Narcissist. Antisocial. Borderline. Histrionic. Paranoid. Dependent. Obsessive. These terms are thrown around in popular culture, often inaccurately, to describe those whose sense of self and behavior toward others isn’t “normal.” We often see traits related to associated personality disorders – which can range from arrogance, self-importance, perfectionism to inadequacy and inferiority – in those with substance use disorder. However, what we found is that, even when clinically appropriate, labeling someone with a personality disorder can hinder treatment for substance use disorder and be a significant barrier to recovery.
Instead, during treatment, it is more useful to concentrate on the individual’s behavior and how it impacts self and others. While some behaviors can be harmful, once they are understood, these can be put to work as tools for recovery. With on-going feedback, people with a potential personality disorder can learn to adjust the way they look at the world and the way they interact with the people around them, putting them well on the way to recovery.
Personality disorders are different than anxiety and depression.
Our personality is how we deal with the world and interact with others.
Personality disorders are different than other co-occurring mental health problems such as depression or anxiety. Marked by rigid and unhealthy ways of thinking and dealing with situations and others, by definition, personality disorders are integral to a person’s core sense of self, how they view the world and how they react to it. Formed in early childhood, they often precede the development of substance use disorder and might complicate their recovery from addiction.
Addiction treatment involves educating people to understand both the positive characteristics of their personalities and the potential roadblocks they may face because of their behaviors. It can be very tough for people, especially those with successful, established careers, when we ask them to give up control and look at how their use of substances have impacted their lives and those around them. Those aren’t terms they’re used to in their lives.
The goal is not to take away parts of their personalities but to give them insight into how those behaviors manifest and how to manage their responses. They must learn to receive feedback and to ask for help, so they can reprogram some of the negative responses that are impeding their growth or recovery.
Connection and isolation.
Those with potential personality disorders often display a profound lack of connection to the people around them. These are individuals who have often put families secondary to their career. They are used to overcoming adversity, doing whatever they must to succeed. They take risks. They demand excellence. While these are all things that helped them become incredibly successful in business, when it comes to connecting with others in an intimate way, they really struggle. They isolate themselves from others emotionally.
This has important ramifications for treatment and recovery. One of the hallmarks of addiction is how it isolates people, so those with personality disorders are at especially increased risk of relapse. They are less likely to ask for help when they need it or be open to hearing people expressing concern or making observations of potential relapse.
Laying the foundation with empathy.
Empathy is the foundation of good treatment. When patients come to treatment, there’s a sense of shame and stigma about needing treatment, admitting they need help, or that they’re an addict or an alcoholic. Dealing with a diagnosis of a personality disorder can be another source of shame and stigma. Labels hurt. The goal is always to reduce the sense of shame and judgment, as it is counterproductive. Empathy and compassion are a better foundation for treatment.
That can be difficult for a clinician who is dealing with a patient displaying the behaviors of a personality disorder, because the patient may not only have a poor connection with family but also a poor therapeutic relationship with the clinician. Clinicians must be mindful of their own reactions in those circumstances, always maintaining an approach of empathy and compassion.
It’s also essential to engage the family, educating them not only on the disease of addiction but also on any potential personality or other mental health disorders. They must learn to conceptualize those aspects as part of the patient and not the patient themselves. Sometimes family members are incredibly angry with the patient, so a big part of family education is helping the family separate their loved one from their disease – to really see their loved one as somebody who is struggling and therefore deserving of empathy and compassion.
Finally, it is important for the patient to develop a greater sense of empathy and compassion, not only for those around them but also themselves. Many times, a patient will think they live in an emotional vacuum and that their addiction and behavior doesn’t affect anybody else. Getting them to connect on an emotional level with how their disease touches others can be a powerful moment in their recovery. Patients should be open to hearing from their loved ones how the experience has affected them without being defensive or trying to rationalize or explain their behavior. Honestly, it takes a lot of time and effort for some people to be able to do that.
Individualized treatment is a must.
Someone with a potential personality disorder needs careful, individualized and integrated treatment that addresses both the addiction and any co-occurring mental health issues. Behaviors related to personality disorders are going to play out over time, showing up in daily interactions with therapists and others, touching the entire community. Those traits are not going to show up once or twice in treatment, but it will pervade how they interact with peers, with staff, and within the context of their family relationship. Treatment needs to touch on those behaviors in real time.
Having a psychologist integral to the team can not only help with the necessary testing but can work with the patient to develop specific coping mechanisms and tools that will be helpful for them as they continue therapy. A spiritual counselor can play an important role, because some of these features play out in relationships or may have begun very early on in childhood. “Family of origin” and attachment are often key to understanding personality disorders and how they play out in the patients’ behaviors.
Finally, it’s not the label that is important; it’s the person. It is so tempting to take a few behaviors or personality traits and immediately jump to declare that someone is “narcissistic” or “borderline.” In treating addiction, it is the behaviors that matter. All behaviors, when properly understood, can be used as a tool to support recovery.
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