Both general principles of crisis intervention and specific responses to individuals in crisis are grounded in a deep understanding of an individual’s experience of and response to crises. The characteristics of crisis and suicidal states have implications for effective intervention. Crises are temporary states of upset and disorganization brought on by an inability to cope with a particular situation using customary methods of problem solving (1). Crises are time limited and present an opportunity for positive or negative outcomes, depending on the application of effective or maladaptive coping, respectively; are characterized by increases in anxiety, which produce cognitive constriction and attenuate problem-solving ability; and are a result of the failure of usual coping mechanisms and heightened vigilance. Individuals are more open to intervention during a crisis (2). These phenomena have several implications. Interventions must be readily accessible to promote adaptive responses and to attenuate maladaptive outcomes. Because of the individual’s reduction in defenses and heightened vigilance during crises, a relatively brief or less extensive intervention may have a significant impact. A collaborative intervention that promotes active problem solving and mobilization of internal and external resources is necessary to take advantage of the opportunity for growth presented by crises (3). In acute crises, the intervention may be less collaborative and more directive, depending on the client’s level of functioning.

It was learned during World War II (4), and recently reiterated (5), that although crisis states mimic major mental disorders, diagnoses of psychopathology are usually not warranted in crises. Thus, in a review of the first American Psychiatric Association Task Force on Psychiatric Emergency Care, Gerson and Bassuk (6) described the goals as rapid evaluation, containment, and referral, with a focus on the patient’s and community’s adaptive resources and competence, and minimization of subtle diagnostic considerations.

Finally, crisis interventions are open ended and continue until there is at least partial resolution to the crisis. That is, the caller must regain emotional stability, marked by a decrease in agitation, anxiety, or other debilitating emotions; or, if the caller had been immobilized or withdrawn, he or she has rallied somewhat. Callers should also evidence increased cognitive grasp, marked by a decreased sense of confusion or feeling overwhelmed by the situation, and awareness of more effective alternatives for coping with their concerns.

Several characteristics of suicidal states have implications for intervention. First, suicide is less a desire for death than an attempt to solve a problem or to escape a painful state that is experienced as intolerable, inescapable, and interminable (7). Moreover, the feasibility of suicide as a solution usually occurs to a person in crisis, which, again, is characterized by cognitive constriction or “tunnel thinking.” As Shneidman (8) noted, the four-letter word in suicide is “only.” The intervention must then focus on what problem is experienced as so
intolerable or unsolvable as to prompt suicide as a solution. During a crisis call, the suicidal feeling must first be acknowledged. This sounds obvious, but it is important to emphasize that callers must be connected to through their pain and reasons for dying first, before identifying reasons for living and alternatives. Unless this connection is made, the assessment is less likely to be valid, as will subsequent alternatives and referrals.

Depending on how acute the situation is, there are three levels of response or foci in a suicide call. If an attempt is in progress, such as ingestion of pills, or the caller expresses an intent to kill himself or herself by lethal and available means within the next few moments or hours, the intervention must focus on keeping the caller engaged while initiating rescue procedures. If there is expressed suicidal intent or a report of suicidal thoughts that are difficult to control, the problem to be addressed and attenuated is the suicidal thoughts or impulse. The focus is on reducing anxiety or arousal through ongoing engagement, opening up the constricted state, and identifying both internal strategies for pain tolerance and control as well as external supports that can be immediately available. If suicide is contemplated and perhaps a plan is considered but suicide does not appear to be imminent, again, the suicidal thoughts must be acknowledged. In this case, the focus becomes the problems and feelings—in essence the reasons for dying (9)—that prompted the suicidal state. The intervention focuses on understanding the problem from the caller’s perspective and addressing reasons for living, as well as internal and external resources that can be mobilized to address the problems. Often, there are precipitating events that can be identified by inquiring what prompted the call at this time. In this regard, psychological autopsy research generally supports the association of stressful life events as precipitants for suicide (10). Table 37.1 provides an overview of these three
levels of response to suicidal callers within a generic crisis intervention framework.

In a crisis phone call the intervention is telescoped or compressed, such that the assessment of precipitants, risk factors, and warning signs is blended into the crisis interventions more often than through a formal, discrete assessment interview. For example, there is a reciprocal relationship between assessment and establishing rapport or a relationship with a caller, which is an essential component of any treatment. The better the rapport with callers, the more likely they are to share
their real concerns; the more accurately the helper identifies their concerns, the more understood and affirmed callers feel. Also, as with any clinical assessment, there must be a direct relationship between the assessment results and the interventions. So, in addition to an estimate of risk level, the assessment yields specific interventions. For example, if an identified risk factor is a specific plan, an intervention is to disable the plan. If a risk factor is mental illness, the intervention is to obtain treatment. If a warning sign is increased isolation, the plan will include the mobilization of supports.

Although crisis phone calls may occur outside of the telephone crisis service (TCS) setting, most crisis phone interventions were developed in TCSs, and therefore a brief review of the research regarding TCSs can inform recommendations for crisis intervention by phone. The need for immediately available interventions gave rise to TCSs, which are one of the oldest crisis intervention and suicide prevention resources in the United States (11) and United Kingdom (12) and are now ubiquitous sources of help worldwide. TCSs have the practical advantage of providing temporally, financially, and geographically accessible services. The goals of TCS are to prevent deleterious outcomes for callers by reducing their current crisis or suicidal states and identifying alternate coping approaches, including referrals to formal or informal community resources.

Early process evaluations of telephone counseling interventions focused on Rogerian (13) helper-offered empathy, warmth, and genuineness. These characteristics of a therapeutic relationship have received empirical support (14) and are representative of the helping approaches of many TCSs to this day. Early studies found moderate levels of these conditions (as rated on simulated calls and role plays), variations between centers, and increased levels associated with training and experience (15,16). However, the relationship between these conditions and call outcomes was not assessed.

A consensus among TCSs has evolved around a four- to six-step model for problem-solving intervention first adopted by the Los Angeles Suicide Prevention Center (17), consisting of establishing rapport, defining the problem(s) (including assessing risk for suicide), exploring affect (including reducing anxiety and other affects that attenuate problem solving), exploring callers’ coping repertoires, and developing alternatives for addressing the problem (Table 37.2

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