Cirsis Textline -

Imminent Risk

The texter has the desire, a plan, the means, and a timeframe in mind to die by suicide within the next 48 hours.

Ladder-Up Risk Assessment

DESIRE/IDEATION - Is the texter thinking of suicide?Crisis PLAN - Does the texter have a plan for completing suicide? MEANS - Does the texter have access to what they would use to kill themself? TIMEFRAME (NEXT 48 HOURS) - Does the texter have a time set, and is it within the next 48 hours?

Paraphrasing/Reflection

"I'm hearing that you're feeling overwhelmed having to deal with your parents' divorce and staying on top of your studies. On top of that, you're now in a big fight with your gf and feeling like it's the last straw." Takes a lot of info from a texter and summarizes it into big points. Shows we're hearing them and that we can step back, see how all the pieces work together to make them feel how they're feeling.

Self harm text example

"I'd like to help keep you safe while we text, Gina. Could you put the nail in your desk drawer for the next 15 minutes?" "I guess I can do that, but it's the only thing that makes me feel good" "It makes sense that you'd want to feel good, everyone deserves some happiness. Can you tell me more about how you were feeling before you started to cut?" "I guess overwhelmed. Everything was chaotic and falling apart and there was nothing I could do to stop it" "It sounds like you were looking for some control in your life. Do you feel like you have more control when you cut with the nail?" "yes and no. I'm happy and in contorl, but then it creates more harm because I have to cover it up, more of a distraction than solution" "what im hearing is that cutting temporarily distracts you from the other chaos in your life but it doesn't make you happy long term. is that right?" "it's okay to want some peace when life is so unpredictable. i'm wondering, are you open to working with me to find ways to distract yourself that would not cause you harm?

Warm response examples

"I see you're feeling devastated. My name is Amy, and I'm here to listen. Tell me more about what's going on that made you text in?" "Hi, I'm Amy. It sounds like you're having a difficult time tonight. Tell me more about what led you to reach out tonight?" Hi. My name is Kate. I'm here to support you. It sounds like you're feeling overwhelmed. Would you be open to sharing more about what led you to reach out?

Empathetic Response Formula

"It sounds like you're feeling anxious because you may not get into the school you want." Reflects what they're feeling and why. Shows that we're listening and following along.

Open-ended questions

"What is going on to make you feel this way?" Gives texters the space to talk broadly about what's on their mind.

A texter says "I cut myself a lot and I want to stop. What should I do?" Which of the following open-ended questions demonstrates collaborative problem solving?

"When you felt this way in the past, what sorts of things did you try to help with stopping

Strength IDs

"You were courageous to reach out and talk tonight." Helps texters see specific positives about themselves.

Take a look at this texter's message and use a validation (plus any other of your awesome good contact techniques) to respond in a supportive, nonjudgmental, and nondirective way: Texter: "I am feeling pretty down right now. I just can't stop crying, and I'm not excited about doing things like I used to be." Texter: "I'm not doing so well today. It's been hard. I'm sad, and I'm alone, and no one cares about me or what I do."

"it sounds like you're in a painful place. Do you want to talk about what's going on? You're brave for reaching out today. It can be overwhelming to feel isolated. Would you be open to chatting about what led you to feel this way?

5 stages of conversation

1. Building rapport: Establish trust, create safe environment, make person feel comfortable opening up. Use open ended questions, validations. 2. Exploring and risk assessment: Use active listening to understand why someone reached out, then Ladder up risk assessment (ideation, means, plan, timeframe) 3. Identifying the goal: Empower them to solve their own problems and identify ways to be their own champion 4. Collaborative problem solving: Identify coping skills 5. Ending the conversation: Recap, review action plan, warm goodbye

Red flag phrases for suicide

I just want to make it stop I really just want to die I've had enough I can't take it anymore No one cares I wish I could go away somehow I feel like I have no one

If texter asks you a personal question

Texter: "How old are you?" CC: "It sounds like you're feeling curious about me, and right now I want to support you. What happened today that prompted you to text in?" Texter: "Has anyone close to you ever died? I don't know why this had to happen to me." Crisis Counselor: "I can understand how losing someone so close to you can be painful." Texter: "Yeah, it's awful. But why didn't you answer me? Has this ever happened to you?" Crisis Counselor: "I want to keep the focus on you. I am here to listen and want to help you get through this. Can you tell me more about how you are feeling?"

[Goal] If texter wants us to solve their goals

Texter: "I just want to know if I should text my ex right now. What do you think?" or, Texter: "I'm so lost. Just tell me what to do." Crisis Counselor: "Feeling lost can be so frustrating. What is it that you want your ex to understand, if you decide to text them?"

Validations

"It's understandable you're feeling stressed with all these deadlines looming." Tells texters it's ok to feel what they're feeling.

Phrases for supporting survivors of sexual abuse

"You're incredibly strong for speaking up about this. I believe you and it can be terrifying to share such an awful experience." "It's normal to feel that this is your fault, but no one ever deserves to be assaulted, no matter what they have done." "I'm here to listen. Your feelings about this are valid. Can you tell me more about these feelings?"

[Goal] Example of dealing with depression

CC: It sounds like you're feeling isolated at work, among other things. I'm wondering, what are you doing to cope? Texter: That's right, but I'm not coping. i'm just sad about it all the time. I cry all the time. CC: I understand you're feeling helpless right now and crying has been your only relief. Texter: Exactly. I'm pathetic CC: Reaching out today shows real strength. You've noticed a problem, and are seeking help. That's brave. I'm here for you. Tell me, what makes you believe your coworkers don't want to work with you?

If texter's goals aren't clear

"I'm curious, what does help look like for you today?" "It took strength to share this with me, and I want to make sure I am able to be helpful. What are you looking to gain from this conversation?" "It makes sense that you're feeling overwhelmed with so many difficult things at once. It would be helpful for me to know which of these are the most painful for you right now?

Third party conversations

Encourage first-party contact. If appropriate, ask the texter to encourage the third party to contact us directly. Direct the texter to emergency services. If the texter believes the third party is at immediate risk of harming themselves or others, advise the texter to call 911. We do not risk assess a third party. Focus on the texter. We still want to ensure that the texter moves from a hot moment to a cool calm. So proceed through the five stages of the conversation with the texter as usual, and be sure to give plenty of strength IDs. If the texter becomes a third party. If the texter becomes a third party (a parent takes the phone, for example) respect the texter's confidentiality. Inform the texter you will be ending the conversation, then close out. One important exception: If the texter met all four criteria for Imminent Risk before they became a third party, flag the conversation for your Supervisor to review.

Vulnerable population abuse

Required to support vulnerable populations (<18, >60) and to report cases to Child or Adult Protective Services. It's up to the texter if they want to share the specific information required. Step 1: D - Determine abuse. Explore details and ensure a report is necessaryStep 2: A - Ask age. Be sure the texter is under the age of 18, an elderly adult age 60+, or legally dependent adultStep 3: N - Nudge Supervisor. Flag Supervisor who will review conversation with youStep 4: C - Clarify role. Describe what it means to be a mandated reporter (after Supervisor confirms convo is MR)Step 5: E - End with info. Request DOB, full name and full address

Self harm example (not willing to put it away)

"It's understandable to not want to stop, it's an extremely difficult thing to do. You're brave to reach out for support today. " "Cutting is the only thing that makes me feel better" "I hear that cutting yourself is the only thing bringing you relief right now. As we continue our conversation, are you willing to try to put the knife away? I care about your safety. I want to help keep you safe" "Maybe. I told you, it's the only thing that makes me feel better. I can't stop" "I appreciate your honesty. Your safety is my top priority. Would you be willing to tell me if you accidentally cut yourself more than you intended to?" "Yeah, okay" ...check in... "We've been chatting...wanted to check in to see how youre feeling? Still cutting Non eed to apologize. YOu're truing your best and that's what matters most. I want to keep you safe. Have you cut yourself tonight more than yu meant to?" No... "Your openness is inspiring. Sometimes it can feel like self harm is the only way to feel better. If you'd like, we can talk about some alternative coping skills to help you through these emotions" Use validations and strong feeling words. Ask them let you know if they cut themselves more severely, so you can flag if needed.

Good contact techniques

- Reflection and paraphrasing: use an empathetic tone, similar words and phrases, be empathetic. If they use sexually abused, don't say raped. Stay away from parroting - this sounds robotic. Use your own words to express your understanding. - Strong feeling words: Reflect their feelings and add an extra degree for intensity. Avoid using maximizers (really, so, very) and minimizers (kind of, a little, a bit) b/c these exaggerate feeling words and don't add substance. Eg: horrible vs bad, devastating vs sad, furious vs mad. - Validation: Recognize, normalize and accept. Eg :it's normal to feel frustrated when you don't feel heard by your parents...". Never validate negative behaviors. Normalize their feelings. "It's understandable" vs "I understand" --> don't make it about you. Most effective words: Reasonable, normal, makes sense, understandable, I see. - Tentafiers: Preface a strong feeling word to make it feel tentative (not permanent). Avoids you making assumptions. It sounds like, you seem, I'm hearing, I get the sense. - Open ended questions: Requires someone to expand on their feelings and give more context. "How did that make you feel?" vs "Did that make you feel sad?". How followed by When followed by What. Avoid Why questions. Do not ask more than one question at a time. - Strength IDs: Empowering, point out the positive qualities and remind people they are strong enough to get through their crisis. Effective words: Strong, impressive, caring, smart, proud, brave. Tie each strength ID to a visible action, need to back it up by pointing to something they said.

Expression of care statements

Clarify a texter's intent. "With all this (insert texter's issue here) going on, I just want to check in about your safety. Have you had any thoughts about death or dying? "Sometimes when people (insert texter's issue here) they may have thoughts of ending their life. I just want to check in, have you had any of these thoughts?" Texter: "My best friend won't talk to me, I'm failing math, and I feel like my parents are yelling at me all the time. I don't know what to do." Crisis Counselor: "Sometimes when people feel overwhelmed they may have thoughts of ending their life. I just want to check in, have you had any of these thoughts?" Texter: "I just wanted to test your system to see if this is real." Crisis Counselor: "Sometimes when people test our system, they may have thoughts of ending their life. I want to check in, have you had any of these thoughts?" Texter: "I'm worried about my friend. I know she's cutting herself and I don't know how to get her to stop." Crisis Counselor: "With all this stress about your friend's self-harming going on, I want to check in about your safety. Have you had any thoughts about death or dying?" Texter: "He was everything to me, and he just broke up with me like I didn't matter at all. I can't stop crying." Crisis Counselor: "Sometimes when people go through a breakup, they may have thoughts of ending their life. I want to check in, have you had any of these thoughts?" Texter: "What's the point in living? I don't want to do this anymore." Crisis Counselor: "Hi there, I'm Abby. I see that you are questioning your life right now. It sounds like you may be feeling hopeless." Plus: the Crisis Counselor introduces themselves and builds rapport with a thoughtful response to the texter's initial message. Texter: "Yeah, I guess hopeless is the word. I screwed everything up and it will never be right again..." Crisis Counselor: "You've mentioned how hopeless you're feeling. When you say you don't want to do this anymore, do you mean you're having thoughts of ending your life?"

Inappropriate text conversation

Crisis Counselor: "Hi, my name is Heather, and I'm here to listen." Texter: "Hi. I'm feeling really ****ed up. I really want to have sex." Crisis Counselor: "It sounds like you're feeling frustrated right now. I'm glad you texted in today." Texter: "Yeah - would you have sex with me?" Crisis Counselor: "I'm here to talk about what's bothering you and to listen. Can you tell me more about what's feeling difficult today?" Texter: "Ok, fine. I guess, I just feel so ugly. No one likes me and I can't get a girlfriend." vs. Texter: "The only thing that's bothering me right now is that you're holding out on me. Why are you being such a prude?" Crisis Counselor: "If you're not ready to talk about your thoughts and feelings, I'm going to have to end the conversation."

If texter isn't at risk of suicide

Crisis Counselor: "Through all of this pain, has it gotten to the point where you've thought about suicide?" Texter: "No." Crisis Counselor : "I want you to know that if you ever do, you can always tell us." Crisis Counselor: "I know this is tough to share. You're so brave for opening up. I'm wondering how you would end your life?" Texter: "I haven't thought about it that much, no. It seems scary to let myself think that way." Crisis Counselor: "It sounds like even though there is a part of you that wants to die, there is also a part of you that wants to live."

Unique Developmental Stressors for LGBTQ+ Texters

Gender Nonconformity: Not following society's traditional gender roles (for example, a woman involved in wrestling instead of cheerleading, or a man in drama club instead of basketball). Gender-Related Victimization: This could include rejection and isolation, verbal harassment, physical and sexual assault, and property damage. Trans women of color are more likely to be murdered than any other group in the LGBTQ+ community. Coming Out: A large source of stress and confusion, during which time the texter might worry about their family's reaction and the fear of never finding a partner, just to give a few examples. LGBTQ+ youth have an increased risk of crisis at this time. Lack of Role Models: Many LGBTQ+ texters experience a lack of role models in their lives, meaning having no support system that they can directly relate to. Rejection After Coming Out: Some texters will have experienced the loss of family and friends and therefore their support system after coming out. Lack of Access to Community: After coming out, a texter might experience a lack of access to the structures and support systems of the heterosexual community. Lack of Relationship Support: The lack of support from family and friends upon entering an LGBTQ+ relationship (for example, not being able to take their partner to a dance, or to openly date). Rejection from family can lead to homelessness.

Crisis definition

Mental or emotional state that has left the texter in a dangerous condition or unable to cope in a functional or productive way.

Exploring (second stage)

Step 1: Identify the precipitating event. Crisis is often precipitated by a sudden and significant change, so try to find out what that was. What was the trigger that led them to text in?Use open ended questions. Understanding the specific event that caused the texter to reach out while assessing their level of risk. Allows the texter to comprehend their feelings on a deeper level and gain insight into why they're feeling that way. Step 1: Identify the precipitating event. Crisis is often precipitated by a sudden and significant change, so try to find out what that was. What was the trigger that led them to text in? Step 2: Dive deeper into the central problem. A texter will often identify a scenario that involves various problems. It's your job as a Crisis Counselor to help figure out the central problem. For example, a texter may share that he is getting bullied at school because he constantly has dirty clothes. The central problem here may not be bullying, but rather a parental neglect situation. If this central problem seems to be disconnected from the precipitating event, try to get a full understanding by:Asking and encouraging them to elaborate (For example "Tell me more", "Go ahead..") Exploring emotions around the crisis, not just facts! And lastly, understanding the history (e.g. How long has this problem existed?) Step 3: Assess for Risk: Every texter will need a risk assessment. Also, you can always return to the risk assessment at any stage of the conversation if the texter says something that implies risk.

Loneliness text example

Texter: "I feel trapped inside this shitty body. there's just no point. it's not going to get better, there's nothing I can do about any of it" Crisis Counselor: "Dealing with everything all at once has been overwhelming, and on top of that, you're feeling like nothing that you do will make a difference." Texter: "Yeah. Pretty much. I don't even know why I texted you guys. doctors tell me i have less than three months to go." Crisis Counselor: "Even though talking about what's on your mind can be helpful, it's understandable to feel frustrated about not getting the solutions or answers that you want." Texter: "Doctors tell me I have three months to live. I'm scared." Crisis Counselor: "It's normal to feel afraid. You're a strong person for fighting for your life."

If texter wants advice

Texter: "Should I talk to someone about this?" Say, Crisis Counselor: "It sounds like you're wondering about whether or not you should talk to someone. What's making you unsure?" or, Crisis Counselor:"What about talking to someone is making you hesitate?" or, Crisis Counselor: "It sounds confusing: on the one hand, you'd like to talk to someone, but it sounds like on the other hand, you are worried that person will judge you?"

Do you say "commit suicide" and why?

These perpetuate the stigma around suicide dating back to when suicide was illegal and considered sinful (little known fact). People who die by suicide are not criminals; they are dealing with an illness. Stick to the terminology "died by suicide" or "completed suicide," both of which are very direct but don't come with any added stigma.

How to ask texter about their goal

What do you think will help you most today? "What do you think might help most tonight?" "What are you hoping for in this conversation?" "What does help look like to you right now?"