Mapping Dialectical Behavior Therapy Skills to Clinical Domains Implicated in Contemporary Addiction Research: A Conceptual Synthesis and Promise for Precision Medicine

Abstract

Recent addiction research has identified clinical domains that are central to the development and maintenance of alcohol use disorder (AUD). Yet existing psychotherapy approaches are not typically organized around these clinical domains and are often limited in scope. Dialectical behavior therapy (DBT) is an intensive, multicomponent cognitive behavioral treatment that includes individual psychotherapy, group-based skills training, phone coaching, and consultation team for DBT therapists. Despite its efficacy on various mental health conditions, access to full DBT is often a challenge. In this paper, we describe how the skills training component of DBT can be flexibly applied to target clinical domains that underlie the three stages of the addiction cycle or impair quality of life during recovery from AUD. Using three clinical case vignettes, we illustrate how DBT skills can be mapped onto addiction clinical domains (e.g., Dialectical Abstinence and Clear Mind on executive function, STOP and TIP skills on incentive salience, Check the Facts and Opposite Action on negative emotionality, and ABC PLEASE skill on quality of life). Based on this integrated framework, we offer practical recommendations for case conceptualization, stigma reduction, and implementation through multiple delivery options. Implications on precision medicine are also discussed. Together, this conceptual synthesis serves as a bridge for practitioners to learn about contemporary addiction theories and for addiction researchers to appreciate the value of DBT in substance use treatment. The promotion of DBT skills training as a stand-alone or adjunctive intervention may help address the significant treatment gap in alcohol and substance use behaviors.

Harmful alcohol use is a major burden of disease worldwide (World Health Organization, 2019). In the United States, 29.1% of the adult population met criteria for a lifetime diagnosis of an alcohol use disorder (AUD) (Grant et al., 2015). According to the 2019 National Survey on Drug Use and Health, among individuals who met criteria for past-year prevalence of AUD (5.6% of the population), only 7.3% reported receiving any alcohol use treatment in the past year (Han et al., 2021). This substantial treatment gap is a public health concern, and the adaptation of innovative intervention approaches that are accessible and user-friendly may help close this gap.

Currently, several evidence-based psychotherapies are available for treating AUD, including motivational enhancement therapy (MET), contingency management, 12-step facilitation/Alcoholics Anonymous (AA), and cognitive behavioral therapy (CBT) (MacKillop et al., 2022). The Food and Drug Administration has also approved several efficacious medications to treat AUD, including naltrexone, acamprosate, and disulfiram (Kranzler & Soyka, 2018). Despite the availability of these treatment options, AUD treatment remains underutilized, possibly due to low perceived need for care (Oleski et al., 2010), self and perceived social stigma (Hammarlund et al., 2018), and other structural and attitudinal barriers such as “didn’t know any place to go for help” or “thought the problem would get better by itself” (Haeny et al., 2021).

One promising avenue to improve the availability and applicability of psychosocial treatments for AUD is to tailor treatment to individuals’ specific needs (Magill et al., 2023). Traditionally, AUD treatment tailoring has emphasized the comparison of discrete treatment approaches, such as comparing between MET, AA, and CBT (Project MATCH Research Group, 1997). This traditional approach is limited because treatment matching was not tailored to specific clinical issues. Moreover, since these manualized treatments covered a range of topics, it is difficult to know which treatment component was the most helpful and for which set of presenting problems.

Contemporary addiction research has adopted a dimensional approach to understand individual heterogeneity in addictive behaviors (Kwako et al., 2018). While many models of addiction exist, the addiction cycle model is unique in its neuroscience-driven conceptualization that postulates circuits in specific brain regions may be altered during the three stages of addiction: binge/intoxication (basal ganglia), withdrawal/negative affect (extended amygdala), and preoccupation/anticipation (prefrontal cortex) (Koob & Moal, 1997; Koob & Volkow, 2016). The three-stage addiction cycle model provides a heuristic framework to explore the heterogeneity of AUD and inform pharmacological and behavioral health intervention approaches that hold potential to address the AUD treatment gap (Koob, 2024).

To facilitate clinical translation of the three-stage addiction cycle model, the Addictions Neuroclinical Assessment (ANA) was developed and identified executive (dys)function, incentive salience, and negative emotionality as functional domains underlying the development, maintenance, and progression of AUD (Gunawan et al., 2023; Kwako et al., 2016). With these three core clinical domains, the ANA framework captures the neuroscience underlying addiction in an accessible way and has received initial and growing empirical support in terms of its construct and predictive validities across multiple samples (Gunawan et al., 2024; Kwako et al., 2019; Nieto et al., 2021; Votaw et al., 2023; Witkiewitz et al., 2023). In addition, the ANA framework addresses the issue of heterogeneity in AUD clinical presentations and can inform precision medicine (i.e., personalized treatment based on an individual’s unique clinical characteristics) by tailoring treatment based on individual differences in executive dysfunction, incentive salience, and negative emotionality. One example is the proposal of using naltrexone to target reward-driven drinking (incentive salience) and using acamprosate to target relief-driven drinking (negative emotionality) (Mann et al., 2018; Witkiewitz et al., 2019). Beyond this example, however, evidence-based personalized treatment options for AUD are limited.

Recent addiction research also highlights improvement in quality of life (QoL) as an integral part of recovery and the role of stigma as a barrier to treatment seeking (see Table 1 for a summary). Incorporating feedback from clinicians and recovery specialists, the new National Institute on Alcohol Abuse and Alcoholism definition of recovery emphasizes the roles of biopsychosocial functioning and QoL as part of recovery (Hagman et al., 2022). As reduction in drinking is associated with better QoL (Luk et al., 2022; Witkiewitz et al., 2018), helping patients improve their QoL can be foundational to successful treatment of AUD. Furthermore, stigma associated with addiction treatment can impede care delivery (Volkow, 2020). While efforts to help healthcare providers adopt nonstigmatizing language is a key step toward reducing stigma (Volkow et al., 2021), addressing the emotional experiences that often underlie mental health and addiction-related stigma would further advance clinical care. To this end, dialectical behavior therapy (DBT) offers highly relevant skills to reduce stigma as emotional experiences such as shame and guilt can be directly targeted in treatment.

Table 1.

Recent Advances in Addiction Theory and Research

Recent Advances in Addiction Theory and Research	Significance	Treatment Implications	How Dialectical Behavior Therapy (DBT) can help
1. The Addictions Neuroclinical Assessment (ANA) framework has been developed to measure three correlated neurofunctional domains that map onto the 3-stage addiction cycle model: executive function, incentive salience, and negative emotionality (Kwako et al., 2019).	The ANA framework helps address the issue of substantial heterogeneity within the spectrum of AUD.	Assessment of the three ANA neurofunctional domains of executive function, incentive salience, and negative emotionality can inform personalized clinical case conceptualization.	DBT skills training can aid recovery through enhancing mindfulness, emotion regulation, and distress tolerance skills. Prioritizing DBT skills that optimally address the ANA domains can lead to more precise prescription of cognitive behavioral strategies to match the clinical presentation of each patient with AUD.
2. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has released a new definition of recovery that underscores the importance of biopsychosocial functioning and quality of life in enhancing alcohol-related recovery outcomes (Hagman et al., 2022).	The new definition of recovery helps improve measurement consistency and stimulate research on quality of life as part of the recovery process.	The promotion of multidimensional quality of life – including physical, psychological, social, and environmental domains – may be an integral part of AUD treatment.	DBT skills can be applied to resolve complex life situations and improve individuals’ overall quality of life and sense of wellbeing. Improvement in quality of life can in turn facilitate and sustain reduction in drinking behaviors.
3. Increased awareness of how stigmatizing language may interfere with help-seeking behaviors has led to the development of best practices on using appropriate language choices to reduce stigma associated with mental illness and substance use disorders (Volkow et al., 2021).	The reduction of stigma associated with alcohol use and substance use disorders helps remove a key barrier to addiction treatment.	Language use in the context of AUD treatment may need to be adjusted by both clinicians and health care systems.	DBT skills can be helpful in processing negative emotional experiences (e.g., shame and anger) associated with internalized and structural stigma. In addition, cultural adaptation of DBT has continued to flourish, setting precedent in tailoring DBT to best fit the needs of specific populations.

The goal of this paper is to demonstrate how the skills training component of DBT can be flexibly applied to target three ANA neurofunctional domains, four QoL domains, and address mental health and addiction-related stigma. First, we review empirical evidence that supports the use of DBT for treating addiction and highlight several implementation challenges. Second, we present our conceptual synthesis and demonstrate how 12 specific DBT skills can be mapped onto the ANA neurofunctional and QoL domains implicated in contemporary addiction research using three clinical case vignettes. Third, we illustrate the translational value of our conceptual synthesis on case conceptualization and discuss how DBT can be utilized to address stigma-related issues. Finally, we articulate the promise of utilizing DBT skills training to inform precision medicine via multiple treatment delivery options.

A Review of the Empirical Evidence Supporting the Use of DBT for Addiction

DBT is a type of cognitive behavioral therapy that was originally developed as a treatment for self-injurious and suicidal behaviors (Linehan et al., 1991). Standard DBT is an intensive treatment that is comprised of four treatment components, including individual psychotherapy, group-based skills training, phone coaching, and consultation team for DBT therapists (Linehan, 1993a, 1993b). DBT is an evidence-based treatment for borderline personality disorder (BPD) (Bohus et al., 2021). In DBT, the development of heightened emotional dysregulation is conceptualized as stemming from complex transactions between biological vulnerability and invalidating environment over time (Crowell et al., 2009). Systematic reviews and meta-analyses support the efficacy of DBT as a treatment for BPD and suicidal behavior (Cristea et al., 2017; DeCou et al., 2019).

Since its original conceptualization, DBT has been proposed to have implications for the treatment of substance use disorders (Linehan, 1993c). The conceptual rationale is compelling, as BPD and substance use disorders often co-occur (Trull et al., 2018), and they share core underlying characteristics, including emotion dysregulation (Sloan et al., 2017) and impulsivity (Bornovalova et al., 2005). Among patients with comorbid BPD and drug use disorder, Linehan and colleagues (1999) found that those who received DBT reported a greater proportion of days abstinent from drugs and alcohol and more gains in global and social adjustment than treatment-as-usual over the course of a year-long treatment and at the 16-month follow-up. Subsequent clinical studies similarly demonstrated the efficacy of DBT in treating co-occurring BPD and substance use disorders (Lee et al., 2015; Pennay et al., 2011).

Despite clear empirical support, the dissemination of DBT is challenging as standard DBT is a resource-intensive treatment that requires a team of DBT trained therapists and long periods of treatment time (Paris, 2009). One potential solution is to prioritize intervention efforts toward DBT skills training, a key mechanism of change in DBT (Neacsiu et al., 2010). In their seminal component analysis, Linehan and colleagues (2015) showed that skills training DBT was as effective as standard DBT in reducing anxiety, depression, and nonsuicidal self-injury. Systematic reviews of the broader literature support DBT skills training as an emerging stand-alone treatment for emotional and behavioral problems such as eating pathology, depressive symptoms, and substance use (Valentine et al., 2015; Valentine et al., 2020). Since DBT skills training group is less resource demanding than standard or individual DBT, it has the potential to facilitate the dissemination of DBT skills.

In a systematic review, DBT skills training as a stand-alone treatment for substance use disorder (SUD) was found to be acceptable, feasible, and to have modest efficacy (Warner & Murphy, 2022). One form of DBT skills training program tailored for addiction was structured into 36 three-hour sessions, beginning with addiction-specific topics such as Dialectical Abstinence and the Path to Clear Mind, and then extending to more general DBT skills modules including Mindfulness, Distress Tolerance, and Emotion Regulation Skills (Maffei et al., 2018). Subsequent trials showed that this 3-month DBT skills training program was linked to improved emotion regulation, reduced impulsivity, and lower severity of AUD and substance use behaviors (Cavicchioli et al., 2023; Cavicchioli et al., 2019). Though promising, this program is quite long (a total of 108 hours) and may be impractical to implement in many behavioral health care settings. In addition, while the treatment components were well-justified for AUD, the intervention was not tailored to individuals’ clinical profile. To address these gaps, we propose that a better alignment between specific DBT skills and the ANA-QoL clinical domains would be valuable.

Mapping a Dozen DBT Skills to Addiction Clinical Domains

The DBT treatment and skills training manuals (Linehan, 1993a, 1993b) offer a comprehensive description of the rationale, structure, and strategies for conducting DBT skills training and should be the primary source that clinicians refer to for guidance in clinical practice. The purpose of mapping specific DBT skills to the conceptual synthesis presented in Figure 1 is to help busy clinicians prioritize skills training for individual patients when it is not feasible to teach all DBT skills. Thus, DBT skills that are excluded in this conceptual synthesis may still be relevant for individual patients, but they are not prioritized because they are less closely tied to the ANA framework or QoL domains. It is also important to acknowledge that clinicians and addiction specialists may find themselves already using some components of DBT skills in their clinical practice, such as pros and cons in MET, opposite action (e.g., behavioral activation) in CBT, and community reinforcement in AA. As such, we do not expect all aspects of this conceptual synthesis to be new information for seasoned clinicians and addiction specialists. That said, this conceptual synthesis may be of great value to neuroscientists and healthcare professionals who are not trained in evidence-based psychotherapy approaches and can be a useful model for clinicians who are less familiar with DBT to learn how DBT skills can be flexibly applied to address addictive behaviors. A summary of DBT skills mapped onto the conceptual model along with key teaching points are presented in Table 2.

Figure 1.

Conceptual Synthesis of DBT Skills and Clinical Domains Implicated in Contemporary Addiction Research

Table 2.

Description of DBT Skills That Map Onto Clinical Domains Implicated in Contemporary Addiction Theory and Research

DBT Skill	DBT Module	Associated Clinical Domain	Description	Key Teaching Points
1. Mindfulness and Wise Mind	Mindfulness Skill	Core competency in DBT	‘Wise Mind” facilitates a synthesis of the “Reasonable Mind” and the “Emotion Mind” ‘What” skills include observe, describe, and participate “How” skills include nonjudgmentally, one-mindfully, and effectively	Recognize how problematic drinking often occurs when “Emotion Mind” dominates Promote awareness of how alcohol consumption versus sobriety impacts the body and the environment
2. Dialectical Abstinence	Distress Tolerance Skill (Addiction)	Executive Function	Synthesize the pros of abstinence and harm reduction approaches to maximize commitment to change while addressing possibility of lapses and relapses Use the Olympic athlete metaphor to illustrate the usage of this skill	Explain the abstinence violation effect and its role in relapse prevention Encourage use of strategies to plan for both abstinence and harm reduction
3. Pros & Cons for Resisting Urges	Distress Tolerance Skill (General)	Executive Function	Discuss pros and cons associated with acting on or resisting crisis urges Rehearse pros and cons before an overwhelming crisis urge hits Review the pros and cons when an overwhelming crisis urge hits	Enhance awareness of the negative consequences that alcohol has brought about Highlight advantages of resisting impulses to support sustained motivation to change
4. Clear Mind	Distress Tolerance Skill (Addiction)	Executive Function	‘Clear Mind” is in between the dangerous extremes of “Addicted Mindset” (impulsive and willing to do anything for a “fix”) and “Complacent Mindset” (naive and oblivious to dangers) Conceptualize “Clear Mind” to be the safest mindset to adopt during recovery	Increase awareness of thought patterns such as “I can do a little” or “I’ve learned my lesson” Watch for behavioral characteristics in the “Addicted Mindset” and “Complacent Mindset” such as isolation or believing that “I can do this alone”
5. Burn Bridges and Build New Ones	Distress Tolerance Skill (Addiction)	Incentive Salience	Cut off all addictive behavior options as though one walks into the garage of abstinence and slams the garage door shut Create images and smells to compete with those associated with craving Engage five senses with stimuli unrelated to the addiction	Identify all cues, temptations, and people/places associated with addictive behaviors Learn about the role of visual and olfactory cues in craving Practice urge-surfing to ride the waves of urges
6. STOP Skill	Distress Tolerance Skill (General)	Incentive Salience	Describe 4 concrete steps to manage impulses: (a) Stop, (b) Take a Step Back, (c) Observe, and (d) Proceed Mindfully	Resolve stressful encounters or challenging situations in a more effective and calm way
7. TIP Skills	Distress Tolerance Skill (General)	Incentive Salience	Summarize 4 skills that can rapidly reduce emotional arousal: (a) Tip the Temperature with Cold Water, (b) Intense Exercise, (c) Paced Breathing, and (d) Paired Muscle Relaxation	Activate the parasympathetic nervous system to decrease emotional arousal and craving urges
8. Check the Facts	Emotion Regulation Skill	Negative Emotionality	Evaluate the validity of an emotional reaction against all available facts Distinguish between interpretations including thoughts and beliefs versus facts Challenge catastrophic outcomes that are unlikely to happen	Appreciate the adaptive function of emotion when the emotion fits the facts Prepare a cope ahead plan for when the worst happens to alleviate negative emotions
9. Opposite Action	Emotion Regulation Skill	Negative Emotionality	Act opposite to the action urge when emotion does not fit the facts or when acting on the emotion is ineffective Identify specific opposite action ideas and strategies to do it all-the-way	Serve as an overarching framework to deal with a range of emotions, including fear, anger, disgust, envy, jealousy, love, sadness, shame, and guilt
10. Radical Acceptance	Distress Tolerance Skill (General)	Negative Emotionality	Understand how nonacceptance of reality can turn painful events into suffering Offer an alternative to change strategies to process painful events in life	Address the adverse impact of unchangeable negative life events on motives to drink or self-medicating with alcohol
11. ABC PLEASE	Emotion Regulation Skill	Psychological and Physical QoL	Reduce vulnerability to the Emotion Mind in 3 steps: Accumulate Positive Emotions, Build Mastery, and Cope Ahead of Time Develop 5 healthy habits: Treat PhysicaL Illness, Balance Eating, Avoid Mood-Altering Substances, Balance Sleep, and Get Exercise	Utilize strengths-based strategies to promote resilience and build a life worth living Establish a holistic routine to care for the mind and the body Facilitate treatment adherence within multidisciplinary care
12. Community Reinforcement	Distress Tolerance Skill (Addiction)	Social and Environmental QoL	Replace addiction reinforcers with abstinence reinforcers Observe positive events and benefits that naturally occur while staying abstinent	Reinforce abstinence within social and environmental contexts Facilitate identification and practice of abstinence reinforcers

Core Mindfulness Skills at the Center

1. Mindfulness and Wise Mind

Given its conceptual underpinnings, DBT primarily targets emotion dysregulation with a particular emphasis on utilizing mindfulness skills to encourage dialectical thinking. Thus, mindfulness skills are considered a core competency underpinning much of DBT. The goals of DBT mindfulness skills are to reduce suffering and increase happiness, increase control over the mind, and experience reality as it is. Within the DBT mindfulness skills, “Wise Mind” is introduced as a concept of an individual’s inner wisdom accessed as a synthesis of one’s “Reasonable Mind” (cool and rational) and “Emotion Mind” (hot and mood-dependent). In the context of addiction treatment, we conceptualize mindfulness skills as relating to all three ANA domains. For example, practicing mindfulness may lead to improved abilities to control and abstain from addictive habits (executive function), tolerate distress associated with urges (incentive salience), and manage one’s emotions associated with withdrawal from alcohol or other substances (negative emotionality).

Skills to Address Executive Dysfunction

In the addiction cycle, executive dysfunction contributes to problematic drinking during the preoccupation/anticipation stage. Individuals with AUD may have difficulty with inhibitory control, shifting attention from addiction-related cues, and making decisions in line with their goals. Three DBT skills align well with the ANA domain of executive (dys)function:

2. Dialectical Abstinence

Dialectical Abstinence relates to the ability to synthesize the benefits of abstinence and harm reduction approaches to maximize one’s commitment to change. The goals of this skill are to promote awareness of the pros and cons of abstinence and harm reduction approaches and to encourage use of strategies to understand “dialectical abstinence” as a synthesis of both approaches. DBT’s dialectical approach to abstinence incorporates both change and acceptance strategies to promote total abstinence, including reframing a slip or a lapse as a problem to solve rather than a reflection of patient inadequacy or treatment failure (Dimeff & Linehan, 2008). In the context of addiction treatment, we conceptualize Dialectical Abstinence as integral in building planning skills to prevent relapse, reduce consequences of potential slips, and anticipate/avoid addiction-related cues.

3. Pros & Cons for Resisting Urges

Pros & Cons for Resisting Urges helps patients consider the positive and negative aspects of both acting and not acting on crisis behavior urges. The goals of this skill are to practice describing the crisis behavior and considering both short- and long-term consequences. In the context of addiction treatment, we conceptualize Pros & Cons as a motivational tool to address ambivalence to change and elicit change talk from patients, in a way that is consistent with the practice of motivational interviewing (Hettema et al., 2005).

4. Clear Mind

Clear Mind refers to a mindset in between the opposites of “addict mind” and “clean mind.” It is important to note that the terms “addict” and “clean” are now recognized as stigmatizing, and their use is discouraged by experts in the field (Volkow et al., 2021). To address this point, Hendler (2023) proposed that “clean mind” can be rephrased as “complacent mind” (other alternatives include “overconfident mind,” “invincible mind,” and “invulnerable mind”), whereas “addict mind” can be rephrased as “addicted mind” or “addiction mind.” In this paper, the DBT terms “addict mind” and “clean mind” (where the mind may be seen as part of a person) are further rephrased as “addicted mindset” and “complacent mindset” (where the mindset refers to a state of mind that people can move in and out of). The addicted mindset represents a set of attitudes and behaviors when a patient is actively engaging with the addiction. The complacent mindset represents attitudes and behaviors that often emerge after a period of sobriety, during which a patient may no longer think they have an addiction problem or become overconfident about their ability to control their drinking habits. Whereas behaviors in the addicted mindset tend to be impulsive and one-minded, behaviors in the complacent mindset are typically characterized by naivete and obliviousness to dangers. Thus, the clear mindset represents a safe zone in the middle, where the patient maintains sobriety yet stays aware of potential risks and utilizes strategies to prevent a lapse or a relapse. In the context of addiction treatment, we conceptualize Clear Mind as integral in building planning skills to prevent relapse and recognize common behavioral patterns associated with the addicted and complacent mindsets. Effective use of this skill can raise awareness of thoughts and behaviors that precede a relapse and help patients remain vigilant and on guard in their recovery journey.

Skills to Address Incentive Salience

In the addiction cycle, incentive salience contributes to problematic drinking during the binge/intoxication stage in which cravings and urges are common. Individuals with AUD may be hypersensitive to addiction-related cues and be drawn to drinking due to its reward properties. Based on prior reinforcement history, individuals with AUD may also find problematic drinking to be habitual and difficult to stop. DBT is especially equipped to advance skills in decoupling automatic behaviors in favor of more mindful and adaptive behaviors. Three DBT skills align well with the ANA incentive salience domain:

5. Burn Bridges & Build New Ones

Burn Bridges & Build New Ones refer to the removal of connections to potential triggers for addictive behaviors while creating new mental images, smells, and habits to compete with addiction urges. The goals of these skills are to recognize overt or habitual cues associated with addiction, remove easy access to addiction-related cues, and identify new “nonaddictive” cues to put into place over time. Specific techniques include “urge surfing,” a relapse prevention strategy to recognize urges as time-limited and to tolerate cravings without acting on them (Bowen & Marlatt, 2009). In the context of addiction treatment, we conceptualize Burn Bridges and Build New Ones as integral in creating distance between the patient and addiction-related cues, creating new nonaddictive cues, and reducing reliance on habitual behaviors. Effective use of this skill creates an initial barrier to reduce the occurrence of high-risk drinking situations, thereby decreasing the likelihood of a lapse or a relapse.

6. STOP Skill

STOP Skill is a crisis management tool to help reduce impulsive behaviors. This skill is introduced as an acronym: Stop or resist the first impulse to act, Take a step back to detach oneself from the situation, Observe and gather information about one’s internal experience and external context, and Proceed mindfully by evaluating potential options and outcomes in light of one’s goals. The goal of this skill is to learn these four steps to cope with stressful encounters or challenging situations more effectively. In the context of addiction treatment, we conceptualize the STOP skill as helpful in reducing impulsive behaviors while managing cravings and urges, weakening reward pathways, and disrupting habitual cues associated with alcohol. Practicing this skill can help patients be aware of their own needs and the situation they are in. Effective use of this skill can help patients avoid overreacting or turning to drinking in their “Emotion Mind” and access their “Wise Mind.”

7. TIP Skills

TIP Skills are tools to help reduce extreme emotional arousal and can be used to manage short-term urges to engage with problematic behaviors. This set of skills is introduced as an acronym: Tip the Temperature (e.g., splashing cold water on one’s face) to elicit the parasympathetic nervous system response, Intense exercise to calm down the body and decrease ruminative thoughts, and Paced breathing/Paired muscle relaxation to reduce heart rate and elicit the parasympathetic nervous system response. In the context of addiction treatment, we conceptualize the TIP skills as helpful in rapidly disrupting cravings or urges by inducing parasympathetic nervous system activity. This skill is particularly helpful for patients who are vulnerable to impulsive behaviors in face of heightened emotional experiences.

Skills to Address Negative Emotionality

In the addiction cycle, negative emotionality contributes to problematic drinking during the withdrawal/negative affect stage. Individuals with AUD may use alcohol to avoid withdrawal symptoms but find that drinking leads to more negative emotions, such as feelings of sadness, anger, shame, and guilt. DBT offers a comprehensive framework to address a wide range of emotions and thus can be flexibly applied to address the specific emotional states. Three DBT skills align well with the ANA negative emotionality domain:

8. Check the Facts

Check the Facts is a meta-cognitive tool to evaluate the validity of beliefs, assumptions, reactions, and interpretations of events. Check the Facts is a way to evaluate if a patient’s emotional response is justified by facts or not, which may reduce catastrophizing, negative self-attributions, or other maladaptive thinking patterns. The goals of this skill are to evaluate the validity of emotional reactions, distinguish between interpretations versus facts, and challenge catastrophic thoughts and emotions. Specific techniques include identifying prompting events, evaluating interpretations and assumptions, evaluating the likelihood of a catastrophic outcome, and thinking of other more likely outcomes. In the context of addiction treatment, we conceptualize Check the Facts as integral in evaluating the validity of responses to reduce negative emotional states associated with addiction.

9. Opposite Action

Opposite Action is an emotion regulation tool to increase engagement in goal-directed behavior contrasting one’s emotional state in cases where emotions do not “fit the facts” of a situation or when acting on the emotions is not effective. This skill seeks to reduce unwanted emotions by acting opposite to action urges prompted by a given situation. The goals of this skill are to identify and name emotions, check the facts to evaluate whether the emotions are justified in the situation, identify and describe action urges, and act opposite to the action urges “all the way.” In the context of addiction treatment, we conceptualize Opposite Action as the behavioral complement to Check the Facts in reducing the impact of negative emotional states associated with addiction.

10. Radical Acceptance

Radical Acceptance aims to reduce suffering and increase a sense of freedom by acknowledging unchangeable elements of one’s life. In the context of addiction treatment, we conceptualize Radical Acceptance as relevant to individuals who experience negative emotion associated with painful yet unchangeable events. In our own clinical experience, the Radical Acceptance skill often requires adaptation for patients with AUD. We illustrate how such adaptation can be done using the Radical Acceptance Worksheet Adapted for Addiction Treatment (Figure 2). For instance, patients with AUD may have to radically accept that alcohol use disorder runs in their family. Such an acknowledgment can help patients challenge and get unstuck from negative thinking patterns that contribute to alcohol misuse (e.g., from “I can’t help but drink because alcohol problems run in my family” to “I radically accept that alcohol misuse runs in my family, and I can at the same time seek help to stay sober and build a life worth living”). Other addiction specific applications of the Radical Acceptance skill include accepting that alcohol is ubiquitous in the culture and that the recovery journey is a life-long process, which may help patients become more vigilant and perseverant in their recovery journey. Examples of specific DBT radical acceptance strategies were taken from the DBT skills training manual (Linehan, 2015). Using this worksheet, clinicians can help patients with AUD clarify that the promotion of Radical Acceptance is not an excuse to continue drinking, but it can serve as a vehicle to promote positive behavior change.

Figure 2.

Radical Acceptance Worksheet Adapted for Addiction Treatment

Skills to Address QoL Domains

Individuals with AUD may have compromised QoL across domains (Luk et al., 2022; Thompson et al., 2024), and improvement in QoL is an integral part of recovery from AUD (Hagman et al., 2022). We conceptualize QoL as foundational to positive changes in the ANA domains and listed the four domains of QoL developed by the World Health Organization (World Health Organization, 1998) beneath the ANA domains in Figure 1. While many DBT skills can help improve QoL, two sets of DBT skills are particularly relevant to the promotion of QoL:

11. ABC PLEASE

ABC PLEASE is a set of tools designed to reduce vulnerability to intense emotions and promote resilience. This skill is introduced as two acronyms: (1) Accumulate positive emotions, Build mastery, and Cope ahead; and (2) treat PhysicaL illness, balance Eating, avoid mood-Altering substances, balance Sleep, and get Exercise. The skills associated with the first acronym (ABC) help build psychological QoL by introducing positive experiences and attaining a sense of mastery to increase feelings of confidence and resilience. These strengths-based skills may broadly help build a meaningful and satisfying life that is worth living. The skills associated with the second acronym (PLEASE) help build physical QoL by establishing a holistic routine to care for the body and promote healthy behaviors. We conceptualize ABC PLEASE skills as important in disrupting the relationship between problematic drinking and poor psychological and physical QoL.

12. Community Reinforcement

Community Reinforcement is a set of tools designed to restructure one’s environment to reinforce abstinence. These skills are introduced in a stepwise fashion to reinforce abstinence, replace addiction reinforcers with abstinence reinforcers, and encourage “abstinence sampling.” The Community Reinforcement skill can be utilized to improve social and environmental QoL by identifying, facilitating, and reinforcing positive environmental factors and supportive interpersonal relationships in recovery. We conceptualize Community Reinforcement as important in disrupting the relationship between problematic drinking and poor social and environmental QoL. Effective use of the Community Reinforcement skill can help individuals with AUD improve their interpersonal relationships and structure their environment in a way that is more favorable to their recovery.

Clinical Case Vignettes

The DBT skills training manual (Linehan, 2015) provides very detailed and practical guidance on how to teach each of the skills referenced in this paper, including prompts, practice exercises, story points, discussion points, and notes to leaders that clinicians can use. Thus, the purpose of the three clinical case vignettes presented in Table 3 is not to show how to teach these DBT skills, but is rather focused on how to select and prioritize DBT skills based on the ANA-QoL case conceptualization. The ability to do so can help clinicians personalize treatment for each individual patient and is particularly useful in behavioral health care settings where access to full DBT is not feasible and patient care time is limited.

Table 3.

Clinical Illustrations of the Conceptual Synthesis to Enhance Patient Care in Behavioral Health Care Settings

Hypothetical Clinical Case Vignettes	Psychosocial Considerations	ANA-QoL Conceptualization	DBT Skills Prioritization and Implementation
1.White bisexual woman in her early 20s presenting to treatment at the insistence of her college counselor after failing several classes in the context of increased binge drinking episodes. She reports drinking socially on weekends, stating “once I start drinking, I just can’t stop.” She reports she is not “out” to her friends, but has had sexual relationships with other women while intoxicated, after which she feels shame. Recent plummeting grades have led to fears about losing her college scholarship.	Minority stressors and internalized stigma related to her sexuality Fear of rejection by her friends Risk of financial loss	Incentive salience as a driving factor for drinking onset Negative emotionality as a maintenance factor for problematic drinking	Burn Bridges & Build New Ones to reduce social drinking and improve healthy relationships STOP Skill to prevent impulsive alcohol use TIP Skills to manage intense emotions that lead to binge drinking and intoxication Opposite Action to address the feeling of shame and self-stigma
2. African American heterosexual man in his mid-50s presenting to treatment following a relapse after the dissolution of his marriage. He feels betrayed by his wife who left for another man but acknowledges that his excessive drinking damaged the relationship with his wife. He had several past relapses and his most recent relapse was precipitated by the thoughts “I can do a little, if only on weekends” and “I can control my habit.” He did not engage in any prior treatment because total abstinence was never his goal, though he is now reevaluating whether it is time for him to change. He is socially isolated and does not have friends who do not drink alcohol.	Social isolation and loneliness Ambivalence in stopping drinking or utilizing treatment for AUD	Executive dysfunction as a driving and maintenance factor for problematic drinking Low social QoL	Dialectical Abstinence to promote use of abstinence and harm reduction strategies Pros and Cons to increase motivation to change and promote treatment engagement Clear Mind to foster awareness of the shift from the Clear Mindset to the Complacent Mindset in prior relapses and prevent future relapses Community Reinforcement to improve social QoL
3. Hispanic heterosexual man in his mid-40s with chronic alcohol use and two prior inpatient detoxifications. He lost his uncle and brother due to alcohol-related liver disease (ALD) and has recently been diagnosed with alcohol-associated cirrhosis himself. Although he is aware of the need for him to stop drinking, alcohol is the only way he knows to cope with negative emotions in his life. Given family history of AUD and ALD, he believes that he is “destined” for a bad outcome regardless of what he does. Moreover, as he has continued to drink, he is worried that his doctors and nurses would think of him as a “bad patient” and does not want to go to the follow-up Hepatology appointments.	Family history of AUD and ALD High service utilization of the medical system	Negative emotionality as a driving and maintenance factor for problematic drinking Low psychological and physical QoL	Check the Facts to build skills to examine automatic thoughts leading to problematic drinking Radical Acceptance to come to terms with how alcohol-related conditions run in the family ABC skill to increase pleasant activities, build mastery, and cope ahead with challenges related to the management of his alcohol-associated cirrhosis diagnosis PLEASE skill to encourage self-care of the body, including going to the Hepatology appointments and considering medication options

Note. All information presented in these clinical case vignettes was generated for demonstration purposes. The patients described are not based on specific individuals. The functional behavior chain analysis in DBT and the Clinicians’ Conceptualization Worksheet (see Figure 4) can be used across these case vignettes to inform the ANA-QoL Conceptualization. The Core Mindfulness Skills in DBT are thought to be universally beneficial for all patients as they navigate their recovery while accessing Wise Mind.

In the first vignette, a White bisexual woman in her early 20s reports increased binge drinking episodes that are driven and maintained by elevations of incentive salience and negative emotionality in the context of minority stressors and declining academic performance. Given that she drinks socially on weekends, Burn Bridges & Build New Ones can help her reduce social drinking and identify alternative ways to manage her cravings (e.g., urge surfing). To target the loss-of-control drinking, she can use the STOP skill as a basic strategy to increase awareness of her internal thoughts/feelings as well as external triggers. Through observing and proceeding mindfully, she can make decisions in her Wise Mind while remembering what her goals are in the situation. On top of that, the TIP skills offer several options to help address intense emotions that trigger binge drinking and intoxication. Finally, Opposite Action can be used to reduce shame related to her prior sexual experiences and help address self-stigma (e.g., sharing her experiences in a safe and accepting peer support group).

In the second vignette, an African American heterosexual man in his mid-50s reports thought patterns that map onto the addicted and complacent mindsets and shows ambivalence to engage in AUD treatment. Given that total abstinence was not his goal, Dialectical Abstinence provides a wide set of tools that can help him move toward abstinence (e.g., using harm reduction strategies). Pros and Cons can also be used to help him evaluate the positive and negative impact alcohol had on his life and increase motivation to change and treatment engagement. The specific thought patterns that he had can be addressed using Clear Mind which may help him gain insight into his prior relapses and be more prepared and vigilant in the future. Finally, given the low social QoL, he can benefit from the Community Reinforcement skill which can help address social isolation and build a social support system that is more favorable to his recovery.

In the third vignette, a Hispanic heterosexual man in his mid-40s with a recent diagnosis of alcohol-associated cirrhosis reports using alcohol to cope with negative emotions. In the context of strong family history of AUD and alcohol related liver disease (ALD), he has the interpretation that he is “destined” for a bad outcome. This type of negative thinking can be addressed using Check the Facts. The reality that alcohol-related conditions run in his family cannot be changed and can be addressed using Radical Acceptance (see Figure 2). Further, the low psychological QoL can be addressed using the ABC skill, such as re-engaging in alcohol-free pleasant events that he used to enjoy or developing new hobbies to increase positive emotions. Additionally, Building Mastery and Coping Ahead can be used to address QoL issues that are specific to liver disease (e.g., memory/concentration problems and health distress; see Luk et al., 2024). Finally, as Hepatology care is critical for the management of alcohol-associated cirrhosis, the PLEASE skill can be used to encourage self-care of his body and mind (consistent with the idea of “whole person recovery”; see Witkiewitz & Tucker, 2024), and promote adherence to medical treatment.

Translational Value of Conceptual Synthesis on Clinical Practice and Implementation

We illustrate the translational value of our conceptual synthesis on clinical practice and implementation in Figure 3. A key innovation of this synthesis is the potential to make addiction treatment more targeted and relatively brief, so that patients might find the intervention materials suitable for their unique situation. As a behavior therapy, DBT offers excellent tools to conduct behavioral assessments that are central to DBT practice (Rizvi & Sayrs, 2020). The functional behavior chain analysis in DBT, which includes an example of analyzing “drinking too much and driving drunk” as the problem behavior, can help clinicians develop personalized clinical profiles along the ANA-QoL domains. As a complementary aid, we outline questions that clinicians can review to inform the ANA-QoL case conceptualization and DBT skills prioritization in the Clinicians’ Conceptualization Worksheet (Figure 4). Using this Worksheet, clinicians can assess which QoL concerns may be present to motivate treatment engagement and behavioral change, and ANA domains that may underlie the maintenance of addictive behaviors. Clinicians can also utilize new measures that assess reward-driven and relief-driven drinking patterns (map onto incentive salience and negative emotionality, respectively), such as the Reward and Relief Inventory of Drinking Situations (Votaw et al., 2022) and the Alcohol Relief Questionnaire (Lac & Luk, 2023), to inform the ANA-QoL case conceptualization and DBT skills treatment planning.

Figure 3.

Translational Value of Conceptual Synthesis on Clinical Practice and Implementation

Figure 4.

Clinicians’ Worksheet to Guide the ANA-QoL Case Conceptualization

Stigma is a significant barrier to addiction treatment (Keyes et al., 2010). As treatment providers, while it is imperative to choose the appropriate language we use carefully (e.g., using person-centered language) to prevent exacerbating stigma (Volkow et al., 2021), mental health and substance use–related stigma is unlikely to be completely eliminated in the public arena. From a DBT perspective, mental health and substance use–related stigma can be conceptualized as part of an invalidating environment that worsens psychological health and can be countered by validation skills within DBT. In addition, DBT offers practical strategies to help patients mitigate the adverse impact of internalized and structural stigma on their own health and recovery. Internalized stigma occurs when individuals believe that they are devalued members of society and anticipate social rejection in the context of widely held stereotypes associated with mental illness (Livingston & Boyd, 2010). Individuals with AUD may experience negative emotions such as shame and guilt due to internalized stigma. The Opposite Action skill is well suited to help individuals with AUD cope with these emotions through the identification of the action urge (e.g., wanting to hide/avoid) and practicing the corresponding opposite action (e.g., tell the secret to people who will accept it). In terms of addressing structural stigma, a DBT informed approach may involve the dialectic of utilizing both change and acceptance strategies, such as advocating for improved access for treatment while also radically accepting that barriers to treatment may always exist.

DBT skills training for addiction can be delivered in multiple ways to increase reach to its target population. Informed by our conceptual synthesis, the length and content of DBT skills training can be adjusted based on availability of resources and tailored based on client needs and preferences. Especially for individuals with AUD who are initially disinterested in or ambivalent about treatment, brief and targeted DBT skills training may be more appealing than traditional forms of psychotherapy. Delivered in a group format, DBT skills training can serve multiple patients all at once, which helps improve equal access to mental health and addiction treatment (Whittingham et al., 2023). Moreover, group dynamics in the DBT skills training can facilitate DBT skills learning and provide mutual social support through sharing of lived experiences (Cavicchioli et al., 2021), making the group format a compelling method of treatment delivery.

DBT skills training can also be delivered in individual therapy sessions or via telehealth approaches. Although individual therapy may be more resource intensive, this delivery method has the advantage of further tailoring DBT skills to fit the specific needs of the individual patient and may be needed for patients with severe AUD and/or complex clinical presentations. As for telehealth approaches, using online methods to facilitate DBT skills training is acceptable to or even preferred by study participants (Lakeman et al., 2022), and it may be an effective approach to reach individuals with co-occuring suicidal and heavy episodic drinking behaviors (Wilks et al., 2018). This delivery method can enable wider dissemination of the intervention materials, making DBT skills training more accessible to individuals who might otherwise not be able to benefit from these skills. However, to realize its potential to increase reach, it is important to expand training in DBT so that more clinicians are equipped and qualified to deliver DBT skills informed interventions across different treatment settings.

Limitations and Future Directions

This conceptual synthesis has several limitations. First, ANA is only one model of addiction and is relatively new and in need of further empirical evaluations. We acknowledge that alternative models of addiction can be equally useful to guide clinical practice. However, we are drawn to the ANA model because it has great potential to bridge the gap between basic neuroscience research and clinical practice since its tenets map well onto evidence-based clinical paradigms (e.g., MET and CBT) currently used in practice. Second, while there is evidence to suggest that DBT skills can be used to treat addictive behaviors, the empirical demonstration of how addiction clinical domains may be altered by specific DBT skills is not yet present. We hope that our conceptual synthesis will serve as a catalyst for future empirical research in this area. Third, although initial data suggest that the ANA model can be applied to individuals who use methamphetamine (Nieto & Ray, 2022), the extent to which the proposed conceptual synthesis can be generalized to other substances beyond alcohol use is unclear and should be examined in future research.

The utilization of DBT skills to target specific ANA domains opens exciting possibilities to improve our understanding of neurobiological changes within the addiction cycle. In a recent review, DBT for BPD has been linked to neurobiological changes over the course of treatment, including reduced activation of the amygdala and anterior cingulate cortex, as well as increased activation of the inferior frontal gyrus in response to inhibitory control (Iskric & Barkley-Levenson, 2021). These findings suggest that neurobiological changes may occur as a function of DBT skills acquisition. While naturalistic studies of patients with AUD help reveal the natural course of AUD through the addiction cycle, changes in ANA domains may be small and heterogeneous across individuals. If specific DBT skills can be used to target and experimentally manipulate ANA domains, the magnitude of changes in neurobiology may be more salient and easier to detect in often underpowered neuroimaging studies. In this way, the mapping of DBT skills to addiction clinical domains offers a valuable opportunity to deepen our understanding of the neurobiology of addictions and the associated improvements in QoL and well-being during recovery as addiction relevant DBT skills are being acquired and practiced over time.

Conclusions

Recent advances in addiction research and theory show that alcohol and substance use disorders are often characterized by executive dysfunction, incentive salience, negative emotionality, and impaired QoL. In this conceptual synthesis, we illustrate how specific DBT skills can be utilized to help patients break the addiction cycle and improve their QoL in recovery with the aid of clinical cases, a practical conceptualization tool, and a tailored worksheet on adapting the Radical Acceptance skill for addiction. The integration of the ANA model with QoL domains is novel and is consistent with the recent call to examine “whole person recovery” in substance use treatment within a larger ecological model that acknowledges the roles of social determinants of health (Witkiewitz & Tucker, 2024). To inform clinical practice, we propose a conceptual model in which a dozen of DBT skills are mapped onto the three ANA domains of executive dysfunction, incentive salience, and negative emotionality, as well as four domains of QoL. Using three clinical case illustrations and the provision of two clinically oriented worksheets, we offer practical guidance on how to conceptualize, prioritize, and adapt DBT skills training within an integrated addiction-focused framework. Given the feasibility of disseminating DBT skills in group and telehealth formats, the utilization of DBT skills training for addictive behaviors holds important public health implications and may help reduce the AUD treatment gap. More research is needed to test DBT skills training as a stand-alone or adjunctive treatment option for AUD and addictive behaviors, which could inform precision medicine and an improved understanding of the addiction cycle and the recovery process.

Highlights.

• There is a significant treatment gap in alcohol and substance use disorders.

• There are many skills in the DBT skills training manual and access to DBT is often limited.

• Mapping DBT skills to addiction clinical domains helps with prioritization and can make the intervention more broadly available in behavioral health care settings.

• Personalized interventions using DBT skills can make treatment more attractive and relevant.

• Multiple delivery options can help with dissemination and reach those in need.