What Are the Principles of Dialectical Behavior Therapy in Treating Substance Abuse?

What Are the Principles of Dialectical Behavior Therapy in Treating Substance Abuse?

Marsha Linehan, the woman who created dialectical behavior therapy, or DBT, was once a patient herself who had a profound desire to end her life.

As a 17-year-old girl in 1961, she was confined to a seclusion room at a Hartford, Connecticut, clinic. The staff put her there because she attacked herself by “habitually, burning her wrists with cigarettes, slashing her arms, her legs, her midsection, using any sharp object she could get her hands on,” according to a 2011 article in The New York Times.

In fact, doctors diagnosed Linehan with schizophrenia and gave her Thorazine (chlorpromazine), Librium (chlordiazepoxide), and other drugs. They also subjected her to hours of Freudian analysis and “strapped her down for electroshock treatments….”

When she was discharged more than two years later, doctors summarized her case thusly: “During 26 months of hospitalization, Miss Linehan was, for a considerable part of this time, one of the most disturbed patients in the hospital.”

In what only could be described as a relentless quest to heal herself and the people around her, Linehan developed DBT for those with borderline personality disorder, a mental illness marked by mood instability, warped self-image, impulsiveness, and intense but unstable relationships.

DBT would be employed for patients afflicted with substance abuse disorders. In fact, DBT has become a staple in the treatment of addiction. Its principles are just as applicable to people with drug or alcohol addictions as those who have BPD and other mental issues. DBT especially possesses great utility in an addiction treatment context because patients with substance abuse disorders often have co-occurring mental health issues.

Read on to learn about the history and principles that undergird DBT and how it is used to treat substance abuse.



The History of DBT

After surviving a suicide attempt, Linehan moved to a Chicago to live at a YMCA. She became an ardent Catholic, started work, and took night classes at Loyola University.

While praying at an on-campus chapel, Linehan experiences an epiphany that would profoundly change her life and plant the seeds that would allow her to develop DBT. She described that moment in that same New York Times article:

“One night I was kneeling in there, looking up at the cross, and the whole place became gold — and suddenly I felt something coming toward me,” she said. “It was this shimmering experience, and I just ran back to my room and said, ‘I love myself.’ It was the first time I remember talking to myself in the first person. I felt transformed.”

Linehan eventually earned a Ph.D. in social and experimental psychology in 1971. When she began working with patients, she began to see the importance of radical acceptance, which is acknowledging reality, a bedrock principle of DBT.


At Home Drug Detox

She would create DBT for highly suicidal patients who felt compelled to hurt themselves, people often diagnosed with BPD. Dialectical behavior therapy incorporates principles of cognitive behavioral therapy (emotion regulation and reality testing) with radical acceptance and distress tolerance. Another key aspect of DBT is mindfulness, a Buddhist principle.

In essence, DBT helps to treat compulsive patterns of self-injury with practical techniques, strategies, and skills. Self-injury, for instance, can mean using drugs or alcohol in the face of adverse situations — legal, professional, or financial. DBT helps those struggling with a substance abuse disorder achieve self-acceptance while acknowledging their need to change.

The Core Principles of DBT

Dialectical behavior therapy is support-oriented in that it helps patients identify and build on their strengths to increase self-confidence. It is cognitive-based, in that it helps people identify patterns — their beliefs, thoughts, and assumptions — that make their lives more difficult. DBT is also collaborative, in that it encourages patients to work out their issues in collaboration with therapists.

DBT asks people to complete homework assignments, to role-play new ways of interacting with others, and to practice skills such as soothing yourself when upset. These skills, a crucial part of DBT, are taught in weekly lectures, reviewed in weekly homework groups, and referred to in nearly every group. The individual therapist helps the person to learn, apply and master the DBT skills.

There are four modules of DBT, which include:


At its core, all of the skills in DBT are centered on mindfulness. This aspect helps patients accept and tolerate the emotions they may be feeling when they are challenging habits or beliefs or confronting upsetting or uncomfortable situations. Though mindfulness derives from Buddhist practice, in DBT it does not contain religious or metaphysical elements. Instead, therapists urge patients to practice mindfulness in a way that they become more aware of their environments via the five senses of touch, taste, sight, smell, and sound.



This involves how patients interact with the people around them and in their relationships. Specifically, they are taught how to ask for what they need, how to say “no,” and how to deal with interpersonal conflict.



This component involves tolerating, accepting, and finding meaning in the distress that occurs in their lives. Those include distressing events such as the death of a relative or friend, the loss of a job, or illness. Patients are taught to accept a distressing event without imposing judgment on the situation. The object of distress tolerance is to develop the capability to recognize a negative event and its impact without becoming overwhelmed or cowed by it.


This DBT aspect teaches people in recovery how to identify, regulate, and feel emotion without it overwhelming them to the point that it triggers impulsive behavior.

In the context of people who are suicidal or have borderline personality disorder, this component teaches them to regulate the intense and labile emotions they tend to experience like being frequently angry, intensely frustrated, depressed, and anxious.

How DBT Treats Addiction

Unlike medication-assisted treatment (MAT), DBT is abstinence-based. An article in The Fix sums up the goal of DBT in an addiction treatment context: “…DBT pushes for immediate and permanent cessation of drug abuse (change) while also offering the idea that a relapse, should it occur, does not mean that the individual cannot achieve the desired result (acceptance).”

While the dialectical approach mandates abstinence, it also provides nonjudgmental, problem-solving solutions to relapse.

This passage from The Fix encapsulates this approach:

DBT treats a lapse into substance abuse as a problem to solve, rather than as evidence of patient inadequacy or treatment failure. When a patient does slip, the therapist shifts rapidly to helping the patient fail well—that is, the therapist guides the patient in making a behavioral analysis of the events that led to and followed drug use and gleaning all that can be learned and applied to future situations.

The therapist is also tasked with helping a patient recover quickly from a relapse episode.

Alternatives to DBT

Studies support DBT as an effective treatment option for people with substance abuse disorders. People enrolled in a professional addiction treatment program have access to services beyond DBT.

Those include the following treatment modalities:


Treatment that addresses the negative thoughts and actions associated with addiction.


A program that provides patients with a supportive recovery community.


This form of therapy focuses on the elimination of addiction and its impact on the family unit as a whole.


A program that addresses a substance abuse disorder and an accompanying mental health issue in a patient.


A therapy model based on the groundbreaking 12-Step program that was pioneered by Alcoholics Anonymous founders Bill Wilson and Bob Smith.


A treatment model that focuses on the whole person, from the addiction to diet and mental health.


A treatment program that involves the use of medications to help someone cycle off of an addiction.

Get Help for Your Addiction

Dialectical behavior therapy is one of the many effective options offered in professional addiction treatment. If you or a loved one is struggling with an addiction, let us help you achieve sobriety and recapture your life.

Call (844) 544-9279 anytime, day or evening, for a free consultation with one of our knowledgeable addiction recovery specialists. They can help you locate the right treatment option. contact us online for more information.