They call me gay and fat and I don’t know what to say… I feel completely invisible… I want to die or run away… I’m recovering from anorexia but I feel like I’m relapsing… I don’t want to live anymore. 

These poignant messages reflect the types of texts the Crisis Text Line, a US organisation offering free 24/7 text support, has seen day in and day out for the past five years. Because the organisation’s counsellors have exchanged a whopping 81 million text messages and counting during this timeframe, it has a lot to teach us about mental health.


To learn more, I spoke to Dr. Shairi Turner-Davis, Crisis Text Line’s first Chief Medical Officer. Turner’s a Harvard-trained internist and pediatrician who began her career as the Chief Medical Officer in the Florida Department of Juvenile Justice, before becoming the Deputy Secretary for the Florida Department of Health.

It was during those years that she became interested in the role trauma plays in mental health.

“I was looking at and working with populations who had experienced childhood trauma, particularly in the juvenile justice setting. This was back in the mid-2000’s. Trauma informed care and our understanding of the impact of adverse childhood experiences was really just surfacing, but for me it was an enlightening connection between child abuse, neglect and family dysfunction and either adolescent or adult mental illness, behavioural issues, learning disabilities, or chronic health conditions”, she explains.

Later, Dr. Turner did consulting for the organisation, Aquifer, and in the course of her work, she created continuing medical education for primary care practitioners.

The aim of the education was to teach doctors, “…how many of their patients probably have experienced trauma and how that would surface within the office setting and with patients compliance and ability to care for themselves, and then also as a tie to substance use and abuse”, she explained.

From there, she moved on to her current position at Crisis Text Line where she focuses on delivering high quality crisis support to texters and being a leading voice for the organisation’s primary goals: innovation and empathy.

A typical day at the Crisis Text Line

 

On a typical day, the Crisis Text Line might have anywhere between 3,000 and 4,000 conversations with people in crisis.

Most frequently, the texts that come in are about relationship problems (41.5%), but depression (33.8%), suicide (19.5%), loneliness/isolation (14.2%), and self-harm (10%) are other common subjects


Co-occurring issues affecting texters. Data valid October 2018. Source: crisistrends.org


Less often, the organisation is contacted about emotional abuse, bullying,  body image, physical & sexual abuse, sexual identity, and substance abuse. 

To handle all the texts, Crisis Text Line has hundreds of volunteer counselors. The crisis counselors are supervised by mental health professionals who oversee their conversations.  Each counselor receives 30 hours of online training focused around de-escalating crises and risk assessment.

Counselors assess texters for suicidal ideation, plan, means and timeframe. If they display all four of those components, counselors send law enforcement to do a wellness check, since they’re deemed a suicide risk. While the need for wellness checks varies, Dr. Turner told us that on the most recent day’s data, it had occurred 23 times.


Statistics taken from Crisis Text Line October 2018. Source: crisistextline.org


Trying to ferret out whether someone’s at risk of suicide is a delicate balance. Dr. Turner explains, “We use what’s called an ‘expression of care model’ to introduce the topic of asking someone if they’re suicidal. So, since we always ask and we do a risk assessment in every conversation, let’s just say at face value, someone is texting in because they broke up with their boyfriend. They haven’t expressed any suicidal ideation.

“Instead of just jumping in and saying very abruptly, ‘Do you think you’re going to kill yourself?’ that’s very off-putting and texters, we found, would disengage.

“So, what we teach our crisis counsellors to do is to express care, so if someone says, ‘I just broke up with my boyfriend’, you respond in more of an empathetic way and say things like, ‘That’s something that could be very stressful and I care about you, I want to ask whether you have had thoughts of death or dying?’

“So, it’s the beginning of the risk assessment asking about suicidal ideations or thoughts of death and dying, but couched in terms of expressing care for the person and their situation”, she says.

In addition to assessing suicide risk, Crisis Text Line also provides resources and referrals to people in crisis. So, the organisation might offer useful links to people dealing with loneliness, PTSD resources for veterans, or meditation referrals for those texters who are stressed out. In this way, they can help texters get ongoing support and assistance once the texting conversation comes to an end.

When asked what she’s learned since working at the Crisis Text Line, Dr. Turner says,

I’ve learned there are a lot of people in pain. I’ve also learned people in general are very resilient, so even though they struggle with their crisis, they are willing and desirous of receiving help 

 

“They will reach out anonymously to a text line and share more things, and we found that people will share things with us that they had not shared with anyone else. So they are willing to be vulnerable in the text modality because there’s a sense of control, so you can stop the conversation at any point.

“There’s the ability to have access to crisis interventions wherever you are, so from the classroom to the boardroom, everybody texts everywhere, no one needs to know that you’re having a panic attack and texting a crisis text line because you’re just texting, that’s all you’re doing. So it allows people a great deal of access to crisis intervention services”, she explains.


Nancy Lublin, Founder and CEO of Crisis Text Line, shares the story that first spurred her to start the organisation. Source: ted.com.

Key findings from Crisis Text Line

 

Texters in crisis tend to skew young. For example, roughly 75% of Crisis Text Line’s texters are under the age of 25. Dr. Turner says, “We do have quite a large percentage of texters who are teenagers… I think it’s 13% of texters who are under the age of 13 and they tend to over-index for self-harm and suicidal ideations given their young age. We are also over-indexed for people of colour and LGBTQ texters”.

Although texters come from all areas of the United States, texts tend to come in more frequently from the East and West Coasts. It’s also been found that texters come from every demographic, although they skew rural and poor. For instance, 19% of texting volume comes from the 10% lowest-income zip codes.

While texts are fairly evenly distributed across every day of the week, they’re lowest on Saturdays (12%) and highest on Mondays (16%). The vast majority of texts occur in the evening hours, typically between 6pm-12pm.

 

As for the data itself, Dr. Turner says, “What’s wonderful is that we make our data accessible either to the general public through our website which is Crisis Trends or we have keyword partners if people want a specific analysis of their data in a given area or school or locale.

“So, we can tell people what the issues are in their particular area. This gives people real-time data to make policy decisions, so they can use the data and draw whatever conclusions they need to based on what they’re looking for.

“We can predict, so to speak, peaks in our volume around celebrity suicides that trigger people either with sadness or thoughts of their own suicide. So we had spikes in the volume of texts around the time of Kate Spade’s and Anthony Bourdain’s suicides”.

The role of artificial intelligence at Crisis Text Line

 

Interestingly enough, artificial intelligence plays a huge role in what the Crisis Text Line does. For instance, Crisis Text Line initially used an algorithm to search for words like ‘die’ and ‘suicide’. However, as machine learning advanced, it found there were other words—like KMS (kill myself), ibuprofen, and a crying emoji that were much better indicators of suicide risk.

Mashable reported last year:

When Crisis Text Line started using artificial intelligence to analyse 22 million messages about emotional distress… researchers discovered the word ibuprofen was 16 times more likely to predict the person texting would need emergency services than the word suicide

 

“Another highly predictive type of content wasn’t even a word but a crying face emoji. When people included that sad character in their messages, Crisis Text Line supervisors were 11 times more likely to call 911 for assistance. In total, Crisis Text Line has integrated 9,000 new words or word combinations that indicate high risk — and expects to add more in the future”.

How can these findings help physicians?

 

Dr. Turner suggests that physicians can use these findings to raise their awareness. In the United States, for example, doctors can see which mental health issues people in the surrounding zip codes are struggling with. This allows them to have real-time feedback and a better understanding of the population they’re serving.

While Crisis Text Line doesn’t offer specific data about Australians in crisis, general practitioners can use the data they’ve collected to gain feedback on issues important to certain demographics.

“A general practitioner in Australia can get a general sense of what are some issues in their population, if they’re treating children, what are some of the things that 13 year-olds or kids under 13 in this day and age are dealing with from an issue perspective. So, in so far as they might be able to extract out from what’s going on in the US to what’s going on in Australia’’, says Dr. Turner.

Future plans for Crisis Text Line

 

The Crisis Text Line has ambitious plans for the future. When asked about what’s ahead, Dr. Turner responded, “So we’re already in the UK and Canada, and we have plans for additional English-speaking countries first. But we’re also developing our French platform for Quebec in Canada and working on multi-languages to include Spanish.

“So we’re really looking to partner with countries around the world, and we have about three other countries that we are in discussions with right now. The plan is to ultimately be a global organisation where we can collect data and more importantly, serve people in crisis across the world”, she concludes.

Based on the millions of people who have been helped by Crisis Text Line already, that sounds like a wonderful thing for the world-at-large.


Dr. Shairi Turner-Davis

Chief Medical Officer, Crisis Text Line

Shairi is a Stanford Alum and Harvard-trained internist and paediatrician with a Master of Public Health from the Harvard School of Public Health. Prior to Crisis Text Line, Shairi was the first Chief Medical Director of the Florida Department of Juvenile Justice. She served as Deputy Secretary for Health and Director of the Office of Minority Health for the Florida Department of Health. Most recently, Shairi was Project Co-Lead for the US Office of Women’s Health-funded Trauma Informed Medicine eCases.

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