Dialectical Behavior Therapy: A Brief Counseling Skill for Clinical Practice

G.C., an adolescent, presents to my office for follow-up after an emergency department visit following a suicide attempt. She is withdrawn, avoids eye contact, and barely speaks. She denies active suicidal ideation but states that self-cutting has provided some temporary relief from ongoing stressors. G.C. is unable to identify any other coping skills. In addition to starting a selective serotonin reuptake inhibitor, I recommend that G.C. begin dialectical behavior therapy, although it could take weeks for her to establish care with a therapist in the area.

J.S., a 49-year-old man, comes to my office with low energy, hopelessness, and intense mood swings. He states that he recently separated from his wife because of anger, financial strain, and infidelity issues. When asked about his anger, he describes intense rages. He reports multiple job changes, frequent interpersonal conflict, and debt from gambling; he states that he uses alcohol as a coping strategy for his stress. J.S. seems particularly upset when I recommend that he schedule an appointment with the clinic’s behavioral health consultant.

Both patients present with different needs that could benefit from ongoing therapy incorporating skills that facilitate emotional regulation. What guidance could I incorporate into my visits to provide interim support? Could I responsibly conduct behavioral interventions for my patients?

Patients experiencing mental health disorders encounter several barriers to accessing appropriate and timely treatment. These barriers may be systemic, such as financial strain, lack of insurance coverage, or limited access to specialty clinicians. Attitudinal barriers, including real or perceived stigma, may also present challenges to patients.¹ For example, the estimated prevalence of depression is nearly 10% of US adults, but less than one-half of these patients receive treatment from a health care professional.² Family physicians can play a central role in meeting these challenges.

A 2022 study found that primary care physicians delivering mental health interventions during standard appointments was associated with improved patient engagement, satisfaction, and trust.³ Identifying strategies to deliver pragmatic behavioral health support in the primary care setting can offset some of the many barriers to mental health care. One skill set that physicians can implement in primary care is dialectical behavior therapy.

Dialectical behavior therapy is a robustly researched treatment protocol originally developed to apply standardized behavioral treatment for chronic suicidality.⁴ Its effectiveness in addressing emotional dysregulation has been demonstrated in the treatment of several mental health diagnoses in adults, including borderline personality disorder and posttraumatic stress disorder and also self-harm and suicidal ideation in adolescents.^5–7

Studies have shown that health care professionals not experienced in a mental health field can effectively facilitate dialectical behavior therapy skills sessions following minimal training and that a single-session therapy may provide significant short-term improvements in suicidal outpatients who are not participating in any other mental health treatment.^8,9 Although continued research is necessary, preliminary evidence suggests that stand-alone dialectical behavior therapy skills training is acceptable for a range of populations and concerns.¹⁰

Learning and then teaching dialectical behavior therapy skills can be challenging when treating high-risk patients with clinically complex needs but can be an effective measure when treatment may be limited based on location, lengthy wait times, or availability of specialist mental health professionals. These interactions can take as little as 5 minutes, depending on patient understanding, symptoms, and presenting challenges. Specific time frames for follow-up vary; for example, patients experiencing suicidal ideation require more frequent (usually weekly) visits, depending on the acuity and severity of their symptoms.¹¹ Implementation of dialectical behavior therapy skills may serve as a temporary strategy, providing support and a bridge to specialty behavioral health care. For patients with minor symptoms, teaching mindfulness and distress tolerance can model useful techniques for managing temporary stressors.