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Journal of Genetic Counseling, Vol. 9, No. 1, 2000
Commentary: What Is and Is Not Telephone Counseling? Vivian Ota Wang1,2
INTRODUCTION “Telephone Counseling: A Forgotten Skill?” by Ormond et al., addresses the important issues of telephone genetic counseling. While the authors raise many valuable issues about telephone counseling, their model primarily describes telephone-based psychoeducation rather than telephone counseling. In this commentary, I will delineate the important advantages and disadvantages among four different types of counseling: (1) crisis intervention; (2) information and referral services; and (3) exclusive or (4) adjunctive counseling. Questions and guidelines will then be posed to counselors as to how and when to incorporate telephone use into their practice. The telephone has long been considered a professionally acceptable tool for helping genetic counselors answer initial inquiries, schedule patients, and manage limited aspects of patient crises. Ormond et al. challenge genetic counselors to further expand the incorporation of telephone counseling into clinical practice. However, some professionals may feel the telephone should be no substitute for direct face-to-face exchanges between counselors and clients. Should this judgment be challenged? In an era that emphasizes immediate access to services and responses, perhaps for some, it is time to consider genetic counseling by telephone as a viable mode of service delivery. In many respects, adjunctive telephone use has been a part of the very nature of genetic counseling. For example, many genetic counselors may have experienced clients’ attempting to turn telephone calls into therapeutic encounters. Counselors may also have been asked to provide genetic counseling services for clients who are unable to receive services in established genetic counseling centers. In response, many genetic 1 Arizona
State University, Tempe, AZ. should be directed to Vivian Ota Wang, Arizona State University, College of Education, Division of Psychology in Education, PO Box 870611, Tempe, AZ 85287-0611.
2 Correspondence
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counselors have often incorporated these expectations into the genetic counseling relationship. CURRENT USES OF THE TELEPHONE IN SERVICE DELIVERY Counseling in the United States has been a largely verbal activity that relies heavily on the exchange of semantic information. If semantic exchanges were merely sufficient for effective genetic counseling, genetic counseling services could theoretically be delivered without any face-to-face interactions—by mail, on the radio, or by interactive media (e.g., telephone, video conferencing, electronic mail, or computer bulletin boards). For those who may find direct face-to-face contacts difficult or impossible, out of many interactive media choices the telephone has been the most widely available, most immediate, least expensive, and easiest to use. Within this context, this adjunctive telephone use has fallen into two pretreatment categories (crisis intervention and information/referral services) and one treatment category (adjunctive and telephone-only services). A description of each with supporting extant literature will be presented. Telephone Crisis Intervention Many community agencies, hospitals, and psychological associations have offered telephone crisis intervention (Lester and Brockopp, 1973). Often provided by trained paraprofessional volunteers, these support lines, suicide call lines, or crisis line services have offered callers nondirective counseling and/or referral advice. Lester and Brockopp (1973) have distinguished general help-giving phone services from crisis intervention phone lines, information phone lines (such as poison control centers, teratogen services), and call-in radio shows that combine radio and telephone services. Help-line services have primarily delivered anonymous emergency care. Thus, callers have not typically been asked for detailed personal information or required to accept a patient or client role, thereby disengaging callers from an informed consent process. In this situation, because the counselorclient fiduciary relationship has not been formally established, the callers’ rights are not clearly defined. Typically, no fee has been charged to the caller, so no financial issues (such as third-party reimbursement or billing requirements) exist. Telephone crisis services often result in a referral of the caller to mental health or social welfare services. Telephone Referral and Screening Many health care providers and consumers use the telephone (and more recently the Internet) to obtain general information about services, specific treatment procedures and issues, fees, areas of expertise, and so on. In this regard, genetic counseling services historically have utilized this type of telephone service
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delivery, capitalizing on its psychoeducational focus by providing immediate, nonlife-threatening information and referrals. Often, telephone access to such information has been obtained anonymously, conveniently, and without any application process. In fact, research has shown that this type of telephone service has been effective in encouraging reluctant or fearful perceptive clients seeking help (Anderson et al., 1992; Mermelstein and Holland, 1991; Shepherd, 1987). Adjunctive Use in Ongoing Treatment After a conventional counseling relationship has been established, circumstances can make it difficult or impossible for client(s) to return for face-to-face appointments. Such events might include client illness, surgery, temporary or permanent moves to a remote location (it should be noted that this might be coupled with a client’s reluctance to change genetic counselors or inability to find a suitable referral in the new location), weather, or incarceration. In addition, clinical problems such as paranoia or agoraphobic symptoms may make it difficult or impossible for a client to visit a genetic counseling center. Telephone-Only Counseling Service Delivery Some professionals have used the telephone as the sole vehicle for establishing and maintaining counseling relationships. Researchers have reported studies describing this type of telephone counseling (Leed-Kelly et al., 1996; McNamee et al., 1989; Mermelstin & Holland, 1991; Shepherd, 1987). However, outcome data have been inconclusive. For example, McNamee et al. (1989) have reported “positive results” in telephone-only treatment of agoraphobic clients; however, few details of the research design and data analysis were provided. Shepherd (1987) also provided case reports of two patients treated with telephone-only therapy by a social worker. The author concluded, “The telephone therapy subsequently provided to these two women was a valuable, although compromised therapeutic experience” (p. 64). These adjunctive and primary therapeutic uses of the telephone have required the provision of informed consent, using techniques to maintain a productive discussion, ensuring that the conversation is taking place in a location conducive to treatment, attending carefully and listening to ensure that meanings are clearly communicated, assessing whether there is increased risk of losing privacy, and ensuring that the client’s safety is protected. ADVANTAGES AND DISADVANTAGES OF TELEPHONE CONTACT IN GENETIC COUNSELING Considering the phenomenological characteristics of telephone conversations, several features of such interactions make telephone encounters unique. For example, while telephone contacts have been suggested to provide client
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advantages, including access, control, privacy, and anonymity, nonauditory cues are also eliminated. The following discussion will summarize noted common advantages and disadvantages of telephone counseling. Telephone Conversation Eliminates Nonauditory Cues Counselors and clients in telephone interactions do not have visual, olfactory, or tactile information. In this regard, Nagy (1987) has suggested that the telephone “impoverish[es] the normally rich array of nonverbal exchanges” (p. 3). Thus, this limitation may significantly compromise the counselor’s ability to make sense of the client’s experience since visual and nonverbal cues can inform both the counselor and the client about their responses to what is occurring in the genetic counseling session. Conversely, auditory cues have been suggested as providing considerable information to the sensitive listener. In fact, Mermelstein and Holland (1991) have suggested auditory cues are important and may change in the context of illness. In this connection, Tausig and Freeman (1988) have argued that “content and emotional factors, the latter being especially important in making clinical assessments, can be made without the benefit of visual access” (p. 148). This was substantiated when Aneshensel et al. (1982) found no statistically significant differences between telephone and in-person interviewing for depressive symptomatology. However, these researchers also suggest that only in specific circumstances where assessment and counseling do not rely heavily on nonverbal cues, the telephone may be an acceptable tool in counseling. This author suggests that given the content nature of genetics, genetic counseling does not fall into this category. Nagy (1987) has also argued that, in the absence of a visual focus, counselors may have significant difficulty maintaining the attention of the client while speaking on the telephone; distraction may be a risk for both participants in a telephone conversation. For example, the genetic counselor and/or the client could become preoccupied with extraneous tasks while on the telephone. Such wandering attention by either party might not be detected or made use of by the other (presumably, it would be noted in a direct interchange). In addition, the quality of the therapeutic process may deteriorate if the counselor and/or the client reverts to a social or conversational, rather than a therapeutic, mode of interaction. However, this risk has a problem with any conversation-based encounter; professional diligence must be maintained regardless of the communication avenue used. Telephone Conversations Provide Immediate Access to Services With the increased availability of cellular telephones, a telephone session can be held almost anywhere (like a car, where some people call from). A telephone conversation can be held in a wide variety of locations, thus bridging geographic
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and other barriers. As Ormond et al. aptly note, the “telephone [has] allow[ed] access to a wider section of the public for geographic or socioeconomic reasons.” While a client’s ability to call a counselor from home or a distant location has been claimed to increase access to counseling, Tausig and Freeman (1988) have showed that this claimed advantage has been more relevant in circumstances where on-call counselors were available. Once the capacity of a given counselor was exhausted, a client’s access was delayed as much as when a counselor’s face-toface appointments had been filled. They showed that the only true time saving involved was the elimination of client traveling time needed to reach the service provider. However, in some circumstances, this amount of time was not a trivial consideration (e.g., clients who have limited time off from work may be unable to obtain treatment if the combination of travel and treatment is excessive). However, the freedom for clients to make telephone contact without the need to visit a specific location may actually have disadvantages as well. It is possible that what make genetic counseling successful is that it occurs in a defined, protected environment. An important but subtle function may be served by the genetic counselor’s having a specific office to which the client travels; a reality of the genetic counselor’s location can be established, thus substantiating the reality of the counseling relationship. It is also worth noting that telephone counseling may only improve access for hearing clients. Deaf or hearing-impaired patients may be limited to face-to-face encounters or possibly to the use of a telephone device for the deaf (TDD). Additionally, multicultural issues based on racial-cultural differences have not been a fully explored dimension of this access issue. For example, Anderson et al. (1992) have shown that whites were more likely than racial-cultural people to use cancer information hotlines for referral and information services. These differences may make telephone counseling services differentially accessible to various groups. Telephone Conversations Give the Caller More Control over the Interaction Researchers have suggested that less interpersonal effort may be required to end a telephone conversation than would be required to walk out of a counseling room. Thus, researchers have suggested that telephone counseling balances the interpersonal power and control over the interaction by clients’ feeling more power in a telephone encounter and increased freedom to hang up (Anderson et al., 1992; Evans et al., 1986). Tolmach (1985) has also noted that this feeling of control has been enhanced by the lower degree of psychological intimacy intrinsic in a telephone encounter. She hypothesized that for disturbed urban youth, the degree of intimacy produced by counseling sessions created an “unbearable anxiety—anxiety that was typically released through explosive behavior and profanity. . . . Calling
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students on the telephone in the evening may not sound like a therapeutic technique, but it has produced surprising results” (p. 218). Evans et al. (1986) also claimed that telephone counseling also equalized power in their group of elderly clients. Although the authors did not specify the source of the equalizing, it may have been due to the diminished nonverbal influence (status cues, nonverbal interruptions) of dominant members. Interestingly, no authors have commented on the diminished control the client may experience as a result of being unable to determine the counselor’s expression, posture, or side activities or the resulting feelings of being unable to use nonverbal tactics to shape the interaction. Telephone Conversations Provide Privacy to Patients Increased privacy of telephone encounters has been claimed by Ormond et al. and others as an advantage of telephone counseling. In part, this advantage emanates from the issue of privacy and a patient’s ability to speak to a counselor without being seen by anyone in the office or outside the office on his or her way to the session. However, this perspective has assumed that the telephone-calling environment is not vulnerable to eavesdropping. Additionally, the sense of privacy may also be psychological (Tausig and Freeman, 1988). A dispassionate analysis may suggest that there is nothing inherently more private in a home environment than a clinical office setting. Indeed, a well-designed clinical office should be arranged to protect patients’ privacy. Telephone Conversations Allow Anonymity An interesting feature of free telephone services has been the anonymity of the client. Presumably, similar conditions would be true if no identification were required for face-to-face counseling. However, can this type of telephone counseling be anonymous? How does technology (e.g., caller ID) influence who can and cannot be anonymous? How likely is it that, after repeat calls, a counselor might recognize the client’s voice? Perhaps an aspect of anonymity preserved in telephone-only counseling has been the clients knowing a counselor would be unable to recognize him or her if a chance encounter put them in contact outside the counseling session. Because such encounters can be embarrassing to clients, anonymity of telephone counseling has been presumed a benefit. However, one might also question the clinical wisdom of the counselor’s leaving intact this particular social phobia about potential contact with the counselor outside the session. Would it not be more helpful to the client to resolve this problem directly? In most aspects, telephone counseling raises issues similar to those that arise in providing ethically sound genetic counseling services of other kinds: the obligation to deliver competent service; the obligation to avoid harm to consumers; the obligation to
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make explicit financial arrangements; the obligation to avoid deceit in public statements; the obligation to obtain informed consent from consumers of services; an the obligation to protect confidentiality (except under certain circumstances (e.g., homicide, suicide). CONCLUSIONS Telephone use is not an emerging area of genetic counseling practice; rather, it has been a long-standing adjunct to many genetic counselors’ sessions. At first glance, what Ormond et al. propose as telephone counseling sounds more like either a crisis intervention and/or a referral and screening service rather than telephone counseling (e.g., teratogen hotlines). In this regard, genetic counseling programs need to prepare students for telephone use with more visibility and formal preparation in training curricula. Additionally, practicing genetic counselors need to take reasonable steps to ensure the competence of their work and to protect clients and others from harm. For example, genetic counselors may have to go beyond general counseling skills to further clarifying to which types of counseling situations nonverbal information is crucial and exclude such approaches from the telephone-only array of services. Also, genetic counselors may have to recognize their vulnerability to distraction while providing services over the telephone and/or develop techniques for focusing to ensure that telephone encounters are productive. WHAT WOULD TELEPHONE GENETIC COUNSELING LOOK LIKE? Counseling in general is a process that focuses on engaging clients to explore issues that directly affect them. Because clients and counselors may have different perceptions about the purpose and nature of counseling, and because structure promotes the development of counseling by providing a framework in which the process can take place, genetic counselors need to discuss issues related to the structure of the genetic counseling process with their clients. For example, clients who may not know what to expect from the counseling session or how they should act may feel uncertainty and inhibition in the counseling process unless some predictability and structure are provided by the genetic counselor. Thus, this structure helps to clarify the relationship between the counselor and the client; gives direction; protects the rights, roles, and obligations of both counselors and clients; and ensures the success of counseling. This structure sets time limits (such as how long session will last), action limits (for the prevention of destructive behavior), role limits (what will be expected from the counselor and client), and procedural limits (when sessions will occur; when a client can contact a counselor and vice versa). In many respects, genetic counselors have been effective in structure issues related to immediate clinic appointment expectations and time limits. However, for
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some genetic counselors, providing structure of when and how additional contacts will be managed are more vague and are on an as-needed basis. How the need is determined is often unclear. If telephone contact will be used for additional contacts, it will be important for the genetic counselor to determine and choose what type of service delivery will suit the needs of the client and institutional expectations and requirements. For example, genetic counselors need to consider the following issues when the telephone is used as part of the genetic counseling process: 1. When the counselor initiated contact, what was the purpose? Delivery of test results? Support and reassurance? Whose needs are being met? The perceived need of the client or of the genetic counselor? 2. Was the telephone contact originally discussed with the client as a part of the genetic counseling process? 3. If adjunct telephone counseling is being used, what arrangements were made in terms of when sessions will occur, how many sessions, what time, and for how long each session will be? What type of documentation will be needed? 4. What does the genetic counselor do if the client telephones the counselor at a time not previously arranged? 5. How many total sessions will the client have? Given client uncertainty coupled with the demands of managed care costeffectiveness, if a genetic counselor would like to make genetic counseling available through other sources (e.g., e-mail, telephone), a total cost for genetic counseling, including a maximum number of well-defined telephone contacts, should be contracted. In this manner, total genetic counseling services, including follow-up, can be accounted for and reimbursed in institutional settings. Within the more general framework of clinical obligations and responsibilities, genetic counselors may need to take particular care to inform potential clients of the realistic limitations of telephone treatment and of the existence of alternative methods of obtaining services, if these exist. In many ways, when considering telephone counseling, genetic counselors will be faced with more questions than answers. Are there types of clients for whom telephone counseling is appropriate? While overly simplistic, an answer to this question is that telephone counseling may be appropriate for those potential clients who would fail to receive any treatment if telephone counseling were not available. How can the genetic counselor determine when there is no preferable alternative form of treatment available? Should the genetic counselor refuse to provide telephone counseling if alternatives are available and the prospective client refuses to accept them? For which types of clients might face-to-face counseling truly not be an option? What risks should genetic counselors be aware of when considering participating in telephone counseling? Issues a genetic counselor may need to consider
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include the difficulty of ensuring the client’s immediate safety should the client need hospitalization; having the available referral information in the area from which the call is being made if local follow-up becomes necessary; and the ability to determine whether the caller is a minor who would require parental consent. Finally, if a genetic counselor has been asked to testify in legal proceedings, such testimony could fail the hearsay test because the information was not obtained in direct contact with the client. To address some of the above concerns, the following questions have been proposed by the American Psychological Association (APA) Board of Professional Affairs (BPA) task force for telephone therapy (APA, 1995) to be addressed by the provider of counseling by telephone that may also be helpful for genetic counselors to consider: 1. Does this choice of treatment benefit the consumer, or should face-to-face treatment be recommended, assuming it is possible to provide? 2. Is it possible to conduct an adequate assessment of the client’s psychological condition? Is the counselor aware of the limits of diagnosis, judgment, or prediction made by telephone evaluation? 3. Are both therapist and caller (and their respective environments) free of distraction and interference with communication and attention? Has the counselor taken steps to ensure the privacy and confidentiality of the telephone assessment or treatment? 4. Does the counselor have the necessary and appropriate training, experience, or temperament to offer services by telephone? 5. Does the counselor have a system for maintaining client records? What is the plan for maintaining client records if the counselor leaves the telephone service? Has the counselor or the company arranged a method for the client to obtain a copy of the records? 6. Does the counselor know how the telephone counseling service is described to the potential user? 7. What are the corporation’s and the counselor’s responsibilities for providing care on the departure of the counselor? 8. Does the counselor understand the telephone service’s financial arrangements, and have reasonable steps been taken to ensure that these are fair and clearly explained to the potential client? Even though the telephone has long been used adjunctively in providing genetic counseling services, genetic counseling has generally been regarded as requiring some face-to-face contact. In some respects, efforts to develop telephonebased services challenge this assumption. Telephone counseling has been claimed to offer ease of access, increased sense of safety and privacy, and lower cost than face-to-face counseling. On the other hand, telephone counseling has also increased the difficulty of providing for client safety in crisis situations, increased the risks to privacy, and may ultimately be more expensive than conventional
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genetic counseling. In addition, serious questions have been raised about the degree to which effective counseling can be carried out without direct experience of the other person in the encounter and without a specifically designated and designed location in which to carry out counseling. Clearly, more research into the relative effects of face-to-face and electronic forms of counseling would be helpful. However, in the absence of definitive data, genetic counselors must rely on inferences made about the potential drawbacks of non-face-to-face counseling. Genetic counselors need to be comfortable with the telephone counseling context, must take into account the relevant risks and minimize or eliminate them, and must be sure that no better alternative exists for the treatment of this particular condition and/or client. If telephone genetic counseling is used, periodic assessments of both the process and the outcomes of treatment should be made. By becoming more aware of counseling process, genetic counselors can begin to sharpen their awareness of what makes conversations therapeutic whether treatment is in person or by telephone.
REFERENCES American Psychological Association (1995) Ethics committee statement on psychotherapy by telephone. APA Monitor, October, p. 15. Anderson MD, Duffy K, Hallett CD, Marcus AC (1992) Cancer prevention counseling on telephone hotlines. Public Health Reports 107:278–283. Aneshensel CS, Frerichs RR, Clark VA, Yokopenic PA (1982) Measuring depression in the community: A comparison of telephone and personal interviews. Public Opinion Q 46:110–121. Evans RL, Smith KM, Werkhoven WS, Fox HR, Pritzel DQ (1986) Group telephone therapy for the housebound elderly. Gerontologist 26:8–10. Lester D, Brockopp G (eds) (1973) Crisis Intervention and Counseling by Telephone. Springfield, IL: Charles C Thomas. Mermelstein HT, Holland JC (1991) Psychotherapy by telephone: A therapeutic tool for cancer patients. Psychosomatics 32:407–412. Nagy T (1987) Electronic ethics. APA Monitor, October, p. 3. Shepherd R (1987) Telephone therapy: An alternative to isolation. Clin Soc Work J 15:55–65. Tausig JE, Freeman EW (1988) The next best thing to being there: Conducting the clinical research interview by telephone. Am J Orthopsychiatr 58:418–427. Tolmach J. (1985) “There ain’t nobody on my side”: A new day treatment program for Black urban youth. J Clin Child Psychol 14:214–219.
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Journal of Genetic Counseling, Vol. 9, No. 1, 2000
Commentary: What Is and Is Not Telephone Counseling? Vivian Ota Wang1,2
INTRODUCTION “Telephone Counseling: A Forgotten Skill?” by Ormond et al., addresses the important issues of telephone genetic counseling. While the authors raise many valuable issues about telephone counseling, their model primarily describes telephone-based psychoeducation rather than telephone counseling. In this commentary, I will delineate the important advantages and disadvantages among four different types of counseling: (1) crisis intervention; (2) information and referral services; and (3) exclusive or (4) adjunctive counseling. Questions and guidelines will then be posed to counselors as to how and when to incorporate telephone use into their practice. The telephone has long been considered a professionally acceptable tool for helping genetic counselors answer initial inquiries, schedule patients, and manage limited aspects of patient crises. Ormond et al. challenge genetic counselors to further expand the incorporation of telephone counseling into clinical practice. However, some professionals may feel the telephone should be no substitute for direct face-to-face exchanges between counselors and clients. Should this judgment be challenged? In an era that emphasizes immediate access to services and responses, perhaps for some, it is time to consider genetic counseling by telephone as a viable mode of service delivery. In many respects, adjunctive telephone use has been a part of the very nature of genetic counseling. For example, many genetic counselors may have experienced clients’ attempting to turn telephone calls into therapeutic encounters. Counselors may also have been asked to provide genetic counseling services for clients who are unable to receive services in established genetic counseling centers. In response, many genetic 1 Arizona
State University, Tempe, AZ. should be directed to Vivian Ota Wang, Arizona State University, College of Education, Division of Psychology in Education, PO Box 870611, Tempe, AZ 85287-0611.
2 Correspondence
73 C 2000 National Society of Genetic Counselors, Inc. 1059-7700/00/0200-0073$18.00/1 °
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counselors have often incorporated these expectations into the genetic counseling relationship. CURRENT USES OF THE TELEPHONE IN SERVICE DELIVERY Counseling in the United States has been a largely verbal activity that relies heavily on the exchange of semantic information. If semantic exchanges were merely sufficient for effective genetic counseling, genetic counseling services could theoretically be delivered without any face-to-face interactions—by mail, on the radio, or by interactive media (e.g., telephone, video conferencing, electronic mail, or computer bulletin boards). For those who may find direct face-to-face contacts difficult or impossible, out of many interactive media choices the telephone has been the most widely available, most immediate, least expensive, and easiest to use. Within this context, this adjunctive telephone use has fallen into two pretreatment categories (crisis intervention and information/referral services) and one treatment category (adjunctive and telephone-only services). A description of each with supporting extant literature will be presented. Telephone Crisis Intervention Many community agencies, hospitals, and psychological associations have offered telephone crisis intervention (Lester and Brockopp, 1973). Often provided by trained paraprofessional volunteers, these support lines, suicide call lines, or crisis line services have offered callers nondirective counseling and/or referral advice. Lester and Brockopp (1973) have distinguished general help-giving phone services from crisis intervention phone lines, information phone lines (such as poison control centers, teratogen services), and call-in radio shows that combine radio and telephone services. Help-line services have primarily delivered anonymous emergency care. Thus, callers have not typically been asked for detailed personal information or required to accept a patient or client role, thereby disengaging callers from an informed consent process. In this situation, because the counselorclient fiduciary relationship has not been formally established, the callers’ rights are not clearly defined. Typically, no fee has been charged to the caller, so no financial issues (such as third-party reimbursement or billing requirements) exist. Telephone crisis services often result in a referral of the caller to mental health or social welfare services. Telephone Referral and Screening Many health care providers and consumers use the telephone (and more recently the Internet) to obtain general information about services, specific treatment procedures and issues, fees, areas of expertise, and so on. In this regard, genetic counseling services historically have utilized this type of telephone service
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delivery, capitalizing on its psychoeducational focus by providing immediate, nonlife-threatening information and referrals. Often, telephone access to such information has been obtained anonymously, conveniently, and without any application process. In fact, research has shown that this type of telephone service has been effective in encouraging reluctant or fearful perceptive clients seeking help (Anderson et al., 1992; Mermelstein and Holland, 1991; Shepherd, 1987). Adjunctive Use in Ongoing Treatment After a conventional counseling relationship has been established, circumstances can make it difficult or impossible for client(s) to return for face-to-face appointments. Such events might include client illness, surgery, temporary or permanent moves to a remote location (it should be noted that this might be coupled with a client’s reluctance to change genetic counselors or inability to find a suitable referral in the new location), weather, or incarceration. In addition, clinical problems such as paranoia or agoraphobic symptoms may make it difficult or impossible for a client to visit a genetic counseling center. Telephone-Only Counseling Service Delivery Some professionals have used the telephone as the sole vehicle for establishing and maintaining counseling relationships. Researchers have reported studies describing this type of telephone counseling (Leed-Kelly et al., 1996; McNamee et al., 1989; Mermelstin & Holland, 1991; Shepherd, 1987). However, outcome data have been inconclusive. For example, McNamee et al. (1989) have reported “positive results” in telephone-only treatment of agoraphobic clients; however, few details of the research design and data analysis were provided. Shepherd (1987) also provided case reports of two patients treated with telephone-only therapy by a social worker. The author concluded, “The telephone therapy subsequently provided to these two women was a valuable, although compromised therapeutic experience” (p. 64). These adjunctive and primary therapeutic uses of the telephone have required the provision of informed consent, using techniques to maintain a productive discussion, ensuring that the conversation is taking place in a location conducive to treatment, attending carefully and listening to ensure that meanings are clearly communicated, assessing whether there is increased risk of losing privacy, and ensuring that the client’s safety is protected. ADVANTAGES AND DISADVANTAGES OF TELEPHONE CONTACT IN GENETIC COUNSELING Considering the phenomenological characteristics of telephone conversations, several features of such interactions make telephone encounters unique. For example, while telephone contacts have been suggested to provide client
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advantages, including access, control, privacy, and anonymity, nonauditory cues are also eliminated. The following discussion will summarize noted common advantages and disadvantages of telephone counseling. Telephone Conversation Eliminates Nonauditory Cues Counselors and clients in telephone interactions do not have visual, olfactory, or tactile information. In this regard, Nagy (1987) has suggested that the telephone “impoverish[es] the normally rich array of nonverbal exchanges” (p. 3). Thus, this limitation may significantly compromise the counselor’s ability to make sense of the client’s experience since visual and nonverbal cues can inform both the counselor and the client about their responses to what is occurring in the genetic counseling session. Conversely, auditory cues have been suggested as providing considerable information to the sensitive listener. In fact, Mermelstein and Holland (1991) have suggested auditory cues are important and may change in the context of illness. In this connection, Tausig and Freeman (1988) have argued that “content and emotional factors, the latter being especially important in making clinical assessments, can be made without the benefit of visual access” (p. 148). This was substantiated when Aneshensel et al. (1982) found no statistically significant differences between telephone and in-person interviewing for depressive symptomatology. However, these researchers also suggest that only in specific circumstances where assessment and counseling do not rely heavily on nonverbal cues, the telephone may be an acceptable tool in counseling. This author suggests that given the content nature of genetics, genetic counseling does not fall into this category. Nagy (1987) has also argued that, in the absence of a visual focus, counselors may have significant difficulty maintaining the attention of the client while speaking on the telephone; distraction may be a risk for both participants in a telephone conversation. For example, the genetic counselor and/or the client could become preoccupied with extraneous tasks while on the telephone. Such wandering attention by either party might not be detected or made use of by the other (presumably, it would be noted in a direct interchange). In addition, the quality of the therapeutic process may deteriorate if the counselor and/or the client reverts to a social or conversational, rather than a therapeutic, mode of interaction. However, this risk has a problem with any conversation-based encounter; professional diligence must be maintained regardless of the communication avenue used. Telephone Conversations Provide Immediate Access to Services With the increased availability of cellular telephones, a telephone session can be held almost anywhere (like a car, where some people call from). A telephone conversation can be held in a wide variety of locations, thus bridging geographic
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and other barriers. As Ormond et al. aptly note, the “telephone [has] allow[ed] access to a wider section of the public for geographic or socioeconomic reasons.” While a client’s ability to call a counselor from home or a distant location has been claimed to increase access to counseling, Tausig and Freeman (1988) have showed that this claimed advantage has been more relevant in circumstances where on-call counselors were available. Once the capacity of a given counselor was exhausted, a client’s access was delayed as much as when a counselor’s face-toface appointments had been filled. They showed that the only true time saving involved was the elimination of client traveling time needed to reach the service provider. However, in some circumstances, this amount of time was not a trivial consideration (e.g., clients who have limited time off from work may be unable to obtain treatment if the combination of travel and treatment is excessive). However, the freedom for clients to make telephone contact without the need to visit a specific location may actually have disadvantages as well. It is possible that what make genetic counseling successful is that it occurs in a defined, protected environment. An important but subtle function may be served by the genetic counselor’s having a specific office to which the client travels; a reality of the genetic counselor’s location can be established, thus substantiating the reality of the counseling relationship. It is also worth noting that telephone counseling may only improve access for hearing clients. Deaf or hearing-impaired patients may be limited to face-to-face encounters or possibly to the use of a telephone device for the deaf (TDD). Additionally, multicultural issues based on racial-cultural differences have not been a fully explored dimension of this access issue. For example, Anderson et al. (1992) have shown that whites were more likely than racial-cultural people to use cancer information hotlines for referral and information services. These differences may make telephone counseling services differentially accessible to various groups. Telephone Conversations Give the Caller More Control over the Interaction Researchers have suggested that less interpersonal effort may be required to end a telephone conversation than would be required to walk out of a counseling room. Thus, researchers have suggested that telephone counseling balances the interpersonal power and control over the interaction by clients’ feeling more power in a telephone encounter and increased freedom to hang up (Anderson et al., 1992; Evans et al., 1986). Tolmach (1985) has also noted that this feeling of control has been enhanced by the lower degree of psychological intimacy intrinsic in a telephone encounter. She hypothesized that for disturbed urban youth, the degree of intimacy produced by counseling sessions created an “unbearable anxiety—anxiety that was typically released through explosive behavior and profanity. . . . Calling
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students on the telephone in the evening may not sound like a therapeutic technique, but it has produced surprising results” (p. 218). Evans et al. (1986) also claimed that telephone counseling also equalized power in their group of elderly clients. Although the authors did not specify the source of the equalizing, it may have been due to the diminished nonverbal influence (status cues, nonverbal interruptions) of dominant members. Interestingly, no authors have commented on the diminished control the client may experience as a result of being unable to determine the counselor’s expression, posture, or side activities or the resulting feelings of being unable to use nonverbal tactics to shape the interaction. Telephone Conversations Provide Privacy to Patients Increased privacy of telephone encounters has been claimed by Ormond et al. and others as an advantage of telephone counseling. In part, this advantage emanates from the issue of privacy and a patient’s ability to speak to a counselor without being seen by anyone in the office or outside the office on his or her way to the session. However, this perspective has assumed that the telephone-calling environment is not vulnerable to eavesdropping. Additionally, the sense of privacy may also be psychological (Tausig and Freeman, 1988). A dispassionate analysis may suggest that there is nothing inherently more private in a home environment than a clinical office setting. Indeed, a well-designed clinical office should be arranged to protect patients’ privacy. Telephone Conversations Allow Anonymity An interesting feature of free telephone services has been the anonymity of the client. Presumably, similar conditions would be true if no identification were required for face-to-face counseling. However, can this type of telephone counseling be anonymous? How does technology (e.g., caller ID) influence who can and cannot be anonymous? How likely is it that, after repeat calls, a counselor might recognize the client’s voice? Perhaps an aspect of anonymity preserved in telephone-only counseling has been the clients knowing a counselor would be unable to recognize him or her if a chance encounter put them in contact outside the counseling session. Because such encounters can be embarrassing to clients, anonymity of telephone counseling has been presumed a benefit. However, one might also question the clinical wisdom of the counselor’s leaving intact this particular social phobia about potential contact with the counselor outside the session. Would it not be more helpful to the client to resolve this problem directly? In most aspects, telephone counseling raises issues similar to those that arise in providing ethically sound genetic counseling services of other kinds: the obligation to deliver competent service; the obligation to avoid harm to consumers; the obligation to
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make explicit financial arrangements; the obligation to avoid deceit in public statements; the obligation to obtain informed consent from consumers of services; an the obligation to protect confidentiality (except under certain circumstances (e.g., homicide, suicide). CONCLUSIONS Telephone use is not an emerging area of genetic counseling practice; rather, it has been a long-standing adjunct to many genetic counselors’ sessions. At first glance, what Ormond et al. propose as telephone counseling sounds more like either a crisis intervention and/or a referral and screening service rather than telephone counseling (e.g., teratogen hotlines). In this regard, genetic counseling programs need to prepare students for telephone use with more visibility and formal preparation in training curricula. Additionally, practicing genetic counselors need to take reasonable steps to ensure the competence of their work and to protect clients and others from harm. For example, genetic counselors may have to go beyond general counseling skills to further clarifying to which types of counseling situations nonverbal information is crucial and exclude such approaches from the telephone-only array of services. Also, genetic counselors may have to recognize their vulnerability to distraction while providing services over the telephone and/or develop techniques for focusing to ensure that telephone encounters are productive. WHAT WOULD TELEPHONE GENETIC COUNSELING LOOK LIKE? Counseling in general is a process that focuses on engaging clients to explore issues that directly affect them. Because clients and counselors may have different perceptions about the purpose and nature of counseling, and because structure promotes the development of counseling by providing a framework in which the process can take place, genetic counselors need to discuss issues related to the structure of the genetic counseling process with their clients. For example, clients who may not know what to expect from the counseling session or how they should act may feel uncertainty and inhibition in the counseling process unless some predictability and structure are provided by the genetic counselor. Thus, this structure helps to clarify the relationship between the counselor and the client; gives direction; protects the rights, roles, and obligations of both counselors and clients; and ensures the success of counseling. This structure sets time limits (such as how long session will last), action limits (for the prevention of destructive behavior), role limits (what will be expected from the counselor and client), and procedural limits (when sessions will occur; when a client can contact a counselor and vice versa). In many respects, genetic counselors have been effective in structure issues related to immediate clinic appointment expectations and time limits. However, for
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some genetic counselors, providing structure of when and how additional contacts will be managed are more vague and are on an as-needed basis. How the need is determined is often unclear. If telephone contact will be used for additional contacts, it will be important for the genetic counselor to determine and choose what type of service delivery will suit the needs of the client and institutional expectations and requirements. For example, genetic counselors need to consider the following issues when the telephone is used as part of the genetic counseling process: 1. When the counselor initiated contact, what was the purpose? Delivery of test results? Support and reassurance? Whose needs are being met? The perceived need of the client or of the genetic counselor? 2. Was the telephone contact originally discussed with the client as a part of the genetic counseling process? 3. If adjunct telephone counseling is being used, what arrangements were made in terms of when sessions will occur, how many sessions, what time, and for how long each session will be? What type of documentation will be needed? 4. What does the genetic counselor do if the client telephones the counselor at a time not previously arranged? 5. How many total sessions will the client have? Given client uncertainty coupled with the demands of managed care costeffectiveness, if a genetic counselor would like to make genetic counseling available through other sources (e.g., e-mail, telephone), a total cost for genetic counseling, including a maximum number of well-defined telephone contacts, should be contracted. In this manner, total genetic counseling services, including follow-up, can be accounted for and reimbursed in institutional settings. Within the more general framework of clinical obligations and responsibilities, genetic counselors may need to take particular care to inform potential clients of the realistic limitations of telephone treatment and of the existence of alternative methods of obtaining services, if these exist. In many ways, when considering telephone counseling, genetic counselors will be faced with more questions than answers. Are there types of clients for whom telephone counseling is appropriate? While overly simplistic, an answer to this question is that telephone counseling may be appropriate for those potential clients who would fail to receive any treatment if telephone counseling were not available. How can the genetic counselor determine when there is no preferable alternative form of treatment available? Should the genetic counselor refuse to provide telephone counseling if alternatives are available and the prospective client refuses to accept them? For which types of clients might face-to-face counseling truly not be an option? What risks should genetic counselors be aware of when considering participating in telephone counseling? Issues a genetic counselor may need to consider
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include the difficulty of ensuring the client’s immediate safety should the client need hospitalization; having the available referral information in the area from which the call is being made if local follow-up becomes necessary; and the ability to determine whether the caller is a minor who would require parental consent. Finally, if a genetic counselor has been asked to testify in legal proceedings, such testimony could fail the hearsay test because the information was not obtained in direct contact with the client. To address some of the above concerns, the following questions have been proposed by the American Psychological Association (APA) Board of Professional Affairs (BPA) task force for telephone therapy (APA, 1995) to be addressed by the provider of counseling by telephone that may also be helpful for genetic counselors to consider: 1. Does this choice of treatment benefit the consumer, or should face-to-face treatment be recommended, assuming it is possible to provide? 2. Is it possible to conduct an adequate assessment of the client’s psychological condition? Is the counselor aware of the limits of diagnosis, judgment, or prediction made by telephone evaluation? 3. Are both therapist and caller (and their respective environments) free of distraction and interference with communication and attention? Has the counselor taken steps to ensure the privacy and confidentiality of the telephone assessment or treatment? 4. Does the counselor have the necessary and appropriate training, experience, or temperament to offer services by telephone? 5. Does the counselor have a system for maintaining client records? What is the plan for maintaining client records if the counselor leaves the telephone service? Has the counselor or the company arranged a method for the client to obtain a copy of the records? 6. Does the counselor know how the telephone counseling service is described to the potential user? 7. What are the corporation’s and the counselor’s responsibilities for providing care on the departure of the counselor? 8. Does the counselor understand the telephone service’s financial arrangements, and have reasonable steps been taken to ensure that these are fair and clearly explained to the potential client? Even though the telephone has long been used adjunctively in providing genetic counseling services, genetic counseling has generally been regarded as requiring some face-to-face contact. In some respects, efforts to develop telephonebased services challenge this assumption. Telephone counseling has been claimed to offer ease of access, increased sense of safety and privacy, and lower cost than face-to-face counseling. On the other hand, telephone counseling has also increased the difficulty of providing for client safety in crisis situations, increased the risks to privacy, and may ultimately be more expensive than conventional
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genetic counseling. In addition, serious questions have been raised about the degree to which effective counseling can be carried out without direct experience of the other person in the encounter and without a specifically designated and designed location in which to carry out counseling. Clearly, more research into the relative effects of face-to-face and electronic forms of counseling would be helpful. However, in the absence of definitive data, genetic counselors must rely on inferences made about the potential drawbacks of non-face-to-face counseling. Genetic counselors need to be comfortable with the telephone counseling context, must take into account the relevant risks and minimize or eliminate them, and must be sure that no better alternative exists for the treatment of this particular condition and/or client. If telephone genetic counseling is used, periodic assessments of both the process and the outcomes of treatment should be made. By becoming more aware of counseling process, genetic counselors can begin to sharpen their awareness of what makes conversations therapeutic whether treatment is in person or by telephone.
REFERENCES American Psychological Association (1995) Ethics committee statement on psychotherapy by telephone. APA Monitor, October, p. 15. Anderson MD, Duffy K, Hallett CD, Marcus AC (1992) Cancer prevention counseling on telephone hotlines. Public Health Reports 107:278–283. Aneshensel CS, Frerichs RR, Clark VA, Yokopenic PA (1982) Measuring depression in the community: A comparison of telephone and personal interviews. Public Opinion Q 46:110–121. Evans RL, Smith KM, Werkhoven WS, Fox HR, Pritzel DQ (1986) Group telephone therapy for the housebound elderly. Gerontologist 26:8–10. Lester D, Brockopp G (eds) (1973) Crisis Intervention and Counseling by Telephone. Springfield, IL: Charles C Thomas. Mermelstein HT, Holland JC (1991) Psychotherapy by telephone: A therapeutic tool for cancer patients. Psychosomatics 32:407–412. Nagy T (1987) Electronic ethics. APA Monitor, October, p. 3. Shepherd R (1987) Telephone therapy: An alternative to isolation. Clin Soc Work J 15:55–65. Tausig JE, Freeman EW (1988) The next best thing to being there: Conducting the clinical research interview by telephone. Am J Orthopsychiatr 58:418–427. Tolmach J. (1985) “There ain’t nobody on my side”: A new day treatment program for Black urban youth. J Clin Child Psychol 14:214–219.
