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

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

3. Designed for this guy

4. A word of caution: disturbing photos

5. 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

6. 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

7. Borderline
Personality
Disorder

8. 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

9. Recurring thoughts or
threats of suicide

10. Unstable and intense relationships
marred by extremes of idealization
and devaluation, closeness and
separation

11. Unstable self image
or sense of self.

12. Highly impulsive -e.g.,
spending, sex, substance
abuse, binge eating,
reckless driving

13. Dramatic shifts in affect
and reactivity- e.g.,
intense episodic
dysphoria, irritability, or
anxiety

14. Self-harming behavior,
such as cutting or
hitting self

15. Chronic feelings of
emptiness

16. Transient, stress-related
paranoid ideation or severe
dissociative symptoms

17. Hieronymus Bosch Painter(c. 1450–1516)

18. Inappropriate, intense or
difficulty controlling anger
(e.g., volcanic tantrums,
steam-pot/kettle anger,
recurrent physical fights)

20. Transactional
Analysis
model

21. 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

22. 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.

23. The art and skills
of letting go

24. Narcissistic Personality Disorder

25. 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

26. 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

27. 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.)

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. High (competent)
vs. Low functioning
(incompetent)
Narcissism

39. Counter-
dependency:
-fear/rejection of
intimacy
-forced tethering
of other
-others as sin
eaters

40. 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

41. 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)

42. Greeks scape-goating
of “beggars and
cripples”

43. Beheading the
Blacksmith of
Balkh

44. The Sin Eater

45. 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.

47. Jürgen
Habermas
Pedal points as a lens and
definer of reality

48. 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”).

49. 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.

51. Schema perpetuation
--automatized daily
processes by which
schemas function
and maintain
themselves.

52. Schemas intensify information that are supportive
and deny/reject facts that contradict.
Destructive behavior patterns maintain the schema

53. 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

54. 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

55. 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=

56. 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

57. 5 Schema Domains
1. Disconnection and rejection
2. Impaired Autonomy and
performance
3. Impaired Limits
4. Other directedness
5. Over-vigilance and Inhibition

58. Schema Domain:
Disconnection & Rejection
-Abandonment/Instability
-Mistrust/Abuse
-Emotional Deprivation
-Defectiveness/Shame
-Social Alienation/Rejection

59. Impaired Autonomy &
Performance
-Dependence/Incompetence
-Vulnerability to Harm/Illness
-Enmeshment/undeveloped self
-Failure

60. Schema domain: Impaired Limits
• Entitlement/Grandiosity
• Insufficient Self-Control/Self-Discipline

61. Schema Domain:
Other-Directedness
-Subjugation
-Self-Sacrifice
-Approval-
Seeking/Recognition-
Seeking

62. Schema Domain: Over-
vigilance & Inhibition
-Negativity/Pessimism
-Emotional Inhibition
-Unrelenting Standards/ Hyper-
criticalness
-Punitiveness

63. Counter-productive strategies
for coping with unhelpful
schemas
-Surrendering (giving in)
-Compliant and dependent
(clingy)
-Avoidance (running away)
-Substance misuse

64. Excessive Self-Reliance
Manipulation
Perfectionism
Demandingness

65. •-Social/emotional
detachment
•-Stimulation/workaholic
•-Overcompensation
(fighting back)
•-Aggression

66. Schemas are not
stored through
logic, but in an
emotional part of
the brain called the
amygdala
The Amygdala Hijack

67. 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.

68. Note—there is
no thinking
occurring in this
process

69. 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

70. Uncovering
schemas

71. Identify
maladaptive
coping
behaviors

72. 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.

73. 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.

74. 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?

75. 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!

76. Assessment of costs:
What are the main
thoughts and feelings
showing up in your life
today that are
problematic for you?

77. Where do
you feel
them (your
thoughts and
feelings)?

78. The quality of your life is based on the quality of your emotional mind.

79. ACT’s Creative
Hopelessness-
the moment a
client sees the
price of their
choices

80. 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.

81. 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:

82. Sometimes hope
creates
hopelessness…
and hopelessness
is your best hope.

83. 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

84. Rabbi: “Most of us waste
our lives trying to avoid
suffering. Instead, we
should wrestle with our
suffering and refuse to
let it go…”

85. 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

87. Show me your habits and I’ll predict your future ( Tom Ferry

88. 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

89. 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

95. 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.

96. 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.

97. 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.

98. Schema analogies: Thoughts are like buses (fear, anger, anxiety, avoidance)…
you choose which one to ride and you choose when to get off

99. Schema analogies:
Negative thoughts &
feelings are like bullies
on a playground

100. Schema
analogies:
Every day we
have >60,000
thoughts and
emotions.
Where do we
focus…or do
we focus?

101. The key—
observe and
wait vs. resist
and fight

102. Mindful focusing—
learning to observe

104. Mindful focusing exercises

105. Practice observation
with triggering
imagery

106. Contrast value based behaviors against SCB’s
(Schema-based behaviors)

107. Building
thought
awareness-
mind as popcorn
machine

108. 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!

109. Thoughts as sales-people at car show-
no need to buy every car with a beauty/hunk showcasing it

110. Cognitive Defusion:
1) observe 2) label 3) release/let it go
(Titchener’s repetition; NLP pulling thoughts out to observe)

111. 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.

112. Feelings and thoughts are like
pawn pieces on
chessboard…they are constantly
moved and repositioned

113. 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

114. Applying
Schema-
Focused
Therapy-
6 key processes

115. Creative
Hopelessness- when
to use:
- Avoidance or change a
tough experience
- When schema coping
behaviors are used

116. 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…

117. Defusion- the mind can be
overprotective,
domineering, critical,
ruminative, shame-based
and hypervigilant.
Thank you mind for that
thought

118. Defusion exercises- how to:
-Tichener’s Repetition
-Physicalize thought
-Card carrying member
-Wear a sign all weekend

119. 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

120. 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

121. 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.

122. When you feel
triggered: FACE
- Feel
- Accept
- Call thought a name—ID it
- Express intention based on your
values

123. 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?

124. 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

125. What I
would
rather do
or say
What I
really
want you
to know
What I do
& say
when
triggered

126. Snakebites
and life

127. A feeling
only has one
purpose…
to be felt.

128. 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

129. Pain Equation:
Suffering = Pain X Resistance
(S=PxR )
“Pain is inevitable… suffering is
optional.” Haruki Murakami

130. Never stop
growing
EDGE