59 THE EFFECTS OF THE SUICIDE PREVENTION CENTER OF ALAMEDA COUNTY TELEPHONE SERVICE ON CLIENT AND COUNSELOR ROLE PERFORMANCE Suzanne Bowler Department of Anthropology University of California Berkeley, California Introduction This paper will examine the effects on counselor and client role performance of the confidential telephone counseling service provided by the Suicide Prevention Center of Alameda County (here- inafter "SPAC") and the repercussions these have for both parties. Since clients' confidentiality and privacy are protected, and they and counselors are strangers who communicate over the telephone, fewer behavioral restrictions can be imposed than in face-to-face encounters. The advantageous and disadvantageous consequences of this situation for both participants will be explored in some detail. The material presented is based on intensive interviews of the staff and 11 volunteer telephone counselors that were conducted during 3 months of fieldwork in the summer of 1979, and on notes I have taken on calls since joining SPAC as a volunteer in March, 1979. The Agency SPAC is a community based mental health agency which was founded in 1966, and operates centers in Berkeley and San Leandro to handle approximately 2,500 telephone calls a month. It receives annual funding from the State (Short-Doyle), Federal Revenue Sharing and United Way. Its 10 member staff includes an Executive Director, Coordinators for each center, assisted in Berkeley by a secretary and in San Leandro by a part-time Coordinator. The Treasurer/ Bookkeeper, Group Therapist for suicide attempters and Consultant Psychologist all work on a part-time basis. Two paid nightwatch supervisors man the 12-8 a.m. shifts for both centers, one for five nights and the other for two. 100 volunteer telephone counselors who work the same four hour shifts each week in pairs provide telephone coverage for all other times. Trainers, who are senior volunteers, work with one or two trainees and one trained volunteer who takes some calls so that the trainer can listen to and instruct trainees on the others. Telephone counselors work together as a team, listening to each other's calls through loudspeaker phone extensions, suggesting questions to ask the caller and giving feedback afterwards. They help each other find names and telephone numbers of other helping agencies if needed, or phone drug informa- tion, the police and hospital if a caller has made a suicide 60 attempt. All volunteers must sign up for one year periods, and if training, take the five training orientation classes while working concurrently on shift with their trainers for three to four months. They must advise their center Coordinator in advance if they plan to be absent, and arrive 10 minutes before their shift begins in order to relieve their predecessors on time. Coordinators maintain shift coverage, filling in themselves when necessary, and visit different shifts to make sure that high quality service is being provided to clients. They select trainers and oversee training of newcomers. They and the Executive Director are available to volunteers to contact at any time for aid in emergencies. The Board of Trustees that meets monthly with the Executive Director to make recommenda- tions and vote on new policies and programs also volunteers its time and services. The Consultant Psychologist meets once a week with the staff to discuss problematic cases of clients who have called the Agency over a long time period, and to mediate when staff members air their grievances. Working conditions at both centers are informal and comfortable. Interpersonal relationships among all Agency personnel are warm, friendly, supportive and fully coopera- tive, and help ease the stress of providing a counseling service to people from highly diverse ethnic and socioeconomic backgrounds. Although SPAC runs other programs such as Bereavement Counsel- ing, Speaker's Bureau talks on suicide to high schools and community organizations, and group therapy for suicide attempters, its main focus is on the 24-hour day, 7-day week confidential telephone service. Agency goals for this program are to prevent people from taking their own lives, and to provide human contact, emotional support and practical help, i.e., referrals to psychiatric counsel- ing services or other pertinent agencies, to anyone who calls, whether suicidal or not. Counselors' dealings with clients are influenced by these goals and premises given to me by the Executive Director. According to Foster, premises are defined as ". . . the unquestioned assumptions, . . . the unrecognized postulates that underline the cultural forms and individual behavior of the members of a group" (1969:67). Those of SPAC include: "clients' needs come first," "human life is sacred and every effort must be made to save it," and "suicide is a transitory stage in life and can be pre- vented." Counselors are dedicated to responding appropriately to people's requests for help by offering whatever aid they can within the limitations imposed by the duration of the telephone call. They also pledge to protect client confidentiality. Confidentiality and Client-Counselor Roles Confidentiality is the most important feature of the Agency's service in that it creates a non-threatening environment within which clients can speak freely on taboo topics such as suicide, alcoholism, homosexuality and mental illness and reveal intimate details of their lives. Furthermore, they can vent emotions, i.e., cry, scream, express extreme fear, "freak out" on drugs or hallu- cinate without fear of the police being called or other negative 61 consequences. Calls are handled only on a first name basis and filed as such. Place of residence, age, marital status and occupation are requested but not demanded, and callers may remain anonymous if they wish. Telephone numbers and addresses are ob- tained or traced only if someone's life is in danger and the police have to be sent to take them to hospital. State law prohibits the release of client records to any non-Agency personnel. Volunteer telephone counselors sign a confidentiality agreement stating that they will not reveal callers' names and details of their cases to outsiders. They cannot visit callers at their homes, call them except in special cases or exploit them sexually or in any other way. The extremely rare violators of these rules are immediately dismissed. Telephone counselors' confidentiality is also protected in that they never talk about themselves during calls, but instead concen- trate on the clients' problems. Since only first names are given and the Agency's location is kept secret, counselors are safe from attack by any hostile clients. This anonymity allows them greater liberty to ask clients personal questions and to be confrontive by insisting they answer important questions so that their problems can be revealed and dealt with during the limited time of the phone call. Duration of calls depends on the seriousness of the clients' situations and can last from less than 2 minutes to 45 minutes or more. Most calls, however, are completed within 25 minutes. Despite its necessity and overriding advantages, confidential- ity can also be highly disadvantageous to both counselors and clients, because it increases the likelyhood of incongruous role enactment. Nadel states that the performance of one role guides or conditions that of another and that this ". . . mutual steering built into the process of interaction functions only inasmuch as the persons involved in it acknowledge each other's role and have con- gruent assumptions about them" (1956:55). He adds that ". . . this steering process is not necessarily held up until the sanctions are actually encountered" (Ibid., 55). Said sanctions cannot, however, be effectively imposed on callers to SPAC without violating their confidentiality. Their role performance is therefore more liable to deviate from that desired by the counselors, since they can be sanctioned with nothing stronger than a sharp verbal response or a hang-up. As Nadel points out, "The mutual role knowledge enables the actors to calculate the consequences of their actions before- hand, so that much of the mutual steering takes place on the level of anticipations" (Ibid., 55). As long as both parties are in agreement as to their respective roles, verbal exchange will produce more positive results. Counselors are trained to interact with clients in the most appropriate manner, for which they must learn to anticipate the types of responses they will receive to their ques- tions, comments and suggestions. Since they are providing a service to callers, their ideal role of server to caller-clients forms the context of their interactions, which closely resembles Goffman's description of the social relationship between the expert server and his client within the framework of personal service occupations 62 (1961:326). He states that the server should recognize the client's autonomy, treat him with "appropriate regard and ritual," and respect his "appraisal of the trouble" (Ibid., 326-329). After introducing themselves, counselors always ask callers what is wrong and how they can be of help. Goffman adds that, "Ideally, the client brings to this relationship respect for the server's tech- nical competence and trust that he will use it ethically; he also brings gratitude . . ." (Ibid., 326). Counselors' expertise in dealing with depression and suicide is generally acknowledged by callers, but they rarely express thanks. Goffman recognizes that the client's contribution of useful information to the server enables both parties to work jointly toward correcting the "malfunc- tion" (Ibid., 329). Counselors also rely on callers' assessments of their problems and work with them in seeking solutions. The condi- tions for this "good service relation" (Ibid., 329), however, rest primarily on both parties' mutual agreement as to definition and enactment of their respective client/server roles--a situation that does not always occur at SPAC. Parsons states that ". . . the basic condition on which an interaction system can be stabilized is for the interests of the actors to be bound to conformity with a shared system of value- orientation standards" (1951:38). He believes that this is met when one party's role obligations to the other coincide with the latter's expectations in any interaction, resulting in his gratification and positive sanctioning of the former. In addition, people appear to be psychologically motivated to solicit favorable reactions more often than unfavorable ones because these have become linked to introjected gratification needs. Furthermore, the actor feels morally responsible to conform to the roles determined by the "social action system in which he participates" (Ibid., 41). Therefore, failure to perform one's role not only deprives another individual of personal gratification but also violates moral standards of society. Parsons' statements on this subject provide a useful framework within which to examine the various results of role interplay between counselors and clients at SPAC. Client-Counselor Role Enactment The counselors I interviewed listed the following role obliga- tions that they believed they had to clients: * Protect their privacy and confidentiality (see page ). * Use the time on the phone call to serve the client's best interests. This sometimes involves their having to be con- frontive with certain people, particularly those who are being manipulative. * Listen carefully to what the caller is saying and be aware of what he/she has omitted. This is particularly important when people make allusions to suicidal intentions, which 6 3 must be discussed and dealt with openly and immediately. Clients who say, "I am tired of it all" or "I want to go away and find peace" must be responded to with "Are you planning to kill yourself?", "When . . . how?" and "What has happened to make you feel this way?" * Accept them as they are. No judgments are made on people because of their ethnic or socioeconomic background, or personal idiosyncracies. An alcoholic would not be con- demned for drinking, but reminded of the consequences if he or she continues. * Respond appropriately to them. When a client is obviously distressed, counselors must acknowledge the fact and show understanding and empathy by saying something like "You sound very upset. Has something happened?" or "from what you have told me, I can understand why you are so upset." * Be with them without trying to change their present mood. Counselors should never try to talk clients out of their depressions but rather express compassion and assure them that their present distress will not last forever. * Help them find more positive solutions than suicide to their current crisis. As suicidal tendencies tend to be transitory and do not necessarily recur, the counselor's intervention can avert a tragedy. * Refrain from giving them advice, but help them decide what to do. Callers are given the responsibility to handle their problems through helpful prompting from counselors. Advice only increases their sense of powerlessness and causes them to respond defensively to suggestions. * Express concern for them. Counselors may tell clients "I am very concerned about you" and ask them how they are going to spend the rest of the day in order to make sure that they will be all right. Those facing serious crises are always encouraged to call back as often as they need. One volunteer told me that a teenage girl who had called him after having turned on the gas finally turned it off and called him back to tell him that she knew he would want to know. Client responses are often a good measure as to whether these obligations are met. One young man complained that a counselor had laughed at him when he told her that he felt suicidal. A woman justifiably hung up when I failed to respond appropriately to her emotional distress, and a counselor was "bawled out" by a woman for having told her that she was to blame for her marital problems. Counselors are sometimes unable to meet clients' needs because of the restrictions of the telephone service. They cannot call friends or relatives on the latter's behalf, or visit them in their homes, 64 and people cannot come to the Agency for face-to-face counseling. Counselors do, however, make every effort to serve clients for whom they have a strong sense of responsibility and concern. Less charitable feelings, however, prevail for those clients who fail to meet role expectations. Although the Agency policy officially states that clients have no role obligations to counselors, in practice this is not the case. Counselors do recognize that certain people cannot be expected to conform to desired roles because they are too distressed, anxious, mentally ill or otherwise incapacitated, but the calls they consider the most rewarding are those with clients who fulfill the following counselor role expectations. * Callers should make their needs known, e.g., they should say "I need someone to talk to" to which the counselor may warmly respond, "I will be glad to talk to you" or request other forms of help such as referrals for psychiatric counseling services, agencies for drug or alcohol abuse, parental stress, battered wives, legal assistance and the like. * They must be calling for help and not for inappropriate reasons such as to chat, be abusive or for a prank. Coun- selors will often ask clients "In what way can I be of help to you?" or "Why are you calling Suicide Prevention?" in order to encourage them to express their needs. In general, those failing to respond to these questions are not seeking assistance. * They should answer counselors' questions and trust them enough to tell the truth. Such questions include not only their first name, town of residence, age, occupation and marital status, but also details of their current problems. This information gives counselors a clearer idea of their clients' predicaments and of the best ways to deal with them. While most people willingly answer these questions, those who refuse to are not pressed to do so. Some people call often, using different names each time, while others tell stories that cannot possibly be true. The majority of clients, however, are truthful. * Clients ought to treat counselors with courtesy and respect, although allowances are necessarily made for those who are hysterical, deeply distressed, or in need to vent their anger before discussing their situation. Counselors will not take rudeness or abuse from people who are warned, "If you continue to abuse me, I am going to have to hang up." This often prompts them to stop. Callers meeting these obligations probably gain as much satis- faction as they give. The most gratifying calls for counselors are those in which someone is in crisis, asks for help which they can 65 provide, and feels better at the end of the call. This help may be giving referrals, practical suggestions or merely listening sympa- thetically and responding warmly to someone in distress. A young man I spoke with was feeling very lonely and suicidal. He lost his fiancee one year ago, was drinking heavily and had a number of unpaid bills. He liked neither his job nor the area where he lived, and did not get on well with his friends. I expressed concern for him and acknowledged his present unhappiness. We then discussed ways of dealing with his unhappy situation that would be less damag- ing than his current drinking, and I urged him to take good care of himself because he was "worth it." His spirits improved markedly by the end of the call, and he was so pleased that he offered to donate money to the Agency. These relatively rare calls help counselors to realize that their work is worthwhile because they have helped their clients and thus performed their role. In addition, counselors take every available opportunity to raise someone's self-esteem when he or she has been left by a spouse or lover, lost a job, or suffered other serious setbacks. According to the Agency Consultant Psychologist, low self-esteem is the most common symptom of suicidal behavior which must be alleviated in order for sufferers to recover. This task is easier for counselors to accomplish for people with crises than with those who call repeatedly, and whose life situa- tions and mental condition are unlikely to ever change. The most distressing calls to handle are those from people who hate them- selves and are so miserable that all counselors can do is show compassion and understanding while hoping that their pain will eventually subside. Although these people cannot be expected to conform to any rules of conduct, others appear deliberately to violate them because of extreme anger, drunkenness, sexual needs, dependency or other reasons. Their responses to counselors quickly reveal their inten- tions. Instead of answering the counselor's greeting, "Suicide Prevention," with a request for help, they become abusive and say something like, "I don't know why I'm calling you. You don't care." or "You're no help anyway." If asked for their name, they may tell the counselor that it is none of his/her business. If they cannot be persuaded to focus on any problems they may have, their calls are quickly terminated. Manipulators are particularly difficult to deal with because they try to lay responsibility for their problems onto the counselors. An alcoholic threatened to jump out of the window if I did not talk to him immediately, although I was on another call and had asked him to call me back in five minutes or give me his number. People threatening to kill themselves if counselors termi- nate the telephone call have to be reminded that "That is your decision, and I hope you don't." One busdriver calls continuously whenever he is on a drinking binge. One night he called 10 times during the busy shift on which I work, to make various incoherent remarks laced with sexual allusions. Whenever I or my co-worker told him to sober up before calling back, he begged and pleaded with us to stay on the line and talk to him. One time he miraculously sobered up enough to talk coherently about his predicament, to the gratification of my co-worker, but his condition had again 66 deteriorated by his next call. Torture callers, i.e., those claim- ing to have made a suicide attempt but refusing to reveal their whereabouts, present considerable problems to counselors in that their statements must be taken seriously until proven otherwise. These people are generally very angry at someone who has hurt them, but choose to vent their wrath against anonymous Suicide Prevention personnel instead of at their assailant. One woman told me that she had taken 30 different pills, was on her third Scotch, and was not going to reveal the type of pills, her phone number or address so that I could have her sent to hospital. She then hung up before I could put a trace on the call. Other callers with whom counselors have difficulty working are those who are abusive, obscene, unresponsive, pranksters, or contin- ually call and immediately hang up. Those who hang up repeatedly are told not to call until they want to talk. Masturbators' heavy breathing generally gives them away, and they are told "We're not here for this type of service. Why don't you call back when you're through if you want to talk about any problems." These people appear not to be contacting the Agency for help, but to exploit its services. Their behavior often resembles the "ritual profanation" of psychiatric ward inmates described by Goffman, whose acts from society's viewpoint ". . . are exactly those calculated to convey complete disrespect and contempt through symbolic means" (1956:495). One volunteer recounted an extreme form of "ritual profanation." A man called the crisis line and remained silent except for one angry exclamation. She told him to call back when he felt ready to talk and that she would be glad to speak with him. A few minutes later, the phone rang and she picked it up to hear a tape recording of everything she had said during that call! Conclusion These people cannot be stopped because they know that they will never be caught, and their "misbehavior" is probably further encour- aged by the fact that they are dealing with strangers on the telephone, rather than with someone they know in a face-to-face contact. Agency policy of confidentiality for its clients, while essential for effective counseling, further decreases the possibil- ity of such callers being sanctioned. The police are not sent to their home by the Agency even if their addresses are known. Since the usual constraints that enforce role conformity in interpersonal interactions do not exist in this environment, counseling work is rarely easy and often quite stressful. Furthermore, volunteers who fail to perform their role adequately are subject to the immediate sanctions of their co-workers or staff members who can hear the calls over the loudspeaker phone. This seemingly unfair situation could not be otherwise, given the nature of the service that the Agency provides, and is accepted by those who become counselors. As they become more experienced, they learn to work constructively with people who seem to deliberately abuse the services offered without becoming angry or distressed. Counselors may at times be able to 67 establish a dialogue with such clients, once they have broken through the external barriers of rage and/or frustration often expressed by verbal abuse, to reach the underlying problems. This could be accomplished by their acknowledging the callers' negative feelings through stating "You are obviously very angry. Why don't you tell me what's made you so angry." They must, therefore, set aside, their role expectations of clients--while guarding against exploitation--in order to deal more objectively with them. One counselor related her extreme satisfaction at having been able to establish a good rapport with a long-time schizophrenic caller, whose abrasive manner and "delusions" alienated others. Although counseling is more pleasant when both parties possess ". . . a shared system of value-orientation standards" (Parsons 1951:38), it is often more challenging and rewarding when a "good service rela- tion" (Goffman 1961:329) can be achieved if they do not. ACKNOWLEDGMENTS My warm thanks to the staff and volunteers at SPAC who patiently answered my numerous questions and provided many useful suggestions and comments, and to the clients who shared their lives and concerns with me. I am indebted to Professor Elizabeth Colson who read the original edition of this paper and recommended a number of improvements in format, style and content. REFERENCES CITED Foster, George M. 1969 Applied Anthropology. Boston, Massachusetts: Little, Brown and Company. Goffman, Erving 1956 The Nature of Deference and Demeanor. American Anthropol- ogist 58:473-502. 1961 Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. Garden City, N.Y.: Anchor Books. Nadel, Siegfried F. 1957 The Theory of Social Structure. Glencoe, Illinois: The Free Press. Parsons, Talcott 1951 The Social System. Glencoe, Illinoi: The Free Press.