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Dialectical Behavior Therapy for Substance Use Disorder -What to Know

a person talks to a therapist

Dialectical Behavior therapy is a form of psychotherapy that treats patients with chronic or severe mental health illness. This form of therapy is often used on patients with substance use disorder because many patients with severe mental illness tend to have co-occurring substance abuse problems. The term dialectical is used to reference the dual integration of the often opposing concepts of situational acceptance and change. The foundation of Dialectical Behavior therapy is the goal of creating the route through which patients can find acceptance of the inevitable concept of change. This form of evidence-based therapy has proven successful for patients who have substance abuse issues that are coping mechanisms for other problems like severe depression or, very frequently, borderline personality disorder. While DBT was initially developed for individuals with deeper rooted mental health disorders, DBT is effective with working with individuals with sole substance use issues, as it helps in creating emotional regulation and distress tolerance tools. These skills are highly effective in helping manage cravings and highly stressful events. Dialectical Behavior Therapy can help to address addictions to everything ranging from alcohol or cigarettes to illegal drugs like heroin. The DBT methods used for mental illnesses other than addiction are the same that are used in treating substance abuse disorders. The techniques of skill building, personalized therapy, and group work can be highly effective for substance abuse problems as well. The primary model of Dialectical Behavior therapy is the Cognitive-Behavioral model, however, with Dialectical Behavioral Therapy, Eastern philosophical principles are used to enhance the Cognitive-Behavioral model. This model is founded on principles from behavioral and cognitive psychology about how thoughts and beliefs affect all other aspects of wellbeing. These guiding principles are the leading notions for creating Dialectical Behavior therapy strategies.

Cognitive and Behavior Theories

Dialectical behavior therapy is based upon the principles of both the cognitive and behavioral theories of psychology. The foundational concept of cognitive theory is one’s schema. The schema represents one’s internal conception of the world (i.e., one’s perspective) as well as a person’s thought and problem-solving pattern. The schema concept is important for therapy practices because it can reflect how a patient tends to react to change. If a person is not adaptable to change, they will adopt a situation in their mind to fit into their existing schema. On the other hand, if a person is more accepting of change, they will alter their schema and change their perspective based on the situation. Behavior theory is based on the idea that behavior is what is observable about what a person does, thinks, and feels. It subscribes to the notion that humans tend to seek pleasure rather than pain, and that behavior is learned. Under this assumption, behavior is changeable, however, it can be a very difficult aspect of the therapy process. Using the behavior theory in therapy usually includes reinforcements and punishments for good or bad behavior. In addition, therapists are usually encouraged not to dwell on the deeper meanings behind behaviors, but rather to proceed based on the simplest explanation and focus energy more on changing what is presently occurring in the behavior pattern.

DBT Techniques for Substance Abuse

There are a lot of components that make up dialectical behavior therapy techniques, and many of them are found useful in cases of healing substance abuse problems. The primary method of DBT is one-on-one therapy with a patient’s individual therapist. However, other methods like group therapy or telephone consultations may also be utilized. The general focus of these therapy sessions is usually to improve the patient’s ability to change and the patient’s level of acceptance of their situation. In the case of substance use disorder, methods like group therapy can be especially impactful when it comes to building up a client’s internal sense of emotional strength.

Individual Therapy

Individual in-person therapy sessions are primarily focused on skill building based off the individual patient needs. Each patient will have different areas of need and different coping mechanisms for their poor behaviors relating to change. In other words, each person with a substance use disorder will have different triggers that cause them to react by abusing a substance. The skill building aspect usually centers around improving coping abilities and trying to improve a patient’s relationship with change in order to improve their behaviors. Individual therapy tends to be the first and most crucial step in the DBT process for many clients. Therapists usually have to work hard in the early stages to keep the patient engaged in therapy without dropping their commitment. With patients who substance abuse, therapists often have to design a backup plan to have in place (such as telephone numbers and addresses where they may be found) if the client becomes “lost” and stops engaging in therapy sessions.


Another method that can be used within the Dialectical Behavior Therapy framework is coaching over the phone. The phone coaching can allow therapists to help patients work through everyday situations or in the case of an emergency situation. This form of coaching aims at strengthening a patient’s ability to handle situations that might be points of stress for them. For some patients who struggle with relapse or fear that they may relapse, having the phone access to a coach in emergency situations can be beneficial.

Group Therapy

Group therapy is another valuable addition to the dialectical behavioral therapy process. Usually focused on skills-training, the group therapy system focuses on four modules. The four categories include mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance. These areas may be better addressed in a group setting rather than solely relying on the individual therapy sessions. The group setting tends to facilitate stronger skill building.


Dialectical Behavior interventions involving someone with substance abuse happen in five stages. The first stage of the intervention is about assuring that the client is committed to healing and working through their substance use problem. The next stage focuses on shifting the patient from feeling out of control to having a grasp on their behavior. Next, traumatic memories and past abuses are confronted in order to heal from negative experiences. In the fourth stage, the client works on developing self respect and autonomy after being in the period of more intensive therapy. Finally, the last stage is all about the client achieving a sense of a fulfilled and happy life.

Behavioral Targets for Substance Abusers

The goals of using DBT for substance abuse problems are focused on an array of behavioral changes. Primarily, the therapy aims to decrease the abuse of all substances that are a problem with the client. In addition, it is important to alleviate discomfort associated with abstinence (i.e. withdrawal symptoms) and diminish the cravings for the substance. Another aspect of the therapy is to eliminate situations and people that may lead to relapse. For example, ending relationships with people associated with the drugs like dealers or bad influencers. It is also important to emphasize community reinforcement of good behavior and a substance-free lifestyle. This is done by fostering new positive relationships and becoming involved in healthier communal activities.

Dialectical Behavior Therapy and Abstinence

Promoting abstinence from substances is a very significant component of DBT when it comes to treating substance abusers. Like many other aspects of DBT, this focuses on coping well with change. Many therapists using DBT have the patient choose small intervals to use abstinence so that the goal feels achievable. They may start the client off by trying one day or even just one hour, without using the substance. This allows the patient to slowly become acclimated to the idea of not using the substance without overstretching their comfort zone all at once. Eventually, the goal is to continue the abstinence pledge indefinitely, when the patient is strong enough to make that promise to themselves. However, if a patient does relapse, DBT therapists like to focus on helping them use the incident to learn what their behavioral triggers might be and to not see the incident as a permanent failure.  

Treating Self Harm Behaviors

Many clients with substance addiction or abuse also deal with suicidal or self-injuring tendencies as well. A crucial part of the DBT process is addressing these behaviors and tendencies in order to optimize the patient’s progress. Many times, the patient has to address these issues first or in direct conjunction with the substance abuse problem because they must first gain respect for their body. The patient needs to first be willing to stop self-harming on all levels, and they need to accept that substance use is another form of this self-harming behavior. Acceptance of the need for change is a critical element of Dialectical Behavior Therapy.

Healing with APEX Recovery

At APEX Recovery, there is a wide range of therapists and trained professionals that are equipped to design the right healing path for each individual patient with substance use disorder. Because Dialectical Behavior Therapy can be implemented in so many different ways, APEX caregivers are prepared to adapt and tailor therapy programs based on each client’s needs. With APEX Recovery therapy programs, there is hope for a brighter future and programs that make recovery a very achievable goal.

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