Key takeaway
Dialectical behavior therapy is a psychotherapy SAMHSA discusses when borderline personality disorder occurs with a substance use disorder. Support is stronger for that pairing than for every addiction. It is not a skill workbook you practice alone. A clinician decides whether it belongs in the plan, and a crisis tonight comes before the brand name.
Last updated: Mon Oct 05 2026 00:00:00 GMT+0000 (Coordinated Universal Time)
Someone is in danger tonight, or you are, and the brochure answered with an acronym. Safety comes before the brand name. Dialectical behavior therapy, usually called DBT, is a form of psychotherapy. In SAMHSA's TIP 42, the place it comes up is specific: borderline personality disorder, including when that disorder and a substance use disorder are both present. Psychotherapy is the main treatment for personality-disorder symptoms. No medicine has been approved to treat personality disorders themselves. Medicine may still be used for particular symptoms, and medicine for a substance use disorder is a separate decision. DBT is not a stack of worksheets, and it is not a default group for every person who enters rehab.
If someone has taken a substance in a suicide attempt, is bleeding from self-injury, or you cannot keep them safe, call 911. For suicidal thoughts or a mental health crisis, call or text 988.
What the diagnosis means, without a quiz
TIP 42 describes the essential feature of borderline personality disorder as a pervasive pattern of instability in relationships, self-image, and emotions, plus marked impulsivity, beginning by early adulthood and showing up in more than one area of life. A checklist is not a diagnosis. The disorder is often misdiagnosed, including because the same kinds of emotional swings, suicidal behavior, and impulsive acts appear in depression, bipolar disorder, post-traumatic stress, and substance use disorders. Stigma and gender bias, the TIP says, push some clinicians to over-diagnose it and others to avoid the name.
The overlap with substance use is large enough that programs should ask, not assume. In the general population, TIP 42 reports a prevalence of about 1.6 percent to 5.9 percent. In substance use treatment, especially inpatient and residential settings, rates across studies average about 22 percent and reach about 53 percent in some research. About 45 percent of people with the personality disorder have a current substance use disorder, and about 75 percent have had one in their lifetime. The substances with the strongest associations, in the TIP's summary, are opioids, cocaine, and alcohol. People with both conditions, compared with either alone, tend to have more severe symptoms, substance use that lasts longer, more other mental disorders, higher mortality, and more dropout from substance use treatment. Those are study patterns. They do not diagnose the person in front of you.
About three-quarters of people with borderline personality disorder have a history of self-harm, and TIP 42 cites about a 10 percent lifetime risk of completed suicide. That is why a human being outranks a therapy referral tonight. The broader idea of treating both together is co-occurring care. DBT is one psychotherapy inside that idea.
Where the evidence actually sits
No evidence-based treatment exists for personality disorders as such. Treatments do exist for symptoms: suicide and self-harm risk, emotion swings, rigid thought patterns, and strained relationships. In that context TIP 42 names dialectical behavior therapy, dynamic deconstructive psychotherapy, and dual-focused schema therapy as promising, particularly for borderline personality disorder. They have been shown to affect both psychiatric outcomes and addiction-related outcomes. The research literature on personality disorders, with or without a substance use disorder, is sparse and needs more evidence.
A systematic review of 10 studies on treatment for borderline personality disorder plus a substance use disorder found good support for dialectical behavior therapy, and for those two other therapies, on substance use, suicidal gestures and self-harm, day-to-day and social functioning, use of treatment, and staying in treatment. In inpatient mental health settings, dialectical behavior therapy for this personality disorder is recommended to help reduce suicide risk, stabilize behavior, and help people regulate emotions.
Read those findings together. The support SAMHSA describes is strongest for a defined pairing, not for addiction as a single word. A program that advertises DBT for every resident is making a broader claim than TIP 42 does.
Someone with problems this serious is unlikely to do well in standard substance use treatment unless they are also in a program qualified to treat borderline personality disorder, preferably one that offers a treatment designed for it, such as dialectical behavior therapy. They are also likely to need detoxification, inpatient care, or a long-term outpatient program that knows how to treat personality disorders. Ordinary group rehab is not automatically that program. Progress is often slow and uneven. Missed sessions are common and should be discussed, not treated as a surprise.
TIP 42 also mentions dialectical behavior therapy for feeding and eating disorders. It can be useful for mindfulness, for managing painful emotions, and for self-regulation in those disorders and in substance use disorders separately. It has not been studied much when both are present at once. That is not a reason to decide you have an eating disorder, and it is not a mindfulness drill. If both problems are in the picture, you need a clinician who will say whether this therapy has a role.
What stays with the clinician
Counselors are told to help people build ways to manage painful memories and emotions, and to see the link between feelings and behavior. Examples inside that relationship include slow breathing, meditation, and cognitive restructuring. Those are tools chosen for a person. Practicing them from an article while a suicidal crisis is underway delays the call for help.
Counselors are also told to watch newly abstinent people with this personality disorder for other compulsive behaviors, such as gambling, spending, or sexual behavior that causes harm. That is a monitoring task. It is not a label for every person who is trying to stop using.
Benzodiazepines need a separate warning. People with borderline personality disorder often obtain favored medicines, including benzodiazepines, from more than one prescriber, and may insist on staying on them to avoid dangerous withdrawal. Do not take those pills away. The warning about a sudden stop is in benzodiazepine withdrawal. An opioid or alcohol medicine is not canceled by a therapy referral either. Those medicines stay with the prescriber.
Bipolar disorder, post-traumatic stress, and anxiety can look similar in a crisis and need their own plans. Bipolar disorder and substance use, PTSD and substance use, trauma, and anxiety are those conversations. The misdiagnosis warning is the reason not to collapse them into one therapy brand. Cognitive behavioral therapy remains a different offer. If admissions says "we do CBT/DBT" as one phrase, ask which diagnosis each one is for, who is trained, and how often it meets.
Questions that separate a program from a slogan
Ask which diagnosis dialectical behavior therapy is offered for, and who assessed it. Ask whether the clinician is trained in that treatment, or whether the word only appears on the website. Ask how suicide and self-harm risk are handled after hours. Ask whether prescribed benzodiazepines, psychiatric medicine, and addiction medicine will be continued, and who watches them. If the program cannot treat borderline personality disorder, ask where the referral is, and how soon.
Search FindTreatment.gov and ask about co-occurring personality disorder care in those words, not only about a skills group. Call or text (800) 653-9376 if you need a level of care that can hold both problems.
Additional Resources
Sources cited on this page:
- SAMHSA TIP 42: Substance Use Disorder Treatment for People With Co-Occurring Disorders
- SAMHSA FindTreatment.gov
- 988 Suicide & Crisis Lifeline
Common Questions
Is dialectical behavior therapy the same as cognitive behavioral therapy?
No. Cognitive behavioral therapy is aimed at situations and thoughts tied to substance use. SAMHSA's TIP 42 discusses dialectical behavior therapy mainly for borderline personality disorder, including when a substance use disorder is also present, with attention to suicide risk, behavior, and emotions. A program that uses the two names as one phrase has not answered which treatment it offers, who is trained, or how often it is on the schedule.
Does everyone in rehab need DBT?
No. TIP 42 ties the stronger evidence to borderline personality disorder plus a substance use disorder, and it says the research on personality disorders, with or without a substance use disorder, is still sparse. Many people in substance use treatment do not have that personality disorder. Asking because a brochure listed coping skills is not the same as an assessment.
Can I learn DBT from a workbook instead of a program?
TIP 42 does not describe homework sheets as a substitute for care. It says psychotherapy is the main treatment for personality-disorder symptoms, that no medicine is approved to treat personality disorders themselves, and that a person with serious borderline personality disorder is unlikely to do well in ordinary substance use treatment unless the program can also treat that disorder. Buying a book does not create that program.
What if someone is self-harming or talking about suicide?
Call 911 if a suicide attempt is underway or you cannot keep the person safe. Call or text 988 for a mental health crisis. TIP 42 says about three-quarters of people with borderline personality disorder have a history of self-harm, and that the disorder carries about a 10 percent lifetime risk of suicide. Those figures are a reason for urgent human help. They are not a diagnosis you make from a list, and they are not a reason to wait for a therapy referral tonight.
Will DBT replace medication for opioid or alcohol use?
No. TIP 42 says both the personality disorder and the substance use disorder need attention. It warns that people with borderline personality disorder may receive benzodiazepines from several prescribers and may need those medicines continued to avoid dangerous withdrawal. Opioid and alcohol medicines are a separate prescriber decision. Do not stop either kind of medicine because a skills group started.