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Ultimate Guide to Starting a Crisis Line

· Dustin

Introduction

Following up on my previous post Starting a Crisis Line or Hotline, I had some reader commentary asking about some more specific nuts and bolts for someone who is passionate and interested in starting a crisis line, hotline or helpline but doesn’t really know where to begin. Obviously, while it is best to bring in experienced individuals sometimes they simply aren’t available. For the purpose of this guide, I will describe the steps to create a fictional crisis line, the Southeast Iowa Crisis Center (SEICC), or “Seek.”

Throughout this article, I use “crisis line”, “helpline” and other terms interchangeably, except in the section “Deciding on Type of Service Provided” where I distinguish between the two.

Staffing a Steering Committee

The first step will be to decide on and form a Steering Committee. This will be a group of individuals who will be responsible for helping to bring your vision of a crisis line to life. Too few people and you may feel overwhelmed. Too many and you risk decision paralysis – not being able to make decisions because of too many disagreements. Perhaps 4-6 people is the optimal size for a Steering Committee.

If (or when) you form a nonprofit, you’ll need a Board of Directors. The members of your Steering Committee often make a suitable Board. Their tasks will include all of the items discussed below.

Choosing a Population and Coverage Area

You likely know this information before you begin, but it’s important to clearly define your population and coverage (or catchment) area as you work on your crisis line. You might choose to create your crisis line based on a specific age range (such as the Kids Help Phone for those 0-25), subject area (like the Rape, Abuse and Incest National Network [RAINN]), geographic region (like Tennessee Statewide Mental Health Crisis Line) or job status such as the Veterans Crisis Line.

Some funders will only fund certain populations or programs but it’s important that you not get into the business of chasing funding by going against your mission – this could lead to you losing your nonprofit status or losing trust among your supporters.

Identifying Mission and Vision

The next step to starting a nonprofit or a new product is to define what you wish to create. An organization’s mission statement is short and punchy, describing what they do. This can be a tagline or slogan, but doesn’t have to be. Distress Centre Durham‘s mission statement is “Helping people in distress to cope.”

Vision is more long-term and describes an outcome. An example vision statement for Habitat for Humanity is “A world where everyone has a decent place to live.” You don’t necessarily have to publicize your visioning statement but your mission and vision will determine whether activities that you pursue are within your organization’s purview.

SEICC’s mission will be “Keeping Iowans safe with 24/7 emotional support”, while the vision will be “Nobody suffers alone.”

Parkinson’s Law of Triviality

There is a concept in management called Parkinson’s Law of Triviality. Essentially it states that organizations spend disproportionate amounts of time on easy-to-grasp issues while neglecting more important but more difficult ones. This is an important trap to avoid when considering things like your organization’s logo, or other elements that are pretty minor in the grand scheme of things.

Picking a Staffing Model

At this stage, you have identified a group of individuals that are going to help you build your crisis line. You’ve also decided on a mission and a vision. You need to decide whether you will use a model of volunteers supported by paid staff, a blended model, or all paid staff. There are pros and cons to each approach.

Volunteers, Staff Supported

Advantages of the volunteers-supported-by-staff model include it is easy to start and individuals can self-select as one or the other (either applying for a staff position in administration or a volunteer position providing direct service.) One downside to this model is that initially your administrative staff will probably have to cover shifts on the helpline until you all get experienced, and that it can be hard to ensure 100% coverage if your service gets popular.

Blended Model

A blended model involves a mix of paid staff and volunteers. This is a more common model in the United States than in Canada, which tends to use purely volunteers. The advantages are that you can attract a more credentialed staff who might hold multiple roles (e.g. a helpline manager might be responsible for 20 hours of helpline work and 20 hours of administration.)

The downsides are that this can make your volunteers uncomfortable, and increase the expenses you need to get your crisis line off the ground.

All Paid Staff

Using all paid staff is an emerging crisis line model. Some helplines like the Veteran’s Crisis Line have used this model for many years. With this model, you can ensure 100% coverage (because your staff are paid to be in the chair), but this will be very expensive. Although research shows that paying crisis line workers does not diminish their importance, it may make it harder for your callers to trust that they’re really interested in listening.

This can also increase the rate of burnout because paid workers are providing many more hours of support each week or month versus a volunteer.

Deciding on Type of Support Provided

It’s important to decide if you’re going to be a distress line, a crisis line, or both. Some organizations will break their services into two distinct phone numbers and lines, with specific caller concerns, while many others (like Distress Centre Durham) will provide all forms of support.

Despite the use of the name “distress line” or “crisis line”, an organization may take all types of calls. You’ll need to read the explanation of the service provided before making a decision about whether or not an agency really does limit or parcel out their support.

Distress Line

A distress line focuses on individuals who are struggling and need to talk to someone but who can still cope. Someone in distress can still think about potential solutions to their problem, is not struggling with high-risk suicide thoughts, and does not need safety planning.

Crisis Line

A crisis line provides support to individuals who are struggling with high-risk suicide, crisis situations (where they can’t think of what to do), or who are otherwise unsafe. Many crisis lines have access to mobile crisis units, may call ambulances to take callers to hospitals or otherwise access more intensive support.

Hours of Operation

Deciding on the hours of operations for a crisis line is an important element. Many crisis lines started as 4-hours a day, 7 days a week operations before moving to 12 or 24 hours. Other organizations started immediately with 24 hours.

Staffing Volume

You’ll need to calculate the amount of staff you need for your crisis line (whether paid or unpaid) once you’ve decided on your hours of operation. One way to do this is the Erlang C formulas that are used to staff call centres (which you can fill with dummy data based on crisis lines in other regions.)

If you’re paying your staff, this will be easier. It might be easier to start small and then build up as your service gets more well known and well supported.

Choosing a Location

Choosing a location for a new crisis line (or any nonprofit really) will depend most commonly on your finances. Many organizations get cheap or free space in an organization like a church starting off, before moving to an office. If you’re really tight on space you might even be able to set up in a large office in someone’s home.

The keys to choosing a location will include availability, security, convenience, and price. While price is obvious, I’ll speak about the others.

One advantage of a stand-alone building is you have 24/7 access to it. If you’re in another type of location you may find it difficult or impossible to access after-hours, which can complicate things. Security is also a factor, in that if you’re not advertising your crisis line location it shouldn’t be obvious where you’re located. While a far-away location might seem to be ideal for security, it complicates accessibility (distance travelled) for your volunteers and limits convenience.

Forming a Nonprofit (or not)

Choosing whether to incorporate is a challenging decision to make. Incorporation provides you with benefits like protection of your assets, tax exempt status (once you’re registered as a charity) and the ability to pursue formal funding. The downsides are that it takes work to form and maintain the nonprofit status.

Finding Sources of Funding

Initial sources of funding may come from your Steering Committee but eventually you’ll need to explore outside sources. When your crisis line has operated for 1-2 years you’ll likely be eligible to apply for formal funding grants such as those at the local, state and federal levels.

Other sources include corporate sponsorship, fundraising events and direct donations.

Developing Policies and Procedures

Policies and procedures are important for ensuring that your volunteers respond in a consistent way. Examples of policies and procedures that you may wish to develop:

  • Call Trace and Intervention
  • Callers as Volunteers
  • Confidentiality
  • Recruitment (Criminal Record Check)
  • Victims of Abuse (Reporting Child Abuse)

Call Trace and Intervention

A Call Trace and Intervention policy will describe under what circumstances you will initiate call trace (to try and find an individual’s address or other identifying information) and under what circumstances you will call police/911 for Active Rescue. Some crisis lines will never initiate Active Rescue, for instance the UK Samaritans, unless the caller requests it. Many crisis lines will always err on the side of caution.

Call Trace will depend on the technology available to your crisis line but may include use of 411 (for non-blocked numbers) or contacting 911 directly to pass available information to them.

Helplines will often describe their intervention policy on the lines as something to the effect of, “We only intervene in cases of imminent homicide, suicide, or disclose of child abuse.”

Callers as Volunteers

Callers to your helpline will usually result in the creation of a call report or other record of that conversation. If you recruit volunteers from the same area that you take calls from, it’s possible that someone who has previously called your line may become a volunteer – and therefore be able to read their call report.

For that reason, you may require that volunteers to your helpline must have not used your service in the amount of time that records are retained. For instance, at Distress Centre Durham call reports are retained for one year so volunteers must not have used the service in that time in order to be eligible.

Confidentiality

Confidentiality is at the core of emotional support. Creating a safe environment is key to helping callers discuss their issues openly. Confidentiality means that volunteers who disclose information about callers outside of the crisis line or make contact with them outside of the line can be dismissed.

Examples of violations of confidentiality:

  • Talking about callers to your friends or family
  • Posting information about callers on social media
  • Giving information from the crisis line to another agency without that caller’s permission

It’s important to establish a very high degree of confidentiality or else callers will quickly lose trust in the helpline.

Data Destruction

A data destruction policy includes information on when and how you’ll destroy data that you’ve collected, such as via call reports or caller profiles. The most important element is to include a timeline for how frequently you’ll destroy data – such as on a quarterly basis for data that is more than 12 months old.

Recruitment (Criminal Record Check)

A Criminal Record Check (CRC), known by other names like a Police Record Check (PRC) or a Disclosure and Barring Service (DBS) Check describes a person’s record of criminal offenses. Many jursidictions include an option specifically for crimes against vulnerable individuals like children or seniors.

Many crisis lines will limit their volunteers only to those who have no criminal record, while some will allow – with approval – individuals who have certain types of non-violent offenses from many years ago.

Victims of Abuse

Nonprofit organizations are often legally required to report abuse, like child abuse or elder abuse. A policy explaining this will help callers better understand when they disclose child abuse, what the volunteer will do. In many crisis lines this means calling Child Protective Services (CPS) or a similar agency (like Children’s Aid Society in Ontario.)

You may also wish to include a statement about how your helpline takes a non-judgemental stance on abuse – not encouraging individuals to leave unless they’re ready to leave on their own.

Volunteers in Counselling or Therapy

Helpline work can be demanding and burnout can be a challenge. For this reason, it’s important to know when your volunteers are undergoing counselling or therapy. One way in which to do this is to have volunteers self-identify if they are receiving counselling or therapy and then giving them a letter to give to their therapist. That clinician will simply sign asserting that the work will not be harmful, and that can be filed away.

Volunteer Recruitment

Recruiting volunteers will depend on your local community. In some communities, United Way may operate a volunteer board online that you can submit your crisis line to. Universities or colleges may allow you to post flyers or distribute information to the students.

A good training class will be between 5 and 20 individuals, but recruiting throughout the year will be important for ensuring consistent service delivery.

Volunteer Screening

Screening involves determining if individuals possess the appropriate attitudes to be successful in helpline training. The American Association of Suicidology Crisis Center Certification identifies these attitudinal outcomes that individuals should experience by the conclusion of training:

  • Acceptance of persons different from oneself, and a non-judgmental response toward sensitive issues (e.g. not discussing suicidal ideation or abortion with a client in terms of its moral rightness or wrongness)
  • Balanced and realistic attitude toward self in the helper role (e.g. not expecting to “save” all potential suicides by one’s own single effort, or to solve all the problems of the distressed person)
  • A realistic and humane approach to death, dying, self-destructive behavior and other human issues
  • Coming to terms with one’s own feelings about death and dying insofar as these feelings might deter one from helping others.

Volunteer screening may include an application form that asks questions about the caller like:

  • Are there situations or topics (such as abuse or abortion) that may place you in a moral or ethical dillema?
  • What are your beliefs on suicide?
  • How do you feel you would talk to someone who is different from yourself?

The screening process does not have to rule out anyone yet, but may be helpful for prepping you on the interview.

Volunteer Interviewing

See also: Interviewing on a Suicide Hotline

The process of the volunteer interview will be to collect more information on the potential volunteer to make sure there is compatibility with your service. For instance, some individuals may only want to work with children or may not want to work with suicide – and your desires for your line may not align with that.

The interview is also an opportunity to see how someone is on the phone, and to help answer more of their questions about what the process looks like.

Volunteer Training

See also: Crisis Hotline Training Curriculum

Volunteer training is the process of teaching a volunteer the core skills that they need to be prepared for the helpline. Rather than reproducing material I’ve written about elsewhere, see the link above. From there you can find posts across my blog that will be useful for building a training program.

Training should run approximately 40 hours, with at least 24 hours of classroom training and 16 hours of supervised “on the phone” training being mentored by a shift supervisor or experienced volunteer before the newly trained volunteer is able to take shifts on their own.

You may find it helpful to bring on a therapist or counsellor to help you develop your initial helpline curriculum, or use a crisis line trainer from an area near you that doesn’t overlap with your catchment area.

Identifying Caller Issues

Caller Issues are the specific issues prevalent in your community that may lead you to develop training modules on them to prepare your volunteers. One example is in college towns where concerns over sexual assault or alcohol and drug abuse may be more prevalent.

The easiest way to do this is with effective helpline management software (see the next section.) With a detailed call report you will be able to pull statistics on exactly what your callers are discussing and this will help you fine-tune your training. Generally, the core elements of emotional support and crisis intervention will be exactly the same.

Helpline Management Software

In order to run a helpline you’ll need some form of helpline management software. I recommend iCarol, which my crisis line has used for several years. iCarol provides all the features you’d expect online helpline software to provide:

  • Shift Calendar so volunteers can sign up for shifts
  • Call Reports so volunteers can record details about their conversations
  • Chatboard for facilitating communication between staff and volunteers
  • Events Calendar
  • News

And a variety of other features, all designed with confidential helplines in mind.

Outcomes Measurement and Evaluation

See also: Methods of Evaluating Helplines and Hotlines

Outcomes Measurement and Evaluation describes the things that you will need to do in order to prove that your helpline is effective. One way in which to do this starts with your Basic Training program. Have your volunteers complete a pre and post training survey that includes questions about the perceived value of the training, their ability to display empathy and their understanding of crisis and suicide risk assessment. You’ll see their scores increase, demonstrating the knowledge transfer.

Another way to evaluate a Basic Training program is with a tool like the Suicide Intervention Response Inventory, which has volunteers rate how effective a series of statements are in providing emotional support. Their scores will change throughout training, indicating their increased skill.

On the phone calls themselves, your call reports can include space for Outcomes Measurement. This can include things like, “Callers says they feel better”, “Decreased distress and anxiety”, “Reduced isolation and loneliness.” These outcomes can be used to show what changes your callers experience throughout the call.

Joining Professional Associations

Finally you may wish to join professional associations like the Association of Crisis Workers or Crisis Lines in your area, or other professional groups that provide support to nonprofits. This will help you network, fundraise and attract volunteers to your organization.

Conclusion

As you can see, a lot goes into developing a crisis line – but it is not unmanageable. If you’ve decided to launch a crisis line, let me know in the comments! And please continue to ask questions if you’d like.

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Counselling and Therapy Credentials

· Dustin

Introduction

I’m about a year (8 courses in fact) away from wrapping up my Bachelor of Professional Arts in Human Services from Athabasca University. This has led me to explore potential graduate schools on my path to becoming a therapist in the future. One thing I’ve discovered is that there’s a lot of confusion around different credentials and what they entitle one to do.

This post is focused on Social Work, Psychology, and Counselling, with an added bonus of identifying distance learning schools where individuals may take these programs.

College Diplomas

College diplomas include 2-year Associates degrees in the United States and Colleges of Applied Arts and Technology CAAT) diplomas in Canada. Examples include:

  • Associates in Human Services
  • Associates in Social Work
  • Social Service Worker, an online version is available through Durham College
  • Community Service Worker

These are entry-level credentials to give you the basic skills to work in the social services. Some of these credentials, such as the Social Service Worker diploma, allow you registration into a professional college (e.g. the Ontario College of Social Workers and Social Service Workers) but most do not.

These programs provide training and experience in assessment (such as suicide risk assessment) and provide training in basic counselling skills but do not prepare students to diagnose or provide therapy.

Job titles for college diploma holders may be:

  • Intake Worker
  • Case Manager
  • Program Manager
  • Shelter Worker

Bachelor’s Degrees

Bachelor’s degrees are the 4-year degree most common in the US and Canada. A 4-year degree may be in Human Services, Psychology, or another discipline. If you earn a Bachelor of Social Work (BSW) you are usually eligible for registration with the appropriate Board of Social Work or College of Social Work. On the other hand, a credential in Psychology or Human Services will not entitle one to registration.

Job titles for Bachelor’s degree holders will be similar to college diploma holders, with the added component that Bachelor of Social Work holders are entitled to the protected job title “Social Worker.” Bachelor’s holders with training may perform assessments and other tasks.

Online programs include Athabasca University’s Bachelor of Professional Arts in Human Services, or Liberty University’s Bachelor of Science in Social Work program.

Bachelor of Professional Arts in Human Services

This is the program I’m completing at the moment. Because I completed a Social Service Worker (SSW) diploma from Durham College (see above), I received 2 years/20 courses of transfer credit towards the 4 year degree, requiring 20 courses to finish.

These courses can be completed online, with no specific semester start and end dates. Instead, if you pay your courses yourself you have 6 months in which to complete them; if you are receiving financial aid (such as through the Ontario Student Assistance Program) you have 13 weeks in which to complete each course.

The fee (approximately $600 CAD for a student in Alberta, $800 CAD for a student elsewhere in Canada and $1000 CAD for a student outside Canada) includes all the course materials including textbooks shipped to you to complete the course. This makes it a very economical option for a Bachelor’s degree.

Examples of courses in the BPA Human Services that are required:

  • Social Work and Human Services
  • Ideology and Policy Evolution
  • Critical Reflection for Practice
  • Professional Ethics
  • Practice and Policy in the Human Services

Master’s Degrees

Here’s where it starts to get complicated. There are a number of Master’s degrees that one may use to enter the counselling or therapy professions. These include a Master of Arts in Counselling Psychology, Master of Counselling, Master of Education in Counselling Psychology, Master of Education in School Psychology, Master of Social Work.

Master of Arts (MA) in Counselling Psychology

The MA in Counselling Psychology may be a practice degree, allowing one to register as a Licensed Mental Health Counsellor (LMHC) or it may be a step on to a PhD or PsyD in Clinical Psychology. Individuals may qualify for registration as Psychological Associates or in Alberta as Psychologists.

Examples of online programs includes Yorkville University‘s program, which is based out of New Brunswick.

Master of Counselling (MC)

The Master of Counselling degree is offered by Athabasca and provides similar training as other counselling degrees such as degrees in Counselling Psychology or other. Athabasca offers specializations in Art Therapy, Counselling Psychology and School Counselling.

Examples of courses taken in the MC degree include:

  • Models of Counselling and Client Change
  • Intervening to Faciliate Client Change
  • Devleoping a Working Alliance
  • Professional Ethics
  • Assessment Processes

This program qualifies for registration with the Alberta College of Psychologists.

Master of Education (MEd) in Counselling Psychology

The Master of Education (MEd) degree in Counselling Psychology is offered through a school’s Faculty of Education rather than a Faculty of Social Work or Faculty of Psychology. One example is University of Toronto’s MEd. This program is designed as a terminal degree to train counsellors and therapists. Courses in this program include:

  • Theories and Techniques of Counselling
  • Critical Multicultural Practice: Diversity Issues in Counselling
  • Group Work in Counselling
  • Ethical Issues in Professional Practice in Psychology
  • Career Counselling and Development: Transitions in Adulthood

Because these programs are in the Faculty of Education they are more likely to cover school counselling and be designed to train counsellors or therapists that work with students and young adults. One example of an online program is the University of Massachusetts–Boston’s MEd in School Counselling.

Master of Social Work (MSW)

The Master of Social Work is the terminal degree for Social Work practice in Canada and the United States. These programs are either one year (for individuals who have already completed a BSW) or two year (for individuals who have not completed a BSW.) These programs qualify for registration with organizations like the Ontario College of Social Workers and Social Service Workers (OCSWSSW) in Canada or a State’s Board of Social Work in the US.

MSW degrees can be focused on macro (community) social work, or micro (individual) social work. Macro social workers are employed in community development, program design, administration and other areas while micro, individual or clinical social workers are employed as counsellors, therapists and other clinical mental health professionals.

An example 2-year online MSW program is that available from the University of North Dakota. Courses in that program include:

  • Human Behavior in the Social Environment I
  • Generalist Practice with Individuals and Families
  • Generalist Practice with Communities and Organizations
  • Social Policy
  • Generalist Research Methods and Analysis

Doctorate Degrees

Doctoral degrees prepare individuals for advanced clinical practice in the fields of Psychology and Social Work. Doctorares usually involve a component of research and practice. Some degrees not listed here (such as the PhD in Social Work) have no practice component and are designed chiefly to train researchers.

Doctorate of Philosophy (PhD) in Clinical / Counselling Psychology

The PhD in Clinical Psychology or PhD in Counselling Psychology are designed to train professional Psychologists. These programs are usually 5-7 years in duration and involve the completion of a PhD dissertation, a book-length research project. In addition to learning these fundamental research skills, Psychologists also learn how to administer and interpret psychological assessments like IQ tests and how to deliver therapy.

These programs are among the most competitive to get into, often admitting 5-10 candidates among the 100+ that apply for admission.

The differences between Clinical Psychology and Counselling Psychology are minor, but Clinical Psychology tends to focus on individuals with more psychopathology than Counselling Psychology.

Examples of courses in the PhD in Clinical Psychology at Ryerson University:

  • Ethical Professional Issues in Clinical Psychology
  • Systems of Psychotherapy
  • Cognitive Neuroscience
  • Community Psychology
  • Mood Disorders

Doctorate of Psychology (PsyD)

The PsyD is a newer program than the PhD, emerging to meet needs of individuals who primarily want to practice therapy and assessment rather than work as scientists or researchers. PsyD programs are offered by a larger variety of educational venues, such as by professional schools of Psychology (like the Chicago School of Professional Psychology) rather than a university.

The PsyD involves learning to utilize research rather than produce it. Because students in a PhD program are creating researcher, they are “paid” to do so, by having their tuition subsidized (often free), and by being given a living stipend, while PsyD students more commonly have to “pay their way” through their program, upwards of $100,000.

Otherwise, PsyD and PhD graduates learn the same skills and are eligible for licensure in the same way – as long as their programs are accredited by the American Psychological Association (APA). Although there are online PsyD programs such as those offered by Walden University and Capella University these are not eligible for APA accreditation and therefore are unlikely to result in licensure.

Examples of courses available in the Chicago School of Professional Psychology’s PsyD program:

  • Biological Bases of Behavior
  • Health and Dysfunction
  • Cognitive Assessment
  • Cognitive Behavioral Theory and Therapy
  • Personality Assessment

Doctorate of Social Work (DSW)

The Doctorate of Social Work is the newest doctorate program. This program is similar to the PsyD in that it is a practice degree rather than a research degree. One example of a DSW is that offered by Tulane University in Louisiana. This program is available online but has significant tuition attached to it, up to $70,000.

Reflecting the existing education of their students (all of whom have an MSW or similar degree accredited by the CSWE) these programs are shorter than a PhD would be, often running 3 years versus the 5-7 years for a PhD or the 5 years for a PsyD.

Examples of courses in the Tulane DSW:

  • Historical Approaches to Social Welfare
  • Social Work Theory, Practice Models & Methods
  • Applied Social Statistics
  • Measuring Social Phenomena: Social and Economic Problems
  • Advanced Clinical Project Seminar

The goal of the DSW program is to train practitioners who are experts in policy analysis, program design and development or implementation of specific therapies.

Cite this article as: MacDonald, D.K., (2017), "Counselling and Therapy Credentials," retrieved on October 23, 2017 from http://dustinkmacdonald.com/counselling-therapy-credentials/.
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Active Listening Process on Crisis Lines

· Dustin

Introduction

The Active Listening Process (ALP) is a set of skills, or what is called by Ivey, Ivey & Zalaquett in their 2014 book Intentional Interviewing and Counselling as “microskills“ are the fundamental skills used to perform the basic skills of displaying empathy and understanding what your caller or client is saying. The ALP is one of the tools used in the basic helpline training adopted by the Distress Centre and other organizations.

Deliberate Practice (Rousmaniere, 2016) describes the work done outside of the therapy or call room. By practicing the basics, therapists and others who are required to use empathy and active listening in their work will be able to improve the skills that are most associated with client improvement (Lynch, 2012).

Three Facilitative Conditions

The three “facilitative conditions” (Rogers, 1957) were developed by Carl Rogers, a pioneer in the field of person-centered therapy. These facilitative conditions are empathy, acceptance (or unconditional positive regard) and genuineness. Empathy describes an effort to understand the caller or client from their perspective and truly see things the way they do. Acceptance or unconditional positive regard means to see the caller as they are, while genuineness means being yourself and not putting on a “therapist” front or trying to be different than who you really are.

Active Listening Process

Different organizations will use a different form of the active listening process. A version of the Active Listening Process used at the Distress Centre includes the following skills in the active listening process:

Opening the Conversation

Opening the conversation describes the first 5 minutes of the conversation. These are the critical first steps that the helpline worker takes as they begin working with the caller.

Voice Tone

Voice tone describes the pitch, volume and intonation of one’s voice. A voice tone that is forceful and assertive may be helpful in policing but may come across as aggressive or overpowering to a helpline caller. On the other hand, when needing to collect information in emergencies, a more assertive tone may be required to keep a caller alert and paying attention.

Pace

Pace describes the speed in which you speak, as well as when and if you interrupt. Interrupting or talking over a caller may damage your rapport with them, while speaking too quickly may create a sense of anxiety or panic in a caller. Instead, letting the caller lead will help them tell the story at their own speed

Setting the Climate

Setting the climate refers to the first few seconds when you pick up the phone. Ensuring a lack of distractions and sound from other calls or activities, and gently saying, “Hello, Distress Centre” or something similar will help your caller feel at ease by helping give them a sense that it’s just you and the caller.

Collecting Information

Collecting information refers to what happens after you’ve established a connection with the caller. The first minute or minutes have gone by and the caller is starting to tell their story. In order to understand it better, you must ask a variety of open and close-ended questions.

Open Ended Questions

Open-ended questions are those that begin with “What?” “How” “Tell me about” and others that cannot usually be answered with yes or no answers. For instance, “Tell me about what’s been troubling you”, “How long have you been feeling this way?” and “What do you usually do when things get tough?” are examples of open-ended questions.

Close Ended Questions

Close-ended questions are those that are designed to collect specific pieces of information from callers. These begin with “Where”, “When” and “Did”, “Do”, or “Does.” For instance, “Where did you live when that happened?”, “Do you feel like talking to him?” and “When did that begin?”

These close-ended questions are important in emergencies or crisis situations when you need to collect specific information but are much less useful when trying to have an open conversation with someone in distress.

Demonstrating Understanding

As you ask open-ended questions and the caller begins to tell their story, you have to demonstrate that you understand what they’re saying. As explained above, the three facilitative conditions are the most important elements of outcome in therapy and on the crisis line they are associated with a decrease in distress. (Mishara & Daigle, 1997)

Empathy Statements

Empathy statements are statements that highlight a feeling word. For instance, “You must be feeling really overwhelmed.” In this case, overwhelmed is the feeling word. Other feeling words you might use include angry, frustrated, devastated, lost, sad, ruined, alone, and so on.

Empathy statements wrap the other statements that we make while actively listening to continually check in with the caller and make sure that we’re on the same page. Even if your empathy statement is incorrect, the caller will explain to you what the correct feeling they are experiencing is, therefore increasing your understanding.

Clarifying

Clarifying refers to questions that are asked to increase your understanding of the content the individual is experiencing. For instance, if a caller says they went to a therapist recently for therapy and then indicates that they received a prescription from that visit, you might ask them if they made two different appointments, or if they saw a psychiatrist.

Clarifying will be more important on crisis chat or text because this form of communication limits how much information can be communicated at one time.

Paraphrasing

Paraphrasing refers to restating what an individual has told you to make sure that you understand what they’ve said. Paraphrases capture both the emotional information and the content of the story. For instance, a paraphrase might be “Since you lost your dog you’ve been feeling really alone and you’re considering whether to adopt a new pet.” This paraphrase has captured an emotion (loneliness) and content (loss of dog, adoption of new pet.)

Wrapping Up

Summarizing

Summarizing is similar to paraphrasing but it is done at the end of a conversation or a significant component in the conversation. A summary is a little longer than a paraphrase and may include contents of a safety plan, referral, follow-up or other tasks that will be completed when the conversation ends.

Referrals

Referrals, resources, community agencies or other terms refer to the helpline worker providing the names, phone numbers and other information about organizations that can be helpful to the caller. Examples include counselling, food banks, or employment support.

Winding Up

Winding up is the end of the conversation. This refers to the end of the conversation when you thank the caller for calling, let them know that you have to let them go for now (or they tell you they need to go) and invite them to call back. This can be challenging for some callers to accept but is a necessary part of the process.

Further Reading


Other posts on my blog that might be useful:

While Gerald Egan’s The Skilled Helper (see right) may be used to practice these core counselling skills.

References

Ivey, A.E., Ivey, M.B. & Zalaquett, C.P. (2013) Intentional Interviewing and Counselling. 8th Ed. Brooks Cole: Pacific Grove, CA.

Lynch, M.M. (2012) “Factors Influencing Successful Psychotherapy Outcomes” Master of Social Work Clinical Research Papers. Paper 57. Retrieved on May 3, 2017 from http://sophia.stkate.edu/msw_papers/57

Mishara, B. L. & Daigle, M. (1997). Effects of different telephone intervention styles with suicidal callers at two suicide prevention centers: An empirical investigation. American Journal of Community Psychology. 25, 861-895

Rogers, C. (1957) The Necessary and Sufficient Conditions of Therapeutic Personality Change. Journal of Consulting Psychology. 21. 95–103. Retrieved on May 5, 2017 from https://app.shoreline.edu/dchris/psych236/Documents/Rogers.pdf

Rousmaniere, T. (2016). Deliberate practice for early career psychotherapists. Psychotherapy Bulletin, 51(3), 25-29. Retrieved on May 4, 2017 from http://societyforpsychotherapy.org/deliberate-practice-early-career-psychotherapists/

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SIMPLE STEPS Model for Suicide Risk Assessment

· Dustin

Introduction

The SIMPLE STEPS Model (McGlothlin, 2008) for suicide risk assessment provides a simple mnemonic similar to others like SADPERSONS (Patterson, et. al., 1983) or IS PATH WARM (from the American Association of Suicidology). Each of these is correlated with increasing suicide lethality and so this can be a useful short-hand to remember these items.

Suicide risk assessment on the crisis line is mostly concerned with imminent risk, and many suicide screeners designed for lay people may miss important variables in a goal to be simplistic; the SIMPLE STEPS model appears to avoid both of these traps, by providing an assessment tool simple enough to be used in the crisis line environment but comprehensive enough to be used by counsellors or therapists for ongoing monitoring of suicide risk.

Items in the SIMPLE STEPS Model

  • Suicidal – Is the individual expressing suicidal ideation?
  • Ideation – What is their suicidal intent?
  • Method – How detailed and accessible is their suicidal method?
  • Perturbation – How strong is their emotional pain
  • Loss – Have they experienced actual or perceived losses? (Relationships, material objects)
  • Earlier Attempts – What previous attempts has the individual experienced, what happened after those attempts?
  • Substance Use – Is the individual abusing drugs, alcohol, or other substances?
  • (Lack of) Troubleshooting Skills – Are they able to see alternatives or options other than suicide?
  • Emotions / Diagnosis – “Assessment of emotional attributes (hopelessness, helplessness, worthlessness, loneliness, agitation, depression, and impulsivity) and diagnoses commonly associated with completed suicide (e.g., substance abuse, mood disorders, personality disorders, etc.)” (McGlothlin, et. al., 2016)
  • (Lack of) Protective Factors – What is keeping this person safe from suicide? Who are their supports (internal such as personal values and external like people), resources and agencies
  • Stressors and Life Events – What has happened in their life to lead them to suicide?

Sharp readers will identify that these elements map very neatly onto the DCIB Model of Suicide Risk Assessment, but perhaps provide a better mnemonic in order to make sure that clinicians who do not have the DCIB in front of them are able to perform that assessment.

Validation of the SIMPLE STEPS Model

McGlothlin, et. al. (2016) used 13,000 calls over six years to a crisis line and correlated the SIMPLE STEPS items with the lethality risk present in that call. One limitation of this study is that it used self-reported (by the helpline worker taking the call) lethality rather than using another evidence-based risk assessment in order to compare with. I am satisfied that McGlothlin addressed this in his limitations section, where he noted the difficulty with using data collected in this manner.

References

McGlothlin, J. (2008). Developing clinical skills in suicide assessment, prevention and treatment.
Alexandria, VA: American Counseling Association

McGlothlin, J., Page, B., & Jager, K. (2016). Validation of the SIMPLE STEPS Model of Suicide Assessment. Journal Of Mental Health Counseling, 38(4), 298-307. doi:10.17744/mehc.38.4.02

Patterson, W.M., Dohn, H.H., Patterson, J. & Patterson, G.A. (1983). “Evaluation of suicidal patients: the SAD PERSONS scale.” Psychosomatics 24(4): 343–5, 348–9. doi:10.1016/S0033-3182(83)73213-5. PMID 6867245

Cite this article as: MacDonald, D.K., (2017), "SIMPLE STEPS Model for Suicide Risk Assessment," retrieved on October 23, 2017 from http://dustinkmacdonald.com/simple-steps-model-suicide-risk-assessment/.

 

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Coping Skills Therapy for Managing Chronic and Terminal Illness

· Dustin

Introduction

I recently had an opportunity to read this excellent book written by Social Worker Kenneth Sharoff. It presents a model of therapy he calls “Cognitive Coping Theory” (CCT) and applies this model to working with individuals who have chronic (or life limiting) and terminal illnesses.

Below I present some of the content from the book I found particularly useful.

Executive, Policy and Operational Beliefs

The first concept in the book, after the discussion of how CCT fits in with CBT and other therapies and models is the idea of policy, executive and operational beliefs. Policy beliefs are the most high-level, and roughly match what is called schema in other therapies. Examples of executive beliefs given in the book include:

  • My body should not interfere with my ability to pursue my career
  • Doctors must find a cure for my disease. Doctors and modern medicine should be able to cure me

Executive beliefs are often “shoulds” or “musts” that frame an individual’s approach to a situation. They dictate rights and beliefs about what an individual will experience – even when those things are out of that individual’s control. These policy beliefs are then carried out by executive beliefs, which explore how the policy belief is carried out.

One example is someone who wishes to join the Police Service even though they have found themselves paralyzed after an accident. They may hold policy beliefs like “I should be able to do whatever I set my mind to” and “My body should not interfere with my ability to pursue my career”, the resulting executive beliefs might look like:

  • Get angry at those around me who do not recognize my struggle
  • Continue trying to join the Service even though I am not able to
  • Vent my jealousy at individuals who are not limited in this way

The policy beliefs influence the Belief part of the Cognitive Behavioural Therapy ABC scale, while the executive beliefs influence the Consequences part:

  • Activating Event – I am not able to pursue my chosen career
  • Belief – I am inferior if I can’t pursue my dreams
  • Consequences – I feel worthless, angry, jealous, etc.

The last type of beliefs are known as operational beliefs. These are the most concrete thoughts that an individual has related to their illness. Examples include:

  • I am worthless
  • My life is awful
  • It’s not fair that I am experiencing this

These might be compared to the unconscious thoughts typical of CBT. Changing the executive beliefs, which dictate coping strategies, or responses is a key part of CCT.

Phases of Coping with Disease or Disability

Sharoff dictates five phases of coping with disease or disability. They are:

  • Crisis
  • Postcrisis
  • Alienation
  • Consolidation
  • Synthesis

Like most models, this is presented linearly but an individual may move back and forth among the phases as they proceed through their illness or disease.

Crisis Phase

In the crisis phase, the individual is first experiencing symptoms. They may be experiencing feelings of threat or loss, and experiencing a loss of self-esteem, self-efficacy, and increases in physical discomfort or other direct impact by the illness.

Sharoff describes “dream crush” – the feelings experienced by someone who has discovered that their plan for themselves is no longer possible because of their illness. He identifies “self-placement” as a significant component of this. Self-placement is the task of comparing yourself to where you want to be in life at a particular point in time; realizing that you are not “living up” to this ideal causes significant distress.

Changes in identity are also common in the crisis stage.

Postcrisis Phase

In the postcrisis phase, an individual has become accustomed to their situation. They begin to stabilize in that things become routine. As they resume as much of their previous roles as possible, the feelings of “anomie” end. The postcrisis state may lead to alienation if they have not are still experiencing negative emotions as a result of their illness’s effect on the body.

Alienation Phase

The alienation phase involves a psychological disconnection from the body. An individual struggling with a chronic disability or disease may actually disscoiate themselves from their body and see it as distant or distinct from themselves. This provides short-term coping but will not allow the individual to progress past this state.

Hostility or indifference towards their body is common, as individuals seek to separate themselves from their disease. The major tasks of this phase are to neutralize bitterness and to work on beliefs of disfiguration. If individuals believe they are disfigured, the negative beliefs that lead tot his will need to be worked on in order to avoid a loss of self-esteem or feelings of inferiority.

Consolidation Phase

The consolidation phase may be entered into directly after the postcrisis phase if the individual is coping adequately, or may require significant work in the alienation phase if they are not. An individual in the consolidation phase feels more in control of their life, and may experience increased self-efficacy.

Although an individual may experience a loss of meaning, they can develop new goals and behaviours that work within the limitations of their body. If they are able to do this successfully they will begin to move to the Synthesis Phase.

Synthesis Phase

The final phase of coping is the Synthesis Phase. This phase is marked by a blending of the old and the new, and a recognition that although an individual is changed by their illness they can still find a quality of life and activities that bring them happiness.

Skills Training

Sharoff suggests a variety of coping skills and strategies for each phase that an individual that will pass through. For instance, for individuals who have magical thinking or wish that they could control things like what activities they can perform now that they are limited by their disability, focusing on “area thinking” is one strategy to work on this. In area thinking, an individual considers each goal and whether that is within their control. If it is not, it is consciously replaced by a different goal that is within their ability to control.

What is below is just a few of the many skills, subskills and microskills contained in each category. They are accompanied by detailed explanations and demonstrations of the skills and other tools to make them as useful as possible in therapy.

Assimilation and Rejection of Suffering

Assimilation of suffering means to cope with suffering and to accept that some degree of discomfort, pain or suffering is a necessary part of the process of coping. It is expressed by complaining and expressions of powerlessness, with an undercurrent of magical thinking that if one rejects or denies their reality or the future that it will go away.

This involves acceptance of the reality (without enjoyment of it), forbearance (accepting showing “patience, tolerance, and restraint” with themselves demonstrating endurance as a personal goal), and forgiveness of one’s body, self, their deity or others they may blame for the illness.

Other coping skills that may be used include guided imagery, therapeutic metaphors (such as David versus Goliath) deep breathing, self-encouragement and substituting automatic thoughts when they occur. Outcome enactment is borrowed from solution-focused therapy and asks clients to identify when they do not suffer, and then to note what thoughts or feelings underlie that lack of suffering.

Discomfort and Frustration Management

Sensory diversion training is used to cope with physical discomfort. It involves choosing a sense like sight, smell, or touch and mindfully focusing on an item involving that sense. For instance, if someone who is experiencing pain focuses on an object they can see, and follows it with their eye, tracing it and creating a mental map. Then, moving to the next object, continuing this process until they are no longer aware of their negative physical symptom.

“No Mind No Thing” is a technique borrowed from Buddhism to deal with frustration or other negative experiences by attempting to clear the mind of conscious thought. This is a meditative technique that involves staying in the present and taking in all sensory input. Use of a white noise machine may be helpful in this regard.

Self-instruction training involves using positive self-talk by examining the positive aspects of thinking well and maintaining mantras. Managing activities can help an individual avoid frustration but running up against the wall created by their illness.

Identity Management

An individual’s identity can be challenged by the onset of their illness. Identity is measured by one’s belief in their membership in a group, such as men, military veterans or construction workers. For instance, a woman who believes that in order to be a woman she must have breasts will experience distress when she loses a breast to a mastectomy as a part of breast cancer treatment.

Identity adulteration describes the process by which an individual’s identity has changed as a result of their condition. Identity alienation is indifference towards the individual’s changed body, while identity loss is the recognition that an individual has (rightly or wrongfully) lost their membership in a chosen group.

Reconciling identity involves realizing that we often adopt restrictive definitions of what it requires for membership in a category. Continuing the example of the woman missing her breast, reconstructive surgery may allow her to feel like she belongs to the group again, or seeing other elements of womanhood like nurturing behaviour.

This is especially important for men who often put high standards on themselves, believing a very narrow definition of manhood. Expanding that definition to include stability, being a provider, being confident and assertive, and other “soft skills” may help reduce the distress an individual feels when they cannot participate in their former vocation, if they are physically not as imposing as they were, or are experiencing other symptoms as a result of their illness.

Self-Support Training

Self-support training involves the reduction of self-criticism and building a strong internal support network so that individuals do not have to rely on others who may be inconsistent in their ability to provide support. Self-support training involves focusing on strengths (known as becoming a self-booster), holding self-compassion, self-advocacy and exoneration training.

Exoneration training is a skill that may be used when someone holds themselves responsible for their shortcomings. For instance, someone who cannot pursue a hobby of running because of their multiple sclerosis may blame themselves for that outcome – even though they have no control over it.

Sharoff recommends instead, staging a “mock trial” in an individual’s mind. Stack all the evidence for the belief, against all of the evidence against. Play prosecutor and defense, in order to stimulate a protective instinct in the client. If they steadfastly hold to their belief that they are responsible, he recommends taking it further and having them determine guilt or innocence, and even prescribe punishment! The reason for this seems paradoxical, but punishing themselves for their own maladaptive beliefs helps them to realize the futility of their thought processes and may enable them to begin moving towards a less blameful attitude.

Uncertainty Tolerance

Uncertainty is at the heart of chronic illness, disability and disease. Although an individual’s disease course may stabilize, in many cases there is an uncertainty about the future. Self-monitoring is suggested in order for clients to recognize when they are feeling uncertain.

Deep breathing and other relaxations exercises can be used to cope with high levels of anxiety, along with “worry management” where an individual decides to limit their thoughts about their illness to a certain time per day (such as 15 minutes in the morning and 15 minutes at night.) This management gives them permission to push those thoughts out of their mind at other points in time, and apply thought-stopping when necessary.

Bitterness Disposal Training

Bitterness is an extremely common part of coping with a chronic illness or disease. Bitterness can be experienced inwardly (such as bitterness with your illness or your body) and outwardly (such as challenges with friends or family.) Examining one’s identity as perceived by others is an element of this process, followed by comparing that image of others to one’s self-image in order to determine if others are making unrealistic demands on them.

Recognizing that the disease is the cause of their feelings may help them externalize those thoughts. Cognitive restructuring allows an individual to compare their thoughts and expectations about those around them with the reality, by examining the other person’s identity (the husband or wife, the brother or friend) and how that affects their behaviour.

Constructive mourning allows an individual to grieve the changes in their life, by allowing that person to ventilate those emotions.

Body Accommodation and Disfigurement Neutralization

Body accommodation is the process of recognizing that one’s body has changed and setting softer standards to accept the body as it is rather than rating it or comparing it with a previous body or someone else’s body. This can be a difficult process as it involves realistic expectations and changing negative attitudes.

Positive self-talk before engaging in activities can help mitigate automatic thoughts of weakness or worthlessness that may occur as a result of the disability.

Disfigurement neutralization involves evaluating the client’s beliefs about themselves, and the words that they use. Assigning meaning to those words as a severe negative evaluation, that can be changed. New beliefs about an individual should be proposed, that see the body objectively, the result of the illness and not the individual’s decisions.

Meaning-Making

Meaning-making is the process of making a new plan for one’s life after the onset of an illness. This can be because depression or physical/emotional limitations have caused an individual to be unable to pursue their dreams or because the onset of a terminal illness makes them feel like their existing plans are no longer powerful enough to satisfy their desire for meaning in their life.

This process involves deciding on new goals, starting from the very small (like waking up at a specified time or engaging in basic hygiene) to larger goals, like exploring new options. Instilling hope will help the client stay curious and continue to move towards their new goals.

This may also involve helping clients learn to be “alone” with themselves to stimulate creativity, and allow clients to explore new options.

Limitation Management

Finally, limitation management involves activities to help clients cope with their “new self.” Limitations caused by illness can create a feeling of helplessness and a lack of control that can cause depression, anger or other sensations. This involves skills previously discussed like deep breathing and relaxation, forbearance, and acceptance of things that one cannot change.

Focusing on elements that are within an individuals’control may help move individuals closer to the things that bring them happiness.  Self talk can also be helpful in this regard.

Cite this article as: MacDonald, D.K., (2017), "Coping Skills Therapy for Managing Chronic and Terminal Illness," retrieved on October 23, 2017 from http://dustinkmacdonald.com/coping-skills-therapy-managing-chronic-terminal-illness/.
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