For someone living with borderline personality disorder (BPD), alcohol or drugs may bring temporary relief from intense emotions. Over time, the cost is high. Substance use is significantly more common among people with BPD than in the general population, and the conditions can intensify each other.
At Anker Huis, we treat BPD with co-occurring substance use using approaches developed for this combination. Understanding the connection helps people and families know what to look for in treatment.
What borderline personality disorder is
BPD is a personality disorder characterised by patterns of unstable relationships, unstable self-image, intense emotional reactivity, and impulsivity. Common features include:
- Intense fear of abandonment, real or imagined.
- A pattern of unstable relationships that swing between idealisation and disillusionment.
- Identity disturbance: an unstable sense of self.
- Impulsivity in at least two areas (spending, sex, substance use, reckless driving, binge eating).
- Recurrent suicidal behaviour or self-harm.
- Emotional instability: intense moods that shift rapidly, often in response to interpersonal events.
- Chronic feelings of emptiness.
- Intense anger or difficulty controlling anger.
- Transient stress-related paranoid thoughts or dissociation.
BPD is not “personality” in the casual sense of “the way someone is.” It is a clinical condition with defined criteria, biological and psychological roots, and effective treatment. It is also one of the most stigmatised mental health conditions, often described in pejorative terms even within clinical settings, which has contributed to under-treatment.
The clinical picture is genuinely difficult, both for the person living with it and for the people around them. It is also treatable. The phrase “BPD does not respond to treatment” is outdated. Specific approaches, particularly Dialectical Behaviour Therapy (DBT), have produced strong outcomes.
Why BPD and substance use are so often linked
Emotional intensity driving self-medication
The defining feature of BPD is the intensity of emotional experience. Emotions are reached more quickly, felt more deeply, and last longer than in people without BPD. The internal experience can be unbearable. Substances offer rapid, reliable suppression of this intensity, even though the suppression is temporary and the rebound often makes the underlying emotion worse.
Impulsivity
Impulsivity is a diagnostic feature of BPD. Substance use is one of the impulsive behaviours that BPD often manifests as, alongside binge eating, sexual risk-taking, and self-harm. The impulse is not “let me carefully decide whether to use a substance.” It is “I need this now.”
Interpersonal crises as triggers
For people with BPD, interpersonal conflict, perceived rejection and abandonment fears can feel intensely painful or catastrophic. Substances often function as a way to manage these crises in the moment. The pattern becomes embedded.
Co-occurring trauma
Many people with BPD have significant trauma histories. Substances may have entered the picture as a way to manage trauma symptoms, alongside or instead of treatment.
Shared neurobiology
The brain systems involved in emotion regulation, impulse control, and reward overlap significantly between BPD and addiction. The conditions are not separable in a clean way.
Why standard treatment often fails this combination
When BPD with substance use is treated using standard addiction approaches alone, the outcomes are usually poor.
The intensity returns
Standard rehab teaches coping skills for cravings and triggers. For someone with BPD, the cravings are often driven by emotional intensity that does not respond to standard coping skills. They need skills specifically designed for high emotional reactivity.
The relational patterns recreate themselves in the treatment setting
BPD frequently produces intense, unstable relationships with treatment providers: idealisation followed by disappointment, rapid attachment followed by anger, splitting between staff members. A treatment programme not specifically trained in this can be destabilised by these dynamics.
Discharge and aftercare
The transitions in and out of treatment, leaving a programme, settling into aftercare, are particularly hard for people with abandonment sensitivity. Standard aftercare structures often do not hold them.
The suicide risk
BPD carries an elevated suicide risk. Substance use compounds it. Programmes not built to manage this combination safely can have catastrophic outcomes.
The stigma
Some treatment providers have been trained to see BPD as “difficult” rather than as a treatable condition. The therapeutic alliance suffers. The client picks up the dismissal.
What works: integrated dbt-informed treatment
The strongest evidence base for BPD treatment is Dialectical Behaviour Therapy (DBT), developed by Marsha Linehan. DBT was developed initially for severe BPD and chronic suicidality, and has been adapted for substance use.
Core DBT components
DBT teaches four core skill sets:
- Mindfulness: the ability to observe one’s own internal experience without immediate reaction.
- Distress tolerance: practical skills for surviving crisis moments without making them worse (TIPP, ACCEPTS, IMPROVE, etc.).
- Emotion regulation: skills for understanding and modulating emotional intensity over time.
- Interpersonal effectiveness: skills for navigating relationships, asserting needs, and maintaining self-respect under interpersonal pressure.
These skills directly address the mechanisms of both BPD and addictive behaviour.
DBT for substance use (DBT-SUD)
Adapted DBT for substance use disorders adds specific elements:
- Dialectical abstinence: holding the absolute commitment to abstinence alongside compassion for the difficulty of maintaining it.
- Skills for navigating cravings.
- Specific attention to the substance-use trigger map.
- Repair work after lapses without catastrophising.
Integrated treatment at Anker Huis
Our treatment of BPD with substance use integrates:
- DBT-informed skills work in individual and group sessions.
- Psychiatric assessment and medication management where appropriate (no medication treats BPD directly, but specific symptoms can be supported).
- Trauma-focused therapy (often EMDR or trauma-focused CBT) where indicated.
- Family and partner work to support understanding and skill development at home.
- Medical management of substance withdrawal.
- Structured aftercare with the continuity that this condition needs.
The clinical team is trained to work with the relational dynamics of BPD rather than be destabilised by them.
Realistic expectations
Treatment takes time, with skills developed during residential care and practised over the longer term.
Recovery is possible
The outdated view that BPD is untreatable is wrong. With appropriate treatment, particularly DBT, people with BPD often improve substantially. Many no longer meet diagnostic criteria after sustained treatment. Adding effective substance use treatment to the picture multiplies the benefits.
It takes time
This is not a 28-day fix. The residential phase is a foundation. The longer-term work is the gradual building of skills and the deepening of new patterns over months and years.
Setbacks are part of the picture
Both BPD and addiction are chronic, relapsing conditions. The treatment plan includes how to manage relapse and emotional crisis when they occur, with the goal of preventing them from becoming catastrophic.
Family engagement helps
Family members who learn the same DBT skills the person is learning can change the home environment from a trigger field to a support structure.
Self-compassion is part of the work
People with BPD often carry a brutal inner critic. Recovery is partly about loosening this. The clinical team works with this throughout.
What families can do
If your family member has BPD and is using substances:
- Educate yourself. Books such as Marsha Linehan’s “DBT Skills Training Manual” and Valerie Porr’s “Overcoming Borderline Personality Disorder” are accessible starting points.
- Avoid invalidating responses. Telling someone in emotional crisis to “calm down,” “stop overreacting,” or “be reasonable” usually escalates the situation. The skills you can learn for validation are not about agreeing with the content; they are about acknowledging the emotion.
- Hold limits clearly and compassionately. People with BPD often respond well to limits that are clearly communicated and consistently held. They respond badly to limits that shift, to threats not followed through, to inconsistency.
- Take care of yourself. Loving someone with BPD is genuinely demanding. Your own wellbeing is part of the picture, not a luxury.
- Get your own support. Family therapy, partner therapy, and family skills groups designed for families of people with BPD are valuable. We can recommend resources.
A note on self-harm and safety
Self-harm and substance use can be linked behaviours in BPD. If you or someone you love is engaging in self-harm or having thoughts of suicide, this is a safety priority. Our admissions team will treat calls about combined BPD, substance use, and safety concerns as urgent.
In an immediate crisis, contact SADAG (the South African Depression and Anxiety Group) on 0800 567 567 or emergency services.
FAQ: BPD and substance use
Is BPD really treatable? Yes. The evidence for DBT in particular is strong. The picture is far more hopeful than older clinical lore suggested.
Can BPD be diagnosed while someone is still using substances? Initial assessment can be made, but formal diagnosis often requires a period of stabilisation since substance use can mimic some BPD features.
Will medication treat my BPD? No medication treats BPD directly. Specific medications can support specific symptoms (mood instability, anxiety, sleep). The primary treatment is therapeutic.
Does Anker Huis use DBT? Yes. DBT-informed therapeutic principles and skills may be incorporated into treatment where clinically appropriate, including for clients presenting with features of Borderline Personality Disorder (BPD). Our residential programme focuses on stabilisation, therapeutic engagement, and skills development within the scope of inpatient care. We do not offer a formal outpatient DBT programme or structured DBT aftercare programme.
Will my partner be included in treatment? With consent, yes. Partner inclusion is often particularly important in BPD presentations because the relational dynamics are central to the work.
Is BPD inherited? There is a genetic contribution, but BPD is not “inherited” in a simple sense. It develops through a combination of biological and environmental factors, often including early relational experiences.
If borderline personality disorder is part of your picture alongside substance use, Anker Huis provides specialist integrated treatment in Cape Town. Call +27 72 088 0446 or email info@ankerhuis.co.za.
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