Active Listening Process on Crisis Lines

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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Providing Emotional Support Over Text and Chat

Introduction to Text and ChatRoleplay Transcript

With text and chat services increasingly moving online, emotional support work – the core element of the work of crisis lines is needing to be adapted to work in new formats that require a change in your perspective and technique. On the telephone, there are a number of ways of providing a warm, genuine experience. For instance, your voice tone and pitch communicates a lot, as well as the speed in which you talk, whether you speak over the caller or let them lead, and so on. There is a lot of non-verbal communication that happens on the phone.

In contrast, online all you have is text. So many of the dimensions that are used to promote warmth, communicate empathy and demonstrate caring are simply absent. This makes it more difficult to build rapport with these visitors and be effective.

The elements of active listening, or the active listening process are the same, although of course it seems unusual to call it “listening” since you aren’t using your ears. There is still an effort made to be alert for and respond to communication, however. Some people prefer “emotional support” instead.

Chat and Text Length

Chat and text conversations tend to be longer than telephone conversations; an average telephone call may be 20 minutes while a crisis chat or text conversation will be 45-60 minutes. This is due to the time required for you to send a text, for the visitor to receive it, read it, decide what they’re going to write, and then write back. You may not send a lot of  messages in this 60 minutes, but that doesn’t mean that you aren’t accomplishing a lot – which is reflected in the outcomes, often up to 30% reduction in subjective distress over an hour.

Opening Conversations

In the opening of a text-based conversation, it’s important to be warm and genuine. Your opening message should give your name, because the visitor doesn’t have anything else to go on. You may want or need to identify your organization as well. Finally, you’ll want to ask the visitor what brought them to text in.

An example of an opening message I could use on the ONTX Project is “Welcome to the ONTX Project. My name is Dustin, what’s going on in your life?”

Sometimes a visitor will text in with a lethality statement, something like, “I want to die.” This doesn’t necessarily change your opening, but it doesn’t hurt to acknowledge the suicidal feeling. “Welcome to the ONTX Project. My name is Dustin, it sounds like you’re really struggling. Did you want to tell me what’s been going on?”

Some visitors though, may need a bit of encouragement. If you ask a visitor how they’re feeling, they may reply “idk” (I don’t know) or “bad”, and not elaborate. Other visitors may be much more articulate and be able to explain what’s going on in their life.

If someone says “idk” or “bad”, usually my next move is to ask them what’s on their mind tonight. This is a gentle way of rewording the question that helps them feel more comfortable. Usually at this point they’ll begin talking, but if not my final option is “What were you hoping to get out of texting in tonight?”

I’ve never had a visitor respond with “idk” or other messages after this much encouragement but I would likely empathize with how difficult it’s been for them to text in before ending the conversation and inviting them to try us again when they’re more able to speak.

Because of a 140 character limit, some of these messages may need to be sent as a pair of messages on text.

Exploring the Issue

Exploring the issue that the visitor is texting in about can be challenging. Unlike the helpline, where you may need to take a while to establish rapport, visitors on text tend to jump right to their primary concern rather quickly. They don’t have the luxury of many messages back and forth.

If you’ve used the above Opening the Conversation ideas, you should be well into exploring the issue. This section should proceed just the same way as an offline conversation does, using all elements of the active listening process (open ended questions, paraphrasing and summarizing.)

You may notice that you need to ask more clarifying questions than usual, because with text and a lack of tone it’s easier for things to be misunderstood or misconstrued.

Demonstrating Empathy

In an online environment, you have no voice tone to demonstrate empathy. For this reason it’s important to write out your empathy statements clearly in order to show that you have an idea what the visitor is going through. Clarifying and paraphrasing can help in rapport building as well, by demonstrating that you are paying attention. It’s important to recognize that clarifying, paraphrasing and other open and close-ended questions are not a replacement for pure empathy.

Empathy: You sound really alone.

Clarifying: You just lost your dog?

Paraphrasing: You’ve been having trouble since you lost your pet.

Note the difference, empathy highlights an emotion (alone) while clarifying and paraphrasing primarily on content without regard to an emotional undertone.

Suicide Risk Assessment and Intervention

Suicide risk assessment and intervention is a challenging topic over chat and text. The primary challenges in this environment include the difficulty collecting the amount of information required to perform a competent assessment in 140 characters and the lack of voice tone and body language.

Typically the first question asked on chat and text after confirming suicide thoughts are present is to determine if they’re at imminent risk. This is usually accomplished by asking something like “Have you done anything to kill yourself?” or “Have you taken any steps to end your life tonight?”

Chatters and texters will sometimes text in immediately after an overdose, and will readily reveal their level of danger but not until you ask. Sooner rather than later!

Next, I’ll ask the visitor what’s led them to feeling suicidal. This, when combined with an empathy statements, helps to begin exploring the visitor’s reasons for living or dying. For example, “You must be feeling so overwhelmed. Tell me what’s led you to feeling suicidal?”

After this, I move onto the elements of the DCIB Suicide Risk Assessment tool.

Winding Up Conversations

Because visitors are using their cell phones, they can put their phone in their pocket, and then pull it out without thinking about the time that passes in a few minutes. It’s not uncommon that at the end of your 45-60 minutes, when it comes to winding up, the visitor doesn’t even realize that amount of time has passed. They find themselves feeling better, however, which is great news!

Winding up has to be deliberate, otherwise the visitor is unlikely to wind up in a decent time. Past experience has shown that crisis chats can last 3 hours or longer lacking a proper wind up. In order to initiate a windup, you simply have to give the visitor an opportunity to express anything else on their mind and then let them know that you have to go. For example,

“We’ve been talking for about an hour so we’ll need to wrap our conversation up soon. I’m wondering if there’s anything else on your mind that you haven’t shared yet.”

Or, more succinctly,

“We’re just coming up on 45 minutes of chatting so we’ll need to wind up soon. Was there anything else you wanted to share before we do?”

This cues the visitor that the conversation needs to end and lets them focus on any outstanding issues. For instance, you may be convinced of their safety and they may not be – and by pointing that out by replying “I don’t know what to do to avoid attempting suicide tonight” then you can spend your remaining 15 minutes implementing a comprehensive safety plan for that visitor. In this way, the windup can be a tool for you and the visitor.

Cite this article as: MacDonald, D.K., (2016), "Providing Emotional Support Over Text and Chat," retrieved on September 21, 2017 from http://dustinkmacdonald.com/providing-emotional-support-text-chat/.
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Active Listening on Crisis Lines

The core of emotional support, which is the service provided on crisis lines, is called active listening. Active listening is a special type of listening, distinct from the regular listening we do everyday.

Active listening should also be separated from the work that counsellors and therapists do, which is called professional listening. While therapists and counsellors certainly use active listening, they also use additional advanced skills not covered here (such as interpretation and challenging.)

Active listening is made up of a number of individual skills that include:

  • Demonstrating attending behaviour
  • Using empathy statements
  • Paraphrasing
  • Reflecting
  • Summarizing

These are reviewed below.

Although active listening skills may seem like common sense, it takes conscious practice to develop use of these skills to be second nature. As is often said about this topic, it’s common for people to “wait to talk” instead of truly listening. They’re not hearing the emotions under the content, they’re just waiting for a pause to jump in with their next sentence.

Attending Behaviour

Attending behaviour refers to your non-verbal behaviours used to show that you’re listening. This includes things like eye contact, where your body is pointed, your posture, and so on. The acronym SOLER is one that is used to summarize attending behaviour. It is important to keep in mind that attending behaviour is culture-specific, and this is written with Western cultures in mind.

Other cultures may have different standards for what is considered attending behaviour. For instance, eye contact is often rude and intrusive in Asian cultures, while in North America it is rude to not maintain eye contact.

SOLER is not relevant to crisis lines (because you’re working over the telephone) but is still covered here because occasional in-person clients may occur in some organizations.

SOLER

  • S – Sit Squarely
  • O – Open Posture
  • L – Learn Towards the Client
  • E – Eye Contact
  • R – Relax

Sit squarely refers to your body positioning, which is to point your body towards client so that they know you’re listening, rather than pointing your body away from the person you’re speaking to.

Open posture refers to keeping your arms and legs open. Crossed arms or legs put together are considered closed body language and are off-putting to clients. Instead, keep your legs apart (though not enough that it could appear unprofessional) and keep your arms at your sides or in your lap rather than closed.

Lean towards the client sounds like what it says – to show interest when a client is speaking, lean towards them rather than leaning back which communicates disinterest.

Eye contact, as well, is important for showing interest and building rapport in western cultures. Keep in mind that some other cultures may place different value on eye contact and so it’s important to know the culture you’re working with.

Relax – Relax! No need to be tense, your discomfort may be interpreted by your client as disliking them, so make sure to take a deep breath, be honest with your client if something bothers you, and always keep the lines of communication open.

Empathy Statements

Empathy statements are the core of emotional support. These are feeling words that allow you to communicate that you have an idea what another person is going through. Empathy is defined as “the ability to understand and share the feelings of another”, which is different from sympathy, which is “feelings of pity and sorrow for someone else’s misfortune.”

With empathy, you are highlighting feelings as if you are experiencing them yourself. Examples of empathy statements are:

  • That sounds really scary
  • You must be feeling so frustrated
  • If I were you in shoes I would be devastated

Empathy statements may initially sound un-genuine or forced, but with practice they will get second nature. You may find it helpful to look at a list of feeling words to develop your skills. For additional practice please see my article Empathy Statements in Helpline Work.

Paraphrasing

Paraphrasing is defined as “express[ing] the meaning of (the writer or speaker or something written or spoken) using different words, especially to achieve greater clarity.” In the emotional support context, paraphrasing means to restate the content that a person has said.

An example of this would be, if someone tells you that their dog died. An example of a paraphrase would be “You lost your pet.” Paraphrasing is used to ensure you’ve heard the content that a person has said while they speak to you.

Reflecting

Reflection is similar to paraphrasing but the goal is to reflect the emotion underlining the statement that a person has said. This is quite a bit different than paraphrasing. For instance, if we return to our example of someone telling you that their dog died, the paraphrase was “You lost your pet.” The reflection would be, “You’re feeling really alone right now.”

A reflection highlights an emotion, and is used frequently to check in to make sure that your empathy statements are on point.

Summarizing

Summarizing is similar to paraphrasing or reflecting but it is a longer statement used to sum up several minutes of conversation. Many counsellors use summaries to open their sessions by reviewing the previous week’s conversations, and periodically throughout their sessions.

An example of a summarize that could apply to our dog-grief conversation would be like follows: “So, from what we’ve been discussing, you lost your dog last month and it’s weighing really heavily on you. You feel alone because your house is empty and you don’t know how to cope.” This highlights some emotional items (feeling alone, weighing really heavily on them) and some content items (dog lost last month, empty house.)

Silence

Silence is an important element in active listening and is often overlooked. Silence can be used to help a person process what has just been discussed – it is not necessary, nor desirable to fill every moment of a conversation with words. Sometimes just sitting with someone and being witness to their pain is helpful.

Advanced Active Listening Training

If you’re interested in developing your active listening skills you may want to join a crisis line, or consider taking an Introduction to Counselling course at a local college or university to build your theoretical skills and practice roleplaying with others.

As well, please my article on Building Communication Skills and on Improving Your Helpline Work.



Cite this article as: MacDonald, D.K., (2016), "Active Listening on Crisis Lines," retrieved on September 21, 2017 from http://dustinkmacdonald.com/active-listening-on-crisis-lines/.

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Empathy Statements in Helpline Work

Empathy statements are one of the most important elements of the work that you do on a crisis line, a helpline or a suicide hotline. Empathy statements are sentences that incorporate feeling words into them, so that the person you’re speaking to realizes you’re making an effort to understand them.

Empathy statements are very useful in communicating that you care to other people, but they can feel unnatural at first before you get used to them. They are a skill though, that you will pick up over time. Your empathy statements will begin to be more variable and feel less robotic as time goes on.

The basic empathy statement formula is an opener, followed by some sort of emotion.

Openers are things that you say to begin the sentence. They include things like:

  • It sounds like
  • You must be feeling
  • That sounds very
  • That seems really

These aren’t really the important part of the sentence. All that matters is that at the end of the sentence, you say an emotion.

  • It sounds like you’re exhausted.
  • You must be feeling frustrated.
  • That sounds really overwhelming.
  • That seems really worrying.

By citing an emotion, the person has something to go on, you’ve reached beneath the content of what they were saying into their emotional state. Even if you’re wrong! If you say “That must be really frustrating” and the person says, “No, it’s not frustrating as much as it is sad”, they still appreciate the effort and now you have a little bit better of a view into their situation.

Keeping a list of feeling words is helpful for making empathy statements. Sometimes people will rely on the same few emotion words like stuck, frustrated, or annoyed while neglecting words that may more accurately express how the person is feeling.

For this reason, developing a wider vocabulary is important to making good empathy statements. Something that is often overlooked is the importance of matching the empathy statement to the person you’re speaking to.

For instance, an elderly person may not say “I’m feeling really depressed” and if you said “You sound really upset” they may say no, but if you said “You’re feeling blue” they may agree. This is similar with denying anxiety but admitting having “nerves.”

Children in particular will often use sentences that are less overt in identifying feelings. “That sucks” or “That sounds really hard/tough” may be acceptable empathy statements when talking to youth. There is an element of intuition and “feeling it out” that develops as you use empathy statements and you will learn over time which ones are more effective for the group you’re speaking to.

Happy Empathy Statements

  • Pleased
  • Comfortable
  • Confident
  • Enthusiastic
  • Cheerful
  • Ecstastic
  • Energetic

Sad Empathy Statements

  • Blue
  • Depressed
  • Unhappy
  • Somber
  • Discouraged
  • Disappointed
  • Hopeless
  • Low

Angry Empathy Statements

  • Irritated
  • Furious
  • Annoyed
  • Boiling
  • Fuming
  • Mad
  • Frustrated
  • Bothered
  • Ticked Off

Hopefully these words give you some examples to help you begin forming your own empathy statements. With practice you will learn to form them unconsciously and weave them naturally into your conversation; this is the sign of someone who communicates really effectively.



Cite this article as: MacDonald, D.K., (2015), "Empathy Statements in Helpline Work," retrieved on September 21, 2017 from http://dustinkmacdonald.com/empathy-statements-in-helpline-work/.

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Building Communication Skills

In the helping professions, including both client-facing roles (like therapy or case management) and other roles, the importance of being able to talk constructively with people is key.

Particularly in areas like nursing or case management where both physical/medical issues need to be taken care of, patients can feel overlooked or like they’re not taken care of, even when they’re instrumental issues (e.g. their medical problems or what brought them into the service) are being handled.

Empathy Statements

The core to making a person feel heard is to use empathy statements. These are statements that allow you to communicate in a way that makes the other person feel heard or understood.

An empathy statement has the following structure: an opening statement (often that references what the person has said), followed by an emotion, and sometimes a statement closer.

For instance, “When you say that nobody cares about you, it sounds like you’re feeling really alone.” The person may say, “Yeah, I do really feel alone, I might talk to one person a week”, that further explores the problem.

On the other hand, they might say “No, I’m not feeling alone at all, I’m more angry than anything”; this is okay! Now you know exactly what emotion they are experiencing.

DESC Model for Assertive Communication / WIN Statements

The DESC Model is one way to communicate assertively when you need something from someone, or you need them to know what you’re feeling. They also have the name “WIN” statement as a short way to remember them.

DESC stands for Describe, Express, Specify and Consequences:

  • Describe the Situation – Say what behaviour the person is doing you wish to change
  • Express Your Feelings – I feel ___________.
  • Specify what you want – I want/prefer/need you to ___________.
  • Consequences – Indicate what you and the person will gain if they give you what you’ve asked for

WIN Statements are a shorter version of this:

  • When you ___________ I feel ___________; I need you to ___________.

 

Active Listening Training Resources

For more indepth training on active listening, you have a number of options: most crisis lines offer basic training sessions (linked here is the ContactUSA helpline accreditation standards) that cover emotional support and active listening, I have an article on building helpline skills that covers active listening, and most counselling courses cover this as well.

There are also private seminars that go over this, such as those offered by the Helplines Partnership in the UK.

Active Listening Barriers

There are some things that you want to avoid in active listening, things that get in the way of providing emotional support.

Interrupting

Interrupting can sometimes be because someone is speaking slowly, they’re speaking too quietly for you to hear them, because you need to get more information from them, or because you’re not sure if the sentence has ended due to a language barrier.

Unfortunately when you interrupt, this gives the person the perception that you don’t care, and that can be very invalidating – even if you knew what they were going to say. Simply practice waiting until the person has finished talking completely or asking them to speak up if you can’t hear them.

“Why” Questions

Why questions are common in our everyday speech, but their use in emotional support conversations can be very judgemental. Instead of saying “Why do you think nobody likes you”, say something like, “Tell me more about that” or “What makes you think that nobody likes you?”

Fixing / Offering Advice

Fixing, or offering advice is a very natural gesture that takes a lot of work to undo. Giving advice promotes dependence on you, which means if you tell them to do something and things go wrong, you’ll be blamed for it, and the person will be unable to make their own decisions.

We want to promote independence and empowerment by helping people to make their own decisions. Rather than making the decision for them, you can explore options with them, by asking “Have you thought about xyz?”, “Tell me how you’ve coped with this situation in the past”, and avoiding use of the word “should.”



Cite this article as: MacDonald, D.K., (2015), "Building Communication Skills," retrieved on September 21, 2017 from http://dustinkmacdonald.com/building-communication-skills/.

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