 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on a strengths-based biopsychosocial approach to recovery from addictions and personality disorders. Now you can see there's a theme here, this whole strengths-based biopsychosocial. And if you've attended many of my workshops or watched many of the videos on YouTube or whatever, you know that I am very adamant about the fact that it's easier to build on what clients are already doing and what they already know than to start from the beginning, although we may have to introduce a few new tools. And it's also generally a lot more effective in terms of a long-term comprehensive recovery to evaluate the person and the situation from a biopsychosocial perspective. What is contributing? What is mitigating and what is exacerbating it? I mean, as we'll talk about here, if somebody has PTSD, yes, you know, sleep may not be the first thing that comes into your mind for things that they need to address. But think about how you feel when you are extremely sleep deprived, especially if it's because you're waking up with night terrors. So we do want to look at those traditional vulnerabilities and preventing them. So the person has as much energy in their storehouse as possible to deal with life on life's terms as it is in this particular moment. All right. So we're going to define personality disorders real quick, just kind of looking at what they are so we can see how they might overlap with some of the addictive behaviors. We'll examine the similarities between the behaviors of certain personality disorders and addictions, namely clusters B and C. And we'll identify ways to address these behaviors and thought patterns and encourage you to critically examine behaviors in patients with addiction or personality disorders in order to effectively, differentially diagnose. Too often when I was working in a co-occurring facility, I would have patients come in and we accepted patients who had a personality disorder diagnosis, even borderline. So we didn't turn people away, which means we got a lot of people who came in and they were diagnosed with conditions that would prevent them from going to other treatment centers. And we would look at those and it wasn't necessarily always that much of a personality disorder as much as it was a way of coping with life on life's terms in order to survive at that particular point in time. And as they got clean and sober, those behaviors started to remit and it made me start thinking, you know, personality disorders are supposed to be pervasive and basically incurable, not to say that we can't address them. Thanks to Marsha Lenahan, I know that we can radically improve people's quality of life who have personality disorder behaviors, but it did make me really start examining the way we look at PDs. So why do we care? Well, you know, we care because it impacts clients' recovery. When personality disorders are viewed as per pervasive and perpetual, in clients, it provides them an excuse for relapse. And remember, I use that term really broadly, not just addiction, but into their personality disorder behaviors, their depression, their addiction. If we tell them at the beginning, there's really no hope for a cure, they're like, well, kind of screw it. That gives me an excuse. I get a, I get a mulligan every time I make a mistake. So their motivation may be undermined to a certain extent. And it often derails treatment because patterns of behavior thought to be a personality disorder in co-occurring disorder or even in mental health treatment are often essentially ignored. Thinking back, and this will kind of throw you back a little bit, to the DSM 3 and 4 when we still had the multi-axial diagnosis. If something was on axis 2, a lot of times what I was taught when I was coming up through the ranks and internship was, well, we leave that alone. There's not much you can do about that. You focus on axis 1 stuff. And I feel in retrospect that that was a great disservice to the clients. Personality disorder and addictive behavior often look the same. And we're going to, as we go through the symptoms, and I'm going to focus mainly on cluster B here, as we go through the symptoms, we will look at the symptoms of the personality disorder and talk about how those are present, potentially, and people with addictions and what's the function. The goals for recovery from both or from the symptoms, instead of looking at this overarching diagnosis, we want to say, you know, if somebody has emotional ability, okay, how can we help them recover and do better with that particular symptom? We may put ourselves in a bind if we start looking too globally and saying we want to cure someone's depression. We want to cure somebody's borderline personality disorder, because like depression, personality disorders and addictions present a little bit differently. So the goals for recovery, honesty with self and others about their thoughts, feelings, needs, and wants. So helping them develop mindfulness and general self-awareness, because in order to deal with those reactive defensive behaviors, they're going to have to know when those are coming. They're going to have to be aware when they're vulnerable. Distress tolerance and the ability to self-soothe. Hope and faith in themselves, the future and others through addressing cognitive errors. And, you know, we find in pretty much most mental health diagnoses, there are some cognitive errors that exacerbate the problem. Development of self-esteem to eliminate the need for external validation. I can't think of any client that I've worked with, and I'm not saying it doesn't happen, but I can't think of any at the moment that has had either an addiction or a personality disorder who has had a, you know, grade A self-esteem. Now, that's not to say that there aren't people out there with it, but we want to really look at what effect self-esteem and lack of self-esteem is having on the patient. And we want them to develop healthy supportive relationships, which begins with, back to self-esteem, developing a healthy self-supportive relationship and accepting themselves as lovable despite being or in addition to being imperfect. Okay, so personality disorders represent a cluster of behaviors that are pervasive beginning before the age of 15. And many addictions also begin before the age of 15. So if you're using this to different, differentially diagnose addiction versus personality disorders, probably not going to do you a lot of good here. Due to the immature cognitive development, children tend to be more egocentric, overgeneralized, and think in terms of dichotomies. So if this situation, whatever it is that's causing the development of these reactive behaviors, that's probably something that's triggering the fight-or-flight response. If the child is egocentric, which we know that a little bit before 15, but up through middle school, children tend to be more egocentric, especially in elementary school. They're going to take things more personally. They're going to take things more globally. And they're going to think in terms of their schemas, which are very, very limited because they're very, very young. And they can't think abstractly. They can't say, well, you know, mom's in a bad mood and relapsed on drugs again or whatever. And that's because she's having trouble in her life. It has nothing to do with me. No, a kid doesn't say that. A kid's like, what did I do? How can I make it better? I don't want you to be sad anymore. From a survival perspective, most of the behaviors that we're going to talk about make perfect sense when viewed through the eyes of a child. So remember, most of these problems, a lot of these problems started before the age of 15. And if you think back to Piaget, we know that there's a lot of stuff going on and the inability to think abstractly and really consider, you know, what are all the reasons this might be happening. And children at that age just don't even have any clue about all the stresses that mom or dad or auntie are going through. So children learn what they live. And I think most of us grew up with this either in our nurseries, in our bedrooms, in our elementary school classrooms. So you're familiar. If they grow up with criticism, they learn to condemn. If they grow up with hostility, they learn to fight. They grow up with ridicule, they learn to be shy. Shame, they learn to feel guilty. But if they grow up with tolerance, they learn patience. Encouragement, they learn confidence. And praise, they learn to appreciate. And it goes on. But you see how the staple in most of our lives that we've seen and we're familiar with highlights from the very beginning that the environment the child grows up with has a huge impact on how they know how to act and react and how safe they feel. Since these behaviors formed the foundation for further development. You know, they're formed when they're knee-high to a grasshopper and a little bit bigger. We need to understand the function of the behaviors in the past. Are they just modeling what mom, dad, grandma, teacher did? Or did they develop those behaviors as a way of protecting themselves? We know in addictive families you have the lost child, the hero, the scapegoat, yada, yada. And those are reactive behaviors designed to help protect the child in a very unstable situation. We want to help clients identify how these behaviors and beliefs are or maybe faulty in the present. Are you still unsafe? And are you going to be abandoned? And are you worthless? Are you all these negative beliefs or threatening beliefs that they hold? We may need to look at. Help them develop alternative skills to deal with distress and deal with distressful thoughts. So they can learn to better evaluate their cognitions and decide whether they're on point or they might be reacting from the past. And we want them to be empowered to interface with the world with the strengths, knowledge, and tools of the adult. So what new tools can we help them learn? And what do they have that we can build on? One of the things that I try to focus on when I work with patients in general is looking at how they've coped until now. Until they've come to my office, they didn't just start having a little bit of a symptom and show up. They had a little bit of a symptom and they tried to address it or they thought it was normal and they tried to live life with it. They didn't come to treatment likely until they were either ordered to or until it got so bad they were throwing their hands up going, I got to do something different, but I don't know what it is. Well, in that time span, from the time that they noticed they were becoming symptomatic or, you know, from the time they were knee-high to a grasshopper and develop these behaviors, how did those behaviors protect them and how did they cope with those behaviors until now? We can start looking at those and trying to build off them. So cluster A is your paranoid, schizoid and schizotypal. Generally characterized by social awkwardness and withdrawal can co-occur with addictions. Now we often see people with cluster A personality disorders having some form of addiction, not always. It doesn't mean that the majority of people with addictions have cluster A personalities, so just kind of putting that out there. Cluster C, and I know this is out of order, but we're going to focus more on cluster B. Cluster C is your obsessive compulsive and your dependent personality disorders, very anxious and fearful. When you work with people who have these traits, addiction or not, we want to say what is causing them to feel so unsafe? Why is it, if they have an addiction, why is it that they feel they need to escape? Why do they feel so out of control and emotionally dysregulated to use a DBT term? And then cluster B is your borderline narcissistic, histrionic and antisocial. These people tend to be dramatic, emotional, erratic. A lot of times, again, the behavior patterns overlap with the addiction. When I see people in early recovery, you know, they went through detox and they ain't feeling well anyway. And they're in treatment. They may have a diagnosis of a personality disorder. They're not feeling well. They are exhausted. They are worn down. They feel out of control. When anything happens, you know, it's kind of like they're just teetering on the edge. And when anything happens, it sort of pushes them over the edge, which can lead to the dramatic emotional and erratic behavior. Think about a time when you have just been stressed to the max, totally stressed out, exhausted. You're like, I just can't take one more thing. And then that one more thing happens. Now, hopefully you have some distress tolerance skills and everything else. But in the first little moment after that happens, a little part of you might want to scream and pound your fists on the, on the table and be like, this is so not fair. Dramatic, emotional, erratic behavior. Now, a lot of times we don't do that. We pull it, pull it together and go, okay, how are we going to deal with it? But a lot of our clients don't have those distress tolerance skills. Where did they learn them from? You know, if they lived in an environment that prompted these behaviors, they're either modeling them or they were formed as a defense, then likely that's not an environment that taught them vulnerability prevention and distress tolerance. We don't just have those as soon as we're born. We have to learn how to use those skills. So one of the things we might start looking at is when you start feeling like you're going to bust, when you start feeling overwhelmed, what do you do? How can you help yourself calm down? And we also, again, going back to those prevention strengths, what do you do to take care of yourself? So you can feel rested and you can feel like you have the energy to kind of try to face the day. We're going to build on those. Those are things people are already doing. If we can help them do them better, then they're going to start feeling a little bit better. I'm not saying it's a panacea, but it's going to give them some forward movement, which is going to increase their motivation and keep them a little bit more, keep a little more momentum going. So cluster B is characterized by dramatic emotional and erratic behavior. A lot of times you'll have clients who get really angry at the drop of a hat or that in the case of people with borderline personality disorder, one of the symptoms is flipping on a dime. You're either loved or you're hated. And that kind of goes to all or none thinking too. If they have all or none thinking, if they have a lot of hostility and aggression or anxiety, you know, anxiety can come out as hostility and nervousness and irritability. I'm thinking what environment did they grow up in that perpetuated this that didn't teach them how to self soothe when they were little and facing smaller stressors. What kind of environment prompted this reaction where when they started feeling hostile and aggressive, if they acted out, that was rewarded in some way, whether it was it diverted the attention of the family unit and they became the identified patient for a moment. You know, mom and dad are fighting junior gets very, very upset. All of a sudden mom and dad aren't fighting anymore. They're focusing on junior. Oh, see, there was a function to that behavior. So now that might be when junior is in the presence of something extremely stressful. The reaction may be look at me. Pay attention to me. You'll forget about whatever's bothering you because if you keep fighting, then I might lose mom and dad and then we got abandonment issues here. Hyper sensitivity. If they grew up in an environment, addicted domestic violence, whatever, where they had to walk on eggshells and be hyper sensitive to one or more people in the household in order to prevent getting yelled at in order to prevent chaos. Then they develop that hypersensitivity. Imagine, if you will, and having to walk around on eggshells 24, 7365, especially as a little kid. I mean, little kids, they're just not programmed for 24, 7 impulse control. I remember when my son used to come home from preschool and, you know, I'd bring him home. It was like three o'clock and I'd tell him to go play in the living room. I'd start making dinner. We always ate early and he would just start bouncing off the walls and, you know, he had a nice safe play area and everything. So I wasn't worried about it, but he would go from, you know, the subdued child that was supposedly loved to wash his hands and like the model student in preschool. He didn't wash his hands at home, but I digress to this little wild man when he got home. And I finally started to learn that while he was in school, he was keeping it together because it wasn't safe to let it go. He had to follow the rules. I mean, true, I get that. But then when he came home, he knew it was safe within reason to let loose a little bit and that's when all that stuff came out. He's just like, I can let my hair down. But if you have to be on that good behavior 24 seven in order to avoid bad things happening, whether you're an adult or a child, that is exhausting manipulation. You know, we all know people who grew up in environments where they were able to split parents where they were able to manipulate one parent over the other with where they were able to use guilt. You know, about whatever the parent did in order to get their own way. So this behavior was probably reinforced and low self-esteem or weak self-concept remembering that clients before the age of especially before the age of eight or nine have difficulty thinking about alternative perspectives and and thinking abstractly when things happen, a lot of times clients take them personally, especially if they started happening when the child was, you know, very, very little before he could when he was very egocentric, you know, before object permanence and all that stuff and diapers. It grows or wears on a child over time, and they start taking that personally going if I were better than my parent wouldn't have to do this. Worst case scenario, the parent goes, if you didn't do this, then I wouldn't have to. So what about people with decent childhoods? I mean, we have people who come in who display these behaviors who have decent childhoods. So I want to think back to how would this these behaviors be functional for the person because then we can look at what do we need to do to change that. So instead of acting out and getting dramatic emotional and erratic when you feel overwhelmed emotionally dysregulated, you know, obviously we can start working on distressed tolerance skills. Because until now, you know, they may have tried to do things to not act out, but they may not have been able to push that pause button. So that may be something we have to work on. One of the things, the strength that you can work on there is the vulnerability prevention, helping them understand that if they're worn down, it's going to be harder for them to deal on with life on life's terms. So let's, again, build on stuff that you've already got. I want them to feel empowered. I want them to feel like they were already doing some of the stuff right. Anti-social people or people with anti-social personality disorder disregard the rights of others. Well, what environment might perpetuate these behaviors? Probably one in which your own rights were disregarded or in which you were able to get away with disregarding the rights of other people. If you've been in a preschool or, you know, childcare sort of situation, young children have difficulty taking perspective. They have difficulty with empathy. That's something they learn. But if that is not taught, if they were not taught to stop and think, OK, how might that other person feel? They may not ever have learned to take the perspective of someone else or care if they don't understand why it's important if that wasn't communicated to them. Impulsivity, reactive behaviors. A lot of times this is either getting what they want or dominating something or pushing something away that they don't want. They don't know how to tolerate the distress of not getting what they want or having to deal with something that they don't want in their life. So with impulsivity, again, we want to teach them about urges and how to ride that wave. The analogy I use to them is imagine a bee landing on your arm. Now, your first impulse for most people is to swat it off partly just because it feels funny. And obviously, if you're allergic to bees, this analogy is not applicable. But your first instinct is probably to wipe it off because it feels weird. But if you swatted a bee, what's going to happen? It's going to get angry, and then you probably are going to get stung. So in dealing with impulsivity, you want to think of urges like that bee. Your first impulse is to try to make it go away. But you need to be able to stop, pause, and look at the situation and go, what is the best course of action in this situation? Hostility and aggression, what are they angry about? Fight or flight? So we go back to those basic fears. If they have low self-esteem, they may fear abandonment. If they fear rejection, isolation, failure, all that kind of goes around. With being unlovable and needing external validation. If they fear the unknown and loss of control, then I want to think back to what happened to them where they felt completely powerless. And it could have been a behavior, it could have been a trauma, or it could have been their own emotional dysregulation that has always left them feeling out of control in their own head. So I want to take a look at what prompts this hostility and aggression. And it's protecting them. Hostility and aggression, anger, fight, pushes away threats. So what's the threat? What are you trying to push away? And how can we either address it and make it go away or help you figure out a different way to deal with it? Deceit and manipulation again and seeming to lack empathy, which kind of goes back up with disregarding the rights of others. So again, I want you to consider the function of these behaviors, the impulsivity, push it away. I can't take it. Distress intolerant thoughts. And hostility and aggression is protective. Lacking empathy can also be a safety mechanism. Not that they can't empathize, but in some cases they don't want to empathize. They don't want to connect with anyone because it's too scary. Fear of abandonment is so terrifying that they just, they ain't going to go there. They have a brick wall built up, a lead wall built up. So understanding the difference or identifying the difference between incapacity for empathy versus unwillingness for empathy. A lot of times can't be gleaned in the initial assessment. It can take a little bit of time. Histrionic. So we're moving on to excessive emotionality and attention seeking. This person has to be center stage. How did that serve them in the past? Did they learn that from a caregiver that if you want something, you have to be the center of attention? Or were things so chaotic in their environment, the only time that there was any sort of sense of calm or focus was when they were in crisis. Or being excessively emotional and attention seeking. Inability to engage in authentic relationships, but uncomfortable being alone. So this goes back to that fear of abandonment in many cases, but also I want to look at why can't you engage in authentic relationships? When did that start? And how does that protect you? How does it protect you to not be in a real relationship? And why is it, what is it about a relationship that you want that would make you comfortable? Because you're in this kind of limbo right now that's a lose, lose, if you ask me. If you're uncomfortable being in a relation, in an authentic relationship, but you're also uncomfortable being alone, what is going to make you comfortable? And so we would look back at other relationships they'd had that went okay. You know, I'm not saying they were lasting relationships, but when they were going well, you know, tell me about them. Tell me about the best relationship, the healthiest relationship you can think of that you ever had. How did that go? They have some relationship skills. I mean, they have to. In 99.99% of the cases, they are interfacing with other people. So we may even drop back to look at, look at more superficial relationships like their coworkers and their boss or their roommate. You know, tell me about those relationships and let's look at what they look like and what does authenticity mean like mean in a relationship. They may imagine relationships to be more intimate in nature than they actually are. Relationships are tricky because you'll learn those through observation in many cases and understanding boundaries, understanding how much to share, understanding reciprocity can be really tricky. And if there's no one there to guide you along the way, then it can be very confusing. So if they are imagining all these relationships is more intimate than they really are, you know, I might look and say, you know, you have this person you've been talking to online for three weeks, and you think that the two of you are completely head over heels in love. So let's look at that. In what way does that help you out going back to the whole uncomfortable being alone thing. And then slowly try to draw the conclusions or draw the connections, if you will, between imaginary intimacy and removing that discomfort with being alone if you can imagine you're in a relationship with someone then you're not, then you may not be alone. And they tend to be suggestible and easily influenced by other people's suggestions and opinions. They want attention. The best one of the best ways to get attention is to agree with people and go along with people and not buck the system a lot of times. So this may be another behavior designed to survive in a very chaotic environment. So there was reward being given they were feeling accepted by a parent, you know, back then, borderline and I say the best for last, if you will. Low self-esteem. You know, people with borderline personality disorder generally, I can't say I've ever met one, whether it was actual borderline PD or borderline personality disorder characteristics, who had a good self-esteem. They felt helpless, anxious and constantly feared abandonment. The world seemed chaotic. Not only did they, their emotions turn on a dime from love to hate from happy to furious, but they also perceived that from the rest of the world. So again, I'm asking you to think back, what would cause that? What would cause such anxiety and such instability in a child's ability and a person's ability to read the environment? And in many cases, it comes down to looking at psychosocial histories. It comes down to an environment that was that chaotic. Some people, as you know, if you've read some of Lenahan's work, some people are born with a propensity to experience emotional dysregulation. So they may not have grown up in a terrifying environment, but their emotions may have overwhelmed them from a very early age and their caregivers didn't know how to respond. So I'm not saying everybody grew up in a dysfunctional household. They may have grown up in a household where their parents just parented the best they could. Where we know that people who do have emotional dysregulation, as is common in borderline personality disorder, really do experiencing things a lot more intensely and have a lot harder time getting back to baseline and re-regulating. But as parents, we may have told our children, when they acted that way, you're overreacting, get over it or quit being a drama queen or whatever the term was. So the child felt even more ostracized, felt even more out of control because they're like, I don't know how. I don't know how to control these feelings. And all they were getting was criticism. Perceptions of themselves and others may quickly vacillate back and forth. So it's not just love or hate for other people. It's love or hate for themselves. Now think about hate. Think about what is that, what underlies it. Some sort of anger. Why are they angry at themselves? Well, anger, fight or flight. So what is it about themselves that terrifies them? And sometimes it'll come back to inability to control their own emotions or feeling out of control, feeling less competent than their other similarly aged counterparts. They're hyper-vigilant. Number one, if they grew up in a household that was chaotic, they're going to be hyper-vigilant for that. But number two, they need to be hyper-vigilant against or with for themselves. Because they can emotionally dysregulate, because they feel things so much more intensely, they're guarded. Because it's almost painful sometimes the intensity of the emotions that they're exposed to. So they walk on eggshells. They don't want to encounter a situation that's going to stress them out. Extremely emotionally reactive with an inability to de-escalate. So when they do fall into that pothole or run into the wall or whatever you want to say. They go from 0 to 120 and they don't know how to get back to baseline nearly as quickly as other people. And it's not necessarily they don't have the skills. You know, they may be able to tell you exactly what they need to do. But the ability to get their body to, you know, catch on, it takes practice. And they may have been told, you know, count to 10 or breathe deep or whatever when they're growing up. And they're like, well, that doesn't work. So we need to help them understand from a broader perspective what may need to happen in order to help them re-regulate. Oftentimes people with borderline personality disorder have a history of neglect abuse or dismissive style of parent-child attachment. So like I said, it's not necessarily that it was this horrible abusive situation, although that occurs very often in people with personality disorder symptoms. We also have to look at this dismissive style of attachment where the parents going, I'm not going to deal with that. You know, come back to me when you can behave the way I want you to behave expresses a lot of conditions of worth does not help the child learn to regulate the emotions. So the child feels unlovable. Narcissistic has a powerful sense of entitlement. Unlike the person with borderline personality disorder, or even histrionic who may for a moment feel like I need to get my own way. The narcissistic person is like, I will get my own way. I deserve to get my own way. It doesn't matter who have to step on to get it. They often believe they deserve special treatment and assume they have special powers are uniquely talented, or that they're especially brilliant or attractive. Not all of these have to come together. It can be one or more of these. But a lot of times if you've ever worked with a patient who has narcissistic traits, they're very condescending. And, you know, again, I ask myself, what's the function of that? Because most people don't like that kind of behavior. So how is that behavior being rewarded and maintained? Well, if they put themselves up here, then they don't have to worry about your opinion. If they already feel bad about themselves, if they have low self-esteem, they don't want to let you anywhere near them. So they will puff up and keep you away. They also use their power or their perceived power, since they're narcissistic, to push people down, to push people away, and they will often be kind of unpleasant to other people. Again, to safe zone. They need to be powerful and admired. Oftentimes, but not always, if you look in some of the more recent literature, there's a lot of indication that people with narcissistic personality disorder don't necessarily have bad self-esteem. Some of them have very, very good self-esteem. They think they are all that a bag of chips and a Coke to boot. So they believe that they are that powerful and that brilliant. Just keeping that in mind when you're working with the client, don't automatically assume, well, personality disorder, low self-esteem. There are some exceptions. Lack empathy for others. I would, again, go back to do they lack it or are they unwilling to engage because it's too scary to feel when they felt before it hurt. So they don't do that anymore. And relationships are often superficial and devoid of real intimacy, which goes back to, again, are you keeping people at arm's length or pushing them down below you feeling superior and devoid the risk of getting hurt. And in some cases that, you know, with personality disorders, it's actually they believe that they are all that in a bag of chips and nobody else is worthy of them. So it's a diagnostic issue, but I do encourage you to consider the function of the behaviors. How does it protect them? If they're in your office voluntarily, clearly they want to do something different. They want to understand other people more clearly. They want to interface with other people better, whatever it is. There's something that motivated them to come to your office. So using a motivational strategy, we would focus on, all right, how can I help you identify interventions and identify things that you're already doing that can help you move closer to whatever your identified goal is. So the take home messages. Many behaviors characteristic of active addiction overlap with personality disorders. So in active addiction, people tend to be very egocentric. They tend to lack empathy. They tend to be very impulsive. Let's see, they tend to be somewhat emotional and intense attention seeking, especially if they're not getting their drugs or their own way. A lot of times people in active addiction, if they're not numb, the feelings are intolerable. So they go back and forth between being numb and being overwhelmed. They may disregard the rights of other people if they get to the point where feeling is so intolerable that they don't feel they can exist. I mean, they just can't exist if they're not high, then they may start stepping on the rights of other people because they want to survive. And the only way to do that is to be numb, not an excuse, just looking at, you know, my experience with clients over about 20 years. A lot of times the ones that present with PD behaviors at the outset who don't end up getting diagnosed with a true personality disorder. And I usually wait six months to a year into recovery before I'm comfortable with a personality disorder diagnosis. But that's me. Partly because that diagnosis can be so damning for people that I want to be very, very conservative with to make sure that that's what we have because it's not something that goes away. So once you put it on their record, it's kind of, it's kind of there. Many behaviors characteristic of addiction are pervasive. So if they are going to be impulsive, if they are going to be lack empathy, if they're going to be ecocentric, they're going to do it at work, they're going to do it at home. They're going to do it in the bathtub. They are in such pain, they are feeling so out of control at times that it may pop up at any point in time. If you think about people with active, significant addictions, you know, it interferes with multiple areas of their life. Even think about people, and I don't want to minimize what we're talking about here, but think about people who are addicted to nicotine. They have to take smoke breaks. They have to do these things. Now part of that's in response to the drug detox or needs or whatever. But some of it is also psychological when they start to feel stressed, they have this urge to go have a cigarette. And those behaviors, you know, they'll have that urge whether it's stress at work or stress at home or stress when they're driving from one place to the other. Recovery from these behaviors requires development of effective coping skills. Look back at what they've used, what's worked, what's helped them for even a few minutes, and then take things like the ACT matrix, acceptance of commitment therapy tools and dialectical behavior therapy tools, those can all be used to help them develop psychological flexibility. And even some basic CBT stuff, looking at irrational thoughts and cognitive distortions to help them start examining what is triggering these behaviors and what is maintaining these behaviors and what would they like to do instead. Recovery requires addressing dramatic emotional and erratic behavior by teaching distress tolerance skills. That's the first thing, you know, we got to help people learn how to press pause. Mindfulness to identify and process the source of the distress. Now ideally there's vulnerability prevention, there's preventative mindfulness. Yeah, we'll get there. But after they press pause and they've tolerated the stress they've gotten out of their emotional mind, then we need them to be able to evaluate the situation and go, All right, what am I dealing with here? And how can I best do it in a way that's going to get me closer to the things that are meaningful to me and help me lead the kind of life that I want. We need to address all or nothing thinking so awareness and elimination of cognitive distortions there. Hostility and aggression comes up in a variety of different ways in the personality disorders, but it's present in most of them in some form. So we want to help them understand their fight or flight response. We want to help them understand that when they switch from being happy to being rageful, when they switch from loving them, loving somebody to hating them. What's going on? What was triggered? What anxiety was provoked in them? Maybe they felt rejected, maybe they felt criticized, which made them bow up, if you will. So we want to help them understand what triggers this hostility and aggression and develop anger awareness and management skills. Most of the time people have some pretty common triggers, you know, they have like their top 10 that in various levels trigger them each time. And I say 10, it's usually only about five. But we want to help them identify what are those five things that really set you off. And let's start working there because those are the ones that are probably most problematic. Hypersensitivity, especially to rejection. So let's look at thinking errors. If you fear rejection frequently, tell me about that. Walk me through what you were thinking when this particular situation had happened that triggered your fears of rejection. So we want to start addressing those thinking errors and addressing abandonment issues. Where did those come from? Help them understand the schemas from when they were little, if they were abandoned or rejected. If their parents weren't there for them emotionally, even if they were there physically, we want to help them look at some of those issues. Not to scold the parents, you know, I'm not saying we're blaming anybody, but I want to look at what is triggering that now. So you can figure out how to address it. And maybe they can look back on their growing up and look at what their parents did and go, you know what? They were just stupid. They didn't know how to deal with this emotional dysregulation. And, you know, back 30 years ago, nobody talked about that. So we can help them develop alternate perspectives and we can help them develop self-esteem so they don't rely on others to tell them, you're okay. They can look in the mirror and go, you know what? I'm okay. If they don't want to hang out with me, tough tiddlywinks. Self-esteem is so important because it helps clients feel worthy of setting healthy boundaries. And it helps clients feel okay being alone. And, you know, a lot of times with my clients, I talk about the difference between being alone and being lonely. You can be lonely in a room full of 80 people. And you can be perfectly content alone. So what's the difference? And which one do you feel? And how can you become content so you're not fearful, so you're not anxious when you're alone? It doesn't mean that you have to say, okay, I can be alone forever and I'm just going to adopt 15 cats as my daughter likes to say. But you can look at it and say, would you rather be alone for a short time or in an unhealthy relationship? And as they develop self, stronger self-esteem, they're going to be able to look at their situation and go, you know what? I deserve better than that. Manipulative. A lot of clients with personality disorder behaviors are manipulative. So we want to help them develop interpersonal skills by not only learning how to set boundaries, but learning how to respect boundaries. And talk with people in a way that does help them create a win-win situation. Win-win is not manipulative. That's logical if you're not lying to somebody about what they're going to get out of it. So help them learn those interpersonal effectiveness skills. Develop self-esteem and the ability to internally validate. Remind them to give themselves credit every day or even throughout the day when they do good stuff. When kids are growing up and even to this very day, you know, think about the past 24 hours. I'm sure you did good stuff. I mean, it may not have been like curing cancer or something, but I'm sure you did nice things or good things or whatever. Did you give yourself credit for it or did you just take it for granted? But then if you made a mistake, did you focus on that more? Now you may say yes or no to either one. But a lot of people disregard their positives. They just say, you know, that's of course everybody holds the door or everybody helps somebody pick up their stuff when it falls. And they don't give themselves credit for that. They don't give themselves credit for working their butt off at work. Yeah, you may not have gotten everything done, but you worked your butt off. You tried and that deserves an A for effort. Help clients learn to start giving themselves reward and a pat on the back in addition to, you know, noticing when they make a mistake. So most patients with addictions have traits associated with personality disorders. These traits can be loosely classified into thinking errors. So when things happen, they perceive some sort of a threat, rejection, isolation, failure, loss of control. Behavioral reactivity develops as a means to escape or eliminate a threat. The first steps in the recovery process are honesty with self and others through mindfulness and self awareness. Hope and faith by identifying cognitive distortions and encouraging clients and encourage and courage and discipline to remain constantly mindful and accept and address thoughts and feelings, making conscious choices based on facts and what is most important to them in their life. A child growing up in an unstable, neglectful, emotionally detached environment may develop personality disorder traits to survive or addictions to numb the pain. A person whose neurochemicals became imbalanced or who was born more emotionally reactive may also have experienced rejection, abandonment and lack of support. Difficulty interpreting the world through because they had cognitive distortions. They weren't helped to move from that concrete thinking to more abstract thinking and or a sense of near constant emotional discontrol. They felt like they were always zero to 120. So what we can do with people with personality disorder traits again is really help them look at it's not ideal. You know those behaviors that that you were exhibiting that you want to address weren't the ideal ways to function, but they helped you they served you in some way. What's a more effective way to meet that same need that will help you get closer to whatever your goals and values are. Alrighty, are there any questions and I am going to try a little experiment. So I think now if you wanted to you could try to unmute yourself and talk or you can type in the window. I'm great with typing. And we can see how that goes. If you don't have any questions and you want to just go take your quiz, you know, more power to you go to it. And I will see you on Thursday. Okay, everybody have a fabulous couple of days and I'll see you on Thursday. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allCEUs.com slash counselor toolbox. 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