Telephone Coaching in DBT: Applying Skills to Prevent Full-Blown Crisis
This presentation is an excerpt from the online course “DBT in Practice: Mastering the Essentials”.
- The DBT therapist provides inter-session contact to:
- Help the patient apply the skills in the moment they are in.
- For contingency management purposes.
- Strengthen the relationship with the therapist.
- A main goal of inter-session contact is to shape the patient to contact the therapist before a crisis is full-blown.
Intersession contact is not meant to be a substitute for therapy. It is not therapy over the phone. However, the patient having access to their individual DBT therapist between sessions can be extremely beneficial for a variety of reasons. There are multiple functions of intersession contact.
One of those is skills generalization. Although the patients are learning skills in group, learning something in a classroom and attaining the ability to apply it to the environment in the moment are two different things. So DBT assists in this learning curve by providing the opportunity for patients to contact their DBT therapists who hopefully are well versed in the DBT skills in order to ask them how they might apply the skills they’re learning in group in the moment.
So a DBT therapist is always going to be thinking about what skills the client could use that they’re learning in group in that moment. So although the situation may be a crisis in the moment and there’s the tendency to want to assess and to do some therapy interventions, we always want to be thinking about how to apply skills like mindfulness, radical acceptance, interpersonal skills, communication. How might each of those or one of those apply to the client’s crisis that they’re calling you about? So a question to ask would be: What skills could you use? So an individual therapist engaging in phone coaching could ask their patient over the phone, what skills could you use given what you’ve told me so far? We want to try to replace dysfunctional behavior that the client has engaged in time and time again with skills use instead. Rather than them going to their same old problem behavior like self-harm or an eating disorder behavior or getting into a conflict with someone, we can catch them before the dysfunctional behavior and try to apply skills.
Another function of intersession contact would be validating the patient’s need for additional contact. So the patient can contact their therapist without a reason. This doesn’t mean that they’re welcome to text 4or call at all hours of the day any time. What this does mean is that we don’t want to have to set something up, a contingency up that they have to have a reason to call us. For some patients, this would make it more likely that crisis would actually occur and that a problem would have to be created in order to have the need for the therapist contact to be reinforced. So I have some of my patients ask for validation actually when they call or text. So they ask for what it is that they need. Hopefully, this reduces the patient’s sense of alienation and depathologizes their need for additional contact.
Relationship repair is another function of intersession contact. Patient may have questions about what transpired during the therapy session. They are often delayed processors. And a question that they may not have had while they were with you comes to the forefront of their mind several hours later or they’re reflecting back on something that you said and really questioning whether they should continue in therapy. While we don’t want it to be a frequent occurrence in that they’re seeking reassurance if that is a problem behavior in and of itself, from time to time, there have been situations that this empowers the patient and helps resolve misunderstandings that have happened in the therapy session overall reducing the risk for dropout.
Another function of intersession contact is that the therapist may have the ability to intervene on suicidal behavior. Rather than expecting that the patient is going to go to the hospital or is going to call mobile crisis or is just going to figure it out, the therapist may actually be able to help save the person’s life by talking to them over the phone and providing some reassurance, some skills use or some other practical solution oriented strategy.
This potentially reduces the need for hospitalization and reduces the risk of completed suicidal behavior. So we also want to consider if we’re intervening on suicidal behavior balancing, reducing the risk of suicide with minimizing reinforcement of suicidal behavior. And sometimes, that can be a very delicate balance.
Another function of intersession contact that we’ve touched a little on is crisis coaching. So although a patient may not have life-threatening behavior, they may still feel that there’s a crisis that they would like help with. But again, the patient does not have to be suicidal in order to call the therapist. When speaking to a patient who is in crisis, we want to make sure that we don’t insist that the problem or crisis be resolved. I have said to patients on a number of occasions “this problem that you have is an ongoing issue and it is unlikely that you and I are going to get it solved tonight over the phone or it’s unlikely that in the 10 minutes we’re chatting over the phone we’re going to get this fixed. Would you agree?” And I have actually never had a patient say “no, we’re going to get this fixed” because many times we’re talking about things like a relationship with a mother or a spouse or a child or a neighbor or an employer. And so those are ongoing pervasive problems that are not going to be solved in a brief phone call. So we want to resist the urge to have the crisis resolved entirely. Shaping the patient to contact you before the crisis is full blown is really a goal. It’s very difficult to intervene on a crisis whenever it is absolutely full blown. We want to try to get them to call far earlier. Sometimes, patient crisis will have been ongoing for a couple of days before they’ll call. And if the crisis is full blown and they are in an emotionally distressed state, they may be sobbing. You may have difficulty understanding what they’re saying. There’s very little that can be accomplished over the phone at that time. So if we can get them to call earlier, it’s a whole lot easier to melt a snowball, so to speak, that’s just been packed by hand as opposed to melting an entire snowman. And when patients have allowed a crisis to continue mounting and packing on more and more emotions and more and more problems, it’s like trying to melt a huge glacier. And that could be too overwhelming for both the therapist and the patient to approach.
Finally, another function of intersession contact is we can use it for contingency management purposes. In other words, we can use it as a punisher, as a reinforcer. We can use the interactions on the phone as reinforcers, punishers in order to bring about a goal. So I have definitely changed up the contingencies with a patient before whom I’ve had multiple aversive interactions with. And this is in order to help strengthen the relationship and to help reinforce more, I guess positive is the word not in the behavioral sense but more behaviors that are conducive to a positive relationship with the therapist. Rather than only calling when in crisis or when they need help or when something negative is occurring, I have asked for a ratio of more positives to negatives. And so then the patient can contact me and let me know a way that they’ve used skills effectively or something that’s gone right during the day or a positive thought that’s crossed their mind. In this way, I am resisting the tendency to only talk to patients whenever they’re in crisis. Second, I’m minimizing the likelihood that I’m going to accidently be conditioned to see this patient’s phone number come up on my phone and have an immediate aversive response because I’ve had so many unfortunate or aversive interactions with them. So I don’t want the conditioning to be such that I’m dreading their phone call and this is one way to minimize the likelihood that that’s going to happen. So the patient can call or text or email about positive events. So we can talk more about other ways to manage problematic phone and text in our section on Setting Limits and Intersession Contact.
Key points The DBT therapist provides intersession contact for a variety of reasons including helping the patient apply the skills in the moment they are in, to intervene in a crisis or when the patient is at risk, for contingency management purposes or to strengthen the relationship with the therapist. A main goal of intersession contact is to shape the patient to contact the therapist before a crisis is full blown
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