Suicide in America: The People who Answer the Phone

The bridge phone inside New York City’s suicide-prevention call center rings only about once a month. But when it does, often in the middle of the night, it emits distinct, deep chirps–as if the phone itself is in distress. The operators manning the 24/7 LifeNet hotline recognize the sound immediately. It means someone’s calling from one of the 11 area bridges, and they’re likely thinking about jumping.

LifeNet, a mental-health and suicide-prevention hotline servicing the New York City metropolitan area, is one of 161 call centers that make up the National Suicide Prevention Lifeline network, which is headquartered in the same building. During its busiest hours, from 9 a.m. to 7 p.m., the hotline has roughly 20 operators working the phones inside an unassuming L-shaped office space in lower Manhattan. The operators could be mistaken for telemarketers. A large computer screen at the head of the call center showing the number of lines being processed might just as easily be registering orders for exercise equipment or beauty products.

You don’t get a sense of what actually happens in this room until you run across the bridge phone, which is a direct line to the call center–LifeNet’s equivalent of the Oval Office’s mythical red phone. On the wall above it, black picture frames from Ikea display detailed information for each bridge and the locations of its call boxes: “Northbound 3rd Avenue Exit,” “Westbound Light Pole 60.” If someone calls, counselors can match the caller ID with the information above the phone and immediately send help.

Suicide rates have been climbing in the U.S. since 2005. In 2009 the number of suicides surpassed deaths from motor-vehicle accidents for the first time. In 2010, the most recent year for which statistics are available, 38,364 Americans killed themselves, according to the Centers for Disease Control and Prevention. From 1999 to 2010, the suicide rate for Americans ages 35 to 64 rose 28.4%. For men in their 50s, the rate rose nearly 50% during that time. And because many suicides go unreported, most researchers believe these numbers undercount the true totals.

The rising number of Americans committing suicide has led to a debate over how best to prevent it. Over the past 15 years, public policy and federal funding have shifted toward a broader mental-wellness movement aimed at helping people deal with anxiety and depression that could eventually lead to suicidal ideation. But critics of the shift worry that it may have left those most at risk of suicide without the support they need.

Experts in the field often use the metaphor of a river to illustrate the divide: Should prevention efforts try to reach a larger group of people upstream, offering counsel before they become suicidal, or concentrate resources on a smaller but closer-to-the-edge group downstream? If it were up to those who work at LifeNet, the bridge phone would not exist at all. “We don’t necessarily want to get people who are on the edge of the waterfall,” says John Draper, director of the National Suicide Prevention Lifeline. “If they are, we can help them. But it’s a huge cost savings for the entire mental-health system if you can get people further upstream.”

Inside the National Suicide Hotline: Preventing the Next Tragedy

LIFENET, 10:15 A.M.

Dely Santiago puts on her black Sennheiser headset and takes a look at the queue. Five callers are waiting to speak with an operator. A dozen others are on the line.

Santiago is one of 50 employees who keep New York City’s suicide-prevention call center running day and night. A psychotherapist and behavior-modification specialist, Santiago, 29, has been working at LifeNet since 2009. She uses just one phone, but 14 separate hotlines feed into it. They range from numbers given out for national and local mental-health issues to ones dedicated to victims of bullying, people struggling since Hurricane Sandy and language-specific hotlines. There is even an NFL Lifeline for those with football-related mental-health issues. Many operators are trained to answer all of them.

This morning, Santiago’s first call is from OASAS Hopeline, the New York State hotline for substance abuse. While she can’t tell who is calling, she always knows which line is coming through. If a LifeNet call pops up on her caller ID, it’s often someone reaching out for basic information. That’s low-stress. But if it’s the National Suicide Prevention Lifeline, she takes deep breaths before answering to stay calm. This one, the state addiction line, is somewhere in the middle.

Santiago runs through a series of questions to gauge the call’s seriousness. Her voice is soothing, lilting even, but firm.

“You obtained a DWI in which county?”

“Has alcohol been an ongoing issue for you?”

“Any thoughts of suicide or hurting anybody else?”

The operators routinely ask callers whether they have suicidal thoughts, no matter which hotline they have called, because there’s no way to tell whether a substance-abuse call will quickly turn into a suicide call. You just have to ask.

The queue doesn’t let up. Several people are on hold. More are talking to operators. Once crisis counselors have finished a call, they get three minutes to log it into the database and take a breath before the phone rings again.

“Hello, LifeNet,” Santiago says. “How may I help you?”

AT THE WATERFALL

The national suicide prevention Lifeline, of which LifeNet is part, deals with those who are upstream and downstream. The organization is marketed to the general public through billboards, transit displays and other outdoor advertising. The hotline is targeted at people suffering from anxiety, depression and loneliness but who may not be actively suicidal, while also serving as an emergency resource for those who are at immediate risk of killing themselves. Calls to the Lifeline increase by about 15% every year. This year, the organization expects to receive 1.1 million to 1.2 million.

Draper is the Lifeline’s soft-spoken, goateed, ponytailed director and a wholehearted advocate for early treatment. A psychotherapist by training, he sounds like someone who has spent a lot of time counseling people in crisis. Draper speaks calmly but with purpose. He looks you in the eye. He routinely uses your name in conversation.

In the 1980s, Draper was part of a team of mobile crisis clinicians who went into the homes of people who were psychiatrically ill but unable or unwilling to get help. The experience convinced him that a major problem with the country’s mental-health system was that it waited for those in need to seek it out, which many who would most benefit from it aren’t able to do. “It says, ‘O.K., you’re mentally ill? I’ll see you Tuesday at 9 a.m. Hope you can make it.’ The system is not set up for the convenience of the user,” Draper says. “As a result, two-thirds of people with mental-health problems never seek care.”

Draper’s conviction that the system was in need of reform brought him to the Mental Health Association of New York City, where he helped launch a 24/7 crisis information and referral network. LifeNet gained wide attention in 2001 when it became a central resource for those affected by the Sept. 11 terrorist attacks. People were reporting depression, anxiety and other traumatic responses in massive numbers. LifeNet’s call volume and staff doubled, and they haven’t gone down since. In 2004 the hotline was chosen by the Substance Abuse and Mental Health Services Administration (SAMHSA) to administer the national suicide-prevention lifeline.

Today, Draper and his staff oversee more than 160 networked call centers around the country. Call 1-800-273-TALK and you’ll be routed to the call center closest to the number from which you’re calling. About 8 million adults in the U.S. are thinking seriously about suicide, but only 1.1 million actually attempt it. So when Draper sees the volume actually reaching that 1.1 million number, which he expects it to this year, he views it as a good thing.

“If your calls are increasing, does that mean more people are in distress?” he asks. “That’s not necessarily true. It means more people may have been in distress all along but didn’t know this resource was there.”

The challenge is determining whether suicide-prevention efforts are working. The only way you know if you’re saving someone’s life is if they come out and say so.

“The lifeline is a valuable addition to our efforts,” says Dr. Lanny Berman, executive director of the American Association of Suicidology. “It’s indeed a resource for people in suicidal crisis to reach out immediately and get help. Whether it is effective in saving lives remains to be seen.”

CASTING A WIDE NET

Many suicide-prevention programs that receive federal funding are advertised nationwide, which critics like DJ Jaffe see as a misguided use of resources.

“A lot of suicide-prevention campaigns are based on reaching out for help if you’re feeling depressed rather than calling if you’re truly suicidal,” says Jaffe, who founded the nonprofit advocacy group Mental Illness Policy Org after his sister-in-law was diagnosed with schizophrenia in the mid-1980s. “Spending massive amounts of money marketing to the public is a giant waste of money because we know where we can focus it.”

According to the National Institute of Mental Health, 90% of people who die by suicide in the U.S. suffer debilitating mental illness or a substance-abuse disorder often in conjunction with other mental disorders. Other risk factors include prior suicide attempts, a family history of mental illness and violence in the home. If we know who’s most at risk, people like Jaffe and Berman argue, shouldn’t we target them in a smarter way? If a factory closes, for example, shouldn’t efforts be made to market prevention services in that community?

SAMHSA is the federal government’s suicide-prevention arm. Though mental-health coverage has been expanded for tens of millions of Americans as part of the Affordable Care Act, SAMHSA’s funding requests for suicide-prevention efforts have decreased over the past two years. For fiscal 2014, SAMHSA requested $50 million for its suicide-prevention measures, $8 million less than in 2012. The agency gives $3.7 million annually to the Lifeline. Funding for National Suicide Prevention Lifeline crisis centers to provide follow-up to suicidal callers and evaluate the lifeline’s effectiveness, which once ranged from $700,000 to $1.7 million a year, was cut completely. SAMHSA did, however, request a $2 million increase for the National Strategy for Suicide Prevention, which, among other things, would be used to develop and test nationwide awareness campaigns.

Richard McKeon, the acting chief of SAMHSA’s suicide-prevention branch, says its strategy has always focused on those most at risk: “Much of our suicide portfolio focuses on those who are actively suicidal.” He says that focus is evident in the national strategy, which was revised last year to offer a comprehensive approach to preventing suicide at the local level. But he acknowledges that the behavioral health of the entire population is also a priority. “Our suicide-prevention efforts do take place within a broad public-health context,” he says. “Ideally, we’d like to be able to prevent people from becoming suicidal in the first place.”

The Good Behavior Game, a program designed to identify early behavioral-health problems, to which SAMHSA awarded $11 million over five years, is one initiative McKeon points to that catches people upstream. It’s used in 22 economically disadvantaged school systems across the country and has been cited as effective by the Institute of Medicine. “A lot of the work we do is aimed at identifying youth who are at most serious risk right now,” he says. “We are dealing with a lot of high-risk situations among very vulnerable people, but there’s also solid scientific basis for early interventions.”

The scientific case for public-awareness campaigns is far less solid. A 2009 study in the journal Psychiatric Services looked at 200 publications from 1987 to 2007 describing depression- and suicide-awareness programs targeted at the public and found that they “contributed to modest improvement in public knowledge of and attitudes toward depression or suicide,” but it could not find that the campaigns actually helped increase care-seeking or decrease suicidal behavior. A similar study in 2010, in the journal Crisis, found that billboard ads actually had negative effects on adolescents, making them “less likely to endorse help-seeking strategies.”

It’s similarly hard to gauge how successful help lines are at deterring suicide. Several studies done in 2007 and 2012 by Columbia University’s Madelyn Gould in cooperation with SAMHSA found that most callers who had contacted crisis centers felt less distressed emotionally and were less suicidal after the call. About 12% of suicidal callers reported in a follow-up interview that talking to someone at the lifeline prevented them from harming or killing themselves. Almost half followed through on a counselor’s referral to seek emergency or mental-health services, and about 80% of suicidal callers said in follow-up interviews that the Lifeline had something to do with keeping them alive.

“I don’t know if we’ll ever have solid evidence for what saves lives other than people saying they saved my life,” says Draper. “It may be that the suicide rate could be higher if crisis lines weren’t in effect. I don’t know. All I can say is that what we’re hearing from callers is that this is having a real lifesaving impact.”

LIFENET, 11:14 A.M.

It took a little less than an hour for Santiago to get her first call on the national suicide hotline.

The male caller has contacted the center six times since 7 a.m. In Spanish, he tells Santiago he’s depressed, anxious. He’s hearing things that aren’t there and can’t connect with his psychiatrist. He says he feels like he’s going to die. None of this is unusual. This is the kind of thing that Santiago and the rest of the operators deal with every day, and they’ve increasingly been hearing from middle-aged men. Suicide rates for men ages 50 to 59 increased by almost 50% from 1999 to 2010. LifeNet’s crisis counselors began observing a change in their callers when Wall Street crashed. More middle-aged men started calling with serious financial concerns.

While rates went up in cities across the country, rural areas saw even bigger jumps. Wyoming has the highest suicide rates of any state. Park County, home to Yellowstone National Park, had 45 suicides per 100,000 people in 2012. The national average is closer to 12 suicides per 100,000 people.

“In Wyoming, we have a tough-it-out mentality,” says Terresa Humphries-Wadsworth, who coordinates the state’s suicide-prevention efforts. “Locally, they call it ‘Cowboy up’–being very independent, solving problems for yourself.”

Rural areas have historically had higher suicide rates than urban areas, and most experts believe it’s a combination of more gun ownership per capita, isolation and a culture that discourages seeking help. In the suicide-prevention field, Wyoming is a perfect storm. Besides its “Cowboy up” mentality, the state has one of the highest gun-ownership rates in the U.S., the lowest population density outside Alaska and only one call center networked to the national lifeline.

To counteract the state’s culture of self-sufficiency, the Wyoming Department of Health began reaching out to men who had attempted suicide and were willing to talk about it.

“We said, ‘Tell us your story, and go way back,'” says Rich Lindsey, a technical consultant hired to work on the campaign. “We discovered that if you’re going to effectively get to them, you need to go upstream in their life, at a point where things are going wrong but they’re not yet thinking about suicide.” The state took that information and developed an awareness campaign of local TV ads, billboards and posters featuring an older, rugged man with lonely eyes and phrases like “We feel ya, brother” and “It’s tough out here.”

The one-county, $50,000 pilot program elicited 10 calls from February to June and has since expanded to two other counties. For those who advocate upstream approaches, the Wyoming experiment may be viewed as a model. But for others, $50,000 on a public-awareness campaign for a handful of calls–and no way to know their effect–may not seem worth it.

LIFENET, 11:25 A.M.

Santiago is logging in her previous caller, the man who had called six times that morning. She says he wasn’t actively suicidal, and he told her that talking to the crisis counselors helped him make it through the day. But she thought if he called back a seventh time, she would explore getting him to an emergency room.

“What are the chances he’s calling back?” I ask.

“Oh, he’s calling back,” Santiago says. By the end of the day, Santiago will have answered 20 to 25 calls from any one of the 14 different hotlines.

A suicide-prevention call center may seem like a dreadful place to work, but it’s a lot like any other office: idle chatter near the watercooler, lunch breaks with co-workers, cinnamon rolls in the break room. It’s just that from this room, it’s quite likely lives are being saved every day–even if the counselors will never know for sure.

“When I tell people what I do, they say, ‘Oh, Draper, that must be really depressing,'” Draper says. “And I say, Man, I’m in the suicide-prevention business, not the suicide business. What I see every day and what our crisis-center staff hears every day is hope. And they know that they’re a part of that.”

He says it’s important to remember that 1.1 million adults are attempting suicide every year but that 38,000 are actually dying by suicide.

“What that is telling us is that by and large, the overwhelming majority of suicides are being prevented,” he says. “And those stories are not being told.”