Suicide Hotlines, Risk Assessment and Rights: Whose Safety Matters?

When you call the national suicide hotline like everyone on social media recommends during May (Mental-Health Awareness Month), September (Suicide Prevention/Awareness month) and for a few weeks after every high-profile suicide, this is what happens: First, you wait, usually over an hour, no matter what time of day, for the next available “counselor.” This wait time means that there are at least 80 people in line ahead of you, which should indicate that there is probably more contributing to your distress than chemicals going haywire or your failure to individually manage your “mental illness.” The “counselor,” who is a trained volunteer with an unspecified background, asks you your name even if you’ve clearly chosen in their pre-chat/call survey to remain anonymous. Anyone who’s experienced lethal levels of despair while living in America knows at least some of the reasons for remaining anonymous, but more on that shortly. They won’t demand you identify yourself if you insist on keeping your name, gender, gender identity, sexual orientation, level of distress and location to yourself, but they do initially ignore the preferences you are compelled to enter into a little window or say on the phone before being granted contact with the “counselor.”

Then they’ll ask you what’s going on. Whatever you say, their next question will be if you’re having current thoughts of suicide. I’m not sure what happens if you say no — my guess is that the conversation is over even faster — but if you say yes, they’ll first ask if you’re able to keep yourself safe during the conversation. I want to think that’s a fair question, that it’s not as condescending and self-protective as it sounds, but even if it is out of genuine concern, it’s really hard to see how this doesn’t contribute to the stigma of the suicidal person as a dangerous, unstable freak who has no agency or control. There’s also no discussion of what “safe” feels like — or really of what anything feels like, which is a sizable problem since one common and major contributing factor to suicidality is the perception that one is unable to communicate the nature and depth of one’s pain to another human being.

It quickly becomes clear, though, that this question about during-conversation safety is not quite out of genuine concern but, rather, another box on their “risk-assessment” checklist. You could say, “no, I do not believe I can keep myself safe, whatever the hell that means, while we’re talking” or “it depends on whether or not you start talking to me about the benefits of journaling or how helpful medication could be after I tell you I have a full bottle of sleeping pills less than ten feet away.” It’s a hard call to make whether that actual occurrence on the hotline is incompetence or apathy.

Your answer about safety in the moment doesn’t matter. Their next question will be if you have a plan, what that plan is and if you have access to the means. If you say no at any point, the “counselor” probably assumes the risk goes down and finds a thinly polite way to extract a safe “for now” plan-that-is-not-one-of-those-patronizing-contracts-no-not-at-all and move on to process the next human being experiencing intolerable psychological, emotional or mental anguish who still managed to attempt some human connection. If you say yes, they express that they’re “very concerned” and ask a series of questions about your support system — immediate supports, social supports, therapists, self-care practices, stuff like this.

If you report (like more and more people in this country are) having few social supports and that the “treatments” you’ve tried for depression haven’t worked, the “counselor” will ask you what you want to do. Now, I’m all for agency. One of the most damning aspects of capitalism is that it reduces our sense of choice to brand loyalty and how we want to sustain ourselves financially (and, more and more, that is becoming an illusion). But if you’re attempting to make contact with another human being because you think you might kill yourself, then it’s clear what your desire is: human connection. Can a bubble bath give you that? Can deep breathing? Hot tea and a good book? Even if self care weren’t so messed up, relationship, connection to another human being is not something you can give yourself no matter how good you are at taking care of yourself.

If you say you don’t know what you’re going to do since it’s now obvious that the thing you want and need in this moment is not going to happen as you were understandably expecting it to, the “counselor” will express alarm they’ll label as “concern” again and tell you that, if you’re unable to keep yourself safe, they will have to send you some “help.” We all know that what they mean is not a friend (if you find that helpful, which this culture thinks you shouldn’t), not a therapist (if you find that helpful like this culture fervently believes you should), but the police. This is one of the reasons people want to remain anonymous.

But if you bring that up, if you remind the “counselor” that you didn’t give them a name or a description and ask how they’ll know where to send this “help,” they’ll say they “can’t disclose that information.” Despite the immense concern expressed moments earlier, the conversation is over within the next five minutes no matter what: you’ll either report whatever you need to to keep the cops away from your house, or the “counselor” will make the judgment that you need them and they’ll be there. “Have a good night,” whatever the outcome. “Take care.”

Another reason people might want to remain anonymous is that one of the things people might be after when they attempt to connect with a human being via the National Suicide Hotline is genuine help from someone who doesn’t know them. This makes sense, especially in the context of our society, which is, among other things, Exhibit A of how to devalue human relationships and the value of interconnectedness. If your friends refer you to experts or “professionals” like the Mental Health First Aid trainings instruct, and if those professionals ignore or minimize your “cries for help” and the experts tell you that “there’s hope” for depression, you just have to try harder at all the things depression makes it impossible (or damn near it) to do, then of course you’re going to want to go to a stranger. But to then have that stranger, who you’ve been set up to believe cares about you (and even if you’re dubious about that, there’s really no other place to turn, is there, when friends and family preach “reaching out” via the suicide hotline whenever they want to feel like they’re being helpful), turn you back on yourself or turn you over to the cops? This is the best a group of people concerned about suicide can do? If those are the two options, it’s no wonder the rate and raw numbers of suicide are increasing.

I’ve attended trainings (for my job at a crisis center) put on by the folks who run the hotline, so I know a bit about the backstory: there is almost always an unannounced third person listening in on the call or monitoring the chat. That person’s job is to trace the call or chat if they think the person who made themselves vulnerable is at imminent risk of suicide. Once they’ve obtained that information — the volunteers will say they “cannot disclose their process” but I’ve heard more than one trainer mention that they don’t themselves know how their own tracking system works — they then call the police (they may or may not inform anyone) and send them pretty much to your door in the name of your safety. Because strangers, usually big white men with guns, keep everyone safe and are not triggering, traumatizing or on power trips at all.

This is what people are advocating every time they post the hotline’s number, complete with #reachout or #youarenotalone, and think their job as friend, family member, fellow caring human being is done.

Now, to be fair, of the 77,000 calls the hotline fielded in 2017, they “only” called emergency services 1,500 times. Did they follow up and see how those calls went? Did they ascertain how many of those 77,000 contacts ended up killing themselves anyway? With over 120 people dying by suicide a day in this country, it’s unlikely that none of the people who attempted to “reach out,” as that infuriating piece of self-serving advice goes, took their own lives after talking to a “counselor” through the hotline. Don’t tell me they didn’t have the data to follow up. If they can send the police to an exact location of a person “in danger” without the name or description (or permission) of that person, they have the data to do due diligence. I doubt they did, but if so, I wouldn’t be surprised if they report they “can’t disclose that information.”

Speaking of data, let’s have a look at the efficacy of involving law enforcement in suicidal crises. Unsurprisingly, current numbers are hard to find. The Guardian has a database that tracked police killings by state, race and gender from 2015-2016; to see if mental and emotional distress was involved, you’d have to click on each profile and read it. There isn’t a quick way to tell because our culture isn’t interested in having that conversation.

In digging around for numbers on police involvement with “the mentally ill,” I came across a telling article posted by NAMI. Acknowledging that there are many issues with the organization, I thought the article, which discussed the relationship between the law, law enforcement and mental-health crisis, was worth discussing. Essentially, though over half of the people murdered by the police that year experienced mental and emotional distress (what the general public calls “mental health problems”), the Supreme Court isn’t willing to hold police forces accountable for learning how to compassionately and effectively handle situations involving mental and emotional crises (what are known as “psychiatric” crises to the general public). The article reports that “the problem seems to have worsened,” apparently because mental health resources have diminished and police have had to shoulder more of the “responsibility” in dealing with these crises.

If one of the most commonly recommended “resources” is purposely involving the police, it’s circular and lazy to report that the huge problem (often ignored by mainstream culture) of police violence against those experiencing mental and emotional distress is because there aren’t enough resources. There aren’t enough appropriate or accessible resources, to be sure. Since the suicide hotline insists on continuing to involve the police, which aren’t ever an appropriate “resource” for mental health issues, the hotline isn’t an appropriate resource, either. Mental Health First Aid trainings direct first-aiders to professionals and the professionals either blow us off or call the police. Friends call the police or direct us to experts or the hotline, and the hotline refers us to the police. So, to summarize, mental health resources and law enforcement are basically the same. That’s the reason why the police are fielding so many mental health calls. That the Supreme Court doesn’t think the ADA requires police to undergo any training beyond what they get to be cops, which is ostensibly to fight crime, means that our legal system still equates “mental illness” with criminality.

Based on my experience doing crisis work, most of the training that social workers and therapists get incorporates the police as well. 911 is always a last resort, of course, and we always want to go least restrictive first, of course. But in practice, how often does it work out that way? The hotline folks who ran the last training I attended for my job have said unapologetically that they “reserve the right to call the police.” When did a conversation between a volunteer and a suicidal person become about the volunteer’s rights? Every therapist I’ve ever talked to says they reserve the same right. Why is this about rights at all? Why isn’t this about life, death and dying?

The last training I attended was about risk assessment with an aim toward prevention. Assessing risk takes the assessor out of the realm the suicidal person is in — wrestling with death and dying — and puts them in the realm of safety, which, because we have a system in which involuntary detainment is still an option, quickly becomes about rights. The way we talked about how to measure risk and the efficacy of the tools was, for the most part, subtly about how the clinician or person administering the assessment tool can protect themselves while calling it assessing the person (which is, I’m pretty sure, a form of gaslighting). In other words, the suicide risk assessment is about how safe (professionally, legally, ethically) the assessor is with the suicidal person, not how safe the suicidal person is from actual suicide.

There was one participant, a therapist, whose two-point pushback helped me not feel like a total alien in this work. 1) While “everyone” thinks that a chronically high suicidality score on the risk measure means the risk goes down, this therapist said, “Chronic suicidality being a low risk for suicide is like expecting them to be fine continuing to live in pretty severe pain. I think that the longer a person’s been depressed or experiencing ideation, the higher their risk goes.” 2) He asked, how accurately can we measure risk if the person doesn’t give us accurate information? The trainer assured us of the assessment’s accuracy, but as for people not giving accurate information? “Well, there’s just nothing we can do about that,” the trainer said.

False. There is a lot you can do if you’re in charge of training volunteers to “counsel” suicidal people. You can’t force people to tell you the truth, but you can make it a safe space for people to tell you the truth. This means taking police involvement completely off the table, no matter what. Calling them for “safety” is about your safety, not the person seeking some type of human connection even from the depths of the hell that is suicidal ideation.

Despite the growing capacity of warm lines and other alternatives, the national suicide hotline is still the most recommended resource out there. Maybe people don’t know how ineffective and damaging it actually is. Maybe they don’t know how to show up for each other, which wouldn’t be their fault. We are formed by a turbo-charged capitalistic, individualist culture that strip-mines the basic skills of friendship from anyone who lives in it for the sake of short-term material gain at the expense of our humanness. But the most powerful way to intervene in a suicidal crisis is being in the physical presence of and being emotionally present with another person. I get the pull toward anonymity, but being in the presence of someone who cares about you and does not have a gun or the means to commit you accomplishes more than “safety” and is more effective than a checklist. The mental health/psychiatric/police-force system doesn’t offer stable human connection: pain is medicalized and weaponized against the person experiencing the pain, and you’re only allowed to stay as long as your “treatment” lasts or for the 50 minutes of your appointment.

The problem isn’t a shortage of inpatient beds or affordable therapists. As long as mental health “services” have any ties with the police or the legal system, the only people who are safe are the ones in the robes or the uniforms. It is hypocritical to use the police not even as a last resort but as a routine part of the treatment of people experiencing extreme distress, while simultaneously failing to hold the police or their jurisdictions responsible for training them to respond to pain like it’s not the crime our productivity-addicted, quick-fix, “self-made” culture wants us to treat it as. It is hypocritical to post the number for the national suicide hotline with the hashtag “you are not alone” (which, I might point out, is in passive voice) while relying, for a growing bulk of the “work” being done with humans who carry a DSM diagnosis, on a legal system that scapegoats those with “mental illness” labels and abuses them with impunity. Stripping someone of their rights in the name of safety and committing them to a hospital because they check off all the boxes for a high risk for suicide is malpractice, since “there is not a single shred of evidence showing that hospitalizations prevent suicide.” That’s probably because violence does not beget safety, just as “mental illness” does not beget (or deserve) violence.