Speaking of Despair

How much can suicide hotlines do?

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I started volunteering at a suicide hotline around three years ago. Whenever I happen to mention to someone that this is a thing I do, they usually seem a bit shocked. I think they imagine that I regularly talk callers off ledges, like a Hollywood-film hostage negotiator. “How many people have you saved?” an acquaintance asked me once. I have no idea, but the answer is probably none, or very few, in the immediate sort of sense the questioner was likely envisioning, where somebody calls the hotline intending to kill themselves and I masterfully persuade them not to. In reality, the vast majority of your time at a hotline is spent simply listening to strangers talk about their day, making little noises of affirmation, and asking open-ended questions.

The conversations you end up having on a suicide hotline are inherently somewhat peculiar. They’re more intimate than you would have in daily life, where an arbitrary set of social niceties constrains us from talking about the things that are close to our hearts. But they are also strangely impersonal. Operators at most call centers are forbidden from revealing personal details about themselves, offering opinions on specific subjects, or giving advice on problems: all of which tend to be central features of ordinary human conversation.

With practice, and a sufficiently lucid and responsive caller, you can sometimes make this bizarre lopsidedness feel a bit less awkward. At the same time, however, you also have to find a way to squeeze in a suicide risk assessment—hopefully, not with a bald non-sequitur like “Sorry to interrupt, but are you feeling suicidal right now?” but in some more fluid and natural manner. The purpose of the risk assessment is to enable the person to talk about their suicidal thoughts, in case they’re unwilling to broach the topic themselves, and also to allow you, the operator, to figure out how close the caller might be to taking some kind of action. From “are you feeling suicidal?” you work your way up to greater levels of specificity: “have you thought about how you might take your life?” “Do you have access to the thing you were planning to use?” “Is it in the room with you right now?” “Have you picked a time?” And so on.

I can’t speak for every operator at every call center, but in my own experience, I would estimate that fewer than 10% of the people I’ve ever spoken to have expressed any immediate desire or intention to end their lives. Well over half of callers, I would estimate, answer “no” to the first risk assessment question. This might, on its face, seem surprising. So who’s calling suicide hotlines, then, if not people who are thinking about killing themselves?

Well, for starters—let’s just get this one out of the way—a fair number of people call suicide hotlines to masturbate.

“Wait, but why?” you, in all your naïve simplicity, may be thinking. “Why would someone call a suicide hotline, a phone service intended for people in the throes of life-ending despair, to masturbate?” Friends, that question is beyond my ken: as theologians are fond of saying, we are living in a Fallen World. If I had to make a guess, I’d say a) suicide hotlines are toll-free, b) a lot of the operators are women, and c) there is a certain kind of person who gets off on the idea of an unwilling and/or unwitting person being tricked into listening in on their autoerotic exploits. The phenomenon would be significantly less annoying if some of the callers didn’t pretend to be kind-of-sort-of suicidal in order to keep you on the line longer: it’s rather frustrating, when one is trying one’s best to enter empathetically into the emotional trials of a succession of faceless voices, to then simultaneously have to conduct a quasi-Turing test to sort out the bona fide callers from the compulsive chicken-chokers.

All right, aside from that, who else is calling?

The other callers are the inmates of our society’s great warehouses of human unhappiness: nursing homes, mental institutions, prisons, homeless shelters, graduate programs. They are people with psychiatric issues that make it difficult for them to form or maintain relationships in their daily lives, or cognitive issues that have rendered them obsessively focused on some singular topic. They are people who are deeply miserable and afraid, who are repelled by the idea of ending their own life, but who still say that they wish they were dead, that they wish they could cease to exist by some other means. Among the most common topics of discussion are heartbreak, chronic illness, unemployment, addiction, and childhood sexual abuse.

Some people are deeply depressed or continually anxious, experiencing recurring crises for which the suicide hotline is one of their chief comforts or coping strategies; while others present as fairly cheerful on the phone, and are annoyed by your attempts to risk-assess them or steer the conversation towards the reason for their call. The great common denominator is loneliness. People call suicide hotlines because they have no one else, because they are friendless in the world, because the people in their lives are unkind to them; or because the people they love have said they need a break, have said don’t call me anymore, don’t call me for a while, I’ll come by later, we’ll talk later, and they are struggling to understand why, why they can’t call their sister or their friend or their doctor or their ex ten, twelve, fifteen times a day, when that’s the only thing that briefly alleviates the terrible upswelling of sadness inside them.

One thing you learn quickly, from taking these kinds of calls, is that misery has no respect for wealth or class. Rich and poor terrorize their children alike. Misery is everywhere: it hides in gaps and secret spaces, but it also walks abroad in daylight, unnoticed. The realm of misery is a bit like the Otherworld of Irish myth, or perhaps the Upside Down on the popular Netflix series Stranger Things. It inhabits the same geographic space as the world that happy people live in. You might pride yourself on your sense of direction, but if you were to wander unaware into the invisible eddy, if you were to catch the wrong thing out of the corner of your eye, you too could find yourself there all of a sudden, someplace where everything familiar wears a cruel and unforgiving face. Somebody you know might be in that place now, perhaps, and you simply can’t see it.

If misery could make a sound like a siren, you would hear it wailing in the apartment next door; you would hear it shrieking at the end of your street; a catastrophic klaxon-blast would shatter the windows of every single hospital and high school in the country, all an endless cacophony of “help me help me it hurts it hurts.” And even if most of the people who call hotlines never come close to taking their own lives, their situation still feels like an emergency.

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We might ask, though, what is the rationale behind a hotline whose protocols are set up for assessing suicidality, when the vast majority of people who call the hotline do not, by their own account, have any concrete thoughts of suicide. The prevailing theory is that suicide hotlines are catching people “upstream,” so to speak, before they find themselves in a crisis state where suicide might start to feel like a real option for them. These people, in theory, are people who are at risk of becoming suicidal down the line if they aren’t given the right kind of support now. But is this actually true?

The fact is, we have no idea. If we take “suicide prevention” as the chief purpose of suicide hotlines, we soon find that the effectiveness of hotlines is very tricky to assess empirically. Of the approximately 44,000 people in the United States who complete suicide every year, we have no way of knowing how many may have tried calling a hotline in the past. Of the people who do call a suicide hotline presenting as high-risk, we don’t know how many ultimately go on to attempt or complete suicide. Small-scale studies have tracked caller satisfaction through follow-up calls, or have tried to measure the efficacy of hotline operators by monitoring a sample of their conversations. But these studies are, by their very nature, of dubious evidentiary value. There’s no control group of “distressed/suicidal people who haven’t called hotlines” to compare to, and the pool of callers is an inherently self-selecting population, which may or may not reflect the population of people who are at greatest risk. There are also obvious ethical concerns about confidentiality when it comes to actively monitoring phone calls by “listening in” without permission from the caller, or placing follow-up calls with people who have phoned the service. A substantial number of people who call suicide hotlines express anxiety about the privacy of their calls. Given the social and religious stigma that continues to be associated with thoughts of suicide, we might posit that the higher-risk a caller is, the more anxious they are likely to be. They may perhaps be reluctant to agree to a follow-up call when asked, and nervous to call the hotline again if they suspect they might be part of some study.

All of this is not to say that we need Hard Numbers to justify the existence of a service that provides a listening ear to people in distress. The value of human connection is self-evident, and when it comes to intangibles like happiness, spiritual purpose, and a sense of closeness to others, so-called scientific studies are mostly bunk anyway. Nonetheless, we can still use our imaginations and our common sense to hypothesize about the limitations of the current system and possible alternatives. I think there are two questions worth considering: first, are suicide hotlines generally accessible or useful to people who are actively suicidal? Secondly, for the “low-risk” callers who appear to be the most frequent users of suicide hotlines, is the service giving them what they need, or is there some better way to provide comfort and relief to these people?

As to whether high-risk individuals are actually being reached by suicide hotlines, as outlined above, it’s hard to tell. Anecdotally, the perception of suicide hotlines seems to differ pretty markedly when you peek in on suicide-themed message boards, as opposed to message boards centered around support for depression or other psychological issues. For example, posters on the mental health support forum Seven Cups describe suicide hotline operators as “supportive,” “non-judgmental,” “patient and understanding,” “some of the most loving people you’ll ever talk to,” and “varied from unhelpful-but-kind to helpful.” By contrast, on the Suicide Project, a site specifically devoted to sharing stories about attempting or losing someone to suicide, posters wrote that their calls were “awkward and forced,” “left me thinking I should just get on with killing myself [and] not speak to anyone before hand,” and “totally useless,” and commented negatively on long hold times or call time limits.

We can’t really draw conclusions from this tiny sample, not least because the kinds of people who frequent message boards and comments sections on the internet are not necessarily representative of broader populations who share some of the same self-identified characteristics. But—again anecdotally—I have noted that high-risk or more despairing callers on the hotline I volunteer for, when questioned about the extent of their suicidal intention, often express sentiments like, “If I were really suicidal, I wouldn’t be calling” or “If I wanted to commit suicide, I would just do it.” It’s hard to say exactly what this means, but it seems as if a general perception among borderline-suicidal callers is that an actively suicidal person wouldn’t bother to call a hotline. Given that suicide is sometimes a split-second decision, and that people who complete suicide tend to use highly lethal means, such as firearms, this perhaps isn’t surprising. (Calls where someone claims to be holding a gun are always the most alarming.)

For lower-risk callers, meanwhile, is a fifteen-minute conversation all we can do for them? People who call hotlines sometimes express frustration at the impersonality of the service. They want a give-and-take conversation, more like a normal interaction with a friend, but many suicide hotlines (including the one I volunteer for) forbid volunteers from giving out personal information about themselves. You never share your own opinion on a topic, even if the caller asks you directly: you merely express empathy, and give short reflective summaries of the caller’s responses to your questions, in order to demonstrate engagement and help the caller navigate through their own feelings.

This isn’t necessarily a bad approach, broadly speaking, since it keeps operators out of the thorny territory of giving possibly-useless, possibly-harmful advice to a person whose full life circumstances they know very little about, or of overwhelming or inadvertently shaming the caller with some inapposite emotional response of their own. For some callers, this non-reciprocal outpouring of feeling may be exactly what they need. But for other callers, who often become wise to a call center’s protocols over many repeated calls, this one-sided engagement is not at all what they say they want. What they want is a real human connection, even its messiness and impracticality, not a disembodied voice that might as well be a pre-programmed conversation bot. Reconciling these conflicting goals is a tricky thing. There are certainly people who use hotlines in what seems to be a compulsive kind of way: they’ll call every half-hour, and if you don’t impose some kind of limit, they’ll tie up the line for less persistent (but perhaps, by some metrics, more vulnerable) callers. But it nevertheless feels cruel to tell desperately lonely people that their insatiable need for the warmth of a human presence is Against The Rules.

“It feels cruel to tell desperately lonely people that their insatiable need for the warmth of a human presence is Against The Rules…”

I often wonder if a suicide hotline’s unique ability to reach a population of acutely unhappy people could be harnessed for more personal, community-based interventions. Currently, there are both national and local call centers, but even on local lines, the caller is still miles away from you, and operators aren’t allowed to set up meetings with the people they speak to. Many people call because of a serious crisis in their lives, but the most you can do is give them a referral to a mental health organization that might be able to help them. I’ve frequently wished it were possible to send an actual human to check up on the person, ask how they’re doing, and see what they might need help with. It would be nice if neighborhoods or cities had corps of volunteers who were willing to be on-call for that kind of thing.

This, it seems to me, might be especially important for callers who seem more desperate and perhaps at higher risk of suicide. When you’re a hotline operator, there’s no middle ground between giving somebody verbal comfort and perhaps a referral, and dispatching emergency services directly to their location. (Some hotlines will only do this if the caller gives permission, while others, if the situation seems imminently dangerous, will send any information associated with the caller’s phone number to local police.) People who have previously had ambulances called on them often express deep shame and embarrassment about the experience. It attracts attention of all their neighbors; depending on the circumstances, the caller might even have been taken out of their home on a stretcher and rushed to an emergency room. Callers who have had this happen, or know someone it’s happened to, will often be especially cagey about sharing their suicidal thoughts, or paranoid about the information that might be being gathered about them. This is extremely problematic, because it means that potentially high-risk callers might deliberately understate the extent of their emotional distress if they ever call again in the future. Moreover, if they’ve been to hospitals before under these circumstances and found the experience traumatizing, they may be unwilling to accept medical interventions in the future. Wouldn’t it be better if instead the caller could consent for a nice person to come discreetly check up on them at their house, have a nice chat, maybe make them a cup of tea? For lower-risk callers, especially people in hospitals or nursing homes who don’t have any company, shouldn’t we be able to find someone living nearby who can pay them a visit during the week?

Of course, suicide hotlines are already understaffed, and so expanding them into an even more labor-intensive grassroots organization wouldn’t be easy. The kinds of callers who call suicide hotlines repeatedly and obsessively would likely be pleading for visits on a constant basis: you would probably need some kind of rationing system to make sure they weren’t overwhelming the entire volunteer network. In a small number of cases, there might be safety concerns about going in person to a caller’s house. (No house-calls for the masturbators, obviously.) The bigger problem, however, is figuring out how to mobilize communities and get people to feel invested in the emotional wellbeing of their neighbors. Personal entanglement is inherently a hard sell. Part of the reason why people volunteer with charitable organizations rather than simply knocking on their neighbors’ doors is because they want to keep their regular lives and their volunteer obligations strictly separate. They want to perform a service for someone without becoming closely enmeshed in the day-to-day reality of that person’s problems. This kind of distance is preferred by most part-time volunteers—I certainly find it more convenient to compartmentalize my life in this way, though I’m not at all sure that’s a good thing—and it may be preferable for some callers, too, especially those who are dealing with issues they intensely desire to keep private, for whom a visit from the wrong neighbor might be mortifying.

But I think we must attempt to surmount these obstacles. When people lament the demise of communities or multi-generation family units in the United States, this is the kind of mutual support they’re thinking of. The extent to which America was once comprised of warm, child-raising villages in its real-life past is, of course, greatly exaggerated, and we certainly shouldn’t romanticize local communities per se: they always have the capacity to be meddling, oppressive, and exclusionary. But all communities don’t have to be like that, and instead of abdicating community ideals as outdated, we could be working to realize them better in the particular places we live. As American lifestyles become increasingly mobile and rootless, close involvement in a community may not be foremost on people’s minds; to the extent that people these days talk about “settling down” somewhere, they usually seem to be thinking in terms of sending their kids to a local school, patronizing nearby restaurants, and attending summer concerts in the park, not trundling around to people’s homes and asking what they can do for them.

But even if we aren’t planning to live in the same town for the entire rest of our lives, we mustn’t allow ourselves to use this as a convenient excuse to distance ourselves from local problems we may have the power to ameliorate. People who come to the U.S. from other parts of the world often find our way of living perverse, in ways we simply take for granted as facts of human nature, rather than peculiar societal failings. I was recently talking to a Haitian-born U.S. citizen who works long hours as a nurse’s aid, and then comes home each night to care for her mentally disabled teenage son. She told me that if it were possible, she would go back to Haiti in a heartbeat. She was desperately poor in Haiti, but there, she said, her neighbors would have helped her: they would have invited her over for dinner, they would have offered to look after the children. “Here,” she said, “nobody helps you.” That’s one of the worst condemnations of American civil society I’ve heard in a while.

As Current Affairs has written in the past, many of the problems that underlie or exacerbate people’s suicidal crises—homelessness, unemployment, lack of access to healthcare—are the result of an economic and political system that is fundamentally profit-driven, and fails to prioritize the well-being of its most vulnerable citizens. Large-scale political changes are necessary to free up the resources that would be necessary to truly tackle these problems in a lasting and meaningful sense, and foster a society that’s better geared towards the health and happiness of all its members. But we must also recognize that government programs—even if well-funded—will never be enough, if they’re administered by an impersonal bureaucracy. What people want, what they need, are real fellow-humans who will come talk to them, and look them in the eye, and genuinely care about what happens to them. At the moment, given the system we currently have to work with, to allocate all that responsibility onto a few poorly-paid, exhausted social workers and health sector employees just isn’t fair—nor is it effective. This is a responsibility that should belong to all of society: to anybody who has even a hour to spare.

Giving people a number to call is a start. It would make sense to use existing hotlines as a tool to find and reach people who need help, both those who are at high risk of harming themselves, and those that are simply unhappy. As for how local volunteer forces could be coordinated, this is something municipalities should trade ideas about: possibly there are communities who have successfully implemented programs like this. Organizations that work narrowly on certain types of social problems might have ideas about how to structure a multi-purpose community-wide organization that could intervene more generally in a variety of contexts. When it comes down to it, actually caring about—and taking care of—your neighbors, even when it’s difficult, is always the most radical form of political activism.