What Reduces Suicide Ideation in Online Crisis Chats? A Study of Crisis Counselor & Client Processes

2 research findings from this AFSP-funded study.

Research finding · March 2025

Individuals experiencing a suicidal crisis process their distress

Understanding how individuals experiencing a suicidal crisis process their distress is essential for improving crisis intervention efforts. Crisis theory suggests that when distress overwhelms coping abilities, individuals may feel their experience is intolerable and inescapable, increasing suicide risk. While previous research emphasizes the importance of distress awareness in reducing suicidal thoughts and behaviors, there is limited knowledge about how individuals in crisis actually process their distress. This study sought to develop and validate a distress-processing model that could enhance interventions by identifying stage-specific needs that could guide crisis counselors in tailoring their support.

Dr. Daniel Cox developed a five-stage distress-processing model based on transcripts from online crisis chats. The model begins with unengaged distress, where individuals either avoid discussing their distress or minimally engage. It progresses to distress awareness, where they acknowledge their distress, and then to distress clarity, where they begin connecting their emotions, thoughts, and experiences. In distress insight, individuals gain a deeper understanding of why they feel the way they do, leading to the final stage, applying distress insight, where they come up with ways to move forward. A follow-up validation study confirmed that distress processing occurs step-by-step and that greater progression through the stages was associated with improved outcomes. These findings offer a framework for understanding how individuals navigate suicidal crises, underscoring the importance of interventions that help people move through the stages of distress-processing and find solutions.

Citation: Mickelson, J. M., Cox, D. W., Young, R. A., & Kealy, D. (2024). A Distress-Processing Model for Clients in Suicidal Crisis. Crisis, 45(1), 18–25. https://doi.org/10.1027/0227-5910/a000907

This finding comes from an AFSP-funded study — see the grant below ↓

Research finding · June 2024

The therapeutic bond between client and crisis counselor affects session outcomes

When people experience suicidal crises, they often struggle with relationships, which can contribute to difficulties in forming a therapeutic bond with clinicians. Even though research has shown that building a strong relationship between clinician and client is crucial for effective outcomes in therapy, especially for those thinking about suicide, we don’t know much about how relationship struggles show up in therapy sessions. We also don’t know much about how relationship struggles can impact one-time crisis therapy sessions.

With this is mind, Dr. Daniel Cox and his team looked at how the relationship between crisis counselor and client affects the client's desire to die by suicide and examined the outcomes of one-time, 30-minute online crisis therapy sessions. Dr. Cox analyzed 354 sessions with clients who were actively suicidal and using an online crisis service for the first time. The team measured suicidal desire, the strength of the therapeutic relationship throughout the sessions, and the outcomes (e.g., acceptance of referral to external services and acceptance of crisis-center follow-up). The results indicated that a strong relationship between crisis counselor and client helped reduce suicidal desire and led to better outcomes. These results highlight the importance of training therapists on how to build strong relationships with clients who are in acute suicidal crises.

Citation: Cox, D. W., Deptuck, H. M., Fischer, O., & Wojcik, K. D. (2024). The role of the therapeutic bond when working with clients in suicidal crisis. Journal of counseling psychology, 71(2), 115–125. https://doi.org/10.1037/cou0000724

This finding comes from an AFSP-funded study — see the grant below ↓

The grant behind this work · 2017 Young Investigator