For A-plus Writer Only

Book Reference

James, R. K. & Gilliland, B.E. (2017). Crisis intervention strategies (8th ed.). Boston, MA: Cengage Learning.

Introduction By far and away the vast majority of crisis counseling is now handled by telephone. Most probably the person on the other end of that telephone is a volunteer who does not hold a degree in social work, psychiatric nursing, counseling, or psychology. As we move further into the 21st century, the Internet is playing a larger and larger part in real-time crisis counseling as is the smartphone with its app and texting ability. Whether the service provider on the Internet will be a professional with credentials, a well- meaning volunteer with no training, a charlatan out to steal your money or your daughter, or a computer programmed to do crisis intervention is an interest- ing question (Hsiung, 2002; Gross & Anthony, 2003; James & Gilliland, 2003, pp. 417- 428).

This chapter is mainly about the large, current venue of telephone use in crisis counseling, but clearly online crisis counseling has arrived, and it is grow- ing at such a staggering rate that books specifically targeted to e-therapy protocol and use are now being written (Adlington, 2009; Anthony & Nagel, 2010; Jones & Stokes, 2009), and an International Society for Mental Health Online has come into existence (https://www.ismho.org/ home. asp). The final section of this chapter will d eal briefly with what is the new, cutting edge of psychotherapy, virtual reality therapy (Gaggiolli, 2014; Stevens, 2014; Wiederhold & Wieder- hold, 2005). Here is a quote from the noted physicist Max Planck: "A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather b ecause its opponents eventually die, and a new generation grows up tha t is familiar with it" (as cited in T. S. Kuhn, 1962). What do you

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think of it? You might want to think carefully about Planck's quote, because these new technologies are going about the business of how the whole notion of therapy is carried out. The problem is that little is still being done in professional programs to train therapists on how to use these new technologies and still focus on face-to-face encounters, and as a result don't believe that therapeutic alliances can be built with computer-based technology (Lop ez, 2014) . Amichai-Hamburger and associates (2014) propose a model for using online therapy with the therapist at the center of the technology. So the question becomes one of, "Will you be at the center of this new technol- ogy or will we be waiting to go to your funeral?"

Case Handling on Telephone Crisis Lines -:-h e telephone has long played an integral role IDJI !n crisis work. The old Bell Telephone advertisement Re ach out and touch someone!" is a slogan that is

?articularly appropriate to crisis counseling. Slaikeu 1990, pp. 105-141) refers to emergency telephone

:ielp as "first-order intervention" or "psychological ~rst aid." Indeed, the telephone is the most prevalent medium for the initial contact in most crisis service aelive ry. There are several reasons for the popularity o the telephone in solving psychological problems.

onvenience. Convenience is paramount (Leffert, _0 03; Reese, Conoley, & Brossart, 2006). Particularly ell phones have become such an easy way of commu-

:llcating that calling for psychological assistance is a :iatural extension of "taking care of business." The cremendous upsurge in the use of cell phones allows a person to call a crisis line from anywhere, including die site of the crisis as it is happening in real time. Further, with the new "smart" phones, not only can clients avail themselves of a crisis hotline or their rherapist, they can also access a variety of self-help qro ups in chat rooms, computer-assisted therapy, and ?sychoeducational materials (Boschen, 2009; Gross & _.\nthony, 2003; Preziosa et al., 2009). As in the case of battering, most crises do not occur during normal

usiness hours. When help is needed in a crisis, it is needed immediately, and mobile phones make 24/ 7 assis tance even more available.

Client Anonymity. Guilt, embarrassment, shame, sel f-blame, and other debilitating emotions make ace-to-face encounters with strangers very diffi-

cu lt, particularly in the immediate aftermath of a craumatic event. Opening oneself to another is an ac t of vulnerability. The ability to hide one's identity :nay facilitate greater openness and freedom from illhibition (Reese, Conoley, & Brossart, 2006). This is particularly true of adolescents (Christogiorgos et al. , 20 10; Tolmach, 1985), those who are socially isolated or psychologically desperate, and the relatively stable tierson who has a one-shot crisis (Lester & Brockopp, 1973, pp. 86-87). Telephone counselors understand th at clients have such feelings and are generally not concerned about identifying a client unless a life- rh reatening emergency is involved. Conversations are u sually on a first-name-only basis for both the worker and the client. Thus, a victim of date rape may call

CHAPTER SIX Telephone and Online Crisis Counseling • 117 .. a rape hotline and freely discuss her emotions with- out having to muster the courage to face what may be perceived as a judgmental human services worker.

Control. A great deal of fear, anxiety, and uncer- tainty occur when a client's life is ruptured by a crisis (Lester & Brockopp, 1973, pp. 81-82). The concept of secondary victimization by institutions (Ochb erg, 1988) is well known to victims of a crisis who have sought assistance from a social agency and then been victimized by its bureaucratic callousness . Going for help may be positively humiliating. In telephone counseling, the client decides when and if assistance is to be sought. At any time during a dialogue on a crisis line, the client may terminate the conversation without fear of recrimination. Finally, looks don't matter in phone counseling. Anybody who is self- conscious about how they look finds the phone a won- derful way to obtain counseling (Wark, 1982).

Immediacy of Access. Crisis intervention can occur any place a telephone, or for that matter a computer, is available (Masi & Freedman, 2001). Most institu- tions and clinics and many private practitioners use pagers. At our own university, a harried residence hall supervisor who is trying to deal with a dis- traught, suicidal student who is suffering from severe homesickness and academic failure can call campus police. The police will page a member of the staff of the student counseling center who is the after-hours "beeper keeper." The psychologist immediately re- sponds to the request for assistance by checking with the residence hall supervisor on the current mental status of the student and will then come to the resi- dence hall, talk to the student over the phone, or request additional help from the police to transport the student to the city crisis stabilization unit. In case of an imminent threat such as a tornado or the presence of a potential assailant on campus, text and computer messages can go out to all the students and university staff.

Cost Effectiveness. Crisis lines are inexpensive-for both the client and the community (Masi & Freedman, 2001). Clients who cannot pay for private therapy or af- ford transportation can usually avail themselves of a phone. Most community agency hotlines are staffed by volunteers and are paid for out of United Way or other charitable funds. Reese, Conoley, and Brossert's (2006) study of telephone counseling strongly implies that, for people of limited financial means , face-to-face

118 • PART ONE Basic Training: Crisis Intervent ion Theory and Application

counseling where money is a factor is not an option as opposed to a free community crisis line.

Therapeutic Effectiveness. Volunteers who staff crisis lines have probably been the single most important discovery in the history of suicide intervention (Dublin, 1969) . Volunteers have few pretensions about their "professional role" and are often seen by callers as having more credibility than a paid professional be- cause they "do it out of the goodness of their hearts ." Although the idea of obtaining counseling from a volunteer may seem no better or worse than talking to a bartender or hairdresser, and when they receive little training they are probably worse (Derkx et al., 2009), volunteers typically go through a good deal of training in initial point-of-contact mental health counseling. Phipps, Byrne, and Deane (2007) found that volunteers who went through training specifi- cally designed to deal with trauma showed significant gain in knowledge and skills from pre - to posttrain- ing. Mishara and his associates (2005) found that less than 0.3% of 2,611 calls they monitored at 14 par- ticipating call-in centers were found to be blatantly unacceptable in helper responses and could possibly put the lives of the callers at risk. Gould (2007) and her associates found a significant decrease in suicidal ideation in the course of crisis line calls and continu- ing decreas es in caller hopelessness and psychological pain in follow-ups with suicidal callers.

While there is still a good deal of contempt by professionals for crisis hotlines, research indicates that they are probably as good as other types of face- to-face counseling and are particularly attractive to young people, old people, and people who do not have financial access to professional therapists (Bry- ant & Harvey, 2000; Day & Schneider, 2002; Evans et al., 1986; Fukkink & Hermanns, 2009; Lester & Brockopp, 1973, p. 86; Reese, Conoley, & Brossart, 2002, 2006; Rohland et al. , 2000).

Access to Support Systems. One of the major reasons people call hotlines is for social support (Watson, McDonald, & Pierce, 2006). Many people who are lonely, anxious, or isolated by physical illness are in ne ed of support (Burgess et al. , 2008). Whether you are a shut-in, shy, ugly, recently divorced, widowed, abused, addicted, or you have leprosy, panic attacks, bad thoughts, or any of the issues of problem callers you are about to meet in this chapter, the need for social support a~d an empathic ear and voice is the common thread that runs through most crisis lines.

Beyond the support of the line itself are the telephone and online support systems to which you can be referred or gain access on your own.

Support groups make extensive use of tele- phone networks (Lester & Brockopp, 1973). From A (Alcoholics Anonymous) to Z (Zen) support groups, telephone support networks provide constant links to group members between organi zed meetings. A Google search conducted on February 23, 2015, identified 371 million sites for support groups. The bottom line is that if you can't find a support group out there somewhere for your problem, you are prob- ably an alien escapee from Roswell's Area 51 and this book isn't going to be a lot of help to you.

Avoidance of Dependency Issues. A user of telephone crisis lines can't become dependent on a particular human services worker who may not always be readily available. Standard practice in most crisis lines dis- courages workers from forming lasting relationships with clients so that dependency issues do not arise (Lester, 2002).

Worker Anonymity. The fact that workers are anony- mous has as many benefits as client anonymity. The absence of body language, facial expressions, and a visual image allows clients to project whatever idealized view they may conjure up of the therapist. By facilitating the development of transference, within limits, the client can make positive changes. The point here is that not only can clients make of the therapist what they will, they can make of them what they need (Lester & Brockopp, 1973, p. 85; Williams & Douds, 2002, pp. 60-61).

Availability of Others for Consultation. Crisis lines are seldom staffed by one person. When someone encounters a difficult client, other staff at the agency are available for consultation. Furthermore, at least one phone line is reserved for calling support agencies when emergency services are needed.

Availability of an Array of Services. A vast array of information, guidance, and social services is quickly available via telephone linkages. The specialized services of different agencies and the expertise they of- fer can provide on-the-spot guidance for emotionally volatile situations. Many an angry mother or father has received "5-minute parenting sessions" from the staff of a metropolitan "parenting line ," thus short- circuiting potential child abuse. Any crisis hotline

should have readily available a list of phone numbers of sp ecialized agencies to which they can refer callers. -:-h e LINC, or Library and Information Network for :he Community, is available in most large metropoli- :an areas and is standard reference for most telephone Jisis lines.

Ser vice to Large and Isolated Geographic Areas and Pop ulations. Many rural areas that have no after- . ours mental health facilities or staff are tied in to :oll-free crisis lines that cover huge geographic areas. -:-h ese crisis lines in turn are tied in to emergency service staff such as police, paramedics, and hospital emergency rooms that serve those rural areas and can :espond to a crisis line call for assistance that may · e 150 miles away. Certainly populations that are · omebound, such as the elderly, physically disabled, or agoraphobic, have a lifeline they would not other- •rise have (Lester & Brockopp, 1973, p. 82; Williams & ;Jo uds, 2002, pp. 59 - 60).

Telephone Counseling Strategies Conducting crisis intervention over the tele- IDJI ?hone is a double-edged sword. Although phone .:ou nseling offers the advantages just listed, for gen- erating responses the crisis worker is entirely depen- d ent on the content, voice tone, pitch, speed, and emo tional content of the client. Telephone counsel- :ag, and Internet counseling for that matter, isn't for e\·e ryone, and that includes both clients and interven- :ionists (Eckardt, 2011). For many human services

orkers, it is unsettling to deal with ambiguous cli- eat responses and not be able to link body language :o verbal content. Furthermore, the worker depends eatirely on his or her own verbal ability to stabilize ille client and has little physical control over the situ- c..rion. It takes only one experience of having a suicidal .:ient hang up on a worker to understand how frus - ::-ating and emotionally draining crisis intervention m·er the telephone can be. Consequently, a great deal of care and effort needs to be taken in responding to -:.ients. The following section outlines some effective : elephone counseling strategies.

11a king Psychological Contact ?irs t, psychological contact needs to be made, and ~s endeavor takes precedence over anything else the :hone worker does. Psychological contact means that :he worker attempts to establish as quickly as possible

CHAPTER SIX Telephone and Onl ine Crisis Counse ling • 119 ...

a nonjudgmental, caring, accepting, and empathic re- lationship with the client that will give the worker credibility and elicit the client's trust. Therefore, pro- vide support becomes the first order of business. It is safe to assume that people who use crisis lines have exhausted or are separated from their support sys - tems. If the client feels no trust in the relationship and hangs up the phone, the crisis worker cannot make an astute dynamic analysis, synthesize mate- rial, diagnose the problem, and prescribe a solution! In establishing psychological contact on the phone, providing support is a first priority and is highly inte - grated with defining the problem through active lis- tening and responding skills.

CW: (Two A .M. on Monday morning. Phone rings.) Metro crisis line. This is Chris. Can I help you?

Telephone caller (TC): (Silence with soft muffled sobs.)

CW: (Waits patiently.) I understand it's pretty hard to talk sometimes, especially when things seem so overwhelming, but if you could, just take a deep breath and then let it out. I wonder if you could just do that?

TC: (Takes a deep breath and exhales. Sobs less frequently.)

CW: (in a soft, modulated, soothing tone) That's good! Just do that a few more times . Just relax . I'll stay right on the line until you feel like talking. We've got plenty of time. I'd like to know your name when you feel ready?

The phone worker must be able to react in a calm and collected manner. Thus, the worker's voice must be well modulated, steady, low keyed, with an adequate decibel level but not high pitched. Neither should the content of the worker's response be deprecating, cyni- cal, cajoling, or demeaning. Although the foregoing criteria may seem obvious, few people realize how their voice sounds or are aware of what happens to their voice level and pitch when they are caught up in a rapidly escalating and evolving emotional event . Furthermore, when the person on the other end of the line is acting out, angry, intoxicated, or otherwise demanding of the worker to "fix things right now," the worker needs a great deal of self-discipline and emotional security to refrain from becoming caustic, judgmental, and demanding.

While crisis line counseling is on first name basis only, making initial contact means getting a name out to the caller and attempting to get one back. As simple as this sounds, in the heat of the initial moments of a call, neophyte workers forget to do this.

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Chris the veteran does not and patiently queries the caller for her name.

Defining the Problem Once psychological contact is established, the worker attempts to define the problem by gaining an understanding of the events that led to the crisis and by assessing the client's coping mechanisms. Open- ended questions on the what, how, when, where, who continuum usually let the worker get a clear picture of the event itself. However, in assessing the coping mechanisms of the client over the phone, it may be hard to get a clear picture of the client's affect. Thus it behooves the worker to become more sensitive to the underlying emotional content and to try to reflect the implied feeling content more than might be required in a face-to-face encounter. Reflecting feelings is a tough job for most beginning mental health work- ers and is even more difficult on the phone. Yet the worker absolutely must try to reflect feelings , because there is no way to visually assess the client.

One real plus of phone counseling is that the beginning crisis worker can have supportive aids readily at hand without detracting from the counsel- ing session. One useful tactic is to have a reference list of feeling words that cover the gamut of emotions. A second tactic is to have at hand a list of standard ques- tions the counselor can check off to be sure that all areas typically pertinent to the problem are covered. A third tactic is to keep handy a notepad on which the worker can jot down the salient aspects of the events and coping mechanisms the client has used and make a rapid assessment on the triage scale.

TC: (timorously) 0 .. . 0 ... 0 . .. K. I just don't know where to start, it's just an avalanche. I've got no place to turn, so I thought this was my only chance, so I called.

CW: I'm glad you did call. Sounds like right now you're really overwhelmed, so perhaps you could just take it from where you felt like things fell apart and tell me about that . And I want you to take your time . Take plenty of time, and tell me what's going on. We've got all the time in the world, and I'm here to listen until you say every- thing you need to and we get a real clear picture of what's going on and what needs to happen.

TC: It's Cicily.

... The client goes on to explain she has just moved

to town from out of state in an attempt to reconcile

with her estranged husband. The husband indicated that he wanted nothing more to do with the marriage and was filing for divorce. She indicates that she was pretty much in denial about the failed marriage and had taken a last chance on getting it back together. The denial has now been given a rude reality check. The job that was supposedly waiting for her has also fallen through. She is cur rently at a friend's house, with her 4-year-old son, with less than $200 and a car on its last wheels. She has no relatives or support system besides her friend from college days.

The crisis worker, Chris, listens intently to the client's story. He interrupts only to clarify and summarize what's going on with the client. Chris deeply reflects the feelings of aloneness, hopelessness , and helplessness that wash over her. The crisis worker allows the client to grieve and ventilate over her failed marriage. When the client's emotional behavior starts to escalate, the crisis worker uses calming techniques such as asking the client to take a deep breath or reinforces the concept that they have plenty of time to work through this problem . As Chris listens to her, he is rapidly jotting notes down and making an assess- ment on the triage scale. Her predominant emotion is anxiety, which is free-floating into all areas of her life. She is having a lot of difficulty controlling her emotions.

Her score on the Affective Severity scale is 7. She indicates that she has been essentially frozen in time for the last 4 days after her meeting with her estranged husband. Her friend has been taking care of her son while Cicily either has sat paralyze d staring aimlessly at TV or has been hysterically sobbing in bed. Finally, at the urging of her friend , she called the crisis line. Her score on the Behavioral Severity scale is 7 because clearly her daily function- ing is impaired. She is immobilized and frozen. As she relates her problems, her thinking seems fairly linear, and she is able to put her story together logically. However, she has been perseverating on the crisis to the exclusion of anything else. There is a lot of wishing and hoping for things to get better and that somehow h er husband will have a change of heart. She is filled with self-doubt and cannot make a decision about what to do. Her score on the Cogni- tive Severity scale is 8.

Overall her triage scale score is 22. This woman is clearly in crisis and may need more help than the cri- sis line can provide over the phone. Chris's immediate concern is with a statement Cicily made that "this was my only chance."

.. 1"' •

Ensuring Safety and Providing Support D uring problem definition, the phone worker must be \·ery specific in determining the client's lethality level. .::f the worker detects the potential for physical injury, chen closed-ended questions that obtain information specific to the safety of the client should be asked, :iot only without hesitation but a lso with empathic understanding that clearly depicts the worker's over- :-iding concern for and valuing of the client. These questions typically start with do, have, and are, and in ?hone dialogues they should be put directly and as- se rtively to the client. (For example, one might ask, "'D o you have the pills there with you now?" Or "Are you alone, or is someone there who might help you ~efore you do it?") The phone counselor should check what support systems are available to ensure the cli- ent's safety. For many phone clients, there will be no support system- the phone counselor is the immedi- ate and sole support system.

CW: I can really hear the hurt and fright in your voice. It's scary b eing all alone, seeming to have nobody to lean on. I'm concerned abo ut your say- ing this was your "last chance." Do you mean by that you're thinking of suicide?

TC: (somewhat emphatically) I had, but I just couldn't bear to see that bastard and his new girlfriend get custody ofJimmy.

CW: OK. That's good! I needed to check that out. Now you said you were staying with an old college friend, and she asked you to call. Is that where you are now?

TC: Yes, but I hate putting her out like this. But I don't have any other place to go. (Starts sobbing heavily again.)

CW.· But she's OK with you staying there?

TC: Yesssss . But I hate being a burden on her.

CW: But that's wh at friends are for. Would you do the same for her if things were reversed?

TC: Well, sure, no question.

CW: So for the time being you've got a roof over your head, something to eat, and are safe?

TC: Yes, I guess so, but I don't know how long this can go on.

CW: What we're going to do is see if we can get some stuff done that will allow you to get back on your own. OK? Are you willing to do that? (Cicily ac- knowledges she'll try.) Good! Although I can't get

CHAPTER SIX Telephone and Online Crisis Counseling • 121

.. your husband back, and I know that really left you feeling hopeless and all alone, I can find out about the job problem and perhaps see if we can't do something about that. So let's start with that if it's OK with you. We've got a number of referral sources here that might be able to match your skills, education, and abilities with a job. Would you be willi ng to tell me a little bit about yourself in that area-education, employment background, desired kind of work? I could pass that on to some of our referral sources and see what we could do. (Chris listens while Cicily goes through her background, education, and other pieces of pertinent information, re- inforcing her for staying on task, mobilizing her thoughts, and keeping her terrifying emotions in control.)

Looking at Alternatives and Making Plans Creating alternatives and formulating a plan are in- tegral to one another in any crisis situation but are even more closely tied together in phone counseling. To alleviate the immediate situational threat, the phone counselor needs to jointly explore a lternatives that are simple and clear-cut. Without the benefit of an eyewitness view or an in-depth background of the client, the worker needs to be cautious about propos- ing alternatives that may be difficult to carry out be- cause of logistical or tactical problems of wh ich the worker is unaware . Alternatives need to be explored in a slow, stepwise manner with checks by the worker that the client can do the physical and psychological work necessary to complete the task . Role play, ver- bal rehearsal, and having the client recapitulate ob- jectives are vit a l ingredients of a functional plan. No plan shou ld be accepted u n t il the client can reassure the worker that he or she thoroughly understands the plan and has the means and ability to put it into action.

CW: OK! I've got that information. I'll pass it along to the day shift, and they'll pass it along to the JOBS Council and a couple of employment agen- cies that work with us. I want you to call back to our number tomorrow about 1 P.M . and we'll have some information for you . Can yo u do that?

TC: Well yes , I can do that. (Cicily has calmed down and is only occasionally sniffling and lamenting her outcast state. Her triage scale score has moved down to about 15. Chris now approaches other areas of her crisis.)

CW: I wonder what you did when you got into pre- dicaments beforehand? Maybe there was nothing

122 • PART ONE Basic Training: Crisis Intervention Theory and Application

quite like this, but I'm guessing there were other times when you were overwhelmed.

TC: Well, nothing like this, but I did take care of my mother before she died, kept a job with a printing company, and worked on my degree. Sometimes that was pretty overwhelming.

CW: So what did you do to take care of being overwhelmed?

TC: I'd make a list and set down my goals of what I was going to do and what I had to do . Like Alcoholics Anonymous , one day at a time , you know. It worked pretty well, but I just have got so many things now, I don't know if I can get it all lined out.

CW: But that worked before, and I understand there are lots of things going on like never before, but if it worked then, how's about giving it a try now? (Chris immediately seizes on her past coping technique and attempts to put it to work. He acknowledges her be- lief that this is indeed different than before and doesn't dis- count the fact that it may be tough. He methodically helps her develop a game plan for tomorrow, not the rest of her life.) So we've got day care for Jimmy taken care of, and you don't really need the car for a while, you can get a bus or streetcar and go anywhere you need to. Even though you've only got 200 bucks cash, you could cash in that $3,000 worth of U.S. savings bonds your mother gave to Jimmy if you had to, until you got back on your feet . You could then repurchase them, so you won't feel like you're robbing your son of his inheritance. So you've written those things down that you can do tomorrow, right? So we're just managing this, like you say, one day at a time, not worrying much beyond that and doing what can be done. Do you feel like we're making progress?

TC: I guess I do. I can do those things.

Obtaining Commitment Commitment to a plan of action generated over the phone should be simple, specific, and time limited. If at all possible, the worker should try to obtain the client's phone number and call the client back at a preset time to check on the plan or, if the agency ac- cepts walk-in clients, the worker should try to have the person schedule an appointment as soon as pos- sible. If the worker is linking with other agencies, then a phone t:all should be made to the referral agent to check whether the client has completed the

task. Although it is preferable to have the client take the initiative in contacting other agencies so that dependence on the worker is not created, conditions may block the client from doing so. In that case, the worker should have no hesitation in offering to make the call.

CW: So there are three things you're going to do to- morrow. First you're going to call the day care number I gave you and get Jimmy in there. Second, you're going to go to the bank and open an ac- count and cash in the bonds. Third, you're going to call back here at 1 P.M. and ask for the infor- mation on the job hunt. Those places I told you about will probably want you to come down, so you'll call them and make an appointment. Will you call back tomorrow night and ask for me? I come on at 11 P.M. I know this has been a pretty upsetting deal, so could you kinda repeat that to me and write down that stuff?

TC: Yes . I've got it. (Cicily repeats to Chris the steps he has outlined.) And I'll call back. Thanks a lot. You're a real lifesaver.

CW: You're welcome. Now get a good night's sleep. It's a fresh day tomorrow, and you'll get through it fine with that attitude. (Chris judges Cicily now to be at a total triage rating of about 8. Affectively she is in control of her emotions. She is thinking clearly enough to help establish a plan in a collaborative manner with the crisis worker and has committed to act on it the next day. Chris judges her to be mobilized enough that he can let her go off the line and reinforces her for getting back into equlibrium.)

The call has taken more than an hour and a half, but in that time a woman who is in a severe develop- mental and situational crisis has been able to grieve away some of the lost relationship with her husband, work through her terror of being all alone and jobless in a strange city, and start to make specific plans on how she'll get out of the dilemma. She still has many issues and a long road ahead of her, but she has re- turned to being a functional human again. By any criterion of therapy, the crisis worker has done a good night's work!

Errors and Fallacies For most of our students who volunteer l:mJI for crisis line duty, to say that they are scared pea green on their first shift is putting it mildly! Lamb (1973, 2002) has listed a number of irrational ideas

:hat beginners indoctrinate themselves with as they start their careers as phone counselors. We list them 3ere as a way to depropagandize and calm those of :·ou who are about to start on this grand adventure.

First, you are not omnipotent! You are not there o be the instant expert. Your thoughts of "if only I

were a psychiatrist, licensed social worker, counseling supercomputer, I could help this person" are doomed to failure. Nobody is an expert on everything that comes into a crisis line. There is no specific piece of information, if found, that will magically transform the caller into a paragon of good mental health.

Second, talking about "it," whatever "it" is, from su icide to getting a hair replacement, will not make "it" happen, and you will not be the instigator of causing "it" to happen. Callers are resilient and need so mebody to talk honestly and openly about "it." Par- ticularly in regard to suicide, tiptoeing around the to pic generally indicates to the client that "it" is in- d eed scaring the daylights out of you too! If you can get an inkling of what "it" is, bring it out into the light of day, specify "it," and talk about "it."

Third, if you feel at times you are being manipu- lated, you probably are, and that is okay too-within li mits. Understand that the caller's need to manipu- late you is serving a purpose. As long as that purpose results in restoring the caller to psychological equi- librium without harming anyone, you are doing what you need to do. On the other hand, you are not a door- m at to be walked over.

Fourth, all callers are not loving human beings, and you do not have to be Mother Teresa, loving and caring and sharing to all . Many people call exactly be- cause they are not loving human beings! They are of- ten overbearing, boring, nasty, insulting, hateful, and a pain in the neck! Having made that assessment, you n ow know why the caller is facing rejection from oth- ers and can directly speak to how his or her actions affect you and reflect on how those actions must be problematic when dealing with others.

By the same token, some callers like to gripe about the incompetence of other agencies, therapists , and significant others who have failed miserably to help t hem and have made their lives worse. They may be right. Agencies, therapists, and significant others are composed of human beings who get tired of be- ing manipulated and taken advantage of. Question- ing your credentials is really more of a question of "Can I really trust you? Can you understand what I am feeling?" Defending yourself and your credentials is pointless. Dr. James, licensed psychologist, licensed

CHAPTER SIX Telephone and On line Crisis Counseling • 123

.. professional counselor, National Certified School Counselor, licensed English teacher, licensed school administrator, licensed real estate agent (retired), li- censed fisherman, and world-renowned author of crisis textbooks can't! So why should you think you can? Don't get caught up in defending yourself, but rather turn the question back on the cal-ler: "I don't think that is really what you are concerned about, but maybe you are wondering whether you can trust me. Why not run it by me, and let 's see?"

Finally, there is the delusion of fixed alterna- tives. The beginner believes either "If I can't think of it, there must be no answer" or "If that's all I can think of, it must be the only answer." Or, alterna- tively, "I'll call a consultant. Surely he or she will know." None of these is correct. When you fall under this delusion, crisis intervention is stopped dead in its tracks. Crisis intervention is one part inspiration and nine parts perspiration. You muddle through this together. Solutions are created, not found. Fur- ther, you need to understand that you can't palm this caller off on another agency just because the problem is a tough one and you are at a loss as to what to do. Calling the police department Crisis In- tervention Team may be appropriate, or it may not. You need to know what other agencies can or cannot do. If you don't know, find out before you embarrass yourself.

What in the world can you do then? You can be yourself. You got into this because you thought you have some pretty good human qualities. You un- doubtedly do, so use them. You are there to listen. Few beginners ever believe this, but sometimes, a lot of times in fact, listening is more than enough. You can help the caller come up with alternatives and solutions, or suggest some resources to pursue. You won't know all the resources available, but as time goes on you will learn more. You will also learn your own limits and can be honest in owning when you are tired, confused, lacking in knowledge, or down- right irritated with the hateful way the caller is act- ing. You are a pretty good human being doing your best under some trying circumstances. That's it! End of omnipotence!

Regular, Severely Disturbed, and Abusive Callers The foregoing dialogue is a textbook ex- IDJI ample of how things ought to go in telephone crisis line work . The problem is that the real world seldom

124 • PART ONE Basic Training: Crisis Intervention Theory and Application

functions in such neat and tidy ways. Many callers use the crisis line for reasons other than its intended use . When this happens, the overriding questions telephone workers must pose to themselves are: What is the person getting out of using the crisis line at this time, and is it helpful to the person? How is this person's use of the crisis line at this time affecting its operation (McCaskie, Ward, & Rasor, 1990)? Crisis lines should not cater to a caller's every whim, fantasy, deviant behavior, or self-indulgence.

Chronic callers can be a plague to crisis lines and devour time and energy of staff, which legitimate callers may desperately need (Peterson & Schoeller, 1991; Spittal et al., 2015). Chronic callers can also be very frustrating to telephone workers because they do not improve (McCaskie, Ward, & Rasor, 1990). These callers can pose a serious morale problem for the volunteers and staff who receive such calls, par- ticularly when the calls become sexually explicit and the deviant fantasies of callers are directed at the cri- sis worker (Brockopp & Lester, 2002; Knudson, 1991; Tuttle, 1991).

A counterpoint to this negative view is the ap- proach of the staff at the Lawrence, Kansas, Head- quarters Crisis Center, who believe that "chronic" is a negative term and implies that these callers will never improve (Epstein & Carter, 1991). All behavior is pur- posive. If seen in that light, no matter how aberrant or weird the content of the call, it is important to re- member that those who regularly use the crisis line do so for a reason-it helps them make it through the day. For these clients, it becomes part of their lifestyle and method of coping. Indeed, Spittal and associates ' (2015) research on Australia's largest crisis line found that undergirding these regular callers were legiti- mate problems that ranged across suicidality, mental health issues, crime, child protection, and domestic violence issues all predicted being a frequent caller. Bassilios and her associates (2015) found from a large national representative survey of Australians that they had a poor clinical profile with increased risk of suicide. Repeat calls were associated with anxiety disorders, receipt of mental health care from general practitioners, and social disadvantage.

Middleton and associates (2014) reviewed research into frequent caller problems and how they were handled by a large sample of call-in centers. The com- posite solutions they found for responding to frequent callers included: limiting the number and duration of calls allowed, assigning a specific counselor to the calls, implementing face-to-face contact with a

mental health or human services agency, initiating contact with the caller instead of waiting for callers to contact the service, providing short-term anxiety and depression treatment by telephone, and creating a spe- cific management plan for each frequent caller.

Therefore, although the term chronic is often used in telephone crisis work, we believe it to be somewhat pejorative and agree with the staff at the Headquar- ters Crisis Center that "regular" better captures the essence of this clientele. If the caller's dynamics are reframed as lonely, isolated, and reaching out, then the response may be very different from one of mere aggravation (Brockopp & Lester, 2002). By setting limits of 10 to 20 minutes for regular callers, work- ers acknowledge their needs but also do not become controlled by the regular callers (Lester, 2002).

Understanding the Regular Caller's Agenda Helping people in crisis is different from being nice to them. The agenda of regular callers places the crisis worker in a dilemma. Although the worker may feel ethically bound to respond to the caller, and the agency's protocol dictates that all calls must be taken, that does not mean that workers need to suffer the abuse and invective leveled at them by such callers. A very real difference exists between what callers may want and what they may need, and helping a caller is generally predicated much more on needs than on wants. Often what these regulars want is a reaf- firmation that their problems are unsolvable. Thus they become dependent on the telephone worker to sustain their problem. The worker therefore needs to recognize such patterns and not support them when this blocks progress (McCaskie, Ward, & Rasor, 1990). Telephone workers do themselves and their callers a service when they show that they are not willing to be manipulated or abused and that they value their own needs as highly as they value those of the caller. Generally, if a telephone worker spends more than 15 to 20 minutes with a caller, the client's crisis becomes the worker's crisis (Knudson, 1991).

Given the foregoing admonition, the telephone worker needs to remember that the sameness of the material and the dependency these clients demonstrate day in and day out make it easy to forecast their repetitious behavior and treat them as bothersome, inept, boring, and unimportant clients. Many of these are "Yes, but ... " callers. Although they seem highly receptive to the suggestions and plans that crisis workers make with them, in the end they find all kinds of excuses and explanations to not

:'"ollow through on what they promised to do-which :nakes them extremely exasperating (Waters & Finn, :995, p. 269). Regular callers may tend to be placed :...1 a stereotypical catchall category because they ::epresent an aggravation to the crisis line. However, :he reasons these people call are diverse. Identifying S?ecific types is at least as important as identifying :he specific caller (Peterson & Schoeller, 1991). To ::hi s end, McCaskie, Ward, and Rasor (1990) have ;::onstructed brief descriptions of some of the more ::y pical personality disorders of regular callers, their outward behavior, inner dynamics , and strategies for ;::ou nseling them.

ar anoid. People with paranoia are guarded, secre- ·ve, and can be pathologically jealous. They live in

~ogic- tight compartments, and it is difficult if not im- ~lOssible to shake their persecutory beliefs. They see :hemselves as victims and expect deceit and trickery :Tom everyone. The counseling focus is to stress their safety needs .

Sc hizoid . Those with schizophrenia have extremely ::estricted emotional expression and experience. They · ave few social relationships and feel anxious, shy, and sel f-conscious in social settings. They are guarded, Lac tless, and often alienate others. The counseling :'"oc us is to build a good sense of self-esteem through acceptance, optimism, and support.

Schizotypal. People with schizotypal behavior have :'"eelings of inadequacy and insecurity. They have srrange ideas, behaviors, and appearances. The focus of counseling is to give them reality checks and to ?ro mote self-awareness and more socially acceptable '.Jeh avior in a slow-paced, supportive manner.

arcissistic. Narcissists are grandiose, extremely self- centered, and believe they have unique problems that orhers cannot possibly comprehend. They see them- selves as victimized by others and always need to be ::igh t. The focus of counseling is to get them to see :iow their behavior is seen and felt by others, while not engaging in a "no-win" debate or argument with ::hem .

istrionic. People with histrionic personality dis- order move from crisis to crisis. They have shallow ;:l.ep th of character and are extremely ego-involved. ~hey crave excitement and become quickly bored with ::outine and mundane tasks and events. They may

CHAPTER SIX Telephone and Online Crisis Co ~nse l ing • 125

behave in self-destructive ways and can be demanding and manipulative. The focus of counseling is to stress their ability to survive using resources that have been helpful to them in the past.

Obsessive-Compulsive. Those with obsessive-compul- sive disorder are preoccupied by and fixate on tasks. They expend and waste vast amounts of time and energy on these endeavors. They often do not hear counselors because of futile attempts to obtain self- control over their obsessions. The focus of counseling is to establish the ability to trust others and the use of thought stopping and behavior modification to di- minish obsessive thinking and compulsive behavior.

Bipolar (Manic Depressive). The extreme mood swings of these callers range from "superman/ superwoman" ideation when in a manic phase to "born loser" ide- ation in a depressive stage. If they feel thwarted in their grand plans, they may become very aggressive to tho se who would stop them. At the other end of the continuum, their depressive "doom, despair, and agony on me" outlook puts them at risk for suicidal behavior. Slowing down and pacing these callers in the manic phase is difficult but needs to be done to put a psychological governor on their runaway behav- ior. Confrontation about their grandiose plans only alienates them. In the depressive stage, suicide inter- vention is a primary priority.

Dependent. People with dependent personality dis - order have trouble making decisions and seek to have others do so-often inappropriately. Feelings of worthlessness , insecurity, and fear of abandonment predominate. They are particularly prone to become involved and stay in self-destructive relationships. The focus of counseling is to reinforce strengths and act as a support for their concerns without becoming critical of them or accepting responsibility for their lives.

Self-Defeating. Those with self-defeating behavior choose people and situations that lead to disappoint- ment, failure , and mistreatment by others. They reject attempts to help them and make sure that such at- tempts will not succeed. The focus of counseling is stressing talents and the behavioral consequences of sabotaging themselves.

Avoidant. People with avoidant personality disor- der are loners who have little ability to establish or

126 • PART ONE Basic Training: Crisis Intervention Theory and Application

maintain social relationships. Their fear of rejec- tion paralyzes their attempts to risk involvement in social relationships. The focus of counseling is encouragement of successive approximations to meaningful relationships through social skills and assertion training.

Passive-Aggressive. Those with passive-aggressive be- havior cannot risk rejection by displaying anger in an overt manner. Rather, they engage in covert attempts to manipulate others and believe that control is more important than self-improvement. The focus of coun- seling is to promote more open, assertive behavior.

Borderline. Borderline personality disorder is so named because such people are chameleon-like and at any given time may resemble any of the foregoing mental disorders. Also, they are always on the "bor- derline" of being functional and dysfunctional. One of the most problematic of callers, they are dealt with at length in Chapter 5.

Handling the Severely Disturbed Caller "The behavior of the severely disturbed is IDB primitive, disorganized, disoriented, and disabling. These people are likely to elicit discomfort, anxiety, and outright fear in the observer. These are strange people. These are different people. These are people we lock away in mental institutions, pumping them full of strong drugs that turn the mania into docileness" (Greenwald, 1985b). This stereotypical public view of the mentally disturbed, quoted in the University of Il- linois at Chicago's Counseling Center hotline training manual, introduces hotline workers to the mentally disturbed. These are many of the people who call crisis hotlines. On the neophyte phone counselor's first meeting with the disorganized and disjunctive thought processes of the mentally disturbed, all the training the crisis worker has ever received is likely to fall by the wayside.

These callers represent a cornucopia of mental illnesses. They may be delusional and hallucinatory; be unable to remotely test what they are doing, believing, or thinking against reality; be emotionally volcanic or conversely demonstrate the emotional- ity of a stone; lack insight or judgment about their problems and be unable to relate any linear or logical history of these problems; be so suspicious in their paranoid ideati~n that they believe even the phone worker is out to get them; be manipulative, resistant,

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and openly hostile and noncompliant to the simplest requests; not have the slightest idea of appropriate interpersonal boundaries with significant others or the crisis worker; demonstrate obsessive behavior and compulsive thoughts that they continually harp on to the exclusion of any effective functioning; have no meaningful interpersonal relationships with the possible exception of crisis line workers; impulsively place themselves in problematic and dangerous situations over and over; and present themselves in childlike or even infantile ways (Grunsted, Cisneros, & Belen, 1991). Whether these behaviors are biochemically or psychologically based makes little difference. These people are so distanced from our own reality and so threatening that the beginning phone counselor's immediate reaction is to get off the line! However, if the worker pictures the disturbed client as a person whose developmental processes have gone terribly awry, then the call may take on structure and sense and become less intimidating. No matter how bizarre the call may be, these primary axioms apply to the caller's behavior (Greenwald, 1985a, p. 1):

1. Behavior is always purposeful and serves motives that may be either conscious or unconscious.

2. Behavior is comprehensible and has meaning even though the language used may not.

3. Behavior is characteristic and consistent with personality even though it is exaggerated.

4. Behavior is used to keep a person safe and free of anxiety.

The following rules for dealing with disturbed callers are abstracted from a number of crisis hotlines (Epstein & Carter, 1991; Greenwald, 1985a, 1985b; Knudson, 1991; Lester & Brockopp, 1973; Tuttle, 1991).

Slow Emotions Down. Although disturbed callers have many feelings that have been submerged from aware- ness, it is not the best strategy to attempt to uncover these feelings. The caller is being besieged by too many feelings and needs to find a way to get them in control. Focusing on here-and-now issues that are concrete and reality oriented is the preferred mode of operation. Do not elicit more feelings with open-ended questions such as "Can you tell me more about that?" Instead., use calming interventions that force the person to or- der thinking in small, realistic bits of detail.

CW: I understand how scary those thoughts are that keep creeping into your mind and the "things" you think are in the room. What I want you to do right now is look around the room and tell me

.;i: ,_..._

tOll!:!:"

what is there. Then tell me what happened to start this thinking.

The idea is to slow emotions down. Although the -;vo rker may acknowledge the feelings , they are not :he focus of attention. By breaking up freewheeling :dea tion into discrete, manageable pieces, the tele- • hone worker gives the caller a sense of regaining .:ont rol. The worker may also bring the caller back to :-eality from a flashback by asking the client what he or she is doing.

CW: You say you're in that alley and he's assaulting you. Were you smoking a cigarette then? I know you just lit a cigarette a minute ago. I want you to slowly inhale, smell that smoke, and tell me where you are. Now blow the smoke out and see where it goes around the room.

efuse to Share Hallucinations and Delusions. If a caller is hallucinating or delusional, the telephone ~orker should never side with the psychotic ideation.

Caller: Do you see, hear, smell, feel those things?

CW· No! I'm sorry, I don't. I understand right now you do, and that's terrifying, but what I want to do is get you some help. So stay with me. What is your address so we can get some support for you?

Little if any good ever comes of participating such thinking, and as the delusion increases, it

~comes difficult to extricate oneself from it. Yet ~andiose thinking, no matter how bizarre, should :10t be denied.

CW: (inappropriate and sarcastic) Come on, now. The CIA isn't really listening to an auto mechanic by electronic eavesdropping. Certainly they've got bet- ter things to do than that. Why do you believe that?

CW:· (appropriate and empathic) It's pretty clear that you re ally believe the CIA is listening to you. When did this start?

T he worker affirms the paranoid delusion is real ·th out agreeing to its veracity. By asking a when

.::uestion, the worker can start eliciting information :=:iat will allow assessment of the scope and extent :JE the paranoia. A why question is never appropriate .::ccause of the defensive reaction it may elicit in any .:aller, especially a paranoid.

etermine Medication Usage. If at all possible, the rker should elicit information as to use of any

CHAPTER SIX Telephone and Online Crisis Counseling • 127

medication, amount and time of dosag~ and particu- larly, stopping medication without consulting the attending physician. Changing, forgetting, or disre- garding medication is one of the most common rea- sons that people become actively psychotic (Ammar & Burdin, 1991). Furthermore, having this information will give the worker a better idea of the type of mental disturbance the caller is being treated for. Regardless of the reasons or excuses clients give for not taking medicine, the worker should endeavor to get them to their pres cribing physician so medication can be ad- justed or reinstituted.

CW: Lemuel, I want you to call up your doctor as soon as we get off the phone. I understand that the medicine gives you a bad taste in your mouth and makes you feel queasy. However, your doctor needs to know that, and you need to let her know you're not on your meds.

Becoming familiar with the major tranquilizers, antidepressants, and antipsychotic drugs is impor- tant for this work (Pope, 1991). However, given all the different kinds of drugs and their numerous generic and trade names, keeping track of them all is extremely difficult. The Physician's Desk Reference (PDR) provides information on what these drugs do, how much is generally given, and what the side effects are . No crisis line office should be without a current edition.

Keep Expectations Realistic. The telephone worker should keep expectations realistic. The caller did not become disturbed overnight. No crisis worker is going to change chronic psychotic behavior during one phone call. The cri sis worker is buying time for the caller in a period of high anxiety and attempting to restore a minimum amount of control and contact with reality. If the caller is trying to "milk" the worker through an interminable conversation, confront- ing the problem in a direct manner will generally determine whether the caller is lonely or is in need of immediate assistance .

CW: It seems as if this can't be solved, and you say you can't wait until tomorrow to go to the clinic. I'm concerne d enough that I think we ought to make arrangements to transport you to the hospital right now .

Maintain Professional Distance. Calls from se- verely disturb ed individuals may evoke all kinds of

128 • PART ONE Basic Training: Crisis Intervention Theory and Application

threatening feelings in phone workers, leaving them feeling inadequate, confused, and in crisis them- selves! Maintaining professional distance when ex- ceedingly painful and tragic stories are related is difficult for even the most experienced phone worker. When these feelings begin to emerge, it is of utmost importance for workers to make owning statements about their own feelings and get supervision imme- diately. Passing the line to another worker in no way indicates inadequacy.

CW: Frankly, I'm a bit confused as to what to do. I've done everything I know, and I'm tapped out. I'd like to connect you with Irma, who may have some other ideas, while I talk to our director.

As confused and disoriented as disturbed call- ers may be, they seem to have a sixth sense about sensitive areas in others. Countertransference (the attributing to clients of the therapist's own prob- lems) is not uncommon, and disturbed callers can sometimes unearth the worker's own hidden agendas and insecurities. A worker's strong reactions, either positive or negative, to these callers should alert the hotline worker that processing and feedback with a coworker or supervisor are needed.

Caller: (paranoid) I know who you are, when you work on the hotline, and where you live.

CW: (inappropriately responding to the threat in a shaky voice) What have I ever done to you? I'm trying to help you, and you get bent out of shape. I've got a good mind to hang this phone up right now or even call the police. We can trace these calls, you know!

CW: (appropriately responding to the implication in a clear, firm, but empathic voice) Jacques, those things are not important to what's going on with you right now. What is important is making you feel safe enough to go back to your apartment tonight and go to the doctor in the morning. I understand why you might get upset over my suggesting you see the doctor, but I also want you to clearly un- derstand it's your safety I'm concerned about. So what's making you angry with me?

By deflecting the caller's paranoia and refocusing the dialogue back on the client's issues, the telephone worker directively forces the caller, in an empathic manner, to respond to his own emotional state.

Avoid Placating. Placating and sympathizing do little to bolster t.fie caller's confidence or to help move the client toward action.

Caller: (depressed) I'm just not any good to anybody, much less myself.

CW: (inappropriately sympathetic) From all you've told me, you've had a really rocky road. Nobody should have to suffer what you have, but things can only look up.

Rather, by empathically responding and exploring past feelings and coping skills when life was bet- ter, the telephone worker not only acknowledges the dilemma but also focuses on the client's strengths.

CW: You do sound pretty hopeless right now, but I wonder how you were feeling when things weren't this way, and what you were doing then that you aren't doing now.

Assess Lethality. Many clients who call crisis lines have active suicidal or homicidal ideation. It may seem puzzling that such people would call a crisis line when they seem so bent on harming themselves or others. Regular callers in particular should be assessed for suicidal or homicidal ideation because they are very prone to underscore the critical nature of their problems and "prove" their need for help by threatening lethal behavior (Brockopp, 2002a). What all suicidal callers are doing is trying to put distance between their thoughts and the actions that might result from those lethal thoughts. As much as the callers may avow intentions of lethality, they are still in enough control of themselves to attempt to place a buffer (the telephone worker) between thinking and acting (McCaskie, Ward, & Rasor, 1990).

Caller: If I can't have him, she sure as hell won't. I'll kill them both, and you, the police, or nobody else can stop me .

CW: Yet you called here, for which I'm glad. Something is holding you back, and I'd like to know what that something is.

Caller: Well, I'm a Christian, but their sins go beyond redemption.

CW: So as a Christian, you probably think the com- mandment "Thou shalt not kill" is pretty impor- tant. What you're saying is you're about to commit sin, just as they did. How will that help you, and how will it look in the eyes of God?

Although it may be construed that the telephone worker is manipulating the spiritual philosophy of the caller to achieve an end, the major goal of the crisis worker is to disrupt the irrational chain of thinking that is propelling the client toward violence. In that

:-egard, when dealing with the disturbed caller, the overriding thesis is "Save the body before the mind" G runsted, Cisneros, & Belen, 1991). Crisis interven- :ion over the telephone with those who are severely tlisrurbed is clearly not meant to be curative. It is a stopgap measure designed to be palliative enough to :..:e ep action in abeyance until help arrives .

Although no crisis line staff members that we know of would ever instruct their workers to give out :h eir full names or home phone numbers, at times callers can be very seductive in their attempts to ex tract personal information from crisis line workers. Ro ok ies on the crisis line may be very taken with the ~ eartbreaking stories they hear or feel very gratified ~y t he strokes that dependent callers can give them. linder no circumstances should a crisis line worker eve r give out his or her full name or other personal infor mation, nor should the worker ever agree to meet die caller for social or professional reasons . The crisis line's credibility is built on anonymity, and that works !:ioth ways. In addition, serious ethical problems may ari se when that anonymity is breached. Finally, crisis line workers who do not observe the foregoing run the risk of putting themselves in physical harm's way.

Given all that we have said about severely dis - ru rbe d callers, our admonition is still to treat these clients not as types, but as individuals with their own idiosyncratic problems. However, those who are severely disturbed are not the only regular or problem callers.

Other Problem Callers Telephone crisis workers must sometimes deal with cover t callers, pranksters, silent callers, manipulators, sex ually explicit callers, or even callers presenting iegitimate sexual problems. It must be remembered and accepted that every call is an attempt by the caller to fulfill some need or purpose. Following are several types of problem callers and suggestions h at should help workers unde rs tand and cope with

such callers.

Rappers. Some callers may just wish to "rap," or talk. -:-he question becomes whether time should be spent :istening to someone who only wants to talk, with ao seemingly pressing issues. However, if "lonely" is :.acke d onto the description of the person, this may change the telephone worker's perception of the prob- . em. It may also be that the caller is having trouble !:>ringing issues into the open and is testing the wa- ;:ers to get enough courage to jump in. By allowing

CHAPTER SIX Telephone and Online Crisis Counseling • 12 9 .. some leeway in approaching issues, but at the same time gently confronting the caller's loneliness, the worker sets reasonable limits on the conversation and still provides a supportive forum (McCaskie, Ward, & Rasor, 1990).

Covert Callers. Callers who ask for help for another individual may actually be asking for help fo r them- selves. As a result, always assume that the call is about the caller, but never attempt to prove the call is about someone else (Brockopp, 1973a, p. 164; Brockopp, 2002a, pp. 171-175). Other callers may act surprised, "Oh, I thought this was a recording." The response is to affirm that it is not. "No it isn't. I am Joe, and this is the crisis line. How can I help you this evening?" Yet others may make humorous jests as a test. "You must be really crazy to work there. I'll bet there are some real nuts who call up." The response to these calls is to avoid the "test" and respond empathically by saying, "I wonder if you're concerned that calls are handled seriously here?" These are most likely ways that timid and embarrassed callers have of checking out the crisis line to see what the opening response is and whether it is safe to talk. Intellectual types, on the other hand, tend to be know-it-alls who prob - ably do have more expertise than volunteers. On their own intellectual ground they always "win." In actuality, these callers are often very insecure and unsure of themselves under their self-assured exte- rior. The key to dealing with intellectualizers is to immediately let them defeat you. "You're right. I am a volunteer here, and I don't know as much as you do about bipolar disorder. What I do know is you sound pretty concerned about it and seem to be looking for some help." Other callers may call and be silent or say they have the wrong number. Particularly at a sui- cide center, there are no wrong numbers. "May I help you?" or "What number were you calling?" are d efault responses to "wrong numbers."

Pranksters or Nuisance Callers. Teenagers who are bored at an overnight party may call the line just to bedevil the workers. If the prank call is treated seri- ously, they will probably hang up and not call back. If they are hung up on, they will continue to call (Brock- opp, 1973b; Waters & Finn, 1995, p. 270). Many calls may appear to be of a nuisance nature. However, any person making a nuisance call should be considered to have a problem. Therefore, it is important that calls not be arbitrarily seen as pranks . The crisis line must answer all calls in a straightforward, no -nonsense

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13 0 • PART ONE Basic Training: Crisis Intervention Theory and App lication

manner. The crisis line must clearly convey that they are not playing games with people but that callers will be listened to honestly and responded to directly no matter what the purpose (Brockopp, 1973b, pp. 206 - 210). By so doing, the crisis line builds the perception in the community that the line is serious about what they do (Brockopp, 2002a, pp. 187-190). The teenager who is a prankster one night may be the suicidal teen- ager another night.

CW.· Is it a prank or a dare you're playing or maybe something else that you really do need to talk about?

CW: I do wonder if there is something you might like to talk about. If you do, feel free to call back.

Silent Callers. One of the most frustrating of call- ers is the person who is silent . Silent callers are ambivalent. Either through embarrassment or hurt they are reticent, or from previous negative experi- ences they fear rej ection and are just plain unable to muster the courage to talk. The worker must overcome his or h er initial reaction to hang up, demonstrate acceptance, and attempt to remove any impediment that may keep the person from communicating (Brockopp, 2002b) . For the silent caller, an appropriate response would be, "I'll be here when you feel you can talk ."

CW: Sometimes it is really difficult to say what you need. Maybe it hurts so much you can't find words. Maybe you are not sure you can trust me. Whatever the reason you feel unable to talk, I am going to wait a little bit before I take another call. Even if you can't talk now, understand that this line is open for you when you need to talk.

If there is still no response, after a minute or so you could say, "I guess it is difficult to talk about this right now. I' ll stay on the line for another minute, and then I'll have to go to another call. Call back when you feel ready to talk."

Manipulators. A variety of callers achieve their un- met needs by playing games with telephone workers. Typical manipulative games include questioning the worker's ability, role reversal in which the worker is tricked into sharing details of his or her personal life, and harassment. Redirecting the manipulative ploy and focusing on the unmet needs of manipulators force them to look at the reasons for their manipula-.., rive behavior (Brockopp, 2002a, p. 174; Waters & Finn, 1995, p. 269).

CW: You certainly know a great deal more about that subject than I do. How does it feel to be in control like that?

CW: When you question my integrity or try to get me to share intimate details, I wonder if you real- ize that is trying to meet some of your own needs for control. I wonder if you have considered what those needs to control and manipulate others are getting you.

Sexually Explicit Callers. "Call 1-900-LUST. Cindy's lonely and wants to talk to you!" The proliferation of these ads on late-night television, the Internet, and in porn magazines is a sad testimony to the existence of tens of thousands of men whose sexual insecuri- ties, aberrance, and deviance make "sex talk" a mul- tibillion-dollar business . An even sadder testimony is given by those individuals who use crisis lines for the same purpose. It should not be too amazing that Wark's (1984) interviews with a number of sexually explicit callers found them to be characterized by low self-esteem, feelings of isolation, lack of trust, a sense of being sexually unfulfilled, and little insight into their behavior. The primary purpose of the sexu- ally explicit caller is to masturbate while talking to a female.

The sexually explicit caller is a particular millstone hung on the crisis line because many female volunteers become angry, embarrassed, and afraid and resign out of frustration with frequent sex calls (Baird, Bossert, & Smith, 1994; Brockopp & Lester, 2002, pp. 133-135; Fenelon, 1990). Brockopp and Lester (2002, p. 136) propose staying on the line and tolerating the behavior while attempting to build a more trusting relationship without condoning the behavior itself. That is a very idealistic way of treating the problem, and in the opinion of your authors is a great way to lose a lot of volunteers in a hurry! We will take a stand here and state that the crisis line is just not the place for that behavior to occur. Switching the caller to a same-sex worker and reframing the call in a context suggesting that the caller needs help put a severe damper on such calls.

Callers With Legitimate Sexual Problems. However, many people who have serious sexual or sexually related problems call crisis lines because of the anonymity allowed to frankly discuss their most private issues. These calls may embarrass workers who are not psychologically prepared for such intimate

det ails, feel shocked at what t hey hear because of :he criminal or exploitative nature, or do not have :he technical expertise to handle them. Telephone wo rkers must have education in dealing with sexual -oncerns and training in legal and ethical knowledge ab out what to do if the caller is a danger to a third ?arty (Horton, 1995, p. 292) . The very nature of calls ~ealing with sexual matters p laces crisis workers in 2 p otentially value-laden, belief-centered moral and :-eligious arena in which the worker's own opinions -ome into play. Although in most instances the ma- : o r role of the worker is to not let his or her opinions aold sway and influence clients, avoiding these hot 2.reas may also mean denying the caller much-needed i:i fo rmation (Horton, 1995, p. 307). Providing op - ::!ons and information about "responsible" sex is a ··iable approach, although it should be understood :hat a very fine line runs between the worker's own :iiases and providing balanced information and must :ie monitored carefully.

Even though the preceding types of callers are striving to fulfill their needs , they often pose ?roblems for telephone workers. Following are some :ech niques to help prepare crisis workers to deal with :his sometimes difficult clientele.

andling the Problem Callers ose Open-Ended Questions. Appropriate use of open-

ended questions can help defuse the problems generated by frustrated callers (Epstein & Carter, 1991).

TC: You people don't know anything. Everything yo u've told me is a bunch of crap.

CW· What did you expect to gain from this call, then?

TC: Just to tell you what I think of your lousy service.

CW: If you were m e, what would you be doing or saying right now?

These questions refocus the problem back to the .::aller and force movement toward problem solving :-athe r than keeping the worker subjected to condem- :iatory statements.

Set Time Limits. When it is apparent that attempts :o refocus the problem to the caller are futile , then a :ime limit should be set (Knudson, 1991).

-:-c: You ought to be congratulating me on getting my act together, no thanks to you.

CW: I'm glad you've done something positive since you last called. Now we can talk about your

CHAP TER SIX Telephone and Online Cris is Counseling • 131 ,..

current situation for 5 minutes. Then I'll have to take another call.

Terminate Abuse. When the caller's behavior escalates to what the worker perceives as abusiveness, the call should be terminated in a clear and firm manner (McCaskie, Ward, & Rasor, 1990).

TC: You bitch! Don't you dare hang up this goddamned phone!

CW: (assertively) I'm sorry, but that is language we do not tolerate, so I'm going to another caller now. When you can talk appropriately, feel free to call back.

Switch Workers. Particularly with a sexually explicit caller, switching the call to another worker, preferably a male, takes the stimulus thrill out of the situation and makes it very difficult for the caller to bring mas- turbation to orgasm, which is usually the end goal of such a call (Knudson, 1991).

TC: I'd love to cover you with honey and lick you all over.

CW (female): (calmly and coolly) Given your specific problem, I'm going to switch you to Ralph. (Sig- nals to Ralph.)

CW (Ralph): (assertively) I understand you have a problem. How can I help you?

If a male is not available, the call should be shifted to a supervisor and terminated. The caller should be told that the worker will hang up and that action should be taken immediately (McCaskie, Ward, & Rasor, 1990).

CW (supervisor): (authoritatively and firmly) We are not here to answer demeaning remarks while you masturbate. You need to know that our calls are taped, and obscene calls and using this service to masturbate are illegal. I am going to hang up . You may call back when you are ready to discuss this problem.

To bait a telephone worker and hold her on the line, sexually explicit callers often externalize their fantasies by reporting some hypothetical significant other's problem in florid d etail. When the first hint of this ploy occurs, the worker should interpret the behavior as the caller's own and make the switch (Knudson, 1991).

TC: I'm really worried about my uncle and his 10 -year-old daughter. She's a little doll, and he's

132 • PART ONE Basic Training: Crisis Intervention Theory and Application

always giving her these massages in her bedroom andI ...

CW: (Interrupts.) That's out of my area of expertise; please hold the line and let me switch you to our child abuse expert, Ralph.

Use Covert Modeling. Covert modeling or condition- ing (Cautela, 1976; Kazdin, 1975) has been used by Baird, Bassett, and Smith (1994) to extinguish re- peated calls, particularly by sexually explicit clients. In covert modeling, the client is asked to use mental imagery to picture either reinforcing or extinguishing a particular behavior. The following worker response is abridged from their technique.

CW: As you're talking, I'm wondering if you recog- nize your real problem and want help with it. I know this would be pretty difficult to give up. But sometime soon, I'm not sure exactly when, as you reach for the phone you'll think to call a therapist instead. And this notion that you'll call a thera- pist and get help will get stronger every day as you think of it. You'll also start to feel better as you realize the crisis line isn't fulfilling your needs as therapy will. I'm going to hang up now and let you think about getting help with your real problem.

By suggesting that the need to call the therapist will grow, the worker plants the seed for anxiety about the caller's present behavior to grow along with the need to change. Both negative and positive reinforcers are used in the image: the need to seek help and the good feeling that will come from doing so. The worker also speaks of seeking help for the "real problem." This unspecified problem allows the worker to re- spond emphatically without accusing the caller of terrible, deviant behavior but still clearly states that the caller needs help. The worker does not continue in a dialogue with the client but instead hangs up to let the seed start to grow.

Formulate Administrative Rules. Administra IDB tively, crisis lines need to set specific rules to extinguish abusive behavior by doing the following (Knudson, 1991; McCaskie, Ward, & Rasor, 1990; Middleton, Gunn, Bassilios, & Pirkis, 2014):

1. Limiting the number and duration of calls from any single caller

2. Limiting the topics that will be discussed 3. Requiring- that only specific workers versed m

handling abusive callers take such calls

4. Using speaker phones for on-the-spot consultation 5. Requiring the caller to establish a face-to-face

relationship with an outside worker and allow communication between the therapist and crisis line personnel

6. Allowing the staff to prohibit calls for a day, a week, or more, if physical threats are made

7. Service initiating contact with the caller instead of waiting for caller contact and coordinating short- term treatment programs for anxiety and depres- sion by telephone

8. Creating a specific management plan for each caller

The Headquarters Crisis Center of Lawrence, Kansas, uses a tracking log for regular callers that lists their name, phone number, address, style ofinteraction, major and tangential issues, effective and ineffective response modes, their physician/ therapist, medica- tions, support groups, and lethality levels. The log is kept current and available to staff, saving them a great deal of time and energy. This center also has an inter- nal messages notebook labeled "Client Concerns." It contains information about regular callers that workers can quickly read to become updated on the caller's circumstances. It is an effective method to keep staff current and can be used to offer feedback and sugges- tions to clients (Epstein & Carter, 1991). Staff should be brought together on a regular basis to discuss these callers, plan strategy for them, make suggestions, and voice personal concerns (McCaskie, Ward, & Rasor, 1990). Finally, supervisors need to be acutely aware of the impact that such callers can have on personnel. Crisis center administrators should be ready, willing, and able to process debilitating emotions that such calls often evoke in workers in a caring, empathic, and sup - portive manner through regularly planned supervision and emergency debriefing sessions when necessary. Crisis intervention over the telephone is tough, grueling work, particularly when clients such as the foregoing emerge. Crisis calls are frequently onetime events with very little opportunity for positive feedback. Particu- larly because crisis lines are run chiefly by volunteers, they need to be aware that not everyone can be helped (Waters & Finn, 1995, p. 271).

Hotlines As noted in Chapter 1, the first telephone cri- l!!iJI sis hotline was established in 1906 by the National Save-a-Life League to prevent suicide (Bloom, 1984). Indeed, the growing suicide prevention movement in

[he 1950s adopted the telephone as the primary mode of treatment because of its immediacy (Lester & Bro ckopp, 1973, p. 5), and over the course of time has be en the most often used method of suicide inter- vention (Lester, 2001; Mishara et al., 2005; National Suicide Prevention Lifeline, 2011; SAMSHA, 2014; Seely, 1997a, 1997b; Slaikeu & Leff-Simon, 1990) with dedicated suicide hotlines in many countries, states, p rovinces, and cities.

Indeed, in the United States, because of the increase in veterans' suicides a suicide hotline 1-800 -TALK was established in 2007 to meet the u n ique needs of veterans (King et al., 2014; Tull, 2013). M ost veterans' calls can be generally categorized as ;nental health issues, suicidal ideation, and substance abuse issues. Research indicates that all age ranges of \'eterans avail themselves of the hotline, but for very di fferent reasons. The middle age and older veterans called with issues that were based in loneliness while yo unger veterans focused on mental health issues King et al., 2014). Britton and his associates (2013)

examined incoming calls for 1 week (October 1-7, 20 10, N = 665 calls) found that the veterans hotline " as highly effective in 84% of the calls received with 25% being resolved on the phone and 59% referrals to a local health care provider. Probably more impressive wa s the finding that callers identified as high risk for su icide had greater odds of ending in referral than no t. Even more importantly those favorable odds were ound on the weekends when essentially few if any

orher mental health resources were readily available. It is with good reason there are telephones with

direct hotlines to crisis intervention call centers placed o n bridges and one of the most notorious jump sites, the San Francisco Golden Gate Bridge 0acobs, 2010). Since its start in 2005, the National Suicide Prevention life line has fielded over 6 million calls (SAMSHA, 2014).

However, suicidal individuals are not the only ca llers. The tremendous growth of "hotlines" and warmlines" in number, types of assistance, kinds of

p roblems handled, and geographical coverage attests w the fact that people in crisis avail themselves of tele- ph ones to solve a wide variety of personal problems. T hese services may range from generic crisis hot- ;ines to a variety of specialized services such as local "warmlines" for latchkey children to the National Centers for Disease Control AIDS Hotline. Generic crisis phone lines are typically open 24 hours a day, 365 days a year, whereas more specialized services may op erate during regular business hours . People who are lonely, have panic attacks , gamble and drink to

CHAPTER SIX Telephone and Online Crisis Counseling • 133

• excess , abuse relationships , grieve, are depressed, suf- fer psychotic breaks, or experience a whole smorgas- bord of crises that could qualify for Ripley's "Believe It or Not" call crisis lines. There is indeed a specific helpline for current and former NFL players, coaches, team league staff, and their family members who may be in crisis (NFL lifeline, 2012).

Time-Limited Hotlines. A time-limited hotline is one that is put into operation for a specified period of time; it is typically used to deal with a specific prob- lem or to engage a special client population, such as immediately before a potential disaster or after a disaster. It may provide brief supportive therapy or serve as an information or referral source.

A particular use of such a hotline was in the wake of 9/ 11. The New York City Missing Persons Hotline was created to develop a database of missing persons and provide crisis counseling and information services. Counselors were given updated daily resource lists to provide information on everything from practical issues about returning to apartments to air toxicity levels. Lists of hospital admissions were compiled to cross-check against missing persons lists, enabling workers to call back to relatives in- quiring about missing persons. However, the primary purpose of the hotline was to help grieving, scared, anxious people work through the trauma. To that end, workers used what would generally be the first four tasks of the model presented in Chapter 3 to provide psychological first aid to the callers.

Continuous National Hotlines. Specialized, toll-free, national hotlines deal with specific topics, such as troubled youth . Although brief supportive therapy may occur on such hotlines, generally the major purpose is to provide information about the geo- graphic location nearest the caller where help can be obtained. These lines are heavily used and cut across all geographic areas, cultural groups, and so- cioeconomic classes. The national runaway hotline (1-800-RUNAWAY) not only spends time talking to runaways about their problems, but also encourages them to get off the streets and into the nearest run- away shelter (National Runaway Safeline, 2015) . The national domestic violence hotline (1-800-SAFE) is available to any victim of domestic abuse in the United States (National Domestic Violence Hotline, 2015) . These are a few of the national call centers that specialize in every kind of imaginable human dilemma.

134 • PART ONE Basic Training: Crisis Intervention Theory and Application

Local Crisis Hotlines. Local crisis hotlines typically handle all kinds of calls, ranging from suicidal ideation to lost cats (some calls are not as life threat- ening as others). They are staffed by volunteers from the local community, are listed in the yellow pages, and provide telephone crisis intervention services for a specific geographic locale or a specific population, such as a university student body.

The Internet's Growing Role in Crisis Intervention Suppose you are a cost-conscious student Im and found a cheap first edition of this book from 1988, you now would be finished reading this chap- ter because what follows didn't exist then. Hard to imagine for all of you 20-somethings because the Internet has always been a part of who you are and what you do to communicate with others. Winston Churchill said, "Take change by the hand, because if you don't it will take you by the throat!" Since the advent of the Internet and websites, there has never been any doubt that there would be counseling services on the "net." However, the computer is not only a communication device; it can also function as a simulation device (Wolf, 2003). Both of these applications have great potential for psychotherapy and crisis intervention. So far, however, most profes- sional therapists do not use computer-assisted coun- seling or provide online therapy. Various reasons are given, including ethical concerns, commitment to humanistic values that conflict with technol- ogy, cost, and the absence of training (Hertlein, Blumer, & Mihaloliakos, 2015; Lawlor-Savage & Prentice, 2014). Yet, if one reads current writing on the use of technology in counseling (Adlington, 2009; Anthony & Nagel, 2010; Cicila, Georgia, & Doss, 2014;Jones & Stokes, 2009; Rose 2014; Parikh & Huniewicz, 2015), it should be patently clear that the Internet and various forms of electronic com- munication have become and will become more important in the delivery of psychotherapy and par- ticularly crisis intervention.

Although therapists have been slow to adopt this mode of intervention, most consumers have not been-particularly young consumers who are not at all intimidated by the Internet (Calam et al., 2000) and see it as an integral part of their lives . Why is this so? Haim Weinberg (2014) has written a very interest-.. ing book called The Paradox of Internet Groups: Alone in the Presence of Virtual Others. This book explores

the multiple paradoxes of being involved in Internet groups. Weinberg states that on the one hand people in their bedrooms are far removed and detached and untouched by what is going on in the group, but on the other they are involved, invested, and perhaps even enmeshed in the group. So does one really care about people thousands of miles away or is it merely curiosity? While these paradoxes exist, they allow us- ers a great deal of freedom to say when they want to be involved and feel an integral and contributing mem- ber to the World Wide Web, but still decide how much they wish to self-disclose, keep self-boundaries, and preserve their own individuality. Thus, while face- to-face encounters with others are usually either/or in nature, online connections with others can be "both," and that is what makes the social medium of the Internet group so attractive according to Weinberg.

Palfrey and Gasser (2009) identify anyone born afrer 1980 as a "digital native." Digital natives have access to digital technology networks, use them, and have never known any other way of life - as opposed to "digital settlers," who use digital technology but still rely heavily on analog forms of communication (which would characterize the authors of this book). So about how many natives and settlers are out there, and are they restless? In 2010, 8 out of 10 Americans used the Internet to find out health information about themselves and 9 out of those 10 worried so much about it they kept digging down until they found out what was TRULY wrong with them and have helped coin a new phobia called cyberchondria (Moyer, 2012).

So people are worried about their health and by the appearance of how many hits and chat rooms there are that are devoted to mental health they number in the many millions (Number of"cyberchondriacs," 2005). Right now on June 1, 2015, at 5:15 P.M. CST on Healthful Chat's website there are 241 people chat- ting about anxiety, bipolar, body dysmorphic, de- pression, eating, gender identity, OCD and PTSD disorders (Healthful Chat, 2015). People log into chat rooms for support groups by the millions to discuss mental health issues , and chat rooms are only one part of what has come to be known as "behavioral telehealth."

Behavioral Telehealth Behavio ral telehea.lth is the use of telecommuni- cation and information technology to provide ac- cess to behavioral health assessment, intervention,

;;:on sultation, superv1s10n, education, and informa- c:ion across distance (Nickelson, 1998); it can include e-mail, chat rooms, blogging, apps, websites, games, and Internet video teleconferencing (Dowling & .!lickwood, 2014; Novotney, 2014). In some shape or form, all of the foregoing are already being done .-\ nthony & Nagel, 2010; Deleon, Crimmins, &

Wolf, 2003; Ho et al., 2014; Kass et al., 2014; Jones & Srn kes, 2009; Marsac et al., 2015; Misurell et al., 2014; _ Tovotney, 2014). Crisis intervention on the web can operate in an asynchronous (time-delayed, such as e-mail, blogging, and websites) or a synchronous :-e al-time, such as chat rooms , videoconferencing,

Skype, and instant messaging) format. The relevant .::uestions, then, are "How can we ethically and effectively do crisis intervention on the Internet?" and ""Wh at crisis intervention services can be ethically 2nd effectively provided on the Internet?" (Ruiz & .-.ipford-Sanders , 1999, p . 12).

Websites that provide opportunities for net "surf- c:-s" to seek emergency help or advice, counseling, or psychological help continue to grow exponen- ~ally. Befrienders International is a component of :he Samaritans in Cheltenham, England. This group ?rovides an excellent example of a website that of.. :'"ers help to suicidal individuals and other people in ;::isis. This group has been in the business of helping ?eople for more than 40 years via letter, telephone, ;md in-person visits. E-mail sent to the Samaritans :cmains anonymous if the sender desires . Responses ;zre asynchronous but trained volunteers read and :-cply to e-mail once a day, every day of the year. There ._:-e 20 centers around the world, and a trained volun- :cer with the universal counselor name "Jo" reads all :'.-m ails and answers them within 24 hours (Hurtig, 3ulitt, & Kates , 2011; Wilson & Lester, 2002) . Their m d ress is [email protected]. However, many tele- ?hone hotlines are also Internet capable and are synchronous. For example, the National Runaway ~irchboard operates a synchronous live chat room :.;.ar can be reached at www.1800runaway.org/.

... he Appeal of Online Counseling 8ea rly, the Internet, websites , e-mail, and other tech- ;::ological, wireless, and online electronic advances ~e much like the telephone in having the potential

p rovide a great deal of help to people who are ~cographically or psychologically isolated from ~cialized crisis services; are suffering physical or

-ent al disabilities that do not permit them to travel - t h ose services; are shy and do not want to meet

CHAPTER SIX Telephone and Online Crisis Counseling • 135

face to face; need anonymity; have time management problems; are unavailable during normal working hours; or find it convenient, cost effective, or simply natural to their way of life (Anthony & Nagel, 2010, p . 35; Harris-Bowlsby, 2000;James & Gilliland, 2003, pp. 416 - 433; Jones & Stokes, 2009, pp. 2- 5) .

Feedback. When it comes to direct therapeutic intervention, not all aspects of online conversation may be seen as better than face to face , but there are many aspects of it that are. In crisis intervention, continuous and immediate feedback is critical, and synchronous Internet applications can serve this function well. Once the client has regained emotional equilibrium, the therapist can use asynchronous e-mail to check on how well the client is maintain- ing homeostasis. Feedback several times an hour, day, or week lets the client know the interventionist is present, listening, and thinking about the client . Clients can initiate contact when they feel the great- est need. Regular and frequent e-mail reports require the client to constantly monitor and report behavior, which is critical in crisis intervention (Castelnuovo et al. , 2003). However, as the interventionist, would you really want to sit at your computer all day long, doing instant messaging, or perhaps text message on your cell phone while eating in a restaurant? Of course, if you could turn your counseling computer on and let "HAL'' do the counseling, you would have ample free time (James & Gilliland, 2003, pp. 420 - 428).

Disinhibition. A phenomenon that Suler (2004) named the disinhibition effect has appeared in e-therapy. What this effect means is that people tend to open up earlier with more distressing issues then they would normally do in an F2F (net acronym for face-to -face) therapy session. It is not clear why this effect happens , but it may be due to the absence of visual cues that might be perceived as judgmental or merely not having to look the therapist in the eye and tell him or her about the seamier side of one's life. The depersonalization and distance involved seem to make it safer to share intimate information. This appears particularly true for males, who may be reti- cent to come for face-to-face counseling or even tele- phone counseling but will use e-mail at least as much as women (Wilson & Lester, 2002).

Whether this phenomenon changes with the increased use of Skype, where there is synchronous F2F, is another interesting e-therapy question. There is also some evidence that there is greater depth of

136 • PART ONE Basic Training: Crisis Intervention Theory and App lication

emotional processing when people have to read some- thing as opposed to listening (Hiltz, 1992). There may also be greater depth to cognitive processing, and that includes both client and worker. Certainly it takes a great deal more time and thought to compose a writ- ten response; a cursory "hmmmm" probably won't be satisfactory (Wilson & Lester, 2002).

Problems of Online Counseling Along with this potential, and even some unique advantages over traditional and telephone interven- tions, some major areas of concern cloud this new electronic horizon. As the flat worlders said to sail- ors who they thought were going over the edge of the world, "Be wary, there be demons and dragons out there!" While it is one thing to chat casually with an- other person half a world away, it is quite another to have people providing therapy or interventions about whose credentials you know nothing more than what they tell you. The reverse may also be true for clients who may not be who they say they are. At their most malevolent, clients could attempt to infect the cri- sis interventionists' computers with viruses or other "malware" that could compromise their files (Maheu, 2001, 2003).

Confidentiality. One of the major issues of therapy on the net is confidentiality. Excellent encryption pro - grams are used by ethical therapists to keep informa- tion confidential. However, there is no such guarantee if you are working out of a cybercafe. Even though websites may guarantee anonymity, once a message goes out, there is no absolute guarantee that it cannot be pulled out of the ether by people or agencies you might not be too thrilled to have read your thoughts and pictures. An e-mail message is less like a letter and more like a postcard (Barnett & Scheetz, 2003). So! Do you really want to talk about your sexual inad- equacies on a postcard? Additionally, the possibility of violating client confidentiality and the Health In- surance Portability and Accountability Act (HIPAA), which carries severe penalties for doing so, are real concerns for practicing mental health professionals (Fisher & Fried, 2003).

It may also be argued that online therapy is prob - lematic because of identity verification in emergency situations involving homicide, suicide, or other life -threatening events. In most telephone crisis intervention, there is usually some way to access emergency h elp for the individual. But if the client is in Vilnius , Lithuania, and the crisis interventionist

is in Brisbane, Australia, this may be more difficult. Sandra DeJong's book (2014) Blogs and Tweets, Texting and Friending: Social Media and Online Professionalism in Health Care is a must read if you are going to venture into online therapy .

Charlatans. Sad to say, the field is ripe for electronic snake oil salespeople and nefarious individuals who may have somewhat less character and goodness in their hearts than Florence Nightingale. In his review ofinternet sites that purport to provide "crisis coun- seling," Myer (1999) reported that not only are some of the fees exorbitantly high, but based on the ques- tionable claims of their promotional advertisements , people who choose some of these services might be putting themselves at risk for even more traumatiza- tion through secondary victimization at the hands of some very incompetent or outright charlatan "service providers." Clearly, although this venue holds much promise, it is a "buyer beware" situation. A cursory review of 1,980,000 hits returned by a search for "crisis intervention therapy" in June 2011 leads us to believe things haven't changed a lot since Myer's study.

Licensing and Insurance. There are other demons that abound in the legal world of the Internet. Do you need to carry professional indemnity insurance even if you are a volunteer at a crisis line (Jones & Stokes, 2009, pp. 141-142)? What happens when you do therapy across state lines or countries? Do you need a license in that state or country, and what can happen if somebody commits suicide or homicide on your watch? Do you know how to be sure your data are encrypted? Do you know how to password pro- tect your files? Do you know how to download files safely, how to keep the downloads secure, how to back them up, and how and where they are stored? Are you familiar with the Online Therapy Institute's Ethical Framework for the Use of Technology in Mental Health (Nagel & Anthony, 2011b) and, for disaster responders, an ethical framework for the use of tech- nology in disasters (Nagel & Anthony 2011a), or other professional ethical standards in your country for the use of technology? If you don't, you have no business doing business on the net.

Learning the Language. If you are going to operate in this world, you not only need to be technologically competent and savvy about the Internet, you also need to know the language. There are now "netizens"

~ong us! Netizens are people who spend a great deal '1: ri me in online communities. They operate in what :.s generally called Web 2.0, which is a way of using :.'-le web to develop cultural communities and social ::erworking sites (Anthony & Nagel, 2010, p. 9). These ..:idividuals and sites are replete with their own lan- = age and netiquette (civil and appropriate rules of :iscourse when operating on the net, particularly in ~-:ichronous time with other netizens) . Anthony and _ -agel (2010, pp. 5-6) contend that real life and on- .-:.::i.e li fe are not separate but more and more blended, :o the point that for millions of people virtual life ;;..:id real life are one and the same! For many of these -erizens , the virtual world they surf through is the ~eal world, so it is not hard to see how they would :-erceive the Internet as the most viable way to access .:=isis intervention services.

et iquette __ - yet, there is no "Miss Manners" to rule on neti- -: ~ene. However, Jenicus (2013) has compiled a list of

ebsites that cover netiquette in regard to general '...:..les, e-mails, listservs, business, Twitter, and neti-

?ette for kids. Following are some basic netiquette · es you need to observe if you are working on the

-::'.r (Anthony & Nagel, 2010;Jones & Stokes, 2009).

A typo or two , particularly in synchronous time, is okay. Sloppy writing with lots of typos and grammar problems is not and indicates you don' t care much about your client. Emoticons can be helpful in conveying an emotion. They also can be too cute! Check with your client before you use them.

- Lo ts of tweeters who use the net have their own expansive set of acronyms. You need to be clear about what those are; don' t hesitate to ask if you don't know an abbreviation. Keep your text neutral by using a simple black fo nt; 12-point Times, for example, is easy to read and even bland. Other fonts and colors can get pretty exotic. Your clients can give you a lot of information through what they use.

- Yo u know what you mean when yo u write so mething. But as people read words (a novel is a good example), they attribute their own meaning and subsequent emotional response. So be careful as you construct your responses .

~ Stay cool! Use standard counseling skill responses to do exploratory work. Let the client talk. Brevity in written responses is a good thing.

CHAPTER SIX Telephone and Online Crisis Counseling • 137

7. Keep flame wars (intentionally written inflam- matory remarks or misinterpreted ones) under control. If you make a mistake, discretely and quickly apologize for it. If you are running a group online, they need to know the limits and that they will be called on their inappropriate behavior.

Congruent with overall netiquette are some basic ways of enhancing tex t to make it more conversational and add emphasis (Anthony & Nagel, 2010, pp. 51-55). On the negative side, conflict seems to occur more in online than in face-to-face intervention, so it appears that communications need to be constantly clarified so they do not get muddled (Mallen, Day, & Green, 2003). Even when emoticons (keyboard symbols rotated 90 degrees clockwise to look like facial expressions), such as :) and :( , or emotional bracket- ing or altered text formats (different type sizes and fonts for emphasis) are used, it may be very difficult to tell when and to what degree emotions are being displayed.

Predispositioning Because of the nature of online counseling and the great possibility that in a text-only situation miscom- munication can occur (Adlington, 2009, pp. 158-159), predispostioning is critical-setting the tone as an empathic, genuine, caring, unconditionally positive regarding intervener on first contact (Jones & Stokes, 2009, p. 17). It is also important to get across to the client how crisis intervention takes place on the In- ternet, and how that is different from typical Internet exchanges, tweets, and chat room dialogue .

E-mailer online to crisis center: I'm Featherlite. I've got a problem at home. I'm a 16 year old girl and I need some help with it. I've never done this before. I'm thinking about running away because I can't take much more of my parents climbing my frame because of my boyfriend. So where do we go from here? Canu help?

Dr. ]: (synchronous online in real time) Featherlite, I'm glad you e-mailed us. Call me Dr. J. Pleased to make your acquaintance, Featherlite. Interesting online name. I am curious. Are you as light as a feather?

While it may seem tangential, the interventionist seeks to establish psychological contact by querying her Internet name.

138 • PART ONE Basic Training: Crisis Intervention Theory and Application

Featherlite: Pretty much I guess. Especially when I dance. I'm on the modern dance team at my high school. Anyways that what Dad used to say when I was a little kid and he'd pick me up on his shoulders and it kinda stuck. Right now I'd like to pick him up and drop him off the Hernando De Soto Bridge .

Dr.]: Okay. I'd like to read what you have to say. Note I said "read" so that is a bit different from listening. There are some different rules of the road here and I'd like to go over them with you so things don't get messed up. First, we can't see each other so a lot of what passes for nonverbal communication won't happen. Also I can't catch the tone of your voice nor you mine. We might use emoticons to convey an expression, and I use things like brackets and boldface and some other ways of attempting to make clear what I am hearing and asking so there are some ways of using the computer to get mean- ings across, but there's still room to misread stuff and I don't want that to happen. I'm not going to worry too much about misspells and grammar, al- though I might ask you to clarify something if I don't understand it and you can do the same with me. I want us to be really clear on what's going on so I won't try to read your mind and misinterpret the issues. So please don't be offended if I ask for clarification, okay? Even though we are working in real time, I may take some time to think about what you are saying. I'll let you know that by using some dots ... so that you know I haven't stopped and there is more to come. If you like you can do the same. This is a crisis Internet center so it is not long-term therapy. My whole purpos e is to get you back on level ground so you can make some good, realistic short-term decisions about your problem and act on it. If you think you need more extensive help down the line we can discuss that. I'll be ask- ing you a lot of questions to get the problem real clear in my mind. I'll probably restate what you say so we are both in agreement on what's going on. To do that I may cut out your words and paste them back into my response in boldface. I'll take some guesses at what you are feeling and think- ing. IfI am wrong, just tell me so and I'll try again. So this is a no fault deal okay? Now, Featherlite, if you would, think a moment ... and then tell me the one main thing that caused you to write in tonight. I do see you are pretty put out with your dad ri'ght now. You said "it" and that "you'd

never done this before." Can you tell me what "it" means and what it is that you haven't done?

This opening statement is designed to give the e-mailer an idea of how online counseling works and to get an idea of what the initiating problem is and the subtext underlying the initial query Gones & Stokes, 2009, pp. 14-16). This rather long introduction gives the client at least a thumbnail sketch of how the interven- tionist will operate. A lot of owning statements are used to convey who and what the interventionist is and what he will and will not do . Not engaging in this prelimi- nary discussion is likely to put the intervention in peril from the start, particularly with a client who has never engaged in crisis intervention let alone done so over the Internet. The interventionist's focus is on the immedi- ate precipitating factors that got her to go online.

Featherlite: Well "it" is like my parents y'know. They 4bid me to see my boyfriend, Arley, who is out of high school. They don't like him because they think he is like 2 old for me and they think he does dope and wants me to do it 2 y'know. We really got in it tonight. I'm down at the city library and just serched u up so I haven't done this crisisline thing ever before . I also haven't run way from home, but Arley says we can go to Kentucky and gt married there without my p's consent. I don't want to gt married right now. I want to fin- ish h.s., but I love Arley and don't know how I can go home. I kinda slapped my mom and then my dad really slapped me and I took off.

Dr. ]: SO YOU'VE BEEN FIGHTING WITH YOUR P'S BECAUSE THEY THINK YOUR BOYFRIEND IS SUPPLYING YOU WITH DOPE AND YOU'RE SO IN LOVE WITH HIM YOU CAN'T SEE ALL THE FAULTS THEY SEE. RIGHT?

Featherlite: Why are you SHOUTING. You sound like my father. Always critical. YOU THINK I M CRAZY TOO! Am I that bad? Maybe I will run off with him.

Dr. ]: Oops $#%$#%%! I accidentally hit the caps lock. Sorry. Not shouting, just old arthritic fin- gers LOL [laugh out loud]. No I don't think you're crazy. The "right" was just asking if I was on the money not whether you are right or wrong about your feelings .

While lots of shorthand and acronyms get used by clients, the interve ntionist needs to be careful in thi s

regard. The word right in the above example can have m any implications. Is our well-intentioned interven- tionist just seeking acknowledgment, or is he imply- ing somebody is "right," and if so, is it Featherlite, her pa rents, or somebo dy else? So it might be a bit bet- ;:er if he were to make things clearer by saying "Am I :i.ght?"

Adlington (2009, pp. 8 - 40) uses a variety of text -or mats to build rapport with clients. Bracketing and '.:>oldfacing serve to indicate that the intervention- ist is listening closely and thinking about what has :ieen said (pp. 13-14). Adding dots conveys some time spent pondering the issue and that the writer is going :o continue with the thought.

D r . ]: Man! That really struck me about comparing me to your dad. Let me think on that a moment ....

As in F2F it is easy, perhaps even easier, to get lost in all the verbiage and as a result come back to the cli- m t with a whole flock of issues that get the client lost :rying to determine which ones are important. A bet- :er way is to think of the core issue you want to cover and, as Adlington suggests, direct one central issue

ack to the client in boldface.

:Jr. ]: Featherlite, I get the sense this is more than me just sounding lik e your dad and being critical of your love life that's making you think of run- ning away with Arley. Could you think a bit and tell me some of the long-term issu es between you a nd your parents? I am guessing there may be a bit more than a boyfriend. Although right now I do understand that the major issue is your want- ing to be with Arley and your folks against it and that's what we will work on right now.

Using the client's own font is one possible way of -}ea rly restating what is being said in the client's own

o rds .

:Jr. ]: So it seems right now you are so sensitive to your parents constant criticism that my goof up puts you on edge and I sound like your dad.

It should also be of interest as to what type f fo nt the client uses (Adlington, 2009, p. 15).

-ou ld you respond differently if Featherlite ~re using llra•1•1adttcitt, fjcttc fjralttur, or ~dUJat~ ({?/mft rather than Comic Sans MS? :Jr, fo r that matter, if the e-mail came with certain ~rds in color (Adlington, 2009, p. 17)? Do you sup - :;<>se it would make a difference in your interpretation _:anger came back in red, purple, blue, or green?

CHAPTER SIX Telephone and Online Crisis Counseling • 139 •

Featherlite: I am so mad [crimson]. They're just jealous [green] because they were never in love like I am with Arley.

Dr. ]: OK. I see the fee lings. I have a series of ques- tions to ask. They'll come one at a time. First, do you feel safe to go home tonight?

Featherlite: I don't know. The library closes at 11. I don't want to be on the streets then.

Dr. ]: Do you have a friend or relative's house you could go to?

Featherlite: Maybe my aunt. Although my p's woud be mad if I went there. Mom doesn't get along with her sister well. Arley would come and take me to his apartment if I called him. He gets off at 11.

Dr.]: You are probably not going to like my response, but right now that might not be your best op- tion. I can get you on the line to Runaway. They would get transportation there, then contact your Ps. That is escalating the situation some because there would have to be a meeting between them and you and your parents and social services would be involved. Right now it is important for you to stay safe. We can continue e-mailing and set some longer term plans up, but I want to see you under cover tonight.

Featherlite: U R probably right. I guess I could call my aunt.

Dr. ]: Please do that and then either call into the crisis line phone number or e-mail me back ... say 10 minutes. OK?

Featherlite: OK. I appreciate u. Pretty kul for an old (((((((gy))))))))) ! ! ! [The parens denote hugs.]

While this online dialogue is representative of what most crisis interveners would do in any format, there are some notable exceptions. First and foremost, triaging Featherlite is difficult because it is hard to put numbers to her affect or cognition without see- ing her facial expressions and hearing her voice. The intervener has to make a best guess based on what he actually knows. Therefore, the default approach is to make best-guess ratings that are generally high . The fact this is a 16-year-old girl about to be on the streets of Memphis alone at night gets her a 9 on the behav- ioral scale and dictates most of the worker's actions in getting her to a safe place. Second, until practice

140 • PART ONE Basic Training: Crisis Intervention Theory and Application

makes the intervener unconsciously competent with the technology, he will have to be very cognizant of operating and conversing in this new system. Invari- ably, then, some focus is taken away from the client to deal with system conversance, as is demonstrated by Dr. J's poor fine motor coordination in hitting the caps lock key.

Texting It may come to pass, and very quickly, that cri- lmJ sis interventionists will need to be better using their thumbs instead of their mouths because texting is be- coming the preferred mode of communication with the coming generation (Ling, Bertel, & Sunds0y, 2012; Zhao, Qiu, & Xie, 2012). The Pew Research Center (2011) reports that cell ownership and text messag- ing are nearly universal among American 18 - 24 year olds-95% own a cell phone and 97% of these cell owners use text messaging-and this group sends or receives an average of 109.5 messages every day. One quarter of 18-24 year old text messaging users report sending or receiving more than 100 texts per day.Just over 1 in 10 say that they send or receive more than 200 messages on an average day- that equals 6,000 or more messages per month, and the open rate ap - proaches 100%. That research indicates a very power- ful and efficient communication system in operation, and note that research is more than 5 years old as you read about it!

Why texting? Survey results indicate that young adults use it because of promptness, convenience, and the ability to be more honest (Crosswhite, Rice, & Asay, 2014). Jacey Eckart (2014), a writer for Military. com Spouse makes this point about her own son as she writes on texting as a preferred technique in sui- cide intervention. "During conflict, my son seemed to need the space and distance that texting could pro- vide in order to get his point across. The sooner he felt 'heard' via text, the sooner he started talking again." When Nancy Lublin, a therapist in New York, started texting teenagers to solicit help with her social advo- cacy organization, she was amazed that numerous re- turn texts were about their own problems ofbullying, depression, and abuse (2012). These texts were numer- ous enough and alarming enough that Lublin has started a text hotline, Text "START" to 741-741. This textline has trained volunteers , supervisors for high- risk texts, and backup and referral ability to other online crisis . centers (crisis textline, 2015). Indeed, it seems to increase participation in help-seeking

behavior among young people. Evans, Davidson, and Sicafuse's (2013) study found that publicizing a crisis line's ability to accept text messages increased youth help-seeking behaviors.

However, it is not just teenagers that textlines are focusing on. The Veterans Administration has, along with it telephone, e-mail, and chat room services, established a textline, Text to 838255 to Get Help NOW (U.S. Department of Veterans Affairs, 2014). Texting is also becoming part of police training to deal with crises. Law enforcement officers are increasingly being called upon to defuse violent, unpredictable situations through the typed word and CIT officers are doing exactly that (Thompson, 2014). It should thus become pretty clear that, if you are going to be in this business, you need to start doing thumb exercises.

Virtual Reality Many computer programs available today l!iJm perform assessment and self-help psychoeduca- tional and therapeutic functions that are seen as effective and reliable (Christensen et al., 2014; Egan et al. , 2014; van Ballegooijen et al., 2014; Twomey et al., 2014). The other great potential use of computer technology in cybercounseling is in simu- lation and interactive virtual reality (Wiederhold & Wiederhold, 2005). Virtual reality (VR) can be defined as a set of computer technologies that when com- bined provide an interface to a computer-generated world (Wiederhold &Wiederhold, 2005, p. 5). A wide variety of computer programs are being tested for use with panic attacks, phobias, anxiety, depression, obsessive-compulsive disorder, addictions , PTSD, sexual dysfunction, eating disorders, obesity, physi- cal rehabilitation, interpersonal skills deficits, and schizophrenic hallucinations.

Many of these programs are designed as games. Called "serious games," they are designed to reduce negative or promote positive behavior change rather than be played solely for leisure. These games are used to treat a wide variety of maladaptive behaviors (Mc- Cann et al., 2014; Swirsky, Carfagno, Milligan, & Raiff, 2014; Quero et al., 2014; Yin et al., 2014). They are re- ported to have a high level of acceptance by clients, and outcomes are comparable with those obtained in working with face-to-face therapists (Castro et al. , 2014; Golomb et al., 2011; Li, Theng, & Foo, 2014; Moritz et al., 2014; Park et al., 2015; Reger et al., 2011; Torrella-Feliu et al., 2011; Wuang et al., 2011).

Probably the most intriguing of these approaches is the creation of virtual reality environments in wh ich clients can be exposed to a variety of situations ch rough a computer simulation of reality (Glantz, Ri zzo, & Graap, 2003; Riva, 2003). Second Life is a virtual reality community that manifests such adj unctive computer therapy successfully (DeAngelis, 20 09; Surano et al., 2011). Clients can choose their avatar, set up housekeeping, and with assistance and as signments from their cybertherapist, try out new behaviors and see how they work. It does not take a great stretch of the imagination to see how these p rograms could be used to relax, calm, and defuse crisis clients who are geographically distant from im mediate help. Anything you can do in real life you ca n do in Second Life (Robbins & Bell, 2008), which m akes it an excellent medium to safely try out new skills and behaviors.

Need for Training Th is brief dialogue is meant to give you a snapshot of how crisis intervention works in real time on the net. It is not meant to make you a net-competent crisis in- [erventionist. Also, reading this brief section in a book :S not going to make you a cyber crisis interventionist. Crisis workers engaging in this work and employing su pportive computer programs need to have train- ing beyond standard computer skills to deal with the inevitable technical problems and computer glitches. Understanding how the new medium integrates tra- ditional and cybercounseling is critical (Anthony & _ agel, 2010, pp. 127-141). Further, cultural diversity a nd linguistic differences make understanding "mul- -iculturalism" as it applies to crisis intervention para- :nount on the net (Anthony & Nagel, 2010, p. 63).

The worker also needs to be comfortable in the medium. Writing counseling responses using instant :nessaging or in chat rooms is altogether different 5-om saying them over the telephone or in a face-to- ~ace dialogue. Recognizing when clients are in trouble by their e-mail message content is very different from cioing a visual assessment of clients face to face. Know- ing how to obtain backup, use referral services, and contact emergency services over vast geographic dis- :ances is paramount. Even more important is getting supervision while doing the foregoing (Anthony & _ ' agel, 2010, pp. 127-141). Finally, the worker needs to educate clients about what cybercounseling can and ;::an not do for them and gain their informed consent Castelnuovo et al., 2003; Maheu, 2003; Ragusea &

· -a ndeCreek, 2003).

CHAPTER SIX Te lephone and Online Crisis Counseling • 141 •

Legal, Ethical, and Moral Issues of Telephone and Internet Counseling The bottom line is that there is still much to be done in the way of research and protocol development in behavioral telehealth and cybercounseling. Certainly, any crisis worker or agency moving into this venue needs to know professional ethical standards and state and federal regulations and laws. The techno - logical advances of caller identification, call blocking, and call tracing pose some complex legal and ethical dilemmas for the telephone hotline. Given the ability to screen and identify calls, is it right to deny services to problem clients? Furthermore, given the expecta- tion and the safety callers feel due to the anonymity of call-in services, using these technologies could easily put confidentiality on a collision course with duty to warn. Could other agencies demand the logs of such hotlines when involved in legal proceedings? Would the hotline workers be held civilly or criminally liable for their actions, given knowledge of whom they were working with and what they might have said?

Because most telephone hotline workers are volunteers , they receive minimal training, and the agencies they work for are not bound by state or federal supervision or legislation (Seely, 1997a, 1997b). These issues further compound the problems of how to ethically use these new technologies. There are no clear answers to these dilemmas at present, but they are issues that need to be addressed at every level of government and most certainly within the agencies that provide such services . It clearly behooves social services agencies and schools to develop policies and pro- cedures for e-mail and texting and determine what role they will play in therapy (Dejong, 2014; Dejong & Gorrindo, 2014; Moon, 2014) .

With all of these forewarnings , crisis inter- ventionists have one clear ethical responsibility, particularly if that interventionist happens to work in a room that has "School Counselor" on the door: Being knowledgeable about digital technologies is a nonnegotiable ethical responsibility because that's the land your natives inhabit.

Does It Work? A number of inexpensive commercial products that are soon to be released will undoubtedly foster need and demand for virtual reality and serious games

142 • PART ONE Basic Training: Crisis Intervention Theory and Application

that target psychological problems (Turner & Casey, 2014). The bottom line for any therapeutic endeavor is how well it works. Doing rigorous controlled- outcome studies is difficult, to say the least, in this anonymous world of electronics. Determining level of expertise and skillful intervention is equally problematic given that the vast number of crisis work- ers are volunteers . However, a number of studies have been done that sampled users of phone and electronic intervention services (Beebe, Smith, & Phillips, 2014; Chiang, 2012; Dalgin, Maline, & Driscol, 2011; Evans et al., 1986; Farrer et al., 2014; Gonzales et al., 2014; Mishara et al., 2005; Padach, 1984; Reese, Conoley, & Brossart, 2002, 2006; Rhee et al., 2005; Swirsky et al., 2014; Tolmach, 1985; Wuang et al., 2011; Wark, 1984). Overall, they consistently rated electronic crisis intervention as helpful, there was a reduction in presenting issues, and a number stated they preferred it to face-to-face counseling. The question remains: Does telephone and Internet counseling work? The

Telephone counseling and cybercounseling account for most crisis intervention work done in the world. Typi- cally, local crisis lines field all kinds and varieties of calls while national hotlines field special, problem-specific issues such as runaways. Special crisis lines that are time limited may be set up immediately after major disasters. These services are staffed mainly by volunteers, who are generally seen as effective helpers by the people who call them. However, there are problem callers who can be- devil crisis lines. Some callers may use crisis lines for their own sexual gratification. Others may constantly call and tie up phone lines because of their loneliness.

Cyber crisis counseling will undoubtedly play a larger part in the future of crisis intervention. Many questions about its use and the ethical safeguards that need to be part of it remain unanswered. However, professional associations such as the American Coun- seling Association, the National Board for Certified

•

answer to that, whether it is done by volunteers work- ing crisis lines or professionals working with their own clientele, is pretty much "Yes."

It appears to be particularly true when we look at a sampling of personal issues where crises are almost always present. Controlled studies and meta-analyses that range across suicide (Rhee et al., 2005), anxiety (Diemer, Muhlberger, Pauli, & Zwanzger, 2014; Nordstrom et al., 2014), cancer (Marcus et al., 2010), depression (Mohr et al., 2008), gambling (Shandley & Moore, 2008), agoraphobia (Castro et al., 2014), stress (Gaggioli et al., 2014), HIV+ (Cook et al., 2009), schizophrenia (Moritz et al., 2014), and incapacitating and debilitating physical disabilities (Dorstyn, Mathias, & Denson, 2011), to name but a few, all indicate gener- ally positive outcomes across a wide range of personality dimensions, coping mechanisms, and positive behav- ioral adaption and change. Telehealth intervention can even help you get off the couch, exercise, eat your veg- gies, and get your daily dose of fiber (Eakin et al., 2007) !

Counselors, and the recently formed International Society for Mental Health Online are working hard on many of the birthing pains of this new baby.

Overall, the use of telephone and online services are seen as beneficial by consumers because they are fast, convenient, accessible, cheap, anonymous, and help- ful, and there is evidence from empirical studies that supports consumer opinion about the efficacy of us- ing these multiple electronic resources during a crisis event.

Visit CengageBrain.com for a variety of study q, tools and useful resources such as video ex- ~ amples, case studies, interactive exercises, Aa:~~ W I cards, and quizzes. __J

P art 2 focuses on applying intervention strat-

egies to several of the currently most preva-

lent types of crises in the human experience.

Th e purpose of Part 2 is to provide crisis workers

with information about the background, dynamics,

and intervention methodologies needed to effectively

ae lp individuals or groups in various kinds of crises.

Part 2 contains a wide array of crisis case illustra-

;:io ns to enhance descriptions of not only the usual

and accepted intervention practices for various types

of crises, but also many innovative and cutting-

edge strategies for intervention. Indeed, some of

i::hese strategies are controversial, but they have

gained enough treatment notoriety and preliminary

:-esearch to be included. Part 2 examines posttrau-

:natic stress disorder (PTSD), suicide, sexual assault,

domestic violence, personal loss , crises in schools,

and families in crises. Three central themes pervade

:hese chapters:

1. Some crises are time limited and some are

transcrisis, in that the person in crisis may

progressively experience severe problems, either

deal with or suppress them, and then experience

and exhibit repeated responses and symptoms of

the same crisis over a period of many years.

2. No one set of theories, assumptions, strategies,

or procedures is appropriate for intervening in all

crisis situations; rather, a systematic and integrative

approach is recommended and demonstrated as the

preferred mode of helping in a broad assortment

of crisis problems and settings. The techniques

employed in these chapters are "best bets" for

the particular kind of client in the particular

environment. They are, however, not the only "bets."

They are meant to give you a variety of approaches

and situations that will start to help you form your

own "Gestalt" of an effective crisis worker.

3. Crisis intervention is hallmarked by elastic,

fluid situations that change in seconds and

minutes and may move from a very benign to a

volatile situation in that time. Many of the case

illustrations model such dynamics to give you a

flavor of what the crisis worker must do to respond

quickly and effectively.

143