Treatment Corner: Dialectical Behavioral Therapy

Dialectical Behavioral Therapy, DBT was developed by Dr. Marsha Linehan in the late 1980s and early 1990s. Dr. Linehan developed DBT in response to the challenges she encountered working with people who were chronically suicidal. Her primary goal was to help people develop
“a life worth living.”

Behavioral therapies were common in the 1970s, and Dr. Linehan found the emphasis on changing behaviors limiting. She observed that many of her clients were extremely sensitive to criticism, including prompts to change their behaviors. They would shut down emotionally or act out in negative and sometimes destructive ways. Many seemed equally distressed when asked to accept and tolerate external circumstances and difficult emotions.

Dr. Linehan developed DBT to add the concepts of validation/acceptance and dialectics (opposites) to the Cognitive Behavioral Therapy framework. In DBT, validation is used to offer an understanding client’s unhealthy action choices.  Validation allows the client to feel heard and understood; it is not to permit or encourage unwanted behaviors. DBT prompts acceptance of unhealthy behaviors and circumstances through validation with the understanding that acceptance (versus resistance and avoidance) is necessary for change.  Acceptance and change are seen as unified opposites that bring balance when brought together.

Individual therapy, group sessions, and between-session telephone consultations are parts of the DBT therapeutic approach. This is a comprehensive model that addresses needs and issues based on the impact they have on the client’s life. Issues are prioritized as follows:

  1. Very serious or life-threatening issues like suicidality or significant substance use issues like intoxication or overdose;
  2. behaviors and actions that are counterproductive to therapeutic improvement, like ongoing substance use, missing sessions, being late, or being disruptive in groups;
  3. factors that increase quality of life, like relationship, communication, and employment issues; and
  4. skill development focusing on behaviors and activities that counter unhealthy behaviors.

DBT was not initially developed to address substance use disorders, but clients who struggle with emotional dysregulation issues often use and abuse substances in addition to other forms of self harm. Dr. Linehan and others have completed research supporting DBT as a treatment protocol for substance use disorders. This intervention is most useful when substance use is motivated by emotional dysregulation, when the client has been chronically suicidal, or when the substance use disorder is co-occurring with Borderline Personality Disorder.

When a serious substance use disorder is the primary issue, abstinence is emphasized from the start of therapy. To improve self-efficacy, clients are encouraged to look at abstinence in achievable chunks, an idea that is similar to the “one day at a time” philosophy in 12-step formats. Clients are also taught to “cope ahead” by deliberately looking for future, potential high-risk situations and planning coping strategies in advance. Further, in DBT, relapse is addressed as an accepted (not preferred) part of the treatment process and is treated as a problem to be solved rather than an indication of failure or personal deficiency. The concept of “failing well” is emphasized; the client is encouraged to analyze what happened with an eye toward problem-solving for the future. There is an aim toward quick recovery, which includes a return to abstinence, mitigation of negative self-talk and self-harming behaviors, and repairing any relationships that may have been damaged during the relapse.

Dialectical Behavioral Therapy is a comprehensive, multi-level therapeutic modality.  While it wasn’t initially developed for the treatment of substance use issues, it is a powerful clinical intervention in many cases. If you or someone you love needs help with substance use and especially if you have a history of suicide attempts, high levels of emotional dysregulation, or a diagnosis of Borderline Personality Disorder, finding a therapist with specific training in DBT or a treatment center with DBT therapists and programming is a great start.DBT is a powerful clinical modality that can be combined with motivational techniques, appropriate pharmacotherapy, other forms of psychotherapy, and the 12-step philosophy to create a strong recovery package.

You can search for a board-certified DBT therapist at the DBT Linehan Board Certification website.  If you are looking for residential or outpatient treatment for substance use disorders, you can ask if DBT is a part of their programming. Call the National Helpline at 1-800-662-HELP or visit to get assistance locating treatment centers near you.