Dialectical Behavior Therapy for Addiction: How It Works

Dialectical behavior therapy teaches skills for riding out a crisis without using, and the addiction version adds targets aimed squarely at substance use. This guide covers the four skill sets, the parts of a comprehensive program and the trials behind the claims, including where those trials stop short. It ends with what to ask a program before enrolling.

Key Points About DBT for Addiction

Mindfulness and distress tolerance come first, then emotion regulation and interpersonal effectiveness, all practiced in a weekly group.
The addiction version asks for complete abstinence and treats a lapse as a problem to solve, without shame.
Comprehensive DBT combines weekly individual therapy, a skills group, phone coaching and a therapist consultation team, all running together.
Both best-known trials enrolled fewer than 30 people with borderline personality disorder, so the evidence is promising, not settled.
NIDA does not list DBT among the behavioral therapies it counts as evidence-based for adults with addiction.

What Is DBT?

Marsha Linehan developed dialectical behavior therapy, or DBT, as a form of cognitive behavioral therapy for people living with borderline personality disorder and chronic suicidal thoughts. It was later adapted for people who have a substance use disorder as well, and that version is now a recognized form of addiction therapy.

The word dialectical names two ideas held together: a person can accept where they are today and still put real effort into changing. DBT asks for both at the same time.

The therapy sets its targets in order, and life-threatening behavior comes first. In the version built for substance use, substance use itself is the top target among the behaviors that stand between a person and a good life, as Dimeff and Linehan described.

Older sources sometimes call this DBT for substance abuse. The current term is substance use disorder.

In 2025, 18.5 million U.S. adults had a substance use disorder and a mental illness at the same time, the Substance Abuse and Mental Health Services Administration (SAMHSA) reports. Behavioral Tech counts four skill sets in DBT.

18.5M

U.S. adults in 2025 with a substance use disorder and a mental illness

DBT skill sets

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The Four DBT Skills

DBT groups usually teach all four: mindfulness, then distress tolerance, emotion regulation and interpersonal effectiveness. Each set gives you something to do in moments when a craving, a painful emotion or a conflict might otherwise lead to using.

The names come from Behavioral Tech, which trains DBT clinicians. The examples are illustrative rather than set scripts: a group teaches the skill, and you find what it looks like in your own week.

Skill	What it does	What it looks like in recovery
Mindfulness	Noticing a thought, a feeling or an urge without acting on it	Watching a craving build and fade without using
Distress tolerance	Staying steady in a crisis so it does not get worse	Using a short coping plan when an urge hits hard
Emotion regulation	Making sense of intense emotions and how to change them	Taking the edge off anger or shame that usually arrives first
Interpersonal effectiveness	Asking for what you need, setting limits and keeping the relationship	Turning down an offer to use from a friend

The four cover different points in one chain. An urge shows up and mindfulness lets you see it without obeying it. A crisis lands and distress tolerance carries you through the hour. An emotion builds over days and emotion regulation offers another answer. A friendship strains and interpersonal effectiveness lets you say what you need.

None of the four needs a quiet room or a good day. They are small, repeatable moves: notice, ride out, reframe, ask. A group practices them out loud, then you try them where urges happen.

How DBT Works for Addiction (DBT-SUD)

Dialectical behavior therapy for substance use disorder, usually written DBT-SUD, keeps the skills the therapy teaches anyone and adds a set aimed at drug and alcohol use. Linehan’s team built the adaptation for people who have borderline personality disorder as well as a substance use disorder. Three things shift: how abstinence is framed, what access to the substance looks like, and how hard the therapist works to keep someone in treatment.

DBT-SUD also fits beside medication for opioid use disorder. In one trial of DBT for opioid use disorder, every participant received an opioid agonist medication as well as the therapy.

Man sitting in a wheelchair next to his doctor

Dialectical abstinence

The therapist asks for immediate, complete abstinence and says so without softening it. A lapse is then handled as a problem to solve: the two of you work out what came before it and set up the next stretch of not using, with no lecture and no shame. Dimeff & Linehan describe people committing for only as long as they feel sure of it, which can be a day or as little as five minutes (2008).

A “clear mind”

The other target is a middle state, away from two extremes. One extreme is a day run by urges, where any strong feeling ends in using. The other is abstinence held with too much confidence, where the safeguards get dropped and the risks are forgotten. A clear mind keeps the skills in play after the crisis that brought someone to treatment has passed.

Practical strategies

The manual adds concrete moves for the stretch between sessions:

Burning bridges

deleting a dealer’s contact details and clearing out the paraphernalia.

Cope ahead

walking through a high-risk situation before it happens.

Riding out urges

skills for a craving and for the discomfort of withdrawal.

Building support

time with people who back the change.

Staying engaged (“attachment strategies”)

Leaving treatment early is common, so DBT-SUD plans for it before it happens. The therapist makes a “just in case” plan in the first sessions, keeps contact close in the early weeks, and can meet the person where they are. If someone stops coming, that person is contacted rather than written off.

What a DBT Program Includes

Comprehensive DBT, as the DBT-Linehan Board of Certification (DBT-LBC) describes it, has four pieces that are meant to run at the same time: one individual therapy session a week, a weekly skills class, phone coaching in between, and a weekly meeting of the therapists on the team.

Individual therapy. One session a week with your own therapist, typically 45-60 minutes.
Skills training group. About 2 hours a week. It is group therapy for addiction with a set curriculum: skills taught in order, practiced in the room, then repeated on the next pass through.
Phone coaching. Short calls or texts between sessions, for the hours when a skill is needed and the next appointment is days away.
Consultation team. The therapists meet weekly to keep one another on model. You do not attend.

The pieces are meant to work together. The group teaches the skills, the weekly session is where you work out how they fit your own life, and coaching covers the stretch in between.

Not every program offers all four. A skills group covers one piece, and so does a therapist who uses DBT skills inside another kind of therapy. A program that calls itself DBT-informed is drawing on parts of the approach rather than the whole of it, which makes the question worth asking before you enroll: which of the four would you actually get? Many programs also run the skills group by video.

How long it takes depends on the program, and many of them run 6-12 months. The DBT-SUD programs in the research ran for 12 months (Dimeff & Linehan, 2008), and DBT-LBC reports that adults do best after two complete passes through the skills curriculum.

Does DBT Work for Addiction?

When a person has borderline personality disorder (BPD) alongside a substance use disorder, DBT looks promising rather than settled. The two best-known trials each enrolled fewer than 30 people, and a 2022 systematic review of DBT skills training could offer only “preliminary support” for reducing substance use.

The limits deserve as much attention as the results. Both trials came from the research group that developed the therapy, both enrolled women only, and every participant already had BPD. In their 2008 summary, Dimeff and Linehan found that no controlled trial had yet tested DBT for substance use in anyone without BPD. The case for DBT outside that group is thinner than the case inside it.

A man speaks with a therapist. Learn more about drug and alcohol addiction therapy, here.

Here is what the research shows, source by source.

Study	Who took part	What it found
Linehan et al., 1999, as Dimeff and Linehan summarized it in 2008	28 women with BPD and a drug use disorder	More of them stayed in treatment on DBT than on usual community care (64% vs 27%), and their drug use fell further
Linehan et al., 2002, from the same summary	23 women who had BPD and an opioid use disorder	Opioid use fell in both arms, but only the DBT group held the gain to the final months; more of the comparison group finished treatment (100% vs 64%)
Warner and Murphy, 2022, a systematic review	9 studies, each one testing DBT skills training for substance use disorder	Acceptable and workable in practice, with “preliminary support” for less substance use and better emotion regulation; the studies ranged from weak to strong in quality
National Institute on Drug Abuse (NIDA), 2018	none	DBT is absent from the behavioral therapies NIDA lists as evidence-based for adults with addiction

None of these results settles how well addiction therapy works across the board, and that gap is a reminder to weigh a claim about DBT against the studies behind it.

Who DBT for Addiction Is For

DBT is often the best fit when drinking or drug use is tied to emotions that arrive fast and hard, to self-harm or thoughts of suicide, or to BPD. Plenty of people in treatment have none of that, and motivational interviewing, contingency management or cognitive behavioral therapy (CBT) may suit them better.

DBT may be the better fit when someone:

Feelings arrive fast

Alcohol or drugs used to settle a feeling that will not ease

Thoughts of suicide or self-harm

Safety work starts early

A diagnosis of BPD

The emotion and relationship patterns the therapy targets

Treatment ended early before

Starting again with more contact built in

DBT or CBT?

CBT goes after the thoughts and behaviors that keep substance use going, usually across about 12 weeks. DBT keeps that work and builds on it with acceptance and skills for handling emotion, inside a program that runs longer and takes up more of a person’s week. Comparing CBT and DBT for addiction often comes down to how much time someone can give and whether intense feelings drive the use.

For stimulant use, contingency management, which ties agreed rewards to progress such as negative drug tests, can suit someone better than a skills-heavy program. Someone unsure about stopping may get more from motivational interviewing, which works from the person’s own reasons to change.

If you are having thoughts of suicide or self-harm, the 988 Suicide & Crisis Lifeline answers calls and texts at 988.

How to Find DBT for Addiction

Look for a program that runs all four parts of comprehensive DBT and has treated substance use before. The DBT-Linehan Board of Certification keeps two lists, one named Find a Certified Clinician and one named Find a Certified Program, and Behavioral Tech, which trains DBT clinicians, runs a Find a Therapist directory.

FindTreatment.gov lists programs, and the SAMHSA National Helpline at 1-800-662-HELP (4357) answers questions about care. The four parts take several appointments a week, so some programs run DBT inside partial hospitalization programs or intensive outpatient rehab.

Cost decides whether a program works, so check your rehab insurance coverage before an intake call, and for a family member, start with help a loved one with addiction and the same how to choose a program questions. If thoughts of suicide or self-harm are part of it, call or text 988 for the 988 Suicide & Crisis Lifeline.

Questions to ask any program:

All four parts

Weekly session, skills class, coaching, consultation team: all covered?

Training

Are the clinicians DBT-trained or certified?

Substance use

Do they use the DBT adaptations for substance use?

Length

How many months, and how many skills cycles?

Video groups

Is there a video option for the skills group?

Cost

What does it cost, and does it take your insurance?

Ask every program the same questions.

DBT for Addiction FAQs

What is dialectical abstinence?

Dialectical abstinence is how DBT frames the goal of stopping substance use, and it asks for two things at once. The first is a full commitment to not using, with a plan for urges and high-risk situations worked out ahead of time. The second is what happens if a lapse occurs: the person and the therapist look at what led up to it as a problem to solve and a signal about which skills still need work, and then the person recommits from that point. Keeping both halves means a single slip does not become a reason to walk away from treatment.

Is DBT better than CBT for addiction?

Not overall. Cognitive behavioral therapy (CBT) has more research behind it for substance use in general, while DBT was built for people whose use goes with intense emotions, self-harm or borderline personality disorder (BPD). Most of the evidence connecting DBT to addiction comes from that group. A side-by-side look at CBT and DBT sets out where the two approaches overlap and where they differ.

Can you do DBT without having BPD?

Yes. A person does not need a diagnosis of borderline personality disorder to learn DBT skills, which are taught for many other conditions as well. Most of the addiction research so far has studied DBT in people who have BPD alongside a substance use disorder, so the evidence for the approach on its own is thinner, and asking a clinician whether it fits your situation is reasonable.

How long does DBT take?

Comprehensive DBT usually runs for months rather than weeks. The research programs that tested DBT for substance use ran 12 months, and the DBT-Linehan Board of Certification (DBT-LBC) reports that adults do best after two complete passes through the skills curriculum. Shorter options exist, including a skills group on its own, and those cover less of the program.

Can DBT be done online?

Yes, and many programs run individual DBT sessions and skills groups over video. Comprehensive DBT also includes phone coaching between sessions, when a person can reach their therapist for help applying skills in a hard moment, so it is worth asking whether the online version includes that and how it works in practice.

Does insurance cover DBT?

Many health plans cover DBT, either as outpatient mental health care or as part of substance use treatment, though what they cover is not uniform. Phone coaching and the long span of a full program are the pieces most likely to be handled differently from a standard therapy session, so confirm the details of your own benefits before enrolling and ask the program which parts of comprehensive DBT it bills and how.

Is DBT the same as a DBT skills group?

No. A skills group is just one of the four components that make up comprehensive DBT, alongside individual therapy each week, phone coaching and a weekly meeting for the treating therapists. Some programs offer only the group, and some describe themselves as DBT-informed when they use the skills inside another kind of therapy, so it helps to ask which of the four parts you would actually receive.