Advanced Crisis Line Training

Introduction

A few years ago when I was working for Distress Centre Durham (DCD), I undertook a project to develop a new advanced training curriculum for telephone responder. Currently the Basic Training is 16 hours of in-class, plus another 16 hours of supervised phone shifts where a responder demonstrates that they have the active listening, empathy, suicide and crisis intervention skills we need for them to be on the phones independently.

After about 3 months or 50 hours they are required to undertake an Advanced Training session. This session helps consolidate some of the learning, revisit some of the classroom skills and then to build some additional skills going forward.

This training was turned into a PowerPoint that I won’t share because it contains some copyrighted Distress Centre Durham material – but you can read below for information that you could use as the foundation of your own advanced crisis line training. I’ve since made some updates so this training goes beyond the original that I developed for DCD.

Session Information

The length of the session was usually about 3 hours. The content covered was as follows:

• Introduction
• Burnout and Stress Management
• Handling Difficult Calls
• Advanced Suicide Intervention
• Advanced Crisis Intervention
• Discussion of Difficult Situations
• Conclusion

Five Step Limit Setting Process

For more information on this limit-setting process, you can see my article Setting Limits and Boundaries with Callers. Briefly, the five steps are:

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

Active Listening Process (ALP)

For more information on the active listening process, you can see my article Active Listening Process on Crisis Lines. As a quick reminder, the different skills in the ALP include:

• Voice Tone
• Pace
• Setting the Climate
• Open Ended Questions
• Close Ended Questions
• Empathy Statements
• Clarifying
• Paraphrasing
• Summarizing
• Referrals
• Winding Up

Burnout and Stress Management

What is Burnout?

Burnout is a “state of physical, emotional, or spiritual exhaustion.” It occurs when we give too much of ourselves for too long and don’t take appropriate steps to recover. Symptoms of burnout can include:

• Becoming cynical or critical of callers
• Being irritable or impatient
• Feeling responsible for the outcome of calls
• Having unexplained headaches or other physical complaints

An example of a situation I knew a responder was feeling burned out was when they took a 20 minute call with a regular caller who was dealing with relationship issues. While their on-the-phone work was good, when the call was over, they were very upset that the caller was not in crisis and just wanted to bounce ideas off the responder.

This responder felt like their time was being wasted by this caller, when we could be taking crisis calls instead. It’s clear that responder cared a lot for our callers – but they were not treating all of our callers like they were important to us. For this reason, we had a discussion about how our service is preventative and designed to both provide emotional support and crisis intervention. The responder took a leave of absence and when they returned several weeks later they were recharged and ready to support all of our callers.

Emotions on the Helpline

We can experience a range of emotions on the helpline. Some of these are positive and some of these are negative.

Positive Helpline Emotions

• Excited
• Grateful
• Happiness
• Hopeful
• Meaningful
• Optimistic

Negative Helpline Emotions

• Anger
• Frustration
• Guilt
• Confusion
• Physical fatigue
• Nightmares
• Intrusive thoughts

What Causes Burnout?

There are a number of causes of burnout. These include working too many hours on the helpline – feeling like you’re a martyr or you always have to be there. Having your expectations set too high and expecting clients to change or improve (they call us because we’re a source of support that don’t ask them to change.)

Being isolated or having a lack of social support can increase burnout, as can a failure to debrief either with peers or supervisors after your calls. Feeling disconnected from the day-to-day events and other things happening at the crisis line can also cause increase your fatigue and burnout.

Overall, if you feel ineffective in your work you’ll be at greater risk for burnout.

Preventing Burnout

To prevent burnout, it’s important that you always debrief after tough calls. You can talk to your peer in the call room, you can talk to your supervisor. You can work fewer shifts or even take a Leave of Absence away from the Centre for a while, to recharge. Adjusting your personal life so you have a better work/life balance, and coming to Team Meetings and other social events can help you.

Finally, stress management techniques and having a strong support network will help you prevent burnout.

Relaxation and Stress Management Techniques

• Bubble Bath
• Hot Shower
• Meditation
• Physical Exercise
• Sleep
• Yoga
• Others…?

Handling Difficult Calls

There are a range of difficult callers that responders can be confronted with. These include individuals with significant mental health issues, “chronic” or repeat callers who are calling for social maintenance reasons and sexual fantasizers or abusive callers who are trying to misuse the service.

Seriously Mentally Ill Callers

These individuals have significant struggles or may be actively in a mental health crisis. They might speak very quickly and not let you get a word in edge-wise, or they may be very impatient. Winding up the call be difficult and these calls can make you feel ineffective or frustrated.

Remember to keep an open mind, and remember why we support these callers. They often have few resources other than us that are non-judgemental and empathic. Let the caller vent their fears, anxieties and frustrations, but always remember the Active Listening Process (ALP).

If a caller is having delusions, we must not feed into those delusions but instead empathize with the underlying emotion. Rather than saying “Yes, there could be vans outside your house monitoring your thoughts”, say something like, “That would be really scary if it were happening.”

Social Maintenance Callers

These individuals are calling because they’re lonely. While our service provides support to them we must make sure that they do not monopolize the lines, or push boundaries in trying to collect personal information on our callers.

We will use our 5-Step Limit Setting Process if the caller wants identifying information, and try to engage the caller openly in things that they can do, or that you and them can talk about, to reduce their loneliness. When the call starts going in circles (they’re repeating themselves and not moving on to anything new), we can begin to wind up the call.

They should call us back tomorrow if they’d like to speak again, and you can discuss with staff the setting of a time limit or other restrictions.

Sexual Fantasizer Callers

These can be some of the most frustrating calls for us to deal with, because they make us question what we’re doing on the helpline. These callers are often difficult to determine as sexual fantasizers at first – they drag it out as long as possible.

When we begin to suspect that we’re speaking with a sexual fantasizer, we must remind them to stick to the discussion of the emotions of their problem. For example, sometimes we get legitimate callers who want to talk about cross-dressing, sexual orientation, or sexual fetishes. If these callers are genuine, they will prefer to speak about the emotions of those elements and how they impact those around them, rather than discussing the specific activities of cross-dressing, having sex with men, or engaging in a sexual fetish.

You might feel angry or used when the call ends if you don’t figure it out early enough. You’ll need to make sure that you debrief and put your stress management techniques into practice.

Angry or Abusive Callers

These callers are those who are calling to take emotions out on you. This can be challenging and is not an appropriate use of our service. Using your Five Step Limit Setting Process, you’ll need to let the caller know that you are here to listen if they are upset but that they cannot direct language at you.

If they would like to make a complaint, they should call the office line. Set the boundary, and if they continue then you’ll end the call. And make sure you follow through!

Suicide/Crisis Intervention

Suicide intervention is the process of assessing and intervening with someone who is at high-risk of suicide. Once you’ve done some risk assessments on the phone you’ll have a better sense of how to weave these questions into your exploration of the caller’s issues.

By starting each suicide assessment with “Have you done anything tonight to kill yourself or end your life?” you’ll be able to move smoothly into the safety planning questions. Your goal is to make sure that you have a sense of whether the caller will be safe tonight. If they will, you don’t have to worry. If they won’t, you can begin building a safety plan or support network collaboratively with the caller to make sure they will be safe.

You’ll want to conduct a suicide risk assessment:

• Any time you suspect a caller is suicidal
• When they tell you they’re having suicidal thoughts
• Even if the person denies current suicidal thoughts

In an emergency, when the caller has already taken steps to end their life, you must:

1. Change your voice tone. Become assertive, to let that caller know that they need to cooperate with you so you can get them help
2. Collect their location, and other identifying information
3. Tell them to unlock their door, open the door if they can, so that emergency personnel can reach them
4. Debrief after the call with your supervisor

Example of Suicide Intervention

• Caller explains they have self-injured today
• Responder assesses suicide risk, they come up medium on the CPR or DCIB Suicide Risk Assessment
• Responder explores coping strategies but they say there’s nothing they can do, they’ve tried it all and they can’t guarantee their own safety
• Responder arranges for a taxi to take them to hospital or mental health crisis bed

Discussion of Difficult Situations

During the discussion of difficult situations, responders would talk about situations that they personally found challenging – whether or not they were covered on the above. A group discussion would help responders get a better sense of how their peers would handle those situations, and the facilitators would share their own thoughts. This helped to increase the confidence of the responders in dealing with those situations in the future.

Conclusion

We would wrap the session by thanking everyone for coming out and presenting them with an Advanced Training certificate. Completion of both Basic and Advanced Training was required for a responder to be considered a Certified Volunteer Helpline Worker.