What 2 Things do Codependency, Borderline Personality and cPTSD

Hey there, everybody, and welcome to this video on what do codependency, cptsd, and bpd, or borderline personality disorder have in common? I'm your host, Dr. Donnellice Snipes. In this video, we're going to explore environments which might lead to the development of codependent or traumatized behavior. We'll examine the similarities between codependency complex post traumatic stress disorder and borderline personality disorder. We'll explore some possible common underlying attachment and trauma issues and identify strategies to help people with these diagnoses start to address their trauma and insecure attachment. So let's start out with a couple of case studies. This first one is the disappearance of the significant other. So this is an adult who was in a relationship that was theoretically healthy to begin with, and then something happened. Sally and Tom's relationship was great until they got into a car accident while Sally was driving and Tom got hooked on pain pills. The more dependent Tom became on the pills, the less tolerant he was of anything or anyone that stood between him and them. Remember, as people become dependent on substances when they're not using them, their neurotransmitters can't rebalance. So they are at a dopamine deficit. They're at a serotonin deficit. Tom became increasingly critical of Sally, telling her that she ruined his life and he needed the pills because of what she did to him. So he's engaging in a lot of blaming. He doesn't feel in control of his pain, and he also doesn't want anybody trying to take away his pain pills. So he makes sure to try to blame other people and justify and rationalize what why he's using his pain pills. When Tom was not using, he had low motivation, was prone to outbursts of anger, and could not focus on anything but getting the next dose. Well, this is what addiction sounds like. To keep the peace, Sally often walked on eggshells trying to anticipate Tom's every need and subconsciously get his forgiveness and hopefully get the old Tom back. So walking on eggshells is a common term that we hear when we talk about people with borderline personality, but it's also very similar when we're talking about someone with an addiction, because when they are not using especially, they tend to be a lot more volatile. Most mostly because their neurotransmitters are out of balance when they begin their addiction. When they become addicted to a substance or activity, dopamine, norepinephrine, and serotonin all get out of whack and impact the balance of just about everything else in the body. And Sally is holding on to this dream of getting the old Tom back. She keeps hoping that he will get out of pain. She keeps hoping that he will recover from his injuries. So she's staying partly because of guilt and partly because she's clinging to this dream she has out here that she's not willing to let go. She's not willing to acknowledge that the old Tom may not be any longer. Sally became a fixer. She learned it wasn't safe to say no Anytime she'd tell Tom no, It was met with a lot of anger and resistance. She started to believe Tom's thoughts, feelings and physical pain were her fault. Yes, she was driving when they got into the car accident. However, she is not completely responsible for his pain at this point. He is partially responsible because when he is not using his pain pills, his opioid system, his endogenous opioids are not compensating because of the addiction. So he feels even more pain than he normally would because of the overuse of the opioid medications. It's also important to recognize that depression, anxiety and anger, all those distress emotions, lower people's pain threshold. So because of his stress, because of the stuff that he hasn't grieved the, because of this trauma that he hasn't processed, he is actually intensifying his own pain. But Sally's taking that on herself. She believes that his thoughts, feelings and physical pain are her fault and that he's incapable of taking steps to fix himself. She doesn't understand maybe the neurobiology of pain, but she also may believe because he's told her that he can't do these things and she has to do these things for him. So he started manipulating her by using pain as a tool. Let's look at a different scenario in which codependent, borderline or trauma related behaviors could develop. When Jamie was born, her father, Gerald was already addicted to alcohol. Jamie's mother, Sarah, did her best to keep peace around the house by making sure that Gerald's every need was met and Jamie didn't cause him extra stress. If you're familiar with addicted households, you know that the enabler will go around trying to keep everything just so. That way, what we'll call the dysfunctional other doesn't decompensate or doesn't go off. When he would get triggered, Gerald would either drink until he passed out or go out drinking and not come home for days at a time. Her mother would be frantic and at the same time angry at Jamie for making Gerald upset. So her mother is blaming this young child, this infant, this toddler for, for causing too much stress to in the situation or for making her unable to keep the peace in the house. So there's a lot of blame that's going on and Jamie's being exposed to that as a very, very, very young child. So she's internalizing all of these messages. She's also internalizing the message that if I make a mistake, if I make somebody mad, they're going to go away, they're going to abandon me, therefore I'm not necessarily safe. So I mean think about being a toddler in this environment. Gerald got angry and he raged for a little while, then he left in a huff to go get drunk and he's gone for a week and her mother is completely frantic. Do you think she's really paying attention to Jamie's needs at this point? She may be making sure Jamie gets fed, but do you think she's meeting her emotional needs? We also know that she's blaming Jamie for Gerald's stress. So Jamie is getting the message from her mother that you're too much of a problem. Sarah's behaviors taught Jamie that the only thing that mattered was keeping Gerald the father pacified. If she did that, he might notice her. The only time Gerald gave her attention was if she was doing exactly what he wanted, when he wanted it. And under those circumstances, maybe not always, but maybe he would notice. Her children are born with the need to connect with their caregivers. And the fact that Gerald was unwilling to connect with her, to give her attention, to acknowledge her, indicated that to her, taught her as a child that you're not worthy of my attention. Sarah was also terrified that Jamie would become addicted to alcohol as well. So she controlled every aspect of Jamie's life. As Jamie grew older, her mother was constantly hovering, was constantly enmeshed, was constantly controlling everything she did because she didn't want Jamie to, to become an alcoholic. Jamie grew up believing her thoughts, feelings and needs were not important because Gerald's were the only ones that were important and she was incapable of self care. Mother hovered over her and second guessed her every decision to quote, keep her safe. Both of these things combined made her terrified of abandonment. If I'm not with somebody, I can't take care of myself and if I'm not with somebody, I don't know who I am because I don't have any idea what my thoughts, feelings and needs are. I attend to other people. If I don't have somebody to Focus on, if I don't have somebody to fix or to need, then nobody needs me. If I'm not needed, then I might be abandoned. And, and if I'm abandoned, I can't take care of myself, therefore I won't survive. Both of those situations can produce traumatic experiences, can produce chronic stress, can produce a variety of things. Now, borderline personality disorder, according to the DSM 5TR, has to start in adolescence or early adulthood at the latest. So in the first case in, in where we had two adults, that person might not qualify for borderline personality because that relationship may have developed later than the cutoff for diagnosis. But a lot of the behaviors may be similar. They would meet the criteria potentially for CPTSD or codependency. Now, codependency is not an official diagnosis in the DSM 5TR. It is just a term we use to describe a cluster of symptoms. So let's talk about the production facility. What was common to both of these situations? Physical neglect or abuse. The adult ignores self care. In the husband and wife scenario, the wife ignored her own self care. She was constantly trying to make sure Tom was okay, was constantly trying to meet Tom's needs at the expense of her own, partly out of guilt and partly because she believed that he was now broken and incapable of fixing himself. Adult or child experience. And then with the adult and child, the mother in that particular case was not taking care of herself. She was too busy taking care of Gerald, trying to make sure that everything was okay with him. When we see caregivers or when we see people not taking care of themselves, we start to see their HPA axis get, get disregulated. We start to see the development of physical health issues, including hypertension, autoimmune diseases, chronic pain. So that's a problem in these conditions. People who are not the quote identified patient or dysfunctional other are often convinced or taught that it's not safe to take care of themselves. They need to take care of this other person and their needs, wants and thoughts don't matter. Adult or child experiences abuse, and in both situations, the dysfunctional other became verbally abusive when they weren't able to get their own way. Now, in both scenarios, I used someone who was addicted. However, the dysfunctional other can be someone who has a personality disorder, who has complex post traumatic stress disorder, who has some other mental health issue that contributes to them getting into relationships in which they try to find someone who is going to care for them or fix them or enable them in some way. And the child's needs are are ignored. In the second scenario, Jamie's needs were regularly ignored because her mom was too overwhelmed trying to keep the lid on everything. And then when Gerald would disappear, she was so terrified of abandonment that she couldn't focus on Jamie's needs. And so Jamie was probably not getting the best nutrition. Jamie was probably not sleeping well. We don't know what else was going on for Jamie, but her needs were being ignored affectively in these environments. It's a minefield. There's a lot of anger, blaming and resentment from everybody. The dysfunctional other, when they don't get their own way, when they feel threatened, they may react in rages. When the enabler, if you want to use that, or the codependent, if you want to use that term, gets raged on, they feel resentful, they feel like the other person is ungrateful. They get angry at the dysfunctional other for not taking the steps that they quote, should in order to recover. So there's a lot of blame going back and forth and a lot of resentment because neither person is doing exactly what the other one wants. There's a lot of anxiety in these households. Anxiety over when is somebody going to start raging, when is somebody going to lose it? Because you never feel exactly safe. You don't know what's going to set somebody off. There's a lot of anxiety about abandonment. When is this person going to just leave? When is this person going to maybe overdose? You know, we don't know. And there's a lot of anxiety, especially in children, because they don't know how to control or deal with all of these emotions that they're feeling. And they feel completely overwhelmed and there's nobody there to help them feel like they can contain that. In these production facilities, emotion regulation often equals ignoring, negating or numbing. The child is told or the person is told to ignore their feelings. Your feelings are not important right now. We need to focus on making sure the dysfunctional other is calm, is getting their needs met. Negating, either telling themselves it's not okay for me to feel angry or I need to feel a different way about this, or having a caregiver, the enabler, for example, tell the child your feelings are wrong, your feelings are not important and numbing, just simply doing something to numb the pain. Whether it is abusing substances, engaging in addictive behaviors or even non suicidal self injury. We and, and those are all tools, dysfunctional tools, but tools that people may use in order to cope with these overwhelming emotions. They're having these tsunamis of stress chemicals and Trying to figure out how do I come up for a rescue breath, how do I deal with this emot so it doesn't feel like it's going to completely suffocate me. Cognitively, the lead dysfunctional other in the family will tell people what to think and feel. If they come home and they're angry, then it's your job as everybody else in the household to try to make them feel better. It's your job to be on your best behavior to not add stress if they're angry and everybody knows how to behave, because if you don't, then it's just going to make them feel more out of control and trigger more anger. Cognitively, people are taught that their thoughts, not feelings and needs don't matter. So they internalize these schema that say my stuff is not important. Your opinions matter, your feelings matter, your needs matter. And you know, if I have time sometime in the future, maybe I'll check in to figure out anything that's going on with me. But that's not important right now because to keep everybody safe, to keep a lid on things, and to keep you from abandoning me, I need to make sure that I focus on your thoughts, feelings and needs. Another message that is created in these environments is that people are incapable of self care. They have to be rescued. Unfortunately, in a lot of these situations, the child is the last one that gets rescued. The dysfunctional other, the dysfunctional caregiver, is often the one that everybody is rushing to rescue. We got to make sure that mom or dad doesn't abandon us. We've got to make sure to keep them around so we can survive as children. Children aren't able to go to the grocery store and function like adults are. So they start seeing that their caregivers, and I use that term very loosely, are not able to care for them. Therefore, they learn that adults aren't real responsible. And when they start having a problem, you may need to rescue them. HPA axis dysregulation also prevents learning new skills. Because of all this chronic stress and chaos and drama and trauma, people are constantly on alert. They're constantly hyper vigilant, walking on eggshells, feeling insecure in what might happen next, not feeling safe or empowered. And that leads to what we've talked about before. That's HPA axis dysregulation, or the stress response becomes dysregulated. The body says, you know what? I'm exhausted. I cannot be this hyper vigilant this long and respond to this many things. So the person goes Into a place where they are flat most of the time. The stuff that may have irritated them before, it's just like they don't have the energy. But when something does trigger them, when they do feel threatened, they have a tsunami of stress hormones and they go into furious, rageful or frantic, terrified. When people are regularly doing this, it keeps them in a stress loop. And when people are terrified or furious, when people are in that stress hormone bath, the brain works differently. You don't process memories the same, you actually glutamate actually prevents memory consolidation. So where children who grew up or people who live in an environment that is safe and empowering are able to learn new information and gradually develop more adult coping skills, more useful, more effective coping skills. The person who was exposed to to a traumatic environment, their learning kind of stopped when that trauma started because they weren't able to process new information. They're not dumb, you know, they are very intelligent people, but their brain didn't want to remember a bunch of the stuff that was going on, didn't know how to categorize it. So it all kind of stayed there in the short term memory soup and then went away. And they weren't able to focus on learning those new skills. It was never safe to try to learn new skills. They were constantly in this state of primitive panic, if you will, relationally or interpersonally. In these environments, people are taught that the only person you need to focus on is the lead dysfunctional other. That person is the one that tells you what to think, what to feel, what to do. They control everything in your life. And if you do exactly what you want, they want exactly when they want you to, then you might be safe. They're taught they're not lovable for who they are. Nobody gives them attention. Nobody says, hey, what? What would you like to do? What are you good at? What are you interested in? The only time they get attention is generally when they are the brunt of a rage. They did something wrong. So they are taught they are only lovable for or they're not lovable at all. They're definitely not lovable for who they are. And they're also taught they're only one mistake away from abandonment. And they never feel secure. They never know if that lead dysfunctional other is going to go away and never come back. When we talk about relationships and secure attachment, we talk about consistency, responsiveness, attention, validation, encouragement and safety. Well, these are not in existence in the production facility. Consistency. These families are characterized by chaos. Whether it's two adults or a Family unit. There is chaos. There's a dysfunctional other that often is leading or directing the play, if you will. But most of the time people are just guessing about what they are exactly the the director wants them to do at any particular time. The dysfunctional other rarely effectively communicates with what their thoughts, wants and needs are. So people are trying to mind read and there's no consistency responsiveness in these households. The significant other is rarely responsive to that person's needs. And people are who, the enablers. The person who's codependent, whatever term you want to use, is often unable to be responsive to their own needs. They are not consistently aware of their needs because they were taught that they don't matter. And they are not consistently responsive to their needs because, hey, they don't know what they are. So how can they respond? They do respond to the dysfunctional other in order to try to keep them from abandoning them. Attention. And this is that proactive, positive attention that says, hey, I enjoy spending time with you. Oh, that's not there. Validation. This is another one that's not there. You don't have to agree with somebody's perspectives. However, acknowledging their feelings is important. Acknowledging their thoughts is important. In a dysfunctional household like this, people are taught that the perception of the dysfunctional other is the right perception and nobody better have any other perception. Ideas, the thoughts and feelings of the dysfunctional other. That's what you think and feel and you better not disagree. So validation's not there. You're taught not to think for yourself and you're taught that your thoughts, feelings and perceptions are wrong, which is just an invasion of those boundaries, encouragement and safety. I can put those together because they're just not there. The in these environments, the rest of the family surrounding the dysfunctional other is not encouraged to do things on their own. Their sole job is to function on the dysfunctional other and keep the peace and go through the motions and do be good little soldiers. And there's no safety. You know, there's just not somebody saying, okay, you messed up, no big deal, you know, I love you for who you are. That message is never communicated. The message that's communicated is you better do the right thing. If you don't, there's going to be hell to pay. So how might this, this environment, how might these situations result in an unstable sense of self? Well, sheesh. The person is never able to look inside and decide, what is it that I like? What is it that I think? What is that I feel? Not only is it not safe to look inside and communicate those thoughts, wants and needs. But they don't have the time. They are spending the majority of their waking and non waking hours usually focused on what is it that I need to do to keep this dysfunctional other from abandoning me and from flying into a rage low Self worth well, especially for children, if they are never taught emotion regulation skills, then it makes it hard to connect in relationships. If they are never given attention, if nobody ever asks what do you like? What do you want to do? If nobody ever shows an interest in them, then they get the message that they are not worthy of love. So they keep getting these messages that they're not good enough and nobody cares. Emotional dysregulation and we already talked about that but I'll highlight it again. Constant stress chronic stress leads to an alteration of the stress response system. So people who've had chronic stress from trauma or something else often develop emotional dysregulation. It can be healed as the HPA axis is healed, as the person starts to feel safer and more empowered and is not on alert all the time. But until that point it's important to recognize that they will often experience this 0 to 250 like that. And that's a protective mechanism impulsive or self destructive behavior. We see this a lot in people with BPD and people with CPTSD and in people with codependency. Staying in relationships because they are terrified of being alone because they don't feel like they can survive by themselves because they feel like it's their duty drinking non suicidal self injury There's a lot of impulsive and self destructive behaviors that we see. But we need to ask ourselves why? What is the function of these behaviors for this person? Why are they choosing to stay in this relationship with this angry person who abuses alcohol? Well, it may be less terrifying than the alternative. So let's take a look. Instead of criticizing, ask yourself how is this helping the person survive? Alternating between the need to control or be controlled and this is really in an interesting dynamic because the person who grows up in these environments often is taught that other people can't control, can't fix themselves, can't be trusted to take care of themselves. So they need to control these other people. However, they don't feel safe unless they're in a relationship. And often this is a relationship in which there's a dysfunctional other who is going to tell you exactly what you need to do in order to not be abandoned. So there's this I need to control you, but I need you to tell me how to do it sort of thing. Intense, unstable relationships, vacillating sometimes between love and hate. Because number one, the person grew up or is in an environment where they may not have learned to modulate their emotions. So just like going from flat to furious, they go from love to hate. There's, there's no middle ground. They go from I love you, I feel safe to I'm afraid I hate you. We want to look at love and hate in these relationships a lot of times instead of as bonding emotions, as representations of safe versus unsafe, safe versus threat. So let's look and let's compare these things because I find that there is so much overlap that it's really important to take a look. Exposure to trauma, helplessness or horror. In cptsd there's also the inability to escape. Now that inability to escape for a child is very obvious. They can't just pack up their things. For an adult, what constitutes an inability to escape? Well, if the person does not feel competent or capable of escaping or if the dysfunctional other has threatened them so they're terrified to leave, then they're unable to escape. Are they adults? Yes. Could they theoretically get a job and feed themselves and keep a roof over their head? Yes. So what is going on in that situation that makes them feel stuck, paralyzed, imprisoned in this dysfunctional situation? Thinking about what is traumatic, what's traumatic to a four year old may be very different than what's traumatic to a 24 year old. But it's important when we talk to people, when we do our assessments, identifying what has they have experienced in their life that they may, that have, may have made them feel unsafe and disempowered because those are the core aspects of trauma. In codependency. It's almost always a dysfunctional home environment. There may be a lot of other stuff that goes along with it, but there's almost always a dysfunctional home environment as well. That home environment is extremely chaotic and there can be a lot of anger, there can be a lot of yelling, emotional abuse, neglect, you know, the list goes on. In borderline personality disorder, every person I've ever worked with with bpd, I, I can safely say that and I think the majority of people with borderline personality have endured as a child adverse childhood experiences. They've been exposed to trauma and helplessness and an inability to escape bpd. Now children can experience adverse childhood experiences and not develop traumatic injury. We know this. So I'm not saying that every child who experiences ACEs also is going to develop CPTSD what I'm saying is those children who experienced ongoing chronic traumatic environments traumatic experiences, especially in the form of emotional or physical neglect or both, and, and maybe even witnessing domestic violence or being abused. Obviously those are traumatic as, as a way to survive. They developed a certain core set of behaviors that helped them survive. So I think we can agree that in most cases of codependency and most cases of borderline personality, there has been at least a period of ongoing traumatic experience where the person felt unsafe and helpless re experiencing avoidance of reminders and hypervigilance. To qualify for chronic complex post traumatic stress disorder, it's important that all three of these characteristics are met. And you might say, well, how does that translate to codependency and bpd? I believe it does a lot of times, and I believe we just don't ask. In codependency, the person may re experience their traumatic household by having abandonment fears. When their significant other starts to act a certain way, they start to feel, feel the same way they did when they were little, when they were growing up, when they were in that past relationship. So they're re experiencing it internally. One of the things we need to ask is, okay, so we've identified what your traumas are. Do you re experience them? Do you have feelings sometimes like you're back there? Do you have feelings like, oh, here we go again. Most of the time you're going to have somebody say yes. So we need to ask. Sometimes people who are self diagnosing as codependent, when we talk to them, they will actually talk about flashbacks and actual re experiencing. But nobody's ever asked. They just assume, well, you're codependent. So let's deal with this, this and this that came out of the book. We need to look at the trauma. Do you have traumatic experiences that you're regularly re experiencing? People with borderline personality, remember, the crux of borderline is this person that's constantly feeling like they're on a tightrope on the borderline between safe and in danger, between the borderline of being loved and being abandoned. Do they experience re experience their childhood traumas in the as adults? Does it come out as abandonment fears? They start having this abandonment fear just like they did when they were little. And again, have you asked? They may have outright flashbacks, night terrors re experiencing that they haven't disclosed because people haven't asked. Avoidance of reminders in cptsd, you know, it's pretty obvious. If they avoid, if they were in a car accident, they may avoid driving or may Avoid driving on the highway or whatever. In codependency, reminders of their chaotic childhood may come in the form of avoiding going home, avoiding talking to their caregivers, avoiding situations that remind them may if their caregiver was an alcoholic, for example, they may become very uneasy when they're around people who are drinking. So they may avoid situations when the person is drinking or controlling. In order to avoid these reminders, they may be very controlling about the environment. Nobody brings alcohol in this household, nobody raises their voice in this household. And they have a very strict set of rules for the people in their life so they don't ever feel like they're back there again. In terms of borderline personality again, have we asked, do they do things to avoid reminders of their childhood trauma? Hypervigilance. This is being on high alert all the time, kind of like a soldier in a foxhole. And in codependency we see it in cptsd, we see it in codependency. People with codependency are hyper vigilant to the needs of the dysfunctional other. Going to the extent of what we call mind reading, trying to guess what this person wants in order to make sure that they have their needs met so they don't get angry, so they don't abandon. So yes, people with codependency are hyper vigilant and they may even look to try to catch people doing wrong. Hyper vigilant to the threat that things might decompensate and borderline personality Most people with BPD are hyper vigilant to those around them, often being hypervigilant to indications of abandonment. People with borderline personality People who've been diagnosed with borderline personality often go from love to hate. They often will split. So they either love somebody or they hate them and they can turn on a dime. Remember I said earlier, the splitting is often better understood as safe versus threatened, loved versus abandoned. And so they are hyper vigilant to minor non verbals to anything that they might interpret rightly or wrongly as indicating that their significant other might abandon them. Low self I'm sorry, severe emotional dysregulation. We see this in cptsd, it's a diagnostic criteria. In codependency we often see people who have extreme bouts of anger and extreme bouts of being frantic if they can't control a particular situation. And emotional dysregulation is a diagnostic criteria for borderline. So I don't even need to go into that one. Low self esteem and persistent beliefs about sexual self as worthless, shamed or guilty person with CPTSD has internalized this message that they are not worthy of love, that it is their fault that anything bad happens. Codependency. The dysfunctional other often communicates this message both overtly and covertly. Anything that goes wrong, it's not my fault, it's your fault. You made me do it. People with borderline personality often have low self esteem and persistent beliefs about self as worthless and they feel guilty. Oftentimes people with BPD recognize their emotional dysregulation and they don't like it, they don't want to have it. They recognize that it's making it difficult to connect with other people. They rec. They feel since they've had difficulty connecting and they've experienced multiple rejections, they feel misunderstood. They often internalize that as being not a good person and they often blame themselves for things that go wrong. So they hold this low self esteem that says I'm not lovable and therefore when I get into relationships it may last for a little while, but I need to be alert to when this person catches on and abandons me. Persistent difficulty in sustaining relationships and intimacy in cptsd the fact that the person is operating in this constant state of feeling unsafe and disempowered, they're hypervigilant, they dysregulate emotionally, they don't have the energy to connect with some someone else to develop intimacy. And the emotional dysregulation is often so overwhelming to people who don't understand that it creates a barrier. So they have persistent difficulty sustaining relationships and intimacy which they internalize as meaning they're not lovable or which just complicates or worsens the problem. Codependency. We see the same thing. The person who is codependent often has difficulty with intimacy. They want to control the other person, they desperately want to be loved. And they may have boundaries that are way too weak and the person, the dysfunctional other, feel smothered. However, if the dysfunctional other is not doing what the enabler or the codependent wants, then they may completely shut off that. That boundary and say, nope, you know, I'm done with you. So they can have this all or nothing sort of behavior as well. And a lot of people with codependency, since they don't have a stable internal sense of self, aren't able to form intimate relationships. They can't tell. They can't figure out who's safe, who's unsafe. They don't know what they like, so they can't connect with people on meaningful levels because their life revolves around the dysfunctional other. And people with borderline personality for the aforementioned reasons also have persistent difficulty sustaining relationships and and intimacy. Now you may be wondering why is emotional disregulation and difficulty in sustaining relationships and intimacy, why are they bolded? Well, because they. These things also are often as well to a certain extent, avoidance of reminders. These can all be represented in by people who are diagnosed with narcissistic traits. And as well, avoidance of reminders. When people are very controlling to try to avoid being triggered, that can be seen as non empathetic. That can be seen as too aggressive and narcissistic. We know one of the characteristics of narcissistic personality is problems with emotion regulation, especially with anger. When they don't get their own way, they feel threatened. When they're not in control, they feel threatened. When they feel threatened, they dysregulate. When they feel unsafe, they dysregulate. And because of their narcissistic traits, they're controlling their seeming lack of empathy, their dysregulation, their anger. They have difficulty sustaining relationships and intimacy. A lot of times they feel that it's silly to even discuss intimacy and empathy and that's just hogwash. Unstable sense of self, a need for frequent reassurance and praise or frequent contact is common in codependency. Now this one is switched. That's why I changed the colors of the chart. That is very common in codependency. It's very common in borderline personality. It's one of the criteria for borderline personality. In complex post traumatic stress. This often comes out as low self esteem and abandonment anxiety. People with codependency often have poor boundaries, can't say no, and often don't respect others boundaries. Remember, they often change to be a chameleon, whatever you want me to be, to keep you from abandoning me. But I'm also going to try to control you. I'm going to try to make myself indispensable and fix you so you need me. And so they're simultaneously getting their boundaries stomped on and just completely ignoring other people's boundaries. We see the same thing in borderline personality. A lot of times people with BPD because they're so afraid of abandonment have difficulty saying no. In CPTSD we see hypervigilance and avoidance of reminders of the trauma. And so we want to look at how does that relate to boundaries. Sometimes people with CPTSD may invalidate other people's feelings and thoughts because it makes them feel unsafe. So let's get to these interventions, how we first need to create safety. Whether it's codependency, CPTSD or bpd, whatever you're calling it, these people don't feel safe. So we need to help them examine how is the present safe? How is it different from the past? What strengths, resources and abilities do you have now that can help you stay safe? So those are three questions that are important for them to answer. Then we need to help them develop emotion and trauma identification skills. A lot of people with these diagnoses characteristics have difficulty identifying their own feelings. So we need to start out with what does anger feel like to you? What does anxiety feel like to you? What does depression feel like to you? Have them start getting familiar with what each emotion feels like to them in their body, in their mind. What are your early warning signs for each each of these emotions? When you're having this emotion, when you're feeling angry, what are your urges? Is it to lash out? Is it to, you know, hide in your closet? What are your urges? And regardless of what your urges are, how do you cope with these feelings when you have them in the present? When you get angry, what helps you de escalate? What helps you cope with it? You can do some imaginary experiencing in the office. If they're not sure about their feelings, you can say, okay, tell me one thing in the past week that's made you angry. All right, let's think about that situation. What did it feel like to you? Think back before you got really angry. What were your early warning signs that you were starting to get frustrated? What were your urges and what ultimately did you do to cope with that situation? It's helpful to do this in session, but then between sessions, the person needs to log when they have these different feelings, at least two or three examples of each emotion. What it felt like, what their early warning signs are, what were their urges and how they coped? And then you can process that in the next session. We also want to ask them, when you feel a particular emotion like anxiety, does it trigger particular memories or images from your past? Now, not everybody remembers trauma with memories or images, but some people do. And if they do, then we can say, okay, when you feel anxious, then let's look at and it triggers this memory. Let's look at what's going on in the present that's reminding you of the past and help the person process that past memory as well as process how they're safe or whether they're safe in the present. Develop distress tolerance skills for People with these diagnoses emotions are overwhelming. So learning that they can feel these emotions and not be overcome, learning how to tolerate the distress without necessarily having to make it go away is very empowering. Have them develop thoughts that are distress tolerant, like this is not the past, I'm stronger, I'm capable and I can handle this activities. Breathing and I try to keep it really simple at first. You can add to these, this list later. But breathing is the first step in triggering the vagus nerve and the relaxation response so they can get into their wise mind. The four square breathing. Breathe in for four, hold for four, exhale for four, hold for four, do that a couple of times. Guided imagery. Now I have them choose one image that they're going to use. They can envision a superhero that's there to protect them or themselves becoming a superhero. They can envision a bubble around them that keeps them safe or a fortress around them that keeps them safe. Whatever image they need to use in order to help them recognize that they're safe from this emotion, it's not going to overwhelm them. This situation is not going to overwhelm them. And then sensations and I have hugs on here and some people think, what's that? Hugs help us feel contained. Think about the thunder vests that they make for dogs. Think about the weighted blankets that help people reduce their anxiety. We have a need to feel pressure when we start feeling out of control. There's something about feeling contained that also helps trigger that relaxation response. So have them put one arm around their rib cage and one arm over their shoulder and as they exhale, they just give themselves a big hug and they notice where their body is, they notice how they feel. The pressure actually causes the release of oxytocin, which can help them calm down as well. So distress tolerant thoughts. Breathing a helpful guided image and using the containment or the pressure or from a self hug in order to help them feel more contained, less out of control. Help them become more mindful. Turning off autopilot to recognize early warning signs and anticipate triggers or vulnerabilities. This means starting out the day being mindful, saying, what are my vulnerabilities? You know, what might make me more likely to react strongly to something or to get irritable. What do I have coming up today that might be a vulnerability or that might trigger my feelings of anger or anxiety and how can I deal with it? So starting the day out there, but also checking in with the self throughout the day to notice how am I feeling? Are there any early Warning signs I need to attend to and if so what can I do? As people start to feel safer in their own state skin, then they're going to feel more empowered. Have them develop an emergency response plan so they know that they have a plan. If they start to feel disregulated, have them begin logging their target behaviors. It can be dysregulation, emotional dysregulation, splitting or the need to control everything I call hyper control. Start logging these for the first time, frequency, intensity and duration that they happen during the week. So how often, how bad was it on a scale of 1 to 5 and how long did it last? What triggered this particular episode and what tools did you use, if any to cope with it that can help you start identifying areas that might need particular coping skills or things that may need to be addressed. Help them develop self esteem. I use the Good Person Checklist. I have them make a list of everything that they identify as being good in a person. What do they think makes a person a good person? And then go back over that list and identify which characteristics they already have. Have them connect with and address the beliefs of the wounded inner child. As long as that inner child is feeling, as long as they have memories of feeling inadequate, unlovable, incapable, it's going to be hard to feel safe. Help them start to believe that their thoughts, wants and needs are valid and important which will come with self self validation. Telling themselves as they check in with their mindfulness, this is how I feel and it's valid. This is what I need and it's important and help them start advocating for themselves. Develop problem solving skills. Helping them observe and describe the facts in the current situation. Work with them to help them describe past traumas that are being triggered in the present and how the present situation is similar to and different from the those past situations and how are they similar to and different from who they were in those past situations? And then have them participate by identifying what they can and cannot control of the things they can control. Which ones are worth their energy? Not everything we can control is actually worth our energy to get to our rich and meaningful life. Of the things we can't control. How is the person going to cope if something happens that's completely out of their control? How can they deal with the distress and then help them participate by deciding the best way to use their energy to move toward the things that are important in their rich and meaningful life. Vulnerability management is the next intervention. Educate them that vulnerabilities are are conditions that increase their stress level and prime them for being triggered. Help them identify and prevent or mitigate what I call their pacer vulnerabilities. Their physical vulnerabilities like pain and exhaustion. Affective vulnerabilities. If they're already feeling depressed or angry, then they're more vulnerable to getting more depressed or more angry. Cognitive vulnerabilities like negativity or self doubt can make them feel unsafe and make them more vulnerable to feeling threatened. Environmental vulnerabilities, being overstimulated or being in an environment that reminds them of the past can put them on edge, can make them feel unsafe and make them more vulnerable. And then relationship vulnerabilities. These are things that people do in relationships that make them feel unsafe. Have them use backward chaining to identify their vulnerabilities. So looking at a time when they dysregulated or looking at a time when they engaged in hyper control of a situation, what triggered that behavior. Look backwards and see what made them more vulnerable to reacting to those triggers. And then forward chaining helps people anticipate future stressors and figure out what can I do to either cope with this situation to mitigate it so it doesn't make me feel as unsafe or to prevent it altogether. And then start working on secure attachment with self. Once people feel safe and they start to understand their triggers and vulnerabilities so they feel safe in their own skin, then they can start becoming more consistently aware of their needs. Responsive to those needs in a positive purposeful way by taking action. Communicating their thoughts and needs with others and or maintaining boundaries. Attending to their self. Spending time with themselves to figure out who they are and what they like and what their thoughts, wants and needs are. Validating the thoughts, wants and needs of their self in the present as well as of their inner child. And I have several videos on inner child work that you can look at. Encouraging themselves to explore it outside of their comfort zone. What did they want to do when they were little that they never got a chance to do? Or what do they want to do now that they may be too afraid to do well? Take a step outside that comfort zone and then create safety by creating a non judgmental inner environment. Recognizing that failing is not the same as being a failure. Help them develop personal empowerment by reframing bad behaviors as the only tools the person had to survive at the time. Educate them about how HPA acts as dysregulation as a result of that chronic stressful environment made learning new tools difficult in the past. It's not their fault they've got to learn them now. But it's not their fault they didn't develop the same skills and tools that some of their peers did. Regularly review their behavior logs for progress. You're charting these target behaviors to see the frequency, intensity and duration. We want to regularly review it for progress. Remember that progress comes in many different shapes and sizes. It's not always progressive and even. Sometimes it's flat and then it goes up and levels off for a while, then goes up again. Sometimes it goes up and down and up and down. But we want to see forward progress and it's okay if you've got periods of consolidation. Exposure to trauma produces a sense of unsafeness and helplessness or disempowerment that results in behaviors designed to help the person survive. Re experiencing happens as a result of what I call unfiled data in their brain that needs to be added to the master plan to stay safe. So the inner person is continually going what do I do with this? And if you don't attend to it, then they're going to come back when it comes comes around again and they're going to say I still have this. What do I do with it? Remember this is not safe. So re experiencing requires integrating that experience and figuring out how they can feel safe and have that memory. Avoidance of reminders through withdrawal or hyper control of people, places and things and hyper vigilance to any hints that the trauma will occur again. We also see severe emotional dysregulation due to chronic stress from feeling unsafe, low self esteem, guilt and persistent belief about themselves as worthless which was internalized from a neglectful or abusive environment. Persistent difficulty sustaining relationships and intimacy due to lack of experience with significant others being consum consistent, responsive or safe. Treatment focuses on increasing a sense of safety and empowerment through developing a secure attachment with self connecting with their inner child. Evaluating their schema to see if they're still accurate what they're anticipating, what they're experiencing in the present is actually what's going on in the present or if they're anticipating or assuming based on the past. Emotional awareness and management skills Trigger and vulnerability awareness and management and HPA axis healing.