Coping with Emotions: Treating Borderline Personality Disorder and Substance Use

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Simone Hoermann, Ph.D., is a Psychologist in private practice in New York City. She specializes in providing psychotherapy for Personality Disorders, Anxiety, and Depression ...Read More

In a previous blog, I wrote about some aspects of substance abuse and its relationship to Personality Disorders. A common problem for people with Borderline Personality Disorder is a tendency to get very overwhelmed by intense emotions. Sometimes, this leads to self-destructive behaviors, such as cutting, bingeing and purging, shopping, spending, or gambling.

My colleague Dr. Karen Frieder, who specializes in treating people with substance abuse issues and also with problems related to a dual diagnosis of substance use  and Personality Disorders, explained to me that in the past, substance use was seen as a different set of problems: “There was so much stigma attached to substance abuse issues, even more than other difficulties, but thankfully that has changed more recently. Nowadays, in people with Borderline Personality Disorder, we tend to see substance abuse as part of the issues with emotion regulation, similar to cutting, spending, or bingeing and purging. Therefore, one way of conceptualizing substance use in people with Borderline Personality Disorder is that substance use can be added to this list of self-destructive, impulsive behaviors.”


Frequently, people with Borderline Personality Disorder feel overwhelmed with intense emotions and use substances in order to avoid or cope with these painful or tense internal states.  Sometimes, the opposite is the case: Some people with Borderline Personality Disorder are very detached from their feelings and feel empty inside.  Using a substance, for instance, using alcohol, can serve as a means to feel things more intensely.  “We call this the self-medication hypothesis”, says Dr. Frieder, “If you’re feeling up, you use the substance to come down, and if you’re down, you use the substance to come back up. The idea is that there is an underlying cause for the substance use.  The person engages in these behaviors in an attempt to find short-term solutions, but they are not very effective.”

The process of stopping the substance use can become very frustrating for someone with Borderline Personality Disorder. Frequently, what people notice is that they stop the substance use behavior, but then another self-destructive behavior, such as spending, gambling, or cutting will creep up. “I often use the analogy of a boat”, explains Dr. Frieder, “Imagine your boat springs a leak: You try to plug it, but the pressure inside get so intense that another leak pops up. You try to plug that, and yet another leak pops up. It’s often the same for people with Borderline Personality Disorder – you stop using one self-destructive way of coping, but the internal pressure get so intense, you resort to another. Often, people are not aware of this connection and get frustrated that they stop using substance but they don’t feel better right away and engage in other self-destructive behaviors. It can be helpful to realize that these behaviors are related, they go together. The idea is that if you patch up all the holes, you feel your feelings and the pressure gets pretty tough. In therapy, you have to learn skills on how to tolerate these intense feelings and to cope.”

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 “The typical recommendation is for people to stop using for three months as a trial period.” states Dr. Frieder. “If someone can’t stop for an extended time period, it is often diagnostic that a person needs specific substance abuse treatment that addresses triggers and cravings and that addresses physiological dependence. A three month period of abstinence allows your body to adjust to not having the substance in the system, and if you are on psychiatric medication, it allows the medication to take effect. Your mood is not constantly changed by a drug. During this time, things can get really frustrating, because you work so hard on stopping, but you may feel worse in other areas. It’s important for people to know that this is pretty normal, and it helps to be aware what this is about. It is also important know that it does get better; that you can develop new skills and feel better.  You have to tolerate your feelings inside, and develop new ways of coping.  Once people manage to do that, they develop a stronger sense of self-esteem. They have been avoiding their feelings their whole lives, but they end up feeling more aware and start addressing their issues. This creates a powerful sense of accomplishment.  Plus, therapy tends to work much better when people don’t use substances, but it’s important to acknowledge that this is not easy.  It’s hard work, but it does pay off.”

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