Antisocial, Borderline, Narcissistic and Histrionic Workbook: Treatment Strategies for Cluster B Personality Disorders

243 Pages·2015·3.01 MB·English

by  Daniel J Fox

Developed from years of experience ANTISOCIAL
working with complex and challenging
clients, Daniel J. Fox, PhD has created BORDERLINE
the ultimate workbook for clients
and clinicians coping with antisocial,
NARCISSISTIC
histrionic, narcissistic and borderline
personality disorders. ANTISOCIAL
& HISTRIONIC
Utilize unique worksheets, checklists
and other exercises to diagnose, tackle
WORKBOOK
specific issues, reduce problematic
symptoms and kep therapy moving BORDERLINE
forward. Take advantage of concrete
methods to:
• Reduce self-mutilation and other risky behaviors
NARCISSISTIC
• Improve attachment, collaboration, and trust
• Conquer maladaptive beliefs and diffuse narcissistic resistance
• Assess transference/countertransference issues
• Determine narcissistic drives for perfection and excellence
• Lesen flirtatious behaviors & HISTRIONIC
• Apply DBT strategies and skills into treatment
WORKBOOK
“Enthusiastically recommended!”
– Lane Pederson, PsyD, LP, DBTC, author of
The Expanded Dialectical Behavior Therapy Skills Training Manual
Daniel J. Fox, PhD, has been specializing in the treatment
and assessment of individuals with personality disorders for over 16 years
in the state and federal prison system, universities, and private practice.
He is currently a staff psychologist at the Federal Detention center in
Houston, Texas. His first book, The Clinician’s Guide to the Diagnosis
and Treatment of Personality Disorders, was published by PESI in 2013. T rea t men t S t ra te g ie s Fo r
Cl u s te r B Pe r sonal i t y Di so r de r s
PUB083610 $29.99 Wo r k shee t s • A s se s s men t s • Exe r c i se s
PESI Publishing & Media
www.pesipublishing.com 9 781559 570183 Daniel J. Fox, PhD
ANTISOCIAL, BORDERLINE, NARCISSISTIC & HISTRIONIC WORKBOOK FOX
ANTISOCIAL
BORDERLINE
NARCISSISTIC
& HISTRIONIC
WORKBOOK
Treatment Strategies For
Cluster B Personali ty Disorders
Daniel J. Fox, PhD author of The Clinician’s Guide to the
Diagnosis and Treatment of Personality Disorders
“Personality disorders are common in clinical practice, but helpful resources are not. Dr. Fox answers the call
with a workbook that will deepen your understanding of the assessment and treatment of Cluster B personalities,
with a dedicated emphasis on handouts and worksheets that guide therapy and provide a catalyst for change.
Enthusiastically recommended!”
-Lane Pederson, PsyD, LP, DBTC, author of
The Expanded Dialectical Behavior Therapy Skills Training Manual
“Full of concrete tools to make successful progress in treatment! The research provides a great foundation for the
use of the materials and Dr. Fox has pulled from multiple resources to create tools clinicians and clients can both
use to promote wellness and growth. I have found that the use of the workbook can be applicable in nearly every
session I have with someone battling with a Cluster B personality disorder. After applying the concepts in this
workbook I have found that Cluster B clients are not the same beasts in treatment that they were in the past.”
-Susan Barris, PhD
“Insightful for the therapist and easy-to-use with clients. The worksheets are very effective in assisting with a more
accurate diagnosis of Cluster B personality types and, even more importantly, understanding the therapists own
responses to the client. This workbook is also helpful when needing to incorporate more tangible and structured
treatment approaches into therapy. The DBT worksheets are easy to follow and use “client friendly” language and
concepts.”
-Meagan N. Houston, PhD
“The collection of exercises for the clinician and the client are practical, useful, and empirically driven. This is a
well written, easy to read, and thorough guide providing a framework and a level of confidence for the clinician
facing the challenges of treating severe personality disorders.”
-Kristy Dromgoole, PhD
“This rich resource assists the clinician in avoiding errors in diagnosis that can often occur when working with
clients with complex symptom presentations. Dr. Fox presents the material in a straightforward, easy to digest,
manner that can be appreciated and utilized by all practitioners. Clinicians, regardless of their training background
or theoretical orientation, will find this to be an invaluable resource in the diagnosis and treatment of Cluster B
personality disorders.”
-Mary Madison Eagle, PhD
“Dr. Fox's passion for this subject shines through in the workbook format. This workbook can serve as both a
reference and a helpful tool for gathering information. Dr. Fox’s style of writing is clear and concise. I was able
to take in the information quickly and see how useful the worksheets could be.”
-Kristin A. Lue King, MSW
Copyright © 2015 by Daniel J. Fox, Ph.D.
Published by
PESI Publishing & Media
PESI, Inc
3839 White Ave
Eau Claire, WI 54703
Cover : Amy Rubenzer
Editing: Blair Davis
Layout: Bookmasters & Amy Rubenzer
ISBN: 9781559570183
All rights reserved.
Printed in the United States of America.
Library of Congress Cataloging-in-Publication Data
Fox, Daniel J., Psychologist.
Antisocial, borderline, narcissist & histrionic workbook : treatment strategies for cluster B personality
disorders / Daniel J Fox, Ph.D.
pages cm
Includes bibliographical references.
ISBN 978-1-55957-018-3
1. Personality disorders. 2. Personality disorders--Treatment. I. Title. II. Title: Antisocial, borderline,
narcissist and histrionic workbook.
RC554.F69 2015
616.85'81--dc23
2015029495
PESI
Publishing
& Media
www.pesipublishing.com
This book is dedicated to my three heartbeats: my wife, Lydia, and my two children,
Alexandra and Sebastian.
Table of Contents
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Who This Workbook Is For and How to Use It . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
Part One: Critical Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Personality Disorders—They’re Not Going Anywhere . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Cluster B Client Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Structure of Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Critical Factors in the Treatment of Histrionic, Antisocial, Narcissistic, and Borderline Clients . . . . 12
Personality Disorder Risk and Protective Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Part Two: Antisocial Personality Disorder Spectrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Antisocial Personality and Its Subtypes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Antisocial Personality Disorder—Homicidal Triad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Oppositional Defiant Disorder—Behavioral Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Conduct Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Antisocial Personality Disorder Core and Surface Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Attachment and the Antisocial Spectrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Antisocial Spectrum and Suicide Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Perception Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
How to Manage and Avoid In-Session Violence and Threats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Secondary Gain/Assertiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Can They Collaborate? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
The “Wrong-Patient Syndrome” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Can You Bond With a Client on the Antisocial Personality Disorder Spectrum? . . . . . . . . . . . . . . 54
Transference and Countertransference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Part Three: Narcissistic Personality Disorder Spectrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Narcissistic Personality Disorder and It's Subtypes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Harm to Self and Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Building Mastery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Attachment and the Narcissistic Spectrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Perfection Versus Excellence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Surmount the Power Struggle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Physical and Emotional Empathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Narcissism Key Target Areas for Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Maladaptive Beliefs About Self and Emotions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Defuse Narcissistic Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Avoiding Session Sabotage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Part Four: Histrionic Personality Disorder Spectrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Histrionic Personality and Its Subtypes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Histrionic Personality Spectrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Histrionic/Borderline Distinction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Attachment and the Histrionic Spectrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Histrionic Spectrum and Suicide Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Flirtation, Avoidance, and Inauthenticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Histrionic Client Dangers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Boundary Securement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Emotional and Behavioral Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
False Self/True Self . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Self-Worth Enhancement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Managing the Session With a Histrionic Spectrum Client . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
DBT: The Six Levels of Validation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Dependent Versus Independent Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Part Five: Borderline Personality Disorder Spectrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Borderline Personality and Its Subtypes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Borderline Personality Spectrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Distinction Between Borderline Spectrum and Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . . . 143
Lessening Self-Mutilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Attachment and The Borderline Spectrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Identifying the Transitional Object . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Concept of “IT” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Motivations and Triggers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Identifying Maladaptive Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Unconscious Wishes and Fears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Part Six: Dialectical Behavioral Therapy Worksheets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Mindfulness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Observe, Describe, Participate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Feel The Moment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Ready, Breathe, Draw . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Let It Melt (Chocolate!!!) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Participating to Do It Differently . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Interpersonal Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Healthy/Hopeless Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Steps to Conflict Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Wants-to-Shoulds Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Getting My Needs Met F-A-S-T . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Moving Beyond the Conflict: G-I-V-E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Get What You Want: D-E-A-R M-A-N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Emotion Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Primary and Secondary Emotions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Acting Opposite Emotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Negative Emotional Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Emotional Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Unhealthy to Healthy Coping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Distress Tolerance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Accept to Surpass (Radical Resistance) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Proof of Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Four Keys to Crisis Survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
viii T a b l e o f C o n t e n t s
Accepting Reality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Willingness Over Willfulness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Appendix A Answer and Scoring Keys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Appendix B Emotions List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
T a b l e o f C o n t e n t s ix