 Hi everybody and welcome to today's presentation on using a strength-based biopsychosocial approach to recovery from antisocial personality disorder. Like we've been talking about through this series, a lot of people think of personality disorders as not treatable and not recoverable. And while the person will always have those behaviors somewhere in the back of their mind, I personally believe that they can learn more effective coping behaviors so they can file away the ineffective ones. We can't completely unlearn any behavior. Once it's been learned, it's kind of in our brains forever. But we can archive it and that's kind of what we're hoping to do with these particular patients. So we're going to define the antisocial personality disorder, examine the similarities between the behaviors of certain personality disorders and addictions. A lot of times when we see people in early recovery, when we see people in residential treatment or detox, you know, really, really early recovery is what we're talking about. They have a lot of antisocial traits. So we're going to talk about why someone in early recovery may present in a way that looks antisocial when they actually don't meet the criteria for antisocial personality disorder. In my 20-some odd years working as a clinician, I think I have encountered two people who I would actually give a APD diagnosis. So, you know, I think while we need to be careful because personality disorders do stigmatize people a lot more than even addictions, you know, we'll just kind of look at those behaviors so you can make your own decision. We're going to identify ways to address these behaviors and thought patterns. And I really want to encourage you to critically examine the behaviors in patients with addiction in order to effectively, differentially diagnose. When I first started working in substance abuse, and I say substance abuse, not co-occurring because this was back in the day before they realized that co-occurring disorders were the expectation, not the exception. That's kind of my key phrase everywhere I go. But when I was working in that particular environment in substance abuse, the psychiatrist that we were working with at that point are attending would not diagnose depression, anxiety, bipolar, any mental health diagnosis at all until the person has six months of clean time. Now, that always made me scratch my head because I'm like, well, if they were drinking because they were trying to, you know, cover up or escape from their depression, granted the drinking is making the depression worse and it could be causing some of the depression. But if we don't treat the depression, all we're going to end up with is with someone who is clean and still really, really depressed and struggling to exist, struggling to survive. So we want to look at characteristics people are expressing in early recovery as things that need to be identified and dealt with. It may be situational, it may be time limited. As they go through early recovery and their brain and body kind of balance out and, you know, find their rhythm again, it may go away. It may quote spontaneously remit. But during that period, in order to help them stay clean and alive, we need to be able to address anything that is causing them difficulty or distress and not get too hung up on if it's a diagnosis or what little cubby we need to stick it in. When personality disorders are viewed as pervasive and perpetual, it provides people with an excuse for relapse. If we tell someone, well, you've got borderline personality disorder, then they have heard over and over again, probably, from other treatment centers that personality disorders are intractable. So if you are going to be emotionally unstable all the time and you're constantly going to have all these difficulties in relationships and communication and emotional control, you know, from that perspective, if somebody is telling me that, I can see why they may not want to give up their addiction because that seems like you would need an outlet somewhere. So I don't want to give them an excuse for relapse. I want to say, let's look at what you're doing, figure out why you're doing it and see if we can figure out a better way to achieve that same end. It also often derails treatment because patterns of behavior thought to be due to the personality disorder are often ignored. I remember working with clients and clinicians in residential treatment and in IOP and we would do our clinical staffing every week and I would hear clinicians say something to the effect of, well, that person's borderline, so there's nothing we can do about that. And I would just want to pull my hair out. I'm like, no, that's not true. The behaviors are serving a purpose. What is the purpose? We need to figure out what that is. It may be in order to artificially change the biochemistry. There's a whole lot of reasons people can do stuff, but there is a benefit. We don't do things that don't have a benefit. Personality disordered and addictive behaviors often look the same. When someone is detoxing or craving or withdrawing from a substance, they're going to tend to be more anger, more emotionally all over the place, have more difficulty focusing and functioning, and they may tend to lash out. The addiction is protecting them. It is keeping them safe, if you will, from the agony that is going on inside their head. It's helping them escape. So when they start to sober up, that agony comes back. It's kind of like after you have surgery and the pain pill wears off, and you're like, oh, this really, really sucks. That person is trying to survive. They're trying to exist. So what happens? Think, you know, again, if you've had surgery and like maybe dental surgery, I'm a big sissy about anything in my head, you know, ears, teeth, whatever. When you wake up and that initial pain medication wears off, are you in the best mood? Are you wanting to be jovial and deal with people? Are you ready to take crap from anybody? Likely not. Physical pain is one thing. Emotional pain is just as real and just as pervasive. So we need to try to understand that this person is hurting and they're lashing out in a way to try to protect themselves and try to survive. Getting in their head and figuring out, and that's whether it's an addiction or a personality disorder, getting in their head and figuring out how their behaviors are helping them accomplish that will help us go. We'll go a long way to helping us help them. Goals for recovery for both addictions and personality disorders. They need to get honest with themselves and others about their thoughts, feelings, needs and wants. They need to figure out what, how am I feeling? A lot of people have just numbed it out. We've talked about borderline. We've talked about histrionic. We've talked about narcissistic. Most of these people don't stop and go, oh what is my internal state today? They are struggling to get approval. They are struggling to be lavished with praise. They are struggling for external validation because they don't know what's going on inside themselves. They rely on other people to tell them. Now the narcissist obviously thinks they're all that, but they still need to be lavished with praise. They also need to start to get honest with others and people with either disorder really have a difficult time communicating in an effective assertive manner. Again, go back to that time when you had oral surgery and the pain pill wore off and people were not doing what you asked them to do and it was so frustrating. Or maybe you were in the hospital and you know how in the hospital they wake you up like every four hours and you're just like, please let me sleep. You can see where this might end up making somebody a little bit cranky. So they end up communicating in a way that's not assertive and they often don't communicate their needs effectively. They're just like get out and leave me alone. Distress tolerance and the ability to self soothe. People with addictions, whatever's going on has just overwhelmed them and they cannot take one more thing. Now while they're in the midst of their addiction, whatever that stuff is that's causing them distress is getting worse because they're not dealing with it. So when they sober up it's like having a wound on your arm that you haven't treated. You haven't put anything on. You just put a bandaid over it and left it all dirty and everything. It's going to get infected. So when they sober up it's just overwhelming times 10 plus whatever substances or activities they're using in order to escape our monkey and with their brain brain chemistry. So we need to help people develop distress tolerance so they don't need to use again. With personality disorders we have talked at length about the fact that when the external validation is not forthcoming the person becomes frantic. This frantic state of being leads to acting out physically, acting out aggressively, maybe towards oneself or towards somebody else. But if we help people with PDs learn distress tolerance and the ability to self soothe then they won't need to act out. That's a whole lot easier said than done so I don't want to make it sound like oh well you just need to teach them to count to 10. If counting to 10 worked they wouldn't be in our office. Hope and faith in their selves, the future, and others through addressing cognitive errors. If they're in your office for either disorder they have experienced disappointment in themselves. They've been betrayed likely by others. They felt let down. They may have been abandoned in their own mind. Now they may not have been abandoned until they were you know chest deep in their addiction and people started cutting them off. But they feel abandoned whether it's right or wrong. This is these are the feelings they have. They don't have faith in themselves others or the process. Starting out with your treatment plan you can help them develop faith and hope in themselves. If you do the next right thing you can do it. You know the little little engine that could. I think I can. I think I can. It's baby steps and I'm not wanting somebody to go from being in residential treatment to being a mid-level manager of a company or thinking that they're fixed when they leave. What I want is for them to see that with time things can get a little bit better. I want them to keep journals. I want them to keep logs. I want them to keep something. So they can review it on a daily basis and see not only vulnerabilities that may be making things worse so we can intervene. But they can see that as they work the process as they work the program whatever the program is things start to get better. And then we can start looking at addressing how they interact with others and any cognitive errors as it relates to their relationships. Development of self-esteem to eliminate the need for external validation. I think that's self-explanatory. And then and only then can they start developing healthy supportive relationships. They need to be able to feel okay about themselves and not be trying to feel avoid. I've made the example before of cookies because I love cookies. Sugar cookies on their own are very very good. Chocolate chips on their own are very very good. We want a relationship that is like sugar cookies and chocolate chips. When you put them together you get chocolate chip cookies and they're very very good. But you can also separate them and they can stand alone. So remembering that personality disorders represent a cluster of behaviors that's pervasive beginning before the age of 15. A lot of times these addictive behaviors also do. Due to immature cognitive development children tend to be more egocentric over generalized and think in terms of dichotomies. They can't say well mom is drinking herself into a stupor. It must be somebody else's fault. Or mom got mad at me and told me I was the worst child ever today. But you know that must be because she had a bad day and she's just lashing out. That's not how kids think. Kids are very egocentric and whatever's going on especially with their primary caregivers not only do you risk them taking personally but even once they get past that egocentric phase a little bit as long as the person is dependent on the family system they can't move out on their own. Then they are also going to try to maintain homeostasis. They don't want mom to go to jail. They don't want mom to overdose. They want to try to keep everything together as dysfunctional as it may be. So we've got to remember what these kids may be going through when you have an eight-year-old tucking their parent in on the sofa because she's too drunk to get up to her own bed. How does that child process things? How does he understand why she's doing what she's doing? From a survival perspective most of these behaviors make perfect sense when viewed through the eyes of the child at that age. So we want to go back and say let's talk about when things you know your childhood and when things got rough and yeah I'm not one to go back and say you know let's go back and blame everything on your mother or your father or your childhood but everything we've learned up until now the good and the bad has gotten us to this point so we need to figure out where we left the tracks. Since these behaviors form the foundation for further development we need to encourage patients to understand their function in the past. In the past when you would you know self-harm why were you doing that? How did it help you? What was its survival function? Identify how these behaviors and beliefs are faulty in the present. Okay so when you got really really stressed and you felt out of control you would self-harm. All right in the present do you need to self-harm? What other options are out there for you that you could choose? And we can even look at some things and I always refer back especially for a borderline but for all of your cluster B dialectical behavior therapy is very very effective. What can you do differently? In terms of self-harm instead of cutting sometimes people will take a red ink pen and draw on themselves. Sometimes they will hold ice cubes in both hands. Both of these are less dysfunctional less injurious but they do serve sort of a distraction from the intracyclic pain that's going on. Is this where I want them to stop? No but is it a stop gap between actually cutting and where I want them to be? Sure. So then we start developing alternate skills to use. When you get distressed what else can you do? What else might help? How can you identify what's going on and be mindful of yourself before you get to the point where you're out of control? And we want to empower our clients to interface with the world with the strengths, knowledge and tools of the adult. Many times they stop learning coping tools, coping skills at a very very young age. So we want to look at that when we work with people with addictions a lot of times their psychosocial development appears to kind of stop wherever the addiction really took hold. Now addictive behaviors were going on before that but when the addiction really took hold and that was the preeminent focus of everything they were thinking about that's sort of where development stopped in many cases. So addictions represent one way to cope with distress and can begin early in life. They have a lot of overlapping symptoms with personality disorders especially cluster B. We're viewing really quick because we've been talking in this series about cluster B but we're going to talk about in general right now. Cluster A is your paranoid schizoid and schizotypal. People in this category are characterized by social awkwardness and withdrawal. When people come into treatment for addiction it's probably been a long time since they've interacted with anybody while they were sober. So they may feel very socially awkward and they may feel withdrawn and they may not make eye contact right away. So I do want to see as they sober up and as they learn to function on a day-to-day basis without using an addiction does this social awkwardness seem to go away? Most of the time yes but you know it happens when you know you might have someone who does have some co-occurring stuff going on. Cluster C and yes I know this is not an order. Obsessive compulsive and dependent. Cluster C is characterized as being anxious and fearful. It may co-occur with addiction. I have not experienced a lot of patients that would meet the criteria for either obsessive compulsive personality disorder or dependent personality disorder. But since the behaviors represent a group of behaviors that are present when someone is anxious and fearful and since addictions tend to numb out anxiety, fear, anger you can see where they might co-occur. And then cluster B is our dramatic emotional erratic behavior which often overlaps with addiction. When you're using your Jekyll, when you're withdrawing you're hide and when you're somewhere in between nobody knows what to expect of you. So you know that's overly simplified but that kind of helps you understand where the erratic behavior comes from. Cluster B dramatic emotional erratic behavior all or nothing thinking, hostility and aggression, hypersensitivity, they're manipulative and tend to have a low self-esteem or weak self-concept except the narcissists. So now to our antisocials. Conformity to law is lacking. Well let's think about that. If they want what they want when they want it then sometimes conforming to the law is just going to be very inconvenient. There's likely been no consequences for them if they have not conformed to the law or the rewards have been greater. If the person is also an addict likely because of their addiction they've also broken the law. Okay so let's think about that. A lot of addictions you know even people who are alcoholics have probably driven drunk. That is a violation of the law. So conformity to the law lacking yeah yeah that could be addiction that could be antisocial. What we want to look for is do they break laws everywhere you know in do they break laws in every at work at home etc and do they commit what you would consider violent or criminal offenses. Their obligations are ignored. This person doesn't have and we're going to get down to it empathy or remorse and I don't want to confuse lack of empathy with lack of feelings because people with narcissism and people with antisocial personality disorder definitely have feelings but it's about what happens to them. Think more in terms of like the five-year-old child. When they don't get their own way all hell breaks loose. It's not because they hurt somebody else it's because they got caught and they didn't get what they wanted. Which brings us to reckless disregard for the safety or self of others. So putting people in harm's way and not respecting their physical and personal boundaries stealing from them using them in any way necessary in order to get what they want because they wanted it. The person with antisocial personality disorder is really focused on rewards through external means. They get something and it makes them happy. They get power when they beat the system and that makes them really really happy. So we're getting the dopamine we're getting the pleasure chemicals which is teaching people. I mean they're learning through this that you know if I break the law that's quite a rush. I want to do that again which is not something we want them to learn. They tend to be underhanded deceitful lying and conning others. When people are in their addictions they will do whatever it takes to get that substance. A lot of times by the time they get to this point sobering up is not an option because the pain is just too great. So they may lie they manipulate they may con others rationalize minimize justify and deny are our big ones in order to try to make sure that nobody takes away their substances. You know I wasn't using or maybe I had a few drinks but so and so had more. They will always try to make themselves look better. The person with antisocial personality disorder will also manipulate and con others to get what they want. Planning is insufficient. They're impulsive. They don't think gee I want to buy a car so I guess maybe I should save up some money and if I put $50 aside each week no they're like I want a car I'm going to go steal one because that is what they want right now. They have no ability to delay gratification. When you're working with someone with an addiction most of their inability to delay gratification involves numbing that pain. Once that pain is under control that impulsivity goes away quite a bit. Now there's some habitual ways of acting and reacting that need to be worked on in treatment but this is another way you can differentiate between the personality disorder and maybe just addiction. Temper irritable and aggressive. Well if you're using stimulants you could be irritable and aggressive. If you are detoxing or withdrawing from any addiction whether it be behavioral or chemical you're not getting as much of the pleasure chemicals. Your brain chemistry is kind of out of whack so you're feeling worse. It's not you're feeling baseline you're feeling well below baseline normal or you know you're feeling pretty bad irritable and aggressive. So when you've got somebody in treatment for addiction and they're also presenting with depression and anxiety symptoms which most people in early recovery do do we really want to start saying okay you have all these symptoms now let's start putting them into categories so we can give you diagnoses. My thought my preference my ethical stance is no. If they meet the criteria for substance abuse we know or or addiction and we know that their brain chemistry is wonky. We know that they're not going to feel happy. We know that there's a chance that they're going to have a lot of anxiety because you know they've disappointed hurt and and messed with a lot of people so there's a reason to be anxious there's a reason to be depressed aside from just wonky neurochemistry. They have these symptoms. Okay so let's deal with those. Let's not worry about saying well but you also didn't you're also broke the law you know you've got a rap sheet three pages long. Let's look at what in what ways they broke the law was it DUIs multiple DUIs well that kind of takes me back to the addiction was it depth and burglary all right possibly personality disorder but that's also possibly supporting the addiction. Did they ignore obligations well if they don't care about anybody else but themselves as in the personality disorder then sure it might qualify over there. If they are in their addiction and they are just they're so focused on getting their drug of choice and not withdrawing to the point where they start feeling the pain again they're not focusing on anything else they're obsessed with that substance so you know most of our addicts really don't have a good track record of showing up to work and picking up kids when they're supposed to have visitation and all that kind of stuff not because they don't care not because they don't have remorse but because they can't do it it's just they can't deal with the pain on their own without any other tools now can they learn tools in 12 step programs sure can they learn tools in smart recovery sure can they learn tools in treatment sure I'm not saying that the tools aren't out there but I'm saying until they decide that they are ready to try something new sobering up or withdrawing is going to be really excruciating in early recovery especially early early recovery when someone is involuntarily referred to treatment there may be a lack of remorse minimization of anything that they're doing justifying their actions what I want to hear is do they not have remorse for anybody is there anybody they care about you know most people you know except for people with antisocial personality disorder do care about other people and other things their mom their spouse their significant other their child their baby mama whatever the case may be there is someone else they care about and if I start seeing that then I start going I don't think this is a personality disorder necessarily now obviously they don't have to have all these criteria but remorse is a big one for antisocial we've already talked about how underhanded presents in both diagnoses and impulsivity and irritability so hopefully I've painted a picture where you can see where someone with an addiction but not a personality disorder may have all of these symptoms in early recovery once they get out of that early recovery three to six months you'll see a lot of these criteria disappear if you can get a accurate report of what their life was like before the addiction especially if their addiction didn't start till later in life you may see that these behaviors didn't exist even if they did if somebody learned a behavior when they were eight in order to survive for some reason it's going to take a while to kind of undo that learning because it's something that they was learned and it was tried and true and it's pretty well ingrained why would some why would a child under the age of 15 not conform to the law well maybe there was no no one there to make them you know my kids sometimes don't want to do their lessons my kid all children want to push their boundaries and if they're in an environment that is supportive of law abiding or law conformity then they're going to learn that if they're in an environment that doesn't set any boundaries that doesn't teach them you know that they have to obey the law for anything worse yet if they're in an environment where people are breaking the law left and right and seem to be benefiting from it then this is going to be ingrained in them they're like why should I conform to the law it doesn't do anything for me and I can get what I want a lot easier if I don't behave the way the law says I should another thing that you can look at and I call it kind of my cockroach theory when someone breaks the law and gets caught they've probably broken the law a bunch of times before that and they just don't get caught every time so you know bearing that in mind as a child obligations are ignored why would a child not learn to adhere to obligations if you're a parent that's probably a pretty easy one to answer children have to be learned have to be taught to adhere to their promises to not let people down they have to learn that if they make an obligation they've got to keep it or there will be consequences if there are no consequences if they grew up in a situation where mom said she was going to show up to your baseball game and she didn't you know dad was supposed to pick you up for visitation and he didn't where the primary caregivers are constantly ignoring their obligations you can see where this child might not learn the value of keeping their promises reckless disregard for the safety of self or others adrenaline is really fun you know and I am not an adrenaline junkie I will not go skydiving I am terribly afraid of heights so I'm probably not a good one to talk about that but there are people who really like adrenaline and they get that rush if they're feeling depressed if they're feeling blah if they're feeling down they get a rush from adrenaline activities which can lead to reckless disregard because eventually the safe activities aren't going to produce that rush anymore the other way this can be learned by a child is if no one was there to protect them if their primary caregivers had reckless disregard for their safety for whatever reason they may figure well I'm going to do what I want and if somebody gets hurt top diddlywinks all three of these can be retaught as the person goes through treatment they can learn to conform to the rules if they're in residential there are a lot of rules and I have had clients come to me and be like I wish I would have done straight time because I hate it here jails easier I'm like well yeah jail is easier go back and finish chores um helping them conform to rules and in the first 30 days of recovery they're still kind of in a fog if they can get up and get to their groups and get to meals and do the basics even if they're not a hundred percent engaged all the time I'm happy so we're going to reward that behavior so they see that there's a benefit to conforming to the rules they're going to get discharged sooner if they conform to the rules with a successful discharge if they adhere to their obligations you know this is another big criteria for successful discharge from IOP or residential are they doing their assignments are they getting to group on time are they staying clean are they staying awake during group are they doing their homework are they coming to individuals those are obligations that they set forth when you create their treatment plan with them and as they complete those we want to make sure that it's building up their self-esteem so they can be like yeah I did that and yes I can rely on myself to complete something disregard for the safety of self or others we're just going to have to talk about this as it comes up um you know in retrospect was that really a good idea to go driving 90 miles an hour whatever this issue is remorse lacking most of the time this is not something that has to be taught for someone with an addiction because as they sober up there's a lot of remorse to deal with but why wouldn't a child you know if they're going to develop a personality disorder why would it be protective to fail to develop remorse if people are hurting you all the time if nobody else seems to have any remorse then I can see where you might put up your walls and go I'm not going to care about anybody else because nobody cares about me thank you very much can that be unlearned certainly it takes a long time it takes a while because this is in my experience one of the hardest issues to deal with when people have put up those walls and they will not make a connection with anybody else and they don't care about the impact of their actions on anybody else because if they care then they risk getting hurt or they risk having to feel bad and they can't can't tolerate that right now because they don't have the coping skills to deal with anything negative coming their way right now they haven't decompressed enough from all the stuff they've been running from underhanded deceitful lies and manipulative well if it's rewarded when you're little or at any point in time if it's rewarded you're probably going to learn this behavior if you learn to manipulate others and it and there's a benefit to it whether it's your job or you get what you want or whatever the case may be yeah you're going to learn that so we need to help people learn that they can get what they want by being honest and assertive but they may have to put the work into it which takes us down to impulsivity children are impulsive children are extremely impulsive if they are not taught distress tolerance and frustration tolerance they're going to continue to be impulsive most people with antisocial personality disorder according to the research because like I said I've only worked with two but according to the research they don't grow up in great environments they don't have somebody going well you know sometimes you're going to fail but you got to get back up and try again or you're not entitled to have this handed to you you need to work for it that's something that active engaged parents do and sometimes that's something that active engaged teachers do but our teachers you know and you know hats off to them there's 30 little you know 30 pairs of eyes and 30 children who are trying to figure out where the boundary lines are to one person so it's really hard to for a teacher to take that over so I don't want to try to put the impetus on the teachers I think the parents need to be involved if that doesn't happen then they won't learn to plan in early recovery and well all the way through but this starts in early recovery planning one of the criteria for treatment for most insurance companies but also it's just a good practice is to start discharge planning from the beginning why we want to know where you're going you know what's this end point that we're looking at for when you're going to leave this episode of care and when you leave where are you going so we can plan because if you need to find a new place to live you can't start looking for that two days before you're supposed to discharge so we need to know what has to be set up so you can be where you want to be in 30 days same thing with APD if you're working with a client with APD you're going to have to set boundaries and set firm hard limits and give people time time limits expectations it will feel like micromanaging at first because it is I need you to do these things by tomorrow and be in my office I worked with a wonderful probation officer in my first job out of college he had the office next to me and all of his probationers would show up that were supposed to be looking for work at 7 30 every morning and they would show up for inspection and he would want to see the business cards from the five places they went the prior day and then he would also look at how they were dressed and you know maybe evaluate their resume or something if they were newer to the program but he held them accountable every single day it wasn't well you know we'll probably meet tomorrow every single day he taught them to be accountable he taught them to plan ahead of time if they were like well I couldn't get there because I slept in late and I missed the bus his response was well you should have had an alternative you should have had a backup plan because poor prior planning on your part does not constitute a crisis on mine and he used slightly different words but we're going to keep it clean and temper and irritability and aggressiveness whether it's a personality disorder or substance abuse and they're sobering up there's a lot of emotions going on there's an inability to control emotions it just feels like a flood one of the greatest feeling things of recovery is feeling feelings and one of the most difficult things of early recovery is feeling feelings because you don't and people don't have the tools mastered yet to handle them in a new way so we can expect irritability and aggressiveness setting boundaries stopping your your client letting them you know if they want to come in and they want to be irritable you know okay the the way I handle it I let them come in and go on their little tirade whatever it is and then I'm like are you finished let's talk about how this could have happened differently or let's talk about what's making you upset I'm not going to get into a power struggle with them when they're already irritable and aggressive that's what they expect that's what they're used to so I am going to let them you know kind of diffuse themselves and then model and walk them through coping and figuring out either how to change the situation or change how they feel about the situation because sometimes situations are unchangeable somebody dies that's not changeable but you can change how you feel about the situation which is why people work through the grief process you know maybe you have your parental rights terminated and that's a done deal you can't change that situation right now how can you change the way you feel about the situation because staying angry and bitter is probably going to lead you back into a relapse regardless of the origins of the irritable and aggressive behavior it probably means the person never learned the coping skills to to deal with the fight or flight reaction they sort of have a short trigger if you will we want to look at what's making them irritable and aggressive and figure out how that might how getting angry and being kind of nasty might have benefited them in the past and in general it gives people power and makes other people feel subservient or pushes them away which is a safety mechanism if I can act like I'm really bad ass people aren't going to mess with me obviously I haven't gone over all the possible reasons someone may develop these behaviors but I hope I've brought it to your attention where you can look at a behavior and go okay whenever this happened whenever this behavior developed what function was it serving how is it beneficial to this person and how is it still beneficial because it still is or they wouldn't be doing it how is it still beneficial many behaviors characteristics of active addiction overlap with PDs they begin in late childhood early adolescence and are pervasive it's not just at work it's not just in their relationships it's not just as a parent recovery from both requires development of effective coping skills and addressing cognitive distortions that have been learned over time recovery interventions for this dramatic emotional erratic behavior well first we got to get out of that emotional surge we've got to get out of the tidal wave so distress tolerance is huge helping people feel a feeling and not have to act on it not even necessarily have to label it they can just sit with it and be like okay this really sucks but it'll be gone in 10 minutes there are a lot of skills for distress tolerance if you get a dialectical behavior therapy skills manual there are tons of them out there you can identify a multitude of distress tolerance activities I like to give my clients a list of different distress tolerance activities and have them practice and pick and choose and say this will work for me or I think this might work or that's an interesting idea and then they try them once they're past that initial rush of emotion anger fear they need to be mindful to identify and process the source of the distress all right what really happened you know I saw today on tv that 80 percent of drivers 80 percent of drivers report having road rage that just blew my mind just absolutely blew my mind anyhow so 80 percent of drivers could use some mindfulness skills to identify and process the source of the distress and figure out whether it's something worth getting upset over or worth letting go changing the way they feel about the situation and then develop coping skills so once you figure out what the source of the distress is then you've got to figure out what to do with it if I'm going to change how I feel about it then I'm going to have to have some kind of coping skill to help me do that if I'm going to change the situation then I'm going to have some have to have some other skills to make that happen all or nothing thinking this is one of our most common cognitive errors so awareness and elimination of cognitive distortions if we start working on that people are going to feel a lot happier because these extremes and these unrealistic expectations start to go away so people aren't feeling disappointed or scared hostility and aggression educate people about the fight or flight response it's normal it is a biological response when your body perceives a threat when your brain perceives a threat real or not it will execute the fight or flight response it says there's a threat I need to protect myself now sometimes we've over generalized and we may perceive a threat where none exists so it's important to help people understand that some of some of those things may need to be counter conditioned a little bit and then development of anger awareness and management skills if this is not something to get angry about how do you de-escalate if this is something that legitimately makes you angry holding it and nurturing it and yelling at people and putting your fist through the wall are probably not going to be effective responses so how do you manage your anger in order to effectively use your energy to fix the situation change the situation hypersensitivity especially to rejection awareness and addressing thinking errors if people are thinking in all or none thinking terms they're going to be more sensitive to rejection if they are very egocentric and somebody walks by and kind of grimaces at them and they take it personally it may not be personal so help them take in stimuli and learn to figure out whether it is a real thing to get upset over to be sensitive about whether it really meant rejection or whether there could be other alternative explanations for why something happened or why someone behaved this way awareness and addressing of abandonment issues whatever those issues are if a person has some stuff that is leading them to have you know i'm kind of a garbage term but abandonment issues we need to help them figure out what those are and address them because as long as they are afraid of people leaving they're going to be hypersensitive to rejection so we need to figure out where that comes from and we need to help people develop self-esteem high self-esteem lower sensitivity to rejection if they tend to be manipulative generally they're being manipulative in order to protect themselves to keep people around to validate them remember they're very little very few situations where they're not wanting to be lavished in praise so we need to help people develop these interpersonal skills with boundary setting communication skills saying what you knowing what you want and how do you say it assertively how do you get into an authentic relationship with yourself and with others so you don't feel like you've got to manipulate them or con them all the time and low self-esteem weak self-concept develop this self-esteem and these ability to internally validate one of the concepts that we talk about a lot when we talk about self-esteem is taking away those roles you know you may be a mother a teacher a spouse a daughter whatever but when all those are taken away what are you and this goes more towards values and attitudes like nurturing creative compassionate you know i made a whole list the other day on a facebook post encouraging people to look at the qualities they have themselves not what they do for other people but what qualities characterize them that they can be proud of if they have those qualities and they feel confident in those qualities then they don't need anybody else to tell them that they are good enough most patients with addictions have traits associated with personality disorders these traits can be loosely classified into thinking errors which causes them to perceive a threat when none exists and behavioral reactivity to escape or eliminate the threat important concepts for our clients in early recovery regardless of whether it's a pd or an addiction getting them to get honest with themselves and others mindfulness self-awareness hope and faith help them identify cognitive distortions and thinking errors that may be kind of zapping their hope and leaving them disappointed if they expect too much if they set the bar too high they can end up losing hope and faith because nobody ever meets that that high bar so what's realistic one technique i use with my clients especially if they're being hard on themselves as i say would you hold anybody else to this standard a lot of our clients will set themselves especially in early recovery we'll try to set a high bar and they may set it too high and set themselves up for failure and then we need to encourage encourage them to develop courage and discipline to remain constantly mindful accept and address thoughts and feelings and make conscious choices based on facts