The impact of their role on telephone crisis support workers’ psychological wellbeing and functioning: Qualitative findings from a mixed methods investigation

Abstract

Little is known about how telephone crisis support workers are impacted by frequent empathic engagement with callers in crisis, including those who are suicidal. This is the only known qualitative study to specifically examine the impact of their role on telephone crisis support workers’ psychological wellbeing and functioning. Eighteen telephone crisis support workers participated in semi-structured interviews, providing detailed accounts of the impact of the role on their wellbeing and functioning. Interpretive Phenomenological Analysis of interview data resulted in four key themes. Results suggest that telephone crisis support workers’ motivations, background, personal help-seeking and coping practices are likely to impact their experiences of psychological wellbeing and functioning in relation to empathic engagement with callers in crisis. Telephone crisis services should seek to integrate an understanding of workers’ experiences into the provision of training, supervision and support strategies to optimize workers’ wellbeing and functioning.

Introduction

Within Australia, non-clinical telephone crisis lines provide essential front-line support to individuals in crisis. Crisis lines meet gaps in other services as universally available and accessible services to support the community, and are a viable alternative for those who would otherwise not seek or receive a service response during their experience of a crisis state. Telephone crisis support lines are effective in attracting people seeking help, especially those experiencing severe mental health issues and/or thinking about suicide (Beckner et al., 2007; Gilat & Shahar, 2007; Leach & Christensen, 2006). Research shows that contact with crisis lines significantly improves the help-seeker’s mental state, reduces their distress levels and suicidality, and often facilitates engagement with interventions that can offer longer term benefits (Gould et al., 2007; Hoffberg et al., 2019; Hvidt et al., 2016; Kalafat et al., 2007; King et al., 2003).

Optimal delivery of support to callers in crisis requires optimal performance on the part of the telephone crisis support worker, including resilience to occupational hazards. Yet, little is known about how telephone crisis support workers are impacted by speaking with people in crisis (Kitchingman et al., 2018a). In fact, the telephone crisis support modality is one of the least understood, particularly in terms of the impact of the role on the worker (Dunkley & Whelan, 2006). Two systematic reviews of available research on telephone crisis support workers’ wellbeing conclude that this population is at risk of decreased mental wellbeing, including symptoms of stress, burnout, compassion fatigue and vicarious traumatization, despite experiencing gratification from their work (Kitchingman et al., 2018a; Willems et al., 2020). However, both reviews highlight the dearth of research in this area, the methodological limitations of the limited number of published studies, and the need for high quality, comprehensive research to assess the impact of their work on telephone crisis support workers’ mental wellbeing and identify influencing factors.

This study formed part of a concurrent, mixed methods study (Creswell & Plano Clark, 2011). The study had two components. Component 1 used a repeated measures survey to gather quantitative data on telephone crisis support workers’ functional impairment related to psychological distress before and after completing a shift on the crisis line (Kitchingman et al., 2018b). Component 2 - the focus of this paper - was designed to obtain qualitative information which may help to provide meaning to the process of functional impairment and delineate core themes for further exploration in future studies. To our knowledge, this is the only qualitative study to investigate the experiences of taking calls and their impact on telephone crisis support workers’ psychological wellbeing and functioning. The aim is to provide a detailed, idiographic and in-depth analysis of the impact of the telephone crisis support role on workers’ psychological wellbeing and functioning, and to identify those aspects of the experiences of taking crisis calls which either positively or negatively impact them.

Materials and methods

Participants and procedure

Participants were recruited from Lifeline, the largest volume telephone crisis support service provider in Australia. In preparation for recruitment, a table was created listing the location and number of Telephone Crisis Supporters (TCSs) working at 42 Lifeline crisis support centers. Center locations were categorized as metropolitan or regional according to the Australian Standard Geographical Classification system (Australian Bureau of Statistics, 2001). Three centers from different location categories were selected to recruit participants to the study to ensure the participants were not all from the same location, which may have influenced their experiences. Participants were recruited directly by the first author, who visited each of the three selected centers to complete interviews over separate two-week periods during May and June 2016. Each TCS who completed a shift on the crisis line during the recruitment period was invited to participate in the study.

Participants in this qualitative component of the study were a self-nominated subset of 18 of the 110 TCSs who completed the quantitative component of the study (Kitchingman et al., 2018b). The sample size for this study is consistent with Interpretive Phenomenological Analysis (IPA) methodology, which typically involves small and homogenous samples, allowing in-depth investigation of a specific issue (Smith, 1996; Smith et al., 1999). Most participants were female, born in Australia, and working in a regional Lifeline center. Participants ranged in age from 29 to 73 years (M = 53.00, SD = 12.46), and had worked as a TCS for 1 to 18 years (M = 4.33, SD = 4.79). More detailed information regarding participants’ demographic characteristics is presented in Table 1. Confirmation of the representativeness of the study sample in terms of age, gender and role type was established by comparison with service operational data current at the time of data collection (Lifeline Australia, 2015).

Table 1. Demographic characteristics of study participants (N = 18).

		Total n(%)
Gender	Male	7(38.9)
	Female	11(61.1)
Relationship status	Single	3(16.7)
	In a relationship	4(22.2)
	De facto	1(5.6)
	Married	8(44.4)
	Separated	1(5.6)
	Divorced	1(5.6)
Highest educational qualification	Year 10/equivalent	1(5.6)
	Diploma/equivalent	8(44.4)
	Undergraduate university degree	7(38.9)
	Postgraduate university degree	2(11.1)
Country of birth	Australia	13(72.2)
	Other English speaking country	4(22.2)
	Other non-English speaking country	1(5.6)
Center	1 – Metropolitan	4(22.2)
	2 – Regional	9(50.0)
	3 – Regional	5(27.8)
Role	Probationary TCS only	5(27.8)
	Probationary TCS plus paid overnight shifts	1(5.6)
	TCS only	9(50.0)
	TCS plus volunteer role	3(16.7)

Semi-structured interview

An interview guide (Appendix A) was developed according to good practice guidelines (Smith & van Langenhove, 1995). This guide was based on the findings of a systematic review of the literature on telephone crisis support workers’ symptoms of psychological distress and functional impairment (Kitchingman et al., 2018a); the results of a preliminary study on telephone crisis support workers’ impairment related to symptoms of psychological distress (Kitchingman et al., 2017); and discussions among the research team. Interview questions were generally related to participants’ experiences of preparing for a shift taking crisis calls, actual experiences during and after a shift, and the impact of calls on their psychological wellbeing and functioning, and were designed to elicit both positive and negative experiences. These questions were used as a guide to explore areas of interest; they did not dictate the interview. Participants were encouraged to tell their stories in their own words, to use narrative expression, to reflect on their experiences, and to raise any additional topics that they felt were important in understanding these experiences.

Participants were given definitions of psychological wellbeing and functional impairment to use as a frame of reference during the interview. To develop rapport and make the participant feel at ease, interviews began by focusing upon background information such as motivations for volunteering as a TCS, and positive and negative aspects of the TCS role. Asked to recall how they generally feel before, during and after completing a shift on the crisis line, participants were also invited to identify moments where the TCS role impacted their wellbeing and functioning. Follow-up questions were used to encourage elaboration on important individual topics which arose. Further contributions were encouraged by asking “Is there anything more you would like to share?” This allowed participants maximum opportunity to tell their own stories to speak freely at length about their experiences, minimized researcher control over the discussion, and facilitated rapport building (Barbour, 2000; Smith & van Langenhove, 1995). These approaches are consistent with IPA, as the research attempts to enter the psychological world of the participant who is seen as the expert (Smith, 1996; Smith et al., 1999).

The interview guide was pilot tested with three TCSs. The interview data from pilot testing was not included in the findings reported in the study, and TCSs involved in pilot testing were excluded from participating in the study. Minor wording changes to questions resulted from pilot testing.

Ethics approval for the study was granted by the University of Wollongong Human Research Ethics Committee (HE15/497). Research aims and potential discussion topics were explained by a Participant Information Sheet and an introductory meeting with the first author. Written consent was obtained from participants before the interview commenced. Interviews were conducted face-to-face at the crisis center at which the participant was based or by phone, according to each participant’s preference. Interviews ranged in length from 21 to 60 minutes (M = 35 minutes). All interviews were audio-recorded with the participant’s written permission.

Analysis of qualitative data

Audio-recordings of all interviews were transcribed verbatim into Microsoft Word by the first author. Transcripts were entered into NVivo (QSR International, 2012) to facilitate data analysis. Interpretive Phenomenological Analysis (IPA; Smith & van Langenhove, 1995; Smith et al., 1999) was used as a guiding approach for qualitative data analysis. The aim of IPA is to explore participants’ descriptions, choice of information, expressions and views and the personal meanings they attached to experiences, rather than trying to align these with objective concepts or explanations (Smith et al., 1999). IPA offers a systematic approach to combining understanding the lived experience of the participant with a belief that to do so requires interpretative work on the part of the researcher (Smith & Osborn, 2008). The researcher aims to get close to each participant’s psychological world and adopt an insider’s perspective (Smith, 1996), while recognizing that access to the participant’s subjective view depends on and is complicated by the researcher’s own conceptions (Smith et al., 1999).

IPA has been used extensively, although not exclusively, within psychology. There is a growing body of IPA research examining aspects of health psychology (Brocki & Weardon, 2006), including the experience of health professionals (Carradice et al., 2002; Michie et al., 2004). IPA was chosen as the method of analysis for the current study because it is a particularly useful approach where the topic under study is relatively under-studied, dynamic, contextual and subjective, and where issues relating to identity, the self and sense-making are important (Smith, 2004). It is also a systematic approach, with clearly described procedures (Smith, 2004).

Data analysis was thematic and followed the inductive coding process outlined by Braun and Clarke (2006), which involves familiarization with the data (the first author conducted and transcribed all interviews), generation of initial codes, collation of codes into potential themes with corresponding quotes and review of themes with credibility checks. Credibility checks were facilitated by a systematic record of how data were collected, maintained, and prepared for analysis. In keeping with guidelines for good practice in qualitative research (Elliot et al., 1999; Smith, 1996; Yardley, 2000), the research team conducted an audit of the paper trail (Smith, 1996) by reviewing transcripts together with the potential themes identified by the first author, and checking that a coherent chain of argument ran from the raw data to the list of themes. This consultation process, referred to as investigator triangulation (Guion et al., 2011) is recognized as important in IPA, given that the analysis of the interview data is inevitably influenced by the researcher’s characteristics. No major changes to the themes identified by the first author were identified as being necessary. Further consultation within the research team followed to discuss specific theme descriptions and selection of the most relevant quotes.

Other strategies employed to enhance the integrity of data analysis included having prolonged engagement with the data, including interview administration and transcription (van den Hoonaard, 2002); and the three methods of bracketing outlined by Tufford and Newman (2012). Specifically, this included: (1) keeping memos during data collection and analysis as a means of examining and reflecting on engagement with the data; (2) engaging in discussions with an outside source to bring awareness to preconceptions and potential biases; and (3) keeping a reflective journal during all stages of the research process to sustain a reflexive stance (Tufford & Newman, 2012).

Regarding positionality, members of the research team had various backgrounds of involvement with telephone crisis support services including in research, clinical, and managerial roles, and lived experience in the telephone crisis support role. Such varying experiences were important in minimizing potential biases in data interpretation (Whittemore et al., 2001). As this was an exploratory study, it was not the aim to achieve data saturation of all themes. To convey the strength of themes, the number of participants who discussed each point is presented.

Results

Results are reported according to four principal themes identified by reviewer consensus from the interview transcripts, each containing several subthemes (see Table 2). The content of these themes and subthemes are summarized in the sections that follow. Direct quotations are presented in indented paragraphs, in which square brackets ([]) indicate information added by the first author for clarification, and ellipses (…) indicate material omitted for conciseness. Identifying information has been removed to preserve participants’ anonymity.

Table 2. Themes and subthemes.

Theme	Subthemes	n
TCS role	Motivations for volunteering	17
	Positive aspects of the role	16
	Negative aspects of the role	12
Impact of the TCS role on psychological wellbeing and functioning	Feelings before, during and after a shift	18
	Factors that influence feelings about the shift	18
	Factors related to impact of the TCS role on psychological wellbeing/functioning	18
	Functional impairment	17
	Psychological distress	2
Strategies used to cope with the impact of the TCS role on psychological wellbeing and functioning	Debriefing	16
	Reflection and self-care	13
	Boundaries	11
	Group supervision	6
	Realistic expectations	6
Suggested service strategies to minimize the impact of their role on TCSs’ psychological wellbeing and functioning	Training strategies	5
	Supervision and support strategies	3

TCS role

This theme captured participants’ motivations for volunteering as a Lifeline TCS, as well as positive and negative aspects of the role.

Motivations for volunteering

Most participants (17/18) discussed their motivations for volunteering as a Lifeline TCS. Many participants (9/18) identified that their decision to volunteer as a Lifeline TCS was influenced by their familiarity with the organization or contact with someone already volunteering as a TCS, made over a considerable period of time (6/10), and prompted by retirement (5/18) or relocation (3/18). Many participants (10/18) discussed volunteering as a TCS to supplement other work or study.

I’m studying a Diploma of Community Services … And I’ve done youth work and mental health studies before … The training … it was all relevant … Everything just puzzled together perfectly at the time I was studying. I would go back to class and think I was sort of a little bit ahead of everyone, if that makes sense. I already knew.

Others reported that their decision to volunteer as a TCS was influenced by their lived experience of mental health issues or suicide (5/18), or desire to support others who are less fortunate (3/18).

I have severe Bipolar I and clinical depression. I tried to take my own life. I was in hospital for nine weeks … It was a long haul … And I thought ‘If I could just help one person who is having thoughts of suicide, just to talk, that would be awesome.’ And (my husband) saw an advertisement for Lifeline, so I went along to the information session.

Positive aspects of the role

Most participants (16/18) discussed gaining a sense of satisfaction for having helped others (15/18).

Sometimes you know that you’ve helped someone. You can tell that you’ve helped them resolve something within their own life. And that makes you feel good.

Participants also discussed feeling part of and supported by the organization (6/18), having gained new knowledge and/or skills (8/18) and a new perspective or increased sense of gratitude for their personal circumstances (5/18).

Almost every caller is dealing with way more than I’m dealing with on any given day. And it makes me grateful for what I have. And I do tend to find that  … particularly that next day, that I will make a particular point of telling family and friends how much I value their friendship, or how much they mean to me.

Negative aspects of the role

Many participants (12/18) also discussed negative aspects of the TCS role, including feeling helpless to assist some callers (6/18), exposure to callers’ stories and distress (4/18), and feeling disappointed in themselves when a call has not gone well (3/18). Some participants (5/18) also identified family members’ concerns and lack of understanding as a negative aspect of their role as a TCS.

My mother says ‘Why do you do that? Why would you do that? Why would you volunteer to do something?’ She still finds it very difficult to understand why I would give my time.

When I first started my husband was really nervous about me [speaking to callers in crisis]. He was supportive, but was nervous on my account, you know, that I would become distressed.

Impact of the TCS role on psychological wellbeing and functioning

This theme captured participants’ descriptions of the impact of the TCS role on their psychological wellbeing and functioning.

Feelings before, during and after a shift

Participants (8/18) used various terms to describe their feelings before starting a shift on the crisis line, including OK/fine (4/18), good/happy/excited (5/18), nervous/apprehensive/tense/stressed (6/18). Some participants (4/18) reported that how they feel before a shift depends on how tired they are. Many participants (10/18) discussed engaging in some sort of routine which helps them to feel ready to complete a shift on the crisis line (e.g., resting, exercising, preparing mentally).

Participants (10/18) described a range of feelings experienced during a shift on the crisis line, including energized (2/18), tired (5/18), calm/relaxed (4/18) and tense (1/18). Some participants (5/18) reported that their feelings during a shift were influenced by the outcomes of the calls they have taken.

And depending upon how well it went, and the last call … If the last call went really well, people were happy, they had a plan, there was a point of recovery, then for me I feel much more confident and ready for the next call. The immediacy of the last call has an impact during the shift. If I think ‘OK that was good. That’s OK’ then I’m back to the base again, ready with anticipation. But if it didn’t go so well it’s sort of, deep breath, ‘Oh boy. OK. You can do this’.

So you kind of have that good call then I think following that you’re kind of feeling positive, and you have a positive outlook for the next calls coming through.

Some participants reported feeling stressed at the beginning of each call due the inability to anticipate the content of the call before answering it (3/18), and the greater level of concentration required at the beginning of the call to assess the caller’s situation (3/18).

You take a call, I still take a deep breath, I nearly close my eyes and try and go into a zone … and totally concentrate on the opening of what the call is to gauge where [the caller is] at. Every call is … it’s not a relaxed call for me. I take a deep breath, think ‘here we go’, press the button and the phone rings.

Some participants (5/18) discussed needing to neutralize any feelings raised by the previous call before taking the next call. Many participants (9/18) described the strategies they employ to do this, including reflecting on the previous call before setting it aside, taking breaks between calls, or debriefing with the in-shift support worker - the staff member trained to provide immediate support to telephone crisis support workers during their shift.

You can’t [say] ‘Hello this is Lifeline’ and be really peppy, because I just don’t think that’s appropriate for someone that’s in a bad place to hear. It’s almost a kind of instant mismatch … I like to be very neutral when I answer the phone so that there’s not … a mismatch in the mood of myself and the caller … So kind of almost like wiping the slate clean before each call. Even though inside you might be feeling positive … just trying to be neutral and aware that you just don’t know what state the next caller is going to be in.

Participants (15/18) used a range of terms to describe their feelings after completing a shift on the crisis line, including tired/fatigued/drained (8/18), good/calm/grounded (6/18), satisfied (6/18), relieved (2/18), and frustrated/angry (1/18). Some participants (3/18) discussed an increase in energy following the shift, which was experienced positively by some participants, and negatively by others.

I’d come home and I wouldn’t sleep well. It would be on my mind. I would be wired when I came home, which is probably adrenaline and nervousness. I was wired.

Factors that influence feelings about the shift

Most participants reported that their feelings about a shift on the crisis line depended on the extent to which callers seem to have benefited from the calls (13/18).

A good shift would be one that you’ve had a challenging call and everything sort of fell into place … You just helped someone to be able to see things from a different angle, to see things a bit clearer.

The not so good [shift] is if there’s a succession of calls that are not, in my opinion, satisfactory in outcome.

Participants’ reported that their feelings about a shift are also influenced by the extent to which they have adhered to the practice model (6/18), which other workers were present at the crisis center (6/18), the number of calls they received (4/18), the extent to which they were able to connect with callers (3/18), and how tired they felt during the shift (2/18).

Psychological distress

Some participants (2/18) reported that engaging empathically with crisis callers caused them to experience symptoms of psychological distress, including anxiety, compassion fatigue and secondary traumatic stress.

If you’ve connected too much with a caller … you could experience what they’re experiencing. You’re getting tense when they’re getting tense.

I had time off because I was … not empathetic enough … It was sort of a bit of a drag at times … I was starting to become … I don’t know if stale is the right word, but I thought that I might not have been empathetic enough. I was getting a bit too clinical.

Sometimes [something about Lifeline or suicide] will come on the radio or on television … there’ll be something that will probably hit me out of the blue and I might get really upset. And I don’t know why, but sometimes it does affect me that way.

Functional impairment

Most participants (17/18) were able to offer an example of a time they believed their role as a TCS had impaired their functioning. For many participants (11/18) this included thinking about calls after completing a shift on the crisis line.

I thought about it a bit when I went home. And probably the next day or two I thought about it … Then I had [group] supervision, and they said ‘Anyone have any calls that they’re thinking about?’ And I thought ‘Oh yeah, that one’ … and just broke down. Just fell in a heap. Because it had been niggling.

One participant reported that the TCS role impaired his functioning in other domains.

We live on six acres and there are projects here that I started and haven’t been able to finish. It’s a cause of frustration … When you do a Lifeline shift in the morning it’s three hours. It takes [out] that morning … You plan your week around it – not going away, or trying not to … In the ten years I’ve been doing it, um … I haven’t been one that’s, you know, skipped along. There are some people that say ‘I can’t wait to get there’. Well, ah, to me, it’s more onerous than it is a joy or a pleasure. It is a commitment … A couple of days preceding [a shift] you think ‘Oh I’ve got Lifeline, I can’t do this, can’t do that’.

Conversely, some participants (2/18) also discussed the impact that their personal wellbeing and functioning has on their ability to support callers.

To be really, really honest, being a TCS at Lifeline does affect my life, but my life affects me being able to be a TCS, if that makes sense.

Factors related to the impact of the TCS role on psychological wellbeing and functioning

All participants discussed role-related factors associated with the impact of the TCS role on their psychological wellbeing and functioning. Many participants (10/18) discussed stressors which are inherent to the TCS role, including the inability to anticipate or control the types of calls received (8/18), the absence of non-verbal communication cues (3/18), and the one-shot nature of contact with callers to the crisis line (1/18).

Participants (9/18) discussed the impact of various difficult tasks on their wellbeing and functioning, including keeping a healthy distance from rather than over-identifying with the caller (8/18), containing calls (2/18), and using the referral database (1/18).

Most participants (16/18) identified specific types of calls which were likely to impact their psychological wellbeing and functioning.

Many participants (11/18) discussed the negative impact of suicide-related calls.

I had a suicide call, and it was fairly traumatic. I was with the [in-shift support worker] waiting for the police to arrive … It was just not knowing how that had gone, because you don’t know whether that person was able to be helped.

Other participants (2/18) reported that suicide-related calls were less likely to impact them because of the highly prescribed and directive procedure they are required to follow, and the support they receive from the in-shift support worker during these calls.

Things like suicide are probably some of the easier, more straightforward calls that are really going to affect me less because we have such a strong model that we follow … There are other calls that we haven’t been trained as extensively in, and may affect you more emotionally, whereas suicide is really straightforward. You have someone in there supporting you … There’s some really clear steps that you do, some very direct questions that you ask … You’re not open to being … exposed, in terms of what you’re hearing, because you’re immediately in reactive or action mode.

Many participants (10/18) reported that their psychological wellbeing and functioning is likely to be impacted by unwelcome calls, including those of a sexually-gratuitous nature.

The sexual unwelcome callers. They sort of take something out of you, which you don’t really expect, but when you put the call down … it’s not a nice feeling … It’s like they’ve invaded your space, even though they’re at the end of a call. It’s like they’ve … overstepped the line. Even though they don’t know you, they can’t see you, you still feel a little bit violated when somebody does that to you.

Some participants (7/18) identified that speaking with callers who are experiencing an issue that is personally relevant to them is likely to impact their psychological wellbeing and functioning. This included receiving calls from those at risk within the local area.

I could really feel for him, in that regard. And I didn’t say ‘Yeah, I know how you feel’. And that was hard, not to say ‘Look mate, the same sort of thing happened to me.’ It was the first time I’ve ever really felt the need to contain saying ‘Oh yeah, I know’ because I could relate … That was the most confronted that I’ve ever been … because it was so jolly similar.

A suicide call … it was local … which is very unusual … I was like ‘Wow. It’s just there.’ And of course [the caller] had no idea [where I was]. But the descriptions … I could picture the street … all that detail.

Participants also identified that their psychological wellbeing and functioning is likely to be impacted by taking non-crisis calls (5/18), calls made by angry/abusive/frequent callers (5/18), victims of abuse (4/18), young people (4/18), people who have been dealing with their problem/s for many years (3/18), taking calls which are long in duration (3/18), and require the TCS to sit with the caller’s distress and/or evoke a high level of empathy (3/18).

Some participants (7/18) discussed specific events during calls which are likely to impact their wellbeing/functioning, including feeling unable to help the caller (6/18), being triggered (3/18), and the call ending unexpectedly (1/18). Others (4/18) discussed personal factors related to the impact of the TCS role on their psychological wellbeing and functioning, including lack of self-awareness (2/18), having the tendency to envisage details of the caller’s story (1/18), and needing to be in control (1/18).

Many participants (13/18) reported that the impact of the TCS role on workers’ psychological wellbeing and functioning differs according to level of experience. They discussed several vulnerabilities associated with being a new TCS, including experiencing anxiety regarding policy and procedures (10/18), having unrealistic expectations (3/18), over-identifying with callers (3/18), taking calls personally and/or taking responsibility for the outcome of calls (3/18), lack of coping skills (3/18), and not realizing the extent of the time required to be committed to the TCS role (1/18).

You’d feel as if you’re [the caller’s] life support. When it didn’t go well you’d think you’d failed. But I think you learn over the years that it’s not a failure. You’ve done your best. You’ve tried to cover all bases, and just sometimes the person on the other end either doesn’t want help, or they’re not ready to listen yet, or you just don’t connect with them … Certainly in the first year or two I was really taking it more personally than what I needed to.

Some participants (2/18) also discussed the risk of becoming complacent as an experienced TCS.

The challenge can be that you start to perhaps become overconfident … You’ve got to be careful you don’t think you know everything, because you don’t … So that’s probably the challenge I’m finding now.

Strategies used to cope with the impact of the TCS role on psychological wellbeing and functioning

This theme captured the range of strategies that participants use to prevent and/or cope with the impact of the TCS role on their psychological wellbeing and functioning.

Debriefing

Most participants (16/18) discussed using debriefing as a coping strategy. Some participants reported debriefing with the in-shift support worker during the shift (5/18), at the end of the shift (4/18), and in the days following the shift (4/18). They identified debriefing as a source of reassurance (4/18), and/or an opportunity for professional development (2/18).

Some participants (2/18) discussed a preference for completing shifts where the in-shift support worker would be present in person.

I only do the shift when I know there’s someone there. I know there are some shifts when they’re not there, and I wouldn’t feel comfortable doing those. I like knowing that that support’s there. That makes a difference … Well I’m just worried, because I haven’t been doing it as long as some people, that um … I’m going to get overwhelmed and need someone to guide me. I just need to know that if I ever need somebody, they’re there.

Some participants (2/18) discussed choosing not to debrief with the in-shift support worker by phone.

I know the [in-shift support worker] is there that you can call. But in reality I don’t like calling them.

It was midnight, and it didn’t seem like I should contact someone that late at night when it wasn’t a crisis call … It didn’t seem like it was going to make a difference to anyone but me if I made the call to [the in-shift support worker] … If you said to me “If there was a mentor in the building would you have talked to them?” yes I would have, because they’re right there. But for me to call someone that I know is at home … I just didn’t see the urgency in doing that. But obviously with other calls where you’re concerned about the caller, then I would call [the in-shift support worker]. But because the concern was probably for me, I didn’t want to disturb someone at that hour.

Some participants discussed preferring to debrief with another TCS (3/18) or a family member (1/18), or to resolve their problems on their own (2/18) or in therapy (1/18), rather than debriefing with the in-shift support worker.

Reflection and self care

Many participants (13/18) discussed monitoring their thoughts, feelings and body sensations. Some identified using these thoughts, feelings and sensations as cues to engage in self-care (6/18), including distracting tasks (5/18), taking a break during the shift (7/18), and finishing the shift early when necessary (4/18).

Boundaries

Many participants (11/18) discussed setting boundaries to cope with the impact of the TCS role on their psychological wellbeing and functioning. This included not “taking calls home” after completing a shift (6/18), not taking calls personally (5/18), being clear about the limits of their role and asserting these limits with callers when necessary (4/18).

Group supervision

Some participants (6/18) reported attending group supervision as a coping strategy. They identified group supervision as a learning opportunity, and the process of engaging in supervision as validating and normalizing of their experiences.

Realistic expectations

Some participants (6/18) discussed the protective value of having realistic expectations of themselves as a TCS, including not measuring their skills as a TCS on the outcome of calls (3/18), knowing that the role involves a continual learning process (1/18), the caller is the only one who can solve their problem (1/18), and that it is normal to respond emotionally to callers’ stories (1/18).

Suggested service strategies to minimize the impact of their role on TCSs’ psychological wellbeing and functioning

This theme captured participants’ suggestions regarding service training, supervision and support strategies to optimize TCSs’ psychological wellbeing and functioning.

Training strategies

Some participants (3/18) suggested that training include more detailed information regarding how to support callers with mental health issues (1/18) and suicidal thoughts (1/18), as well as to prepare workers for sexually-gratuitous calls (3/18).

I think they should do more about the [sexually gratuitous] calls. I think you need to have them almost described in graphic detail. I wasn’t quite prepared for how devious they can be, and how graphic they can suddenly become.

One participant suggested that training should also provide further information to prepare TCSs for the occupational hazards inherent to the role.

I think the training needs to be less cognitive … There needs to be a component of it that’s more about the person … They don’t cover that [in the Lifeline training]. We need to be telling our people ‘This work is difficult. You are going to be triggered. Some of these calls are going to get to you’.

Supervision and support strategies

Participants offered several suggestions regarding supervision and support strategies, including adopting a more proactive approach to monitoring TCS wellbeing (2/18), holding group supervision more frequently (1/18), and having supervision provided by qualified mental health professionals (1/18).

Whilst there’s a big emphasis on self-care, and always ring a mentor if need be, that’s very true but it’s quite a passive approach, in that it’s up to the individual to ring the [in-shift support worker] … It’s also up to you if you want to debrief, and it’s up to the person to do self-care. So it’s a very passive approach in some regard, although it’s very high on the agenda … I think a more direct [approach] could be made.

One participant also suggested that supports which are external to the organization be made available to TCSs.

I believe we should have an employee assistance plan. Someone you can ring who is a qualified mental health practitioner … There’s bound to be [TCSs] who won’t feel comfortable accessing their supervisor or manager … when something has triggered them quite deeply.

Discussion

To our knowledge, this is the only qualitative study to explore the experiences of telephone crisis support workers and investigate the impact of the role they perform on their psychological wellbeing and functioning. The study design permitted an in-depth investigation into the experiences of a small, but typical group of telephone crisis support workers. The following section will discuss the main themes in the context of existing literature, and implications for telephone crisis support services.

Experiences of the telephone crisis support role

Telephone crisis support workers who participated in the current study reported that they had spent a considerable amount of time weighing up their decision to take on this role. It was common for participants to volunteer in the role to supplement other work or study. Fewer participants reported motivations related to their lived experience of mental health issues or suicide, or a desire to support those less fortunate. Research indicates that not all motives are created equally regarding their impact on outcomes from volunteering. Volunteers who engage in service primarily for other-related reasons (e.g., to express prosocial values, reaffirm their relationships with others, to learn more about other people and the world) are more likely to report higher levels of personal wellbeing, satisfaction, perceived support from the organization, longer tenure and greater intentions to continue volunteering (Stukas et al., 2014). In contrast, those with primarily self-orientated motivations (e.g., career enhancement) are more likely to report lower levels of personal wellbeing, reduced satisfaction and lower intentions to continue volunteering (Stukas et al., 2014). While volunteers’ motivations are rarely purely other- or self-oriented (Clary et al., 1998), the results of the current study suggest that telephone crisis support services should seek to recruit individuals with other-oriented motivations for volunteering, and to affirm these motivations in order to retain current volunteers.

Participants discussed a number of negative aspects of the telephone crisis support role in relation to their psychological wellbeing, including family members’ concern or lack of understanding of their reasons for volunteering, feeling helpless to assist some callers, and exposure to callers’ stories and distress. Despite these challenges, most participants also identified positive aspects of the role in relation to their wellbeing, including a sense of satisfaction from helping others, and having gained valuable knowledge and skills. They also reported increased gratitude for their personal circumstances, and sense of belonging to the organization. These experiences are consistent with the theoretical concepts of compassion satisfaction (Stamm, 2010) and post-traumatic growth (Calhoun & Tedeschi, 2006), which recognize that distress and psychological growth often co-exist. Research suggests that the positive outcomes of working in this field make the difficult aspects easier to deal with (Schauben & Frazier, 1995), and active reflection on levels of satisfaction acts as a buffer against psychological distress (Samios et al., 2013). In addition to promoting this reflection, crisis support organizations should aim to foster an environment where volunteers feel valued, and are made aware of the difference their work makes, in order to promote compassion satisfaction and personal growth (Howlett & Collins, 2014).

Experiences of the impact of taking crisis calls on psychological wellbeing and functioning

Participants described experiencing a wide range of feelings before, during and after a shift on the crisis line. They were most likely to report feeling nervous before the shift, and tired during and after the shift. Participants indicated that their feelings are primarily influenced by who else is on shift and how tired they feel, suggesting that having the ability to choose which shift they will complete may promote workers’ psychological wellbeing. Some participants reported experiencing a high level of stress at the beginning of each call due to the inability to anticipate the content of the call before answering it, and the high degree of perceptual energy concentrated on the caller’s voice in the absence of non-verbal cues. While these factors are not directly amendable, workers may benefit from training in skills to reduce this anticipatory stress (e.g., relaxation and grounding strategies).

Most participants discussed at least one experience of functional impairment. Most commonly, these experienced entailed preoccupation with particular calls during the hours or days following a shift on the crisis line. It is possible that these results simply indicate workers’ commitment to the telephone crisis support role. However, many participants also described experiences of functional impairment which occurred in the context of psychological distress. While it has been previously been suggested that telephone crisis support workers may be less impacted than those who deliver face-to-face support due to the shorter-term nature of their work and the protection afforded by working anonymously over the phone (Ghahramanlou & Brodbeck, 2000), findings from the current study are consistent with more recent studies indicating that telephone crisis support workers are at risk of experiencing symptoms of psychological distress as the result of their engagement with callers in crisis (Kitchingman et al., 2018a; Willems et al., 2020), which may impair their functioning if help is not sought for, or other adaptive strategies are not used to manage this distress (Kitchingman et al., 2017, 2018b).

Participants identified several specific factors which influence the impact of the telephone crisis support role on their psychological wellbeing and functioning. These included a number of difficult tasks inherent to the TCS role, such as keeping a healthy distance from rather than over-identifying with the caller, and containing calls. Research suggests that over-identifying with the help-seeker, which leads to the delivery of compassion and sympathy alone, rather than the effective communication of empathy, increases the risk of compassion fatigue (Clark, 2007). Maintaining boundaries while empathizing with others in distress is crucial, as it protects against countertransference and encourages growth (Harrison & Westwood, 2009). Results of the current study suggest that telephone crisis support workers’ psychological wellbeing and functioning may be enhanced by training and supervision strategies which focus on the development of skills to communicate empathy and maintain appropriate boundaries.

Participants identified a number of specific types of calls as being detrimental to their wellbeing and functioning, including those made by unwelcome and abusive callers. With the exception of a small number of participants who identified being relatively less impacted by suicide-related calls due to the expected nature, specific training and clear protocols to follow, many participants experienced these calls as distressing. Participants also described being particularly impacted by calls where the nature of the caller’s crisis was relevant to their personal circumstances. As it is not possible to anticipate or control the types of calls received during a shift on the crisis line, these results suggest that telephone crisis support workers are likely to benefit from training and supervision which explicitly anticipates the likelihood of receiving a personally-relevant call, normalizes experiencing this as distressing, and offers adaptive strategies to reduce the impact on their wellbeing and functioning.

Participants discussed using a range of strategies to manage the impact of the telephone crisis support role on their psychological wellbeing and functioning. Many participants described setting boundaries, including not “taking calls home” after completing a shift, as a coping strategy. However, the majority of participants reported having ruminated on particular calls during the hours and days after completing a shift. Participants discussed the protective value of having realistic expectations of oneself, and not taking calls personally. However, participants also reported feeling disappointed in themselves when they believe a call has not gone well, and identified less experienced telephone crisis support workers as particularly vulnerable to experiencing this. Research suggests that personal feelings or responsibility for the outcome of calls increases workers’ risk of distress (Mishara & Giroux, 1993). Therefore, workers’ psychological wellbeing and functioning may be improved by service training, supervision and support strategies to reduce workers’ sense of responsibility for the outcome of calls.

Participants reported mixed feelings regarding engaging with their in-shift support worker to manage the impact of calls on their wellbeing and functioning. Some described this engagement as a source of reassurance and a professional development opportunity. However, despite service policy mandating debriefing with the in-shift support worker at the end of each shift, a number of participants were not willing to seek this support to manage personal symptoms of psychological distress. Previous research has offered a number of explanations for helpers’ failure to seek help for their own symptoms of distress, including impaired decision making (Bora & Berk, 2016), putting aside their personal needs in order to care for others (Meyer & Ponton, 2006), and believing that seeking help for personal problems will reflect poorly on their competence (Charlemagne-Odle et al., 2014; Siebert & Siebert, 2007; Wallace & Lemaire, 2009). Participants in the current study described actively choosing not to debrief with the in-shift support worker. Some cited a preference for managing symptoms independently or with informal supports. Others expressed beliefs that personal symptoms of distress did not warrant debriefing with, or would inconvenience, the in-shift support worker. As seeking help for personal symptoms of distress has been established as a key variable in the process of preventing telephone crisis support workers’ functional impairment related to symptoms of psychological distress (Kitchingman et al., 2017, 2018b), the results of the current study suggest that services should provide a clear rationale for, and interventions to correct workers’ unhelpful beliefs regarding debriefing and help-seeking.

Improving the psychological wellbeing and functioning of telephone crisis support workers

Participants in the current study made a number of suggestions regarding training, supervision and support strategies to reduce the impact of the telephone crisis support role on their wellbeing and functioning. They proposed that training include explicit information regarding the risks of personal distress and impairment. They requested additional information be provided to increase their preparedness for particular calls, including those sexually gratuitous in nature. Correspondingly, research indicates that clinicians who are explicitly informed about occupational hazards are less likely to experience distress and impairment as the result of empathic engagement with distressed others (Cheng et al., 2007; Decety et al., 2010).

In relation to supervision and support, a small number of participants suggested that the service adopt a more proactive approach to monitoring telephone crisis support workers’ wellbeing, including by employing appropriately qualified clinicians to provide internal supervision, or offering alternative options for those wishing to receive this externally.

While most telephone crisis support workers are supported by nonprofessional peers (Spittal et al., 2015), the results of this study suggest that those who provide supervision and support to telephone crisis support workers require skills in the identification and rehabilitation of symptoms of psychological distress and functional impairment - professional competencies beyond a peer support role. Research suggests that telephone crisis support workers who receive professional supervision are less likely to experience various symptoms of psychological distress, including vicarious trauma (Dunkley & Whelan, 2006), and are more likely to experience personal growth (O’Sullivan & Whelan, 2011).

Strengths, limitations, and recommendations for future research

The current study has addressed a significant gap in the literature regarding how telephone crisis support workers experience and are impacted by their role. A primary strength of the study was its use of qualitative methodology and Interpretive Phenomenological Analysis (Smith, 1996; Smith et al., 1999), producing a detailed, in-depth analysis of telephone crisis supporters’ experiences which may inform the development and/or modification of existing service strategies to optimize workers’ psychological wellbeing and functioning. The time which has elapsed and significant world events which have occurred since data collection may impact the relevance of study findings. Participants in the current study were from one Australian national telephone crisis support organization. Further quantitative research is therefore needed to confirm the extent to which the findings of this study remain current and are generalizable to telephone crisis support workers from other Australian and international organizations.

Conclusions

The current study demonstrates that differences in telephone crisis support workers’ background, personal help-seeking and coping practices are likely to impact their experiences of psychological wellbeing and functioning in relation to empathic engagement with callers in crisis. Telephone crisis support services should seek to apply an understanding of the individual worker’s experiences with the design and provision of training, supervision and support strategies to optimize workers’ wellbeing and functioning. In particular, as assumptions about crisis support workers’ willingness to engage in appropriate self-care, debriefing and supervision may not be realized depending on the individual worker’s experiences, motivations and outlook, greater attention to policy and procedural requirements, alongside the involvement of clinical expertise in supervision and support is warranted.

Acknowledgements

The authors would like to thank the telephone crisis support workers who took part in this study and the service managers and supervisors who provided feedback and support.

Disclosure statement

The authors report there are no competing interests to declare.

Data availability statement

Data from this study cannot be made publicly available for ethical reasons. A condition of ethical approval for this study, which was included in the information sheet used to inform participants’ written informed consent was that individual data would not be reported.

Additional information

Funding

This work was supported by the Australian Government Research Training Program Scholarship; and the Dr Barbara Wright Postgraduate Scholarship awarded by the Central West Branch of the Australian Federation of Graduate Women.

Appendix A.

Interview guide

I’m going to ask you some questions about your role as a Telephone Crisis Supporter (TCS), and how your role impacts your wellbeing and functioning. When I ask about wellbeing, I’m referring to both positive feelings like satisfaction and happiness, and negative feelings like stress, anxiety, depression and thoughts of suicide. When I ask about functioning, I’m referring to the impact of these feelings on your ability to support callers on the crisis line, complete your other work or study, take care of family responsibilities, and participate in your normal social activities. Does that make sense? Do you have any questions before we start?

1. How did you decide to become a TCS?

2. What makes you feel good or less good about being a TCS?

3. What makes a TCS shift good or less good?

4. How do you feel before starting a shift on the crisis line?

5. How do you feel during a shift on the crisis line?

6. How do you feel after a shift on the crisis line?

7. Can you tell me about a time when your role as a TCS impacted your wellbeing or functioning?

8. Can you think of anything that would help you to manage the impact of your role on your wellbeing or functioning?

9. Is there anything else you would like to share?