Dialectical Behavior Therapy (DBT) has changed the way many therapists assist and address suicidal and self-harming behaviors and intense emotions. One of the key elements that sets DBT apart is its emphasis on phone coaching, as well as the 24-hour rule. In this two-part blog post, we’ll explore the significance of phone coaching and the 24-hour rule in DBT and why they are invaluable tools in balancing acceptance and change when it comes to self-harm.

Part 2: The 24 Hour Rule

What is the 24 Hour Rule in relation to phone coaching? The 24-hour rule in phone coaching is that a therapist cannot engage in unscheduled contact with the client if self-harm behavior has occurred. This means that if you were a current DBT client who engaged in self-harm behaviors and then chose to use phone coaching, you would essentially be told that the therapist could no longer continue the call and to contact either 988 or a local crisis line for support. If the injury were serious, you would be redirected to a hospital.

Why on Earth would we turn individuals away when they are clearly struggling and intentionally injured themselves?

While I’m sure that sounds aversive, that’s somewhat the point. We want to express concern and validation of feelings AND also disengage so as not to become a negative reinforcer (relief). A reinforcer is anything that increases the likelihood of a behavior to reoccur. If a therapist were to continue to engage in a conversation with a client after they have self-harmed, there is the risk of reinforcing the behavior. It is difficult to change when a behavior is reinforced, especially if there is not a more effective replacement behavior for it. If the therapist were to continue a conversation with the client after self-harming, the behavior could even possibly increase. It could even become more reinforced if the client wanted to engage in more contact with a therapist. Additionally, if the therapist and client continued the phone call after a self-harm incident they missed the window of opportunity for effective skills to replace the self-harm behavior itself.

Therapists would then discuss the self-harm behavior in the next session with the client. If the session is far off, the clinician may decide to reach out to the client AFTER the 24-hour mark to discuss this (this may be clinician-dependent). The clinician would check to see if the client had engaged in any further self-harm behaviors, so as to not reinforce that either.

When engaging in DBT, we have clients agree to work on decreasing self-harm behaviors. The reason being is because self-harm behaviors are destructive. While self-harm behaviors come in various forms and intensities, they run the risk of permanent physical damage and sometimes even death. Due to the release of chemicals the brain releases when we are hurt, it makes sense that some people engage in self-harm but it is not an effective way of coping or solving problems. If self-harm behaviors continue to occur, they are consistently targeted by the therapist as a focus of therapy to decrease change. The 24 hour rule is working to assist with changing self-harm behaviors outside of session, just as much as we work on decreasing it in session. We hope that if a client has experienced the 24 hour rule, it will create a pause for the future to consider how their therapist may respond if they act on their crisis behavior.

Why is it important to use phone coaching before self-harm behaviors?

Choosing phone coaching lets your brain begin to learn that there are alternative routes to regulation that do not require you to engage in self-damaging behaviors. DBT skills work with your thoughts as well as your body to increase your self-awareness and self-control. If you choose to utilize phone coaching prior to self-harm, you are actively learning to replace ineffective coping strategies with more effective ones. While I understand it can be difficult for some to ask for help, or they are worried about being a bother to their therapists, we are happy that you have chosen to try a more effective route! In most experiences with my clients, they have felt more empowered learning new skills to replace self-harm and that they feel more in control of their behaviors.

DBT takes self-damaging and self-destructive behaviors seriously, as we are focused on creating a life worth living.

The 24 Hour Rule works to create change as well as reinforce that:

• change is possible
• your therapist is rooting for you
• your therapist has skills to provide an alternative solution
• you have support

I can personally say, I understand that any of the 24 Hour Rule would be difficult to hear as a client, and at the same time, it is coming from a place of caring and hope for change.

Read Part 1 here

About the Author

Alyssa Eichhorn (she/her), M.A., LPCC-S, is a Licensed Professional Clinical Counselor that specializes in dialectical behavior therapy. Alyssa works with all ages in a radically genuine and nonjudgmental setting to help individuals identify more effective and balanced behaviors to create a life worth living. Alyssa provides a directive and warm approach with her clients to facilitate solutions, growth, and change where they want it. Click here to learn more about Alyssa and her therapeutic approach.

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder.

Linehan, M. M. (2015). DBT® skills training manual (2nd ed.). Guilford Press.