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What Research on Crisis Intervention Teams Tells Us and What We Need to Ask

Affiliations.

1 Dr. Watson is Professor at Jane Addams College of Social Work, University of Illinois at Chicago. Dr. Compton is Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons. Dr. Watson serves on the Board of Directors of CIT International, a nonprofit organization. Dr. Compton previously served on the Board. [email protected].
2 Dr. Watson is Professor at Jane Addams College of Social Work, University of Illinois at Chicago. Dr. Compton is Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons. Dr. Watson serves on the Board of Directors of CIT International, a nonprofit organization. Dr. Compton previously served on the Board.
PMID: 31676505
DOI: 10.29158/JAAPL.003894-19

Developed over 30 years ago, the Crisis Intervention Team model is arguably the most well-known approach to improve police response to individuals experiencing mental health crisis. In this article, we comment on Rogers and colleagues' review (in this issue) of the CIT research base and elaborate on the current state of the evidence. We argue that CIT can be considered evidence based for officer level outcomes and call level dispositions. We then discuss the challenges that currently make it difficult to draw conclusions related to arrest, use of force, and injury related outcomes. More research, including a randomized, controlled trial is clearly needed. But we caution against focusing narrowly on the training component of the model, as CIT is more than training. We encourage research that explores and tests the potential of CIT partnerships to develop effective strategies that improve the mental health system's ability to provide crisis response and thus reduce reliance on law enforcement to address this need.

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Effectiveness of Police Crisis Intervention Training Programs. Rogers MS, McNiel DE, Binder RL. Rogers MS, et al. J Am Acad Psychiatry Law. 2019 Dec;47(4):414-421. doi: 10.29158/JAAPL.003863-19. Epub 2019 Sep 24. J Am Acad Psychiatry Law. 2019. PMID: 31551327 Review.

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Crisis Intervention and Trauma: New Approaches to Evidence-Based Practice

Anthony T. Ng , M.D.

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Myriad clinical modalities have been proposed for the treatment of trauma, in the form of both crisis intervention and longer-term interventions. However, increasing emphasis has been placed on identifying more evidence-based practices. A consensus panel on mass violence was sponsored by the National Institute of Mental Health in 2001 to review some of those modalities, such as critical incident stress management, cognitive-behavioral therapy, and eye movement desensitization response ( 1 ).

The publication of Crisis Intervention and Trauma: New Approaches to Evidence-Based Practice, by Jennifer L. Hillman, is very timely. As chair of the American Psychiatric Association's committee on psychiatric dimensions of disasters, I am pleased to see that this book attempts to provide a review of some of the current findings on crisis intervention and discusses how they can be applied in a practical manner to clinical practice. The book presents an overview of trauma and crisis intervention, followed by discussion of special topics such as suicide and violence, domestic violence, workplace violence, and special populations, including children.

Crisis Intervention and Trauma is readable and is very applicable to a diversity of disciplines. Case vignettes are used throughout to illustrate key points. The book begins with a discussion on the role of crisis counseling and raises concerns such as the role of profit versus nonprofit services in the delivery of trauma care. Hillman nicely describes the role of social psychology of trauma and what clinicians need to know. She touches on such issues as how individuals in crisis are perceived by others and emphasizes the role of clinicians' feelings and countertransference in the treatment of traumatized individuals. Practical issues of personal contact—for example, hugging—are also addressed. In addition, Hillman stresses the importance of addressing safety concerns before delivering care, especially after a disaster. This is an extremely critical point: mental health clinicians, however good their intentions, should not blindly rush in to assist others; often, the situation is not safe for the clinicians or for the individuals they are trying to help.

A comprehensive basic review of posttraumatic stress disorder (PTSD) is also provided. Guilt, a frequent reaction among persons experiencing trauma, is discussed in detail. However, it might have been useful if the author had spent more time discussing the issue of trauma in general rather than PTSD alone, because many traumatized individuals do not necessarily develop PTSD. The author describes the role of eye movement desensitization response, and this discussion is comprehensive, but she does not provide adequate discussion of other treatment modalities, such as the role of cognitive-behavioral therapy. She also makes brief mention of nontraditional treatment of PTSD. However, more mention of the role of social support and the role of community in PTSD would have been useful.

The book also reviews the specific trauma of suicide and violence and their consequences for caregivers, including clinicians. Hillman provides concrete practical steps for clinicians' self-care in these clinical situations. This section is nicely illustrated by case examples, as is true of many sections of this book. The author also provides a useful violence guideline for clinicians. However, this section might have been strengthened by a more comprehensive description of the various tools currently available to clinicians for assessing the risk of suicide and violence.

Several specific issues related to trauma are described in Crisis Intervention and Trauma, including substance abuse, partner abuse, the elderly, and workplace violence, especially the relationship between abuse and reproductive issues, a topic that has not received much attention in the past. Hillman provides a thorough discussion of critical incident stress management (CISM). However, she presents a primarily pro-CISM view. Such a stance may be contrary to the goal of this book, which has a focus on evidence-based treatment, because there has been increasing evidence and debate on the effectiveness of CISM. Hillman provides a fairly descriptive narrative on how CISM is conducted. However, some readers may try to conduct CISM on the basis of this reading. It would have been better if the author had qualified the chapter with a statement that the section is not intended to teach CISM.

In general, Hillman attempts with some successes to address a wide range of trauma-related issues. Although the book is readable, I did think that some of the topics could have been better linked together to improve flow. Furthermore, a comprehensive discussion of both pros and cons of the topics, especially as they relate to treatment, would have been useful. However, despite these weaknesses, I believe that Crisis Intervention and Trauma is a nice resource for clinicians working in a rapidly evolving field.

Dr. Ng is chair of the American Psychiatric Association's committee on psychiatric dimensions of disasters and a clinical instructor at New York University School of Medicine in New York City.

by Jennifer L. Hillman; New York, Kluwer Academic/Plenum Publishers, 2002, 317 pages, $65

1. National Institute of Mental Health: Mental Health and Mass Violence: Evidence-Based Early Psychological Intervention for Victims/Survivors of Mass Violence: A Workshop to Reach Consensus on Best Practices. NIH pub 02–5138. Bethesda, Md, National Institutes of Health, 2002 Google Scholar

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What Research on Crisis Intervention Teams Tells Us and What We Need To Ask

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There continues to be a great deal of much-warranted attention on strategies to improve police responses to individuals with mental illnesses and those experiencing mental health crises. The Crisis Intervention Team (CIT) model, which was developed over 30 years ago, is arguably the most well-known approach to address this issue. As discussed by Rogers and colleagues, 1 a growing body of research suggests that the CIT model is effective for at least some of its articulated goals. We have previously argued that it can be considered evidence-based for officer-level outcomes such as improved knowledge about mental illnesses; enhanced attitudes about mental illnesses, individuals living with mental illnesses, and treatments for mental illnesses; self-efficacy during interactions with persons with mental illnesses; use of force preferences; and call-level outcomes related to linkage to mental health services. 2 But evidence is more mixed or lacking for “rare event” outcomes related to arrests, injury, and deaths. In this commentary, we briefly describe the CIT model, and then discuss the current state of CIT research laid out by Rogers et al . 1 We will then elaborate on the challenges presented in conducting research on the model, which also have implications both for drawing conclusions from the available evidence and for future research. We argue that a full conceptualization of the model will push us to ask different questions and to consider the danger in limiting our focus to making law enforcement better prepared to intervene in mental health crises rather than shifting responsibility for this function to the mental health system and thereby minimizing the role that law enforcement needs to play in the provision of mental health care.

The Crisis Intervention Team (CIT) Model

Rogers et al. 1 aptly describe the origins of the CIT model following the shooting of a man experiencing a mental health crisis by a Memphis police officer. They note that the original articulated goal was to improve safety in police encounters, which was a key concern on the heels of that tragedy. The University of Memphis CIT Center, Memphis Police Department, National Alliance on Mental Illness, and CIT International also list goals related to improving police responses to people in crisis and diverting individuals from the criminal justice system when appropriate. Until recently, increasing transports of persons in crisis to hospital emergency departments was considered an improvement in response (and it still is if it avoids an unnecessary arrest or leaving someone in need of care without proper linkages). As emergency departments have become overwhelmed, however, there is recognition that they are not an ideal place to address mental health crises. Indeed, over time, the stated goals of CIT have become more nuanced and now include developing more robust community-based crisis-response systems that minimize both the role of law enforcement and the need to utilize emergency departments. 3

Rogers et al. 1 also cover several of the Core Elements of the model: CIT training for a select group of officers, training of communications and dispatch personnel and special coding processes for dispatched calls, and a centralized mental health facility for easy drop-off. What is often overlooked or mentioned only in passing is the foundational element of strong and ongoing community partnerships. These may be evidenced by a steering committee that is formed to initially implement a CIT program and continues to meet and support ongoing operations of the program. Indeed, the “T” of CIT is not “Training,” as suggested in the title of the Rogers et al. article; rather, it is “Team.” Team refers to the community collaboration (including local law enforcement, local mental health advocacy groups, local mental health services, and oftentimes many other stakeholders) that works to improve the local crisis-response system, of which officer training is one element. While generally not examined in CIT research, this foundational collaboration is believed to be essential to successful implementation of the CIT model. 3

What Does the Existing Research Tell Us?

Rogers and colleagues 1 state that “most of the studies on CIT involve analysis of the planning, deployment, and procedural functioning of the CIT process itself, including the selection, training, operations, and measurement or self-report of CIT-trained officers” (Ref. 1 , p xxx). This statement seems overly dismissive and suggests an absence of research that has rigorously examined important outcomes of CIT. It is difficult to know what studies were reviewed by the authors, but it appears that they failed to consider a number of them in drawing conclusions. For example, Rogers et al. 1 are correct when they indicate that we have evidence of CIT training's effectiveness for “increasing officer satisfaction,” though it would be more accurate to indicate that the evidence supports CIT's effectiveness for improving other, more important officer-level outcomes in terms of knowledge, attitudes, self-efficacy, force preferences, and decision-making. 2 The authors failed to report on the most robust and large-scale study in this area, in which Compton et al. 4 , 5 recruited 586 police officers from six police agencies that had implemented CIT; 251 of those officers had previously received CIT training, at a median of 22 months before the in-depth research assessment. Officers spent about three hours completing an extensive battery of measures. Compared with non-CIT officers, CIT-trained officers had greater knowledge about mental illnesses and their treatments, better attitudes (across 17 different domains), greater self-efficacy, lesser stigma, better de-escalation decisions, and better referral decisions. Effects were apparent, even at a median of 22 months after the training, and even when controlling for age, gender, years having served as an officer, years of education, officers' extent of personal experience with the mental health system, and empathy. These are much more robust findings than “increased officer satisfaction.” Additionally, while Rogers et al . 1 indicate “some positive but mixed outcomes or trends toward statistical significance, in terms of increased diversion to psychiatric services” (Ref. 1 , p xxx), there is actually good, statistically significant evidence from several studies that CIT increases the use of mental health service linkages to resolve mental health-related encounters. 2 , 5 There is also evidence that these effects are strongest when officers self-select into the specialist role 6 and in areas with greater availability of mental health services. 7

The evidence of CIT's impact on safety outcomes is limited. While we did not find a direct effect of CIT on use of force in one of our own studies, we did find that CIT officers used less force with more resistant subjects. 8 Likewise, the evidence of CIT's impact on injuries is understandably very limited given that injuries are rare. In terms of outcomes related to arrest, findings are mixed, with some studies indicating reductions of arrests of persons with mental illnesses and others finding no effect.

The lack of strong evidence for the impact of CIT on arrest and safety outcomes has led some to conclude that CIT is not effective. For example, the National Institute of Justice's CrimeSolutions.gov 9 rated CIT as not effective for the outcomes of processing offenders (arrest) and use of force based on a meta-analysis by Taheri that included five studies. 10 This rating was broadcast in the Office of Justice Programs' Daily Digest Bulletin (November 20, 2018) with the heading “Crisis Intervention Teams Rated: Crisis Intervention Teams Do Not Reduce Arrest, Use of Force, or Officer Injuries.” Given the many difficulties identifying appropriate studies to include in the meta-analysis, which Taheri herself discusses in her article, 10 applying meta-analytic methods was likely premature, as are the conclusions drawn by CrimeSolutions.gov. More recently, in their systematic review of the research on police-mental health interventions that included CIT, Kane and colleagues note, “Due to the limited and varied research evidence in this field, it was not appropriate to produce a GRADE table of findings to identify relevant results, nor was it possible to pool data from included studies nor conduct a meta-analysis” (Ref. 11 , p 111). Thus, for arrest and safety outcomes, we cannot yet draw conclusions.

As researchers working in this area for some time now, we have struggled to examine the impact of CIT on arrest, use of force, injuries, and deaths. There are a number of factors that have made this very difficult. First, each of these outcomes occurs relatively infrequently (and for deaths, extremely infrequently) in the course of police work. Low base rates mean that large samples are needed to detect effects. This would seem simple because police agencies document many aspects of police work, such as arrests and uses of force. One might think that we should be able to pull the relevant call data from agency data systems, but many agencies do not have codes that are used consistently to identify calls involving a mental health crisis or a significant mental health component. Those working to implement such coding struggle with the appropriate definition of a mental health call and getting officers to use those codes reliably. This makes it difficult to examine patterns of arrests, force, and injuries in mental health-related calls in a single agency; furthermore, comparing data across agencies is hampered by significant variation in data systems and coding practices. Additionally, while measurement of arrest is straightforward, definitions of force and policies around what, when, and how force is documented are not uniform. For example, in some communities, use of handcuffs is documented as a use of force, and in many cases, when officers transport a person for psychiatric evaluation, agency policy requires the use of handcuffs. In these programs, if CIT officers are doing more transports, they may be using force (by this definition) as often as or more often than their non-CIT counterparts because they are taking more steps to get individuals in crisis into care.

It is even more difficult to consider the impact of CIT on lethal encounters between persons with mental illnesses and police. While extremely tragic, such events are complex and occur rarely. Rogers et al. point out that “studies have not shown consistent benefit in terms of a reduction in the risk of mortality or death during emergency police interactions” (Ref. 1 , p xxx), but it is not clear what studies they are referencing. We know of no such studies.

Recent attention to police shootings has led to work to improve tracking of these incidents nationally. To test the impact of CIT on such events, however, we will need to be able to measure CIT implementation. This leads to an additional challenge of conducting and considering research on CIT. We know there is significant variation in CIT implementation, with some communities only training a group of officers (or mandating the training for all), and others that work to build partnerships and implement the full model. To date, there is no fidelity tool to support measurement of this variation. Such a tool, if rigorously developed and tested, would be useful to the field.

According to the model and one of its founders, Retired Major Sam Cochran, “CIT is more than just training” (Ref. 12 , p 3); nevertheless, much of the available research on the effectiveness of CIT, our own included, may have perpetuated the misunderstanding of CIT as primarily a training model. It is much more feasible to conduct rigorously designed research in a single agency or training academy and compare officers who are CIT trained with those who are not than it is to compare across agencies with and without CIT programs. Such a comparison would require agreements with a large number of agencies and extensive resources, complicated by the lack of good, consistently coded administrative data within and across agencies. There are, however, studies that have examined outcomes both before and after CIT program implementation in single programs, including one using a time series design conducted by Kubiak and colleagues 13 that found an increase in transports to a crisis triage center following implementation (this study was not included in the Rogers et al. review).

Rogers et al. express a concern that “with the thousands of CIT programs deployed, there may be a publication bias in terms of a reduction in the likelihood of publication or dissemination of studies identifying a null effect or adverse cost increases or shifts associated with a specific CIT program” (Ref. 1 , p xxx); yet, there is no evidence supporting this. The vast majority of CIT programs do not conduct research, consider publication of any data, or disseminate studies.

More research, including a randomized controlled trial, is clearly needed. This, of course, begs the question of what should be randomized. Randomizing officers to the training may be feasible, but this approach suffers from the narrow focus on CIT as a training program. Randomizing calls to a CIT response or not would be operationally very difficult and potentially unethical (unless the other condition is another specialized model such as a co-responder team) given the evidence that we do have for the benefits of CIT. Randomizing agencies to implement CIT or not would require a larger number of agencies of adequate size (or a very large agency with many precincts) willing to let researchers dictate when and if they implement CIT. While a randomized controlled trial would be informative, practical and rigorously designed studies have given good evidence of CIT's effectiveness and have emphasized where evidence is currently lacking, which is very different from being ineffective.

What About Opportunity Costs?

Rogers and colleagues 1 note the potential opportunity costs of spending money on CIT programs that might otherwise be spent on alternative services such as street triage (which involves clinician-officer teams), increased funding for assertive community outreach programs, or psychiatric beds. This is a rather abstract argument given that money saved in law enforcement budgets is not generally available to be transferred to the mental health system. It also misses the fact that CIT programs implemented with fidelity develop partnerships between law enforcement, mental health, and advocacy that work together to coordinate existing services, identify system gaps, and garner resources to develop needed mental health services.

While we hope to continue to do research on CIT and related models, we worry about the opportunity cost of focusing so much on the law enforcement component of CIT and other police-based interventions (e.g., embedded co-response teams) that we and others in this field will fail to explore and test the potential of CIT partnerships to develop effective strategies that improve the mental health system's ability to provide crisis response and thus reduce reliance on law enforcement to address this need. CIT International emphasizes this as a goal of CIT programs in its newly released publication, “Crisis Intervention Team (CIT) Programs: A Best Practice Guide for Transforming Community Responses to Mental Health Crises.” 3 Research is needed that conceptualizes CIT as an organizational and community-level intervention and examines its effectiveness not only for improving officer and call-level outcomes, but also for system-level outcomes related to reducing the role of law enforcement in a mental health crisis-response system.

Disclosures of financial or other potential conflicts of interest: None.

© 2019 American Academy of Psychiatry and the Law
Rogers MS ,
McNiel DE ,
Watson AC ,
Compton MT ,
Bakeman R ,
Broussard B ,
Ottati VC ,
Morabito MS ,
9. ↵ CrimeSolutions.gov : Practice profile: crisis intervention teams (CITs) . Available at: https://crimesolutions.gov/practicedetails.aspx?id=81 . Accessed September 13, 2019
Shokraneh F
Comartin E ,
Milanovic E ,

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Crisis Intervention : Crisis Intervention Handbook: Assessment, Treatment, and Research

Harriet S.MeyerMD, Contributing EditorDavid H.MorseMS, Journal Review EditorRobertHoganMD, adviser for new media

Not Available

This five-part book looks at the theory of crisis intervention and recent research applied to various populations (youth, the mentally ill, the chemically dependent, victims of violence, and health workers). It illustrates well how doctors can benefit from knowledge in ancillary areas. The editor, Albert R. Roberts, DSW, professor of social work at Rutgers University, is ably assisted (in the foreword and a chapter on crisis intervention with people having clinical diagnoses) by Ann Wolbert Burgess, RN, CS, DNSc, whose research is frequently cited by other authors (mainly social workers) throughout the book.

Crisis Intervention : Crisis Intervention Handbook: Assessment, Treatment, and Research . JAMA. 2001;286(14):1769–1770. doi:10.1001/jama.286.14.1769-JBK1010-3-1

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Assessing the Impact of Crisis Intervention Teams: A Review of Research

This document reviews the available research on the implementation and effectiveness of Crisis Intervention Team (CIT) programs, organized into five major sections that provide an overview of the CIT, its organization and effectiveness, the impacts of the CIT model, stakeholders’ perceptions, and practical and research implications for agencies seeking to implement or evaluate CIT programs.

This research review examines more than 50 resources relating to the implementation of Crisis Intervention Team (CIT) programs, which are a police-led strategy for improving police interactions with individuals experiencing behavioral health crises and to direct those individuals away from the criminal justice system, into the appropriate treatment and services. Conclusions suggest that training officers in CIT improves their knowledge of behavioral health conditions and that this appears to be a promising model, however research has not yet conclusively supported the use of CIT programs to reduce the use of arrest or force, or to prevent injuries during police encounters. Although calls for further research have been placed, barriers include data collection challenges and the infeasibility of randomization in many locations.

Additional Details

How a Crisis Intervention Provides Mental Health Support

Dr. Amy Marschall is an autistic clinical psychologist with ADHD, working with children and adolescents who also identify with these neurotypes among others. She is certified in TF-CBT and telemental health.

Yolanda Renteria, LPC, is a licensed therapist, somatic practitioner, national certified counselor, adjunct faculty professor, speaker specializing in the treatment of trauma and intergenerational trauma.

Tara Moore / Getty Images

What Causes a Crisis?

How crisis intervention works.

Potential Risks

Crisis intervention is a short-term (usually single session) technique used to address an immediate mental health emergency, stabilize the individual in crisis , and create and implement a safe, appropriate plan for next steps and future treatment.

Although crisis intervention can be used in therapy if a client presents in an emergency, crisis hotlines also offer this service using appropriately trained volunteers or employees.

A mental health crisis can occur for many different reasons. By definition, we often do not know when a crisis may occur, and we might not be able to wait for a regularly-scheduled therapy appointment or standard business hours to address it.

Stressful and Traumatic Events May Lead to Crisis

When a person experiences a highly-stressful or traumatic event , they can go into crisis afterward because they cannot process what happened independently. Crisis intervention can help determine what they need to do to ensure their immediate safety, de-escalate their feelings, and make a plan for appropriate resources and ongoing treatment.

If someone experienced a traumatic event a long time ago, they can still go into crisis if they are triggered in the present moment. Crisis intervention can help them return to the present moment, process the trigger, and manage their symptoms until they can connect with their treatment team.

People with various mental health diagnoses, including mood disorders, psychotic disorders, or substance use disorders might experience a sudden, acute increase in their symptoms. They can benefit from crisis intervention to ensure immediate safety, utilize appropriate coping skills, and connect with ongoing treatment options.

Someone who experiences suicidal ideation can experience a crisis if they feel that they might act on these thoughts. Crisis intervention addresses any specific triggers for these thoughts and manages the individual’s safety.

Effective crisis intervention involves connecting to the person in crisis and talking them through specific steps to ensure their immediate safety as well as make appropriate plans for future care.

Many crisis resources utilize a six-step model developed by Dr. Richard James. This model includes the following six steps:

Define The Problem. In this stage, the responder establishes a connection with the person in crisis and helps them articulate their crisis as well as what caused it, using active listening and empathy.
Ensure Client Safety . This includes making sure that the client is in a safe place and is not at risk for immediate harm, both self-inflicted and abuse by another person.
Provide Support. Once the client is physically safe and the responder understands the nature of the problem, the responder helps determine appropriate options for both immediate and long-term support.
Examine Alternatives . The responder encourages the client to explore options for people who care for and want to help them, coping skills they can use in the moment, and appropriate re-frames or new ways of looking at the problem.
Make Plans. In this stage, the client and responder develop specific plans for how to implement the chosen alternatives, focusing on realistic and manageable steps that the client can take.
Obtain Commitment. Finally, the responder helps the client commit to these steps. This includes putting the plan in writing so that the client knows what they need to do and can remember what helped them during the crisis.

These steps help the client work through the emergency both in the moment and by taking steps to get further support in place in the future. Getting ongoing support in place can prevent future crises.

Impact of Crisis Intervention

Outpatient crisis intervention services can give clients the option to work through an immediate crisis in a safe environment without requiring hospitalization . It can assess risk level and connect clients to services that can help them in the moment. Typically, crisis intervention services are free to use and therefore accessible to anyone regardless of income or financial means.

Phone and text-based crisis hotlines allow clients to access services from anywhere because they do not have to travel to a specific location to access support. Research has shown consistent outcomes for both phone and text-based hotlines.

When clients have access to crisis resources that they can use at any time, they can sometimes avoid a higher level of care or hospitalization for mental health needs. Crisis support can provide a safety net for the client in between their other treatments.

Potential Risks of Crisis Intervention

Let's take a look at some potential risks of crisis intervention.

Crisis Intervention Is Not a Substitute for Therapy

Crisis intervention only addresses the immediate emergency and is not a substitute for therapy services. While most crisis hotlines are free to use, it can be difficult for people in rural areas or those with low income to access and afford ongoing treatment and support.

If a client’s only accessible option is crisis support , they are unlikely to see improvement in their symptoms.

Crisis intervention is a tool, but no one tool can fix everything. People need access to a variety of resources in order to get the support that they need.

Crisis Responders May Not Know How to Deal With Every Situation

Not all crisis resources are created equal. Responders do not need an advanced degree or licensure in order to provide crisis intervention. This makes crisis intervention accessible, as responders can be trained quickly. However, responders might not feel equipped to manage a client’s needs or have the knowledge to make appropriate referrals.

This occurs most frequently with suicidal clients and can lead to the client not getting appropriate follow-up care.

There Is No Prior Therapeutic Rapport

Although crisis intervention can effectively help a client through a difficult time, clients are connected with whichever respondent is available rather than a provider that they know well. This can create an added challenge for clients who have difficulty trusting new providers.

Help Is Limited If a Client Remains Anonymous

Finally, some crisis hotlines allow users to be anonymous . While this can help clients feel more comfortable sharing, this means that the responder cannot verify their location or put them in touch with emergency services if the need arises.

A Word From Verywell

Several qualified crisis resources exist if you are experiencing a mental health crisis. If you are experiencing suicidal ideation, substance dependence, abuse, domestic violence, or another crisis, help is available. Asking for help can be difficult, especially if you are in crisis, but support is available.

If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 988 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.

For more mental health resources, see our National Helpline Database .

Wang D, Gupta V. Crisis Intervention . In: StatPearls . Treasure Island (FL): StatPearls Publishing; April 28, 2022.

James, RK; Gilliand BE. Crisis Intervention Strategies. 8th Edition. Cengage Learning; 2016.

Mazzer K, O'Riordan M, Woodward A, Rickwood D. A systematic review of user expectations and outcomes of crisis support services . Crisis . 2021;42(6):465-473. doi:10.1027/0227-5910/a000745

Substance Abuse and Mental Health Services Administration (SAMHSA). National Guidelines for Behavioral Health Crisis Care: Best Practice Toolkit .

Gould MS, Kalafat J, HarrisMunfakh JL, Kleinman M. An evaluation of crisis hotline outcomes part 2: Suicidal callers . Suicide and Life-Threatening Behavior . 2007;37(3):338-352. doi:10.1521/suli.2007.37.3.338

By Amy Marschall, PsyD Dr. Amy Marschall is an autistic clinical psychologist with ADHD, working with children and adolescents who also identify with these neurotypes among others. She is certified in TF-CBT and telemental health.

Counseling & Crisis Intervention

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118 Crisis Management Essay Topic Ideas & Examples

🏆 best crisis management topic ideas & essay examples, 💡 interesting topics to write about crisis management, 📝 good research topics about crisis management, 👍 simple & easy crisis management essay titles, ❓ crisis management questions.

Crisis Management: Nissan Company and the 2011 Earthquake Expand on the points made in the case to identify the potential costs and benefits of these actions. The sharing of information was quite beneficial to Nissan in its response to the disaster.
AirAsia: Crisis Management Case Study The crash was the first to be recorded in the eighteen years of operation of AirAsia. It was described as the third worst plane crash in the year 2014.
Fraud at Bank of Baroda: Risk and Crisis Management The negative publicity that BoB received as a result of its recklessness has clearly affected the investment risks to a considerable degree, yet the current strategy used by the company to manage the situation does […]
Critical Analysis of Crisis Management Theory and Frameworks If the event of September 11, 2001 is recalled then one would realize that the events of September 11, 2001 were an overwhelming reminder of the need to be prepared for crises.
The Role of Social Media in Aviation Crisis Management Therefore, this paper considers the general role that social media might play in a crisis or emergency in the airline industry and describes methods that could be used to deal with the potential adverse outcomes […]
Tourism Industry: Emergency and Crisis Management The technological and scientific breakthrough that has been witnessed over the past several decades has created the foil for the rapid development of the tourism industry. What are the primary causes of emergencies and crises […]
Tesco Plc’s Crisis & Communication Management The company, Tesco Plc, must prioritise its activities, decision, and other factors to resolve the effects of the current economic depression on the company with the resolve to avoid such pitfalls.
The Carnival Triumph Cruise Ship’s Crisis Management This paper is a critical analysis of the crisis communication surrounding the marooning of the Carnival Triumph Cruise ship. The contribution of the Carnival’s PR in addressing the Triumph crisis is subject to analysis to […]
Crisis Management Models for Risk Assessment To assess the relative risk of each of the risk events, the assessment tool quantified the probability of occurrence, impact on students, impact on staff, impact on learning, the preparedness of the institution, and the […]
Public Transportation in Dubai: Critical Factors Affecting Crisis Management Problems RTA is currently facing are related to the sector’s exposure to numerous environmental and market forces that require constant changes and foster relational complexity.
Public Relations and Crisis Management Link The significance of developing a CMP lies in the fact that it aids in the process of collecting the necessary information to deal with the crisis.
The 2012 Tel Aviv Bus Bombing and Crisis Management Musa was the manufacturer and detonator of the bomb, which he used Mafarji to deliver inside the Tel Aviv-based commuter bus.
Crisis Management & Communication During COVID-19 Topic of the Paper: The actual effectiveness and success of the various crisis communication and management methods used by the governments of different countries. 3, 2021, pp.1-7.
Understanding Crisis Management and Resilience The book is especially interesting for understanding the global financial crisis, the climate crisis, the poverty crisis, and the financial crisis of 2008. In this book, the author discusses the origin, dynamics, and uses of […]
Pennsylvania’s Crisis Management and Response For instance, the development of relationships between service agencies, national and local crisis responding organizations, state and local affiliates, and even governments is required for efficient planning that allows to minimize the consequences of a […]
Poor Communication in the National Emergency Crisis and Disaster Management Authority The UAE National Emergency Crisis and Disaster Management Authority is a quite essential and recently introduced government department that addresses various natural and man-made accidents and issues and maintains the safety of the community.
Managing an Organization During a Crisis To alter the negative consequences of the crisis and enhance our situation, we need to create a video message in which our company will express our concerns and regrets about the tragic death of a […]
Being a Public Manager in Times of Crisis Stakeholder Engagement and Storytelling might be implemented to acquire the public’s confidence, and public managers need to understand how their citizens will view their ideas and activities.
COVID-19 Crisis Management in China vs. the US The current paper is going to provide a detailed analysis of crisis management approaches taken by China and the United States in an attempt to curb the Covid-19 pandemic and protect the local population from […]
Aviation Crisis Management Toolkit The impacts on these organisations vary considerably depending on the type of crisis, the severity of the crisis and the way in which the organisation has planned for, and responded to the crisis.
Crisis Management: The Interactive Simulation The objective of this article is to outline and explain one of these new techniques, the interactive simulation, and to discuss some of the problems and possibilities of this approach.
Crisis Management in the Healthcare Setup The process starting from the reception up to the discharging of the patient needs much attention in order to avert any crises.
Tsunami: Crisis Management The saving of lives during a disaster and emergency incident will depend on the proper coordination of the rescue team, delivery of the right skills to the scene which can only be achieved through the […]
Crisis Management: 1998 North American Ice Storm According to the academy of management executives the field of crises management is still in the young stages of development and thus more is required to be done so as to get the required effectiveness.
Crisis Response, Behavior Intervention, and Management Safety of the children is a priority, and the crisis management team ought to be trained on the identification of stress-induced symptoms in children as a result of a crisis.
Financial Crisis Management in the United Nations A crisis can be defined as the perception of an abnormal situation that is beyond the capability of the business and its scope to deal with.
Crisis Management and Environmentalism: A Natural Fit For an organization to be effective in planning, it should integrate both global and the local aspects of managing a crisis.
Templeton Engine Company’s Crisis Management The advantage of this alternative is that it will help the company to regulate the price of its products because it will be using its own raw materials.
Clinical Aspects of Crisis Management What I realized working on the case is that there are differences between the patients who are in crisis and the ones who are not, and the primary is their desire to cooperate with me […]
Hurricane Harvey Crisis Management This paper will provide a series of bullet points that will outline the damage, how it was handled, what outcomes were present, and the possible ways in which it could have been done better.4.
Crisis Management in the Film “Apollo 13” However, it was also a success, as, despite major damage to the spaceship, all astronauts returned to the Earth in safety. The film shows that the crew and the team worked hard to develop ways […]
European Union: Legitimacy and the Euro Crisis Management Chapters included in the paper will discuss such topics as sources of legitimacy in the EU, the Eurozone crisis, main actors that should participate in the management of the crisis, as well as problems of […]
Crisis Management and National Security Strategy This is a crisis because the company will lack the expertise to enhance the operations of the business. In addition, crisis assessment is a vital approach to ensure that the crisis does not affect or […]
Crisis Management: British Petroleum Company It was claimed to be one of the greatest disasters that led to human deaths and oil spills that affected the ecosystem adversely. In addition to that, the management team was affected because it had […]
Risk and Crisis Management and Business Continuity The lack of clarity in the definitions of the identified concepts and the vagueness of the relationships between them undermine the field of risk management in several areas.
Crisis Management for Vulnerable Populations The main goal of this paper is to assess alternative systems for communication and describe vulnerable populations and strategies for reaching and communicating with them during a crisis.
FlyDubai Company’s History and Crisis Management The company takes pride in its comfortability and environmental friendliness, presented by loyalty and security of the staff, and by fuel productivity. Despite a horrific incident, the company made everything possible to sustain its popularity […]
School Crisis Management: Bomb Threat and Shooting As for the shooting incident, the initial step was to calm down the students to avoid the panic, and after that, inform the rest of the school about the red code situation and initiate the […]
Business Continuity and Crisis Management The biggest challenge for an organisation operating in a disaster-prone business environment is the development of mechanisms of predicting risks and ways of protecting their brands from collapsing in the event of organisational crisis.
Crisis and Risk Management Communication: Qatar World Cup 2020 While the willingness of the Qatar government to look innocent is quite understandable, the fact that the authorities’ statements conflict with the ones that cycle around the modern media exacerbates the situation for Qatar, creating […]
Crisis Management: Overdose of Premature Babies in Indianapolis, Indiana The hospital was quick to respond to the issue and it gave details of the error that had led to the death of the premature babies.
Toyota Recall – Global Crisis Management Devlin asserts that it is the premise of an organization’s management and the Public Relation offices to ensure that in the event of a crisis, the organization recovers gracefully and in a timely manner.
Crisis Management in the Organization Crisis is an unexpected catastrophe happening in or to a company and it threatens the operations of the company. Recognize the crisis Identify the potential effect of the crisis on the company and take action.
PRs Role in Crisis Management: BP and Toyota Provision The department of PR should ensure that there is the improvement of an even provision at the crisis management stage.
Crisis Management: Toyota Company and EU Crisis is subject to a domain of several variables particularly in international business which include; the features of the event, the significance to both parties, the magnitude of the impact on both parties and the […]
How McDonalds Handles Their Crisis Management Program Globally? Crisis management, therefore, becomes a crucial factor of checking and controlling the performance of the organization by acting in a proactive and active way to prevent an event which has a potential likelihood of leading […]
Crisis Management at Organizational Level They have also put in place measures to be taken and how the public is expected to respond in case of a tsunami emergency.
Organizational Crises: Management or Crisis Response System Some of key learning points include: Planning for crisis Stages of crisis Causes of crisis Consequences of crisis Cautions of crisis Traditional approach on crisis management New approach to crisis management Complexity-informed framework for effective […]
Crisis Management: Online Banking Security Breach Despite the initial statement, the negative media attention given to the company, and growing concerns from our consumers, clients, stakeholders and the public as a whole, the company has taken upon itself to get to […]
Crisis Management: Fire and Rescue Services The model postulates that for a crisis to be effectively managed there is need to define the crisis that has occurred and the factors that have contributed to the occurrence of the crisis.
Crisis Management From the Perspective of the Austrian Business Cycle
Crisis Management and Emergency Response Plans: OSHA Standards
Financial Crisis Management: Why Did Alitalia Go Out of Business
Difference Between Crisis Management and Risk Management
Learning From the Katrina About Crisis Management
Effective Crisis Management Techniques
Bhopal Disaster – an Example of Unsuccessful Crisis Management
The Crisis Management Lesson From Toyota: The Smart Business Process
Conceptual Dynamic Framework for Crisis Management
Afghanistan Public Sector: From Crisis Management to Comprehensive Reform Strategy
Funding Hungary: Exposing Normal and Dysfunctional Crisis Management
Crisis Management and Financial Stability: Some Lessons from the United Kingdom
Baderman Island Crisis Management Plan
Crisis Management Approaches and Philanthropic Motives
Gender and Rescue Services in Crisis Management: Male Leadership Positions and Women’s Personal Experiences
The Crisis Management System in Germany
Information Literacy Skills Assessment in Digital Crisis Management
Crisis Management: The 2010 Melbourne Storm Salary Cap Scandal
Crisis Management’s Psychological Aspects
Analysis of Maggi Crisis: Crisis Management and Image Restoration through Social Networking
Crisis Management Strategies and the Long-Term Effects of Product Recalls on Firm Value
Nestlé Crisis Management: The Baby Killer
Mattel Crisis Management or Management Crisis: Barbie Dolls and Hot Wheels Cars
Preparing for Future: Creating a Crisis Management Team
Business Ethics and Crisis Management: Circumstances for a Second Chance
Crisis Management Dilemmas: Differences in Attitudes Towards Reactive Communication Strategies
Crisis Management in the Reformed European Agricultural Policy
Crisis Management: the Most Important Factors in the Hospitality Industry
Systemic Crisis Management and Central Bank Independence
Crisis Management Impact on the Accounting Policy of Enterprises
General Motors: The Crisis Management and Controversy Today
Crisis Management: Cathay Pacific Labor Dispute Analysis
What Roles Does the Media Play in Crisis Management
Crisis Management in Belgium: The Case of Coca‐Cola
Role of Apologies in Crisis Management
Crisis Management: Resolution for a European Banking System
Role of Public Leaders in Crisis Management
Crisis Management at Lego: Save the Whales
Which Company Has the Best Crisis Management
Integrating the Crisis Management Perspective into the Strategic Management Process
Are Labor Market Reforms the Answer to Post-Euro-Crisis Management?
Why Is Social Media Monitoring an Important Part of Issue and Crisis Management?
What Is the Most Important Thing in Crisis Management?
Is Crisis Management a Part of Risk Management?
What Are the Most Important Components of a Tourism Crisis Management Plan?
What Makes a Good Crisis Management Plan?
How Does Having an Ethical Crisis Management Plan Benefit a Company?
What Is Considered the Most Important Step of Crisis Management?
What Are the Tools of Crisis Management?
How Are Risk Management and Crisis Management Similar?
What Is the Relationship Between Crisis Management and Crisis Communication?
What Is the Purpose of Crisis Management?
Is Crisis Management Part of the Business Continuity Plan?
What Is the Importance of Disaster Risk Reduction Management and Crisis Management?
Why Should Ethical Decision Making Be Incorporated Into Crisis Management?
Does Starbucks Have a Crisis Management Team?
What Is the First Rule of Crisis Management?
Is There a Correlation Between Organizational Culture and Crisis Management?
What Is the Role of Internal Audit in Crisis Management?
Is Crisis Management and Disaster Management the Same?
What Skills Are Required for Crisis Management?
Who Is Responsible for Crisis Management?
How Does Crisis Management Affect Organizational Culture?
What Is the Difference Between Crisis Management and Disaster Recovery?
What Is Crisis Management in Public Relations Strategies?
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IvyPanda. (2023, November 9). 118 Crisis Management Essay Topic Ideas & Examples. https://ivypanda.com/essays/topic/crisis-management-essay-topics/

"118 Crisis Management Essay Topic Ideas & Examples." IvyPanda , 9 Nov. 2023, ivypanda.com/essays/topic/crisis-management-essay-topics/.

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IvyPanda . 2023. "118 Crisis Management Essay Topic Ideas & Examples." November 9, 2023. https://ivypanda.com/essays/topic/crisis-management-essay-topics/.

1. IvyPanda . "118 Crisis Management Essay Topic Ideas & Examples." November 9, 2023. https://ivypanda.com/essays/topic/crisis-management-essay-topics/.

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Research: Using AI at Work Makes Us Lonelier and Less Healthy

David De Cremer
Joel Koopman

Employees who use AI as a core part of their jobs report feeling more isolated, drinking more, and sleeping less than employees who don’t.

The promise of AI is alluring — optimized productivity, lightning-fast data analysis, and freedom from mundane tasks — and both companies and workers alike are fascinated (and more than a little dumbfounded) by how these tools allow them to do more and better work faster than ever before. Yet in fervor to keep pace with competitors and reap the efficiency gains associated with deploying AI, many organizations have lost sight of their most important asset: the humans whose jobs are being fragmented into tasks that are increasingly becoming automated. Across four studies, employees who use it as a core part of their jobs reported feeling lonelier, drinking more, and suffering from insomnia more than employees who don’t.

Imagine this: Jia, a marketing analyst, arrives at work, logs into her computer, and is greeted by an AI assistant that has already sorted through her emails, prioritized her tasks for the day, and generated first drafts of reports that used to take hours to write. Jia (like everyone who has spent time working with these tools) marvels at how much time she can save by using AI. Inspired by the efficiency-enhancing effects of AI, Jia feels that she can be so much more productive than before. As a result, she gets focused on completing as many tasks as possible in conjunction with her AI assistant.

David De Cremer is a professor of management and technology at Northeastern University and the Dunton Family Dean of its D’Amore-McKim School of Business. His website is daviddecremer.com .
JK Joel Koopman is the TJ Barlow Professor of Business Administration at the Mays Business School of Texas A&M University. His research interests include prosocial behavior, organizational justice, motivational processes, and research methodology. He has won multiple awards from Academy of Management’s HR Division (Early Career Achievement Award and David P. Lepak Service Award) along with the 2022 SIOP Distinguished Early Career Contributions award, and currently serves on the Leadership Committee for the HR Division of the Academy of Management .

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New Research in April: Col...

New Research in April: Colorectal Cancer, Kidney Health, OR Supply Costs, and More

March 15, 2024

CHICAGO: The April issue of the Journal of the American College of Surgeons (JACS) , which includes research presented at the Southern Surgical Association 135th Annual Meeting, features new research on topics ranging from colorectal cancer and social vulnerability to operating room supply costs, the rise in school shootings since 1970, and the impact of permitless open carry laws on suicide rates, among others.

Read highlights from the issue below. The full issue is available on the JACS website .

Social Vulnerability Index and Survivorship after Colorectal Cancer Resection

Researchers analyzed whether data from the Social Vulnerability Index (SVI) can help predict complications and survival rates for colorectal cancer (CRC) patients. A high SVI rating was independently associated with major perioperative complications and survival rates after resection of 872 CRC patients. Findings indicate the SVI may be a useful measure to determine CRC patients who may benefit from outreach interventions.

DOI: 10.1097/XCS.0000000000000961

Health Inequities in Likelihood and Time to Renal Recovery after Living Kidney Donation: Implications for Black American Kidney Health

There exists a lack of live kidney donation studies examining health inequities in renal recovery post-donation. Researchers retrospectively analyzed 100,121 living kidney donors reported to the Scientific Registry of Transplant Recipients between 1999-2021. Findings revealed:

Black living kidney donors, especially young Black males, were less likely to recover kidney function
Time to renal recovery for Black patients was significantly longer than their White counterparts
Black living donors appear to have the greatest future risk of end-stage kidney disease

There is a need for enhanced living kidney donor follow-up, authors note.

DOI: 10.1097/XCS.0000000000000970

Decreased Operating Room Supply Costs and Increased Value of Care after Implementing a Sustainable Quality Intervention

Operating room costs are the second most expensive element of surgical care. To reduce costs, researchers implemented a sustainable quality improvement intervention using automated electronic health record data to analyze operating room supply cost data with patient and case characteristics and outcomes. Results show:

A decrease in operating room supply costs
A decrease in incidence of cases with out-of-control costs
No difference in duration of surgery or patient outcomes
An increase in the value of care

DOI: 10.1097/XCS.0000000000000972

Patients With Obesity and Kidney Failure May Be Newly Eligible for Kidney Transplants

A collaborative study between bariatric and transplant teams has created a viable pathway for patients with obesity who also have end-stage renal disease to become eligible for kidney transplants through weight loss surgery. Postoperative outcomes indicate significant improvements in BMI, hypertension, and diabetes management, enhancing patients’ overall health and transplant viability.

Read the press release

Study Reveals the Impact of Behavioral Health Disorders on Cancer Surgery Outcomes

One in 15 cancer patients in the Medicare system have at least one behavioral health disorder (BHD). BHDs, which include substance abuse, eating disorders, and sleep disorders, are linked to worse surgical outcomes and higher health care costs in cancer patients. Patients with BHDs are less likely to undergo surgical resection and have higher odds of postoperative complications.

Study Quantifies Dramatic Rise in School Shootings and Related Fatalities Since 1970

In the 53 years leading up to May 2022, the number of school shootings annually increased more than 12 times. The likelihood of children being school shooting victims has increased more than fourfold, and the rate of death from school shootings has risen more than sixfold. The incidents studied involved 3,083 victims, including 2,033 children ages 5-17 years, and 1,050 adults ages 18-74 years.

Permitless Open Carry Laws May Lead to More Firearm-Related Suicides

Suicide by firearm rates increased 18% in nine years in states that began allowing firearm owners to openly carry a firearm without a permit. U.S. rates of firearm-related suicide rose from 21,175 in 2013 to 26,328 in 2021, an increase that may be related to more permissive open carry laws.

Journalists should contact [email protected] to receive a full copy of any of these studies or to set up an interview with a researcher.

About the American College of Surgeons

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for all surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has approximately 90,000 members and is the largest organization of surgeons in the world. "FACS" designates that a surgeon is a Fellow of the American College of Surgeons.

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A prosthesis driven by the nervous system helps people with amputation walk naturally

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A person wears a prosthetic leg with a circuit board while walking up stairs in a lab.

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State-of-the-art prosthetic limbs can help people with amputations achieve a natural walking gait, but they don’t give the user full neural control over the limb. Instead, they rely on robotic sensors and controllers that move the limb using predefined gait algorithms.

Using a new type of surgical intervention and neuroprosthetic interface, MIT researchers, in collaboration with colleagues from Brigham and Women’s Hospital, have shown that a natural walking gait is achievable using a prosthetic leg fully driven by the body’s own nervous system. The surgical amputation procedure reconnects muscles in the residual limb, which allows patients to receive “proprioceptive” feedback about where their prosthetic limb is in space.

In a study of seven patients who had this surgery, the MIT team found that they were able to walk faster, avoid obstacles, and climb stairs much more naturally than people with a traditional amputation.

“This is the first prosthetic study in history that shows a leg prosthesis under full neural modulation, where a biomimetic gait emerges. No one has been able to show this level of brain control that produces a natural gait, where the human’s nervous system is controlling the movement, not a robotic control algorithm,” says Hugh Herr, a professor of media arts and sciences, co-director of the K. Lisa Yang Center for Bionics at MIT, an associate member of MIT’s McGovern Institute for Brain Research, and the senior author of the new study.

Patients also experienced less pain and less muscle atrophy following this surgery, which is known as the agonist-antagonist myoneural interface (AMI). So far, about 60 patients around the world have received this type of surgery, which can also be done for people with arm amputations.

Hyungeun Song, a postdoc in MIT’s Media Lab, is the lead author of the paper , which appears today in Nature Medicine .

Sensory feedback

Most limb movement is controlled by pairs of muscles that take turns stretching and contracting. During a traditional below-the-knee amputation, the interactions of these paired muscles are disrupted. This makes it very difficult for the nervous system to sense the position of a muscle and how fast it’s contracting — sensory information that is critical for the brain to decide how to move the limb.

People with this kind of amputation may have trouble controlling their prosthetic limb because they can’t accurately sense where the limb is in space. Instead, they rely on robotic controllers built into the prosthetic limb. These limbs also include sensors that can detect and adjust to slopes and obstacles.

To try to help people achieve a natural gait under full nervous system control, Herr and his colleagues began developing the AMI surgery several years ago. Instead of severing natural agonist-antagonist muscle interactions, they connect the two ends of the muscles so that they still dynamically communicate with each other within the residual limb. This surgery can be done during a primary amputation, or the muscles can be reconnected after the initial amputation as part of a revision procedure.

“With the AMI amputation procedure, to the greatest extent possible, we attempt to connect native agonists to native antagonists in a physiological way so that after amputation, a person can move their full phantom limb with physiologic levels of proprioception and range of movement,” Herr says.

In a 2021 study , Herr’s lab found that patients who had this surgery were able to more precisely control the muscles of their amputated limb, and that those muscles produced electrical signals similar to those from their intact limb.

After those encouraging results, the researchers set out to explore whether those electrical signals could generate commands for a prosthetic limb and at the same time give the user feedback about the limb’s position in space. The person wearing the prosthetic limb could then use that proprioceptive feedback to volitionally adjust their gait as needed.

In the new Nature Medicine study, the MIT team found this sensory feedback did indeed translate into a smooth, near-natural ability to walk and navigate obstacles.

“Because of the AMI neuroprosthetic interface, we were able to boost that neural signaling, preserving as much as we could. This was able to restore a person's neural capability to continuously and directly control the full gait, across different walking speeds, stairs, slopes, even going over obstacles,” Song says.

A natural gait

For this study, the researchers compared seven people who had the AMI surgery with seven who had traditional below-the-knee amputations. All of the subjects used the same type of bionic limb: a prosthesis with a powered ankle as well as electrodes that can sense electromyography (EMG) signals from the tibialis anterior the gastrocnemius muscles. These signals are fed into a robotic controller that helps the prosthesis calculate how much to bend the ankle, how much torque to apply, or how much power to deliver.

The researchers tested the subjects in several different situations: level-ground walking across a 10-meter pathway, walking up a slope, walking down a ramp, walking up and down stairs, and walking on a level surface while avoiding obstacles.

In all of these tasks, the people with the AMI neuroprosthetic interface were able to walk faster — at about the same rate as people without amputations — and navigate around obstacles more easily. They also showed more natural movements, such as pointing the toes of the prosthesis upward while going up stairs or stepping over an obstacle, and they were better able to coordinate the movements of their prosthetic limb and their intact limb. They were also able to push off the ground with the same amount of force as someone without an amputation.

“With the AMI cohort, we saw natural biomimetic behaviors emerge,” Herr says. “The cohort that didn’t have the AMI, they were able to walk, but the prosthetic movements weren’t natural, and their movements were generally slower.”

These natural behaviors emerged even though the amount of sensory feedback provided by the AMI was less than 20 percent of what would normally be received in people without an amputation.

“One of the main findings here is that a small increase in neural feedback from your amputated limb can restore significant bionic neural controllability, to a point where you allow people to directly neurally control the speed of walking, adapt to different terrain, and avoid obstacles,” Song says.

“This work represents yet another step in us demonstrating what is possible in terms of restoring function in patients who suffer from severe limb injury. It is through collaborative efforts such as this that we are able to make transformational progress in patient care,” says Matthew Carty, a surgeon at Brigham and Women’s Hospital and associate professor at Harvard Medical School, who is also an author of the paper.

Enabling neural control by the person using the limb is a step toward Herr’s lab’s goal of “rebuilding human bodies,” rather than having people rely on ever more sophisticated robotic controllers and sensors — tools that are powerful but do not feel like part of the user’s body.

“The problem with that long-term approach is that the user would never feel embodied with their prosthesis. They would never view the prosthesis as part of their body, part of self,” Herr says. “The approach we’re taking is trying to comprehensively connect the brain of the human to the electromechanics.”

The research was funded by the MIT K. Lisa Yang Center for Bionics and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Hugh Herr, who wears two prosthetic legs, speaks to someone holding a prosthetic leg.

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Front Public Health

The Effectiveness of Crisis Line Services: A Systematic Review

Adam s. hoffberg.

1 Department of Veterans Affairs, Rocky Mountain Mental Illness, Research, Education and Clinical Center, Aurora, CO, United States

Kelly A. Stearns-Yoder

2 Department of Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical Campus, Aurora, CO, United States

Lisa A. Brenner

3 Departments of Psychiatry and Neurology, University of Colorado, Anschutz Medical Campus, Aurora, CO, United States

Associated Data

Background: Crisis lines are a standard component of a public health approach to suicide prevention. Clinical aims include reducing individuals' crisis states, psychological distress, and risk of suicide. Efforts may also include enhancing access and facilitating connections to behavioral health care. This review examines models of crisis line services for demonstrated effectiveness.

Methods: Literature searches of Medline, EMBASE, PsycINFO, Web of Science, CINAHL, Cochrane Library, and Google Scholar were conducted from January 1, 1990, to May 7, 2018. Experts were contacted, and references were mined for additional studies. Eligible studies provided health- or utilization-related effectiveness outcome(s). Results were graded according to the Oxford Centre for Evidence-Based Medicine and evaluated for risk of bias using the Effective Public Health Practice Project quality assessment tool for quantitative studies.

Results: Thirty-three studies yielded effectiveness outcomes. In most cases findings regarding crisis calls vs. other modalities were presented. Evaluation approaches included user- and helper-reported data, silent monitoring, and analyses of administrative records. About half of studies reported immediate proximal outcomes (during the crisis service), and the remaining reported distal outcomes (up to four years post-contact). Most studies were rated at Oxford level four evidence and 80% were assessed at high risk of bias.

Conclusions: High quality evidence demonstrating crisis line effectiveness is lacking. Moreover, most approaches to demonstrating impact only measured proximal outcomes. Research should focus on innovative strategies to assess proximal and distal outcomes, with a specific focus on behavioral health treatment engagement and future self-directed violence.

Introduction

In the United States (US), from 1999 through 2017, the age-adjusted suicide rate increased 33% from 10.5 to 14.0 per 100,000 ( 1 ) and worldwide suicide remains a pressing concern. Upstream efforts to prevent suicide include crisis line services (e.g., call, chat, text). During such interactions, responders address the crisis at hand with the aim of reducing crisis states, psychological distress, and risk of suicide. This may include facilitating evaluation of imminent risk by local first responders. In addition, within the context of a crisis line contact, responders may provide resources and strategies to facilitate treatment referrals and engagement in care. Given the key role of crisis lines within a comprehensive public health strategy for suicide prevention, it is critical to know whether they are meeting their intended goals. The primary goal of crisis line effectiveness research is to evaluate the immediate proximal and/or longer-term distal effect(s) of such interventions. These effects may be measured using a wide-range of outcomes, including health- and service use-related client outcomes data regarding prevention of self-directed violence, enhanced mood, satisfaction, compliance with responder interventions, and/or service utilization, as well as outcomes regarding responder responses, such as intervention style and referral recommendations.

The purpose of this systematic review is to establish the state of the science on crisis line effectiveness research. This review provides an exhaustive account of published literature, identifying not only strengths and biases present in the evidence, but also gaps, limitations, and future research opportunities. Within this framework, we specifically examined the literature to identify and appraise: ( 1 ) immediate proximal as well as longer-term distal outcomes measuring crisis line effects; ( 2 ) data collection approaches utilized to measure impact; and ( 3 ) study design and risks of bias informing the strength of current evidence.

Research Question

The key question (KQ) of interest inquired whether there are models of service delivery (crisis line phone, chat, or text) with demonstrated effectiveness.

Study Design

This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines ( 2 ). A completed PRISMA Checklist is available (See Supplementary Table 3 ).

Participants, Interventions, Comparators

For the PRISMA screening and eligibility stages, each study was assessed independently by two reviewers (LAB, KSY) and a third reviewer (ASH) resolved disagreements. Eligibility Criteria were defined according to the PICO(TS) framework: ( 2 , 3 )

Population—Crisis line users consisted of any age.
Intervention/Exposure—Use of crisis line phone, chat, or text services (see Supplementary Table 2 ). An intervention was not required for inclusion (e.g., surveys or administrative data were included). However, studies were excluded if they only provided results on demographic profiles of crisis line utilizers without effectiveness outcomes as described below.
Comparison—Not required for inclusion.
Outcomes—All health- and use-related effectiveness outcomes both immediate proximal and longer-term distal, including SDV, client mood, satisfaction, compliance, and service utilization, as well as responder responses (e.g., referrals, intervention styles) (see Supplementary Table 2 ).
Timing/Setting—Restrictions were not based on timing, setting, or study design.

Only studies including original data and published in a peer-reviewed journal from January 1, 1990 through May 7, 2018 were included.

Systematic Review Protocol

A protocol for this review is registered in PROSPERO International prospective register of systematic reviews under registration number CRD42019127249 ( 4 ).

Search Strategy

Databases were searched using controlled subject heading vocabulary and key words for suicidal self-directed violence (SDV), ( 5 ) combined with controlled subject heading vocabulary and key words for crisis line services (see Supplementary Table 1 ). Searches were limited to English language only. Experts were contacted, and references were mined for additional studies. Complete references were exported from each literature source into EndNote X8, duplicates were removed, and the remaining entries were imported into Covidence review software.

Data Sources, Studies Sections, and Data Extraction

The final literature search of OVID Medline, EMBASE, OVID PsycINFO, Web of Science, CINAHL, Cochrane Library, and Google Scholar was conducted on May 7, 2018. Data from included articles were abstracted into evidence tables by two authors (ASH, KSY; conflicts resolved via discussion with LAB). Extracted data from each article included a description of the crisis line service, sample characteristics, study time period, effectiveness domains measured, source of outcome measurements, proximity of outcome measurement to the intervention, and effectiveness findings (see Supplementary Table 4 ).

Included studies were independently evaluated by two reviewers (ASH, KSY) in a custom Research Electronic Data Capture (REDCap) database ( 6 ) with disagreements resolved by consensus discussion with a third reviewer (LAB).

Strength of Evidence and Risk of Bias

Included studies were graded by level of evidence according to the Oxford Centre for Evidence-Based Medicine ( 7 ) (See Table 1 ). In some cases, “higher level” Oxford grades from well-designed and executed observational studies provided stronger evidence (lower risk of bias) than “lower level” Oxford graded randomized controlled trials (RCT) with extensive biases. To address this limitation and complement the Oxford quality ratings, risk of bias was also assessed independently by two raters using the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies ( 41 ). The EPHPP assessment was conducted in a custom REDCap database. The EPHPP tool bias items included selection bias, study design, confounders, blinding, data collection, withdrawals/dropouts, and other sources (e.g., no disclosure of conflicts of interest) ( 41 ). To inform the study design appraisal, included studies were classified by study design using the Taxonomy of Study Design Tool ( 42 ). Guidance for bias ratings was drawn from the EPHPP data dictionary, and summarized as follows: Selection bias considered to what extent study participants were likely to be representative of the target population, as well as the proportion of selected individuals who agreed to participate in the study; Study design considered the likelihood of bias in the allocation process for experimental designs, and for observational designs, the extent that assessments of exposure and outcome are likely to be independent; Confounding examined to what extent important variables were controlled for in the study design (by matching or stratification), and/or in the analyses; Blinding assessed detection and reporting bias, such as whether the assessors were aware of the research condition and/or the participants were aware of the research question(s); Data collection methods were rated on the validity, reliability and use of standardized outcome measures, including distinctions between self-reported data, objective data retrieved by investigators, and extracted data from administrative records; Withdrawals and drop-outs assessed the proportion of participants remaining in the study through the final data collection period (if applicable); and Other sources of bias included intervention integrity and utilizing appropriate analyses for the research questions ( 43 ). Each of these domains, if applicable, was rated as having a low, moderate, or high risk of bias based on these standard guidelines. An overall risk of bias rating was then generated ( 43 , 44 ). Ratings were based only on information reported in the study. All discrepancies were discussed until reviewers reached consensus regarding the extent of bias present in each domain and overall.

Design, sources of bias, overall bias, and oxford quality rating by study.



de Anda and Smith ( )	Cross-sectional	4
Daigle and Mishara ( )	Cross-sectional	4
Jianlin ( )	Before-after	4
Leenaars and Lester ( )	Retrospective cohort	3
Mishara and Daigle ( )	Before-after	4
King et al. ( )	Before-after	4
Leenaars and Lester, Study 1 ( )	Cross-sectional	4
Leenaars and Lester, Study 2 ( )	Retrospective cohort	3
Mishara et al. ( )	RCT	1
Latzer and Gilat ( )	Cross-sectional	4
Gould et al. ( )	Before-after	4
Kalafat et al. ( )	Before-after	4
Mishara et al. ( )	Cross-sectional	4
Mishara et al. ( )	Before-after	4
Fukkink and Hermanns ( )	Controlled before-after	4
Witte et al. ( )	Before-after	4
Chavan et al. ( )	Cross-sectional	4
Coveney et al. ( )	Cross-sectional	4
Gould et al. ( )	Cross-sectional	4
Knox et al. ( )	Cross-sectional	4
Tan et al. ( )	Cross-sectional	4
Britton et al. ( )	Cross-sectional	4
Gould et al. ( )	RCT	1
Pil et al. ( )	N/A	4
Britton et al. ( )	Retrospective cohort	3
Gould et al. ( )	Cross-sectional	4
Mishara et al., Study 1 ( )	Cross-sectional	4
Mishara et al., Study 2 ( )	Before-after	4
Tyson et al. ( )	Before-after	4
Mokkenstorm et al. ( )	Before-after	4
Ramchand et al. ( )	Controlled before-after	4
Rasmussen et al. ( )	Cross-sectional	4
Chan et al. ( )	Retrospective cohort	3
Gould et al. ( )	Before-after	4
Mejias-Martin et al. ( )	Cross-sectional	4

An external file that holds a picture, illustration, etc.
Object name is fpubh-07-00399-i0004.jpg

Data Analysis

Variability of study designs and outcome measurement precluded a meta-analytic approach to synthesis. Findings were not quantitatively synthesized because included studies were mostly a mix of observational and quasi-experimental design, and often utilized unstandardized measurement approaches to assess a variety of outcomes across many effectiveness domains. Therefore, a descriptive synthesis approach was utilized.

Study Selection and Characteristics

Of the 757 studies screened, 33 met eligibility criteria and were included in the review (See Figure 1 ). Whereas the vast majority of studies described outcome data measured from crisis calls, three included effectiveness outcomes from crisis chat ( 21 , 30 , 35 ). No studies examined crisis line text outcomes. Crisis line call centers included in the review were staffed by a range of responders (e.g., volunteers, paid employees). Approaches to effectiveness outcome measurement also varied, and included user- and responder-reported outcomes, ratings by silent monitors unobtrusively observing crisis line calls, and coding of administrative records (e.g., from clinical forms, chat logs, and call recordings) (see Supplementary Tables 2 , 4 ).

An external file that holds a picture, illustration, etc.
Object name is fpubh-07-00399-g0001.jpg

PRISMA literature flow diagram.

Synthesized Findings and Risk of Bias

The overall risk of bias of included studies was high, and the most frequent Oxford level of evidence was four. Only one study identified was low risk of bias, five studies were rated moderate risk of bias, and the remaining were high risk of bias (See Table 1 ). There were many common sources of bias found in the moderate and high risk of bias studies. Specifically, selection bias was highly prevalent (e.g., many studies excluded crisis line users with the highest [imminent] suicide risk and also inconsistently approached crisis line users for participation). The vast majority of included studies had risks of bias in confounding in the study design and/or analyses, leading to challenges in interpreting potentially spurious associations or findings that could be related to a variable other than the crisis intervention. Furthermore, data collection, measurement, and detection biases (e.g., using unblinded approaches and tools not shown to be valid), as well as attrition bias (e.g., when measuring distal outcomes) contributed to downgraded ratings in the strength of the evidence. Based on these appraisals, the overall strength of evidence for outcomes measuring crisis line effectiveness was determined to be low.

Only two studies were RCTs [Gould et al. ( 29 ) moderate risk of bias and Mishara et al. ( 15 ) high risk of bias; Oxford quality ratings of 1]. Additionally, there were four cohort studies ( 11 , 14 , 31 , 38 ), and the remaining studies were a mix of observational and quasi-experimental design, most of which were cross-sectional or single group before-after designs (high risk of bias; Oxford quality ratings of 4).

Immediate Proximal Evidence of Effectiveness

In about half of studies (16 studies) immediate proximal outcomes during and/or at the end of a crisis line service were evaluated (See Supplementary Table 4 ). Immediate proximal evidence consisted almost exclusively of cross-sectional studies of a single measurement timepoint or single-group before-after study designs measuring change from the beginning (pre-) to the end (post-) of the crisis line intervention; one proximal RCT was noted. For the most part, adolescents and adults utilized the crisis lines services evaluated, however there were five adult only samples, which included three US Veteran studies, and four studies in which age was not reported. Regarding location of crisis lines evaluated, eight studies were from the US, two from the United Kingdom (UK), and one each from Australia, Israel, Canada, Amsterdam, and Spain. Proximal outcomes measured included client mood/satisfaction at the end of the call or change from the beginning to the end of the call (nine studies), helper responses/approaches used during the call (eight studies), the provision of referrals (seven studies), and changes in SDV such as suicidal thoughts (four studies).

Approaches to outcome measurement also varied, including six studies that utilized silent monitors or call/chat log ratings that were shown to be reliable, and three studies incorporated validated assessment tools. However, seven studies relied on administrative/clinical records such as routine call sheets completed by responders, and five studies used approaches not shown to be reliable or valid. Note some studies measured effectiveness across more than one domain and using a mixture of validated and unvalidated approaches.

Notable immediate proximal evidence included a before-after study by King et al. ( 13 ) (high risk of bias; Oxford quality rating of 4) in which 100 taped calls between March 1998 and March 1999 to the Kids HelpLine in Australia were analyzed. Callers were assessed for suicidal ideation, intent, and mental state using a mixture of standardized and unstandardized approaches, including assessment items adopted from the Mini-International Neuropsychiatric Interview (MINI) Modules A and C ( 45 ). Two independent raters analyzed each tape for changes and identified a significant decrease in suicidal ideation and improvement in mental state from the beginning to the end of a call (both p < 0.0005). A substantial decrease in the proportion of callers rated imminent risk at the end of calls was also noted. However, 14% of callers remained suicidal at the end of the call ( 13 ).

In another study employing reliable independent raters and the use of a validated assessment tool, Mishara and colleagues ( 19 , 20 ) (high risk of bias; Oxford quality rating of 4) analyzed 1,431 adults crisis calls to the Hopeline Network in the US between August 2003 and May 2004. Caller mood/states and helper responses were evaluated via ratings by two silent monitors observing unobtrusively, and differences between centers were evaluated by the Crisis Call Outcome Rating Scale (CCORS) ( 46 ). Reliability analyses were performed for silent monitor observations of helpers, and interrater agreement was found to be quite high throughout ( 19 , 20 ). They found an overall positive mean effect ( p < 0.001), but many variables did not significantly change from the beginning to the end of the call according to ratings by the silent observers ( 19 , 20 ). Responder approaches were found to impact caller outcomes, with a supportive approach and good contact associated with positive mood/state changes ( p < 0.001). Furthermore, there was significant variability in effectiveness across call centers, measured via the CCORS ( p < 0.03), and a supportive, collaborative approach with good contact, empathy, and respect were all associated with higher CCORS scores and fewer hang ups (all p < 0.001) ( 19 , 20 ). The authors also noted that 50.5% of callers were not asked about suicidal ideation, and responders failed to meet minimum acceptability standards in 15.6% of calls, including lacking empathy, respect, poor initial contact, and stunningly in four cases the helper told the caller to go ahead and kill himself ( 19 , 20 ). In two cases, an emergency rescue protocol was initiated by the research team when the helper failed to do so with callers at imminent risk.

A more recent example of a reliable silent monitoring approach was conducted by Ramchand et al. ( 36 ) (high risk of bias; Oxford quality rating of 4) in which 241 calls from 10 American Association of Suicidology-accredited hotlines in California during the Spring and Summer of 2014 were monitored. The protocol was developed from existing work by Gould and colleagues ( 25 , 29 ) and included use of the Lifeline Quality Improvement Monitoring Tool. Monitors identified a mean 43% decreased caller distress from beginning to end of call (range 28–64%), with decreased distress associated with the crisis center NSPL network membership (Odds Ratio [OR] 2.72; p = 0.024) ( 36 ). Responders at NSPL centers were also more likely to ask about current suicide ideation (77 vs. 52%; OR 3.6; p < 0.01), recent ideation (31 vs. 16%; OR 2.5; p = 0.02), and past attempts (27 vs. 10%; OR 3.7; p < 0.01) ( 36 ). The researchers also noted that a mean of 7% of all calls were put on hold (range 0–26% across centers) ( 36 ).

In terms of crisis services provided to Veterans, Knox et al. (high risk of bias, Oxford quality rating of 4) analyzed the implementation and early utilization of the Veterans Crisis Line (VCL). Between July 2007 and September 2010, 171,000 calls were made to the VCL. Effectiveness was analyzed via responder referrals to either Suicide Prevention Coordinators (SPC) and/or other Veterans Health Administration (VHA) and community programs. From VCL inception in July 2007 through 2008, approximately 4,000 referrals were made to SPCs, and this increased to 16,000 total referrals by the end of September 2010.

Also of note, in a cross-sectional study of VCL, Britton et al. (high risk of bias; Oxford quality rating of 4) analyzed 646 calls during a 1 week period in 2010 to ascertain responder referral actions at the end of each call ( 28 ). Results indicated that 84% of calls ended with a favorable outcome, defined as either resolution during the call or referral to a local health care provider, with the remaining 16% classified as unresolved/declined referral. In the univariate analysis, higher risk callers had significantly higher odds of the call ending in a referral (77 vs. 49%; Relative Risk Ratio [RRR] 2.70; 95% Confidence Interval [CI] 1.64–4.47), and in the multivariate analysis callers at higher risk approached significance in more calls resolved vs. unresolved compared with lower risk callers (RRR 0.56; 95% CI 0.30–1.04; p = 0.067). For 54% of callers, responders provided reasons for determining higher vs. lower risk callers, and reported these judgments were based on intent to die (OR 8.47; 95% CI 3.85–18.63) and absence of future plans (OR 10.45; 95% CI 2.84–38.40) ( 28 ).

In the most robust proximal evidence of effectiveness, Gould et al. ( 29 ) conducted the first national RCT to evaluate the immediate proximal effect of a crisis center intervention and training strategy using a dynamic wait-listed roll-out design across the US National Suicide Prevention Lifeline (NSPL) network of crisis hotline centers. Effectiveness was measured by silent monitoring of 1,507 calls between June 2008 and December 2009 via adapted 4-point rating scales of positive/negative behaviors and affects. They found that counselors with Applied Suicide Intervention Skills Training (ASIST) were significantly more likely to positively impact caller behavioral and affect changes during the call, including callers feeling less depressed (OR 1.31; 95% CI 1.01–1.71; p < 0.05), less overwhelmed (OR 1.46; 95% CI 1.18–1.82; p < 0.05), less suicidal (OR 1.74; 95% CI 1.39–2.18; p < 0.001), and more hopeful (OR 1.35; 95% CI 1.04–1.77; p < 0.05), compared with counselors without ASIST ( 29 ). Furthermore, counselors with ASIST were significantly more likely to apply positive supportive and collaborative approaches, including exploring reasons for living (OR 1.46; 95% CI 1.03–2.07; p < 0.05) and ambivalence about dying (OR 1.65; 95% CI 1.19–2.28; p < 0.01). However, those with ASIST were not more likely to ask about suicide plans, preparatory behaviors/actions, intent, and prior suicide thoughts or attempts compared with counselors without ASIST (all p > 0.05) ( 29 ).

Gould and colleagues ( 32 ) (high risk of bias; Oxford quality rating of 4) cross-sectionally analyzed 491 calls to the NSPL between February and September 2012. This study is noteworthy because it consisted entirely of imminent risk callers and provided insights into the utilization of first responders to support crisis line services. Data were drawn from responder self-report questionnaires regarding imminent risk assessments and interventions provided. Interventions were classified according to four levels: active collaborative non-invasive; active collaborative invasive; active non-collaborative invasive; and, active non-collaborative noninvasive (See Supplementary Table 2 ). Collaborative calls included any active engagement by the caller to take action on her or his own behalf to work toward safety, and invasive interventions included the provision of emergency first responder services, sometimes referred to as “emergency rescues.” Results indicated that 76.4% of callers were collaborative in securing their own safety, and the remaining 24.6% required a non-collaborative and involuntary use of emergency services ( 32 ). A novel approach to developing risk profiles was also explicated by classifying callers along two continuums based on level of risk and level of engagement.

In the only study focused exclusively on crisis chat outcomes, Mokkenstorm et al. ( 35 ) (high risk of bias, Oxford quality rating of 4) analyzed 526 administrative records of chat logs from April to June 2013 to measure immediate proximal change from the beginning to end of a crisis chat, and found that suicidal ambivalence worsened for 15 of the users (2.9%), 156 (29.7%) had no change, and 18 improved (3.4%). Missing data was an issue for this outcome (337; 64.1%). The CCORS was also used to assess chatter's positive and negative experiences and behaviors. The mean score was 114.1 (Standard Deviation [SD] 16.8; range 61–150), though “a mixed picture emerges,” (p. 289) with 27.6% of chats rated to be dissatisfied, and 28.7% were satisfied; 33.1% said she or he did not seem to feel better, while 20.2% felt better ( 35 ).

In the most recently published study regarding immediate proximal evidence of effectiveness, Mejias-Martin et al. ( 40 ) (moderate risk of bias; Oxford quality rating of 4) analyzed 20,942 calls to the EPES public emergency healthcare service of Andalusia, Spain between January 2007 and December 2013. Based on records from the phone operator and healthcare team labeling, the researchers noted 516 caller deaths prior to evacuation (2.46% of analyzed calls), and that males died significantly more frequently than females (4 vs. 0.98%; p = 0.001) ( 40 ). Almost three-fourths (72.37%) of calls resulted in an emergency rescue evacuation to the emergency department, while 13.05% were resolved in situ , 4.61% were referred to a professional, and 1.96% denied to be attended ( 40 ). In analyses to understand groups with more frequent evacuation, callers over 65 years old had two times lower likelihood of evacuation compared with younger callers (adjusted OR 0.53; 95% CI 0.47–0.59), and females were more frequently evacuated compared with males ( p = 0.001), while also having calls more frequently resolved in situ ( 40 ).

Distal Evidence of Effectiveness

The remaining 17 studies measured more distal outcomes and were categorized by proximity of outcome measurement from the time of crisis line service. Distal evidence ranged from follow-up about 1 week after the crisis line service, to up to 4 years (See Supplementary Table 4 ). For three studies, the outcome measurement was distal but the time elapsed between the call and the follow-up was not clear. Distal evidence consisted largely of single-group before-after study designs measuring initial outcomes during the crisis line intervention, along with a single follow-up assessment after the crisis line service. Several before-after studies included multiple assessment timepoints for distal outcome measurement. One RCT measuring distal outcomes was noted, along with a few retrospective cohort studies. Crisis lines evaluated for distal outcomes also served both adult and adolescent populations, including one adolescent only study, five mixed adult/adolescent samples, seven adult only samples (including one US Veteran study), and four studies in which age was not reported. Distal studies were conducted in Canada (seven studies), the US (six studies), and one each from Amsterdam, China, Hungary, Belgium, and India. Distal outcomes measured included SDV (13 studies), client mood/satisfaction (eight studies), helper responses/approaches (four studies), the provision of referrals (six studies), as well as service utilization (seven studies).

Similar to the proximal studies, approaches to distal outcome measurement varied, including one study that utilized silent monitors, and four studies that incorporated validated assessment tools. However, five studies relied on administrative/clinical records, four studies used approaches not shown to be reliable or valid, and one study did not report source of data. Selected distal results are presented by proximity of the most distal outcome measurement to the crisis line service.

In the most proximal distal study with outcome measurement via follow-up calls at 1 week, Mishara and colleagues Study 2 ( 33 ) (high risk of bias; Oxford quality rating of 4) analyzed 1,206 calls to Quebec suicide prevention centers in Canada. Outcome measures included a mix of standardized and unstandardized approaches, including ratings by silent monitors, Helper Response Scales, CCORS, the Psychological Symptom Index (abridged), and the Brasington Indication of Depression. Significant decreases were noted in suicidal urgency from the beginning to the end of the call ( p < 0.001), although there were no changes in 76% of calls. Additionally, suicidal urgency decreased in 16% of calls, but increased in 7.8% of calls ( 33 ). For this study, suicidal urgency was defined along a seven-point scale ranging from one (thinking about suicide with no plan, time frame, or method), to seven (decided to take own life in the next 24 h with a specific method determined and available). Follow-up outcomes regarding distal effectiveness of the crisis line were mixed and consisted of outcome data for just 8.7% of the baseline sample. At 1 week, 69.2% of callers were satisfied with help received, but 31% were not. A substantial proportion (42%) reported they did what they said they would do since the initial calls, but 40.2% admitted they did not ( 33 ). The authors also noted gender differences in effectiveness; female callers improved more frequently than males (18.6 vs. 11.8%; p < 0.05), and CCORS was significantly higher in females compared with males ( p < 0.001) ( 33 ).

Kalafat et al. ( 18 ) (high risk of bias; Oxford quality rating of 4) analyzed 1,617 callers to local crisis hotlines and the 1-800-SUICIDE network from March 2003 to July 2004. Distal outcomes covering a variety of client domains were measured a mean 13 days from the baseline call (range 1–52 days) for about half (49.5%) of baseline callers. Assessment approaches were both standardized and unstandardized, including a 14-item measure adapted from the Profile of Mood States-A Modified (POMS-M) ( 47 ) and Likert scales. Findings revealed that 11.7% of callers had suicidal thoughts since the initial call ( 18 ). Callers who participated in the follow-up assessment were significantly more overwhelmed and received significantly more referrals compared with callers without follow-up ( p < 0.001). POMS-M, caller distress, confusion, depression, anger, anxiety, helplessness, feelings of being overwhelmed, and hopelessness all significantly reduced from the beginning of the call to the end of the call and from the end of the call to the follow-up at 2 weeks (all p < 0.001) ( 18 ). 57.9% of those who completed follow-up initiated an action plan with their counselor, and among those only 35 had not carried out any of the plan. Among those who completed follow-up and had been referred to a mental health resource (392), 33.2% had kept or made the appointment at follow-up ( 18 ). Of the three rescues initiated during the crisis call, two completed follow-up and one did not.

Gould et al. ( 25 ) (high risk of bias; Oxford quality rating of 4) analyzed 654 NSPL callers between January 2006 and December 2007 who were referred to health care. Standardized telephone interviews were conducted a mean 14 days after the initial call to the center (range 3–72 days), and they included suicide risk status, Beck Depression Inventory-II ( 48 ), along with other unvalidated questions. Overall, 41.9% of callers followed through with their referral, with the highest follow-through rate to mental health providers ( 25 ). However, 151 suicidal callers did not follow through with a referral, albeit 25% of those reported accessing a comparable mental health resource. Utilizing a mental health referral was not related to demographics, depression, or suicidal risk profile, although unsurprisingly utilization rates were higher among those with insurance compared with those without insurance (59.6 vs. 35.6%; OR 0.37; 95% CI 0.19–0.72; p < 0.01), and among those already in treatment compared with those who were not (76.7 vs. 26.1%; OR 9.32; 95% CI 5,91–14.70; p < 0.0001) ( 25 ). Perceptions about barriers to utilizing mental health resources among crisis line callers were also explored.

In the only other RCT evaluating crisis line effectiveness (and the only RCT measuring distal effects), Mishara et al. ( 15 ) compared the effects of four suicide prevention program arms for crisis line callers between February 2000 and January 2002. This approach was unique in that the study participants were family and friends who had called the crisis line with concern about high-risk suicidal men who did not seek help themselves. Using a mixture of standardized and unstandardized assessment approaches, they found that overall, the crisis line caller participants reported that the suicidal men they were concerned about were significantly less likely to have seriously considered suicide after participation in any of the crisis line programs (at 2 months p < 0.001; at 6 months p < 0.01), and less frequently attempted suicide in the previous 2 months (at 2 months p < 0.02; at six months p < 0.001) ( 15 ). However, problems with the design and execution of this trial introduced high risks of bias and cast doubt about the validity of these findings. Issues included discrepancies in the reporting of number of participants, errors in the table reporting results, the abandonment of the family session arm of the trial due to lack of participation, and low completion and analysis rates with missing reasons for dropout.

In the most thorough examination of service utilization after a crisis call, Britton et al. ( 31 ) (high risk of bias; Oxford quality rating of 3) retrospectively investigated distal VCL effectiveness by examining caller service utilization within 180 days of index referral during the crisis call. Referrals were made for 21,130 callers (20.6% of all calls), and the analysis included 13,444 callers (64% of eligible referrals) during calendar year 2010. Based on precise linkage of VCL call records with VHA medical files, it was revealed that VCL is most frequently used by Veterans already engaged in VHA care (91% of the sample had prior VHA use within the past 5 years). The majority of callers presented for in-person VHA care within seven days of referral (71% of callers without prior VHA use and 91% with prior VHA use). Callers with prior VHA use were more likely to present for same-day care; however, callers without prior VHA use were more likely to present for care after 15 days ( p < 0.0001) ( 31 ). There were few other differences in service utilization observed between the two groups.

The only study across the entire body of evidence rated as low risk of bias was by Chan et al. ( 38 ) who conducted a retrospective cohort study analyzing death by suicide among elderly users and non-users of a telephone helpline between January 2012 and December 2015 (Oxford quality rating of 3). Outcomes were assessed via sociodemographic data from the service's computerized system, as well as suicide mortality status from the Coroner's Court matched against crisis line users using the unique Hong Kong Identity Card. In this study, helpline users accounted for 14.4% of known suicides in Hong Kong during the 4 year follow-up period, and the suicide rate among helpline users was far higher than the general Hong Kong older adult population (Males: 86.3 vs. 32.6 per 100,000; Females: 42.8 vs. 16.7 per 100,000; both Incident Rate Ratio [IRR] = 2.6) ( 38 ). The majority (60%) of the helpline suicides occurred within 5 years of the service. Significant predictors of suicide among the helpline users included older age, male, living alone, and self-reported mental illness. Protective factors were also identified including skeletal system diseases and brain and nervous system diseases ( 38 ).

Work by Pil et al. ( 30 ) (moderate risk of bias; Oxford quality rating of 4) was unique in that the team modeled cost-effectiveness of Flemish suicide chat and phone helpline services using 2011 data from 3,785 users in a 10-year simulation to predict distal future effects. Findings suggested that telephone and chat crisis line services could avoid 36% of projected future suicide attempts and provide modest cost-savings.

Volunteer vs. Paid Responders

Two studies provided additional insights into the effects of characteristics of crisis line responders on outcomes. These studies sought to identify differences between volunteer vs. paid responders (both high risk of bias; Oxford quality ratings of 4). In a study by Gould et al. ( 32 ) volunteers were significantly less likely to engage in a collaborative active rescue compared with non-volunteers (OR 0.41; 95% CI 0.23–0.74; p = 0.003), and volunteers were significantly more likely to implement a non-collaborative active rescue compared with non-volunteers (OR 2.31; 95% CI 1.40-3.81; p = 0.001) (see Supplementary Table 2 ). For each additional 4 h per week shift answering calls, helpers had 8% higher odds of collaboratively engaging caller ( p = 0.006), 8% lower odds of implementing a non-collaborative rescue ( p = 0.008), and 8% increased odds of reducing a caller's imminent risk so no rescue was needed ( p = 0.03) ( 32 ). Mishara et al. ( 33 ) found that overall, there were no significant differences between volunteers and paid employees on outcomes. However, volunteers and paid staff with over 140 h of call experience had significantly better outcomes compared with those with less experience. More experienced helpers (140+ h) were less likely to have an increase in suicide risk from beginning to end of call (5.4 vs. 12.2%), more likely to have improvement in suicide urgency, defined along a seven-point scale from thinking about suicide with no plan to decide to take own life in the next 24 h with a specific method determined and available (16.8 vs. 14.7%; p < 0.02); significantly higher CCORS ( 46 ) scores ( p < 0.025), and were more likely for the safety contract/agreement to be respected (50.1 vs. 31.1%; p < 0.04) compared with less experienced helpers (<140 h) ( 33 ).

Summary of Main Findings

Although the state of the science regarding the effectiveness of crisis response services remains limited, overall results provide support for such services. However, such support is largely from uncontrolled studies indicating the positive effect of crisis line calls on immediate proximal outcome measures (e.g., changes in distress over the course of the crisis line call) and short-term distal effects. Many studies evaluating distal effects after the crisis service suffered from substantial dropout, thereby increasing the risk of bias interpreting findings. However, some distal studies utilizing administrative data were able to retain complete follow-up data [e.g., suicide mortality data ( 38 ); medical records ( 31 )], but they did not benefit from participant self-report to contextualize findings. Cautious interpretation of Chan et al. findings is warranted. While the study found significantly higher rates of suicide among crisis line callers, this is not necessarily an indication of lack of crisis line effectiveness. Rather, this study confirmed that crisis line callers are at increased risk for suicide, reinforcing the need for high quality wrap-around services and follow-up care to promote recovery and well-being. While reliability of outcome measurement has been shown in some approaches (e.g., silent monitoring, rating transcripts), further research is needed to establish validity in outcome ascertainment (e.g., measure SDV using standardized assessment tools). Promising approaches to outcome measurement have incorporated validated assessment tools, often modified for brevity (e.g., CCORS, MINI, POMS, BDI); however, more research is needed.

The strengths of this review lie in the rigorous methodological approach utilized that is consistent with PRISMA guidelines. An in-depth examination of individual study characteristics combined with a descriptive synthesis of key features and findings contextualize the state of crisis line effectiveness research and illuminate opportunities for future studies. Strengths of the literature include an increased focus over the last decade on crisis line effectiveness evaluation research, in which almost two-thirds of included studies were published since 2010. The evidence is also growing to include research using longitudinal study designs with a comparison group [e.g., ( 38 )], as well as a landmark RCT by Gould et al. ( 29 ) that used a dynamic wait-listed roll-out to evaluate a network of call centers. These exemplar studies prove that it is possible to implement rigorous and sophisticated study designs in the understandably complex and complicated field of crisis line evaluation. Current evidence supports the continuation and expansion of crisis line services as an important safety net for comprehensive suicide prevention care.

Limitations

As outlined above, the limitations of the literature are that the overall quality of studies conducted to date are low, and risk of bias is concerning. Significantly less evidence was available to review in terms of crisis chat, and no studies have been conducted to evaluate the effectiveness of text-related services. In addition, there was substantial variability in what outcomes were measured, and the timing of those measurements. A key limitation emerged in defining what truly is effectiveness in crisis line evaluation. The measurement of effectiveness was discerned to be a multi-faceted domain covering much more than the central outcome to prevent suicide and other self-directed violence, and included measures of mood, satisfaction, referrals, and utilization/engagement in care. Furthermore, half of studies measured only immediate proximal outcomes of effectiveness, and studies measuring more distal outcomes widely varied in terms of time to follow-up for outcome measurement (1 week to up to 4 years). The inconsistent use of standardized tools to measure outcomes along with the variety of outcome domains made it challenging to integrate effects across studies, leading to uncertainty in the extent to which crisis line services truly are meeting their intended goals. Also notable are the high losses to follow-up as well as current dearth of evidence regarding the highest risk callers. That being said, such work is complicated by the imminent risk presented by such callers. Exploration of means to evaluate these interactions is warranted (e.g., reviewing recorded interactions).

Additionally, longer-term outcomes would be expected to be improved if crisis line users could be connected to behavioral health services. Most basically, this might include responders offering users resources regarding providers in their community. In particular, opportunities exist in terms of crisis lines following individuals until they engage in treatment. Though ultimately this is an empirical question, models exist, such as Safety Planning Intervention plus follow-up (SPI+) ( 49 ), that could be modified to meet the needs of crisis line service users. With that in mind, such interventions are contingent upon users being willing to self-disclose information regarding their identity. This runs counter to the historical anonymous culture of crisis services ( 50 ). This culture of anonymity poses clinical and research considerations in regards to challenges associated with providing users with follow-up care and evaluating distal effects of services. Moreover, such interventions are often dependent upon follow-up services being available. Progress on health equity in the US and other countries must remain a priority to meet the behavioral health follow-up service needs of crisis line users ( 51 ).

The limitations of this review are that included literature was limited to English language only, and synthesis was not quantitative (e.g., no meta-analysis was performed).

Future Directions

Additional work is needed to evaluate the impact of responder experience on user outcomes. The most robust immediate proximal evidence from a national RCT indicates that counselors with ASIST had improved user outcomes during the call ( 29 ). Findings from both Gould et al. ( 32 ) and Mishara et al. ( 33 ) suggest that factors associated with responder characteristics impact outcomes. It remains unclear whether paid responders simply have more time to become “experienced.” It may also be that those who are paid receive additional resources (e.g., training) that support better outcomes. The evidence to date provides strong indications that responder experience improves outcomes, and it is imperative that all responders are trained to consistently incorporate standardized SDV risk assessment and develop a supportive/collaborative approach to assisting crisis line users. Future studies should incorporate participatory approaches to increase responder engagement in the research process. This will encourage the initiation of study procedures as part of a continuous feedback loop for quality improvement.

Computational linguistics and natural language processing are ripe evaluation paradigms to complement effectiveness research. Various linguistic aspects of conversations can be measured and correlated with crisis service outcomes. Natural language interfaces may be able to assist human responders in linguistic development ( 52 ) as well as provide real-time emotional and practical support to responders during crisis chat and text interactions ( 53 , 54 ). It is critical that a rigorous framework of principles and protocols is applied to ensure the safe and ethical conduct of these research paradigms, as this approach requires the sharing of highly sensitive data between technology companies and crisis line academic researchers, as piloted in the Crisis Text Line platform ( 55 ).

Conclusions

Despite the fact that research regarding the effectiveness of crisis line services remains limited, studies overall provide initial support for such services, particularly in terms of calls impacting immediate proximal and short-term distal outcomes. Crisis line callers are a high risk population, confirming the need for competent responders trained in suicide-specific assessment and care. Optimal models of crisis lines should implement proactive follow-up services that incorporate distal evaluation. Additional high quality research is needed particularly among the highest risk callers. Further exploration of proximal and distal outcomes regarding call, chat, and text services will benefit this population.

Author's Note

A version of this work was previously presented: Hoffberg AS, Stearns-Yoder KA, Brenner LA (Oral presentation). The Effectiveness of Crisis Line Services: A Systematic Review of the Past 30 Years and Opportunities for the Future. 52nd American Association of Suicidology Conference. 2019 Apr 26; Denver, CO.

Author Contributions

LB contributed conception and design of the study, and contributed to the selection of studies, grading of evidence, and interpretation of results. KS-Y contributed to the design of the study, protocol development, selection of studies, and grading of evidence. AH contributed to the design of the study protocol development, selection of studies, grading of evidence, interpretation of results, and wrote the first draft of the manuscript. LB and KS-Y wrote sections of the manuscript and contributed to manuscript revision. All authors have contributed substantially to the paper and read and approved the manuscript and its submission to this journal.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The authors would like to acknowledge the Veterans Crisis Line Clinical Advisory Board for their consultation on this review. Many thanks to Molly Penzenik for coding the custom REDCap database utilized in study design and risk of bias assessment. The authors were supported by resources of the VA Rocky Mountain MIRECC for Suicide Prevention and the Health Sciences Library of the University of Colorado, Anschutz Medical Campus.

Funding. This manuscript is based on work supported, in part, by the Department of Veterans Affairs, but does not necessarily represent the views of the Department of Veterans Affairs or the United States Government.

This publication was supported by NIH/NCRR Colorado CTSI Grant Number UL1 RR025780. Its contents are the authors' sole responsibility and do not necessarily represent official NIH views.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2019.00399/full#supplementary-material

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