Text-Based Crisis Counseling: An Examination of Timing, Pace, Asychronicity and Disinhibition

Abstract

Texting-based crisis counseling is increasingly used to reach young people in acute crisis. Drawing on the online disinhibition effect (ODE), this U.S. study explored how asynchronicity and invisibility contribute to how users reveal their presenting problem and engage with counseling. A random sample of 49 text crisis line sessions with youth averaging 18 years was used to assess response lag times and flow as well as their impact on the session. Interviews with crisis counselors provided supplemental context. Content analysis identified patterns in the presenting problem, reasons for response lags, and patterns in how the sessions ended. The overall duration of text sessions was substantially longer than that of voice calls, to cover comparable content. Users frequently multitasked or become engaged in other activities between texts, creating a more disjointed flow. This also allowed the user to take time with responses to difficult questions. Counselors had to match their pace with users, make decisions when to discontinue the session, and use intentional language to develop a therapeutic connection. In line with the ODE framework, the findings suggested that the invisible nature of texting allowed users to reach out for help at the moment they needed it, regardless of their location. Implications for using texting-based interfaces are discussed.

1. Literature Review

Telehealth, in the form of online, web-based, video, voice, or text-based psychological and social services, is taking hold in the world of mental health services, expanding both the geographic reach and demographic range of clients served. While this was already in motion prior to COVID-19, the pandemic greatly accelerated the use of remote forms of therapeutic services, which have continued to be popular even after the world reopened. The use of a virtual means of communication for health and mental health care, also known as “telehealth”, has increased dramatically worldwide since COVID-19 [1,2]. In a study of 849 million service records in the U.S., where the present study takes place, the rate of telehealth behavioral health claims represented about 1% of all claims in early 2020, then spiked during the peak of the pandemic to represent 51% of all claims, but never returned to pre-pandemic rates, remaining at 40% by the end of 2021 [3]. Research on the newer interfaces has not kept pace with the usage, with only a small, albeit growing number of studies examining the effectiveness of using a texting interface for crisis intervention help lines.

Texting-based crisis counseling is the same type of service that voice-based phone crisis lines offer, though using a texting interface. It offers access to mental health care that may reach an underserved population that is in great need of services. Mental, behavioral, and developmental disorders typically begin in early childhood, and anxiety and depression diagnoses increase as children enter adolescence [4]. In fact, the most predominant chronic conditions found in pediatric health care are mental health disorders, which have reached epidemic proportions in recent years [4,5]. In a national study among youth aged 12 to 17 years reporting on the previous year, 15.1% had a major depressive episode, 36.7% experienced persistent feelings of sadness or hopelessness, and 18.8% seriously considered attempting suicide [4]. Untreated mood disorders such as depression are directly linked to suicidal behavior, which is the third-leading cause of death among young people aged 10 to 24 [6].

Adolescents with depressive disorders are often hesitant to pursue professional help; moreover, the more severe the depressive symptoms are, the less likely adolescents are to seek help [7]. Adolescents are the most underrepresented users of voice-based crisis call lines. They comprise as little as 2% of hotline callers in some studies [8]. However, texting-based helplines have proven to be popular amongst young people, and many are heavily used [9,10]. For example, the Crisis Text Line, the largest such service in the U.S., claims nearly 8 million text conversations since its inception in 2013 [11]. In an assessment of 800,000 of their texters seeking help, 74% of their services users were 24 years or younger; 34% were 14 to 17; and another 13.7% were 13 or younger [12].

Those living in rural areas have limited access to resources, so texting-based crisis lines address a significant service gap [13]. Importantly, for a user with suicidal ideations, texting can serve as an outlet to express their feelings as a coping strategy—one that not only avoids the waitlist of in-person therapy but also allows them control over whether or not an emergency crisis team should arrive to interview them in person [10,14].

Texting-based crisis counseling introduces new challenges for the counselor and service user, including how to convey empathy, multi-tasking during sessions, and the asynchronous nature of the conversation that can cause text exchanges to become off-sync [9,15]. Clinicians tend to prefer the modality that most closely resembles in-person services: video over phone and phone over email or text, though the issues of hardware and Internet capabilities can be a barrier for some clients, especially in poor or rural communities [9,16]. One recent study of professionals’ perspectives on text-based counseling found that with the right skills, this interface could be effective, but that the slow pace of the exchanges and absence of nonverbal cues posed significant challenges to its effectiveness [15]. The professionals reported that session lags due to the overall slow response time or technology issues increased the chances of dropout from the session. There is a dearth of information about how these issues unfold throughout the counseling session and how to address them when there is only the written word as the means of communication.

Online Disinhibition Effect

Research on the use of social media, email, other online communication, and texting reveals that users may behave differently when using an electronic form of communication rather than voice or face-to-face communication. The online disinhibition effect (ODE) has been applied to make sense of this phenomena and understand the context behind the way and timing that users disclose private information in both social and counseling settings [9,17,18]. Much of the research focuses on the negative and dangerous impacts of ODE, such as cyberbullying, cyber aggression, or online deviant behavior [19,20]. However, some of the core concepts of ODE can serve as a benefit to service users as well. Three of these concepts are particularly applicable here: asynchronicity, dissociative anonymity, and invisibility [21].

The asynchronicity of the exchange permits users to insert a pause before revealing their emotions or reactions, which, in essence, gives them space to deliberately “suspend time” while thinking through their response [21]. This allows the user a moment to gather their thoughts and express themselves clearly. There is a tension, however, between the user and counselor experiences, since “communication by text message is halting and asynchronous, which can be frustrating when you’re waiting for a reply but liberating when you don’t want to respond” [22]. While response lags are inherent to the texting experience, they can be difficult to interpret. It may be that a user is silent as they consider their next statement, but because texting can occur in any setting and is often part of multitasking, pauses may also represent distraction and attention to other simultaneous demands.

Another ODE concept is dissociative anonymity. This refers to the option to hide one’s identity or selected identifying features [21]. The user has control over nearly all information that is revealed about themselves. That control may produce a sense of safety when discussing painful topics. Conversely, there is some evidence to suggest that the anonymity that comes with the online interface can also enhance or serve as a precursor to self-disclosure, which is critical to the counseling exchange [9,23].

Invisibility overlaps with anonymity but is not the same. Even in the case where an individual has revealed their identity, they can be invisible in that their reactions and expressions can continue to be hidden from others. In text counseling, this works both ways. The user not only can conceal their own emotions, but also is protected from the facial expressions and sounds of the counselor that can be inhibiting [24,25]. “Seeing a frown, a shaking head, a sigh, a bored expression, and many other subtle and not so subtle signs of disapproval or indifference can inhibit what people are willing to express” [23] (p. 322). As a result, it can embolden the user to reveal information in texting that they may not share in other contexts.

The invisibility and anonymity of texting also offer flexibility—individuals can seek help silently and quite literally engage in a counseling session in the presence of others while maintaining privacy. For example, a youth may text for help while at school, in the presence of peers [9]. This means that one can receive the help that they need, in the moment that they need it [14].

Given the rapid increase in anxiety, depression, and other mental health concerns and the significant growth in the use of text crisis lines, it is imperative to understand how the modality of texting influences the therapeutic experience for both the service user and the counselor.

2. Present Study

This study sought to examine how the interface of texting affects the exchange between counselor and service user. It investigated how communication, using only the written word and the asynchronous nature of texting, unfolds in a crisis counseling setting and how that may impact the counseling process.

This study used data from a comprehensive integrated human service center in a Midwestern U.S. state that provides a wide range of mental and physical health services in several locations. One of the services offered was texting-based suicide prevention counseling, which typically reached individuals in the age range of 12 to 24 years. The service was primarily marketed to all locations across the state but was accessible as a toll-free number to anyone in the U.S. Using this HIPAA-compliant technology, young people in crisis could receive confidential texting-based services with a trained counselor. Texters are given a brief overview of the service and how to opt in or out and told that the transcript is stored off-sight confidentially in a HIPAA-compliant location and may be used for training and research purposes. At this time, they are also given a link to a program website that provides greater detail about their privacy. If texters want to continue to the session and connect with a counselor, they are given a four-letter code to enter to continue on to the call.

3. Methods

This study sought to answer the following research question: what role do the timing, pace, and asychronicity of texting play in the crisis intervention process for both client and counselor?

The research protocol was approved by the principal investigator’s university institutional review board for research on human subjects in advance of any data collection. The transcripts were de-identified prior to analysis. However, as a matter of protocol, crisis line users are not asked to provide identifying information except in cases of mandated reporting. Due to the intentionally anonymous nature of the services, in most cases the agency staff and counselors did not know the identity of the users.

3.1. Sampling and Data Collection

Two forms of data were collected for this study: text crisis counseling session transcripts and counselor interviews.

Texting-based crisis counseling sessions. To ensure a representative sample of the texting sessions held throughout the course of the year, four randomly selected dates from each month were used, and, within the selected date, one session was randomly selected. This resulted in 48 sessions representing 48 unique texters.

A preliminary analysis found that short sessions tended to be contacts for quick information or referrals that were easily resolved and did not delve into issue details nor counseling. These comprised 4.2% of the calls. To capture sessions that were more likely to include a counseling exchange, only sessions 30 min or longer were included (95.8% of the text calls). Any identifying information from the extracted transcripts was then redacted.

Key informant qualitative in-person interviews. These were conducted with three crisis counseling supervisors to gather contextual information about why and how certain techniques were used and their observations about the interactions between counselors and texters. The interviews explored differences between voice and text in regard to counseling approaches and how they interpreted caller and user comments. The interviews also examined whether there were differences with voice calls in terms of methods used to connect with users and elicit critical information. The interviews helped to address how the texting medium affects the communication style and how that influenced their agency’s approach to intervention.

3.2. Analysis

Demographic information was gathered from the text sessions to the best extent possible. Although users were asked to provide basic demographics, this was not required, so many opted not to provide it. Information gathered and summarized here includes the gender, age, and ethnicity of users. Statistics regarding the session timing were also examined. These included documenting the time of text, duration, who answered, if it was a repeat call, and if the counselor shifted mid-session. A more in-depth content analysis also broke down the conversation by lag time between the counselor’s posted message and the user’s response.

The presenting problems were assessed using content analysis, by identifying specific words that texters used to describe the reason for their call. Two reviewers organized the presenting problem into categories. These were compared with each other and with the agency’s categories of reasons for seeking help. Categories that were similar (e.g., different types of relationship problems) were collapsed. The list of specific subthemes that were combined into each category are outlined in Section 4.1.

3.3. Obtained Sample

Text counseling transcripts were examined from 49 sessions. While 48 sessions were originally identified, one additional session was included, as it was a continuation from the same individual earlier in the day, raising the number of sessions to 49 with this one known repeat user. These represented 48 unique service users.

The service users who reported their gender were disproportionately female. Twenty-nine identified as female, eight as male, and one as transgender, and the remaining did not indicate their gender. This gender disparity among users was representative with the agency’s overall text data. Two-thirds of the users did not provide their age. All but one of the users who reported their age were between 12 and 28 years old. There was one outlier, a 44-year-old user. The average age was 18.5 years old. Removing the 44-year-old outlier, the average was slightly younger, at 17.6 years old. Most of the users did not report their ethnicity. Of those who did, most identified as White, 20% identified as African American, and 10% identified as Hispanic.

Seventeen counselors responded to the text calls. All counselors, including the supervisors, were trained in motivational interviewing techniques. On average, counselors facilitated three text sessions in the sample. Their identities were not revealed to the research team.

The program had three crisis counseling supervisors with expertise in crisis intervention in both voice-based lines and text-based lines. They both practiced as counselors and had trained and were supervising the counselors that were using the text-based crisis line. All three were invited to be interviewed, and all three participated. They were two men and one woman, each with five or more years of experience in crisis intervention therapies. All three held a master’s degree in social work. Each of the supervisors began their work as a crisis line counselor and then moved into training and supervising the counselors.

4. Findings

The roles of timing, pace, and flow surfaced in three components of the transcripts. One area regarded the timing and user’s choice of language to communicate their reasons for seeking help. Another was asynchronicity. Factors pertaining to asynchronicity emerged in an examination of lag times, meaning the delay between a counselor’s question and a user’s response. These affected the pace and flow of the sessions as well as how the sessions closed. Finally, the transcripts demonstrated that the asynchronous nature of texting allowed room for multitasking during a counseling session in ways that would not occur on a voice call or in person.

All quoted text exchanges are documented here exactly as written, without being corrected for typographical or grammatical errors. The findings presented here include data from the data transcripts. Additionally, excerpts from the key informant interviews with counseling supervisors are included, as they speak to the text session’s findings. These quotes are included to add context and understanding to the information revealed in the text sessions.

4.1. Revealing the Motive for Seeking Help

The first analysis examined how users started the text session and the nature of their presenting problem. When it could be identified, the presenting problem fell into three main categories and a fourth that combined the less common problems:

• Mental health (60%): A pre-existing mental health disorder or condition causing chronic bouts of depression, anxiety, suicidality, or self-harm.
• Love relations (35%): Rejection, conflict, or abuse as part of a romantic interest—a boyfriend, girlfriend, or desired relationship.
• Family and peer relations (19%): Typically, feeling isolated, unwanted, or unloved by family or peers; including bullying.
• Other (less common) (8%):

  ○

  Struggling in school academically;

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  Addiction;

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  Unplanned pregnancy.

Importantly, the texter also sometimes presented multiple problems at the outset. How they communicated these problems was often ambiguous. Texting exchanges by nature are comprised of short statements, making it challenging to assess a user’s emotional state or the safety of their situation. The most common opening text was not so much a specific presenting problem as a vague, brief feeling statement. In these cases, the users offered a few words and nothing more until the counselor followed up by asking for more information. (see

Table 1. Opening Texts.

I hate myself	I’m feeling sad today
I’m just so stressed	I just feel terrible
I’m lost	I hate my life
I feel like I died	I feel really down
im not sure i can do this

).

This led, slowly, to the slow onset of the intervention. One of the counseling supervisors explained that text counseling requires a different approach from voice-based hotlines to enable users to reveal enough information to adequately help them.

The one- or two-word answers are tough. It is hard to pull them out. I’m constantly having to ask more prodding questions. Like, [if a user writes] “I’m having a really bad day”, I’ll say “what’s going on today that’s making you have a bad day?” On the call [voice hotline] side, they’d usually just keep going. But on the text side, they don’t. They have to be asked directly.

This, in turn, stretched out the initial assessment longer than it would take in a voice call. Even after the counselor elicited more details, the users did not always begin the exchange by naming their highest priority problem. They sometimes presented a less significant issue and then eventually divulged the more serious problem after several exchanges with the counselor. For example, in one session, the user initially said she was worried about her boyfriend, and it was an hour before she reported that she was actively suicidal.

In their interview, one of the counselors demonstrated a typical introductory exchange in which he introduced himself, briefly explained a couple points regarding the text process, asked the user the reason for calling, posed one follow-up question for more detail, and received a user response.

That probably took, what, 30 s for me to say that? In a text, that would take 10 to 15 min…If it was really cooking it would be six minutes. So right there, if someone’s in crisis, it’s just, we have to constantly wait to get this information out. Whereas on the call side [voice hotline], you can really move very quickly to put them in safety. Where on the text side it might take 15–20 min before we can confirm they are safe—without even knowing what else is going on.

One user began her session writing by stating that she was overwhelmed with financial issues but later revealed that she was primarily concerned about her unplanned pregnancy. Another young service user began by stating that he hated his life; only 15 min later did he reveal that his parents had kicked him out, and he had no place to stay. Conversely, there were other users who began with a statement of suicidality but then later shared that this was actually only a vague thought.

While most users began vaguely, there was a subset that began with direct statements, usually about harming themselves:

I hurt myself.

Help me. I’m so suicidal.

im trying to forget about trying to commit suicide and im scared really scared.

In these instances, the counselors could delve immediately into risk assessment and then either move to a safety plan or, if the risk was minimal, discuss the underlying problem in more depth.

4.2. Impact of Asynchronicity on Pace and Flow of Sessions

The flow of any conversation is affected by the pace of responses. Due to its asynchronous nature, text conversations require different conventions than other forms of communication. Users may have delayed response times of several minutes, while still sustaining the conversation, which would not occur in a voice call. The users in this sample disappeared at times for 10 or 15 min without notice and several of them later told counselors they had been doing something else in the middle of the text session.

To understand how these silences unfolded during the sessions, the analysis examined the lapse between texts and responses (lag time). Every text in the data was time-stamped to the second. Lag time was calculated as the time lapsed from a counselor’s posted message until the service user responded. If the counselor posted several texts with no response between, the lag time was calculated from the first counselor text of that interaction.

Text exchanges were also tabulated. These exchanges were defined as a counselor message paired with a user response. Each paired exchange was tallied to determine the total overall range of communication. The average number of counselor–user exchanges was 17.3, representing a range from 5 to 27 exchanges (

Table 2. Time variables during text sessions (n = 49).

Variable	Mean (Average)	Median	Range
Exchanges	17.3	16	5 to 27
Session duration	1 h 11 s	1 h 8 min	30 min to 2 h 30 min
Lag time	2 min 48 s	1 min 14 s	1 s to 36 min

).

The average session length of the text sessions was 1 h 11 s. In a voice call, a similar number of brief exchanges would take about 10 min at the most. For the purposes of planning, staffing, and effective service delivery, the agency conducted an informal comparison of the duration of counseling sessions between voice and texting.

Since we offer both a call line and text line services, last year we measured approximately how long it took to cover the same amount of content and we found that texting takes about six times longer than calls. When possible, we try to keep our calls to ten minutes. For the text line, that translates to an hour.

The long duration of text sessions was primarily due to two factors. First, the fact that the shortest sessions were excluded from the analysis skewed the average duration toward longer conversations. Second, there is the frequently slow user response following a counselor text. Although counselors, naturally, also take more time to type statements than when speaking, their lag times were negligible compared with those of the service users. In this sample, the mean user lag time was close to 3 min: 2 min, 48 s (Table 2). This figure is affected by a couple extraordinarily long gaps. Since one outlier lag was exceptionally long, at 36 min, the median provides a better sense of the more typical lag time, which was 1 min 14 s.

A lag time of one to three minutes reflects, in part, the additional time it takes to type out a text exchange. In a voice call, a one-to-three-minute silence would likely lead a counselor to close the call, because it is not convention to have silences that long in a voice call. A silence of even 20 s in a voice call would warrant a question of whether the caller was still on the line. The counselors demonstrated patience during these gaps as well as agility in picking up the conversation where it left off after a long lag, even if they had been answering other calls in the interim.

Even when the text conversation moved with very short lags, the flow of the exchanges was affected by the time that it takes to type and send a message. Responding too quickly made the text session flow less smoothly. When the exchange was very fast, the user or counselor response would sometimes fall one text behind—such that the conversations were off-sync, and the participants risked reacting to the wrong messages. Similarly, the counselors learned to ask only a single question at a time and to wait for a response before asking the next.

One of the things we’ve learned between text and call is that I can ask two questions in the same breath in a call, and they will answer both questions. In a text, I can ask two questions and they’ll answer the first one and forget the rest. So we stick to one statement one point at a time and let them respond, then one more question and one more statement. So a lot of waiting for them.

4.3. Lag Time and Severity of the Problem

The next analysis examined whether the length of the average lag time was aligned with the severity of the problem, using the hypothesis that a person in severe crisis would be more attentive to the conversation and would respond quickly. Overall, 25% of the sessions had lag times long enough that the counselor suggested ending the call due to the lack of response.

Most often, once the counselor recommended ending the session, the user immediately texted and began actively responding quickly after that. When a counselor moved to end a session after a long lag, the user would sometimes quickly re-emerge to rejoin the conversation from precisely where it left off. As an example, the excerpt below begins 13 min into the session, as they discussed the user’s eating disorder and how she might tell her parents and receive professional help. The user was a high school senior and worrying about the impact on her plans to leave the state for college.

User: I’m worried they’ll [parents] want me to stay home and go to community college so they can keep their eye on me.

Counselor: [1 min later] If you like I can look up some outpatient programs in your area. Some of them offer free assessment.

User: [90 s later] That would be cool. But I don’t know where I’m going to college yet. I’m worried if I tell my parents they’ll be mad at me for lieing to them.

Counselor [1 min later] Do you have any friends or adults you trust who can help you talk to your parents? Maybe they could there for support while you start this conversation with your parents.

Counselor [20 s later] Ok great. I want you to check out this eating disorder program in [city]. Here’s the website so you can read some info. Call [number] to schedule an appt.

[no response from user].

Counselor [20 min later] Do you still want to talk?

[no user response].

Counselor [5 min later] Okay, I haven’t heard from you in a while. I’m closing this message. Text back if you need help in the future.

User: [30 s later] Sorry! My phone ran out of battery. I’ll check out the website. What should I say to my teacher?

We do not know at what point the user’s battery died, but it was not uncommon for silent users to suddenly reemerge seconds after a counselor suggested ending the session. While it was tempting to assume that a long lag was an indicator of disengagement or loss of interest in the session, this was seldom the case. The presence of longer lag times did not correlate with users who presented milder problems. In fact, some of the users who began by stating they were suicidal had some of the longest and most persistent lags.

User: I was thinking about commiting suicide.

Counselor: Can you tell me why you are thinking about suicide today?

[no response from user].

Counselor: [5 min later] Are you still there? I’d like to help you.

[no response from user].

Counselor: I’m worried about your safety and I’d like to know if you are OK, before we stop talking today.

[no response from user].

Counselor: [16 min into session] I haven’t heard from u in awhile. I’m closing this msg. If ur in danger call 911; if u need help in the future txt back or call [phone number].

User: [21 min after first counselor text] Because my bf left me and i dont believe i will find someone else becauwe im not pretty and im fat or chunky.

Here again, once the counselor suggested ending the session, the user rejoined the conversation, picking up right where she left off 21 min earlier. After this last exchange, the user was engaged for the remainder of the session, responding regularly and quickly. It is unknown what the cause was for the delay in this and many instances.

The setting from which the user was texting may play a role in the lags. Users disclosed that they texted from a wide variety of locations including school and work and while doing other activities. Due to the privacy that texting permits as well as its level of familiarity in all settings, users can—and do—engage in a crisis counseling session in a place such as a school cafeteria, where they may be distracted between texts or may have to physically move mid-text (e.g., when the lunch hour ends). As such, multitasking was a factor in the flow of many sessions.

4.4. Multitasking

Multitasking appeared frequently in both the transcript data and the supervisor interviews. In this sample, there were users who, while receiving counseling, were simultaneously preparing dinner for their children, watching TV, sitting in class, at work, in the halls between classes, and eating lunch with friends in the school cafeteria. Without the invisibility feature, this would not be possible in a voice-based or in-person counseling session.

Invisibility appeared to work in both directions. That is, the user could hide their setting and situation from the crisis counselor, and a young person in crisis could discuss their pain while in the presence of their peers. The user did not need to wait for a private space to text for help, and in fact they did not. One of the counseling supervisors explained:

One of the biggest things we’ve noticed is that people do this—text—without people knowing. I can pull out my phone right now and I could text somebody and you would never know what I was writing. Because we don’t say like, “hey what are you doing?” That’s none of my business. People don’t do that. Even parents for the most part don’t see what their kids are texting. We’ve had plenty of kids who have texted a while and then wrote “well I’m in the car with my dad.” They do it in class all the time. Lunch time is a pretty popular time.

Some users stopped responding to messages while they engaged in unrelated activities, usually without explaining to the counselor that they had temporarily left the conversation. When prompted, often the user would jump back into the conversation as if there had not been a break. The counselor below was trying to wrap up the session when the user disappeared for 8 min:

Counselor: How do you feel about the rest of the day today? Do you have any plans?

Counselor: [7 min later] Are you still there?

User: [8 min after first counselor text] Yes I’m sorry I wasn’t by my phone. But I’m just going to go to work later I guess.

Yet, that user continued the conversation after that. Another user dozed during the session:

Counselor: I know you are dealing with some persistent suicidal thoughts—are you planning to act on any of these thoughts today?

Counselor: [14 min later] are you still there?

User: Oh.. I fell asleep for a few minutes.

Sometimes the users were engaged in simultaneous chat sessions and forgot which they were responding to. A supervisor explained:

Oh, we’ve had several instances of counselors who will get a weird link that says, “here try this” with a link. Then it’s “oh I’m sorry. I was playing a game with my friend and I meant to send her that link”… They forget who they’re texting… but as a counselor I think, at least they’re connected to people.

In addition to the sessions with long response lags that led counselors to recommend closure, it was also common to have a long enough period of nonresponse that counselors asked “are you still there?” Here are examples of responses from users when they received that message from the counselor:

Yes I am here. I had to feed my child.

I apologize for that, I’m having to take care of my little brother at the moment.

Sorry my phone died and my daughter was screaming so I put her down for a nap.

Sorry! My phone ran out of battery.

Yes just at work sorry.

In these instances, barring battery issues, users frequently sought help while simultaneously engaging in other activities. This can affect how and why a user may end a session as well. Some abrupt endings may be due to external factors, unseen and unheard by the counselor, that compel a user to close quickly, such as someone walking into the room. One young user who had shared his serious suicidal ideations suddenly wrote: “I have gym class so I have to go.”

4.5. Session Closure

The response lags, whether due to multitasking or the user falling into a deeper crisis, affected how and when counselors handled session closures. Invisibility offered a mechanism for closing the conversation: the user could name virtually any interruption as a reason to end, which would not be possible in an in-person session. Given that it was not uncommon for users to reappear after an absence, it was not always obvious to counselors when a user was genuinely ready to wrap up a session. When there were increasingly delayed responses, it was nearly always incumbent upon the counselor to formally end the session:

It seems to be harder to cut people off, to wrap up and say, “I have to attend to other people.” Whereas the call side it seems to be easier to transition. When there is a text, there seems to be a need on our end to respond to it…but [counselors] can ignore a text. They’ve texted 50 times. You’ve told them 50 times it’s time to finish up.

In voice-based hotlines, when a caller wishes to close the session, they will typically indicate that they are ending the call. However, in these sessions, the users were more likely to dwindle off slowly, with increasingly delayed responses to counselor prompts.

5. Limitations

This study has a number of limitations. The inclusion criteria limited data to sessions lasting 30 min or longer, which potentially excluded some users who received what they needed quickly or who perhaps did not feel enough of a connection with the counselor to remain in the session. Relative to the number of text-based crisis conversations nationally, this sample is small and not necessarily representative. Finally, the anonymous nature of crisis lines makes it difficult to know the outcomes of the sessions after they end. While such text-based crisis lines are used in countries throughout the world, this study took place in the U.S. and may reflect American cultural norms that can be different from those of other countries.

6. Discussion

This study elucidates some of the unique nuances of the text-based crisis counseling experience in the U.S. for both the service user and the counselor, which do not exist on voice calls or in-person sessions. Since this is a relatively new—albeit expanding—medium for service delivery, much of the existing research provides data on the volume of text calls, demographics, presenting problems, and services provided. However, there is little research examining the impact of the timing, pace, and flow of text sessions and how they influence counselor interpretation and response to the situations.

The findings here found that several components of the online disinhibition effect impacted the counseling process in ways that are quite different from a voice or in-person intervention. The service users are attracted to the texting interface because of the asynchronicity, invisibility, and anonymity it offers, which are all precursors to becoming disinhibited enough to disclose the primary problem and discuss it over text [15,23].

In this study, the texters were disproportionately young and female. Of the total sample, 60.4% were female. Although there do not appear to be differences in the reasons for calling a hotline between men and women, women tend to use them more. A recent scoping literature review found that women represent a higher percentage of calls to crisis hotlines worldwide, despite men having higher rates of suicide [26]. They found that for voice-based phone hotline calls, the percentage of female callers was 62.4%. In fact, they found that females tend to use crisis hotline services more than men globally. This was true regardless of culture or geographic location [26].

The texting interface offered a great deal of flexibility. Invisibility and the silence and normality of texting in any situation gave users the freedom to reach out for help from the school lunchroom, on the way to gym class, or while babysitting a little brother. The asynchronous feature meant they could engage in a counseling session while also feeding their child or getting ready for work. Multitasking meant divided attention, sometimes while engaging in radically disparate activities—expressing deep sadness while simultaneously playing a video game or pausing to take a nap. These are activities that the users bounced between, while the counselor remained engaged in a singular activity. Such behaviors simply would not occur in an in-person venue, and it places the counselor in the uncomfortable position of repeatedly trying to re-engage the service user.

There is a dearth of research and understanding about the presence of response lag times. While some research reports that professionals find these lags challenging and frustrating [15], they have not been fully explored. In this study, there was a frequent pattern of slow and drawn-out departures. The user response lags averaged close to three minutes; longer lag times were also common. This introduced complexity to the counseling process, particularly in terms of interpreting the cause or meaning of the delay as well as the appropriate response. Invisibility allowed the user to end the conversation via passive non-response rather than activity. The field of counseling is familiar with premature departure, in which clients do not return for their subsequent appointments or to establish closure. Frequent or long lags could signal declining interest in the counseling session or perhaps that the user is not in a serious crisis [14]. It may be that the lack of response or delayed responses is the texting version of the premature departure seen in other contexts. Xu and colleagues (2021), in one of the only studies to examine lag responses, found a relationship between premature departure and the service user’s report that the session was not helpful or effective in reducing their stress. This study also found that some lags were not intentional signals of a problem with the session itself but rather an artifact of invisibility—because they could reach out for help from any location, the presence of others or context of work and school may require they intermittently step away from the session [27].

The conundrum for the counselor is that the wrong interpretation could lead to severe consequences. In highly risky situations, where a suicide attempt may be imminent and could quite literally occur mid-session, making assumptions of user disinterest is dangerous, so it is incumbent upon the counselor to re-engage the user at least enough to determine the cause of the non-response. In these data, there was not evidence of a specific connection between the severity of the problem and the duration of the lag time, but this needs to be confirmed with more extensive research.

Both the overall prolonged time it takes to run a text session and the delay, at times, in revealing the true reason for the text call can make the counseling process more complicated. Some of this may be due to the slow overall nature of the interface and that it takes time to develop enough trust to reveal the true problem. It also may be that it requires more time to develop the trust necessary to reveal the reason for the call. One way to address this is to train counselors to use very specific “feeling” words, which can help the texters to describe their own situation and make them more at ease with the stranger on the other end of the chat [12]. This is an explicit method of demonstrating empathy combined with clear active listening.

As noted by the counselors in this study, the pace of the conversation is also affected by an absence of cadence, meaning the inability to insert a specific pace while delivering a single statement. A text statement arrives all at once, whereas over the phone or in person that same statement might arrive haltingly, rushed, or slowly and calmly. Those features add nuance and information to the exchange that simply is not there with text. Without any other nonverbal cues, which counselors use to assess the situation, such as whether or the caller is crying, out of breath, or has a flat tone, the counselor must rely exclusively on the written word. The user too must find other ways to convey emotion and express their needs. The counselors learned that they must be patient and ask one question at a time, waiting for a response before asking more.

Finally, there is virtually no research examining what happens on the counseling end during lag times. There is the risk that the counselor too can become disengaged, start multitasking, or engage in two different texts simultaneously. There is much to explore regarding the impact and actions of counselors as they wait for service users to respond.

Text-based crisis counseling has become critical in this age of electronic communication. This service reaches youth and young adults through a venue in which their generation is comfortable and adept at communicating. The evidence to date, though limited, indicates that this is a modality worthy of expansion and more extensive support. Given that the primary demographic that text crisis counseling reaches is the most underserved in crisis counseling and also the most vulnerable [4,7,28], text counseling shows much promise for young people suffering from mental health and other socio-emotional problems but may not be ready or feel comfortable with voice-based or in-person services. There remains much to learn about the most effective counseling approaches to adequately assess, engage with, and intervene with young people in crisis who seek help through text-based crisis lines.