Systematic Review of Research and Interventions With Frequent Callers to Suicide Prevention Helplines and Crisis Centers
Abstract
Abstract:Background: Helplines worldwide have frequent callers who may occupy a large proportion of call volume. Therapeutic gain from frequent calling has been questioned. We conducted this review to identify the characteristics of frequent callers and to compile recommendations about how best to help them. Method: Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) standards, we searched for all empirical research in English and French from inception to May, 2020 in PubMed, PsycInfo, and the CRISE library. Results: We identified 738 manuscripts and retained 27 for analyses. Nine provided no definition of frequent callers; nine mixed frequent callers with repeat callers (>1 calls); nine concerned frequent callers (≥8 calls/month). The limited data suggest frequent callers are similar to other callers and often experience mental health problems, loneliness, and suicide risk. From recommendations in all 27 studies, we identified 10 suggestions to better manage and help frequent callers that merit validation. Limitations: The small number of empirical investigations and the diversity of their goals and methodologies limit generalizations. Although recommendations for helping callers may have face validity, empirical data on their effectiveness are scarce. Conclusion: Rather than focusing on reducing call frequency, we should empirically evaluate the benefits of interventions for frequent callers with different calling patterns, characteristics, and reasons for calling.
Helplines worldwide have a small proportion of callers who call quite often, called “frequent users,” “frequent callers” or “repeat callers,” and “chronic callers.” For example, 3% of Australian Lifeline network users call 20 or more times per month, but their calls constitute 60% of all calls received (Spittal et al., 2015). The definitions of “frequent” vary, with many studies including infrequent callers. For example, Greer (1976) included people calling at least 19 times in 2 years, which averages to less than one call per month. Publications indicate concerns about the management of frequent callers. Frequent callers have been reported to occupy so much time that other callers are unable to reach the service. A second concern is the emotional drain on helpers (people answering the phone calls on helplines; e.g., Haycock, 1998). Helpers may feel that frequent callers' calls are difficult because of the complexity of their problems (Vivekananda, Bamford et al., 2019). Helpers have experienced a lack of competence in dealing with these callers (Brockopp et al., 2002; Haycock, 1998; Kinzel & Nanson, 2000), feelings of being manipulated (Kinzel & Nanson, 2000), frustration and resentment (Brockopp et al., 2002; Haycock, 1998), and sometimes burnout (Kinzel & Nanson, 2000). Third, since most helplines are designed for callers who are in crisis or currently suicidal, some think (e.g., Hall & Schlosar, 1995) that repeat callers are manipulating, bored, chatty, or needy of human contact, but not actually suicidal. Fourth, one may question whether the management approaches to frequent callers ignore their needs and the potential benefits from their calling often, and ask how helplines can better meet their needs. Helplines often have an objective of helping people who are in an acute crisis situation and persons at risk of attempting suicide. This objective implies that a crisis intervention approach should be used and that helpline activities should consist of a small number of brief interventions. This contrasts with more long-term intervention approaches, such as psychotherapy, which involve a sustained therapeutic relationship over a long period.
It is also possible, as suggested in the qualitative study by Middleton, Gunn et al. (2016), that different subgroups of frequent callers may benefit from specific services and approaches tailored to address their needs. To help clarify these concerns, we present a systematic review inspired from scoping studies of empirical research in order to summarize (a) empirical data on the nature of frequent callers and (b) current evidence and proposals on how best to help them.
Rationale for This Review
Several systematic reviews reported that many callers call repeatedly (Hvidt et al., 2016; Middleton et al., 2014), although only a small proportion of repeat callers may be considered to be frequent callers. Callers who reuse services include people at high risk of suicide (Ramchand et al., 2017). When studying frequent callers, researchers have often included all repeat callers, usually defined as people who called more than once. For example, the review by Middleton et al. (2014) of research on frequent callers included all empirical studies of persons who called more than once. Thus, their conclusions concern an undifferentiated combination of truly frequent callers and low-frequency repeat callers. The present review initially cast a large net, seeking all studies that ostensibly concerned frequent callers. However, in our analyses of the characteristics of frequent callers, we limited our focus to research on more frequent callers, eliminating studies of an undifferentiated mix of frequent callers and low-frequency repeat callers. When all repeat callers are included in samples of frequent callers, anyone who calls as little as twice or three times in a month would be included in the sample. We adopted the definition of frequent callers as people who call eight or more times in a month, which is the lowest limit set in the empirical investigations we included. We recognize that some studies adopted the threshold of 20 or more calls per month (e.g., Bassilios et al., 2015; Spittal et al., 2015). In our analyses of the empirical data, we also excluded studies that did not indicate their inclusion criteria for being a “frequent caller.” However, in our description of the recommendations of how helplines should react to frequent callers, we included all recommendations in the literature. We did so because the recommendations were based on clinical experiences, and have not been determined based on empirical data.
Some people consider the reuse of a calling service to indicate efficacy. Calling back could indicate that callers want to continue to use the service they think is helpful (Apsler & Hoople, 1976). Others see it as inconsistent with the crisis intervention model (Vattø et al., 2019). The review by Middleton et al. (2014) concluded that research on frequent callers was quite limited. Our review includes more recent research, but limits the scope of our summary of the empirical data to callers who could be considered to call frequently. However, in our summary of recommendations on how to manage calls and be of help to frequent callers, we include all studies where the authors make recommendations.
Method
Our methodology is inspired by scoping studies (Arksey & O’Malley, 2005; Levac et al., 2010; O’Brien et al., 2016; Tricco et al., 2016) and rapid reviews (Tricco et al., 2015). These reviews are exploratory, addressing various elements of a topic, not just one specific aspect, as in a systematic review. Scoping studies meet the same scientific criteria as systematic reviews and proceed with a logical set of identifiable steps. We used PRISMA standards (Shamseer et al., 2015), including the PRISMA-ScR extension for scoping reviews (Tricco et al., 2018) with the following methodology:
Populations
The only criterion that characterizes frequent callers consistently in the literature is the number of calls (Middleton et al., 2014). We used the most inclusive definition in the literature for our initial search, including all research on callers who called at least twice. We then classified studies into those including only callers who called at least eight times a month, studies using the threshold of more than one call per month, and studies that did not indicate how callers were classified.
Documents Retained
We included all research papers presenting original results, using qualitative, quantitative, or mixed methods, published in English or French from the inception of the databases we searched (see Sources of Information section) to May 1, 2020. We excluded manuscripts with no empirical data.
Context
All articles that present data from any type of call center likely to receive calls from suicidal people were included (i.e., helplines, crisis call centers, suicide prevention centers, distress centers, etc.). However, some form of the word “suicide” had to be included as an initial search criterion.
Intervention
When documents described an intervention, no criteria discriminating the types or the nature of the interventions were applied.
Outcomes
In accordance with the descriptive and exploratory approach, all outcome variables were permissible.
Sources of Information
PubMed and PsycInfo were chosen because of their low coverage overlap and their relevance to the research questions. We used natural and controlled vocabulary to increase the specificity and sensitivity (Sampson et al., 2008) and also searched the library of the Centre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices at the Université du Québec à Montreal, which has over 35,000 documents.
Eligibility Criteria
No restriction on the study design or type of data (qualitative, quantitative, mixed-methods) was applied. Exclusion criteria were: no empirical data, non-telephone crisis services, and in languages other than French and English.
Research Strategy
Table A1 in the Appendix shows the terms used to identify the key concepts “frequent callers” and “call centers that may respond to suicidal people.”
Selection of Studies
We identified 738 records after removing duplicates. We read the title and summary to assess eligibility against inclusion and exclusion criteria and initially included 38 peer-reviewed articles that were read entirely. Of these, 27 were retained for analyses (see Figure 1). L.-P. C. and L. D., who each have several years’ experience in screening articles for published systematic reviews, screened the 738 records. When a record raised a doubt, B. L. M. decided on its inclusion according to the eligibility criteria, after discussion with the other authors.
Information Extracted
The information extracted from the articles comprised:
- 1.Objectives: as expressed by the authors
- 2.Sample selection: sampling method
- 3.Type of study: the methods described by the authors including records audit, intervention study, survey of helpline callers, and case or qualitative study
- 4.Variables: dependent variables
- 5.Frequent callers definition: definitions by the authors
- 6.Sample description: qualitative and quantitative information
- 7.Intervention description: nature of the intervention
- 8.Caller characteristics: comparisons with another group
- 9.Description of frequent callers: demographic, psychological, and suicide-related variables. The distinction between this category and sample description is that sometimes the sample is composed of frequent callers and other callers, without distinguishing between them.
- 10.Intervention outcome: effects reported in intervention studies
- 11.Main results
- 12.Limitations: stated by the authors
- 13.Discussion: issues presented
- 14.Methodology
Data extraction was coordinated by B. L. M. and executed by L.-P. C. and L. D.
We were unable to evaluate systematically the methodological quality due to the heterogeneity of methodologies and the lack of sufficient information on the reliability and validity of the data (Tricco et al., 2016) reported in each study. However, it should be noted that several studies used interesting and relevant data sources whose validity and reliability may be difficult to establish (e.g., call logs, survey data).
Results
Nine of the 27 studies failed to provide a clear definition of frequent callers. Nine included all people who called more than once during the entire period under study. Nine studies clearly defined frequent callers, one defining them as eight or more calls a month; the others as 10 or more calls a month, with some using the criterion of 20 or more calls per month. Studies varied in their research methodologies and their data sources (see Table A2 in the Appendix). All of the results we report concerning the characteristics of frequent callers are based on the nine studies that included only persons who called eight or more times in the preceding month. However, the other studies that mixed frequent and infrequent repeat callers and those that said they dealt with frequent callers, but failed to indicate how they identified callers as frequent, all appeared to include some very frequent callers in their sample. Although we could not use their data to describe frequent callers, because of the methodological issues, there is no reason to believe that their clinical insights on how to respond to frequent callers should not be considered and researched in the future.
Differences Between Characteristics of Frequent Callers and Infrequent Callers
Most of what we know comes from a few studies conducted in Australia. Burgess et al. (2008) found that frequent callers appeared to be older and were more likely to have never been married and to report concerns with loneliness, physical illness, and anxiety. Using the Goldberg Anxiety Scale, they found that frequent callers had higher anxiety scores, more panic attacks, as well as more social and simple phobias. Frequent callers were more likely to have seen psychiatrists in the past month but were less likely to have seen other mental health professionals. Middleton, Gunn et al. (2016) found that over half of the frequent users (55%) reported being unable to work due to sickness or disability, compared to 35% of episodic and 19% of one-off users. Frequent callers generally called for similar reasons to nonfrequent callers. However, they called more often to talk about their feelings. Spittal et al. (2015) found that being male or transgender, being older, never married, and having mental health issues were associated with frequent calling. Suicide and self-harm were also more often identified as safety issues by telephone crisis workers. De Carli (1988) found that frequent callers were rated by helpers as being higher than “typical callers” on Dominant, Hostile, and Exhibitionistic of the Kiesler scales. They were also rated as more controlling, self-focused, and angry, and less tactful and accepting than typical callers.
Some studies found that frequent callers share common features with other callers (Burgess et al., 2008; Spittal et al., 2015). Considering the limited research to date, it appears that frequent callers could have much in common with other callers (see Table A3 in the Appendix). They usually have serious problems, and they have persistent mental and physical health problems (Burgess et al., 2008). Although there are indications that frequent callers are not a homogeneous group (Middleton et al., 2017), most of the studies compared all frequent callers with other callers, without considering that different subgroups of frequent callers may have different characteristics and needs. Furthermore, Spittal et al. (2015) observed that when frequent callers are defined by their call frequency, some barely attain the threshold of the number of calls needed to be classified as frequent callers and others call 10 or 20 times more often. Some frequent callers are long-term callers, calling often for years, while others call often for only a brief period. Frequent callers with different call patterns may have different characteristics.
Frequent callers may be more anxious, use more mental health services, and often have experienced traumatic events (Middleton, Gunn et al., 2016; Middleton, Pirkis et al., 2016; Pirkis et al., 2016). They generally call to talk about current mental health problems, loneliness, and other difficulties (Middleton, Gunn et al., 2016), and may be at twice the risk of suicidal behaviors as less frequent callers (Spittal et al., 2015).
Recommendations Made
To date, there are insufficient empirical data to indicate how to best be of help to frequent callers in general, or how to best help subgroups of people who call frequently. Still, the published literature includes several not mutually exclusive recommendations for their management, to reduce their frequency of calling and to help them better:
- 1.Encouraging frequent callers to stop or severely limit use of the helpline (Brockopp et al., 2002). This is based on the belief that crisis centers should only respond to acute crises, unlike other interventions, such as psychotherapy, which maintain an ongoing long-term relationship. Limiting calls may increase capacity and decrease difficulties experienced by personnel. This has been criticized because:
- a.Frequent callers often have serious physical and mental health problems, frequently experienced traumatic events, and are often at risk of suicide. This approach may be considered as abandoning callers who are in need of help (Apsler & Hoople, 1976).
- b.If frequent callers stop calling, it is inferred that there are other services better able to help them. However, research indicates that they often already use several other services, but feel that these services do not meet their needs (Middleton, Pirkis et al., 2016; Pirkis et al., 2016).
- 2.Limiting the number and duration of calls allowed to help frequent callers gain better control of their behaviors (Brockopp et al., 2002; Hall & Schlosar, 1995; Middleton, Gunn et al., 2016; Pirkis et al., 2016), accompanied by continued suicide risk assessment to ensure that help is provided when needed (Brockopp et al., 2002; Hall & Schlosar, 1995). The advantages and disadvantages of this approach are the same as for encouraging callers to stop calling.
- 3.Assigning a specific helper to respond to all calls from each frequent caller (Brockopp et al., 2002; Pirkis et al., 2016; Vivekananda, Bamford et al., 2019). The advantage of this is a more consistent approach tailored to each caller. The disadvantage is that it may foster dependency and may deprive callers of the benefits of interacting with other helpers with different and potentially more helpful approaches.
- 4.Creating individualized case management plans followed by all helpers (Brockopp et al., 2002; Pirkis et al., 2016; Vivekananda, Cuppari et al., 2019). The advantage is a more consistent approach tailored to each caller. A disadvantage is the amount of personnel time needed to develop, monitor, implement, and update the plans.
- 5.Initiating regular contacts rather than waiting for (or allowing) callers to contact the service (Barmann, 1980; Vivekananda, Bamford et al., 2019). Advantages of this approach are that it solves the problem of “overburdening” the lines, and may foster a more consistent approach and better continuity of care. A disadvantage is that when unable to call, help may not be available when most needed. Necessary resources may not be available. In some centers, calling callers is against the philosophy that callers must take the initiative as an indication of their motivation.
- 6.Having members of the caller’s social support network involved in the interventions (Pirkis et al., 2016). This may include supporting family and friends in helping the caller (Apsler & Hoople, 1976). Family and friends have the advantage of being constantly available and thus better able to monitor the caller’s needs. A disadvantage is that some frequent callers lack supporters willing to help.
- 7.Providing brief structured interventions to reduce anxiety and depression, including coping with chronic stressors, using a trauma informed care model (Pirkis et al., 2016; Vivekananda, Bamford et al., 2019). This may help reduce anxiety and depression. However, it may be considered a substitute for psychotherapy, thus not following the crisis intervention mandate of helplines.
- 8.Continuing to accept calls from frequent callers whenever there are personnel available, without modifying practices (Brockopp et al., 2002). This has the advantage of not requiring additional resources. However, it does not address the negative feelings some helpers experience.
- 9.Providing regular clinical supervision and support for helpers in their interventions with repeat callers (Pirkis et al., 2016; Vivekananda, Cuppari et al., 2019). This addresses helpers’ negative feelings and may assist helpers to meet callers’ needs better. However, this may not limit the number of calls. If the supervision is only for calls from frequent callers, they may get better services than other callers, which may seem inequitable.
- 10.Having paid staff rather than volunteers respond to their calls (Pirkis et al., 2016; Vivekananda, Cuppari et al., 2019). This may ensure regular availability and better continuity and uniformity in approaches, and may protect volunteers from negative experiences. A disadvantage is the added costs. Furthermore, there is no empirical support for paid staff being better for the callers.
Cogent arguments, sometimes bolstered by case examples, have been made to support these recommendations. For example, Vivekananda, Bamford et al. (2019) reported on their Wellbeing Support Program, where callers received 12 calls from trained helpers. Semistructured interviews with 20 participants and a study of written records indicated caller satisfaction and some caller improvements. However, without a comparison group, one cannot determine if the improvements were associated with program participation, or if there were more improvements than one would expect from “usual” responses. Furthermore, there was a retention rate of only 45% by the end of the program.
Discussion
At conferences worldwide and in training for helpline helpers, the management of frequent callers is a recurring topic. Frequent callers are of concern because of the large amount of resources needed to respond to this small percentage of service users. Furthermore, helpline workers often experience frustrations and negative feelings about frequent callers and concerns about their abilities to help them. Therefore, it would be useful to have empirical research to identify best practices with frequent callers.
Unfortunately, the small number of empirical investigations and the diversity of their goals and methodologies limit generalizations. Moreover, the variables included in the studies comparing callers who call at least eight times a month with infrequent callers are different in each study, which precludes the possibility of summarizing and assessing the reproducibility and generalizability of results. Although at least 10 recommendations on how to manage and help may appear to have face validity, there are few data on their effectiveness. Part of the problem is that researchers have often included infrequent repeat callers or those who call more than just once in their definition of frequent callers, making it impossible to draw conclusions about frequent callers. Furthermore, one third of the studies did not include any definition of frequent callers. It is impossible to confirm that their results are relevant to frequent callers.
Usually, frequent callers were identified by the number of calls they made during a specific period. This is simplistic. People who call the same number of times may have different calling patterns, which could indicate different presenting problems and needs, and may warrant different intervention techniques. It is important in future research to define frequent callers clearly. It is equally important to examine similarities and differences between people who have different patterns of frequent calling. Because of the limited data currently available, it is impossible to determine whether they are different from infrequent callers, regardless of how they are defined. We do know that frequent callers generally do not appear to be calling for trivial reasons. They often have serious difficulties, including health and mental health problems, and they appear to have at least a similar suicide risk to infrequent callers.
It would be useful to categorize frequent callers in terms of their problems and needs in order to determine how to offer better help. Pirkis et al. (2016) proposed a categorization based on analyses of 19 interviews conducted with frequent callers (Middleton, Gunn et al., 2016). They suggested there are three types of callers: addicted callers (who call out of habit and are unable to resist the urge to call), support-seeking callers (who call looking for emotional support to cope with life stressors), and reactive callers (who call when they become unsettled by an external trigger event). These categorizations may be a useful heuristic if corroborated in studies with larger samples.
Researchers have focused on reducing call frequency. They rarely investigated whether callers have improvements in symptoms, decreased suicide risk, or fewer problems that motivated their calls. When the mental health characteristics of frequent callers were investigated, only depression and anxiety were assessed. Future research should include assessment of other mental health issues, such as borderline personality disorder and traumatic events in the past. In addition, future research should include comparisons with infrequent callers, to determine how frequent callers may be similar to or different from others.
Unfortunately, we lack sufficient data to provide empirical support for the advantages or disadvantages of the 10 recommendations we identified. If the main goal is to reduce call frequency, then any recommendation that achieves this goal could be considered a success. However, one must also ask: “Does the strategy help the frequent callers?” Several of the recommendations require the callers to lose their anonymity. There is an important distinction to be made between anonymity and confidentiality. Some helplines permit and encourage anonymity, without asking or retaining information allowing persons to be identified. Others guarantee confidentiality, but encourage callers to identify themselves and may (confidentially) retain a telephone number and identifying information in order to call back or ensure continuity of care.
One may question whether the negative feelings helpers report are associated with characteristics of the frequent callers and the nature of their calls, or if these feelings are a result of a limited mission and philosophy of helplines involved in suicide prevention. Helplines often describe their mandate as offering immediate crisis interventions. Helper training commonly insists on the helper’s role in providing immediate help and not developing a continuing relationship with callers, as in psychotherapy. Providing longer-term continued emotional support or therapeutic interventions is often actively discouraged. However, there may be benefits from repeated use of helpline services that would be observed only after long periods of continued contacts. It is important to conduct research to better understand potential long-term benefits of frequent calling, as well as the role of helpline cultures and values in how helpers feel about their interactions with frequent callers.
Limitations
The small number of empirical investigations and the diversity of goals and methodologies limit the extent to which findings can be generalized. Although recommendations for managing and helping callers may have face validity, sufficient empirical data on their effectiveness are lacking.
Conclusion
The limited data suggest that frequent callers are similar to other callers in many ways, often having serious mental health problems, experiencing loneliness, and being at least as suicidal as infrequent callers. Helpers may experience negative emotions concerning their calls: frustration, being manipulated, and feeling incompetent. The source of these negative feelings may be the focus of many helplines on immediate crisis intervention, rather than on longer-term supportive or therapeutic interventions involving frequent contacts with the caller. If this is the case, the solutions involve modifications of the organizational philosophy and approach, rather than attempting to “manage” the frequent callers.
It is important that future research clearly define the criteria for being identified as a frequent caller. Care should be taken to analyze data from repeat callers who have low call volume separately from data on more frequent callers. We identified 10 suggestions to better manage and help frequent callers that merit validation. There is a need for more research to identify characteristics of subgroups of frequent callers, each with different motivations for calling and needs, who may need to be studied independently. Rather than focusing mainly on reducing call frequency, we should empirically evaluate the benefits of different intervention approaches for subgroups of frequent callers.
Electronic Supplementary Material
The electronic supplementary material is available with the online version of the article at https://doi.org/10.1027/0227-5910/a000838
Brian L. Mishara, PhD, is Director of the Centre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices (CRISE) and professor in the Psychology Department at the Université du Québec à Montréal, Canada. His diverse research interests include studying best practices in helplines.
Louis-Philippe Côté is a psychology doctoral candidate and research coordinator at the Centre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices (CRISE), Université du Québec à Montréal, Canada. His research focuses on best practices in text and chat, and new technologies in suicide prevention.
Luc Dargis is the documentation center director at the Centre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices (CRISE), Université du Québec à Montréal, Canada, and co-researcher in several suicidology studies.
This literature review was part of a larger study that was commissioned by the National Suicide Prevention Lifeline (NSPL) and funded by Vibrant Emotional Health. The authors thank Nancy Logue for her comments on a draft of this manuscript, as well as John Draper, Alena Goldstein, and Gillian Murphy for their support of this project.
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