The Veterans Crisis Line's hardest calls go to untrained responders
Summary
Veterans die by suicide at more than twice the rate of nonveterans, and VA calls suicide prevention its top clinical priority. Two GAO reports, about 16 months apart, trace what that priority looks like in practice at the Veterans Crisis Line. In February 2024, GAO described VA's 2023 plan to pull the crisis line out of a shared mental-health office and give it more autonomy as a standalone program, in part to reflect its priority. In June 2025, GAO found the line's operational reality still strained: as of March 2025, 84% of its main-line responders had no training for the complex-caller unit they were increasingly being routed to, and the line had quietly withdrawn its own procedure for disclosing when its actions or inactions contributed to a customer's death.
A reorganization meant to raise the priority
VHA created the Office of Mental Health and Suicide Prevention (OMHSP) in May 2017, folding the Veterans Crisis Line and the Suicide Prevention Program in alongside its broader mental-health and analytics functions. By September 2023, OMHSP's Suicide Prevention branch was allocated more than 2,600 full-time staff -- nearly all of them, 2,568 positions, dedicated to the Crisis Hotline itself, which had grown after joining the national 988 suicide hotline in 2020. But branch officials said being embedded in a larger, more clinically-focused office cost them autonomy: decisions required multiple levels of approval. In July 2023, VHA approved pulling the Suicide Prevention Program and Crisis Hotline out of OMHSP into their own standalone office reporting directly to VHA's Office for Clinical Services -- a change affecting about 2,000 employees, planned for 2024, intended partly to signal that suicide prevention is a priority in its own right.
A crisis line answering more calls than ever
Whatever else changed, the workload didn't shrink. The VCL logged about 3.8 million customer interactions -- calls, texts, and chats -- from fiscal year 2021 through fiscal year 2024, growing every year. Calls still made up the bulk of contacts, at 83%, but texts, though only 7% of the total, grew fastest: more than 80% over the period, versus nearly 40% growth for interactions overall.
View data as table
| All interactions (calls, chats, texts) | 40% |
|---|---|
| Texts specifically | 80% |
The overflow goes to responders who were never trained for it
The VCL's main phone line is staffed by responders who answer general calls; a smaller, specially trained unit handles 'customers with complex needs' (CWCN) -- high-frequency or difficult callers who need a different approach. In March 2024, the VCL changed its procedure so that when no CWCN responder is available, callers are immediately redirected to the main line instead of waiting -- a wait that used to run 180 seconds. As of March 2025, 84% of main phone line responders had received no training for CWCN calls. Yet from the procedure change through September 2024, main-line responders answered more than 6,000 calls meant for the CWCN unit -- about a quarter of everything the CWCN unit handled in that stretch. In the previous three and a half years combined, fewer than 14,000 such redirects had happened at all.
View data as table
| Prior 3.5 years (avg. redirects/month) | 333.3 |
|---|---|
| March-September 2024 (avg. redirects/month) | 1,000 |
's own survey of responders backed up the concern: main-line staff described struggling with abusive or difficult CWCN callers they weren't trained to handle. VCL officials acknowledged those responders may need more recovery time after such calls, but the line hadn't compared the quality of CWCN calls handled by trained versus untrained responders -- the comparison that would show whether the shortcut is actually working. Responder turnover ran 17% in 2024.
And when something goes wrong, there's no procedure to say so
The VCL does review flagged incidents -- checked 17 of them and found the line reviewed each one and, where warranted, identified what went wrong and coached the responder involved. But in July 2024, the VCL withdrew the section of its policy that spelled out which incidents warranted telling a customer or their family, and how -- after concluding, in consultations with 's Office of General Counsel and other offices, that the clinical directive it had been relying on didn't actually apply to a non-clinical service like the crisis line. No replacement procedure has been established, and officials told it's unclear whether VHA plans to write one. made four recommendations covering the CWCN routing risk, digital-services staffing, a chat-platform technical fix, and the missing disclosure procedure; concurred with all four.
The takeaway
- The line is handling more calls with a training gap at its most sensitive point. Complex-caller calls redirected to untrained main-line responders ran at roughly three times the prior rate after a March 2024 procedure change, even as 84% of main-line responders remained untrained for those calls as of March 2025.
- A structural fix arrived before an operational one. VHA's 2023-approved plan to give the Crisis Line its own standalone office, implemented in 2024, was meant partly to raise its priority -- but 's 2025 follow-up found the day-to-day realities of staffing, training, and routing still unresolved.
- The line has no way to tell a grieving family what went wrong. withdrew its own procedure for disclosing critical incidents in July 2024 and hasn't replaced it, even as 's strategic plan lists transparency and accountability as an organizational goal.
Findings on VCL operations, interaction volume, the CWCN routing procedure, and the withdrawn disclosure procedure are from -25-107182, 'Veterans Crisis Line: Actions Needed to Better Ensure Effectiveness of Communications with Veterans' (June 2, 2025), read directly in full. Findings on OMHSP's organizational history and VHA's 2023 restructuring plan are from -24-106023, ' Health Care: Organization of the Office of Mental Health and Suicide Prevention' (February 2024), read directly in full via an archived copy after the current gao.gov asset URL blocked direct access. The two reports examine the same suicide-prevention apparatus from two angles about 16 months apart -- one on how it's organized, the other on how it actually operates.
Sources(2) ▾
- U.S. Government Accountability Office, Veterans Crisis Line: Actions Needed to Better Ensure Effectiveness of Communications with Veterans (2025-06-02) — -25-107182, a report to the Chairman of the Senate Committee on Veterans' Affairs, examining Veterans Crisis Line (VCL) call/text/chat volume, operating procedures, and incident-monitoring practices. Distinct from doc-gao24-106023 (the organizational-placement facet, published about 16 months earlier). Direct gao.gov PDF fetch returns HTTP 403; fetched directly from files.gao.gov (HTTP 200). gao.gov · original document
- U.S. Government Accountability Office, VA Health Care: Organization of the Office of Mental Health and Suicide Prevention (2024-02-29) — -24-106023, a report to congressional committees (mandated by the Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019) examining how organized its suicide-prevention programs, including the Veterans Crisis Line's home office, and VHA's 2023-approved plan to restructure that placement. Published about 16 months before doc-gao25-107182's operational findings. Direct gao.gov PDF fetch returns HTTP 403; fetched via an existing Wayback capture. gao.gov · original document
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An average of 17.6 U.S. veterans died by suicide per day in 2022 -- more than double the rate for nonveterans -- and calls suicide prevention its top stated clinical priority. runs the Veterans Crisis Line (VCL), a 24/7 phone, chat, and text service, to help. In February 2024⧉, examined how organizes its suicide-prevention programs, including VHA's 2023 plan to restructure the VCL's place in that organization. In June 2025⧉ -- about 16 months later -- examined how the VCL actually operates, and found the line handling record volume with training and accountability gaps that put both customers and responders at risk.