TELEPHONE COACHING

If you have the training, experience, support and supervision, providing telephone coaching when people are contemplating suicide can be invaluable. However, a lone counsellor or therapist could be vulnerable doing this. Rather you would then want to consider other services your client could use at their most challenging times, notably Samaritans or the mental health service if they are open to that service.

Staff are generally anxious that clients will overuse or misuse telephone coaching, but this rarely happens. Many people have anxiety or shame, or believe they are undeserving or their needs are invalid, all of which tends to inhibit help-seeking. Telephone coaching aims to provide opportunities to change these patterns. Telephone calls may need to be shaped to increase or decrease; the great majority of patients under-use telephone coaching. Few patients find a middle way, either calling for minor reasons or calling too late (when drunk or standing on a bridge).

There are a number of reasons for maintaining contact with your client at unscheduled times if you are able to: [1]

Suicidal thoughts and urges tend to fluctuate and clients during scheduled sessions may be quite upbeat and may even minimise the severity of their suicidal risk, which can limit how much skills- coaching you can do at those times.

• As well as coaching and practising new coping behaviours you can provide on-the-spot positive reinforcement for these behaviours by cheerleading.

If a client phones to avert self-harm or suicide, assess risk and problem- solve. “What have you tried?” “What skills could you use right now?”Think of it as doing something akin to a sports coach before a game, i.e. keep the discussion relatively brief and focused and dealing with the immediate task at hand to avert suicide.

It may be helpful to establish and actively request willingness, explaining that you can’t help someone who is unwilling to keep themselves safe. Although this sounds challenging in fact it is generally well received and demonstrates how focused and committed you are to helping the person stay alive. Using a metaphor can help clients remember how critical it is for them to contact you before acting on urges to attempt suicide, such as emphasising they need to contact you before “walking to the edge of the cliff”. This is also a compassionate way of explaining that you want them to seek professional help before self-harming.

Obviously, this needs to be done with clear expectations and do agree some rules beforehand, planning for all contingencies. There a number of things that can go wrong for you or them. Think together about these:

  • • They call you in a desperate state and you can’t answer.
  • • Clients asking you to call them back communicate their acute distress to you and then you can’t get hold of them.
  • • Their phone runs out of charge or funding.
  • • They call too late for you to help, e.g. after an overdose.

I would discourage texts unless they are about a request for a call or very brief practical information, e.g. cancelling sessions. From experience, they have a higher chance of not arriving or being missed and also of people using them inappropriately. I would not provide coaching if someone has already self-harmed (in DBT the rule is within the last 24 hours), as the person has passed the window for skills-coaching and you do not want to provide positive reinforcement. At these times you courteously provide the minimum duty of care: Do you need to go to A&E? Do you or I need to call an ambulance? If you fear for their safety and they are unable to assure they can keep themselves safe, consider calling the police or involving someone else who may keep them safe. This requires a careful balance between keeping the client safe and supporting their independence. Most people in this situation have a legal capacity to make choices. (This would not be the case if the person was acutely psychotic.)

As stated in Part 1, positive risk taking is identifying the potential risks involved, and developing plans and actions that reflect the positive potentials and stated priorities of the service user. It involves using available resources and support to achieve the desired outcomes, and to minimise the potential harmful outcomes. It requires an agreement of the goals to be achieved, or a clear explanation of any differences of opinion regarding the goals or courses (Southern Health NHS Trust 2012). Positive risk taking is about individuals taking control of their lives and making choices - either positive or negative - and learning from the consequences of those choices - again positive or negative. In practice this requires a balance between the interests of the individual and societal pressures to control risk (Felton et al 2017).

Suggested guidelines for telephone coaching:

  • • 24-hr rule. No coaching after self-harm for 24 hrs.
  • • Agree times when the clinician or team are available.
  • • Agree the time frame in which a telephone call by the client will be responded to.
  • • Length of call should be 10-20 minutes.
  • • You may also want to agree the process, i.e. is the call prefaced with a text and, if so, set limits on purpose and length of texts.

Encourage clients wherever possible to take action to ensure their own safety. If they require medical attention, ask the person to seek assessment or treatment from a walk-in centre or ED. You may want to request the client tells you the outcome if you agree they will take some action. If you have serious doubts they will do this and believe they could be at risk, you may need to contact mental health crisis service or, if more urgent, the police. Depending on what you have agreed with your client, it may be appropriate to politely end the call (courteously) if the client:

  • • has already self-harmed (ensure they don’t need medical help or encourage them to seek this if they do);
  • • is intoxicated or has taken illegal drugs;
  • • refuses to engage in problem-solving.

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  • [1] Build therapeutic rapport and repair ruptures in the therapeuticalliance. • Shape safety behaviours and provide in vivo coaching. Suicide ratesfluctuate over time and providing coaching during a critical windowcan save lives. • Positively reinforce behavioural change (e.g. “text me or give me acall when you have got rid of the tablets/moved them to the shed”). • If you are able to provide it, maintaining contact between scheduledsessions has multiple benefits. • It demonstrates your genuine commitment to that individual andyour desire to help them and support them when they most need it. • You get to know the true nature of the difficult mind states yourclient can get in. You are much more likely to pitch expectations andcoping strategies accurately when you are familiar with these states. • Just being there then and listening increases human contact,connection and compassion, all of which are antidotes to suicidality. • You can then give in vivo coaching (any parent, teacher or CBTtherapist will understand the merits of coaching “in the moment”).
 
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