Transcript Document

By: Dina Crowell
The internet is booming with online crisis
counseling. The majority of crisis counseling
now is dealt with on the phone. The other
person on the other end of the phone/internet
could possible be a volunteer(that does not
hold a degree in social work/ psychology/
counseling), or a professional with credentials.
This presentation focuses on the large current
venue of telephone use in crisis counseling.
Telephone has played a major role in crisis work. Bell
telephone advertisement “Reach out and touch
someone” is a slogan that is appropriate for
counseling.
 The suicide prevention in the 1950’s started using the
telephone as the primary mode of treatment.
 It offers immediate service
 It is used mostly in suicide intervention.
 Is suicide intervention only for suicide callers?-No
-Gamblers, people who suffer from panic attacks,
domestic violent victims, depressed, alcoholics,
grievers, lonely, and people who suffer from psychotic
breakdowns.

Convenience
 Client Anonymity
 Control
 Immediacy Access
 Cost Effectiveness
 Therapeutic
Effectiveness
 Availability of Array of
Services

Access to Support
Systems
 Avoidance of
Dependency Issues
 Worker Anonymity
 Service to
large/isolated
populations
 Availability of others
Consultation

Convenience- The use of cell phones allows a person to call a crisis hotline from
anywhere.
Access a variety of self help groups(e.g. chat rooms, computer assisted therapy, and
psychoeducational materials)
Client Anonymity- Opening up to another person is vulnerability. (guilt,
embarrassment, shame, self-blame, and other emotions makes face to face therapy
with stranger difficult)
*Hiding your identity can make it easier for a person to open up more.
*Telephone/online counselors are not concerned with revealing identity unless it is a
life threatening situation.
*Conversation is on a first name basis for client/worker.
Control- Going for help may be positively humiliating. The client decides when and if
assistance should be sought. Anybody who is self conscience about how they look finds
the telephone wonderful for counseling.(Wark, 1982)
Immediate Access- A crisis can occur at anyplace/anytime. Most clinics and institutions
keep beepers.
Cost effectiveness- Crisis hotlines are inexpensive. Clients who cannot afford
therapy/transportation can use the phone/computer.
Therapeutic effectiveness- Volunteers are often seen by callers as having more
credibility than a paid professional. Why? They do it out of the kindness of their
hearts.
Access to support systems- The main reason people call hotlines is for social support.
(Watson, McDonald, & Pierce, 2006) Telephone/online counseling can be referred or
gained access on your own.
Avoidance of dependency- A person who uses telephone crisis lines cannot become
dependent upon on a particular worker who may/may not be always available.
Standard practice in most crisis lines discourage workers from forming lasting
relationships with clients.(Lester, 2002
Worker Anonymity- Workers who are anonymous have many benefits as clients.
1. Body language
2. Facial expression
3. Visual image
Availability for other consultations- One line is reserved for calling support agencies
when there is an emergency.
Crisis hotlines staffs more than one person, especially when they encounter
a difficult client.
Availability of services- A large amount of info, guidance, and social services is
available by telephone. They can provide on the spot guidance. Any crisis hotline
should have a list of numbers available of special agencies to refer call.
*LINC- Library and Information Network for the Community is standard reference for
most telephone crisis lines.
Service to large/isolated areas- Rural areas that have no after hours mental health
facilities or staff have a toll free crisis line. These lines are tied in to emergency
services such as police, paramedics, and hospital emergency rooms.

Conducting crisis intervention on telephone is a double edged
sword. Why?
The crisis worker is dependent on
1.
Content
2.
Voice tone
3.
Pitch
4.
Speed
5.
Emotional content of client
*Telephone/Online counseling is not for everyone (Eckardt, 2001)
-The worker depends on their verbal ability to stabilize the client.
-The worker has little control over the physical situation.
-Psychological contact is where the worker attempts to establish a quick,
nonjudgmental, caring, accepting, and empathetic relationship with the client
that will give the worker the client’s trust.
*Support is the first order of business. You can do this by defining the problem
through active listening and responding skills. You do not want the client to hang
up.
-Here are some good techniques for the worker
1. React in a calm manner
2. Worker’s voice should be modulated
3. Steady
4. Low keyed
Only interrupt to clarify and summarize with the client
The worker should never respond
1.Deprecating
2.Cynical
3.Demeaning
4.Cajoling
*When the client is acting out, angry, intoxicated, or demanding, The worker
needs to remember these techniques.
The worker can define the problem by:
-Gaining an understand of the events that led to the crisis
-Assessing the client’s coping mechanisms
-Open ended questions are a good solution. For example, what, how,
when, where, and who? This gives the worker a clear picture.
How would you assess the coping mechanisms of the client over the
phone?
A.
Be more sensitive to emotional content
B.
Reflect the implied feeling content
What are the plus signs to phone counseling?
 Have supportive aids readily at hand without detracting from the
counseling session
 Have a reference list of feeling words that covers the emotions.
 Have a list of standard questions the counselor can check off
 Keep a notepad handy for events and coping mechanisms and the
triage assessment scale.
-
The worker must determine the clients lethality
level.
- If the worker detects physical injury, closed ended
questions should be asked for safety of the client
with understanding and concern. For example,
questions may start with do, have, and are? (e.g. Do
you have the pills there with you now?)
- The phone counselor should check what support
system is available for client’s safety.
- There will be no support system for many phone
clients.
*The phone counselor is the immediate and sole support
system.
-
*Having a plan and creating alternatives in important in a crisis
situation especially in phone counseling.
-
Alternatives needs to be simple and clear.
-
The worker needs to avoid giving alternatives that are difficult to
do because of tactical and logistical problems
-
Alternatives needs to be done in a slow manner to ensure that
the client can do the physical/ psychological work
-
Here are some helpful tactics:

Role play

Verbal rehearsal

Have client recapitulate objectives

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Commitment to a plan over
the phone should be simple,
specific and time limited.
Try to obtain the client’s
phone number and call the
client back at a present time
to check on the plan/ try to
have client schedule an
appointment a.s.a.p..
If worker is linked to other
agencies a phone call should
be made to the referral to
see of the client has
completed the task.

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

First you are not omnipotent,
you are there to be a instant
expert.
Second callers are resilient
and need somebody to talk to
honestly and openly.
Third if you feel
manipulated, it’s okay.
Understand that the caller’s
need to manipulate serves a
purpose. That purpose should
result in restoring the caller’s
psychological equilibrium
without harming anyone.
Fourth all callers are not
loving and you do not have to
be loving and caring to all
callers(Lamb, 1973)

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Crisis lines should not cater to a caller’s every, whim,
fantasy, deviant behavior, or self indulgence.
Chronic callers can devour time and energy of staff.
These callers can pose a serious morale problem for
the volunteers and staff who receive calls that
become too explicit and it is directed to the crisis
worker.(Brockopp & Lester, 2002; Knudson, 1991;
Tuttle, 1991)
All behavior is purposive. If seen this way it helps
workers make it through the day.
By setting limits 10-20 minutes for regular callers,
workers won’t become controlled by regular callers.

Helping a person in a crisis is different. The agenda of regular
callers places a dilemma on the crisis worker.

All calls must be taken but it does not mean that workers should
suffer from the abuse.

Helping a caller is more of what they need than what they want

Regulars often want reaffirmation that their problems are
unsolvable. Why?
-They become dependent on the telephone worker to sustain
their problem.

Telephone workers do themselves and their callers a service
when they show that they are not willing to be manipulated or
abused.
*Generally if the telephone worker spends more than 15-20 minutes
with a caller, the client’s crisis becomes the worker’s crisis
(Knudson, 1991)


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Paranoid- they are guarded
secretive and can be jealous. It is
difficult to shape their
persecutory beliefs. They see
themselves as victims. The
counseling focus is to stress their
safety needs.
Schizoid- restricted emotional
expression and experience. They
have few social relationships.
They are anxious, shy, and self
conscious in social settings. The
counselor focus is to build self
esteem through acceptance, and
support.
Schizotypal- are insecure and have
inadequate feelings. The focus of
the counselor is to give them
reality checks and promote self
awareness in a supportive manner.

Narcissistic- are self centered and believe
they have unique problems that others
cannot comprehend. They see themselves as
victims by others and always need to be
right. The focus of the counselor is to get
them to see how their behavior is seen and
felt by others.

Histrionic- move from crisis to crisis. They
are ego involved and have a shallow
character. They crave excitement and
become bored with routine tasks and events.
They may also behave in self destructive
ways. The counselor focus is to stress their
ability to survive using resources that have
been helpful to them in the past.

Obsessive Compulsive- fixated on tasks. They
waste large amounts of time on endeavors.
They often may not hear counselors. The
counselors duty is to establish client to trust
others and the use of stopping behavior
modification to stop obsessive thinking and
compulsive behaviors.

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
Bipolar- extreme mood swings of
callers. May become aggressive or
suicidal behavior. Counselors
responsibility is to slow down the
client. Confrontation about their plans
only alienates them. In depressive
stage suicide intervention is a priority.
Dependent- have trouble making
decisions and seek others to do so.
They feel worthless, insecure, fear of
abandonment. Prone to become
involved in self destructive
relationships. Focus of counselor is to
reinforce strengths and support their
concerns without becoming critical for
their lives.
Avoidant- are loners and have little or
no social relationships. Focus of the
counselor is encouragement through
social skills and assertion training.

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Passive Aggressive- cannot risk
rejection by displaying anger. They
engage in attempts to manipulate
others and believe control is more
important than self improvement. The
counselor is to promote more open
and assertive behavior.
Borderline- are chameleon like and
may resemble any mental disorders.
Always on the borderline of being
functional and dysfunctional. *one of
the most problematic callers.
Self defeating- choose people and
situations that lead to failure,
mistreatment by others. They reject
attempts to help them and make sure
they won’t succeed. The counselor
should stress talents and the
behavioral consequences of sabotaging
themselves.
The behavior of the severely
disturbed is disorganized,
disoriented, and disabling.
They elicit discomfort, anxiety,
and fear in the observer.
 These callers represent mental
illnesses.
 They may be delusional and
hallucinatory.
 Lack insight of judgment about
their problems
 Be manipulative, resistant, and
hostile.
*They are usually locked in
mental institutes, and are
threatening.

What are behaviors that can
be recognized by the
counselor?
-Behavior is always purposeful
and serves motives that may
be either conscious or
unconscious.
-Behavior is comprehensible
and have meaning even
though the language used may
not.
-Behavior is used to keep a
person safe and free of
anxiety.
1.
2.
3.
4.
5.
6.
7.
Slow emotions down
Refuse to share hallucinations and delusions
Determine medication usage
Keep expectations realistic
Maintain professional distance
Avoid placating
Assess lethality
Remember every call is an attempt by
the caller to fulfill some need or purpose.
-Rappers- some may just want to rap or
talk. They may be testing the waters to get
enough courage to call.
-Covert callers- callers that ask for help for
another person. They may be actually asking
for help for themselves. These may be timid
callers.
-Pranksters/nuisance callers- teenagers who
are bored.
Silent callers- They are usually hurt or fear
rejection and don’t have the courage.
•
-Sexually
explicit callers- They have
low self esteem and, lack of trust, and
feelings of isolation. These callers are
usually hung on the crisis line because
the worker may become angry,
embarrassed, and afraid.
Callers with legitimate sexual
problems- They call because it is
anonymous to discuss private issues.
These calls may embarrass the worker
who are not psychologically prepared
for intimate details.
-Manipulators- a lot of callers play
games by achieving their unmet
needs. Usually it is role reversal .

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1.
2.
3.
4.
5.
6.
Set time limits
Terminate Abuse
Switch Workers
Use Covert Modeling- example ask client to use mental
imagery to picture or extinguish a particular behavior.
Formulate Administrative Rules
Limit the number and duration of calls from single caller
Limit the topics that will be discussed
Require specific workers for handling abuse callers
Use speaker phones
Establish face to face relationship with outside worker
Allow staff to prohibit calls for a day/week/or more.

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Hotlines are growing
tremendously.(e.g. there are pet
loss support groups)
Crisis phone lines are open 24
hours a day 365 days
Specialized services may operate
regular business hours(e.g. Disease
and Control Aids)
Warmlines deal with less than life
threatening matters(e.g.
homework)
Hotlines deal with life
threatening/endangering problems
National hotlines can be reached
anywhere. Local is limited
Hotlines
This is a specified
period of time
 Used to deal with a
potential disaster or
after a disaster.
 It may provide brief
supportive therapy or
for
information/referral
source

Time Limited Hotlines
Continuous National
Hotlines
-Toll free; deal with specific
topics (e.g. troubled youth)
-Major purpose is to provide
info about geographic
location nearest the caller.
-These lines are heavily used
-They encourage runaways
to get off the streets and
talk problems.
-Domestic violence hotline is
available for any victim of
abuse in the U.S.

Local Crisis Hotlines
-Handle all kind of calls (e.g.
suicidal, lost cats
 They are staffed by
volunteers from local
communities
 Provide telephone crisis
for a specific
region/population

The computer is not only a communication
device; it functions as a simulation device (Wolf,
2003)
 Both have potential for psychotherapy and crisis
intervention
 Most professional therapists do not use computer
assisted counseling/ or provide online
counseling.
 Here are some reasons:
A. Ethical concerns
B. Commitment to humanistic values that conflict
with technology
C. Cost
D. Absence of training (Murphy, 2003)

What is behavioral telehealth? It is the use of
telecommunication and information technology
to provide access to behavioral health
assessment, intervention, consultation,
supervision, education, and information across
distance (Nickelson, 1998)
-This can include email, chat rooms, websites, and
internet teleconferencing (Barnett & Scheetz,
2003)
-Crisis intervention on the web can be time
delayed such as websites and emails.
-Real time such as chat rooms, videoconferencing,
Skype, and instant messaging

-Websites that provide
opportunities for net “surfers”
to seek emergency help or
advice,
Counseling, or psychological
help continue to grow.
-For example Befrienders
International provides a website
that offers help to suicidal and
other
People in a crisis.
-They have helped people for
40 years by letter, telephone,
and in person. Emails remain
Anonymous if requested.
-There are 20 centers around
the world
What are the appeals of online counseling?
-people who are psychological/geographically
isolated from crisis services
-suffering from mental/physical disabilities
-shy/don’t want to meet face to face
-needs anonymity
 Feedback- continuous and immediate
feedback is critical
-Use email to check on the client several times
an hour/day/week
 Disinhibition-people tend to open up earlier
with more distressing issues than they would
face to face.

Problems of online counseling
-You only know about how much credential a person has by what they tell you.
-Clients could possibly effect the crisis computers with viruses/spyware
• Confidentiality- once a message goes out there is no guarantee anonymity
• Identity verification in emergency situations involving homicide, suicide, or other
life
threatening events.
• Charlatans-fees are extremely high
• Licensing and insurance
• Learning the language-netiquette
• Netiquette
1. Sloppy writing and typos means you don’t care about your client
2. Emoticons can be helpful/too cute
3. Be clear on the acronyms
4. Keep text neutral(e.g. black font, 12 point times)
5. Be care constructing your responses
6. Use standard counseling skill responses to do work/let the client talk
7. Keep inflammatory remarks under control/quickly apologize/client needs to know
limits
Predispositioning- miscommunication can occur. Set the tone as
a) Empathetic
b) Genuine
c) Caring
d) Positive
There is still much to be done in research and
protocol development in behavioral telehealth
and cyber counseling
 You need to know professional ethical standards
and state and federal regulations and laws
 Most telephone workers are volunteers and
receive minimal training. The agencies are not
bound by state or federal supervision or
legislation (Seely, 1997a, 1997b)
 Does it work? It is helpful but others have stated
they would prefer face to face counseling

References
James, R. K. & Gilliland, B.E. (2013). Crisis Intervention
Strategies (7th ed.).
Discussion Questions for Presentation Outline
1. Why do you think it is hard for a person to trust and discuss
their personal issues online with someone who you cannot
see, or hear their empathizing tone?
2. Why do you think online and telephone counseling is/isn’t
effective?