Death Studies

ISSN: 0748-1187 (Print) 1091-7683 (Online) Journal homepage: https://www.tandfonline.com/loi/udst20

Changes in prospective helpline volunteers'

suicide intervention skills throughout the initial
training

Paulius Skruibis, Kasparas Astrauskas & Egle Mazulyte-Rasytine

To cite this article: Paulius Skruibis, Kasparas Astrauskas & Egle Mazulyte-Rasytine (2019):
Changes in prospective helpline volunteers' suicide intervention skills throughout the initial training,
Death Studies, DOI: 10.1080/07481187.2019.1671538

To link to this article: https://doi.org/10.1080/07481187.2019.1671538

Published online: 03 Oct 2019.

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DEATH STUDIES
https://doi.org/10.1080/07481187.2019.1671538

Changes in prospective helpline volunteers’ suicide intervention skills

throughout the initial training
Paulius Skruibisa, Kasparas Astrauskasb, and Egle Mazulyte-Rasytinea
a
Suicide Research Centre, Institute of Psychology, Vilnius University, Vilnius, Lithuania; bInstitute of Psychology, Vilnius University,
Vilnius, Lithuania

ABSTRACT
The objective of this study was to evaluate the changes in prospective helpline volunteers’
suicide intervention skills throughout the training in Lithuania. In total, 90 participants of
the Youth Line volunteer initial training course completed the Suicide Intervention
Response Inventory (SIRI-2) before any training, before and after the suicide intervention
module, and after all training. There was a steady and significant increase in the trainees’
suicide intervention competencies during the training. Younger and less skilled trainees
benefited more from the training. These results indicate that helpline volunteers can be
trained in suicide intervention skills in a relatively short time.

Suicide is a major public health problem that requires
evidence-based prevention efforts. One of the most
common methods of suicide prevention around the
world is helplines. World Health Organization (2014)
has listed helplines as one of the recommended suicide
interventions among other typical components of
national strategies for suicide prevention. Despite their
common practice, studies on helpline effectiveness in
suicide prevention and the quality of service they pro-
vide are scarce (Hvidt, Ploug, & Holm, 2016; Zalsman
et al., 2016). The lack of empirical evidence of the effect-
iveness of helplines could be ascribed to major meth-
odological challenges and ethical considerations of such
studies, for example, the common policy of using caller
anonymity or infeasibility of randomized controlled trial
(Hvidt et al., 2016). However, available studies with out-
come measures such as changes during calls, reutiliza-
tion of service, compliance with referrals, caller
satisfaction and Counselor satisfaction showed helplines
having a positive impact on callers’ suicidal urgency and
depressive mental states (Hvidt et al., 2016).
There are some discussions, whether helpline vol-
unteers are sufficiently prepared for such responsible
work. Would answering emergency calls be better
done by mental health professionals? Mishara et al.
(2016) concluded that, based on previous research and
their own findings, there is no justification for requir-
ing that suicide prevention helpline workers be mental
health professionals. On the contrary, paid professio-
nals may be less helpful and less effective on the tele-
phone with people in crisis compared to trained
volunteers. Mishara et al. (2016) argue that mental
health professionals are mainly trained for a continu-
ous face-to-face therapy with the same client and
those skills may be less helpful when talking with an
anonymous person on the phone. Also, interacting as
a peer during a call may be better than interacting in
the role of an expert. Nonetheless, the training of
helpline volunteers is a crucial part of their prepar-
ation to provide help via telephone. However, there is
a lack of studies evaluating the effectiveness of
such training.
Evaluation is necessary to determine not only
whether the training is effective but also whether help-
line volunteers have necessary competencies to achieve
their goals. We also need to better understand how
suicide intervention skills are gained during training.
Does the effect occur gradually throughout the train-
ing program, or only in those parts where suicide
intervention is the main focus. There are two types of
methods for assessing the suicide intervention skills of
helpline volunteers after or during training (Neimeyer
& Pfeiffer, 1994). One method, evaluation via simu-
lated calls or role play, requires a lot of resources.
Another method, knowledge and skills tests, are cost-
effective and easy to administer. One of the most

CONTACT Paulius Skruibis paulius.skruibis@fsf.vu.lt Faculty of Philosophy, Suicide Research Centre, Institute of Psychology, Vilnius University,
Universiteto 9, 01513 Vilnius, Lithuania.
ß 2019 Taylor & Francis Group, LLC
2 P. SKRUIBIS ET AL.
Pre-training (n = 90):
SIRI-2Mean = 75.84, SIRI-2Df = 21.31
Before suicide intervention module (n = 75):
SIRI-2Mean = 62.34, SIRI-2Df = 16.82
After suicide intervention module (n = 70):
SIRI-2Mean = 57.28, SIRI-2Df = 13.25
Post-training (n = 50):
SIRI-2Mean = 55.04, SIRI-2Df = 13.02
Figure 1. The flow of participants throughout the training and their SIRI-2 scores at each time point.
widespread questionnaire specifically aimed at suicide
intervention skills is the Suicide Intervention
Response Inventory (SIRI-2; Neimeyer & Bonnelle,
1997). This questionnaire has proven to be a reliable
tool to assess suicide intervention competencies and
because of easy administration it is a convenient
method for repeated evaluation during the training.
The aim of the current study was to evaluate the
volunteer initial training program at a helpline for
young people in Lithuania and measure the changes
in suicide intervention skills during the training. We
hypothesized that the trainees’ suicide interventions
skills would improve the most after one specific part
of the training, namely suicide intervention module.
Method
Participants
In total, we recruited 90 people, from 17 to 55 years
old (M ¼ 27.89, SD ¼ 8.63) to participate. Most (68,
76%) were women. They were all participants of the
Youth Line volunteer initial training course, which
took place in autumn of 2016 in three major
Lithuanian cities. Almost half (40, 44%) of those who
started dropped out (see Figure 1). However, as Youth
Line volunteer training is also aimed at recruiting the
best candidates for helpline work, such rate of drop-
out is common and in some ways desirable.
Procedure
We asked participants to complete questionnaires
during four time points: before the training, two times
during the training (before and after the suicide
Dropouts (n = 15):
SIRI-2Mean = 95.85, SIRI-2Df = 21.11
Dropouts (n = 5):
SIRI-2Mean = 55.63, SIRI-2Df = 25.75
Dropouts (n = 20):
SIRI-2Mean = 55.46, SIRI-2Df = 12.41
intervention module), and after the training. All partici-
pants signed an informed consent form, and their
participation did not have any consequences for their
recruitment.
Youth Line is a Lithuanian helpline service, provid-
ing emotional support for adolescents and young
adults since 1991. All Youth Line emotional support
volunteers have to complete the initial training course.
The training program, updated in 2015, consists of
39 hr of group learning activities with homework
assignments, 9 hr of helpline work observation, and
17 hr of supervised practice. Group learning activities
consist of mini-presentations and discussions, but the
biggest part is roleplaying. Normally the program is
delivered over a period of 4–5 months. At the begin-
ning of the training, trainees learn general skills for
providing emotional support (mostly active listening
skills). During the middle of the training, leaders dis-
cuss the topic of suicide. In the third part of the train-
ing, participants practice both general emotional
support and more specific suicide intervention skills.
To graduate, trainees must complete at least 33 hr
of training.
Instruments
The Suicide Intervention Response Inventory (SIRI-2;
Neimeyer & Bonnelle, 1997) is 24 item scale testing
the responders’ ability to evaluate the appropriateness
of two hypothetical caregiver replies to each of 24 cli-
ent remarks. Answers are on a 7-point Likert scale
from –3 (highly inappropriate response) to þ3 (highly
appropriate response). A final score is based on the

discrepancy between responders’ rating and the mean
rating endorsed by the experts and ranges from 0 to
124. A higher score reflects higher discrepancy and
thus poorer competencies in suicide intervention.
Among US Counselor trainees and students from
introductory psychology classes the SIRI-2 was highly
internally consistent and reliable over time (Neimeyer
& Bonnelle, 1997). For the present study, after acquir-
ing the consent from the authors, we translated the
SIRI-2 into Lithuanian, back-translated it to English,
and discussed and corrected discrepancies. The
Lithuanian version of SIRI-2 showed acceptable
internal consistencies, with Cronbach’s alpha ranging
from .69 to .72 across the time points.
Data analysis
Because of a large number of dropouts, we used
paired samples t-tests instead of a Repeated Measures
ANOVA to assess the differences in means across all
time points. We used listwise deletion to handle all
missing data (including both dropouts and non-
available responses). Non-available responses occurred
due to some participants not being present at the time
of the questionnaires being administered (participants
were allowed to miss up to 6 hr of training due to
unforeseen circumstances) and were independent of
parameters of interest. A priori power analysis indi-
cated that we needed to have 33 subjects in each of
time points to have 80% power for detecting a
medium-sized effect and 14 subjects for detecting a
large-sized effect when employing the traditional .05
criterion of statistical significance.
Results
The flow of participants through the Youth Line vol-
unteer training and their basic competencies in suicide
intervention, measured by SIRI-2 inventory, at each
time point are presented in Figure 1. A comparison of
SIRI-2 scores pre- (M ¼ 71.84, SD ¼ 19.62) and post-
training (M ¼ 55.10, SD ¼ 13.14) revealed a statistically
significant decrease, t(46) ¼ 6.24, p < .001, with a large
effect size (d ¼ 0.91). Approximately, two-third of the
participants experienced at least a 10-point decrease
in their SIRI-2 scores. The vast majority (90%) of the
participants finished the training with SIRI-2 scores
below the pre-training mean. As higher SIRI-2 scores
indicate poorer competencies in suicide intervention,
participants’ competencies significantly improved dur-
ing the training.
DEATH STUDIES 3
Table 1. Relationship between SIRI-2 scores and trainees’ age
during the training.
1 2 3 4 5
1.Age –
2.Pre-training –.06 –
3.Before suicide intervention module .28 .60 –
4.After suicide intervention module .20 .53 .69 –
5.Post-training .36 .43 .79 .80 –
Note: p < .05. p < .01. p < .001.
Pairwise comparisons across all 4 time points also
showed a significant improvement in participants’
basic competencies with medium effect sizes through-
out the training accordingly: pre-training and before
the suicide intervention module (M ¼ 71.16,
SD ¼ 18.99 and M ¼ 62.14, SD ¼ 16.59, respectively),
t(68) ¼ 4.67, p < .001, d ¼ 0.56; before and after the
suicide intervention module (M ¼ 62.29, SD ¼ 15.94
and M ¼ 56.99, SD ¼ 13.42, respectively), t(64) ¼ 3.63,
p < .001, d ¼ 0.45; after suicide intervention module
and post-training (M ¼ 58.03, SD ¼ 13.64 and
M ¼ 54.28, SD ¼ 12.41, respectively), t(48) ¼ 3.14,
p ¼ .003, d ¼ 0.45. Note, the mean of the same time
point is slightly different when a comparison is made
with the previous or the next point because we are
performing a pairwise comparison and therefore we
include only those participants who filled in the ques-
tionnaire at both those specific time points.
There were no significant gender differences in par-
ticipants’ basic competencies in suicide intervention at
any of the time points. However, participants’ age was
not significantly associated with competencies in sui-
cide intervention at pre-training but was significantly
associated with training at the other three time points
(Table 1). Younger participants performed signifi-
cantly better on the SIRI-2 during the training and
post-training.
Also, as would be expected, we found moderate to
strong correlations between the SIRI-2 scores across
all time points (see Table 1).
Multiple linear regression was calculated to
predict the change in participants’ basic competencies
in suicide prevention (difference in SIRI-2 scores at
pre- and post-training) based on participants’ age and
pre-training competencies. A significant regression
equation was found, explaining 66% of the variation
in the change of SIRI-2 scores, F(2, 44) ¼ 42.15,
p < .001. Both participants’ age (b¼–0.274, p ¼ .003)
and pre-training SIRI-2 scores (b ¼ 0.761, p < .001)
were significant predictors of the change in suicide
intervention competencies. Hence, younger partici-
pants with poorer pre-training competencies benefited
from the Youth Line training the most.
4 P. SKRUIBIS ET AL.
Discussion
Our study shows that the Youth Line training signifi-
cantly improved these Lithuanian hotline volunteers’
suicide intervention skills. The mean SIRI-2 score
before the training (75.84) in our study is comparable
to the mean (82.18) of low experienced group (e.g.
first-year undergraduate psychology students) in a
Dutch study with community and health professionals
(Scheerder, Reynders, Andriessen, & Van Audenhove,
2010). After 4 months of training (39 hr of training
plus 17 hr of supervised practice), the mean score of
Youth Line trainees improved to the level of Dutch
moderately experienced group (e.g. second-year post-
graduate psychology students), which were 55.04 and
59.92, respectively. These results show that lay volun-
teers can be trained in a relatively short time to reach
the competency level in suicide intervention compar-
able to that level of professional education in psych-
ology. Therefore, we believe that our study supports
credibility of helplines.
It is interesting to note that the biggest improve-
ment in suicide intervention skills occurred in the first
five weeks (18 hr) of the training, during which time
there was no specific reference to the topic of suicide.
Teaching active listening skills, discussing ethical prin-
ciples of the helpline, and reflecting on attitudes
towards emotional support apparently was sufficient
to produce a change in trainees’ skills. This finding
remains true, even if we compare pre-training mean
score with before suicide intervention module means
without the first dropouts (as they had very poor sui-
cide intervention skills). Therefore, it is evident that
our hypothesis was not confirmed – suicide interven-
tions skills did not improve the most after the suicide
intervention module.
Another important finding is that Youth Line
Suicide Intervention training module (9 hr) also pro-
duced a significant improvement in trainees’ suicide
intervention skills. This module includes a reflection
on attitudes towards suicide, suicide warning signs,
suicide risk assessment, and intervention skills role-
play. The suicide intervention module due to its
emphasis on attitudes and skills practice in Youth
Line training course can be compared to the Applied
Suicide Intervention Skills Training (ASIST) by Living
Works. ASIST is also very practical and relatively
short (16 hr) program, which is shown to be effective
by multiple studies (e.g. Gould, Cross, Pisani,
Munfakh, & Kleinman, 2013; Shannonhouse, Lin,
Shaw, & Porter, 2017; Shannonhouse, Lin, Shaw,
Wanna, & Porter, 2017). Role-plays are used not only
in suicide intervention module but also in the whole
Youth Line training. Several other studies have identi-
fied role-plays as an important component of suicide
intervention and crisis support training that is well
accepted by trainees (Cross, Matthieu, Cerel, & Knox,
2007; Dong, Zhong, Haghighi, Xu, & Pulma, 2016).
We also found that younger and less skilled train-
ees benefited relatively more from the Youth Line
training course. An important part of training suicide
intervention skills is attitudes and according to a life
stages explanation, younger people are more suscep-
tible to attitude change than middle-aged people
(Visser & Krosnick, 1998). The explanation is that
core attitudes, beliefs and values are crystalized during
a period of great plasticity and then remain
unchanged for many years. Only in older age suscepti-
bility again increases because of diminished social
support mainly due to deaths of friends or social
withdrawal. The results of our study seem to go along
with this explanation – skills of younger trainees (and
we presume that their attitudes as well) changed more
during the training than skills of somewhat older
trainees. These results speak in favor of early educa-
tion on suicide and suicide intervention – starting at
higher education or even at high school. Naturally,
more skillful trainees do not benefit from the training
as much as the less skilled. It is possible that confi-
dence improved as well as skills, but we did not meas-
ure trainees’ confidence in using their skills.
In this study, we assessed suicide interventions
skills only with one instrument, namely SIRI-2. This
inventory is based on common mistakes in suicide
intervention, but it does not measure what a volunteer
does, especially what kind of methods he or she
employs. Also, we did not measure volunteers’ confi-
dence in their suicide intervention skills, which could
be a useful indicator of the effectiveness of the train-
ing. Another limitation of our study is that we did
not have a control group, which leaves the possibility
that some change in skills could occur merely because
participants completed the same questionnaire repeat-
edly. To eliminate this possibility, however unlikely it
can be, we suggest that future studies on this topic
should include a control group, perhaps those sched-
uled for upcoming training. Finally, we fully acknow-
ledge a possible bias to results due to listwise deletion
method used in our study. However, we chose not to
apply multiple imputation as the proportions of miss-
ing data (due to 44% drop-outs) are too large. Even
though the attrition rate in our study may seem rela-
tively low with 56%, similar studies (Gask, Dixon,
Morriss, Appleby, & Green, 2006; Gask, Lever-Green,
& Hays, 2008) show only 30% and a very recent study

by Ferguson et al. (2019) report their follow-up
response rate of approximately 70% as large.
We were able to compare SIRI-2 scores of Youth
Line volunteers with the scores of various community
and health professionals’ scores in a Dutch study
(Scheerder et al., 2010). However, it would be more
informative (in terms of effectiveness) if we were able
to compare scores of Youth Line volunteers with local
Lithuanian mental health professionals. Unfortunately,
the data from a study on Lithuanian mental health
professionals’ suicide intervention skills is not pub-
lished yet.
Youth Line training was effective in developing
trainees’ suicide intervention skills. Not only specific
suicide intervention module but also general emo-
tional support skills, such as active listening, contrib-
uted significantly to improving suicide intervention
skills. Younger and less skilled trainees benefited more
from Youth Line training course.
Acknowledgement
The study received no funding from Youth Line or
other sources.
Disclosure statement
Paulius Skruibis at the time of the study was the chairman
of Youth Line Board. Kasparas Astrauskas at the time of
the study was a Youth Line volunteer and a trainer. Neither
of them received any financial benefit from the Youth Line
for carrying these volunteer roles or conducting the study.
Youth Line training course evaluated in this study is a
usual practice.
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