Do use a calm but firm voice tone to communicate both caring and certainty to the Caller. This can be calming and provide direction to the Caller whose feelings are at a fever pitch
Do use a calm but firm voice tone to communicate both caring and certainty to the Caller. This can be calming and provide direction to the Caller whose feelings are at a fever pitch.
Do acknowledge feelings but do not allow them to be the focus of the conversation. Instead get a sense of the facts of the Caller’s situation, summarize them, validate that the contact indicates the desire to change, and engage the Caller in discussing what they want to do to change. If the Caller returns to or dwells on the retelling of their personal history explain to them you understand their past and firmly, yet respectfully, explain you will not discuss it with them.
Do let the Caller know if you are familiar with them and their situation it you have spoken to them before. Summarize your familiarity and invite them to explore what is happening for them in the present.
Do accept that your skills work for the majority of your Callers but maintain the pragmatism to recognize they may need to be adapted for the Difficult Caller.
Do recognize that change can be difficult, scary, and tiring. Validate this for the Caller adding that they have probably faced difficult, scary, and tiring things in the past and succeeded.
Don’t ask the Caller how they thought you could help them. You already know the answer to that question . . .They want us to make things better. It is more effective to point out to the Caller that their call indicates they want us to help them and reflect their frustration that their attempts to resolve the issue at hand have not been successful.
Don’t strive to uncover feelings that lie beneath the surface. Generally, the Difficult Caller is flooded with or overwhelmed by too many feelings and needs a way to put a lid on those feelings. The most effective way to confront this situation is to reflect the Caller’s sense of being overwhelmed and explore the issue inducing the helplessness as opposed to exploring the helplessness.
Don’t enter the “world” of the delusional or hallucinatory Caller. If they ask you if you can “hear” or “see” what they are experiencing reply in a direct and firm manner that you cannot. Entering the delusion or hallucination serves little purpose in telephone Crisis Intervention and extricating yourself at a later point can prove problematic.
Don’t give, or allow yourself to be manipulated into giving advice or information about a topic you are not familiar with. We are not all knowing and questions which you are not versed in should be referred to the appropriate professionals. We can acknowledge that that answers to the Caller’s questions are important while reinforcing that the people best qualified to provide an answer is the referral.
Don’t be surprised if these Callers make you feel confused and helpless. The empathic level in which we interact with our Callers gives us passage into the Caller’s world which is, by the Caller’s design, quite different then your own. The safety net of your own ego will prevent you from being totally engulfed by the Caller’s world. However, maintaining our own sense of self can be a draining and exhausting process. Make sure you know your limits and when you approach those limits establish clearly defined boundaries. It is reasonable and acceptable to let the Difficult Caller know what you are and are not willing to discuss with them. It is also a more honest manner of interaction.
Don’t invalidate the Caller by replying you are not a talk or chat line if they ask your purpose. Most Callers equivocate the terms talk line, chat line, help line, and crisis line. They are all places to call when they feel alone and need help. It is more appropriate to simply reply that you are a place people call when they need help with problems.
Don’t allow the Caller to dictate to you how the interaction should be carried on. For example, if the Caller insists you listen and provide no input while they talk you can respectfully explain that such a request indicates that they seem frustrated they have no one to talk to the moment. Generally, this will encourage the Caller to open up to input. If it does not, allow the Caller to talk until you have a sense of their situation, summarize your understanding, and explain to them that we need to end the interaction.
Don’t get trapped in the Callers rehashing of what has been already discussed. If this happens point out to the Caller that you are covering old territory and suggest they work with you to explore what they want to do to resolve the issue. If the Caller insists on reviewing “old stuff” point out to them that is seems more important to relay the story than do anything about it and the frustration evoked by that.
Don’t reinvent the wheel. People usually do not contact hotlines as a primary or secondary resource for coping. If the person appears to be an experienced with the operations of hotlines point out to them that they sound like someone who has tried many ways to deal with their issue. Specifically mention their method of presentation makes it seem they have either contacted hotlines before or they have been in therapy. Explore with them how they felt they were treated and what help they did or did not receive. This exploration precludes a search for a service you may not be able to find or a duplication of services.
There will be people you will have to interact with who you will not like.
That does not mean you cannot interact with them in a respectful manner. It does mean you will need to adapt your “style” to meet the “demands” of certain Callers.
Be realistic in your assessment of what you can and can’t do. There is no one of us who can do it all.
Make use of the staff support your agency provides. None of us in this field have to go it alone.
When working with a Difficult Caller establish firm but respectful boundaries.
Keep in mind that the basic tenets of the Crisis Intervention Process provides for equality and respect . . .and that applies to the Caller as well as us.
And last but not least. You may not have control over who is on the phone each time you pick it up. But, you do have control over how you will adapt to dealing with that Caller and how you will allow the interaction to affect you. Your choices are two in number.
Either this.
Or This. (Turn page)
The choice is really up to you.
The Never-ending Ever-present Crisis: Dealing With the Experienced Caller
Introduction:
As we learned in our basic crisis intervention training, crisis is a situation that exists for our Callers within a finite time frame that their usual coping mechanisms can’t resolve. Crisis has a definite beginning and end. We learned that effective intervention can result in a Caller who can develop enhanced coping skills allowing them to transcend their situation and thrive. This is a process, which is beneficial to the Caller and satisfying to the Crisis Worker. In this view crisis is not a clinical disorder.
However, not all crises are confronted effectively and the “crisis” becomes a chronic situation. While not a clinical disorder, a severe or protracted response to personal crisis may lead to a clinical disorder such as major depression or an adjustment disorder. Frequently, we are faced with Callers who present their lives as one continuous crisis having no definable beginning or end. Their contacts seem to be structured to provide momentary relief from a usually undefined situation with no desire to engage in resolution. Dealing with such Callers, which we will term “Experienced Callers”, can be challenging. The challenge is the results from the fact that we are not addressing a personal crisis. Experienced Callers present a chronic, on going, never changing situation. The Crisis Intervention Model structured to deal with the Crisis Caller doesn’t maintain its effectiveness when used with the Experienced Caller. We can use our usual crisis intervention skills to interact with the Experienced Caller but we cannot and should not expect The Model to work in its usual fashion.
It is the intent of the following presentation to:
Define which Callers are “Experienced Callers”
Discuss behavioral concepts as they relate to our Callers.
Discuss coping defenses as they relate to our Callers.
Develop a strategy for effective interactions with Experienced Callers.
Who Is an Experienced Caller?
To discuss the Experienced Caller we must first understand the Crisis Caller. The basic definition of the Crisis Caller holds that they are a person who has encountered a change in their life’s situation they are unable to address using their usual coping skills. The Theories of Crisis Intervention maintain that effective and timely intervention can enable the Crisis Caller to confront and understand the issue precipitating the crisis and, in doing that, that they can develop new or enhanced coping tools. This allows them to move beyond the paralysis of crisis and continue with their life. Central to this concept is the theme that crisis is finite with a beginning, middle, and end and that crisis represents an opportunity for growth.
For our purposes the Experienced Caller is one who has entered the continuum of crisis but failed, for whatever reason, to successfully resolve that crisis. As a result their coping skills have not advanced. Instead they try to resolve their “issue” over and over using the same defenses they have used, unsuccessfully, in the past. This places them in a never-ending cycle of anomie. They most likely have had extensive contacts with various hotline services under the pretense that, “Talking is good”.
While hotline contact for a Crisis Caller can be an adaptive means of coping, the Experienced Caller’s repeated contacts is a blind pursuit to thrive for the moment. For the Experienced Caller, hotline contact becomes a maladaptive means of coping because it helps them avoid needed (adaptive) formal counseling or treatment. Their hotline contacts become “on demand” temporary relief. Frequently, they will have either a physiological or psychological diagnosis or both.
Having all experienced crisis at one time or another we have an empathic understanding of the Crisis Caller. This understanding allows us to assume the fulfilling role of caregiver. We do not see the Experienced Caller in the same light. Depending on their level of distress we view them as primitive, disorganized, disoriented, and dis-enabled. The Experienced Caller presents themselves in many ways. They can be flamboyantly bizarre, vividly hallucinatory, or frighteningly and dangerously out of control. They can also present themselves as simple and childlike, speechless, immobile, or regressed to a seemingly vegetative state. Persons presenting themselves in such a fashion generally elicit discomfort and anxiety from us. They seem to be completely unlike us. These are the people we cross the street to avoid. These are the people we lock away in institutions pumped full of drugs intended to turn their mania into docileness. Their behavior seems so much different from what we accept as “normal”. However, if we view their behavior as an attempt to cope with life’s stressors we can accept that the behavior is comparable to our own personally logical and understandable strategies for living and surviving. In short, the difference between Crisis Callers, Experienced Callers, and us is all a matter of degree.
Behavioral Concepts and How They Relate To Hotline Callers
In talking about the “Experienced Caller”, and Callers as a whole, we must keep certain generalities regarding the behavior of all people:
A person’s behavior is purposeful. Even those behaviors that seem not to have an obvious purpose may have a motivation that is either conscious or unconscious to the Caller. The Crisis Intervention Process is structured to help the Caller identify and confront behaviors in an effort to initiate resolution.
All behavior is understandable. Even the delusions and hallucinations of the psychotic individual are understandable if we take the time and possess the skill and humanity to nurture the openness necessary to understand what is being communicated. Just because the Caller is talking with us in a manner we don’t immediately understand or we are uncomfortable with, doesn’t mean we can’t understand what lies behind the presentation if we make the effort.
People respond predictably to the fear, stress, and anxiety of crisis.As individuals develop they evolve their personal coping style. They establish methods of coping (defenses) consistent with their personality. People in crisis do not independently invent new coping styles. Their emotional state will often exaggerate the proportion in which they implement their established methods of coping causing them to appear new when they are not. However, appropriate, supportive intervention can help a person amend or change their coping style.
People generally hide from their feelings. This is especially true if they see their feelings as jeopardizing their personal sense of well being, their self-esteem, or the esteem of those around them. It is this hiding from feelings which makes the skill of reflection so powerful in Crisis Intervention.
Anxiety and fear, while seemingly related, are actually two different feelings. When a person is “afraid” they can concretely identify the source of their fear. Callers will talk of fearing the breakup of a relationship; a fear of confronting superiors; a fear of snakes; a fear flying. In each of these cases and many other situations there is a definite “something” the Caller fears. Anxiety is different from fear in that the Caller is unable to concretely identify the source of their dread. There is “something” of which they are afraid but it is nameless and vague. The un-identifiability of the dread creates an anguish that can become paralyzing.
Sources of Anxiety are:
The loss, actual or perceived, of someone on which the individual is dependent. In the most severe manifestation of this feeling the loss places the individual's existence in danger.
The loss of love from someone important to the individual. Alone, lost, abandoned, empty, meaningless are but a few of the feelings associated with this source of anxiety. The need to maintain the “good will’ of the person becomes overwhelming.
The fear of bodily injury. These takes the form of exaggerated worry about one’s own body and are demonstrated when the individual is in imminent physical danger or, perhaps, an invasive medical procedure is likely.
The loss of self-esteem by failing to live up to internalized standards and mores. This is often expressed as a sense of failure perceived through the individuals own eyes rather than those of the people around them.
What all this says is there is a universality in which all people strive to flourish. We do not do anything without a purpose and that which we do attempt is predictable and understandable by the person who takes the time to understand us. Accepting and understanding the basic consistency of behavior among all people provides us a stepping off point from which Crisis Intervention can be initiated. The Caller in crisis may feel their behavior surrounding a situation is motivated by serendipity and is irrational. Accepting the above, we can help them discover and understand there are reasons they are doing what they are doing. While their behavior may not seem clear to them, defining and exploring the issue at hand can help them attain clarity. We can point out to them that their response to their situation is just like anyone else’s. We can help them understand that feelings are a valid reaction to situations and they exist to motivate us to change. They also exist to validate acceptable behaviors. When we work with a Caller and their fears we can help them develop specific methods of addressing the issues evoking those fears. Helping a Caller explore their anxieties allows them to concretize the realities creating their generalized apprehension. Doing this opens the door to potential resolution.
Coping Defenses
In our field we frequently speak of coping defenses. An understanding of the manner in which coping defenses work can establish a basis upon which we can build a method for understanding, accepting and dealing with Experienced Callers.
Coping defenses are designed to protect the individual from consciously experiencing anxiety and engage automatically when the homeostatic balance of our thoughts, feelings, and behaviors is upset. When the person’s established pattern of defense is initiated and is working they do not experience the pain of anxiety and therefore would not seek the help.
When a person reaches out for help it is an indication their anxiety level has become untenable and their usual defenses are not working. The reason for this situation lies in the fact that coping styles are adapted to a specific developmental period in the Caller’s life. The youth who used denial to cope with their life situation as a pre-teen will find denial doesn’t alleviate the anxiety of their current crisis. This is because they do not take into account that there are more mature or effective manners of coping. The basic reasoning here is, “If it worked before it has to work again”.
An interesting dynamic occurs when a person reaches out for help. Because of their automatic implementation The Caller is most likely notaware they are employing any coping defenses. Since they are not conscious of their attempt to cope they call hoping, if not directly asking, to be told what to do. If it is pointed out that they have initiated their defense system they will respond in a defensive manner. The automatic implementation of their defense strategy is transparent to the Caller and they see their lack of awareness of its existence as a sign of personal weakness.
We have been talking about defenses in general terms. But just what exactly are these “defenses”. The following is a list and description of the major coping defenses used by all of us, Crisis Worker, Crisis Caller, Experienced Caller when we deal with life’s stresses and anxieties:
Avoidance: Involves the individual rearranging their life in a manner that allows them to avoid whatever it is that causes them stress. A Caller who is uncomfortable with close relationships will not enter into a situation where there is a risk of intimacy.
Delusions: When an individual presents a personal belief system or ethic that has little or no grounding in reality they are experiencing delusion. Generally, delusions are either delusions of grandeur (“I am the King of the World”) or persecution (“The UN is after me because I have the nuclear secrets”). Delusions are attempts to resolve problems by a person whose personality and sense of self is in severe disintegration.
Denial: Involves the individual saying that something too painful to bear just isn’t so. The statement, “I don’t believe it!”, by a Caller faced with the death of a loved one is really saying, “I don’t want to believe it!”
Displacement: When the individual expresses emotions caused by one person or situation toward another person or situation they are exhibiting displacement. A familiar situation might be the person who has a flat tire and kicks their car.
Dissociation: Think of the times you’ve left someplace and ended up at your destination but can’t recall exactly how you got there. The sense of being on “autopilot” is an example of dissociation. Amnesia or the sense of experiencing something from outside the individual’s body is more serious manifestations of dissociation.
Hallucinations: When the individual substitutes sensory fantasies for a painful or conflicted reality they are exhibiting coping thorough hallucination. Generally, the hallucinations are initially a respite from whatever is causing the pain but they can become threatening to the individual. As with delusion, hallucination reflects serious personality disorganization.
Intellectualization: The individual who discusses issues in a “hyper-intellectual” manner is defending themselves from hurtful feelings by not allowing them into the consciousness. Everything is analyzed in minute detail from every possible and impossible angle. Humor is not a possibility for these individuals.
Isolation of Affect: When the individual defends their emotions by splitting their thoughts and how they feel about them they are demonstrating Isolation of Affect. The EMT who can discuss an accident scene in coolly and calmly in clinical terms is adaptively using Isolation of Affect. Isolation of Affect is related to Intellectualization.
Projection: Involves the individual disowning painful or uncomfortable thoughts and emotions. The statement, “I am not angry. You are angry at me”, demonstrates projection by a Caller who may be angry with a teacher because they didn’t get the grade they felt they deserved.
Rationalization: Rationalization is when the individual offers sound, seemingly well thought out reasons for a particular behavior or pattern of behaviors. This permits the person to keep the actual, less acceptable, behaviors out of conscious awareness.
Reaction Formation: Involves the individual turning behaviors that are forbidden into something eminently acceptable. An example would be someone who has an alcohol abuse problem yet participates actively in measures and actions that would prohibit drinking. The key here is that the involvement is generally unrelenting and rigid.
Repression: The individual dismisses the painful issue from conscious awareness. All the psychological defenses mentioned here have a component of repression to a greater or lesser degree.
Somatization: The individual translates an emotional conflict into a physiological symptom. A mother who speaks of headaches and ulcers caused by an unruly child is demonstrating somatization.
Splitting: When the individual identifies uncomfortable parts of themselves and separates them from their total persona by burying them in a seemingly inaccessible part of their personality they are practicing splitting. It is as if the person surgically removes a piece of who they are that they are uncomfortable with and throws it “away”.
Suppression: While similar to repression, suppression is different in that it is a conscious effort to forget that which is painful. The individual who says’ “I’m don’t want to think about that”, is practicing suppression.
While the list is by no means complete we can see the defenses individuals utilize to cope are many and varied. Germane to our discussion is the fact that the defenses are used day in and out by persons, including ourselves, whom we consider “normal”. However, the list delineates behaviors that are symptomatic of any of a number of psychological disorders our “Experienced” Callers are diagnosed with. The only difference between the typical Crisis Caller and them is a matter of degree. However, we tend to view the “Experienced” Caller in an entirely different light. We equate the Experienced Caller’s repetitious behavior with their expectation of a different outcome as an indication of their “insanity”. Our frustration with this category of Callers is evidenced in our unnecessarily pejorative references to them as Chronic Callers, Repeat Callers, Demanding Callers, Babblers and so on.
Many reasons are given for this dichotomy:
Our fear of being similarly incapacitated
Our fear of being overwhelmed by the proportion of their defense
Our anger at being overwhelmed by their presentation
Our projection of our own ability to resolve significant issues in our lives
All of the above affects our interactions with the Experienced Caller. The list could go on but for our purposes it is important that we look at the list and understand the counter-transferential issues presented. Our interactions with the Experienced Caller leave us stressed, anxious, lost, overwhelmed, frustrated, and angry. . .much like the Caller.
In every call both participants, the Worker and the Caller, bring “stuff” to the interaction. Both react to this stuff and those reactions set the tenor of the interaction. While we might pride ourselves in our “ability” to keep our own feelings out our interventions we must be aware that such pride is merely a delusion. Even though we are trained professionals our feelings “leak” into our interactions. This is the basic nature of empathy. Usually, this leak helps establish trust and assures a smooth intervention. However, there are times when the leak is counterproductive. The leak allows the intense feelings of the Experienced Caller into our emotional environment and we find it uncomfortable and it changes the substance of our interactions.
It is frequently said the Crisis Hotline is not the appropriate venue for the Experienced Caller. That there is nothing the hotline can provide the Caller. This is a myth. Crisis hotlines were developed with three levels of preventive intervention in mind.
The Primary Prevention level is the one we are most familiar with and find most satisfying to both the Caller and ourselves as professionals. The person experiencing developmental or situational crises call and with the focused exploration of their situation The Crisis Intervention Model provides are able to develop the personal, social, cultural, or professional resources to address their crisis and get on with their lives. This intervention is intended to prevent the development of psychiatric illness.
The Secondary Prevention level accepts that a psychological disorder has manifested itself. It is the goal of this level to mitigate the severity and duration of the disorder or risk of relapse. In this case it is the purpose of the intervention to enable the Caller to engage local services geared toward the primary treatment of the disorder impairing the Callers functioning.
The Tertiary Prevention level is aimed at reducing the level of disability created by the psychiatric disorder suffered by the Caller. This is the prevention level designed to assist most of those people we have termed Experienced Callers. At this level the Crisis Worker works with the Caller who has early or acute mental illness. The intent is to prevent suicide and promote recovery for those whose vulnerability and life stressors have upset the homeostatic balance of their treatment modality.
What this says is, even though we may assume the needs of the Experienced Caller are beyond our scope of operation, there is a valid therapeutic precedent for interacting with them. The question now becomes. . .”But how?”
A Strategy for Interacting with Experienced Callers
In order to work effectively with the Experienced Caller we must come to accept the following regarding all Callers:
The Caller is doing the best they can. They are doing all they know how to do to resolve their situation. It is the task of the Crisis Worker to validate this then engage the Caller in an exploration of what they can do differently to effect resolution
The Caller wants to improve. If the Caller were comfortable in their anomie they would not reach out. The Crisis Worker needs to point out to the Caller that their call indicates they are not satisfied with the status quo and validate the desire to change.
The Caller needs to do better, try harder, and be more motivated to change. Having validated that the Caller is doing the best they can the Crisis Worker now needs to point out and explore, with the Caller, what aspects of their lives they need to change in order to effect the enhanced coping they desire.
The Caller may not have caused all their own problems but they have to solve them. In short, “There ain’t no free ride”. This is useful when working with the Caller expecting a miraculous resolution. We can validate that it is true they did not create their situation. We can then engage them in empowering themselves to effect change.
The Caller’s life is unbearable to them as they are currently living it. If everything were OK they would not be reaching out.
The Caller can’t “fail” the interaction. This is a trap we frequently fall into when working with the Experienced Caller. In an accepting, non-judgmental environment there can be no failure.
This is all wonderful theory and generally acceptable to us for the vast number of our Callers, including some Experienced Callers. There is a continuum of functionality that marks the genesis of psychosis. We all have Experienced Callers we enjoy working with. Generally the only issue involved in dealing with them appropriately is that of boundaries and accepting that we are limited in what can be accomplished in a phone call.
On the other end of the spectrum are those Callers that make us wonder what possessed us to pursue work in the field of Crisis Intervention. These are the Callers representing the psychotic end of the spectrum. These are the individuals with Impaired Reality Testing, Thought Disorders, Inappropriate Affect, or Poor Impulse Control. Callers exhibiting Delusions and Hallucinations, or living in the Borderline State are challenging because their reality and functioning is significantly different from that with which we are accustomed. Because there is a clinical term associated with these people we deem them different and lower functioning. The truth is they are not different and they are functioning. They are attempting to ensure the survival of their personality using the coping defenses we have previously reviewed. Remembering that these coping defenses are used by all of us should remind us that these Callers are not different. That they are endeavoring to “strive and thrive” shows an elevated level of functioning. The reality is that we replace the person’s identity with the identity of their diagnosis. In our thoughts the diagnosis becomes the person or a description of the person. The reality is that the diagnosis tells us what the person has, not who they are or what they are trying to cope with. To develop a method of interacting with these Callers let’s start by understanding their diagnoses.
Impaired Reality Testing: Everyday of our lives we are in a constant testing of our perceptions of our reality. We reach consensual validation with the world at large that a bus is a bus, a chair is a chair and so on. Interestingly, there are times when our reality testing is impaired (meaning not consistent with the actual global reality). When we are in the Dream State we reside in a reality our subconscious creates. In our dreams “fairy tales can come true” and the only reality we need to validate is our own. The person experiencing impaired reality testing has lost the ability to reach consensus with their environment. The person feeling helpless feels they can fly. The victim feels they can be a superhero. What this represents to the individual is isolation from the actual world. They feel misunderstood because they interact with us in terms of their reality. . .a reality we don’t understand. This misunderstanding contributes to a generalized sense of isolation or abandonment. The misunderstanding, isolation, and abandonment become the commonality we can use to interact with such Callers, as these feelings are universal in both of our realities. Depending where the Caller is in their state, it might help to re-establish contact with the more universally accepted reality of society by testing their reality against societal norms. The danger here is invalidating the Caller or the possibility they may be so entrenched in the validity of their reality they feel attacked and communication shuts down.
Thought Disorder: Thought disorders or severe thinking disorders are related to the loss of reality testing. In this instance the internalized representation and organization of the individual's perceptions is altered. Logic disappears. Para-suicidal behaviors might be engaged because consequences are ignored or underestimated. For this person 2+2 equals anything except 4. Conclusions bear no relationship to presented or observed facts. Obvious conclusions or answers are ignored or invisible. The idiosyncratic thought process of the individual, just as with impaired reality testing, is isolating because the logic the person incorporates bears no resemblance to accepted norms. Attempts to point out the lack of logic will prove fruitless as the Caller’s views their logic system as the true logic. Additionally, engaging the Caller within their own reality or logic is not helpful because it serves to validate a thought and value system which can prove ultimately harmful to the Caller. In this case we can interact with the Caller by addressing the behavior represented by their contact. This means we would point out the fact they called represents a frustration or anxiety they are unable or uncomfortable dealing with. This provides a commonality for focused engagement.
Inappropriate Affect: A person’s emotional response (affect) generally reflects a person’s psychological equilibrium. We laugh and are joyful when we are happy. We cry and are sad when we are hurt by life’s circumstances. The emotional response of the person exhibiting Inappropriate Affect is not congruent with the situation or environment that evoked them. An example would be laughter during a time of death or disaster. Those around the person exhibiting Inappropriate Affect view the behavior as being bizarre and will tend to distance themselves from the person creating feelings of isolation and abandonment. This sense of loss and isolation can become the focus of the interaction instead of addressing the Caller’s demonstrated emotional response.
Poor Impulse Control: The ability to observe situations and react or interact in an emotionally and societally appropriate manner in an effort to attain a desired end is a critical skill we learn as we develop. Persons with severe psychological disturbances loose this ability and their action take on an impulsive quality that, ultimately, could be dangerous to the person and/or those around him. In working with this type of Caller it is important to assess possible danger and act accordingly. In working with the Caller with Poor Impulse Control it can be helpful to point out how they feel those around them are reacting to their behavior and how they experience and feel about that behavior. It is important accept the behavior without attaching a personal judgment. All behavior is neutral. It is the emotional reactions of the person and those around them, which lends substance and meaning. This provides the even playing field we need to interact with such Callers.
Delusions: Delusions are a system of beliefs held by the Caller that represent a severe distortion of reality. The delusional person accepts the delusions as real and clings to them tenaciously, frequently arranging their lives to accommodate them. Delusions frequently represent a desire for grandiosity (I’m the King of the World”) in an effort to compensate for feelings of low self-esteem. In short, delusions represent a method for the Caller to cope with internal emotional conflicts by reshaping the reality of their perceived environment. This could be a common ground for interaction but care needs to be taken not to invalidate the Caller. Generally, the delusional individual progresses from delusions of persecution (“The FBI is hiding in my closet”) to delusions of grandiosity. It is important to remember the person feeling persecuted might be prone to impulsive behavior designed to protect themselves from their persecutors. This means we must evaluate the danger to the person or others should the Caller opt to act impulsively. Callers who present grandiose delusions represent a lower risk of impulsive behavior as their reality has placed them above the perceived threats or turmoil. However, it is good practice to explore that they don’t plan to use their power to hurt others. Delusions of invincibility represent a danger in that the Caller may not be aware of the real dangers involved in their actions. Again, this is an area to explore. Engaging the Caller in an exploration of the inappropriateness of their “reality” is invalidating and generally fruitless because the reality we present as appropriate does not exist for them. It is preferable to accept their reality (providing it doesn’t represent a physical danger to the Caller or those around them) and address the stressors it creates for them in living their day to day life.
Hallucinations: Hallucinations can affect any of the five senses but the most common are visual and auditory. The Caller who is hallucinating sees or hears things that are not there yet they are convinced the perceptions are real. Hallucinations represent a major splitting off of parts of the persona the Caller experiences as unacceptable. Frequently, forbidden thoughts and impulses take a hallucinatory form with a life and force of their own (“It’s not that I want to die. The voices are telling me I have to die.”). Hallucinations and delusions may seem bizarre to us but we must keep in mind they are an attempt of the individual to maintain the life force of their personality. The initial hallucinations and delusions represent a kinder, gentler reality for the Caller. They seem to take on the role of escape from a harsh and brutal reality the Caller feels they have no control over. Unfortunately, all to often the sanctuary afforded by the original hallucinations and delusions become transformed by the unresolved crisis it become more cruel and frightening than the reality they were designed to replace. The Crisis Worker may feel it beneficial to enter the Caller’s reality. While in a therapeutic setting this may be appropriate it is not appropriate in our venue. Our posture in the interaction with these Callers should be to assess immediacy issues regarding the safety of the Caller and those around them and addressing any stress and anxiety presented. It is interesting to note the hallucinatory or delusional Caller frequently will not present any stress or anxiety as their state has bought them comfort from the pain of their existence. In this case it is sufficient to explore how the Caller feels they are coping with current issues.
The Borderline State: Originally the Borderline State was thought to be the last ditch defense of the personality on route to psychotic decompensation. It was seen as a transitional stage between higher level functioning and psychotic functioning. Recent thinking places the Borderline State on the pathology continuum as being less disturbed than psychosis but closer to that level of disturbance than the other disorders we have discussed. The person in the Borderline state has managed, although not altogether successfully, to master the basic developmental tasks of Body Boundaries, Basic Trust, and Object Constancy. The primary emotional conflict involved seems to be rage and frustration at not having created a fully formed core identity. Borderlines often present themselves as depressed, feeling dead or lifeless inside, empty, without energy, without goals. They are not dysfunctional in the sense of being unable to hold down a job or even enter into a stable, long-term relationship. It is the lack of zest, the lifelessness of these people that suggest the severity of their disturbance. While not psychotic, they may often have periods when they behave, think, and experience the world psychotically. They are often highly suicidal and it is not unusual for them to become actively suicidal and require hospitalization. The borderline represents a large number of Experienced Callers. In working with these Callers it is helpful to explore and validate the positive responses they present. We must remember the positives presented might be as “trivial” as waking up in the morning or as important as finding employment. Completing the task of remembering to take ones medication can be a milestone. In any case it is helpful point out the positive and engage the Caller in a discussion how they might take that positive and apply it in another area of their life.
With all that has been presented what can we develop as a strategy for effectively interacting with the Experienced Caller? Previously we listed six assumptions regarding our interactions with all Callers. Let’s apply those assumptions specifically to the Experienced Caller.
The Caller is doing the best they can.
We can point out and validate that the Caller is doing all they can to cope. Even if we are aware of other things they could do we must realize the Caller either not be aware of them or their anomie is preventing them from seeing other possibilities. There may also be constraints due to economic or physical ability preventing them from following through on anything else. Remember, even the delusional Caller is doing something to cope with their situation.
The Caller wants to improve.
This is a given. If the Caller was satisfied with their lot they would not be on the phone. Point this out to them. This can open the door to exploring what they have done or considered doing in the past or an exploration of what has worked or not.
The Caller needs to do better, try harder, and be more motivated to change.
This can be ticklish but we can point out that the Caller that they have tried many things and they still feel stuck. What can follow can be a discussion of how maybe they were expecting an instant solution to a long-term problem. A discussion of the Caller’s perception of their self-value might be engaged. For example: “It seems like the frustration has you feeling worn out. Yet it seems you feel you deserve better. Maybe you can decide to try again to make changes for yourself”. Also, recognizing that trying to change is emotionally hard work we might mention that the Caller feels comfortable with the way they feel because it is easier not to change than change.
The Caller may not have caused all their own problems but they have to solve them.
This comes into play when dealing with the Caller who demands that the Crisis Worker solve their problem. Point out to the Caller that it is clear circumstances that are beyond their control may have precipitated their current situation but those influences were in the past. In the present there is only one person who will ultimately create a resolution and that person is them. At this time it can be helpful to point out they don’t have to go the road alone and appropriate referrals or interventions could be introduced.
The Caller’s life is unbearable to them as they are currently living.
This is helpful with the Caller who is doing your basic “pity party”. Point out the Caller’s dissatisfaction with there state. You can then point out that if they choose they can get concrete help to change. In most cases the reply will be that they have tried everything and nothing worked. In this situation it can be helpful to point out that they do, in fact have a choice. They can either accept nothing will work and do nothing. In that case nothing will change. The choice is that they can try to make a change and have a chance that trying may in fact work this time or not. However, if they don’t try “nothing” is guaranteed to happen.
The Caller cannot fail therapy.
Again this is helpful with the Caller who is from the Been There – Done That – Nothing Works school of thought. We can validate their feeling that nothing is working but offer that it’s not solely the fault of the Caller. We can then point out that just as there was a lot of stuff that got them to the point they are at it takes a lot of stuff to make things better. That things didn’t work out right doesn’t mean they didn’t do their job. All it means is that they need to try again. Everybody who has ridden a bicycle remembers the first time they tried it without training wheels. The following poem illustrates this concept:
