Providing Emotional Support Over Text and Chat

Introduction to Text and ChatRoleplay Transcript

With text and chat services increasingly moving online, emotional support work – the core element of the work of crisis lines is needing to be adapted to work in new formats that require a change in your perspective and technique. On the telephone, there are a number of ways of providing a warm, genuine experience. For instance, your voice tone and pitch communicates a lot, as well as the speed in which you talk, whether you speak over the caller or let them lead, and so on. There is a lot of non-verbal communication that happens on the phone.

In contrast, online all you have is text. So many of the dimensions that are used to promote warmth, communicate empathy and demonstrate caring are simply absent. This makes it more difficult to build rapport with these visitors and be effective.

The elements of active listening, or the active listening process are the same, although of course it seems unusual to call it “listening” since you aren’t using your ears. There is still an effort made to be alert for and respond to communication, however. Some people prefer “emotional support” instead.

Chat and Text Length

Chat and text conversations tend to be longer than telephone conversations; an average telephone call may be 20 minutes while a crisis chat or text conversation will be 45-60 minutes. This is due to the time required for you to send a text, for the visitor to receive it, read it, decide what they’re going to write, and then write back. You may not send a lot of  messages in this 60 minutes, but that doesn’t mean that you aren’t accomplishing a lot – which is reflected in the outcomes, often up to 30% reduction in subjective distress over an hour.

Opening Conversations

In the opening of a text-based conversation, it’s important to be warm and genuine. Your opening message should give your name, because the visitor doesn’t have anything else to go on. You may want or need to identify your organization as well. Finally, you’ll want to ask the visitor what brought them to text in.

An example of an opening message I could use on the ONTX Project is “Welcome to the ONTX Project. My name is Dustin, what’s going on in your life?”

Sometimes a visitor will text in with a lethality statement, something like, “I want to die.” This doesn’t necessarily change your opening, but it doesn’t hurt to acknowledge the suicidal feeling. “Welcome to the ONTX Project. My name is Dustin, it sounds like you’re really struggling. Did you want to tell me what’s been going on?”

Some visitors though, may need a bit of encouragement. If you ask a visitor how they’re feeling, they may reply “idk” (I don’t know) or “bad”, and not elaborate. Other visitors may be much more articulate and be able to explain what’s going on in their life.

If someone says “idk” or “bad”, usually my next move is to ask them what’s on their mind tonight. This is a gentle way of rewording the question that helps them feel more comfortable. Usually at this point they’ll begin talking, but if not my final option is “What were you hoping to get out of texting in tonight?”

I’ve never had a visitor respond with “idk” or other messages after this much encouragement but I would likely empathize with how difficult it’s been for them to text in before ending the conversation and inviting them to try us again when they’re more able to speak.

Because of a 140 character limit, some of these messages may need to be sent as a pair of messages on text.

Exploring the Issue

Exploring the issue that the visitor is texting in about can be challenging. Unlike the helpline, where you may need to take a while to establish rapport, visitors on text tend to jump right to their primary concern rather quickly. They don’t have the luxury of many messages back and forth.

If you’ve used the above Opening the Conversation ideas, you should be well into exploring the issue. This section should proceed just the same way as an offline conversation does, using all elements of the active listening process (open ended questions, paraphrasing and summarizing.)

You may notice that you need to ask more clarifying questions than usual, because with text and a lack of tone it’s easier for things to be misunderstood or misconstrued.

Demonstrating Empathy

In an online environment, you have no voice tone to demonstrate empathy. For this reason it’s important to write out your empathy statements clearly in order to show that you have an idea what the visitor is going through. Clarifying and paraphrasing can help in rapport building as well, by demonstrating that you are paying attention. It’s important to recognize that clarifying, paraphrasing and other open and close-ended questions are not a replacement for pure empathy.

Empathy: You sound really alone.

Clarifying: You just lost your dog?

Paraphrasing: You’ve been having trouble since you lost your pet.

Note the difference, empathy highlights an emotion (alone) while clarifying and paraphrasing primarily on content without regard to an emotional undertone.

Suicide Risk Assessment and Intervention

Suicide risk assessment and intervention is a challenging topic over chat and text. The primary challenges in this environment include the difficulty collecting the amount of information required to perform a competent assessment in 140 characters and the lack of voice tone and body language.

Typically the first question asked on chat and text after confirming suicide thoughts are present is to determine if they’re at imminent risk. This is usually accomplished by asking something like “Have you done anything to kill yourself?” or “Have you taken any steps to end your life tonight?”

Chatters and texters will sometimes text in immediately after an overdose, and will readily reveal their level of danger but not until you ask. Sooner rather than later!

Next, I’ll ask the visitor what’s led them to feeling suicidal. This, when combined with an empathy statements, helps to begin exploring the visitor’s reasons for living or dying. For example, “You must be feeling so overwhelmed. Tell me what’s led you to feeling suicidal?”

After this, I move onto the elements of the DCIB Suicide Risk Assessment tool.

Winding Up Conversations

Because visitors are using their cell phones, they can put their phone in their pocket, and then pull it out without thinking about the time that passes in a few minutes. It’s not uncommon that at the end of your 45-60 minutes, when it comes to winding up, the visitor doesn’t even realize that amount of time has passed. They find themselves feeling better, however, which is great news!

Winding up has to be deliberate, otherwise the visitor is unlikely to wind up in a decent time. Past experience has shown that crisis chats can last 3 hours or longer lacking a proper wind up. In order to initiate a windup, you simply have to give the visitor an opportunity to express anything else on their mind and then let them know that you have to go. For example,

“We’ve been talking for about an hour so we’ll need to wrap our conversation up soon. I’m wondering if there’s anything else on your mind that you haven’t shared yet.”

Or, more succinctly,

“We’re just coming up on 45 minutes of chatting so we’ll need to wind up soon. Was there anything else you wanted to share before we do?”

This cues the visitor that the conversation needs to end and lets them focus on any outstanding issues. For instance, you may be convinced of their safety and they may not be – and by pointing that out by replying “I don’t know what to do to avoid attempting suicide tonight” then you can spend your remaining 15 minutes implementing a comprehensive safety plan for that visitor. In this way, the windup can be a tool for you and the visitor.

Cite this article as: MacDonald, D.K., (2016), "Providing Emotional Support Over Text and Chat," retrieved on November 17, 2017 from http://dustinkmacdonald.com/providing-emotional-support-text-chat/.
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Beginnings of an Online Crisis Chat Service

On June 29th, the Distress Centres of Dufferin/Wellington, Durham, Peel and Toronto joined together to launch an online crisis chat service. Texting through an unadvertised shortcode based on a service in the US or visiting our website provides access to a trained volunteer responder between 2pm and 2am.

After running the service for a few months, we’ve begun seeing some important elements emerge from the data. They include elements like the length of the chats, the service volume, the elements necessary for high-quality chats and texts,

Chat Length

The average interaction is 45-60 minutes. This is much longer than helpline conversations which tend to be closer to 20-30 minutes for individuals who are not in crisis. This is because of the time required to process what you’re reading and to consider writing your response.

Service Volume

The service operates for approximately 12 hours a day and fields an average of 10-15 text sessions and 5-10 chat sessions a day, but has received as many as 64 chat/text interactions in a week during periods of high volume.

Number of Responders

We are close to 150 responders covering a 12 hour period with double coverage. Because commitments can vary based on the partner Centres we estimated that we would need about 50 responders per Centre in order to meet this base level of service.

Level of Distress

Currently, there is a pre-chat survey for visitors entering the system where they can indicate their level of distress on a 5 point scale:

  • 1 – I’m doing okay
  • 2 – A little upset
  • 3 – Moderately upset
  • 4 – Very upset
  • 5 – Extremely upset

At the end of the chat, they are redirected to a post-chat survey where they have the option to note if their level of distress has changed. Approximately 20% of the chat visitors complete the pre and post chat surveys.

The results of preliminary analysis show that their level of distress drops 1 full point from 3.8 to 2.8, on average after an interaction with a responder.

Chat and Text Issues

The most common issues that chatters report are anxiety, depression, relationship concerns and suicidal thoughts. This is very similar to the helpline, though the rate of suicidal ideation is 2-3x higher (10-15%) on the service than the provincial average on the helpline (approximately 5%.)

This range of issues is similar to the helpline.

Age Range

Right now the service sees 100% of it’s usage between 0-44, no visitors over 45 have visited. The most common age range is 15-24, though I’ve seen some as young as 12 accessing the service. Only 5% of the visitors on the telephone helpline are 15-24, suggesting the service is much more popular for youth.

Crisis Chat / Text Training

The training is approximately 4 hours in length and covers a review of active listening and emotional support, the DCIB Suicide Risk Assessment, how to use the iCarol messaging system and then some time for roleplays.

It’s important to recognize that there is a different skill set required for communication through a text environment versus communication over the telephone. For instance, the lack of voice tone makes it very difficult to recognize when you are de-escalating a visitor.

This required consistent checking in with the visitor to make sure they are actually improving.

Crisis Chat / Text Suicide Risk Assessment

The suicide risk assessment we use is the DCIB Suicide Risk Assessment. This assessment contains four elements: desire, capability, intent and buffers. This is different than our previous risk assessment, the CPR Risk Assessment.

Follow Up

An important element of working with suicidal individuals is follow up. Studies (e.g. Brown & Green, 2014) have demonstrated that follow up has the potential to reduce the likelihood of future suicide attempts and ideation.

Bibliography

Brown, G.K., Green, K.L. (2014) In Expert Recommendations for U.S. Research Priorities in Suicide Prevention, American Journal of Preventive Medicine. 47(3) Supplement 2:S209-S215 DOI: 10.1016/j.amepre.2014.06.006,

 



Cite this article as: MacDonald, D.K., (2015), "Beginnings of an Online Crisis Chat Service," retrieved on November 17, 2017 from http://dustinkmacdonald.com/beginnings-of-an-online-crisis-chat-service/.

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@RealTimeCrisis, Tweeting those in distress

A shorter post this Family Day, I thought I would take a few minutes to talk about the Twitter handle @RealTimeCrisis. Started by a Toronto police officer and a street nurse, they trawl Twitter for people demonstrating signs of lethality and reach out to them.

As I’ve written about in the past on my article on responding to suicide on social media, many people give people hints of their behaviour who never receive the support that they need. Sometimes family members and friends don’t know what to do – or, worse, they’re afraid of the answer they might get.

Enter Marie Batten and TPS Constable Scott Mills. Since 2012 they have been tweeting individuals in crisis and offering a helping hand, connecting them to resources in the community. Sometimes the Toronto Police will directly contact them and sometimes they’ll reach out. But either way – it is heartening to see people getting the support they need.

As online crisis chat and SMS/texting services become more common avenues for receiving emotional support and crisis intervention I suspect we’ll see more services like @RealTimeCrisis. For now they represent a best practice – an innovative strategy of reaching out when people need them most.



Cite this article as: MacDonald, D.K., (2015), "@RealTimeCrisis, Tweeting those in distress," retrieved on November 17, 2017 from http://dustinkmacdonald.com/realtimecrisis-tweeting-those-in-distress/.

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How to Respond to Suicide Threats on Social Media

As social media finds a greater and greater importance and significance in our lives, it’s important that we get better at responding to suicidal threats that appear on social media sites like Twitter, Tumblr and Facebook.

Failures To Respond

There have been a number of situations where a failure to respond appropriately (or simply an inability to locate an individual in time) when threats on social media are posted has led to suicides and homicides.

In December 2014, Amber Cornwall, aged 16, died of suicide by hanging after posting on Facebook “If I died tonight, would anyone cry?” She killed herself later that night, and was found the next morning by her parents. Her parents say she was heavily bullied before her death. (WLOS News 13, 2014)

Adrian Alvarez shot himself at his school in October, 2013 after posting on Facebook that he was sorry for all the pain he caused his friends and family. The father of an infant son, he was 16 years old. (NY Daily News, 2013)

A woman from Shanghai, going by the instagram username jojostai1012 posted a series of pictures including the lines “I will haunt you day and night after I’m dead”, and burning her possessions before she jumped out of a high-rise building in March of 2014. (Daily Mail, 2014)

In each of these situations, evidence of statements of lethality was present hours before the individual took their own life. Dozens, in some cases hundreds of people saw these messages and nobody reached out to ask the individual if they were feeling suicidal.

In the case of the woman from Shanghai, the photos of her destroying her possessions represent an imminent risk factor that required immediate intervention to preserve life.

How to Respond

The process for responding to online posts that make you concerned a person may be considering ending their life is similar to the process you would take if they were in person or on the telephone.

Start by reaching out via private message (if possible), and asking the person if they are feeling okay. Incorporate an empathy statement and begin to build that rapport.

This process will be easier if you have a pre-existing relationship with the individual, but even if you don’t, getting them talking will demonstrate that someone out there does care about them.

Once you have built up a rapport and began to have a conversation about how they are feeling, ask the question! All you have to do is ask. “Sometimes when people say they’re sorry for all the pain they’ve caused, they’re thinking about suicide. Have you thought about suicide?”

Then you can move into the CPR Risk Assessment. Do they have a plan? Means and access? A timeline? Do they have any previous history of suicidal behaviour or bereavement by suicide? What kind of coping mechanisms do they have? Who in their life can they rely on?

Once you’ve determined the depth of their suicidal danger you can work collaboratively with them to establish a safety plan, as per the ABC Model of Crisis Intervention. Is there somewhere they can go (hospital, friend’s house, mental health crisis bed) for more intensive support than they can get right now? Can their access to lethal means be mitigated?

In the aftermath of the suicidal crisis, you’ll want to help them connect to counselling, case management or therapy to help them cope better in the future.

Emergency Intervention

If you have access to their location, 911 or emergency services can dispatch a police officer or paramedics to provide them with transportation to the hospital or immediate medical care. If you lack specifics, this may be a more difficult process.

Police often work with phone companies to provide the GPS of individuals in a rough area, and this may aid in your locating them if they have a cell-phone.

Facebook provides an option to report posts that are of a suicidal nature but as they point out, “If you’ve encountered a direct threat of suicide on Facebook, please contact law enforcement or a suicide hotline immediately. If the person you’re worried about is a member of the US military community, be sure to mention this so they can provide this person with custom support.”

Correct Responses

For all of the failures to help people feeling suicidal, there are some examples of proper responses online, although it’s likely most of these are not published, as the person simply stays alive rather than their death being reported in the media.

An 18 year-old man who posted “Thinking of jumping” next to a photo of the George Washington Bridge was helped by officers of the Port Authority police, after they were tipped off by a concerned friend.The Emergency Services Lieutenant sent the man his phone number, and he reached out. The officer convinced him to meet in person, and after talking he agreed to go to a local hospital for help. (CNN, 2013)

In 2009, a woman used the social networking site Twitter to send a message to the actress Demi Moore detailing her plan to kill herself using a large knife, followed up with “gbye … gonna kill myself now”.

Moore responded to the tweet publicly which led to people reporting the threats to the San Jose Police Department. The woman was found, uninjured, and taken for mental health evaluation. (ABC News, 2009)

In each of these successes, a person posted obvious statements of lethality, and individuals reached out. They reported the threats, built empathy with the persons in distress and referred them to the support they needed.

Additional Resources

The Suicide Prevention Resource Centre publishes a guide (PDF) on Suicide Threats on Social Networking Sites which provides a brief overview, some risk management pointers for helpers and social networking sites and some guidelines for both your safety and the safety of the distressed person. (Olson, 2011)

Bibliography

ABC (2009, Apr 3) “Did Demi Moore’s Twitter Feed Stop a Suicide? | ABC News” Accessed electronically from http://abcnews.go.com/Entertainment/AheadoftheCurve/story?id=7248406 on February 3, 2015

CNN (2013, Nov 15) “Teen’s remarks on Facebook sends cops into social media action to save a life – CNN.com” Accessed electronically from http://www.cnn.com/2013/11/15/us/social-media-suicide-stop/ on February 3, 2015

Daily Mail (2014, Mar 17) “Chinese woman appears to post her suicide on Instagram | Daily Mail Online”, accessed electronically from http://www.dailymail.co.uk/news/article-2582395/Did-hundreds-people-ignore-girls-cry-help-Chinese-woman-appears-post-suicide-Instagram.html on February 3, 2015

NY Daily News (2013, Oct 17) “Texas teen posted Facebook warning before school suicide”, accessed electronically from “http://www.nydailynews.com/news/national/texas-teen-posted-facebook-warning-school-suicide-article-1.1488343” on February 3, 2015

Olson, R., (2014) “Suicide threats on social networking sites”. Suicide Prevention Resource Centre. Accessed electronically from http://www.sprc.org/library_resources/items/suicide-threats-social-networking-sites on February 3, 2015.

WLOS. (2014. Dec 22) “Bullying Led To E. Henderson Student’s Suicide, Says Family”, accessed electronically from “http://www.wlos.com/news/features/top-stories/stories/bullying-led-e-henderson-students-suicide-says-family-18998.shtml#.VNEA6J3F-Ck” on February 3, 2015



Cite this article as: MacDonald, D.K., (2015), "How to Respond to Suicide Threats on Social Media," retrieved on November 17, 2017 from http://dustinkmacdonald.com/how-to-respond-to-suicide-threats-on-social-media/.

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Online Counselling and Suicide Intervention Specialist (OCSIS) Review

The Online Counselling and Suicide Intervention Specialist (OCSIS) course is an online, self-study 40-hour course designed to teach basic suicide intervention skills and focusing on online and chat environments, offered by the QPR Institute.

Given the changes in help-seeking behaviour, with more people, especially youth moving online (Horrigan & Rainie, 2006) it’s important that helplines also begin to expand services in this area so that they can better support their clients.

Few online services have been reviewed, but the RAINN online chat has experienced positive reviews. (Finn & Hughes, 2008)

I completed the OCSIS certificate in August 2014, and feel it is an excellent value for the money (the course is approximately $200). It is split into the following modules:

  • Orientation and Introduction to Suicide Prevention
  • Ethics Education for Online Helpers
  • Basic Helping Skills
  • QPR Gatekeeper Training for Suicide Prevention
  • Foundations in Understanding Suicidal Behavior
  • QPR Suicide Triage Training
  • Suicide: The Forever Decision – A text-based Intervention
  • Crisis Mitigation: Part 1
  • Crisis Mitigation: Part 2
  • Course Wrap-Up

Each part of the course includes PowerPoints, audio to listen to and a series of roleplays demonstrating best practices along with explanations for the incorrect answers.

The course is obviously designed for individuals who have had no other experience in helping (with the QPR Gatekeeper Training and the Basic Skills modules included along with the more online-focused skills).

As an experienced helper, I feel like this was a weakness of the course. Lots of the course time was spent reviewing information not relevant specifically to online helping, but general helping skills.

Like many helping skills courses, I felt the roleplays were the most useful element, and any crisis chat training program would do well to spend a minority of the time covering the logistics of online crisis chat and the remainder of the time practicing with roleplays.

Specific elements identified in the course that I have found hold true in the crisis/emotional support chats that I’ve participated in include:

  • The length of chats can be much longer, easily an hour where a similar call can be 20 minutes
  • Chats can be more asynchronous (depending on the platform) and so can stretch on for several days or weeks; this can lead to burnout if helpers are not careful
  • Because of technology limitations, active rescue is more difficult or impossible. This can cause helpers to experience a sense of powerlessness if they experience a suicide attempt in progress.

The course is also a prerequisite for IMAlive, the online crisis chat run by the Kristin Brooks Hope Center, the organization that (formerly) ran the 1-800-SUICIDE line.

Bibliography

Horrigan J., & Rainie, L. (2006). The Internet’s major role in life’s major moments.
PEW Internet and American Life Project (2006)

Finn, J., & Hughes, P. (2008). Evaluation of the RAINN National Sexual Assault Online Hotline. Journal Of Technology In Human Services, 26(2/4), 203-222. doi:10.1080/15228830802094783



Cite this article as: MacDonald, D.K., (2015), "Online Counselling and Suicide Intervention Specialist (OCSIS) Review," retrieved on November 17, 2017 from http://dustinkmacdonald.com/online-counselling-and-suicide-intervention-specialist-ocsis-review/.

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