Dialectical Behavior Therapy Implications for Substance Abuse 

By N.I. D.A. | Published 03/20/2006 | 

 

 

 

N.I. D.A. 

The National Institute on Drug Abuse was established in 1974, and in 1992 became part of the National 
Institutes of Health, Department of Health and Human Services. The Institute includes various programs on drug 
abuse research. 


Dialectical Behavior Therapy for Treatment of Borderline Personality Disorder: 

Implications for the Treatment of Substance Abuse 

By Marsha M. Linehan 

The purpose of this chapter is to describe a behavioral treatment approach designed specifically for 
chronically parasuicidal individuals meeting criteria for borderline personality disorder (BPD). 

Both the overlap between substance abuse and BPD as well as common correlates between the two 
disorders suggest that Dialectical Behavior Therapy (DBT), in whole or in part, might be effective as a 
treatment for substance abuse in general and for substance abusers who also meet criteria for BPD in 
particular. 

The chapter will first give a brief overview of the overlap between substance abuse and BPD. Second, it 
will describe the central elements of a broad-band, behaviorally based treatment (DBT) for BPD. 

Finally, it will briefly describe the empirical evaluations of the effectiveness of this treatment regime. 

BORDERLINE PERSONALITY DISORDER AND SUBSTANCE ABUSE 

Overlap 

Impulsiveness in areas that are potentially self-damaging is part of the criteria for BPD. Substance abuse 
counts as half of this criterion in both DSM-III-R (American Psychiatric Association 1987) and DSM-IV 
(American Psychiatric Association Task Force on DSM-IV 1991). 

Thus, it is not surprising that, compared with individuals with all other personality disorders (except 
antisocial disorder) and with psychiatric patients with no personality disorders, individuals meeting criteria 
for BPD score higher on substance abuse scales (Pitts et al. 1985; McCann et al. 1992), more commonly 
report a history of substance abuse (Akiskal et al. 1985), and also meet criteria for current substance 
abuse (Loranger and Tulis 1985; Zanarini et al. 1989; Dulit et al. 1990; Koenigsberg et al. 1985). 

In the study conducted by Zanarini and colleagues (1989), 84 percent of 50 borderline outpatients had 
met criteria for substance abuse/dependence at some point in their lives. In the study conducted by Dulit 
and coworkers, 67 percent of BPD patients met criteria for substance abuse disorder. 

When substance abuse was not used as a criteria for BPD, the incidence dropped to 57 percent, still a 
significant portion of the population. Koenigsberg and colleagues (1985), reporting on a sample of 2,462 
inpatients and outpatients, found that 21 percent of borderline patients had a primary Axis I diagnosis of 
substance abuse. 

Furthermore, two studies suggest that BPD individuals are more likely to be polydrug abusers, usually 
combining drug and alcohol abuse, than are non-BPD individuals (Kosten et al. 1989; Nace et al. 1983). 
The high incidence of substance abuse among borderline individuals suggests that, at least some of the 
time, patterns diagnosed as indicative of BPD may be better viewed as sequelae of substance abuse 
patterns. 

Indeed, Zweben and Clark (1990-1991) argue that the overlap between substance abuse and BPD may 
be a result of correlates and consequences of substance abuse that masquerade as BPD symptoms. 




For example, they note that instability of mood, inappropriate expression of anger, chaotic interpersonal 
relationships, impulsiveness, and persistent feelings of emptiness or boredom (all criteria for BPD) are 
characteristic patterns found among serious substance abusers and may clear up with sufficient 
abstinence. 

However, although the BPD-substance abuse overlap is substantial, not all substance abusers meet 
criteria for BPD. In a study of 64 female psychiatric outpatients meeting criteria for substance abuse, 
Vaglum and Vaglum (1985) found that 66 percent also met criteria for BPD. 

In a more restricted sample, Nace and colleagues (1983) found that 13 percent of 94 consecutive 
admissions to an alcohol treatment program also met criteria for BPD. Tousignant and Kovess (1989) 
found that one-third of substance abusers showed a high number of BPD traits. 

BPD substance abusers, however, are uniformly more disturbed than those abusers who do not meet 
criteria for BPD. Studies have shown that they are more commonly comorbid for depressive disorders, 
have more frequent suicide attempts and accidents, and score higher on impulse dyscontrol and 
antisocial tendencies and lower on reality testing (Kosten et al. 1989; Inman et al. 1985). 

Of particular interest for treatment is the overlap between suicidal behaviors and both substance abuse 
and BPD. Suicidal behaviors, including threats, “gestures,” and suicide attempts, represent one of the 
eight (or nine in DSM-IV) criteria for BPD. Parasuicidal behavior (all acute, intentional, nonfatal, self-
injurious behavior, including suicide attempts) has been called the behavioral specialty of BPD 
(Gunderson 1984). 

Although much of this behavior is without lethal intent, the percentage of those followed after an index 
treatment who eventually die by suicide is at least 5 to 10 percent (Stone et al. 1987; Paris et al. 1987; 
Frances et al. 1986). 

Similarly, substance abuse is associated with an increased risk of suicidal behaviors, including both 
completed suicides and parasuicide (see Lester 1992). Roy and Linnoila (1986) estimated that 18 percent 
of alcoholics subsequently complete suicide. What is not clear at this point is whether the high rate of 
suicidal behaviors among substance abusers is mediated by the concomitant BPD associated with the 
substance use disorders. 

Achieving treatment success with both BPD and substance abuse has been notoriously difficult. Although 
there have been few randomized controlled trials investigating treatment for BPD, followup studies of 
individuals who have received substantial inpatient and outpatient psychiatric care suggest that current 
treatments are marginally effective at best when measured 2 or 3 years following treatment (Perry and 
Cooper 1985; Tucker et al. 1987). 

In contrast, there have been many controlled trials of treatments for both alcohol and drug abuse. 
Although efficacy of treatments has been demonstrated, lasting positive outcomes have been difficult to 
achieve (Marlatt and Gordon 1985; Miller and Rollnick 1991). 

Substance abuse combined with BPD may be particularly difficult to treat. Nace and colleagues (1985) 
reported that at several years following treatment for substance abuse, these individuals have more 
severe problems remaining than do non-BPD substance abusers. 

OVERVIEW OF DBT 

DBT was developed from a combined motivational and capability deficit model of BPD. The idea was 
twofold: (1) borderline individuals lack important interpersonal, self-regulation (including emotional 
regulation), and distress tolerance skills, and (2) personal and environmental factors inhibit the use of 
behavioral skills that the individual does have and often reinforce inappropriate borderline behaviors. 

The emphasis on capability enhancement is similar to that in substance abuse treatment models that 
stress relapse prevention (Marlatt and Gordon 1985). The emphasis on changing motivational factors is 
similar to the motivational interviewing proposed by Miller and Rollick (1991) and to aversive conditioning 
models (although DBT provides a greater emphasis on reinforcement than on punishment). 

DBT presumes that attention to both skill acquisition and behavioral motivation is essential. In developing 
the treatment, however, it quickly became apparent that (1) skill training to the extent believed necessary 




is extraordinarily difficult, if not impossible, within the context of a therapy oriented to reducing the 
motivation to die or act in a borderline fashion, and (2) sufficient attention to motivational issues cannot be 
given in a treatment with the rigorous control of therapy agenda needed for skill training. 

From this, the idea developed to split the therapy into three components, one that focuses primarily on 
skill acquisition, one that focuses primarily on motivational issues and skill strengthening, and one 
designed explicitly to foster generalization of skills to the everyday life outside the treatment context. 

The three modes in standard outpatient DBT are psychosocial groups (for skill training), individual 
psychotherapy (addressing motivational issues and skill strengthening), and telephone contact with the 
individual therapist (addressing generalization). 

Within each treatment mode, DBT is characterized by a philosophy of dialectics, a biosocial theoretical 
perspective, a hierarchy of treatment targets specific to the mode, and a set of treatment strategy groups. 
Space here is too brief to give a detailed description of each component of the treatment. 

The interested reader is referred to the treatment manual and associated updates (Linehan, 1993a, 
1993b). 

Theoretical Base 

As one might suppose from the title of the treatment, DBT flows from a dialectical philosophical position. 
“Dialectic” is used here in two contexts, that of persuasive dialogue and relationship and that of the 
fundamental nature of reality. 

From the point of view of dialogue and relationship, it refers to change by persuasion and by making use 
of the opposition inherent in the therapeutic relationship, rather than by formal impersonal logic. 

Thus, unlike analytical thinking, dialectics is personal, taking into account and affecting the total person, 
and it does not seek absolute truth but instead attempts to facilitate the construction or evolution of truth 
over time. 

As a world view, dialectics convey these coexisting multiple tensions that must be addressed within the 
therapeutic relationship, as well as the emphasis in DBT on (1) a systems perspective (asking always, 
“What is being left out of our understanding here?”), (2) searching for synthesis and balance (to replace 
the rigid, often extreme, and dichotomous response characteristics of suicidal and borderline patients), 
and (3) enhancing comfort with ambiguity and change, which are viewed as inevitable aspects of life. 

The overriding dialectic for the therapist is the necessity of acceptance of the patient as he or she is within 
the context of simultaneously trying to produce change. Treatment strategies are polarized into those 
most related to acceptance and those most related to change, although it is this very polarization that is 
the mot of many therapeutic failures. 

DBT requires that the therapist balance use of these two types of strategies within each treatment 
interaction. The author has proposed elsewhere (Linehan 1993a) that BPD is primarily a systemic 
disorder of emotion regulation. 

Characteristics of this dysregulation include a high sensitivity to emotional stimuli, intense response to 
even low-level stimuli, and a slow return to baseline combined with an inability to modulate emotional 
states. 

Borderline behavioral patterns either function to remediate negative emotional arousal directly (a view 
similar to one that sees substance abuse as self-medication) or indirectly (e.g., by eliciting help from the 
environment) or are inevitable outcomes of unregulated and unstable emotionality. In short, borderline 
patterns either are attempts to solve problem emotions or are problematic sequelae, either of the initial 
emotions or of the dysfunctional attempts to reduce emotionality. 

The author has further hypothesized that this pattern of dysregulated emotion and behavior is a result of 
an initial temperamental disposition to emotionality, and perhaps inadequate modulation, combined with 
an invalidating rearing environment. 

Such an environment is characterized by a tendency to disregard emotional experiences, especially 




negative ones, and oversimplify the ease of solving difficult problems, and it puts a high value on positive 
thinking. Although such attitudes are certainly beneficial for some, if not most, this type of environment 
invalidates the experiences of vulnerable individuals and does not take seriously their communications, 
especially when such communications have to do with nonpublic events and with difficulties in meeting 
social expectations. 

Invalidating environments, especially physically and sexually abusive families, contribute to the 
development of emotion dysregulation and fail to teach the child how to label and regulate arousal, how to 
tolerate emotional distress, and when to trust one’s own emotional responses as reflections of valid 
interpretations of events. 

At the adult level, borderline individuals adopt the characteristics of the invalidating environment. Thus, 
they tend to invalidate their own affective experiences, look to others for accurate reflections of external 
reality, and oversimplify the ease of solving life’s problems. 

This oversimplification leads inevitably to unrealistic goals, an inability to use reward instead of 
punishment for small steps towards final goals, and self-hate following failure to achieve these goals. The 
shame reaction, a characteristic response to uncontrollable and negative emotions among borderline 
individuals, is a natural result of a social environment that “shames” those who express emotional 
vulnerability. 

These two polar extremes, vulnerability versus invalidation, represent the central dialectical dilemma of 
the borderline patient and therapist. 

Treatment Targets 

Treatment targets for individual DBT therapy and for DBT as a whole are the same and are hierarchically 
arranged as follows: 

1. Reducing high-risk suicidal behaviors (parasuicide and high-risk suicide ideation and plans); 

2. Reducing therapy-interfering behaviors-all responses or behaviors of both the patient and the therapist 
that make therapy progress or continuation difficult (e.g., missing or coming late to sessions, phoning at 
unreasonable hours, refusing to collaborate or work in sessions, remaining interpersonally aloof or too 
clinging, invalidating the other, and not returning phone calls); 

3. Reducing behavioral patterns serious enough to substantially interfere with any chance of a reasonable 
quality of life (serious substance abuse would qualify here); 

4. Behavioral skill acquisition (skills in emotion regulation, interpersonal effectiveness, distress tolerance, 
and selfmanagement, as well as a number of “core” [mindfulness] abilities to observe, describe, 
participate spontaneously, be nonjudgmental, focus awareness, and focus on effectiveness); 

5. Reducing posttraumatic stress responses related to previous traumatic events; 

6. Increasing self-respect; and 

7. Meeting other goals of the patient. 

With respect to each target, the task of the therapist is first (and many times thereafter) to elicit the 
patient’s collaboration in working on the target behavior, then to apply the relevant treatment strategies 
described below. 

Attention to each target within individual therapy, ordinarily involving direct and focused work on the 
behaviors relevant to the target, is jointly determined by the hierarchy list above and by the behaviors and 
problems that have surfaced since the last session or during the current session. Thus, treatment is 
oriented to current behaviors. 

Therapy is somewhat circular in that target focal points revolve over time. The hierarchy of targets (i.e., 
what is attended to) is somewhat different in group skills training and in phone calls. In skills training, as 
one might imagine, skills acquisition is the top priority. 




The only behaviors that would take precedence are behaviors that threaten to destroy skills training (e.g., 
aggression toward other group members or not coming to sessions). 

Behavioral skills are taught in modules concentrating on mindfulness skills (observation, description and 
spontaneous participation, nonjudgmentalness, focused attention, and “doing what works”), interpersonal 
effectiveness for conflict situations, emotion regulation, and distress tolerance. 

During telephone calls, generalization of skills is the top priority, preceded only by threats to the patient’s 
life. Thus, during phone calls the focus is always on, “What skills could you use here?” 



 

Treatment Strategies 

DBT addresses all problematic patient behaviors and therapy situations in a systematic, problem-solving 
manner that includes conducting a collaborative behavioral analysis, formulating hypotheses about 
possible variables influencing the problem, generating possible changes (behavioral solutions), and trying 
out and evaluating the solutions. 

The context for this analysis- and solution-oriented approach is that of validation of each patient’s 
experiences, especially as they relate to the individual’s vulnerabilities and sense of desperation. In 
standard outpatient DBT, individual therapy sessions meet weekly for 60-90 minutes. 

During the first year of therapy, all patients attend the weekly 2- to 2½-hour weekly skills training class. 
Phone calls for extra coaching between sessions are encouraged and are accepted within the therapist’s 
personal limits. 

There are five strategy groups that are combined to deal with specific problematic situations. Not all 
strategies are necessary or appropriate for a given session; the pertinent combination may change over 
time, and the emphasis on particular strategies varies depending on mode of treatment. These are more 
fully described in the treatment manual (Linehan 1993a, 1993b). 

Dialectical strategies are woven throughout all treatment interactions and involve both a focus upon the 
dialectical issues in the therapistpatient relationship as well as promotion of dialectical thought on the part 
of the patient. 

The primary dialectical strategy is the balanced therapeutic stance described above. Thus, the constant 
attention to combining acceptance with change is the essence of the dialectical strategy. The goal is to 
bring out the opposites both in therapy and the patient’s life and to provide conditions for syntheses. The 
key idea guiding the therapist’s behavior is that, for any point, an opposite position can be held. 

Thus, synthesis and growth require a continuous search for what is being left out in both the therapist’s 
and patient’s current ordering of reality and then assisting the patient to create new orderings that 
embrace and include what was previously excluded. 

The therapist helps the patient move from “either-or” to “both-and.” Strategies include extensive use of 
stories, metaphors, myths, and paradoxes; the therapeutic use of ambiguity (i.e., removing ambiguity is not 
necessarily a goal); drawing of the patient’s attention to the fact of reality as constant change as well as the 
nonavoidance of change in the therapeutic conditions; cognitive challenging and restructuring techniques; 
and reinforcement for use of intuitive, nonrational knowledge bases. 

Dialectical strategies, especially a dialectical framework on the part of the therapist, are essential in every 
interaction with the patient and also inform the treatment supervision and staff meetings. Core strategies 
consist of the balanced application of validation and problem-solving. 

Validation requires the therapist to search for, recognize, and reflect the current validity, or sensibility, of 
the individual’s response. Pointing out how a response was functional in the past but is not now is 
invalidating, not validating. 

Nor is validating simply building up self-esteem, although cheerleading – focusing on the strengths of the 
individual and believing in the individual no matter what - is an important part of validation. If a person says 
that he or she is stupid, saying that the person is smart invalidates the experience of being stupid. 




The therapist invalidates the patient’s comment if he or she interprets it as indicative of the patient’s 
experiences in similar relationships in which hostility may have been the norm, rather than searching 
openly for his or her own behavior that might actually communicate anger. 

The essence of validation is the communication that a response is understandable in the current context. 
At times, it is like searching for a speck of gold in a cup of sand. Not every part of a response is valid, nor 
is that which is invalid ignored. 

However, enough valid responses (or parts of responses) can be found that validating is done in every 
interaction. 

Problem-solving strategies are a two-stage process involving, first, an acceptance of the problem at hand 
and, second, an attempt to generate, evaluate, and implement alterative solutions that might have been 
made or could be made in the future in similar problematic situations. 

The acceptance stage employs both insight and behavioral analysis strategies; the second stage, targeting 
change, employs solution analysis, commitment, and orientation to change and treatment plans. 

Behavioral analysis requires a very detailed chain analysis of the events and situational factors leading up 
to and following the particular problematic response at hand. Insight strategies, no more different here than 
in other treatment approaches, include observing and labeling patterns of behavior and situational 
influence over time. 

The behavior analysis strategy is repeated for every instance of targeted problem behaviors until the 
patient achieves an understanding of the stimulusresponse patterns involved. The second stage requires 
the generation of alternate response chains (i.e., adaptive solutions to the problem) as well as an analysis 
of the individual’s response capabilities. 

This process usually leads into skills training and work on motivation through attention to reinforcement 
contingencies, therapeutic exposure to reduce emotions inhibiting functional behavior, and changing of 
cognitions that lead to dysfunctional behaviors. There are three case management strategies designed to 
guide each therapist during interactions with individuals outside the therapy dyad. 

The consultation/supervision strategy requires that each DBT therapist meet regularly with a supervisor or 
consultation team. DBT is designed as a treatment of a community by a community. 

Thus, in most settings this strategy will dictate a weekly meeting of all therapists applying DBT. The 
treatment specifies a number of guidelines for conducting these meetings. The consultant-to-the-patient 
strategy is simple in concept but very hard to carry out. The strategy is the application of the principle that 
the DBT therapist teaches patients how to interact effectively with their environment rather than teaching 
the environment how to interact with the patients. 

As a general norm, DBT therapists do not intervene to adjust environments for the sake of the patient, nor 
does the DBT therapist meet or consult with other professionals about how to treat the patient unless the 
patient has an active part in it. 

This strategy represents a point of view that looks at adversity and “bad” treatment of the patient by the 
environment (including other professional helpers) as an opportunity for practice and learning. From 
another perspective, it views the role of the therapist as teaching the patient to adjust to the world as it is, 
with all its problems and inequities. 

Patients are dealt with as responsible parties in their interactions with others. A key aspect of the strategy, 
of course, includes a definition of who the therapist is. For example, on an inpatient unit, the entire staff 
might be deemed the “therapist.” 

However, even within the staff, application of the strategy is possible. It simply requires that each 
therapeutic agent be responsible for his or her own behavior and not each other’s Thus, it is not the job of 
one therapist to defend another therapist, nor is treatment consistency particularly valued in DBT. 

As in the real world, rules may change depending on who is enforcing them. Although patients not present 
are discussed in staff meetings, the goal is to obtain information, not necessarily to influence or change the 




other therapist. 

The information then is used in working with the patient. (One can immediately see why that is easy in 
concept and difficult in practice! Humility is a requisite for this strategy not to go astray.) The exception to 
the consultant strategy is in the following circumstance: the patient does not have the requisite capability 
(or sometimes willingness) to influence the environment, the immediate outcome is very important, and the 
therapist can influence it. 

In this instance, the therapist uses the environmental intervention strategies to effect immediate changes 
that are both essential and that the patient cannot yet produce. For example, the therapist will consult with 
emergency room staff about medications taken by an uncommunicative patient who overdosed, send 
required treatment plans to insurance companies, and possibly go and pick up a teenager trying to come to 
a session whose car breaks down. 

In DBT, the therapist balances two communication strategies that represent rather different interactional 
styles. The modal style is the reciprocal strategy that includes responsiveness to the patient’s agenda and 
wishes, warmth, and self-disclosure of personal information that might be useful to the patient as well as 
immediate reactions to the patient’s behavior. 

Reciprocity is balanced by an irreverent communication style that is characterized by a matter-of-fact 
attitude. The therapist takes the patient’s underlying assumptions or unnoticed implications of the patient’s 
behavior and maximizes or minimizes them in either an unemotional or overemotional manner to make a 
point the patient might not have considered before. 

The essence of the strategy is that it “jumps track,” so to speak, from the patient’s current pattern of 
response, thought, or emotion. A set of structural strategies specifies for the therapist how to start and end 
therapy, how to set an agenda and organize time during sessions, and how to terminate DBT. 

For example, DBT uses a number of strategies drawn from social psychology to create and enhance 
commitment to therapy and to change. There are, as well, a number of integrative strategies covering crisis 
management, suicidal behavior, compliance and relationship issues, medication, and use of ancillary 
treatments. 

TREATMENT EFFICACY FOR DBT 

DBT has been evaluated in a controlled treatment trial comparing DBT to treatment-as-usual (TAU) in the 
community (Linehan et al. 1991). Forty-seven women meeting criteria for BPD with a history of multiple 
parasuicides (including one within 8 weeks of referral) were randomly assigned to the two treatment 
conditions. 

Treatment lasted 1 year, and evaluations were conducted at 4-month intervals during a 1-year followup. 
Results indicated that DBT was significantly better than TAU at reducing parasuicidal behavior (including 
suicide attempts), days of inpatient hospitalization, and treatment dropouts. 

In a reanalysis of the data, Linehan and Heard (1993) found that the superiority of DBT could not be 
accounted for by the simple fact that subjects assigned to DBT had greater access to psychotherapy or to 
telephone contact with their therapist. 

The original study was conducted in two somewhat independent waves with approximately equal numbers 
of subjects in each. Analyses of the second wave (Linehan et al. 1992), in which a number of additional 
outcome measures were added to the assessment battery, indicated that subjects assigned to DBT, as 
compared with those assigned to TAU, also reported significantly less anger, greater social adjustment 
(including better employment performance), better work (in employment, school, and household roles) 
performance, and less anxious rumination, and they were rated by the interviewer as more socially 
adjusted and as less severely disturbed on the Global Adjustment Scale. 

At followup (Linehan et al., in press), gains were maintained in almost all areas of therapy improvement. 
The finding that DBT reduces parasuicide episodes has been replicated by Barley and colleagues (in 
press) in an inpatient sample. 

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ACKNOWLEDGMENT 

This chapter was based on research supported by grant MH34486 from the National Institute of Mental 
Health, Bethesda, Maryland. 

AUTHOR 

Marsha M. Linehan, Ph.D. Department of Psychology NI-25 University of Washington Seattle, WA 98195 

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