State of Mind

Who’s Listening When You Call a Crisis Hotline?

A person cupping their hand around their ear as if they're listening
Photo illustration by Slate. Photo by Getty Images Plus.

State of Mind is a partnership of Slate and Arizona State University that offers a practical look at our mental health system—and how to make it better.

Earlier this year, an operator at Trans Lifeline picked up the phone. On the line was a caller who needed support following a traumatic experience they had had after calling another hotline for LGBTQ youth. The caller shared with the operator that at some point during their other call, they got disconnected due to cell reception issues. Soon after, police officers with a K-9 unit arrived at their location. This understandably deeply unsettled the caller. What’s more, the caller did not know how to prove that they did not need what is euphemistically called “active rescue,” or police intervention. Operators at Trans Lifeline (where one of us, Yana, is the director of advocacy) say that they often get calls like this one, where callers reach out to deal with the aftermath of nonconsensual intervention.

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Many people call for crisis care on behalf of themselves or loved ones on the assumption that they present an alternative to policing and forced psychiatric holds. Indeed, in calling a crisis line, each caller has made a determination that they are not calling 911. Yet most crisis and text lines can lead to unknowing, unwanted, and violent interventions by police, and the phenomenon is exacerbated by technology.

Every crisis call has two components: what a caller thinks is happening in their conversation with their counselor, and what is happening on the other end. The caller might be trying to access up-to-date resources (housing, health care) or find a nonjudgmental person to talk to. They may be in crisis and need help with safety planning. Either way, they tend to think of it as a one-to-one conversation between them and the person who picks up the phone.

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But when you call or chat with many hotlines, algorithms may be listening in. They’re working in the background to triage and sort which callers are most likely to be at risk, pushing them to the top of a call or text queue, performing sentiment analysis, and searching for a set of trigger words.

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After the algorithm may have flagged a caller as particularly high-risk, the human counselor, in conjunction with their supervisor, uses often faulty assessment metrics to determine if the caller is an “imminent risk.” Meanwhile, many of these hotlines that call themselves confidential will also geolocate callers (via landline, cell company, IP address, or GPS chip in your mobile phone)—which you might not know unless you’ve read the terms of service in full before dialing the number. If the operator, influenced by the assessments, thinks that the person is in danger, they may initiate what’s known as nonconsensual intervention, sharing the person’s location with police and other emergency responders. On many lines, when operators loop 911 in, they are instructed to stay on the line with callers and not let them know that police or other first responders are on their way.

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The National Suicide Prevention Lifeline, or NSPL, reports that it uses “active rescue” in 2 percent of its calls—but the actual number has been shown to be significantly higher. Dozens of interactions between the police and those in the midst of mental health crisis turn fatal annually. Yet many—including the federally funded NSPL; its nonprofit manager, Vibrant Emotional Health; and the U.S. Substance Abuse and Mental Health Services Administration, which it’s contracted by—argue that this mode of intervention is worth it: If police intervention saves just one caller, it is justified, no matter the cost to that individual or others.

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We disagree. The recent Trans Lifeline caller’s story is no statistical aberration; patient advocacy groups have shown, time and time again, that callers who have police dispatched to their location often are saddled with unaffordable hospital bills, lose jobs, incur criminal records. Rather than having helpful interactions, many experience traumas that lead to increased suicide rates after psychiatric facility discharge and elevated risk for suicide in the year following psychiatric hospitalization. As studies show, even many years after forced hospitalization, the suicide rate remains approximately 30 times higher than typical global rates—and those who might be forced into hospitalization are likely to be at their most vulnerable. As suicide rates continue to increase, it’s important for hotline administrators to understand that these interventions do not prevent suicidality in the long term. In fact, they do the opposite.

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This summer, 988 will roll out as our national suicide and mental health support number. 988 calls will route to the National Suicide Prevention Lifeline and all its 170 local affiliates—all of which mandate the use of geolocation surveillance and sending law enforcement nonconsensually for “imminent risk.” The imminent risk policy involves “(1) taking all actions necessary to prevent a caller from dying by suicide; (2) active collaboration with the caller to secure his or her own safety; and (3) collaboration with community crisis and emergency services to ensure the safe, continuous care of callers at imminent risk.” This means that if a caller is understood to be at “imminent risk” of a suicide attempt, and an operator finds the caller unable to “contract” safety, police intervention will be initiated without the caller’s knowledge. Yet “imminent risk” is decided by faulty assessment metrics and, as we saw with the Trans Lifeline caller’s story, can stem from a simple disconnect—whether accidental or purposeful.

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The turn away from confidentiality toward surveillance and datafication has been met with widespread criticism on other fronts. Just recently, Crisis Text Line, a nonprofit SMS-based suicide prevention program, received an outpouring of outrage after users found it was profiting off the data generated by those in crisis; the Federal Communications Commission went so far as to demand Crisis Text Line cease the practice. It did so almost immediately (and now the FCC has called on the Federal Trade Commission to investigate), but Crisis Text Line remains, as so many other hotlines do, in partnership with the police. Even after the protests to defund police departments and to remove police from mental health care in summer 2020, even after the World Health Organization and U.N. Office of the High Commissioner for Human Rights called for an end to forced treatment, crisis lines and police departments continue to cooperate.

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We know that police violence, criminalization, and forced treatment are racialized. If historically suicidality has been understood as a white, adult, male mental state, in our contemporary moment, this is no longer the case. The fastest-growing demographic of suicidality is now Black youth ages 10 to 19, with attempts up 73 percent since 1991, while attempts among white youth declined in the same period. Meanwhile, interaction with the police while in crisis increases suicidality at the individual level and decreases trust in hotlines at the community level. Where will Black callers—and others—turn next time?

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By only contracting with providers that use nonconsensual intervention, 988 guts the confidentiality that has long been a core feature of the hotline, while increasing surveillance on the most targeted and vulnerable in our communities. Not every hotline currently puts its callers at greater risk. Trans Lifeline, BlackLine, Samaritans, DASHR, MH First Oakland, and many others continue the legacy of early crisis care work, as do others not gathered under the NSPL network. They find that, for their callers to trust them and therefore receive the help they need—and only that help—the threat of nonconsensual intervention must be off the table or at least much further down the list.

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Trans Lifeline has served on NSPL’s Lived Experience Committee and has consistently drawn attention to the unintended harms of nonconsensual police intervention. Yet the NSPL maintains that

Aside from concerns related to the potential effect of involuntary hospitalizations on suicidal callers, some crisis center staff members report reluctance to call 911 for fear of local law enforcement officials resorting to inappropriate force, arrest or causing other undesirable outcomes for the caller in need of care. While such incidences are tragic when they do occur, and may occur more frequently in jurisdictions where specialized police services for mentally ill persons are unavailable, fears of how the police may respond should not be a determinant in decision-making related to active rescue.

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Fears of surveillance and rejection of hotlines due to police response are, in fact, valid. Even if a current suicide attempt is prevented by nonconsensual police intervention, such interactions often cause more short- and long-term trauma, disproportionately to people of color, trans people, minors, undocumented people, and people living with mental health disabilities. This problem, of course, is not contained to the hotline form; many mental health services are implicated. In September 2021, Cedric Lofton, a Black 17-year-old boy in the Kansas foster care system, was one of hundreds of thousands who, last year alone, in the middle of mental anguish, were engaged by the police. His foster father did what many do when those in their care need help: He called 911, believing that Lofton would be taken to Wichita’s mental health center, ComCare. Instead, police arrived and took him to the Sedgwick County Juvenile Intake and Assessment Center. There, Lofton was handcuffed and restrained in a prone position, leading to cardiopulmonary arrest. His autopsy listed his cause of death as homicide.

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It doesn’t have to be this way. When hotlines first emerged in the United States in the 1950s and 1960s, they were intentionally designed as an alternative to policing and medicalization—a new way to offer care in and by community. And they were effective at lowering suicide rates without surveillance or resorting to sending the police to callers. Bernard Mayes, a “closeted queer priest,” set up the first U.S. hotline in San Francisco’s Tenderloin District to care for the suicidal who, crucially, wanted help, and for the queer community. Mayes decided to make his hotline volunteer-led—a first in the United States—to remove the bias inherent in psychiatry (“homosexuality” was still pathologized in the Diagnostic and Statistical Manual of Mental Disorders) and policing. The service was predicated on offering an “anonymous ear” and the shield of total confidentiality. It was immediately successful. While the service had its detractors (some questioned the use of the telephone, others the use of volunteers), its greatest opponents soon adopted this method for crisis care, which then became standard. The suicide rate in the United States has, in the 60 years since, declined overall. It’s impossible to say how much exactly hotlines were responsible for this drop, but we believe that, coupled with shifting societal factors, they played a major role.

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Today, well-intentioned hotlines and mental health centers are serving marginalized callers in their time of greatest need and should not further exacerbate their callers’ crises via surveillance and recourse to nonconsensual intervention. With the 988 rollout scheduled to take place over the coming months, it is urgent that Congress and the FCC protect callers from the blanket surveillance that enables these harms. Otherwise, 988 might as well be 911.

​​If you need to talk, or if you or someone you know is experiencing suicidal thoughts, text the Crisis Text Line at 741-741 or call or text 988 to reach the Suicide & Crisis Lifeline. If you are concerned about calling a crisis line that uses police intervention, consider reaching out to Trans Lifeline, BlackLine, Samaritans, DASHR (in Denver), or MH First Oakland if they are appropriate for you.

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