Dialectical behavioral therapy (DBT) is an evidence-based form of psychotherapy that stems from cognitive-behavioral therapy (CBT). While initially developed to treat individuals with borderline personality disorder (BPD) and suicidal thoughts, DBT is shown to be effective in treating substance abuse disorders and a range of mental health conditions.

Dialectical Behavioral Therapy (DBT) primarily involves skills training that is designed to help people better navigate and tolerate emotional distress, including cravings for drugs and alcohol. DBT also helps people learn how to identify extreme or maladaptive behaviors, such as drug and alcohol abuse, and replace them with healthier behaviors and coping mechanisms.

We are here to provide trusted information and guidance which will allow you to understand more about how DBT works and how it can assist in addiction treatment.

What is Dialectical Behavioral Therapy?

DBT was developed in the 1970s by Marsha Linehan, a psychology researcher at the University of Washington, with the intent to primarily treat women with suicidal tendencies. Over the past 40 years, DBT has proven to be very effective in treating individuals with borderline personality disorder (BPD) when compared to other group therapy approaches.

Research suggests that between 65 percent and 90 percent of individuals with substance use disorders have at least one co-occurring personality disorder, such as BPD. Borderline personality disorder is a mental health condition that impacts the way people think and feel about themselves and others, making it difficult to function in everyday life. According to the Mayo Clinic, it includes self-image issues, difficulty managing emotions and behavior, and a pattern of unstable relationships.

In addition to treating BPD, DBT treatment is now used to treat a range of substance use disorders and co-occurring mental health problems, including:

Substance use disorder (SUD)
Anxiety disorders
Attention deficit hyperactivity disorder (ADHD)
Bipolar disorder
Depression
Eating disorders (including, anorexia, bulimia, and binge eating disorder)
Other personality disorders (such as antisocial personality disorder and narcissistic personality disorder)
Post-traumatic stress disorder (PTSD)
Tobacco or nicotine addiction
Self-harm behaviors

Treatment Goals and Benefits

The word “dialectic” refers to the synthesis of two opposites. The guiding principle of DBT is to promote two opposed goals for patients: change and acceptance.

According to Linehan, through skills training which focuses on acceptance and change, DBT can help patients create a life worth living, where the quality of life and overall well-being is paramount. When DBT treatment is successful, individuals learn how to envision, articulate, pursue, and sustain goals that are independent of their history of self-destructive behavior, including substance abuse.

How Does Dialectical Behavior Therapy Work?

Dialectical behavior therapy views the main source of people’s distress as a lack of adaptive skills. Therefore, the DBT approach is multifaceted and relies heavily on learning skills to change destructive behaviors and thoughts.

Patients are taught how to accept the world, themselves, and others as they are, while also learning skills that help them more effectively manage their own behavior, feelings, and interpersonal relationships.

The Four Modules of Dialectical Behavior Therapy

DBT therapists teach individuals critical behavioral skills through modeling, providing instructions, telling stories, practicing, giving feedback, and coaching. This is accomplished through the following techniques:

Mindfulness: A core tenet of DBT, mindfulness skills teach individuals how to focus on the present moment and their feelings, impulses, thoughts, and sensations. By tuning into their senses and the environment around them, people learn how to press pause on negative thoughts. Instead, they learn how to focus on healthy coping mechanisms whenever they experience emotional distress or are triggered to use substances.
Emotional regulation: This module is focused on identifying, naming, and changing the negative aspect of an emotional response. Emotional regulation helps individuals identify and cope with intense negative emotions and create an opposite action, so they can have more positive emotional experiences. For example, when individuals have more positive emotional experiences, the need to self-medicate with drugs and alcohol is lessened.
Distress tolerance: This technique teaches individuals to sit with difficult feelings and experiences, without turning to drugs and alcohol. Instead of abusing substances, patients learn how to create healthy distractions and self-soothe, which provides a sense of empowerment during recovery.
Interpersonal effectiveness: Many people in addiction treatment struggle with challenges in their personal lives. Interpersonal effectiveness teaches individuals how to understand and name feelings, manage extreme emotions and change responses to these feelings, with the goal of repairing, maintaining, and establishing healthy relationship behaviors. This module also includes assertiveness training where individuals learn how to communicate effectively, manage conflict and create healthy boundaries.

Behavior Chain Analysis

In addition to the modules above, DBT also uses chain analysis to teach people how to better understand their behavior. Chain analysis consists of a very detailed examination of an individual’s actions, emotions, thoughts and sensations that lead up to a problem behavior, such as using drugs and alcohol. The goal is to help people identify triggers and find solutions to stop the problem behavior at different points.

The DBT practitioner works with the patient to identify each link in the chain (i.e., behaviors, thoughts, feelings) leading up to the decision to use substances. A common framework for behavior chain analysis includes the following points:

Prompting event: What occurrence prompted the start of the chain of events that led to the problem behavior? (I.e, an argument with a loved one, losing a job, a breakup).
Vulnerability: What feelings occurred as a result? (I.e. feeling lonely, sad, or anxious)
Links: What other behaviors led to the problem behavior? For example:
They saw their roommate drinking and using drugs.
The roommate offered them a beer.
They went to a party where drugs and alcohol were present.
Problem behavior: What is the problem behavior being analyzed? (I.e. abusing substances).
Consequences: What was the result of the problem behavior? (I.e. shame, financial hardship, engaging in more problem behavior).

Next, the therapist will help the patient to identify the links that they need to focus on in order to interrupt or break the chain. The therapist will then work with the patient to help them make the desired changes in behavior.

Through the chain analysis process of DBT, individuals learn how to control their attention and shift it away from thoughts, sensations, or situations that increase emotional distress (for example, the urge to use drugs and alcohol) and instead, divert their focus to ideas and scenarios that reduce distress and/or increase positive feelings. The primary goal is to help people develop healthy coping mechanisms and adaptive problem-solving strategies that allow them to live a life free of addiction.

What to Expect From DBT

Dialectical behavioral therapy typically takes place in community treatment centers, inpatient rehab facilities, mental health programs, hospitals, and sometimes schools or workplaces.

DBT treatment is highly individualized. As a result, a patient will work with the therapist to create treatment goals that align with their personal needs. However, DBT programs generally include the following elements:

DBT Skills Training

Skills training consists of group therapy sessions which are designed to help individuals increase their ability to change negative behaviors. These group skills training sessions are led by a therapist who teaches various techniques and skills that are helpful to people in recovery. In addition to attending these sessions, participants are required to complete homework assignments. Skills training sessions take place weekly for about 2.5 hours over the course of 24 weeks. It’s not uncommon for the sessions to be repeated if a patient remains in the program for an entire year.

Individual Therapy

During these one-on-one therapy sessions, the therapist works with the patient to find ways to apply the skills they are learning to the daily challenges they face, such as avoiding drug-seeking behavior or coping with cravings. Individual therapy sessions take place once a week and run concurrently with group meetings.

Phone Coaching

DBT therapists are available by phone to provide live coaching for participants who are faced with a difficult situation, such as relapse. This means that participants can call their therapist outside of normal therapy hours whenever they’re in need of essential support.

Therapist Consultations

Therapist consultations refer to a built-in platform that’s designed to support the therapists who are providing DBT. The consultation team helps DBT therapists be effective and stay motivated while working with patients that have challenging-to-treat disorders such as substance abuse. This peer support helps the therapist to provide the best possible treatment to their patients.

How Long Does DBT Last?

DBT is a lengthy but finite course of treatment, which is designed to last for around one year. Its effectiveness over 12 months is well documented. Therefore, if someone begins DBT during addiction treatment and their program is less than one year in length, they will need to find a DBT practitioner when they return to their daily lives, in order to receive the full benefit.

DBT and Substance Abuse Treatment

DBT is a well-established treatment for people who suffer from severe and often multiple mental health conditions. Since more than 20% of people with mental health conditions have a co-occurring substance use disorder, DBT is frequently used to treat substance abusers. Dialectical behavioral therapy, when applied in an addiction treatment setting, uses concepts and modalities that are designed to promote abstinence and reduce the length and negative impact of relapses.

How Effective is DBT?

While there isn’t any conclusive evidence that DBT single handedly can treat substance use disorder, plenty of research suggests that it can be incredibly helpful when included as part of a comprehensive addiction treatment program.

For example, a 2011 study found that DBT treatment dramatically improves the outcomes of individuals who are suffering from co-occurring disorders, specifically, substance abuse and borderline personality disorder. In particular, DBT is linked to increased social functioning and a noticeable reduction in the following areas:

Anger
Depression
Non-suicidal self-injuries
Suicidal behavior
Psychiatric hospitalizations
Substance abuse
Treatment dropout rates

A 2008 study also found that when used in an addiction treatment setting, DBT treatment led to a decrease in substance abuse. Some of the other benefits include:

Ability to create and enforce boundaries necessary for abstinence.
Ability to avoid triggers and other events that could lead to substance use.
A decrease in the physical discomfort associated with withdrawal symptoms.
Reduced substance-related impulsivity, cravings, and temptations.
Reduced problematic behaviors that contribute to substance use.

There’s also evidence that suggests that dialectical behavior therapy can be very effective in treating substance abusers with other co-occurring psychiatric conditions, such as eating disorders, mood disorders, and post traumatic stress disorder. According to a 2006 study published in Psychiatry, women with BPD and co-occurring substance use disorders who received DBT had exhibited less substance misuse during a year of treatment. They also dropped out of rehab less often than women who did not receive DBT as part of their addiction treatment program.

How Does DBT Differ From Cognitive Behavioral Therapy?

While DBT is a form of cognitive behavioral treatment, there are several notable differences. According to the National Alliance on Mental Illness (NAMI), CBT is primarily about learning to change your negative thoughts and behaviors, whereas, DBT is focused on the validation and acceptance of uncomfortable thoughts, feelings, and behaviors so that patients can then learn to change them.

While CBT is mainly focused on individual therapy, DBT takes place in a group setting and also includes individual therapy sessions and phone coaching. The four clearly defined modules of DBT allow multiple therapists to work together. This allows for more variety and flexibility when it comes to helping patients reach their goals.

Cost of DBT Treatment

The cost of DBT varies depending on the facility and an individual’s insurance coverage. A year-long DBT program costs $6000 on average, which includes skills group sessions ($1,900+) and individual therapy sessions ($4,800+).

While treatment timelines also vary, the cost of DBT typically ranges between $100 to $200 per session. There are also many therapists that offer DBT virtually online, which is often more affordable than in person sessions.

DBT is frequently offered as part of inpatient and outpatient addiction treatment programs and therefore, included in the overall cost of rehab.

Insurance

Depending on your insurance plan, the cost of DBT treatment may be covered to a certain extent. The upfront costs could be significantly lower if the DBT provider is in-network for your insurance plan. Individuals may also receive coverage if DBT is part of a comprehensive addiction treatment program.

Under the Affordable Care Act (ACA) in the United States, substance abuse treatment must be covered under ACA insurance plans. ACA plans also can’t disqualify you for having a pre-existing substance use disorder or cap spending on addiction treatment. Many private medical insurance providers also offer addiction treatment coverage to varying degrees.

Other ways to pay for addiction treatment include the following:

Medicare and Medicaid: Those who qualify can get inpatient rehab covered, depending on the facility.
Financial aid and/or sliding scale payments: Some long-term drug rehab centers offer a sliding scale according to income.
Grants and subsidies: Some types of treatment are covered for certain populations. The Substance Abuse & Mental Health Services Association (SAMHSA) provides grants for drug addiction treatment and more. Additionally, tax credits and subsidized addiction treatment may be available, depending on the state.
Other health insurance: Veterans Affairs (VA) Health Care and other workplace health insurance plans may provide some coverage for long-term rehab.

When researching rehab options that include DBT treatment, consult your insurance provider to find out what kind of coverage is available.

What to Look for in a DBT Therapist

DBT treatment has grown in popularity and is available widely. With that said, it’s crucial that you look for a treatment provider that is certified by the Linehan Board of Certification (LBC).

The DBT-LBC program is the only developer-approved treatment program in the US. Other programs may not provide DBT providers with the necessary training to administer training effectively. Receiving treatment from a provider who is not certified may be unsuccessful and at worst, cause harm.

In addition to having the appropriate credentials and training, it’s important that a DBT therapist is a good overall fit for your treatment goals. Here are a few key questions to ask a therapist before treatment:

Educational background: Are they licensed to provide mental health therapy in this state or geographic area?
Advanced training: What advanced training have they completed in DBT?
Treatment structure: Do they offer individual and group DBT therapy?
Payment options: Do they offer a sliding scale of fees (I.e. based on a patient’s income)? If so, what is the range and how is it determined?
Insurance: Do they accept payment directly from health insurance plans?
Therapeutic specialities: Do they offer DBT only or do they use DBT interventions with other types of therapies? If so, what other therapeutic approaches do they use?

Critiques of DBT and Other Considerations

While there is substantial research that shows DBT is effective in treating substance abuse and co-occurring disorders, there are some limitations.

Time commitment: With the average program length being around 12 months, DBT requires a significant time commitment from both the patient and the therapist.
Skill learning. There are many different skills taught in DBT, therefore some people find it overwhelming. As a result, those who could benefit the most from DBT may find it overly complex and give up.
Homework: DBT requires homework, which may not be well suited to a wide range of people and learning abilities.
Structure: DBT is rigidly structured with strict boundaries that must be adhered to. This very structured approach may not be suitable for some people.
Trauma processing: There is no formal trauma processing in DBT, which means some people may need additional therapy to process traumatic experiences.
Eastern philosophies: Certain facets of DBT are derived from Eastern religious philosophies such as Zen Buddhism. Individuals whose Judeo-Christian faith plays a large role in their lives may struggle with some of the philosophies used in DBT.
Risky behavior: There’s a possibility that individuals may engage in increased risky behavior during DBT treatment. Therefore, DBT providers must be highly trained mental health professionals who can safely and effectively help patients navigate the therapy process.
Research: Most of the research included very small sample sizes of people with specific conditions such as BPD and did not indicate how long therapeutic benefits remained following treatment. Therefore, critics suggest that more long-term research should be done into the effectiveness of DBT treatment for people with complex and varied mental health conditions.

Get Help With DBT Today

If you or a loved one is struggling with addiction or a co-occurring mental illness, DBT treatment when combined with a comprehensive addiction treatment program can help provide a pathway to recovery. By focusing on mindfulness, emotional regulation, and distress tolerance, DBT can assist individuals in developing the necessary skills for a life free of addiction. If you need further information on DBT treatment, we’re here to help.

Dialectical Behavior Therapy (DBT): What It Is & How It Works