Psychotherapy is regarded as the most effective treatment for BPD as a single disorder [1516] and is the recommended first-line of treatment for BPD in Australian and international guidelines [555, 1517–1519]. A Cochrane review of psychotherapies for BPD concluded that psychotherapy is an effective treatment for reducing BPD symptom severity, depression, and suicidality in people with BPD, but the vast majority of studies reviewed excluded people with co-occurring AOD use disorders [1516].
Although a large number of treatments have been developed for BPD, Dialectical Behaviour Therapy (DBT) and Mentalisation Based Treatment (MBT) are the most researched to date [1516]. DBT is a complex, skills-based, psychological intervention and has been modified for people with co-occurring BPD and AOD use disorders (DBT-S). In this model, the symptoms of BPD and AOD use are viewed as attempts to regulate emotions [162]. Using some of the same principles as CBT, the client is supported with strategies to promote abstinence and is more likely to remain engaged in treatment. Although research to date is limited to a small number of studies, DBT-S is the preferred treatment approach to date, having demonstrated improvements in relation to both BPD symptoms and AOD use [724, 1520].
MBT is an evidence-based treatment for BPD that focuses on mentalising, rather than cognitions or behaviours [1516, 1521]. Mentalising, or mentalisation, is a general term used to describe how we make sense of ourselves and the world around us. Although difficulties with mentalisation may be associated with many mental health conditions, people with BPD in particular may be more limited in their capacity to mentalise [1521]. In targeting mentalisation, MBT aims to improve some of the core characteristics of BPD, such as impulsivity, emotional instability, impaired interpersonal functioning, fractured identity, and chronic emptiness [1522]. Philips and colleagues [1523] conducted a feasibility study comparing the effectiveness of MBT provided in combination with AOD treatment, to AOD treatment alone among people with co-occurring BPD and AOD use disorders. No significant differences were found between groups with regard to changes in BPD symptom severity or substance use, but a trend towards a reduced number of suicide attempts among those who received MBT was found relative to AOD treatment alone. It should be noted, however, that therapist adherence to the treatment manual in this study was low.
Another promising treatment is Dynamic Deconstructive Psychotherapy (DDP) [1524, 1525]. DDP is a modified form of psychodynamic psychotherapy, and was initially developed for particularly challenging cases of BPD, including those with co-occurring AOD disorders [1525]. In a systematic review of the literature, Lee and colleagues [724] found three studies had evaluated DDP among those with co-occurring BPD and AOD use. These studies found that DDP had a significantly greater effect on symptoms of both BPD and alcohol use disorder compared to treatment as usual (i.e., treatment in the community), which were maintained over 30 months [1524, 1526, 1527]. DDP also effectively reduces some secondary treatment outcomes related to personality disorders, such as suicidal behaviour [1515].
Several other treatments have also been developed and undergone preliminary examinations for co-occurring BPD and AOD use but require further research [1528, 1529]. One treatment that does not appear to be of benefit in the treatment of co-occurring BPD and AOD use is Dual Focus Schema Therapy (DFST) [704, 1530], a combination of relapse prevention and therapy focused on early maladaptive schemas (such as continuing negative self-beliefs, negative beliefs about others or events), as well as coping styles [724, 1531]. DFST has only been examined in a single study to date, but appeared to be of limited benefit, and greater reductions in AOD use were found among those in the control condition (individual drug counselling) [724].