Preventing Burnout on Crisis Lines

Introduction

Burnout is defined as a state of ineffectiveness comprising “emotional exhaustion, depersonalization, and reduced personal accomplishment.” (Maslach, 1982) It is a pervasive and frustrating state, accounting for a large portion of the turnover experienced in mental health services, including volunteer and paraprofessional organizations like crisis lines.

There are a number of models of burnout, but one stage model is presented below from Cherniss (1980) and reproduced in Kinzel & Nanson (2000):

Stage 1: Stress

Stress is the first stage of burnout, when an individual is functioning at a level that exceeds their optimal operating conditions. This could be because of internal factors (like wanting a promotion or being intensely devoted to work), external factors (like being given a larger caseload due to budget cuts) or interpersonal factors (like a negative relationship with a colleague or supervisor.)

Stage 2: Strain

When a person experiences strain, they have now operated in a state of stress long enough that they are reaching a point of emotional exhaustion. Their coping begins to be maldaptive and they often experience negative somatic or physical complaints like headaches.

Stage 3: Defensive Coping

In the final stage of burnout, an individual’s burnout begins negatively impacting their ability to take calls or otherwise perform their helpline work. There is a lack of empathy or concern for the callers and this may be accompanied by blaming the callers or detachment from the situation. At this stage

Causes of Burnout

There are a variety of causes of burnout. Some listed by Kinzel & Nanson (2000) include:

  • Nature of crisis calls
  • Negative emotions experienced during the calls like anger or guilt
  • Countertransferrence (being triggered by one’s own experiences while supporting another)
  • Repeat or regular callers creating a feeling of powerlessness or ineffectiveness
  • A lack of effective coping skills

Additionally Kinzel & Nanson note studies that revealed the presence of magical thinking (assuming the situation would get better on its own) and escape-avoidance coping skills were associated with an increase in burnout, along with detachment and personality responsibility.

Paradoxically, workers who were too involved (taking personal responsibility for callers) were more likely to experience burnout as were volunteers who were detached. The least likely to experience burnout is the crisis line worker who stays emotionally connected to a caller but also recognizes that their life is their life and it is not the worker’s responsibility to change it. (Mishara & Giroux, 1993)

Assessing Burnout

The Maslach Burnout Inventory (MBI; Maslach, C., Jackson, S.E., & Leiter, 1996) is the most common measure for assessing burnout. It is a 21-item scale that produces scores on three subscales: Emotional Exhaustion, Personal Accomplishment and Depersonalization.

Morse et. al. (2012) notes example cut-off scores for the three scales as follows “emotional exhaustion scores of at least 21, depersonalization scores of at least 8, and personal accomplishment scores of 28 or below” but with the caveat that those scores may be lower than necessary, artificially inflating the presence of burnout in mental health professionals.

Helpline managers will need to take the lead in determining whether their workers are experiencing symptoms of burnout. This may be witnessed in the quality of listened calls, in the comments made on call reports, or contacts that occur off the lines. For instance, volunteers who:

  • Started giving more advice to callers
  • Talked to staff about frustration with non-suicidal callers “wasting” distress line time
  • Missed shifts because of not being emotionally capable

These may be situations where you would recommend burnout prevention activities. Potential treatments for burnout are discussed more in-depth below, but in the helpline environment a leave of absence (LOA) from the lines for a while, increased self-care or decreased activity (e.g. limiting hours weekly or monthly) can help avoid burnout.

Treatments for Burnout

Smullens (2013), writing for Social Worker magazine notes a number of strategies including:

  • Stimulus control and counterconditioning. Stimulus control involves active decisions like not choosing to eat lunch at your desk or bringing a plant into the office while counterconditioning involves physical exercise, hobbies, or other diversions
  • Mental health treatment. Therapists should seek their own therapy when their personal issues interfere, and someone who is experiencing or worried about experiencing burnout is certainly under that category
  • Diversify. This refers to the idea of changing your responsibilities to give you non-clinical activities that help to refresh and restore you. For many social workers, this involves teaching, conferences, or other activities, but for heplline workers it can also involve becoming a leadership volunteer, serving on a non-profit Board or another form of volunteerism

Oser et. al. 2013) added to this with burnout prevention strategies including:

  • Coworker support. Being able to vent to colleagues who have a sense of what you’re going through and understand your organizational culture can be very helpful. Feeling like (or being) isolated without anyone to discuss concerns with can exacerbate feelings of ineffectiveness. This applies to helpline workers as well, who can make frequent use of debriefing
  • Clinical supervision. Supervision can also help reduce feelings of isolation and ineffectiveness by giving individuals an opportunity to identify maladaptive coping strategies or other issues that may lead to burnout

Research is continuing so hopefully in the future we have specific therapies designed for burnout and options; a number of individuals leave the helping professions each year because of burnout, which is obviously not ideal.

References

Bowden, G. E., Elizabeth Smith, J. C., Parker, P. A., & Christian Boxall, M. J. (2015). Working on the Edge: Stresses and Rewards of Work in a Front-line Mental Health Service. Clinical Psychology & Psychotherapy, 22(6), 488-501. doi:10.1002/cpp.1912

Cherniss (1980). Staff Burn-Out. Job Stress in the Human Services. Sage Publications.

Kinzel, A., & Nanson, J. (2000). Education and debriefing: Strategies for preventing crises in crisis-line volunteers. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 21(3), 126-134. doi:10.1027//0227-5910.21.3.126

Maslach, C. (1982). Burnout: The Cost of Caring. New Jersey: Prentice-Hall, Inc.

Mishara, B.L., Giroux, G. (1993). The relationship between coping strategies and perceived stress in telephone intervention volunteers at a suicide prevention center. Suicide and Life Threatening Behavior, 23(3).

Maslach, C., Jackson, S.E., & Leiter, M.P. (1996) Maslach Burnout Inventory (3rd ed.). Palo Alto, CA: Consulting Psychologists Press.

Morse, G., Salyers, M. P., Rollins, A. L., Monroe-DeVita, M., & Pfahler, C. (2012). Burnout in Mental Health Services: A Review of the Problem and Its Remediation. Administration and Policy in Mental Health, 39(5), 341–352. http://doi.org/10.1007/s10488-011-0352-1

Smullens, S. (2013) What I Wish I Had Known: Burnout and Self-Care in Our Social Work Profession. Social Worker. Retrieved on December 28, 2016 from http://www.socialworker.com/feature-articles/field-placement/What_I_Wish_I_Had_Known_Burnout_and_Self-Care_in_Our_Social_Work_Profession/

Cite this article as: MacDonald, D.K., (2017), "Preventing Burnout on Crisis Lines," retrieved on November 17, 2017 from http://dustinkmacdonald.com/preventing-burnout-on-crisis-lines/.
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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 November 17, 2017 from http://dustinkmacdonald.com/active-listening-on-crisis-lines/.

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What Makes a Good Crisis Line Volunteer

So, you want to become a crisis line, or suicide hotline volunteer. Congratulations! Not a lot of people feel like they’re able to do this work. It’s very difficult to spend hours alone in the middle of the night listening to someone talk about their depression, or about feeling suicidal, relationship issues, or all the other things that brought them to call in.

This article reviews some of the qualities required to be a good crisis line volunteer and also some of the steps that someone joining a crisis line might need to go through before they begin.

Becoming a crisis line volunteer isn’t an easy process. Most crisis lines require a minimum of 40 hours of training, passing a reference check, being able to display empathy and handle crisis situations, and learning how to perform suicide risk assessments and interventions.

Additionally, after you’ve passed the training you usually have to complete a period of on-the-phone apprenticeship which can add another 8-20 hours to the time that it takes to be fully trained. This is because the standard in which crisis line volunteers are expected to perform is very high.

There are some elements you should consider before deciding to become a hotline volunteer:

  • Can you work well under pressure?
  • Can you be empathetic to other people?
  • Can you resist the urge to fix people’s problems?
  • Are you a team player?
  • Do you have good mental health yourself?

Some of these are obvious: crisis lines can be stressful when you’ve got people in intense situations who need a calm person to listen to. If you can’t empathize with people who are in distress – and communicate that – people won’t feel like you truly understand. And having good mental health is important to ensuring you aren’t negatively affected by your work.

On the other hand, some of these items are less obvious. Often people feel like crisis lines help people by giving them advice. This is in fact not the case; providing advice to people to solve their problems promotes dependance.

Let’s say you tell someone to break up with their boyfriend because he’s treating her badly. She breaks up with him but then decides she really wants to be with him. He refuses to take her back. You’ll be blamed! This can also cause legal issues; people in professional fields have been sued for giving bad advice, and crisis lines are not immune to the impacts of their decisions.

Of course, being a team player is important. Crisis lines are often comprised of large groups of volunteers, or a mix of paid and volunteer staff. Learning to get along with a variety of diverse people is an important skill. Don’t underestimate the benefits that enjoying your coworkers and being able to make friends with them.

To review, in order to become a crisis line volunteer you’ll probably have to go through several or more of the following steps:

  • Information Night
  • Submit Application
  • Interview
  • Reference Check
  • Complete Training
  • Complete apprenticeship on the phone lines

Additionally, you will likely to complete additional in-service trainings and be supervised. If it’s something you’re interested in however, you can gain a lot of great benefits including boosting your resume, learning new skills, networking and meeting people and getting into graduate school.



Cite this article as: MacDonald, D.K., (2016), "What Makes a Good Crisis Line Volunteer," retrieved on November 17, 2017 from http://dustinkmacdonald.com/makes-good-crisis-line-volunteer/.

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Beginnings of an Online Crisis Chat Service

On June 29th, the Distress Centres of Dufferin/Wellington, Durham, Peel and Toronto joined together to launch an online crisis chat service. Texting through an unadvertised shortcode based on a service in the US or visiting our website provides access to a trained volunteer responder between 2pm and 2am.

After running the service for a few months, we’ve begun seeing some important elements emerge from the data. They include elements like the length of the chats, the service volume, the elements necessary for high-quality chats and texts,

Chat Length

The average interaction is 45-60 minutes. This is much longer than helpline conversations which tend to be closer to 20-30 minutes for individuals who are not in crisis. This is because of the time required to process what you’re reading and to consider writing your response.

Service Volume

The service operates for approximately 12 hours a day and fields an average of 10-15 text sessions and 5-10 chat sessions a day, but has received as many as 64 chat/text interactions in a week during periods of high volume.

Number of Responders

We are close to 150 responders covering a 12 hour period with double coverage. Because commitments can vary based on the partner Centres we estimated that we would need about 50 responders per Centre in order to meet this base level of service.

Level of Distress

Currently, there is a pre-chat survey for visitors entering the system where they can indicate their level of distress on a 5 point scale:

  • 1 – I’m doing okay
  • 2 – A little upset
  • 3 – Moderately upset
  • 4 – Very upset
  • 5 – Extremely upset

At the end of the chat, they are redirected to a post-chat survey where they have the option to note if their level of distress has changed. Approximately 20% of the chat visitors complete the pre and post chat surveys.

The results of preliminary analysis show that their level of distress drops 1 full point from 3.8 to 2.8, on average after an interaction with a responder.

Chat and Text Issues

The most common issues that chatters report are anxiety, depression, relationship concerns and suicidal thoughts. This is very similar to the helpline, though the rate of suicidal ideation is 2-3x higher (10-15%) on the service than the provincial average on the helpline (approximately 5%.)

This range of issues is similar to the helpline.

Age Range

Right now the service sees 100% of it’s usage between 0-44, no visitors over 45 have visited. The most common age range is 15-24, though I’ve seen some as young as 12 accessing the service. Only 5% of the visitors on the telephone helpline are 15-24, suggesting the service is much more popular for youth.

Crisis Chat / Text Training

The training is approximately 4 hours in length and covers a review of active listening and emotional support, the DCIB Suicide Risk Assessment, how to use the iCarol messaging system and then some time for roleplays.

It’s important to recognize that there is a different skill set required for communication through a text environment versus communication over the telephone. For instance, the lack of voice tone makes it very difficult to recognize when you are de-escalating a visitor.

This required consistent checking in with the visitor to make sure they are actually improving.

Crisis Chat / Text Suicide Risk Assessment

The suicide risk assessment we use is the DCIB Suicide Risk Assessment. This assessment contains four elements: desire, capability, intent and buffers. This is different than our previous risk assessment, the CPR Risk Assessment.

Follow Up

An important element of working with suicidal individuals is follow up. Studies (e.g. Brown & Green, 2014) have demonstrated that follow up has the potential to reduce the likelihood of future suicide attempts and ideation.

Bibliography

Brown, G.K., Green, K.L. (2014) In Expert Recommendations for U.S. Research Priorities in Suicide Prevention, American Journal of Preventive Medicine. 47(3) Supplement 2:S209-S215 DOI: 10.1016/j.amepre.2014.06.006,

 



Cite this article as: MacDonald, D.K., (2015), "Beginnings of an Online Crisis Chat Service," retrieved on November 17, 2017 from http://dustinkmacdonald.com/beginnings-of-an-online-crisis-chat-service/.

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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 November 17, 2017 from http://dustinkmacdonald.com/empathy-statements-in-helpline-work/.

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