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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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 July 21, 2017 from http://dustinkmacdonald.com/setting-limits-and-boundaries-with-callers/.
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Cultural Competence in Social Work

Introduction

Cultural competency is one of those words that may seem like a bit of a buzz word, but is actually very important to being an effective counsellor. The National Center for Cultural Competence cites the definition given in Cross et al. (1989), which is that “Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situations.”

Having an awareness of different cultures and how they influence the counselling process helps you ensure that your work takes into account the unique values, beliefs and circumstances of individuals and do not impress your values on them.

For instance, if a Vietnamese student tells you that his family wishes him to study medicine, and he does not want to do so, you may advise him to assert his individuality and tell him otherwise. Unfortunately, in a collectivist society like Vietnam this would be considered an extreme social violation and could lead to the father never speaking to him again.

The APA has developed a set of guidelines for multicultural competence, while Ivey, Ivey & Zalaquett (2007) in their book Intentional Interviewing & Counselling explain the RESPECTFUL Model as a set of multicultural dimensions that can help you identify areas where you are similar or different than your client for the purpose of assessing potential cultural barriers.

Assessing Cultural Competency

The National Center for Cultural Competence has produced a variety of assessment tools, including ones for organizations to build their competence, and a number of individual cultural competence assessment tools depending on the area you work in (including family service, youth, and primary care.)

RESPECTFUL Model

  • Religion/Spirituality
  • Economic/Class Background
  • Sexual Identity
  • Personal Style and Education
  • Ethnic/Racial Identity
  • Chronological/Lifespan Challenges
  • Trauma
  • Family Background
  • Unique Physical Characteristics
  • Location of Residence and Language Differences

In order to develop your cultural competency, it is important to not only be aware how you differ from your clients in the above dimensions, but also allowing your client to take the lead and explain to you the impact their culture has on their unique experiences.

Etic and Emic Multicultural Counselling

Daya (2011) reviews the two opposing schools of thought in multicultural counselling, that it should focus on elements unique to specific cultures (emic) or universal to all cultures (etic). The etic approach focuses on the basic counselling relationship and the specific techniques that the counsellor uses, while those who believe in the emic approach stress the importance of knowing the specific beliefs and values that the client brings into the counselling session.

Cultural Competence Interventions

Sue et. al. (2009) explored a variety of interventions for cultural competence. With African Americans, he noted a study that used “spirituality, harmony, collective responsibility, oral tradition, holistic approach, experiences with prejudice and discrimination, racial socialization, and interpersonal/communal orientation” to work with African American clients, while story telling was found to be helpful for those of a Latino background.

With individuals of an Asian background, Iwamasa (n.d.) recommends challenging myths such as asians being a “model minority” or always academically or financially successfully, and recognizing cultural specific mental health issues like hwa-byung and taijin kyofyusho.

Bibliography

Cross, T., Bazron, B., Dennis, K., & Isaacs, M., (1989). Towards A Culturally Competent System of Care, Volume I. Washington, DC: Georgetown University Child Development Center, CASSP Technical Assistance Center.

Daya, R. (2011) Changing the Face of Multicultural Counselling with Principles of Change. Canadian Journal of Counselling. 35(1). 49-62.

Ivey, A.E., Ivey, M.B. & Zalaquett, C.P. (2007) Intentional Interviewing & Counselling: Facilitating Client Development in a Multicultural Society. Brooks/Cole: Belmont, Ca.

Iwamasa, G.Y. (n.d.) “Recommendations for the Treatment of Asian-American/Pacific Islander Populations”. American Psychological Association. Accessed electronically on Jun 4 2016 from http://www.apa.org/pi/oema/resources/ethnicity-health/asian-american/psychological-treatment.aspx

Sue, S. Zane, N. Hall, G.C., Berger, L.K. (2009) Annual Review in Psychology. 60: 525–548. doi:10.1146/annurev.psych.60.110707.163651

Cite this article as: MacDonald, D.K., (2016), "Cultural Competence in Social Work," retrieved on July 21, 2017 from http://dustinkmacdonald.com/cultural-competence-social-work/.
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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 July 21, 2017 from http://dustinkmacdonald.com/active-listening-on-crisis-lines/.

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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 July 21, 2017 from http://dustinkmacdonald.com/building-communication-skills/.

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