352.771.2700 Your recovery is our mission.
Don't wait another day. Help is a phone call away.
352.771.2700

Breaking the Cycle: Understanding Personality Disorders and Inter-generational Trauma in the Treatment of Substance Use Disorders

Personality disorders develop due to a variety of factors, but interactions with caregivers and other childhood experiences often seem to play a role.

Estimated watch time: 54 mins 

Available credits: none

Presentation Materials:

Presenter, Alex Ribbentrop, is a Licensed Clinical Social Worker in both Virginia and Florida, Qualified Supervisor, EMDR Trained Clinician, and Certified Family Trauma Professional. Alex received his B.A. in Philosophy from George Mason University where he also completed a Master’s Degree in Clinical Social Work and was twice recognized with the “Outstanding Master of Social Work Award”. Alex’s clinical career has included work in for-profit and non-profit settings, levels of care ranging from residential treatment to community-based mental health care, and time working with one of the top co-occurring treatment facilities in the country.

Alex’s clinical training has focused on the areas of complex trauma, family systems, personality disorders, and substance use disorders; his approach integrates trauma-informed care and existential considerations to support individuals in the development of personal meaning and value for their lives.

Alex currently owns and operates Live Free Psychotherapy, a private practice with locations in Palm Beach County, Florida, and Northern Virginia. In addition to clinical practice, Alex works as a consultant, speaker, and facilitator of psychotherapeutic group and family workshops.

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems. Super excited to be able to have Alex Ribbentrop, LCSW-QS, CFTP. He’s a licensed clinical social worker in both Virginia and Florida, qualified SU supervisor, EMDR-trained clinician and certified family trauma professional.  

Alex received his BA in Philosophy from George Mason University, where he also completed a master’s degree in clinical social work and has twice been recognized with the Outstanding Master of Social Work board. Alex’s clinical career has included work in for-profit and nonprofit settings, levels of care ranging from residential treatment to community-based mental health care and time working with one of the top co-occurring treatment facilities in the country.

Alex has clinical training focused on areas of complex trauma, family systems, personality disorders and substance use disorders. His approach integrates trauma-informed care and existential considerations to support individuals in the development of personal meaning and value for their lives.

Alex currently owns and operates Live Free Psychotherapy, a private practice with locations in Palm Beach County, Florida, and Northern Virginia. In addition to his clinical practice, Alex works as a consultant speaker and facilitator of psychotherapeutic groups and family workshops. Alex, thank you so much for being here, and you can take it away.

Alex:
Thank you very much, Mike, for the introduction. I appreciate it. Thank you, Ashley, for all your work as well on the back end getting us set up, and thank you to The Recovery Village and Advanced Recovery Systems for putting this on. As you guys can see, I’m located in the car; we’ve had a last-minute change of scenery.

So, I had my trauma response earlier and I think I’ve pulled it together at this point, so we’ll see how the presentation goes. As Ashley said at the beginning as well: At any point, if somebody has a question, please feel free to throw that into the chat. Ashley can jump in at any point and kind of ask that question on y’all’s behalf. Happy to kind of start and stop as we move forward here over the next hour. To get us started, I’ve done this presentation now for probably, like, a year and a half — maybe closer to two years at this point. And every time I prepare for this talk, whether it’s an hour long or sometimes longer, I have the opportunity to do a little bit more research, a little bit more preparation.

One of the biggest things that sticks out to me at this point and that’s also really encouraging is the amount of information out there that has to do with improving the quality of care that we’re able to provide as clinicians or administrators or service providers. Whatever it is we’re doing is outstanding.

Every time I prepare, whether it’s a month, two months, whatever it may be, there’s always new information out there. It’s really, really encouraging as a practitioner to see that, and I think it underpins my experience that as providers or as clinicians, we are really at this unique intersection. A lot of different disciplines, and we’re able to draw from a lot of different academic disciplines and practices to inform quality care, and the better that we can inform our quality of care, the more lives we get to save and the more families we get the support and the more people we get to help.

So, it’s edifying for me every time I get to do this, and I feel very fortunate to be able to do so. As I noted, as clinicians or as practitioners, we definitely are in a unique position and we stand at the intersection of a lot of different disciplines. In this presentation, we’re going to touch on some of those, and it’s going to range from genetic factors, psychology, biology, environment. Obviously, pulling from psychotherapeutic models and theories as well. An overarching goal of the presentation — in addition to learning more about trauma, intergenerational trauma, personality disorders — is to reinforce the idea that we are working with interconnected systems across a spectrum. So, as we work with an individual — yes, we’re working with that single person, but they are part of a deeply woven, interconnected system that connects the family, society and history. 

And we want to kind of bring that into the mix more and more as we’re considering our understanding of those we work with, and also our treatment approaches as well. Over the years, maybe especially the past 10, capital T trauma and lowercase T trauma has become more and more a term used today in the treatment world. Improvements in the treatment and our understanding of trauma go back decades. However, terms like dual diagnosis, family systems, PTSD, complex trauma — these are all increasingly prevalent in the field and in our practice. A part of this presentation is wanting to understand what it is we really actually mean when we’re using these terms. And as we investigate the meaning of terms like trauma or family treatment or dual diagnosis treatment, we’re going to begin to peel back layers.

That directs us to a need to understand evolutionary underpinnings and some of the survival mechanisms that we have adapted and held onto as a part of our survival. So, as we get a clearer understanding of what we mean by trauma, what we begin to understand is that we’re really talking about our body and our brain’s stress response system. That’s going to be another key theme that we return to throughout the presentation. Furthermore, the better that we have an understanding of some of these underpinning or foundational elements, the better we can inform our treatment. If we’re looking at presenting issues as isolated or existing in silos, we’re not as effective as we should be in terms of treating those that we have a chance to work with.

And that not only includes the individuals with the presenting issues, the acute issues and substance use issues or depression, anxiety, et cetera. That includes the family as well. Again, because rarely — arguably never — does somebody presenting in treatment without something else going on in the system that contributes to or perpetuates some of the maladaptive functioning that’s causing them trouble. Bear with me as I shuffle through my notes. As I said, the motivation here is to gain further clarification on what’s meant by some of these terms that you hear very often. How do we take a better understanding of these terms to inform our quality of care?

I’m going to move on to evolution, survival and trauma. As I said, much of what we see in terms of a presenting issue can ultimately be traced to an evolutionary survival response. This is something that a woman named Janina Fisher — she’s done a lot of work in the field of trauma — refers to as the neurobiological legacy of trauma. It’s a fantastic term because it brings together our understanding of the mind and the body, and it also integrates and reinforces that term legacy — that there’s a historical component to this stuff. So, when we’re looking at a presenting issue and we’re understanding that as linked to a survival mechanism, we can also understand that there’s a historical precedent to that presentation. And oftentimes, that is perpetuated throughout family systems, again, from an evolutionary standpoint, from an adaptive standpoint. Families and systems and groups are going to pass along those things that have helped to keep them safe. 

We run into issues when those skills and those adaptations and those coping strategies no longer fit our environment. And that’s a part of what trauma treatment is — how do we take the trauma response, the stress response that continues to play out for a person in the present, and how do we break that up so that they can function in greater accordance with what’s actually happening for them in the present moment? A lot of times, when you’re working with somebody dealing with trauma, it’s reiterations of past emotional responses over and over and over and over again. We have a lot of neuroscience that backs up that understanding, and we also have more and more information about how deeply ingrained the brain function is with the entire nervous system’s function throughout the body. Again, a theme of the overall presentation is how do we integrate our understandings? And a part of that is how do we integrate and break up this view of the mind being separate from the body when, in reality, it’s a collective, integrated system. The better that we can understand that, the better our treatment is. 

There’s a lot more somatically oriented treatments that are gaining popularity. EMDR has a heavy semantic element, for example. As we move forward. I mentioned I use the term stress response system, and what exactly do we mean by that? Or what exactly is our stress response system or a stress response system. In humans, it’s a deeply evolved survival mechanism. It’s hardwired into our brain. It’s hardwired into our body. It’s connected to our nervous system functioning. So, a lot of these things are also preconscious. Our frontal lobe is not online when we’re responding to stressors, and it breaks down a little bit. We have a few different systems, nervous systems, and these can all be broken down in smaller pieces as well, but three of the primary systems are the autonomic and the sympathetic and the parasympathetic nervous system. The importance of discussing these when talking about trauma, personality and family is that personality disorders, quote-unquote “acute presenting issues” — again, they start with this. They start with the survival mechanism and the stress response.

They start with that deeply ingrained fight-or-flight response, and as we develop, they take on more nuanced presentations. But if we’re talking about somebody that’s presenting with aggressive antisocial traits and characteristics, or if we’re talking about or we’re working with somebody that is emotionally reactive and characteristic of the histrionic or the borderline makeup, all that is when we break it down is a fight response. It’s a trigger and it’s a fight response, and it activates very simply to keep people at a distance. A lot of what we’re going to look at more and more as we go forward is that trauma’s generally connected to interpersonal issues.

There are capital T traumas — car crashes, more acute single or repeated experiences — but oftentimes, again, the underpinnings exist in small, nuanced, interpersonal interactions that go back to very, very early childhood. That’s what we’re going to talk about — attachment theory a little bit as well — but when we’re talking about trauma, capital T trauma, somebody dealing with PTSD related to a car accident, we want to support coping with that incident and coping with the emotional consequences and the symptoms of that incident. However, we will also generally be able to find a lot of what the presenting difficulty is for that person is going to be rooted in earlier experience. And it’s generally going to be related to interpersonal difficulty, and that interpersonal difficulty is generally related to the caregiver’s trauma. Now, we’re getting into that intergenerational theme. 

So, the person with the anxious-avoidant mother who didn’t get some of the nurturing or connection necessary during the early, very, very formative years of their lives, they’re going to develop strategies to cope with that. The second that we begin to not get our needs met — we feel as though we’re not getting our needs met — we’re going to create strategies in order to meet our own needs. They may not be healthy because we’re not working with a lot of resources. Early on in our lives, we’re working with resources that involve disassociation or crime. And again, we’re going to see examples of that in adulthood for people. We’re going to see people that when confronted with a challenge, they detach; we’re going to see people that present with benzodiazepine, addiction and alcohol addiction because it helps them to detach.

A lot of times, in the treatment setting, it’s not right. Okay, you drink a lot or you use a lot of benzodiazepines, but what that’s really telling us is that that’s the goal. That’s the go-to defense for that person — what they’re doing is that they’re keeping a strategy online that was activated most likely a long time ago when they were very young and they didn’t have a lot of other options available to them. So, that’s going to be somebody that coped with stress, disassociation early on in life. Our person that — maybe their drug of choice is amphetamines or cocaine. So, there’s somebody that has a desire to be on the hyper-aroused end of the spectrum — to be closer to being able to fight, to feel the power, to feel a greater sense of control or clarity. Again, these are coping mechanisms. These are ways of making up for unmet needs. 

It’s not about getting high, it’s not about getting drunk; 99% of the population generally enjoys a feeling of intoxication, of being high. Only a percentage of the population becomes addicted to the point of self-destruction, and that’s because there’s a survival mechanism built into the substance use. Even though it’s destroying a person’s life, it’s connected to that feeling of safety that the person has been recreating over and over again throughout their lives. And again, a part of the reason that’s so difficult to break up is because these things are happening on that preconscious level. Its nervous system activation. The person isn’t going — early on in their life when they’re first trying to take care of themselves — they’re not going, “Oh gosh, what made this? I’m going to decide to disassociate.” That’s just happening, right? That’s happening in the same way that our nervous system controls the beating of our heart. So again, we have an extension of that preconscious operation in substance dependence. It’s a part of the reason it can be so difficult to treat. 

I spoke some on differences between trauma — acute is our capital T PTSD. There’s a high correlation between those presenting with PTSD and those that are experiencing or have experienced complex trauma. Complex trauma is really the name of the game, and again, it’s those attachment-related traumas or experiences or interactions that are stress-inducing very early on in our lives. It doesn’t take a lot for something to be very, very stress-inducing when we are young because we are so dependent on our caregivers for our safety and survival.

So, if our caregivers aren’t consistently in tune, which the reality is very few are — it’s not easy to do, it’s arguably impossible to do — we are very quickly going to feel stressed. We’re very quickly going to feel afraid; we’re very quickly going to feel uneasy. So then, if that’s not responded to consistently — if the unease isn’t responded to consistently, if the fear or the hurt isn’t responded to consistently in a supportive capacity — that’s where we’re going to start to come up with some ways of meeting our own needs. And again, it’s a way of coping with the stress response. It’s a way of trying to regulate, essentially, feelings of fear because our go-to caregiver isn’t filling that space for us. So, we’re going to fill it somehow. From that evolutionary perspective, this is hundreds of millions of years in the making. Essentially, our range of defenses includes fight, flight freeze; the more nuanced one is fawn, but our range of initial defense mechanisms is relatively small. As we develop, they become more nuanced.

And as I noted, that’s where the personality disorder traits and characteristics emerge. So, like I noted before, aggressive behavior, emotional reactivity — those are fight responses. Something like a freeze response — we may be seen, in some way, that’s presenting with schizophrenia or schizotypal personality disorders or paranoid personality disorder traits and characteristics. They have very much gone inward. They’re not right. They have an active inward world, but they’re not right. They’re not engaged in their interacting with the outside world in the quote-unquote “normal way” or more normal way. That’s a freeze, so there’s activity going on in the mind and paranoia —  very active, scanning everything going on for potential threat — but there’s not the same level of engagement. It’s not interpersonal engagement going on. And if it is, it’s going to be of a defensive nature. It’s going to be trying to determine whether or not defenses should go further up. 

Fawning is an extension of avoidant dependent or people-pleasing behavior — that I’m going to ingratiate myself to a person to give them as little reason as possible to hurt me. So, I’m going to go above and beyond to be nice, to be conscientious, be overly conscientious. I’m going to put myself out there again to back off any potential assault, give somebody no reason to be hurtful toward me. That’s a fawning response; it’s saying, “I’m a zero threat to you, so please do not hurt me.” So, there’s a more primal defense strategy, but as it emerges and as it evolves in our life, it takes on these personality disorder features of avoidance or dependence.

So, how does this connect to the family? Why is the family important? The family is the place where we, ideally, are learning how to feel safe. The family is the place — is the system — where, ideally, we’re learning the skills and strategies not only to feel safe, but also to help ourselves feel safe. If some of that is not going on in a good enough way — that’s the criteria: good enough parenting, good enough caretaking. Again, we’ll fill in that gap. Another relevant consideration is that unless intervened upon, we’re not giving up our coping strategies. So, unless the coping strategy is acutely problematic, we’re not inclined to change it. 

So, just because somebody presents at the treatment center with substance use disorder — that’s that presenting issue tip of the iceberg that that requires everybody’s attention, but everything else is going on beneath the surface and probably has been for generations in one way or the other. I see this a lot. One of the classic studies is looking at children of Holocaust survivors and why did children of Holocaust survivors have higher rates of depression and suicide. A part of the reasoning for that is that the Holocaust survivors — those that survived — develop a skillset and strategy for coping with that experience and that involved looking on the bright side, for example. 

Now, that’s a tremendous coping strategy that helped these folks to survive arguably some of the most horrendous conditions imaginable. But what they saw happen is that when they had kids and the kids would come home from a bad day at school and say, “Mom and dad, school was bad today. It was a really hard day,” the parents would take their strategy of looking on the bright side and say, “Hey, look, it could always be worse. It’s not that bad.” That’s a supportive interaction. That’s an interaction that’s done with the best intentions. That’s an interaction that had served those survivors a tremendous purpose. It’s also an interaction that that child takes as minimizing and dismissing their emotional experience. And so, rather than maybe learning how to manage their experience and manage their emotion, they’re left feeling shut down. 

This contributes to a pattern of internalized emotion. This maybe contributes to a pattern of avoidance, and now, we see some of the underpinnings of where depression can take hold — oftentimes, anxiety and depression. There’s genetic components to that, but oftentimes as well, there’s a personality function that’s contributing to the severity of those issues. So, there we have it — it’s a clear-cut example of that generational lead. Adaptive, healthy, super helpful coping strategy that, when transferred to the next generation, doesn’t click. Doesn’t fit, and actually ends up having a detrimental impact.

So, the family system, in terms of developing that sense of safety and supporting the development of the healthy coping mechanism, that’s where that happens. You can’t really get away from it. And again, there’s an evolutionary component to that that we’ll see when we look at attachment theory a little bit more as well. I can pause. Ashley, do you know if there are any questions or does anybody listening have any questions? No questions yet in the chat, but if anybody has a question, please feel free to unmute yourselves or put it in the chat, and then I can address it for you. If somebody puts something in, just let me know and I’ll keep rolling. 

So, what I’ve talked a lot about when I’m talking about the importance of the interpersonal interactions as quote-unquote “dramatic,” these are implicit factors. These are not those acute, direct, in-your-face experiences that we can point to as trauma. And a lot of times, in direct practice, if you’re talking to somebody and you’re doing an assessment or a history, you say, “Any trauma history?” Some people are going to say yes; some people have a very clear trauma history. Some people are going to say no. I’m not saying everybody has trauma. What I am saying is that if we’re showing up with a presenting issue around substance use and/or personality — depression, anxiety, something on the more acute end of the spectrum — there are going to be underlying factors. 

And we talk about — again, sort of a term that’s thrown around often in the treatment world — getting to the root causes. Well, what exactly are the root causes? And this is what we’re taking a look at — is that the root causes are a combination of factors that involve the family system, attachment, evolution, the mind-body connection, nervous system response — the root causes are all of these factors. And what we’re getting when we’re working with somebody are just the signals, the signs of what’s going on beneath the surface for a person. Some of these implicit considerations include the following, and I’ll hone in further on one of them, which is the child’s feelings of responsibility for parental well-being. This is stuff that’s happening before a child is talking. And again, it’s connected to the human dependency on the adult caregiver for safety and survival. 

One of the things that’s unique about us is that we are born early. Very, very few species — arguably, any species — are born with so few skills that we require a tremendous amount of care and time and energy to keep us going right from the get-go. As a part of that, we are hardwired and fine-tuned to attend to the well-being of the caregiver. So, if we’re not getting that the caregiver’s okay, we’re not going to feel okay, and it’s the argument or the view that codependency is a natural state for the child of the caregiver — that there should be natural codependency there, where the okayness of each party is dependent on the other. That’s a survival mechanism. 

We get into problems when a person goes through life and that codependency isn’t broken; when that codependency isn’t broken, then we see broader issues. We see broader relationship issues, we see issues with the person’s sense of self and see issues with their ability to practice life interdependently versus dependently because they’re still feeling a responsibility for the adult caregiver. Ideally, as we grow up, we’re moving away from one another in a healthy distance and we’re taking all responsibility for ourselves, and the parent is demonstrating responsibility for themselves. That happens a lot, and that’s a very hard one to break up in addiction treatment — is that the parent’s anxiety about the child’s behavior reinforces that instinctual codependency. And that’s a part of what we have to really work to break up in treatment settings, especially if we’re able to work with family, so that the individual child — the adult child — can develop some of the more mature skillset and ego functioning to support them in a recovery process. If we’re not able to break up some of that dynamic and the person leaves treatment and falls back into the codependent pattern, their opportunity at recovering — developing that healthy ego structure — is greatly minimized and inhibited.

I mean, again, we’re going to see — as an offshoot of that — personality features, disorder traits and characteristics come into the picture as well. I love this slide. This is my favorite slide because it does a great example of just very clearly identifying the number of factors that go into a discussion and assessment and treatment of quote-unquote “trauma” and the number of factors that go into treating somebody in a treatment setting or clinical setting. And the treatment setting is phenomenal because you have the person available to do so much work, and if we’re able to capitalize on engaging the family, it is that much more effective. Connecting and doing the work with the family to address the intergenerational patterns that support family members and looking at their own family of origin stuff is where our greatest chances of long-term recovery can be found. And again, one of those things — why is it so hard to get a person in treatment and to have them engage in a successful recovery process? It’s hard to break up the dynamics in the system that have existed for generations. So, if we’re not getting connected to the family members, it’s that much more heavy lifting focused on the individual. And it’s going to be that much more difficult, again, for that individual to maintain and develop healthy, consistent boundaries that will support their recovery moving forward.

Attachment I’ve noted a number of times before, and what we see — I have a note on this one, actually, from Janina Fisher as well and some of her review of attachment theory — but throughout history, independent of culture, the markers of attachment-seeking behavior have functioned to maximize safety under threat. So again, we’re going back to our fight-or-flight response and our nervous system activation — that attachment is our response to threat and stress. That we go to the attachment, the caretaker. Again, the caretaker isn’t providing us with the sense of safety — that puts us in a bind because now we have the sense of threat and we’re looking to our caretaker to alleviate that stress. And if the caretaker’s not able to do that, then our child, our individual, is left to themselves. And as a child, again, that’s a very helpless, powerless position to be in — at six months, at six days, six months, a year, two years, three years, 10 years, 13, 14. There’s not an adult skill set available to the kid. 

The attachment figures, the secure base — the child can go and explore the environment, but if that stress comes up, they can go back to the base. But if that base isn’t consistent or if that base is still dealing with trauma of their own — that they’re chronically anxious or they’re chronically depressed — the child is not able to explore, feel stress and then experience stress regulation through the connection to the caregiver. That’s our template for interpersonal connection. That’s our template for communication. That’s where neural pathways are getting away; in the first two years, those pathways are getting away.

So, if in the first two years of your life, you’re not practicing that dynamic, we’re going to have to practice something different later on. And again, all that is is an unregulated or a dysregulated stress system. It’s not like we turned 10 or we turn 18 and, all of a sudden, we’re equipped with different neural networks and a new stress response system. The reality is we’re still fundamentally operating in a lot of the ways that we learn in the first two or three years of our life. They’re more nuanced patterns, they’re more nuanced presentations, but we can trace it down very early on in a person’s life. That attachment piece is enormous, and that’s the link between — in my view — that’s the link between the evolutionary considerations, the adaptation and the family. And that’s why we have the discussion: intergenerational trauma and personality. The list goes on in terms of the scope of trauma, from biology to self-concept, and each one of these is a presentation in and of itself. We can go on and on; for the sake of time, I will not. I definitely could though — I like this slide. 

I’ll jump into a more kind of concrete point on personality disorders, and I have an asterisk there because this stuff is not concrete. It’s not set in stone; it’s not black and white. Historically, there was a view that personality was pretty much set in place, especially if a person was 18 or older, but that’s not the case. The reality is these personality features and characteristics exist along a spectrum. They are connected essentially to early efforts at stress response and stress response regulation. Through treatment, intervention and through work, personality disorder traits and characteristics can be amended, and people with personality features that have caused them significant impairment over the course of their life can make significant changes. And oftentimes, again, if we’re looking at the treatment of depression, anxiety, substance use, we need to look at the treatment of personality issues.

The personality issues are also very helpful in terms of informing treatment efforts, in that the person presenting with the antisocial personality traits and characteristics requires different interventions compared to the person struggling with avoidant personality traits and characteristics. So, substance use treatment is not — this is one of the reasons why this is not a one-size-fits-all approach. If we’re treating the antisocial traits the same as we’re treating the avoidant traits, we’re not being effective. If anything, we might be contributing to and reinforcing some of the antisocial traits. 

So, we have to adapt. We can use these as guides to inform our treatment. They’re also helpful guides to inform family systems. So borderline, again, quote-unquote, is like the personality disorder. What we see is that there’s a five-fold likelihood of a borderline presentation when a parent has the borderline presentation. The presentation of the individual can oftentimes be diagnostic or informative to a degree about the family system functioning as well. And that should inform our approach and our interventions on the system. That, again, an avoidant dependent system — we’re not treating the same way as the narcissistic borderline system. They require different approaches in order for us to be effective. Now, again, both of those presentations, both of those systems, are rooted in the same efforts at stress response and stress regulation. They’re offshoots of the same thing. They’re showing up in different ways. 

Personality, some of that as well — there are some genetic markers for personality, and there is what’s referred to as a temperamental predisposition. But again, that’s a heritability factor in family systems and another reason why the family system is so important to address. I’m going to wrap up here. Like I was saying, the disorder — it’s pathologizing. The pathology, I think, is helpful in terms of informing communication and some clarification amongst practitioners, that we feel like we’re sort of on the same page, but I would hesitate to hit somebody with a hard and fast personality disorder label. I think it’s more a tool to inform our treatment, and that’s an opinion, really. 

So, sort of wrapping up and trying to weave some of this together at this point, I come to this final slide and I have the little photo here of a chart graphic. This is from a study that was done on historical factors connected to epigenetic function, and that’s the study and whether or not, in humans, our genes or gene functioning turns on and off based on experience. There’s evidence of that happening, I believe, in animal studies; there’s some indication that happens for humans, but there’s still a lot more research to be done. Definitely something to be mindful of in terms of trauma treatment is epigenetic functioning.

So, this is a study in looking at how historical factors impact gene expression. And it’s a tremendous example of that interconnection theme that we’ve talked about throughout the presentation. What we see here is, starting at the national level and working our way through community, family, all the way down to the individual, you see the impact and interconnected effect of a quote-unquote “traumatic, stressful experience.” And they nail it with this chart as well because these arrows go both ways and it takes us through three generations. It’s not that somebody experiences a trauma and then we all move on. It’s going back to that phrase by Janina Fisher: the neurobiological legacy of trauma.

Just as we pass on the good things about us and about our families and about our communities and about our cultures, we pass along some of the not-good things. The reason that we pass those along, again, is because that’s rooted in this primal feeling that it’s keeping us safe. But they nailed it here, and this, like, if the presentation — really, you know, put it in the one graphic, one slide — this is that. It’s a top-down, bottom-up, interconnected view of treating individuals and families and understanding that the issues that we see is just the presenting issue. 

And what that is doing — it requires our attention, but what it’s really doing is telling us that there’s more beneath the surface that requires further attention. And then if we really want to be effective in our treatment of the substance use, of the personality, then we have to go beneath the surface. And going beneath the surface means looking at this neurobiological legacy. Love that phrase, I wish I came up with it. I’m not that smart, so we’ll cite Janina Fisher over and over again. With that, I’ll wrap and I guess hand it off or see if there are any questions. 

Thank you for watching this video. We hope you enjoyed the presentation.

Objectives and Summary:

Interactions with our caregivers and other experiences during childhood play a large role in shaping who we become. If these experiences are traumatic, a child can potentially develop mental health conditions such as a personality disorder later in life. In this presentation, Alex Ribbentrop, LCSW-QS, CFTP, provides an overview of the many factors that can contribute to personality disorders and other conditions.

After watching this presentation, the viewer will:

  • Understand the factors that contribute to personality disorders
  • Be aware of how the caregiver-child relationship affects development
  • Know more about coping mechanisms and how they relate to substance abuse

Presentation Materials:

Presenter, Alex Ribbentrop, is a Licensed Clinical Social Worker in both Virginia and Florida, Qualified Supervisor, EMDR Trained Clinician, and Certified Family Trauma Professional. Alex received his B.A. in Philosophy from George Mason University where he also completed a Master’s Degree in Clinical Social Work and was twice recognized with the “Outstanding Master of Social Work Award”. Alex’s clinical career has included work in for-profit and non-profit settings, levels of care ranging from residential treatment to community-based mental health care, and time working with one of the top co-occurring treatment facilities in the country.

Alex’s clinical training has focused on the areas of complex trauma, family systems, personality disorders, and substance use disorders; his approach integrates trauma-informed care and existential considerations to support individuals in the development of personal meaning and value for their lives.

Alex currently owns and operates Live Free Psychotherapy, a private practice with locations in Palm Beach County, Florida, and Northern Virginia. In addition to clinical practice, Alex works as a consultant, speaker, and facilitator of psychotherapeutic group and family workshops.

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems. Super excited to be able to have Alex Ribbentrop, LCSW-QS, CFTP. He’s a licensed clinical social worker in both Virginia and Florida, qualified SU supervisor, EMDR-trained clinician and certified family trauma professional.  

Alex received his BA in Philosophy from George Mason University, where he also completed a master’s degree in clinical social work and has twice been recognized with the Outstanding Master of Social Work board. Alex’s clinical career has included work in for-profit and nonprofit settings, levels of care ranging from residential treatment to community-based mental health care and time working with one of the top co-occurring treatment facilities in the country.

Alex has clinical training focused on areas of complex trauma, family systems, personality disorders and substance use disorders. His approach integrates trauma-informed care and existential considerations to support individuals in the development of personal meaning and value for their lives.

Alex currently owns and operates Live Free Psychotherapy, a private practice with locations in Palm Beach County, Florida, and Northern Virginia. In addition to his clinical practice, Alex works as a consultant speaker and facilitator of psychotherapeutic groups and family workshops. Alex, thank you so much for being here, and you can take it away.

Alex:
Thank you very much, Mike, for the introduction. I appreciate it. Thank you, Ashley, for all your work as well on the back end getting us set up, and thank you to The Recovery Village and Advanced Recovery Systems for putting this on. As you guys can see, I’m located in the car; we’ve had a last-minute change of scenery.

So, I had my trauma response earlier and I think I’ve pulled it together at this point, so we’ll see how the presentation goes. As Ashley said at the beginning as well: At any point, if somebody has a question, please feel free to throw that into the chat. Ashley can jump in at any point and kind of ask that question on y’all’s behalf. Happy to kind of start and stop as we move forward here over the next hour. To get us started, I’ve done this presentation now for probably, like, a year and a half — maybe closer to two years at this point. And every time I prepare for this talk, whether it’s an hour long or sometimes longer, I have the opportunity to do a little bit more research, a little bit more preparation.

One of the biggest things that sticks out to me at this point and that’s also really encouraging is the amount of information out there that has to do with improving the quality of care that we’re able to provide as clinicians or administrators or service providers. Whatever it is we’re doing is outstanding.

Every time I prepare, whether it’s a month, two months, whatever it may be, there’s always new information out there. It’s really, really encouraging as a practitioner to see that, and I think it underpins my experience that as providers or as clinicians, we are really at this unique intersection. A lot of different disciplines, and we’re able to draw from a lot of different academic disciplines and practices to inform quality care, and the better that we can inform our quality of care, the more lives we get to save and the more families we get the support and the more people we get to help.

So, it’s edifying for me every time I get to do this, and I feel very fortunate to be able to do so. As I noted, as clinicians or as practitioners, we definitely are in a unique position and we stand at the intersection of a lot of different disciplines. In this presentation, we’re going to touch on some of those, and it’s going to range from genetic factors, psychology, biology, environment. Obviously, pulling from psychotherapeutic models and theories as well. An overarching goal of the presentation — in addition to learning more about trauma, intergenerational trauma, personality disorders — is to reinforce the idea that we are working with interconnected systems across a spectrum. So, as we work with an individual — yes, we’re working with that single person, but they are part of a deeply woven, interconnected system that connects the family, society and history. 

And we want to kind of bring that into the mix more and more as we’re considering our understanding of those we work with, and also our treatment approaches as well. Over the years, maybe especially the past 10, capital T trauma and lowercase T trauma has become more and more a term used today in the treatment world. Improvements in the treatment and our understanding of trauma go back decades. However, terms like dual diagnosis, family systems, PTSD, complex trauma — these are all increasingly prevalent in the field and in our practice. A part of this presentation is wanting to understand what it is we really actually mean when we’re using these terms. And as we investigate the meaning of terms like trauma or family treatment or dual diagnosis treatment, we’re going to begin to peel back layers.

That directs us to a need to understand evolutionary underpinnings and some of the survival mechanisms that we have adapted and held onto as a part of our survival. So, as we get a clearer understanding of what we mean by trauma, what we begin to understand is that we’re really talking about our body and our brain’s stress response system. That’s going to be another key theme that we return to throughout the presentation. Furthermore, the better that we have an understanding of some of these underpinning or foundational elements, the better we can inform our treatment. If we’re looking at presenting issues as isolated or existing in silos, we’re not as effective as we should be in terms of treating those that we have a chance to work with.

And that not only includes the individuals with the presenting issues, the acute issues and substance use issues or depression, anxiety, et cetera. That includes the family as well. Again, because rarely — arguably never — does somebody presenting in treatment without something else going on in the system that contributes to or perpetuates some of the maladaptive functioning that’s causing them trouble. Bear with me as I shuffle through my notes. As I said, the motivation here is to gain further clarification on what’s meant by some of these terms that you hear very often. How do we take a better understanding of these terms to inform our quality of care?

I’m going to move on to evolution, survival and trauma. As I said, much of what we see in terms of a presenting issue can ultimately be traced to an evolutionary survival response. This is something that a woman named Janina Fisher — she’s done a lot of work in the field of trauma — refers to as the neurobiological legacy of trauma. It’s a fantastic term because it brings together our understanding of the mind and the body, and it also integrates and reinforces that term legacy — that there’s a historical component to this stuff. So, when we’re looking at a presenting issue and we’re understanding that as linked to a survival mechanism, we can also understand that there’s a historical precedent to that presentation. And oftentimes, that is perpetuated throughout family systems, again, from an evolutionary standpoint, from an adaptive standpoint. Families and systems and groups are going to pass along those things that have helped to keep them safe. 

We run into issues when those skills and those adaptations and those coping strategies no longer fit our environment. And that’s a part of what trauma treatment is — how do we take the trauma response, the stress response that continues to play out for a person in the present, and how do we break that up so that they can function in greater accordance with what’s actually happening for them in the present moment? A lot of times, when you’re working with somebody dealing with trauma, it’s reiterations of past emotional responses over and over and over and over again. We have a lot of neuroscience that backs up that understanding, and we also have more and more information about how deeply ingrained the brain function is with the entire nervous system’s function throughout the body. Again, a theme of the overall presentation is how do we integrate our understandings? And a part of that is how do we integrate and break up this view of the mind being separate from the body when, in reality, it’s a collective, integrated system. The better that we can understand that, the better our treatment is. 

There’s a lot more somatically oriented treatments that are gaining popularity. EMDR has a heavy semantic element, for example. As we move forward. I mentioned I use the term stress response system, and what exactly do we mean by that? Or what exactly is our stress response system or a stress response system. In humans, it’s a deeply evolved survival mechanism. It’s hardwired into our brain. It’s hardwired into our body. It’s connected to our nervous system functioning. So, a lot of these things are also preconscious. Our frontal lobe is not online when we’re responding to stressors, and it breaks down a little bit. We have a few different systems, nervous systems, and these can all be broken down in smaller pieces as well, but three of the primary systems are the autonomic and the sympathetic and the parasympathetic nervous system. The importance of discussing these when talking about trauma, personality and family is that personality disorders, quote-unquote “acute presenting issues” — again, they start with this. They start with the survival mechanism and the stress response.

They start with that deeply ingrained fight-or-flight response, and as we develop, they take on more nuanced presentations. But if we’re talking about somebody that’s presenting with aggressive antisocial traits and characteristics, or if we’re talking about or we’re working with somebody that is emotionally reactive and characteristic of the histrionic or the borderline makeup, all that is when we break it down is a fight response. It’s a trigger and it’s a fight response, and it activates very simply to keep people at a distance. A lot of what we’re going to look at more and more as we go forward is that trauma’s generally connected to interpersonal issues.

There are capital T traumas — car crashes, more acute single or repeated experiences — but oftentimes, again, the underpinnings exist in small, nuanced, interpersonal interactions that go back to very, very early childhood. That’s what we’re going to talk about — attachment theory a little bit as well — but when we’re talking about trauma, capital T trauma, somebody dealing with PTSD related to a car accident, we want to support coping with that incident and coping with the emotional consequences and the symptoms of that incident. However, we will also generally be able to find a lot of what the presenting difficulty is for that person is going to be rooted in earlier experience. And it’s generally going to be related to interpersonal difficulty, and that interpersonal difficulty is generally related to the caregiver’s trauma. Now, we’re getting into that intergenerational theme. 

So, the person with the anxious-avoidant mother who didn’t get some of the nurturing or connection necessary during the early, very, very formative years of their lives, they’re going to develop strategies to cope with that. The second that we begin to not get our needs met — we feel as though we’re not getting our needs met — we’re going to create strategies in order to meet our own needs. They may not be healthy because we’re not working with a lot of resources. Early on in our lives, we’re working with resources that involve disassociation or crime. And again, we’re going to see examples of that in adulthood for people. We’re going to see people that when confronted with a challenge, they detach; we’re going to see people that present with benzodiazepine, addiction and alcohol addiction because it helps them to detach.

A lot of times, in the treatment setting, it’s not right. Okay, you drink a lot or you use a lot of benzodiazepines, but what that’s really telling us is that that’s the goal. That’s the go-to defense for that person — what they’re doing is that they’re keeping a strategy online that was activated most likely a long time ago when they were very young and they didn’t have a lot of other options available to them. So, that’s going to be somebody that coped with stress, disassociation early on in life. Our person that — maybe their drug of choice is amphetamines or cocaine. So, there’s somebody that has a desire to be on the hyper-aroused end of the spectrum — to be closer to being able to fight, to feel the power, to feel a greater sense of control or clarity. Again, these are coping mechanisms. These are ways of making up for unmet needs. 

It’s not about getting high, it’s not about getting drunk; 99% of the population generally enjoys a feeling of intoxication, of being high. Only a percentage of the population becomes addicted to the point of self-destruction, and that’s because there’s a survival mechanism built into the substance use. Even though it’s destroying a person’s life, it’s connected to that feeling of safety that the person has been recreating over and over again throughout their lives. And again, a part of the reason that’s so difficult to break up is because these things are happening on that preconscious level. Its nervous system activation. The person isn’t going — early on in their life when they’re first trying to take care of themselves — they’re not going, “Oh gosh, what made this? I’m going to decide to disassociate.” That’s just happening, right? That’s happening in the same way that our nervous system controls the beating of our heart. So again, we have an extension of that preconscious operation in substance dependence. It’s a part of the reason it can be so difficult to treat. 

I spoke some on differences between trauma — acute is our capital T PTSD. There’s a high correlation between those presenting with PTSD and those that are experiencing or have experienced complex trauma. Complex trauma is really the name of the game, and again, it’s those attachment-related traumas or experiences or interactions that are stress-inducing very early on in our lives. It doesn’t take a lot for something to be very, very stress-inducing when we are young because we are so dependent on our caregivers for our safety and survival.

So, if our caregivers aren’t consistently in tune, which the reality is very few are — it’s not easy to do, it’s arguably impossible to do — we are very quickly going to feel stressed. We’re very quickly going to feel afraid; we’re very quickly going to feel uneasy. So then, if that’s not responded to consistently — if the unease isn’t responded to consistently, if the fear or the hurt isn’t responded to consistently in a supportive capacity — that’s where we’re going to start to come up with some ways of meeting our own needs. And again, it’s a way of coping with the stress response. It’s a way of trying to regulate, essentially, feelings of fear because our go-to caregiver isn’t filling that space for us. So, we’re going to fill it somehow. From that evolutionary perspective, this is hundreds of millions of years in the making. Essentially, our range of defenses includes fight, flight freeze; the more nuanced one is fawn, but our range of initial defense mechanisms is relatively small. As we develop, they become more nuanced.

And as I noted, that’s where the personality disorder traits and characteristics emerge. So, like I noted before, aggressive behavior, emotional reactivity — those are fight responses. Something like a freeze response — we may be seen, in some way, that’s presenting with schizophrenia or schizotypal personality disorders or paranoid personality disorder traits and characteristics. They have very much gone inward. They’re not right. They have an active inward world, but they’re not right. They’re not engaged in their interacting with the outside world in the quote-unquote “normal way” or more normal way. That’s a freeze, so there’s activity going on in the mind and paranoia —  very active, scanning everything going on for potential threat — but there’s not the same level of engagement. It’s not interpersonal engagement going on. And if it is, it’s going to be of a defensive nature. It’s going to be trying to determine whether or not defenses should go further up. 

Fawning is an extension of avoidant dependent or people-pleasing behavior — that I’m going to ingratiate myself to a person to give them as little reason as possible to hurt me. So, I’m going to go above and beyond to be nice, to be conscientious, be overly conscientious. I’m going to put myself out there again to back off any potential assault, give somebody no reason to be hurtful toward me. That’s a fawning response; it’s saying, “I’m a zero threat to you, so please do not hurt me.” So, there’s a more primal defense strategy, but as it emerges and as it evolves in our life, it takes on these personality disorder features of avoidance or dependence.

So, how does this connect to the family? Why is the family important? The family is the place where we, ideally, are learning how to feel safe. The family is the place — is the system — where, ideally, we’re learning the skills and strategies not only to feel safe, but also to help ourselves feel safe. If some of that is not going on in a good enough way — that’s the criteria: good enough parenting, good enough caretaking. Again, we’ll fill in that gap. Another relevant consideration is that unless intervened upon, we’re not giving up our coping strategies. So, unless the coping strategy is acutely problematic, we’re not inclined to change it. 

So, just because somebody presents at the treatment center with substance use disorder — that’s that presenting issue tip of the iceberg that that requires everybody’s attention, but everything else is going on beneath the surface and probably has been for generations in one way or the other. I see this a lot. One of the classic studies is looking at children of Holocaust survivors and why did children of Holocaust survivors have higher rates of depression and suicide. A part of the reasoning for that is that the Holocaust survivors — those that survived — develop a skillset and strategy for coping with that experience and that involved looking on the bright side, for example. 

Now, that’s a tremendous coping strategy that helped these folks to survive arguably some of the most horrendous conditions imaginable. But what they saw happen is that when they had kids and the kids would come home from a bad day at school and say, “Mom and dad, school was bad today. It was a really hard day,” the parents would take their strategy of looking on the bright side and say, “Hey, look, it could always be worse. It’s not that bad.” That’s a supportive interaction. That’s an interaction that’s done with the best intentions. That’s an interaction that had served those survivors a tremendous purpose. It’s also an interaction that that child takes as minimizing and dismissing their emotional experience. And so, rather than maybe learning how to manage their experience and manage their emotion, they’re left feeling shut down. 

This contributes to a pattern of internalized emotion. This maybe contributes to a pattern of avoidance, and now, we see some of the underpinnings of where depression can take hold — oftentimes, anxiety and depression. There’s genetic components to that, but oftentimes as well, there’s a personality function that’s contributing to the severity of those issues. So, there we have it — it’s a clear-cut example of that generational lead. Adaptive, healthy, super helpful coping strategy that, when transferred to the next generation, doesn’t click. Doesn’t fit, and actually ends up having a detrimental impact.

So, the family system, in terms of developing that sense of safety and supporting the development of the healthy coping mechanism, that’s where that happens. You can’t really get away from it. And again, there’s an evolutionary component to that that we’ll see when we look at attachment theory a little bit more as well. I can pause. Ashley, do you know if there are any questions or does anybody listening have any questions? No questions yet in the chat, but if anybody has a question, please feel free to unmute yourselves or put it in the chat, and then I can address it for you. If somebody puts something in, just let me know and I’ll keep rolling. 

So, what I’ve talked a lot about when I’m talking about the importance of the interpersonal interactions as quote-unquote “dramatic,” these are implicit factors. These are not those acute, direct, in-your-face experiences that we can point to as trauma. And a lot of times, in direct practice, if you’re talking to somebody and you’re doing an assessment or a history, you say, “Any trauma history?” Some people are going to say yes; some people have a very clear trauma history. Some people are going to say no. I’m not saying everybody has trauma. What I am saying is that if we’re showing up with a presenting issue around substance use and/or personality — depression, anxiety, something on the more acute end of the spectrum — there are going to be underlying factors. 

And we talk about — again, sort of a term that’s thrown around often in the treatment world — getting to the root causes. Well, what exactly are the root causes? And this is what we’re taking a look at — is that the root causes are a combination of factors that involve the family system, attachment, evolution, the mind-body connection, nervous system response — the root causes are all of these factors. And what we’re getting when we’re working with somebody are just the signals, the signs of what’s going on beneath the surface for a person. Some of these implicit considerations include the following, and I’ll hone in further on one of them, which is the child’s feelings of responsibility for parental well-being. This is stuff that’s happening before a child is talking. And again, it’s connected to the human dependency on the adult caregiver for safety and survival. 

One of the things that’s unique about us is that we are born early. Very, very few species — arguably, any species — are born with so few skills that we require a tremendous amount of care and time and energy to keep us going right from the get-go. As a part of that, we are hardwired and fine-tuned to attend to the well-being of the caregiver. So, if we’re not getting that the caregiver’s okay, we’re not going to feel okay, and it’s the argument or the view that codependency is a natural state for the child of the caregiver — that there should be natural codependency there, where the okayness of each party is dependent on the other. That’s a survival mechanism. 

We get into problems when a person goes through life and that codependency isn’t broken; when that codependency isn’t broken, then we see broader issues. We see broader relationship issues, we see issues with the person’s sense of self and see issues with their ability to practice life interdependently versus dependently because they’re still feeling a responsibility for the adult caregiver. Ideally, as we grow up, we’re moving away from one another in a healthy distance and we’re taking all responsibility for ourselves, and the parent is demonstrating responsibility for themselves. That happens a lot, and that’s a very hard one to break up in addiction treatment — is that the parent’s anxiety about the child’s behavior reinforces that instinctual codependency. And that’s a part of what we have to really work to break up in treatment settings, especially if we’re able to work with family, so that the individual child — the adult child — can develop some of the more mature skillset and ego functioning to support them in a recovery process. If we’re not able to break up some of that dynamic and the person leaves treatment and falls back into the codependent pattern, their opportunity at recovering — developing that healthy ego structure — is greatly minimized and inhibited.

I mean, again, we’re going to see — as an offshoot of that — personality features, disorder traits and characteristics come into the picture as well. I love this slide. This is my favorite slide because it does a great example of just very clearly identifying the number of factors that go into a discussion and assessment and treatment of quote-unquote “trauma” and the number of factors that go into treating somebody in a treatment setting or clinical setting. And the treatment setting is phenomenal because you have the person available to do so much work, and if we’re able to capitalize on engaging the family, it is that much more effective. Connecting and doing the work with the family to address the intergenerational patterns that support family members and looking at their own family of origin stuff is where our greatest chances of long-term recovery can be found. And again, one of those things — why is it so hard to get a person in treatment and to have them engage in a successful recovery process? It’s hard to break up the dynamics in the system that have existed for generations. So, if we’re not getting connected to the family members, it’s that much more heavy lifting focused on the individual. And it’s going to be that much more difficult, again, for that individual to maintain and develop healthy, consistent boundaries that will support their recovery moving forward.

Attachment I’ve noted a number of times before, and what we see — I have a note on this one, actually, from Janina Fisher as well and some of her review of attachment theory — but throughout history, independent of culture, the markers of attachment-seeking behavior have functioned to maximize safety under threat. So again, we’re going back to our fight-or-flight response and our nervous system activation — that attachment is our response to threat and stress. That we go to the attachment, the caretaker. Again, the caretaker isn’t providing us with the sense of safety — that puts us in a bind because now we have the sense of threat and we’re looking to our caretaker to alleviate that stress. And if the caretaker’s not able to do that, then our child, our individual, is left to themselves. And as a child, again, that’s a very helpless, powerless position to be in — at six months, at six days, six months, a year, two years, three years, 10 years, 13, 14. There’s not an adult skill set available to the kid. 

The attachment figures, the secure base — the child can go and explore the environment, but if that stress comes up, they can go back to the base. But if that base isn’t consistent or if that base is still dealing with trauma of their own — that they’re chronically anxious or they’re chronically depressed — the child is not able to explore, feel stress and then experience stress regulation through the connection to the caregiver. That’s our template for interpersonal connection. That’s our template for communication. That’s where neural pathways are getting away; in the first two years, those pathways are getting away.

So, if in the first two years of your life, you’re not practicing that dynamic, we’re going to have to practice something different later on. And again, all that is is an unregulated or a dysregulated stress system. It’s not like we turned 10 or we turn 18 and, all of a sudden, we’re equipped with different neural networks and a new stress response system. The reality is we’re still fundamentally operating in a lot of the ways that we learn in the first two or three years of our life. They’re more nuanced patterns, they’re more nuanced presentations, but we can trace it down very early on in a person’s life. That attachment piece is enormous, and that’s the link between — in my view — that’s the link between the evolutionary considerations, the adaptation and the family. And that’s why we have the discussion: intergenerational trauma and personality. The list goes on in terms of the scope of trauma, from biology to self-concept, and each one of these is a presentation in and of itself. We can go on and on; for the sake of time, I will not. I definitely could though — I like this slide. 

I’ll jump into a more kind of concrete point on personality disorders, and I have an asterisk there because this stuff is not concrete. It’s not set in stone; it’s not black and white. Historically, there was a view that personality was pretty much set in place, especially if a person was 18 or older, but that’s not the case. The reality is these personality features and characteristics exist along a spectrum. They are connected essentially to early efforts at stress response and stress response regulation. Through treatment, intervention and through work, personality disorder traits and characteristics can be amended, and people with personality features that have caused them significant impairment over the course of their life can make significant changes. And oftentimes, again, if we’re looking at the treatment of depression, anxiety, substance use, we need to look at the treatment of personality issues.

The personality issues are also very helpful in terms of informing treatment efforts, in that the person presenting with the antisocial personality traits and characteristics requires different interventions compared to the person struggling with avoidant personality traits and characteristics. So, substance use treatment is not — this is one of the reasons why this is not a one-size-fits-all approach. If we’re treating the antisocial traits the same as we’re treating the avoidant traits, we’re not being effective. If anything, we might be contributing to and reinforcing some of the antisocial traits. 

So, we have to adapt. We can use these as guides to inform our treatment. They’re also helpful guides to inform family systems. So borderline, again, quote-unquote, is like the personality disorder. What we see is that there’s a five-fold likelihood of a borderline presentation when a parent has the borderline presentation. The presentation of the individual can oftentimes be diagnostic or informative to a degree about the family system functioning as well. And that should inform our approach and our interventions on the system. That, again, an avoidant dependent system — we’re not treating the same way as the narcissistic borderline system. They require different approaches in order for us to be effective. Now, again, both of those presentations, both of those systems, are rooted in the same efforts at stress response and stress regulation. They’re offshoots of the same thing. They’re showing up in different ways. 

Personality, some of that as well — there are some genetic markers for personality, and there is what’s referred to as a temperamental predisposition. But again, that’s a heritability factor in family systems and another reason why the family system is so important to address. I’m going to wrap up here. Like I was saying, the disorder — it’s pathologizing. The pathology, I think, is helpful in terms of informing communication and some clarification amongst practitioners, that we feel like we’re sort of on the same page, but I would hesitate to hit somebody with a hard and fast personality disorder label. I think it’s more a tool to inform our treatment, and that’s an opinion, really. 

So, sort of wrapping up and trying to weave some of this together at this point, I come to this final slide and I have the little photo here of a chart graphic. This is from a study that was done on historical factors connected to epigenetic function, and that’s the study and whether or not, in humans, our genes or gene functioning turns on and off based on experience. There’s evidence of that happening, I believe, in animal studies; there’s some indication that happens for humans, but there’s still a lot more research to be done. Definitely something to be mindful of in terms of trauma treatment is epigenetic functioning.

So, this is a study in looking at how historical factors impact gene expression. And it’s a tremendous example of that interconnection theme that we’ve talked about throughout the presentation. What we see here is, starting at the national level and working our way through community, family, all the way down to the individual, you see the impact and interconnected effect of a quote-unquote “traumatic, stressful experience.” And they nail it with this chart as well because these arrows go both ways and it takes us through three generations. It’s not that somebody experiences a trauma and then we all move on. It’s going back to that phrase by Janina Fisher: the neurobiological legacy of trauma.

Just as we pass on the good things about us and about our families and about our communities and about our cultures, we pass along some of the not-good things. The reason that we pass those along, again, is because that’s rooted in this primal feeling that it’s keeping us safe. But they nailed it here, and this, like, if the presentation — really, you know, put it in the one graphic, one slide — this is that. It’s a top-down, bottom-up, interconnected view of treating individuals and families and understanding that the issues that we see is just the presenting issue. 

And what that is doing — it requires our attention, but what it’s really doing is telling us that there’s more beneath the surface that requires further attention. And then if we really want to be effective in our treatment of the substance use, of the personality, then we have to go beneath the surface. And going beneath the surface means looking at this neurobiological legacy. Love that phrase, I wish I came up with it. I’m not that smart, so we’ll cite Janina Fisher over and over again. With that, I’ll wrap and I guess hand it off or see if there are any questions. 

Thank you for watching this video. We hope you enjoyed the presentation.

Share on Social Media:

FacebookTwitterLinkedIn