Practical Guide to Sending Caring Contacts

Introduction

Let’s get started implementing Caring Contacts in your organization! This guide offers advice and recommendations for all phases of design, planning, and implementation, along with guidance on how to manage day-to-day implementation challenges. We’ve also provided decision support tools, pre-scheduled message templates, and quick-reference guides for your team to use, as well as links to further information and interactive trainings.

Here’s some terms you should know:

Author: the person from whom the Caring Contacts are sent – whose name and responsibility is the Caring Contacts for their clients.

Recipient: the person who is receiving the messages

Sender: a person who does the work to send the Caring Contacts who is not the Author, if any

1. Structure Caring Contacts Intervention: Designing to fit your organization

Identify Population

Your organization will need to decide which of your clients/patients should receive the intervention – that is, who are the “recipients” of the Caring Contacts. This will be highly dependent on the population you serve and what their needs and desires are.

Perhaps,

You want to send them to individuals tied to a particular event (e.g., patients who are discharged from the hospital, clients who completed behavioral health treatment, veterans who stopped attending programming, first responders working during a pandemic, a service member who seeks help with suicidal thoughts)

You might want to send them based on a rating scale or measure of stress or distress (e.g., veterans who are unemployed or unhoused, patients who report depression or suicidality on a rating scale, staff who report high burnout)

You might want to send them to all participants in your program or at the completion of your program (e.g., send to veterans after a women’s retreat for PTSD, patients after an intensive outpatient or partial hospitalization program, crisis line callers, Employee Assistance program for burnout)

You might want to send them to people who were uninterested or unable to participate in treatments you recommend (e.g., patients experiencing suicidality but uninterested in psychotherapy or medications, rape survivors who could come to treatment any time but can’t face it right now)

The Caring Contacts Intervention can be implemented via emails, texts, physical mail, and phone calls. Digital options such as email and text are familiar to the recipient and are easy to track.

While it can be more cost-efficient and timesaving to send Caring Contacts through email or texts, it has been theorized that physical mail might carry a certain emotional impact that digital communication does not. While phone calls have been previously tested, they require a greater workload for the organization and can lead to conversations that veer away from the Caring Contacts message. Our team has found that the majority of participants prefer to be contacted via written communication.

Message Format & Medium

How do you want to send the messages?

Best evidence is for postal mail and text messages

Study with email was not successful; perhaps because email has become more about business communication, bills, and spam and less about personal communication

Medical systems have considered using eCare, MyChart, or similar options to send the Caring Contacts, which to them seems simple and appealing, but for the recipient, is neither. They will get a message that requires them to login to the system only to arrive at a message that says, “Hope you are doing well.” We doubt that recipients will have the simple positive response that is intended after the trouble of typing the login and password (especially on their phones), and we suspect they might just stop opening eCare messages.

Phone calls are tricky – if you don’t get voicemail then you are now in a conversation that can quickly (and naturally) veers to other things than the caring message.

What platform will you use to track and send the pre-programmed messages?

Text messages can be sent through a web-app that sends pre-programmed messages on schedule

Postal mail can be tracked with an excel sheet and staff to keep track of when to send letters by hand

Postal mail can also be tracked in an app and pre-programmed letters send via a contract with a postal service

How do you want to manage replies from recipients?

Postal mail can include either a self-addressed stamped envelope or a phone number included if the person wants to respond

Text messages can be sent through a web-app that receive replies and through which you can respond

You can tell them you cannot respond – but this is not recommended as likely to feel less caring and, to date, no study has shown a benefit to this method

Identify who will author the Caring Contacts intervention

Your organization will also need to decide who will send the Caring Contacts to the recipients, that is, who are the “authors” of the Caring Contacts.

You might be considering having authors sending Caring Contacts to their own patients or clients who they are working with. Don’t Do It! It's a good idea in theory, but it falls apart when you consider how well pre-programmed messages—set up days, weeks, or even months in advance—would need to align with your actual interactions with the recipient.

Can you imagine having an emotional therapy session or having to say “we can’t do that” to a veteran for something that is beyond the scope of your program and then having a pre-programmed message arrive that day from you saying “Just wanted to text you a big HELLO. Hope your day is going well!”

Caring Contacts are best sent as a stand-alone intervention by the author.

The author has no other ongoing relationship with the recipient – they are an independent person who is there just to be support and connection. This is what the successful research on Caring Contacts is based on.

It is reasonable that using Caring Contacts as aftercare for a hospitalization or outpatient treatment would also be effective where the author knows the recipient but isn’t otherwise interacting with them

It doesn’t take much time to implement Caring Contacts so one author can serve many recipients.

In a large organization with thousands of patients or clients, a substantial amount of staff time might be given to one or two people to program, send, and respond to Caring Contacts with hundreds of recipients

In a small organization with closer to 50 or 100 likely recipients, this could take just a few hours per week for one person.

Caring Contacts Authors don’t need a clinical degree or experience.

Each organization needs to use their judgment on authors based on their context and staff

Research assistants supervised by a psychologist sent the original model of Caring Contacts, and this has been replicated in other Caring Contacts studies that have demonstrated success

Peers, mentors, leaders, or elders within a community might be much more powerful and meaningful authors from the recipient’s perspective

The vast majority of replies to Caring Contacts are positive (e.g., thanks to much, 😀, or “same to you”), with some statements of distress that don’t suggest a crisis (e.g., things aren’t great – got laid off) or requests for resources

Across multiple studies, crisis replies or “suicide note” replies occur extremely rarely (less than X%), so they can be handled in consultation with a clinician who doesn’t need designated effort to the Caring Contacts program

"Senders" – when someone other than the Author does the work to send the Caring Contacts

In large systems like the VA, an administrative or other assistant (the “sender”) can support clinicians who are Authoring messages. This can look like addressing and stamping postal mail, setting up mail merges to send all the messages for that day, programming the messages for new recipients into an Excel sheet or online messaging platform, etc.

Technology can replace this effort as described in our messaging platform

If someone is assigned as the Sender, there needs to be a plan for how the Author receives replies and responds. Will the Author dictate their response for the Sender to send, or will replies go directly to the Author’s phone? There are several options.

Regardless of whether Caring Contacts are pre-programmed and sent by a Sender or technology, you will need to establish processes for the Author to stay engaged. You will want a way to alert them when they are sending what messages, so they are ready for possible replies. For instance, an email that says, “You are sending 4 messages today; click here to see what is being sent to whom”

2. Develop the Message Schedule

Intervention Length

You’ll need to decide how many messages to send, how often to send them, and for how many months or years. These are your choices; there is no single standard.

Based on our interviews with Caring Contacts recipients in research studies, they report being happy with the number of messages they receive, whether 11 or up to 25.
Typically, organizations send between 8 and 25 messages over the course of 6 to 18 months, but we recommend a minimum of 12 months.
Consider more frequent messages at the beginning and tapering off toward the end (e.g., Next Day, then Month 1, 2, 3, 4, 6,8,10, 12 and their birthday)
Consider the message form. Text message schedules might feel more comfortable if sent more often at the start (e.g., weekly) than postal mail.
For suicidal recipients, we recommend a message soon after identification for the program (e.g., after an initial meeting or assessment with the Author), such as the next day or next week. In previous studies where the first message arrived a month later, some suicidal recipients had already re-attempted before the intervention could reach them.

Principles of Non-demanding Caring Contact Message Content

In following the principle of being non-demanding, messages should just be kind reminders that we are thinking of them and emphasize care, support, and inclusion.

This follows Motto’s 4 key principles described in the background section to stay true to the Caring Contacts model.

So, avoid messages that ask or demand anything.

For example, advice like “be kind to yourself” or “exercise can be helpful” may be said with supportive intent but is often are experienced by stressed or distressed individuals as demands – “if I could be kind to myself, I wouldn’t be suicidal” or “as if I’m not stressed enough - now I’m supposed to exercise?!”).

Even avoid sentiments like, "I want you to believe in yourself," which puts the responsibility on them.

Similarly, appointment reminders can often distract from the Caring Contacts message or a reminder of something they don’t want to or must do.

The general approach in Caring contacts is to welcome and invite replies to messages but not to expect or demand this – so you may want to include comments such as, “if you would like to respond, I’d be happy to hear from you” or equivalent in various messages from the pre-programmed list.

Your team should develop your own messages to ensure that they appropriately reflect and respect your local culture(s) and context(s). Here are some thoughts to consider:

Emphasize personal connections as much as possible.

This is admittedly a tricky task as many organizations have implemented Caring Contacts with pre-scheduled message systems and/or staff send Caring Contacts to those they don't know.

Taking time to compose a few genuinely compassionate messages will go a long way toward building rapport.

Avoid “Hope you’re doing ok”!

We try to avoid just saying, “Hope you’re doing ok,” "I hope your day is going well," etc. as those can feel very surface-level

We also don't want to assume that their day is going well. The recipient might be having an awful day, and getting a "Hope you're well" message could make them feel worse!

Rather than sending “I hope you’re well”, emphasize what you know to be true:

You care about them, and you are there for them, even when things are hard.
Consider doing this rather than just saying, "Hope you're good!" or
We've often gotten positive responses to messages that acknowledged how things might be hard or that they might be going through a tough time but that we believe in them.

Keep it simple

We have found that authors often feel compelled to make their messages longer or “more meaningful” in some way, but it is unclear that doing so makes for a better message.

Longer Message Example: “We delight in the beauty of the butterfly, but rarely admit the changes the butterfly had to go through to achieve that beauty.” - Maya Angelou. We, too, go through many changes. Hope you are having a good day. - Sasha
Shorter Message Example: [name], you have overcome so much! I believe you’re going to do great things! - Alan

The First message:

Here are some ideas that we have found helpful in crafting the first Caring Contact you send.

Your team should also establish the monitoring hours, within which the team can respond, whether every day from 9 to 5 or specific days or times of the week. These hours should be included in the first message so that recipients will be aware.

Additionally, it may be good to remind participants that this intervention does not serve as a substitute for a 24-hour crisis line.

Depending on the constraints of your chosen implementation platform, we encourage you to ask the recipient to respond to their first message so you know they received it and can reply. Then, you can, in turn, respond with an individualized response to demonstrate that you can receive and will respond personally to their messages.

As this is a request, it should be considered in terms of Motto’s principles. We believe the benefit of them seeing the two-way communication in action is worth the small demand for text messaging platforms.

However, to minimize the demand, we do not persistently remind recipients to reply to the first Caring Contact (beyond the original request to confirm receipt of the first message).

Suggested Strategies:

If you are sending Caring Contacts by postal mail, consider enclosing a self-addressed stamped envelope or other information such as a phone number or address they can use to respond to shows you welcome a response as Motto did.

To prevent messages from being perceived by recipients as automated or “spammy,” you may want to send the messages at varying times of day and at varying intervals between messages rather than a set day and time.

If your team wants every recipient to get the same number of messages, you will want to make sure that if a recipient’s birthday or any relevant holidays or seasonal messages occurs during the projected Caring Contacts period, one of the existing scheduled messages is replaced by the birthday/holiday message.

The Last message:

Do you want the last message to say it is the last message?

Research has shown that participants like to be told that their messages will be ending.

Some studies have mentioned that the intervention will be coming to an end in the second to last message, so that recipients have time to process and perhaps reach out if they feel they need more support.

Consider including directions for future contact in case the recipient wants to get back in touch.

Tailor Messages to the Audience

Your organization might consider culturally adapting the messages you team will send to fit the personalities, preferences, and dispositions of your diverse client population (e.g., veterans, active duty military, healthcare workers, American Indian/Alaska Native communities, Hispanic/Latino youth, etc.)

A team brainstorming session might clarify issues. We recommend reviewing our sample lists of pre-programmed Caring Contacts as a group. You can do an exercise of giving everyone the samples and having everyone select or write messages to get the discussion moving
You might also meet with representatives of your customers/clients/patients in the same way to gather their reactions to the options.
Be sure to check your pre-programmed messages against the Caring Contacts principles to be sure they stay in fidelity with the intervention

Within a Caring Contacts program where multiple people will be “authors” of the messages, each author may want to write their own pre-programmed messages based on the Caring Contacts message principles but reflecting their own style and turn of phrase

This adds complexity with multiple versions of the pre-programmed messages within an organization
On the other hand, it maximizes Caring Contacts as a genuine human-to-human intervention

Concerns about negative responses to the intervention messages by a third-party

A specific situation has occurred very rarely (with about 3 participants out of over 1,500 across 4 research studies) which we would like to offer recommendations on how to prevent or resolve.

There is a possibility that a recipient’s partner or someone else might see a Caring Contacts message and become distressed by it. In the few cases that have arisen, the recipient’s partner saw a kind, empathetic message on their phone and erroneously thought that their partner was getting romantic messages or that perhaps the recipient was cheating.

Suggested strategies to prevent this situation from arising include:

Sending a link to your organization’s webpage at the end of the message: We don’t recommend sending the URL at the end of every message as it can come across as spam-like, but including it in the first message as well as occasionally throughout the remainer of the intervention period might be helpful.
Suggesting to the recipient to add your organization name to the contact info for the message author, so that it’s obvious at a glance how the recipient might know the author.
Referencing the organization’s name in the message itself: For example, “Hi, this is Joan from Sesame Street Clinic...” We still recommend that a message always be signed off by a real person’s name (e.g., not an anonymous or group sign-off), but including your organization’s name during or at the end of a message along with the author’s name can be helpful.
Asking the recipient to share with their partner that they will be enrolled in a Caring Contacts program with your organization: This is recommended at the discretion of the author and the intervention team, but can be a very easy and direct way to establish the nature of the recipient’s relationship with their Caring Contacts author.

Specific recommendations for sending Caring Contacts to military veterans

You may want to review different approaches to messages and different message content at the VA/DoD Clinical Practice Guidelines for Caring Contacts website.

There has been extensive research into the preferences of veterans for their Caring Contacts. Here we have summarized a few of the relevant studies which may provide more guidance as your organization develops your pre-scheduled messages.

Survey of the preferences regarding physical Caring Contact letters by veteran patients admitted to an in-patient unit (these participants did not actually receive Caring Contacts). In general, they found that some strong preferences were shown, and that demographic-specific preferences were not so strong that it would greatly impede intervention implementation. There were minor differences between ages, genders, and races, but no differences between various numbers of combat deployment or military ranks. (Keep in mind that only 18 of the 154 participants in this study were women, and over half were white.)

Author:

Veterans did have a stronger preference for an inpatient or outpatient mental health counselor or primary care physician as compared to preferences for other correspondents (such as a provider from a Caring Contacts program, a fellow veteran they had not met, a crisis worker, or a non-provider from a Caring Contacts program)

Modality:

First choice to last choice as follows: letter, postcard, greeting card, email, text.
More women's first choice was a greeting card.
Male participants chose text or email as their first choice more than women (of whom, 0 chose text or email as their first choice).
More older veterans said they prefer physical mail.
The authors note that this may be due to the age of their study sample being higher and smartphone use being lower. Another study with active duty military members have found that three-quarters preferred email. And in recent studies with veteran and non-veteran participants, texts was the preferred method, followed by email.
Tailoring the messages to fit the population served will be important for increased effectiveness.
The type of stamp had no bearing on the appeal of the letter

Typed vs handwritten:

A little over half said they were fine with a letter being typed, and if anything were to be handwritten, the signature and perhaps a short personal note at the bottom of the card were most important.

For younger veterans, having the physical cards be handwritten was more important than for the older veterans. Younger respondents also liked the idea of colorful envelopes.

Frequency:

just under half said monthly was the best option, followed by quarterly, weekly or biweekly, individual schedule, and finally the last choice was annually.

Duration:

just over one-third said one year was preferred, followed by 6 months, 3 months or less, individual schedule, and the last choice was over a year.

Taper:

two-thirds said they'd like the messages to continue at the same frequency while the other third said they'd like the messages to taper off toward the end.

Holidays:

When asked to choose from a list, the most frequently indicated day was Veteran’s Day which just over two-thirds chose, followed by their birthday, Memorial Day, Armed Forces Day, July Fourth, Christmas, and 9/11.
The younger veterans were more likely to indicate Christmas.
Women were more likely to choose Christmas and Armed Forces Day
The authors also noted that this preference for Veteran's Day is probably due to the study population.
Other feedback has suggested that, again, tailoring the messages to fit the population served will be important for increased effectiveness.

Imagery on the physical letter:

Participants showed a strong preference for an image of an American flag and the 5 seals from each branch of military.

Black, White, and multiracial participants were more likely to indicate preference for images of the VA seal and the American flag.

Two-thirds approved of the example letters they were given, and a strong majority recommended their use in the VA and said they thought the letters could help someone who is in distress or feeling suicidal.

A little over half said they thought the messages could make them feel connected to others. A small portion mentioned that the messages might remind them of who to contact if they were having problems. Both of these sentiments have been reiterated by other veteran and non-veteran participants in more recent studies who did actually receive the Caring Contacts intervention.

A couple of participants mentioned concerns about the cost, confidentiality, embarrassment, and that the messages might have their impact lessened by too many being sent. In recent studies, questions regarding these concerns were asked of veteran and non-veteran participants. Only a couple out of a very large sample shared that they had concerns with confidentiality, and even in a study which sent 25 messages, participants indicated that they were content with the number they had received.

Reger, M. A., Jegley, S. M., Porter, S. A., Woods, J. A., Liu, L., Markman, J. D., & Landes, S. J. (2022). Implementation strategy to increase clinicians’ use of the caring letters suicide prevention intervention. Psychological Services. https://doi.org/10.1037/ser0000637
Ammerman, B. A., Gebhardt, H. M., Lee, J. M., Tucker, R. P., Matarazzo, B. B., & Reger, M. A. (2019). Differential preferences for the caring contacts suicide prevention intervention based on patient characteristics. Archives of Suicide Research, 1–12. https://doi.org/10.1080/13811118.2019.1632231
Reger, M. A., Gebhardt, H. M., Lee, J. M., Ammerman, B. A., Tucker, R. P., Matarazzo, B. B., Wood, A. E., & Ruskin, D. A. (2019). Veteran preferences for the Caring Contacts suicide prevention intervention. Suicide & Life-Threatening Behavior, 49(5), 1439–1451. https://doi.org/10.1111/sltb.12528

Message Schedule Tool

The toolkit gives sample lists of messages of different content, frequency, and duration

[add instructions for how to use]

Download Schedule Builder Tool

3. Delivery Platform

Options for Implementation

A primary consideration your team will need to take into account is if you are allowed to use an outside party’s technology.

Existing services have been developed to automate many of the time consuming and tedious steps of the Caring Contacts intervention to allow the author to focus on their communication and connection with the recipient. These HIPAA secure systems can be purchased for your organization at a monthly or annual fee.
Smaller programs may decide to implement the program manually using a simple tracking process such as a spreadsheet. Activities to do this are described here
For larger organizations which are obligated to build their own delivery app, we have provided general guidance on the features and capabilities that are needed for a modern and effective intervention delivery service.

Selecting a System

An organization who might choose an

Existing Service...

Serves a very large population/client pool
Has a low ratio of provider to recipients
Has adequate funding to pay for costs up front
Has flexibility with using outside systems

An organization who might choose to

build a Manual System...

Serves are a very small population/client pool
Doesn’t justify the cost of an existing service
Looking for option with lower overhead, more staff availability
Has a high ratio of provider to recipients

An organization who might choose to

build an Automated System...

Is prevented from using outside systems
Has an in-house development team to work on the system
Has a low ratio of provider to recipients

C. Finding an Existing Service

Finding an existing Caring Contacts service

Mosio/new ISACC

[Platform] is a pioneering informatics solution that seeks to optimize the administration of Caring Contacts to individuals in need of emotional support and ongoing connection. It has the potential to revolutionize the way we offer care to be proactive instead of reactive with the aim of cost-effectively improving mental health outcomes and overall well-being. We continue to gather valuable insights that inform decisions on how to refine [the platform], ensuring its maximum efficacy to provide compassionate and personalized care to those who need it most.

Our aim is to make sending Caring Contacts almost as effortless as receiving them. Though we may never fully achieve that, [this platform] securely tracks all the necessary details, ensuring that the correct messages are sent to the appropriate individuals at the right moment. It alerts you with a secure link to key information to know what to do when someone responds. [The platform] allows for secure replies from both phones and computers.

Create a Manual System: Design and Develop Your Own Manual System

Caring Contacts has also been implemented via methods which require less overhead cost but may require higher costs for fidelity and adherence over time. These strategies may be more accessible for organizations with smaller client bases or where the ratio of authors to recipients is much higher. Message schedules can be built in programs like Microsoft Excel or Google Sheets, and the messages can be manually scheduled and delivered via email or text message. With these implementation strategies, there is substantially more work and monitoring required to ensure that the messages are delivered and responded to in a timely manner.

Recommended capabilities:

Basic Capabilities

Ability to track name, identifiers and contact information, any other unique elements about the recipient such as suicide risk as well as the list of pre-programmed messages to be sent on the days selected (e.g., next day, in two weeks, Month 4) – these might be columns in your spreadsheet, then rows in the spreadsheet contain the information about the recipient and the date each of the pre-programmed messages that needs to be sent

Method to track when each message needs to be sent and that each message was sent

Method to sort by author (if multiple authors in the program) so each author can review just their own recipients

Method to send the messages

If sending by postal mail, have a supply of cards. The message indicated in the spread sheet is written into the card to the indicated recipient and mailed. (It is possible to work with postal mail companies to bulk send. Click here to learn more about that.)

If sending by email, text, or other digital service accessible by a computer, the author can send the message that way

Some programs send messages via text on a dedicated Caring Contacts mobile phone (one for the program or one per author)

Tracking outgoing messages

It is important that there is a way to tracking failed/undeliverable messages (either texts or letters) so that the intervention authors can troubleshoot.

Method for recipients to reply

The original Caring Contacts program included a self-addressed unstamped envelope for replies to their postal mail Caring Contacts

Other postal mail programs provide a phone number to call in order to reply

Digital messages by text or email need regular tracking to be sure replies are not missed

If one-way Caring Contacts and the recipient cannot respond, an orientation message about this needs to be included at the beginning of the pre-programmed message schedule with alternate contacts if they need help

Monitoring

How often will notifications be checked? Who will be responsible for checking them?

Will one person or multiple people be notified?

If a team member is sick or on vacation, who will cover for them?

If/how would you like to communicate among your Caring Contacts team about who is responding to the message?

Method and plan for how authors will respond to replies from recipients

Responses to replies from recipients should be individualized natural responses from the author

Since many responses are pretty standard, standard text in the author’s voice can be prepared that can be sent as-is or edited can reduce the time for author to prepare a response – e.g., a message that has contact information for crisis help, a message that clarifies how to re-engage with care

Be very cautious about autoreplies with crisis information. This may seem like a good idea to authors who are concerned the person is at risk but may be received as uncaring

May be experienced as spam or automation that tells the participant there isn’t a real person sending messages, which leads the recipient to disregard the messages or choose not to reply in the future
This message implies the person is in crisis that they need this sent to them. Even for people who are highly suicidal, suicidal thoughts and feelings change through the day and throughout the week. Many Caring Contacts arrive when someone is doing fine as can be seen by the majority of replies being positive.
If someone says “hey, thanks for this – things are good” and an auto-response reminding them where to call if they are in crisis may be very invalidating. A reply of a happy face that doesn’t arrive till the next day is a much better fit

If there is a sender assisting the author to send the messages, the sender may be the one tracking replies and can have the author dictate a response they can send to the recipient

Create an Automated System: Design and Develop Your Own Automated System

For organizations with the need and capacity to build their own automated system, we have developed a functionality matrix of user needs and intervention functionality solutions based on human centered design in collaboration with experts in Caring Contacts, outpatient clinicians and staff at a service organization. This can be found here. The functionality matrix can provide a blueprint for developers of an internal system.

For organization leadership or potential authors, review of this toolkit and the steps for a manual system will provide a high level overview of what such a system will need to do.

4. Documentation

This is important to think through if you want to be consistent across your Caring Contacts team.

Do you want to document Caring Contacts anywhere other than the platform you're using?

In a healthcare environment, it may be important to document in the medical chart or electronic health record.

If so, do you want to document every pre-programmed message you send? Every Caring Contact interaction following a reply from a recipient? Or a more limited set of information such as the patient’s start and end date of the Caring Contacts intervention.
It may also be important to document any distressed or high risk replies and how they were handled.

Outside of healthcare, are there other systems for tracking membership that need to have information transferred or updated if they are in the Caring Contacts program?

Other aspects your team might want to keep track of in order to provide updates on successes and barriers of the intervention at your organization

Document number of recipients receiving Caring Contacts cards, replying to Caring Contacts, etc for tracking staff demands, costs, or successful re-connection of recipients to care

Collect anecdotal evidence (quotes from staff and/or recipients about the initiative/messages)

Identify ways to recognize staff that participate in process (e.g., awards, performance plan)

Consider highlighting on leadership performance plan

5. Starting the Intervention

Assign Roles

Based on the Caring Contacts structure you developed, it is important to determine and communicate who will do what, so nobody falls through the cracks. Here are a few suggestions from our previous research:

Author: the person from whom the Caring Contacts are sent – whose name and responsibility is the Caring Contacts for their clients.

Recipient: the person who is receiving the messages

Sender: a person who does the work to send the Caring Contacts who is not the Author, if any

Identify & Enroll Individuals

Based on the intervention enrollment criteria that your team decided on when planning the intervention, you’ll need to create a process through which individual recipients are "assigned" to start getting Caring Contacts. This may occur through routine screenings, referrals between case workers, or other workflows.

Once potential recipients are identified, your team may want to reach out to those clients and confirm their willingness to participate. Then, follow the enrollment steps for whatever system you’re using. [link to section on Mosio/ISACC specific instructions for those that are using our system]

Personalize Messages: Revise the pre-programmed messages for that recipient

Review all of the dates and times of the messages on the schedule to be sure that they fall on the days and time windows your Caring Contacts team wants them to be sent.

Messages scheduled for a Friday that say something about an upcoming week will sound off – either move the day to earlier in the week or change the message to comment on the week they had or specify next week

Time and date should be edited for any message to individualize it for a recipient’s needs (e.g., your messages generally go out in the morning but the recipient works nights, and you know they never wake up before noon).

Important reminders:

If their birthday falls on a weekend, your team may decide to adjust the date for the message to a day or two early and adjust the text to say, “Happy early birthday!...”

If there are holiday messages you want to send, be sure they are programmed to be sent on the correct day.

Remember that the messages should appear as if they were individually sent by your team and come across as naturally as possible. Avoid having all of your messages come on the same day or time each week as this can look like spam.

If your messages will be coming from an unrecognized number, you may want to explain this to the recipient and even have them add the number from the initial contact to their Address Book with yours or your organization’s name so they recognize it in the future.

6. Running the Intervention

This is not an automated intervention. There’s a real relationship whether or not the author has met the recipient. The recipient should expect the author is paying attention to their replies and that the author will be sending the messages thoughtfully and with care.

If the author becomes aware of new information about the recipient based on replies or other information, the next scheduled message might need to be changed accordingly

For example, if they replied to a message that their father died, the next scheduled message a few weeks should probably be modified from something like, “hope all is well with you.”

Your organization is responsible for monitoring and responding to all incoming messages from your recipients (what we call “replies” to differentiate from what you send which we call “responses”). Here are some points to consider in planning your Caring Contacts program:

Replies from Recipients

This is a two-way communication intervention, so recipients can reply at any time.

Outgoing scheduled contacts are often sent earlier in the day to maximize the chance that replies come during that author’s business hours.

The intention is that the messages are non-demanding, so pre-programmed messages are statements of care, concern, and support that don’t require a reply.

To the extent that the author does not want to encourage an extended dialogue, the author can plan a delay of 1-2 hours when responding to messages containing positive or neutral content.

In our previous study, the mean number of messages back and forth, including the pre-programmed message that opened the exchange, was 3.5.)
Nonetheless, 67% of the time in our text message study, participants replied to at least one message. The majority were positive or neutral or an emoji that required a comparable simple, polite response, but not immediately.

Types of Replies you might see:

Doing Better/Well/OK

Thanks. We have some new leadership and everything has completely turned around.
Yep, I'm feeling better today than I have in a while, thank you.
Yea things are going way way better
Yes ma'am things are slowly coming back together.
I'm doing good getting my life right

Appreciation

Well I'm glad you are able to check on me. Not many have since I got out.
Thanks for checking in.
Thank you for checking on me it helps a lot

Reciprocation

I am thanks so much. I hope all is well with you too.
Yes ma'am thank you for thinking of me. And I wish the same to you.
Hope ur well also!

Difficulty / Adversity (not in distress)

It's a bit of a rocky road at the moment but I'm doing alright
It’s kinda rough right now to be honest...but I’m striving along trying to get to the next level
It's a pretty stressful week but I've had worse before
Hard that all my buddies are deployed and I'm not with them, but I'm doing well considering.
I go to a therapist who isn't helping, but work is good and I bought a new vehicle.

Non-urgent Distress

Thanks for asking but it’s a terrible day
Today's hard
Just really stressed out
Things aren't going so good lately.
Rough.

Urgent Distress

Can I talk to someone? I'm feeling really down
Screw everything
No things aren't going well they're never going well
Someone close to me killed himself. Been dealing with that. Sucks a lot.
Just feeling like it's all too much. Really overwhelming.

Crisis

I almost killed myself yesterday.
Not feeling safe today.
Almost ended up at hospital last night, I feel off like something is wrong again.
Having strong suicidal desire… sick of everything.

Responding to Recipients

Replies to at least some of the pre-programmed Caring Contacts are expected. In our experience the vast majority of responses tend to simply show gratitude (“thanks so much”) or reciprocity (“I hope you have a good day too”) or something general like a thumbs-up emoji.

In the minority of situations, the reply will indicate distress or request assistance. This may occur when they are getting Caring Contacts and no other services from your organization, so this offers an opportunity to support someone who is in distress that might otherwise be missed.

Not responding to a recipient’s reply may well be taken as either uncaring or that Caring Contacts are from a bot, spam, or otherwise disingenuous, so it is important to reply.

Responses do not have to be immediate. It is important to orient recipients at the beginning of the program about how long they can expect to wait for a response. It can also be strategic to let time pass before responding if the organization is less interested in getting into a text dialogue with the recipient. It is common in our programs to hold “by next business day” as a standard for a reply that does not indicate distress. Programs vary in how quickly a response is expected if the message indicates distress or risk. Agencies are advised to follow their existing crisis response protocols.

Caring Contacts is a behavioral health intervention but not intended to function as a crisis line. Recipients should be oriented up front about when to expect a response and when not to. It is important to communicate in advance what recipients should do if they need help at a time no one can respond. We have found that recipients are flexible and respectful of this, and it has not been an issue.

For the majority of replies, the author is just responding with an emoji or a “You’re welcome” or a “That’s great!” or a “Hoping things keep getting better this week”…

When someone sounds like things are tough but not anything emergent, the typical response is a message of validation and caring. When appropriate, a separate second message is sent, assuring the recipient is aware of relevant resources, formal support or crisis resources they can follow-up with (if they choose).

Most authors/agencies’ initial concern is responding to recipient replies after hours and on weekends. Most clinics do not respond to recipient contacts at those times, instead orienting recipients on what to do when the clinic is closed. We argue the same should be true for Caring Contacts, which is a long-term psychosocial intervention, not a crisis intervention. In our study, the vast majority of messages came during work hours and it was cost-inefficient to have authors (or a backup clinician) on call for the 38% of the 1% of messages that were time-sensitive that came outside of business hours.

A common strategy for managing after-hours replies is an “autoreply” or “out of office” message that includes who to call in a crisis. However, the vast majority of responses are positive or neutral, e.g., a happy face or thank you to a message that said, “Hope you are doing well.” We are concerned that such a response is invalidating, is inappropriate for 99% of replies, and will communicate that we expect them to be in crisis. Individuals with lived experience of suicidality on one study’s advisory board did not like this idea at all.

Suggested responses:

Showing Care

Sending good thoughts your way as the week goes on.
Thinking of you this week!
It's good to hear from you.

Acknowledging Challenges

That sounds really tough.
It makes sense you’d feel that way.
I can see how much you’re dealing with.

Celebrating Progress

That’s great! Sending good vibes your way that it continues!
I am sending you positive vibes and wishing you well.

Giving Encouragement

It’s okay to feel how you feel right now.
You matter so much, and I’m always cheering you on.
I can see how much you’re dealing with.
The world is brighter because you’re in it—never forget that.
I’m glad to hear things are good even though there’s stress. I’m sending positive thoughts your way that things keep getting better 😊
[name], I’m glad you’re persevering, and I hope things keep getting better for you. I’m sending good thoughts your way.

Validating Hardships

[name], I’m glad you’re ok but I wish things were better.
I’m sorry to hear you’re stressed. Please let me know if you need me to connect you with someone. Just in case, I want you to have the [relevant crisis line info] handy
Hopefully your provider is giving you some support but just in case, I’m also texting you some info…
I think you know who to reach out to for support, but if not, let me know and I can connect you with someone.
Just in case, I want you to have this: 988 is there 24/7, or you can text [relevant textline #], or chat confidentially on [relevant online crisis support website]
You should be able to walk in to the clinic that serves your unit between 07:30-16:30, M-F, if you want to talk to someone.
I'm here to listen if you want to share about it. Would you be interested in some online resources for [specific topic]?

Crisis Response Plan

In the event of a reply indicating suicidality or another crisis, how will this be handled?

Does your organization have existing protocols?

Are there specific protocols you expect to be followed or should Caring Contacts program staff follow general protocols for crisis intervention or high-risk circumstances?

Who should your Caring Contact authors escalate to if a participant indicates distress or suicide risk?

Do you have a clinician on staff; and do they have licensure that would impact their participation?

Who will make the decision to pursue rescue?

How will this rescue take place?

What are the implications of this “lights and sirens” approach?

Who should be informed about the crisis, if anyone, and when? Does this need documentation outside of the Caring Contacts intervention system.

Outside Individuals: Occasionally, participants might give their Caring Contacts author permission to reach out to a friend or loved one as a risk-management solution. Does your organization have the appropriate release of information on file?

Quick Reference Guide [also make printable PDF]

This is an editable guide for authors to have for daily reference while a Caring Contacts intervention is running.

Download Document

7. End of Intervention Plan

Your team should already have planned out what the last message will contain. Following the end of an intervention period for a given recipient, there will be some important points to consider:

Where should the recipient turn for reconnection with your organization or immediate assistance now that Caring Contacts are over?
Will recipients be able to re-enroll in the intervention?
How might your team gather feedback on the intervention which they received?

We recommend administering a short survey about their experience getting the intervention. Here’s an example you can use or modify to fit your organizations needs Caring Contacts Reception Survey 2025

Download Document

This can be sent to them to complete online or you can ask them to complete it during their next appointment/meeting
This allows for more honest feedback
Directly asking recipients their experiences is not recommended as participants might be unwilling to share their honest feedback if they feel it might hurt the author’s feelings. Asking them to complete the survey on their own allows more time for them to think through their answers.