Telephone emergency services (TES) provide an essential part of suicide prevention and emotional support services across different health care settings. TES are usually provided by paraprofessional counselors, who need specific training in listening skills to meet the demands of callers.
This project developed a competency-based training for listening skills which was then evaluated in a randomized controlled waitlist study across four EU countries (Germany, Hungary, Italy, and the Netherlands). Each country provided one training group and one waitlist group. Across countries, a total of 71 (trained: n = 36, waiting: n = 35) counselor trainees were assessed in a standardized, simulated emergency call with an actor client either before or after training participation. Calls were audiotaped and competencies in listening skills were evaluated by external raters using a standardized rating form.
Trained counselors showed significantly better listening skills than participants from the waitlist condition.
Results provide support for the efficacy of a competency-based training for listening skills in the field of TES across Europe. Furthermore, results demonstrated that a standardized competency-based assessment with an actor client is suitable to assess listening skills.
A competency-based training can improve paraprofessionals’ listening skills in a relatively short training time. Listening skills can be assessed in a simulation with an actor client. The use of competency-based training and assessment methods could be expanded to the field of paraprofessional counseling.
Telephone Emergency Services (TES) form an important part of psychosocial health care, emotional support services, and suicide prevention (
As opposed to psychotherapists, psychiatrists, and social workers who participate in year-long professional training curricula before providing mental health services, TES counselors are paraprofessionals with limited and regionally different training. A study conducted on the German
Training is important not only to provide adequate service to callers, but also for the well-being of TES counselors themselves. In a meta-analytic review,
Since TES are local organizations without uniform training standards, there is a need for more research on time-efficient, focused training opportunities that equip volunteer counselors with the key competencies they require. Listening skills form an integral part of many counselor trainings and are the core of TES trainings (
This study aimed to develop and evaluate a competency-based training for listening skills. To account for the heterogeneity of TES and extend the generalizability of our results, the study was conducted as an international multisite project in Germany, Italy, Hungary, and the Netherlands. Furthermore, while research in psychotherapy and counseling mostly relies on self-report measures, these are likely biased due to limited introspectiveness of respondents. Counselors, for instance, might over- or underestimate their skills depending on their level of self-criticism (
The Ethics Committee (Institutional Review Board) of the department of psychology at Heidelberg University approved the study procedures (reference number: AZ Jenn 2020 1/1). Participants were informed about all study procedures by the local member of the research team and provided informed consent prior to participation.
The study was designed as a randomized-controlled waitlist trial. Participants were recruited at local TES posts in Germany, Hungary, Italy, and the Netherlands via participating institutions in the Erasmus+ funded network EmPoWEring (Educational Path for Emotional Well-Being). As a widely known organization, TES posts are regularly contacted by individuals who are interested in becoming a volunteer counselor for TES. During our study period from November 2016 to April 2017, those who contacted TES about becoming a volunteer counselor were informed about the study and the opportunity to participate in the listening skills training. Those consenting to the study procedures were then cluster-randomized within site to start training either immediately (training group) or delayed (waitlist group). Within each country, the research team randomized each individual to either an immediate training group or a waitlist group. Participants in the training group immediately started the listening skills training. After the training groups had completed their training, listening skills of participants in both training and waitlist groups were assessed in a standardized, simulated emergency call with an actor client. After the assessment, the waitlist group received their listening skills training. Due to the naturalistic recruitment, there is no information available on the number of individuals who decided against participating in our study. There were no dropouts after enrollment.
Participants had to be 18 years or older to be eligible. A total of
Characteristic | Training group |
Waitlist group |
Difference test |
|||
---|---|---|---|---|---|---|
40.1 | 15.7 | 36.9 | 16.1 | -0.848 | .400 | |
2.4 | 6.0 | 3.8 | 7.5 | 0.832 | .408 | |
Gender | 2.53 | .112 | ||||
Male | 4 | 11.1 | 9 | 25.7 | ||
Female | 32 | 88.9 | 26 | 74.3 | ||
Highest educational level | 1.283 | .733 | ||||
Basic secondary school | 5 | 13.9 | 7 | 20.0 | ||
High school | 12 | 33.3 | 10 | 28.6 | ||
Bachelor’s degree | 10 | 27.8 | 12 | 34.3 | ||
Master’s degree | 9 | 25.0 | 6 | 17.1 | ||
Former experience in listening | 0.137 | .712 | ||||
Yes | 17 | 47.2 | 15 | 42.9 | ||
No | 18 | 52.8 | 20 | 57.1 |
A focus group of professionals in TES counseling and pastoral care developed a manual for the listening skills training. The 120 hr training is split into three parts: a 30 hr self-study online module to convey the theoretical basis of listening, a 40 hr practical group training in listening which is provided in 10 structured sessions, and a 50 hr module for in-depth practice and supervised training calls.
Module | Content |
---|---|
1. Self-study (30 hrs) | Using an e-learning tool, participants are provided with 100 multiple choice questions regarding the theoretical basis of listening. After each question, participants receive feedback on their selected answer(s) and are presented with a brief theoretical explanation. Topics include cognitive-behavioral, psychodynamic, systemic, and humanistic/client-centered theories. |
2. Practical group training (40 hrs) | This part of the training is performed on site in groups of maximum 15 participants. |
Session 1: Introduction | focuses on a personal introduction of group members, self-reflection of training goals and motivations, and the assessment of existing knowledge and views on listening |
Session 2: Active Listening | teaches the principles of active listening (how to ask for thoughts/feelings/behaviors, give the other person space, and paraphrase meaningful contents) |
Session 3: Emotional stability | teaches ways to regulate one’s own and the other person’s feelings |
Session 4: Respect and boundaries | fosters acceptance of differences between people teaches ways to set boundaries in the listening process |
Session 5: Empathy | fosters perspective taking and empathic responses to another person’s story |
Session 6: Mirroring | teaches ways to reflect the other person’s feelings or statements |
Session 7: Self-reflection | encourages reflection on own feelings, motivations, and resources |
Session 8: Structuring conversations | teaches the five-phase model of the listening process (welcome, exploration, goal setting, elaboration, conclusion) |
Session 9: Strengths and resources | teaches how to ask for resources and foster strengths of the other person |
Session 10: Feedback and conclusions | summarizes acquired listening skills and encourages reflection on personal progress |
3. In-depth practice (50 hrs) | Having acquired the theoretical knowledge as well as practical experience in role plays and group exercises, the final part of the listening skills training is focused on supervised training cases. This module should be adapted to suit the needs of listeners in their specific work environment. |
Listening skills were assessed in a standardized, simulated emergency call with a trained actor client. The actor role represented a typical TES caller. Actors received a standardized role script with a detailed description of their role as well as instructions for a 15-minute TES call. There was one native speaking actor in each country. Before the assessment, actors prepared their role and practiced the simulated call with paraprofessional counselors of different experience levels. This ensured that actors were trained to respond realistically to a variety of possible interventions by participants. Furthermore, these practice calls were recorded and used as training material for the observer ratings of listening skills. During the assessment period, a local member of the research team listened to recordings of the standardized, simulated emergency call and gave feedback regarding role adherence to the trained actor client on a weekly basis.
Assessments were conducted by telephone to mimic a naturalistic TES setting. Calls were recorded for assessment purposes. Participants were called by blinded research assistants and instructed to be a good listener for an actor client for about 15 minutes. After assuring that the instructions were clear, the actor then took over the phone and presented herself as “Laura”, a 27-year-old office clerk, who was struggling in her relationship and also stressed out by her current job workload. “Laura” was calling TES when she was home alone in the evening and overwhelmed by her feelings. She was severely distressed, but not in an acute suicidal crisis. “Laura” was struggling to identify her own emotions, but she was willing to respond to the paraprofessional counselor’s questions and able to benefit from the listening process.
Listening skills were assessed using an observer rating measure. The Listening Skills Scale (LSS) was developed by members of the research team (SJ, UD) based on several validated psychotherapy process scales, i.e. the Multitheoretical List of Therapeutic Interventions (MULTI;
Ratings were provided by at least on trained research assistant in each country. Recordings of practice calls from the actor training were used to train raters in the application of the LSS. During the assessment period, at least once per week the local member of the research team listened to recordings of the standardized, simulated emergency calls, gave feedback to the actor (see above), and supervised the local research assistant in ratings on the LSS. In the German subsample, all LSS ratings were performed by two independent observers. Interrater reliability of these two raters was excellent, ICC(3,1) = .86.
As a first step, we explored missing data and investigated the factor structure of the listening skills scale as a basis for further analyses. We performed a principal component analysis (PCA) using the Scree criterion for factor retention to determine whether calculating a mean score for listening skills was appropriate. Next, we assessed whether our data was normally distributed. Since each of the four countries provided one training group and one waitlist group, groups were nested within country. We therefore assessed whether this introduced dependency in our data by calculating the intraclass correlation (ICC) within countries in a multilevel intercept only model. We intended to employ a multilevel model to assess group differences if there were an ICC ≥ .05. An ICC < .05 would indicate that country does not affect outcome and therefore single level multiple regression models would be appropriate (
Missing data analysis demonstrated more than 5% missing values in six items of the LSS. We therefore excluded these items from the following analysis.
Next, we conducted a principal component analysis (PCA) to explore the factor structure of the LSS. The Kaiser-Meyer-Olkin score of KMO = .86 and the significant Bartlett’s test of sphericity, χ2(351) = 1562.15,
Since groups were nested within countries, we first assessed the dependency in our data by calculating the ICC within countries in a multilevel intercept only model. With an estimated ICC of .01, the model suggested negligible dependency in the data. Hence, multiple regression was deemed an appropriate method to test for group differences. The first model predicted listening skills as measured by the LSS from group (waitlist group vs. training group). Group was a significant predictor of listening skills with a large standardized regression coefficient of
Parameter | Model 1 |
Model 2 |
Model 3 |
|||
---|---|---|---|---|---|---|
Coefficient ( |
95% CI | Coefficient ( |
95% CI | Coefficient ( |
95% CI | |
Intercept | 3.20 (0.11)* | [2.97, 3.42] | 3.46 (0.27)* | [2.93, 4.00] | 3.20 (0.12)* | [2.96, 3.45] |
Age | -0.01 (0.01) | [-0.02, 0.00] | ||||
Gender | -0.06 (0.21) | [-0.48, 0.35] | ||||
Experience | -0.00 (0.01) | [-0.03, 0.02] | ||||
Group | 0.79 (0.16)* | [0.48, 1.11] | 0.82 (0.16)* | [0.50, 1.14] | 0.79 (0.16)* | [0.47, 1.11] |
Model Fit | ||||||
0.27 | 0.28 | 0.27 | ||||
Adjusted |
0.26 | 0.26 | 0.25 |
*
The difference between the groups is significant (
This study aimed to develop and evaluate a competency-based training for listening skills in an international multisite project across Europe. Results provide support for the efficacy of the 120 hr training. Trained individuals demonstrated significantly better listening skills than their untrained counterparts. The effect size for this group difference was large, which implies that this relatively short training makes a meaningful difference in paraprofessional counselors’ abilities to adequately respond to TES calls. Furthermore, the effect of the training was independent from participants’ age, gender, and previous experience as a listener in other contexts. Although approximately half of the participants reported previous experiences in the field of “listening”, e.g. in their profession as social workers, nurses, or pastoral care workers, or as a volunteer for other services, these experienced participants benefitted as much from the training as inexperienced participants. This implies that the training is suitable for groups with different levels of expertise and equips paraprofessional counselors with specific competencies needed within TES. Listening on the telephone may require a different set of skills than listening in a face-to-face setting, such as the ability to fully rely on verbal expressions in understanding the client, without the option to consider nonverbal cues (
In this study, the assessment of listening skills was realized with an actor patient in a simulated emergency call. This method was chosen not only for a more objective assessment, independent of participants’ ability to accurately report on their own listening skills, but also to tap into the exact competencies needed for the later task as a paraprofessional counselor in TES. Competency-based assessment methods have gained increased popularity in medical education and psychotherapy over the last decades (
This study is limited in generalizability by the recruited sample. Although we performed the study as a multisite project across four different European countries, TES operate internationally, and future studies will determine whether the listening skills training is effective in other than the investigated countries. However, investigating the training across four countries with very different local structures (Germany, Italy, Hungary, and the Netherlands) is a major strength of this study and the focus on European countries seems sensible since a large number of TES sites operate in Europe (
Next, although actors received a detailed role script, prepared their role thoroughly, and were trained and supervised frequently, the actors had to react flexibly to participants’ interventions and therefore the assessment was not completely standardized. Future studies could investigate whether presenting pre-recorded audio sequences is a viable alternative, although this comes at the cost of a less ecologically valid assessment situation.
Furthermore, although participants received a standardized training of 120 hrs in total, their attendance in the 30 hr online module was not monitored by the research team and thus may have varied. Further evaluations of the training should assess attendance in all modules and control for missed classes in statistical analyses.
Next, though reliability measures within this study demonstrated excellent interrater agreement and internal consistency of the LSS, further validation of the scale, preferably with listening skills measures from different perspectives, would be useful.
Lastly, due to limited resources we designed the study as a randomized controlled waitlist trial with a single assessment in each group. Assuming randomization was successful, this procedure should result in correct effect size estimates for the training. However, a baseline assessment in the training group could have been used to examine the successfulness of randomization and could also have served as a more direct measure of existing knowledge than asking for previous experiences in listening. Furthermore, future evaluations of the listening skills training may want to include a follow-up assessment to examine long-term effects of the training.
Our findings have several implications. First and foremost, demonstrating the efficacy of the training in participants from several European countries suggests that the listening skills training can be used to train paraprofessional counselors at TES from different countries. The modular structure allows for flexibility while also providing an evaluated and effective basis. International TES sites may use the listening skills training as a basic curriculum and adapt it to their regionally different needs. To monitor their trainees’ development of competencies, they could also make use of the assessment method with the standardized acting role. Although role-plays are typically part of the TES group training, introducing a standardized assessment could help trainers and trainees identify their specific needs while also providing a consistent background against which paraprofessional counselors’ listening skills can be evaluated.
Furthermore, the increased demand for mental health services during the COVID-19 pandemic together with the necessity to reduce in-person contact between individuals has highlighted two core competencies of TES: they are widespread available and offer emotional support in a socially distant manner (
Lastly, this study aimed to evaluate the use of competency-based training and assessment methods in the field of paraprofessional counseling. Although commonly accepted as beneficial in medical education (
To conclude, this international multisite study demonstrated the efficacy of a competency-based training for listening skills across Europe. Trainees successfully acquired listening skills in the 120 hr course, as demonstrated in a standardized simulated emergency call with an actor representing a typical TES caller. Findings encourage the application of the training in TES to prepare volunteers for their tasks as paraprofessional counselors. Furthermore, results suggest that competency-based assessment in a simulated TES call is a suitable method to measure listening skills.
This research was supported by a grant from the Erasmus+ program of the European Union (2015-1-DE02-KA204-002492), which is gratefully acknowledged.
We thank our project partners Frank Ertel from IFOTES EUROPE, Bence Buza and Linda Engwau from Magyar Lelki Elsosegely Telefonszolgalatok Szovetsege Hungary, Monica Petra and Christina Rigon from Telefono Amico Italia, Ulrike Dahme and Ulrike Zeller from Telefonseelsorge München, Noor Bossers and Cootje Roosenboom from Sensoor Zuid-Holland, Luca Rusi from Studio Rucli, and Valeria Puletti and Silvia Cordellini from Scuola Nazionale Servizi Italy for their support.
Provides an observer-rating measure of listening skills (Listening Skills Scale). The Listening Skills Scale (LSS) was used by independent observers to rate listening skills of participants in simulated emergency calls (for access see
The authors have declared that no competing interests exist.