Otherwise, there is very little the therapist can do to be of assistance but call 911. Orienting the client to call prior to escalation of suicidal impulses and nonsuicidal self-injurious acts is an important step in shaping future skillful, effective behaviors. Baddeley (2007) has stated that when emotional arousal becomes too high, no new learning can occur. Thus, as emotional arousal increases, the ability to take in, profit from, and effectively use feedback decreases. When orienting clients to DBT, it is important to also explain that most people are unable to effectively take in and use feedback when emotional levels are high. This communicates to the client that

they are not being punished for escalation but rather are encouraged to BMS-387032 nmr call when coaching is likely to be most successful. Below is a vignette that demonstrates how clinicians can orient clients to this first function of DBT phone coaching. THERAPIST: What I would like to do is describe for you the first function or goal of after hours telephone coaching. E7080 Related to the first function in phone coaching is the 24-hour rule. While instructing the client to call prior to the crisis is designed to reinforce skillful behavior, the 24-hour rule is designed to extinguish unskillful behavior.

During phone coaching orientation, clients are informed that they are explicitly forbidden to call their therapists after a nonsuicidal self-injurious act until a 24-hour time period has elapsed. Clients should be informed that the goal of phone coaching is to assist clients in managing emotions without acting impulsively. Given that nonsuicidal self-injury serves to reduce emotional pain, calling after a nonsuicidal self-injurious event is unnecessary given that the client has already reduced their emotional Dolichyl-phosphate-mannose-protein mannosyltransferase response (Linehan, 1993). While not the desired outcome, the client has already solved the problem, albeit unskillfully, thus the therapist must be mindful not to reinforce the unskillful behavior. While these clients may obtain relief from extreme psychological pain, some will experience guilt and shame after a nonsuicidal self-injurious

act. These individuals may call after a nonsuicidal self-injurious event to seek reassurance and/or absolution from their therapist. By talking to a client after a nonsuicidal self-injurious behavior has occurred, here again, the therapist may inadvertently reinforce the very behavior they are seeking to eliminate. On occasion a client who has already engaged in a nonsuicidal self-injurious behavior may call. Concerns often arise for clinicians about what to do if a client has violated the 24-hour rule. While data are limited in this area, the one study conducted on frequency and topology of DBT phone coaching reported no occurrences in which the 24-hour rule was violated, suggesting that this behavior is rare (Limbrunner et al., 2011).