Suicide Calls

Guidance on how to talk with suicidal callers and suitable policy arrangements.

Table of contents

1. Suicide Calls Guidance
2. Contents
3. Background
4. Good Practice Guidelines
5. External input
6. Legal requirements
7. Research
8. References
9. Suicide Policy
10. Purpose
11. Scope
12. Definitions
13. Policy statement
14. Responsibilities
15. Legal considerations
16. Reviews and amendments
17. If there are any substantial changes to the content of this policy that you would like to keep a record of, include them here. E.g. May 2021: changed wording on ___, updated definitions.
18. Suicide call thermometer
19. Suicide Procedure
20. Clarifying the situation
21. Exploring the situation and assessing risk
22. Asking about plan and steps
23. The caller has a plan but no intent
24. Suicide calls over email
25. Offering help
26. The caller has imminent intent
27. The caller has taken action
28. The caller has already disclosed their specific location
29. Signposting to other services
30. Calling for help
31. Asking the caller to call for help themselves
32. Obtaining identifying information from the caller
33. Calling emergency services
34. Continuing the conversation
35. The caller refuses help
36. Discussing suicide and facilitating hope
37. Responding to direct questions
38. Call duration
39. Call time limits
40. Limited callers
41. If the caller becomes silent
42. Logging the call
43. Categorising the call
44. Call description
45. Support and volunteer welfare
46. Internal Nightline support
47. External support
48. Appendix A: Example phrases
49. Appendix B: Continuum of Suicide - triangle

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This document has been automatically migrated from the Nightline Association’s guidance library, and formatting has not yet been corrected. View the PDF version of this guidance.

Suicide Calls Guidance

Contents

Background

Good Practice Guidelines

External input

Legal requirements

Research

References

Policy and procedure design

Template policy

Template process

Suicide call thermometer

Template procedure

Appendix A: sample phrases

Appendix B: continuum of suicide - triangle

Background

This document was revised following publication of the most recent Good Practice Guidelines (GPGs): version 4 which was published in July 2022 and can be accessed in full here.

Good Practice Guidelines

This suicide policy review implemented the use of ‘must’ and ‘should’ statements in the GPGs. ‘Must’ statements are practices that all Nightlines must adopt and evidence within their documentation in order to be legally compliant and accredited or reaccredited. ‘Should’ statements are practices that Nightlines are encouraged to include in their practices, but they are allowed some more flexibility in doing so in a way that suits their Nightline. In the GPG reaccreditation process Nightlines are expected to either evidence that they have included these practices or explain in sufficient detail why they have not. These ‘should’ statements allow Nightlines a degree of flexibility and do not force them to adopt particular practices, while still stating the direction of best practice for the Nightline movement.

The latest version of the GPGs state with regards to suicide calls:

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External input

In collating this guidance for taking suicide calls, we consulted lawyers, the Helplines Partnership, the National Suicide Prevention Alliance, and many established helplines (including Samaritans, HOPEline UK, Self Injury Support, Lifeline, Missing People, Childline, SANEline, CALM, and Get Connected).

Liaising with these external helplines helped get an understanding of common practice in the helplines sector. While common practice is not necessarily always correct practice, it is a good starting point of understanding prevalent practices.

All of the external helplines we consulted will:

• Offer to call emergency services in the case of a suicide attempt.
• Under certain circumstances, call emergency services even if the caller does not want them to.

Usually, helplines will:

• Call an ambulance, even if the caller does not consent, if:
  • The caller has taken steps to end their life, and
  • The helpline knows details of the caller’s location
  • The caller is incoherent and/or unconscious
• Ask for consent to call emergency services before doing so, and will at the very least inform the caller if they are calling emergency services.
• If they have time limits on calls, will often make suicide calls an exception to this rule, staying on the line as long as the caller wants.

Some helplines will:

• Explain their policy to the caller as soon as they mention suicide, including explaining that they may have to break confidentiality if the caller is at immediate risk and gives their location. This allows the caller to decide whether they want to disclose their location and get help.
• Sometimes callers are not forthcoming about suicidal feelings, so some helplines will introduce the topic of suicide or have a policy of asking about suicide in every call (e.g. Samaritans).
• Give practical advice to prevent suicide. This might include things like flushing pills or putting dangerous items out of reach. Farther reaching advice might be considering therapy or medication. Usually helplines that make such suggestions are staffed by professionals.

Helplines rarely:

• Break confidentiality in suicide calls where there is no immediate risk to the caller (e.g. suicidal ideation).
• Make a distinction between suicide and self-harm, offering to call emergency services if there is any immediate risk of suicide or serious self-injury.
• Choose to trace calls, but those that do may choose to pass this information on to emergency services in the case of suicide.

Legal requirements

There is no legal obligation under the for Nightlines to call for help on behalf of a caller [England & Wales: Mental Capacity Act 2005; Northern Ireland: Mental Capacity Act (NI) 2016; Scotland: Adults with Incapacity (Scotland) Act 2000; Ireland: Assisted Decision-Making (Capacity) Act 2015].

As Nightline volunteers are not qualified mental health practitioners, they should not make any assessment of a caller’s mental capacity, nor should they make any decisions about keeping the caller safe based on their capacity or incapacity. Helplines have no legal obligation to assess capacity. Even healthcare professionals struggle to assess capacity, so you cannot expect your volunteers to do this.

An individual can only be held criminally liable for complicity in another person’s suicide if they encourage or assist suicide or an attempt at suicide

Research

In certain areas of suicide policy, it is useful to look at the research supporting the practices. The sections below provide an overview of research in each area.

Clarifying Suicidal Intent

Callers often do not volunteer information about suicidal feelings, even if they are feeling suicidal. In a monitoring study of suicide helplines, Ramchand and colleagues (2017) found that callers were over 5.6 times more likely to admit to current suicidal ideation when being asked rather than bringing it up themselves. In this way, clarification opens up an opportunity for callers to talk openly about suicide, which reduces suicidal ideation and distress (e.g. Mishara & Diagle, 1997)

Introducing the topic of suicide rarely gets a negative response from a caller, and is often not even memorable to the caller. On a feedback survey from Samaritans, who ask about suicide on every call, 41% of callers did not remember being asked. Of those that remembered, over half of callers felt positive (51%) about the topic of suicide being introduced, and only 6.4% felt negative (Coveney et al., 2012). Although this doesn’t mean that asking about suicide in every call would be appropriate for a more general helpline like Nightline.

Some volunteers may fear that introducing the concept of suicide could increase risk, but research has shown that bringing up suicide does not increase risk of suicide attempts or ideation (Gould et al., 2005; Eynan et al., 2014; Dazzi et al., 2014). Experts agree that if a person is suicidal, asking them about suicidal thoughts will not increase the risk that they will act on their thoughts (De Silva et al., 2016). They also recommend further clarification of:

• Whether the caller has already taken steps to secure the means to end their life
• Whether the caller has ever made a suicide attempt in the past
• The method and specific modality (e.g. quantity of poison) the suicidal person plans to use, which can indicate the seriousness of the suicidal intention

In three-quarters of monitored suicide calls to a suicide helpline, the caller doesn’t bring up the topic of suicide on their own. When a volunteer on a helpline finds it appropriate to ask about suicide (in one third of calls where the caller hasn’t brought up suicide), over half of the callers asked responded they were indeed thinking of suicide (Mishara et al., 2007a). This makes a strong case for the volunteer to bring up suicide, when they feel it is appropriate. It may allow callers to discuss suicide when they otherwise may not bring it up. HOPELINE UK specifies that clear questions about suicide identifies you as a safe and supportive person who is willing to listen.

Facilitating hope

One study of suicidal callers showed that a supportive approach and good contact, and to a lesser degree, collaborative problem-solving, were most related to positive outcomes such as fewer hang-ups and higher levels of helper-caller agreement (Mishara et al., 2007b). Non-directivity alone was not significantly associated with these positive outcomes, and an approach that was mixed between directive and non-directive on calls was found to be most effective (ibid).

Applied Suicide Intervention Skills Training (ASIST) across the National Suicide Prevention Lifeline’s national network of crisis hotlines includes exploring reasons for living and informal support contacts. These explorative strategies were linked to improvement in suicidal callers’ outcomes (Gould et al., 2013). Actively engaging callers in a discussion about reasons for living and ambivalence about dying was significantly associated with reductions in suicidal feelings (ibid). This service evaluation study additionally noted that helping suicidal callers identify informal supports was also associated with reductions in suicidal feelings (ibid).

Many helplines and support services explicitly include the concept of facilitating hope in their call-taking guidance. Self Injury Support (SIS) is a UK-wide multi-channel support service for women and girls affected by self-injury, trauma, and abuse. Their call-taking guidance reminds volunteers that “until someone has their feelings of wanting to die listened to and accepted, it is hard for them to authentically reach a place of wanting to live”. Therefore, SIS guides volunteers to ‘hold the hope’ by: validating the caller’s need for connection, letting them know you’re glad they reached out, supporting the exploration of what is underneath a caller’s suicidal feelings, and using the model “a part of you wants to die right now”, which opens up the idea that it’s not the only option available. Volunteers are reminded that their role is not to talk anyone out of suicide, and that ultimately someone talking about wanting to die is closer to living than someone not talking about those thoughts.

Offering help multiple times

Interviews with suicide attempt survivors indicate that two-thirds of attempts were considered for less than an hour, and for many people it only took 5-10 minutes from making the decision to acting on these thoughts (Deisenhammer et al., 2009; Cáceda et al., 2020). This indicates that the tone of a call can change greatly over its course, as a caller’s suicidal ideation and intent often change over time. This impulsivity in decision making means that there is scope for change in the caller’s feelings about accepting help, and it is in this time that protective factors such as offering help can make the difference between life and death.

Practical suggestions for staying safe

Limiting access to a chosen means of suicide greatly decreases suicide risk (Florentine & Crane, 2010). Some helplines make practical suggestions to do this (e.g. by flushing pills or putting weapons out of reach).

Call duration limits

Research indicates that in a call to a helpline, the average caller has significantly lower intent to die, hopelessness, and psychological pain at the end of the call (Gould et al., 2007). Therefore, many helplines try to keep a suicidal caller on the line for as long as possible, as this provides a distraction that may help keep the caller safe while their acute suicidality lessens. If your Nightline has a maximum call duration, you may choose to make suicide calls an exception to this rule.

Implicit consent

A volunteer may breach confidentiality without the explicit consent of the caller, provided the caller has given sufficient details about their location for emergency services to help. This is argued to be “implicit consent” as the caller has implied they want help by giving their location.

In a review of helpline practice, less than a third (30.3%) of imminently suicidal callers agreed to have emergency services sent to them. Of the remaining two-thirds, half were sent emergency services against their will (Gould et al., 2016).

Individual and organisational moral stances on suicide can range from interventionist (also known as moralist) to non-interventionist (also known as libertarian) beliefs and actions to save another’s life (Nashnoush & Sheikh, 2021). Helplines have differing stances on their actions to help suicidal callers, as do individual Nightline services. However, common practice in the sector is that specific details about a caller’s location will be taken as implicit consent by many helplines.

A panel of suicide helpline experts (Draper et al., 2015) recommended a policy of actions to save a caller’s life without their explicit consent based on the following research evidence:

• When someone calls a service whose clear mission is to prevent suicide, there is some implicit understanding that this service will act to secure the caller’s safety.
• Suicidal individuals can be cognitively constricted and have ‘tunnel vision’ where the options for alleviating their pain seem narrow and dichotomous, so they are not able to make a rational, responsible decision (Schneidman, 1996).
• Evidence from survivors of suicide attempts indicates that individuals often have a great deal of ambivalence about dying even until the instant of their attempt (Joiner, 2005).

On the other hand, experts also agree that helpers should treat a suicidal person with respect and involve them in decisions about who else knows about the suicidal crisis (De Silva et al., 2016). In another study, which investigated optimal crisis intervention models used by professionals, findings indicated that, while professionals preferred an authoritarian approach, the style that clients found most helpful was one that treated them as an active participant, if not the expert, in their care (Thomas & Leitner, 2005).

Therefore, recommended best practice for Nightlines in this area is to promote the caller’s agency as much as possible when assessing the level of risk for suicidal action and offering help. However, if the caller discloses their specific location, based on the research above this will be considered as implicit consent and help can be called on the caller’s behalf.

References

Cáceda, R., Carbajal, J. M., Salomon, R. M., Moore, J. E., Perlman, G., Padala, P. R., Hasan, A., & Delgado, P. L. (2020). Slower perception of time in depressed and suicidal patients. European Neuropharmacology, 40, 4-16.

Coveney, C. M., Pollock, K., Armstrong, S., & Moore, J. (2012). Callers’ experiences of contacting a national suicide prevention helpline. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 33(6), 313-324.

Dazzi, T., Gribble, R., Wessely, S., & Fear, N. T. (2014). Does asking about suicide and related behaviours induce suicidal ideation? What is the evidence? Psychological Medicine, 44(16), 3361-3363.

De Silva, S. A., Colucci, E., Mendis, J., Kelly, C. M., Jorm, A. F., & Minas, H. (2016) Suicide first aid guidelines for Sri Lanka: a Delphi consensus study. International Journal of Mental Health Systems, 10(1), 53.

Deisenhammer, E. A., Ing, C. M., Strauss, R., Kemmler, G., Hinterhuber, H., & Weiss, E. M. (2009). The duration of the suicidal process: How much time is left for intervention between consideration and accomplishment of suicide attempt? Journal of Clinical Psychiatry, 70(1), 19-24.

Draper, J., Murphy, G., Vega, E., Covington, D. W., & McKeon, R. (2015). Helping callers to the National Suicide Prevention Lifeline who are at imminent risk of suicide: The importance of active engagement, active rescue, and collaboration between crisis and emergency services. Suicide and Life-Threatening Behavior, 45(3), 261-270.

Eynan, R., Bergman, Y., Antony, J., Cutcliffe, J. R., Harder, H. G., Ambreen, M., Balderson, K., & Links, P. S. (2014). The effects of suicide ideation assessments on urges to self-harm and suicide. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 35(2), 123-131.

Florentine, J. B., & Crane, C. (2010). Suicide prevention by limiting access to methods: A review of theory and practice. Social Science & Medicine, 70(10), 1626-1632.

Gould, M. S., Cross, W., Pisani, A. R., Munfakh, J. L., & Kleinman, M. (2013). Impact of Applied Suicide Intervention Skills Training on the National Suicide Prevention Lifeline. Suicide and Life-Threatening Behavior, 43(6), 676–691.

Gould, M.S., Kalafat, J., Harrismunfakh, J.L., & Kleinman, M. (2007). An evaluation of crisis hotline outcomes. Part 2: suicidal callers. Suicide and Life-Threatening Behavior, 37(3), 338-352.

Gould, M. S., Lake, A. M., Munfakh, J. L., Galfalvy, H., Kleinman, M., Williams, C., Glass, A., & McKeon, R. (2016). Helping callers to the National Suicide Prevention Lifeline who are at imminent risk of suicide: Evaluation of caller risk profiles and interventions implemented. Suicide and Life-Threatening Behavior, 46(2), 172-190.

Gould, M. S., Marrocco, F. A., Kleinman, M., Thomas, J. G., Mostkoff, K., Cote, J., & Davies, M. (2005). Evaluating iatrogenic risk of youth suicide screening programs: A randomized controlled trial. JAMA, 293(13), 1635-1643.

Joiner, T. (2005). Why people die by suicide. Cambridge: Harvard University Press.

Mishara, B. L., Chagnon, F., Daigle, M., Balan, B., Raymond, S., Marcoux, I., Bardon, C., Campbell, J. K., & Berman, A. (2007a). Comparing models of helper behavior to actual practice in telephone crisis intervention: A silent monitoring study of calls to the U.S. 1-800-SUICIDE network. Suicide and Life-Threatening Behavior, 37(3), 291–307.

Mishara, B. L., Chagnon, F., Daigle, M., Balan, B., Raymond, S., Marcoux, I., Bardon, C., Campbell, J. K., & Berman, A. (2007b). Which helper behaviors and intervention styles are related to better short-term outcomes in telephone crisis intervention? Results from a silent monitoring study of calls to the U.S. 1-800-SUICIDE network. Suicide and Life-Threatening Behavior, 37(3), 308-321.

Mishara, B. L., & Daigle, M. S. (1997). Effects of different telephone intervention styles with suicidal callers at two suicide prevention centers: An empirical investigation. American Journal of Community Psychology, 25(6), 861-885.

Nashnoush, M., & Sheikh, M. (2021). The morality of suicide. Healthy Populations Journal, 1(1).

Ramchand, R., Jaycox, L., Ebener, P., Gilbert, M. L., Barnes-Proby, D., & Goutam, P. (2017). Characteristics and proximal outcomes of calls made to suicide crisis hotlines in California. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 38(1), 26-35.

Schneidman, E. (1996). The suicidal mind. Oxford, UK: Oxford University Press.

Thomas, J. C., & Leitner, L. M. (2005). Styles of suicide intervention: Professionals’ responses and clients’ preferences. The Humanistic Psychologist, 33(2), 145-165.

Suicide Policy

Purpose

This policy and related procedure outline the practices [X] Nightline’s volunteers must follow for suicidal contacts, including situations where a caller’s confidentiality may be broken. This policy and procedure can be adapted to all methods of contact, with exceptions for particular methods noted where relevant.

This policy ensures [X] Nightline’s practices meet the requirements for Nightline Association Good Practice Guidelines and wider sector best practice.

Scope

This policy applies to all contacts made with [X] Nightline through its official listening channels [phone, IM, email, Skype, drop-in, etc] that discuss the topic of suicide. All listening volunteers at [X] Nightline must adhere to this policy and related procedures when providing support to callers.

Definitions

In this policy and procedure “calls” and “callers” may refer to all uses of Nightline’s student support and information service whether in verbal or written communication.

Note: The word ‘commit’ is often associated with illegality, negativity, and wrong-doing; therefore [X] Nightline avoids using this term in policy and training documents.

Policy statement

Being there for individuals who may be considering ending their life by suicide is a vital part of the listening service that [X] Nightline provides. As the vision of the Nightline movement is for fewer students to die by suicide, [X] Nightline will make help available to a caller if it is required to keep them safe. Nightline volunteers are encouraged to clarify if a caller is feeling suicidal where appropriate.

If a caller is imminently suicidal or has taken action towards taking their own life, listening volunteers will ask the caller if they are able to call for help themselves, or if they would like emergency services to be contacted on their behalf. If the caller refuses help, help will be offered again at regular appropriate intervals, offering the caller an opportunity to seek help if their situation has changed.

[X] Nightline is part of [governing body]. When dealing with suicidal contacts, [X] Nightline will ensure they act in accordance with [governing’s body’s] Safeguarding Policy. In the event of any conflict between this policy and this Safeguarding Policy, [X] Nightline will follow the Safeguarding Policy.

[Option 1A: implicit consent]

[X] if the caller discloses their specific location the listening volunteer will take this as implicit consent and call for help on the caller’s behalf. This policy is based on the assumption that a caller would not provide the required location specificity unless a part of them wanted help, so Nightline will call for help in an effort to keep the caller safe. Therefore, [X] Nightline will inform the caller that unless they end the call, the listening volunteer will call for help on their behalf.

[Option 1B: implicit consent only if incoherent or unconscious]

[X] if the caller discloses their specific location and then becomes incoherent or unconscious during the call the listening volunteer will take this as implicit consent and call for help on the caller’s behalf. This policy is based on the assumption that a caller may not understand the risks or consequences of their actions while in a state of distress, but they may not be able to communicate this. Therefore, [X] Nightline will inform the caller that unless they end the call, the listening volunteer will call for help on their behalf.

[Option 1C: explicit consent]

[X] Nightline will not call for help unless the caller gives explicit consent to do so. This policy respects the caller’s wishes while maintaining the confidentiality and non-judgementality of the Nightline service.

Listening volunteers must inform the caller if their confidentiality is to be broken and that emergency services will be called on their behalf, unless the volunteer reasonably believes this would cause the caller further distress or risk of harm.

[Option 2A: if your Nightline has no call duration limits]

[X] Nightline does not limit call duration and will stay on the phone as long as necessary.

[Option 2B: if your Nightline has call duration limits, and wish to maintain this on suicide calls]

For sustainability of the service, calls are subject to a maximum duration of [X] hours. This also applies to suicide calls.

[Option 2C: if your Nightline has call duration limits, but wishes not to have limits on suicide calls]

For sustainability of the service, calls are typically subject to a maximum duration of [X] hours. However, in calls where the caller is imminently suicidal, the volunteer will always stay on the call for as long as necessary.

Responsibilities

Legal considerations

There is no legal obligation under the [England & Wales: Mental Capacity Act 2005; Northern Ireland: Mental Capacity Act (NI) 2016; Scotland: Adults with Incapacity (Scotland) Act 2000; Ireland: Assisted Decision-Making (Capacity) Act 2015] for Nightlines to call for help on behalf of a caller. As Nightline volunteers are not qualified mental health practitioners, they should not make any assessment of a caller’s mental capacity, nor should they make any decisions about keeping the caller safe based on their capacity or incapacity.

An individual can only be held criminally liable for complicity in another person’s suicide if they encourage or assist suicide or an attempt at suicide. By following this policy and procedure, [X] Nightline’s principles, and training provided to all volunteers, [X] Nightline will in no way be responsible or legally liable for the actions of a caller.

Reviews and amendments

If there are any substantial changes to the content of this policy that you would like to keep a record of, include them here. E.g. May 2021: changed wording on ___, updated definitions.

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Suicide call thermometer

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Suicide Procedure

1. Clarifying the situation

Some callers may not explicitly say that they are feeling suicidal, but there may be cues that the call-taking volunteer can listen/look out for to ascertain if this is the case.

Cues can include things like:

• talking about feeling hopeless, helpless, trapped, or alone
• expressing emotional distress or a sense of desperation
• feeling that they don’t deserve support or help
• saying they have no reason to go on living
• making a will or giving away personal possessions
• searching for a means of doing personal harm
• sleeping or eating too much or too little
• engaging in reckless behaviour, including excessive alcohol or drug consumption
• avoiding social interactions with others, less interest in hobbies
• expressing rage or intentions to seek revenge
• showing signs of extreme anxiousness or agitation
• having dramatic mood swings
• talking about finding a way out or a way to end the pain

There is no set number of cues that indicate a caller may be feeling suicidal, so it is up to the volunteer to decide when they feel it is appropriate to directly ask the caller if they are feeling suicidal. Asking about suicide reduces uncertainty for the listener and reassures the caller that you are there to support them, no matter what. If the call-taking volunteer has picked up on cues and feels it is appropriate to clarify the situation, they should ask the caller directly, for example:

“You mentioned X, Y, and Z. Have you ever had thoughts of ending your life?”

Appendix A provides several sample phrases for how to clarify suicidal ideation with the caller.

1. Exploring the situation and assessing risk

   1. Asking about plan and steps

If a caller answers yes to a clarifying question around suicide or has explicitly told you that they are thinking about suicide, the call-taking volunteer should sensitively and empathetically explore their current situation and the level of risk present, for example:

“I’m glad that you could trust me with this. Are you feeling suicidal now?/ Have you taken any action?

If the caller answers no to feeling suicidal now or taken any action continue to actively listen as normal, using the guidance from Section 5 to support you in discussing their suicidal ideation. The volunteer may choose to clarify risk again if the call lasts a long time, or if they feel the caller’s situation has changed at all.

Appendix A provides several sample phrases for how to explore the caller’s level of planning and risk.

1. The caller has a plan but no intent

If the caller expresses that they have thought about a plan for taking their life, the call-taking volunteer should explore this further with them. This may include asking when and how they plan to do it, whether they currently have the means, as well as how this plan makes them feel, for example:

“Have you thought about when or how you would take your life?”

“How does it feel to tell me about this plan?”

“Do you have the means to harm yourself right now?”

Being willing to discuss this with the caller helps develop a rapport and gives the caller permission to talk openly about their thoughts about suicide. It may also be helpful to ask if the caller has attempted suicide before or whether they have spoken to anyone else about how they are feeling, as these are important risk and protective factors.

Appendix A provides several sample phrases for how to explore the caller’s level of planning and risk.

By engaging with the caller about their suicidal ideation, the call-taking volunteer will hopefully begin to ascertain whether or not the caller is at imminent risk of acting on their thoughts of suicide. If the volunteer feels that there is a high level of risk or that the caller would benefit from hearing about options available to them, they may want to offer help, as outlined in Section 3. Otherwise, the conversation should be continued as normal, using the guidance in Section 5.

1. Suicide calls over email

When a suicide call is received over email, the steps below often cannot be followed in the same way. Therefore, it is up to the judgement of the volunteer(s) responding to and reviewing the responses that are sent as to how they explore the situation with a caller.

If a caller has not explicitly mentioned they are feeling suicidal, this should first be clarified. Then, it may be necessary to simultaneously ask the caller about the extent of their plans/intent and signpost the caller to sources of support, such as in Section 3.4. Since email communication is asynchronous, it is best practice to err on the side of caution and outline to the caller what support is available to them so that they can access this if needed. It may be necessary to explicitly state that Nightline is not able to call for help on a caller’s behalf if they have contacted the service through email.

1. Offering help

   1. The caller has imminent intent

If the exploration of the caller’s current situation indicates that they are imminently planning to act on their thoughts of suicide, the call-taking volunteer should calmly and sensitively explain [X] Nightline’s policy around suicide and ask them if they need immediate help. It is important to do this in a way that promotes the caller’s agency and empowers them to make their own decisions, while still informing them of the options available to them.

The options for help are [delete/amend as necessary]: the emergency services, university crisis team, campus security. The sample phrase below may be adapted to offer the most appropriate service, dependent on the caller’s current situation.

The volunteer should first ask the caller if they want help:

“Would you like me to call for help [an ambulance/ campus security etc]”

Either at the same time, or as a follow-up, the volunteer should explain [X] Nightline’s suicide policy and the conditions in which the volunteer will call for help on the caller’s behalf [ie if implicit consent is used]. The sample phrase below may be adapted to offer the most appropriate service, dependent on the caller’s current situation.

“If you tell me where you are, it is Nightline’s policy to call the emergency services, but it is completely up to you whether you wish to share your location with me. No matter what, I’m here to listen. Would you like to tell me where you are so that I can call for help?”

If the caller accepts help being called on their behalf, follow the guidance in Section 4.

If the caller refuses help, continue the conversation and exploration of how they are feeling, using the guidance in Section 5.

The call-taking volunteer should offer to call for help again every 15-20 minutes, or as they deem appropriate, depending on the level of risk and intent the caller is expressing.

1. The caller has taken action

If the exploration of the caller’s current situation indicates that they have already taken action and are attempting suicide, the call-taking volunteer should calmly and sensitively explain [X] Nightline’s policy around suicide and immediately offer to call for help.

The options for help are [delete/amend as necessary]: the emergency services, university crisis team, campus security. The sample phrase below may be adapted to offer the most appropriate service, dependent on the caller’s current situation.

The volunteer should immediately offer the caller help:

“Would you like me to contact the emergency services [or the university crisis team] to help you?”

Either at the same time, or as a follow-up, the volunteer should explain [X] Nightline’s suicide policy and the conditions in which the volunteer will call for help on the caller’s behalf. The sample phrase below may be adapted to offer the most appropriate service, dependent on the caller’s current situation.

“If you tell me where you are, it is Nightline’s policy to call the emergency services, but it is completely up to you whether you wish to share your location with me. Nightline wants to support you and help keep you safe. Would you like to tell me where you are so that I can call for help?”

If the caller accepts help being called on their behalf, follow the guidance in Section 4.

If the caller refuses help, continue the conversation and exploration of how they are feeling, using the guidance in Section 5.

The call-taking volunteer should offer to call for help again every 15-20 minutes, or as they deem appropriate, depending on the level of risk and intent the caller is expressing.

1. The caller has already disclosed their specific location

If a caller has disclosed their general location earlier in the call before Nightline’s policy was explained to them, the call-taking volunteer should reflect on this and ask the caller if they want to reveal their specific location so that help can be called on their behalf:

“You previously told me that you were at ___. In order for me to call for help, I need to know specifically where you are so the emergency services/university crisis team can get to you. It is completely up to you whether you wish to share your location with me, and I am here to listen no matter what. Would you like to tell me where you are so that I can call for help?”

If the caller accepts help being called on their behalf, follow the guidance in Section 4.

If the caller refuses help, continue the conversation and exploration of how they are feeling, using the guidance in Section 5.

The call-taking volunteer should offer to call for help again every 15-20 minutes, or as they deem appropriate, depending on the level of risk and intent the caller is expressing.

1. Signposting to other services

Regardless of the caller’s current level of suicidality, the call-taking volunteer may find it appropriate to signpost the caller to other services that can better support them. This is an important protective factor to offer to the caller, who can then choose whether or not to exercise their agency in accepting the signposted information.

Appropriate times to signpost might be if the caller has: suggested speaking to someone about how they are feeling, indicated they don’t know who to speak to, refused help, or the caller otherwise feels that it would be appropriate to present the caller with options they may not presently be aware of, for example:

“I have some information about specialised services that can help with what you’re going through, and I really encourage you to talk to them. I have their details right here if you want them, but I’m not forcing you to go anywhere. I’m here for you for as long as you want.”

If the caller is receptive to hearing about these services, the call-taking volunteer can pass on any of the following information, as they deem appropriate:

• University mental health services
• GP
• NHS 24 / NHS 111
• Samaritans
• Papyrus
• Other local mental health services
• And those noted on https://nightline.nsn.org.uk/ which is kept up to date by another provider (ie not something the Nightline has to keep updating).

1. Calling for help

   1. Asking the caller to call for help themselves

If the caller has accepted the offer of help, the call-taking volunteer should first ascertain whether it is appropriate to ask the caller to call for help themselves. If the caller is in a state of crisis and is not able to convey the relevant information, it may not be appropriate to ask the caller to do this.

If the volunteer feels the caller is able to do this, they should ask the caller if they are able and/or willing to call for help themselves, whether this be emergency services, the university crisis team, or a friend/family member. This helps promote agency for the caller and in the case of contacting emergency services, could lead to help arriving faster as the caller can more easily relay the appropriate information to the operator. The volunteer could ask:

“The fastest way to get help is for you to call the emergency services yourself. Are you able to call 999/112 just now?”

“Is there anyone nearby who you could call to help you?”

If the caller has questions about what will happen when they call the emergency services, the volunteer should answer to the best of their ability, using the information in Section 4.3. If the caller has contacted Nightline via telephone, the volunteer should encourage the caller to hang up and call for help themselves, but that they are welcome to call back later should they need.

If the caller is not able or willing to call for help themselves, the volunteer should proceed to Section 4.2 and obtain the necessary identifying information from the caller.

1. Obtaining identifying information from the caller

If the caller has consented to help being called on their behalf, calmly and clearly tell them that you will need to ask them for some information to pass on to the emergency services:

“In order for me to get you help, I will need some information from you. Are you able to tell me your name and where you are just now?”

The caller’s name and specific location is the most important information to obtain. Their location needs to be specific enough for emergency services to find them, e.g. a specific floor and room in student halls, or an identifiable outdoor location. If this is the only information the caller is able or willing to provide, it is enough for emergency services to be contacted.

If the call-taking volunteer feels it is safe to do so, explain to the caller that you will pass their details to their shift partner, who will call for help while you stay on the call with them:

“Another volunteer is going to call the emergency services, and I will stay on the line with you throughout. I will need to ask you some details, and I will write them down for my colleague, who will pass them on.”

If the caller is conscious and able to provide other information, gently ask them for the following:

• The caller’s phone number
• Name and date of birth
• What action they have taken or are about to take on their life
• Whether they are able to open the door for the emergency services
• Age and sex
• Any relevant medical history

Continue to reassure the caller and answer any questions they may have about what will happen next. If possible, ask the caller to ensure that any doors are unlocked, pets are shut away, and lights are turned on to make their location more visible.

It is important not to promise that a particular service will arrive, such as the ambulance, because it is possible that the police or other services may also be called out, depending on the circumstances of the call.

1. Calling emergency services

After receiving the relevant identifying information from the call-taking volunteer, the support volunteer should use the office landline phone (dial 9 to call out) to call 999/112. When asked which service is required, answer “ambulance”.

The volunteer should explain that they are calling from [X] Nightline and the emergency is not related to them, using the sample phrase below.

“I am calling from [X] Nightline, a student-run listening and information service. The emergency is not related to myself. We have a service user contacting us [over the phone, over instant message, other] who is at imminent risk of dying by suicide and Nightline’s policy requires passing on their details to the emergency services.”

The support volunteer should collaborate with the emergency services by providing all relevant identifying information and answering any questions as best they can. It may be helpful to let the emergency services know whether or not the caller has consented to emergency services being contacted, and describing in detail what actions the caller has taken. The volunteer making the call has no obligation to provide any personal details to the emergency services.

If you do not have the caller’s phone number, explain to the operator that calls to our service are anonymous and you do not have access to the number. The operator may ask further questions about the caller’s condition, such as whether they are conscious and breathing. Depending on the caller’s condition, the operator may give further instructions as to how the volunteer taking the call can assist before the ambulance arrives. Depending on the context of the call and whether or not the caller has consented to help being called on their behalf, this may or may not be information that the call-taking volunteer can safely relay to the caller.

1. Continuing the conversation

   1. The caller refuses help

If the caller refuses the offer of help at any point, the volunteer should not push this. It is important however, to make sure that Nightline’s policy of implicit consent is explained to the caller so that they are aware of how their disclosure of information will be used. The volunteer could read out the statement below and then continue the conversation and exploration of how they are feeling, using the guidance in Section 5:

“Just so you know, I can’t call for help unless you ask me to. [If you tell me where you are, it is Nightline’s policy to call the emergency services, but it is completely up to you whether you wish to share your location with me.]”

The call-taking volunteer should offer to call for help again every 15-20 minutes, or as they deem appropriate, depending on the level of risk and intent the caller is expressing.

1. Discussing suicide and facilitating hope

Throughout their conversation with the caller, the call-taking volunteer should endeavour to engage as much as possible with the topic of suicide and anything else the caller brings up. Nightline’s basic active listening skills are always at the core of handling any call but when it comes to calls around suicide, it is even more important to engage with the caller as empathetically and supportively as possible.

After clarifying with the caller whether they are feeling suicidal, volunteers should strive to organically respond to the caller and whatever they wish to talk about. Appendix A includes sample phrases for discussing the concept of suicide and facilitating hope if the volunteer is feeling stuck. By delving deeper into the caller’s current situation, the volunteer may ask more questions around their thoughts and feelings around suicide, how they feel about the concept of dying, identifying and exploring any protective factors, and exploring coping mechanisms or positive things the caller has mentioned. All of this is done in a non-directive way to maintain an empathetic rapport with the caller.

There is a balance to be struck in not asking too many questions, not just focusing on the positives, and still utilising all of the core Nightline active listening skills while engaging with the caller.

1. Responding to direct questions

In most situations, if a caller asks the volunteer a direct question, the aim is to deflect the question and try to not offer an opinion to remain impartial and non-advisory. However, there are circumstances in calls about suicide where [X] Nightline feels that it can be beneficial to a caller in crisis to receive a direct response to ultimately attempt to prevent someone taking their own life. Some sample phrases that can be used in these (rare) situations include:

1) If a caller asks directly whether you think they should kill themselves

“[X] Nightline wishes none of their callers would take their own life but ultimately it is your decision, and I will be here for you no matter what.”

2) If a caller asks directly what they should do to stay safe and not act on their thoughts of suicide

“You’ve told me that you don’t want to die, but [the pills are right there in front of you]. Are you able to [get rid of them] to keep yourself safe?”

[Optional phrase:] It is up to each volunteer whether they feel comfortable answering such direct questions, so volunteers’ actions will be respected and supported no matter what.

1. Call duration

   1. Call time limits

The normal maximum call time limit for telephone (X minutes) and instant messaging (X minutes) does not apply to calls about suicide. Volunteers are encouraged to stay on the call as long as the caller needs, within reason. If the caller is no longer in a situation of imminent risk and the call has lasted longer than 2 hours, the call-taking volunteer is encouraged to summarise elements of the call and try to get the caller to reflect on their current state of mind. This may help bring the call to a natural close. Calls can be brought to an end by the time the service closes. However, if the volunteer feels it is beneficial to extend the call past service times they will be supported in this temporary instance.

1. Limited callers

Repeat callers who have been assigned a specific policy are to be released from any time limits on their calls only if the caller has taken steps to end their life.

1. If the caller becomes silent

If the caller becomes silent, the call-taking volunteer should continue to provide reassurance and ask the caller if they are able to indicate in any way that they are still there, either by blowing or tapping into the phone. The usual silent call time limits should be followed for suicide calls. For phone calls, the volunteer may want to ask the caller to indicate if they are still there, for example:

“I’m not sure if you’re there anymore but if you are, could you make a sound by tapping or blowing into the phone? If I don’t hear anything from you in the next 30 minutes, there may be an issue with the line and I will hang up the phone. Please feel free to call back, we are open until 8am.”

If the emergency services have been contacted on behalf of the caller, the call-taking volunteer should stay on the line either until the connection is ended or the emergency services arrive. If the line is still open, it may be that the emergency services let the volunteer know that they have the situation in hand. If this does not happen but the emergency services are heard to arrive, the volunteer may end the call.

1. Logging the call

   1. Categorising the call

Suicide calls should be logged on Portal as per [X] Nightline’s usual call recording procedures. Importantly, it should be distinguished whether the call was about “suicidal thoughts” or “suicide attempt”. “Suicidal thoughts” is the category that applies to all suicide calls where the caller does not act on their thoughts, so can include suicidal ideation and intent. “Suicide attempt” applies to calls where the caller makes an attempt on their life or this action is so imminent that the call-taking volunteer phones for help on their behalf.

1. Call description

The call-taking volunteer should take care to only record factual information about the call they have taken, and not include any identifiable information. In the description of the call, they should note whether the caller was experiencing any of the following: suicidal ideation, suicide plan, suicidal intent, imminent suicidal intent, and/or suicide attempt. The volunteer should also record whether or not the emergency services were called, and whether the caller consented to this.

1. Support and volunteer welfare

   1. Internal Nightline support

[This is where Nightlines would include details of internal support provisions for their service.]

Suggestions of details that should be included are:

• Who should be contacted for extra support when taking a suicide call (i.e. Coordinator(s), Welfare Officer) and what responsibilities they have in supporting with the call
• Whether the call-taking volunteer can pass the call on to another volunteer or committee member
• What debrief provisions there are for all volunteers involved in the call
• Whether the shift can be ended early after a suicide call
• Whether volunteers are encouraged to take a break from doing shifts after taking a suicide call

• What support will be offered the morning/day/week after

  1. External support

[This is where Nightlines would include details of external support provisions for their service.]

Suggestions of details that should be included are:

• Whether any stakeholders need to be contacted and informed about suicide calls
• Whether there are any external support provisions available to volunteers who have taken a suicide call, e.g. emergency counselling, chat with university welfare support

Appendix A: Example phrases

[You might find this useful for putting up in the office as a supplement to your procedure, or adding some select phrases to your procedure documentation. You may wish to make this shorter for ease of reference by eliminating some options, but a long list of options is included here]

Clarifying if a caller is feeling suicidal:

• “(Do you mind me asking,) are you feeling suicidal?”
• “Can I ask if you’re feeling suicidal?”
• “Have you ever thought of harming yourself?”
• “Are you planning to take your own life?”
• “You mentioned [insert phrases], have you been having suicidal thoughts?”
• “Have you ever had thoughts of ending your life?” - “Are you feeling suicidal now?”
• “When you say [x], do you mean that you’ve been having suicidal thoughts?”
• “Have you been thinking about ending your life?”
• “Sometimes when people feel [x], they may consider suicide. Is this something you have thought about?”
• “Do you mind me asking if you have taken any steps towards suicide this evening? It doesn’t make a difference to me being here to listen, however we are able to offer a couple of options if you’d like.”

Assessing level of planning:

• “How strong do you find these thoughts?”
• “Have you thought about how you might end your life?”
• “Have you made any plans towards suicide?”
• “Have you taken any steps or made any plans towards this?”
• “Have you taken any suicidal action?”
• “When are you thinking of ending your life?”
• “Have you thought about when or how you would take your life?”
• “When did you begin considering suicide as an option?”
• “How did you come to this decision?”
• “How do you feel about your plan?”
• “Have you ever felt suicidal before?”
• “Have you ever made a suicide attempt before?”
• “Have you felt like this before?”
• “What are your plans beyond this conversation?”
• “Do you have an intention/plan to act on your thoughts of suicide?”

Establishing connection and empathy:

• “You are not alone in this, I’m here with you.”
• “I may not be able to understand exactly how you feel, but I care about you and want to help.”
• “It can be really difficult to talk about this, I’m glad you’ve reached out.”
• “How can I best support you right now?”
• “These feelings don’t last forever, I’m here for you.”
• “How do you find talking about this makes you feel?”
• “How does it feel to be speaking [about this / to me] right now?”
• “Can I ask what made you decide to talk about these feelings tonight?”

Exploring positives:

• “You mentioned [something good here], would you like to tell me a bit more about that?”
• “How would you feel if you didn’t end your life (at X time)?”
• “Is there anyone you think could support you as you go through this difficult time?”
• “Where do you see yourself in five years?”
• “Is there any part of you that doesn’t want to die?”
• “Would you say that you want to die or is it that you want the problems you’re experiencing to stop?”
• “Would you still want to die if your circumstances changed?”
• “When you’re feeling just a little more optimistic, what thoughts about the future might you be having?”

Engaging with the concept of death:

• “What do you think dying will be like?”
• “How do you feel about (the idea of) dying?”
• “What do you think it will be like to be dead?”
• “What does death mean to you?”
• “What’s the worst thing you’re thinking right now?”
• “What do you think happens next?”

Exploring coping mechanisms:

• “What has made you feel better in the past?”
• “What’s kept you going in the past when you’ve had these thoughts?”
• “How have you coped with this situation up to now?”
• “Is there anything that helps relieve the [way/pain] you’re feeling?”
• “Is there anything you could do to distract yourself right now?”
• “What things could help you with these thoughts?”
• “Are there times you don’t feel this way?”
• “Is there anything you think might help right now?”
• “What would you like to happen?”

Offering referral:

• “I’m glad you called us today, but I’m aware I don’t have the specialised knowledge that I think could be useful for you. I know of some services that could be helpful… would you be interested in me sharing these with you? I am of course happy to stay on the phone with you for as long as you’d like.”
• “I care about your safety even if you think nobody else does, and I really recommend that you speak to a specialised service about how you have been feeling.”
• “We have some information about specialised services that can help explore what you’re feeling, and I really encourage you to talk to them. I have their details right here if you want them, but I’m not forcing you to go anywhere. I’m here for you for as long as you want.”
• “We have some information available about other services that may be able to help you, would you be interested in this? However, I’d like to stress that I’m happy to talk to you for as long as you want.”

Offering help:

• “Would you like me to call [an ambulance / emergency services]?”
• “If at any point you would like me to call for emergency services, just let me know.”
• “If at any point you decide that you would like an ambulance, I am able to call one for you. If you do not want this, we can continue talking for as long as you’d like.”
• “If you do take any action, would you like me to call an ambulance?”
• “Nightline can’t trace your call, so I need to know where you are if you want me to get help.”
• “Can I ask you for some details so that I can inform the emergency services and get help if you need it?”
• “You have told me that you have taken action towards ending your own life. If you disclose your location at any point during this call, then I can and will ring an ambulance for you. If you do not disclose your location, then I will not be able to ring an ambulance. Would you like to tell me where you are so that I can call for help?”
• “It is your choice whether you want an ambulance to be called, and I am not going to try and influence that. However, if at any point you change your mind about wanting to die, tell me your location and I can ring an ambulance for you. In the meantime, I’m still here to listen for as long as you need.”
• “Would you like me to take down your details in case you change your mind?”
• “If you tell me where you are, it is Nightline’s policy to call an ambulance on your behalf. It is completely up to you whether you wish to share your location with me so I can call for help.”
• “It’s okay if you don’t want me to call anyone else and I’m not going to pressure you into it, but if you do change your mind, please feel free to say at any time.”

Responding to “Do you think I should kill myself?”:

• “For what it’s worth, Nightline wishes nobody would kill themselves, but ultimately it’s your decision.”
• “[X] Nightline wishes none of their callers would take their own life but ultimately it is your decision, and I will be here for you no matter what.”

Practical suggestions for staying safe:

• “You’ve told me that you don’t want to die, but [the pills are right there in front of you]. Are you able to [get rid of them] to keep yourself safe?”

Appendix B: Continuum of Suicide - triangle

The model below was created by Professor Andrew Reeves of the Charlie Waller Trust to illustrate the varying states of suicidal ideation and intent. Please do not use it without acknowledgement.

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