Crisis TextLines Are Saving Lives By: Jonathan Holly Two-way text programs in public health and safety

are exploding. Crisis lines, hot lines, help lines, warm lines, sex information lines, smoking cessation lines, bullying tip Lines, are all moving to two-way sms support. Why? Talking about emotional issues is very difficult for most people. Texting makes people feel more confident when discussing complex emotional components about themselves. Whether thats a false sense of security or not, the fact is, people of all ages, demographics are using textlines in rapidly growing numbers. Text can interrupt the thought processes that lead to self-harm and suicide by providing something for individuals to focus on other than themselves. Its not that were doing anything different. Were just using a different tool to do it. (Kathy Jacobs, Executive Director, CCC) In 2006, texting in any marketing or health promotion activities were singularly focused on one-way alerts. For example, in 2006-2007, I spoke with San Franciscos SEX INFO creator, Deb Levine, and they had developed the first text message based sex information service in the US. While this program is still in operation, she explained to me at that time, that they had tried to make the program entirely automated, but some people would become lost. Either their issue didnt fit in one of the custom triages, or they just wanted to get their question answered quicker by a real person. Debbie Levine also stated that she was spending quite a bit of time responding to what are referred to as the outliers or those individuals/mobile numbers, the automated system could not handle. During that same time, we were powering a smoking cessation program for LGBTs in Las Vegas, under a grant from American Legacy Foundation, and in collaboration with the Southern Nevada Health District. We were finding the same to be true. There were a certain number of participants who signed up for the one-way alerts (tailored content for smokers who want to quit, or individuals that want to help their partners quit) but selfselected out of those two categories by responding to the content, or asking specific questions about events. So, even though they were informed that this is a one-way alert program, and their questions would not receive a reply, they are still texting back to the short code and requesting more information. Further, it seems the primary motivation is to be acknowledge by a live person and move out of the auto-response paradigm. This was occurring quite frequently across all our one-way alert programs and partnerships. In fact, any program that has a stigmatized issue at its core will also have a cohort of users that insist on texting with real people.

2012 Educational Message Services, Inc. 1252 Devon Lane, Ventura CA 93001 www.educationalmessageservices.com

Organically, these programs took our team into two-way helpline support and what we now refer to as TextLines. In early 2007 we began the process of seeking public collaborations in order to obtain a grant to support the development of a two-way textline for suicide prevention. We researched this topic abroad and found two examples of this type of service already in development, and in one case, being piloted in a small area of Great Britain, using a similar model: a private company collaborating with a public non-profit entity to build a texting service for suicide prevention. Their team was extremely open and willing to share their preliminary findings. We also researched a similar project that was just about to launch, in South Africa, called SADAG. Both services are still operational today and seem to be doing extremely well. In fact, the Samaritans project sent preliminary findings and reported that they had to limit their outreach efforts because their volunteers were simply not able to keep up with the demand. We found no examples of crisis textlines in the United States. We only found examples of one-way alert programs designed to educate people about various health issues (as was the case with SF Sex Info). After finding a researcher in Nevada, Dr. William Evans, UNR, and a willing hotline, the Crisis Call Center, in Reno Nevada, we began seeking funding. Several early proposals were turned down including an R21 to NIMH. I recall, during a conference call with our grant advisor who told us that we had an original idea, but that she didnt think texting would be durable enough for crisis work. I recall her asking if we had any mental health video games, that we might be better off pursing a project that explored suicide prevention through video games that focus on healthy decisionmaking skills. We were dismayed by the early feedback, but not deterred. Wherever we went, refusals varied from: resources are limited, you have no preliminary findings, or, a unique idea is fine, but not enough to get funding from our agency. Fortunately, our team persevered despite the countless setbacks. In 2008, the funding clouds parted, and Verizon almost awarded the project a small grant to develop a textline. Its a shame they didnt; PPTMS Textline would look really nice on their philanthropic portfolio today. Even though it was another missed opportunity, they provided us with the jumpstart we desperately needed. The Verizon name reignited interest in the project. If a big corporation like Verizon Wireless was willing to fund the project, certainly, other agencies would be willing to do so as well, right? Within days of receiving yet another rejection from yet another grant opportunity, we were notified by the Nevada State Health Department that they were awarded a 3-year SAMHSA grant under the Garrett Lee Smith funding mechanism and the textline was included in their program aims.

2012 Educational Message Services, Inc. 1252 Devon Lane, Ventura CA 93001 www.educationalmessageservices.com

This was incredible news for everyone on the team. We began developing the system immediately. In early 2009, with the help and amazing work of the Crisis Call Center, we launched the first 24-hour crisis textline in the United States. The team piloted the service in a very small, rural high school in Pyramid Lake, Nevada, comprised of primarily low-income Native American middle and high school students. Within hours of placing awareness materials on campus, Crisis Call Center counselors were responding to their first smsbased crisis interventions. Focus groups later revealed that Pyramid teens owned cell phone at about 30-40 percent rate. But that didnt stop them from using the service. There were several instances where teens texted in using a friends or parents cell phone. Pyramid Lake was also unique because Native Americans in the region tend to view help seeking as a sign of weakness. Theres a strong culture of we dont need outside help, we can handle our own problems. Despite an inordinate number of barriers, the program is still available and used by Pyramid Lake students today. Over the next year, the team rolled out the program to 14 additional schools throughout Washoe County, Nevada. Each time the materials were installed, within hours, CCC staff responded to new texts. Some of them were prank texts, however, many pranks were later revealed to be teens with real issues. They used prank texts to obtain more info about the service and most importantly gauge the value of the help. Quite often, prank texts returned days later presenting with a real issue. Early adopters presented with a variety of issues ranging from trouble with parents, school work or relationship issues to more severe problems like rape, and self-harm (cutting/overdose). During the piloting phase, the team also learned that a good textline responder must suspend their individual perception of crisis before working with teens. While adults may not view missing a homework assignment as a crisis, that doesnt mean teenagers will share that perception. Teenagers experience crisis more frequently, and in some cases more severely than adults. Their mood swings also tend to be more extreme due to the hormonal changes occurring in their bodies. Most importantly, the early data revealed that teens have always experienced crisis, we just werent using the right tools to communicate with them. Texting has unlocked that door. Today, the Crisis Call Center receives text messages from teens, young adults, and the hearing/speech impaired, from across the country. Their numbers this year are on pace to quadruple last year. This project could not have launched without the persistence and visionary work of Executive Director Kathy Jacobs. She had the courage and the prescience to take a risk on a communication channel that was not being considered for two-way texting at that time! Their work has been highlighted in

2012 Educational Message Services, Inc. 1252 Devon Lane, Ventura CA 93001 www.educationalmessageservices.com

several conferences including the 2011 American Association of Suicidology, SAMHSA 2011, SAMHSA 2011 GLS Summit, SEX:TECH 2012, and more recently, Crisis Call Center was honored as an Exemplary Crisis Center due in large part to their innovative work with the Crisis Textline. We are now working with several national helplines and crisis line consortiums including North American Alliance of Child Helplines and sites that operate under the Mental Health America banner (hotline/helpline accreditation and certification). We are honored to be working with so many amazing helplines. If theres one thing weve learned from our work in developing Textline services, the responder is paramount. Recent data is showing a more than 50% repeat user rate on all the Textlines under the PPTMS umbrella. The quality and timeliness of the response is the most crucial ingredient. If you listen well and provide sound feedback that comes from your own experiences and you come across as genuine, then they will text back repeatedly (until they graduate and move beyond the incredible stress of being a teenager among other teenagers). During that terribly difficult time, for some, textlines represent one of the most important contacts in their phone. And if being there saves just one of their lives, it makes it all worthwhile in a very big way.

Jonathan Holly is Executive VP and Co-Founder of PPTMS TextLines (Crisis Textline, Help lines and warmlines including TXT211 Info & Referrals, and Text Alerts) and a principal partner in the social marketing agency, Educational Message Services Inc. Contact: jonathan@emsmail.org For more info about textline services visit: www.preventionpaystext.com

2012 Educational Message Services, Inc. 1252 Devon Lane, Ventura CA 93001 www.educationalmessageservices.com