A Clinical Perspective of Substance Use and Borderline Personality Disorder


The majority of people with Borderline Personality Disorder will also have a substance use disorder during their lifetime (1).


But why?


In order to understand the high co-morbidity rates, we need to understand BPD in the first place.


I prefer to explain BPD using a metaphor. I could give you a list of symptoms, but the problem with that is it gives you an outside-in perspective of BPD. Symptoms describe what other people can observe, not what it’s like to live with the diagnosis.


When we try to distill someone’s lived experience down to a list of symptoms, we can inadvertently contribute to the stigma associated with the diagnosis – and since more than half of all healthcare providers already have negative opinions of people with BPD (2), I don’t need to add any fuel to that fire.

 

Imagine that you’re born into a world where everyone wears steel-toed boots – but for some reason, you’re barefoot.


In this world, people step on each other’s toes all the time. It doesn’t hurt them, because they all wear the same boots. They don’t apologize for it when it happens, because there’s nothing to apologize for. No harm has been done.


But you’re barefoot. When people step on your toes, it hurts.


Let’s be clear: you haven’t done anything wrong. You didn’t ask to be born barefoot. And they haven’t done anything wrong either. They don’t know what it’s like to be barefoot because they’ve never experienced it. They’ve probably never met anyone who was barefoot before.


You can explain yourself all you’d like, but most people will never get it. Some people might go out of their way not to step on you – but that’s an inconvenience to them, since it’s outside of their norm.


Most people will keep treating you normally – which means your toes will keep getting stepped on.


The first several times someone steps on your toes, you’ll say, “Ouch!” That’s a natural reaction to having your toes stepped on.


But no matter how many times you say “ouch,” the other people won’t get it.


Unfortunately for you, most of them will correct you instead of apologizing.


“That didn’t hurt,” they’ll say. “People step on my toes all the time and it never hurts me. You’re just being dramatic.”


They might even step on your toes again, to prove a point.


Imagine that this happens every day, wherever you go.


After a while your toes are mangled and broken, and it’s hard to walk.


How long would it take for you to snap?


How many times would someone have to step on your toes before you started screaming “Get away from me!” every time someone walked near you?


How long before you screamed insults at someone who stepped on your toes? How long before you broke down and cried, refusing to leave your house, because going anywhere means pain?


How many days, months, or years would it take before you gave up?

 

This cycle of misunderstanding – one person expresses their pain, and the people around them don’t understand – is what Linehan calls the invalidating environment (3).


People with BPD are theorized to have a predisposition to emotional sensitivity – they are born emotionally barefoot. As children, they may have emotional responses that are above and beyond the average, and will be slow to return to baseline.


In an invalidating environment, the adults around the sensitive child are unable to teach the child how to regulate their emotions. Instead, they respond to the child’s emotions with corrections or criticism, or even outbursts of their own. Once in a while, they might reward the child’s emotions (reward is a relative term – this might mean removing a punishment or giving in to a tantrum).


Think of a competent parent comforting a crying toddler. She or he might say things like, “Oh no, are you sad?” and make a frowning face. This will teach the toddler the name of the feeling and reassure them that their parent understands. The parent might add, “It’s going to be okay,” or some other comforting platitude. This will teach the toddler that the emotion is temporary.


In an invalidating environment, the crying toddler is met with hostility. “Look at you, crying again,” the invalidating parent might say. “You always cry, cry, cry! You don’t even have any real problems!” In this scenario, the toddler does not learn the name of the emotion. They do not have any reason to believe the parent understands – in fact, they are likely to feel that they are being punished because they are sad. They feel even worse than when they started crying, and have no idea when the feeling will end.


What they do know, for a fact, is that their crying has upset their parent – but they have no tools to comfort themselves. They begin to feel like a burden.


As the child ages, they will hopefully meet adults – teachers, parents of friends, etc – who can provide them with at least some emotion regulation skills. They may be able to model emotion regulation behaviors after peers.


But if they don’t meet these adults, or don’t have peers to model after, where are they supposed to learn these skills as they age?


Instead, the child with emotional sensitivity grows into a teenager with no ability to manage their emotions or behaviors. They will feel intense shame and anger, knowing they are different than others, but not knowing how to change themselves.


Every emotion sets off a cycle – it feels overwhelming, and confusing, and permanent. Without the skills to regulate the intensity of the emotion, acting on the emotion becomes the only available option. When they act on the emotion, other people won’t understand why they’re doing what they’re doing. Because of the misunderstanding, they will likely be criticized for their behavior. Yet no one will address the underlying emotion that drove the behavior in the first place.


By adolescence, the individual has probably been experiencing the invalidating environment for over a decade – day in, day out.


Existence itself becomes unbearable, because every day just brings more pain, anger, and shame, with no hope of being understood. This is why one of the most common symptoms of BPD is suicidal ideation. Why would someone want to live in a world where every day was so painful?

 
 

Let’s pause here. If you are a healthcare provider, you have likely come into contact with people with BPD. More importantly, you have likely met other healthcare providers who feel comfortable speaking negatively about people with BPD.


The healthcare community has made great strides in reducing the stigma of most mental health diagnoses. We do not blame individuals for their own depression or psychosis – we call these chemical imbalances. We do not blame individuals for their hyper-reactivity following a trauma – we call it PTSD.


And yet, despite the fact that Linehan’s biosocial theory was published in 1993 – almost 30 years ago – and draws a clear line between the causes of BPD and the behaviors associated with the diagnosis, the healthcare community seems to think it’s fair game to blame people with BPD for their behavior.


As I often say to my clients and to other mental health professionals, nobody wakes up in the morning and chooses to be Borderline. If people with BPD had any other choices, they’d take them.

 

Let’s get back to it. This is, after all, an article about the high rates of co-occurring substance use disorders in people with BPD.


I hope that by now the reader understands that every day in the life of someone with Borderline Personality Disorder is painful. Your toes are broken, and never get a chance to heal. Anywhere you go, your toes will be stepped on. And no matter how well you explain yourself, the people around you will never understand that it hurts. If you try to protect yourself from the pain of being stepped on, you’ll be criticized or mocked.


You become hyper-reactive, fearful, maybe paranoid. People will perceive you as moody or even aggressive. You might even be considering suicide to escape the cycle. These feelings are the logical, but unfortunate, consequence of your circumstances.


Now imagine that in the midst of all this, after a decade or more of having broken toes, someone offers you a drink or a drug.


For the first time, you have relief.


You can’t stop people from stepping on your toes, but you can numb the pain.


It makes things better (for a little while, at the very beginning).


When your toes don’t hurt, you can interact with others without being fearful.


When you can interact with others without being fearful or hyper-reactive, you’ll receive less corrective criticism from them about your behavior.


In the short term, things seem to be getting better. So you drink or use more – why would you want to return to the pain?


Soon you’re stuck in the trap of addiction. Life without substances is painful, so you drink or use. When you drink or use, you feel better – but you start to develop a tolerance. In order to avoid the pain of an unaltered (barefoot) life, you drink or use even more.


Eventually you are drinking or using so much that it’s no longer numbing the pain – it’s making things worse. The way you behave when you’re under the influence starts to drive people away, and you’re left back where you started. Except that now, you might have a physical dependency on your drug of choice.


And still, you don’t know how to regulate your own emotions.

 

Addiction doesn’t work any differently for someone with BPD. Addictive substances affect all human bodies in similar ways. The liver and kidneys of a person with BPD aren’t different than anyone else’s.


What makes addictive substances so dangerous for someone with BPD is the fact that by the time they are introduced to the substance, they have already lived through years of intense emotional pain with no escape.


Substances provide the first opportunity for escape, and thus are wildly attractive. The peer reinforcement that comes along with early substance use is doubly attractive to someone with BPD, who has dealt with rejection for so long.


We have long accepted that people with Post-Traumatic Stress Disorder turn to substances to numb the emotional pain from their traumatic experiences. People with BPD are doing the same – but instead of episodic, life-threatening traumas, they suffer from the compound effects of repeated invalidation.*


*Actually, most people with BPD have a big-T trauma history too, but that’s a story for another post.

 

What should you do with this information? If you’re a healthcare worker, it’s imperative to understand the nature of BPD and how it contributes to SUD, so you can adjust your own approach to treatment.


The most important thing we can do for someone with BPD and SUD is to stop perpetuating the invalidating environment. The second-most important thing we can do is to teach them ways to regulate their own emotions. Yes, it’s in that order. We can’t teach someone until we have made them feel safe – otherwise we are only criticizing.


Here are some action steps you can take when working with people who have co-occurring BPD and SUD:


First: Understand that people don’t do things that don’t make sense. Every time someone with BPD says or does something you don’t understand, remember that they are emotionally barefoot. Just because you can’t understand their behavior, doesn’t mean it’s irrational. It may be the only option that person has in the moment, given the intensity of their emotions and the skills they have at the time.


Second: Instead of correcting, start with “It makes sense that you feel that way.” You may be bursting at the seams to tell someone what they should do instead, but if you open with a correction, you are just perpetuating the invalidating environment. Since we’ve agreed that people don’t do things that don’t make sense, it naturally follows that they have a good reason for feeling and acting the way they are.


Third: List the events that you think led up to the current emotion and validate the emotion. You aren’t egging them on – this will show the person that you are trying to understand instead of dismiss.


Fourth: AFTER you validate the emotion in step two and list the facts in step three, offer the option to regulate the emtead of a criticism of the existing emotion. Make it clear that you are offering them an option, and that they can choose to continue feeling the way they already feel (unless the person is exhibiting dangerous behavior, in which case you should use your agency’s crisis protocol).


Let’s use these steps in an example: a young person in a treatment center becomes angry when they are not able to access the telephone to call a loved one. They begin yelling.


First: Get your own head right! Remember that people don’t do things that don’t make sense. Even if you know that it would be more effective to politely ask for the telephone, this person may not have that option right now given the intensity of their emotion and the skills they have today. Maybe they are yelling because they are overwhelmed with fear that they won’t get to speak to their loved one – on top of the anxiety of being in an unfamiliar environment with new treatment professionals.


Second: “It makes sense that you’re angry.”


Third: “You had planned on using the phone to talk to your loved one, but right now the phone is not available. I can see how that would make anyone upset.” (Notice what’s not here: a suggestion that they just wait patiently).


Fourth: “If you’d like, I can notify you when the phone is available. You can spend some of that time practicing a breathing exercise or reading in the group room. If you’re feeling too upset for that right now, that’s okay.”

 

Notice how when you follow the steps, you are acknowledging that the person is experiencing strong emotions without judging them. Second, you are not offering to regulate the emotion for them. You’re just offering them the opportunity to regulate their own emotion using skills they may have forgotten about in the moment due to the intensity of their feelings.


Our job as healthcare professionals is to help people live better lives.


By addressing our own biases, validating peoples’ experience, and offering them the opportunity to improve their own lives, we can assist our patients and clients in living better lives long after they leave treatment.



(1) Trull et al, 2018: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6145127/pdf/40479_2018_Article_93.pdf

(2) Sansone & Sansonse, 2013: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3719460/pdf/icns_10_5-6_39.pdf

(3) Crowell, Beauchaine, & Linehan, 2009: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696274/pdf/nihms114226.pdf





Holistic Interventionist thanks Catherine for her insightful contribution to the Human Potential Blog. Catherine Humenuk, LCSW can be reached at www.catherinehumenuklcsw.com for further information and consultation. The views of the individual contributors are their own and do not constitute advice or recommendation from Holistic Interventionist LLC. Holistic Interventionist selects a variety of guest blog writers for their expertise, insight, and willingness to collaborate for the wellness of as many individuals as possible.


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