Crisis counseling via text

By Bethany Bray

July 2021

People in distress send messages to the Crisis Text Line 24/7 looking for help and support. The organization has responded to nearly six million chat conversations since the nonprofit was established in 2013. Some people find the text line more accessible and comfortable than in-person talk therapy, notes Ana Reyes, a licensed professional counselor and bilingual manager of clinical supervision at the Crisis Text Line.

In crisis counseling, clients need a safe and empathic environment to disclose deeply troubling thoughts and emotions. But how can crisis responders create this same environment using text messages, which don’t allow the clinician and client to see or hear each other?

Reyes acknowledges that crisis counseling through text feels much different than in-person counseling and demands a different approach from the responder. Words sent via text must be chosen very carefully, with the intent of validating the texter’s experience and building rapport.

“During in-person [counseling] services, my face responds to someone’s sadness. In text messaging, my words have to be that mirror, have to communicate that empathy,” says Reyes, who does group and individual counseling at a private practice in Denton, Texas.

Reyes is among Crisis Text Line’s staff of licensed mental health practitioners who oversee the organization’s volunteer crisis counselors, who are located across the United States and come from a wide variety of backgrounds. These volunteers undergo more than 30 hours of training, a large portion of which is focused on ways to ensure safety and build rapport through text messaging, Reyes notes.

Responders are encouraged to frequently use “feeling words,” Reyes says, because they reflect the emotions a texter is describing and help them feel heard, understood and validated. “Perhaps a texter describes that they’re feeling frustrated,” she explains. “We would name that [in a text response]: ‘It feels like you seem frustrated because your mom didn’t respond in the way you hoped she would’ or ‘It sounds like you’re feeling stuck, and it’s normal to feel stuck when things aren’t going the way you hoped or planned.’” These types of statements not only validate what the texter is saying but also act as a gentle way to de-escalate the crisis, she points out.

Many of the aspects of Crisis Text Line’s response model mirror the work a crisis counselor would do in a traditional session with a client, either face-to-face or via telebehavioral health. Crisis Text Line responders begin by introducing themselves and sending the texter a confidentiality disclosure, Reyes says. They use a warm tone throughout the conversation and use open-ended questions to fully understand the texter’s situation and allow them to talk through the issue and emotions that prompted them to contact the organization.

The responders also assess for abuse, homicidal and suicidal ideation as well as self-harm or nonsuicidal self-injury. However, they don’t begin to weave risk assessment questions into the conversation until after report and trust is established. Letting the texter know that Crisis Text Line asks everyone these questions also keeps them from feeling singled out, Reyes adds.

“We acknowledge their braveness,” Reyes says, and continue to use warm tones and statements that communicate care and validation when determining risk. For example, a responder may text, “Thank you for telling me about the stress you’re facing. I just want to make sure you’re safe, and to make sure I’d like to ask, Do you have thoughts about ending your life?” If they answer in the affirmative, the responder would follow-up with more assessment questions, including whether the person has a plan, time frame or means to carry out their thoughts of suicide.

Crisis Text Line responders do not know the location, name or phone number of the person with whom they are texting, although some texters do choose to disclose their name, Reyes says. However, a supervisor does have access to a texter’s phone number and can arrange for external intervention if the texter is deemed a danger to themselves or others, she adds.

Supervisors monitor anywhere from three to 20 conversations happening live on their computer screen, and they can step in anytime a crisis responder needs additional support. They also triage the incoming texts to immediately assign those with the greatest need and queue other less urgent conversations to wait for the next available responder.

In addition to risk assessment and validation, Crisis Text Line responders help texters identify goals and next steps that could improve their situation in the short or long term, Reyes says. Responders then work collaboratively with the texter to explore the resources they have in their life, from self-care to community and social supports. If needed, they may also suggest resources to help texters with a limited or inadequate support system. They share links to national organizations that can direct them to support in their local area because they do not know where the texter is located, Reyes explains.

At the end of the conversation, the responder checks in with the texter one final time to assess how they’re feeling and validate the work they’ve done. They also summarize the next steps and resource options they discussed during the chat. Most importantly, the responder honors the courage it took for the texter to reach out and reminds them that the Crisis Text Line is available 24/7 if they need to chat again, Reyes says.

Many of the people who reach out to the organization in distress are younger, simply because younger generations are usually more comfortable with text messaging. Reyes, who recently completed a doctorate in the counseling program at the University of North Texas, notes that common presenting issues include anxiety, stress, depression, and feelings of isolation and uncertainty — many of which have been heightened during the COVID-19 pandemic — as well as bullying or academic or school-related pressures. There is also a subset of texters who struggle with sexual or gender identity issues, such as the decision to come out to family or friends, she says.

The organization hopes to reach more people with its upcoming launch of Spanish-language services, which Reyes is helping to plan.

Crisis Text Line isn’t meant to be a substitution for long-term counseling, Reyes notes, but it can be a big help to people in moments of despair. The organization does see an increase in text volume in the evening hours, which is often when people are experiencing acute moments of despair, she says. It can also be a first step toward connecting with a local counselor for long-term care.

“It’s beautiful to see how our volunteers learn and blossom through training and experience. This work is meaningful, and it is heavy, but there is also this deep knowledge that you’re helping someone who hasn’t otherwise received any support that day,” Reyes says. “The need at the center of that is decreasing the stigma of mental health services and increasing access to services regardless of financial need or language.”

In 2020, the Crisis Text Line engaged in 1.4 million conversations with 843,982 texters.

The organization began receiving a higher-than-usual volume of texts in March 2020, as the COVID-19 pandemic began to affect Americans’ daily life. Perhaps unsurprisingly, the most common struggles these texters identified were stress and anxiety. However, the Crisis Text Line reports that the volume of conversations in which texters disclosed feelings of depression or sadness dropped by 10% between 2019 and 2020.

Additionally, conversations in which texters expressed thoughts of suicide dropped by 20% from 2019. The Crisis Text Line supported 26,629 conversations in 2020 during which the texter was deemed to be “at imminent risk of suicide because they mentioned that they had thought about ending their lives, they had a plan, the means, and wanted to make an attempt within 48 hours.”

The Crisis Text Line has made this data publicly available in a report, “Everybody hurts 2020: What 48 million messages say about the state of mental health in America.” View the report, including data breakdowns by issue, demographics and state-by-state, at crisistextline.org/everybody-hurts.