 Hi everybody and welcome to today's presentation on strengths-based biopsychosocial approach to recovery from personality disorders. Now a lot of times personality disorders kind of get a bad rap because they are perceived to be intractable or untreatable and in this presentation I really want to look at some of the characteristics of personality disorders in ways they can be modified. Will people always have those behaviors available to them in the back of their head? Certainly, but can we help them develop new healthier behaviors? I do believe so. So over the next 45 minutes or an hour we're going to review the characteristics of cluster B personality disorders and this is the cluster that's characterized with narcissistic antisocial borderline and histrionic personality disorders. We'll explore the functions of the symptoms for people, identify what may cause these symptoms to develop, explore what's maintaining these symptoms that is what's the benefit because we know we don't do things unless there's a benefit, and explore the effects of these symptoms on significant others. Finally, we'll identify interventions to help the person more effectively manage emotions and relationships. So your first step is really going to be to address the emotional and or behavioral discontrol. If someone is infringing upon the rights of others, hurting other people or hurting themselves, they're not going to be able to engage in treatment right now. We need to get that under control. So the first thing we need to identify is what are some of the vulnerabilities when you feel more impulsive, when you feel more emotional, when you feel more scared, what types of things are going on that kind of prompt you to feel that way? Sometimes it's not getting enough sleep, sometimes too much stress at home. Maybe it is upcoming holidays. Everybody has different vulnerabilities, but we need to know what's going to make you more likely to become emotional or act out. Then we'll identify what works to help the person self-soothe. When they have experienced these situations in the past, what have they done that has worked to help them not hurt themselves or someone else? Then we'll identify some helpful distraction techniques, things that they can do while they're trying to figure out what to do next. We'll take all this and put it together in a written safety plan. And I really want to emphasize written because if someone is in a very emotional or wound up state and they're at risk of emotional or behavioral discontrol or acting out, they're not thinking, what was it that I talked about with my therapist last week? They're just thinking they need the pain to stop. So you want to write the safety plan down so they can refer to it. Hopefully we can help them develop enough self-awareness that they can stop, pull out the safety plan and go, okay, what do I need to do? The next step is that when we start identifying the salient symptoms, their function and alternate ways to meet that need. Like I said, these behaviors have a purpose. They're serving a purpose for the person and we need to figure out what that is so we can help them either change the way they feel about the situation or change the situation in a healthier way. We need to find out what it looks like for different people. For example, being dramatic. Being dramatic looks different for different people. Some people may get loud and aggressive. Some people may play the damsel in distress. What does it look like for your particular client? Then look at how the behavior is being maintained. When they do act out, when they do engage in this behavior that's theoretically dysfunctional, what are the rewards? What do they get out of it? Because there's something and we can figure out different ways to meet that need or to quell that need in the treatment process. So we're going to start out talking about generalities. There are four core features of personality disorders. Rigid and extreme and distorted thinking patterns. So in therapy, when you were in counseling 101, you learned about cognitions and cognitive distortions and all that kind of stuff. Well, take that and intensify it times 10. Problematic emotional response patterns. When people start to have these distorted ways of thinking, they get upset. But since their thinking patterns are so distorted times 10, then the emotional response seems to mirror that. And their emotional response seems to be excessive or times 10. When they're that upset, when they're that emotional, when they're that scared, when they're that angry, they need to make the pain stop, which is where our impulses come in. This impulse control problem, the person needs to make it stop. And they're going to start probably sort of flailing to try to figure out how to make that stop. Sometimes it's self injurious. Sometimes it's injuring others. Sometimes it is using addictions in order to numb the pain. But this impulse control is generally or this impulse of behavior is generally used to quell the fear and the negative thoughts that are flooding this person's mind. When you behave that way, when everything is extreme, when everything you think is times 10, when your reactions are times 10, it can make it more difficult for people to be in relationships with you. When they see something happening and it's a one on their scale, and you're acting like it's a 10, they can get very confused. So we understand that all of these kind of interrelate and it's a matter of figuring out where the person is motivated to start pulling the strings. Cluster B, which is what we're going to talk about today, is considered the dramatic emotional and erratic cluster. People in this cluster tend to have a whole lot more difficulty managing their emotions, managing their thought patterns, and they act out in a way to try to make the behavior stop, whether that's controlling you or controlling themselves. So borderline, we're going to go through each of these and kind of talk about them a little bit. If somebody has borderline personality disorder traits, and I emphasize traits, because a lot of us, you know, just about everybody, has some personality traits that may fit here. Now we've got to remember that when we're diagnosing a personality disorder, this is a pervasive method of interacting with people that goes over time and in multiple situations and causes clinically significant distress or impairment in functioning. Okay, so that being said, even if your patient does not meet the criteria for a borderline diagnosis, a lot of these traits we're going to talk about are common among people. So if it's bothering them, if it's causing them a problem, let's work on it instead of saying, well, it doesn't meet the criteria for a disorder. So, you know, you'll be fine. No, let's help them work on it before it becomes a problem. So borderline, despairer is one of the acronyms that can be used to help remember some of the characteristics for borderline personality disorder. One of the hallmark characteristics for not only borderline, but this whole category is disturbance of identity. People with borderline personality disorder don't have a sense of self at all. They don't know who they are. They exist exclusively based on what they are to other people. So they are a spouse, they are a daughter, they are an employee, they are something else. So when that threatens to go away, they don't have anything to replace it with. They can't say, well, I'm a good person. They're like, well, if I'm not a mother anymore, what am I? If my children move out and they don't need me anymore, then my life is kind of over. And we want to help them address those cognitive distortions. So this disturbance of identity, lack of not only a self-esteem, but lack of self-concept, they don't know who they are. What does it look like? A lot of times people with low self-concept or no self-concept will tend to define themselves based on their roles, based on what they do for other people, and based on what they think you want them to be. They're chameleons. A lot of times this develops because they grew up in households where it wasn't safe to have their own opinions. It wasn't safe to develop a personal identity. It was controlled by the addict, the borderline, the person with depression, whatever was going on in that household, the child was not able to develop a sense of self safely. They had to be whatever they were expected to be by other people. What's maintaining it now? Well, if they haven't ever learned who they are or developed a sense of who they are, then they've got to know that they're missing it before they can start to develop it. Remember that personality disorders are egocentonic. That means the person doesn't realize it's not normal, if you want to use that word, to feel this way. One of the things we can help people identify as they go through treatment is kind of what is underlying their emotional reactions. Disturbance of identity will come up a lot with your your cluster B characteristics. Emotionally, all over the place, people who are empty inside who don't know who they are, it's scary. It is terrifying to think that they may lose part of themselves. They are afraid of being abandoned. They are afraid of basically disappearing because they are not somebody's something. So whenever they perceive the slightest hint of disapproval, criticism or rejection, they respond with that times 10. And to use a clinical term, they freak the freak out. It is just not even fathomable to expect that they'll be able to exist if they get rejected. So then they start frantically trying to hold on to somebody. When this happens, the relationship becomes very tenuous because the person with borderline personality traits may start to act out, may start to get very angry, may start to try to bully or control the other person because they're so afraid of being abandoned. The person in the relationship with the client or the person with borderline traits doesn't understand what's going on. It's like, why are you getting all worked up over this? It wasn't a big deal. Which creates a miscommunication. The person in the relationship starts feeling like they have to walk on eggshells because they don't know what is going to set off their significant other. And they know that if they set them off, even with the slightest hint of anything, that it's not going to be an irritation or a momentary sadness or whatever. It's going to be a complete episode of rage or terror or crying or pleading. It's exhausting. They also know that when a person with borderline characteristics, they have no internal identity, they fear being abandoned. In order to keep you, and this is one of our sort of trademarks of BPD as opposed to other personality disorders in this cluster, when they're afraid of being abandoned, a lot of times they will act out in self-injurious ways in order to communicate partly to numb their own internal pain and distress and everything that's going on because they're focusing on managing the physical pain so they can't focus on the interpsychic pain. But it also is a way of manipulating other people because it's either look what you made me do and if you would have just done what I asked you to do, I wouldn't have had to hurt myself. So this is your fault. So I'm going to use that guilt and I'm going to work on it. They can also use it in a way of saying I can't take care of myself. I need you here to take care of me. Neither is really functional in an adult relationship. Paranoia or dissociation. Again, in this situation, these people tend to be very hypervigilant. They are aware of the slightest look that says I disapprove or the slightest sound or the slightest action, which tends to make them, you know, we call it hypervigilant. Sometimes it's called paranoia because everything is perceived through an abandonment lens. So anytime you do anything, it's going to be taken personally. You can see some of these or hear some of these cognitive distortions coming out now. Personalization, all or nothing thinking abandonment. They are constantly waiting to be abandoned. They don't feel worthy of love because they don't even know who they are. They don't love themselves. And they've never probably been loved for who they are. So there's this fear of abandonment, which again, if my role goes away, if I'm not your girlfriend anymore, or I'm not your wife anymore, then part of me dies because I don't have a me. I exist purely as a conglomeration of roles. Impulsive. We talked about it earlier. When the thoughts are so extreme and so fast and so negative and the emotions follow at a certain point, a person has to make it stop. It's just, it's overwhelming and it's oppressive, which often results in impulsive behaviors. Just finally, make it stop. I can't do it anymore. Relationships are going to be unstable, even if somebody understands what's going on. It's very difficult to be in a relationship with somebody with borderline traits because they are so all over the place cognitively and emotionally and there's always this worry that they're going to hurt themselves. You've got to keep your own guilt in check. So there are a lot of boundary issues with a person with borderline personality disorder and a lot of guilt. So people in relationships with people who have borderline personality tend to be the type that want to rescue if they stay in this relationship. So then we need to look at some of those boundary issues and what need the borderline's behaviors are filling for the significant other. Feelings of emptiness. Well, if you don't know who you are, if you've never been loved for who you are only appreciated for what you do, I can see where you might feel empty inside. You might not have a feeling of satisfaction because you're always afraid you're not going to be good enough and you're always afraid that you're going to be abandoned which can lead to inappropriate rage. Remember I said times 10 when most of us face a threat to our self esteem to our person to whatever the body sends out a fight or flight reaction and we either hit the fear which says you need to get out of there or the fight which says you need to conquer this you can do it. It's not worry and irritation for the person with borderline. It is always just overwhelming anxiety or rage. Again, this is exhausting not only for the people that are in relationships the significant others of the person with borderline personality but for the person with borderline personality. Imagine being in your own head or there's this constant fear this constant battle this constant not feeling good enough and frequent bouts of rage at others for potentially abandoning you because that's terrifying and at yourself for not being good enough. If you can put yourself in their head you can kind of understand where these behaviors might come from. Now the key is figuring out what to do with them. The first step and we're going to talk about this towards the end of the presentation is to help the person develop a stable sense of self who are they apart from their roles who are they. Distress tolerance and coping skills and develop a support system that understands how they react and can help them navigate through the initial phase of distress. People with histrionic personality disorder HPD the the mnemonic that you can use to remember this is praise provocative or seductive behavior instead of the self-injurious acting out behavior that you see in borderline personality. In histrionic personality you see someone who is going to be overly sexual overtly sexual. One example you might think of is Jessica Rabbit from who who framed Robert Roger Rabbit. She was overly sexual and she controlled people using her sexuality. Relationships with the person with histrionic personality are considered more intimate than they actually are. This person will meet you and within 30 minutes be telling you their deepest darkest secrets and you're going to be best as best as friends forever and ever. Normal relationships don't develop that quickly. If you meet somebody who has this complete absence of boundaries and just automatically clings on to you it's a pretty good guess that there are some histrionic traits there. The person with histrionic personality disorder also doesn't have a good sense of self. They have been approved of or learned to manipulate people or whatever you want to say through sexual and seductive behavior. They don't know who they are so they look to others for external reinforcement to tell them that they're okay. They want to be your best friend. They need to be your best friend because they need to be validated which leads to the attention seeking. They need to be constantly reminded or reinforced that they are your best friend, your bestest friend and you're not going anywhere. They need to be the center of attention and this can be very dramatic. This can be very kind of over the top sometimes because they need to be the center of attention and it can be negative or positive. They can start a shouting match in the middle of the mall or they can be being extremely seductive at a party. Whatever is going to get them the most attention at the time. They're influenced easily by others or circumstances just like the BPD and others in this cluster. The person with HPD needs to be validated externally because they don't know who they are. They don't know what they're good at. They don't know what you know they don't have a good sense of self and they don't have a good self-esteem. So they are going to jump on the popularity bandwagon. Whatever happens to be the most popular they're going to do which means other people may have difficulty trusting them. If circumstances change this person's whims may change with the circumstances. You never know what this person's going to do from moment to moment. It's always very dramatic and it's always very grandiose. They use a speech style to impress that lacks detail and one of the best examples I can give of this is if you've ever listened to a politician on the campaign trail. They will make these just glorious grandiose campaign promises but they never tell you how they're going to do it. I'm going to reduce taxes. Well score that's what we want. How are you going to do it? We'll get to that later. People with histrionic personality disorder do the same thing. They will tell you that they are going to start a company that they are going to do something huge and impressive but they won't have all the details worked out. Again you have some emotional lability, shallowness. Their emotions switch depending on what is going to give them the most attention. They can be sad, they can be angry, they can be fearful. Their emotions are generally not genuine. They are a production. They are a facade that this person is putting on. Not because they are intentionally trying to they're going oh what's going to get me the most attention but because this has been reinforced in their life they have learned to use emotional displays and dramatic displays in order to divert attention from something that's bad or to get attention and be reinforced, be taken care of, be coddled by the people that they care about. Now we're going to switch gears a little bit because antisocial and narcissistic are different in many many ways than borderline and histrionic. Borderline and histrionic have no stable sense of self and they're desperate for external validation. Antisocial and narcissistic don't have exactly those same traits. People with antisocial personality disorder have difficulty conforming to the law. They have difficulty respecting others' needs, wants, you know, preferences. They will steal from you just as soon as they will look at you. They are determined to satisfy their own needs because they want to. Complete lack of empathy. Obligations are often ignored unless it suits them. There's a reckless disregard for the safety of themselves or others. Again they're going to do what they want to do because it suits them at the time and they don't think about how it may impact other people. They only think about satisfying their own wants needs and desires immediately. They have an inability to feel remorse or empathy for other people. They don't feel bad about what they do. If they get caught and they seem to feel bad, it's probably that they feel bad that they got caught, not because they hurt somebody else. They tend to be deceitful, lying, and manipulative because that's how they get what they want from other people. They don't plan with sufficient time. They don't say, okay, I want to buy a car so I'm going to need to save up money so let me develop a plan. They say, I want a car, I'm going to go steal one, or I want a car, you will let me borrow yours. If not, I will just take it from you. Their temper tends to be irritable and aggressive. This is a person who has no regard for your feelings. The only thing that keeps them in check is getting their own wants, needs, and desires met immediately. And if that doesn't happen, they throw a temper tantrum. Very similar, if you will, to a three or a four year old in the middle of the cereal aisle, wanting some super sugary cereal and not getting their own way. Now I don't expect a three or four year old to plan and to conform to social norms and yada yada. This is something they have to learn. A 34 year old, on the other hand, should know better. What are the benefits to this? Well, I think I've said them repeatedly. This person gets their needs met all the time. And they don't care whether other people like them or not, which is another key difference between histrionic, borderline, and antisocial. They are all about being their own best friend and making themselves happy. Now a lot of times they also have an unstable self concept, which is why they've put up these walls and said, I don't need anybody. I can make my own self happy. Thank you very much. Everybody I've ever trusted has let me down. Everybody I've ever cared about has betrayed me. So, you know, screw y'all, I'm going to do what I'm going to do for me because everybody else has always done that to me. That all or nothing thinking again. And finally, people with narcissistic personality disorder think that they're special and the mnemonic special represents the characteristics of NPD. They believe that they are unique. And this research has shown lately is not a way of covering up a lack of self-esteem. They truly believe that they are all that a bag of chips and a soda to boot. They're preoccupied with and they use the term fantasies a lot in the literature. In this person's mind is not a fantasy. They're preoccupied with delusions, if you will, of unlimited success, power, brilliance, beauty, or ideal love. They think they're all that. Put yourself in the mind of somebody who is just the best thing since sliced bread. They feel entitled. They feel entitled for you to worship them. They do need approval all the time. Similar to people with, for example, histrionic personality who need to be the center of attention all the time. The person with narcissism needs to be revered all the time. So they will seek positions, they will seek situations where people have to admire them. They are not above interpersonal exploitation. If it gets them power, if it gets them on top, if it gets them to be revered, they'll exploit anybody. They will walk all over them. They tend to be arrogant and very self-important. If you've had someone with narcissism as a friend or as a client, you'll recognize some of these because a lot of times you leave an interaction with them feeling bad about yourself or wondering why you aren't as successful. The person with narcissism really carries a cloud with them that they are the preeminent being and they lack empathy. They don't really care how it makes you feel. What's most important is how you make them feel and how you make them look. A lot of people with narcissistic personality disorder grew up in a family that communicated these messages. As a child, they got the message, it's not about how you feel, it's how you make us as the parents look. So you will suck it up and you will do what I tell you to and you will be the best at it or you will not be loved. There are some varying theories about how narcissistic personality disorder develops and there's a really good book called Disarming the Narcissist, New Harbinger Publications, that goes into great detail and it's really well written if you want to take a look at that. Suffice it to say, the person with narcissism is not going to come into therapy and say, you know, I'm having a real hard time getting along with other people and I want to address some of my character defects. They don't think they have any. So this is a particularly challenging client to work with. Most of the time, the person with narcissistic traits or narcissistic personality disorder only comes to counseling, only comes to therapy because somebody has made them. They have given them an ultimatum, you will go to counseling or I am going to divorce you and take the kids or you will go to counseling or I'm going to fire you. So the person comes to counseling under duress and they will present in the office like there's nothing wrong with them, they are perfect and any hint of criticism or questioning that the therapist does will be met with anger and condescension. Just be prepared for it because that's how they protect themselves because remember if they are not revered then they are nothing and it's very confusing to them if you don't jump into their delusion. So what do we do about it? Well let's start with the rigid extreme and distorted thinking patterns whether it's all or nothing thinking, thinking that they have to be the best at everything all the time or that you have to love them all the time or if you go away I'm going to die. These extreme thought patterns tend to create a lot of emotional turmoil so we need to start addressing those. Cognitive processing therapy, the challenging questions worksheet I love because it gives the person multiple different avenues to challenge some of these beliefs that are keeping them upset. Examine common cognitive distortions with them all or nothing thinking. If they start talking about something that made them mad, made them scared or you just wouldn't believe what happened keep an eye out for all or nothing thinking because generally it's extreme. Everybody always leaves. Nobody can be trusted. In this case you know counseling 101 we're going to start looking for exceptions. The mental filter is viewing the world through sort of colored glasses and it's not usually not rose colored that we're worried about. If they perceive the world to be a scary place then everything they see is going to reinforce that. Think about one time when you got up and you were getting ready for work and you were just in a bad mood. As you're driving to work are you noticing the bunny that hops across the road and the fact that it was a beautiful sunrise or are you noticing the fact that you had to slam on brakes for that stupid rabbit and the sun's in your eyes? Mental filters. Overgeneralization partly all or none thinking but taking one instance maybe a bad relationship and saying all men are untrustworthy or all women are untrustworthy or this will always happen. Discounting the positive, forgetting to focus on the things about themselves and others that are good. If my clients start talking about somebody and something that was really really negative I say okay you know and we talk about it and I hear their point of view but then I also ask them to find a couple of positive things to say about it. When I go home and the house looks like a tornado hit it it's frustrating to me. However the positive that means that my kids were having a good time and that also means that my kids are there and having a good time and I love my children you know immensely. So yeah is it irritating to go home and find the house looking like a tornado hit it? But there are positive things that I can focus on too so it's choosing which you focus on. Jumping to conclusions assuming that just because somebody didn't call you when they were supposed to that they're they're leaving they hate you. No it could be that they were stuck in traffic or their phone died or there are a billion different explanations for things. When I hear this type of cognitive distortion I will stop my client and I will say okay that's definitely possible. Give me the facts to support it and then I want you to tell me two other possible reasons this may have happened or this person may have acted this way. Let's see if we can look at some different perspectives. Once you bring in that idea of reasonable doubt it starts to make the person think a little bit more and helps them de-escalate some because it's not of course this must be the answer it's like okay what are some possible reasons this might have happened? Now true they may come back to the the worst possible answer but at least they're thinking about other options and eventually hopefully you can encourage them to start thinking for their own sanity and their own health and wellness what is the least offensive explanation for this? Well being careful obviously we don't want them to be taking advantage of and then emotional reasoning. If I'm afraid of something then it must be dangerous. I'm terrified of bridges I hate driving over bridges and there's absolutely no logic to that at all and I realize this. So if I thought because I'm afraid to drive over bridges it must be dangerous to drive over bridges that's emotional reasoning and I can counter that by looking at facts and statistics and saying you know it's really not dangerous am I afraid? Yes so let's look at the reasons why and you know there are reasons why I was but bringing that to the forefront of somebody's mind to help them identify irrational conclusions. Then we want to help them examine prior experiences which may be influencing perceptions of current events so we can help clients challenge their schemas. That's a really long way of saying if something happened 10 years ago with some other person and they're expecting every other person today to behave that way is that realistic? If something happened when they were a child that made them feel helpless and unloved that sucks yeah like we got to deal with that no doubt but when that same thing happens today what does that mean to them? As an adult as a person who's able to rationalize things and provide self-soothing is that the best way to react? Is that the best schema to have? And yeah some people from your childhood are equally as dangerous in adulthood but sometimes like being a bully or being bullied on the playground at school may not be as salient today because you are an adult and likely that same kind of bullying does not happen but if you expect it to happen then you're going to look for it and you're going to look for signs and be hyper vigilant so we want to examine prior experiences that provide negative interpretations of today's events. Rigid extreme and distorted thinking patterns can also keep creeping back in we need to help people address faulty cognitions that enable them to evaluate and act based on facts not feelings you know I talked about that in a little a little while ago problematic emotional responses now we're down to feelings we talked about the thoughts let's talk about the feelings mindfulness to prevent vulnerable abilities and become aware of distress sooner if clients are mindful on a day-to-day basis they will realize that there are certain things like not getting enough sleep or staying up too late the night before or having to drive through really really heavy traffic there are things that will put them on edge and make them more likely to overreact or to act out or to engage in some of these dysfunctional behaviors we also want them to become aware of distress sooner so when they feel themselves starting to become excessively upset they can stop it instead of letting it go all the way to a thousand they can stop it maybe at you know 750 and then 500 we want people to be aware of themselves what are their physical symptoms that they're starting to get stressed what's going on in their mind when they're starting to get stressed and then how do they deal with that distress which brings us to distress tolerance skills we can't keep people from getting distressed it happens so my question is when you get distressed how can you ride through it so you're not making decisions just based on wanting to make the distress go away you're making rational decisions that get you closer to where you want to be for most people anywhere from a minute and a half to 10 minutes is the time it takes for them to kind of de-escalate enough where the adrenaline's not just pumping all the way through and they can start to cognitively evaluate what's going on depending on your client some clients may want to start working on dealing with their emotional responses because they feel like they're always angry or they're always upset some clients may want to start dealing with their cognitions first that is up to your client but you know what if they're able to calm down their emotions if they're able to get control of their feelings then they're going to be better able to address the cognitive distortions if they address the cognitive distortions first then they're probably not going to get so worked up so it doesn't matter where you start start where the client is willing to start impulse control problems if they're not into stress they're much less likely to be impulsive so we want to identify and address triggers that may contribute to someone being impulsive having access to whatever it is and this is true with substances or addictive behaviors but what triggers your impulsive behavior have them define what their impulsive behaviors are it can be screaming it can be throwing things it can be substances of abuse it can be going out on a run it can be just getting in the car and driving what are your impulsive behaviors and how can you address them let's look at what they mean like I said most of the time impulsive behaviors come from a need to just make that distress stop so what distress tolerance skills do you have what can you do instead that is less harmful or less counterproductive how can you distract yourself sitting there and waiting for this flood of anger to go away can feel like an eternity and trying to control it and wait for it to go away can make it worse so how can you distract yourself what can you do for that first minute and a half to 10 minutes until you can you know think with a clear head and then what are your coping strategies coping strategies are really either changing the situation because something's amiss and it needs to be changed or addressed or changing your reaction to it there are some things that cannot be changed other people cannot be changed so you can either choose to not engage with them which is changing the situation or you can choose how you react to the situation maybe you have somebody who is always going to find fault with something that you do family member maybe it's a family member that you have to see at every holiday so knowing that that holiday is coming up is a vulnerability because the person is probably going to start getting all fired up stressed out wondering what is going to be criticized this time so you've got two options one not go to the family function for the holiday which is often not an option or two figure out how to deal with that for example just accepting that for whatever reason this person has to find fault they're going to find fault so just expect it and let it roll off your back take what you need and leave the rest if they find fault with something that can be addressed that you think yeah you're right you know I could work on that great if they find fault with something that you really don't have any issue with then let it go that's their issue that's on them not on you and then significant interpersonal problems another behavioral issue if you're impulsive if you are constantly looking for the negative if you have all of these cognitive distortions that continue to get you upset all of the time it's going to be really difficult to stay in a relationship with you so regardless of what the specific diagnosis or criteria are helping people develop mindfulness and empathy to an increase the awareness of themselves and others so they can become aware of when they are being emotional when they are being sensitive when they are being hyper vigilant but they can also increase their awareness of how they impact others when they behave that way develop a stable positive internal sense of self to reduce the need for external validation if you can be okay for who you are then if somebody decides to leave you don't need to be on on guard all the time you don't need to be hyper vigilant you don't need to be proving something you don't need to be the center of attention you're comfortable in your own skin and that's all you need for a lot of clients when I say that they look at me like I've got three heads because that's just not something that they can even conceptualize at the beginning and that's okay you know I want to know three months from now what are you hoping is going to be different along with addressing these interpersonal issues and helping people develop mindfulness we want to help them develop interpersonal skills we know that personality disorders develop really early in life and they're not diagnosed until someone reaches adulthood but since they develop early that means they probably were not able to develop healthy communication skills and healthy boundaries they weren't able to develop the ability to see another person's reaction and look for possibilities they weren't able to develop the ability to not see everything as their fault they didn't develop the ability to say I am sorry you're upset but that's not my fault you know I'll be here to support you but I am not going to feel bad because you're upset so developing those emotional boundaries and allowing others to have feelings that are divergent from yours are going to be key features in helping people develop a healthier way of interacting so general tips personality disorder behaviors are egocentonic I said that before I'll say it again most of the time people will present in treatment for something that is not a personality disorder is the result of these behaviors they lost a relationship they lost their job they lost their house they whatever the case may be I have never had somebody come into my office and go I'm borderline help me figure that out I have had people's significant others bring them in and say she's borderline fix her and my responses usually can't do that she can fix herself but first we need to figure out what's going on before we even start putting labels on it and then it's going to be up to her to be able to figure out how to meet her needs as therapists we can help people work backwards and identify what caused whatever the presenting issue is so if the person comes because they just and ended a long-term relationship and they are clinically depressed what happened that made the relationship end have you experienced this before have you had other relationships end for similar reasons let's look at some of these common themes about why these relationships end a lot of times you will hear from the reports some of these personality disordered behaviors and you can start identifying them I am not going to tell somebody well sounds like you overreact all the time we're going to look at what happened and I'm going to let the client draw their own conclusion about what's going on with them for themselves because they're in their own head they know what's an appropriate reaction and what's an overreaction we'll do some cognitive distortion and cognitive disputing to help them figure out if they are using some of those cognitive errors in order to help them live a happier life so if we can figure out some common themes that generally present in every relationship that's what we can focus on in treatment how can we make your relationships less conflictual well let's look at what causes the conflicts okay now how can we deal with that a person with personality disordered traits will likely demonstrate these same traits and behaviors in session so we need as therapists to compassionately identify and address these relationships if you notice someone is trying to take over a session and every time you say something they counter it you may ask you know if this is because they feel the need to know everything that's going on you may ask what the benefit is or what they're needing from you at this point in time it's going to depend on your client exactly how you address it but not addressing it just reinforces it so it's important to know how to deal with your particular clients in a manner that is compassionate but firmly setting boundaries cluster B disorders are characterized by a lack of a sense of self difficulty forming authentic relationships and high levels of anxiety and emotionality mainly because of a lack of sense of self and difficulty forming relationships so they don't have social support they don't feel good about themselves they don't even know who they are so they're constantly worried about basically disappearing one of the first goals of treatment is to identify what the behaviors are that are causing their distress identify that function and help them start figuring out ways to deal with it most personality disordered behaviors egocentronic help the patient identify the behaviors they exhibit which may be problematic so you know if they start acting in a way that you can see may cause conflict in relationships outside of the therapy session you may want to point those out and say I'm wondering how other people perceive it when you do this discuss in session what triggers those behaviors what function the behavior served in the past you know obviously you develop this for a reason everything we do is basically to help us survive and exist and because it's reinforced so where did this come from what function it did it serve and then let's figure out a different way to meet that same need I'm not going to tell them that they're pathological because I don't believe they're pathological I believe that what they did was the best thing that they could do given the tools that they had at that point in time and I still believe that today it's just they don't have any new tools so therapy and self-help books are the way for them to start getting those tools so they can respond differently while it's true the behaviors characteristic of personality disorders cannot be completely erased you learn them you can't just completely unlearn them they can be sort of boxed up and stored in the mental archives they need to have alternate behaviors to replace those if you're not going to do something you need to replace it with something else you can't just not do something the key here is the fact that personality disorders oppositional defiant disorder um any variety of issues and problems can be treated but you can relapse or they can those behaviors can emerge again if the current behaviors and current tools are not meeting the person's need in the same way