Telephone and Online Crisis Counseling

1. TelephoneandOnline Crisis Counseling By: Dina Crowell

2. Background The internet is booming with online crisis counseling. The majority of crisis counseling now is dealt with on the phone. The other person on the other end of the phone/internet could possible be a volunteer(that does not hold a degree in social work/ psychology/ counseling), or a professional with credentials. This presentation focuses on the large current venue of telephone use in crisis counseling.

3. Case Handling on Telephone Crisis Lines • Telephone has played a major role in crisis work. Bell telephone advertisement “Reach out and touch someone” is a slogan that is appropriate for counseling. • The suicide prevention in the 1950’s started using the telephone as the primary mode of treatment. • It offers immediate service • It is used mostly in suicide intervention. • Is suicide intervention only for suicide callers?-No -Gamblers, people who suffer from panic attacks, domestic violent victims, depressed, alcoholics, grievers, lonely, and people who suffer from psychotic breakdowns.

4. What does telephone/online counseling offer? • Convenience • Client Anonymity • Control • Immediacy Access • Cost Effectiveness • Therapeutic Effectiveness • Availability of Array of Services • Access to Support Systems • Avoidance of Dependency Issues • Worker Anonymity • Service to large/isolated populations • Availability of others Consultation

5. Convenience- The use of cell phones allows a person to call a crisis hotline from anywhere. Access a variety of self help groups(e.g. chat rooms, computer assisted therapy, and psychoeducational materials) Client Anonymity- Opening up to another person is vulnerability. (guilt, embarrassment, shame, self-blame, and other emotions makes face to face therapy with stranger difficult) *Hiding your identity can make it easier for a person to open up more. *Telephone/online counselors are not concerned with revealing identity unless it is a life threatening situation. *Conversation is on a first name basis for client/worker. Control- Going for help may be positively humiliating. The client decides when and if assistance should be sought. Anybody who is self conscience about how they look finds the telephone wonderful for counseling.(Wark, 1982) Immediate Access- A crisis can occur at anyplace/anytime. Most clinics and institutions keep beepers. Cost effectiveness- Crisis hotlines are inexpensive. Clients who cannot afford therapy/transportation can use the phone/computer. Therapeutic effectiveness- Volunteers are often seen by callers as having more credibility than a paid professional. Why? They do it out of the kindness of their hearts. Access to support systems- The main reason people call hotlines is for social support. (Watson, McDonald, & Pierce, 2006) Telephone/online counseling can be referred or gained access on your own.

6. Avoidance of dependency- A person who uses telephone crisis lines cannot become dependent upon on a particular worker who may/may not be always available. Standard practice in most crisis lines discourage workers from forming lasting relationships with clients.(Lester, 2002 Worker Anonymity- Workers who are anonymous have many benefits as clients. Body language Facial expression Visual image Availability for other consultations- One line is reserved for calling support agencies when there is an emergency. Crisis hotlines staffs more than one person, especially when they encounter a difficult client. Availability of services- A large amount of info, guidance, and social services is available by telephone.They can provide on the spot guidance. Any crisis hotline should have a list of numbers available of special agencies to refer call. *LINC- Library and Information Network for the Community is standard reference for most telephone crisis lines. Service to large/isolated areas- Rural areas that have no after hours mental health facilities or staff have a toll free crisis line. These lines are tied in to emergency services such as police, paramedics, and hospital emergency rooms.

7. Telephone Counseling Strategies • Conducting crisis intervention on telephone is a double edged sword. Why? The crisis worker is dependent on • Content • Voice tone • Pitch • Speed • Emotional content of client *Telephone/Online counseling is not for everyone (Eckardt, 2001) -The worker depends on their verbal ability to stabilize the client. -The worker has little control over the physical situation.

8. Making Psychological Contact -Psychological contact is where the worker attempts to establish a quick, nonjudgmental, caring, accepting, and empathetic relationship with the client that will give the worker the client’s trust. *Support is the first order of business. You can do this by defining the problem through active listening and responding skills. You do not want the client to hang up. -Here are some good techniques for the worker • React in a calm manner 2. Worker’s voice should be modulated 3. Steady 4. Low keyed Only interrupt to clarify and summarize with the client • The worker should never respond 1.Deprecating 2.Cynical 3.Demeaning 4.Cajoling *When the client is acting out, angry, intoxicated, or demanding, The worker needs to remember these techniques.

9. Defining The Problem • The worker can define the problem by: -Gaining an understand of the events that led to the crisis -Assessing the client’s coping mechanisms -Open ended questions are a good solution. For example, what, how, when, where, and who? This gives the worker a clear picture. How would you assess the coping mechanisms of the client over the phone? • Be more sensitive to emotional content • Reflect the implied feeling content What are the plus signs to phone counseling? • Have supportive aids readily at hand without detracting from the counseling session • Have a reference list of feeling words that covers the emotions. • Have a list of standard questions the counselor can check off • Keep a notepad handy for events and coping mechanisms and the triage assessment scale.

10. Ensuring Safety and Providing Support • The worker must determine the clients lethality level. • If the worker detects physical injury, closed ended questions should be asked for safety of the client with understanding and concern. For example, questions may start with do, have, and are? (e.g. Do you have the pills there with you now?) • The phone counselor should check what support system is available for client’s safety. • There will be no support system for many phone clients. *The phone counselor is the immediate and sole support system.

11. Looking at Alternatives and Making Plans *Having a plan and creating alternatives in important in a crisis situation especially in phone counseling. • Alternatives needs to be simple and clear. • The worker needs to avoid giving alternatives that are difficult to do because of tactical and logistical problems • Alternatives needs to be done in a slow manner to ensure that the client can do the physical/ psychological work • Here are some helpful tactics: • Role play • Verbal rehearsal • Have client recapitulate objectives

12. Obtaining Commitment/ Errors and Fallacies • Commitment to a plan over the phone should be simple, specific and time limited. • Try to obtain the client’s phone number and call the client back at a present time to check on the plan/ try to have client schedule an appointment a.s.a.p.. • If worker is linked to other agencies a phone call should be made to the referral to see of the client has completed the task. • First you are not omnipotent, you are there to be a instant expert. • Second callers are resilient and need somebody to talk to honestly and openly. • Third if you feel manipulated, it’s okay. Understand that the caller’s need to manipulate serves a purpose. That purpose should result in restoring the caller’s psychological equilibrium without harming anyone. • Fourth all callers are not loving and you do not have to be loving and caring to all callers(Lamb, 1973)

13. Regular, Severely, Disturbed, and Abusive Callers • Crisis lines should not cater to a caller’s every, whim, fantasy, deviant behavior, or self indulgence. • Chronic callers can devour time and energy of staff. • These callers can pose a serious morale problem for the volunteers and staff who receive calls that become too explicit and it is directed to the crisis worker.(Brockopp & Lester, 2002; Knudson, 1991; Tuttle, 1991) • All behavior is purposive. If seen this way it helps workers make it through the day. • By setting limits 10-20 minutes for regular callers, workers won’t become controlled by regular callers.

14. Understanding the Regular Caller’s Agenda • Helping a person in a crisis is different. The agenda of regular callers places a dilemma on the crisis worker. • All calls must be taken but it does not mean that workers should suffer from the abuse. • Helping a caller is more of what they need than what they want • Regulars often want reaffirmation that their problems are unsolvable. Why? -They become dependent on the telephone worker to sustain their problem. • Telephone workers do themselves and their callers a service when they show that they are not willing to be manipulated or abused. *Generally if the telephone worker spends more than 15-20 minutes with a caller, the client’s crisis becomes the worker’s crisis (Knudson, 1991)

15. Regular Callers can tend to be placed in a stereotypical category • Paranoid- they are guarded secretive and can be jealous. It is difficult to shape their persecutory beliefs. They see themselves as victims. The counseling focus is to stress their safety needs. • Schizoid- restricted emotional expression and experience. They have few social relationships. They are anxious, shy, and self conscious in social settings. The counselor focus is to build self esteem through acceptance, and support. • Schizotypal- are insecure and have inadequate feelings. The focus of the counselor is to give them reality checks and promote self awareness in a supportive manner. • Narcissistic- are self centered and believe they have unique problems that others cannot comprehend. They see themselves as victims by others and always need to be right. The focus of the counselor is to get them to see how their behavior is seen and felt by others. • Histrionic- move from crisis to crisis. They are ego involved and have a shallow character. They crave excitement and become bored with routine tasks and events. They may also behave in self destructive ways. The counselor focus is to stress their ability to survive using resources that have been helpful to them in the past. • Obsessive Compulsive- fixated on tasks. They waste large amounts of time on endeavors. They often may not hear counselors. The counselors duty is to establish client to trust others and the use of stopping behavior modification to stop obsessive thinking and compulsive behaviors.

16. Regular Callers can tend to be placed in a stereotypical category • Bipolar- extreme mood swings of callers. May become aggressive or suicidal behavior. Counselors responsibility is to slow down the client. Confrontation about their plans only alienates them. In depressive stage suicide intervention is a priority. • Dependent- have trouble making decisions and seek others to do so. They feel worthless, insecure, fear of abandonment. Prone to become involved in self destructive relationships. Focus of counselor is to reinforce strengths and support their concerns without becoming critical for their lives. • Avoidant- are loners and have little or no social relationships. Focus of the counselor is encouragement through social skills and assertion training. • Passive Aggressive- cannot risk rejection by displaying anger. They engage in attempts to manipulate others and believe control is more important than self improvement. The counselor is to promote more open and assertive behavior. • Borderline- are chameleon like and may resemble any mental disorders. Always on the borderline of being functional and dysfunctional. *one of the most problematic callers. • Self defeating- choose people and situations that lead to failure, mistreatment by others. They reject attempts to help them and make sure they won’t succeed. The counselor should stress talents and the behavioral consequences of sabotaging themselves.

17. Handling the Severely Disturbed Caller • The behavior of the severely disturbed is disorganized, disoriented, and disabling. They elicit discomfort, anxiety, and fear in the observer. • These callers represent mental illnesses. • They may be delusional and hallucinatory. • Lack insight of judgment about their problems • Be manipulative, resistant, and hostile. *They are usually locked in mental institutes, and are threatening. What are behaviors that can be recognized by the counselor? -Behavior is always purposeful and serves motives that may be either conscious or unconscious. -Behavior is comprehensible and have meaning even though the language used may not. -Behavior is used to keep a person safe and free of anxiety.

18. How should the counselor deal with disturbed callers? • Slow emotions down • Refuse to share hallucinations and delusions • Determine medication usage • Keep expectations realistic • Maintain professional distance • Avoid placating • Assess lethality

19. Other Problem Callers Remember every call is an attempt by the caller to fulfill some need or purpose. -Rappers- some may just want to rap or talk. They may be testing the waters to get enough courage to call. -Covert callers- callers that ask for help for another person. They may be actually asking for help for themselves. These may be timid callers. -Pranksters/nuisance callers- teenagers who are bored. Silent callers- They are usually hurt or fear rejection and don’t have the courage. -Sexually explicit callers- They have low self esteem and, lack of trust, and feelings of isolation. These callers are usually hung on the crisis line because the worker may become angry, embarrassed, and afraid. Callers with legitimate sexual problems- They call because it is anonymous to discuss private issues. These calls may embarrass the worker who are not psychologically prepared for intimate details. -Manipulators- a lot of callers play games by achieving their unmet needs. Usually it is role reversal .

20. How to Handle Problem Callers • Set time limits • Terminate Abuse • Switch Workers • Use Covert Modeling- example ask client to use mental imagery to picture or extinguish a particular behavior. • Formulate Administrative Rules • Limit the number and duration of calls from single caller • Limit the topics that will be discussed • Require specific workers for handling abuse callers • Use speaker phones • Establish face to face relationship with outside worker • Allow staff to prohibit calls for a day/week/or more.

21. Hotlines • Hotlines are growing tremendously.(e.g. there are pet loss support groups) • Crisis phone lines are open 24 hours a day 365 days • Specialized services may operate regular business hours(e.g. Disease and Control Aids) • Warmlines deal with less than life threatening matters(e.g. homework) • Hotlines deal with life threatening/endangering problems • National hotlines can be reached anywhere. Local is limited • This is a specified period of time • Used to deal with a potential disaster or after a disaster. • It may provide brief supportive therapy or for information/referral source Hotlines Time Limited Hotlines

22. Hotlines continued….. • Continuous National Hotlines -Toll free; deal with specific topics (e.g. troubled youth) -Major purpose is to provide info about geographic location nearest the caller. -These lines are heavily used -They encourage runaways to get off the streets and talk problems. -Domestic violence hotline is available for any victim of abuse in the U.S. • Local Crisis Hotlines -Handle all kind of calls (e.g. suicidal, lost cats • They are staffed by volunteers from local communities • Provide telephone crisis for a specific region/population

23. Internet’s Growing Role in Crisis Intervention • The computer is not only a communication device; it functions as a simulation device (Wolf, 2003) • Both have potential for psychotherapy and crisis intervention • Most professional therapists do not use computer assisted counseling/ or provide online counseling. • Here are some reasons: • Ethical concerns • Commitment to humanistic values that conflict with technology • Cost • Absence of training (Murphy, 2003)

24. Behavioral Telehealth • What is behavioral telehealth? It is the use of telecommunication and information technology to provide access to behavioral health assessment, intervention, consultation, supervision, education, and information across distance (Nickelson, 1998) -This can include email, chat rooms, websites, and internet teleconferencing (Barnett & Scheetz, 2003) -Crisis intervention on the web can be time delayed such as websites and emails. -Real time such as chat rooms, videoconferencing, Skype, and instant messaging

25. How can we ethically and effectively do crisis intervention on the internet?What crisis intervention services can be ethically and effectively provided on the internet? -Websites that provide opportunities for net “surfers” to seek emergency help or advice, Counseling, or psychological help continue to grow. -For example Befrienders International provides a website that offers help to suicidal and other People in a crisis. -They have helped people for 40 years by letter, telephone, and in person. Emails remain Anonymous if requested. -There are 20 centers around the world • What are the appeals of online counseling? -people who are psychological/geographically isolated from crisis services -suffering from mental/physical disabilities -shy/don’t want to meet face to face -needs anonymity • Feedback- continuous and immediate feedback is critical -Use email to check on the client several times an hour/day/week • Disinhibition-people tend to open up earlier with more distressing issues than they would face to face.

26. Problems of online counseling • -You only know about how much credential a person has by what they tell you. • -Clients could possibly effect the crisis computers with viruses/spyware • Confidentiality- once a message goes out there is no guarantee anonymity • Identity verification in emergency situations involving homicide, suicide, or other life • threatening events. • Charlatans-fees are extremely high • Licensing and insurance • Learning the language-netiquette • Netiquette • Sloppy writing and typos means you don’t care about your client • Emoticons can be helpful/too cute • Be clear on the acronyms • Keep text neutral(e.g. black font, 12 point times) • Be care constructing your responses • Use standard counseling skill responses to do work/let the client talk • Keep inflammatory remarks under control/quickly apologize/client needs to know limits • Predispositioning- miscommunication can occur. Set the tone as • Empathetic • Genuine • Caring • Positive

27. Legal, Ethical, and Moral Issues of Telephone and Internet Counseling • There is still much to be done in research and protocol development in behavioral telehealth and cyber counseling • You need to know professional ethical standards and state and federal regulations and laws • Most telephone workers are volunteers and receive minimal training. The agencies are not bound by state or federal supervision or legislation (Seely, 1997a, 1997b) • Does it work? It is helpful but others have stated they would prefer face to face counseling

28. References • James, R. K. & Gilliland, B.E. (2013). Crisis Intervention Strategies (7th ed.). • Discussion Questions for Presentation Outline • Why do you think it is hard for a person to trust and discuss their personal issues online with someone who you cannot see, or hear their empathizing tone? • 2. Why do you think online and telephone counseling is/isn’t effective?