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Simone Hoermann, Ph.D.Simone Hoermann, Ph.D.
A blog about the personality disorders (borderline, narcissistic, etc.) with a focus on research and therapy

Dual Diagnosis - Personality Disorders and Substance Use

Simone Hoermann, Ph.D. Updated: Jun 4th 2009

yellow swirl graphicMy colleague Dr. Barbara Kistenmacher, a fellow psychologist who is Director of Addictions Treatments at Bronx-Lebanon Hospital, and I just talked about the fact that many people who have personality disorders also have issues with substance use. The co-occurrence of substance use with another mental illness is referred to as “dual diagnosis”.

Oftentimes, the use of drugs or alcohol is a way in which people with personality disorders have learned to cope with difficult feelings or difficult situations. The substance might appear to provide instant relief or instant gratification, but has destructive consequences at the same time that can massively impact a person’s life and relationships.

We talked about the example of a man in his thirties with a history of being bullied in school, being emotionally abused by his parents, and feeling like he did not fit in anywhere. He would develop a relationship with cocaine in order to deal with these feelings and end up using a dating service to meet women, doing lines of cocaine in order to feel confident and accepted, hoping for respect and love. The irony is that ultimately in the long term he might be perpetuating the very thing he is hoping to overcome – he might become isolated in his world of fantasy and cocaine, having superficial relationships that don’t provide him with the genuine and secure love that he wants and deserves.

“What I have come to realize in working in dual diagnosis treatment, is that, as a loved one or heath care professional, it is important to understand the function that the substance use serves for the person” says Dr. Kistenmacher. “People with personality disorders who use substances usually do so because the substance appears to provide some sort of instant solution. For example, someone who as a child has had to develop an avoidant coping style in order to stay away from difficult feelings or situations can use marijuana or alcohol as a way of coping with conflict. This usually happens for a good reason, because avoidant behavior either worked as a coping strategy, or it was one of very few options. The problem is that at some point it does not work anymore.”

Dr. Kistenmacher stresses the importance of making the person separate from the substance use. “It is one thing to say that ‘my husband is a pothead’ or ‘my wife is an alcoholic’ versus understanding that “my husband or wife copes by avoiding and pot or alcohol help him or her do that’” she explains. “Being that simplistic means to cut off the very vulnerable part of the person that needs understanding and healing. It is important to understand that it is less helpful to demonize the substance use itself, or to reduce the person to just the substance, and that it is more helpful to acknowledge that using alcohol or drugs provides a powerful and seemingly instant solution for the person. Of course, at the same time, we need to acknowledge that it has destructive consequences and provide appropriate treatment.”

Simone Hoermann, Ph.D.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. She is a faculty member of Columbia University, and facilitates psychotherapy and skills training groups at the Columbia East 60th Street Day Treatment Program.

Reader Comments
Discuss this issue below or in our forums.

dual personality - yogita - Nov 4th 2009

hello Ma'm

please tell me something about Dual Personality at Workplace...organizations.

people who posses this kind of to handle them and all about this.


Thanks and Regards




Understanding anti social personality - caregiver - Jun 17th 2009

What about people with anti social personality and using their prescription drugs and other drugs too?

Semantics - Clean for Fifteen Years - Jun 8th 2009

Good article, as are all I've read here.  As a Been There Done That person, I would suggest one change:

Article says:

“People with personality disorders who use substances usually do so because the substance appears to provide some sort of instant solution."

I would change "solution" to "relief" perhaps "relief and fortification," or "solution or relief."

"Solution" is correct, but I believe inadequate to the pain/difficulties that self-medicators experience.

integrated treatment - Ray Smith - Jun 8th 2009

I currently work for an ACT program in North Carolina, previously for an ACT program in upstate NY.

I checked out Columbia East 60th Street Day Treatment Program web page and must say that I am impressed.

Far too often, the best most dually diagnosed clients can hope for are separate, parallel mental health and substance abuse treatments, often at odds with each other. Each system views it’s own slant on recovery to be the primary diagnosis.

Kathleen Sciacca said: "Addiction professionals may believe that mental illness is a symptom or manifestation of substance abuse; mental health professionals may believe that substance abuse is a symptom of mental illness. Neither group is therefore likely to provide effective treatment for multiple diagnosed patients in their usual treatment setting."

I wish there were more programs like yours, the need is there.

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