The impact of telephone crisis services on suicidal users: a systematic review of the past 45 years

Publication Date13 Jun 2016
AuthorElisabeth Assing Hvidt,Thomas Ploug,Søren Holm
SubjectHealth & social care,Mental health
The impact of telephone crisis services
on suicidal users: a systematic review
of the past 45 years
Elisabeth Assing Hvidt, Thomas Ploug and Søren Holm
Elisabeth Assing Hvidt is based
at the University of Southern
Denmark, Odense, Denmark.
Thomas Ploug is based at
the Department for
Communication, Aalborg
University Copenhagen,
Copenhagen, Denmark.
Søren Holm is based at the
Centre for Social Ethics and
Policy, School of Law,
University of Manchester,
Manchester, UK.
Purpose Telephone crisis services are increasingly subject to a requirement to prove their worthas a
suicide prevention strategy. The purpose of this paper is to: first, provide a detailed overview of the evidence
on the impact of telephone crisis services on suicidal users; second, determine the limitations of the outcome
measures used in this evidence; and third, suggest directions for future research.
Design/methodology/approach MEDLINE via Pubmed (from 1966), PsycINFO APA (from 1967) and
ProQuest Dissertation and Theses (all to 4 June 2015) were searched. Papers were systematically extracted
by title then abstract according to predefined inclusion and exclusion criteria.
Findings In total, 18 articles met inclusion criteria representing a range of outcome measures: changes
during calls, reutilization of service, compliance with advice, caller satisfaction and counsellor satisfaction.
The majority of studies showed beneficial impact on an immediate and intermediate degree of suicidal
urgency, depressive mental states as well as positive feedback from users and counsellors.
Research limitations/implications A major limitation pertains to differences in the use of the term
suicidal. Other limitations include the lack of long-term follow-up and of controlled research designs. Future
research should include a focus on long-term follow-up designs, involving strict data protection. Furthermore,
more qualitative research is needed in order to capture the essential nature of the intervention.
Originality/value This paper attempts to broaden the study and the concept of effectivenessas hitherto
used in the literature about telephone crisis services and offers suggestions for future research.
Keywords Suicidality, Evaluations, Suicide prevention, Evaluation studies, Telephone crisis services,
Telephone crisis interventions
Paper type Literature review
According to World Health Organisation reports, deaths by suicide have increased globally with
800,000 deaths due to suicide annually (World Health Organisation (WHO), 2014). This number
does not include suicide attempts, which can be 20 times more common than the number of
completed suicides (Scott and Guo, 2012). Suicide has, therefore, been recognized as a serious
global health problem in most Western countries and suicide prevention strategies have received
increased attention over the past couple of decades (WHO, 2014).
In the literature, many types of suicide prevention approaches and strategies are described, for
example, those that focus on medical means to prevent suicide (pharmacological), those
proposing restricted access to lethal means (e.g. pesticides and firearms) and those attempting
to enhance affective contact (counselling, psychotherapy, text messaging, postcards, etc.)
(Goldney, 2005, p. 131; WHO, 2014).
Received 8 July 2015
Revised 16 October 2015
22 February 2016
Accepted 20 April 2016
The first author participated in the
design of the study, developed the
search strategy, extracted the data
and drafted the manuscript. The
third author conceived of the study
together with the second author,
participated in the design,
contributed to the search strategy
and helped to draft the
manuscript. All authors read and
approved the final manuscript.
DOI 10.1108/MHRJ-07-2015-0019 VOL. 21 NO. 2 2016, pp. 141-160, © Emerald Group Publishing Limited, ISSN 1361-9322
PAG E 14 1
The present review focuses on those services that go under the popular term of hotlineor
helpline. These are services whose main focus is to provide a telephone-based listening
service that offers emotional and psychological support to individuals in distress, including those
in suicidal states, and whose ultimate goal is to help prevent suicide. Such crisis intervention
services operate under many names such as: Befrienders Worldwide(,
the International Federation of Telephonic Emergency Services(, Lifeline
International( and Samaritans (
Todays telephone crisis services can be dated back to the last part of the nineteenth century,
when telephone crisis services were established for a short period of time in Central Europe and
the Eastern part of the USA before subsequently dying out.
At that time they were established on the assumption that the potential suicidal individual
would when prompted by national and local advertising either visit or telephone the
organization as a cry for help(Barraclough et al., 1977, p. 237). A further assumption behind the
establishment of suicide prevention centres and telephone crisis services worldwide was that
the acute affective state and suicidal behaviour of callers might be reduced, interrupted or even
prevented as a result of immediate access to psychological and emotional first aid provided by
the usually non-professional volunteers working at the centre (Dew et al., 1987, p. 239; Speer,
1971, p. 83). Furthermore, providing help in finding alternate coping strategies for the caller as
well as action plans for the future including referrals to mental health services constituted one of
the centresmain goals (Hoff, 1989; Lee, 1999, p. 4).
In recent years traditional telephone support has been extended to encompass new technologies
such as e-mail, internet chat forums and text messaging (Luxton et al., 2011, p. 50; Krysinska
and De Leo, 2007, p. 238). As survey questionnaire studies indicate, an increasing number of
users choose these newer communication means as their method of contact (Pollock et al.,
2010, p. 60; Lester, 2008, p. 233). In the light of these competing new technological methods of
contacting crisis services, the question of the impact of telephone crisis support becomes
re-actualized, as does a discussion of the methodological difficulties and challenges entailed by
effect studies within suicide prevention.
Over the past 45 years, the effectiveness of suicide prevention centres and their services has
been examined by a number of researchers, most of them reaching the conclusion that the
suicide preventive effects of telephone crisis services remains uncertain and equivocal (Gould and
Kalafat, 2009, p. 459; Mishara et al. 2007, p. 309).
In the literature this lack of evidence has been ascribed to major methodological challenges and
ethical considerations pertaining to the area of suicidology (Oquendo et al., 2004; Streiner
and Adam, 1987, p. 93; Mishara and Daigle, 1997, p. 862; Strohl, 2005, p. 5; Hornblow, 1986,
p. 732). One major ethical consideration that makes effective evaluation methods difficult to
implement (e.g. a rigorous follow-up design using before and after measures) is the common
policy of using caller anonymity.
Several studies have attempted to determine the effectiveness of the activities of a suicide
prevention centre by comparing the suicide rate in towns in which a suicide prevention centre
was present with the suicide rate in towns where a suicide prevention centre was absent. In order
to control for variables other than the centre activity, the studies used ecologically similar towns as
controls, that is, towns that matched economic, social and demographic characteristics
(Dew et al., 1987, p. 239; Mishara and Daigle, 2001, p. 156). Ecological and time-series studies
measuring a distal effect of suicide prevention centres have demonstrated inconsistent and
conflicting results. For that same reason the studies have been subject to critique by several
researchers, who have argued that it is impossible both empirically and theoretically to isolate the
effect of a specific suicide prevention centre from other social factors influencing the setting up of
a suicide prevention centre and the incidence of suicide (Mishara and Daigle, 2001, p. 156;
Hornblow, 1986, p. 23).
Randomized controlled trials are also questionable in this context. Setting up a project in which
only a proportion of research subjects receive crisis services may not only be counter to research
ethics but may also involve insensitivity towards the research subjectsexistential crisis condition.
VOL. 21 NO. 2 2016

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