The easy-to-remember three-digit number for suicide crises means that people in need of immediate support can call or text for help.

In early November, American actor Mark Duplass wrote about his mental health challenges on Instagram, including hosting a live space to discuss his strategies for coping, a part of which involves “a temporary denial of some of the heavy darkness so that I can focus on the light.”

Duplass, who has appeared in The Morning Show and The Mindy Project, encourages followers to phone the 988 any-time call and messaging service, which began in the U.S. in July 2022. As posts, mentions, articles, and conversations increase, there’s hope that those three digits will become common knowledge like 911.

Canada’s 988 suicide crisis helpline, which launched on November 30, means that people across the country can receive support via phone or text 24 hours a day. Callers will receive bilingual, trauma-informed culturally appropriate support from trained responders. While the service is designed to respond to those at risk of suicide, no one will be turned away. Those seeking to access other mental health supports, may be directed to other services in their area, for example.

“This will save lives,” says Michel Rodrigue, president and CEO of the Mental Health Commission of Canada (MHCC). “The 988 service is a vital support and more than just a number — a simple call in a time of crisis can be a turning point. This helpline breaks the silence and offers support to individuals.”

How it works

After texting or dialing 988, callers will receive a brief message to confirm that they have reached the right number. They will then be asked a few basic questions — for example, if they’d like to speak to someone in English or French — after which they’ll be connected with a trained responder in their community who will listen and provide support.

Calls or texts to 988 are confidential. No personally identifiable information will be disclosed or shared outside the 988 network, except as required or permitted by law, or when emergency intervention is needed to support the safety and well-being of the caller or texter, and/or the safety of others. The service is based on collaborative, person-centred approaches that use the least intrusive interventions to increase safety.

The service was established by the federal government and delivered by the Centre for Addiction and Mental Health (CAMH). When people call 988, they’ll be supported by a decentralized, community-based service delivered through 39 partner centres and agencies across the country. These include distress centres and crisis lines, national agencies like Kids Help Phone and the Hope for Wellness Helpline, and local organizations such as South Asian Canadians Health and Social Services, an Ontario-based non-profit in Brampton.

The Distress Centre of Ottawa and Region, one of the centres in the 988 helpline network, takes calls from 613 and 343 area codes. Its responders are trained via the internationally recognized, certified suicide prevention model Applied Suicide Intervention Skills Training — also known as ASIST.

Its responders take ASIST as part of their 60-hour training, which covers everything from the phone system to active listening to crisis intervention. Kathyrn Leroux, the centre’s manager of media, marketing, and communications, has also taken the training.

She notes that having responders nearby enables 988 organizations to draw on local knowledge when callers need other social or emergency services. In cases where a centre is receiving a “rollover” call — that is, from another community or city when the local lines are at capacity — responders rely on services like 211 – a publicly accessible database of community supports – for referrals. Having these designated rollover services helps to avoid long wait times. Where there is a wait time, callers will receive a message encouraging them to stay on the line or the text thread.

Learning from the U.S.

Concerns about capacity have been part of studies about Canada’s 988 rollout, including those the MHCC raised in a 2021 policy brief. Planners of the 988 launch were able to gain insights on this topic based on experiences in the U.S. and the Netherlands (where the number is 113) ahead of implementation.

Since July 2022, the U.S. has invested nearly $1 billion in the service and has responded to nearly five million contacts. In the first year, it has been able to decrease its average response time from 2 minutes 39 seconds to 41 seconds. Its 988 number is supported by more than 200 local and state-run call centres, and over time has expanded to add text and chat services in Spanish along with specialized services for 2SLGBTQI+ youth. Future developments include video phone access to better serve deaf and hard-of-hearing individuals. As the service ramps up, more public campaigns may be on the horizon. A recent USA Today story showed that a year after its implementation, awareness rates (13%) still have a ways to go.

Even with the insights from other countries, Canada’s launch and maintenance of 988 is a complex task. Alongside the country’s vastness, diversity, and principles of inclusion, it needs to deal with technical considerations. To give just one example, the Canadian Radio and Telecommunications Commission (CRTC) had to transition to 10-digit dialing in Newfoundland and Labrador, northern Ontario, and Yellowknife before they could get the 988 number up and running.

People in Canada will start to see information across social media between now and February as the service launches and service providers acclimate. So far, the federal government has allotted $156 million over three years for the service.

As it rolls out, 988 providers will be tracking the number of contacts (calls and texts), wait times, and the abandonment rate – when a caller or texter ends the contact before connecting with a responder – with a view to improving service times.

Say it early, say it often

The phrase “say it early, say it often” serves as shorthand, both for responders and for anyone involved in conversations about suicide. Why? Because it emphasizes an open, straightforward, and non-judgmental dialogue that is at the heart of training initiatives.

“Conversation is important,” Leroux says. “We want to get away from ‘Are you thinking about hurting yourself?’ and ask more straightforward questions such as ‘Are you thinking of suicide?’ and then ‘Have you done anything to harm yourself today?’ Doing that really allows you to focus in and helps people open up. It demonstrates that you are willing to talk about it and talk about it in a straightforward way. It allows you to determine where they are and get people the help they need.”

Distress Centre responders are also trained in crisis de-escalation that uses a range of questions to assist with identifying the scale of the issue and the next steps. No matter the call, the goal is the same, Leroux says: to get people to safety or to a safety plan.

The scale of the issue
Suicide remains a significant public health concern in Canada, affecting individuals of all ages, genders, and backgrounds. It also disproportionately affects certain populations, including girls, men and boys, people serving federal sentences, survivors of suicide loss and suicide attempts, 2SLGBTQI+ groups, and some First Nations, Métis, and Inuit communities.

According to Statistics Canada, about 4,500 people in our country die by suicide every year, which is around 12 people a day. And for every person lost to suicide, many more experience suicidal ideation or attempts.

The reasons for suicide are complex: they include biological, psychological, social, cultural, spiritual, economic, and other factors. According to a leading researcher in the field, the people who think about and attempt suicide are seeking an end to deep and intense psychological pain.

When it comes to preventing suicide, how we talk about it matters. Safe, factual, and responsible portrayals and messaging can have a positive impact. When discussing suicide, it’s also important to include any preventive actions taken, convey narratives that demonstrate hope and resilience about recovery, and mention the resources available for help and support.

Societal shifts
And as we learn more about suicide, the conversation is shifting. The Senate standing committee on social affairs, science, and technology’s recent update to the federal framework for suicide prevention included recommendations to:

• recognize the impact of substance use on suicide prevention
• fund research into interventions
• create a nationwide database to better collect national data related to suicides, attempts, and effective prevention measures
• replace the concepts of “hope and resilience” with “meaning and connectedness.”

This shift in language also resonates with other perspectives; for example, the terms life promotion and wellness, which many Indigenous communities use when discussing suicide prevention. The First Nations Mental Wellness Continuum Framework — developed by the Thunderbird Partnership Foundation with Indigenous and non-Indigenous partners — identifies hope, meaning, belonging, and purpose as underpinning many Indigenous ways of knowing. As the framework explains, aligning these four aspects in a person’s everyday life brings that person a feeling of wholeness that protects them and acts as a buffer against mental health risks and potential suicidal behaviours.

Moira Farr has also noticed a change in the conversation since After Daniel: A Suicide Survivor’s Tale was published in 1999 — a book that delves into the death of her partner. Farr is a journalist and an instructor who researches and writes on a variety of topics for international and national publications.

“I would say there has definitely been a shift in people’s willingness to openly discuss mental health issues, including suicide, in the past 20 years,” she says. “The campaigns to raise awareness about how and where to get help and to get people talking more honestly about their own mental health struggles seem to me to have been a positive force.”

By promoting understanding and empathy, we can create an environment where people feel safe and comfortable discussing their mental health challenges. This includes recognizing that seeking help is a sign of strength — not weakness — and that mental health is just as important as physical health.

“The new helpline underlines the reality and importance of suicide prevention,” Rodrigue says. “It speaks to the fact that suicide is a significant public health issue that affects people of all ages and backgrounds — and can be prevented. This is a collective effort that will help to reach more people in Canada to support their well-being.”

Fateema Sayani is the manager of content & strategic communications at the Mental Health Commission of Canada.

Tools and resources

• If you are thinking about suicide, or worried about someone else thinking about suicide, call or text 988 for suicide prevention support, any time of day or night.
• The Hope for Wellness Helpline continues to provide immediate non-judgmental, culturally competent, trauma-informed emotional support, crisis intervention, or referrals to community-based services for Indigenous Peoples. You can reach Hope for Wellness by calling 1-855-242-3310.
• Children and young adults in Canada in need of mental health support and crisis services can continue to contact Kids Help Phone by calling 1-800-668-6868 or texting CONNECT to 686868 from anywhere in Canada, at any time.
• Non-crisis support. Tip sheet: Where to Get Care — A Guide to Navigating Public and Private Mental Health Services in Canada.
• Resources: Suicide Prevention (MHCC)
• Postvention Resources: Postvention activities are crucial for helping those affected by suicide (e.g., those bereaved after suicide loss) and for reducing the risk of further suicides or crises.
• Further reading: Surviving Suicide Loss.

In this fourth and final piece in the series, we explore the costs of therapy and the financial decisions people make when seeking help.

When Affordable Therapy Network founder Katie McCowan was in her final year of therapist training, she started experiencing mental health challenges and decided to seek therapy.

“I was in school, working as a waitress, not making a lot of money. So I found myself Googling ‘affordable therapy options Ontario,’” she says, referring to her inspiration for launching the Canada-wide online database in 2015. To meet her needs, she used one option (provided by her school) at $40 per session and also tried a private therapist at $140. But while the private sessions were helpful, they cost her a day’s wages. “$40 was affordable, but I wasn’t able to choose my therapist, and therapeutic fit is very important.”

McCowan realized that this was a common challenge and thought, “What if I built a website and listed therapists who offer lower rates so people can connect with them?” She began with her esteemed colleagues, since new graduates often charge less. Word spread. The network grew. And during the pandemic, demand exploded.

The website now lists more than 550 vetted therapists, all with sliding-scale fee options and about half offering subsidized spots at $65 or less (including some pay-what-you-can and pro bono options). “A wide variety of therapists list with us, and most offer a certain number of low-cost spots, maybe five or so, that are subsidized.”

While these lower-cost rates tend to be less than half the price of private therapy, considering today’s socio-economic realities, “I know that’s a stretch for a lot of people,” she says. Still, McCowan acknowledges that fees in the private industry are fair and appropriate. “Therapists don’t charge more than they should. There is extensive training, extensive supervision, and it’s quite challenging work.”

Financial insecurity and therapy
If you feel that life seems more expensive lately, you’re right. According to the Canadian Social Survey on quality of life and cost of living, the consumer price index rose 6.8 per cent in 2022 — the biggest jump in forty years — with costs for food (up 8.9 per cent), shelter (up 6.9 per cent), and transportation (up 10.6 per cent) increasing the most.

Such pressures have had a mental health impact on many people. Half of our population has been affected by “inflation, the economy and financial insecurity,” according to a post-pandemic survey from Mental Health Research Canada (MHRC), and are “showing signs of worsening mental health.” In fact, since the previous year’s poll, this group reported “higher self-rated anxiety (33%) and depression (32%), higher suicide ideation (31%) and alcohol (23%) or cannabis dependency (22%),” among other issues.

Indeed, not only can financial stress impact mental health, it can affect decisions about therapy and other mental health resources. In Canada, psychotherapy and psychology services may be covered (in part or completely) by private health insurance, such as insurance plans provided by an employer, or purchased directly by an individual. Mental health service providers offer more specialized care, which ranges depending on the severity of the issue. Certain services need a doctor’s referral, while some are self-directed and available online or by phone or text message. Others are public (funded by governments) or provided by charities, community groups, and other organizations. The Canadian Mental Health Association, for example, has branch offices to direct people to support, including free counselling provided in some of its 70 regions in 330 communities across Canada.

CMHA programs are “culturally safe and meaningful,” which is significant when looking at the impact of financial insecurity on mental health and access to supports, including therapy, for various populations. To cite just one example, the MHRC survey found that racialized persons, people from 2SLGBTQI+ communities, young adults (ages 18 to 34), students, and those who are unemployed, have low incomes, or are in financial trouble are more likely to report high levels of anxiety.

Fee scales to improve access
To help clients get access to mental health services, the Calgary Counselling Centre has had a sliding fee scale since it opened in 1962, says CEO Robbie Babins-Wagner, who is also an adjunct professor and special instructor at the University of Calgary.

“We have to make sure we meet the needs of vulnerable people, including those vulnerable financially because of health issues, mental health problems, or other social issues,” says Dr. Babins-Wagner, whose passion is “clinical practice and making sure clients get the results they deserve.” Babins-Wagner and her team employ scientific, data-driven research methods and tools, including “session-by-session” outcome measurement (with questionnaire tools in 24 languages) and financial modelling. “We use that data to try and understand how we’re helping people and improve what we’re doing.”

The centre assigns new clients to a counsellor “no later than noon the next day” after receiving a request and uses no formal means testing. “We ask a client what their income is, and we trust them,” she explains. “When a client says they can’t afford the suggested fee, we say, ‘Your counsellor will discuss that with you; the fees are not a barrier to service.’ The counsellor has the discretion to bring it down to, generally, as low as $8 an hour, but if necessary, we’ll bring it lower. We truly don’t want fees to be a barrier.”

The centre collects this data, Babins-Wagner says, “because we want to understand what’s happening for clients and where the pain points are.” Through an internal process using blind data, every time there’s a fee change, we “look at what the suggested fee was, what the client could afford. Then we put that in our database and run that data to see whether clients from certain income groups are struggling more than others and if we need to make changes. Those are the kind of changes we typically make to the fee scale, and we test it to see if it’s achieving the intended benefit, which is meeting client needs.”

With the economic challenges Calgary has endured since late 2014, she says the centre now reviews its fee scale every year or two instead of every five years “because we know we can’t wait, and people are being more impacted than we’ve seen historically. So, we use data and current conditions to look at these factors.”

Finding a way
Dr. Elana Bloom, psychologist and director of campus wellness and support services at Concordia University agrees that “navigating mental health resources can be challenging.” While her expertise isn’t related to affordability per se, she understands the issue based on her clinical practice and is familiar with the mental health resources in her province, particularly for the student population.

“In Quebec, individuals (including young adults) can access mental health and psychosocial services, including psychotherapy and crisis supports, at CIUSSSs” [integrated university health and social service centres and community-based organizations]. At Concordia, we offer an array of mental health services, including wellness programming and psychotherapy with counsellors and psychotherapists. If you’re not able to access services or resources in a timely manner, if there’s a wait-list, another option is to seek services privately.”

Dr. Bloom advocates an “expansive view of wellness and well-being” — where seeing a therapist may be part of a broader wellness strategy that can include self-care, social interactions, physical well-being — and “leveraging technology” to make the most of self-directed mental health tools and resources. “Being a psychologist myself, I believe in the positive impact of psychology and in seeing a therapist,” she says. “But I also think mental health is more than just meeting with a psychologist; it’s important to take care of our own mental health and well-being using many different resiliency-based strategies beyond going to see a psychologist or therapist.”

She also notes that services are available to meet the particular needs of specific populations, such as Indigenous, 2SLGBTQI+, and African, Caribbean, and Black individuals.

Therapy 2.0?
While young people (and the rest of us) are increasingly living their lives online — and this extends to therapy — not all mental health apps are the same. For example, people’s personal data has been shared for marketing purposes and, in one case, a crisis line number in an app was wrong. The Mental Health Commission of Canada discovered that error when consulting with young people to develop Canada’s first e-mental health strategy to improve e-mental health solutions, which will be released in early 2024.

To make sure mental health apps are evidence-informed and safe, the commission also launched a Mental Health App Assessment Framework. App developers, designers, and owners can use it to assess their apps and improve their safety, quality, and effectiveness. The framework includes information as well on safety, social responsibility, and equity and outlines the perspectives of diverse groups, ages, and populations.

In addition to digital options, McCowan says talking to your family doctor can also be important. “I think it’s easy to fall into a spiral where it feels like there’s no way out. Checking in with someone, having an outside perspective, someone offering you any kind of resources, any kind of support is super helpful.”

 Resource: Where to Get Care — A Guide to Navigating Public and Private Mental Health Services in Canada.

 Further reading: How to Break Up With Your Therapist.

Read the entire Money & Mental Health series.