Conducting telephone work in IAPT Services

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Will
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Conducting telephone work in IAPT Services

Post by Will » Sun Feb 26, 2012 2:10 pm

Many IAPT services now recommend delivering low intensity interventions and guided self-help through the telephone. Some services offer it as an option, whilst a growing number of teams operate exclusively via telephone contact. I’m not going to get into a discussion of how I think IAPT services ‘should’ utilise telephone appointments as I don’t think this would be useful to those working in services different to mine – instead this article will discuss some of the issues around telephone work and offer some tips!

I think it’s fair to say that telephone work often gets quite a bad press. It can be anxiety provoking for staff, especially if they haven’t received adequate training. Risk management is often a concern. I’ve heard people describe it as not ‘feeling like proper therapy’, and many people seem to see it as a less intensive form of treatment. Then there’s also the old “I don’t want to work in a call centre!” argument. In the interests of full disclosure…this was the way I felt about telephone work for a long time.

However, a great deal of evidence has emerged in recent years supporting the use of the telephone in primary care mental health services. Telephone contacts have been found to be as effective as face-to-face sessions for a range of disorders including depression (Mohr, 2005), OCD (Lovell, 2006) and panic disorder with agoraphobia (Swinson et al, 1995). Additionally, telephone contacts appear to be acceptable to service users (Bee et al, 2008). The telephone may offer positive solutions to many of the social, physical, psychological and economic barriers to psychological treatments in primary care.

Offering telephone appointments undoubtedly improves access for patients, as the session doesn’t need to be arranged around clinic availability. Appointments can be planned around work or childcare issues, further improving flexibility. Additionally, patients are provided with a level of anonymity – they don’t need to worry about seeing their friend in the waiting room or bumping into you at Asda. Most people have access to a phone.

Increasing flexibility improves a service’s ability to efficiently meet activity targets, in addition to reducing DNAs and cancellations. If a patient cancels at short notice, an appointment could be instead conducted over the telephone. Phone sessions can be conducted from anywhere, producing less demand on clinical space. Organisations such as NHS Direct and the Samaritans have been effectively delivering telephone based services for years, often to high risk patients.

For practitioners, the ability to deliver interventions by telephone is certainly a good tool to have in your arsenal. Telephone work is challenging and is an important skill to develop in itself. However working in this way offers the opportunity to build on your abilities to communicate effectively and foster effective therapeutic relationships. Additionally, I’ve often found using the phone makes it a bit easier to keep interventions in a guided self-help framework. It adds a focus to sessions and keeps off-topic discussions to a minimum.

What can help?
Organisation
It is vital to be organised and ensure both parties are ready for telephone appointments. In addition to planning a date and time, encourage the patient to find a quiet place and have their materials or homework in front of them – telephone work becomes almost impossible if the person is in the middle of a shopping centre or on a bus. It is often useful to have a discussion in advance about what to do if someone else answers the phone or if they are not available to talk – one useful approach is to agree a ‘code’ in advance. For example, you might agree that if not free to talk, they decline an offer of double glazing or a fitted kitchen – this can allow confidentiality to be protected if they have an unexpected visitor. Agreeing plans for how to manage these possible eventualities will go a long way to encouraging people to give telephone sessions a try.

And whilst it should go without saying…check in advance you have the right phone number!

Agenda setting
This is something which should be done at the start of every session anyway, but with telephone appointments it is especially important. A conversation should start with confirmation of who you’re speaking to, followed by an introduction of yourself. Once you have checked the patient is still okay to talk, agree a clear plan and agenda for the session (including how long the appointment is expected to last). This can ensure both parties can cover what they need to, minimising the level of off-topic discussion.

Outcome measurements
In IAPT services outcome measures are an integral part of the process. If conducting telephone appointments you will still be expected to complete the questionnaires. In my opinion the best way to do this is for patients to fill in copies of the questionnaires before their appointment time, allowing them to read out the answers for you to record. This requires some organisation, as they will have to be given out or posted in advance. When this isn’t possible, it can be quite time consuming to work through questionnaires so be sure to highlight the benefits of completing them every session, giving feedback on scores and progress.

Communication
In face-to-face sessions, we naturally pick up on the non-verbal cues that form such a big part of conversation. Facial expressions, posture, gestures and eye contact all contribute to the way we communicate and are understood. Obviously speaking on the phone prevents this. Both parties need to be conscious of the elements of conversation which can be missed and compensate for this accordingly. Listening to what is said and regularly reflecting, paraphrasing, summarising, and clarifying the information you receive can help facilitate the discussion. It is vital to be aware of words and phrases you use and be mindful of how things may be misinterpreted.

Another factor to consider is silences. Small silences are natural in conversation and are a useful way of encouraging people to open up or expand on a particular point. Silences may also occur when you are writing notes. These seconds without conversation would most likely go unnoticed when face-to-face with someone, however they feel much more uncomfortable when on the telephone. Without non-verbal cues a person might interpret silence in a negative way, or they may feel obliged to fill the ‘gaps’ in conversation. It is often useful to discuss this at the start of a telephone contact and explain that there might be times where you do not speak if, for example you are reading or writing what is in front of you.

Missed appointments and DNA’s
Whilst services may differ on their exact policy with regards to how you should respond to missed contacts, this is an important area to consider with telephone appointments. Staff and service users should treat telephone appointments as they would a face-to-face. This means sticking to set times and managing missed contacts appropriately. I tend to ring a patient at the arranged time, then after ten minutes, then after fifteen minutes. If they have still not answered I will consider it a ‘Did Not Attend’ and will send them a letter in line with our service policy. This approach reduces the number of DNAs caused by people going out or not being free to talk, but also improves the service people receive – it may be easier for you to tell a patient you will call sometime in a few days, but having a specific prearranged time allows them to prepare appropriately and make the most out of the sessoin.

Risk management
This seems to be a common area of concern. Managing risk is stressful at the best of times, however many people worry about how they might deal with such issues on a telephone call. However, Samaritans have been supporting people with active suicidal ideation for many years, and many NHS crisis services triage patients over the phone. In terms of IAPT workers conducting telephone appointments, risk is managed in exactly the same way it would be during a face-to-face session. Supervisors, GP’s, gateway workers or crisis teams should be contacted in line with local policy.

Conclusion
Many services are now encouraging their practitioners to offer telephone appointments. This may or may not be optional, however I hope this article has prompted you to consider giving it a go. Many of the problems with telephone contacts can be overcome with a little effort and forward planning. Often patients may be wary or unsure, but a “let’s see” attitude from you may encourage them to give it a try.

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Content checked by qualified Clinical Psychologist on 12/02/2018
Last modified on 12/02/2018
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cleather
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Re: Conducting telephone work in IAPT Services

Post by cleather » Tue Feb 28, 2012 9:07 pm

A valuable post, thanks Will.

We use some telephone contact within our organization and whilst some people are reluctant to provide it, there is no doubt that it provides a valued service to the clients who choose to take it up.

I just wanted to add that I find providing telephone sessions much more tiring than face to face sessions. Our policy is that we offer a half-hour session on the phone compared with an hour session face-to-face. The phone session is much more intense, with less "down time" so I find we cover more ground in less time, although a (bereavement support) session is less structured than a CBT approach, so we have a degree of flexibility in this respect. I think that the process is tiring because of the level of concentration required to achieve a mental representation of the absent client and the embodiment of their concerns.
Last edited by BenJMan on Tue Feb 28, 2012 9:29 pm, edited 1 time in total.
Reason: Quote of full text removed.

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Will
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Re: Conducting telephone work in IAPT Services

Post by Will » Tue Feb 28, 2012 10:48 pm

I'd never thought of that but now that you've mentioned it, I totally agree. I think you really have to concentrate to get "in the zone", especially if there's other people talking or noise distractions around you. Thanks for the feedback :D
Ponderings and wonderings in 140 characters - @willcurvis

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