Observing Limits, Liability, and Other Concerns in DBT Intersession Contact

By Stephanie Vaughn, PsyD

This presentation is an excerpt from the online course “DBT in Practice: Mastering the Essentials”.

Highlights

  • It is essential to provide inter-session contact for patients at risk for life-threatening behavior.
  • Inter-session contact is less likely to be an intrusion when they:
  1. Observe their limits
  2. Engage in frequent discussions with the patient 
  3. Conduct a thorough orientation
  • Problems with inter-session contact are considered therapy-interfering behaviors and should be addressed as such.

 

Transcript

For therapists new to DBT, the concept of providing patients with their personal cell phone numbers and emails may be enough to prevent them from offering DBT at all. This is a shame considering all the evidence supporting DBT’s utility for a variety of populations.

There are a few therapist beliefs I’ve encountered which get in the way of offering intersession contact. One of those is a fear of liability risk. The thing that I usually ask therapists is whether they take any calls now. And most of the time, they say that yes, they do. So of course, there is a risk to taking any calls. So I want to validate that that’s the case. But I also want to emphasize the fact that most of the time therapists are not attorneys. And so for us to speak about things like liability I think is a bit of a stretch. I encourage therapists to consult attorneys for specific questions about telephone coaching but as a rule, DBT requires telephone coaching actually to minimize the risk to the patient. The way that we look at intersession contact is that we’re helping reduce the overall risk to the suicidal patient and that the risk of not taking calls is greater than the risk of taking calls.

Some therapists fear that they will miss a call and in missing a call, they’re going to increase their liability risk. You will definitely miss calls and you are missing calls now if you are not taking calls. Nowhere does DBT insist that immediate responsive is required. In fact, it is argued by some that immediate responsiveness, consistent immediate responsiveness, always, all the time kind of thing could be detrimental. So it’s actually not required to be immediately responsive.

In thinking about the fear of liability risk, I also will challenge therapists with Kohlberg’s stages of moral reasoning and how we want to make sure that our motives in doing things are not necessarily simply to avoid punishment and to gain reward. Most of us got into the profession because we have a desire to help people and we feel an obligation to help people. And this is yet another way that we can help people and is vitally necessary for treating people who are at high risk for life-threatening behaviors. So we need to encourage people to go back to the reasons why they’re doing what they’re doing and that we all have to be able to sleep with ourselves at night. And I can sleep more easily knowing that I’ve done the best that I can, that I’m providing the best care that I can and the full comprehensive package rather than simply trying to avoid punishment or risk.

Another belief that gets in the way that I’ve touched a bit on is this availability concern. So some therapists will say that they have a new baby or they’re afraid when they get ill or they go on vacation or they’re traveling and this 24-hour availability isn’t something that they feel like they can provide. It’s important to recognize that just because patients have the potential for accessing their therapists 24/7 doesn’t mean that they actually will access their therapists 24/7. So the possibility and the reality may not coincide.

In DBT, the word limits is used rather than boundaries. This can be what some therapists refer to as a boundaries discussion but in DBT, the word is limits. It’s important that therapists practice observing their limits when it comes to intersession contact. Observing limits means observing limits as an individual. When you’re on vacation, you may want to take phone calls or you may not. Depending on the severity of your illness, you may feel less inclined to take intersession contact. DBT takes this into account. Failure to observe one’s limits as a therapist can lead to burnout. We have more discussion on how a therapist can observe limits in the Therapy-Interfering Behaviors Module.

That being said, it is helpful to discuss your expected limitations with the patient early.
So I travel for business purposes more frequently than other therapists in my practice. So I usually discuss this with my new intakes immediately thereby giving them informed consent and opening up their options for securing treatment with another provider if they felt that they needed more availability, more contact.
For our therapists who are either expecting a baby or have a new baby, we have also let patients know and they have let their patients know upfront that they’re going to be less willing both emotionally, physically and logistically to be able to provide phone coaching. So that patient has the option of either securing treatment with someone else or arranging some sort of backup which is something that we highly encourage.

You can have a backup system so that each one of your DBT providers rotates and some take calls one week and others take calls another week. You can have a designated backup person. You could make your backup the 911 service or mobile crisis service. Optimally, the backup that you provide will be trained in DBT. But in the case that none of those options are available, it is important that you provide your patients with options for backup in crisis. If you think about it, this is more than they would’ve had if you didn’t provide contact at all. So I don’t believe that providing more opportunity takes anything away from the patient.

Another belief that can be a barrier is the therapist’s fears of creating dependency in the patient. They’re afraid that they’re going to make the patient somehow dependent upon their advice or reassurance from them. What we don’t want to do is pathologize the patient’s need for increased contact. And the differences between therapists in the limits that they observe can be great. Some therapists will take calls late into the evening. Some put a hold on coaching calls after 8 PM, for example. Some therapists are early birds and others are night owls. So we don’t want to pathologize the patient’s need for increased contact in thinking that more frequent contact makes them dependent.

At the same time, we want to keep in mind that it is possible that patient may utilize phone coaching at the expense of using skills on their own or to reduce anxiety rather than using exposure protocols to do so or other skills-based measures. So we want to keep the contingency management principles in mind. When providing phone contact, we don’t want to be overly warm. We don’t want to linger on the call. We don’t want to make calls too reinforcing if there is behavior going on on the other end that we don’t want to see more of.
We want to keep track of the frequency and duration of the calls and keep track of whether it’s increasing, decreasing, staying the same.

And the therapist needs to consider whether or not they’re observing their limits. Sometimes, therapists will blame the patient and say that the patient is becoming dependent when in fact it’s actually the therapist who is not observing their own limits.
They’re not discussing this with the patient and they’re not being frank and open. In my experience, it’s important to as early as possible be genuine and disclose when your limits have been crossed or when you’re feeling like you’re taking more calls than you are comfortable with doing. And the earlier you address it, the less awkward it’s going to be. You want to use those same DBT skills that you’re teaching your patients. You want to dive right in. You want to use DEAR MAN. You want to reinforce. You want to validate. But you do not want to pathologize the patient.
When all else fails, you can take a holiday from telephone coaching and either give another one of your colleagues the opportunity to provide phone coaching, get a backup or just take a holiday all together for a finite period of time.

To minimize the risk of problems, we go back to that orienting and reinforcement in the beginning of treatment where you can provide examples of reasons for calling. I like to share my pet peeves when it comes to phone coaching and I’ll illustrate examples with a role play with the patients. I let them know, for example, that I’m not a fan of what I refer to as the FYI text in which someone will, and this goes for anybody, a patient or a friend, family member, when someone will send me a text about a problem, doesn’t ask me a question, doesn’t elicit my thoughts about it and just sort of drops something in my lap that I’m not sure how to respond to. So sharing your pet peeves, giving a general idea about your schedule and giving feedback both during and after a call can really help head off the risk of problems.
Discussing those calls in session and how you feel like that they went, giving praise where you felt like that patient used skills and effectively utilized telephone coaching can help keep things moving and prevent problems.

You can also encourage patients to use their skills prior to calling. And it has been suggested from some providers to ask patients to use X number of skills before they’ll make a call. And in my experience if that’s required, if you ask patients to use skills before calling, you’re actually increasing the likelihood that those skills wouldn’t work, meaning that if the function of the intersession contact is to get in touch with one particular therapist, then they’re going to need to create a situation that will make that happen.

So be sure that you’re not setting yourself up for problems with your contingency management. Make sure the patient does not have to do X, Y and Z in order to get in touch with you.

If there is a limit that’s crossed and say that the patient violates 24-hour rule, violates one of your discussed limits and/or you’re just burnt out, you’re going to want to manage it as you would any therapy-interfering behavior. You’ll want to do a behavioral chain analysis, come up with a solution analysis. You’ll want to have continued discussion. This can be one of the most awkward and uncomfortable parts of doing DBT but this really is where excellent therapeutic progress can be made when we’re able to have open and transparent discussions with patients about our limits and their use of intersession contact. Don’t assume. It’s very important that you not assume that a patient is familiar with your limits, knows when your limit is being crossed and otherwise knows better. Be sure that you are being clear in what bothers you and when your limits are crossed. And finally, worst case scenario, a holiday from phone coaching, a defined period of time away from phone coaching could be the answer when all else fails.

Key points
From a DBT perspective, it is essential to provide intersession contact for patients at risk for life-threatening behavior.
Intersession contact is less likely to be an intrusion for the therapist when they observe their limits, engage in frequent discussions about their experience with the patient during intersession contact and conduct a thorough orientation.
Problems with intersession contact are considered therapy-interfering behavior and should be addressed as such.

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