This feature by Dr. Alexander Chapman is the first part in a two-part series about phone coaching in Dialectical Behavior Therapy. In part 1, Dr. Chapman begins by explaining how phone coaching works as well as clearing up the most common concerns therapists may have about phone coaching.
In DBT, phone coaching involves the primary individual therapist being available to clients by phone between therapy sessions.
The primary aim of phone coaching is to generalize the skills clients are learning in therapy to their everyday lives. As such, calls primarily focus on how the client can figure out what skills to use and how to use them to navigate difficult everyday situations. Sometimes, calls also focus on how to get through a crisis (suicidal or otherwise).
Clients can call, for example, when they are overwhelmed, at their wit’s end and at risk of harming themselves. When I tell my clients about phone coaching, however, I usually encourage them to get into the habit of calling me well before a suicidal crisis emerges. That way, we can (a) focus on how to use skills to avert rather than simply how to manage a crisis, and (b) avoid getting into a pattern of repeated crisis calls.
A third reason for clients to call is if there has been an issue in the therapy session or relationship that needs to be discussed sooner rather than later. In those cases, a brief heart-to-heart phone call, focused on skills the client can use to manage emotions about therapy, can be very helpful. The bottom line with phone coaching is that, no matter the purpose of the call, the focus should almost always be on how the client can effectively use skills.
I’ve been giving workshops on DBT for over 15 years, and I still find that the idea of phone coaching strikes fear into the hearts of some clinicians. Knowing that people with borderline personality disorder (BPD) often struggle with emotional instability, suicidality, and relationship problems (sometimes with their therapists!), clinicians probably envision clients calling at all hours, yelling at them, staying on the phone for hours, and interrupting their leisure time with suicidal threats and crises. Some clinicians may also have concerns about fostering dependency or blurring therapy relationship boundaries such that the client starts to see the therapist as a friend they can just call up for support. I believe phone coaching can be a valuable aspect of therapy, and that many of these concerns are exceedingly rare, although not completely unheard of.
I would say 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). I often feel a sense of satisfaction after getting off the phone with a client, feeling like I’ve really helped someone through a tough situation. My clients often have expressed a lot of gratitude for our calls as well.
I also find the time-limited, directive nature of phone coaching calls to be quite appealing. You have a short time (usually between 5 and 15 minutes) to be very helpful. It’s a brief, circumscribed intervention (phone coaching is not therapy on the phone, nor does it usually delve into long-term goals or problems), and then you can move on to other things, like that fourth glass of wine (kidding, of course!). A really effective phone coaching call reminds me of when airlines used to serve decent meals, before everything changed and flying became much, much worse (except for improved smoking laws). The meals were neat, tidily arranged in little containers, and satisfying.
The research also supports the idea that phone coaching is generally brief, effective, and should be possible to incorporate into even very busy clinicians’ lives. One study of complex clients with eating disorders receiving 13 weeks of DBT, for example, found that fewer than half of clients made use of phone coaching. The average duration of calls was around 6 minutes and the average number of calls throughout the 13 weeks was fewer than 5 (Limbrunner et al., 2011). Another study of adults attending 6 months of DBT (Oliveira & Rizvi, 2018) found that clinicians received an average of 2.55 calls per client per month. Although the highest utilizers of phone coaching made 79-143 calls in the 6-month period, this group only comprised 11% of the clients in the study.
Watch for part 2 of this blog coming soon, in which Dr. Chapman will take a closer look at how to manage the situations when phone coaching does not go as smoothly and how DBT offers a proactive approach.
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.