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Systematic review of research into frequent callers to crisis helplines

Summary We conducted a systematic review of research into callers making multiple calls to crisis helplines. Two databases were searched, identifying 561 articles from 1960 until 2012, of which 63 were relevant. Twenty-one articles from 19 separate studies presented empirical data about callers making multiple calls to crisis helplines. Of the 19 studies, three were intervention studies, five were surveys of callers and 11 were call record audits. Most studies were conducted in the USA and defined frequent callers as people making two or more calls. Frequent callers were more likely to be male and unmarried compared to other callers. There were no reported differences between frequent callers and other callers with regard to age, mental health conditions or suicidality. Three studies tested interventions designed to better manage frequent callers. These studies, even though small, reported reductions in the number of calls made by frequent callers. Suggested techniques for responding to frequent callers included: limiting the number and duration of calls allowed, assigning a specific counsellor, implementing face to face contact, the service initiating contact with the caller instead of waiting for callers to contact the service, providing short term anxiety and depression treatment programmes by telephone, and creating a specific management plan for each frequent caller. Future work requires robust study design methods using larger sample sizes and validated measurements.


INTRODUCTION
Crisis helplines for emotional wellbeing have existed since the 1950s, 1 each with their own purpose and target group. [2][3][4] Most were established to provide timely assistance to people who were experiencing a crisis of suicidality or depression. 5 Crisis helplines have varied in the service model provided, from a non-directive, listening approach to a more directive approach. 2,4,6,7 Callers to crisis helplines typically remain anonymous, call any time of the day, and speak to trained personnel who assist them to manage their crisis. 2, 5 8 Support provided is usually not of an ongoing nature. 2 A mix of lay and professional personnel operate crisis helplines, some on a paid basis and some as volunteers.
Research suggests that people who make multiple calls to crisis helplines may be using services inappropriately. 9,10 These callers are commonly known as frequent, 11 chronic, 10 multiple or repeat callers. 12 In this paper we refer to them as frequent callers. The first study of frequent callers to crisis helplines for emotional wellbeing was published in 1965 and described them as callers who took up a lot of time with complex physical and mental health issues. 13 Crisis helplines struggle to know how to best respond to callers as they challenge the traditional crisis model of care with their contacts. 6,8,9,12,14 Frequent callers seek help on a regular basis from crisis helplines and do not always appear to have an immediate crisis. 10,12 They are also seen to take up time which prevents other crisis calls from being taken. 8,11 Crisis helplines have begun to consider different ways to respond to frequent callers, including limiting their access. 10,11 However, concern exists over whether limiting their access may trigger a further crisis. 9 Currently, crisis helplines manage this subgroup of callers in an ad hoc manner. There is a need for an evidence informed approach. This paper presents the first systematic review of the published literature about frequent callers to crisis helplines. The aims of the systematic review were to: • describe frequent callers, in terms of their socio-demographic and clinical characteristics, the nature and frequency of their calls, their use of other services and treatments, and the outcomes of their contact; • discuss the impact that frequent callers have on crisis helplines; and, • identify potential interventions designed to respond to the needs of frequent callers. year, study aim, crisis helpline name and location, frequent callers definition, sample selection and size, time period and follow-up, data collection methods, variables measured, interventions, results, limitations, and conclusion. Data for each of these variables were directly taken from each article, categorised under the aims of this review and summarised in the tables. The ratio between calls and callers and the 95% confidence interval was calculated using STATA 12 15 for the studies that provided sufficient information of the caller population. These results were discussed with JG, JP and BB. This paper provides a synthesis of these findings.

RESULTS
A total of 561 articles were identified through the database search and from within text references, after duplicate records were removed. Four hundred and ninety-eight articles were excluded after reading the title and abstracts as they did not have crisis helplines as their primary focus. Of the 63 full text articles reviewed, an additional 29 articles were excluded as they did not relate to callers making multiple calls. Thirty-four articles discussed callers who made multiple calls; however on further review only 21 presented empirical data, the remaining articles comprised opinion pieces and brief case studies ( Figure 1). The review synthesises the findings of the 21 articles deemed to meet the inclusion criteria; a summary of these studies can be found in Table's 1 -3. The 21 articles represented 19 separate studies as Gould et al. 16 and Kalafat et al. 17 reported on an evaluation of crisis helpline outcomes at eight sites in the United States; and Farberow et al. 18 and Litman et al. 13 presented findings on a study of frequent callers to a Los Angeles crisis helpline. In the 21 articles included in this review, callers who made multiple calls to crisis helplines were referred to as frequent, chronic or repeat callers. These callers are referred to as frequent callers in this review.
A range of interview techniques were used in the studies that surveyed callers, with most completing one-off surveys. [22][23][24][25] Nearly all of the survey studies defined frequent callers as making more than one call. 16,17,22,24,25 Only the studies by Apsler 22 and Coveney et al. 24 surveyed more than 1,000 callers. All studies analysed a sub-sample of callers to crisis helplines. The studies by Apsler, 22 Burgess et al. 23 and Coveney et al. 24 compared frequent callers with other callers.
The majority of the call record audit studies were completed before 1980 in North America. 13,18,27,29,30,32,33,35 Only the studies by Ingram et al. 28

<TABLE 3>
Of all the studies, nine defined frequent callers as callers who made more than one call to a crisis helpline. 13, 16-18, 22, 24, 25, 28, 31, 33, 34 Other studies defined frequent callers as callers who made a specific number of calls over a period of time. These definitions ranged from three calls over one month, 23 10 calls over one, 20 six 26 or eight 30 months or 19 calls over two years. 27 The study by Johnson and Barry 29 discussed the need for a definition of frequent callers to include not only the number of calls but also the pattern of calls and follow-up policy of the crisis helpline. Their definition separated callers into six types of calling patterns based on number of calls made, the time period over which the calls occurred and whether each call was related to the same problem or multiple problems. 29 There were four studies that did not provide a specific definition of frequent callers but referred to them as a subgroup of callers who made multiple calls. 19, 21,32,35 Ten of the studies reported on a representative sample of all callers to crisis helplines. 13, 22-25, 28-31, 33 Table 4 presents for these studies the number of calls made, the number of individual callers, the number of callers making two or more calls and 10 or more calls, and the ratio between callers and calls per month. Together these studies reported on over 520,000 calls to ten separate crisis helplines. An example of the information presented in this table can be explained through the study by Lester. 30 Over one year this crisis helpline received 3,910 calls from 2,128 individuals (callers). All of the calls received in the year of follow-up were analysed in the study. Of the 3,910 calls, 90% of calls were by people who called two or more times, and 17% of calls were made by people who called ten or more times. Of the 2,128 separate callers, 82% called two or more times, and 1% called ten or more times. The ratio between callers and calls was calculated to be one caller to 1.20 calls (95% CI 1.14 -1.26).
The ratio between callers and calls in all of the studies was more than one call per caller.
In the 2006 study by Burgess et al. 23 completed in Australia, the ratio between callers and calls was one caller to 4.14 calls (95% CI 3.90 -4.39) for one month of follow-up.
Due to the wide variation in the methods, sample size and follow-up time period the ratio calculated for these studies cannot be compared. The call ratio could not be calculated for three of the studies as insufficient information of the caller population was provided. 22,24,28

<TABLE 4>
The different study designs, sampling strategies, definitions of frequent callers and methods made it difficult to combine the data or to undertake a formal meta-analysis of the intervention studies. However, the studies addressed similar issues relating to frequent callers allowing the findings synthesised below to be presented around common themes.

FREQUENT CALLERS' CHARACTERISTICS
Seven studies reported on the demographic characteristics of frequent callers. 22 Frequent callers contacted crisis helplines because they were seeking social support, 23,24,26,34 had mental health concerns, 24,28 and/or experienced a physical illness. 23 Mental health concerns were identified in three studies as the main reason for frequent callers contact. 24,26,28 However, whether these issues were more commonly experienced by frequent callers compared to other callers remains unclear. 22,24,30 In the five studies reporting on suicidal behaviour, at least half of frequent callers were identified to have a history of suicidal behaviour. 25-27, 30, 32 Frequent callers were more likely to have a history of suicidal behaviour than other callers. 17, 25-27, 30, 32 The severity of suicidal behaviour was higher for frequent callers compared to other callers in the studies by Greer 27 and Sawyer and Jameton. 32 Frequent callers experienced mental health issues that included depression, 17, 26 panic attacks, 23 confusion and overall distress, 17 and personality disorder problems. 18 Frequent callers were also identified in some studies as having a diagnoses of schizophrenia, 32 possible psychosis, 18 and social and simple phobias. 23 These studies did not use validated measurements. The use of alcohol and drugs by frequent callers was unknown as only the studies by Greer 27 and Sawyer and Jameton 32 found an association but were completed in small samples in the 1970s. The study by Burgess et al. 23 found frequent callers in Australia in 2006 were less likely to drink alcohol than other callers.
Using validated measurements, frequent callers in the study by Burgess et al. 23 had significantly higher anxiety scores on the Goldberg Anxiety Scale (GAS). However, there was no difference between frequent and other callers on the Goldberg Depression Scale (GDS). 23 Using the Profile of Mood States (POMS) scale, the study by Kalafat et al. 17 found frequent callers experienced hopelessness and were more anxious compared to other callers. The study by Mishara and Daigle 31 found frequent callers were less likely to have decreases in depression scores over time.
Four studies found that frequent callers were seeking help from several mental health professionals, with many already in formal treatment. 18,23,25,32 Up to 85% of frequent callers in the study by Murphy et al. 25 had a history of previous psychiatric treatment.
However, in the study by Sawyer and Jameton 32 there were some frequent callers (11%) who only used crisis helplines for support and reported no contact with other mental health services.
The duration of calls made by frequent callers were found in the studies by Greer 27 and Ingram et al. 28 to be shorter than the calls made by other callers. Contracts for follow-up and referrals were often arranged by crisis helplines to ensure further support for frequent callers. 27,31 It is unknown whether these contracts were more likely to be prepared with frequent callers compared to other callers. However, it has been estimated that between 16 -50% of frequent callers follow through with the advice provided by the crisis helpline. 16,25 Reductions in the level of urgency during crisis calls were less likely to be seen with frequent callers compared to other callers in the study by Mishara et al. 31 The study by Apsler 22 explicitly made the assumption that frequent callers found crisis helplines helpful because they continued to call. This assumption was supported by the findings of the study by Coveney et al. 24 that measured frequent caller's overall perception of helpfulness. This study found that frequent callers gave an average score of eight out of ten for helpfulness. 24

IMPACT OF FREQUENT CALLERS ON CRISIS HELPLINES
The studies in this review did not formally measure the impact of frequent callers on crisis helplines. However, some studies commented on the frequency, nature and appropriateness of calls made by frequent callers as being problematic for crisis helplines. 13,18,19,27,28,30,32,34,35 Frequent callers were described as time wasters who took up a significant amount of time for crisis helplines, limiting the amount of time available for other callers. 13,17,18,29,33,34 They were seen to contact crisis helplines continuously with recurring problems without appearing to make discernable positive changes over time. 18,27,28,35 In responding to frequent callers on an ongoing basis, crisis helpline workers were described as developing feelings of frustration and resentment 27 and experiencing an overall emotional drain. 32 These feelings have been associated with crisis helpline workers thinking of themselves as ineffective counsellors. 27,28 One study also described frequent callers being treated differently to other callers as a result of these feelings. 27

INTERVENTIONS FOR MANAGING FREQUENT CALLERS
Three intervention studies were identified in the review (described in Table 1). The study by Barmann 19 tested different responses to frequent callers. Fourteen frequent callers were identified from call records and seven were randomly assigned to the intervention. A counsellor was assigned to each caller with a limit on the amount of calling time they were permitted each week. If a crisis was experienced, callers were allowed to call at any time; however they were reminded of these restrictions. The mean number of calls for the intervention group reduced from 24 to 11 calls over a nine week period compared to 24 to 21 calls in the control group. 19 The study by Hall and Schlosar 21 limited frequent callers to a maximum of two calls per day for 15 minutes per call with no contact allowed between midnight and 8:00am.
Changes in suicide risk before and after the intervention were used to measure improvement, with minor reductions in frequent callers' suicidal behaviour observed.
The number of hours spent on the phone by frequent callers reduced from 172 hours before the intervention to 82 hours five months post the intervention. 21 The study by Brunet et al. 20 implemented a 6-month written correspondence intervention with 22 frequent callers. Callers were assigned a counsellor with whom they started a writing correspondence. No limitations were made on the number of calls they could make to the crisis helpline. Only 23% (n=5) of the frequent callers, all female, completed the trial. 20 Before the intervention the five frequent callers took up a mean total of 541 minutes over a three-month period compared to three months after the intervention where the mean total was 261 minutes. 20 Based on the findings in the survey and audit studies, they suggested techniques for responding to frequent callers that included: using a directive and rigid management technique, 32, 33 discouraging the caller from contacting the service, 30 limiting the call duration allowed, 30,32 implementing face to face contact, 32 the service initiating contact with the caller instead of waiting for callers to contact the service, 32 providing short term anxiety and depression treatment programs over the phone, 23 and creating a specific management plan for each frequent caller. 30

DISCUSSION
This is the first systematic review of the research investigating the nature of callers making multiple calls to crisis help lines and the challenges they present. The review found that the research into frequent callers to crisis helplines is limited and of highly variable quality. Frequent callers were more likely to be male and unmarried. There were no reported differences between frequent callers and other callers with regards to mean age, employment, ethnicity, mental health conditions and suicidality. No study reported data on the impact of frequent callers on crisis helpline staff. Responses to frequent callers could include limiting the number and duration of calls allowed, and/or assigning a specific counsellor. These responses have been shown in the three intervention studies to reduce the number of calls made by frequent callers.
The strength of this review is that we have conducted an extensive search of the articles conducted in this area and have synthesised their findings according to themes. We have documented the research techniques utilised by studies investigating frequent callers in crisis helplines and provided an in-depth analysis of frequent caller characteristics. This review also provides a synthesis of the interventions for frequent callers and identifies areas for further research. The limitations of this review are that it can only be as strong as the studies that underpin it and as we have noted, there are various definitional and methodological limitations with the studies included in the review. This review includes studies from over 40 years ago when telephone access was limited, and therefore the characteristics of frequent callers may have since changed.
A range of terms were used in the studies to refer to a group of callers who made multiple calls to crisis helplines. Most of these terms simply referred to callers who made more than one call. However, throughout the studies an underlying assumption emerged that crisis helplines are more concerned about the callers who may be using the service inappropriately rather than just callers who made multiple calls. A definition of calling more than once appeared to be used as a convenience definition to try and identify those callers that may be inappropriately using the service. Crisis helplines are interested in understanding those who may call inappropriately so that they can respond to them more effectively.
In order to understand the callers who may be calling inappropriately, an improved definition of frequent callers is needed. Such a definition cannot simply be more than one call to crisis helplines, as one would expect people to commonly make a follow-up call after their initial crisis call. As suggested by Johnson and Barry 29 the definition needs to extend beyond the number of calls made to consider the length, nature, appropriateness, and the period of time over which the calls are made. Having a definition that considers more than the number of calls made, will assist crisis helplines in identifying the frequent callers in their caller population who may require a different response.
For crisis helplines to effectively respond to frequent callers they also need to understand the impact that frequent callers have on crisis helpline staff and how they differ from other callers on personal characteristics and mental health. In order to achieve this future research needs to include representative samples and validated measures. Crisis helplines could also explore a response that includes collaboration with external mental health professionals. This could be through referrals to mental health professionals or running telephone based cognitive behavioural therapy programs.
In conclusion, most callers to crisis helplines make more than one call. Future studies need a definition of frequent callers that considers more than the number of calls made.
To understand how frequent callers impact on crisis helplines and differ from other callers, robust study design methods using larger sample sizes and validated measurements are required. Once these differences are understood, crisis helplines will be able to appropriately respond to frequent callers.