104 The role of volunteer organizations in suicide prevention

Contemporary suicide prevention emerged, to a large extent, as a result of groundwork conducted by volunteers. This chapter focuses on the involvement of volunteers in suicide prevention organizations throughout history and across the world, without forgetting the involvement of volunteers in suicide bereavement support. The characteristics of volunteers and volunteer organizations are presented. The question regarding the effectiveness of volunteer organizations is addressed, e.g. the available evidence regarding the positive effects of telephone crisis lines, online chat, and ‘befriending’ in rural areas are discussed. However, further research is needed given the shortage of studies. The chapter concludes with a plea for increased cooperation between volunteer and professional organizations, and integration of volunteer work in national suicide prevention policies in order to provide optimal care to the people in need.

A volunteer is a person who provides ‘an unpaid direct service [to people] to whom the volunteer is not related’ (Scott and Armson 2000, p. 700). The services are provided via ‘some kind of formal scheme’ (Scott and Armson 2000, p. 700). As such, volunteer work derives from kindness between relatives and friends, and consists of services provided to other third persons in a (semi-)structured framework.

This chapter focuses on the important role of volunteers in suicide prevention, as well as what is known about the effectiveness of volunteer organizations.

The development of contemporary organized suicide prevention is relatively due to volunteer work. The eldest records of volunteer organizations involved in suicide prevention go back to the end of the nineteenth century. A survey conducted by Farberow and Shneidman (1961) found a local German volunteer rescue organization that operated from 1893 to 1906. The survey also showed a similar organization in Budapest. In 1906, the Anti Suicide Bureau of the Salvation Army was established in London; simultaneously, the National Save-a-Life League emerged in New York, and both organizations relied on voluntary donations and some volunteer involvement.

Among the services started up in Vienna, during the first half of the twentieth century, the Lebensmüdenstelle der Ethischen Gemeinde (Ethical Community for Suicidal Persons) started in 1927 with a staff of volunteer counsellors and social workers. The organization did rather well in attracting suicidal persons from the community. In 1928, Victor Frankl initiated a youth counselling service for suicide prevention, with various professionals providing counselling in their own houses (Farberow and Shneidman 1961). However, these, as well as other promising services, were closed due to the Second World War (Dublin 1963).

After the war, a few new suicide prevention organizations emerged, including three influential organizations involving volunteers:

Currently, similar organizations such as Befrienders, International Federation of Telephonic Emergency Services (IFOTES), Lifeline, American Association of Suicidology (AAS), and The International Association of Suicide Prevention (IASP) are well-respected suicide prevention organizations, representing thousands of centres that apply high-quality standards for volunteers and care given from telephone support.

It is estimated that 100,000 volunteers worldwide are directly involved in suicide prevention (Vijayakumar and Armson 2005). In addition, volunteers are active in less developed or rural regions (e.g. African and Asian countries) with low health resources for mental health care (Ratnayeke 1996; Gulvady 2001).

Worldwide, thousands of volunteers are involved in suicide bereavement services. In fact, given that suicide-bereaved relatives have a 2–3 times elevated risk for suicidal behaviour (Qin et al. 2002), post-vention is prevention (Andriessen 2006). By far, the majority of suicide support groups are facilitated by survivors and/or by a duo of a survivor and a paid professional (Farberow 1998; Andriessen 2004).

In a suicide-prevention organization, volunteers are selected, trained, and supervised to provide services for telephone, online, or face-to-face support. They need qualities rather than qualifications (Scott and Armson 2000). Experienced volunteers are a valuable resource for training and supervising new volunteers (Mishara and Giroux 1993).

The volunteer is primarily interested in the person rather than the problem, i.e. ‘tell me who you are’ rather than ‘what is your diagnosis?’ The volunteer provides active, empathic and non-judgemental listening. The focus of the exchange is predominantly on the here and now and crisis situation, as well as the related experiences of distress, hopelessness, anger, anxiety, etc., rather than causal and distal factors. Volunteers (and paid clinicians) should inquire about suicidal ideation as a regular part of the risk assessment, and certainly become more directive in acute life-threatening situations when, for example, a caller threatens or attempts suicide during the conversation.

The work of volunteers is demanding. Suicide-prevention training, coping skills education, limiting volunteer working hours, and psychological debriefing could prevent compassion fatigue and vicarious traumatization (Kinzel and Nanson 2000).

One study of volunteers in a suicide prevention centre found that up to 50% of the volunteers have had suicidal ideation, 13% had attempted suicide, and some were bereaved by suicide (Mishara and Giroux 1993). These figures are significantly higher than in non-suicide specific crisis lines (Vijayakumar and Armson 2005). Perhaps the close experience of suicidal behaviour contributes to an openness of mind and motivation necessary for suicide-prevention volunteer work. The question remains open for further research.

Scott (1996) and Scott and Armson (2000) identified four characteristics of volunteer organizations: availability, accessibility, acceptability, and adaptability. Here, we summarize and update these characteristics.

In Western countries, volunteers complement the work of the professional sector by the type of work (befriending versus psychotherapy) and the timing, e.g. 24-hours and during weekends. Volunteers may reach people in need who are unable or reluctant to visit a professional clinician, where, otherwise, would not receive support. As such, they bridge the gap between receiving professional care or no care whatsoever. In regions with few professionals, volunteers may be the only caregivers available (Ratnayeke 1996; Marecek and Ratnayeke 2001; Gulvady 2001).

Volunteer organizations have become active throughout the world, with the ability to reach people in need via various channels, i.e. telephone, online, drop-in centres, home visits, etc. Help-seeking and mental health problems are taboo subjects in many cultures. The threshold to anonymously contact a volunteer organization might be lower than immediately stepping into a clinical setting.

Historically, some cultures are not familiar with seeking help from third persons. Scott and Armson (2000) gave an example of the role of the extended family in Africa. The more such traditional support mechanisms weaken, the more alternative support systems should be developed.

Volunteer work is often grass-rooted. It emerges as a response to local needs. Volunteer organizations may adopt formulas, procedures, and quality criteria that were developed elsewhere; still, these formats/programmes need to be evaluated against the local culture, the identified needs and resources. In addition, as society evolves, the programme should be flexible to allow for modifications when necessary. This implies that evaluation should be included from the onset of the implementation process.

Since their inception, there has been a debate on the effectiveness of suicide-prevention centres (mostly staffed by volunteers) in reducing suicide and attempted suicide. Vijayakumar and Armson (2005) listed a few ecological and time-series studies respectively, with the focus on suicide mortality. The findings of these studies conflict with other study results, as some discovered a preventive effect, whereas others did not.

Lester (1997) reviewed fourteen studies that reported suicide rates of the regions served by suicide-prevention centres. The results of the meta-analysis provided a significant preventive effect, though the effect was small. Leenaars and Lester (2004) looked at changes in suicide rates in the Canadian provinces correlated with the establishment of suicide-prevention centres over time, and found a preventive, but not significant, effect. Though the effect sizes are not impressive, the findings are encouraging. Questions that remain to be answered include the potential causal relation between the centres and suicide rates, the effectiveness on certain subgroups (rather than on the overall population), and effects on attempted suicide rates, e.g. on hospital admissions for suicide attempts.

Other important questions are related to proximal factors, such as what happens during a call to a crisis line and its short-term outcomes. That was the focus of a series of studies conducted by Mishara et al. (2007a) who silently monitored 2611 calls to 14 US suicide-prevention centres. A surprising finding was that the majority of the volunteers didn't systematically assess suicide risk. The implementation of risk-assessment guidelines seems highly necessary (Joiner et al. 2007). Furthermore, Mishara et al. (2007b) reported that empathy and respect, supportive approach, good contact and collaborative problem-solving were related to positive endings of a call. A 3-week follow-up study of 800 non-suicidal callers found decreased levels of crises and hopelessness. One-third of the callers who had received a mental health referral had complied (Kalafat et al. 2007), and a 3-week follow-up study of suicidal callers found that the levels of hopelessness and psychological pain had decreased, but the intensity of the intent did not continue to decrease after the call. The results illustrated that 43% kept feeling suicidal and 3% had made a suicide attempt, 30% called the centre again, and only 16% of those who received a mental health referral had complied with the referral (Gould et al. 2007).

This landmark study provides evidence for the potential effectiveness of suicide-prevention centres. At the same time, the necessity of thorough selection, training, and supervision of volunteers is apparent.

Barak and Bloch (2006) reported promising results regarding the perceived helpfulness of an online chat programme provided by trained volunteers. Depth and smoothness of the writing were significantly related to improved client mood at the end of the chat, which was not the case in bumping and shallow conversations. The length of the helper's and client's writing contributed to the positive effect.

Responding to alarmingly high suicide rates in rural villages in Sri Lanka, the local Befrienders branch Sumithrayo, started a controlled outreach programme in 1996 (Ratnayeke 1996; Marecek and Ratnayeke 2001). Trained volunteers made themselves available in one village by visiting the leaders, facilitating community meetings, and visiting every household. Special attention was given to families where suicides or attempted suicides had occurred as well as economic hardship or violence. Before the project, the number of suicides and attempted suicides were similar in the intervention village and the comparison village. During the next four-and-a-half-years, the number of suicides and attempted suicides dropped to zero in the intervention village, whereas the numbers remained stable in the comparison village (three suicides and ten attempts during two observation years, after which the project was expanded to this comparison village) as well as in the whole district. Though it concerns a small-scale project, the results are impressive, and show the impact of this pioneer volunteer initiative.

Given the extent of volunteer involvement in suicide prevention, the shortage of qualitative and empirical studies regarding effectiveness is striking, and research on the effects of volunteerism on volunteers is notably absent. As telecommunication and its use by volunteers in suicide prevention evolves rapidly (Krysinska and De Leo 2007), this warrants research regarding effectiveness of volunteer organizations in well-defined populations, cost-efficiency, sustainability, and psychological impact on the volunteers.

Sufficient funding would be a prerequisite to develop comprehensive long-term coordinated programmes (Wasserman 2004). This is as much true for suicide prevention, in general, as for volunteer organizations specifically. Volunteer organizations could benefit from community linkages and professional marketing by raising governmental and corporate funding.

Volunteers are available and accessible. Their actions are culture-sensitive and have low threshold for contact. Thoroughly selected, trained and supervised volunteers provide unique services to the persons in need. They develop support complementary to paid professionals; alternatively, they are the major service providers in the absence of professionals. As such, volunteer and professional organizations should join hands in a win–win situation for optimal service delivery. Moreover, the work of volunteer organizations should be integrated in national and regional suicide prevention programmes and policies, guarding quality levels and programme sustainability.