Mental Health Helplines
The helpline as a mental health space
Dominant images of mental health include a therapist's sofa; perhaps a mental health hospital. Such images are emblematic of pivotal power relations in the psy disciplines – between expert and user, or inherent in the clinic. However, technology too is ushering in newer sites for MH practice – online spaces, artificial intelligence (AI), text lines (that offer support via texting) and, of course, phone helplines.
Samaritans, the first ‘crisis line’, begun in 1953, used volunteers to offer support, along with non-judgmental and empathetic listening.(1) Helplines have since proliferated, using both expert-led and lay-counselor-based models. Some questions arise in the process: how does a phone line or chat box become a safe space to communicate distress? Can such services address problems of discrimination and exclusion due to marginalization? How much does the heritage of psy-disciplines with its more medicalized approach to distress, influence such alternative sites of MH care?
Phone lines are accessible to people across geographies and communities.(2) However, access may depend on gender, age, socio-economic status. While telephone counseling has enabled quick and relatively inexpensive psychosocial support, easing concerns of time, distance, and costs,(3) not only must such interventions be mindful of individual client resource constraints, they must also remain aware of cultural contexts and community needs.
Expert-speak or peer-speak?
‘All helplines, irrespective of whether they are serviced by lay counselors (paid or voluntary), or by professional MH personnel, work on some common principles.’(4) These principles may reflect knowledge from psy-disciplines such as active listening skills, psychological first aid, knowledge of trauma, resilience, cognitive behavioural therapy principles.(5) Definitions of stress or resilience might hinge on ideas of a “normal” derived from the clinical; yet MH helplines differ from traditional clinical spaces in some critical ways.
Helplines offer possibilities for anonymous help-seeking – allowing callers a sense of control. While this is partly dependent on their ethics and confidentiality policies, helplines do circumvent some of the stigma around physically accessing clinical spaces. The caller also has some power, knowing they can disconnect and end the interaction at any point.
While some telepsychiatric and/or professionally staffed MH helplines may use talk therapy to meet goals of diagnosis, prognosis, intervention, thereby mirroring the clinic, many others aim mainly to assist and support, share information, offer a safe space for expressing distress, provide interim comfort – and referrals if needed. Such a space of care versus treatment marks an important departure from the clinical mainstream. Peer-run helplines epitomize this approach, and cannot be assumed to be merely “task-shifting” or providing only basic services. Rather, helplines run by peers with lived experience can be highly effective in ways the clinical may not be. For example, LGBTQIA+ helplines, and youth MH or substance use helplines staffed by peers, rely on knowledge from both individual and collective lived experiences of social contexts and unique life stressors.
However, peer-based helplines could encounter challenges in terms of boundary setting, confidentiality, further training, supervision, self-care, besides being adversely affected by having to engage with mainstream and possibly oppressive institutions and services.(6) The critical need remains, to engage with traditional MH knowledge bases as well as knowledge from the lived experiences of marginalized communities. Specific examples from the Indian context could help us explore how some helplines inculcate both systems.
“Helplines offer possibilities for anonymous help-seeking – allowing callers a sense of control”
iCALL: a national helpline run by psychologists
The iCALL (Initiating Concern for All) Psychosocial Helpline was set up in 2012 to provide free, professional, psychosocial counseling via phone, email or chat to persons from across India in need of emotional support, with an emphasis on making MH accessible for socioeconomically marginalized persons, survivors of violence, and communities that have faced historical discrimination.
The team, comprising qualified professionals with a Master’s in Psychology, receive additional training in areas such as substance use, queer affirmative counseling practice, kink affirmative MH, sexual and reproductive health, sexual harassment and violence against women. Many of the trainers come from a locus of relevant lived experience. The extensive referral system that iCALL uses also connects callers to community resources, as peer support is seen as critical. This centering of knowledge beyond traditional MH allows iCALL to be accessible to a range of marginalized communities that may find mainstream helplines uninformed with respect to their specific concerns.
While many helplines are instituted in times of humanitarian crisis, Kashmir Lifeline (KLL) is a permanent helpline that services a region beset by long-term conflict, and is the world’s most militarized zone. There is a grave shortage of MH resources in the Kashmir Valley. Apart from the lack of services, access to care is affected by a variety of factors, including harsh winters, curfews. and the perpetual threat of violence.
KLL was founded in 2009 in Kashmir with the aim of addressing MH needs using both conventional and alternative therapies.(7) Staffed by a team of Kashmiri psy professionals providing services in Urdu, Kashmiri and Hindi, KLL has a toll-free number to enable free and consistent access to psychosocial counseling and trauma support, especially during curfews and restrictions on net connectivity. The anonymity and confidentiality of the KLL helpline is crucial, given the profound social stigma in Kashmir around going to a psychiatric setting.(8)
In the context of long-term violence, KLL creates a safe space as the counselors are all Kashmiri themselves, and share their clients’ lived experience of ongoing conflict. Further, given that the institutional, bureaucratic response to the widespread trauma has been biomedical, with an over-reliance on medication, KLL’s referral system to their own centers, NGOs, hospitals and other support systems has been noteworthy. The KLL model demonstrates the effective use of both traditional clinical systems of knowledge and peer knowledge to address psychosocial support in a region of conflict.
Manipur is home to a significant LGBTQIA+ population that is largely invisibilized. LGBTQIA+ youth with privilege may migrate out of the state; others have few options. The multiple oppressions that Manipuri youth routinely face include a heavy military presence by and conflict with the hegemonic mainland. Besides the scarcity of MH services, and poor public transport, the situation is compounded by most practitioners in the state following traditional clinical paradigms that are not queer affirmative. Such institutionalized transnegativity and homonegativity render psychosocial support even more precarious and inaccessible.(9)
Against this backdrop, Ya_All, an LGBTQ+ Allies Youth Network/Collective, runs a helpline operating in English and Meitei, based in Imphal. Besides the helpline, Ya_All also does crisis support work for individuals in distress. Its center is accessible to helpline callers who may want to meet face-to-face, or access community. The peer support and provision of community space play crucial roles. Members handling the helpline have acquired training through MHI’s Queer Affirmative Counselling Practice course and/or its Peer Support Practice course, and use skills and guidelines from psy-disciplines that enable boundary-setting, staff well-being, and the ability to challenge any essentializing of LGBTQIA+ experiences.(10)
Negotiating traditional and peer expertise
These various helpline models illustrate their potential for MH work that is able to traverse, through experience, the binary of traditional, clinical knowledge and that of expertise through experience. It must be pointed out here that psy expertise is coded with privilege, neoliberal approaches and mainland hegemony – of especial relevance to KLL and Ya_All.(11)
While helplines may not yet offer fully-fledged counter-narratives from the MH arena, they do hold exciting possibilities for the subversion of dominant tropes in the psy-disciplines – foregrounding individuals and their contexts even as they retain core tenets of ethics and accountability.
 Telephones save lives: The history of the Samaritans. (2018, October 16). Science Museum. https://www. sciencemuseum.org.uk/objects-and-stories/telephonessave- lives-history-samaritans
 Godbole, K., Kulkarni, S., Godbole, G., & Kulkarni, A. (2015). Experiences from Garbha-Swasthya helpline. Indian Journal of Public Health, 59(2), 149. https://doi. org/10.4103/0019-557x.157538
 Itzhak Gilat & Sarah Rosenau (2011) Volunteers' perspective of effective interactions with helpline callers: qualitative study, British Journal of Guidance & Counselling, 39:4, 325-337, DOI: 10.1080/03069885.2011.567327
 Sriram S., Aparna Joshi, Paras Sharma (2016) Telephone Counselling in India: Lessons from iCALL. In: Sriram S. (eds) Counselling in India. Springer, Singapore. https://doi.org/10.1007/978-981-10-0584-8_11
 Juen, B., Siller, H., Lindenthal, M., Snider, L., Nielsen, M., Muff, M. L., & Wiedemann, N. (2013). Lay counselling in humanitarian organisations: a field report on developing training materials for lay counsellors. Intervention, 11(1 Special Anniversary Issue: Part 2), 77-88.
 Basset, T., Faulkner, A., Repper, J., & Stamou, E. (2010, August). Lived Experience Leading the Way. Together. https://www.slamrecoverycollege.co.uk/ uploads/2/6/5/2/26525995/lived_experience_peer_ support_in_mental_health.pdf
 Singh, R. (2016, July 13). Kashmir: The World’s Most Militarized Zone, Violence After Years Of Comparative Calm. Forbes. https://www.forbes.com/sites/ ranisingh/2016/07/12/kashmir-in-the-worlds-mostmilitarized- zone-violence-after-years-of-comparativecalm/# 14d743a43124
 P. (2019, February 19). Our History. Healing Minds Foundation. https://www.healingmindsfoundation.org/ our-history/ accessed 9.09.2020
 Chakravarty, S., (2019, September). Queering Mental Health. Bridging The Care Gap: ReFrame, ed, Mariwala, R, MHI. https://mhi.org.in/media/insight_files/MHI_ ReFrameII_19.09.30_DIGITAL_bXDTARb.pdf
 Refer to Nair, P, (2020, October). “I get you”: Strengthening Peer Counseling within the Queer Community. Mental Health Beyond Clinical Contexts: ReFrame, ed, Mariwala, R, MHI.
 Dave, A. K. [Queer-C. T. (2020, July 26). Queer- Crip Trip on mental health systems [Tweet]. Twitter. https://twitter.com/TheHoleyBibli/ status/1287406281624616960