OPINION | Crisis Hotline Counselors Want Better Training

Earlier this month, pediatrician and investigative journalist Eli Cahan reported that turnover within a crisis counselor’s first three months of service can be as high as 60%. Feeling under-trained to answer challenging calls emerged as a central theme in why many counselors resign.

Cahan spoke with several counselors who served at a for-profit crisis center in the mostly non-profit 988 network — one owned by Elevance Health, the $170 billion healthcare giant formerly known as Anthem. One counselor came to the job there with 25 years of robust and diverse experience in front-line behavioral health work, but felt under-trained and under-supported as a 988 counselor, and left after months of unabating nightmares and panic attacks. Another, who joined without previous behavioral health experience, said the on-the-job training lasted only two weeks and mainly consisted of 45-minute modules that felt like “intro courses, like me reading something online.”

Last month, colleague Greta Opzt and I released the 2023 CrisisCrowd study, a first-ever national survey of crisis hotline counselors. Counselors reflected on their experiences serving on nearly 10% of the country’s suicide crisis lines, including many of the largest. Many cited inadequate training as a top obstacle to feeling the work was psychologically sustainable. One said the brevity of their training felt “downright dangerous,” and another said the training suggested “you didn’t need to know ‘about’ a particular struggle” like anxiety, depression, child abuse, or eating disorders. Cahan’s reporting found, similarly, that new counselors can feel overwhelmed by interactions that run “the gamut of mental illness,” involve struggles with hallucinations and delusions, or involve desires or plans to kill someone.

Many counselors in the CrisisCrowd study got no exposure to what either end of a crisis call might actually sound like before being on one themselves, with someone else’s life in their hands. And ongoing learning, whether incidental or systematic, was also often limited. Counselors working remotely are especially limited in receiving exposure to how experienced colleagues sound on their own crisis calls, because they no longer sit alongside them in a call center. When asked how frequently any kind of formalized continuing education is offered at their crisis center, one counselor said, “I was there for three years and not once.” About one in three said ongoing learning was offered to them rarely or never.

How decentralized the 988 system is — states and individual crisis centers are largely on their own to develop counselor training materials from scratch — could end up being a strength in the effort to fix gaps in training. Some states and centers have developed robust and comprehensive new-counselor training, and offer ongoing learning as frequently as every week, which many counselors rate as excellent, suggesting that all it might take to shore up the system nationwide is to get existing training materials circulating more freely across the country. Simply put, let’s share what we’ve already got.

Among the areas in which they would like better training, many counselors in the CrisisCrowd study pointed to abusive calls, especially those where someone calls the hotline for sexual gratification. Calls of this kind can be the disturbing hallmark of some counselors’ experience serving on the line. One counselor said they received “no training on how to deal with prank calls or sex calls, which we get on a nightly basis; sometimes multiple times a night,” and another shared: “I don’t even remember this being touched on in the training.” Some feel caught off guard by these calls if there is no tracking of caller phone numbers responsible for continual abuse. Some feel they are expected to stay on the line for as long as an abusive caller wants. One told me they are expected to hang up only after the caller has ignored multiple warnings to stop sexually abusing them and called it “appalling” to expect counselors to “endure abuse and sexual harassment before we are ‘allowed’ to take any type of action.” 

Reflecting on these themes in 2016, Patia Braithwaite, now a senior staff editor at The New York Times, described, in an article for Vice, a debrief “with the male supervisor who’d reprimanded me for prematurely ending an obscene phone call” after her first, and last, shift as a volunteer crisis counselor. At least one-quarter of the calls she answered were obscene. 

Training protocols we might mistakenly assume are validated by research sometimes have their origins elsewhere. The Third Edition of Crisis Intervention and Counseling by Telephone and the Internet, published in 2012, includes a contributor’s note on one-time and occasional obscene callers, arguing that a “counselor must clearly keep in mind the concept that she is and must be a transitional, social object for this type of caller and recognize that, in order to be a pipeline for this individual to a resource in the community that is more appropriate for his treatment, she will need to accept his frustration, irritation, and obscene language.” The field has evolved, but evidently not as uniformly as it should, as some counselors still say they are being trained to endure abuse. Crisis hotline work is, in many ways, more a received tradition than an evidence-based field. This makes it essential to examine where training protocols come from and whether they respect the humanity of the counselor and serve a valid purpose toward suicide prevention.

Many 988 centers do train counselors to hang up when they are being sexually abused. One told me they had just rolled out an in-house refresher training on how to end an abusive call. This center regularly uses recorded calls, including ‘staged’ calls between supervision staff, as group discussion material for counselors. This learning format — listening to experienced counselors in action, as opposed to reading slides — is what our study found counselors value most.

When I asked the center whether they have shared this kind of ongoing learning material nationally, they answered that they have never before been asked to.

We should foster an exchange of information by developing simple, cost-free ways for centers to share information. Any institution willing to step up and serve as a national clearinghouse for existing crisis counselor training materials would fill a vital gap and help counselors everywhere to do better work, more sustainably, and with considerably less strain and hardship. The institution stepping up need not be one that already works in the 988 ecosystem. Any school of social work or clinical counseling program that already hosts continuing education material for licensed professionals might be well-equipped to step in and help. They could host existing crisis counselor learning modules at no cost to crisis centers wishing to access them and potentially offer these same modules for continuing education credit to clinicians interested in how their patients will be served if they call 988.

My other ask is that institutions supporting 988 open the door to regular input from front-line counselors. Crisis counselors have no professional association or other body directly advocating for them. Setting up a dedicated email address for confidential input, convening a virtual town hall specifically for counselors, inviting counselors to speak at upcoming conferences, or forming a standing counselor-only advisory panel could begin to transform how included counselors feel in the development of their own field. Through the CrisisCrowd study, counselors shared a range of creative ideas for improving the system, from creating hybrid trainer-counselor roles within crisis centers to rolling up local referral resources nationally for the benefit of national call centers. There is so much more where those brilliant ideas came from. Engaging directly with counselors at the front lines will be motivating, eye-opening, and profoundly constructive for institutions that take it on.