This feature by Dr. Alexander Chapman is the second part of a two-part series about phone coaching in Dialectical Behavior Therapy. In part 1, Dr. Chapman explained how phone coaching works and cleared up the most common concerns therapists may have about phone coaching (read here for part 1). Today’s focus is on how to manage the situations when phone coaching does not go as smoothly and how DBT offers a proactive approach.
In part 1 of this blog on Phone Coaching in DBT, I noted that, at least 90% of the time, phone coaching calls go quite well. I and my fellow clinicians are usually able to keep the calls brief, focus on skills the client can use to get through difficult situations, and manage risk effectively (when applicable).
Phone coaching does not always go smoothly, though. Clients will sometimes call completely emotionally distraught to the point of incoherence. It is sometimes hard to help clients focus on skills they can use, and at times, they might even refuse to use or talk about skills. They sometimes misconstrue the purpose of the calls and vent at length or even threaten self-harm or suicide. Despite your best efforts, clients might call more frequently than you want, stay on the phone longer than is desirable, fail to return your phone calls, leave you feeling unsettled and worried about their suicide risk, and the list goes on. Indeed, if you do DBT for long enough, you will inevitably encounter at least a couple of clients who will make you wish that you never signed on to do phone coaching in the first place!
Moreover, therapists often engage in all sorts of therapy interfering behavior during phone coaching, such as not returning clients’ calls, staying on the phone too long, missing important points to cover in a risk assessment, reinforcing dysfunctional behavior (e.g., staying on the phone for longer when the client is critical or refuses to try skills), and failing to notice the early signs of burnout until it’s too late. It probably shouldn’t come as a surprise that there are sometimes bumps in the road when you use phone coaching with clients who have complex problems.
Fortunately, in DBT, there are built-in ways to deal with problems that emerge during phone coaching.
One invaluable resource for clinicians is the therapist consultation team, a team of DBT therapists who meet weekly to help each other maintain high motivation and skill in the treatment of complex clients. The consultation team is there to help clinicians when things go astray, such as when phone coaching starts to go off the rails. The team can provide validation and support for the overwhelmed clinician, help them figure out how to prevent burnout, and provide strategies to help the phone coaching get back on track.
During our team meetings, when therapists have problems with phone coaching, they are encouraged to bring these issues up before they worsen and get help, support, and advice from team members. When they are not sure how to deal with difficult phone calls or ask their clients to call less often, we often practice effective strategies for these situations in role plays during our team meetings. At times, other clinicians have offered to help stressed out therapists by taking calls for a period (e.g., the next couple of weeks). I would highly recommend that anyone engaging in phone coaching with complex clients have a network or team of like-minded professionals that they can turn to for help and support.
DBT also takes a very active and proactive approach to the management of therapy-interfering behavior, such as the aforementioned problems with phone coaching. When therapy-interfering behavior occurs, the therapist usually brings it up, tries to understand why it is happening, and problem solves collaboratively with the client.
One way to get into the routine of proactively addressing issues with phone coaching is to always debrief calls during the next therapy session. This can be as simple as saying something like, “We spoke on Tuesday evening, and I wanted to check how that call went for you and talk about my thoughts about it….” Getting into the routine of debriefing calls gives therapists and clients the regular opportunity to check in, make sure phone coaching is effective, and address any potentially therapy interfering behaviors on the part of the therapist or the client. When problems emerge, we address them head on, for example: “I’ve noticed that our calls are getting a little long, such as the 30-minute call we had last week. I’d feel relieved and probably be more helpful to you if we could get them back to 5-10 minutes. I’ll do my best to keep better track of time and let you know how much time I have. I’m wondering if you have any other ideas about what we can do to keep the calls short but helpful.”
In conclusion, in my experience and that of many other clinicians, phone coaching can be an effective, helpful, brief intervention. Effective phone coaching can help clients transfer what they’re learning in therapy to their everyday lives. This is critically important, as clients probably spend less than 2% of their waking hours in therapy (likely considerably less than most of us spend in the bathroom). It’s hard to expect that 2% to be so miraculously helpful that the remaining 98% is somehow transformed.
Also, many of the clients we work with have a hard time effectively asking for help. They either don’t ask for help and then resent the people who aren’t helping them, ask for help in an aggressive way that burns out or pushes people away, don’t ask for the type of help they really need, and so on. Phone coaching, therefore, is another way to practice effectively asking for help, and therapists are in an excellent position to provide feedback and coaching on help-seeing skills. In addition, phone coaching is usually very brief, to the point, and focused on the client’s use of skills. Therapists struggling with phone coaching should consider seeking help from colleagues, regularly debriefing calls with clients, and directly, collaboratively, and compassionately addressing problems when they arise.
Read here for more information about staying balanced when treating patients at risk for suicide.
Alexander L. Chapman, PhD, R.Psych, Professor and Clinical Science Area Coordinator in the Department of Psychology at Simon Fraser University (SFU), is a Registered Psychologist and the President of the DBT Centre of Vancouver. Dr. Chapman received his B.A. (1996) from the University of British Columbia and his M.S. (2000) and Ph.D. (2003) in clinical psychology from Idaho State University, following an internship at Duke University Medical Center. He completed a two-year post-doctoral fellowship with Dr. Marsha Linehan (founder of Dialectical Behaviour Therapy) at the University of Washington. Read his full biography here.