Abstract
Objective: Crisis Text Line (CTL), the largest provider of text-based crisis intervention services in the U.S., has answered nearly 7 million conversations since its inception in 2013. The study's objective was to assess texter's perceptions of the effectiveness of CTL crisis interventions. Method: Survey data completed by 85,877 texters linked to volunteer crisis counselor (CC) reports from October 12, 2017, to October 11, 2018 were analyzed. The relationship of several effectiveness measures with texters' demographic and psychosocial characteristics, frequency of CTL usage, and texters' perceptions of engagement with their CCs was examined using a series of logistic regression analyses. Results: By the end of the text-based conversation, nearly 90% of suicidal texters reported that the conversation was helpful, and nearly half reported being less suicidal. Conclusions: Our study offers evidence for CTL's perceived effectiveness. These findings are of critical importance in light of the launch of a nationwide three-digit number (988) for suicide prevention and mental health crisis supports in the U.S., which will include texting.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 583-595 |
| Number of pages | 13 |
| Journal | Suicide and Life-Threatening Behavior |
| Volume | 52 |
| Issue number | 3 |
| DOIs | |
| State | Published - Jun 2022 |
Funding
This project was funded by the American Foundation for Suicide Prevention (SRG‐0‐110‐15) and Crisis Text Line. MSG is an uncompensated member of Crisis Text Lines' Clinical Advisory Board. AP and CG are uncompensated members of Crisis Text Lines' Data Advisory Board. AE, DH, and CK have no conflicts to declare. SG is employed by the Crisis Text Line. Our findings from 85,877 texters indicated that most people who text CTL perceive their CC as having genuine concern for them. Most CTL texters (86.5%) found their conversations with a CC helpful, with a substantial minority reporting feeling more hopeful (37.8%), less depressed (27.6%), less overwhelmed (39.5%), and suicidal texters reporting feeling less suicidal (46.1%). A broad theme across our findings was their similarity to results of the evaluation of Lifeline's chat crisis services (Gould, Chowdhury et al., 2021), which provides a key benchmark due to similarity in measures and setting, something found rarely in this field. In comparison to current CTL findings, that evaluation found that 66.8% of Lifeline chatters reported finding their conversation helpful, 31.5% were more hopeful, 26.8% were less depressed, 37.5% were less overwhelmed, and 45% of suicidal chatters were less suicidal. When interpreting comparisons with the chat evaluation, it should be noted that the CTL sample was 23% suicidal, whereas the Lifeline chat sample was almost 84% suicidal. As the current findings note, suicidal texters had somewhat less positive outcomes than non-suicidal texters, which might partially explain the slightly less positive perceptions among Lifeline chatters, most of whom were suicidal, compared to CTL texters—most of whom were not. Texter perceptions of CCs' genuine concern for them had the strongest associations with perceived effectiveness of the text conversation in the current study. This association is highlighted in earlier studies of crisis interventions. Mishara et al. (2007) found that counselors' behaviors underlying callers' engagement with counselors were significantly related to positive outcomes for crisis callers. Similarly, an earlier Lifeline evaluation (Gould et al., 2016) found that higher levels of engagement enhanced counselors' chances of mitigating imminent suicide risk through collaborative interventions and reduced needing to involve emergency services. Lifeline chatters' engagement with counselors—measured by the feeling that their counselors were genuinely concerned for their well-being and understood them, or that they agreed with the counselor on plans—had the strongest associations with chatters' perceptions that the chat was effective. Counselors' success in engaging callers, chatters, and texters may facilitate “comforting communication” to reduce emotional distress (Caplan & Turner, 2007). These findings support CTL's emphasis on training volunteer CCs in building rapport using “good contact” techniques (Crisis Text Line, 2017) and Lifeline's policy on good contact and active engagement with all callers (Draper et al., 2015). Younger texters were more likely to find the conversation helpful than older texters, despite controlling for younger texters' more favorable perception of the CC's genuine concern and the remaining covariates. Older texters were more likely to be less hopeful, and more depressed, overwhelmed, and suicidal at the end of the conversation. While CTL appears to address the needs of individuals aged 24 years or younger, who represent three-quarters of CTL texters, more attention is needed to appeal to and more effectively intervene with texters across the lifespan. Lifeline's chat services were similarly more effective for minors than older age groups (Gould, Chowdhury et al., 2021). To our knowledge, this is the first study examining the association of a crisis service's effectiveness with a client's race (although limited information is available regarding association with ethnicity). Thus, the current study addresses a critical knowledge gap about disparities in health care quality in the U.S. (Fiscella & Sanders, 2016). Texters who identified as Black or African American had higher odds than White texters of reporting being more overwhelmed or suicidal at the end of the conversation, even after controlling for all covariates. However, the magnitude of the differences in outcomes reported by Black or White texters was relatively small and, importantly, no differences emerged concerning perceptions of CCs' genuine concern, the conversation's overall helpfulness, or their hopefulness or depression at the conversation's conclusion. Texters who identified as Hispanic/Latinx/of Spanish origin provided more favorable feedback than White texters about the helpfulness of CTL's conversations. This is consistent with findings from an evaluation of Lifeline's crisis center follow-up initiative showing that Hispanic callers had a more positive perception of the intervention—specifically, they had higher odds than non-Hispanic callers of saying that follow-up calls stopped them from killing themselves and kept them safe (Gould et al., 2018). Given the high prevalence of mental health symptoms among CTL texters and the small proportion who reported receiving professional help (Pisani et al., 2022), our findings underscore a need to focus within and beyond CTL on long-term needs of texters with the most severe mental health concerns. Several of the current findings highlight that the most distressed texters (those with high depression, anxiety, social isolation and frequent texting) felt less relieved at the end of their crisis conversation than asymptomatic texters or those who texted only once during the study period. Depressed, anxious and socially isolated texters had lower odds than less symptomatic texters of reporting the conversation as helpful or feeling more hopeful afterward and had significantly higher odds of reporting feeling more depressed, overwhelmed, or suicidal at the end of the conversation. Individuals who frequently texted (i.e., 10 or more times in the one-year study period) had a similar pattern of results as symptomatic texters. Providing relevant and accessible referrals to texters is a key component of CTL's training (Crisis Text Line, 2017); its enhancement is recommended to build more effective ways of connecting the most distressed texters with various kinds of follow-up care and evidence-based interventions. Crisis Text Line's ability to reduce suicidality in nearly half of suicidal texters can be considered a clinically meaningful accomplishment. This reduction in risk at a moment of crisis can provide texters with an opportunity to seek further help and engage in additional interventions that could save lives and have prolonged impact. Our finding that nearly half of suicidal texters reported feeling less suicidal after the text conversation is comparable to the reduction in suicidal ideation among chatters at the end of Lifeline crisis chat interventions (Gould, Chowdhury et al., 2021). This level of improvement mirrors the range of improvements reported after psychotherapy (Strauss et al., 2021). In contrast to CTL's positive outcomes, yet consistent with Lifeline crisis chat outcomes (Gould, Chowdhury et al., 2021), a small minority of all texters did not feel their conversations were helpful (13.5%) or felt less hopeful (6.4%), more depressed (5.9%), more overwhelmed (6.3%) or more suicidal (5.1%) after their conversations. While it would be ideal to have all or nearly all texters experiencing an improvement at the end of conversations, this is an unrealistic expectation given this population's distress levels (Pisani et al., 2022) and similar findings of worsening symptoms for a small portion of patients following psychotherapy (Strauss et al., 2021). This study has several limitations. Firstly, only 22.5% of texters completed the voluntary post-conversation survey. The survey weighting strategy we explored did not add meaningfully to our understanding of the population (Pisani et al., 2022). However, there are likely to be other factors, not measured in this study, that are associated with the completion of the survey and could yield some unknown bias. Second, we defined our sample for the current evaluation based on whether texters answered the first item in the survey. While this choice produced the largest sample size, it introduced a great deal of item-level missingness. This was the rationale for conducting weighted analyses to account for missingness in both covariates and outcomes. Third, this evaluation focused on post-conversation surveys from texters who exchanged at least 10 messages in their conversation. Thus, we do not know anything about individuals who disengaged before reaching a CC or abandoned the conversation before exchanging 10 messages. Finally, this evaluation covers short-term self-reported outcomes, and includes no follow-up beyond the immediate post-conversation period. Notwithstanding these limitations, the study has numerous strengths. This is the first study to estimate the effectiveness of CTL, the largest provider of crisis text-based services in the U.S. Furthermore, the size and diversity of the sample provided enough statistical power to assess the differential effectiveness of the intervention by race—the first such assessment for any crisis intervention. The large sample size also allowed us to examine the relationship of the outcomes with several texter characteristics and their perceived engagement with their CCs, crucial elements to person-centered care. In conclusion, our study offers novel empirical evidence for the short-term effectiveness of CTL's services. The vast majority of texters reported that the conversation was helpful, and a sizeable minority reported feeling more hopeful, less depressed, less overwhelmed, and less suicidal after their conversation. The finding that nearly half of suicidal texters reported feeling less suicidal after the intervention aligns with Lifeline crisis chat intervention's reduction of suicidal risk and may represent the level of accomplishment that is feasible in one crisis session. Our findings also provide some empirical evidence for CTL's success in addressing unique needs of racially and ethnically diverse populations. Overall, texters across different races and ethnicities perceived their CTL CCs as having genuine concern for them and the effectiveness of the service was largely similar for all texters. This is a step toward overcoming racial and ethnic disparities in mental health care in the U.S. (Substance Abuse and Mental Health Services Administration, 2015). Suicide prevention and mental health crisis intervention services in the U.S. are receiving unprecedented attention as evidenced by the Department of Health and Human Services' mid-2022 launch of the 988 nationwide mental health crisis response line (Federal Communications Commission, 2022). The Federal Communications Commission mandated that the national crisis line offer texting alongside voice to access the service (Federal Communications Commission, 2021). This is important because online and texting crisis interventions are more likely than telephonic options to be used by young people (Haner & Pepler, 2016; Mokkenstorm et al., 2017). Young people are also more likely to discuss “weighty problems,” like mental health problems and suicide, on an online platform than by telephone (Haner & Pepler, 2016; Fukkink & Hermanns, 2009). Calls, texts, or chats to 988 will connect distressed individuals to trained crisis counselors of the National Suicide Prevention Lifeline (Lifeline) network of over 200 certified crisis centers in 50 U.S. states and the District of Columbia. The positive impact of 988 depends upon the effectiveness of the services provided by the U.S. mental health and suicide crisis response system (Gould & Lake, 2021). The nation's largest provider of crisis counseling via text is Crisis Text Line (CTL) (https://www.crisistextline.org/). CTL is a non-profit organization that provides free, 24/7 crisis counseling services via text messaging across the country; their volunteer crisis counselors (CCs) have engaged in nearly 7 million text-based conversations since its 2013 inception (Crisis Text Line, 2022). CCs receive 30 h of interactive online training in building rapport using de-escalation and good contact techniques; risk assessment; collaborative problem-solving; and action planning. Once on the proprietary platform, they receive close supervision from salaried mental health professionals monitoring the text conversations. Research using CTL anonymized data has contributed to knowledge about texters' presenting psychosocial issues (Szlyk et al., 2020), help-seeking behavior by rural adolescents (Thompson et al., 2018), and suicide contagion following Netflix's release of 13 Reasons Why (Sugg et al., 2019). However, no study has yet focused on texters' perceptions of effectiveness of CTL's service. Numerous pertinent evaluations have been conducted of the Lifeline (see Gould & Lake, 2021 for a summary of this evidence). These evaluations bolstered support for establishing the national three-digit crisis number and provided substantial evidence regarding effectiveness for suicidal individuals. Findings include: significant reductions in intent to die, hopelessness, and psychological pain over the course of their crisis call (Gould et al., 2007); post-call follow-ups with callers have a positive impact—80% of interviewed callers indicated that the follow-up intervention stopped them from killing themselves, and 91% reported that it kept them safe (Gould et al., 2018); crisis counselors secure caller collaboration on an intervention on over 75% of imminent risk calls (Gould et al., 2016); and emergency services are involved on 43% of imminent risk calls from the person at risk (Gould et al., 2016), and on 58% of calls from concerned third parties (e.g., friends or family members) (Gould, Lake et al., 2022). In February 2022, CTL officially became a Lifeline network center. The Lifeline Crisis Chat (LCC) network, which serves all ages, has grown extensively since its formal establishment in 2013, answering over 200,000 chats in 2020 (Gould, Chowdhury et al., 2021). A study assessing the effectiveness of LCC employed 13,130 linked pre- and post-chat surveys (Gould, Chowdhury et al., 2021). Chatters were significantly less distressed at the end of the chat intervention than the beginning. This is important because the vast majority seeking help from LCC were highly distressed. Moreover, almost 84% of LCC chatters endorsed either current or recent suicidal ideation on the pre-chat survey-markedly higher than the estimated 23% of Lifeline callers identified by silent monitors as suicidal on the day of or day before their calls. Findings aligned with research reporting that crisis chatters reveal higher rates of suicidal ideation than crisis callers (Fukkink & Hermanns, 2009; Haner & Pepler, 2016; Lake et al., 2022). By the chat's conclusion, two-thirds of suicidal chatters reported the chat as helpful and nearly half reported being less suicidal, offering empirical evidence for the effectiveness of Lifeline's crisis chat services. Lifeline added crisis text services in 2021; this service has not yet been evaluated. Thus, the current evaluation of CTL is both novel and critically needed. We designed this evaluation to parallel our earlier evaluation of LCC (Gould, Chowdhury et al., 2021), employing similar measures and methods where feasible, to provide comparable effectiveness information. This study's overarching goal is examining texters' perceptions of the effectiveness of CTL's intervention for the general population of texters and particularly suicidal texters. Specific aims focus on (i) the extent to which texters feel their CCs are genuinely concerned about them; (ii) texters' perceptions of CTL's effectiveness, as assessed by the extent to which texters feel the conversation was helpful and whether they reported feeling more hopeful, less depressed, less overwhelmed, and less suicidal at the text intervention's conclusion; and (iii) the relationship between texters' perceptions of CTL effectiveness and texters' personal characteristics, number of CTL conversations during a 12-month period, and perceptions of CCs' genuine concern. With the imminent transition to 988 as the nationwide number for suicide prevention and mental health crisis response, the role of text-based crisis interventions in the U.S. will increase greatly. The current evaluation of CTL is thus more important and timelier than ever. Crisis Text Line (CTL), the largest provider of text-based crisis intervention services in the U.S., has answered nearly 7 million conversations since its inception in 2013. The study's objective was to assess texter's perceptions of the effectiveness of CTL crisis interventions.
Keywords
- 988
- CTL
- crisis interventions
- effectiveness
- suicide
ASJC Scopus subject areas
- Public Health, Environmental and Occupational Health
- Psychiatry and Mental health
- Clinical Psychology
