Setting Limits and Boundaries with Callers

Introduction

Setting limits with Helpline callers is one of the most difficult tasks for a new helpline worker to master. It may go against a volunteer’s nature for them to be required to end calls with callers who still feel they need support or to set limits with callers who may be struggling with mental or cognitive disorders that make it more difficult for them to understand these limits.

The opposite side of that coin is that if volunteers do not set adequate limits with their callers, they will experience increased levels of burnout as they handle calls that are upsetting or even abusive; additionally, if limits are not placed on regular callers, they will “crowd out” crisis callers who may have less of an opportunity to receive support while at imminent risk because a repeat caller is using a disproportionate amount of service delivery.

5 Step Limit Setting Process

There is a 5-step process to setting limits with callers that is commonly used at the Distress Centre and I imagine other helplines or organizations where limit-setting is required. The five steps are as follows:

  1. Identify the inappropriate behaviour
  2. Identify what correct behaviour is
  3. Indicate the consequences for failing to change behaviour
  4. Give the caller an opportunity to change their behaviour
  5. Follow through on consequences (e.g. hanging up) if behaviour does not change

Let’s examine each of these steps in sequence:

Identify the inappropriate behaviour

The first step is to identify what inappropriate behaviour is. This can be an agency limit such as a prohibition on the discussion of sexual explicit content or of a caller masturbating on the phone, or this can be a personal limit like a volunteer being uncomfortable with a caller swearing.

The volunteer will identify the inappropriate behaviour, e.g. “I recognize you’re very angry but I need you to refrain from swearing during our conversation”

Identify what correct behaviour is

In a situation where there is a correct behaviour, the volunteer should indicate that. For example, “We can discuss this sexual experience but I need to stay focused on the emotions and not the physical elements of the act.”

Indicate the consequences for failing to change behaviour

This identifies what happens if a caller does not change their behaviour. “If we can’t stay focused on the emotions, I’m going to have to end the call.”

Give the caller an opportunity to change their behaviour

This is to allow the caller to show us they have recognized the issue, such as by refraining from swearing.

Follow through on consequences (e.g. hanging up) if behaviour does not change

In this step, the caller has not changed their behaviour so the volunteer ends the call. “I’m sorry, but I asked you to refrain from discussing the physical elements of this call. As you have continued to do so, I have to end the call now.” This should be followed by the volunteer hanging up!

This limit setting procedure can be used in a variety of settings, both in person and on the phone.

Call Restrictions

Call restrictions are different from in-call limits (described above), and instead describe things such as a caller being put on a 20 minute time limit per call, or being limited to one call a day. These limits are best deployed when a caller is using significantly more service than average.

One way that Distress Centre determines limits is by examining how often a caller uses our services and for how frequently. Our goal is to limit most callers (who have limits) to one call, once per day, and then to decide on how long. For instance, if a caller tends to call twice a day and speak for 30 minutes, we may set their restriction to one call a day, for 30 minutes.

This restriction is always suspended when a caller is in crisis so that we can de-escalate them or connect them to emergency support.

When placing a caller on restrictions it’s important to speak to them about the rationale for that. A caller who calls repeatedly is likely getting less out of each call than they would otherwise. One focused 30 minute call may deliver much more support to a caller than three 10 minute calls, for instance. One focused hour long call will provide more support to a caller than three hour long calls.

Speaking to the caller, you can explain that we want to make sure our service is available for that caller and help meet their needs but also meet the needs of our other callers and volunteers. If a caller is upset, we can help them find additional supports in their community in addition to the Distress Centre that can help meet their needs.

Working with Abusive Callers

Abusive callers can be very challenging. These are callers that frequently disregard the Five Step Limit Setting Procedure above and instead abuse volunteers by being insulting, sexually graphic or simply by disregarding their time limits consistently.

Abusive callers may need to be temporarily blocked until a staff member can speak with them, in order to reign in that behaviour. If a caller continues to be abusive, the best option may be to simply block that caller from using your service, referring them to alternates in your community.

Winding Up on Text and Chat

Text and chat is a different beast from the telephone. Conversations can stretch much longer if your responder is not careful. Fortunately there are a variety of winding up strategies that can be used on text and chat conversations.

When it comes time to wind up a conversation, you have a few options:

  • We’re just coming up on (45/60/75/90) minutes so we’ll need to wrap up soon. I’m wondering if there’s anything else on your mind?
  • We’ve been talking for (45/60/75/90) minutes, how are you feeling?
  • I’m going to have to open up our queue soon, is there anything you haven’t told me yet that you want to?
  • We’ve been talking for about an hour now so I’ll have to let you go for now

In situations where someone is using the service multiple times per day, you may wish to try things like:

  • I saw that you’ve spoken to one of our responders earlier today, how did that conversation go?
  • I’m wondering if we can focus on some coping strategies that can help you get through the rest of the night

In my experience most visitors respond positively to these gentle wind-ups and allow you to move towards wrapping up the conversation at the appropriate point.

Call Blocking

In a future post I will discuss the technological options available for call blocking; it’s a good idea to check with your telephone provider about the option of blocking abusive or harassing callers from your helpline.

Conclusion

Limit setting can be a challenging task for your volunteers to master but is essential for their continued success on your lines!

Cite this article as: MacDonald, D.K., (2017), "Setting Limits and Boundaries with Callers," retrieved on November 23, 2017 from http://dustinkmacdonald.com/setting-limits-and-boundaries-with-callers/.
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Childhood and Adolescent Taxon Scale (CATS)

Introduction

The Childhood and Adolescent Taxon Scale (CATS) worksheet was originally created to accompany the Violence Risk Appraisal Guide (VRAG) and the Sex Offender Risk Appraisal Guide (SORAG). Although the Psychopathy Checklist-Revised (PCL-R; Hare, 1991) can be used to assess psychopathy, there are many situations where a Psychologist or other individual trained in the administration of this tool is not available. In this situation, the CATS tool can be used to assess psychopathy instead.

Quinsey et. al. (2006) determined that the CATS tool is an appropriate replacement for the PCL-R assessment when determining psychopathy on the VRAG and SORAG assessments. Lister (2010) examined the CATS and found that there were no differences in rates of psychopathy as determined by the PCL-R and the CATS with Caucasian and African-American individuals.

Conduct Disorder Symptoms

In order to answer question 4 below, it’s necessary to identify how many conduct disorder symptoms are present.

Count those present those that occurred before age 16 except for items 13 and 15 which are before aged 16:

  1. Often bullied, threatened or intimidated others
  2. Often initiated physical fights
  3. Used a weapon that could cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
  4. Was physically cruel to people
  5. Was physically cruel to animals
  6. Stolen while confronting a victim (e.g., mugging, purse snatching, extortion, robbery)
  7. Forced someone into sexual activity
  8. Deliberately engaged in fire setting with the intention of causing serious damage
  9. Deliberately destroyed others’ property (other than by fire setting)
  10. Broken into someone else’s house, car, or building
  11. Often lied to obtain goods or favors or to avoid obligations (i.e., “cons” others)
  12. Stolen items of nontrivial value without confronting a victim (like shoplifting, theft, or forgery)
  13. Before [age] 13, stayed out late at night, despite parental prohibitions
  14. Ran away from home overnight (or longer) at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
  15. Before [age] 13, was often truant from school

Childhood & Adolescent Taxon Scale (CATS) Items

The CATS scale has 8 items that are reviewed below, along with supplementary scoring guidelines.

Elementary School Maladjustment

This refers to the first 8 years of formal schooling after kindgarten. A couple of incidents of truancy, smoking on school property or other minor incidents like this would be classified as Mild or Moderate. Severe incidents include repeated truancy or violent actions like assault. Also included in Severe is actions that result in criminal convictions like selling drugs at school.

  • 0 – No Problems
  • 0 – Slight (Minor discipline or attendance) or Moderate Problems
  • 1 – Severe Problems (Frequent disruptive behavior and/or attendance or behavior resulting in expulsion or serious suspensions)

Teenage Alcohol Problem

The National Institute on Alcohol Abuse and Alcoholism produces a guide to screening and intervening with youth (NIAAA, 2015) who consume alcohol. Their screening and assessment rubric can be used to determine if there is a teenage alcohol problem.

Based on the empirically determined risk guidelines, someone who is 12-15 and drinks more than 6 days in the past year would indicate a 1 below, someone who is 16 and drinks more than 12 days in the last year, someone who is 17 would need to drink more than 24 days while an individual who is 18 or higher would need to drink more than 52 days a year.

  • 0 – No
  • 1 – Yes

Childhood Aggression Rating

  • 0 – No Evidence of Aggression
  • 0 – Occasional Moderate Aggression
  • 1 – Occasional or Frequent Extreme Aggression

More Than 3 DSM Conduct Disorder Symptoms

These are the conduct disorder symptoms filled out below.

  • 0 – No
  • 1 – Yes

Ever suspended or expelled from school

  • 0 – No
  • 1 – Yes

Arrested under the age of 16

  • 0 – No
  • 1 – Yes

Lived with both biological parents to age 16 (except for death of parents)

Separation for more than one month is required for coding a “no” on this item. This could be because of institutionalization, divorce, or other separations but does not include death of one or both parents.

  • 0 – Yes
  • 1 – No

Scoring the CATS

Each of these items will result in a 0 or 1 score. All items are summed and the value can then be used to complete Item 12.b on the VRAG or item 14b on the SORAG.

References

American Psychological Association. (2006) Quinsey, V.L., Harris, G.T., Rice, M.E. & Cormier, C.A. (2006) 2nd Ed. Violent Offenders: Appraising and Managing Risk. Washington D.C: American Psychological Association.

Hare, R.D. (1991) The Hare Psychopathy Checklist-Revised (Hare PCL-R). Toronto: Multi-Health Systems.

Lister, M.B. (2010) A Comparison of the Violence Risk Appraisal Guide, Psychopathy Checklist, and child and Adolescent Taxon Scale: Predictive Utility And Cross Cultural Generalizable. Dissertation.

National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2015). Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide. Retrieved on January 28, 2017 from https://pubs.niaaa.nih.gov/publications/Practitioner/YouthGuide/YouthGuide.pdf

Cite this article as: MacDonald, D.K., (2017), "Childhood and Adolescent Taxon Scale (CATS)," retrieved on November 23, 2017 from http://dustinkmacdonald.com/childhood-adolescent-taxon-scale-cats/.
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Using the Sex Offender Risk Appraisal Guide (SORAG)

Introduction

Following up on my article about how to use the Violence Risk Appraisal Guide (VRAG), this article reviews how to use a tool that is bundled with that tool, the Sex Offender Risk Appraisal Guide (SORAG). Like the VRAG, this is an actuarial tool that can be used to predict the risk of re-offending among sex offenders.

Before reading about the SORAG, it is helpful to review the VRAG post as many of the elements that are covered in that post are required before proceeding to the SORAG items. It is recommended that any completion of the SORAG be preceded by a completion of the VRAG as this will save you a significant amount of time.

Completing the SORAG

Like the VRAG, the first step is to complete the Childhood & Adolescent Taxon Scale (CATS) worksheet and the list of Conduct Disorder Symptoms.

Cormier-Lang Criminal History Scores

In order to answer item 5 on the SORAG, Criminal History Score for Non-Violent Offenses Prior to the Index Offense, it’s necessary to complete the Cormier-Lang Criminal History worksheet also provided on the SORAG. This worksheet is completed by filling out the number of non-violent offenses and applying the weight to them noted on the sheet.

Sex Offender Risk Appraisal Guide (SORAG) Items

The SORAG itself has 14 items that are similar to those found on the VRAG.

  1. Lived with both biological parents to age 16 (except for death of parent)
  2. Elementary School Maladjustment
  3. History of alcohol problems
  4. Marital status (at the time of or prior to index offense)
  5. Criminal history score for nonviolent offenses (from Cormier-Lang system)
  6. Criminal history score for violent offenses (from Cormier-Lang system)
  7. Number of previous convictions for sexual offenses (pertains to convictions known from all available documentation to be sexual offenses prior to the index offense)
  8. History of sex offenses only against girls under 14 (including index offenses; if offender was less than 5 years older than victim, always score +4)
  9. Failure on prior conditional release (includes parole or probation violation or revocation, failure to comply, bail violation, and any new arrest while on conditional release)
  10. Age at index
  11. 11. Meets DSM criteria for any personality disorder (must be made by appropriately licensed or certified professional)
  12. Meets DSM criteria for schizophrenia (must be made by appropriately licensed or certified professional)
  13. Phallometric test results
  14. 14. a. Psychopathy Checklist score (if available, otherwise use item 12.b. CATS score)
    14. b. CATS score (from the CATS worksheet)
    14. WEIGHT (Use the highest circled weight from 12 a. or 12 b.)

You’ll note that many of these items are available from the VRAG. The tool indicates where there are overlaps in order to save you time filling out the worksheets and tools.

Determining Risk Level of Sex Offenders

After completing the tool, you must take the total score of the SORAG and compare it to the below levels.

  • A score of -17 to +2 indicates an individual is at Low risk for re-offending
  • A score of +3 to +19 indicates an individual is at Medium risk for re-offending
  • A score of +20 to +34 indicates an individual is at High risk for re-offending

An individual who is on the border between these two levels should have that indicated. For instance, someone who scores at +1 or +2 should be noted as “Low-Medium Risk” to highlight that they are at the edge of the established risk level.

Recidivism Rates using the SORAG

Rather than grouping an individual into low, medium or high risk categories, it is often more illuminating to examine the recidivism rates. These come from Violent Offenders as well.

Probability of Recidivism
SORAG score 7 years 10 years
< − 9 0.07 0.09
−9 to -4 0.15 0.12
-3 to +2 0.23 0.39
+3 to +8 0.39 0.59
+9 to +14 0.45 0.59
+15 to +19 0.58 0.76
+20 to +24 0.58 0.80
+25 to +30 0.75 0.89
> +31 1.00 1.00

References

American Psychological Association. (2006) Quinsey, V.L., Harris, G.T., Rice, M.E. & Cormier, C.A. (2006) 2nd Ed. Violent Offenders: Appraising and Managing Risk. Washington D.C: American Psychological Association.

Cite this article as: MacDonald, D.K., (2017), "Using the Sex Offender Risk Appraisal Guide (SORAG)," retrieved on November 23, 2017 from http://dustinkmacdonald.com/using-sex-offender-risk-appraisal-guide-sorag/.
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Coping with Flashbacks and Dissociation

Introduction

There are a variety of situations where a client or helpline caller may experience negative emotions and need to use coping strategies to help themselves cope. These can include flashbacks to abuse or trauma (such as in child sexual abuse or Post Traumatic Stress Disorder), dissociation, or simply intrusive thoughts or memories of a variety of painful experiences.

In these situations, there are a variety of techniques that can be taught to clients to help them stay grounded and cope. They are summarized below.

Physical Techniques for Coping with Flashbacks

Physical techniques focus on using your physical body or space to reduce your flashbacks or dissociation.

  • Plant your feet on the ground or grasp the arms of a chair
  • Repeat one’s name, age or location
  • Go to a safe space (e.g. home), a place where you feel calm and safe

Behavioural Techniques for Coping with Flashbacks

Behavioural techniques are actions that you can take when you feel stressed or overwhelmed. Ways of expressing yourself can give you a sense of control that will make it easier to cope.

  • Journal or writing
  • Verbalizing emotions
  • Calling a crisis line or mobile crisis team
  • Going to the hospital
  • Taking a walk

Cognitive Techniques for Coping with Flashbacks

Cognitive techniques are those things that involve your thoughts. These may be more challenging than the other techniques but with practice will become easier to use when you are feeling overwhelmed. Because these are hard to summarize they’ve been listed with more detail than the above techniques.

Identify Internal Cues

Internal cues are those things that prompt you to think that you are going to dissociate or experience flashbacks. Sometimes they come on randomly, but for other individuals there is a period of feeling flushed, having a racing heart, feeling anxious or restless, or other symptoms that precede the flashbacks or dissociation. When you recognize these occurring, using the other techniques on this list can help you cope.

Identify Associational Cues

Associational cues are those things that you associate with safety and security. These can be objects, sources of support like pets or other things that remind you that things will be okay. The association between the item and the positive thoughts it brings can help ground you.

Safe Space (Mind)

Going to a “safe space” mentally and remembering that what you are experiencing is temporary can be helpful. Guided imagery (described below) can help you find this safe space, which can also be a place in your own memory where you felt safe and protected.

Meditation and Guided Imagery

Meditation is a very common strategy for coping with flashbacks and dissociation. Meditation takes practice, but by using slow and steady breathing and trying to clear your thoughts when you are not in a state of dissociation or flashbacks, you will build this skill up to where you can implement it when you sense you are going to dissociate.

Guided imagery is similar, but rather than meditating or focusing on your own breathing, you focus on a guided story that will help keep you grounded.

Label Emotions

Labeling your emotions can be a very effective way of reducing immediate stress. This can be both to yourself (merely talking out loud), or to a support like a friend, a pet or a crisis line. Many people who experience trauma have difficulty labeling their emotions and this exercise (especially when practiced as part of comprehensive therapy) can help keep you grounded.

Cognitive Restructuring

Cognitive restructuring refers to techniques of identifying and challenging automatic or maladaptive thoughts. The simplest way to do this is with an ABC (Action, Behaviour, Cognition) worksheet. An ABC worksheet lists actions that made you feel bad, behaviours or results from that, and the cognitions that went along with that.

For instance,

  • Action: A girl didn’t smile at me when I smiled at her
  • Behaviour: I felt bad
  • Cognition: I’m not attractive

This is an example of a common ABC scenario. The goal is to identify other possible cognitions so that you can “rewrite the script.” An example of a different script:

  • Action: A girl didn’t smile at me when I smiled at her
  • Behaviour: I realized she probably didn’t see me
  • Cognition: Nobody has judged my attractiveness yet

This process is best accomplished with a therapist, but can be done in a self-help format. The book Mind Over Mood utilizes many of these techniques.

General Self Care for Coping with Flashbacks

  • HALT – Hungry, Angry, Lonely, Tired. These are the 4 states that make it harder to regulate your emotions and increase your impulsiveness.
  • Eating Healthy
  • Exercising
  • Medical Evaluation

5-4-3-2-1 Coping with Flashbacks

This technique is a very popular technique for coping that focuses on what you identify as real and also serves as a form of meditation.

  1. In 5-4-3-2-1 coping, you begin by thinking about five things that you can see around you. Listing them off out loud can help you with this exercise. Study them and describe them to yourself. Performing deep breathing (a slow inhale over 5 seconds, holding for 5 seconds, and exhaling over 5 seconds) can help with this as well.
  2. Next, describe 4 things that you can feel, such as your heart beating, your feet on the floor or your back in your chair.
  3. Next, 3 things that you can hear, like a television in another room, traffic outside or birds singing.
  4. After that, 2 things that you can smell – or two smells that make you happy, like fresh baked cookies.
  5. Finally, end with one thing you can taste. Your saliva, gum, or food you ate recently? Some people also substitute “One thing you like about yourself” for this exercise as well.
Cite this article as: MacDonald, D.K., (2017), "Coping with Flashbacks and Dissociation," retrieved on November 23, 2017 from http://dustinkmacdonald.com/coping-flashbacks-dissociation/.
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