Saving lives, showing care via text messaging

As problems like depression, suicidal thoughts and substance abuse soar, a national network of counsellors in the US offers intervention 24 hours a day

Right now, algorithms are scouring vast data sets to determine the news you will be exposed to today on social media, the advertisements that will appear alongside your search results and what you will end up being charged for your next car ride.

But can algorithms be used to address more urgent social and individual problems, like how to build trust or provide effective care? Can algorithms be used to increase love and kindness in the world?

These are the sort of questions that the people at the Crisis Text Line - a non-profit organisation that provides crisis intervention 24 hours a day via text messaging to the number 741741 - have been focusing on for four years.

Their goal is to improve their own crisis counselling, shed light on the pain and suffering that Americans are experiencing every day and show how we can all find ways to respond better. Given the alarming rates of anxiety, loneliness, suicidal ideation, depression and substance abuse nationwide, this work warrants major attention.

Two years ago, I reported on the Crisis Text Line and explained how it vets, trains, coaches and supervises volunteers scattered across the country, enabling them to provide high-quality counselling over a digital platform.

At that time, the service had 600 counsellors who had exchanged eight million messages with people seeking assistance. Today, it has over 3,700 counsellors who have exchanged 56 million messages.

And that number is expected to double within a year.

"We're in a growth industry," said Ms Nancy Lublin, who founded the Crisis Text Line "because pain is a growth industry".

The Crisis Text Line works in partnership with close to 200 city-and state-level agencies, as well as universities and non-profit services that offer assistance for a range of issues, including eating disorders, addiction, suicide prevention and child abuse. It is demonstrating the value of having a single national text-based hotline for crisis intervention that cuts across issue areas and geographies.

Text messaging has turned out to be a surprisingly effective way to do crisis counselling. To begin with, it is the default mode of communication for young people.

Three-quarters of Crisis Text Line's users are under 25 years of age and 12 per cent are under 13.

"Texting also offers anonymity," said licensed clinical social worker Becka Ross, who spent 12 years as a therapist for youths at risk and now works as a supervisor for Crisis Text Line. "Almost two-thirds of the people who text in tell us something they've never told another human being. And they can text us from anywhere and nobody knows.

"If they were talking to a friend or calling a hotline, they'd have to go somewhere private. But a student can text us from the lunchroom when they're being bullied or the school bathroom."

Crisis Text Line concludes every conversation with an automatic message asking users if they found the conversation helpful. Over all, 86 per cent respond yes, up from 76 per cent four years ago, reflecting improvements in the organisation's training and supervision.

Twenty per cent of users also complete a post-conversation survey, providing additional information about themselves and their experience. Recently, the organisation hired Dr Shairi Turner-Davis, a physician with experience in trauma, to serve as its chief medical officer. "My job is making sure that counsellors don't get burned out and ensuring that we're keeping them up to speed on the latest in the fields of trauma, social work and crisis intervention," she said.

An ideal conversation involves 40 to 60 messages exchanged over 45 minutes. Effective conversations go through five stages - building rapport, exploring support systems, identifying a goal, collaborative problem-solving and wrapping up and sharing resources.

Users often end conversations with messages like "Thanks for showing me love and humanity"; "Thanks for helping me feel more in control"; "Thank you for letting me know I'm not alone"; "You made me feel valuable and worthy"; "It helped so much just to have someone on the other line in the middle of the night".

These are successful outcomes, but a person who is depressed, has an eating disorder, is engaged in self-harm, or is in despair because of bullying or academic pressures often needs longer-term support.

Crisis counselling is not meant to be therapy. "The job of a crisis counsellor is to help move someone in pain from a hot moment to a cool calm," Ms Lublin says.

Counsellors will often offer connections to local services for follow-up help. In the 1 per cent of cases in which counsellors and supervisors believe a texter is at serious risk for suicide, the service initiates what is called an "active rescue", calling the local police or 911.

What those 56 million text messages add up to is an extraordinary opportunity to save lives. The data can help identify when and where problems are spiking, and what interventions are warranted.

A LISTENING EAR

Almost two-thirds of the people who text in tell us something they've never told another human being. And they can text us from anywhere and nobody knows. If they were talking to a friend or calling a hotline, they'd have to go somewhere private. But a student can text us from the lunchroom when they're being bullied or the school bathroom.''

MS BECKA ROSS, a licensed clinical social worker who spent 12 years as a therapist for youths at risk and now works as a supervisor for Crisis Text Line.

A HELPING HAND

This is all about strangers helping strangers. It's such a hopeful thing in these strange, dark times.''

MS NANCY LUBLIN, who founded the Crisis Text Line.

For example, although National Suicide Prevention Awareness Month is observed in September, data show that suicidal ideation peaks in April and May - critical information for mental health counsellors in schools and universities.

Suicidal ideation is also triggered by popular culture aimed at youth.

"Last year was a particularly strong spring in part because of 13 Reasons Why, the Netflix show," Ms Lublin said. "Close to 5 per cent of our traffic explicitly mentioned the show last spring."

The data can be used to flag issues that require greater attention.

For example, one in five conversations from users under the age of 13 mention self-harm, usually cutting.

In 40 per cent of those conversations, the words "scared" and "alone" show up. After counselling, 62 per cent of those texters report feeling less alone or more hopeful.

These sentiments have a direct implication for counsellors, said the organisation's chief data scientist Bob Filbin. "These texters want to be heard," he said.

"Another thing we've seen that has been surprising," Ms Lublin said, "is the number of kids who are feeling something intensely - a break-up, suicide, depression, school pressure - who have a parent in the house with them while they're texting us and don't feel they can communicate with their parent. It's heartbreaking."

Some of the insights from the data raise questions about prevailing assumptions in crisis counselling. One is the belief that counselling must be tailored by issue.

"There's this idea that a person experiencing a particular crisis needs a particular type of care," Mr Filbin said. "So if it's sexual abuse or LGBTQ (lesbian, gay, bisexual, trans and queer) or suicidal ideation, the care or the training would need to be different in each case." But when Mr Filbin examined the data, he found that not to be the case.

Similarly, it has been assumed that counsellors do better when they come from the same geographic area or have the same gender identification as the person they are assisting.

This assumption has implications for the placement and staffing of crisis centres. "We tested if matching by locality or gender matters," Mr Filbin said.

"The data showed that it didn't."

"Other things matter a lot more," he said. "There are universal skills that make or break a conversation: active listening and collaborative problem-solving are the big two."

Here, too, the data has been instructive. "The most important part of what we do is 'strengths identification'," Mr Filbin added.

"Words like 'smart', 'brave' and 'proud' show up a lot in highly rated conversations. What really turns conversations from hot to cold is reminding people that they are powerful enough to move themselves out of crisis.

"The data shows that it has to be reinforced."

"Strength identifications can't be false," Ms Lublin adds.

"It has to be authentic. We're really just echoing back to you and reminding you how strong you are."

Recently, Crisis Text Line has anonymised its data and opened it up to researchers. Currently, 15 teams have received access and are exploring questions like: How can we better understand the extent of child abuse by examining the language that children use in conversations (they often don't mention the word 'abuse')? How do hate crimes, legalisation of gay marriage or anti-gay bias at the local level impact mental health in LGBTQ communities? What is the relation between suicidal ideation and altitude? (Montana, Utah and Idaho rank first, second and third for highest levels of suicidal ideation.)

Researchers at Stanford University are using the data to determine why some crisis counsellors are more effective than others at making people feel better.

With millions of messages, it is likely that similarities will be discoverable among some types of interactions, according to Stanford associate professor of computer science Jure Leskovec.

A smart system can then analyse what successful counsellors did and provide feedback in real time.

"One thing we know is that successful talk therapists adapt their therapy to the patient," said Mr Tim Althoff, a doctoral candidate in computer science at Stanford who collaborated with Prof Leskovec and another colleague on a paper published last year that applied large-scale computational linguistics to millions of conversations from the Crisis Text Line.

"We found that better counsellors are aware of how the conversation is going and change their language along the way," Mr Althoff said. "The less successful counsellors are either not aware that things are not going well - they're missing subtle signs - or maybe they are aware but they don't know how to adapt their counselling."

He added: "We can build tools to help them. Like a little traffic light in your chat box offering ideas for how to personalise something better, or how to make a generic response more creative."

The Crisis Text Line is preparing to begin work in Canada and Britain, and is exploring expansion to 17 other countries. "The technology is going to be done out of New York," Ms Lublin said.

"We're about to hire an army of engineers who carry blue light sabers to make it happen!"

The main bottleneck for growth has been the time it takes to recruit and train counsellors. "We need more counsellors," Ms Lublin added, "especially on the West Coast and Hawaii" - since the time difference allows wide-awake counsellors to deal with people in crisis farther east, when usage spikes in the middle of the Easterners' night.

"This is all about strangers helping strangers," she said. "It's such a hopeful thing in these strange, dark times."

NYTIMES

A version of this article appeared in the print edition of The Sunday Times on December 17, 2017, with the headline 'Saving lives, showing care via text messaging'. Print Edition | Subscribe