Rapport Building in Written Crisis Services: Qualitative Content Analysis

BACKGROUND

Building therapeutic relationships and social presence are challenging in digital services and maybe even more difficult in written services. Despite these difficulties, in-person care may not be feasible or accessible in all situations.

OBJECTIVE

This study aims to categorize crisis counselors' efforts to build rapport in written conversations by using deidentified conversation transcripts from the text and chat arms of the National Child Abuse Hotline. Using these categories, we identify the common characteristics of successful conversations. We defined success as conversations where help-seekers reported the hotline was a good way to seek help and that they were a lot more hopeful, a lot more informed, a lot more prepared to address the situation, and experiencing less stress, as reported by help-seekers.

METHODS

The sample consisted of transcripts from 314 purposely selected conversations from of the 1153 text and chat conversations during July 2020. Hotline users answered a preconversation survey (ie, demographics) and a postconversation survey (ie, their perceptions of the conversation). We used qualitative content analysis to process the conversations.

RESULTS

Active listening skills, including asking questions, paraphrasing, reflecting feelings, and interpreting situations, were commonly used by counselors. Validation, unconditional positive regard, and evaluation-based language, such as praise and apologies, were also often used. Compared with less successful conversations, successful conversations tended to include fewer statements that attend to the emotional dynamics. There were qualitative differences in how the counselors applied these approaches. Generally, crisis counselors in positive conversations tended to be more specific and tailor their comments to the situation.

CONCLUSIONS

Building therapeutic relationships and social presence are essential to digital interventions involving mental health professionals. Prior research demonstrates that they can be challenging to develop in written conversations. Our work demonstrates characteristics associated with successful conversations that could be adopted in other written help-seeking interventions.

Exploring the lived experience of receiving mental health crisis care at emergency departments, crisis phone lines and crisis care alternatives

BACKGROUND

Mental health crisis care includes emergency departments (EDs), crisis phone lines and crisis alternatives. Currently, there is an overreliance on EDs to provide mental health crisis care, with evidence that responses are often inadequate to meet the needs of people experiencing mental health crises. However, the complexities of how individuals experience crisis care across the varying contexts of EDs, crisis phone lines and crisis alternatives remain underresearched.

METHOD

This study used a hermeneutical phenomenological approach to understand the lived experience of accessing care during a mental health crisis. Thirty-one Australian adults who had accessed crisis services at ED, phone lines and/or crisis alternatives participated in in-depth interviews.

RESULTS

The findings are organised across the temporal narratives of participants' experiences from (1) point of contact, (2) positive and negative care experiences and (3) enduring impacts. Several themes were generated during these phases. The findings demonstrate the interrelated nature of care experiences and enduring impacts. With some exceptions, care received within EDs was harmful, resulting in lasting adverse effects. Responses from crisis phone lines were mixed, with participants appreciating the accessibility of after-hour phone support but finding standardised risk assessments unhelpful. Responses from crisis alternatives to ED were promising, aligning with the need for validation and human connection, but were not always accessible or easy to mobilise during a crisis. Notably, across all settings, positive effects were firmly attributed to the quality of the relationship with specific crisis providers.

CONCLUSION

The findings bring into sharp focus the lived experience of people accessing crisis care and contribute to the shortage of literature on subjective experiences. Providers may better meet the needs of those experiencing mental health crises by understanding the enduring impact of these interactions and the role of human connection beyond a focus on risk assessment, thereby providing opportunities for a joint understanding of risk and meaning-making. Furthermore, understanding the subjective experience of crisis care can guide reforms to ED and develop crisis alternatives to better meet the needs of people in crisis.

PATIENT OR CONSUMER CONTRIBUTION

The first author and the third author are in designated lived experience (Consumer) roles. The first author conducted the interviews and was explicit regarding their lived experience when engaging with participants. Service users were involved as advisors to the study and provided input into the design.

Linguistic Variables and Gender Differences Within a Messenger-Based Psychosocial Chat Counseling Service for Children and Adolescents: Cross-Sectional Study

BACKGROUND

Text messaging is widely used by young people for communicating and seeking mental health support through chat-based helplines. However, written communication lacks nonverbal cues, and language usage is an important source of information about a person's mental health state and is known to be a marker for psychopathology.

OBJECTIVE

The aim of the study was to investigate language usage, and its gender differences and associations with the presence of psychiatric symptoms within a chat counseling service for adolescents and young adults.

METHODS

For this study, the anonymized chat content of a German messenger-based psychosocial chat counseling service for children and adolescents ("krisenchat") between May 2020 and July 2021 was analyzed. In total, 661,131 messages from 6962 users were evaluated using Linguistic Inquiry and Word Count, considering the following linguistic variables: first-person singular and plural pronouns, negations, positive and negative emotion words, insight words, and causation words. Descriptive analyses were performed, and gender differences of those variables were evaluated. Finally, a binary logistic regression analysis examined the predictive value of linguistic variables on the presence of psychiatric symptoms.

RESULTS

Across all analyzed chats, first-person singular pronouns were used most frequently (965,542/8,328,309, 11.6%), followed by positive emotion words (408,087/8,328,309, 4.9%), insight words (341,460/8,328,309, 4.1%), negations (316,475/8,328,309, 3.8%), negative emotion words (266,505/8,328,309, 3.2%), causation words (241,520/8,328,309, 2.9%), and first-person plural pronouns (499,698/8,328,309, 0.6%). Female users and users identifying as diverse used significantly more first-person singular pronouns and insight words than male users (both P<.001). Negations were significantly more used by female users than male users or users identifying as diverse (P=.007). Similar findings were noted for negative emotion words (P=.01). The regression model of predicting psychiatric symptoms by linguistic variables was significant and indicated that increased use of first-person singular pronouns (odds ratio [OR] 1.05), negations (OR 1.11), and negative emotion words (OR 1.15) was positively associated with the presence of psychiatric symptoms, whereas increased use of first-person plural pronouns (OR 0.39) and causation words (OR 0.90) was negatively associated with the presence of psychiatric symptoms. Suicidality, self-harm, and depression showed the most significant correlations with linguistic variables.

CONCLUSIONS

This study highlights the importance of examining linguistic features in chat counseling contexts. By integrating psycholinguistic findings into counseling practice, counselors may better understand users' psychological processes and provide more targeted support. For instance, certain linguistic features, such as high use of first-person singular pronouns, negations, or negative emotion words, may indicate the presence of psychiatric symptoms, particularly among female users and users identifying as diverse. Further research is needed to provide an in-depth look into language processes within chat counseling services.

The Prevalence of Nonsuicidal Self-Injury in Military Personnel: A Systematic Review and Meta-Analysis

Military service members and veterans (SMVs) are at risk for self-directed violence, including nonsuicidal self-injury (NSSI). While NSSI is an important construct worthy of independent study, it is understudied among SMVs and, when included in research, typically examined in the context of suicide risk. Consequently, lifetime prevalence rate estimates of NSSI among SMVs vary. This Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review and meta-analysis estimated the average lifetime NSSI prevalence among SMVs and explored demographic and methodological factors that may account for observed variability. Based on a search of Ovid MEDLINE, Embase, PsycINFO, and Web of Science, 47 samples from 42 articles across five countries met inclusion criteria. Results revealed an average NSSI lifetime prevalence rate of 15.76% among SMVs. Significantly higher prevalence rates were observed among clinical (28.14%) versus community (11.28%) samples and studies using interviews to assess NSSI (23.56%) versus self-report (13.44%) or chart review (7.84%). Lifetime prevalence increased as publication year increased and decreased as sample size increased. In contrast to prior literature, prevalence rates were comparable between active-duty SMVs, and studies collecting data anonymously versus those that did not. Lifetime prevalence was not moderated by age, gender, race, country, primary research focus, quality of NSSI operationalization, or whether NSSI methods were assessed. Findings suggest NSSI is a pervasive problem among military personnel, particularly within clinical settings, highlighting the need for systematic assessment of this important but understudied clinical phenomenon among SMVs. Further research is necessary to elucidate additional risk factors for NSSI among SMVs, including trauma exposure.

Who are frequent chatters? Characterization of frequent users in a 24/7 messenger-based psychological chat counseling service for children and adolescents

Background

Online helplines have shown a high acceptance, feasibility, and usability, especially with young people. Helplines usually aim to provide one-time crisis intervention; however, there are users who frequently use such services, tying a disproportionately large proportion of service capacities. To date, there is no research on the characterization of frequent users of online helplines. Therefore, the aim of the present study is to characterize frequent chatters in a chat-based counseling context.

Methods

This cross-sectional study retrospectively analyzed anonymous data of users who approached the German messenger-based psychological chat counseling service krisenchat between May 2020 and July 2021 (N = 6657), with a focus on frequent users - the "frequent chatters". Frequent chatters were defined as those who received an above average (M + 2 ∗ SD) amount of messages from counselors over a period of one week and had at least 7 days of contact with the service over the entire data collection period. Chi-square-tests and Mann-Whitney-U tests were conducted to identify differences between frequent users and the population of all users.

Results

In total, n = 99 (1.5 %) users met the definition for frequent chatters and accounted for roughly a tenth (9.85 %) of all chats of the service. The mean frequent chatter was 17 years old (M = 17.29, SD = 3.56), female (n = 78, 82.1 %), and approached the service in the late afternoon (M = 5:00 pm, SD = 5:25 h). Compared to the general user population, frequent chatters reported significantly more severe concerns to counselors, of which 81.8 % included psychiatric symptoms, such as suicidality (43.4 %) and non-suicidal self-injury (41.4 %). In addition, frequent chatters were significantly more likely to contact krisenchat alongside the use of other professional help services. Further, frequent chatters wrote significantly longer and more messages during the counseling process and within a session than the general user population of krisenchat. Compared to the general user population, frequent chatters did not differ in their satisfaction with the service.

Conclusion

Frequent users are known from telephone helplines and are also represented in a chat-based context. Compared to the general user population, they are more likely to report serious mental health conditions and half of them currently receive professional help, suggesting a high need for social support. In light of the increasing development of chat-based helplines, there is a need for further research on frequent chatters to develop tailored counseling strategies for their needs and to analyze options for an optimized service provision.

Study registration

DRKS00026671.

Crisis Lines: Current Status and Recommendations for Research and Policy

OBJECTIVE

The 988 telephone number was established by the National Suicide Hotline Designation Act of 2020 and implemented in July 2022 as a more accessible way to reach the National Suicide Prevention Lifeline. Current financial and training resources, however, are insufficient to ensure effective implementation.

METHODS

To better understand the state of the literature on crisis support lines in light of the 988 transition, the authors summarized research on suicidal and nonsuicidal outcomes of callers, research on other types of crisis support services, and the benefits of text- and chat-based crisis lines.

RESULTS

Overall, existing evidence for the effectiveness of crisis lines has been weak and has primarily focused on short-term improvements in user distress and on user satisfaction. In addition, research on crisis lines specifically targeted to marginalized populations (e.g., sexual minority groups) and on text- or chat-based crisis lines is lacking.

CONCLUSIONS

The policy-focused recommendations derived from this review include the need for additional research on crisis lines, design and evaluation of culturally tailored training for volunteers and staff, and ethical oversight of private data collected from crisis services. Scaling up state-level planning and comprehensive crisis systems is necessary to successfully implement 988 and to fill current training and research gaps.

Mental Health Emergency Hotlines in the United States: A Scoping Review (2012-2021)

OBJECTIVE

Mental health emergency hotlines provide clinical supports and connection to services. This scoping review describes the current literature on hotlines in the United States, including which populations they do and do not reach, typical call volumes and engagement levels, barriers to and facilitators of implementation, and common call outcomes. The review also identifies gaps in the literature and presents recommendations.

METHODS

A systematic search of peer-reviewed articles on U.S.-based telephone, text, and chat hotlines published between January 2012 and December 2021 retrieved 1,049 articles. In total, 96 articles met criteria for full-text review, of which 53 met full inclusion criteria.

RESULTS

Approximately half of the included studies (N=25) focused on descriptive information of callers, most of whom were females, younger adults, and White; veteran hotlines typically reached older men. Common reasons for calling were suicidality, depression, and interpersonal problems. Of studies examining intervention effects (N=20), few assessed hotlines as interventions (N=6), and few evaluated caller behavioral outcomes (N=4), reporting reduced distress and suicidality among callers after hotline engagement. However, these studies also suggested areas for improvement, including reaching underrepresented high-risk populations. Six studies reported implementation needs, such as investments in data collection and evaluation, staff training, and sustainable funding.

CONCLUSIONS

Hotlines appear to be more effective at reaching some populations than others, indicating that more intensive outreach efforts may be necessary to engage underrepresented high-risk populations. The findings also indicated limited evidence on the relationship between use of hotlines-particularly local text and chat hotlines-and caller outcomes, highlighting an area for further investigation.

Creating a Digital Trauma Informed Space: Chat and Text Advocacy for Survivors of Violence

There is little research on virtual service models like chat and text services in agencies that work with survivors of intimate partner violence (IPV) and sexual assault (SA). This study fills a gap in the research by exploring how chat and text services are provided in one IPV and SA-focused community organization. We analyzed chat and text transcripts (n = 392) from a large multiservice, multivictimization focused agency, and conducted interviews with 11 advocates providing chat and text services through the agency hotline. Staff interviews were analyzed using grounded theory and transcripts were analyzed using content analysis. Results indicate chat/text services provide a space for connection, resource provision, education, and access to resource gain in a timely, concise, and survivor-centered way. The five major goals for chat/text advocacy models include the following: (1) rapid access to support and connection; (2) identification of options and needs for each service user; (3) increased access to resources and supports; (4) expanded understanding of violence, abuse, and harm; and (5) improvement of survivor safety. The research team identified 15 general advocacy skills and 4 chat and text specific skills used by chat/text advocates to reach program goals. Findings highlight the utility of chat/text services for increasing access to support services for survivors of violence, particularly adolescents, emerging adults, those living with an abusive individual, and during times of emergency. Future research should continue to explore the promising practice modality of chat/text services for providing advocacy to underserved and hard-to-reach populations.

"It's Hard to Show Empathy in a Text": Developing a Web-based Sexual Assault Hotline in a College Setting

To increase access to counseling and advocacy services and respond to changes in communication preferences, many victim service programs are expanding their traditional telephone hotlines and adding web chat or text hotlines. However, there is little research available about these web and text-based hotlines. We examined program data collected in the first year of operation of a web-based crisis hotline for sexual assault survivors at a large Midwestern university in the United States as part of a larger evaluation project. We examined how often the web-based chat hotline was used and explored patterns of use by time of day and month, comparing to records from the phone hotline operated by the same campus-based victim service program. We also conducted interviews and two group discussions with volunteers and staff about their experiences with providing crisis intervention in a web-chat medium. Findings suggest that the web-based crisis hotline is being used frequently, nearly as often as the telephone hotline and doubling the total number of crisis contacts the organization had in the year prior to adding the web-based chat hotline. Staff and volunteers identified a number of advantages of a web-based hotline, including increased privacy and accessibility for survivors. Difficulty identifying and conveying emotions in the web-chat context was one of the primary challenges described by staff and volunteers. Operating the web-hotline, therefore, requires additional training for volunteers and staff on how to translate crisis intervention skills into a text-based medium. Suggestions for how to communicate effectively in text-based crisis intervention are discussed, along with other considerations for designing a web or text hotline.

Satisfaction and Mental Health Outcomes Associated with a Large Regional Helpline

We surveyed users of a behavioral health helpline serving New York City and surroundings, to assess their helpline experiences, changes in psychological distress after contacting the helpline, and factors associated with differences in these measures. We surveyed users twice: roughly 2 weeks following their helpline contact, from 4/2019 to 9/2019 (N = 1097 respondents) and again 6 months following contact, from 10/2019 to 3/2020 (N = 732 respondents). Eighty-nine percent of respondents reported that contacting the helpline helped them deal a little or a lot more effectively with their problems. Rates of psychological distress decreased from 41.3% 2 weeks following helpline contact to 29.0% 6 months after (P < 0.05). Improvements in psychological distress were found across a range of demographic characteristics and were greatest for repeat users. Users reported broadly positive experiences with the helpline and improved psychological distress 6 months later. Behavioral health helplines can offer beneficial services to diverse populations, complementing the formal behavioral healthcare system.

Lifeline Crisis Chat: Coding form development and findings on chatters' risk status and counselor behaviors

OBJECTIVE

This study aimed to develop a reliable tool for the abstraction of data from crisis chat transcripts; to describe chatters' suicide risk status and selected counselor behaviors; and to examine the relationship of chatters' self-reported pre-chat suicidal thoughts to counselor behaviors and to chatters' disclosures of suicide risk during the chat conversation.

METHODS

Coders used an instrument developed for this study to abstract data from 1034 crisis chats handled by the National Suicide Prevention Lifeline Crisis Chat network in 2015. The relationship of transcript coding data to data from an automated pre-chat survey (PCS) was examined.

RESULTS

Lifeline Crisis Chat serves a young (median age = 21), high-risk population: 84.0% of chats (869/1034) came from chatters endorsing current or recent suicidal thoughts on the PCS. Counselors engaged in rapport-building on 93.3%, problem-solving on 70.1%, and suicide risk assessment on 67.7% of these 869 chats. Counselor risk assessment behavior, and the availability of information on suicide risk in the chat transcript, varied significantly by the chatter's PCS response.

CONCLUSION

Crisis counselors are able to implement keystones of Lifeline's crisis intervention model over the medium of online chat. Additional efforts are needed to ensure that suicide risk is assessed on every chat.

What twitter can tell us about user experiences of crisis text lines: A qualitative study

Mental health problems are the leading cause of disability worldwide. Despite the prevalence and cost of mental illness, there are insufficient health services to meet this demand. Crisis hotlines have a number of advantages for addressing mental health challenges and reducing barriers to support. Mental health crisis services have recently expanded beyond telephone hotlines to include other communication modalities such as chat and text messaging services, largely in response to the increased use of mobile phones and text messaging for social communication. Despite the high uptake of crisis text line services (CTLs) and rising mental health problems worldwide, CTLs remain understudied. The current study aimed to address an urgent need to evaluate user experiences with text-based crisis services. This study explored user experiences of CTLs by accessing users' publicly available Twitter posts that describe personal use and experience with CTLs. Data were qualitatively analyzed using thematic analysis. Six main themes were identified from 776 tweets: (1) approval of CTLs, (2) helpful counselling, (3) invalidating or unhelpful counselling, (4) problems with how the service is delivered, (5) features of the service that facilitate accessibility, and (6) indication that the service suits multiple needs. Overall, results provide evidence for the value of text-based crisis support, as many users reported positive experiences of effective counselling that provided helpful coping skills, de-escalation, and reduction of harm. Results also identified areas for improvement, particularly ensuring more timely service delivery and effective communication of empathy. Text-based services may require targeted training to apply methods that effectively convey empathy in this medium. Moving forward, CTL services will require systematic attention in the clinical research literature to ensure their continued success and popularity among users.

Suicidal Ideation Among Children and Young Adults in a 24/7 Messenger-Based Psychological Chat Counseling Service

BACKGROUND

Suicidality in children and young adults is a pervasive problem: approximately 40% of respondents in epidemiological surveys in German schools reported suicidal ideation, while up to 9% reported a suicide attempt in the past. While there is compelling evidence for the effectiveness of telephone-based hotline services, an increasing preference of adolescents for messenger-based counseling services can be observed. Therefore, the present study aims to investigate the utilization behavior and user satisfaction of users contacting a German messenger-based chat counseling service ("krisenchat") regarding suicidal ideation.

METHODS

The present cross-sectional study analyzed retrospective anonymous data on sociodemographic variables, utilization behavior, and user satisfaction of krisenchat users who used the service between May 2020 and July 2021. Chi-square-tests were used to identify associations of sociodemographic characteristics and utilization behavior with suicidal ideation. Mann-Whitney-U-tests were used to compare the user satisfaction and the recommendation-to-others-rate between suicidal and non-suicidal krisenchat-users.

RESULTS

In total, chat data of N = 11,031 users were collected. Of the n = 6,962 users included in the final analysis, n = 1,444 (20.7%) contacted krisenchat because of suicidal ideation. The average user experiencing suicidal ideation was 17 years old, female and currently not receiving other treatment. Further, suicidal ideation was significantly and positively associated with age and non-suicidal self-injury. Regarding utilization patterns, there were significant positive associations between suicidal ideation and counseling session count, mean amount of messages sent, and mean amount of words used per message by the user. User satisfaction was high, with 64.7% (n = 413) of users that answered the feedback survey and experiencing suicidal ideation rating the help they received as at least "good" and a recommendation rate of 89.6% (n = 571). Most importantly, no differences were found between users reporting suicidal ideation and those that do not regarding satisfaction and the probability of recommending the service.

CONCLUSION

Results imply satisfaction with the counseling service among users with suicidal ideation. Nevertheless, there is a need for further research into messenger-based counseling services regarding the prevention of suicidal behavior in children, youths, and young adults. Longitudinal studies are especially needed to assess the effectiveness of messenger-based interventions.

STUDY REGISTRATION

DRKS00026671.

National Suicide Prevention Lifeline crisis chat interventions: Evaluation of chatters' perceptions of effectiveness

OBJECTIVE

As part of the National Suicide Prevention Lifeline's crisis response system, the Lifeline Crisis Chat Network (LCC) answers chats from hundreds of thousands of at-risk individuals yearly. The study's objective was to assess the effectiveness of these online crisis interventions.

METHOD

Data from 39,911 pre-chat surveys and 13,130 linked pre- and post-chat surveys completed by LCC chatters from October 2017-June 2018 were analyzed. The relationship of several effectiveness measures with chatter demographics, pre-chat distress, suicidal ideation, and chatters' perceptions of engagement with their counselors was examined using a series of logistic regression analyses.

RESULTS

Chatters were significantly and substantially less distressed at the end of the chat intervention than at the beginning. By the end of the chat, two-thirds of suicidal chatters reported that the chat had been helpful, while just under half reported being less suicidal.

CONCLUSIONS

Our study offers empirical evidence for the Lifeline's online crisis chat services' effectiveness, but also highlights areas for improvement. This is of critical import in light of the recent designation of 988 as the nationwide number for the Lifeline beginning in 2022, which will increase the Lifeline's prominence in providing suicide prevention and mental health crisis interventions in the United States.

PositiveLinks and the COVID-19 Response: Importance of Low-Barrier Messaging for PLWH in Non-urban Virginia in a Crisis

PositiveLinks (PL) is an evidence-based mobile health intervention promoting engagement in care for people living with HIV. PL offers secure, in-app patient-provider messaging. We investigated messaging during the early COVID-19 pandemic, comparing messages exchanged between 01/13/2020 and 03/01/2020 (“Pre-COVID”) to messages exchanged between 03/02/2020 and 04/19/2020 (“early COVID”) using Poisson regression. We performed qualitative analysis on a subset of messages exchanged between 02/01/2020 and 03/31/2020. Between “Pre-COVID” and “early COVID” periods, weekly member and provider messaging rates increased significantly. Of the messages analyzed qualitatively, most (53.3%) addressed medical topics, and more than a fifth (21.3%) addressed social issues. COVID-related messages often focused on care coordination and risk information; half of COVID messages contained rapport-building. PL patients (“members”) and providers used in-app secure messaging to reach out to one another, identifying needs, organizing receipt of healthcare resources, and strengthening patient-care team relationships. These findings underscore the importance of low-barrier messaging during a crisis.

Information and Communication Technology Use in Suicide Prevention: Scoping Review

BACKGROUND

The use of information and communication technology (ICT) in suicide prevention has progressed rapidly over the past decade. ICT plays a major role in suicide prevention, but research on best and promising practices has been slow.

OBJECTIVE

This paper aims to explore the existing literature on ICT use in suicide prevention to answer the following question: what are the best and most promising ICT practices for suicide prevention?

METHODS

A scoping search was conducted using the following databases: PubMed, PsycINFO, Sociological Abstracts, and IEEE Xplore. These databases were searched for articles published between January 1, 2013, and December 31, 2018. The five stages of the scoping review process were as follows: identifying research questions; targeting relevant studies; selecting studies; charting data; and collating, summarizing, and reporting the results. The World Health Organization suicide prevention model was used according to the continuum of universal, selective, and indicated prevention.

RESULTS

Of the 3848 studies identified, 115 (2.99%) were selected. Of these, 10 regarded the use of ICT in universal suicide prevention, 53 referred to the use of ICT in selective suicide prevention, and 52 dealt with the use of ICT in indicated suicide prevention.

CONCLUSIONS

The use of ICT plays a major role in suicide prevention, and many promising programs were identified through this scoping review. However, large-scale evaluation studies are needed to further examine the effectiveness of these programs and strategies. In addition, safety and ethics protocols for ICT-based interventions are recommended.

Crisis line services: A 12-month descriptive analysis of callers, call content, and referrals

Crisis lines are a valuable community resource that anonymously and freely serve those in acute crisis. As a result of anonymity, it has been difficult to fully characterise crisis line services. However, appraising and improving crisis line services for the communities they serve is essential, even with the additional difficulty anonymity poses. This study seeks to increase our understanding of current crisis services and utilisation via a characterisation of various aspects of a United States crisis line service centre over 12-months including features of calls (e.g. call length), callers (e.g. victimisation history), and information provided to the caller (e.g. referrals). We examine five crisis lines totalling 5,001 calls from October 2018 to September 2019. Descriptive information is provided on call volume, patterns across time, caller characteristics, victimisation types, and referrals. Although we were unable to assess prospective outcomes due to anonymity, 99.5% of callers that were asked (61.35% of all calls; n = 3,068) reported the call as helpful. This provides an important overview of crisis line services and suggests they are a valuable community health resource serving a range of callers. Given the findings of the present study, we conclude with a discussion of recommendations and implications for community crisis line centres and future research.

Live-Chat Support for People Bereaved by Suicide

Background: People bereaved by suicide often face isolation, complicated grief, and increased suicide risk. Aims: We aimed to explore how live-chat can support survivors in their bereavement process. Method: A thematic analysis was carried out on 30 live-chat conversations through the software ATLAS.ti8. Transcripts were retrieved from a major Italian association providing online support. The users had different ages (18-60 years), degrees of kinship with the deceased (blood-related and not), and time distance from the loss (between 48 hr and 10 years). Results: Five themes were identified: meaning-making, reactions to the loss, resources, needs, and interactions with the operator. Survivors used the live-chat as a safe space in which to disclose nonsocially desirable details and to make sense of suicide through the reconstruction of events and the deceased's motivations. Given the limited social resources and the dissatisfaction with the available formal support, users resorted to justification, rationalization, or faith and found support and reassurance in the live chats. Limitations: Some conversations were fragmented and lacked detailed information on the users. Conclusion: Because of their anonymity and accessibility, live-chats represent a valid first-line form of support, from which survivors may obtain useful information and start a meaning-making process.

Implementation of a Pilot SMS-Based Crisis Support Service in Australia

Background: Australia's first short message service (SMS) crisis support service was launched by Lifeline Australia in July 2018. The pilot program was independently evaluated over a 240-day period. Aims: We aimed to examine the experiences of key staff employed in the Lifeline Text pilot and identify the skills and types of support required to deliver a high-quality SMS-based crisis support service. Method: In total, 22 interviews were conducted with 14 Lifeline Text crisis supporters and in-shift supervisors (supervisors) at two time points in September 2018 and March 2019. A modified framework approach was adopted to undertake qualitative data analyses. Results: Delivering crisis support via text was initially challenging as a result of the need to translate skills from telephone crisis support to the SMS platform. This was compounded by the high degree of suicidality of help-seekers and volatility in demand for the service. Limitations: The independent evaluators were not involved in the design of the pilot. Conclusion: Lifeline text is providing an important and necessary service, using a novel mode of delivery in Australia. Maintaining service quality at peak demand, with many distressed and suicidal help-seekers, requires specialized training, experience, and exceptional skills.

Engagement With Crisis Text Line Among Subgroups of Users Who Reported Suicidality

OBJECTIVE

Despite the interest in technology-enhanced preventive interventions for suicidality, there is minimal peer-reviewed research on conversations of text message hotlines. In this large-scale study, the authors explored distinct classes of users of the Crisis Text Line who reported suicidality. Classes were based on texters' presenting psychosocial issues and were explored across frequency of hotline use and conversation number.

METHODS

Data included 153,514 conversations from 122,909 individuals collected by the Crisis Text Line (2013-2017). Analyses were restricted to conversations from users who mentioned current or previous suicidality and excluded texters who discussed a third party. The authors used latent class analysis to identify distinct classes of texters on the basis of crisis counselor-assigned issue tags and across subgroups reflecting whether the conversation was the first or last contact with the hotline and frequency of use (one-time, two-time, or ≥3-time texters).

RESULTS

Three classes emerged in all subsamples. The largest class, "lower distress," had the lowest prevalence of all issues. The second largest class, "anxious distress," had the highest prevalence of anxiety or stress and elevated depression. The smallest class, "relational distress," had the highest prevalence of depression and self-harm and higher probability of endorsing relational indicators.

CONCLUSIONS

Psychological and relational issues mostly distinguished the three classes. Despite differing frequency of hotline usage, most texters who reported suicidal ideation and behaviors endorsed similar issues, and these issues did not seem to vary across conversations. Yet there appeared to be distinct subgroups of texters with different presenting issues, which may inform how crisis counselors tailor strategies for both low- and high-volume texters.

Analysis of Answers to Queries among Anonymous Users with Gastroenterological Problems on an Internet Forum

Internet forums are an attractive source of health-related information. We aimed to investigate threads in the gastroenterological section of a popular Polish medical forum for anonymous users. We characterised the following aspects in threads: the main problem of the original poster, declared ailments and rationale of the responses (rational, neutral, harmful or not related to the problem of the original poster). We analysed over 2717 forum threads initiated in the years 2010–2018. Users mostly asked for diagnosis of the problem [1814 (66.8%)], treatment [1056 (38.9%)] and diagnostic interpretation [308 (11.3%)]. The most commonly declared symptoms were abdominal pain [1046 (38.5%)], diarrhea [454 (16.7%)] and bloating [354 (13.0%)]. Alarm symptoms were mentioned in 309 (11.4%) threads. From the total 3550 responses, 1257 (35.4%) were assessed as rational, 693 (19.5%) as neutral, 157 (4.4%) as harmful and 1440 (40.6%) as not related to the user’s problem. The original poster’s declaration of blood in stool, dyspepsia, pain in the abdominal right lower quadrant, weight loss or inflammatory bowel disease was positively related to obtaining at least one potentially harmful response. Advice from anonymous users on Internet forums may be irrational and disregards alarm symptoms, which can delay the diagnosis of life-threatening diseases.

Suicide and suicide risk

Although recent years have seen large decreases in the overall global rate of suicide fatalities, this trend is not reflected everywhere. Suicide and suicidal behaviour continue to present key challenges for public policy and health services, with increasing suicide deaths in some countries such as the USA. The development of suicide risk is complex, involving contributions from biological (including genetics), psychological (such as certain personality traits), clinical (such as comorbid psychiatric illness), social and environmental factors. The involvement of multiple risk factors in conveying risk of suicide means that determining an individual's risk of suicide is challenging. Improving risk assessment, for example, by using computer testing and genetic screening, is an area of ongoing research. Prevention is key to reduce the number of suicide deaths and prevention efforts include universal, selective and indicated interventions, although these interventions are often delivered in combination. These interventions, combined with psychological (such as cognitive behavioural therapy, caring contacts and safety planning) and pharmacological treatments (for example, clozapine and ketamine) along with coordinated social and public health initiatives, should continue to improve the management of individuals who are suicidal and decrease suicide-associated morbidity.

Use of Telepsychiatry in Emergency and Crisis Intervention: Current Evidence

PURPOSE OF REVIEW

The aim of this review is to evaluate recent literature on the use of telepsychiatry in mental crises or emergency situations.

RECENT FINDINGS

Results from recent studies which evaluated the implementation of a telepsychiatric consultation model in emergency departments point at a reduction of length of stay and a drop in admissions, increased cost-effectiveness, and improved satisfaction of patients and staff. There was almost no empirical evidence on videoconferencing in crisis intervention within the context of crisis resolution teams or online therapies. No study reporting on telepsychiatry videoconferencing in the context of disasters was found. There is still very little but increasing empirical evidence supporting the implementation of telepsychiatry in emergencies. Other mental crisis-related implementation settings remain to be researched. The implications and future research potential are discussed.

Poison control centers and alternative forms of communicating with the public: what's all the chatter about?

Context: Short messaging service (SMS or text messaging) allows for the exchange of electronic text messages. Online chatting refers to Internet-based transmission of messages for real-time conversation. Poison Control Centers (PCCs) in the United States communicate with the public primarily via telephone. However, people increasingly prefer the convenience of SMS and chatting. Our objective is to describe the use of SMS and chatting by PCCs in the United States. Methods: An electronic survey questionnaire was distributed to all 55 US poison control center members of the American Association of Poison Control Centers. The survey assessed protocols for SMS and chatting, inquiry volume, and staff satisfaction. Centers reporting use of SMS or chatting services were administered follow-up questions, which further documented SMS and chatting interfaces and startup and maintenance costs. Descriptive statistics were used to describe the data. No statistical analysis was performed. Results: Of the 55 PCCs, 51 (93%) responded to the survey, 6 (12%) of which currently use or formerly used SMS and/or chatting. Inquiry volume ranged from 0 to 1 per day for SMS and 0 to 20 per day for chats. Startup costs ranged from $0 to $25,000. The most beneficial aspect, reported by 4 of the 6 PCCs (66.6%), was providing an alternative contact for inquiries. Most SMS and chatting interactions were completed within 10 and 30 min, respectively. All six centers completed telephone interactions within 10 min. The most disadvantageous aspects, reported by 2 of the 6 PCCs (33.3%), were staff apprehension and interaction length. Technology, such as syncing with existing call queuing software and databases, presented the greatest barrier to implementation. Conclusions: A minority of PCCs in the United States use SMS and chatting. Further research may investigate the economic feasibility of these systems, if SMS and chatting effectively expands public access, and patient comfort in contacting PCCs.