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The Children of Zeus and Hera: ACT and Schema-Focused Therapy for Narcissistic & Borderline Personality Disorder

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Applying Schema Focused & Acceptance and Commitment Therapy for Narcissistic and Borderline Personality Disorders. Understanding the inner dynamics of Borderline and Narcissistic Personality Disorders.

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The Children of Zeus and Hera: ACT and Schema-Focused Therapy for Narcissistic & Borderline Personality Disorder

  1. 1. The Children of Zeus and Hera ACT and Schema-Focused Therapy for Narcissistic & Borderline Personality Disorder David O. Saénz, PhD, EdM, LLC Clinical & Forensic Psychology 1000 Brooktree Rd, Ste 209 Wexford PA, 15090 412.853.2000 www.wexfordpsychologist.com e: dosaenz@psych-consulting.com
  2. 2. Designed for this guy
  3. 3. A word of caution: disturbing photos
  4. 4. AUTHOR NACE DEJONG BROONER MORGEN -STERN BROONE R ROUNSA- VILLE KOKKEVI DRIESSEN VERHEUL BOWDEN-JONES ZIKOS CASSADIO Year 1991 1993 1993 1997 1997 1998 1998 1998 2000 2004 2010 2012 Substance Alcohol -Drugs Alcohol Drugs Drugs Alcohol Alcohol- Drugs Alcohol- Drugs Drugs Alcohol Alcohol- Drugs Alcohol Drugs Alcohol Alcohol- Drugs Sample 100 178 86 203 366 716 370 173 250 370 64 216 138 320 Setting In In In Out In – Out Out In – Out In – Out In In – Out Out Out Out Out Instrument Scid Sidp Sidp Scid II Scid II Scid II Scid II Scid II Ipde Scid II Pas-Q Pas-Q Scid II Scid II Prevalence of PDs 57.0 78.0 91.0 37.0 57.9 34.8 57.0 59.5 33.6 57.0 53.2 37.0 59.0 62.2 Cluster B 30.0 – – 37.7 – 45.7 48.6 7.6 45.7 24.2 30.1 32.0 32.8 Antisocial 3.0 5.1 47.7 23 22.7 25.1 27 33.5 4.4 27.0 11.3 10.2 5.0 13.8 Borderline 17.0 17.4 65.1 7.9 22.4 5.2 18.4 27.7 3.2 18.4 9.7 7.7 13.0 15.0 Narcissistic 4.0 6.7 12.8 0.5 6.6 0.8 9.5 11.6 0.4 9.5 – – 7.0 2.5 Histrionic 6.0 33.7 64.0 3.4 4.4 1.4 11.9 11.0 0.8 11.9 3.2 3.6 – 1.5 Principal studies in literature regarding the prevalence of PDs in substance addicted patients
  5. 5. Humans have been storytellers for thousands of years. To understand NPD and BPD, one must experience it in stories Stories are a medicine in most cultures
  6. 6. Borderline Personality Disorder
  7. 7. Fears of impending separation or rejection, intolerance of being alone What to look for: -clingy, desperate to stay connected -anger when partner/other leaves - Being alone creates great anxiety, tends to drink, abuse substances, spend, become sexually promiscuous to self soothe
  8. 8. Recurring thoughts or threats of suicide
  9. 9. Unstable and intense relationships marred by extremes of idealization and devaluation, closeness and separation
  10. 10. Unstable self image or sense of self.
  11. 11. Highly impulsive -e.g., spending, sex, substance abuse, binge eating, reckless driving
  12. 12. Dramatic shifts in affect and reactivity- e.g., intense episodic dysphoria, irritability, or anxiety
  13. 13. Self-harming behavior, such as cutting or hitting self
  14. 14. Chronic feelings of emptiness
  15. 15. Transient, stress-related paranoid ideation or severe dissociative symptoms
  16. 16. Hieronymus Bosch Painter(c. 1450–1516)
  17. 17. Inappropriate, intense or difficulty controlling anger (e.g., volcanic tantrums, steam-pot/kettle anger, recurrent physical fights)
  18. 18. Transactional Analysis model
  19. 19. Chaotic Childish Clingy Cranky Demanding Desultory Going to Extremes Adoring and Contemptuous Fickle Flighty Fragile Hostile Importunate Inconstant Irritable Manipulative Mercurial Moody Possessive Reckless Seductive Shallow Unpredictable Unreasonable Vehement Volatile Clinicians have described BPD traits as being willfully imposed on others, rather than symptoms of an illness: --Michael H. Stone, MD
  20. 20. However, this is how people with BPD describe themselves: Feeling completely overwhelmed by life…worthless…hollow/empty… misunderstood… thinking that no one cares about me…want to kill myself every day…believe I am evil or rotting inside. I feel like an infant, always needing to cry because it hurts inside…feeling damaged or soiled inside…alone… unlovable… not able to love because I can’t control my rage and emptiness …abandoned…hate- filled…empty to my core.
  21. 21. The art and skills of letting go
  22. 22. Narcissistic Personality Disorder
  23. 23. A desire for unwarranted admiration: What to look for: -fragile self-esteem -preoccupation with the opinions others have of them -expectation of others to covet their belongings and achievements -fishing for compliments -highly pious
  24. 24. A fixation with fantasies of infinite success, control, brilliance, beauty, or idyllic love What to look for: -comparing themselves to famous or prestigious/privileged people -believing they know more than others -a need to be right or have last word - Tossing in statements about having more than others or being more intelligent
  25. 25. A belief that he or she is extraordinary and exceptional and can only be understood by, or should connect with, other extraordinary or important people or institutions What to look for: -excluding others because they are not good enough (looks, money, fame). -saying they can only be understood by important and/or approved people -placing a high value on the people chosen to associate with (name droppers) -insisting on always having the “best” individual provide services for them (teacher, doctor, etc.)
  26. 26. Resentment of others or belief that others are resentful of them What to look for: -Constant competition with others -Repeated negative comments about other’s looks, status, education, common sense Every other therapists has sucked
  27. 27. A sense of entitlement What to look for: -clients who expect others to cater to them -belief that the work they do is “very important” and others should help them unquestioningly, or should look up to them -believing that others and life owes them -mistakes made or problems are because of others
  28. 28. A display of egotistical and conceited behaviors or attitudes What to look for: -boastful, pretentious behavior -surprise or anger when they don’t receive praise -minimizing the efforts and contributions of others -pointing to their own accomplishments, exaggerating accomplishments
  29. 29. Other Characteristics • “Haunted” by criticism. Flight, fight or freeze under scrutiny or criticism • Intolerance to humiliation • Severely impaired relationships • Highly fearful of failure or being out of control
  30. 30. Covert NPD 1. Quiet Smugness/ Superiority (“One cries because one is sad…I cry because others are stupid, and that makes me sad.”) 2. Self-Absorption 3. Lack of empathy (“You’re sick? But what about driving me to the movies?”) 4. Passive-Aggressiveness
  31. 31. Overt narcissist What to look for: 1) will openly intimidate, diminish and slander others 2) rage just beneath the surface 3) openly manipulative and oppressive 4) will question your therapy technique, process, outcomes, intent
  32. 32. Covert NPD- What to look for: 5. Highly Sensitive 6. The “Misunderstood Special Person” 7. Impersonal and Difficult Relationships 8) Depressed and often withdrawn, and projects these feelings on to close intimates in withholding and passive aggressive ways (often very quiet, “vulnerable” when moving in) 9) Often anxious, pessimistic, unmotivated, and blames his or her past for insecurities and inadequacies
  33. 33. In-session behaviors: -gaslighting- nope, never said that - fantasy based thinking - lies and distorts facts - emotionally distant and unavailable - difficulty accepting responsibility -no shame or embarrassment over behavior -poor boundaries
  34. 34. Parasitic Narcissist - “needs” to be taken care of -feed off their host -often sickly or need to be nursed -often partner with an overt narcissist, or empaths with means
  35. 35. High (competent) vs. Low functioning (incompetent) Narcissism
  36. 36. Counter- dependency: -fear/rejection of intimacy -forced tethering of other -others as sin eaters
  37. 37. Interpersonally oppressive and manipulative behavior with no empathic ability What to look for: -treating others as if life is a chess game -no empathy for others -exploits others for own gain -Divides family and friends into camps to take advantage of them -if they can’t overcome a person, will get others to do so to discredit them -forming relationships that simply enhance their self-esteem -being greedy with material resources
  38. 38. And Aaron shall cast lots upon the two goats: one lot for the LORD, and the other lot for Azazel. — Leviticus 16:8, Jewish Publication Society (1917)
  39. 39. Greeks scape-goating of “beggars and cripples”
  40. 40. Beheading the Blacksmith of Balkh
  41. 41. The Sin Eater
  42. 42. A Side Note…Don’t toss the word out like it’s M&M’s-NPD is only a Disorder when the characteristics are inflexible, maladaptive, and cause significant impairment or distress.
  43. 43. Jürgen Habermas Pedal points as a lens and definer of reality
  44. 44. A schema is a: • stable network of core beliefs (“I’m no good”), • conditional beliefs (“If people get close to me they’ll discover the “real me” and reject me”), • interpersonal strategies (“I’ll be charming to hide my faults”), • assumptions (Someone who loves me will know what I want and do it without my having to ask them” and “If he’s upset with me, he’s rejecting me”).
  45. 45. Schemas expands CBT/REBT theory -rather than purely cognitive in nature, they also include memories, images, emotions, and somatic sensations. -Maladaptive schemas are created when basic needs are not fulfilled during childhood. The schemas then prevent emotional/ psychological needs from being satisfied in adulthood.
  46. 46. Schema perpetuation --automatized daily processes by which schemas function and maintain themselves.
  47. 47. Schemas intensify information that are supportive and deny/reject facts that contradict. Destructive behavior patterns maintain the schema
  48. 48. Core emotional needs most humans have: • secure attachments, safety, stability • autonomy, competence, sense of identity • freedom to express needs and emotions • spontaneity and play, realistic limits and self-control
  49. 49. Jürgen Habermas Goals of Schema Therapy • To strengthen Healthy Adult mode • weaken Maladaptive Coping Modes • to break schema-driven life patterns • to get core emotional needs met
  50. 50. Schemas (road maps) guide behavior, how you see yourself and how you see the world/others. A schema of: -Cops will shoot you if they catch you would lead to____? -It’s dangerous to trust others would lead to________? -Everyone I see is there for the taking and using would lead to_____? -People are all basically good? Bad? - Black folk, Muslims, Hispanics, White folks are bad=
  51. 51. Early Maladaptive Schemas: a. are pervasive and enduring themes or patterns b. have their origins in early adverse experiences 3. are elaborated over the course of a lifetime 4. are highly dysfunctional
  52. 52. 5 Schema Domains 1. Disconnection and rejection 2. Impaired Autonomy and performance 3. Impaired Limits 4. Other directedness 5. Over-vigilance and Inhibition
  53. 53. Schema Domain: Disconnection & Rejection -Abandonment/Instability -Mistrust/Abuse -Emotional Deprivation -Defectiveness/Shame -Social Alienation/Rejection
  54. 54. Impaired Autonomy & Performance -Dependence/Incompetence -Vulnerability to Harm/Illness -Enmeshment/undeveloped self -Failure
  55. 55. Schema domain: Impaired Limits • Entitlement/Grandiosity • Insufficient Self-Control/Self-Discipline
  56. 56. Schema Domain: Other-Directedness -Subjugation -Self-Sacrifice -Approval- Seeking/Recognition- Seeking
  57. 57. Schema Domain: Over- vigilance & Inhibition -Negativity/Pessimism -Emotional Inhibition -Unrelenting Standards/ Hyper- criticalness -Punitiveness
  58. 58. Counter-productive strategies for coping with unhelpful schemas -Surrendering (giving in) -Compliant and dependent (clingy) -Avoidance (running away) -Substance misuse
  59. 59. Excessive Self-Reliance Manipulation Perfectionism Demandingness
  60. 60. •-Social/emotional detachment •-Stimulation/workaholic •-Overcompensation (fighting back) •-Aggression
  61. 61. Schemas are not stored through logic, but in an emotional part of the brain called the amygdala The Amygdala Hijack
  62. 62. The flight/fight/freeze/fawn response triggered by the Amygdala can take 30 milliseconds and can hijack” the rational, thinking response, which can take 250 milliseconds.
  63. 63. Note—there is no thinking occurring in this process
  64. 64. 6 steps to overcoming schemas • Uncover schemas • Identify maladaptive coping habits • Identify core values and beliefs about relationships • Learn to observe and accept painful schema driven or grounded thoughts • Turn values and ideas about who they want to be in a relationship into action
  65. 65. Uncovering schemas
  66. 66. Identify maladaptive coping behaviors
  67. 67. TRIGGER SITUATION FEELING THOUGHTS Husband is playing video games while the children watch TV, the house is a mess, dinner has to be made by you still. Helpless, emotionally drained and exhausted, angry and disappointed What a sloth, lazy SOB! I married the wrong guy, same issues as before. What’s wrong with me that I’m still here. I’m stuck. Nothing I do will change this.
  68. 68. Schema Coping Behaviors Worksheet Schema Triggering situation Schema coping behavior Visualize situation/live it Notice emotion or feeling Notice any action impulse that surfaces What does client want to do with coping pain? What does client actually do? Husband is playing video games while the children watch TV, the house is a mess, dinner has to be made by you still. Start yelling at husband, walk out in anger. Shut down. Leave house and smoke weed or drink. Stay out until 12AM. Son sarcastically responds when I try to talk to him . Raise my voice, curse, put my finger in his face, tell him he’s an ingrate and rude. Get angrier, explode. Attack and find something wrong with him Wife not listening when I talk Go quiet, shut her out, leave room, ignore her for the rest of the evening, yell at her when she tries to make up Boyfriend wants to spend time with his friends Sulk, beg him to stay, cry, become clingy. Then get angry and kick him out because he doesn’t love me enough.
  69. 69. Assessment of costs -Describe the outcomes you’re having with this coping behavior. -Do your coping behaviors help or hurt you? -Can you provide a little more detail on how they help or hurt your relationships?
  70. 70. Schema Coping Behaviors Worksheet Schema coping behavior What I did with emotions Costs of schema behaviors and emotions? Start yelling at husband, walk out in anger. Shut down. Leave house and smoke weed or drink. Stay out until 12AM. Become more depressed, self isolate, reject family when they approach Others are hurt and withdraw from me. Arguments increase. Family starts to not trust me and begins to walk on eggshells. Yelled at wife. Told her she was an idiot. Walked away and sulked all day. Ignored/avoided her. Slept in guest room. Projected it towards my wife and children. Felt guilty about behavior after the fact. Lost day with her. Lost day to enjoy off. Wasted emotions hurt both of us. Slept alone!
  71. 71. Assessment of costs: What are the main thoughts and feelings showing up in your life today that are problematic for you?
  72. 72. Where do you feel them (your thoughts and feelings)?
  73. 73. The quality of your life is based on the quality of your emotional mind.
  74. 74. ACT’s Creative Hopelessness- the moment a client sees the price of their choices
  75. 75. Creative Hopelessness Worksheet 1 Write down all of the issues, struggles, events, and negatives that occur throughout your day or week Write down every solution you’ve tried over the last year to solve these issues. Summarize the costs of your solutions over the past 2 weeks.
  76. 76. 1) How long the struggle has been there for you and reflect on the feeling of being in this struggle. 2) Write a paragraph on your experience of being stuck in the struggle. 3) Reflect on the costs that you have experienced as a result of being stuck in the struggle. 4) Describe some of those costs and how you have felt as a result. 5) Now, monitor your negative experiences such as bad moods or negative thoughts. When these experiences are present, notice what it is that you try to do to deal with these experiences. Take notes regarding these efforts. However, don’t try to change anything at this time. If nothing happens on a particular day of the week, leave the boxes blank. Hopelessness Worksheet 2: Being stuck-Between now and the next session, I would like you to spend time noticing that you’re stuck. Notice:
  77. 77. Sometimes hope creates hopelessness… and hopelessness is your best hope.
  78. 78. I can’t have you feel your way to a new behavior, but I can easily have you behave your way to a new feeling
  79. 79. Rabbi: “Most of us waste our lives trying to avoid suffering. Instead, we should wrestle with our suffering and refuse to let it go…”
  80. 80. The 3 R’s of Habit Change-Every habit you have — good or bad — follows the same 3–step pattern: 1)Reminder (the trigger that initiates the behavior) 2) Routine (the behavior itself; the action you take) 3) Reward (the benefit you gain from doing the behavior) James Clear
  81. 81. Show me your habits and I’ll predict your future ( Tom Ferry
  82. 82. 2. Increase your habit in very small ways. Success is a few simple disciplines, practiced every day; while failure is simply a few errors in judgment, repeated every day. —Jim Rohn One percent improvements add up surprisingly fast. So do one percent declines. James Clear
  83. 83. 2. What action is taken 3. Result from action 4. Reinforces or undermines their belief- can create habit over time 5. Ritual or pattern repeat leads to stronger or weaker potential & belief 1. Strength of potential & belief Client complains they can’t do it or it’s too hard High potential & belief + high positive action = better result >75% of time High potential & belief + low action = poor result >75% of time Low potential & belief + low action = poor result >90% of time Low potential & belief + no action = poor result >95% of time
  84. 84. Assessing Barriers Worksheet Intention (commitments to self to do what matters) Emotional Barrier Cognitive barrier THE COMMITMENT: I will do this because it’s important, because the old ways of coping are damaging to me and my relationships, and because there is a better way to lead life. Fear I might lose my job. Fear I might be alone. Review these commitments in every session to see if there is a change, to motivate, and to help direct focus.
  85. 85. Event Schema emotions Schema thoughts Physical sensation Schema urges or impulses How did you react or respond What was outcome? Any costs or benefits? Did you see any fluctuations in your thoughts or feelings throughout the day? Notice waxing and waning of feelings, thoughts and sensations. Focus on choices you can make.
  86. 86. Schema analogies: Schema feelings are like the weather. Some days it rains, other days you have sun, or snow. If you wait it out, it changes.
  87. 87. Schema analogies: Thoughts are like buses (fear, anger, anxiety, avoidance)… you choose which one to ride and you choose when to get off
  88. 88. Schema analogies: Negative thoughts & feelings are like bullies on a playground
  89. 89. Schema analogies: Every day we have >60,000 thoughts and emotions. Where do we focus…or do we focus?
  90. 90. The key— observe and wait vs. resist and fight
  91. 91. Mindful focusing— learning to observe
  92. 92. Mindful focusing exercises
  93. 93. Practice observation with triggering imagery
  94. 94. Contrast value based behaviors against SCB’s (Schema-based behaviors)
  95. 95. Building thought awareness- mind as popcorn machine
  96. 96. Resisting/arguing with thoughts is akin to tug of war—the more you struggle, fight with, try to refute-- the more it is able to create new thoughts to counter. It will win!
  97. 97. Thoughts as sales-people at car show- no need to buy every car with a beauty/hunk showcasing it
  98. 98. Cognitive Defusion: 1) observe 2) label 3) release/let it go (Titchener’s repetition; NLP pulling thoughts out to observe)
  99. 99. Observer self is akin to a movie--- client is writer, casting director, costume creator, main actor, producer, executive director, sound mixer, etc. Client is also the screen where movie highs and lows, emotions, high speed chases, crime, love stories, all take place simultaneously and no one scene is static.
  100. 100. Feelings and thoughts are like pawn pieces on chessboard…they are constantly moved and repositioned
  101. 101. 4 critical questions: 1) How old is this thought 2) What is it’s function/purpose 3) How well is it working for you 4) Are you OK with having this thought and sill acting out your values
  102. 102. Applying Schema- Focused Therapy- 6 key processes
  103. 103. Creative Hopelessness- when to use: - Avoidance or change a tough experience - When schema coping behaviors are used
  104. 104. Creative Hopelessness- how to use: 1) Identify maladaptive coping behavior 2) Explore outcomes of behavior 3) Ask for when this has occurred in the past 4) Challenge to step forward, experiment for a day, week…
  105. 105. Defusion- the mind can be overprotective, domineering, critical, ruminative, shame-based and hypervigilant. Thank you mind for that thought
  106. 106. Defusion exercises- how to: -Tichener’s Repetition -Physicalize thought -Card carrying member -Wear a sign all weekend
  107. 107. Head-on facing of schema emotions -Recall recent event -Notice body sensation -Take note of actual schema emotion, label it -Notice and label thoughts -Notice any action urges -Notice urges to block emotion -Stay in the moment, stay with exposed sensation in all spheres and describe each wave
  108. 108. Head-on facing of schema emotions- extend exposure to present day emotion and situation 1) Notice and resist urge to engage in any SCB 2) Take break from stimuli ASAP 3) Observe emotions, stay with them until they can be accepted and not resisted 4) Connect urges to values based behavior 5) Move towards values based behavior 6) Assess outcome, make adjustments
  109. 109. Exposure Record Emotion Trigger Exposure type (IB or PM) (Imagined or Present moment) Outcome Proposed change based on values Questions to ask self: --Did you feel accepting and less avoidant of emotion? --Did the emotion morph or stay the same? --Did you find yourself getting used to the emotion? --Did you act on urges? If so, was the action values based on Schema based? --Has anything changed in your relationship t the emotion? Describe in detail.
  110. 110. When you feel triggered: FACE - Feel - Accept - Call thought a name—ID it - Express intention based on your values
  111. 111. FACE card F: Name feeling A: Do you accept this feeling? Y/N Describe feeling C: Name the thoughts that came up E: Name your intention at the time. Did you follow your intention? What was the outcome? Does the outcome align with your values?
  112. 112. Getting at the truth What I do & say when triggered What I would rather do or say next time What I really want you to know
  113. 113. What I would rather do or say What I really want you to know What I do & say when triggered
  114. 114. Snakebites and life
  115. 115. A feeling only has one purpose… to be felt.
  116. 116. Trapped in a BOX we call PAIN •3 Pains: •Physical sensations •Emotions we have about pain •Psychological- the story we tell ourselves/others •Pain is there whether we remove bandage quickly or slowly
  117. 117. Pain Equation: Suffering = Pain X Resistance (S=PxR ) “Pain is inevitable… suffering is optional.” Haruki Murakami
  118. 118. Never stop growing EDGE

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