The present review focuses on those services that go under the popular term of “hotline”or
“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”(www.befrienders.org),
the “International Federation of Telephonic Emergency Services”(www.ifotes.org), “Lifeline
International”(www.lifeline.org.au) and Samaritans (www.samaritans.org).
Today’s 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 centres’main 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 subjects’existential crisis condition.
MENTALHEALTH REVIEW JOURNAL
VOL. 21 NO. 2 2016