 Welcome everybody. Today we're going to be discussing strengths-based biopsychosocial approach to recovery from addictions and personality disorders. Now this one is going to be a little bit unique, I think, because I have a slightly unique approach or take on personality disorders, which you'll become familiar with as we go through this. I do believe that personality disorders are treatable, like I believe addictions are treatable. So we're going to talk about how these things kind of look alike and how they may be long-standing patterns of behavior that have been learned that can also be replaced. So we're going to define personality disorders, examine the similarities between the behaviors of certain personality disorders and addictions, specifically cluster B, identify ways to address these behaviors and thought patterns, and encourage clinicians to really critically examine behaviors and patients with addictions in order to effectively, differentially diagnose. When I worked in community mental health, one of the things that I was pretty adamant about with my staff, obviously especially my unlicensed staff, was the fact that we really wanted to see people work through the program and get a certain amount of clean time under their belt before we started willy-nilly throwing personality diagnoses at them. Part of this is because personality disorders as a term has really gotten a bad rap, if you will, as being persistent and untreatable. And I would encourage you to think about that as we go through this presentation as to how untreatable they are. Yes, they're going to be more difficult to treat than something somebody started doing a year ago if they've been doing it since they were knee-high to a grasshopper. But I don't believe that personality disorders are completely untreatable or intractable. So why do we care? When personality disorders are viewed as pervasive and perpetual, it provides an excuse for the patient for relapse. Well, I'm borderline, you know, I had this impulse control issue and I relapsed. I'm never going to be normal, so I relapsed. It often derails treatment because patterns of behavior thought to be due to the personality disorder are essentially ignored sometimes, not all the time, by staff and clinicians because they see personality disorders as something that can't be fixed, changed, or modified. And I really disagree with that. Personality disordered and addictive behavior often look very, very similar or the same. And the goals for recovery from both include honesty with self and others about thoughts, feelings, needs, and wants. So thinking about those personality disorders, a lot of people, especially again with cluster B, have difficulty identifying, let alone communicating their own thoughts, feelings, needs, and wants. Both addictions and people with personality disorders need to address distress tolerance and develop the ability to self soothe. They need to develop hope and faith in themselves, the future, and other people through addressing cognitive errors because we find that this hope and faith is often dashed by very negative or very polarized thinking errors. They need to develop self-esteem to eliminate the need for external validation. If you're constantly looking to other people to tell you you're okay, then you're going to fear abandonment because if they go away, then essentially you disappear. And they need to work on the development of healthy supportive relationships. A lot of times people with addictions and with personality disorders get into relationships, true. I mean, they may have a lot of friends, they may have family, they may have lots of relationships. The healthy supportive ones are usually few and far between. So we want to look at what does that look like and who in your support system might most closely qualify as being a healthy supportive relationship. So personality disorders generally represent a cluster of behaviors that's pervasive. That means it's not just at school or not just at home, but everywhere, beginning before the age of 15. We're really looking for some of that stuff and we know we can't diagnose a personality disorder this early. We're going to have conduct disorder or oppositional defiant disorder, something like that. Addictive behaviors also often begin before age 15. A lot of my more clinically challenged clients, severe whatever, however you want to phrase it, their addictions began significantly earlier than people who had milder issues or milder addictions. Their issues all often began back in early adolescence, maybe even late childhood. So we want to look at how long has this behavior been going on because it's pervasiveness and the degree of how firmly entrenched someone is in these behaviors probably makes sense. If they've been doing it for 25 years, it's going to be something that they use pretty frequently. Due to immature cognitive development, children tend to be more egocentric over generalized and think in terms of dichotomies. You either love me or you hate me. If you are my parent and you hurt me, you're supposed to love me and you're supposed to take care of me. So if you hurt me, it must be my fault. So you can see how these cognitive errors that children make because they don't have any other frame of reference. They don't have the ability to really look in terms of shades of gray. Can create a situation where they start seeing the world in terms of polarization. They see the world in terms of distorted thinking. From a survival perspective, most of the behaviors that we're going to talk about make perfect sense when you view it through the eyes of a 7, 8, 9, 10 year old. Does that mean that we're dealing with somebody who is cognitively 7, 8, 9 or 10? No. But what I'm saying is that some of the ways that we have organized our world or the schemas that we've created may have been constructed back then and may never have been challenged. Since these behaviors form the foundation for further development, so they built upon this negative conceptualization of the world, patients must understand the function of the symptoms and the thoughts in the past. Identify how these behaviors and beliefs are faulty in the present. What was true when you were 7 may not be true now that you're 27. Develop alternative skills and be empowered to interface with the world with the strengths, knowledge and tools of the adult. Children think differently. I mean Piaget spent his whole life proving that children think differently. They don't have that ability for abstract reasoning. So if a lot of really bad stuff happened when the child was young, they may not have started developing all of the abstract reasoning skills that a person who had the support and a nurturing environment would have. Addictions represent one way to cope with distress. It's not a good way. It's not a good way at all because all it does is numb it out. But it does represent the person's desire to survive what they cannot tolerate in terms of distress. They can begin in early life. Eating disorders, we see eating disorder behavior begin as early as seven or eight years old. We see addictive behavior, use of marijuana, use of alcohol. I've had patients tell me that they started smoking marijuana as early as nine. So we're dealing with people who are, for one reason or another, engaging in some dysfunctional coping behaviors at a very, very early cognitive and developmental age. That also tells me, and from the research that we've looked at on what happens when a child is exposed to abuse or neglect, the brain is developing so rapidly at that point that people who experience this kind of distress, this kind of adversity early in life probably are going to have some different wiring in their brains than the rest of us do because their brain was trying to compensate and deal with that neglect and everything else that was going on. It's important to understand this. It doesn't mean that the person is permanently broken. It just means we need to figure out a way to help them work with the wiring that they have. So real quick review. Cluster A is your paranoid schizoid and schizotypal personality disorders. Social awkwardness, withdrawal. I've had several patients over the years who have had cluster A diagnoses and they've co-occurred with the addictions. People with social awkwardness and withdrawal. I mean, think about going through middle school and high school without the ability to trust with some paranoid ideation with difficulty making eye contact. It's a difficult place to be. So some of these people and by and large, not all of them, but some of these people will develop addictions or will start using substances in order to feel part of a group in order to feel less isolated, less of an outcast. Others don't care and they are more than happy to withdraw into their room, but they may still engage in addictive behavior. Cluster C, and yes, I know it's out of order, your obsessive compulsive and your dependent personality disorders, these tend to be more anxious and fearful. This again may co-occur with addiction, but I haven't really experienced and what I've experienced over 20 years is just a really small sample of what's out there, but I have not experienced a lot of people coming through with OCD or dependent personality disorder. That being said, when those characteristics occur, if the personality disorder is there, it wouldn't surprise me to see some addictive behaviors in addition in order to help the person cope in the obsessive compulsive area, help them cope with the fact that they can't control everything in the dependent area, help them cope with potential fear of abandonment. But then there's Cluster B, your borderline narcissistic, histrionic and anti-social characterized by dramatic emotional or erratic behavior. These behavioral patterns often overlap with addiction, so let's look at some of these characteristics. Cluster B, you have your dramatic emotional erratic behavior. Think about somebody who is in the middle of an addiction. We talk about them being emotionally all over the place. We talk about them being dependent upon the substances to numb the pain. We talk about erratic, unpredictable behavior and mood swings. Okay, you see that in Cluster B too. All or nothing thinking. We see this in personality disorders and we see it in addiction. People start seeing the world as all good or all bad and there's nothing in between. You're going to fit into one of those categories if I have to squeeze you into it. Hostility and aggression. The world starts getting to be a very, very, very scary place if you have this all or nothing situation going on. Everything you see is always extreme and you're hypersensitive. People who grow up in addictive households, people who grow up in neglectful households, people who grow up with a personality disordered parent become hypersensitive. They want to be attuned to all the clues that way they can best protect themselves from any fallout. They want to be able to fight or flee at the first sign of negativity or the first sign that something's going to go down. Manipulative. Well, we know that people with addictions are manipulative because they're trying to protect that addiction. That one thing that helps them survive. People with personality disorders can also be manipulative. We're going to look at some of the ways that they want to protect themselves from what seems to be a very, very scary world. All of these personality disorders tend to have low self-esteem and a weak self-concept with the exception of narcissistic personality disorder where they tend to be on the other end of the spectrum all or nothing again with very grandiose ideas about what capacity they have and what strengths they have. So let's look at antisocial. Disregard for the rights of other people. They do what they want, when they want to, because they want to in order to get whatever they want to. Is this true of people with addictions? Yeah, it is especially if it involves doing whatever they need to do to access their addiction of choice. Do people in active addiction do things that they wouldn't normally do with regard to disregarding the rights of other people? Oh yeah. So one of the things that we want to look at if we're differentially diagnosing is is this behavior, this disregard for the rights of other people, limited only to the time when the person is symptomatic of addiction. With a lot of our patients we're not going to be able to look back and see when they've been asymptomatic because it's been going on for so long. But we need to kind of start looking at it. We need to look at do they have empathy? Is there a sense of guilt for impinging upon the rights of someone else? Not just they're upset because they didn't get their own way. Impulsivity. People with antisocial personality disorder and you know this is also common in criminogenic thinking. It's like there's not enough time. They want what they want and they want it yesterday and they can't wait. People with addictions are often the same way. They need to have their own way and they need to have it now. They're trying to control their environment because the world as they know it is very chaotic and or they're in distress. So if they can't numb it out, if they can't control it, then it needs to go away. So there's a lot of impulsivity, reactivity, trying to protect themselves and it really comes down to a survival function. Hostility and or aggression. In antisocial personality disorder, we see people who are hostile and aggressive generally when they don't get their own way because they want to get stuff. Now whatever that stuff is is dependent on the person. Sometimes it's just power and control. When we look at people with addictions, hostility and aggression, what do we know about anger? Anger is a power move. That's your fight of the fight or flee. So hostility and aggression is a way of getting control over other people, getting the upper hand, the power position or pushing people away so they can't hurt you. Either way, you're in a dominant position which is protective. Deceit and manipulation. People with antisocial personality disorder can look at you and lie to your face and you won't even know it. But so can people with addictions. Part of it is just practice because they need or they feel they need to access whatever it is. There's also a There's also a certain amount for both groups of a thrill of being able to manipulate and deceive people in order to keep them kind of your puppets. And that sounds horrible, but when you think about it in terms of somebody with an addiction who has been victimized, who feels out of control, who wants to keep people from hurting them, one of the best ways to keep people from hurting you is to control them. Now, obviously that's not the healthy way to go about things. But when again, I want you to just kind of think of it, step out of your therapist mind and try to get into the mind of somebody with an addiction or with one of these personality disorders and view the world through their eyes. This is one of the challenges that a lot of us have when we're working with people with a variety of things, you know, we can get into the mind or we can get into the shoes of somebody with depression. But when it comes to addictions or personality disorders or schizophrenia, sometimes it's harder for us to want to put ourselves in their shoes in order to understand the reward function, the motivation behind these behaviors. But we're not going to be able to help them address them unless we see what the motivation is, how it is functioning for them right now, and how we could find other healthier ways to help them meet those needs. And then a lack of empathy. And I put seam there. People with antisocial personality disorder typically don't know how to empathize with other people. Now, if you remember back in preschool, one of my son's preschool teachers was just fabulous. But I remember distinctly watching her sometimes on the playground work with little children that were trying to negotiate things. And one child would hurt another child and she'd pull them aside and go, you know, how do you think Tommy felt when you took his toy or when you hit him? And the offending child often would shrug his shoulders. And she would say, okay, well, how would you feel if he took your toy or he hit you? Then the child was like, oh, that wouldn't be so good. Alright, so if you don't think it would be so good if he did it to you, then how do you think he felt? We teach children empathy. Now, some of it is inborn. Some of it is just part of being human. But the degree of empathy that helps us engage in healthy relationships is partly learned and crafted through social interactions as you grow up. And if all of your social interactions are abusive, negative or dysfunctional as you're growing up, then you may not learn to take empathy or have empathy like other people do when they get to be older. So I really want to look at empathy in terms of is it something the person is just not wired for and they're not capable? Or is it something they haven't learned? Another thing to remember in both is cluster B people. 99% of the time you don't look back over their childhood and go, hey, you had a great childhood. What in the world happened? Most people with personality disorders, especially cluster B, tend to come from very chaotic, dysfunctional, neglectful environments. So seeming to lack empathy. If everybody you were supposed to be able to trust has let you down. If nobody has ever had empathy for you, it makes sense that you may not have empathy for other people, you may have just given up. And if that's the case, we can, you know, re-inspire hope and stuff. But we need to figure out where these symptoms are coming from. Why do you lack empathy? Do you not know how? Do you just not have the capability? Or have you given up and you just, you know, so many other people have hurt you, you don't care about their feelings anymore. Histrionic. Now this takes a little twist on it. Excessive emotionality and intention seeking. They may become enraged at perceived rejection. Now remember we talked about all of the people in this cluster tend to be very hyper vigilant. People with histrionic tendencies tend to be flirtatious, need to be the center of attention and when they're not, they feel lost. They feel very out of control. They derive a lot of their self-worth and a lot of their ego strength from other people valuing them, from other people falling over them. And when they don't have that, since they can't self-soothe, they like freak out. They have an inability to engage in authentic relationships but they're uncomfortable being alone. They can't be their true selves because they don't know who they are. They can't be authentic because they're so afraid of being abandoned or rejected that they are going to be whatever they think you want them to be. Now this is starting to sound a little bit like borderline now, isn't it? We'll get there. They're uncomfortable being alone because they haven't any internal ego strength. They haven't any internal idea of who they are. They're relying on everybody else to shower them with praise for what they do. You are an excellent fill-in-the-blank. Okay, if I'm the center of attention because I'm an excellent fill-in-the-blank, then if I'm not a fill-in-the-blank anymore, I disappear. They imagine relationships to be more intimate in nature than they actually are. They so desperately want to fill that hole inside them that they start imagining this relationship to be more intimate. If somebody is paying attention to me, then you must love me. They tend to be suggestible and easily influenced by other people, which is not good especially in a situation where there are also addictions and people who have ulterior not-so-nice motivations. Histrionic personality disorder is not uncommon, and a lot of times you will notice it because these people, particularly females, it tends to be diagnosed more in females, try to use this power in order to control people. My thought when I'm working with someone who's histrionic is what happened in the past that has taught you that this is how to interface with people and that this is the safest way to interact. Borderline, people with borderline personality disorder, and we have all worked with somebody who has borderline tendencies, and I use that word a lot, tendencies, because I find that true borderline personality disorder isn't nearly as common as we might think because these behaviors are so similar to those that we see in addiction treatment. Low self-esteem. Okay, how many different diagnoses have low self-esteem as a characteristic? The person with borderline personality disorder is empty inside and they're relying on other people again to tell them who they are, what they are, and they are very chameleon-like. Just like in addictions, the chameleon comes out in order to keep people from abandoning them. They feel helpless, anxious, and constantly fear-abandonment. What would have created this situation in a person when they were growing up or when they got older, that they constantly fear that people are going to leave them. They constantly feel like they're not good enough. And I'm kind of putting that out as a question for you to think about when you're working with people with addictions or with borderline personality disorder, this is a devastating place to be where every time you walk into a room or you think you are starting to have a friend, you're just like, well, I better not get too attached because they're going to leave. Their perceptions of themselves and others may quickly vacillate back and forth. People with BPD, we think about them turning on a dime. They love you or they hate you and there is no middle ground. It's protective. If you are filling a need, if you are filling the void, if you are reinforcing them as a human being, they will love you. The minute they start to perceive that you might be critical, that you might be getting ready to leave, that you might be doing something they don't like, it will turn. It will turn to something of closer to hate. Why? It's protective. They are going to be the dumper instead of the dumpy. They are not going to let you abandon them. They are going to push you away. A lot of this deals, comes from their hypervigilance. They grew up in an environment where they had to be sort of on their toes all the time because it was very chaotic and very unpredictable. And that's what they see everywhere they look now. I mean, if you're always looking for somebody to disappoint you, you're going to find somebody to disappoint you. On top of this, they tend to be emotionally reactive with an inability to de-escalate. So they see something. They are hypervigilant. They are looking. They see the slightest hint of disappointment or abandonment or disapproval. They go into a full-out fight-or-flight reaction and they cannot self-soothe to come back down, which is why we see a lot of self-injurious behavior and addictions in people with personality disorders because they're trying to numb out the intracyclic pain. They often have a history of neglect, abuse, or a dismissive style of parent-child attachment. So they never felt like they were important or good enough in their family of origin. How must that affect a child when they grow up in an environment where the people who are supposed to approve of them and protect them, their parents, are neglectful, abusive, and dismissive? So if those people can let you down, then everybody else most certainly can let you down because they have less of a stake in it. People with narcissistic personality disorder, I say this one for last because they're kind of on the other end of the spectrum. People with narcissism have this powerful sense of entitlement. And I can say that in my career, I've worked with two people who had narcissistic tendencies. They thought they were smarter than everybody else. They believed they deserved special treatment. They didn't think they had special powers, but they did think that they were all that a bag of chips and everybody else was an idiot. They needed to be in control. They needed to be powerful and admired. They didn't have empathy for their impact on others because it was just like, well, I am the queen and you are all my subjects. So I don't really care how you feel. What everything is about is how you make me feel. And relationships are also often superficial and devoid of real intimacy because they're not engaging with the other person. They are wanting people to fawn over them. Again, what must have happened in this person's life to develop this set of behaviors, this sense of entitlement that everything they want, they get, that they always deserve special treatment. I've known people who've grown up and everything they've wanted, they've gotten, and whenever they got in trouble, they got rescued. They learned to believe they deserved special treatment, not because of any reason, but just because they said so. They didn't develop so much a sense of who they were. They developed a sense of the fact that they could control and bully people. People with narcissism, if they're ever confronted with the fact that they may not be as powerful and as admirable as they think they are, it is a crushing blow. But most of the time, they're going to blame others. If anything they do has a hiccup in it or is incomplete or imperfect, it's not their fault. They will not take responsibility for it because they're perfect in their own eyes. People with narcissism have a very, very difficult time forming healthy relationships because most healthy people don't want to be around it. So a lot of times you see people with narcissism are surrounded by people who are codependent or who are dependent and need to take care of someone else. They have a need to fawn over someone and the narcissist has a need to be fawned over. So it's not a match made in heaven, but a dysfunctional match, if nothing else. So what are our take-home messages? Many of the behaviors that we've talked about are characteristic of active addiction. People in active addiction are manipulative. Yes, they are. When they sober up, the world is a scary, terrifying, depressing, hostile place. And the reason they started using was to get away from the terrifying, scary, depressing, hostile place. So they tend to be manipulative in order to protect their addiction. They protect that one thing that's helping them survive right now because they don't know how to deal with all this stuff that they have to deal with. And it's overwhelming to even think about starting to deal with it. They tend to lack empathy for others. They don't even have empathy for themselves most of the time. They just, they're just trying to exist. A lot of times they're numb inside. Addictions and personality disorders often begin in late childhood or early adolescence. And not saying that they're one in the same because we know that there is no such thing as an addictive personality. But I do believe that people who develop personality disorder behavior often also develop addictive behavior as a way to deal with all the negativity. As the person deals with the addiction and a lot of the stuff that we talk about that they need to address in their addiction is really stuff we're talking about in terms of coping and personality disorder behaviors. Recovery from addiction requires people develop effective coping skills and address their cognitive distortions. Recovery from personality disorders also requires that. I mean you can't be viewing the world as a scary place. You can't be viewing the world in all or nothing terms. You can't always be fearing abandonment and expect to be able to be happy. So addressing the cognitive distortions that makes the world such a scary, unwelcoming or hostile place and developing coping skills to help the person self soothe. True for both addictions and personality disorders. Recovery from addiction also requires addressing dramatic emotional and erratic behavior. In their addiction whether they're using or they're not using if they're still engaging in this kind of behavior they need to develop some mindfulness to identify and process the source of their distress. They need to identify some distress tolerance skills. If you look at some of the DBT skills workbooks they talk about distress tolerance and most of you probably are aware that DBT was initially developed to work with people with borderline personality disorder. We want people to develop the ability to feel distress and ride the wave through it without having to act out, without having to use, without having to cut, without having to engage in some other sort of reckless self-destructive behavior. Once you get past that initial distress people still need to have coping skills to deal with whatever it was that caused the emotional upset to begin with. This all happens really fast. You get upset, you have to acknowledge that you're upset, get through the initial rush of emotion with the distress, with your distress tolerance skills and then cope with it. That's a lot to learn. It can be done but it's a lot to learn. Mindfulness is the first step no matter what the diagnosis we're talking about. People need to understand when they get upset. They need to start identifying that because that's what leads up to their acting out. I've talked before ad nauseam about the fact that relapses don't come from out of nowhere. They come from a whole host of things building up and stuffing this distress and failing to deal with it and a lack of mindfulness. If you're mindful then stuff doesn't build up. If you're mindful you're aware of problems and you can start to address them from the get-go. All or nothing thinking like I said it's common and a bunch of different diagnoses. People need to be aware of the fact that this is a cognitive distortion and start identifying ways that it makes sense for them to address it. Not everybody is going to address their polarized thinking the same way but we need to start asking them what is it that can help you get away from this all or nothing thinking or identify when they start to get distressed what parts of that distress were due to viewing the world in terms of all or nothing or extremes and then helping them figure out other ways to deal with it like identifying exceptions. This doesn't always happen because there are at least one or two exceptions to it. Hostility and aggression these are again protective so we need to help people understand the fight-or-flight response and the function of this hostility and aggression. When you start feeling this way something's going on that is telling your brain that there's a threat so what are these threats and how can you best deal with them now when you were seven eight what how when you were a child you may not have been able to deal with them you may not have had the skills or the ability to deal with whatever it was that was causing the threat so you had to get away from it in your own head now that you are 38 you have more skills you have more tools you have more things at your disposal you're not dependent upon your parents you're not dependent upon certain things how can you deal with it differently as a 38 year old when something like this happens development of anger awareness and management skills what triggers your anger you can do you know eight ten twelve weeks on anger management helping people understand what triggers their anger because a lot of times what it is is only sort of the tip of the iceberg it's representative of a lot of other stuff underneath a lot of conceptual stuff remembering that anger is a response to a threat so why are you feeling threatened when somebody looks at your cross side why are you feeling threatened when somebody sighs the wrong way why are you feeling threatened when you know and have people keep playing that tape over in their head why am i threatened when until they start identifying the underlying cognitive issues that need to be addressed the things that they learned when they were growing up those negative tapes those hecklers in the gallery that are still telling them they're not good enough or that they're in danger hypersensitivity especially to rejection we know people with addictions tend to be very chameleon like because that's the best way to manipulate someone if they want to appease you if they want to keep you happy if they want to pull something over on you the best way to do that is to be hyper aware so they can manipulate you by the same token being hyper aware means they're also hyper aware when they're about ready to lose control which may mean rejection which may mean abandonment which may mean they get their addiction taken away could mean a lot of things but when somebody's hypersensitive it's exhausting we need to help them develop an awareness of their thinking errors if your boss walks down the hall and sighs or doesn't say hi to you if you automatically think that means that you're in trouble and you're getting ready to get fired let's talk about that let's talk about how that might be a thinking error and where did that come from at what time in your past has a situation but similar to this happened and it did end up with something very dramatic have them develop an awareness of their abandonment issues why people are why certain people are so important to them what it means if people leave who's abandoned them in the past and how they need to deal with that and what that means to them and then also developing a sense of self-esteem so they can be okay with who they are and not need to have everybody's approval all the time manipulative people with addictions and personality disorders manipulate other people it helps them stay in control in control is a safe place if you're out of control it's potentially an unsafe place helping people identify what they need and what they want what their boundaries are and effectively communicate that is going to go a long way towards addressing some of the manipulative behavior a lot of times in clients in addiction treatment we see them being manipulative because they don't know how to ask for what they want they may not even know exactly what they want but they certainly don't know how to say i'm feeling this way and this is what i need a huge portion of early recovery with addictions is helping people identify what their boundaries are and what their needs and wants are because they've gotten so detached from themselves and the same thing is true with personality disorders whatever happened back then the child pretty much had to give up a lot of what he or she was in order to be whatever the caregivers needed him or her to be in order to survive low self-esteem and weak self-concept you know develop self-esteem and the ability to internally validate so we're not reliant on anybody to validate us we can reserve that for people who aren't we are in healthy relationships with we're not going to go out and just start pulling anybody in going i need somebody to be my friend it's okay to be alone you can be alone and not be lonely and you can be in a room of people and still be lonely because loneliness and being alone are not the same thing most patients with addictions have traits associated with personality disorders so i really encourage people who are working in the field of addictions or co-incurring disorders to try to understand the function of those behaviors instead of just slapping a diagnosis on it many treatment centers will not accept people with personality disorder diagnoses so am i saying not to diagnose a personality disorder if it exists no what i'm saying is let's make sure that that's what we're dealing with before we put it there because it's going to stay in that person's record these traits can be loosely classified into thinking errors where they're perceiving threats all over the place and behavioral reactivity to escape or eliminate the threat so when we're looking at the motivation behind these behaviors or the reward from acting this way where is it coming from why would somebody behave this way and that involves getting in their head and going okay what why are they perceiving a threat or how is this giving them control the first steps in the recovery process are going to be to help them to get honest with themselves and others develop a sense of mindfulness and awareness of what's going on and how they impact others and how others impact them that's you know phase one of treatment is just kind of getting grounded and trying to figure out what's going on the next step is developing hope and faith identifying those cognitive distortions and thinking errors that are keeping the world scary if you can address those cognitive distortions and start saying okay you know some people are bad people and that's true but all people are not bad people some people and I mean it depends on your person how they're going to phrase it they may say everybody has the ability to do bad things and you know that's potentially true how can they look at it in terms of sort of shades of gray where most of the time most people are not going to do bad things this will help them develop hope that they can be happy and they can be safe without having to try to control and manipulate everything and finally they need to develop courage and discipline to remain constantly mindful of their own feelings if they've been acting this way if they've been behaving this way if they've been thinking this way for 20 years guess what that's always going to be there you know you have behaviors that you learned when you know when you're 23 if you want something and you don't get it you're most likely not going to throw yourself on the floor in the middle of the grocery store and start pounding your fists a three-year-old might do that we've learned not to use that but does that mean that that behavior is completely gone no we know that behavior is there we just know as a 23-year-old is most likely to get you committed instead of get you the cereal that you want my point being when we're quote curing or treating or eliminating behaviors they're always going to be somewhere back in that mental toolbox children growing up in unstable neglectful and emotionally detached environments develop traits to survive a lot of these traits we call personality disordered because if you grew up in a normal family or what you expect in a healthy situation and I don't like either those either those words normal or healthy but then these behaviors seem very confusing when you put yourself in that dysfunctional environment the behaviors make a lot more sense and addictions often numb the pain and escape from this lack of control you know yeah addictions do nothing to solve the problem but it may help somebody survive when they can't fix or change something that is just untenable and behaviors characteristic of addictions and personality disorders were learned and reinforced we don't do things that are not beneficial or rewarding in some way so we've got to figure out what that is they will always be in the recesses of the toolbox if somebody was a cutter when they were eight if things get bad enough when they are 28 might they think about self-injurious behavior again sure will they do it hopefully we've provided them or help them develop enough tools that they won't need to regress to that behavior but it's always going to be there the dysfunctional behaviors have to be made less rewarding than alternative healthy behaviors you don't want to replace chocolate with celery you know if something did the job and it did it really really really well then telling them oh you know just sit through it or do something that just kind of maybe sort of addresses it that's not going to work you need to replace it roughly one for one if it did a really good job in the past whatever it was that was dysfunctional we need to find something that's functional that meets the same need to the same degree in order for it to replace the old behavior