[00:00:00] Jesse Mangan: Previously on Committable...
[00:00:03] Cassidy Wilson: On Saturday morning, I woke up and I was still feeling really distressed. So I called student counseling services. It was a long call, but at some point in the call, I heard this banging on the door and it was the campus police. And then another officer came and told me, like, stand up and turn around. And they handcuffed me and took me down to a police car. And I think they said that they were gonna take me to get evaluated.
[00:00:44] Jesse Mangan: When Cassidy made that call to Student Counseling Services, a process was triggered, a process that led to police officers showing up at her home, handcuffing her, and transporting her to an ER for evaluation. This was all in response to a person who was experiencing distress, asking for help. So where did this practice come from?
[00:01:06] Have police always been connected to crisis hotlines? To better understand the history of these sorts of hotlines, I spoke to Hannah Zeavin.
[00:01:15] Hannah Zeavin: Hi, I'm Hannah Zeavin. I teach at UC Berkeley in the Department of History and I'm the author of The Distance Cure: A History of Teletherapy.
[00:01:23] Jesse Mangan: When was the first suicide hotline created?
[00:01:26] Hannah Zeavin: So this is an interesting question, and I'm gonna answer it two ways: incorrectly, but mythologized and then correctly. So the first suicide hotline was understood to be for quite some time in the historiography, a suicide hotline pioneered by the Los Angeles Suicide Prevention Center. Now, that center is very famous because it really pioneered the field of suicidology at mid-century.
[00:01:55] You know, they became especially famous when they diagnosed after death... Marilyn Monroe, with likely having died by suicide. And this was the kind of grand debut of a new theory of thinking suicidality in the US context, really after much stagnation in that area after Durkheim say, you know, who famously gives a, a theory of dying by suicide. Who is most likely to, why, when et cetera. And that center was set up by a triad of two psychologists and one psychiatrist. It was highly medicalized and had a lot of funding.
[00:02:32] And so it, it galvanized sort of the nation as having made the first ever suicide hotline, except this wasn't the case. The first suicide hotline was not started by two psychologists and one psychiatrist. It was started much earlier in London in the early 1950s. The first suicide hotline was started by Chad Varah and Viviana Prosser in the UK in London.
[00:03:01] And as I write about in my book, Varah had been attuned to suicidality in his work as a vicar since the very beginning of his life in the church. The first act he ever did as a man of the cloth, so to speak, was to preside over the funeral of a 13 year old girl who had died by suicide. She had taken her own life thinking that she'd contracted what we would now call an STI.
[00:03:27] But in fact, she had begun to menstruate. 13 years old. And this heartbreaking story stuck with Varah. He wondered what he could have done if his first act had actually been to be a pastoral counselor rather than to preside over a funeral. And what it would've taken, he assumed, was something like the destigmatization, right?
[00:03:47] That's already, we can hear opera around sexuality and after World War II Varah had the opportunity to think about this further because unfortunately, suicide rates in the greater London area were skyrocketing. He wanted to figure out a way to have his parishioners again... right… this is in the church context... have a different form of care because every time he counseled his depressed or suicidally ideating parishioners to go seek help of a psychiatrist, they never did. 0% of any of his parishioners went to the psychiatrist.
[00:04:26] So he began to think about how people were being helped at mid-century in the UK context. They were being helped ostensibly by psychiatrists, but no one seemed to want that form of care. And additionally, they would call on the phone. But the options were the police and the fire department. And Varah's point was, well, suicide was a felony as was quote unquote, attempted suicide.
[00:04:51] We don't use that term anymore, but that was the term of then. Suicide was a felony as was attempted suicide. So calling the police was gonna be a no go. So no one wanted to talk to psychiatrists. No one wanted to call the cops. Well, there needed to be a third thing and that's what he made. So he started a new church in a former bombed out rectory of St. Stevens Walbrook in London that hadn't yet been rebuilt fully after the blitz, after the war. So there was no congregation. He started a brand new church, just made out of essentially telephone wire with Viviana Prosser who helped him triage calls. And he became a full-time counselor, pure counselor in the sense that he wasn't being paid.
[00:05:34] He never met the people who are calling in and the service was immediately greatly desired and needed and successful. So he quickly had to train many more counselors, but instead of training fellow clergy, that bit came later he trained peers. And they became known as the Samaritans and were just there to provide a kind of simple consoling non-judgmental interaction called befriending.
[00:06:01] And that is still the world's most greatly used suicide hotline today. And it exists in many, many, many countries around the world. And that was the first one, not this Los Angeles Suicide Prevention Center.
[00:06:14] Jesse Mangan: Is there a, a direct connection there between the end of World War II, a rise in suicidal ideation and I guess a need in the community? Is there some connection between all of those factors?
[00:06:28] Hannah Zeavin: Yeah, I mean, so we could sit here and talk about that for hours, right? The Durkheimian idea would be something to do with big social upheaval will bring an increase in suicidal ideation and, and in ways that's been borne out. But also it's not just that it was post-war, right...
[00:06:44] What happened next is also really interesting. And part of why the Los Angeles Suicide Prevention Center is misremembered in the US context as being the first suicide hotline, which is that, of course, the reason you wouldn't wanna go see a psychiatrist to talk about shame at mid-century had to do with psychiatry's increasingly heteronormative stances at midcentury.
[00:07:09] So if Freud in fact was quite anti-normative. Everyone is bisexual according to Freud. In the US and the UK, there was a conservatizing impulse, especially in the US, amongst psychiatrists who at this period include psychoanalysts, right... So psychoanalysts are in this moment, almost exclusively psychiatrist.
[00:07:29] And the Diagnostic Statistic Manual, the DSM had just been published in this period and it included, you know, a horrific quote unquote personality disorder called homosexuality. So in the US also in the 1950s, there was a, a for suicide hotline. Again, not the Los Angeles Suicide Prevention Center helmed by Bernard Mayes. And Bernard Mayes by his own self appelation was a closeted queer priest. He was British and had known of Varah's work in the UK context, had emigrated first to New York and then to California and he hated it here. I'm calling from the Bay Area. He hated it here because he thought it was actually rather conservative and was surprised that it was so, but also because he saw San Francisco as almost celebrating in a kind of ironic and mocking way, the fact that it had the highest suicide rate of anywhere in the world outside of West Berlin, which was completely isolated from the rest of Western Germany at the time. And he thought to himself that this also was attributable to the increased violence against the queer community in this period. It was the era of the lavender raids. And Mayes signified on, in a way Varah's system in the UK, he kept the telephone, he kept the peers, but he abandoned any idea of the psychiatrist.
[00:08:57] There was no idea that you should call a psychiatrist. In fact, it was quite the opposite and so much like, you know, Varah's hotline was not psychiatric and it was not carceral Mayes made that a kind of central convening notion of his hotline because of course non-consensual hospitalization for the queer community in that moment could have resulted in everything up to lobotomy.
[00:09:23] That was a quote unquote cure in that moment. This was life or death. So that hotline attracted some attention a little bit skeptical in the late 1950s, but was also immediately successful. So successful that it caught the attention of the Los Angeles Suicide Prevention Center. They moved to shut the hotline down because not only was it using the telephone around the clock, but it was making use of peers, not experts. And they thought that this was a double mistake. And eventually they couldn't shut the hotline down. And so they copied it. And this is why in the historiography of suicide hotlines, such as it exists, this is often a misremembering that the very hotline that tried to restrict and control the more radical expressions of community based peer to peer care ends up being given the sort of crowning name of first suicide hotline in the US.
[00:10:22] Jesse Mangan: While discussing the history of suicide hotlines, hannah mentioned the falsity of saving a life at any cost. So I asked Hannah if there was a specific moment where the idea of saving a life at any cost became part of the hotline.
[00:10:37] Hannah Zeavin: The idea that we have to save lives no matter what is present from the very earliest moments on the hotline, especially once you get experts involved, because then there's a whole new kind of ethical and legalistic sets of code that are overrunning a hotline like Mayes', which was interested only in what we might call prevention, but not intervention. And that's a very signal difference. That really is part of how one can think of contemporary hotlines as well is a hotline going to, no matter what, intervene? Or is the hotline seated at a place where it waits for the caller to come to them and then sticks with the caller, no matter the outcome. And so these are, you know, still ongoing massive debates. Although the intervention side has largely won, which, you know, colleagues and I are very saddened by because it often is this kind of false idea that well, you know, and it's very hard to speak back to the kind of straw person argument of, you know, something like horrific, like, well, you must just not care or want people to die. Precisely no. But that studies and studies and studies have shown that both forced hospitalization and police intervention actually increased suicidality, not just for individuals, but in communities.
[00:11:59] Which, you know, makes all the sense in the world if you sit and think about the history of policing and the history of psychiatry in the United States specifically, and, and who is most targeted by the agents of, of the state, the police and hospitals and so on. So even if there's this argument that well, you should do everything to save a person, those very means of saving a person, A) might save them today, but B) will in the long term actually harm them quite significantly. And my colleague Yana Calou, who's the Director of Advocacy at Trans Lifeline, and I have been working on this because it's actually become ever more pressing because these sort of tools and techniques of the hotline are becoming unified and will be unified this summer when the government and the FCC roll out a new number for all national hotlines 988, which is to make it like 911, but with a difference, however, as I've just sort of run through, the difference isn't going to actually be there if the hotline is a feeder to both psychiatric and carceral intervention.
[00:13:07] Jesse Mangan: Imagine a moment where the thoughts swirling in your head seem inescapable, where the world around you feels like it's falling apart. You feel irreparably vulnerable. And you don't know what to do, but you remember a flyer or you remember a slogan. You remember that there is a hotline. So with the last vestiges of will that you have left, you make that call, you ask for help. And in that moment, who is it that you're hoping responds?
[00:13:39] Police involvement in these types of situations is often encouraged or even mandated as a matter of policy, but why do we involve police in this type of distress and what impact do those policy choices have on the people asking for help?
[00:13:53] Jamie Livingston: I think it's really weird and unacceptable that police are involved in the first place.
[00:13:58] Jesse Mangan: This is Jamie Livingston.
[00:14:00] Jamie Livingston: I'm Jamie Livingston. I'm a criminologist in Halifax, Nova Scotia, Canada. And the work that I do is at the intersection of the mental health, substance use, and criminal justice systems with a particular interest in understanding people's experiences at that intersection in relation to stigma.
[00:14:19] Jesse Mangan: So when we're talking about stigma and it's this identifying characteristics and sort of grouping people by perceived characteristics, one of the the bigger talking points around mental illness is the interaction between people living with mental illness and, and law enforcement. What role does stigma play in those interactions between law enforcement and people living with mental illness?
[00:14:40] Jamie Livingston: It plays a major role, especially when you view it as a structural stigma. So I think that if you look at history, but also the current context, there's been a tremendous amount of policies and social processes that have channeled people with mental health issues into the criminal justice [00:15:00] context. And those policies and practices are often rooted in stigma.
[00:15:04] So... stigma by defining people with mental health issues as being dangerous and risky, as being manipulative and untrustworthy, as people who are unable or incapable of making decisions for themselves and all of that kind of musters the state to use these coercive tools in order to impinge on the rights and liberties of people with mental health issues.
[00:15:29] So I think it's from that fundamental basis of defining people in particular ways and viewing people in particular ways that allows the state to intervene in people's lives in ways that they wouldn't for other sort of health conditions and other types of contexts. But beyond that, it's also kind of the deficiencies that have been built into our social institutions, including our healthcare system that create acceptable ways of discriminating against people with mental health issues in education and housing and healthcare, in all sorts of different realms. And that discrimination leads to the neglect of people with mental health issues. It escalates their chances of experiencing crisis and then increases their risk for their liberties to be impinged upon by the state.
[00:16:20] So the neglect of our healthcare system and by our governments to meet the needs of people with mental health issues places people in situations in which they're more likely to experience crisis, more likely to have their rights being jeopardized, and more likely to be put into contact with someone like the police.
[00:16:40] Jesse Mangan: When a mental illness is diagnosed, it's diagnosed based on the perception of symptoms believed to be present. And throughout the US, every state has a law that gives individuals within law enforcement the legal authority to detain someone based solely on the concern that a mental illness might be present and that possible mental illness might lead to a dangerous situation. So I asked Jamie, what sort of training are police receiving to effectively interpret perceived symptoms?
[00:17:12] Jamie Livingston: That's a great question. And it's all over the map. So there's no general kind of statement that could be made about how well prepared police are to interact with people who are in mental health crisis.
[00:17:25] I did a study like a decade ago that was on the heel of a really tragic event in Vancouver, British Columbia, where a man was shot fatally shot by police. He was clearly in mental distress at the time that he was shot. He was on his hands and knees and not capable of threatening at anyone. And that led to a lot of questions involving people in mental distress.
[00:17:52] At the time 10, you know, 10 years ago, we designed a study based on some research that had been done in Chicago around understanding the perceptions and experiences with people with mental health issues in relation to their interactions with police and, you know, people who came up with really great sort of recommendations for improving police training. And it's now 10 years later and we're still asking the same questions and the gaps that we identified 10 years ago have not been addressed. And so I've almost given up on the question of police training. And I'm more interested in doing something completely different than improving police training, because I think that the police have demonstrated that they're, they're not taking seriously these, these issues of better preparing their police officers to handle these interactions.
[00:18:44] And we're repeatedly seeing people with mental health issues being placed at risk and dying during these interactions, particularly if people are poor, are homeless, are racialized, so black or indigenous, those sort of things increase their risk of dying during these interactions. So, you know, over the past few years, certainly after the Black Lives Matter protests and after the George Floyd death, I've been more seriously contemplating how to remove police from these interactions rather than improving these interactions, redesigning systems so that police are taking out of the equation to the extent that it's possible.
[00:19:24] Jesse Mangan: What are some examples of alternatives that might remove police from responding to someone in distress?
[00:19:31] Jamie Livingston: There's lots of examples. I think it's really weird and unacceptable that police are involved in the first place. So you have something that's clearly a health event, like a mental health crisis. And police are in many jurisdictions are the default response to these events. So someone calls 911, because they're concerned about, you know, a loved one or a neighbor or someone in their neighborhood that is displaying concerning behavior, not always threatening, you know, and not always violent, but regardless of what the circumstances, in many communities, including my own community that I live in, in Halifax, the police are the default response to these circumstances, which I think is a form of structural stigma.
[00:20:18] So baking law enforcement or police into the mental health system in this way, I think is a form of structural stigma in that it's clearly designed in ways that leverage this idea that people are dangerous, risky, and, and facilitates their criminalization. And I think that it's a sign of health systems not taking care of their clientele or the, the people that they should be taking care of, including people who are in mental distress that need a mobile response to come to them. There's now plenty of examples of communities that have redesigned their mobile crisis response systems, such that the police are removed from the equation as much as possible.
[00:21:06] And the most kind of renowned example is in Eugene, Oregon, and a program called Cahoots that have been doing this for, you know, over two decades in which they came to the kind of solution that police should not be the default response. It should be clinicians that are the default response to people who have a mental health related crisis. And so for many of the calls crisis calls, they would dispatch like a, a paramedic with a nurse to attend to these calls and more and more communities are jumping on board and recognizing that that makes the most sense to achieve a whole bunch of goals like a goal of not shooting and killing people during mental health crisis.
[00:21:56] That's an important goal, but also, you know, other sort of social goals of how to, you know, support anti-racist efforts, such that people from communities that are harmed by the police feel more comfortable for calling for help if someone's in, in distress. In Canada here, but also in the US, but strongly in Canada, you know, social movements built around anticolonial types of efforts... so how do support indigenous communities who've had historically and ongoing really terrible relationships with the police, how to support those communities to take care of the mental health needs, particularly when their community members are in, in crisis. So decoupling police, which for many communities have had really violent and harmful histories, decoupling police from a health response.
[00:22:52] So there's more and more models that have been developed and have been established, many of them in kind of a precarious pilot basis, but you see more evidence and more models being mobilized to provide alternatives to the police to people who are experiencing mental health crises.
[00:23:09] Jesse Mangan: On a Saturday morning, Cassidy called Student Counseling Services for help. That call led to her being handcuffed, transported to an ER, and detained for evaluation. That evaluation, that risk assessment, seems to be the goal, seems to be the tool that policy makers depend on to safeguard a person in distress and a significant amount of coercion and manipulation goes into getting that assessment to happen.
[00:23:33] So, how effective is it? How reliable is this type of risk assessment? Next time on Committable...,
[00:23:42] Tim Wand: There's a culture of blame around mental health services. You're supposed to be able to identify with some accuracy that this person is gonna act in that way despite no evidence that we can do that.
[00:23:53] Morgan Shields: Of all of the places in a hospital, you would hope that the psychiatric units would be the most mindful of psychological safety, of trauma, of interpersonal relationships. And I have found that that is really not the case. For some people, it could be helpful, but for a lot of people it's, it's actually left them with PTSD. Psychological treatment should not give you PTSD.
[00:24:27] Jesse Mangan: This episode of Committable was produced by Michelle Stockman, Cassidy Wilson, Jim McQuaid, and me Jesse Mangan. All music is from the song Reasonable by Christopher G. Brown.