DBT Secrets No More: Animated Role Plays

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DBT Phone Coaching: Validation, Vulnerabilities, and Self-Disclosure

By Stephanie Vaughn, PsyD

This presentation is an excerpt from the online course “DBT Secrets No More: Animated Role Plays“.



Initial Commentaries

So now, we’ve discussed the relationship between asking for help and providing help as it applies to phone coaching with me.

We’ve done a role play and it is clear that she very much wants, even in the role play, some immediate response in how to feel better. Her hesitancy to reach out to me for phone coaching is not something that I’m going to continue pushing for because we have not resolved this therapy-interfering behavior of insisting that the health provider help. It’s not always possible for any of us to help simply when called upon. And so, one of my limits is feeling like I’m not making the problem worse. And she is not aware of my limit yet. So I’m not going to continue to push that she do phone coaching just yet, not until we have a resolution on what to do if she calls me for help that I am unable to provide.

One of the biggest mistakes a DBT therapist can make is not being genuine or authentic about their limits to the patient. So if I were to insinuate that I would be able to help her in any circumstance and she should call me no matter what, then I would be leaving out the part about me getting frustrated and disappointed if and when I am unable to help her.

The alternative interpretation from the patient would be, “Well, it must be me. It’s my fault that I can’t derive benefit from this therapist’s recommendations,” when, in fact, I could just give a terrible intervention. It’s possible. No therapist is infallible. So I am radically accepting my own fallibility and acknowledging that I can fail.

The patient can’t fail. That’s an important point in DBT. The patient cannot fail. DBT can fail and the therapist can fail, but the patient cannot fail. So I don’t want her coming to the conclusion that she has somehow failed. At the same time, I don’t want to give the impression that no matter what she does I’m going to be thrilled to take a phone call from her. And so addressing these therapy-interfering behaviors doesn’t just come after the behavior has happened. So let’s say that the patient gets off the phone with me when I’ve tried to help and she goes and cuts herself. For me, that would be very aversive, particularly if I gave it my very best effort. So to not address that until something like that happens is doing a disservice to the patient and our relationship.

So I’m going ahead and anticipating that’s most likely going to occur so that we can problem solve it ahead of time. A common way that I have heard therapists respond to patients who say, “Well, I wouldn’t want to bother you by calling you. It was 11 o’clock. And if I called you for coaching, it would be a bother and I don’t want to do that,” a common way that I have heard therapists respond is to reassure their patient that it would not be a bother. This inadvertently invalidates the patient’s perception of what is probably actually true that it would be perceived by the therapist as a bother if they were called late in the evening. And it’s important to validate this if it’s true and to validate that there are potentially ways to alleviate or minimize the risk of this becoming an issue within the therapeutic relationship.

Clinical Vignette

Dr. Vaughn: So I mean, I want to come up with some way to be able to communicate that. I mean, I think that might be helpful if you were to say that wasn’t helpful and maybe then ask for it. Can we role play really quick?

Julie: Okay.

Dr. Vaughn: Okay. So like imagine that you called me on phone coaching and I answer. Hello.

Julie: Hey, Dr. Vaughn. It’s me, Julie.

Dr. Vaughn: Hey. What’s going on?

Julie: Hey, I’m not – I’m just so stressed out and I need some help.

Dr. Vaughn: Okay. I would love to help and I appreciate you calling. What do you need help with?

Julie: I don’t want to feel stressed anymore.

Dr. Vaughn: Okay. Now, let’s pause right here and let’s talk about what would you ideally, what do you need at that moment? Like ideally, if you could just program whatever you wanted in from me, what would you have me do?

Julie: Like if I want to make me feel better?

Dr. Vaughn: Yeah.

Julie: I don’t know. Tell me how to make my stress go away.

Dr. Vaughn: Don’t you feel like if I told you something that it would feel like I was oversimplifying it? Like that I was just – Well, all you have to do is, you know.

Julie: Absolutely. Oh no. Okay.

Dr. Vaughn: I mean, we don’t have to solve that problem right now. I just want to point that out. And the reason I want to point out, it’s a fear of mine, not that I wouldn’t take a phone coaching call or not that I wouldn’t mess up or whatever but I just want to point that out that I could want to as much as possible and I can tell you I really want to help but the likelihood that I’m going to be able to help, I’m just not sure because it feels kind of like a toss-up. If I could just sit beside you at that point and help you hammer out that project, you know, if I was like your assistant or something, I think that would be the most validating thing possible.

Julie: Right.

Dr. Vaughn: But in that moment, it’s not possible and I’m sure I’d probably not be the greatest at whatever it was you’re writing. What project is it that you’re doing or assignment?

Julie: So it’s kind of like a thesis. I’m just getting my Masters. So it’s just a really long paper and I’ve gotten feedback from my teachers and they basically just gave me criticisms and don’t tell me how to fix it. And so I’m just trying to figure out what I can do to make it better and it’s so overwhelming.

Dr. Vaughn: It’s kind of ironic, isn’t it? It’s sort of like what we’re talking about with your boyfriend. Does he know what he could do? Not to take it for him because, you know, I’ll just throw him under the bus all day long. But does he know that what he does doesn’t work or how he responds doesn’t work and what you need instead?

Julie: I mean, he knows it doesn’t work because I blow up at him and tell him he’s the worst person in the world. But I don’t think he knows what he could do instead which – I mean, he can’t help me on this project either.

Dr. Vaughn: Which generally just sucks. It’s like in that moment where nothing is going to work and you’re just like frustrated sometimes it feels like you just want to grab someone and just pull them right down with you, you know, like grab hold and pull down with you.

Julie: I know. I kind of want to shake him and be like you don’t understand.

Dr. Vaughn: Yeah. So if you hadn’t have – Like was it always going to happen that you would’ve called your boyfriend? Or did you consider something else before you called him?

Julie: It’s always him.

Dr. Vaughn: Always.

Julie: It is so crazy. I don’t know why but it is. I call him first every time and I’m sure he’s kind of annoyed of that too but –

Dr. Vaughn: Is that true? Has he said anything about it or –

Julie: No. But you just kind of feel it like when he answers.

Dr. Vaughn: Yeah.

Julie: Like a little, he’s exasperated or whatever.

Dr. Vaughn: Exasperated, yeah, yeah. And then after, did he find out that you self-harmed or did you not –  did you keep that to yourself?

Julie: I haven’t told him yet. I’ll see him tonight.

Dr. Vaughn: You’re smiling. What does that mean?

Julie: I just – I guess I’m a little embarrassed that I haven’t told him yet.

Dr. Vaughn: I mean, I’m sure you have your reasons.

Julie: Yeah.

Dr. Vaughn: Are you going to?

Julie: Yeah, I’ll tell him.

Therapist’s Conclusion

The therapist acknowledging their own vulnerabilities and self-disclosing in this way is essential in DBT.

It helps to even the playing field so that the therapist is not in a position of power such that it interferes with the real relationship between equals. And that’s a phrase in DBT that’s very important, is that the relationship between the therapist and the patient is a real relationship between equals.

So when the therapist admits to vulnerabilities, fallibility, this can be a level 6, the highest level of validation in DBT of radical genuineness. It also models to the patient how to continue to accept one’s self, feel good about one’s self, and at the same time, admit to not being perfect. After I introduced this idea of being fallible, I recognized by the patient’s expression and also by, sort of, empathically feeling the intensity of the discussion that there is an intensity here.

That being said, it is an exposure to discuss the relationship between the therapist and the patient. So I’m aware of that. I’m doing a bit of exposure with the emotional intensity, but then I shift it very quickly back onto less emotionally intense topics, which is why I asked, “What project is it that you’re doing?” because that is a very rational-minded question. 

It brings us back on track to continue pursuing the behavioral chain analysis. And I don’t want to stay in an emotionally intense discussion for too long because the purpose of what we’re doing is to uncover some of the variables that lead to self-harm. It is not to expose the patient to intense emotions further. She is already vulnerable and we are in stage 1.

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