My Notes About Working at San Francisco's HIV/AIDS/HepC Nightline

• The goal: Help people cope in the moment.

• Ask: "Why tonight?"

• The most effective techniques are Socratic.

• If suicide is mentioned:
  • Get right to the action e.g., "I wonder what you mean by that. Are you thinking of suicide?" It's ok to broach the subject, to break the ice. Be matter-of-fact.
  • They may be using this merely as an attention-getter.
  • They may need to face getting tested for STIs. Might it be "rational suicide"?
  • Assess. Here are questions to ask:
    1. Now?
    2. Has means?
    3. Has plan?
    4. Prior attempt(s)?
    5. Traumatic event?
    6. Alone?
    7. Predisposition
    8. Options
    9. Support
    10. Health condition
    11. Mental disorder
    12. Substance/drug use

• Answers to common questions; learn this repertory by heart:
  • The only way to know if you're infected is to get tested. No one can tell you on the phone.
  • Is there a reason why you might be worried?
  • What exactly happened?
  • How comfortable are you with risk?
  • (Caller just rec'd + HIV test result.) How are you handling it?

• Don't:
  • Give advice
  • Attempt to diagnose
  • List symptoms
  • Be a rescuer
  • Take responsibility for the caller's problems

• Pay attention to emotions; callers are often unaccustomed to talking about them.

• Strategy for Fielding a Call:
  • Get the facts.
    • HIV status of partner
    • Needle-cleaning practices
    • Body fluids exchanged
  • What behaviors have more/less risk
    • Prevention methods for the future
  • Assess risk
    • Even if little HIV risk, there may still be STD risk, e.g. from oral sex. Refer to STD hotline.
  • Emotional issues: how do they sound?
    • "Tell me more about what's going on."
    • "Have you discussed this with your partner?"
    • "Do you have someone you can talk to about this?"
  • Give info as briefly as possible.
    • Steer conversation to emotional issues.
    • "You sound like you may be concerned that you are at risk..."

• The primary function of Nightline is emotional support.
  • "I'm aware that this is difficult."
  • "It can be hard to discuss these things with a stranger."
  • Use their own words; may need to be less clinical or less personal.
  • "Were body fluids transmitted? Were any of these involved: semen, blood, mother's milk, vaginal fluid."

• Callers are often feeling hopeless, without options.

• Point out things they have done that were courageous, significant, showed strength.

• If caller panics:
  • "I'm here. Can you hear my voice?"
  • "What are you thinking about right now?"
  • "Are you at home right now?"

• Common caller condition is chronic depression.

• We may be their only outlet.

• Likely to reject suggestions of getting help.

• The toughest calls are from emotionally "flat-lined" (unresponsive) callers. A strategy is to be tender; "I notice this must be really hard to talk about but I'm glad you called."

• Reflecting the emotion is helpful. "I hear you saying that you're feeling X; am I hearing you correctly?"

• Phases of a call:
  1. Create rapport
     • Encourage caller to express feelings
     • Esp. pent-up, hidden, misunderstood
     • Achieve a feeling of release
     • Pay attention to your own language and voice
     • E.g. use street terms if they do
     • Respond in a calm, personal voice
     • May need to explain that we are an emotional support line
     • "How are you feeling about (what they said) right now?"
     • Can personalize (I had that, too) but don't shift focus
     • If they ask, reply: "No I'm not HIV+. Is it important for you to talk to someone who is? We don't identify our nightline volunteers by HIV status. I'd be happy to talk with you anyway."

  2. Reflect back to them
     • Summary and clarification
     • Content (facts) -- may need to clarify
     • Reflect feelings in empathic way -- "It must be difficult when it begins to impact your family." "You sound concerned about how your boss might react."
     • Use open-ended questions:
       • "How do you feel about that?"
       • "How are you handling it?"
       • "Is that a decision you feel you must make right now?"
       • "Why is this an issue tonight?"
       • "I'm glad you called. How are you feeling now?"
     • Paraphrase, condense

  3. Identify the problem; ask perceptive questions
     • Especially when they ramble
     • Focus on what's bothering them at this moment
     • Most calls are driven by a main problem

  4. Guidance to self-discovery
     • Discover and examine options for progress, mitigation
     • Remind: "You've been in moments like this before; how did you handle it then?" e.g. for anxiety
     • Discover and examine resources he/she has to draw on

  5. Making decisions
     • Be sure they're ready.
     • Support them, validate the plan they make.
     • "Call us back and let us know how it goes."

  6. Referrals
     • Technical info
     • Treatment providers

  7. Remind: We're here every night

• Common concerns:
  • Disclosure:
    • How can I (should I) tell my parents, my boss, my partner?
    • "Have you thought about how you might present that to him?"
    • "What if you flat-out told him?"
    • "What problems might there be if you don't tell?"
  • Engaging in risky activity:
    • Make an informal contract, e.g. "Do you think you can make that phone call tomorrow? Call us back and let us know."
    • Evaluating the result of a risky activity: Did I expose myself to disease? The fear can be stressful, incapacitating.
  • Loneliness, isolation:
    • Sometimes the main thing they need is a listener.
    • Make it clear that it's safe.
    • Depression
    • Anger

• Controlling the call
  • Esp. with callers who are obsessed
  • Keep the material fresh; draw the line on repetition
  • Remind that they can call us back

• Substance users/callers
  • Alcohol: by far the most common
  • Need not dismiss if there's a possibility for productive dialog; otherwise, explain why and terminate
  • ...But without being judgmental, demeaning, angry
  • Get them to identify the substance abuse behavior, e.g. "I notice that your thoughts are jumping around a lot; what could be causing this?"
  • Make sure they take responsibility for the behavior, without making excuses for them or justifying.
  • They may be in a lot of denial; it's not our job to confront them on it (nor to criticize nor to diagnose).
  • Talk about harm reduction, esp. not sharing paraphernalia
  • What kinds of changes do you think you could make tonight?
  • Drug users' riskiest behavior -- even more than sharing paraphernalia -- is unprotected sex when high.
  • Often "triple-diagnosis": HIV, mental illness, and substance abuse -- complex to manage medically

• HIV+ women:
  • 25% of HIV+ population
  • Mostly black
  • Mostly from hetero sex
  • Must have a good relationship with medical caregiver
  • Encourage communication around condom use with partner

    • Pregnant HIV+ women:
      • Give the virus to their babies less than 10% of the time
      • Pregnancy does not alter progression of HIV

• Difficult callers
  • Mentally ill
  • Nonresponsive
  • Broken record
  • Story teller
  • Manipulator
  • Angry
  • Depressed
  • Sex caller
  • Obsessive