Addiction — formally described as a substance use disorder (SUD) — often co‑occurs with other mental health conditions, and effective treatment hinges on choosing a therapeutic modality appropriate for an individual’s needs.
Two frequently employed talk therapies are cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT). Though they share roots and some overlapping techniques, their emphases, structures, and ideal use‑cases differ significantly.
In this article, I’ll explore their similarities, their key differences, their roles in addiction treatment, and how a mental health clinician might select the right approach — or combine them — for a given person.
What are CBT and DBT?
CBT (cognitive behavioral therapy)
CBT is a well‑established therapeutic approach developed in the 1960s (notably by Aaron T. Beck) that holds that people’s beliefs, thoughts, and interpretations influence emotional and behavioral responses. By identifying distorted or maladaptive thoughts (“negative thought patterns”), CBT helps individuals restructure those thoughts and build healthier coping strategies to change maladaptive behaviors.
CBT is used to treat a variety of mental health conditions, including:
- Anxiety disorders
- Post-traumatic stress disorder (PTSD)
- Obsessive-compulsive disorder (OCD)
- Depression
- Eating disorders
- Substance use disorders
Therapists complete CBT in individual therapy sessions and/or group sessions. The sessions tend to be somewhat structured and goal‑oriented (e.g., “identify triggers, challenge dysfunctional beliefs, learn coping strategies”)
DBT (dialectical behavior therapy)
Dialectical behavior therapy (DBT) was originally developed by Marsha Linehan in the 1980s to treat people with borderline personality disorder (BPD) who exhibited chronic suicidal ideation, self‑harm, and severe emotional dysregulation.
Dialectical means “synthesis of opposites.” DBT emphasizes acceptance (validating current emotional experience) and change (learning new skills) — recognizing that a person may be doing the best they can while also needing to change behaviors.
DBT emphasizes emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness skills. Delivery often involves skills training groups, individual therapy, phone coaching, and consultation teams for therapists.
Over time, DBT has been adapted beyond BPD to other mental health conditions, including eating disorders, self‑harm, and substance use disorders.
Why Do These Modalities Matter for Addiction Treatment?
Addiction treatment is not just about stopping substance use — it’s about identifying and treating the underlying drivers of harmful behaviors, addressing co‑occurring mental health disorders, building coping skills to prevent relapse, and learning new ways to respond to intense emotions, triggers, and interpersonal conflicts.
According to a review by the National Association of Addiction Treatment Providers, CBT is an evidence‑based behavioral therapy for SUDs that helps clients manage negative thoughts, learn coping skills, identify triggers, and restructure behaviors.[1]
DBT is being utilized in addiction settings, particularly when emotional dysregulation, self‑harm, or co‑occurring personality or mood disorders are present. For instance, in one study of DBT for substance‑abusing individuals with BPD, those receiving DBT had greater treatment retention and greater reductions in drug use on follow‑up than those in treatment‑as‑usual.[2]
Thus, understanding the key differences between CBT and DBT helps a mental health professional decide what modality — or combination — best matches a person’s pattern of maladaptive thoughts, behaviors, emotional dysregulation, interpersonal difficulties, and relapse risk.
What are the Similarities Between CBT and DBT?
Before diving into the differences, it’s helpful to note where CBT and DBT overlap:
- Both are “talk therapy” modalities delivered by a trained mental health professional in individual therapy sessions and/or group sessions.
- Both target maladaptive behaviors (e.g., substance use, self‑destructive behavior) and aim to build practical skills (coping strategies, problem‑solving, behavioral change).
- Both emphasize the connection between thoughts, emotions, and behaviors (though the emphasis differs).
- Both can address mental health conditions such as anxiety disorders, mood disorders, eating disorders, and co‑occurring disorders alongside SUDs.
- Both can be evidence‑based components of addiction treatment programs, often in integrated or multimodal settings (alongside medication, peer support, housing, and lifestyle‑change interventions)
What are the Differences Between CBT and DBT?
CBT focuses primarily on changing negative thought patterns (for example: “I’ll never be able to stay sober,” “I always fail”) and learning coping skills to replace maladaptive behaviors. It emphasizes that beliefs influence behavior and that changing beliefs leads to changes in emotion and behavior.
On the other hand, DBT emphasizes emotion regulation, distress tolerance, mindfulness, and interpersonal effectiveness skills, with particular attention to intense emotions, self‑harm, suicidal ideation, and unstable interpersonal relationships. DBT accepts that some emotions are valid and invites skillful acceptance as well as change.
It is also important to note that CBT typically teaches cognitive restructuring (challenging and changing distorted beliefs), behavioral activation, problem‑solving, exposure (in anxiety/OCD cases), and relapse prevention.
Instead of cognitive restructuring, DBT uses four core skills modules:
- Mindfulness skills: being present, observing without judgment
- Distress tolerance skills: coping with crises without making them worse (for instance, by substance use or self‑harm)
- Emotion regulation skills: identifying, labeling, and modulating intense emotions rather than being overwhelmed.
- Interpersonal effectiveness skills: maintaining relationships, setting boundaries, asserting needs, and avoiding destructive relational patterns.
CBT doesn’t always include such structured modules around mindfulness, distress tolerance, and interpersonal effectiveness to the same degree.
Approach to Thoughts vs Emotions
CBT treats negative thoughts as central drivers of maladaptive behavior; changing those thoughts changes the behavior.
DBT grants a larger role to intense emotions and emotional dysregulation: rather than only changing thoughts, it emphasizes learning to ride out emotional storms, tolerate distress, stay present, and engage effectively in relationships. It also uses acceptance strategies (e.g., “you are doing the best you can right now”) alongside change strategies.
In short, CBT often says “change your thinking to change your behavior”; DBT says “accept your emotions, ride them, build skills to respond differently; change behavior and regulate emotion.”
Structure and Format
CBT is often shorter‑term, structured, and goal‑oriented. The therapist and client collaboratively identify goals, monitor progress, and use homework tasks (thought‑logs, behavioral experiments).
On the other hand, DBT is more intensive for complex cases: individual therapy, weekly skills‑training group sessions, phone coaching between sessions, and therapist consultation teams. Designed for chronic emotional dysregulation and self‑destructive behavior.
DBT emphasizes a group skills component (skills training group) explicitly. While CBT may be delivered in groups, it’s not as central a feature in standard CBT protocols.
Uses and Symptoms Treated
CBT is broadly applicable across many mental health conditions and addictions, especially when the primary issues are negative thoughts, behavioral activation, avoidance, maladaptive thinking, cravings, and triggers.
DBT is especially indicated when there are intense emotions, emotional dysregulation, impulsivity, self‑harm, chronic suicidal ideation, unstable interpersonal relationships (for example, those with borderline personality disorder), or co‑occurring conditions like eating disorders, BPD,or bipolar disorder.
For example, DBT was developed to treat borderline personality disorder and self‑harm behaviors; CBT is used widely for anxiety disorders, OCD, panic disorder, and generalized anxiety disorder.
How They are Used in Addiction Treatment
CBT in addiction treatment focuses on identifying triggers, monitoring automatic thoughts (“I need a drink to cope”), developing coping strategies, preventing relapse, and modifying maladaptive behaviors.
DBT in addiction settings offers additional value when addiction is paired with emotional dysregulation, self‑harm, or personality pathology. For example, a trial showed that DBT recipients had significantly better retention and reduced drug use compared to controls in opiate‑dependent persons with BPD.
Thus, the key difference in addiction treatment: CBT frequently targets the behavior-thought interface (what am I thinking, what behavior follows, how to change that); DBT adds a stronger emphasis on emotional regulation, distress tolerance, acceptance of painful emotions, interpersonal relationships, and thus is especially suitable for complicated clinical pictures.
How Does this Translate into Practice: When to Use CBT, When DBT, or Both?
Here is how a mental health clinician might decide or integrate both modalities:
When CBT may be the primary modality:
- A person with a substance use disorder whose main issues include cravings, triggers, maladaptive thinking patterns (“once I slip, I’ll fail”), behavioral patterns of use, avoidance of feelings, but without severe emotion‑dysregulation, self‑harm, or unstable interpersonal patterns.
- The client is motivated to engage in a structured program: learn coping strategies, develop a relapse‑prevention plan, identify and restructure negative thoughts, and practice behavioral experiments.
- For example: a person with alcohol dependence, some anxiety disorder, no history of self‑harm, who struggles with “I’m stressed → drink” automatic behavior.
When DBT may be more appropriate (or as an adjunct):
- The person has a substance use disorder plus one or more of: intense mood swings, impulsivity, chronic self‑harm or suicidal thoughts, a diagnosis (or features) of borderline personality disorder (BPD), emotional dysregulation, eating disorders, bipolar disorder, or unstable interpersonal relationships. DBT skills like interpersonal effectiveness, distress tolerance, and emotion regulation become critical.
- For example, a person with a history of self‑harm and substance use, frequent relapses triggered by interpersonal conflict, and difficulty tolerating negative emotions may have comorbid BPD or an eating disorder. In these cases, DBT offers a richer skills base for emotion regulation and crisis coping.
- Because DBT can be longer and more resource‑intensive (skills groups, coaching, possibly phone contact), it may be chosen for higher‑complexity cases or as a next step when CBT alone has not been sufficient.
When integration may be best (CBT + DBT):
- In many addiction treatment settings, a combined approach is used. CBT provides the core relapse‑prevention, behavior-change, and thought‑restructuring framework; DBT contributes modules of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness that address the underlying emotional/relational drivers of substance use.
- For someone with addiction plus anxiety disorders, eating disorders, or personality disorder features, an integrated protocol might begin with DBT‑skills training, then target cognitive restructuring via CBT, or embed CBT components into a DBT framework.
- The clinician must tailor the therapy to the individual’s mental health conditions, level of emotional dysregulation, relapse risk, interpersonal functioning, and motivation.
Is CBT or DBT Right for Me?
Choosing between CBT and DBT depends on the specific challenges you’re facing in your recovery. If you tend to struggle with negative thought patterns, cravings, and learned behaviors that lead to substance use, Cognitive Behavioral Therapy (CBT) might be the best fit. CBT helps you identify harmful thoughts, reframe them, and build healthier coping strategies to avoid relapse.
On the other hand, if your addiction is often tied to intense emotions, impulsivity, relationship difficulties, or self-destructive behaviors—especially if you’ve been diagnosed with borderline personality disorder or experience frequent emotional distress—Dialectical Behavior Therapy (DBT) may offer more support. DBT provides structured skills for emotion regulation, distress tolerance, and navigating interpersonal conflicts.
In many cases, a blend of both therapies works best. A qualified mental health clinician can help assess your emotional, behavioral, and relational patterns to determine the right therapeutic path—or combination—for you.
Get Connected to a Rehab Center that Combines CBT and DBT Therapy
In the world of addiction treatment, both CBT and DBT are powerful therapeutic approaches — each with distinct strengths and ideal applications. CBT excels at restructuring negative thoughts, changing learned behaviors, and building coping strategies to prevent relapse. DBT adds a richer layer of emotion regulation, distress tolerance, mindfulness, and interpersonal effectiveness — invaluable when addiction is entwined with emotional chaos, self‑harm, suicidal ideation, borderline personality features, or intense interpersonal conflict.
Rather than viewing CBT vs DBT as a competition, it can be more helpful to view CBT + DBT as complementary tools in the therapist’s toolkit. The smart practitioner will match the modality (or combination) to the individual’s unique mental health conditions, emotional regulation capacity, interpersonal functioning, behavioral patterns, and recovery goals. With the right fit, both therapeutic modalities can contribute substantially to recovery — turning maladaptive behaviors and negative thoughts into skills, stability, and healthier relationships.
If you are interested in using CBT and DBT to recover from addiction, you’ve come to the right place. At Alamo Behavioral Health, we combine these techniques to ensure you learn the skills needed to achieve long-term sobriety. Contact us today for more information on our addiction treatment center.
FAQ: CBT vs DBT in Addiction Treatment
1. Can I switch from CBT to DBT (or vice versa) during treatment?
Yes. Therapy isn’t static. If you’re not making progress or new emotional or behavioral challenges emerge, your therapist may suggest transitioning between CBT and DBT—or incorporating elements of both. Many treatment centers already integrate both approaches, tailoring the focus as your needs evolve.
2. Do I need a specific diagnosis to benefit from DBT?
No formal diagnosis is required to benefit from DBT. While it was originally designed for borderline personality disorder, its skill-based modules—like emotion regulation and distress tolerance—are helpful for anyone struggling with impulsivity, intense emotions, or interpersonal conflict. It’s increasingly used with clients experiencing addiction, trauma, or mood disorders, regardless of diagnosis.
3. How long does CBT or DBT take to work in addiction recovery?
Timeframes vary. CBT programs can range from 8–20 weeks, while full DBT programs typically last 6–12 months, due to their intensive structure. That said, many people begin to see benefits within the first few months. Progress depends on the complexity of your symptoms, consistency in applying skills, and the presence of co-occurring disorders.
4. Is group therapy required in DBT?
Yes, in standard DBT, weekly group skills training is a core component. It’s where clients learn and practice the four key skill areas: mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. However, some modified DBT programs may offer individual-only formats if group participation isn’t possible.
5. Can I use CBT or DBT alongside medication-assisted treatment (MAT)?
Absolutely. Both CBT and DBT are often used in combination with MAT (such as Suboxone or methadone) in treating opioid use disorders. Therapy addresses psychological, behavioral, and emotional patterns, while medication helps manage physiological dependence. This dual approach is considered best practice in many addiction treatment models.
6. How do I find a therapist trained in CBT or DBT?
Look for licensed therapists who specialize in addiction and explicitly list CBT or DBT in their credentials. You can search directories like Psychology Today, ask your primary care provider, or contact local treatment centers. For DBT, it’s especially important to ask if the provider offers comprehensive DBT or just uses elements of it, as fidelity to the model impacts outcomes.
References:
- National Association of Addiction Treatment Providers: Treatment Methods and Evidence-Based Practices
- The National Library of Medicine (NLM): Dialectical Behavior Therapy for Substance Abusers
