Exploring DBT in the treatment of drug addiction

While the physical and social consequences¹,² of addiction are widely recognised³, its emotional landscape is often less openly discussed – and yet, it is here that some of the most entrenched challenges reside.

At the heart of many addictive behaviours lies challenges associated with emotional regulation: the ability to recognise, tolerate, and modulate intense affective states. Research consistently shows that individuals with substance use disorders are significantly more likely to exhibit symptoms of affective instability, emotional lability, and chronic distress⁴. In one large-scale population study, up to 43% of those currently in SUD treatment (for nonmedical use of prescription painkillers) also experienced mental health disorders, particularly depression and anxiety⁵.

Similarly, approximately one-in-four (potentially as high as 29%) of individuals with one or two anxiety disorders exhibit signs of at least one SUD⁶ – with this figure rising to 46% or more for individuals with three anxiety disorders.

The relationship is often cyclical. Emotional pain – whether stemming from trauma, attachment disruption, or ongoing psychological stress – may prompt the use of substances as a means of self-soothing or escape⁷. Over time, these behaviours reinforce maladaptive coping strategies and further erode an individual’s internal capacity to regulate mood or respond to stress adaptively.

Within this emotional terrain, therapeutic models that address the underlying emotional and cognitive drivers of drug addiction are increasingly being recognised as both valid and effective⁸. It is in this context that Dialectical Behaviour Therapy (DBT) – originally developed for individuals with severe emotional dysregulation⁹ – has garnered growing recognition in the treatment of drug addiction.

DBT – origins and clinical principles

Dialectical Behaviour Therapy (DBT) was developed in the late 1980s by psychologist Marsha M. Linehan¹⁰, chiefly as a response to the limitations of traditional Cognitive Behavioural Therapy (CBT) when applied to individuals with chronic emotional dysregulation – especially those with borderline personality disorder (BPD). 

Over time, DBT has demonstrated efficacy across a broad range of high-risk behaviours, including self-harm, suicidality, and substance use disorders¹¹. At its core, Dialectical Behaviour Therapy integrates two seemingly opposing strategies: acceptance and change. It teaches individuals to accept themselves and their current emotional state while simultaneously working toward healthier behavioural choices¹². This duality – the “dialectic” – underpins every aspect of DBT’s design.

Core principles of DBT

DBT is a modular, skills-based treatment grounded in both behavioural science and mindfulness practice. It consists of four primary domains:

Together, these components work to enhance behavioural control, improve emotional stability, and reduce maladaptive coping strategies. This renders DBT particularly suited to individuals for whom substance use has become an entrenched form of emotional regulation.

A structured, evidence-based framework

Unlike some talk therapies, DBT is often more structured and manualised¹⁴, typically delivered (at the discretion of a clinician) through a combination of:

• Individual therapy (to target personalised treatment goals)
• Group skills training (to teach and reinforce DBT modules)
• Phone or virtual coaching (for in-the-moment support and skills generalisation)
• Therapist consultation teams (to ensure clinician adherence and mitigate burnout)

This integrated, multi-pronged approach is especially valuable in treating clients with complex presentations, such as dual diagnoses or high relapse risk. The flexibility and replicable structure of DBT also make it suitable for residential addiction treatment settings, where consistency and skill reinforcement are essential to long-term recovery.

DBT for drug addiction

While DBT was not initially developed to treat substance use disorders, its application to drug addiction has grown steadily in recent decades – with mounting evidence¹⁵ supporting its effectiveness in treating clients with co-occurring emotional dysregulation and substance misuse.

Substance use (particularly in cases involving opioids, stimulants, or sedatives) is often an attempt to escape, numb, or control overwhelming emotional states¹⁶. In this context, drug use becomes a form of maladaptive emotion regulation¹⁷: a behavioural pattern that aligns precisely with DBT’s therapeutic targets.

Through the teaching of more adaptive ways to tolerate distress, regulate emotions, and navigate interpersonal stressors, DBT addresses the underlying drivers of drug use, rather than simply focusing on abstinence. This makes it especially useful for individuals who:

• Experience impulsivity and self-destructive behaviour
• Experience intense shame, self-criticism, or emotional volatility
• Have a history of trauma, attachment difficulties, or invalidating environments
• Present with dual diagnoses, such as borderline personality disorder, PTSD, or mood disorders

In these populations, DBT has been shown to reduce relapse rates, increase treatment retention, and significantly improve emotional functioning¹⁸-²⁰. DBT for substance use – sometimes referred to as DBT-SUD – maintains the foundational structure of standard DBT, but includes additional strategies tailored to addiction recovery.

The DBT-SUD model²¹ recognises that relapse is not failure, but an opportunity to build skills and insight; a key philosophical departure from punitive or abstinence-only frameworks.

Suitability for high-profile individuals

For high-level professionals, public figures, or elite performers, the emotional costs of substance use often extend beyond physiological dependence²². The stigma, secrecy, and fear of reputational damage may deepen shame and hinder help-seeking.

DBT’s discreet, evidence-based, and skills-focused nature could be particularly beneficial in these contexts. For example, a senior c-suite executive whose stimulant use masks burnout and perfectionism may benefit from emotion regulation and mindfulness strategies, to enhance resilience and clarity under pressure.

Delivered within a confidential, one-to-one therapeutic alliance, DBT allows clients to preserve their privacy while receiving robust, clinically grounded care.

Integration with multidisciplinary and personalised treatment pathways

Drug addiction seldom exists as a standalone condition²³. It often intersects with complex emotional, psychological, social, and physiological factors: from early attachment trauma and affective disorders to chronic stress, neurodivergence, or underlying pain conditions. 

As such, truly integrated care extends beyond symptom suppression or detoxification, and engages the whole person within their full clinical and personal context.

At its most effective, DBT is not delivered in isolation. Instead, it is curated within a multidisciplinary care pathway that combines psychiatric, psychological, somatic, and behavioural interventions. 

Depending on an individual’s profile, this may include:

• Psychopharmacological input: to manage co-occurring mood, anxiety, or sleep disorders
• Trauma-focused therapies: such as EMDR or sensorimotor psychotherapy for clients with developmental or acute trauma histories
• Functional medicine or neuropsychology: where substance use is linked to executive dysfunction or neurological insult²⁴
• Medical monitoring and harm reduction strategies: particularly in clients withdrawing from alcohol, benzodiazepines, or opioids
• Family and systemic therapy: when relational dynamics are central to the client’s presentation

In this setting, DBT offers a stable therapeutic scaffold: a structured, evidence-led framework that supports emotional regulation and behavioural change, while complementary interventions address other axes of distress. 

DBT, as part of the substance addiction toolkit

Often, substance abuse disorders include matters of self-regulation, relationship, and relief, in addition to the dependency itself. Dialectical Behaviour Therapy offers a structured, evidence-based pathway toward enduring recovery, helping individuals replace self-destructive coping with meaningful, adaptive strategies.

When embedded within a tailored, clinically rigorous treatment plan, DBT acts as a bridge; enabling a reconnection to self-agency, resilience, and an enhanced sense of wellbeing.

References

1. https://www.medicalnewstoday.com/articles/effects-of-drug-abuse
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC4158844/
3. https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/addiction-health
4. https://pmc.ncbi.nlm.nih.gov/articles/PMC10087816/
5. https://www.ncbi.nlm.nih.gov/books/NBK571451/
6. https://www.sciencedirect.com/science/article/abs/pii/S0887618507002058
7. https://pmc.ncbi.nlm.nih.gov/articles/PMC6837512/
8. https://www.sciencedirect.com/science/article/pii/S0376871616001174
9. https://www.britannica.com/topic/dialectical-behaviour-therapy
10. https://psychiatryonline.org/doi/10.1176/appi.psychotherapy.2015.69.2.97
11. https://pmc.ncbi.nlm.nih.gov/articles/PMC2963469/
12. https://www.yalemedicine.org/conditions/dialectical-behavior-therapy-dbt
13. https://www.psychologytoday.com/gb/blog/being-your-best-self/202203/the-healing-power-of-radical-acceptance
14. https://pubmed.ncbi.nlm.nih.gov/21496511/
15. https://pmc.ncbi.nlm.nih.gov/articles/PMC2797106/
16. https://pmc.ncbi.nlm.nih.gov/articles/PMC2732004/
17. https://www.psychologytoday.com/gb/blog/understanding-addiction/202107/is-emotion-regulation-the-key-to-addiction-prevention
18. https://pmc.ncbi.nlm.nih.gov/articles/PMC2797106/
19. https://pubmed.ncbi.nlm.nih.gov/17376574/
20. https://pmc.ncbi.nlm.nih.gov/articles/PMC6875843/
21. https://www.sciencedirect.com/science/article/abs/pii/B9780128163849000075
22. https://www.businessinsider.com/sober-celebrities-who-dont-drink-do-drugs
23. https://www.nature.com/articles/s41386-020-00950-y
24. https://www.sciencedirect.com/science/article/abs/pii/S0022510X20300472