Section 5 of the National Suicide Hotline Designation Act requires the Federal Communications Commission (FCC) to submit a report to the appropriate Congressional committees “that examines the feasibility and cost of including an automatic dispatchable location that would be conveyed with a 9–8–8 call, regardless of the technological platform used and including with calls from multi-line telephone systems.” (See the full Public Notice here.)

As the administrator of the National Suicide Prevention Lifeline and other crisis lines, including the Disaster Distress Helpline, NYC Well, and NFL Life Line, Vibrant Emotional Health encourages crisis centers, stakeholders, and advocates to submit comments regarding this important issue.

Regarding Vibrant Emotional Health’s position and recommendation regarding geolocation and 988:
A brief summary of our recommendation can be found in our “988 Serviceable Populations and Contact Volume Projections” Report, available at this link.
Talking points related to Vibrant’s position on geolocation can be found below.

Geolocation Talking Points

• Location information is identified as a key component for best practices and guidelines for behavioral health crisis care by the Substance Abuse and Mental Health Administration (SAMHSA). (https://www.samhsa.gov/sites/default/files/national-guidelines-for-behavioral-health-crisis-care-02242020.pdf)

  • Activating location information capabilities and designating local crisis centers as public safety answering points (PSAPs) can reduce routing mismatches and provide life-saving pathways to care.

• Location information for 988 calls ensures individuals will be routed to the crisis center nearest to their physical location.

  • Like 911, the Lifeline provides immediate assistance, yet telecommunications service providers are unable to offer accurate caller location at this time.

  • The Lifeline currently routes calls based on area code. With over 80% of calls placed by cell phone and the mobility of these wireless devices, a number’s area code may not correctly reflect the caller’s actual location.

  • With the current area code routing, states also may experience challenges in gathering accurate metrics of usage for their state. This can affect the understanding of the crisis intervention needs and resources within a state.

• Individuals receive better support when connected with their community’s crisis center.

  • Crisis counselors who are more familiar with their community’s unique stressors (i.e. local events, recognizable locations) may be able to build a trusting connection with callers more quickly.

  • Local centers are able to provide connections to and knowledge of local resources and services, including follow-up care, that reduce the risk of suicidality in individuals in crisis.

• In the rare cases where emergency services may be deployed, geolocation would reduce delays in identifying the physical location of an individual needing intervention.

  • Almost 90% of callers interviewed 9 days on average after the call reported that the Lifeline helped stopped them from killing themselves.

  • Emergency services are utilized in only 2% of all calls answered by the Lifeline, in instances where someone is in immediate danger of harming themselves or others. At those times, every minute counts.

  • Location information could be the difference between life and death for hundreds of thousands of people annually with 988. Vibrant Emotional Health, administrator of the Lifeline, estimates between 6-12 million individuals will utilize the new number in its first year and as many as 40 million by year five.

• Privacy is critical to the protection of individual callers who utilize the Lifeline and 988.

  • Calls to the Lifeline are confidential and require a court order for disclosure.

  • With geolocation, 988 will continue to protect the privacy and confidentiality of callers. Crisis counselors are required to use the least invasive intervention necessary, while making every reasonable effort to ensure the safety of the caller.

• Providing location information for 988 calls outweighs any associated costs for the reasons above.

THE PROBLEM

WITH 988:

HOW AMERICA’S

LARGEST HOTLINE

VIOLATES CONSENT,

COMPROMISES SAFETY,

AND FAILS THE PEOPLE

This file contains the report text only. To download the supplementary

information or the full report, visit translifeline.org/988-report

CREDITS AND ACKNOWLEDGEMENTS

RESEARCH STUDY DIRECTOR:

Yana Calou

REPORT PROJECT MANAGERS

AND EDITORS:

Olka Forster, Nemu HJ

RESEARCHERS:

Naifa Al-Anbar, Yana Calou, Álvaro Gamio

Cuevo, Olka Forster, Nemu HJ, Selima

Jumarali, Sara Kasler, Emily Krebs, Liz Latty,

Jenny Leigh, Gabe Lockett, Max Osborn, Jane

Palmer, Jennelle Ramdeen, Zoe Smith, Jules

Sostre, Sunnie Townsend, Ollie Trac, Suisui

Wang, Jakiah Webb

WRITTEN BY:

Jenny Leigh, Liz Latty, Olka Forster, Nemu HJ,

Jules Sostre, M Pease,

Suisui Wang

SPECIAL THANKS TO:

Mi Aniefuna, Suzanne Bernstein, Maria Villegas

Bravo, Adam Callahan, Yana Calou, Vanessa

Cervantes, Enji Chung, Junior Claros, Sera

Davidow, Pascal Emmer, Chris Frascella, Jasmin

Hoo, kai alviar horton, Nev Jones, Stefanie Lyn

Kaufman-Mthimkhulu, Melissa Kilmer, Irene

Knapp, Emily Krebs, Margo Kulkarni, Ariel

Lipson, Taegen Meyer, Emma Moscardini, Mary

Naoum, Kieran Patel, León M Powell, Andrea

Ritchie, Jahmil Roberts, Adriel Rodriguez, Jessie

Roth, Rebecca Ruechel, Raymond Tucker, Kara

Williams, Rob Wipond, Hannah Zeavin, and all

the participants in our study.

FUNDED BY:

Trans Lifeline, Interrupting Criminalization,

American University School of Public Affairs,

and a Faculty-Led Initiative Grant from

Fordham University’s Center for Community

Engaged Learning.

THE

PROBLEM

WITH

988:

HOW AMERICA’S

LARGEST HOTLINE

VIOLATES CONSENT,

COMPROMISES SAFETY,

AND FAILS THE PEOPLE

HOW 988 OPERATES:

A GUIDE TO HOTLINE

POLICIES AND

PRACTICES

HELP-SEEKER

PRIVACY AND

LOCATION-TRACKING

TECHNOLOGY

A BETTER SYSTEM IS POSSIBLE:

CONCLUSION & RECOMMENDATIONS

26

10

36

46

60

POLICING AND

CRIMINALIZATION:

WHY COPS DON’T

BELONG IN CARE

FORCED

HOSPITALIZATION:

A JAIL BY

ANOTHER NAME

1

2

3

4

5

Resisting Transparency:

988 Dodges Requests for Public Data

11

The 988 Landscape

13

Non-consensual Interventions

14

988’s “Safety” Assessment

18

The Role of the Hotline Operator

23

Help-Seekers Want Law Enforcement Out of

Mental Health Crisis Response

28

Crisis Response Reforms: The Continuation

of Police Involvement

32

Consequences of Psychiatric

Hospitalization for Help-Seekers

38

Identity Specific Consequences

of Psychiatric Hospitalization

42

Major Red Flags: 988 Hotlines and AI Data-Sharing

48

Opaque and Insufficient: 988’s Disclosure on

Data-Sharing for Emergency Interventions

49

988’s Location Tracking Capabilities

53

Geolocation: A Technical Overview

55

988’s Attempts for In-House Geolocation

56

Surveillance ≠ Safety

57

INTRODUCTION

EXECUTIVE SUMMARY

CREDITS AND ACKNOWLEDGEMENTS

7

4

2

APPENDICES

BIBLIOGRAPHY

GLOSSARY

83

67

64

Appendix A: Safe Hotlines Project Research Design

83

Appendix B: Safe Hotlines Survey Data Chart

88

Appendix C: FOIA Request to SAMHSA

103

Appendix D: Data Request Questions to Hotlines

104

Appendix E: The Trevor Project’s Voluntary Data

107

Appendix F: Regulatory Concerns and Legal Frameworks

108

This file contains the report text only.

To download the supplementary

information or the full report, visit

translifeline.org/988-report

4

This report aims to be a source of clarity about

dimensions of hotlines that are often hidden from

public knowledge, including the unique pipeline

from hotlines to harmful emergency interventions

involving police and psychiatric hospitalization.

** For the purpose of this report, “mental health” is used as a colloquial umbrella to encapsulate a broad range of emotional or*

psychological experiences that vary from what is perceived as normative. There are many other valid ways of understanding

one’s self outside of this Western framework through various spiritual, cultural, and trauma-related interpretations.

This report addresses critical issues related

to suicide and crisis hotlines in the United

States, particularly focusing on the 988

Suicide and Crisis Lifeline. Though originally

intended as a safe and confidential support

service, many crisis hotlines, including all

crisis centers within the 988 network, have

evolved to adopt policies and practices

that compromise the safety, privacy, and

autonomy of those seeking help. This

report aims to be a source of clarity about

dimensions of hotlines that are often hidden

from public knowledge, including the

unique pipeline from hotlines to harmful

emergency interventions involving police

and psychiatric hospitalization.

The first section of this report, How 988

Operates: A Guide to Hotline Policies and

Practices, provides an overview of how 988

hotlines operate, with a specific focus on

non-consensual interventions and the lack of

transparency surrounding the practice. The

second section, Policing and Criminalization:

Why Cops Don’t Belong in Care, explores

the connection between hotlines and law

enforcement in crisis response. The third

section, Forced Hospitalization: A Jail By

Another Name, analyzes experiences of

psychiatric hospitalization – a potential

outcome of a hotline call – with a specific

focus on involuntary and coercive

experiences. The fourth section, Help-Seeker

Privacy and Location-Tracking Technology,

examines the issues of geolocation and the

use and misuse of hotline users’ data. Finally,

this report concludes with a discussion of

Recommendations for hotlines guided by

the input of people who have sought support

from suicide and crisis hotlines.

EXECUTIVE SUMMARY

TRIGGER WARNING: This report discusses suicide and suicidal ideation,

self-harm, mental illness, violations of consent, police violence, physical

and sexual assault, racism, transphobia, forced psychiatric intervention,

and death. Some quotes from study participants use profanity.

5

Central to this report is an awareness that

the perspectives of help-seekers, especially

those with marginalized identities, are

underrepresented – or entirely absent – in

both research efforts and the development

of hotline policy. This report centers the

voices of help-seekers in its analysis, building

on original research data from 210 survey

responses and 26 interviews with people

who have lived experiences of mental health*

crises. The survey collected reports on both

helpful and harmful impacts of hotline use

and other forms of crisis care, perspectives

on emergency interventions, and how the

threat of non-consensual intervention affects

help-seekers. The interviews explored hotline

users’ experience of hotline conversations,

as well as non-consensual interventions

and psychiatric hospitalizations initiated

by a hotline call. This original data offers

a multifaceted understanding of crisis

hotline users’ experiences, adding to the

existing knowledge of crisis hotlines, crisis

intervention, and the mental health care

system more broadly. For more information

on the original survey and interview research

design, see Appendix A.

In tandem with the lived experiences of help-

seekers, this report brings together existing

research and a diverse catalogue of policy

documents to provide a clearer image of

the current hotline landscape. The report

concludes with concrete recommendations to

transform crisis hotlines in ways that center

life-affirming, transparent, and consensual

crisis support. Primarily informed by help-

seekers, we call for increased investment in

non-punitive, consent-driven crisis care and

the end of non-consensual interventions.

KEY FINDINGS:

1. 988 Suicide and Crisis Lifeline:

The creation and funding of the 988

Lifeline presents a major opportunity to

improve the quality and efficacy of crisis

intervention services. However, the new

Lifeline is missing the mark on providing

crisis care that is safe, consensual, and

effective. Instead, 988 has systematized

the use of non-consensual interventions

and has obscured information about this

practice from public view. Efforts to obtain

data from 988 administrators have been

largely unsuccessful, with officials refusing

to disclose critical information about the

frequency and outcomes of emergency

interventions.

2. Non-Consensual Interventions:

This report exposes the negative

consequences that can result from

emergency interventions, especially those

that violate consent. These consequences

can include forced hospitalization, police

involvement, physical violence, and long-

term psychological harm. Non-consensual

interventions can lead to traumatic

outcomes, particularly for marginalized

groups, including Black, Brown, LGBTQ+,

disabled and low-income individuals.

3. Help-Seeker Needs:

This analysis illuminates the perspectives

of help-seekers, who too often are

ignored in the creation of hotline

policy. Help-seekers’ experiences and

needs are centered in the discussion

of current harmful practices and inform

recommendations for improving suicide

and crisis hotlines.

6

RECOMMENDATIONS:

1. Policy Change:

The findings in this report emphasize

the need to end non-consensual

interventions, suicide risk assessments,

law enforcement collaboration, and the

use of forced and coercive psychiatric

hospitalization. This report further

advocates for policies that prioritize

informed consent, transparency, and

increased accountability to the needs of

help-seekers.

The report concludes with a strong call to

action for transforming crisis hotlines into

truly safe and supportive resources. By

centering the experiences and needs of help-

seekers, especially those from vulnerable

populations, the report advocates for a more

humane and life-affirming approach to mental

health crisis care. Everyone deserves safe

and effective care during experiences of

crisis, and approaches to crisis support that

center the needs of help-seekers are within

reach. We hope that this report will provide

readers with the knowledge to envision

better solutions, as well as the determination

and direction to make them a reality.

2. Training and Support:

Help-seekers highlight the importance of

and need for improved training for hotline

operators to better understand and

support individuals in crisis, particularly

those from marginalized communities.

3. Investment in Non-Punitive Crisis Care:

This report recommends increased

funding for alternative crisis support

systems that do not involve

law enforcement or forced

psychiatric interventions.

7

Suicide hotlines originally began as a

unique form of support rooted in human

connection: a space to share and be heard in

a vulnerable moment. One of the first suicide

hotlines in the United States started in the

early 1960s and consisted of a single phone

in the basement of a tattoo parlor in San

Francisco’s Tenderloin District. The founder,

Bernard Mayes, envisioned a service that

offered “unconditional listening” from an

“anonymous ear.”1 This community-based

model of support gave people a space where

they could talk openly about their reality

without the fear of being institutionalized or

the threat of social and legal punishment.

Over 60 years later, suicide and crisis hotlines

remain a space that neither close friends nor

mental health professionals can replicate. In

a context where high-quality care is regularly

denied to survivors of trauma, people with

psychiatric diagnoses, and those who are

experiencing life-interrupting challenges,

suicide and crisis hotlines fill a major gap in

social support.

While suicide and crisis hotlines have

continued growing in popularity, the

promise of anonymous and safe support

has all but disappeared. In the United

States, the majority of crisis hotlines have

adopted policies and practices that violate

the privacy, trust, autonomy, and safety of

people who are reaching out for support.

INTRODUCTION

In a far cry from their safe and effective

origins, many suicide and crisis hotlines

have become entrenched in a system that

links crisis response to police, prisons,

and psychiatric hospitalization. These

hotlines now play a major role in initiating

emergency interventions for people in

crisis, and most disturbingly, are able to do

so without consent.

Though emergency interventions can

occur voluntarily or involuntarily, this report

draws specific attention to the practice of

non-consensual intervention, a potential

consequence of contacting crisis hotlines

that is both hidden from help-seekers and

understudied in existing research. Non-

consensual intervention is the process

through which an emergency response

occurs without a help-seeker’s knowledge or

consent. Non-consensual interventions can

include both the initial response of emergency

responders at a help-seeker’s location and

any additional interventions that take place

from there, such as incarceration or forced

hospitalization. Non-consensual intervention

also includes instances where a help-seeker

may be coerced into consenting to an

emergency response. Crisis hotlines employ

non-consensual interventions by initiating

processes for sending emergency responders

– often law enforcement – to the location of a

help-seeker perceived to be at risk of harming

8

While suicide and crisis hotlines have

continued growing in popularity,

the promise of anonymous and safe

support has all but disappeared.

themselves or others. Although often framed

as necessary for the safety of an individual

or their community, in reality, non-consensual

interventions set the stage for traumatizing

experiences that can exacerbate crises and

decrease trust in hotlines.

In the United States, non-consensual

interventions pose an enormous threat to

people in crisis, particularly Black and Brown

people, LGBTQ+ people, disabled people,

poor people, and those at the intersections

of these and other marginalized identities.

Encounters with emergency responders,

especially law enforcement, too often

escalate to physical violence, psychiatric

hospitalization, incarceration, and even

death.2-3 In fact, emergency interventions,

even those that start out consensually,

can quickly become non-consensual as

dynamics of race, gender, and perceptions

of risk play out between emergency

responders and people experiencing crisis.

The repercussions of these interventions

can mean long-lasting emotional, financial,

and physical injuries – conditions that

prolong and exacerbate crisis and thoughts

of suicide. Non-consensual interventions

are often condemned by people who have

experienced them,4-5 but U.S. policymakers

and crisis hotline administrators have

ignored these voices and continue the

practice. Rather than centering the well-

being of help-seekers, non-consensual

interventions center the subjective

perceptions of hotline operators and the

legal liability of hotlines themselves.

Recently, with the creation of the largest

hotline network in the United States, the

issue of safety and consent on crisis hotlines

has grown all the more urgent. In 2022, the

U.S. government introduced the 988 Suicide

and Crisis Lifeline, transitioning the former

ten-digit number for the National Suicide

Prevention Lifeline into a new three-digit

dialing code: 988.6 Presented as an easy-to-

remember alternative to 911, the 988 Lifeline

has been promoted as a way to divert calls

related to psychological and emotional crisis

away from law enforcement.7 988 has been

celebrated as an advancement for the mental

health system, as its introduction expanded

the Lifeline into a systematized network with

over 200 crisis centers providing access to

24/7 crisis response and resources.8 To date,

federal funding made available for the rollout

9

of 988 has invested almost $1.5 billion into

suicide prevention and crisis response.9

While 988 represents a significant expansion

of crisis care, it also represents an expansion

of location tracking capabilities and non-

consensual practices in social support

services. 988 policymakers have adopted

and defended the practice of non-consensual

intervention, disregarding the voices of

hotline users, psychiatric survivors, human

rights organizations, and crisis care experts

who condemn the practice.10 In addition to

defending non-consensual intervention, 988

administrators have advocated to increase

the surveillance of hotline users, asking the

federal government to grant the Lifeline

unprecedented location tracking capabilities.11

Simultaneously, the Lifeline has avoided calls

for transparency and maintained secrecy

around the number of non-consensual

interventions their hotlines are initiating

and the negative consequences that help-

seekers have faced as a result. Undeterred

by the contradiction of the life-threatening

harms that can be caused by non-consensual

interventions, 988 officials continue to make

claims that the use of these interventions

allows them to better achieve their goal of

providing “life-saving services.”12

Since its creation, the 988 Suicide and

Crisis Lifeline has increased its reach

to the U.S. public through a national

marketing campaign. In this campaign, 988

regularly advertises itself as a “private”

and “confidential” resource for people in

crisis, offering a safe space to discuss one's

struggles.13 Not included in this advertising

is any disclosure about the possibility of

emergency interventions, which can include

law enforcement, and in particular that such

interventions can occur without a help-

seeker’s knowledge or consent. In spite

of efforts by advocates and survivors of

non-consensual intervention, 988 officials

have continued to obscure the policies

and practices that render their advertising

misleading and dishonest. This lack of

transparency has meant that the public is

largely unaware of the potential negative

consequences of calling 988.

Despite good intentions in its design, in

reality, 988 has created another pipeline

for people experiencing crisis to come

into contact with potentially unwanted and

unhelpful interventions. These interventions

can ultimately harm, traumatize, and

discourage people from reaching out for

help. The next section examines the policies

and practices in place that enable 988 to

initiate non-consensual interventions on

help-seekers.

10

** For the purpose of this report, the term crisis hotline is used to generally describe suicide and crisis call centers,*

warmlines, peerlines, helplines, etc

HOW 988 OPERATES:

A GUIDE TO

HOTLINE POLICIES

AND PRACTICES

1

CHAPTER

“I need genuine human

connection. I need validation.

I need compassion and

empathy and people who

are trained to offer that.”

The suicide and crisis hotline landscape in

the United States is made up of national,

local, and grassroots hotlines.* These hotlines

operate within a convoluted patchwork of

regulatory bodies, disjointed policies, and

inconsistent practices. Within this landscape,

the most expansive and well-funded hotline

is the 988 Suicide and Crisis Lifeline, self-

described as “a national network of local

crisi ...

Since George Floyd’s murder and the uprising that followed in June 2020, the demand by abolitionist activists and mental health advocates to remove police officers from mental health crisis intervention—especially from the response to mental health-related 911 calls and suicide hotline calls—has intensified. The federal response to those demands launched nationally on July 16: 988 Lifeline, a crisis call line designed by the Substance Abuse and Mental Health Services Administration (SAMHSA) that provides an alternative to 911 for people experiencing mental health crises, especially suicidality.

Accessing 988 Lifeline is purposely simple—as easy as dialing or texting 9-8-8. From there, callers are routed to a trained crisis counselor local to their area code who is part of the Lifeline network. The call lines and organizations who have opted into that network all have one thing in common that caused near-immediate backlash to the initiative: Contractually, they are all obligated to call 911 under certain circumstances without informing the caller on the other side of the phone.

A representative from SAMHSA told VICE that 988 crisis counselors contacted 911 without consent for “less than half of 2 percent” of its annual callers, and only when said caller was “unwilling or unable to take actions to remain safe,” in scenarios like “active suicide attempts (overdoses, etc.) and/or stated intent to use weapons or other lethal means with the intent to cause imminent harm or death.”
The Trevor Project’s director of advocacy and government affairs, Preston Mitchum, responded to critiques of the 988 launch in an Instagram statement that said callers do not need to share their location or any personal information with 988 crisis counselors. “For the past year, I have worked on 988,” Mitchum wrote. “I don’t pretend that 988 is perfect. It is created within a system that we have yet to see. While criticism is valid, it should be honest. Yet, I have seen a lot of misinformation.”

https://www.instagram.com/p/CgS1bI4MmCH/

However, investigative reports from Mad in America found a continued practice of non-consensual call tracing by SAMHSA’s National Suicide Prevention Hotline. It is unclear if those practices have been amended with the launch of 988, and they’ve never been publicly disclosed or discussed by the agency in a caller-facing forum. SAMHSA did not directly respond to VICE’s questions about its use of geolocation surveillance to direct cops or emergency services to their callers. (Update: In a statement, a representative for SAMHSA told VICE, “988 does not currently use geolocation.”)

There are many well-publicized stories about what can happen when cops and people in mental health crises collide. Cops in Salt Lake City, Utah’s police department shot Linden Cameron, a 13-year-old child, after responding to a 911 call from Cameron’s mother in 2020; Springfield, Oregon police officers killed Stacy Kenny, a trans woman reportedly diagnosed with paranoid schizophrenia, in 2019 while she was on the phone with a 911 operator.
According to a report by the Washington Post, cops shot and killed 178 people between 2019 and 2021 in response to calls for help with a mental health crisis—and that’s the number of documented cases. Yana Calou, director of advocacy at Trans Lifeline, a non-profit peer and crisis hotline, said the hotline’s crisis counselors never contact 911 without explicit caller consent, which is why they are not a part of 988 Lifeline’s partner pool. Their concern is that 988 Lifeline and its partners don’t share the same policy. “I have so much respect for the people working to create this system,” they said. “I do really think it is a great opportunity to expand resources to people in need. But there are these problems with it that are really, really long-term.”
As part of Trans Lifeline’s #SafeHotlines campaign, launched the same day as 988 Lifeline and partially in response to an anticipated uptick in 988 Lifeline calls, the organization created a Crisis Callers’ Bill of Rights. Calou said the section around transparency is especially relevant to their concerns about 988 Lifeline: demands for “clear and upfront information about which situations hotlines use police and emergency services—to be included on websites, apps, chatbots, and greeting/hold recordings, including geotracking,” along with information about what could trigger a police/EMS response and when one has been triggered.
“[988] is taxpayer-funded, so we should actually know what we’re getting when we call, what the policies are—not have that buried on page 65 of your terms of service or privacy policy,” Calou said. (Update: Currently, 988’s “imminent risk” policies, which include police intervention, are linked on a drop-down menu on its FAQ page titled “Does Vibrant use police intervention for callers, texters, and chatters to the Lifeline?”)

At the core of those concerns is the sickening possibility that callers don’t know a call to 988 could lead to a visit from the police or emergency medical services, leading to arrest, detention, involuntary hospitalization, or worse. “People know the number for 911, and they made a different decision in the moment to call the crisis hotline,” they said. “We should be able to determine what supports and care we utilize and which ones we refuse in order to be able to protect ourselves from further harm.”
Calou cited the financial burden of an unexpected ambulance ride or hospital visit for an uninsured caller; the fallout from 72 hours in jail on a caller’s employment or child care situation; and the trauma and potential for injury or death during an unexpected, unwanted police encounter as possible outcomes from non-consensual crisis intervention.
“One of the big things [for trans people] is that an involuntary psych hold in your medical history can be used by other medical providers to deny us the ability to give informed consent for life-changing trans health care, like surgery or hormones,” they said. Obviously, these aren’t intended outcomes of 988 Lifeline’s emergency intervention policy—but Calou said that a lack of consistent transparency means they remain all-too possible.

John Palmieri, acting director of SAMHSA’s 988 and Behavioral Health Crisis Coordination Office, told VICE in a statement that, of the “fewer than 2 percent of calls to the 988 Lifeline require an emergency response, most of those are done with the consent and cooperation of the caller… Those who contact the 988 Suicide & Crisis Lifeline can expect compassionate, accessible care and support for their mental health-related needs—whether that is thoughts of suicide, mental health or substance use crisis or any other kind of emotional distress.”

Still, Calou worried that the uptick in publicity around 988 Lifeline will cause the number of callers who involuntarily come into contact with cops or EMS to rise. “There’s a big problem when there are Reddit forums and like Quora boards about how to call a suicide hotline and [not have the police or EMS called on you],” they said. “You’re trying to offer somebody a service, and the people that you’re actually trying to help are trying to figure out ways around you.”
Correction: An earlier version of this article stated that Linden Cameron was fatally shot by police. He survived his injuries. The original story also contained an incorrect location: Stacy Kenny died in Springfield, Oregon, not Springfield, Ohio. We regret these errors. This story has been updated for accuracy and clarity.

Katie Way is a senior staff writer at VICE. Follow her on Twitter.

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THE PROBLEM

WITH 988:

HOW AMERICA’S

LARGEST HOTLINE

VIOLATES CONSENT,

COMPROMISES SAFETY,

AND FAILS THE PEOPLE

CREDITS AND ACKNOWLEDGEMENTS

RESEARCH STUDY DIRECTOR:

Yana Calou

REPORT PROJECT MANAGERS

AND EDITORS:

Olka Forster, Nemu HJ

RESEARCHERS:

Naifa Al-Anbar, Yana Calou, Álvaro Gamio

Cuevo, Olka Forster, Nemu HJ, Selima

Jumarali, Sara Kasler, Emily Krebs, Liz Latty,

Jenny Leigh, Gabe Lockett, Max Osborn, Jane

Palmer, Jennelle Ramdeen, Zoe Smith, Jules

Sostre, Sunnie Townsend, Ollie Trac, Suisui

Wang, Jakiah Webb, M Pease

WRITTEN BY:

Jenny Leigh, Liz Latty, Olka Forster, Nemu HJ,

Jules Sostre, M Pease, Suisui Wang

SPECIAL THANKS TO:

Mi Aniefuna, Suzanne Bernstein, Maria Villegas

Bravo, Adam Callahan, Yana Calou, Vanessa

Cervantes, Enji Chung, Junior Claros, Sera

Davidow, Pascal Emmer, Chris Frascella, Jasmin

Hoo, kai alviar horton, Nev Jones, Stefanie Lyn

Kaufman-Mthimkhulu, Melissa Kilmer, Irene

Knapp, Emily Krebs, Margo Kulkarni, Ariel

Lipson, Taegen Meyer, Emma Moscardini, Mary

Naoum, Kieran Patel, León M Powell, Andrea

Ritchie, Jahmil Roberts, Adriel Rodriguez, Jessie

Roth, Rebecca Ruechel, Raymond Tucker, Kara

Williams, Rob Wipond, Hannah Zeavin, and all

the participants in our study.

FUNDED BY:

Trans Lifeline, Interrupting Criminalization,

American University School of Public Affairs,

and a Faculty-Led Initiative Grant from

Fordham University’s Center for Community

Engaged Learning.

THE

PROBLEM

WITH

988:

HOW AMERICA’S

LARGEST HOTLINE

VIOLATES CONSENT,

COMPROMISES SAFETY,

AND FAILS THE PEOPLE

HOW 988 OPERATES:

A GUIDE TO HOTLINE

POLICIES AND

PRACTICES

HELP-SEEKER

PRIVACY AND

LOCATION-TRACKING

TECHNOLOGY

A BETTER SYSTEM IS POSSIBLE:

CONCLUSION & RECOMMENDATIONS

26

10

36

46

60

POLICING AND

CRIMINALIZATION:

WHY COPS DON’T

BELONG IN CARE

FORCED

HOSPITALIZATION:

A JAIL BY

ANOTHER NAME

1

2

3

4

5

Resisting Transparency:

988 Dodges Requests for Public Data

11

The 988 Landscape

13

Non-consensual Interventions

14

988’s “Safety” Assessment

18

The Role of the Hotline Operator

22

Help-Seekers Want Law Enforcement Out of

Mental Health Crisis Response

28

Crisis Response Reforms: The Continuation

of Police Involvement

32

Consequences of Psychiatric

Hospitalization for Help-Seekers

38

Identity Specific Consequences

of Psychiatric Hospitalization

42

Major Red Flags: 988 Hotlines and AI Data-Sharing

47

Opaque and Insufficient: 988’s Disclosure on

Data-Sharing for Emergency Interventions

49

988’s Location Tracking Capabilities

53

Geolocation: A Technical Overview

54

988’s Attempts for In-House Geolocation

56

Surveillance ≠ Safety

58

INTRODUCTION

EXECUTIVE SUMMARY

CREDITS AND ACKNOWLEDGEMENTS

7

4

2

APPENDICES

BIBLIOGRAPHY

GLOSSARY

81

67

65

Appendix A: Safe Hotlines Project Research Design

81

Appendix B: Safe Hotlines Survey Data Chart

86

Appendix C: FOIA Request to SAMHSA

102

Appendix D: Data Request Questions to Hotlines

103

Appendix E: The Trevor Project’s Voluntary Data

106

Appendix F: Regulatory Concerns and Legal Frameworks

107

4

This report aims to be a source of clarity about

dimensions of hotlines that are often hidden from

public knowledge, including the unique pipeline

from hotlines to harmful emergency interventions

involving police and psychiatric hospitalization.

** For the purpose of this report, “mental health” is used as a colloquial umbrella to encapsulate a broad range of emotional or*

psychological experiences that vary from what is perceived as normative. There are many other valid ways of understanding

one’s self outside of this Western framework through various spiritual, cultural, and trauma-related interpretations.

This report addresses critical issues related

to suicide and crisis hotlines in the United

States, particularly focusing on the 988

Suicide and Crisis Lifeline. Though originally

intended as a safe and confidential support

service, many crisis hotlines, including all

crisis centers within the 988 network, have

evolved to adopt policies and practices

that compromise the safety, privacy, and

autonomy of those seeking help. This

report aims to be a source of clarity about

dimensions of hotlines that are often hidden

from public knowledge, including the

unique pipeline from hotlines to harmful

emergency interventions involving police

and psychiatric hospitalization.

The first section of this report, How 988

Operates: A Guide to Hotline Policies and

Practices, provides an overview of how 988

hotlines operate, with a specific focus on

non-consensual interventions and the lack of

transparency surrounding the practice. The

second section, Policing and Criminalization:

Why Cops Don’t Belong in Care, explores

the connection between hotlines and law

enforcement in crisis response. The third

section, Forced Hospitalization: A Jail By

Another Name, analyzes experiences of

psychiatric hospitalization – a potential

outcome of a hotline call – with a specific

focus on involuntary and coercive

experiences. The fourth section, Help-Seeker

Privacy and Location-Tracking Technology,

examines the issues of geolocation and the

use and misuse of hotline users’ data. Finally,

this report concludes with a discussion of

Recommendations for hotlines guided by

the input of people who have sought support

from suicide and crisis hotlines.

EXECUTIVE SUMMARY

TRIGGER WARNING: This report discusses suicide and suicidal ideation,

self-harm, mental illness, violations of consent, police violence, physical

and sexual assault, racism, transphobia, forced psychiatric intervention,

and death. Some quotes from study participants use profanity.

5

Central to this report is an awareness that

the perspectives of help-seekers, especially

those with marginalized identities, are

underrepresented – or entirely absent – in

both research efforts and the development

of hotline policy. This report centers the

voices of help-seekers in its analysis, building

on original research data from 210 survey

responses and 26 interviews with people

who have lived experiences of mental health*

crises. The survey collected reports on both

helpful and harmful impacts of hotline use

and other forms of crisis care, perspectives

on emergency interventions, and how the

threat of non-consensual intervention affects

help-seekers. The interviews explored hotline

users’ experience of hotline conversations,

as well as non-consensual interventions

and psychiatric hospitalizations initiated

by a hotline call. This original data offers

a multifaceted understanding of crisis

hotline users’ experiences, adding to the

existing knowledge of crisis hotlines, crisis

intervention, and the mental health care

system more broadly. For more information

on the original survey and interview research

design, see Appendix A.

In tandem with the lived experiences of help-

seekers, this report brings together existing

research and a diverse catalogue of policy

documents to provide a clearer image of

the current hotline landscape. The report

concludes with concrete recommendations to

transform crisis hotlines in ways that center

life-affirming, transparent, and consensual

crisis support. Primarily informed by help-

seekers, we call for increased investment in

non-punitive, consent-driven crisis care and

the end of non-consensual interventions.

KEY FINDINGS

1. 988 Suicide and Crisis Lifeline:

The creation and funding of the 988

Lifeline presents a major opportunity to

improve the quality and efficacy of crisis

intervention services. However, the new

Lifeline is missing the mark on providing

crisis care that is safe, consensual, and

effective. Instead, 988 has systematized

the use of non-consensual interventions

and has obscured information about

this practice from public view. Efforts to

obtain data from 988 administrators have

been largely unsuccessful, with officials

refusing to disclose critical information

about the frequency and outcomes of

emergency interventions.

2. Non-Consensual Interventions:

This report exposes the negative

consequences that can result from

emergency interventions, especially those

that violate consent. These consequences

can include forced hospitalization, police

involvement, physical violence, and long-

term psychological harm. Non-consensual

interventions can lead to traumatic

outcomes, particularly for marginalized

groups, including Black, Brown, LGBTQ+,

disabled and low-income individuals.

3. Help-Seeker Needs:

This analysis illuminates the

perspectives of help-seekers, who too

often are ignored in the creation of

hotline policy. Help-seekers’ experiences

and needs are centered in the discussion

of current harmful practices and inform

recommendations for improving suicide

and crisis hotlines.

1

2

3

6

Everyone deserves safe and

effective care during experiences

of crisis, and approaches to crisis

support that center the needs of

help-seekers are within reach.

RECOMMENDATIONS

1. Policy Change:

The findings in this report emphasize

the need to end non-consensual

interventions, suicide risk assessments,

law enforcement collaboration, and the

use of forced and coercive psychiatric

hospitalization. This report further

advocates for policies that prioritize

informed consent, transparency, and

increased accountability to the needs

of help-seekers.

1. Training and Support:

Help-seekers highlight the

importance of and need for

improved training for hotline

operators to better understand

and support individuals in

crisis, particularly those from

marginalized communities.

1. Investment in Non-

Punitive Crisis Care:

This report recommends increased

funding for alternative crisis support

systems that do not involve law

enforcement or forced

psychiatric interventions.

The report concludes with a strong call to

action for transforming crisis hotlines into

truly safe and supportive resources. By

centering the experiences and needs of help-

seekers, especially those from vulnerable

populations, the report advocates for a more

humane and life-affirming approach to mental

health crisis care. Everyone deserves safe

and effective care during experiences of

crisis, and approaches to crisis support that

center the needs of help-seekers are within

reach. We hope that this report will provide

readers with the knowledge to envision

better solutions, as well as the determination

and direction to make them a reality.

1

2

3

7

While suicide and crisis hotlines have

continued growing in popularity,

the promise of anonymous and safe

support has all but disappeared.

Suicide hotlines originally began as a

unique form of support rooted in human

connection: a space to share and be heard

in a vulnerable moment. One of the first

suicide hotlines in the United States started

in the early 1960s and consisted of a single

phone in the basement of a tattoo parlor

in San Francisco’s Tenderloin District.

The founder, Bernard Mayes, envisioned

a service that offered “unconditional

listening” from an “anonymous ear.”1 This

community-based model of support gave

people a space where they could talk

openly about their reality without the fear

of being institutionalized or the threat of

social and legal punishment. Over 60 years

later, suicide and crisis hotlines remain a

space that neither close friends nor mental

health professionals can replicate. In a

context where high-quality care is regularly

denied to survivors of trauma, people with

psychiatric diagnoses, and those who are

experiencing life-interrupting challenges,

suicide and crisis hotlines fill a major gap

in social support.

INTRODUCTION

While suicide and crisis hotlines have

continued growing in popularity, the

promise of anonymous and safe support

has all but disappeared. In the United

States, the majority of crisis hotlines have

adopted policies and practices that violate

the privacy, trust, autonomy, and safety of

people who are reaching out for support.

In a far cry from their safe and effective

origins, many suicide and crisis hotlines

have become entrenched in a system that

links crisis response to police, prisons,

and psychiatric hospitalization. These

hotlines now play a major role in initiating

emergency interventions for people in

crisis, and most disturbingly, are able to

do so without consent.

Though emergency interventions can

occur voluntarily or involuntarily, this report

draws specific attention to the practice of

non-consensual intervention, a potential

consequence of contacting crisis hotlines

that is both hidden from help-seekers and

understudied in existing research.

8

Non-consensual intervention is the process

through which an emergency response

occurs without a help-seeker’s knowledge

or consent. Non-consensual interventions

can include both the initial response of

emergency responders at a help-seeker’s

location and any additional interventions

that take place from there, such as

incarceration or forced hospitalization.

Non-consensual intervention also includes

instances where a help-seeker may be

coerced into consenting to an emergency

response. Crisis hotlines employ non-

consensual interventions by initiating

processes for sending emergency

responders – often law enforcement – to

the location of a help-seeker perceived to

be at risk of harming themselves or others.

Although often framed as necessary for the

safety of an individual or their community,

in reality, non-consensual interventions set

the stage for traumatizing experiences that

can exacerbate crises and decrease trust

in hotlines.

In the United States, non-consensual

interventions pose an enormous threat

to people in crisis, particularly Black

and Brown people, LGBTQ+ people,

disabled people, poor people, and those

at the intersections of these and other

marginalized identities. Encounters with

emergency responders, especially law

enforcement, too often escalate to physical

violence, psychiatric hospitalization,

incarceration, and even death.2-3 In fact,

emergency interventions, even those

that start out consensually, can quickly

become non-consensual as dynamics

of race, gender, and perceptions of risk

play out between emergency responders

and people experiencing crisis. The

repercussions of these interventions can

mean long-lasting emotional, financial, and

physical injuries – conditions that prolong

and exacerbate crisis and thoughts of

suicide. Non-consensual interventions are

often condemned by people who have

experienced them,4-5 but U.S. policymakers

and crisis hotline administrators have

ignored these voices and continue the

practice. Rather than centering the well-

being of help-seekers, non-consensual

interventions center the subjective

perceptions of hotline operators and the

legal liability of hotlines themselves.

Recently, with the creation of the largest

hotline network in the United States,

the issue of safety and consent on crisis

hotlines has grown all the more urgent.

In 2022, the U.S. government introduced

the 988 Suicide and Crisis Lifeline,

transitioning the former ten-digit number

for the National Suicide Prevention Lifeline

into a new three-digit dialing code: 988.6

Presented as an easy-to-remember

alternative to 911, the 988 Lifeline has

been promoted as a way to divert calls

related to psychological and emotional

crisis away from law enforcement.7 988

has been celebrated as an advancement

for the mental health system, as its

introduction expanded the Lifeline into a

systematized network with over 200 crisis

centers providing access to 24/7 crisis

response and resources.8 To date, federal

funding made available for the rollout of

988 has invested almost $1.5 billion into

suicide prevention and crisis response.9

9

While 988 represents a significant

expansion of crisis care, it also represents

an expansion of location tracking capabilities

and non-consensual practices in social

support services. 988 policymakers have

adopted and defended the practice of non-

consensual intervention, disregarding the

voices of hotline users, psychiatric survivors,

human rights organizations, and crisis

care experts who condemn the practice.10

In addition to defending non-consensual

intervention, 988 administrators have

advocated to increase the surveillance of

hotline users, asking the federal government

to grant the Lifeline unprecedented location

tracking capabilities.11 Simultaneously, the

Lifeline has avoided calls for transparency

and maintained secrecy around the number

of non-consensual interventions their

hotlines are initiating and the negative

consequences that help-seekers have faced

as a result. Undeterred by the contradiction

of the life-threatening harms that can be

caused by non-consensual interventions,

988 officials continue to make claims that

the use of these interventions allows them

to better achieve their goal of providing

“life-saving services.”12

Since its creation, the 988 Suicide and

Crisis Lifeline has increased its reach

to the U.S. public through a national

marketing campaign. In this campaign, 988

regularly advertises itself as a “private”

and “confidential” resource for people in

crisis, offering a safe space to discuss one's

struggles.13 Not included in this advertising

is any disclosure about the possibility

of emergency interventions, which can

include law enforcement, and in particular

that such interventions can occur without

a help-seeker’s knowledge or consent. In

spite of efforts by advocates and survivors

of non-consensual intervention, 988

officials have continued to obscure the

policies and practices that render their

advertising misleading and dishonest. This

lack of transparency has meant that the

public is largely unaware of the potential

negative consequences of calling 988.

Despite good intentions in its design,

in reality, 988 has created another

pipeline for people experiencing crisis

to come into contact with potentially

unwanted and unhelpful interventions.

These interventions can ultimately harm,

traumatize, and discourage people from

reaching out for help. The next section

examines the policies and practices in

place that enable 988 to initiate non-

consensual interventions on help-seekers.

In the United States, non-consensual interventions

pose an enormous threat to people in crisis, particularly

Black and Brown people, LGBTQ+ people, disabled

people, poor people, and those at the intersections

of these and other marginalized identities.

10

** For the purpose of this report, the term crisis hotline is used to generally describe suicide and crisis call centers,*

warmlines, peerlines, helplines, etc

HOW 988 OPERATES:

A GUIDE TO

HOTLINE POLICIES

AND PRACTICES

1

CHAPTER

“I need genuine human

connection. I need validation.

I need compassion and

empathy and people who

are trained to offer that.”

The suicide and crisis hotline landscape in

the United States is made up of national,

local, and grassroots hotlines.* These hotlines

operate within ...

Content warning: This article includes mention of suicide and police violence.

The suicide prevention nonprofit Trans Lifeline is blowing its whistle on the 988 crisis hotline in a new report this week, saying the hotline’s collaboration with police exposes callers to additional harm, among other ethical concerns.

The report, The Problem with 988: How America’s Largest Hotline Violates Consent, Compromises Safety, and Fails The People, was released on Thursday this week to coincide with World Mental Health Day, according to a Trans Lifeline press release. In it, researchers argue that 988’s policies “compromise the safety, privacy, and autonomy” of its callers by exposing them to nonconsensual interactions with the police and forced hospitalizations, which they said often lead to new traumas and worse mental health outcomes.

988 launched in 2022 as an alternative to the U.S.’s 911 emergency hotline, overseen by the Substance Abuse and Mental Health Services Administration (SAMHSA). Operators are required to alert emergency responders, including police, if a caller is considered an “imminent risk” of harming themselves or others, the report noted. This is also true for outside organizations like the Trevor Project, which has partnered with 988 since launch to provide LGBTQ+-specific crisis counseling through the hotline.

A large percentage of trans students reported being bullied in the last year.

But as Trans Lifeline researchers reported, 988-initiated encounters with police — with or without a caller’s consent — can lead to “life-altering and sometimes lethal harm.” Study participants who had experienced nonconsensual “wellness checks” by police described a range of interactions from “unpleasant to violent” in interviews with researchers. Some reported that they were called homophobic and transphobic slurs, subjected to police violence, and even sexually assaulted. One respondent said they were coerced into allowing police into their home after calling 988, when an officer told them they would either be hospitalized “voluntarily” or be “involuntarily taken.” Researchers said that kind of punitive and carceral approach “showcases how emergency interventions can present a help-seeker with a false illusion of choice that offers coercion rather than consent.”

Fears of police violence among trans people are well-founded. In 2022 — the same year 988 was founded — 47-year-old Korean transgender woman Maddie Hofmann was shot three times by police during a “wellness check” at their home in Pennsylvania. A judge later found her death to be a justifiable use of deadly force. Between 2019 and 2021 alone, at least 178 people in the U.S. were killed by police during “wellness checks” ostensibly initiated to aid and protect them. Outside of responses to mental health crises, contention between police and LGBTQ+ people at large dates back to, and before, the events of the Stonewall Riots or the Compton Cafeteria Riots, which were sparked in reaction to police violence specifically targeting bars for queer and gender nonconforming people.

In a 2022 statement celebrating a $30 million SAMHSA budget increase for 988 Lifeline services, the Trevor Project’s Director of Advocacy and Government Affairs Preston Mitchum said his organization “must also [...] build upon its infrastructure to expand access to non-police crisis intervention responses and long-term mental health, behavioral health, and addiction care.” But although civilian co-responder programs and other initiatives have since taken root in some areas of the U.S., non-police crisis support in the U.S. is still patchwork and frequently underfunded, as researchers noted in this week’s report. “When funding is invested in non-police crisis intervention, large amounts are allocated to short-term solutions, such as creating more psychiatric beds,” researchers wrote, “which do little to meaningfully address the root causes of distress and trauma.” The result has been “a landscape that offers few resources to confront the social and economic factors that often cause or exacerbate crises,” they said.

Other study respondents who did not experience direct violence still told Trans Lifeline researchers that because 988 operators would effectively report suicidality to the police, they were less willing to be open about what they were really going through — especially because operators also provide police with access to a caller’s cell phone geolocation data, with or without the caller’s knowledge or consent. Some have refused to call at all. “I have actively avoided calling 988 since it’s come out because of the people who have shared that [they] called 988 and the cops showed up,” one respondent told researchers. “I don’t need the cops when I’m having emotional distress.”

“Our Safe Hotlines report came into existence through a deep awareness that trans and queer folks, Black and brown folks, folks living with disabilities, folks experiencing poverty, and all people living within those intersections and beyond, deserve better,” said kai alviar horton, Executive Director of Trans Lifeline, in the organization’s press release this week. “We deserve the safety to unravel and be held without fear of being pathologized, locked up, harmed, and abused. We deserve to ask for help without experiencing state-sanctioned violence.”

The study is the first to “firmly establish causality” between legislation and attempted suicide rates among trans youth.

The Trans Lifeline report also criticized 988’s complicity in forced hospitalizations, calling them “a jail by another name.” After a caller is forced into psychiatric hospitalization, or “involuntary commitment,” they may experience nonconsensual sedation, physical restraint, and racial or sexual harassment; even after being released, researchers reported that many developed PTSD symptoms and increased feelings of suicidality. “I never had a concrete plan until after that happened,” one respondent who was involuntarily hospitalized said. “Then I immediately had a concrete, fail-proof plan, because that was never gonna happen again. If anyone ever tried to call anyone on me again, I had my failsafe [...] I still have that plan. I don't like that I have that, but I do.”

Researchers also called for greater transparency around data about 988 and its activities, alleging that SAMHSA has dragged its feet for two years on providing such data under the Freedom of Information Act. Researchers also said Vibrant Emotional Health — a 988 administrative partner that came under fire last year for abruptly laying off contractors who were working with the Trevor Project — actively resisted attempts to gather more information, even “denying the existence of requested data” outright.

To improve on current policies, researchers recommended that 988 and its partner organizations divest entirely from law enforcement and halt nonconsensual interventions of all kinds. Instead, suicide prevention workers should move to a model of “consent-driven, request-only transfer and emergency dispatch policies,” invest in “non-carceral peer support,” and attempt to address “the root causes of crises” rather than the individual crises themselves. This reflects Trans Lifeline’s stated principles for its own hotline, operators of which “will not call emergency services or law enforcement without [callers’] specific request,” according to the organization’s website.

“This report is a collective offering to give people the tools to humanize each other again, to understand more deeply the ways oppression informs policy,” horton said, “and to build new worlds where carceral and coercive control are not at the root system of how we show up for each other.”

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403 Forbidden

Suicide Life Threat Behav. 2022;52:37–48.

| 37

wileyonlinelibrary.com/journal/sltb

Received: 22 January 2021 | Revised: 8 March 2021 | Accepted: 11 March 2021

DOI: 10.1111/sltb.12769

O R I G I N A L A R T I C L E

Third- party callers to the national suicide prevention lifeline:

Seeking assistance on behalf of people at imminent risk of suicide

Madelyn S. Gould PhD MPH****1,2,3

| Alison M. Lake MA****4

| Marjorie Kleinman MS****4 |

Hanga Galfalvy PhD****5,6 | Richard McKeon PhD MPH****7

1Division of Child and Adolescent

Psychiatry, College of Physicians &

Surgeons, Columbia University, New

York, NY, USA

2Department of Epidemiology, School of

Public Health, Columbia University, New

York, NY, USA

3New York State Psychiatric Institute,

New York, NY, USA

4Division of Child and Adolescent

Psychiatry, New York State Psychiatric

Institute, New York, NY, USA

5Department of Psychiatry, College

of Physicians & Surgeons, Columbia

University, New York, NY, USA

6Department of Biostatistics, School of

Public Health, Columbia University, New

York, NY, USA

7Division of Prevention, Traumatic Stress,

and Special Programs in the Center

for Mental Health Services (CMHS),

Substance Abuse and Mental Health

Services Administration, Rockville, MD,

USA

Correspondence

Madelyn S. Gould, Division of Child

& Adolescent Psychiatry, NYSPI, 1051

Riverside Drive, Unit 72, New York, NY

10032, USA.

Email: madelyn.gould@nyspi.columbia.

edu

Funding information

This project was funded by the Substance

Abuse and Mental Health Services

Administration (SAMHSA) through a

subcontract from ICF Macro, Inc

Abstract

Objective: To assist suicidal individuals, people in their social network are often

directed to the National Suicide Prevention Lifeline (Lifeline). The study's objec-

tive was to provide information on third- party calls made out of concern for another

person.

Method: Reports on 172 third- party calls concerning individuals deemed to be at

imminent suicide risk were completed by 30 crisis counselors at six Lifeline crisis

centers.

Results: Third- party callers were most likely to be calling about a family member

or friend and were significantly more likely than persons at risk to be female and

middle- aged or older. Counselors were able to collect information about suicide risk,

and counselors and third- parties were nearly always able to identify at least one inter-

vention to aid the person at risk. Emergency services were contacted on 58.1 percent

of the calls, which represents a somewhat higher rate of emergency services involve-

ment than previously reported on imminent risk calls placed by the person at risk.

Characteristics of third- parties and persons- at- risk each predicted emergency service

involvement, but counselor characteristics did not. Non- emergency interventions

were implemented on 68.6 percent of calls.

Conclusions: Individuals calling the Lifeline when they are worried about someone

are provided a range of interventions which can supplement, and at times replace,

calling 911.

This is an open access article under the terms of the Creative Commons Attribution- NonCommercial- NoDerivs License, which permits use and distribution in any medium,

provided the original work is properly cited, the use is non- commercial and no modifications or adaptations are made.

© 2021 The Authors. Suicide and Life-Threatening Behavior published by Wiley Periodicals LLC on behalf of AmericanAssociation of Suicidology.

38 |

GOULD et aL.

INTRODUCTION

Suicide continues to be a major public health problem in the

United States, with rates increasing more than 35% between

1999 and 2019, the year for which the latest data are avail-

able (Drapeau & McIntosh, 2020). Suicide was the 10th lead-

ing cause of mortality in 2018, claiming over 48,000 lives.

Moreover, in 2018 approximately 10.7 million adults had

thought seriously about killing themselves (4.2% of adults),

3.3 million had made suicide plans (1.3%) and 1.4 million

made a nonfatal suicidal attempt (0.6%) (Substance Abuse

& Mental Health Services Administration, 2019, 2020).

Enhancing help- seeking is a key strategy to address the rising

rates of suicidal behavior. However, of concern is the finding

that negative help- seeking attitudes are greatest among in-

dividuals with the greatest mental health needs (Hoge et al.,

2004; Mackenzie et al., 2008; Mojtabai et al., 2002). Much

evidence indicates that suicidal individuals negate, refuse, or

avoid available help (“help negation effect”; e.g., Dean et al.,

2001; Rudd et al., 1995). Furthermore, low perceived need

for services has been reported as the most important reason

that suicidal individuals do not seek help (Bruffaerts et al.,

2011; Gould et al., 2012; Han et al., 2014).

Given the reluctance of many suicidal individuals to seek

help for themselves, suicide prevention initiatives often en-

courage people in the social networks of at- risk individuals

to seek help on their behalf. This is one underlying premise of

gatekeeper training programs (e.g., Gould et al., 2013; Wyman

et al., 2008) and public messaging that directs individuals to

the National Suicide Prevention Lifeline (Lifeline) when they

are worried about a friend or family member. Working with

individuals calling on behalf of someone else (“third- party

callers”) is as much a Lifeline priority as working with in-

dividuals calling on their own behalf (“direct callers”). It is

believed that those who do not call on their own behalf may

be at higher risk of suicide than those who do (Mishara et al.,

2005). As such, a particular emphasis of Lifeline interven-

tions is to collaborate with third- party callers to help indi-

viduals at imminent risk of suicide who have not themselves

reached out to the Lifeline. Lifeline's policy for helping call-

ers at imminent risk of suicide recommends that the crisis

counselor “practice active engagement with persons calling

on behalf of someone else (“third- party callers”) toward de-

termining the least invasive most collaborative actions to best

ensure the safety of the person at risk.” (Draper et al., 2015, p.

264). The Lifeline's Tip Sheet for Working with Third- Party

Callers (National Suicide Prevention Lifeline, 2019) includes

the following advice to crisis counselors:

1. gather sufficient information from the third party to

gauge the safety and severity of the risk of the person

of concern, including an evaluation of the source and

validity of the information;

2. gather contact information and any identifying informa-

tion about the person at risk that the third party is able to

share;

3. coach the third- party caller on how they might best talk to

the person at risk and how they might help the person con-

nect to more help. This may include facilitating a three-

way call with the third- party caller, the person reported to

be at risk and the crisis counselor (or a treatment profes-

sional working with the person at risk); removing access

to lethal means; maintaining close watch on the person

at risk; escorting the person at risk to a emergency care

facility;

4. reach out directly to the person at risk to offer assistance,

when the third- party caller is unwilling or unable to take

further steps to keep the person at risk safe;

5. Contact 911 if the risk is imminent and other solutions are

not possible to keep the person at risk safe.

Preliminary data from the Lifeline network of over 165

crisis centers indicate that approximately 25% of calls are

from a third party (National Suicide Prevention Lifeline,

2011). Given nearly 2.2 million calls to the Lifeline in 2019

(personal communication, National Suicide Prevention

Lifeline), there would have been approximately 550,000

third- party calls that year. This number is apt to increase

given the increased visibility and accessibility of the

Lifeline that would result from establishing a new three-

digit number (988) for a national suicide prevention and

mental health crisis hotline, as signed into law in October

2020 (National Suicide Hotline Designation Act of 2020;

https://www.congr ess.gov/116/plaws/ publ1 72/PLAW-

116pu bl172.pdf). This makes the evaluation of services

provided to third- party callers of critical import. However,

to date, the evaluations of the Lifeline (e.g., Gould et al.,

2016) have focused only on “direct” callers who call on

their own behalf. There has been no evaluation of the in-

terventions with third- party callers to the Lifeline network.

Moreover, there is little existing information on third- party

callers in the literature. Mishara et al. (2005) compared the

effect of four suicide prevention programs in Quebec for

family and friends who called on behalf of suicidal men

who did not seek help for themselves. Follow- up with 131

third- party participants found that all four interventions re-

sulted in reductions in suicidal ideation, suicide attempts,

and depressive symptoms in the suicidal men about whom

they were concerned. Mishara et al. (2005) also reported

on the 1998 program development of the services to third-

party callers that laid the groundwork for their interven-

tion study. They reported that in the 1998 investigation of

321 third- party calls, women made up three- quarters of the

callers, but over half of the third- party calls (51%) con-

cerned a suicidal man. The vast majority (75%) of the calls

gave the third- party callers information about how to help

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GOULD et aL.

the suicidal person. The remaining 25% of calls focused

on the third party's expressing their own feelings. This is

the extent of the existing research specifically focusing on

third- party callers. To date, there is no information about

the nature of the relationships between the third- party call-

ers and the people they were calling about, the extent to

which counselors are able to assess someone's suicide risk

based on third- party reports, and the interventions that the

counselors and third- party callers engaged in to enhance

the safety of the persons at risk.

The current study addresses the sparsity of information

about third- party calls to crisis hotlines by describing the

demographics of the third- party callers and the persons at

risk, the relationship between the third- party callers and

the persons at risk, the source of the third- party callers’

information about the persons at risk, the suicide risk

characteristics of the persons at risk based on third- party

reports, and the interventions implemented on third- party

calls, with particular emphasis on interventions involving

emergency services, their predictors, and their outcomes

(e.g., whether the emergency service located the person at

risk, and whether the person at risk was transported to a

hospital). Our study focuses on third- party calls concern-

ing a particularly high- risk group— individuals deemed by

crisis counselors to be at imminent risk of suicide (Draper

et al., 2015). Information on the characteristics of third

parties and the individuals they call about, and on the

types of assistance Lifeline counselors are able to offer

third- party callers will provide an empirical foundation

for the Lifeline's continuing efforts to enhance the safety

of persons at risk of suicide who are not seeking help for

themselves.

METHODS

Sample

Crisis centers

Building upon our previous data collection of imminent

risk calls at eight Lifeline centers (Gould et al., 2016),

crisis counselors at a new sample of eight Lifeline cent-

ers were recruited for the current study based on centers’

responses to the Lifeline's 2015 Crisis Center Survey.

Selection criteria included center's call volume, census

region, and whether or not the center used volunteers to

answer crisis calls. The goal was to select centers which

were broadly representative of the diversity of Lifeline

crisis centers overall. Also based on centers’ responses

to Lifeline's 2015 Crisis Center Survey, we selected only

centers which had not made regular use of the Lifeline's on-

line caller simulation training for crisis helpers (“Lifeline

Caller Simulation”). Lifeline had informed us of their plan

to actively promote the Lifeline Caller Simulation during

our study period. By selecting centers not already exposed

to the training prior to this upcoming promotion effort, we

anticipated that our sample would include sufficient vari-

ability in counselors’ exposure to this training to allow us

to examine its impact on counselors’ interventions. Our

evaluation of the Lifeline Caller Simulation is the focus of

another paper. The recruitment of the eight centers focused

on their ability to provide data on imminent risk callers

calling on their own behalf. Six of the eight centers also

provided data on third- party callers calling about someone

deemed by the counselor handling the call to be at immi-

nent risk. Two centers’ protocols did not include assess-

ing the suicide risk of individuals who were the focus of

a third- party caller's concern, but who did not themselves

participate in the call.

Crisis counselors

All counselors at participating centers responsible for an-

swering calls to the Lifeline and the centers’ local crisis

lines were eligible for participation in the study. Of the

92 participating counselors, 30 (33%) ultimately completed

questionnaires on at least one third- party imminent risk

call. The remaining participating counselors did not answer

a third- party imminent risk call during the data collection

period. Of the 30 counselors, all were paid employees.

Less than 14% of the counselors did not have bachelor's

degrees, over 48% had bachelor's degrees as their highest

level of education, and approximately 36.6% had gradu-

ate degrees. One- third were licensed clinicians/mental

health professionals. Counselors had spent an average of

79.6 months working as telephone crisis counselor (range:

8– 260 months), spent an average of 23 hours per week an-

swering calls (range: 2– 42 h), and handled an average of

7.5 suicide calls per week (range: 1– 20).

No clinical training was provided as part of the current

project. Participating counselors had all received Lifeline-

approved trainings at their centers and had diverse histories

of participation in supplementary trainings and experience

providing systematic follow- up to suicidal callers. Either

Applied Suicide Intervention Skills Training (ASIST,

Gould et al., 2012) or training in safety planning protocols

(other than those derived from ASIST) were completed

by approximately 80% of counselors. Most counselors re-

ported using safety planning protocols developed at their

crisis centers, with smaller numbers reporting using pro-

tocols derived from ASIST, or from the Safety Planning

Intervention developed by Stanley and Brown (2012).

Approximately midway through data collection, 40% of

the counselors made use of one or more modules of the

40 |

GOULD et aL.

Lifeline Caller Simulation. The impact of this training is

the focus of another paper.

Calls from third- party callers concerned about

individuals at imminent risk of suicide

Over the course of data collection, which took place from

December 2016 through October 2018 and spanned between

12 and 18 months at each center, counselors handled 172 calls

from third- party callers concerned about individuals the

counselors considered to be at imminent risk. Each counselor

answered a median of three third- party calls (range = 1 to 39;

interquartile range = 8). Due to the lack of identifying infor-

mation collected on callers, we are unable to say whether our

sample included more than one call from the same individual.

The unit of analysis is therefore not the imminent risk third-

party caller, but the imminent risk third- party call.

Procedures

Counselors were asked to complete an assessment similar

to the one employed in our earlier imminent risk protocol

evaluation (Gould et al., 2016). At the outset of data collec-

tion at each center, information on participating counselors’

training and experience as a telephone crisis counselor was

obtained from counselors and/or from their centers’ supervi-

sory staff (see Counselor Questionnaire below). Thereafter,

for the duration of the data collection period, counselors

were asked to provide information about each call from an

individual they deemed to be at imminent risk of suicide or

from a third party concerned about someone the counselor

deemed to be at imminent risk. The primary means of data

collection was for the counselor handling the call to com-

plete our evaluation questionnaire using REDCap, a secure

online data entry platform. According to center preference,

at some centers where the centers’ own record- keeping con-

tained the data elements necessary for the evaluation or was

programmed at the outset of data collection to do so, the data

were transcribed from the counselor's record into REDCap

by center supervisory staff. Because a goal of the study was

to assess the extent to which counselors were adhering to the

Lifeline policy on helping imminent risk callers, with which

the counselors were expected to be familiar, counselors were

not instructed by research staff in how to define imminent

risk. Instead, counselors were instructed to use and to docu-

ment on their questionnaires, their own understanding of this

term. Counselors were instructed not to use the questionnaire

as an interview, or to collect any data directly from the call-

ers for study purposes. Instead, counselors were instructed

to conduct the calls according to their center's protocols and

their own clinical judgment and to describe their perception

of and intervention with the caller immediately after the in-

tervention was completed.

Measures

The Counselor Questionnaire, developed for our ear-

lier Lifeline evaluations (e.g., Gould et al., 2016), asked

the counselors to describe their employment status at their

center (whether paid employee, volunteer, and/or supervisor/

trainer), how long they had been working/volunteering as a

telephone crisis counselor, the average number of hours per

week they spent answering crisis lines, the average number

of suicide calls they handled per week, their highest level

of education, whether they were licensed clinicians/mental

health professionals, whether they had completed training in

ASIST or in the use of any other Safety Planning protocols,

and whether they made use of the Lifeline Caller Simulation

during the study period.

The Imminent Risk Form expanded the questionnaire

we employed in our earlier study (Gould et al., 2016) and

contained questions relevant to the present analyses that fell

into the following categories: (a) information about the third-

party caller (including gender, age, location, relationship to

the person at risk, and source of information about the person

at risk); (b) demographics of the person at risk (including

gender, age, and location); (c) suicide risk characteristics of

the person at risk, including the components of suicidal "de-

sire" (suicidal ideation, hopelessness, helplessness, feeling

trapped, feeling alone, perceived burden, psychological pain,

reasons for dying); suicidal "intent" (attempt in progress, plan

to kill self, method chosen, preparatory behaviors, expressed

intent to die, timeframe for acting on thoughts); and suicidal

"capability" (history of suicide attempts, means available,

current intoxication, history of substance abuse, exposure

to someone else's death by suicide, recent dramatic mood

change, being out of touch with reality, agitation/restlessness,

aggression/a ...