Co-occurrence of BPD and Substance Abuse
Patients with concurrent diagnoses of Borderline Personality Disorder (BPD) and substance abuse (SA) often face substantial obstacles when seeking treatment. For example, if they go to a mental health clinic for help with their symptoms of BPD, they may be turned away until they stop using substances. In the same vein, patients seeking to enter substance abuse treatment may be delayed until they are able to get their suicidal ideations and self-harming behaviors under control. Data show that, within SA populations, the “prevalence of BPD ranges from 2%-66%, with a median rate of 18%” (van den Bosch, Verheul, Schippers, van den Brink, 2002, p. 912). With a relatively high rate of co-morbidity between BPD and SA, it is essential for clinicians to better formulate and test treatments that address the often overlapping symptoms of each, concurrently.
Does Treatment Need to Be Different?
Dialectical Behavior Therapy (DBT), the standard treatment for BPD, has been adapted to treat patients with SA diagnoses. Yet, van den Bosch et al. (2002) note that this differentiation in treatment is substantiated only if data indicate different treatment outcomes for individuals with and without diagnoses of SA undergoing standard DBT. Without said substantiation, there exist tremendous organizational challenges with a large number of treatment modules to account for the specifics of a whole clinical population. Thus, van den Bosch et al. (2002) designed a study to assess the effect of standard DBT on both BPD pathology and SA issues.
Recommendations for DBT when One of the Dual Diagnoses is Substance Abuse
A standard DBT program, focused on targeting suicidal and self-harming behaviors initially, was implemented at a treatment center in Amsterdam. Participants, with dual diagnosis of BPD and SA, committed to the standard 12-month DBT program with weekly individual sessions, weekly supervision and consultation meetings for therapists, weekly group skills-based sessions, and as-needed phone consultations. The results of the study indicated that DBT can be applied to patients with a dual diagnosis and that standard DBT is “as effective for substance abusing borderline patients as for non-substance abusing borderline patients when suicidal and self-destructive behavior are focus of treatment” (van den Bosch et al., 2002, p. 920). However, standard DBT did not significantly impact SA symptoms. Further, examination of DBT-SA programs found that symptoms connected to SA were targeted far more than suicidal or self-harming behaviors. The researchers note that in published DBT trials, it is apparent that DBT is effective in terms of specific behavioral targets. There does not, however, seem to be generalizability to other domains. Thus, instead of creating a different treatment model, van den Bosch et al. (2002) are calling for a modification of standard DBT practice to include multiple behavioral targets, versus different treatment programs for distinct populations. Their proposed modifications include prioritizing SA next to or just after suicidal and self-harming behaviors, as well as additional training for DBT therapists to include techniques for working with substance abusers and addictive behavior.
Van den Bosch, L., Verheul, R., Schippers, G., & van den Brink, W. (2002). Dialectical behavior therapy of borderline patients with and without substance use problems: Implementation and long-term effects. Addictive Behaviors, 27, 911-923.