Got Hang-Ups? Counseling by Phone May Be Answer

The ads sport such catchy phrases as TLC (Telephone Link Counseling) and Dial-a-Shrink.

By picking up the telephone, with credit card ready, a caller can get professional psychological advice with a new degree of convenience, anonymity and cost control.

Thus are therapists in Orange County and elsewhere trying to crack a pillar of traditional therapy: the office visit.

But in doing so, they have raised a few eyebrows in the mental health professional community. This month, in fact, the ethics committee of the American Psychological Assn. in Washington will consider taking a stand on this nascent approach to therapy.

Decades ago, a psychotherapist was an authority who camped behind a desk or sat at the end of a couch, out of the sight of a reclining patient lost in free association.

Therapy took years. Deep psychoanalysis was reserved for the well-to-do who had hours every week to spend probing their psyches.

But the rigid barriers of formality softened, yielding bit by bit, until the therapist sat facing the client and became something akin to a close confidant.

“It’s a natural progression of events,” Caren Croxen said of telephone counseling. A licensed marriage, family and child counselor, Croxen practices in-person and telephone therapy out of her Fountain Valley home.

“We live in a world that’s fast-paced, and there are a lot of demands on us. Time demands. And people are not always willing to give the time to therapy. It used to be that therapy literally meant a five-year commitment, several times a week. And nobody wants to do that today.”

Croxen recently started advertising her telephone counseling, a service she said she has offered on a referral basis for about eight years.

She and other therapists-by-phone say the informality and immediacy of telephone counseling offer distinct advantages to clients.

Jeanne Nelson, who with husband Lee Hachey opened TLC, said phone counseling provides “more of a client-oriented approach to therapy.”

Nelson and Hachey, both licensed marriage, family and child counselors, operate the Newport Harbor Counseling Center in Costa Mesa.

“The one-hour-a-week therapy session works very well for a lot of people,” Nelson said, “but it very often can be a therapist- oriented approach that fits into the structure (in which) a therapist most conveniently works.”

Added Hachey: “(A caller) can deal with the problem when it happens, not a week later,” as might be the case if the caller had to arrange an office appointment.

Not for Crises

Who should call for counseling-by-phone?

People with short-term problems that are not crises, the therapists say. They cited relationship difficulties, employment anxieties, trouble dealing with children and “what should I do?” situations as appropriate.

Not the province of telephone therapy, they said, are sexual problems, crisis intervention, psychosis, physical abuse or ailments needing medical attention. The therapists said callers wanting help in those situations are referred elsewhere.

Each call begins with basic questions: your name and MasterCard, Visa or American Express card number, please? Then a caller can limit the cost by controlling the time spent in counseling, Nelson noted.

“But if they want to talk for an hour,” she said, “(the cost is) comparable to what they would pay for an office visit.”

Some Prefer Anonymity

Face-to-face counseling frightens some people, Croxen said, and they may associate seeking psychological help with admitting they are “crazy.”

“There’s something about not being seen,” Croxen said. “It’s like, nobody knows who you are. There’s that anonymity factor that a lot of people prefer.”

Also, “when people get depressed . . . they may not want to go through the process of finding a therapist and making an appointment and leaving the house to see the therapist,” Croxen said.

“They need help right then, right there, without going through a big hassle. So for the depressed person, it’s a big help because they don’t have to get dressed, they don’t have to go and find somebody, they can get immediate help without doing what’s impossible when you’re depressed, and that is getting motivated.”

But psychologist Eugene A. Ericson, a director of the Orange County Psychological Assn., is skeptical.

Communication by Sight

“Much communicating is done by sight,” Ericson said. “Body language is used constantly by everybody. A great deal of therapy that’s done is accomplished through the rapport of a therapist with the patient.”

Conceding that telephone counseling could be helpful “in a rather superficial way,” he cautioned: “You have to assume that the patient is able to give enough information and the right kind of information” so the therapist can quickly evaluate the caller’s problem.

“I hate for human problems to be treated lightly,” Ericson said. “I believe therapists need all the information and data they can get” to understand and help solve a client’s real problem.

Hachey of TLC maintains, however, that an adept therapist need not be hindered by knowing a client in voice only.

“For me at least,” he said, “the intimacy goes much faster on the phone. Because they are less exposed . . . and they feel much more comfortable.”

So far, no laws or guidelines govern counseling by telephone, according to psychologist David H. Mills, administrative officer for ethics at the American Psychological Assn. in Washington.

“Our ethical code says that psychotherapy is done only in the context of a personal and professional relationship,” Mills said in a telephone interview. But with regard to telephone therapy, he continued, it is not clear what a “personal and professional relationship” means.

Traditionally it has been understood to mean the client is in the physical presence of the therapist, he said.

Mills is bringing the issue before the association’s ethics committee when it meets June 26 in Washington. The group could then decide whether such a practice is ethical and what guidelines and standards should apply to it, he said.

No Complaints for Adjudication

“We’re wrestling with this,” he said. “It’s still too new for us to have a feel for it.” While no complaints have come to the ethics committee for adjudication, Mills said he has received reports and inquiries about telephone therapy services “starting up all over the country.”

Just where, when and by whom it all started is uncertain.

Nelson said she and Hachey had been informally counseling regular clients by phone in between sessions, but not charging for the calls.

TLC, with its credit card billing, was born after Nelson read a newspaper story about Shrink Link, a New York service operating since October on a credit card billing arrangement.

Another Orange County telephone counseling business, called Tele Counseling Medical Group, also was inspired by Shrink Link, according to Tele Counseling medical director Samuel E. Gendler.

First of Its Kind

Kathryn Hahner, psychologist and coordinator of Shrink Link, says the New York service was the first of its kind. And she is careful to point out that what Shrink Link does “is not therapy, it’s counseling.”

Five psychologists, including Hahner, perform Shrink Link’s telephone counseling, along with one psychiatrist.

“We don’t see ourselves as a substitute for psychotherapy,” Hahner said in a telephone interview. “We’re filling a gap that exists in the mental health system. A lot of people who call us would never have gone to therapy about a problem, but they want professional feedback.”

That gap, she said, is between traditional, ongoing therapy and the type of emergency aid offered by crisis hot lines.

The volume of callers seeking counseling, she said, is not great. With the recent addition of an 800 number, Shrink Link gets “a few calls every day, and they tend to be coming from all over the country,” Hahner said.

Hachey estimated that TLC has received 50 or so calls in 2 1/2 months of operation.

Gendler, a Garden Grove family physician with a year of training in psychiatry, employs a full-time administrator to market Tele Counseling, employing the slogan “Dial-a-Shrink.” Gendler answers most of the 20 or so calls a week--not counting cranks--that his service receives, administrator James Graf said.

Different Approach

The rest are handled by psychologists, licensed clinical social workers and licensed marriage, family and child counselors who work on call, Graf said.

Gendler’s approach, though, is decidedly different from those of Croxen, Nelson and Hachey.

Lunging headlong into serious marketing, Gendler installed an 800 phone number when he launched Tele Counseling in late March. Then he advertised as far afield as the San Fernando Valley, trying both classified advertisements and standard display ads.

“He likes to think he’s Toni Grant,” administrator Graf confided, referring to the popular radio psychologist who counsels callers on the air. Therapists Nelson and Croxen dismiss comparisons to radio counseling, however.

“A radio talk show is radio-oriented,” Nelson said. “Its primary purpose is to entertain an audience, not so much to do therapy with the individual. So you’re talking to a therapist who’s going to be able to give you maybe three minutes between commercials.”

Croxen concurred: “There’s more anonymity in this situation (private telephone counseling) because the whole world isn’t listening to them, and they can say more private things that they want to say. And they can get much more detail, because on the radio it’s a quick answer, then it’s the next call.”

‘Indication of the Trend’

“I think it’s kind of an indication of the trend that therapy is going through in the last 20 years,” Hachey said. “It started out being very formal . . . and it’s opened up more and more.

“I think the therapist is getting more out into the community and becoming more of a person that you talk to like you’re talking to a good friend rather than talking to that doctor who scares you. So I think the Telephone Link opens up that aspect. Here you can talk to someone who’s well trained, very casually.

“I think it’s here to stay.”