Peer Perspectives

Texting as a Means to De-escalate Crises Holds Promise to Advance Equity and Access in the Mental Health Space Through the New 988 Shortcode

Here’s how the free nationwide service can be operationalized to meet the needs of people who have historically faced barriers to mental health care.  

By Shairi Turner, MD, MPH

When it comes to mental health, we are a nation in crisis. Too many Americans have not received the access to the mental health services they need and deserve. Crisis Text Line has valuable lessons to share from working in the trenches of this crisis for the past eight years by supporting roughly 3,500 conversations a day with people in pain in a medium that works for them: text messaging.   

988 is the new shortcode created to expand access to mental health services provided by the National Suicide Prevention Lifeline. As the nation charts a plan to specifically include text messaging as part of this service, it is essential that we meet this moment in our national history. We can do that by integrating texting to this hotline, to advance equity in the mental health space and ensure that people historically marginalized from access to mental health care are at the center of this service. 

To fully operationalize text-readiness for 988, providing increased access to mental health support for marginalized and intersectional communities is paramount. While only one-half of U.S. adults with mental illnesses receive treatment, texting breaks through some of the barriers to access, and addresses the economic and lifestyle needs of Americans who need and deserve support.  

Limits on access to mental health care is particularly problematic for Black, Indigenous and People of Color (BIPOC), low income and people of other marginalized identities who experience the dual realities of high need for mental health support and barriers to care. We know that deficiencies in our mental health care systems have disproportionately affected African-American, Latinx, Native Americans/Indigenous peoples, LGBTQ+, and other underresourced communities. In fact, according to the Center for Disease Control (CDC), racism is a public health threat that affects the entire nation. Furthermore, the CDC found that the COVID-19 pandemic increased risk factors linked to suicidal behavior and that young adults, American Indian Alaska Native, Black, and Latinx people have been affected more. Structural inequities and racial violence have compounded trauma in these communities. 

The federally funded 988 service must address and counteract these inequities. Incorporating experienced text-based mental health support that utilizes best clinical practices in 988 is one major step in the right direction.   

There are five key characteristics of texting that break through barriers to mental health care.

First, texting can be designed to be free. We know that far too many American families in the United States live paycheck to paycheck. Studies show that Black, Latinx, and particularly multiracial families are more likely than white families to experience food insecurity during the pandemic, putting the possibility of spending on mental health care out of reach. To limit the economic burden of mental health care, Crisis Text Line worked with major phone carriers to ensure that most texters are not charged standard messaging rates for our service. As the federal government works to build the infrastructure to support text to 988, it is imperative that they follow this kind of best practice for removing barriers to care by collaborating with major phone carriers to make sure mental health support is free. 

Second, texting is temporally flexible. Americans deserve mental health support with flexibility that fits into their busy lifestyles. Many people don’t have a standard 9-to-5 job, flexible work schedules with time off or free time after school. Nearly 20% of high school students hold a job while also managing to attend school. Texting offers people adaptability to reach out for support when and where they need it. People can text while on a break at work or school, making dinner, hanging out with friends, or caring for a loved one. 

Third, texting is the dominant, preferred mode of communication for many Americans, especially young people. It is part of their way of life. If we’re working to build 988 into a service that is truly accessible to all, we must consider the needs of young people who may not have autonomy over their own mental health care. Inclusion of a free, flexible, text-based service in 988 enables youth to get a high standard of care in a medium that is comfortable to them. 

Fourth, texting is anonymous and confidential. People in dangerous situations can text to reach out for help while in the presence of an abuser without ever needing to speak about it verbally, and without placing themselves in further danger. 

Fifth, optimization of technology can ensure that text-based crisis support works to consistently help those at greatest risk first. Crisis Text Line uses patented triage technology that flags and prioritizes people who are at imminent risk for harming themselves or others and moves them to the front of any line. This technology works so well that we connect these high-risk texters to a live volunteer in eight seconds or less. This technology will also be key to the success of 988.   

Finally, texts to 988 will offer large-scale positive change in mental health support. However, this program will only be as effective as its ability to meet our country’s urgent and high-volume demand for care. Crisis Text Line has found that a strong volunteer base is key to maximizing mental health support at a national scale. Responders must be knowledgeable and capable to handle a multitude of crises including but not limited to, bullying, eating disorders, self-harm, and substance use disorders. 

As our country works to utilize 988 as a way to address inequities in our health care system across race, gender, and sexual orientation, the federal and state governments must implement best-in-class services to meet the moment. 

— Shairi Turner, MD, MPH, is chief medical officer of Crisis Text Line.