Between-Session Contact and Therapist Burnout in DBT
Ms D is a 28-year-old woman with borderline personality disorder, recurrent self-harm, and two brief admissions after overdoses. She has been in dialectical behavior therapy for 7 weeks. At 02:10 she sends her therapist a photograph of a superficial forearm cut and texts, “I need you now; everyone leaves me.” Her therapist is on annual leave until Monday; a covering clinician is available by phone. The therapy contract says between-session contact is for emergencies only and does not include extra sessions. Ms D has previously sent late-night messages and once attended the clinic without an appointment. She denies suicidal intent but says she may cut “deeper” if no one responds. The covering clinician must decide what to do overnight and how to hand this back to the therapist. The therapist feels both worried and irritated and is considering ending therapy because “the boundaries are impossible.”
1. What should the covering clinician do overnight?
Read the worked answer
The covering clinician should first assess immediate risk, not simply enforce the contract. Ask about suicidal intent, plan, access to means, the wound, any overdose, and whether she is alone. If there is imminent danger, arrange emergency assessment or emergency services. If not, respond briefly and calmly: acknowledge the distress, state that the photo has been seen, confirm that she is not alone if that is true, and reinforce her safety plan and skills.
The clinician should not offer a lengthy late-night therapy session or promise an extra appointment. The contract should be restated clearly but without punishment: between-session contact is for emergencies, and the therapist returns Monday. A short follow-up contact or check-in the next day may be appropriate. Document the risk assessment, advice given, and any emergency plan. The handover to the therapist should be factual and include the clinician’s concern about the escalation.
2. How should the therapist address the 2am text and their own irritation in the next session?
Read the worked answer
The therapist should use a dialectical stance: validate that the text came from intense abandonment fear while also setting the limit. Start with the chain of events, including what happened before the urge to cut and what she hoped the therapist would do. Then review the contract and the effect of late-night contact on therapy.
The therapist’s irritation is useful information, not a reason to terminate. It should be taken to supervision or the consultation team, where it can be examined without acting it out. In session, the therapist can say that the contact was answered because safety mattered, but that repeated 2am texts cannot become the main treatment. Problem-solve alternative actions: skills use, calling a crisis line, contacting the covering clinician, or waiting until the next session.
The aim is not to shame her for attachment needs but to make the therapy predictable enough to continue.
3. What are the risks of continuing versus ending therapy, and what safeguards are needed?
Read the worked answer
Abruptly ending therapy risks reinforcing her belief that everyone leaves, increasing self-harm or suicide risk, and confirming that distress destroys relationships. Continuing without limits risks reinforcing escalating contact, exhausting the therapist, and making the therapy inconsistent.
The safer course is usually to continue with a tightened frame, not to terminate in reaction to irritation. Safeguards include consultation or team supervision, a written crisis and contact plan, clear arrangements for leave and cover, and regular review of therapy-interfering behavior. If the therapist cannot maintain the frame, a planned transfer with an overlap period is better than an abrupt ending. If the therapist feels unsafe or unable to provide competent care, this should be addressed through supervision and a structured handover. Document the plan and the reasons.