Dialectical Behavioral Therapy

What Is Dialectical Behavior Therapy?

Dialectical behavior therapy (DBT), also called dialectical behavioral therapy, is a structured talk therapy that combines acceptance with practical behavior change. It teaches skills for being present, tolerating distress, managing emotions and handling relationships.^[1]

In addiction care, DBT can help you examine what happens before and after substance use and practice different responses to cravings or difficult situations. Its substance-use adaptation also addresses staying engaged in treatment and getting back on track after a return to use.^[2]

How Acceptance and Change Work Together

Acceptance means acknowledging what is happening, not approving of harmful behavior. Dorset HealthCare explains the central DBT balance this way: therapists accept people as they are while recognizing that change is needed to reach their goals. Mindfulness and distress tolerance emphasize acceptance, while emotion regulation and interpersonal effectiveness emphasize change.^[1]

For an illustrative example, imagine feeling rejected after an argument and wanting to drink. Acceptance might sound like, “I am hurt, and I want relief.” Change adds, “Drinking would create problems I do not want. I need another response.” Neither statement requires pretending that the argument was harmless or that the urge is easy to manage.

The same balance applies after harmful behavior. Dimeff and Linehan describe reviewing the sequence that led to substance use, learning from it and repairing harm to oneself and others. A nonjudgmental response does not erase responsibility. It makes responsibility something to act on rather than a reason to give up.^[2]

When DBT May Fit Your Needs

DBT is worth discussing when intense emotions, impulsive actions or repeated difficulty staying in treatment are closely connected with substance use. Dimeff and Linehan also caution that comprehensive DBT may be more treatment than some people need. Fit depends on the problems being treated, previous treatment experiences and the role emotions play in continued use.^[2]

Difficulty managing strong emotions is often called emotion dysregulation. DBT was developed for people with borderline personality disorder (BPD), and the National Institute of Mental Health describes its focus on managing intense emotions, reducing self-destructive behavior and improving relationships.^[4]

Recognizing these difficulties does not establish a diagnosis. NIMH describes BPD assessment as a thorough discussion of symptoms and personal and family history, with a medical exam sometimes helping rule out other causes. Overlapping symptoms can make assessment especially important when several concerns occur together.^[4]

What to Bring to an Assessment

Ask the clinician to connect your treatment recommendation to your actual pattern of substance use, mental health concerns and daily responsibilities. The National Institute on Drug Abuse (NIDA) recommends tailoring addiction care to the person’s drug use and medical, mental and social needs. DBT may be one part of that broader addiction treatment plan.^[5]

Bring brief notes rather than trying to remember everything during the appointment:

• What you use, approximately how much and how often, and what happens when you reduce or stop.
• A recent difficult moment: what happened, what you felt, what you did and what followed.
• Current medications, other treatment and previous approaches that helped or were hard to continue.
• Concerns about trauma, self-harm, mood, relationships, sleep, work or housing.
• Your priorities, such as reducing substance use, staying in care or handling conflict without acting impulsively.

A useful question is, “Which of my difficulties would DBT address, and what else needs treatment?” If substance use and another mental health condition are both present, ask how the providers will coordinate care for co-occurring conditions, rather than assuming one therapy will cover every need.

The Four DBT Skill Areas

The four skill areas provide different responses to a difficult moment: notice what is happening, get through distress, work with the emotion and communicate effectively. These are the four broad categories described by Dorset HealthCare.^[1] The examples are illustrations, not patient reports or a substitute for an individualized plan.

Mindfulness Helps You Notice Before Reacting

Mindfulness means paying attention to the present moment. In DBT, that includes noticing your emotional state instead of immediately acting on it.^[1]

Imagine a friend cancels plans and you immediately think, “Nobody wants me around.” Practice could mean naming three separate things: “My chest feels tight. I am having a thought about rejection. I want to use.” For this exercise, the task is to observe those experiences, not settle whether the thought is true or force the feeling away.

Distress Tolerance Helps You Get Through the Moment

Distress tolerance focuses on tolerating emotional pain in a difficult situation when changing it immediately is not the task.^[1]

In the canceled-plans example, an illustrative response is to put down the phone, postpone an angry reply and choose a safe activity from a plan made with your therapist. The immediate goal is not to enjoy being disappointed. It is to avoid adding substance use or another regretted action to an already painful evening.

Emotion Regulation Helps You Work With the Feeling

Emotion regulation involves becoming more aware of emotions and learning ways to change emotions you want to change. Unlike simply enduring a difficult moment, this work asks what can be understood or changed about the emotional response.^[1]

Later that evening, practice might involve separating the event from the interpretation: “My friend canceled because of work” is different from “I do not matter.” You could discuss with your therapist whether loneliness, anger or fear is the main feeling, then choose a response that fits that feeling and the available facts.

The work need not focus only on unpleasant emotions. In a 2026 review, Eric Garland highlights diminished positive feelings and reduced responsiveness to everyday rewards in addiction. That supports discussing enjoyment and meaningful activities in recovery, but the review is not a trial showing that DBT itself restores those responses.^[6]

Interpersonal Effectiveness Helps You Ask, Refuse and Set Boundaries

Interpersonal effectiveness addresses asking for what you need and saying no while considering your relationships and self-respect.^[1]

An illustrative message might be, “I was disappointed when our plans changed. Could we choose another day?” A substance-related boundary might be, “I would like to see you, but I am not going to the bar. Could we meet for lunch?” Practice means making the request clearly, not controlling whether the other person agrees.

How Is DBT Adapted for Addiction Treatment?

DBT adapted for substance use disorders, often called DBT-SUD, keeps the acceptance-and-change approach while addressing substance use, cravings, high-risk situations and treatment engagement. It adds specific strategies for pursuing abstinence and reducing the duration and harmful consequences of a return to use.^[2]

Dialectical Abstinence

Dialectical abstinence means committing to abstinence while preparing a constructive response if use occurs. The two parts work together: the goal remains change, and a setback becomes a problem to address rather than evidence that recovery is impossible. The substances targeted are determined through assessment, not a blanket rule against prescribed medication.^[2]

Coping Ahead and Staying Alert to Risk

Coping ahead means anticipating a difficult situation and preparing a response before it happens. Dimeff and Linehan also describe “clear mind”: maintaining awareness of relapse risks even when abstinence is going well, rather than assuming those risks have disappeared.^[2]

For an illustrative plan before a family gathering, you might rehearse how to decline a drink, arrange your own transportation and decide whom to contact if an urge becomes difficult to manage. Rehearse the awkward part too: “What will I say if someone keeps asking?” The DBT addiction skills guide develops these substance-use concepts further.

Returning to Care After Use

A return to use calls for prompt contact and a review of what needs to change. NIDA describes relapse as a reason to resume, modify or try treatment, not proof that treatment has failed. It also warns that returning to a previously used amount can cause overdose after the body has lost tolerance.^[5]

In DBT-SUD, the response includes examining what led to use, addressing its consequences and renewing the plan. Dimeff and Linehan explicitly reject making continued treatment or prescribed anti-craving medication contingent on abstinence. Their model includes active efforts to reconnect with people who miss sessions.^[2]

Before a setback occurs, ask, “Who should I contact if I use, what medical risks should we plan for, and how will we restart or adjust care?” A useful plan makes the return route clear without treating use as inevitable.

What a Full Course of DBT Involves

Comprehensive DBT combines four treatment components. The skills group teaches tools, individual therapy applies them to your life, coaching supports their use between appointments, and the clinician consultation team supports the people delivering care.^[1]

• Individual therapy: Standard DBT includes weekly one-to-one sessions alongside the group. The therapist helps apply skills to specific problems and strengthens motivation to change.^[1]
• Skills training: A DBT skills group runs more like a class than an unstructured discussion. A facilitator teaches skills and assigns practice for everyday life.^[1]
• Between-session coaching: Coaching helps you apply a skill when a difficult situation occurs, rather than only discussing it afterward. Ask about the actual hours, response process and boundaries.^[1]
• Clinician consultation team: Therapists and group leaders meet for support and consultation about delivering treatment. This is a component of the program, not another group that the patient must attend.^[1]

Do not assume coaching means unlimited or round-the-clock access. NHS Gloucestershire explains that therapists offering between-session calls set ground rules about when to call and what help they can provide. Ask separately what to do when urgent help is needed outside those arrangements.^[7]

Practice and Session Priorities

DBT is not just learning the names of skills. Dorset HealthCare describes homework that brings skills into daily life. Dimeff and Linehan describe prioritizing life-threatening behavior, then behavior that disrupts treatment, followed by problems affecting quality of life.^[1][2]

Ask your therapist what to record between sessions. You can use our DBT diary card guide to prepare that conversation. For example, discuss tracking urges, substance use, difficult emotions, skills attempted and what happened afterward. Bring unsuccessful attempts too, so the next session can address where the plan broke down.

Duration and Less Comprehensive Services

Ask about the actual program length rather than assuming every DBT service follows one schedule. For example, Dorset HealthCare describes a 25-week skills curriculum, often repeated to make a one-year program, with individual therapy running alongside it. That is a service example, not a universal duration for U.S. care.^[1]

Skills-only treatment is not the same package as comprehensive DBT. It may teach DBT skills without providing all four treatment components. Research on standalone skills training for substance use has used inconsistent adaptations, so its findings cannot automatically be treated as evidence for every service using the DBT name.^[1][3]

If a provider says “DBT-informed,” ask which DBT methods they use and which components are absent. Do not judge the service by the label alone. Ask why that level of care fits your needs and who will address concerns outside its scope.

What Research Shows About DBT for Addiction

DBT-based treatments have encouraging findings for substance use, but the evidence does not establish one universally effective DBT program. A 2022 review of nine studies found standalone skills training generally feasible and acceptable, with preliminary support for reduced substance use and better emotion regulation. Study quality ranged from weak to strong.^[3]

A broader 2026 review included 47 studies of acceptance and commitment therapy, mindfulness-based programs and DBT skills training in adults with substance use disorders. Across these approaches, benefits for substance-use outcomes were small to moderate, with generally low-to-moderate certainty. Those combined findings are not a DBT-specific effect estimate.^[8]

Substance Use With BPD or Trauma

Early comprehensive-DBT research included people with both substance use disorders and BPD. Dimeff and Linehan summarize a 1999 trial comparing 12 women assigned to DBT with 16 assigned to community treatment as usual^[2]. All had BPD and dependence on multiple substances.^[2] Compared with community treatment as usual, DBT produced greater reductions in drug use and higher treatment retention, 64% versus 27%.^[2]

A second trial, published in 2002, involved 23 people with opioid dependence and BPD.^[2] Both groups received opioid medication. DBT better maintained reductions in opioid use during the final four treatment months, but the comparison therapy, validation therapy plus Twelve Steps, retained more participants: 100% versus 64% with DBT.^[2]

These findings support considering DBT, not declaring it best for everyone with both conditions. A 2011 review of six trials covering DBT and two other therapies found treatment gains over time but insufficient evidence to recommend one approach over another.^[9]

Trauma adds a separate treatment question. A 2026 review identified emotion dysregulation as an important factor in co-occurring post-traumatic stress disorder (PTSD) and substance use disorder. It supports assessing emotion regulation in this overlap, but it does not establish that any standard DBT program treats both disorders fully.^[10]

A 2021 analysis of 93 women with BPD and childhood-abuse-related PTSD compared DBT adapted for PTSD with cognitive processing therapy.^[11] Both improved PTSD and BPD symptoms. DBT-PTSD produced greater improvements in PTSD, BPD and dissociation, but the groups did not differ significantly in depression or global functioning. This was not a substance-use treatment trial.^[11]

Digital DBT Skills

A 2024 trial randomized 72 treatment-seeking adults with substance use disorders to immediate access to a self-guided DBT website or access delayed by four weeks. At four weeks, immediate access did not produce greater improvement in the primary outcome, substance dependence. Depression and anxiety did improve more in the immediate-access group.^[12]

At follow-up, the immediate-access group had greater reductions in alcohol and other substance consumption, while both groups improved in dependence. All outcomes were self-reported. Engagement was uneven: 68 participants started, and 34 were still active four weeks later.^[12] The study supports further use and testing of digital skills, not equivalence with comprehensive DBT.^[12]

A 2025 exploratory analysis of those same 72 participants linked pretreatment depression and anxiety symptoms with inactivity at four weeks.^[13] This was not an independent replication. Its practical message is to discuss what support you may need to keep using a self-guided program, rather than assuming access alone will be enough.^[13]

DBT for Cannabis Addiction

A 2021 pilot trial assigned 61 people with cannabis use disorder to DBT or psychoeducation.^[14] Abstinence, assessed using urine tests, was higher with DBT: 46% versus 16% after treatment and 40% versus 9.5% at two-month follow-up.^[14] Among participants who returned to use, those receiving DBT had fewer consumption days.^[14]

Overall craving did not differ significantly between groups. DBT improved the questionnaire’s emotionality subscale, which is narrower than showing an overall craving benefit. The study offers promising short-term abstinence findings, not proof that DBT reliably eliminates cannabis cravings.^[14]

Alcohol Use and Suicidal Thoughts

A 2018 pilot trial included 59 people with suicidal thoughts and heavy episodic drinking.^[15] Immediate internet-delivered DBT skills produced faster reductions in alcohol consumption than an eight-week waitlist. Across the four-month study, participants improved on alcohol use, suicidal thoughts and emotion dysregulation, but technological barriers made engagement and retention difficult.^[15]

A 2021 review of six trials involving 400 participants examined several therapies for alcohol problems and suicidal behavior.^[16] DBT findings included abstinence and consumption benefits, but one study showed only a trend toward fewer suicide attempts compared with usual care. The reviewers found no strong evidence for an intervention that reduces both alcohol consumption and suicidal behavior in adults.^[16]

DBT Skills Alongside Methadone Treatment

A 2019 field test enrolled seven people receiving methadone in a smoking-cessation and opioid-relapse-prevention program. They received 12 weekly DBT-based skills groups and eight weeks of nicotine patches. Cigarette consumption fell, six people made a quit attempt, and one had seven-day smoking abstinence at week 12.^[17]

No participants used illicit drugs during the field test, but there was no comparison group to establish relapse-prevention efficacy. Emotion regulation, distress tolerance and mindfulness measures did not improve significantly. With seven participants and nicotine patches provided alongside the groups, the results cannot isolate a DBT effect.^[17]

A trial published in 2024 studied 50 men receiving methadone in Kashan, Iran, in 2018.^[18] Adding twelve 90-minute DBT skills sessions improved cognitive and executive-function measures compared with methadone alone, including attention, planning and decision-making. These were thinking-task outcomes, not demonstrated improvements in abstinence or relapse.^[18]

Emotional Improvement Is Not the Same as Substance-Use Improvement

A 2026 naturalistic study reported improvements in emotion regulation and impulsivity among 35 participants in mixed-diagnosis DBT groups held from 2021 through 2023.^[19] Most participants had a substance use disorder, and the dropout rate was 21%.^[19] These are encouraging emotional-functioning results, not a demonstrated substance-use remission rate.^[19]

A 2023 French study interviewed 22 of 31 participants one year after a skills program for people with BPD, bipolar disorder or attention-deficit/hyperactivity disorder.^[20] Most respondents reported continuing to use the skills and experiencing improvements. This supports studying lasting benefits, but the self-reported findings from an uncontrolled, mixed-diagnosis group are not a general addiction-treatment success rate.^[20]

Adapted services have also been studied in inpatient settings. A 2022 South African review of 349 records from 2014–2019 found that about two-thirds completed a modified inpatient skills program.^[21] It described a diagnostically mixed population, not a controlled test of addiction treatment effectiveness.^[21]

For your own care, ask to track both the problems that brought you to treatment and the skills you are building. Feeling less overwhelmed matters, but so do changes in substance use, safety, attendance, relationships and daily functioning. Ask, “What would count as meaningful progress for me, and when will we review it?”

How DBT Compares With CBT

DBT is a form of cognitive behavioral treatment, not the opposite of CBT. Both address thinking, feelings and behavior. DBT gives explicit emphasis to acceptance alongside change and organizes comprehensive treatment around its skills curriculum and four treatment components.^[1][7]

The shortcut “CBT treats thoughts, DBT treats feelings” leaves out too much. NIDA describes CBT for addiction as helping people recognize, avoid and cope with situations in which they are likely to use drugs. That is practical behavioral work, not just correcting inaccurate thoughts.^[5]

For an illustrative comparison, consider wanting to drink after criticism at work. A CBT discussion could examine the interpretation of the criticism and rehearse another response. A DBT discussion could also examine that sequence, while emphasizing acceptance of the painful feeling and practicing a distress-tolerance or communication skill. The examples overlap because the approaches are related.

A more useful choice question is, “Which treatment addresses my main problems, and what structure will help me practice?” Ask why a clinician recommends a particular approach, what alternatives fit and how it will work alongside other care. Our DBT versus CBT guide offers a further comparison.

How to Find and Compare DBT Programs

Start with a conversation about your needs, then compare what programs actually provide. NIMH recommends talking with a primary care provider about mental health concerns and obtaining a referral to a qualified mental health professional.^[4] You can also ask your current therapist or addiction treatment team for help identifying an appropriate service.

In the United States, if you are facing a self-harm or suicidal crisis, call or text 988 for immediate support.^[4]

When searching locally or online, use the treatment structure as your comparison point. A program’s DBT label does not answer whether it includes individual sessions, a skills group, coaching and clinician consultation. Ask for an explanation of the service, its intended patients and the assessment required before enrollment.

Questions About Training and Treatment Fit

Ask who will deliver your care and why the proposed DBT service fits your needs.

• Training: “What professional license do the treating clinicians hold, and what DBT training and supervised experience do they have?”
• Consultation: “Do the clinicians participate in a DBT consultation team? How does that support my treatment?”
• Addiction experience: “Do you treat the substances I use and the other concerns I have? Do you use DBT-SUD strategies?”
• Recommendation: “Why do you recommend comprehensive DBT, skills-only treatment or DBT-informed therapy for me?”
• Other needs: “If I need trauma treatment, medication management or a different level of support, who will provide it and coordinate the plan?”

Questions About Appointments and Access

Compare the schedule and access arrangements with your work, caregiving and other commitments.

• Weekly commitment: “How often are individual sessions and groups? How long are they, and how much practice is expected between visits?”
• Program length: “How long is the course? Can skills modules be repeated, and how do you decide when treatment should end or change?”
• Availability: “Are you accepting new patients? When could assessment and treatment begin, and what care should I arrange while waiting?”
• Coaching: “When and how can I contact someone between sessions? What happens outside those hours?”
• Online delivery: “Which parts are live video appointments, which are self-guided, and can you provide care where I will be located?”
• Practical needs: “What accommodations, language support or technology requirements should we discuss?”

Online care can mean very different things. The self-guided website studied in the 2024 trial was not a test of a complete therapist-led DBT program delivered by video. Its engagement findings make it useful to ask who will notice if you stop participating and what support is available.^[12]

Questions About Cost and Coordination

Request the cost of the whole proposed program, not only one appointment. Ask whether individual sessions, groups, assessment, materials and coaching are billed separately. If you plan to use insurance, confirm the specific provider and services with both the program and your insurer. Ask about out-of-pocket costs, missed-session charges and any financial-assistance options rather than assuming coverage.

DBT should fit into the rest of your care rather than force an unnecessary choice between therapy and medication. NIDA describes behavioral treatment and medication as complementary parts of addiction care when medication is indicated. Its guidance recommends medication first for opioid addiction, usually with behavioral therapy or counseling.^[5]

Ask, “With my permission, how will you communicate with my prescriber and other clinicians? Who will review withdrawal concerns, medication questions and changes in substance use?” Also ask what happens after a missed appointment or return to use, so continuing care is part of the plan from the beginning.

Agree on a Progress Review

Before starting, choose a few concrete goals with your clinician and set a review date. Examples might include attending scheduled care, using a planned response during conflict or reducing substance-use days. Ask how symptoms and daily functioning will also be assessed. A completed worksheet is practice, not by itself evidence that the main treatment goals have been met.

If progress is limited, bring that information to the review. Ask whether the skills need more practice, the format needs adjustment or another treatment need has been missed. The question is not simply whether you tried hard enough. It is whether the plan is addressing the problems you need help with.

If you are considering our online therapy pathway, ask directly about DBT training, addiction experience and the components offered. Do not assume a general therapy service provides a comprehensive DBT program or a guaranteed specialist match.

A Guide to DBT Skills, Worksheets and Related Pages

Use these pages to clarify a concept, prepare for a session or choose a practice topic to discuss with your therapist. A worksheet or app does not supply the individual treatment, coaching and clinician team that distinguish comprehensive DBT.^[1]

Start With the Overall Picture

Start with the skills overview before choosing an exercise to discuss with your therapist.

• Use the DBT skills guide as a map of the skill areas.
• See DBT worksheets and the DBT House page for practice topics to discuss, rather than treating an exercise as a treatment plan.

Notice What Is Happening and Work With Acceptance

Alongside the mindfulness explanation above, read about wise mind, radical acceptance and willingness and willfulness. Bring a specific situation to your therapist and ask what acceptance would mean there without abandoning your boundaries or goals.

Build a Distress-Tolerance Practice Plan

For a more focused look at distress-tolerance skills, choose one topic rather than trying to memorize every acronym at once:

• The STOP skill and the TIPP skill.
• The ACCEPTS skill, self-soothe skills and IMPROVE the Moment.
• Urge surfing and pros and cons.

Ask which exercise fits your situation and health needs, when to practice it and what to do if it does not help. The goal is a usable response plan, not a test of how many skills you can name.

Work on Emotional Patterns

Related pages include Check the Facts, Opposite Action and ABC PLEASE. Pair your reading with the emotion-regulation and coping-ahead sections above. Ask which part of a recent emotional sequence would be most useful to practice changing.

Practice Requests and Boundaries

For relationship-focused topics, see DEAR MAN, GIVE and FAST. Try bringing a real request you want to make to a session. Discuss both what you hope to communicate and how you will respond if the answer is no.

The addiction-skills, diary-card and skills-group pages linked earlier connect these topics to treatment planning and practice. You do not need to master the whole library before seeking help. A useful first step is to identify one recurring difficulty and ask a clinician how DBT, or another approach, could help you work on it.