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The Highest Level of Care: What Happens When You Call the Crisis Line

Updated: Sep 11, 2019

If you've been involved in suicide prevention on a personal or professional level, you know the drill. It's summed up best by the Question, Persuade, Refer method. Ask if someone is suicidal, persuade them to accept help, and connect them with professional services (usually 911 or the emergency room). It's just like CPR, the Institute states, and should be treated as a similar emergency. This pathway makes sense: it urges us to speak directly about suicide and it is a fast-track to professional help in a life-or-death situation. But what happens after the call? What happens if we resist the idea of calling or of going to the hospital? What happens if we have willingly presented at the emergency department only to be turned away or placed in handcuffs? What happens if we're suicidal most of the time? Are we always in a state of cardiac arrest? This model of suicide prevention ignores so many of us. This week, I will be talking about it. Today: so you've questioned, persuaded and referred. What happens next?

Crisis Center Responses to Imminent Suicide Risk

Every day during suicide prevention month, crisis center phone numbers are shared on social media. But what happens when we call the crisis center? Will it lessen our desire for death or help us keep ourselves safe? Is it another person asking us questions and persuading us to go to the hospital?

Responses: 911, Emergency Room, Safety Planning

A study of National Suicide Prevention Lifeline-affiliated crisis center responses to callers at immediate risk for suicide found that 24.6% of call-takers sent emergency services to the caller's location without their consent. In the remainder of calls, callers either collaborated on safety planning with the call-taker in order to reduce their imminent risk (i.e. removing access to means, involving a third party to ensure safety, or receiving a follow-up call from the center), agreed to have the call-taker send emergency services to their location, or agreed to take themselves to the hospital.The majority of calls resulted in emergency services arriving at the caller's location, whether with or without their consent.

Gould et al. (2016)

Of the calls that resulted in 911 calls, the majority were without the caller's consent.

Gould et al. (2016)

Crisis lines, emergency services, and hospitals comprise the highest level of care in mental health. One would expect that the highest level of care would, in fact, provide care and treatment to patients. However, inpatient hospitalizations not only fail to treat mental illness but are associated with worse symptoms in both the short- and long-term.

After the Call: The Effect of Hospitalization on Suicide Risk

Hospitalization is Associated with Increased Risk for Suicide

The strategies employed to keep patients alive in psychiatric hospitals include 24/7 surveillance (even while using the toilet and showering), anti-suicide smocks, seclusion in a furniture-less room akin to a jail cell (usually with a bed that is formed from a ledge in the wall), restraints, and forced medication (See "Seclusion and Restraint in Psychiatric Hospitals" for an overview of these practices). The effect of these interventions is a profound sense of dehumanization, isolation, helplessness and misery. If theories of suicide posit that the desire for death is based around lack of belonging, pain, and hopelessness; a psychiatric hospital is a breeding ground for suicidal desire. Personally, I have never felt so hopeless and disconnected as I did in hospital.

As Jess Stohlmann-Rainey writes in her article Hegemonic Sanity and Suicide: suicide rates increase dramatically in recently-discharged and frequently-admitted inpatients. This increased risk is highest in the first three months following discharge, a proximity that suggests a direct effect of hospitalization on suicide risk.

Additionally, Slemon and colleagues write:

“Although most unethical practices from the era of institutionalization have been identified as inhumane and discontinued, many of today’s practices still resemble those from the past, including confinement from the outside world, seclusion and restraint, observation and surveillance, denial of leave and removal of personal belongings including clothes.” (p.3)

Rather than engaging patients in meaningful treatment programs, the hospital turns basic human needs – fresh air, companionship, entertainment – into privileges. Patients are framed as incompetent at best and dangerous at worst, and denied meaningful involvement in their care. They are too fragile to understand. They’re too sick. It seems unethical, but it’s for their own good.

The response of many to these harmful effects of restrictive care is to weigh the risks and benefits of life and death. Slemon and colleagues investigated what they termed "risk management culture": taking every measure necessary to force a patient into safety. These two outcomes ignore quality of life interventions that reduce suicide by creating lives worth living. Ideation-to-action theories of suicide tell us suicide risk increases with pain and disconnection. These factors should be targets of treatment, rather than restrictions and punishments that hamper connections to living and cause emotional and physical pain.

Alternatives to Hospitalization

Creating a Life Worth Living

Dr. Marsha Linehan describes the problem of hospitalization as treatment for suicidality in this video. In it, she states that dialectical behaviour therapy (the recommended treatment for borderline personality disorder) is "not a suicide prevention program". Instead, its goal is to build a life worth living. Dr. Linehan acknowledges the difficult reality that focusing on building a life worth living rather than "locking [the patient] up and keeping a nurse with [them] 24/7" might result in death. While acknowledging this risk, she works with patients and families to make an informed, collaborative decision about inpatient treatment.

Collaborative Safety Planning

A safety plan is a tangible, step-by-step directive for coping with suicidal crises. Safety plans are powerful because they are created by the suicidal individual, tailored for their specific needs, likes, and dislikes. They also reduce the risk of non-consensual interventions, 911 calls, or police encounters. The goal of a safety plan is to employ distress tolerance skills, interpersonal support, and means safety to reduce suicidal desire and stay safe outside of the hospital. Crisis management skills are individual; what works for one person might be harmful to another.

At a time when we're not feeling suicidal and can think clearly, we complete the safety plan either alone or with the help of a therapist, friend, or family member. It's a good idea to review and update the safety plan regularly as triggers, warning signs, skills, and contacts can change between crises. Individuals dealing with suicidal thoughts can involve a trusted person in their safety planning by letting them know where to find a copy of the plan, talking about the items in the plan, and walking through scenarios that might arise. A friend of mine keeps a copy of her safety plan in her purse, and lets her friends know it's there if she needs it.

Crisis centers are crucial components of suicide prevention, but the conversation is larger than a simple three steps. To effectively reduce suicide rates, we must strive to think of suicide as a long-term, complex process that is often worsened by our current model of intervention.

Gould, M. S., Lake, A. M., Munfakh, J. L., Galfalvy, H., Kleinman, M., Williams, C., … McKeon, R. (2016). Helping callers to the National Suicide Prevention Lifeline who are at imminent risk of suicide: Evaluation of caller risk profiles and interventions implemented. Suicide and Life-Threatening Behavior, 46(2), 172–190. doi:10.1111/sltb.12182

Slemon, A., Jenkins, E., & Bungay, V. (2017). Safety in psychiatric inpatient care: The impact of risk management culture on mental health nursing practice. Nursing Inquiry, 24. doi: 10.1111/nin.12199

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