weeks. The expansion allowed BHR to add follow-up clinicians whose sole job was to manage outbound follow-up to everyone in follow-up care. Each clinician has a dedicated caseload of follow-up clients so that youth and families speak to the same clinician to maintain continuity. Text and chat options were added over time so that youth could reach the YCH in a mode of their choosing. Mobile outreach services were also expanded so that all callers were eligible for mobile outreach, rather than only the most urgent cases. System of care referrals was built into the electronic health care record so staff could not only see each referral that was provided but, on follow-up, BHR could record each referral that resulted in a service linkage. Outcome variables on every single call are tracked. The YCH thereby became the first fully integrated, 24/7 system of care for youth in the nation.

Best Practices Drive the System

The YCH integrated best practices from Lifeline’s standards for assessment and intervention and added non-demand care follow-up for all callers. The standards guiding YCH training include the following: Lifeline Suicide Risk Assessment (Joiner, et al., 2007); Helping Callers at Imminent Risk of Suicide (Draper, et al., 2015); National Suicide Lifeline Follow Up Procedures (National Lifeline, 2021); Counseling on Access to Lethal Means (Frank & Ciocca, 2009); and Stanley and Brown’s (2012) Collaborative Suicide Safety Planning.

In addition, all callers received follow-up, including referral sources and any of the caller’s active treatment providers. BHR discovered that often the caller’s therapist was unaware of the caller’s suicide crisis or that when there were multiple providers, the providers were not coordinating care with each other. BHR found that by calling all identified providers and the referral sources, we could improve care coordination and outcomes. YCH follow-up clinicians actively reached out to guardians, teachers, primary care providers, and therapists to ensure clients were linked with appropriate services and everyone in the youth’s treatment team was involved with coordinating care. This wraparound approach was key in making sure that it is not just the youth who is the focus of care but that the entire system is responding and adjusting to the needs of the youth. Renaud et al. (2009) found that youth who died of suicide either were not connecting with a care system at all or had inadequate care that was not coordinated across multiple providers and caregivers. The YCH system was designed to ensure callers get established best practices in suicide prevention at each contact using a well-coordinated system-based approach to meet the needs of youth in crisis.

Data and Outcomes

One of the goals of creating the YCH system was to have better data and track the outcomes of our interventions. The following BHR data is from July 1, 2019, to June 30, 2020, and describes the nature of presenting issues, caller responses, and disposition outcomes. Youth-related calls to BHR increased tenfold during the first 3 years of the program. Having youth-specific services (e.g. text, chat, and YCH helpline marketing) significantly increased access to the crisis system. All callers were eligible to participate in the postcrisis follow-up program and 78% (1780/2283) of callers accepted follow-up. A clinical care coordinator contacted callers within 48 hours of their initial call and stayed in touch with the caller on a weekly basis until the crisis was resolved or until the caller decided to no longer participate. The average length of calls between clinical care coordinator and caller was approximately 10 minutes.

The most common presenting problems were non-acute mental health needs such as depression, anxiety, and concentration problems (982/2283), followed by current suicidality (365/2283) and behavioral issues including truancy, running away, risky behaviors, and defiance (320/2283). The most common callers were youth calling for themselves (799/2283); other callers included parents/legal guardians (639/2283), friends/concerned others (502/2283), school staff (159/2283), and social service agency staff (160/2283). Callers reported hearing about YCH from a number of referral sources, including school (753/2283), social service agencies (616/2283), prior use of YCH (410/2283), marketing campaigns (158/2283), family and friends (137/2283), medical providers (114/2283), and police (91/2283).

The majority of calls by YCH were not of immediate life-threatening or acute psychiatric crises, but rather, calls were from youth experiencing significant distress or behavioral disruption with need for in the moment emotional support and connection to services. Providing immediate assistance to parents/guardians, concerned third parties, and agency/school staff also plays an important role in connecting youth to services. School and social service agencies generate the plurality of referrals. Having a system that can support outreach from many different individuals including trusted adults and those who work with youth likely enhances a youth’s safety network and ensures that there is no wrong door to getting help.

Of youth accepting follow-up, BHR verified linkage to ongoing care 58% (1032/1780) of the time. These data were especially promising as they also include cases where BHR was unable to reach anyone in follow-up. In cases where BHR did reach someone in follow-up, 72% (1282/1780), linkage to services was verified in 80% (1032/1282) of those cases. Common reasons for failing to connect with ongoing services were that the inability to reach the caller after repeated follow-up attempts (349/498/), declined/discontinued follow-up before linkage verification (125/498), and transportation, insurance, and appointment accessibility issues (25/498).

Several encouraging outcomes emerged; 88% (1566/1780) of clients were diverted from presenting to the emergency department for psychiatric services during follow-up. Of the clients that did present to emergency departments, 75% (160/214) were admitted for inpatient psychiatric treatment. Less than 1% (<18) of clients attempted suicide while receiving follow-up services and there were no reported deaths by suicide.

Case Study: Preteen Suicide

This case study illustrates crisis hotline standards and processes relevant to youth. An elementary school counselor called the YCH after a particularly intense outburst from an 11-year-old girl named Kylie (name and details changed to protect privacy). Kylie recently had several disruptive episodes in class and stated she wanted to kill herself. The phone clinician completed a brief assessment, provided de-escalation support, and recommended a mobile outreach clinician to assist further. The counselor explained they had been unable to reach parents, who were newly divorced and shared custody. A short-term safety plan was developed, and a mobile outreach clinician was dispatched. The phone clinician reached out to both parents and, after a brief dispute, the father agreed to meet the outreach team at the school.

On scene, the clinician completed a detailed risk assessment and determined that the disruptive behaviors had started shortly before the divorce, the distress was serious, but there were no imminent safety concerns or severe symptoms that required inpatient psychiatric care. The clinician developed a collaborative safety plan, ensured the home was free of lethal means of suicide, and referred family for counseling services. The case was transferred to a YCH clinical care coordinator (CCC). The CCC contacted the school and both parents the next day. The school reported that Kylie had not yet scheduled an appointment and the parents provided conflicting accounts of barriers to treatment. After several calls with all three parties, the CCC was able to resolve the communication challenges and arrange a same-day appointment. A week later, Kylie started texting the YCH because she was experiencing thoughts of suicide. The texting clinician reviewed the safety plan with Kylie, connected with her father, ensured immediate safety, and arranged for next-day follow-up. During this follow-up, the CCC contacted all parties, reinforced the safety plan, and made sure the family and treatment agency had a plan in place to address Kylie’s needs. After three weekly follow-up calls, the agency was able to confirm ongoing engagement with parents and Kylie with noted improvement. Kylie’s parents confirmed she was doing well. No additional texts/calls came through from Kylie. Two weeks later, the CCC followed up with all parties and determined no further assistance was needed.

Recommendations for Youth Connection Helpline Services

In order to establish a feasible and innovative youth connection helpline service, there are several organizational approaches to consider. Continuous quality improvement is key. How youth reach out and the systems that serve youth are ever-changing. It is essential to develop and maintain close relationships with stakeholders, including referring agencies (especially schools) and accepting agencies, law enforcement/juvenile officers, hospitals/urgent care providers, and children and family service organizations. Organizations should also track outcome data such as where callers were referred to, barriers to linkage, use of emergency services, and suicide attempts while in care coordination to improve systems and care. Our experiences with the YCH highlight the importance of follow-up care with callers as well as those who have a role in care coordination. It recommended that care coordinators are available to provide youth with immediate emotional support and resources using a structured approach to follow-up.

Youth connection helpline services should be rooted in a strong evidence base and utilize best practices in service delivery. For instance, it is important to use standardized screening and assessment processes to evaluate suicide risk (see Mournet et al., Chap. 7, this volume) and to minimize coercive interventions whenever possible. Additionally, crisis hotlines for youth should integrate technical strategies to provide alternate modes for crisis contact, such as text, chat, and more structured phone assessment/intervention when mobile outreach services are not available. Using these organizational and technical best practices can allow for the implementation of impactful youth-serving helplines that are able to provide support in times of crisis and allow for connection to potentially lifesaving care.

While suicide prevention via crisis lines has improved, notable gaps still exist. For example, the implementation of 988 has the potential to reshape crisis care across the USA. However, 988 legislation requires states to individually fund 988 services. Without sustained federal support, there are concerns many states may not increase funding to meet 988 and other crisis needs. When the “911” emergency number was rolled out, there was already an existing infrastructure (e.g., law enforcement, jails, ambulances, hospitals) – it was just a matter of making it easier to access those resources. Comparatively, mental healthcare infrastructure is limited and underfunded. If we are going to make significant steps in creating a true system of care, where a call to 988 will lead not only to effective crisis line services but direct and immediate connection to urgent mental health services, national funding will be required to improve the capacity of the crisis systems. Additionally, national funding is needed to create a system of mental health services, from crisis stabilization to urgent mental health clinics and emergency housing. We also need to establish a standard of care that mandates care coordination between providers and verifying linkage to services as opposed to just making a referral. When a clinician makes a referral, it is incumbent upon them to make sure the receiving agency/provider is aware and has accepted the referral. If we do not ensure sustainable, nationwide funding for 988 and enhanced crisis services, we may be creating a highway of crisis line services that dead-end when it is time to connect those callers with ongoing services. A call to a crisis line, in an appropriately funded system, would mean every caller who wanted and needed services would be connected quickly to appropriate ongoing care. Despite progress, we are not there yet.