How suicide prevention hotlines struggle with repeat callers

Over the past 15 months, the phones at Family Services of Northeast Wisconsin have not stopped ringing.

The center, which runs the 988 crisis hotline for the state, worked hard to expand its mental health services following the hotline's national relaunch. Like many centers across the country, they have has experienced surging demand that has outpaced anything experienced prior, Shelly Missall, the organization's 988 program manager, told ABC News.

That level of surging demand has led Missall to make tough decisions. She says among them: limiting services provided to frequent users of the line.

"Restricting callers is not ideal for anyone," Missall said. "But given the extent of the demand, and the state of their staffing, few choices remain."

"We're looking at our needs as a call center, to be able to meet the needs of the entire state and to be able to get to the...other folks who need help," she added.

Since its launch in July 2022, demand for 988 has swelled. As of September 2023, five million individuals had received support by calling, texting or messaging the line. During that time, the federal government has invested nearly $1 billion into the hotline, including specific subnetworks for veterans, LGBTQ+, Spanish speakers and users of American Sign Language designed to meet each group's distinct needs.

In the face of widespread staffing shortages amid the ballooning demand, 988 centers all over the country are being forced to make these same tough decisions for frequent callers, sources informed ABC News.

According to Vibrant Emotional Health, the national organization administering the new 988 hotline, crisis centers across the country are using callers' names, numbers or even "the sound of their voice" to potentially limit services.

"Based on our policy requirements, centers are able to determine for themselves how they want to address familiar voices," Divendra Jaffar, a spokesperson for Vibrant, told ABC News.

In an ideal world, the goal of a crisis hotline is to stabilize symptoms-not provide ongoing care-according to Tia Dole, 988 lead at Vibrant. But experts say that restricting callers goes against best practice for mental health care in a world where non-crisis care-like regular therapy-is hard to come by. With waitlists stretching into the hundreds -and wait times of weeks or months-988 is the backstop.

Yet, centers are struggling to be that backstop for recurrent users while also staying available for everyone.

In response to this reporting, the Substance Abuse and Mental Health Services Administration (SAMHSA) said it is now working with Vibrant, and in turn local centers, to evaluate the need for restrictions on frequent callers and develop alternatives to those measures.

"Even with familiar callers, each contact is unique and crisis counselors use their experience to listen, support and connect people to various types of community-based care, if needed, while [also] making sure they are able to respond to incoming calls," Monica Johnson, SAMHSA's 988 director, told ABC News.

Difficult trade-offs

According to data from Vibrant, at least 1,000 callers across the country have been flagged as familiar voices. Centers in 39 states have consulted with Vibrant about placing restrictions on frequent callers, Jaffar told ABC News. The organization declined to share additional statistics or resources for determining how frequent callers are managed.

While a frequently asked questions page on SAMHSA's website states that the line is "confidential," that does not preclude cataloging callers' phone numbers, names or the sound of their voice in order to identify frequent callers, Jaffar said.

Vibrant also does not have a universal definition for "familiar voices," he added, "so some centers may identify an individual as being familiar to them with relatively few contacts, while others...may have a higher threshold."

Family Services of Northeast Wisconsin has restricted frequent callers in various ways, Missall said. In some cases, they're limiting calls to 20 minutes each, in others, they're limiting individuals to 3 calls over a certain period of time and for some, they're referring callers out to other resources such as a National Alliance for Mental Illness "warmline," before terminating the call. Such non-crisis helplines are typically less equipped to respond to emergency situations, according to the American Psychiatric Association.

"Some of those boundaries might be necessary to help them build some of their own personal skills as far as being able to self-manage," she said, "it's never healthy for somebody ... to become too overly dependent on any singular resource."

Leading mental health professionals disagree that such an approach is likely to help patients.

"I am aware of no evidence that restricting crisis mental health services leads to positive outcomes," Mark Olfson, a psychiatrist at Columbia University and former chairman of the scientific advisory committee for the American Psychiatric Association, told ABC News.

If resources are limited, "some mechanism may unfortunately be needed to ration care," he acknowledged. But an inherent challenge persists in determining who needs care first, and whether calling frequently means each call is less serious, Chinmoy Gulrajani, a psychiatrist at University of Minnesota and medical director with the state's Department of Human Services, told ABC News.

Tia Dole, at Vibrant, said that the organization encourages call centers to ensure a safety plan is in place and to coordinate other follow-up care when possible.

"[But] boundaries need to be set for a certain group of people," Dole added, "and that's the reality of running a crisis center."

Nowhere else to go

Experts say there are ways to help frequent callers other than restrictions alone, which SAMHSA says it's helping to roll out.

One approach involves developing specific protocols for brief, recurring check-ups with frequent callers, Madelyn Gould, a professor of psychiatry at Columbia University whose research informed the 2020 law inaugurating 988, told ABC News. Another strategy includes using peer supporters-a historically underutilized group of behavioral health workers who have been largely excluded from the 988 rollout-to staff hotlines devoted specifically to familiar callers.

These pathways, using 988 centers to direct those in need to additional follow-up care, would be consistent with SAMHSA's 2020 guidelines on crisis care. But until that process is readily available, advocates worry about the effect restrictions may have on those in need.

Ellen Dayan, for one, is concerned.

Dayan herself has faced an enduring battle with mental illness time and time again, after a diagnosis of bipolar disorder in her twenties, she's found herself relying on strangers on the other end of a telephone for support in moments of crisis, including suicidality.

Later, she took on the role herself, answering calls for a Toledo crisis prevention center, Help Network of Northeast Ohio. Dayan's own experience with calling the helpline left her appalled when she was increasingly pressured by management to restrict services offered to repeat callers. They were only to be allowed a certain number of calls per week, or for a certain duration per call.

"The attitude was ... that they're clogging up the lines," Dayan said, "but that's a problem, you have to sustain those relationships because otherwise it's just a slamming door."

Help Network of Northeast Ohio did not respond to requests for comment.

Dayan said she tried to do what she could amid the restrictions, she had a list of roughly three dozen local mental health organizations that she'd distribute to callers to get plugged in. But those would often have months-long waitlists if they'd take her callers at all.

Which meant for many of those callers, 988 was the only option left.

In those cases, Dayan said, "a conversation - that's all we have."

If you or a loved one is struggling with a mental health crisis or considering suicide, call or text 988.

ABC News is looking into challenges and successes with implementation of the 988 Suicide and Crisis Lifeline. If you have had issues or successes with the line, please contact us here.