International Journal of Emergency Mental Health and Human Resilience
Open Access

Suicide prevention, Crisis, Crisis center, Crisis Counseling, Active listening, Creativity, Counseling strategies.

You are presented with a box of tacks, a candle, and several matches. The challenge is to affix the candle to the wall without any wax dripping on the floor. How would you approach this problem. Duncker used this same task to determine if participants would figure out that they need to remove the tacks from the box and then pin the box to the wall as the candle holder. Surprisingly, many adults struggled to envision the box as anything other than a container to hold tacks. Why is that the case? People have, through experience, learned to see boxes as simply holding devices. For people to see the container of tacks, as a box and potential candle holder, they needed to see beyond their fixed perspective (Acar OA, 2019). A possible solution to their challenge was in front of them, but they could not see it. This same struggle is prevalent among individuals in acute emotional crisis, where seeking the help of crisis counselors can becomes essential, as they find themselves unable to see beyond their limited and fixed perspective, often leading to contemplations of suicide (Beck RJ, 1999). Suicide could be looked at as ‘coping overkill’, how someone hopes to cope with their stress or pain when they cannot see that any other options exist and all other coping strategies have been exhausted (Ben-Porath DD,2005). Regardless of if it's sticking a candle to the wall, or one’s own well-being and survival, our fixed perspectives limit us. This is when crisis counselors can provide the necessary empathy, support and guidance to help hotline callers feel heard and find new solutions they couldn’t see before. The goal of a crisis counselor is to de-escalate acute emotions that keep callers entrenched in distress (Bi H, 2020). This is achieved by creating an empathetic environment where callers feel genuinely heard, validated, and affirmed (Caseras X,2007). This supportive approach aims to enable callers to explore alternatives to suicide. However, in some cases, this empathetic approach alone may not be sufficient to help the caller move past their fixed perspective. It may become necessary for counselors to gently introduce subtle reframing techniques. While reframing techniques have proven effective in counseling, their application in crisis counseling is challenging due to the unique and time-sensitive nature of this context (Chen T,2018).

Recognizing the existing gap in available resources for crisis counselors, we seek inspiration from various approaches used in related fields, specifically in design and creativity. Our aim is to provide crisis counselors with valuable insights and tools, creating a guiding framework for their training and development. Our ultimate objective is to introduce flexible reframing strategies tailored to the crisis counseling context. These strategies are designed to help shift a caller's perspective, fostering hope and resilience even in the midst of the darkest moments, all while minimizing the risk of invalidation. By expanding the metaphorical toolbox of crisis counselors, they can help callers discern the cracks in the tunnel that surrounds them, reigniting a sense of hope and resilience (Cox DW,2021).

This paper addresses the dual challenge of providing empathetic responses and addressing callers' fixed perspectives within the context of crisis counseling, an area lacking structured guidance. In the following section, we delve into this challenge, introducing our response—the SCAMPER reframing strategy. We explore the limitations of established reframing techniques and leverage insights from creativity and design research to bridge this gap. Our comprehensive introduction to Scamper's reframing techniques follows (Draper J, 2015).

THE PARADOX: NURTURING CALLERS' ROOTS WHILE AIMING FOR THEIR TRANSFORMATION: We can picture a crisis counselor as a gardener tasked with tending to a tree firmly rooted in rocky soil. The tree represents the caller's current state, firmly entrenched in their crisis, while the rocky soil symbolizes their fixed perspective resistant to change. The counselor's role is to nurture the tree where it stands while, paradoxically, guiding it toward a more fertile, expansive landscape. All of this must be done once the tree is at its most vulnerable with limitations in how much time the gardener can work with the tree. This paradox encapsulates the intricate challenge crisis counselors encounter regularly.

Callers in crisis often find themselves trapped in a mental terrain, much like barren ground, unable to envision solutions beyond their immediate hardships. This predicament arises from acute distress, severely limiting their ability to identify alternative approaches, creating tunnel vision, and obstructing any view beyond their fixed perspective . Under intense stress, the brain becomes singularly focused causing individuals to selectively concentrate on mood-aligned information, making it difficult for them to entertain alternative viewpoints Consequently, distress hinders callers' problem-solving abilities and restricts their capacity to explore alternatives effectively (Gaynes R, 2017).

This inflexible mindset, akin to the unyielding rocky soil, poses significant challenges for counselors. The persistence of fixed perspectives significantly impacts the outcomes of these vital conversations. It restricts callers' problem-solving capabilities while simultaneously challenging counselors' understanding of the overall situation. This limitation amplifies feelings of isolation, entrapment, and hopelessness, further hindering callers' problem-solving abilities. Left unaddressed, these fixed perspectives may tempt counselors to prematurely take control of the problem-solving process leading counselors to not fully comprehend the caller's underlying problems or to reach a mutually agreed-upon safety plan. This challenge is emphasized in Ramchand and colleagues' study that found 51% of calls utilizing the non-invasive approach of collaborative problem solving showed weaknesses in its implementation such as failing to agree upon or jumping to early solutions. This study underscores the delicate equilibrium crisis counselors must maintain. Even active listening, a cornerstone of trust-building, can unintentionally confine counselors within the boundaries of the caller's fixed perspective, obstructing both problem understanding and solution generation.

The persistence of fixed perspectives may also lead to disagreements between counselors and callers regarding problem-solving strategies. Sometimes this case being that a caller’s fixed perspective is that there are no possible solutions except for suicide, automatically putting the caller and counselor on opposing sides, adding an additional layer of complexity and demand to the counselor's role, impacting their own long-term well-being . To navigate this intricate landscape, counselors can employ reframing techniques as a valuable tool. In the following section, we will explore the existing gaps in counseling reframing techniques and assess their adaptability to the unique dynamics of crisis calls (Mishara BL,1997).

THE CRUCIAL ROLE OF ACTIVE LISTENING AND REFRAMING TECHNIQUES: In the realm of counseling, active listening stands out as one of the most powerful and effective yet low-demand tools at a counselor's disposal. It goes beyond merely hearing the client; it involves fully comprehending their perspective and emotions. However, active listening encompasses more than empathetic listening; it can also be utilized to employ cognitive reframing techniques. These techniques are therapeutic approaches designed to alter or shift the client's viewpoint and assessment of a situation, event, or emotion, with the goal of fostering a more positive and adaptive mindset.

This process is fundamental in various therapeutic models, including cognitive-behavioral therapy, acceptance and commitment therapy, and dialectical behavior therapy. Moreover, the efficacy of cognitive reframing is well-established in addressing a wide spectrum of psychological conditions, from anxiety disorders to depression and post-traumatic stress disorder. Notably, reframing plays a pivotal role in helping clients challenge and reshape cognitive distortions or unhelpful thinking patterns. By actively listening and skillfully employing reframing techniques, counselors guide clients toward a more constructive and adaptive way of thinking. This seamless integration of listening and reframing is a hallmark of effective counseling and integral to crisis counseling. In traditional counseling, reframing techniques are most effective when utilized over multiple sessions across an extended period. Callers generally seek to build trust and feel understood by their counselor before being open to direct suggestions for reframing.

Reframing techniques, though proven effective in traditional counseling settings, face notable challenges when transposed into the context of crisis counseling. These challenges emerge from the stark disparities between these two contexts, thereby highlighting the necessity for novel approaches that cater to the specific demands inherent in crisis situations. In traditional therapy, therapists typically conduct multiple one-hour sessions spread across several weeks, allowing for the gradual establishment of trust and rapport with their clients. The extended duration and regularity of these interactions create an environment conducive to the direct and active engagement with reframing prompts, thus contributing to their efficacy (Ottens A, 2009).

However, the dynamics of crisis counseling contrast sharply with those of traditional therapy. In this domain, time is of the essence, with calls lasting an average of just 15 minutes. These brief encounters often serve as the caller's initial and sole interaction with the counselor, a critical consideration given that callers do not have the liberty to choose or see their counselor. Crisis counselors must adeptly and swiftly establish trust, respond to immediate distress, and offer safety-focused interventions. Moreover, crisis counseling occurs at the zenith of the caller's emotional turmoil, a point where they may feel trapped and perceive limited options. The intensity of these emotions can significantly fortify fixed perspectives, intensifying the challenge of working effectively with callers.

As a result of these disparities, conventional reframing techniques, which typically prove effective in traditional settings, may inadvertently convey invalidation or appear confrontational in the time-sensitive and rapport-building phases of crisis counseling. This realization emphasizes the need for innovative tools and techniques specifically tailored to the exigencies and limitations of crisis counseling. These tools should be designed to enhance the effectiveness of crisis counseling by addressing its unique requirements and constraints (Table 1).

Table 1 Principle Components of Contrast between Counseling Modalities.

To address these specific demands of the hotline context, new reframing techniques should harmoniously align with active listening, prioritizing non-confrontational approaches to minimize the risk of invalidation. They must also exhibit flexibility to adapt to the iterative and dynamic process of collaborative problem-solving while being efficiently applicable in short calls. To address these gaps and demands, we can find inspiration from fields outside counseling to develop these techniques (Rosenbaum A, 1977).

EXPLORING REFRAMING TECHNIQUES FROM THE CREATIVITY FIELD: The creativity field is uniquely positioned to provide additional ideas to address the issue of functional fixedness within crisis counseling. The field began conceptualizing these techniques within Guilford’s APA Presidential Address during which he advocated for additional psychological research to examine creativity. He outlined specific creative cognitive abilities to be intentionally developed in classrooms and explored in future research. Specifically, creative individuals exhibit the ability to generate many different, novel ideas as well as the ability to synthesize, analyze, and elaborate upon complex ideas. From this address, the field of creativity grew, established a definition, built assessments, and importantly, designed interventions. Many of these interventions include specific techniques to use during the creative process to develop more innovative ideas in business, science, and the arts. These interventions have been successful in helping individuals develop their creative abilities, more creative solutions, and their creative self-concepts. It is from these techniques and interventions that we derive the foundation of crisis counseling reframing techniques.

At the core, the creativity techniques that are taught as reframing techniques to help creators break out of their functional fixedness to develop new and useful solutions . Therefore, these reframing techniques are not restricted by context and could be applied to a variety of challenges across fields and prove adaptable wherever implemented. Within this paper, we demonstrate how these techniques may be applied within a crisis counselling situation. Crisis counselling and the creative process surprisingly share significant philosophical foundations, including the importance of withholding judgement during idea generation, developing solutions that are useful for helping people to move forward, and recognizing the importance of constraints. This latter point may be counter-intuitive, but it is the foundation for techniques that impose structure on the creative process.

Merely encouraging creators to brainstorm without any constraints can sometimes prove overly open-ended. Constraints have been shown to have surprising benefits for enhancing creative thinking. This concept parallels the lack of a structured framework available to crisis counselors for engaging in effective reframing strategies. These counselors are often left to navigate the development of such strategies through trial and error. To address this issue, some reframing techniques provide valuable structure to the brainstorming process. Techniques like the power impose a structured approach to the reframing process. These techniques, originating from diverse fields, offer promising frameworks to aid counselors in maintaining flexibility in their thinking and supporting their callers in doing the same. Additionally, these methods can be implemented within a short timeframe, making them particularly suitable for the fast-paced environment of crisis counseling (Sawyer C, 2013).

Before introducing the techniques that we built upon and adapted for crisis counseling, we want to recognize that the context in which these creativity techniques are typically deployed vary significantly from the counseling context in which we hope to extrapolate to. The suicide counseling setting is a serious context where callers are completely vulnerable with their pain and humanity. Bringing in the ‘playfulness’ that is encouraged by these creativity techniques should be done with prudence for the situation and is not reflective of the primary advantage of bringing in these cognitive reframing strategies. While a common context that these creative strategies are implemented include intentional brainstorming sessions, the crisis counseling context calls not for counselors to think of novel and useful ideas, but to help guide the caller to them.

In preparation for a detailed exploration of the scamper strategy's application in the crisis counseling context, it is imperative to establish its foundations within the realm of creativity. Additionally, we will introduce two complementary cognitive strategies, the Power of 10 and Perspective Swap, which play pivotal roles in shedding light on the underlying mechanisms behind each of scamper's reframing strategies. While these strategies are not exhaustive and may not be as integral to our adaptation of scamper, they are highlighted here to emphasize the wealth of insights drawn from the creativity and design literature that inform our approach.

THE COGNITIVE FRAMEWORK: POWER OF 10, PERSPECTIVE SWAP AND SCAMPER: Suicide prevention counseling presents a heightened level of the universal challenge of expanding one's perspective beyond the current constraints. Entrepreneurs, engineers, and any variety of creative positions can inadvertently restrict their potential by remaining within a narrow frame of reference. For years, green mold or Penicillium digitatum was considered just a nuisance for researchers conducting scientific study with petri dishes. It was here green mold was fixed within the minds of scientists as a problem, and not a potential solution. That was until, in 1928, Dr. Alexander Fleming saw past that fixed perspective and saw its potential. To date, penicillin has saved hundreds of millions of lives.

PERSPECTIVE SWAP: The "Perspective Swap" technique offers a valuable tool for reframing by prompting counselors to envision how diverse individuals might respond to a given situation. This technique encourages counselors to step into the shoes of specific people or individuals possessing distinct characteristics, effectively dismantling entrenched viewpoints and facilitating the exploration of innovative solutions. For instance, counselors may contemplate how the issue at hand would appear when viewed through the lens of a lawyer, a sculptor, a scientist, or even a child. While traditionally this technique has been used to help break the counselor of their own fixed perspective, we looked to apply this method externally, in efforts to provide alternative viewpoints. Instead of asking the counselor to reframe swap their own perspective, through its integration with active listening, the counselor can rephrase or ask varying questions to the caller from an alternative perspective. This can often work as a strong form of validation as well (e.g., “If I was in that position, I know I'd be feeling the same way”). One of the scamper techniques soon to be discussed, “Reverse roles”, pulls from perspective swap directly; but the underlying mechanism of presenting alternative perspectives and viewpoints on the caller’s challenges through questions and rephrasing, is a core mechanism of our adaption of scamper for the crisis counseling context. This indirect method allows for the caller to choose to fully engage with or disregard the reframing techniques as is best for them, reducing risk of invalidation and confrontation.

POWER OF TEN: The "Power of Ten" creativity technique encourages a dynamic shift in perspective, prompting individuals to explore problems or concepts across a wide spectrum of scales, essentially altering the magnitude of the solution space. For instance, consider a scenario where a community garden aims to utilize the "Power of Ten." Instead of merely expanding the size of the garden, they might contemplate what it would be like to have ten times the number of volunteers, ten times the number of plant varieties, or even ten times the land area for cultivation. Conversely, it encourages contemplating scenarios at a reduced scale. What if they had ten times less volunteers, plant varieties, land area? By adjusting the scale, this technique provides a simple jumping off point that allows them to generate fresh ideas and strategies for community engagement, sustainability, and food production, offering a broader perspective beyond the immediate constraints.

Crisis counselors can harness the "Power of Ten" technique as a valuable means of assisting those facing extreme circumstances. This involves envisioning scenarios where individuals have access to an abundance of options or, conversely, scenarios with very limited choices. Adjusting the magnitude of the situation encourages the generation of diverse solutions that may not have been previously considered. For instance, callers may grapple with issues related to self-worth or self-efficacy during moments of crisis (e.g., “It's not that big of a deal,” or “I’m just being oversensitive and weak”), which can obscure their ability to perceive available resources, support, and solutions. In such situations, the counselor can manipulate the magnitude in which they present (rephrase) the caller’s existing challenges to provide an alternative perspective, effectively helping them break free from their current fixed perspective.

However, it's essential to note that while Power of 10 would encourage counselors to apply this reframing technique directly, asking callers to actively and consciously consider an alternative perspective during their crisis, our integration of creative reframing techniques, including Power of 10, alongside active listening skills, allows counselors to engage in a less confrontational and more indirect form of reframing.

SCAMPER: A CREATIVE PARADIGM: Scamper is an acronym that provides prompting questions to reframe opportunities and solutions. SCAMPER has been applied across various settings to dismantle ingrained, static perspectives, encouraging individuals to explore diverse possibilities and ignite innovation this approach encompasses several critical elements.

• SUBSTITUTE: This prompts individuals to contemplate potential substitutions or alternatives in place of existing elements or methods. For instance, in a business context, it might involve pondering what could be substituted for a traditional resource or process to enhance efficiency and effectiveness.

• COMBINE: This aspect encourages the amalgamation of diverse ideas, concepts, or components. By combining elements, individuals can create novel synergies that may lead to innovative solutions. In a crisis counseling scenario, this may involve merging various therapeutic modalities or strategies to address complex caller needs comprehensively.

• ADAPT: Adaptation involves modifying existing ideas, processes, or approaches to suit a particular context or requirement. In suicide crisis counseling, this may include adapting conventional therapeutic techniques to cater to the unique needs and sensitivities of individual callers, enhancing the relevance and effectiveness of the intervention.

• MODIFY/MINIMIZE/MAXIMIZE: These three facets encompass the adjustments and variations possible for an idea or concept. Modification allows for alterations to enhance functionality or efficiency, while minimizing entails reducing elements to streamline processes or alleviate burdens. Conversely, maximizing aims to optimize components to achieve the best possible results. For crisis counselors, these concepts may translate into fine-tuning crisis intervention strategies to suit the specific circumstances of a caller in distress.

• PUT TO ANOTHER USE: This facet encourages considering alternate applications for an idea or resource. For instance, in suicide crisis counseling, information collected during crisis assessments can be put to another use by informing the development of targeted suicide prevention initiatives or public awareness campaigns.

• ELIMINATE: This component invites individuals to consider the elimination of unnecessary or redundant elements, streamlining processes and reducing complexities. In counseling, this could involve removing obstacles, such as stigmatizing language or administrative barriers, that may hinder effective communication and support.

• REVERSE/REARRANGE: These facets focus on reordering or reversing the sequence of actions or ideas. In a crisis counseling context, this might entail initially addressing immediate safety concerns and then transitioning to deeper therapeutic work, offering a reversed approach to crisis resolution.

This easy to recall set of prompts provides a range of queues for the generation of alternative and novel ideas. For instance, consider children aspiring to create an innovative lemonade stand, where scamper would encourage them to substitute cups, combine different fruits for unique flavors, or eliminate straws for environmental reasons. This simple example exemplifies the technique's capacity to generate a myriad of creative ideas.

Scamper was selected for its adaptable and mnemonic nature, employing a simple acronym that serves as a readily accessible guide for crisis counselors to enhance their active listening skills. This choice of acronym aids in quick recall during crisis calls and offers a diverse set of cues to bolster active listening. Importantly, Scamper's seven prompts are deliberately non-linear, non-hierarchical, and non-exhaustive in their definition. This flexibility aligns with the inherent uniqueness and context-dependence of each crisis call and caller. Recognizing that the caller is the expert in their own life and that counselors are experts in addressing specific calls, scamper is designed as a supportive tool, intentionally free from unnecessary limitations that might hinder collaborative problem-solving between counselors and callers.

Our adaptation of scamper provides unique techniques from the creativity field that crisis counselors could adopt to break their own functional fixedness as they strive to support their callers. These sets of strategies provide non-judgmental approaches that encourage flexible thinking and can be used in a short amount of time. In the subsequent section, we will elaborate upon how the scamper could be used during a crisis situation (Scott G, 2004).

SCAMPER: AN APPLICATION FOR CRISIS COUNSELING REFRAMING: The scamper technique equips crisis counselors with a versatile tool for applying non-confrontational active listening and reframing techniques during crisis calls. It provides a structured yet flexible framework, catering to the diverse demands of crisis intervention. This flexibility, which lies at the core of scamper's effectiveness, unfolds in two key aspects. Firstly, it seamlessly integrates with active listening skills, a crucial component for fostering effective counselor-caller engagement . Moreover, scamper's prompts are intentionally open-ended, empowering counselors to apply them with flexibility, drawing upon their expertise, intuition, and the unique context of each call. Prior research has found that the use of active listening vs collaborative problem solving in crisis chats unfolds over the call/chat and any strategies introduced to the crisis counseling context must be adaptive to these changes . This adaptability ensures that counselors can respond dynamically to the ever-evolving nature of crisis calls. While callers are the experts of their own lives the counselor is the expert of their own respective calls and caller interactions. It is this principle in which scamper is designed to act as a supporting tool and not as instructional criteria (Figure 1).

Figure 1: Scamper techniques.

In our adaptation of scamper to the context of crisis counseling and collaborative problem-solving, we leveraged prior uses of scamper in the realm of creativity. We simplified the framework, crafting concise, customized prompts designed for counselors. Our adapted version of scamper introduces new acronyms, each representing a specific approach.

It's important to note that this adapted version of scamper doesn't introduce entirely novel strategies; rather, it draws from established practices like dialectical behavior therapy and recognizes common, unstructured techniques frequently employed by seasoned crisis counselors. The primary contribution of our adapted scamper lies in its role as a guiding framework, amalgamating various constructs. These constructs encompass strategies grounded in existing knowledge structures as well as those emerging from experiential practices. This framework offers a starting point to the development and enhancement of current crisis counseling practices, delivering benefits to both counselors and call centers, particularly during the onboarding process. To be clear in its implementation, scamper is designed to be used by and supportive of the counselor, not the caller directly. The role of scamper is to aid counselors in their attempts to guide callers out of a fixed perspective. This tool was not designed to be shared with callers directly and would likely not prove effective, though the decision to do so is up to the counselor's discretion. In the following seven sections, we will delve into the implementation and purpose of each technique listed under scamper in the context of crisis counseling.

SUBSTITUTE THE LANGUAGE: Scamper is founded on the principle that by changing the language, you can change the perspective. This is a popular heuristic in the field of creativity and design, and one that is at the core of many reframing techniques. Minor adjustments in the wording of prompts or instructions can profoundly affect their interpretation. Consider the classic example where a group is asked to sketch a "house" in a matter of seconds. Upon examination, the drawn houses tend to resemble one another, with familiar features such as a boxy foundation, triangular roof, and rectangular door. The word "house" conjures a fixed mental image for most, limiting the diversity in their drawings. Now, envision an alternative scenario where participants are prompted to sketch a "dwelling," a "lodge," or even their "own house." These slight language shifts yield a considerably broader range of home designs. While these terms are essentially synonymous, minor changes in verbiage have opened the door to more varied and creative interpretations.

Counselors are acutely aware of the power of words, particularly in addressing their callers' emotions and feelings . In the helpline context, being a good listener is found to be much more supportive than giving direct advice or guidance . Central to the dynamics of caller-counselor interactions are active listening skills, with rephrasing serving as a cornerstone. Rephrasing involves articulating back to the caller what the counselor has understood, playing multiple crucial roles. It not only demonstrates comprehension but also builds trust and rapport with the caller. Furthermore, it acts as a reflective mirror, enabling callers to gain insight into their own emotions.

Modifications in language or substitutions of emotion-related terms can range from subtle shifts, like replacing "anger" with "frustration," to more profound interpretations. For instance, instead of merely equating anger with frustration, a counselor might identify that the caller's anger is rooted in the pain of a recent breakup, describing it as a sense of betrayal and deep hurt. This reframing holds the power to provide callers with a fresh perspective through which they can view themselves and their emotions.

The most effective applications of language substitution go beyond the caller merely feeling listened to; they result in the caller feeling truly understood. Rephrasing doesn't require identical cognitive understanding to convey the caller's feelings; it is about showing comprehension and engagement. The substitute language technique is designed to convey to the caller that the counselor stands with them, seeing their perspective.we provide an example illustrating the difference between a well-rephrased statement and a restated statement (Table 2).

Table 2 Substitute the Language.

The restated example presented in can negatively affect the relationship-building process between the counselor and the caller. They can create significant obstacles when it comes to problem-solving or safety planning. Conversely, the rephrased example in takes the caller's statement of "not knowing what to do anymore" and rephrases it as "feeling out of options." Similarly, the caller's frustration about not being "listened to" is substituted with "being heard or supported."

In our hypothetical example from, the caller's understanding of what support looks like from their family can prompt various thoughts that were previously hindered by a narrow focus on not being heard. By substituting the language used, we can open new doors and opportunities for the caller to perceive their situation differently. It's essential to note that the counselor doesn't have control over which new perspectives these language shifts will reveal or whether the caller chooses to explore them. scamper, starting with the "substitute the language" technique, is a comprehensive approach designed to weaken the barriers around the caller's fixed perspective, introducing potential new perspectives through various openings in the existing framework. A single word change can introduce fresh perspectives for the caller, but as the expert of their own life, must independently explore and embrace these new viewpoints. The counselor's role is to gently guide and reflect, fostering a safer outlook.

COMBINE ACCEPTANCE & CHANGE: The second technique in scamper involves the combination of acceptance and change, offering a more complementary approach to addressing fixed perspectives. Acceptance entails recognizing the caller's challenges, setbacks, and their feelings of hopelessness and helplessness. In moments of crisis, people primarily seek to feel heard and supported. However, what if the caller firmly believes that there is no escape from their current despair? The key lies in finding a delicate balance between validations and introducing new perspectives.

Dialectical thinking provides a powerful solution. This cognitive approach reconciles seemingly opposing ideas. Instead of searching for a single "right" answer, it acknowledges and accepts the existence of multiple truths. In the context of Dialectical Behavior Therapy (DBT), dialectical thinking helps individuals develop more flexible and balanced thinking patterns . It encourages the simultaneous acceptance of both change and the caller's current sense of hopelessness, promoting a synthesis of these seemingly conflicting perspectives. This means that the caller can acknowledge their feelings of being trapped by depression and their despair about finding love and support while also recognizing the existence of hope, available resources, and the potential to escape the darkness.

Breaking free from a fixed perspective doesn't mean negating it but rather introducing additional viewpoints. Engaging in a power struggle to overshadow the caller's hopelessness with hope can be counterproductive for both the counselor and the caller. By combining the caller's acceptance of their hopelessness with the potential for change, counselors can offer validation and introduce alternative perspectives, nurturing a more comprehensive approach to fixed viewpoints.

In practice, the Combine Acceptance with Change technique follows a "Yes, and" approach rather than a "Yes, but" approach. This concept originates from the performing arts domain of improve theatre. In this approach, actors accept and build upon the ideas and contributions of their fellow performers. The essence of "Yes, and" is to embrace and affirm what is offered by your scene partner, adding to it rather than denying or contradicting it. By adopting a "Yes, and" approach, both actors and counselors create a collaborative and supportive environment conducive to creativity. This approach fosters trust and open communication, both of which are crucial for effective collaborative problem-solving. Refer to below for an example of a potential interaction between a caller and counselor that utilizes the "Yes, and" approach to combine acceptance and change (Table 3).

Table 3 Combine Acceptance & Change.

This use of dialectical thinking, combining acceptance and change, is by no means novel to the counseling field nor crisis counseling in particular. This is a core principle taught in most counseling programs and crisis counselor training. It’s place within scamper is to help reframe this approach as one that serves multiple purposes, including that of expanding callers’ vision past their fixed perspective. Lastly, it serves as a prompt reminder to counselors that breaking a caller’s fixed perspective does not need to be literal. A caller does not need to abandon their hopelessness or even their perspective of dying by suicide. The goal is that those perspectives are not the only ones they consider. Crisis counseling services, such as those provided on the national call and chat lines, are designed for and work as short-term buffers, or “band-aids.” They cannot function as long-term care or be expected to achieve the level of support/efficacy that long-term care can offer . This has led some call centers to adopt the 51/49 rule when training new counselors of their scope and aims. Often times, when someone calls the hotline, they are 51% committed to attempting suicide, 49% committed to life. The role of the counselor and their call center is to reverse that percentile and get them back onto the side of being 51% committed to life.

ADAPT PROBLEMS TO FEELINGS: The third component of our revised scamper acronym involves encouraging the counselor to (A)dapt caller’s problem statements to feeling statements. For instance, imagine a counselor working to de-escalate the distress of someone in crises over a breakup. It's not the breakup itself that directly triggers thoughts of suicide; it's the overwhelming heartbreak and loneliness stemming from the breakup. These emotions are the core of the crisis, serving as significant barriers to dismantling the caller's fixed perspective.

As mentioned previously, the caller is the expert on their own life and the most knowledge of their current circumstances and crisis, not the counselor . It is the role of the counselor to understand the caller. Adapting caller problems to feelings when rephrasing caller statements helps to place the counselor and caller on the same page while additionally helping to change the focus from what may be an uncontrollable stressor (I.e., the breakup) to a controllable stressor (the feeling of loneliness). This distinction between controllable and uncontrollable stressors will be further developed in section 3.6, Eliminate uncontrollable concerns.

Adapting problems to feelings while using active listening skills supports the continued building of understanding and of trust and rapport while limiting the risk of invalidation. However, a restatement of the caller’s concerns as a feeling rather rephrasing brings with it a higher risk of invalidation (Table 4).

Table 4 Restated vs Rephrased.

The call invalidation that can occur when the attempt to adapt to feelings is too direct in its rephrasing and comes across as invalidating to their experiences. Recall back to the issue discussed in section 3.1., active listening skills calls for counselors to rephrase not restate, or parrot, caller statements.

The caller may gain the misunderstanding that the counselor views their feelings are separated from the reality of their situation and/or that the counselor does not believe them. This could be reflective of the experiences they were having with their family or friends that subsequently acts against counselor goals to make the caller feel heard and supported, while also providing the risk of losing trust and willingness to speak openly with the counselor. Accordingly, while adapting the caller’s statements to feelings is absolutely pivotal, it is often best accompanied with other principles such as the substitution of language, or the combination of acceptance and change. This is demonstrated in the second counselor statement of While both examples are rephrasing the caller’s problem statement to reflect the problem as a feeling, the second example acknowledges the caller’s challenges and changes the verbiage of “supporting me” to “feeling like your family is there for you.” There is still a limited risk present that a caller can see this as invalidating. However, by changing the language and putting the validation of their experience first, we limit this risk as the statement becomes less contrary and more complimentary towards the caller’s problem statement (Willems R, 2020).

Adapting caller problem statements is also commonly paired with the principle of either or both eliminating uncontrollable concerns and/or minimizing the problem-solving focus to one concern. Collaborative problem solving that is targeted towards things more within the callers control, commonly feelings, leads to more available solutions. As stated previously, the seven techniques of the scamper acronym are in no way meant to be exhaustively defined and have tremendous overlap. They function more as distinct prompts to help counselors adjust their active listening skills and active engagement with callers. Lastly helps demonstrate how scamper may flexibly be applied, including when not to use it. Every caller has their own unique needs and situations. Counselor judgment that this caller has faced significant invalidation, and may have a higher sensitivity to feeling invalidated, takes precedence over the attempt to adapt their problem statements to feeling statements. Counselor judgment, in correspondence with their team and advisors, comes first.

MINIMIZE TO ONE CONCERN: Many callers in crisis who reach out for support have a litany of different issues and feelings that have either built up or culminated into their current crisis. One incredibly helpful process that counselors help engage the caller in through working out and discussing what they are going through is what problems matter now, what problems carry the most weight, and which of those issues are and are not in our control. Minimizing the plethora of potential concerns and issues a caller has to a singular or manageable amount is not a novel concept. It aligns with the idea of problem prioritization, or the assessment and evaluation of a caller’s concerns, challenges, and goals reported during collaborative problem solving to determine some form of priority ranking based on severity, urgency, daily impact, or potential for emotional relief .A common approach often utilized in cognitive behavioral therapy is to typically address the most recent distressing problem to the individual. This has seen previous implementation within the crisis call context. For example, the Seven-Stage Crisis Intervention model focuses on uncovering the inciting incident that led to their call or crisis and active engagement principles list it as a primary concern to be discussed. Helping the caller select one primary concern can be done using a rephrasing statement, similar to the previously discussed techniques, or through a question. See for an example of both applications to one caller statement (Table 5).

Table 5 Minimize to one concern

We can see how the counselor rephrases the problem statement to reflect a singular challenge to examine. Looking at the first counselor statement in focusing on just one concern in a rephrasing statement is better when the counselor and caller are further into the call and have defined the problems as well as when a caller is overwhelmed and seems to be unable to pick out a singular issue. This may at first seem contrary to fixed perspectives, but in situations like this, a caller is still trapped by a fixed perspective that either there is no solution to any of these problems, or the only solution is one that addresses every problem. This may indicate more support and guidance is needed from the counselor.

When used as a more direct question for the callers, as seen in counselor statement number two of you can put more autonomy and control in the hands of the caller in deciphering what their primary concern is or what they want most out of the call. The number of problems a caller may be facing, how willing and able they are to focus on one, and if these problems do or do not converge to a singular point will always vary and should be considered by the counselor independently for each call. Regardless of the application as a rephrasing statement or question, the primary aim is to have a single (or at least manageable amount) agreed upon concern to address together.

PUT CALLER CHALLENGES TO ANOTHER USE: Holding a fixed perspective isn’t always a result of not seeing any possible solution or way out. Sometimes it comes as a result of seeing a way out but feeling you don’t have the strength or ability to make it happen, like seeing the escape hatch out of the dark tunnel but feeling too weak to reach it. This is where the additional support and encouragement from crisis counselors can play an influential role. Regardless of fixed perspectives, crisis counselors are trained to build up and encourage the caller, while providing the support to take those first couple of steps to the hatch. Empowerment is essential in collaborative problem solving and active engagement. One way to empower callers, while simultaneously showing active listening and validating the experiences of the caller, is by putting the callers' challenges to another use. More simply, reframe their weaknesses as strengths. Like other techniques, framing the caller’s challenges as evidence of their strengths or resilience has its risks and due to its overuse, and can run the risk of patronizing or seeming cliché. See below for an example demonstrating this risk, and how the practice of reframing challenges as strengths can be counterproductive to trust and rapport building (Table 6).

Table 6 Caller-Counselor Dialogue & Reframing

The counselor’s good use of validation and reflection of statement, as well as taking the next step to put the caller’s challenge of feeling hopeless to another use, one that highlights their strength. However, the timing of this technique may act as a barrier to developing the caller and counselor connection. A key aspect of using this reframing technique is that the caller’s primary challenge must be identified, and the caller must believe they are fully understood by the counselor. In this way, putting a caller’s challenges to another use works as a tertiary reframing strategy to be utilized only after rapport has been built and as the caller and counselor work towards a solution reframing technique was used too soon, before the caller provided any indication that the counselor understands them. In below, a more opportune point in time is demonstrated (Table 7),

Table 7 Put Caller Challenges to Another Use.

After rapport has been established between caller and counselor, and through active listening skills and validation. The caller trusts that the counselor is truly hearing them and their challenges. This is when the technique of putting caller challenges to another use can be its most powerful. This validation-turned-encouragement can act as a turning point in the call to begin the construction of an action or safety plan for the caller. Working collaboratively with the caller to find the just one or two small steps towards the goal of ‘resurfacing.’

ELIMINATE UNCONTROLLABLE CONCERNS: Eliminating the focus on uncontrollable stressors and concerns is an essential reframing technique for effective collaborative problem solving and directly correlates with the technique of minimizing to one concern. In the context of scamper, it acts as a prompt to dissect the aspects of the caller’s crisis between what is and is not within their control. For example, a crisis emerging from a relationship ending may be better focused on what the caller can do to make themselves feel better and supported by their loved ones (something more controllable) than trying to rekindle the relationship (likely uncontrollable). However, a caller may not be ready to explicitly hear that they need to let go of the relationship, confront that they can’t control it, and focus on rebuilding themselves. Instead, through rephrasing statements and continued validation of their experiences, counselors can highlight what aspects may or may not be within the realm of their control and the different outcomes each may come with (Table 8).

Table 8 Eliminate Uncontrollable Concerns.

REVERSE ROLES FOR NEW PERSPECTIVES: The seventh and final scamper technique involves reversing the roles of the caller and counselor to facilitate the emergence of new perspectives. This reframing approach doesn't intend to put the caller in the counselor's shoes; rather, it encourages the counselor to present the caller's own circumstances. This prompts the caller to temporarily view their situation from a birds eye view, opening up possibilities for fresh insights.

In this technique, the counselor can either present the caller's circumstances as if they were their own, effectively stepping into the caller's shoes, or create an objective and unrelated hypothetical scenario for the caller to evaluate. The first method often takes the form of a statement like, "If I were in your situation, I might also do X," aimed at validating another person's responses to a stressful situation. In contrast, an example of this technique not utilizing the perspective of the caller or counselor can use other external roles to swap perspectives such as caller’s friends and family, medical professionals, or even a ‘collective’ perspective. An example of both these methods is provided (Table 9).

Table 9 Caller-Counselor Dialogue & Reframing.

To address the weaknesses of implementing and lack of structure in collaborative problem-solving approaches, we utilized the combination of existing reframing techniques and those adopted from the creativity field. The flexibility of the scamper model allows for the development of i006Enovative solutions tailored to individual callers' needs, addressing the unique challenges and constraints that arise during crisis calls and chats. In contrast, other creative problem-solving approaches that are already seeing success in the mental health/counseling field lack the necessary flexibility to fit the constraints of modality, time, and resources. The scamper model also provides a concrete framework for call centers and other intervention/prevention organizations to teach more experienced skills that initially were only learned with experience–while also providing the necessary foundations for developing new adaptive strategies, methods, and models.

Collectively, the principles of scamper can be integrated into existing active listening skills to enhance how crisis counselors help caller’s address their fixed perspectives by both providing a supportive and empathic environment in which they felt heard and in providing less direct and confrontational alternative perspectives. With scamper’s implementation, counselors are better prepared to address the hurdle of callers' fixed perspectives while reducing risk of invalidation, all while not adding additional time or resource demands on the call itself. This allows counselors to function more as an empowering force for the caller, as the caller develops their own solutions, rather than jumping prematurely to solutions or relying upon the counselor to be the primary idea generator.

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