Volunteers working at suicide prevention helplines undergo high-stress situations daily and need to be able to assess matters and act quickly. Since, most of the time, they don't have any educational qualifications in psychology or psychiatry, they have to undergo rigorous training to be able to speak to callers experiencing suicidal thoughts and help them.

While the World Health Organization (WHO) says that "suicides are preventable with timely, evidence-based and often low-cost interventions", most non-governmental suicide prevention helplines in India don't run 24X7. This means people may not be able to get timely care. Moreover, the Centre-run helpline KIRAN, which claims to be operational at all hours and days, fails people seeking help. FactChecker called up KIRAN more than 40 times from seven states and 3 Union Territories, but go through to a human voice only thrice.

People facing suicidal thoughts refrain from seeking help from therapists, friends or family and find confidential services offered by crisis helplines helpful in overcoming the barrier of stigma surrounding suicide and mental health problems.

The WHO reported that a study (Gould et al., 2007) on outcomes achieved by callers of a crisis line in the USA revealed that intent to die was reduced by the end of the call. Another 2016 study (Tyson et al., 2016) in the UK found a crisis line was effective in reducing suicidal and self-harm ideation with callers.

FactChecker spoke to 10 helplines to understand their methods of recruitment and training. All of them said they bring in counsellors/psychologists and psychiatrists to train volunteers.

While KIRAN, Sahai and Vandrevala Foundation helplines practice a two-week training period, other helplines like iCall, Aasra, Samaritans Mumbai, Parivarthan, Roshni, SNEHA (Society for Nutrition, Education and Health Action) and Yenepoya Medical College helpline said their training period ranges from a month to about a year.

"Most of our students are already sensitised and trained in courses that deal with different psychological issues but we make sure to select a volunteer only after six months of training," said Dr Anil Kakunje, Head of Department of Psychiatry, Yenepoya Medical College, Yenepoya deemed to be University, Mangalore.

Most volunteers are trained in empathetic and non-judgemental listening skills, building a rapport with the caller and assessing suicide risk. "It's very different from a general therapist counselling setting. For marital counselling, counsellors know that their clients will speak of marital issues, but here volunteers have no clue what their next call will be," said Dr Teena Augustine, head of training at Vandrevala Foundation.

Here are the training methods used to prepare them to help callers.

Gatekeeper's Training

Most organisations we spoke to say they focus on Gatekeepers training. It is an educational programme for laypersons to help them understand the warning signs of a suicide crisis and learn how to respond.

Vandrevala Foundation, which has a rigorous training programme, uses this method to train its volunteers. "People often are confused if they need psychological first aid or mental health first-aid. If a person says a sleep issue is affecting their work, it's a mental health first-aid since the person is trying to identify and understand if they have a problem that requires a therapist. We help them understand this," explained Dr Augustine.

She highlighted that psychological first aid is given after someone has experienced a tragic incident. "For instance, when a person loses their job, the hopelessness may lead to suicidal ideation. The reason they ring the helpline is to process their trauma," she said.

The foundation also puts its volunteers through rigorous assignments, including responding to crisis messages, and trains them in micro skills. "Crisis texting is completely new to our culture. We train them to read between nomenclatures, syntax, etc," said Dr Arun John, Chief Excutive Officer of the Vandrevala Foundation.

The experts highlighted that a gatekeeper is not just someone working at these helplines, but anybody who believes that suicides can be prevented and is willing to give time and energy for this cause. "Anybody can act as gatekeeper if he or she is primed and oriented. There is always a limit to what a helpline can do, so educating the community can help too. Considering the rising suicides in the country, we should try to combine both helplines and communities trained in gatekeepers' method," said Dr Vinay Kumar, Vice President, Indian Psychiatric Society.

Suicide Ideation Scale

The Suicide Ideation Scale (SIS) is a 10-item scale designed to assess the severity or intensity of suicidal ideation. Each item is scored from 1 (Never or none of the time) to 5 (Always or a great many times), according to how the caller felt or behaved during the past year.

Dr Janiser Javed, a consultant psychiatrist based in Bhopal and former volunteer at a helpline in a medical college, said volunteers are trained to use the Suicidal Ideation Scale, a clinical tool used to assess a person's risk of ending his/her life. "This scale includes questions about the intensity of certain thoughts and behaviours of a person in the past year. The callers are asked to describe the worst point in their life while answering the questions. This helps us assess the risk," said Dr Javed.

The volunteers are also trained to assess if the caller falls under active or passive suicidal ideation. "If a person says he is planning to commit suicide, we will immediately ask him if he has a plan, how he plans to do it, etc. If he says he has a plan and describes it to us, we try to counsel him against it. We also request him to pass the phone to a family member so that they are with him to comfort him," explained Dr Javed. If they don't have any family member or friend around, the volunteers contact the nearest mental health institution or finally resort to calling the police.

Most helplines said their main purpose is to buy time and listen to the caller without any prejudice. Their basic training includes improving active listening skills, understanding grief and bereavement, identifying a person who is suicidal and who is not. Only 5% of callers are high-risk, said Johnson Thomas, director, Aasra, a crisis intervention centre. "Most callers just want to confide in us and not all callers are suicidal," said Thomas.

Moreover, SIS helps volunteers measure the risk and accordingly help the caller. "There are callers who are suicidal and those who are ideating suicide. There are vulnerable moments where we think of ending our lives, but it's just a passing thought," said Dr Augustine. "When a passing thought is consistent over a period, it leads to a fixed plan. We measure that and help the client deal with it."

ASIST Training

ASIST (Applied Suicide Interventions Skills Training) programme helps volunteers recognise when someone may have thoughts of suicide and work with them to create a plan to support their immediate safety. It's a two-day interactive programme designed to teach how to intervene and prevent the risk of suicidal thoughts from becoming suicidal behaviours.

It's a form of suicide first-aid where participants learn to use a suicide intervention model to identify persons with thoughts of suicide, seek a shared understanding of reasons for dying and living, develop a safe plan based upon a review of risk.

"Our training is intense. About 60 hours of training is spread over four weekends, which includes mostly experiential and role play," said Sunitha Ramachandran, Assistant Director, Capacity Building, Samaritans Mumbai.

Refresher Training

Most helplines also have refresher training based on the cases they come across and learnings they bring back from the field. "These trainings are a mix of theories and practical experiences so counsellors feel comfortable catering to the caller's emotional needs," said Madhuri Tambe, Programme Associate, iCALL, a psychosocial helpline run by the Tata Institute of Social Sciences.

While most helplines deal with all issues, SNEHA, a helpline that operates from Dharavi in Mumbai, exclusively deals with gender-based violence. "We conduct workshops which help build capacity of counsellors on issues related to gender-based violence, understanding the laws and rights of women. It's mostly a word-of-mouth contract to not end life," Priyanka Arisham, communications coordinator at SNEHA, told FactChecker.

'Helplines Can't Alone Prevent Suicides'

While suicide prevention helplines are needed, they only act as an initial step in the process of preventing suicides. A concerted effort from the government and other stakeholders is necessary, say doctors.

They highlighted that preventing a crisis is most important and that would require making efforts and investing resources in addressing the structural drivers of suicides, such as domestic violence, alcohol misuse, financial difficulties, unemployment, access to mental health treatment, etc.

"Suicide prevention helplines are useful and required. They have to be seen as one part of a broader co-ordinated inter-sectoral suicide prevention strategy. On their own, suicide prevention helplines are less effective," said Dr Soumitra Pathare, Director, Mental Health Law and Policy, Indian Law Society, Pune.