Dialectical Behavior Therapy (DBT): Skills for Emotional Balance in Recovery

Dialectical Behavior Therapy (DBT) is a comprehensive, evidence-based treatment that combines cognitive-behavioral techniques with concepts from Eastern mindfulness practice. Developed by psychologist Marsha Linehan in the late 1980s, DBT was originally created for borderline personality disorder but has proven highly effective for addiction, especially when intense emotions play a significant role.

The Dialectical Philosophy

DBT teaches four sets of skills, typically in a group setting with homework practice between sessions. These skills address the core difficulties that often underlie addiction.

Mindfulness

Distress Tolerance

Emotion Regulation

Interpersonal Effectiveness

DBT helps with addiction by targeting the emotional dysregulation that often drives substance use. Many people turn to drugs or alcohol to cope with intense, overwhelming emotions — anxiety, shame, anger, loneliness, or emotional numbness. DBT provides healthier alternatives by teaching specific skills for managing these emotional states without substances.

The "dialectical" in DBT refers to balancing two seemingly opposite ideas: acceptance(acknowledging your current situation, including addiction, without judgment) and change(actively working to develop new skills and behaviors). This balance is particularly powerful for addiction — rather than demanding immediate perfection, DBT validates the struggle while building the capacity for change.

In practice, DBT for addiction works through several mechanisms. Mindfulness skills help you recognize urges and cravings as temporary experiences that can be observed without acting on them. Distress tolerance skills provide specific techniques (like the TIPP method — Temperature, Intense exercise, Paced breathing, Paired muscle relaxation) for surviving intense craving episodes without using substances. Emotion regulation skills help you identify, understand, and manage the emotions that previously triggered use. And interpersonal effectiveness skills help you navigate relationships and social situations — including saying no to substance use and asking for help — without conflict or guilt.

Research shows that DBT for substance use disorders reduces drug use, decreases dropout from treatment, and improves emotional wellbeing. The structured nature of skills training gives patients concrete, practical tools they can use immediately in their daily lives.

Comprehensive DBT includes four components that work together:

Components

DBT and CBT share common roots — Dr. Marsha Linehan developed DBT as a modification of CBT — but they differ in important ways that affect which is better suited for a particular patient:

Philosophy: CBT focuses primarily on change — identifying and modifying maladaptive thoughts and behaviors. DBT balances change with acceptance, incorporating mindfulness and radical acceptance alongside behavioral change strategies. For people who feel invalidated by a pure change-focused approach, this balance can be the difference between staying in treatment and dropping out.

Structure: Standard CBT involves individual therapy sessions (typically weekly for 12-16 weeks). Comprehensive DBT includes four components: individual therapy, skills groups (usually weekly for 6-12 months), phone coaching for between-session crises, and a therapist consultation team. This more intensive structure provides greater support for people with complex needs.

Emotional focus: CBT addresses emotions primarily through changing the thoughts that produce them. DBT directly teaches emotional regulation skills, distress tolerance, and mindfulness — making it particularly effective for people who experience intense, rapidly shifting emotions that CBT alone may not adequately address.

Best fit: CBT is often the first-line therapy for addiction, especially when there is no significant emotional dysregulation or personality disorder. DBT is typically recommended when patients also struggle with intense emotions, self-harm, suicidal behavior, borderline personality traits, or have not responded well to standard CBT. Many treatment programs offer both, and your therapist can help determine which approach — or which combination — is best for your situation.

While DBT can help anyone with addiction, it is particularly effective for people who also struggle with emotional intensity and related challenges:

• People with borderline personality disorder (BPD) — DBT was originally developed for BPD, and the combination of BPD and addiction is extremely common. DBT remains the gold standard treatment for this dual diagnosis
• Those who use substances to manage emotions — if you drink or use drugs primarily to cope with overwhelming feelings (anxiety, anger, sadness, emptiness), DBT's focus on emotional regulation directly addresses the root cause of your substance use
• People with self-harm or suicidal behaviors — DBT has strong evidence for reducing self-destructive behaviors, including both self-harm and substance use that functions as a form of self-damage
• Patients who have struggled with other therapies — people who have dropped out of or not responded to standard CBT often do well in DBT, partly because of its emphasis on acceptance and validation alongside change
• Those with eating disorders and addiction — the emotional dysregulation that underlies both conditions responds well to DBT's skills-based approach
• People with chronic suicidal ideation — DBT's crisis survival skills and emphasis on "building a life worth living" provide both immediate coping tools and long-term motivation for recovery
• Those with trauma who aren't yet ready for trauma processing — DBT's stabilization-focused approach can prepare patients for later trauma-focused therapy by building the emotional regulation skills needed to tolerate trauma work

If you're unsure whether DBT is right for you, a qualified therapist can assess your needs and recommend the most appropriate approach. Many people benefit from starting with DBT to build foundational skills, then transitioning to other therapies as their emotional stability increases.

DBT is available across multiple treatment settings, though the comprehensiveness of DBT programming varies by level of care:

• Residential treatment — many residential programs offer DBT-informed or comprehensive DBT programming. Patients receive daily skills groups, individual DBT therapy sessions, and have access to coaching support from staff trained in DBT. The immersive environment provides ample opportunity to practice new skills with guidance
• Partial hospitalization (PHP) — PHP programs often incorporate DBT skills groups into their daily schedules, with individual DBT therapy 1-2 times per week. This level is well-suited for patients stepping down from residential who still need intensive emotional support
• Intensive outpatient (IOP) — DBT-based IOP programs typically include weekly skills groups (2-2.5 hours), weekly individual therapy, and between-session phone coaching. This format allows patients to practice skills in their real-world environment while maintaining strong therapeutic support
• Standard outpatient — comprehensive outpatient DBT includes weekly individual therapy, weekly skills groups, and phone coaching. This is the format closest to Linehan's original model and typically lasts 6-12 months
• Aftercare — many patients continue DBT skills groups or periodic individual sessions after completing primary treatment, using the skills framework as an ongoing recovery tool

When choosing a program, ask specifically about their DBT implementation. "DBT-informed" means the program incorporates some DBT concepts and skills but may not offer the full model. "Comprehensive DBT" or "adherent DBT" indicates the program delivers all four components (individual therapy, skills groups, phone coaching, consultation team) as designed. Both can be beneficial, but comprehensive DBT has the strongest evidence base.