Digitizing Mental Health: Text-based Therapy

Abstract

This research looks at the digitization of mental health treatments specifically as it concerns text-based therapies. Primarily, this study centers on New Yorker journalist Alice Gregory’s piece R U THERE? that examines Crisis Text Line, the first and only national, free 24/7 crisis-intervention hotline. The hotline is mostly accessed by teen-agers and is noteworthy because its highly trained counselors conduct all of their correspondence and interventions exclusively via text messaging. For teens, SMS is the main form of digital communication, and according to the Pew Research Center, the average teen exchanges over 5,000 texts per month. Moreover, this paper explores the consequences and implications of text based therapies, not only in terms of their efficacy in supporting teens in crisis, but also, in the ways in which they are reconstructing notions of what constitutes language within the field of linguistics. Crisis Text Line is also amassing an unprecedented amount of mental health data on suicide, cutting, rape, eating disorders and other forms of distress that conflict teenagers. Given this, CTL’s data-informed approach has the potential to inform future legislation, academic research, practitioner interventions and school policy. Finally, Digitizing Mental Health: Text-based Therapy, presents recommendations for future scholarly research. The shift in therapeutic and crisis intervention towards new technologies is currently under researched; therefore, this paper suggests various analytical frameworks within which additional research can be conducted.

Digitizing Mental Health: Text-based Therapy

“He won’t stop rapping me. He told me not to tell anyone. It’s my dad. R U THERE?”

- Anonymous Crisis Text Line User

New Yorker journalist Alice Gregory, author of R U THERE? A New Counseling Service Harnesses the Power of the Text Message explores not only the convergence of mental health, therapy and digital technologies, but also, the transformative power of Short Message Service (SMS) texting, especially as it pertains to crisis hotlines and youth outreach services. Gregory’s pioneering piece of journalism correlates well with design studies because it illustrates how such design innovations are fundamentally transforming the tech and mental health industries, as well as people’s literacy, behavioral and communication skills. The healthcare industry is arguably undergoing an irreversible paradigm shift and organizations like Crisis Text Line have shown that such interventions are actually meeting many of the needs of their target population. SMS has been proven to be a safe, efficient and practical means to contact and coordinate interventions with adolescents ages 13–25.[1] According to the Journal of Community Psychology, CTL has been found to increase the number of youth seeking support. It is necessary to explore the implications of these dramatic changes in both crisis services and mental healthcare because the pervasiveness of text-based therapy is transforming the very nature of therapy. Moreover, R U THERE? is provocative because it forces both designers and consumers alike to question issues of technological determinism, social constructivism, and new practices of social behavior including, the notion of self-care.

The revolutionary impact of Computer-Mediated Communication (CMC) has undoubtedly led to changes in social behavior, psychological discourse, language development and spelling adaptations.[2] Alice Gregory’s work highlights this, but primarily focusing on Crisis Text Line, which is the first and only national, free 24/7 crisis-intervention hotline, accessed by mostly teen-agers, to conduct its conversations exclusively by text message. The average adolescent communicates via text message more than any other form of communication, including face-to-face conversations.[3] Texting has become today’s default form of writing. Since texting is the primary way in which people under 20 communicate, crisis groups are adopting new methods of providing emergency services.[4] The value of CTL is multifaceted; however, its efficacy can be attributed to its familiar interface which resembles a Facebook feed. Also, CTL aims to bring a data-informed approach to crisis services by developing the nation’s largest database on teens in distress; the service collects data on suicide, eating disorders, rape, cutting, bullying, among others in real time; therefore, it is constantly recording data on every one of those issues. This data is revolutionary because it has the potential to inform legislation, academic research, practitioner interventions and school policy.

According to Gregory, the system receives an average of 15,000 texts a day and is programmed to flag words such as “kill,” “rape” “suicide” and “hopeless.” CTL is also revolutionary in how its counselors are trained to respond to texters. This training includes not only appropriate language use, but also how to type messages carefully and tactfully. The Knight Foundation’s online article, How can we Harness Data and Information for the Health of Communities, notes that every “empathetic” message is reviewed by CTL’s mental health experts as well as rigorously A/B tested (a form of statistical hypothesis testing) in order to continue to evolve both their language and approach to better deliver emotional support via SMS. Additionally, the service conducts extensive data analysis of follow-up messages, which lead to improvements in both prevention and long-term care. Fundamentally, the article notes that, “CTL is innovative in three ways: it will reach more teens than ever before, bring a data-informed approach to crisis services, and provide follow-up support that will ultimately reduce teens’ need for mental health services.”[5] Finally, given that CTL follows the privacy guidelines developed by the University of Michigan’s ICPSR (Interuniversity Consortium for Political and Social Research), the world’s largest archive of computer based data for the social sciences, teens private information is responsibly guarded.

Texting “culture” and “language” has produced an entirely new form of writing that is extremely under-researched. Although this paper will not provide an exhaustive account of the intricacies of CMC or SMS, it does outline an approach for further scholarly analysis. According to the editors of SMS Communication: A Linguistic Approach, “Today a global phenomenon called “digital convergence” is reshaping the world of information technologies, communications, electronics and entertainment. This powerful trend goes in the direction of a general merging of devices and services that were formerly independent such as phones, television, the radio, cameras and computers.”[6] The ubiquity of Smartphones greatly impact CMC tools, and as the market grows, they will become even more mobile and pervasive worldwide. Technologies will only continue to converge and instant messaging, blogging, emailing, texting and social networking will inevitably combine and integrate themselves into a unified system, which can also be framed as ubiquitous computing.

Design is difficult to define because there is no concrete consensus as to what the notion fully means and encompasses. If perceived as a fundamentally hybrid human activity that provides a framework through which we can begin to understand our built environment, then CMC and SMS both serve as clear examples of how design mediates the relationship between humans and the artificial. Design Studies scholar Tim Marshall substantiates this claim in noting, “Design has always served as the midwife of technologies into our lives, creating collective practices and lifestyles. In so doing, design has been the medium of the material and technological transformations our lives and, consequently, of our shared communities.”[7] Ubiquitous mediated electronic discourse methods, including and extending far beyond text messaging, represent the ways in which the current era is evolving technologically and otherwise. Additionally, exploring the notion of the inherent intelligence of things (Smartphones) fundamentally reconstructs the relationship between objects and people because it suggests that they are sensitive to our limitations and vulnerabilities. If this is the case, how should humans interact with “things” that may in fact have the capacity to educate us? Here academic Elaine Scarry’s argument that humans embed their built environment with humane awareness and consciousness is evocative. To assert that people design objects to not only serve as extensions of themselves, but also to extend the powers of sentience, establishes a framework upon which objects can be seen as working on behalf of our wellbeing, or in her words, the interior structure of things have become, “the champions of human beings.”[8] If this were not the case, why then would humans invest so much in both the material and technological realm? Although it is common to outwardly dismiss materiality, Scarry discredits this behavior because she writes that in clinging to objects, we acknowledge their importance; and once we establish their value, it becomes self-evident why our desire for them must be controlled and why their benefits must be equally accessible throughout the world.[9] Finally, and this point relates specifically to the discussion of Smartphones and CTL, the human imagination is configured such that the work of imagination is to make the inanimate world animate-like, as Scarry states, “to make the world outside the body as responsible as if it were not oblivious to sentience.”[10]

Another crucial question this research raises is could texting be considered a language (r)evolution? Given that texting is constantly reinventing scriptural practices, its critical to delve deeper into these complex inquires. Technologists Rachel Panckhurst and Claudine Moise, write in French Text Messages: From SMS Data Collection to Preliminary Analysis, “Some people dislike texting. Some are bemused by it. Some love it. I am fascinated by it, for it is the latest manifestation of the human ability to be linguistically creative and to adapt to language to suit the demands of diverse settings. In texting we are seeing, in a small way, language in evolution.”[11]

Furthermore, specialists such as Columbia University linguist John McWhorter, have even gone so far as to suggest that if one can text, then perhaps one can be considered multi-lingual or bi-lingual. The universal nature of texting has fundamentally expanded the field of linguistics and is pushing the boundaries of what language and writing are. From a sociolinguistic lens, McWhorter refers to texting as “fingered speech” because its enables the user to write how they actually talk.[12] He notes that it is a new linguistic form that has its own structure and rules that are constantly developing. McWhorter writes that texting is driven by adolescents and “emerging adults.” It is interesting to note his bold assertion that, “This language is not effectively “spoken” by older adults and behavioral scientists; like most learning a new language, when we write texts we sound like non-native “speakers.”[13]

This loose casual structure or “language” is partly the reason why CTL is so successful; people can connect very quickly and on an intimate yet distant level. Typical texting words such as ‘LOL’ (laughing out loud), ‘GTG’ (got to go) and ‘WUU2’ (What are you up to today?) are now considered to be markers of empathy and accommodations, and linguists refer to them as “pragmatic particles.”[14] This construction is critical to note because text messaging has influenced the syntactic aspects of language. Given this, entirely new constructions are developing which illustrate the importance of deconstructing and analyzing the culture of texting and how it is evolving and transforming entire industries. Young people have and continue to create a whole new wave of writing, thus prompting questions revolving around what are the implications and consequences of such developments.[15]

Texting is an unexceptional and commonplace activity in today’s world; therefore it provides privacy to its users that can be vital if a person feels threatened either in a public setting or is directly near someone who is causing them to feel anxious. In response to this, clinical psychologist Jerry Weichman notes that, “They (adolescents) can still look ‘cool’ to their peers or friends while receiving assistance that they are in desperate need of.”[16] Moreover, CTL is beneficial because counselors have greater capacity in that by texting, they are able to support more than one person. Also, texting leaves a record, which may be helpful for users to refer back to. The system is designed to automatically pull up old messages for counselors on duty even if the texter disappears for a short while. This enables the user to begin again without having to retell their stories. CTL details their mission in stating on their website that, “We bring a new technology to an old problem. Our specialists practice active listening to help texters in crisis move from a hot moment to a cool calm — all through a medium they know and trust: text. Crisis Text Line is free, 24/7 emotional support for those in crisis.” These are factors which non-text-based therapies and interventions lack. The values of texting within the field of mental health and social justice is so profound that now it is possible to reach large-scale organizations like the National Dating Abuse Helpline and National Human Trafficking Resource Center by text.[17]

In order to garner a more holistic view of CTL, it is important to detail how the service understands itself and its function within society. The site makes it very clear that its core mission is to “fight for the texter,” in order to carefully guide him or her in creating a plan to stay safe and healthy. The organization positions itself as practicing a human centric approach to everything it does. Moreover, CTL has three types of live, trained crisis counselors: rigorously trained volunteers, who before aiding texters, must graduate from a 34 hour training program designed in partnership with experts at Common Ground, a New York City based NGO that provides transitional housing for the homeless. The second tier of counselors are crisis center partners who work at already established organizations that are well versed in crisis counseling. Finally, CTL’s head supervisors manage all crisis counselors and offer support on “high-risk text correspondence.” CTL has proven immensely successful; however, it is only one of the ways in which the therapy industry is changing in terms of the convergence of technology, therapy and counseling.

Talkspace is also a recent addition to e-therapy; however, it is a paid service and primarily geared towards adults rather than youth. The service frames itself as “Therapy for how we live today” and is composed of over 200 professional licensed therapists. Unlike CTL, it is a for-profit business and also the first of its kind to provide unlimited messaging therapy, that is affordable compared to regular therapy, confidential and anonymous. The appeal of Talkspace, like CTL, lies in its convenience and intuitive user interface. With Talkspace, a client can message their therapist anytime and anywhere, from their Smartphones or computers. Talkspace aims to normalize itself by advertising that its, “Just like texting with a close friend, you can message your therapist every day for an entire week, writing as many times as you want, for only $25/week…” Talkspace even offers text-based couples therapy and soon live video therapy. Two similar services to Talkspace have also emerged. BetterHelp and eCounseling Network are both paid services that portray themselves as providing professional therapy via “The Electronic Revolution.” Text messaging has been characterized as a “technology of sociability,” expressing both “immediacy and intimacy” and “metapragmatic awareness,”[18] nevertheless, all these service raise the question of what is being lost through the use of these text-based crisis and counseling services? Unlike traditional therapy, those who utilize these resources never meet the people who are supporting them, and inversely, their therapists never get the opportunity to gauge their patient’s body language and or facial expressions; facets of the field that are arguably critical and therefore, cannot be easily dismissed. Lastly, these services are unprecedented, therefore, legally; they largely exist without government policies and governmental regulations.

The technological CMC revolution is neither all completely positive nor fully supported. There are still those who argue that texting is fundamentally ruining language and the ways in which we use it. Although journalist John Humphrys expresses an extreme opinion in I H8 TXT MSGS: How Texting is Wrecking our Language, he has some valid points concerning literacy, written discourse and how people have become careless and even sloppy with how they correspond with one another. Humphrys finds texting immensely troubling and writes, “It is the relentless onward march of the texters, the SMS vandals who are doing to our language what Genghis Khan did to his neighbors eight hundred years ago. They are destroying it: pillaging our punctuation; savaging our sentences; raping our vocabulary. And they must be stopped.”[19] Humphrys represents the old vanguard who refuse to acknowledge that texting is here and not going anywhere. If anything, SMS will only further weave itself into the fabric of our daily lives. Text messaging or “netspeak,” as Humphrys refers to it, has economy on its side and its convenience and privacy is what enables services like CTL and Talkspace to thrive.

Moreover, currently there is a debate within the mental health field over whether, with the rise of smart technologies, traditional methods of care are going to become obsolete. Smart devices are now so responsive and can be hyper personalized to the point where eventually some contend that the patient will know more about their personal health than their healthcare provider. This raises Michel Foucault’s notion of “Care of the Self and the Will to Freedom.” Foucault was concerned with one’s ability to exert freedom in a society dictated by forces of power, which in this case would be these socially constructed technological mechanisms that mediate human behavior. His major work concerns the integrated forces of power, truth and subjectivity, which he believed when working in tandem greatly impacts the formation of the individual being. [20] According to Foucault, care of the self is essentially concerned with individual freedom, positive relationships and most importantly, the creation of governing the self and its relationship to active awareness. Foucault would likely critique text-based therapies and the digitization of mental health because he would question whether there was a critical awareness of not only oneself and one’s surroundings, but also the status quo. In one respect, the proliferation of text-based therapies is helping to lessen the dangerous stigmas and taboos around mental health; however, it is largely being accepted wholesale and may be contributing to the creation of “pharmaceutical selves” in today’s ever-changing world.

Despite the fact that text counseling is still a nascent field, CTL has produced unique and valuable collection of mental-health data that is enabling the organization to work on predictive analysis; such a wealth of data is new to the field.[21] Crisis Text Line; however, is not the first organization to monitor and track their clients using digital health technology; nonetheless, it is amassing a wealth of invaluable clinical and sociological data that falls beyond intention and into the consequences of design. Because of this, public health officials are even considering the use of text-based crisis data in shaping public policy solutions.[22] Founder of CTL, Nancy Lublin, notes that CTL data can suggest for example when children with eating disorders will seek the most help, and ensure that self-cutters do not wait until after school has let out to abuse themselves. This is unprecedented and in order to understand the phenomenon of text-based therapies, it is useful for future research to analyze these therapies through the lens of material semiotics also known as Actor Network Theory, “New Object Theory,” gamification of medical technologies and user behavior, Michael Foucault’s work on care of the self, Bruno Latour’s notions of “Missing Masses,” and also his theories on “Matters of Fact and Matters of Concern.” These concepts will be integral to unpacking the consequences and implications of this paradigm shift in therapy because collectively they illustrate how both the sociotechnical and material worlds have the capacity to irreversibly reshape human actions, language and behavior.

Bibliography

Anonymous (CTL). How Can we Harness Data and information for the Health of Communities? Knight Foundation, September 17, 2013, https://www.newschallenge.org/challenge/healthdata/refinement/texting-that-saves-lives.

Batters, Stephanie M. “Care of the Self and the Will to Freedom: Michel Foucault, Critique and Ethics.” (2011).

Bock, Beth, Nancy Barnett, Rochelle Rosen, Kristen Walaska, Herpreet Thind, and Victoria Cobb. “Building an Evidence Base Using Qualitative Data for mHealth Development.” In System Sciences (HICSS), 2014 47th Hawaii International Conference on, pp. 2655–2664. IEEE, 2014.

Cougnon, Louise-Amélie, and Fairon, Cédrick, eds. SMS Communication : A Linguistic Approach. Amsterdam, NLD: John Benjamins Publishing Company, 2014. Accessed April 27, 2015. ProQuest ebrary.

Cougnon, Louise-Amélie, and Cédrick Fairon, eds. SMS Communication: A linguistic approach. Vol. 61. 4. John Benjamins Publishing Company, 2014.

Evans, William P., Laura Davidson, and Lorie Sicafuse. “Someone To Listen: Increasing Youth Help Seeking Behavior Through A Text Based Crisis Line for Youth.”Journal of Community Psychology 41, no. 4 (2013): 471–487.

Fried, Mirjam, and Jan-Ola Östman. “Construction Grammar and spoken language: The case of pragmatic particles.” Journal of pragmatics 37, no. 11 (2005): 1752–1778.

Furber, Gareth V., Ann E. Crago, Kevin Meehan, Tom D. Sheppard, Ken Hooper, Dorothy T. Abbot, Stephen Allison, and Clive Skene. “How adolescents use SMS (short message service) to micro-coordinate contact with youth mental health outreach services.” Journal of Adolescent Health 48, no. 1 (2011): 113–115.

Gregory, Alice. “RU there? A new counseling service harnesses the power of the text message. The New Yorker. 9. February, 30–35.” (2015).

Humphrys, John. “I h8 txt msgs: How texting is wrecking our language.” Daily Mail Online (2007).

Kaufman, Leslie. In Texting Era, Crisis Hotlines Put Help at Youth’s Fingertips.” The New York Times (2014): A1

Palasick, Kristen Elizabeth. “LOL MY THESIS: An Exploration of the Written and Oral Linguistic Effects of Text Messaging.” (2014).

Panckhurst, Rachel, and Claudine Moïse. “French text messages: From SMS data collection to preliminary analysis.” Lingvisticæ Investigationes 35, no. 2 (2012): 163.

Scarry, Elaine. The Body in Pain: The Making and Unmaking of the World. Oxford: Oxford University Press, USA, 1985.

Stark, Elisabeth. “Negation marking in French text messages.” Lingvisticae Investigationes 35, no. 2 (2012): 341–366.

Urgelles-Coll, Miriam. The syntax and semantics of discourse markers 3. A&C Black, 2010.

Urgelles-Coll, Miriam. Continuum Studies in Theoretical Linguistics : Syntax and Semantics of Discourse Markers. London, GBR: Continuum International Publishing, 2010. Accessed April 27, 2015. ProQuest ebrary.

Yelavich, Susan, and Barbara Adams, eds. Design as Future-making 242. Bloomsbury Publishing, 2014.

[1]Furber, Gareth V., Ann E. Crago, Kevin Meehan, Tom D. Sheppard, Ken Hooper, Dorothy T. Abbot, Stephen Allison, and Clive Skene. “How adolescents use SMS (short message service) to micro-coordinate contact with youth mental health outreach services.” Journal of Adolescent Health 48, no. 1 (2011): 113–115.

[2] Urgelles-Coll, Miriam. The syntax and semantics of discourse markers 3. A&C Black, 2010.

[3] Gregory, Alice. “RU there? A new counseling service harnesses the power of the text message. The New Yorker. 9. February, 30–35.” (2015).

[4] Kaufman, Leslie. The New York Times, In Texting Era, Crisis Hotlines Put Help at Youths’ Fingertips. Feb 4, 2014.

[5] Anonymous (CTL). How Can we Harness Data and information for the Health of Communities? Knight Foundation, September 17, 2013, https://www.newschallenge.org/challenge/healthdata/refinement/texting-that-saves-lives.

[6] Cougnon, Louise-Amélie, and Cédrick Fairon, eds. SMS Communication: A linguistic approach. Vol. 61. 4. John Benjamins Publishing Company, 2014.

[7] Yelavich, Susan, and Barbara Adams, eds. Design as Future-making 242. Bloomsbury Publishing, 2014.

[8] Scarry, Elaine. The Body in Pain: The Making and Unmaking of the World 306. Oxford: Oxford University Press, USA, 1985.

[9] Ibid., 306.

[10] Ibid., 306.

[11] Panckhurst, Rachel, and Claudine Moïse. “French text messages: From SMS data collection to preliminary analysis.” Lingvisticæ Investigationes 35, no. 2 (2012): 163.

[12] Palasick, Kristen Elizabeth. “LOL MY THESIS: An Exploration of the Written and Oral Linguistic Effects of Text Messaging.” (2014).

[13] Bock, Beth, Nancy Barnett, Rochelle Rosen, Kristen Walaska, Herpreet Thind, and Victoria Cobb. “Building an Evidence Base Using Qualitative Data for mHealth Development.” In System Sciences (HICSS), 2014 47th Hawaii International Conference on, pp. 2655–2664. IEEE, 2014.

[14] Fried, Mirjam, and Jan-Ola Östman. “Construction Grammar and spoken language: The case of pragmatic particles.” Journal of pragmatics 37, no. 11 (2005): 1752–1778.

[15] Evans, William P., Laura Davidson, and Lorie Sicafuse. “Someone To Listen: Increasing Youth Help Seeking Behavior Through A Text Based Crisis Line for Youth.”Journal of Community Psychology 41, no. 4 (2013): 471–487.

[16] Kaufman, Leslie. In Texting Era, Crisis Hotlines Put Help at Youth’s Fingertips.” The New York Times (2014): A1

[17] Kaufman, Leslie. In Texting Era, Crisis Hotlines Put Help at Youth’s Fingertips.” The New York Times (2014): A1

[18] Stark, Elisabeth. “Negation marking in French text messages.” Lingvisticae Investigationes 35, no. 2 (2012): 341–366.

[19] Humphrys, John. “I h8 txt msgs: How texting is wrecking our language.” Daily Mail Online (2007).

[20] Batters, Stephanie M. “Care of the Self and the Will to Freedom: Michel Foucault, Critique and Ethics.” (2011).

[21] Bock, Beth, Nancy Barnett, Rochelle Rosen, Kristen Walaska, Herpreet Thind, and Victoria Cobb. “Building an Evidence Base Using Qualitative Data for mHealth Development.” In System Sciences (HICSS), 2014 47th Hawaii International Conference on, pp. 2655–2664. IEEE, 2014.

[22] Gregory, Alice. “RU there? A new counseling service harnesses the power of the text message. The New Yorker. 9. February, 33.” (2015).

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