Users’ Perspectives on Crisis Helplines in Relation to Professional Mental Health Services

Crisis helplines have since the 1950s comprised an important resource in the wider set of suicide prevention services (Gould et al., 2021; Mishara et al., 2007; Mazzer et al., 2021). Trained volunteers, who provide peer support, often staff such services, while advice or interventions tend to be seen as tasks for professionals within health care or social services (Mishara et al., 2016; Pollock et al., 2010). With the rise of online support in suicide prevention, web-based crisis helplines have developed with the aim of providing low-threshold, short-term support (Mazzer et al., 2021; Sindahl et al., 2019; Westerlund & Krysinska, 2021). However, we know little about how users view crisis helplines in relation to their professional mental health contacts. Drawing on thematic analysis of online crisis helpline interactions, this study aimed to examine users’ views on the helpline’s role in relation to their contacts with professional mental health services.

These interactions come from Sweden’s only crisis helpline, The Suicide Line, founded in 2012 by a nonprofit organization and staffed by volunteers. Like the UK Samaritans (see Mishara & Weisstub, 2010), the helpline’s work is based on the idea that talking to another person can prevent suicide, but users are seen as ultimately responsible for their own decisions. The helpline explains this approach with the ideal of peer support (medmänskligt stöd, literal translation co-human support): Callers are considered experts while the call-taker is an anonymous friend who can assist the caller in exploring their situation (Iversen, 2021; Kevoe-Feldman & Iversen, 2022; see Pollock et al., 2012). Anonymity limits information about users, but volunteers’ estimates show that the most common reasons for contacting the helpline is suicide thoughts (49%), sadness (41%), anxiety (24%), and loneliness (17%). Although the helpline’s target group is persons in crisis, volunteers are instructed to offer all users 10 friendly minutes.

Previous research into online chat and text services has shown positive results related to short-term improvement (Gould et al., 2021; Mazzer et al., 2021), while cautioning against conclusions about long-term suicide preventive effects (Westerlund & Krysinska, 2021; see Hvidt et al., 2016). In a study based on users’ reports, Gould et al. (2021) showed that chatting could reduce experiences of distress and feeling suicidal. Other studies (Mokkenstorm et al., 2017, 2020; Sindahl et al., 2019) showed that service users’ satisfaction and positive change during the contact were related to helpers’ responsive approach, such as active listening. However, Westerlund and Krysinska (2021) noted that brief online sessions, even by a highly skilled and experienced volunteer, are not likely to stop or reverse the suicidal trajectory. The suicidal process is complex and develops over time (Wasserman, 2016), involving factors such as social conditions, mental health issues, and interpersonal dynamics (Sveticic & De Leo, 2012). Even after care, suicidal thoughts and behavior often persist (Kemp et al., 2021). In line with this, Sindahl et al. (2019) argue that crisis helplines should aim to reduce imminent risk of suicide and encourage the use of long-term counseling, which can address issues contributing to the onset and maintenance of suicidality.

The view of helplines – online and offline – as a short-term intervention that should provide a way into professional mental health services is present in many agenda statements of crisis helplines (Mazzer et al., 2021). However, research has shown that this goal is at odds with the way many people use crisis helplines, which is as a regular source of support (Pollock et al., 2012). In an evaluation of UK Samaritans (Pollock et al., 2010), volunteers reported user dependence on the helpline as a problem, which was actively discouraged. Frequent helpline users have been discussed for over 50 years as challenges to organizations’ limited resources and volunteers’ communicative strategies (Pirkis et al., 2016). Yet, research indicates that this group represents a major proportion of all users: Spittal et al. (2015) showed that three percent of the callers to telephone crisis lines produce 60% of the calls. Furthermore, Pirkis et al. (2016; see Pollock et al., 2010) showed that frequent callers tend to have substantial needs and use helplines together with other health and social care interventions. In fact, Bassilios et al. (2015) showed that the proportion of people with poorer mental health and people consulting various providers increase with call frequency. In addition, the group of frequent users may use helplines because they are dissatisfied with public welfare services (Middleton, Pirkis et al., 2016) or because they want to want to engage with volunteers on the basis of being a person rather than a patient (Pollock et al., 2010; see Mazzer et al., 2021). In interviews with self-identified frequent users, Middleton, Gunn et al. (2016) found that their reasons for returning were connected to their problems (e.g., persisting needs) as well as the response they received (e.g., availability) and their caller behavior (e.g., calling when triggered).

To address this gap between crisis helplines’ ascription of users’ needs and the needs many users themselves seem to identify, more knowledge is needed about users’ perspectives on the role of helplines in relation to professional mental health services. This study contributes knowledge on this matter by analyzing how users referred to other services when chatting with volunteers. We show that rather than describing online chatting as a first step, users treated it as a safe space, a partner, or an alternative to professional mental health services. By unpacking these different professional care relations, we call for the need to rethink the role of crisis helplines in relation to the complexity of the suicidal process.

Materials and Methods

At the time of data collection, volunteers at the Suicide Line were trained in a 3-day workshop that covered information about suicide risk factors, suicide myths, and communication training, mainly in active listening and motivational interviewing (Ortiz, 2014). Volunteers were expected to listen and provide emotional support, but not give advice or practical help. In line with previous findings on volunteer behavior (e.g., Pollock et al., 2010; Kevoe-Feldman & Iversen, 2022), however, volunteers were often engaged in advice-related activities.

The dataset used in the study included 2,000 chats, randomly selected from an existing database including all chats received by the helpline between 2012 and 2016 (approximately 20,000 chats). To avoid an unbalanced sample, we randomly sampled 20 chats for each year (in total 100). For the current study, we excluded five chats with contacts on behalf of someone else. Accordingly, the analysis was based on 95 chats. In addition to chats, one of the authors (Iversen) conducted ethnographic research at the helpline, including participating in the volunteer training and discussing preliminary findings with experienced volunteers who participated with written informed consent. The study received ethics approval from the regional ethics committee in Uppsala [Dnr 2017/510].

The study used a phenomenological approach to data analysis, which means that we limited our analysis to the users’ accounts, without taking a stance about their ontological underpinnings. Instead of assumptions about data, phenomenology focuses on people’s lived experiences of different aspects in life, as described by themselves (McLeod, 2001). In the current study, this meant that we focused on the topic of professional contacts as initial analysis showed that this was a highly relevant theme for users. We used thematic analysis to identify recurrent and meaningful themes in the users’ accounts (Braun & Clarke, 2006). In our close reading of the chats, users’ accounts about professional mental health services appeared as a central theme, both in its occurrence (in 60 of 95 chats) and in the weight the users placed on these services related to their reason for contacting the helpline.

Therefore, these 60 chats were further analyzed resulting in three subthemes related to the helpline’s role in relation to professional mental health services (a safe space, a partner, an alternative), independently agreed upon by both authors. To systematically identify and sort different themes, we used the qualitative analysis tool NVivo (v.12 Plus). Although the same user’s accounts often belonged to one of the themes, it is possible that the same user described different experiences of mental health services. We present the quotes with the anonymized reference number from the database. In the translation from Swedish to English, we have tried to retain misspellings and grammatical errors.

Results

Among the 60 chats where users described professional mental health contacts, 45 users explicitly described suicidal ideation and/or previous suicide attempts. Most users described being in contact with two or more professional mental health services. Having an ongoing mental health care contact, including medication, was the main type of professional service users described, for example with psychologists (N =30), psychiatrists (N =24), physicians (N =15), counselors (N =10), school personnel (N =9), and social workers (N =8). Users described being admitted to voluntary or involuntary inpatient care at hospitals (N = 5) and specialist centers (N = 4), as well as being subjected to emergency care interventions (N = 4). In the following sections, we explicate how users described their contacts with professional mental health services and the role of the crisis helpline as (1) a safe space alongside a working professional contact, (2) a partner in the struggle to pursue services that work, and (3) an alternative to bad professional services.

Discussion

Recurrent in all three themes are the users’ descriptions of serious and long-term problems, which affect numerous aspects of their lives. This resonates with previous research about the needs of helpline users, especially those who use helplines frequently (see Bassilios et al., 2015; Middleton, Gunn et al., 2016). Similarly, the way users describe being able to talk about things that they cannot raise with professionals is reminiscent of previous findings (see Middleton, Pirkis et al., 2016; Pollock et al., 2010). Thus, this study suggests that the ideal of a one-time crisis intervention or a first step in a suicide preventive system (see Sindahl et al., 2019; Westerlund & Krysinska, 2021) is at odds with users’ views on crisis helplines (see Pollock et al., 2012). In addition, our thematic analysis of helpline chat data enables us to unpack the different ways in which people – chatting with volunteers – make sense of their use of support. We thereby respond to calls for differentiating between reasons for (frequent) helpline usage (Hvidt et al., 2016; see Middleton, Gunn et al., 2016).

A central aspect is users’ control, most evident in how they treat the helpline as a safe place and an alternative but also in how they request advice and encouragement from nonexpert partners. For people with chronic mental health problems, the suicidal process can be lifelong: Thoughts about suicide occur with different intensity and can be absent at times but return in response to new difficulties (Middleton, Pirkis et al., 2016; Wasserman, 2016). In line with this, our findings show that many users describe crisis as a constant in their lives, to which professional services, with high thresholds, short time frames, or focus on particular symptoms, may not sufficiently or adequately respond. In this sense, frequent users can be seen as a resourceful group: They have found a crisis intervention that is continuous and easily accessible, either as a safe place, a partner, or an alternative (see Mazzer et al., 2021).

From an organizational point of view, the downside of users’ control is misuse of the helpline: Frequent users are a challenge to limited resources, and both previous research and our ethnographic work indicate that user anonymity facilitates abuse toward volunteers (see Pollock et al., 2012). Previous efforts to deal with such problems, such as blocking users or developing care plans (e.g., Middleton, Gunn et al., 2016), are in opposition with unconditional acceptance (see Pollock et al., 2010) and user control. Although no solution to this problem is readily available, it is important to acknowledge that volunteers and organizations need resources for dealing with crisis as sometimes potentially involving user dependence. While frequent usage can contribute to users’ problems (e.g., retelling of traumatic events; Middleton, Gunn et al., 2016), it may also resonate with needs of available social contact. Being prepared to offer every user 10 friendly minutes is a step in the direction of responding to those needs, but it may not be sufficient for callers who experience not being taken seriously, have given up on professional services, or deal with severe anxiety on a daily basis.