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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Manage Stress Like a Marine

Military members salute

Introduction

Nobody knows stress management like the US military. Stress management has been recognized as an important part of ensuring an effective fighting force since the First World War. The US Marine Coprs manual MCRP 6-11C, “Combat and Operational Stress Control” (2010) is one part of this program.

Bite-sized takeaway: Know yourself and your team (whether that’s fellow Marines in a military environment or family and coworkers in a civilian enivronment) and be alert for any sudden, persistent or progressive change in their behaviour

Combat Stress Reactions

A combat stress-reaction (CSR) is the military equivalent to acute stress reaction, the state of agitation seen as a response to combat or other stressful or traumatic situations. These symptoms, if not properly managed, can lead to Post-Traumatic Stress Disorder (PTSD.)

The most common combat stress reaction symptoms include:

  • Slow reaction time
  • Difficulty with tasks and prioritizing
  • Excessive concern with minor issues
  • Indecision
  • Focus on familiar tasks
  • Loss of initiative

It can be hard to recognize when something is a normal reaction to battle or something that requires more intense medical or psychological support. One example given is that mild shaking while being fired upon or mortar rounds are incoming is very normal. On the other hand, intense shaking post-battle can be incapacitating and will require additional support.

Normal reactions to battle can include:

  • Perspiration
  • Chills
  • Nausea
  • Vomiting
  • Loss of appetite
  • Abdominal distress
  • Frequent urination
  • Incontinence

Dreams and flashbacks are one area that are commonly associated with PTSD. MCRP 6-11C notes that vivid battle dreams are a totally normal part of working through and processing combat experiences. Additionally, flashbacks are normal as long as they are recognized as flashbacks. These may become part of PTSD if the acute stress reaction is not managed but can be treated.

Some issues that may require more intensive support are stress-related blindness/deafness or partial paralysis. These can improve with reassurance from comrades, unit medical personnel or the batallion physician. As well, a reaction known as a panic run, where the service member rushes about without self-control or awareness (US Army, 1950) also requires evacuation for treatment.

Managing Combat Stress Reactions

If you need to, remove a soldier’s access to his weapon if he is experiencing combat stress reactions and you’re not sure he can keep himself safe. Additionally, give him simple tasks to do when not sleeping, eating, or resting. Strategies to manage combat stress reaction include:

  • Treating the service member close to the front (better outcomes happen when the service member is out of danger but still in theatre)
  • Utilize the BICEPS Model of Combat Stress Control
    • Brief (they should be out of the field no more than 3-4 days)
    • Immediate (treatment should be identified and started quickly)
    • Centrality (they should be treated out of hospital but close to the front)
    • Expectancy (the chain of command should have faith the service member will recover)
    • Proximity (keep the service member close to the rest of their unit so they can offer support)
    • Simplicity (the treatment should focus on the member’s return to duty)

Sleep Deprivation

Night time is the time to retain or gain the initiative, so it is common for operations to occur then. This increases the chance that sleep deprivation affects military member abilities to manage combat stress. Increasing circulation through activities like moderate exercise or drinking hot beverages may shorten start-up time after a short time sleeping.

After 36-48 hours of complete sleep loss, a minimum of 12 hours of sleep will be required to regain functioning. Keep watch for sleep drunkenness, which is the opposite (reduced functioning as a result of sleeping too much.)

Grief and Death

One area that many military members struggle with is grief and death. So-called open grieving, talking about grief and loss with comrades can help alleviate anxiety, whether this is a fear of the military member’s own death or survivor guilt from having lost friends and fellow military members on the battlefield.

Stress Management Techniques

It’s recommended that each service member know two stress management techniques: a slow or long one that can be used for deep relaxation and a quick one that can be deployed on-the-job.

Psychological Stress Management

Confidence is one of the strongest defences against stress. “If men can’t fight back, fear will overtake; as long as they can return fire they will not fear.”

Cognitive exercises include positive self-talk, visualization, rehearsal and meditation. Positive self-talk involves telling yourself that things will work out for you, rather than assuming and thinking the worst. Replacing bad self-talk with good self-talk can help increase your resilience.

Visualization is a cognitive technique that involves imagining good things. When you remember something that made you angry, your body reacts the same (your blood pressure rises and constricts), and you’re “right back there” mentally. By visualizing happy things, your blood pressure reduces and you find yourself more able to cope.

Rehearsal is similar to visualization but specifically involves yourself going over the tasks in your mind that you are about to perform. This helps to give you more confidence that you’re able to perform these tasks. Finally, meditation is a form of deep breathing and relaxation to improve one’s emotional state.

Physical Stress Management

Good nutrition and hydration is important. Remember the acronym HALT, the four items that make regulating our emotions more difficult (HALT is “Hungry, Angry, Lonely, Tired.”) If the service member only drinks when they are thirsty, they’ll become dehydrated.

Increasing your aerobic fitness increases your ability to handle stress

Mastering relaxation techniques allows you to reverse the combat stress process. Physical stress management techniques include deep breathing, and progressive muscle relaxation.

Breathing Techniques

Deep Breathing involves slow, deep inhaling. Deep breathe for 2-5 seconds, then exhale slowly over 2-5 seconds
Perform this exercise 5 times for a quick mind-clearing, or continuously at night to promote sleep. Diaphragmatic breathing (which is deep in the chest, as opposed to shallow) is especially helpful for stress control

Muscle Relaxation is a special form of relaxation where you concentrate on one muscle group at a time, tensing and relaxing your limbs in order to relax your entire body. The quick version involves tensing all your muscles simultaneously, holding this state for 15 seconds, letting your body relax, and shaking out all the tension.

The long version involves starting in your feet and working up, body part by body part until you reach your head, tensing and then relaxing the limbs.

Pre and Post-Deployment Reactions

New members to a unit are more likely to become casualties than experienced members. Keeping this in mind, experienced members can help mentor new ones to build resilience and support. “Startle reactions to sudden noise
or movement, combat dreams and nightmares and occasional problems with sleeping, and feeling bored, frustrated and out of place” wee all identified as being common after deployment, as the service member re-integrates into their community.

References

US Army. (1950) TM 8-240 Psychiatry in Military Law. Washington, DC: Department of the Army and the Air Force.

US Marine Corps. (2010) MCRP 6-11C, “Combat and Operational Stress Control”. Retrieved on September 5, 2016 from http://www.marines.mil/Portals/59/Publications/MCRP%206-11C%20%20Combat%20and%20Operational%20Stress%20Control.pdf

Cite this article as: MacDonald, D.K., (2017), "Manage Stress Like a Marine," retrieved on May 29, 2017 from http://dustinkmacdonald.com/manage-stress-like-marine/.
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Bereavement Risk Assessment Tool (BRAT)

Introduction

Bereavement Risk Assessment Tool (BRAT) Sample
Bereavement Risk Assessment Tool (BRAT) Sample

From September 2012 to April 2013, I had the pleasure of completing an 400 hour field placement with Durham Hospice (now VON Durham Hospice). During the first 200 hours (my first semester), I completed the Fundamentals of Hospice Palliative Care Course, learned how to perform psychosocial assessments and assisted in the facilitation of a Day Hospice group.

My second semester and final 200 hours, I completed an 8-week Bereavement Volunteer Peer Support Program that focused on the fundamentals of providing individual and group peer support to grieving individuals. That’s where I learned about this tool, the Bereavement Risk Assessment Tool (BRAT).

The BRAT was developed by Victoria Hospice Society to help “communicate personal, interpersonal and situational factors that may place a caregiver or family member at greater risk for a significantly negative bereavement experience” (Victoria Hospice Society, n.d.)

The version of the BRAT I worked with is the 2008 version, though the 2013 manual is available for purchase on the Victoria Hospice website.

Bereavement Risk Assessment Tool (BRAT) Items

The BRAT is organized into 11 domains for a total of 40 items. Each is scored on a yes/no basis and a risk level (unmitigated and mitigated.) The “unmitigated risk” level is the raw score from the first 10 domains, while the “mitigated risk level” takes into account the 11th domain. The domains are listed below, though the items themselves are not, out of respect for the author’s copyright:

  1. Kinship
  2. Caregiver
  3. Mental Health
  4. Coping
  5. Spirituality/Religion
  6. Concurrent Stressors
  7. Previous Bereavements
  8. Supports & Relationships
  9. Children & Youth
  10. Circumstances Involving the Patient, the Care or the Death
  11. Protective Factors Supporting Positive Bereavement Outcomes

Scoring the Bereavement Risk Assessment Tool

The BRAT is scored using an Excel sheet that automatically calculates the correct score and prepares the document for printing. Documentation information includes the date, the assessor and client’s names, an ID number (e.g. case/file number) and the name of the deceased.

Five Levels of Risk

  • Risk Level 1: No Known Risk
  • Risk Level 2: Minimal Risk
  • Risk Level 3: Low Risk
  • Risk Level 4: Moderate Risk
  • Risk Level 5: High Risk

Research Support for the Bereavement Risk Assessment Tool

The BRAT has received some, though very minimal, research exploration. Rose et. al. (2011) explored the inter-rater reliability of the BRAT and found it adequate (inter-class correlation of 0.68.) Qualitative responses indicated it was a useful tool for assessment of bereavement risk.

The lack of other published work significantly limits the usability of these tool in a research environment. Other reviews (e.g. this presentation by Bill Palmer) fail to identify the BRAT in a list of bereavement assessment tools which suggests it may not be well-known outside of the Canadian Hospice environment.

Other Bereavement Risk Assessment Tools

These tool recommendations come from Bill Palmer’s presentation:

  • Adult Attitude to Grief Scale (AAG)
  • Core Bereavement Items (CBI)
  • Grief Evaluation Measure (GEM)
  • Inventory of Traumatic Grief (ITG)
  • Texas Revised Inventory of Grief (TRIG)

Other Resources

References

Rose, C., Wainwright, W., Downing, M., & Lesperance, M. (2011). Inter-rater reliability of the Bereavement Risk Assessment Tool. Palliative & Supportive Care, 9(2), 153-164. doi:10.1017/S1478951511000022

Victoria Hospice Society. (n.d.) “Clinical Tools | Victoria Hospice Society” Retrieved on October 17, 2016 from http://www.victoriahospice.org/health-professionals/clinical-tools

Cite this article as: MacDonald, D.K., (2016), "Bereavement Risk Assessment Tool (BRAT)," retrieved on May 29, 2017 from http://dustinkmacdonald.com/bereavement-risk-assessment-tool-brat/.
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Law Enforcement Suicide Prevention

Introduction

Organizations like the Tema Conter Memorial Trust in Canada and Reviving Responders in the US have highlighted the skyrocketing rate of suicide among first responders, including police officers, paramedics and firefighters. In 2015, there were over 100 suicides by law enforcement officers in the US. (Kulbarsh, 2016) They note the high incidence of PTSD among law enforcement officers and the stigma that prevents them from seeking support.

One way to reduce law enforcement suicide is through police academy training that provides all officers with suicide awareness training. This helps reduce the stigma of receiving mental health support and gives police the opportunity to act as peer supporters for their colleagues.

Overview of Curriculum

The material below comes from the Basic Course for Police Officers authored by the New Jersey Police Training Commission (2016). This 262-page manual provides a complete review of the curriculum that police officers in that state learn during their 24 weeks at the Academy.

One of the instructional units is named “Suicide Awareness and Prevention for the Law Enforcement Officer”. The description is as follows:

The trainee will understand the causes, symptoms, warning signs and risks associated
with officer suicide, and will identify appropriate intervention and prevention strategies
to effectively deal with this issue.

The outcomes of this module are as follows. Once completed, the police recruit will be able to:

  • Define suicide
  • Identify demographics associated with law enforcement suicide
  • Know stressors that contribute to suicide
  • Explain risk factors associated with suicide
  • Identify warning signs associated with suicide
  • Understand suicide myths
  • Explain and apply the AID LIFE acronym for intervening with suicide
  • Identify obstacles to effective suicide intervention
  • Note professional resources helpful to an officer
  • Identify strategies to prevention law enforcement suicide

The content from these modules is summarized below, but I’ve added references where appropriate to back up the un-cited information. The goal is to provide added-value and confirm the veracity of the material.

Defining Suicide

Suicide is defined as the intentional taking of one’s own life (Stedman, 2016).

Demographics of Law Enforcement Suicide

  • There are more deaths to police suicide than in the line-of-duty (Kulbarsh, 2016)
  • The police officer life expectancy is less than the general population (Violanti, 2013)
  • The suicide rate is approximately 14 deaths per 100,000 (Badge of Life, n.d.) compared to 13 per 100,000 in the general population (AFSP, 2014)
  • Although the curriculum maintains that the divorce rate is higher among police officers, the opposite is actually true. The divorce rate is slightly lower, at 14.47% versus 16.96% for all professions over the lifetime (Roufa, 2015)
  • The rate of substance abuse is higher among police officers (Cross & Ashley, 2004)

Stressors Contributing to Law Enforcement Suicide

In addition to the normal stressors such as depression, anxiety, substance abuse and relationship issues, the curriculum identifies some specific job-related stressors. These include:

  • Discipline issues (internal affairs and/or
    criminal investigations); and
  • Management issues (assignment – lack of promotion – supervision);
  • Retirement (loss of identity and sense of belonging).
  • Shift work;
  • Sleep deprivation;
  • Unfulfilled job expectations;

Risk Factors Associated with Law Enforcement Suicide

This section identifies historical, demographic risk factors that may increase suicide. These are listed below, and correspond to those in the SAD PERSONS Scale and the CPR Risk Assessment:

  • Knowledge of and access to lethal means;
  • Age;
  • Gender;
  • Ethnicity;
  • Previous history (self or family member);
  • Cumulative stressors;
  • Feeling of hopelessness and helplessness; and
  • Lack of intervention resources.

Warning Signs of Law Enforcement Suicide

Warning signs, as defined by the AAS (n.d.) are items that represent an imminent, increased risk (active factors) rather than the stable historical factors that don’t necessarily represent increased risk. For instance, being a male does not itself mean someone is suicidal, but being a man does increase the chances someone will die.

The warning signs listed in the curriculum (reproduced verbatim below) represent a mix of risk factors and AAS-type warning signs.

  • Depression:
    • Attitude of hopelessness and helplessness;
    • Unexplained changes in appetite, weight, appearance, and/or sleep habits;
    • Difficulty making decisions;
    • Difficulty concentrating;
    • Overly anxious;
  • Previous suicide attempt;
  • Increase in the use of alcoholic beverages;
  • Overly aggressive or violent behavior;
  • Any changes in mood or behavior that are out of the ordinary, including a neutral mood;
  • Changes in work habits;
  • Behavioral clues of suicidal thoughts:
    • Giving away possessions;
    • Making a will;
    • Talking about a long trip;
    • Sudden interest or disinterest in religion;
    • Substance abuse relapse; and
    • Taking inappropriate duty-related and personal risks.
  • Anger / irritability; and
  • Concern expressed by family / friends / colleagues about a specific individual;

Identifying Common Suicide Myths

The myths that are discussed here include:

  • People who talk about suicide won’t attempt
  • Talking about suicide with someone does not reduce their risk
  • Warning signs are not present before a person dies by suicide
  • Suicidal individuals must have a mental illness
  • Suicidal individuals are beyond help
  • Suicidal individuals are committed to dying

See my article on suicide myths for a more complete discussion of these

AID LIFE for Suicide Intervention

AID LIFE is an acronym that is given in the training for a simple intervention procedure. The steps in AID LIFE are as follows:

  • A – Ask if the individual is thinking about suicide
  • I – Intervene immediately. Listen and let the person know they are not alone.
  • D – Don’t keep their suicidal thoughts a secret. Seek assistance
  • L – Locate help. This can include a supervisor, chaplain, physician, or other members of their support network. (Including crisis workers or the Emergency Room.)
  • I – Inform the Chain of Command. This can help get important resources like counselling in place.
  • F – Find someone to stay with the individual. (Dustin’s note: I’m actually not a big fan of this one, it shows up in the Marine Corps suicide awareness program as well; this is more important for high-risk, imminent suicide than it is for someone who may be low or moderate risk.)
  • E – Expedite. Get help now, rather than delaying it.

Obstacles to Effective Suicide Intervention

These obstacles are reproduced directly from the manual and include a variety of police-specific and more general obstacles to effective intervention with police officers who are struggling with suicidal thoughts.

  • Fear of stigma, isolation, humiliation, suspension, job loss;
  • Fear of change in duty status;
  • The police culture; (seeking mental health support may be perceived as a character weakness)
  • Denial that there is a problem; (by the officer, peer officers, supervisors, the command staff)
  • Reluctance of the officer to seek help for fear of the officer losing control of the situation;
  • The officer’s fear that confidentiality will not be maintained;
  • The officer’s distrust of management;
  • Supervisors and peers who protect or shield a troubled officer; and
  • Lack of knowledge by a troubled individual about the availability of counseling resources, and concern about being able to afford such services.

Professional Resources for Law Enforcement Suicide

Although this is a New Jersey Police manual, the resources presented are general enough to be a good reference. The resources that are recommended include:

  • Crisis Line
  • Employer Assistance Program (EAP)
  • Faith-based support (e.g. Chaplain or Church official)
  • Hospital emergency room
  • Mental Health Counselling (in person or otherwise)
  • Peer Support (from another officer or supervisor)

Strategies to Prevent Law Enforcement Suicide

The following 4 strategies are generally recommended for preventing suicide by both law enforcement officers and the general public. They include:

  1. Understanding the risk factors and warning signs of law enforcement suicide
  2. Using available resources and building a support network
  3. Challenging the stigma in seeking support
  4. Using the AID LIFE mnemonic

Other Police Suicide Prevention Programs

Together for Life was developed by Psychologists as a comprehensive suicide prevention program in Montreal. This program includes a half-day training session for all officers, a confidential telephone helpline, a full-day training session in more in-depth techniques for supervisors and awareness materials. Mishara & Martin’s 2012 evaluation showed:

  • 99% of those who attended the sessions said they would recommend the sessions to a colleague
  • 84% of supervisors were aware of the program
  • Positive increases in knowledge of risk factors and warning signs, and how to intervene
  • A nearly 80% decrease in the rate of Montreal police suicides (versus no change in the rate of police suicides in other police services in Quebec)

Badge of Life: Psychological Survival for Police Officers (Levenson, O’Hara & Clark, 2010) makes “emotional self-care (ESC)” the focus of a series of training modules delivered to police officers, along with mental health screenings and the delivery of peer support by other officers and the use of Critical Incident Stress Debriefing (CISD).

Police Organization Providing Peer Assistance (POPPA) (Dowling, et. al., 2006) is a New York Police Department (NYPD) based program for preventing suicide. It combines a confidential helpline, support groups, printed suicide awareness and intervention materials distributed to all police officers, and tools to assess resiliency and stress. Applied Suicide Intervention Skills Training (ASIST) is also provided yearly.

Additional Resources

The book Police Suicide: Tactics for Prevention provides a comprehensive review of police suicide causes and potential interventions to reduce suicidal behaviour in this group.

References

American Association of Suicidology. (n.d.) “Warning Signs | American Association of Suicidology” Retrieved on September 4, 2016 from http://www.suicidology.org/resources/warning-signs

American Foundation for Suicide Prevention (AFSP). (2014) “Suicide Statistics — AFSP” Retrieved on September 4, 2016 from https://afsp.org/about-suicide/suicide-statistics/

Badge of Life. (n.d.) Police Suicide Myths. Retrieved on September 4, 2016 from http://www.badgeoflife.com/myths/

Cross, C.L. & Ashley, L. (2004) Police Trauma and Addiction: Coping With the Dangers of the Job. FBI Law Enforcement Bulletin. 73(10) Retrieved on September 4, 2016 from https://www.ncjrs.gov/App/Publications/abstract.aspx?ID=207385

Dowling, F.G., Moynihan, G., Genet, B. & Lewis, J. (2006). A Peer-Based Assistance Program for Officers With the New York City Police Department: Report of the Effects of Sept. 11, 2001. American Journal Of Psychiatry: Official Journal Of The American Psychiatric Association, (1), 151. doi:10.1176/appi.ajp.163.1.151

Kulbarsh, P. (2016) “2015 Police Suicide Statistics” Officer.com. Retrieved on September 4, 2016 from http://www.officer.com/article/12156622/2015-police-suicide-statistics

Levenson Jr, R. L., O’Hara, A. F., & Clark Sr, R. (2010). The Badge of Life Psychological Survival for Police Officers Program. International Journal Of Emergency Mental Health & Human Resilience, 12(2), 95-101.

Mishara, B. L., & Martin, N. (2012). Effects of a comprehensive police suicide prevention program. Crisis: The Journal Of Crisis Intervention And Suicide Prevention, 33(3), 162-168. doi:10.1027/0227-5910/a000125

New Jersey Police Training Commission. (2016) Basic Course for Police Officers.

Roufa, T. (2015) “What is the Divorce Rate for Police Officers?” The Balance. Retrieved on September 4, 2016 from https://www.thebalance.com/what-is-the-divorce-rate-for-police-officers-974539

Stedman, T. (2016) Stedman’s Medical Dictionary (28th ed.). Philadelphia: Lippincott Williams & Wilkins.

Cite this article as: MacDonald, D.K., (2016), "Law Enforcement Suicide Prevention," retrieved on May 29, 2017 from http://dustinkmacdonald.com/law-enforcement-suicide-prevention/.
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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 May 29, 2017 from http://dustinkmacdonald.com/providing-emotional-support-text-chat/.
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