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DBT for Substance Use: How It Works and What It Helps

November 1, 2026
DBT for Substance Use: How It Works and What It Helps

Dialectical behavior therapy (DBT) is a structured, skills-based talk therapy that is used to treat substance use disorders, especially when intense emotions, impulsive behavior or a co-occurring mental health condition drive the drinking or drug use. It began as a treatment for borderline personality disorder and has since been adapted for addiction. It teaches four sets of skills (mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness) that give you something to do with an urge other than act on it. Research is encouraging but still developing, so DBT works best as one part of a broader treatment plan.

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TL;DR

  • DBT was built for borderline personality disorder and has been adapted to treat substance use, and DBT groups are a common component of addiction treatment programs.
  • It combines individual therapy, group skills training and, in standard versions, between-session phone coaching.
  • The core skills are mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness.
  • Evidence is promising but preliminary: a 2019 review found benefits over usual treatment, and a 2022 review urged caution because of small studies.
  • DBT fits best inside integrated care, especially when addiction and a mental health condition occur together.

Table of Contents

What DBT is, and why it was adapted for addiction

DBT is an evidence-based psychotherapy developed by psychologist Marsha Linehan in the 1970s and 1980s to treat chronic suicidality in people with borderline personality disorder (BPD). The word "dialectical" points to its central idea: two things can be true at once. You can accept yourself as you are and still work hard to change. You can be doing your best and still need to do better.

That balance turns out to matter in addiction. Many people who struggle with substances feel shame about their use, and many have also been told, again and again, to simply try harder. Pure acceptance can feel like permission to stay stuck, and pure pressure to change can feel like another failure. DBT holds both.

The adaptation for substance use came from a practical observation. Linda Dimeff and colleagues developed DBT for substance abusers because many patients with severe psychosocial problems also have substance use disorders, and the aim was to promote abstinence and reduce relapse. Standard DBT did not address the specific traps of addiction, so the adapted version adds strategies for them.

Two concepts from that adaptation are worth knowing:

  • Dialectical abstinence. The goal is complete abstinence, paired with a clear plan for what happens if a slip occurs, so one lapse does not become a full return to use.
  • Clear mind. A state in which emotional and rational thinking are balanced, which the same paper describes as supporting sobriety.

The four DBT skill sets and how they apply to cravings

DBT teaches mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness so people can stay present, regulate emotions, get through crises and handle relationships. Here is how each one shows up in recovery.

Four DBT skill sets applied to recovery

Mindfulness

Mindfulness is the practice of noticing what is happening, thoughts, body sensations, urges, without immediately reacting. For a craving, it means observing the urge rise, peak and fall instead of treating it as an order. A 2023 study found that people entering treatment with frequent alcohol or substance use reported the sharpest drops in urges when they used more mindfulness skills. The researchers also suggested that it may help to teach mindfulness early in DBT programs focused on alcohol and substance use.

Mindfulness

Distress tolerance

These are crisis skills: ways to get through a painful hour without making it worse. Examples taught in most DBT programs include changing body temperature with cold water, paced breathing, intense exercise and deliberate distraction. They are not meant to fix the underlying problem. They are meant to keep a hard moment from becoming a relapse while you work on the problem.

Emotion regulation

Many people use substances to turn emotions down or up. Emotion regulation skills teach you to name what you feel, understand what triggered it, reduce your vulnerability through sleep, food and routine, and act opposite to an unhelpful urge. If you want a plain-language look at how regulation strategies work for anxiety and depression, emotion regulation strategies explains several techniques you can practice alongside a treatment plan.

Interpersonal effectiveness

Relationships are often both a trigger and a lifeline in recovery. These skills cover asking for what you need, saying no to an offer of a drink or drug, setting limits with people who still use, and repairing relationships without losing yourself in them. Saying no in a way that feels firm and kind is a skill, and it can be rehearsed.

What DBT treatment for substance use looks like

Standard DBT has several parts, and programs adapted for addiction usually keep most of them.

  1. Individual therapy. One-on-one sessions, often using a diary card. Individual sessions often include a diary card to track emotions, daily urges and drug use so treatment can be tailored to you.
  2. Group skills training. A class-like group where you learn and practice the four skill sets, often with homework.
  3. Phone coaching. DBT typically includes between-session phone coaching so you can use skills in real situations rather than only in the office. Not every residential or group-based program offers it, since the care team is on site.
  4. Therapist consultation. The clinicians meet to support each other and keep the treatment consistent.

The Washington State Institute for Public Policy describes the adapted model as focused on motivating patients to change, building skills, making sure skills are used in daily life, structuring the environment, and training counselors. In plain terms, DBT does not just teach a skill and hope. It checks whether you are using it at 11 p.m. on a bad day.

How long does it take?

There is no single answer. Traditional outpatient DBT is commonly delivered as a program of several months, while residential programs often fold DBT skills into a shorter, more intensive stay and then hand you a plan for continuing. The right length depends on severity, history and what else is going on, and a clinical assessment is the way to find out. A program that gives you a firm number before assessing you deserves a second look.

What the research shows

The honest summary: DBT has real support, and it also has real limits in the evidence.

Promising findings

Limits worth knowing

What this means for you: skills take time to become automatic. The 12-week pattern in the 2024 trial fits what clinicians see, which is that skills are learned early and pay off later with practice. It is a reason to stay with a program, and to plan for continuing care after it ends.

Who DBT tends to fit best

DBT was designed for people whose emotions run hot and fast, and that is still where it has the most support. It may be a strong fit if:

  • Intense mood swings, anger, shame or emotional pain are a regular part of your use.
  • You have a history of self-harm or suicidal thoughts alongside substance use.
  • You have been diagnosed with BPD, or have traits of it, along with a substance use disorder.
  • Anxiety, depression or trauma symptoms and substance use feed each other.
  • You want concrete, learnable tools rather than only talking through the past.

It is a less natural primary treatment if someone is in active, unmanaged withdrawal or medically unstable. In that case, safety and stabilization come first, and therapy skills build on top of that. Alcohol and benzodiazepine withdrawal in particular can be dangerous without medical oversight, so talk with a doctor or a medical detox team before stopping on your own.

Why integrated treatment matters

For people with both BPD and a substance use disorder, psychiatrists Jonathan Avery and John Barnhill emphasize that success is more likely when treatment is integrated, evidence-based and addresses all diagnoses at the same time. Treating the addiction first and the mental health condition later, or the reverse, often means the untreated one pulls the other back down.

How DBT fits with detox, medication and residential care

DBT rarely stands alone in a serious addiction. A typical path looks like this:

  1. Medical detox to get through withdrawal safely, with clinicians monitoring around the clock. See our medical detox program.
  2. Residential treatment for a structured, protected setting where you practice skills daily. Details on our residential treatment page.
  3. Medication where appropriate. For opioid and alcohol use disorders, medication can quiet cravings so skills have room to work. Read about medications for alcohol cravings or our medication-assisted treatment approach.
  4. Group and individual therapy that uses skills-based approaches. Our group therapy for addiction recovery page explains how groups are used.
  5. Aftercare and relapse prevention so skills carry into daily life. See relapse prevention.

If you are searching for urge-management tools you can start with today, our article on craving management techniques is a practical companion. And if anxiety is part of the picture, anxiety and addiction treatment covers how the two interact.

A worked example: using skills on a hard evening

Imagine someone in early recovery who has a tense phone call with a family member, then feels the old pull to drink. A DBT-informed response might run like this:

  • Notice (mindfulness). "I am feeling anger and shame, and I am having an urge. The urge is a wave, not an instruction."
  • Get through the peak (distress tolerance). Cold water on the face, slow exhale breathing, a walk around the block.
  • Understand the feeling (emotion regulation). Name what happened, check whether hunger, poor sleep or isolation made it heavier, and do something that is the opposite of what the urge wants, such as calling a supportive person instead of withdrawing.
  • Repair (interpersonal effectiveness). Later, when calm, ask the family member for a different kind of conversation.
  • Record it. Write the urge, what you did and what happened on the diary card, which becomes material for the next session.

None of those steps is complicated. The difficulty is doing them when you are upset, which is why DBT insists on repetition and coaching.

Perspective: why a small setting changes how DBT lands

We are an intentionally small, 12-bed facility, and that size shapes how we think about skills-based therapy. Skills are learned by repeating them, and repetition only happens when a clinician knows you well enough to notice that your jaw tightened before a phone call or that evenings are your hardest hour.

We treat substance use and co-occurring mental health conditions together, because in our experience they rarely arrive separately. When emotion regulation, trauma or anxiety sit underneath the use, a plan that addresses only the substance leaves the driver untouched. That is the reason our dual diagnosis work is built into treatment instead of added on at the end.

With 24/7 medical supervision, a team can steady the body first and then teach the skills when you are able to absorb them. A boutique setting that feels like a private retreat rather than an institution also matters: people practice vulnerability more easily when they are not a number on a large unit.

Our advice is to ask any program you consider how skills are actually practiced day to day, who coaches you through a bad night, and what the plan is after discharge. Those answers matter more than the name of any single therapy.

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How to choose a program that uses DBT well

Many facilities say they offer DBT. The label can mean anything from a weekly lecture to a fully trained team. Questions worth asking:

  • Who delivers it? Ask about the clinicians' training in DBT and how they are supervised.
  • What is included? Individual therapy, skills groups, diary cards and some form of between-session support are the core pieces.
  • Is it integrated with mental health care? If you have anxiety, depression, trauma or BPD, treatment of those conditions should happen at the same time as addiction care.
  • How is detox handled? Medical supervision should come first when withdrawal is a risk.
  • What happens after discharge? Look for written aftercare, continuing therapy, and a relapse prevention plan, not just a handshake at the door.
  • How does it handle insurance and cost? Ask for a benefits check before you commit, so there are no surprises.

If you want a broad look at what is available, our addiction treatment programs page lists the conditions and therapies we treat.

Treatment at Connected Recovery

Connected Recovery is a boutique, accredited 12-bed facility in Van Nuys, Los Angeles, serving adults who need medically supervised detox and residential treatment. We treat substance use together with co-occurring mental health disorders, and we plan for aftercare from the start. If you or someone you love is ready to talk about admission, start with our dual diagnosis treatment page or contact our admissions team for a confidential conversation.

Connected Recovery

We accept private pay and insurance-funded admissions. Call or message us to learn what your plan may cover.

FAQ

Is DBT used for substance abuse?

Yes. DBT began as a treatment for borderline personality disorder and has been adapted for substance use. DBT groups are a component of most substance use treatment facilities according to clinicians writing in Psychiatric News. The adapted version adds strategies such as dialectical abstinence to address relapse risk.

What are effective coping skills for people with addiction?

DBT teaches four sets: mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness. In practice that means riding out an urge without acting on it, using cold water or paced breathing in a crisis, naming and addressing the emotion underneath, and rehearsing how to say no. Practicing them daily matters more than knowing them.

Who is DBT not appropriate for?

DBT is not a stand-alone answer for someone in dangerous, unmanaged withdrawal, who needs medical detox first. It may also be a weaker fit for people who want only medication management or whose main need is a different therapy, such as trauma processing. A clinical assessment is the best way to decide, and integrated care for all diagnoses is more likely to succeed.

What is the 24-hour rule in DBT?

It is a policy in some standard DBT programs about phone coaching: after an episode of self-harm, the therapist generally does not offer coaching calls for a set period, so crisis contact is not reinforcing the behavior. Regular sessions continue. It is about self-harm, not substance use, and policies vary by program, so ask any program how it handles crisis support. If you are in crisis right now, call or text 988 or call the SAMHSA National Helpline at 1-800-662-4357.

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