The call came in late one summer night. Immediately, Paul Butler’s stomach sank and his heart sped up.
“It’s always a worry in the back of your mind that somebody is going to do something that ends up harming themselves,” Butler said.
It’s the kind of call Butler dreads, but it’s also the reason he does what he does.
Butler works on the front lines of prevention, averting crisis and other incidents you may never hear about. Because behind countless tragedies that weren’t – from suicides to active shooter incidents – are people listening and problem solving, on the other end of the nation’s crisis intervention hotline.
TheNational Suicide Prevention Lifeline is a network of 165 crisis lines around the country. When people call 1-800-273-TALK, they’re then routed to a local line, depending on the area code from which they’re calling from.
For eight years, Butler has helped staff the 24-hour hotline at the main psychiatric hospital in Montgomery County, Pennsylvania. Montgomery County Emergency Service, or MCES, joined the national network in 2014, so that any calls from area codes that fall within the six-county Philadelphia region are then routed there. The center averages 100 calls a week. Depending on the time of day, two to five people staff the crisis line, taking eight hour shifts.
Butler says his conversations last, on average, 10 to 15 minutes. But the one call that stands out from a few summers ago, was different.
“He specifically stated, ‘I called you because I’m in a very rural area. You’re not going to find me. But, I want you to make sure that someone finds my body,’” Butler remembers. “My heart was surely jumping out of my chest at the time.”
The man, Butler recalls, was in the woods with a weapon. He had been drinking. He had picked out a spot. He had made a plan, and he did not see any other way around.
Butler went into de-escalation mode, searching for ways to work with the man so that collectively, they could develop an alternate plan.
“I really wanted to try to establish who this person was. And so I worked through him telling me about himself, you know what kind of life did he live, did he have family, did he have kids, the people he was connected to,” he recalled. “I think that at that time he had felt really abandoned.”
An effective model
Federally funded studies have shown that a 24-hour hotline, where people like Butler are available to listen and be with callers in real time, can be a lifesaver for many in their most vulnerable moments.
“We found that it does significantly reduce suicidal risk during the course of the call,” Madelyn Gould said. “It definitely can save lives.”
Gould, a professor of epidemiology in psychiatry at Columbia University, has been researching suicide prevention hotlines since their early days, monitoring conversations, following up with callers who agree to participate in surveys, and assessing the trainings that counselors get.
“There was an unsubstantiated claim, a myth, that people who call weren’t really seriously suicidal, that it was mainly women, disparagingly, who just wanted to talk,” Gould said. Her research found quite the opposite. Though, of course, not everyone with an imminent risk of suicide calls, “seriously suicidal people do call.”
Gould’s research has involved at least a third of the participating crisis lines. Between March 2003 and July 2004, for example, her teamassessed 1,617 crisis calls and found major declines in callers’ “sense of hopelessness” and crisis states during the course of the conversation. About half, 801 of those callers, agreed to participate in follow ups with her team three weeks later. A majority had been given referrals and mapped out action plans during the initial call. One third reported having followed up with a mental health referral afterwards. Of the separate 1,085 suicide calls the researchers reviewed during that time, she found big decreasesin suicidality during the course of the conversation.
This research points to the positive impact the hotline can have, but Gould notes that because the studies observed what was happening already, as opposed to bringing in a control group (which would be difficult to do), it’s hard to fully parse out other possible factors beyond the call to the hotline that may have contributed to what people reported feeling and doing afterwards.
Meanwhile, her more recent research is finding that to be truly effective, the hotline can’t be the only solution.
Hotline limitations
The national network of crisis lines, with its routed 1-800 number, didn’t actually get started until the early 2000s. In 1999, the Surgeon General’s landmark report which outlined a national strategy for suicide prevention didn’t mention the role of hotlines. Within a few years, though, Gould says there were beginning efforts to network individual crisis lines across the country, to create more standardization and ensure people didn’t fall through the cracks.
While that’s been an important turning point, the national hotline was never designed to fund local crisis centers and their hotline counselors. The more than 150 local lines operate on their own local and state budgets. For that reason, Gould has seen some close over the years.
The actual national lifeline is based out of the Mental Health Association of New York City and gets about $6.2 million annually from the federal Substance Abuse and Mental Health Administration (SAMHSA), according to John Draper, director of the national lifeline.
That money goes toward the administrative and operational costs for routing calls, for developing best practices and trainings for counselors, and for coordinating a handful of call centers that serve as national backups for people who reach out in regions that don’t have locally affiliated crisis lines.
“There are a few states we have particular problems with, that there’s not enough funds set aside to answer lifeline calls,” Draper said. “Texas, Pennsylvania, New York state, Georgia and Illinois are probably the top five that have the biggest struggles in terms of funding.”
In Pennsylvania, for example, the state supports 24/7 crisis lines, but not all of those local centers are part of the national lifeline network or answer lifeline calls. Philadelphia also has its own 24/7 line.
The volume of calls coming through the national lifeline has also grown a lot, surpassing a record two million calls last year. Eighty five percent are answered within 30 seconds, Draper says, but in areas without a local crisis hotline or an understaffed one, the wait can be longer. If those calls are routed to the backup centers, counselors there may not be as familiar with resources and referrals in the area where the caller is located. The lifeline has an around the clock web chat service, too.
A paradigm shift
While being available 24/7 to listen is critical, Gould’smore recent research has focused on the important role of counselors in working with callers to come up with post-call plans and helping connect them with specific follow-up care and referrals.
In one study, when her team was able to connect with people in the days or weeks after they called the hotline, she found that “not surprisingly, all the problems in their life were not going to be resolved by one crisis call.”
In other words, the crisis could reemerge.
A more recent pilot initiative she’s following goes a step further, with counselors themselves following up with callers in the days and weeks after to check in with them.
“Having someone call them back might be the first time that anyone showed that type of caring for them,” Gould said, adding that the additional follow-ups appear – via self reports – “to have prevented a significant degree of people from killing themselves.”
Montgomery County’s crisis line
While Montgomery County Emergency Service is not part of the national pilot, in some ways it’s already practicing that model.
On the other side of the wall where Paul Butler sits, is the intake counter, where people come and go for around-the-clock emergency crisis services and other psychiatric care. Butler knows that other side, too: he’s also a case manager.
When he staffs the crisis line on a recent afternoon, someone he recognizes calls in twice.
In the middle of another call with someone new, Butler conferences in a supervisor from a neighboring agency. The individual had complained about getting through to care there but Butler surpassed the potential hurdles, waits and frustrations of a patient calling a health care agency directly when in distress.
“When you say you’re struggling, have you had thoughts about harming yourself again? What keeps you safe?” Butler asked the caller, sussing out whether the individual has thought through a concrete plan, which can be a red flag. The person’s spouse has dementia, amplifying a sense of grief.
The conversation lasts about 15 minutes, with the caller planning to follow up with a same-week appointment with a therapist, and agreeing to call Butler directly to report how things are going.
Butler fiddles his pen, taking deep breaths while listening.
“I’m on board with that,” Butler said, reiterating to the caller to follow up with him if the appointment doesn’t go well.
As part of best practices at any suicide prevention line, counselors contact emergency services or 911 dispatchers if someone appears to be an imminent risk of harming themselves or others. That conclusion comes out of information gathered during the course of the call, all of which can guide next steps.
“Obviously, our goal is to have someone agree they need help and work with them to get that help. Most of the time that is the resolution,” Butler said.
Lessons in patience with the man in the woods
As the conversation continued with the man in the woods on the other end of the line, Butler began noticing “some ego and some gravitas.”
Part instinct, part training, he decided to zero in on that trait.
Butler’s voice is gentle and calm.
He recalled initially trying to find commonalities with the man and ways they could connect. They both had kids, for example, with parenting challenges. That wasn’t enough. So playing to the man’s personality, Butler then challenged him.
“I said, ‘you’re not going to do this because you don’t want to do this.’ I think that line I used to him was, ‘You’re not going to call in and schedule a suicide with me, you know? I’m not the schedule-a-suicide-line. And you’re not going to put me in a position where I have to find somebody to locate your body, that’s not fair to me. If you’re not going to do it for yourself and your family, you’re going to do it for the poor call taker on the other side of the line!”
It’s not an approach, Butler says, that he would take with just any caller. But in this case, the man responded. Butler says ultimately, he could hear through the phone the man dismantle his weapon and start walking home.
“I remember he said ‘I really just appreciated having somebody listen,’ and that ultimately that’s when he decided he wasn’t going to do this,” Butler recalled.
By that point, the conversation had lasted two and a half hours. The sun was coming up.
Emergency responders located the man and connected him, voluntarily, with crisis services (WHYY’s The Pulse did not see the records, but Butler’s supervisor confirmed this).
Even though a couple years have passed since that call, Butler says it’s one he’ll always remember.
“The cardinal rule would be, you’re never going to rush the conversation. It’s going to take as long as it’s going to take,” Butler said. “And I think that’s probably one of the most important things.”
This story originally appeared on WHYY Philadelphia's The Pulse, a podcast covering national stories on health, science and innovation.