My Job: Dual Diagnosis Counselor at a Womens' Prison

Today's post is a little off topic, but today was the inmates graduation and being the emcee I posted about my nerves on Facebook and told my friends with an interesting response.  I have been working there for 8 months and it always seems to be an interesting topic to talk about with friends, family even strangers.  The reactions are mixed, but people have the same few questions so here goes.  If I seem vague it's because well it's a prison and although some information is open, certain some things are not.

• My job is Dual Diagnosis therapist, although not all my clients are what the program considers DD.  To them DD is MH medication+therapist+diagnosis of MH & Addiction.  The medication they can receive is not the same medication they often have Rx with their regular MH doctor.
• The programs main focus is substance abuse and they attend 16+ hours of group a week including cognitive skills, seeking safety, and process.  They learn a lot of skills for their recovery and must attend 2-12 step meetings a week.  
• We have a wait list of over one year most times, some of them are parole-board recommended- which translates that they need to complete the program.  
• The program is 6 months long.  There are reviews of their progress every 30 days- it's very time consuming.
• My caseload is about 20 people, although not all people graduate due to various reasons most are due to lying, manipulating and confidentiality.
• The "program" is all housed together- the rooms hold from 2-6 people, most are "2-man cells."
• We utilize a peer-support program which includes 10 "lifers," all which are murderers some of which have been incarcerated for 25 years.
• We are contracted by the state.
• A vast majority of these women have been the victim of horrific abuse as a child (often sexual,) abusive relationships, raped, started using substances around age 13 and have or in the process of losing their kids permanently.  Most would meet the criteria for PTSD.

Now to the questions people have most often:

• I always feel safe- the rare time I don't is when I am with general population and someone s cursing or yelling at someone else.  There are physical fights- but rarely .  There has been 1 in the 8 months I have been there, and I don't think there was more than one prior.
• The "lifers" and inmates in general are not scary or mean.  Part of it is because they in some way need the program to parole or stay out of another more-strict.more dangerous unit (or they have an extra 2 years+ typically.)
• Some do recovery- this is probably the #1 question.  Some come back.  We don't know statistics on how many, but I would assume half of them relapse on substances with in first 2-3 years.  If they relapse they often go to a different program, rather than repeating this one although we have had a few come back 5 years later.
• Half of my co-workers are in recovery, my boss has 33 years and my co-worker has 13 years clean! We had a counselor pass this year and she has 13 as well, she died due to complications from her Hep C she contracted at age 17 using heroin.
• It's very, very stressful- these women have been through so much and get "caught up" in what we call "prison bullshit," relationships, manipulation and lying to staff.  A lot of my time is spend in crisis mode, especially in the beginning of the 6 months.  
• I cry, I try not to and most of the time I am fine.  They write an autobiography about halfway through and share it with the group- it's all triggering.  Some stories don't affect me so much and then there are a few that keep me up at night, make me cry or change the way I look at the inmate.  These women have such strength and perseverance and their stories are so tragic.  
• We can't hug!  Nope, no touching on shoulder, no embracing at all.  This is a strict rule and could lead to termination.  It is difficult and un-natural at times, especially when someone comes to be on-on-one and tells me their child died in the streets selling dope or there mom has terminal cancer.  Life goes on while they are in jail and they often feel and are powerless.I am called by my last name only
• Yes, they eat crap.  Carb and calorie heavy food is the norm around here. They are allowed to work out at times and watch videos during the day.  There really isn't healthy options and most gain weight while incarcerated. Food is a commodity and is traded like cash.
• There are drugs in the prison.  Seems strange, but like all institutions there are drugs.  Most often it's Rx drugs that another inmate "cheeks" and sells, but there is also narcotics.
• 3" toothbrushes, and other strange things (to me) are used as if it's normal.  They are allowed to purchase (or someone purchases it for them) certain products these mostly include non-name brand lotions and such.  They are not allowed make-up (they use paint,) nail polish, headbands, etc.  Many still have them though.  A "full size" toothbrush that is easily 15 years old can go for $25.

That's all I can think of off-hand, I am open to answering any questions as I often think people think I work in one of those "reality" TV shows that fill prime-time TV now.  Here's a secret- the inmates in one of those shows is told to yell obscenities and appear aggressive for the cameras...I know I have 3 people in my group that were on it!

**Trigger Warning: There is a movie Sin By Silence (trailer here) which is a documentary about abused women who kill their husbands.  It's very sad, and triggering but very empowering as they work to change California laws and get out**

Is Mental Illness a Lack of Healthy Coping Skills?

I few months back I was at a 4-day training to learn about  a new group to work with the women in prison whom have violent pasts.  One of the members of the training introduced herself on day 1 to our table, she owned a residential drug and alcohol treatment center and had been using the new program at her site.  On the 4th day we had to do an exercise where we talked about something important to us to another member of our group.   She told me she did not believe in mental illness, thought the DSM IV-r should be "thrown out" and that all disorders were from a lack of coping skills.  I was dumbfounded, but she continued to explain using this analogy; someone whom is neglected as a child is going to need to find a different way to get their needs meet.  At age 2 that means having tantrums, crying excessively and being loud to get mom or dad's attention.  Age 6 may be ongoing conflict with other students to get teachers attention, age 10 bullying other students, being suspended in order to get attention and power, age 15 acting promiscuously to gain male/female attention and at 19 they will continue aggressive behaviors, possibly use substances and have abusive relationships.  At the time I thought this woman was way off base, how can mental illness be from a lack of coping skills?

It has been 2 months and although I believe in mental illness, chemical imbalances and medication, I can see how especially with those with personality disorders how this algorithm works:

Invalidating Environment+Trauma+Lack of Coping Skills= Personality Disorder

I often talk on here and on Twitter about how many women are misdiagnosed have trauma and/or anger issues, instead of BPD.  Someone on Twitter told me last week she was diagnosed with Bipolar, Schizoaffective disorder and attended anger management classes for years and was medicated for such and just found out her "only" diagnosis was Borderline Personality Disorder.

As someone without a mental illness, it is difficult for me to fully comprehend what the experience of having one is like.  I grew up in a mostly validating environment, the trauma I did experience was immediately remedied (due to the validating environment) and I was taught coping skills.  I can remember having anxiety and trouble sleeping as a adolescent and my mom teaching me mindfulness techniques, validating my feelings, normalizing the stress of that age and giving me tapes she has bought to help, while my dad made me chamomile tea and listened to my woes.

More than any other post I would really like feedback from the Borderline Personality Disorder Community about how accurate this "formula" sounds to your life experiences.

Why I Became a Therapist?

This week a client in my group asked me how old I was.  I didn't even think before responding "29."  All the Graduate School training about boundaries and "turning the question" to "Why is that important to you?" went out the window quickly.  Later in the day when another person (not in my group) said "you are only 29!" I realized maybe I shouldn't be answering questions about my private life.  Then I meet with my one Borderline Personality Disorder client and hand her the DBT manual and give her the overview of DBT and say to her "DBT is collaborative between myself and you, so come directly to me with any questions you have."  I set up a weekly time to see me and walk back to my office thinking..."collaborative."  DBT is very collaborative and much time is spent on the relationship of both the client and the facilitator (individually and as a team.)  I remember using some personal examples in a DBT group a few years ago and made huge strides with my own "issues" facilitating DBT.

I tell you all this to share with you the question I get asked most often by clients, "What made you decide to become a Counselor?"

It was my last year in Undergrad and I was about to graduate with a degree in Legal Studies, had taken the LSAT's and was about to apply to Law Schools

Just like DBT, there is no black and white and no one answer for this question, but here's how the formula worked for me:

20% My own personal issues, without getting into too many details I had experienced my own trauma in my life as an adolescent and had been through therapy at age 10 for this as well as a few bouts of depression and anxiety in my young adulthood.

20% This was a few years after 9/11 and was still deeply affected by it (still am, if I am being honest with myself.)  I was a participant in a PTSD study from a major university where I took PTSD tests at intervals for a few years and although I never got results, with 1 psych class under my belt knew I probably meet the criteria.

60% My room mate at the time, was my best friend for 10 years when we moved in together at age 22.  I had known her family had a huge mental health history, including a grandfather whom killed himself as well as  a mother whom was unable to work and debilitated by even the smallest tasks.  After a few years (and a lot of therapy) we decided it would be a great idea for us to live together in Manhattan.  Things went well for almost 6 months and then she essentially "cracked,"  without getting into details she became psychotic  thought I was trying to kill her, would accuse me of things I didn't do, and attempted to take her life with pills.  (Remarkably she is fine now, turned out to be a rare blood disorder and she takes medication for it and has not had any issues since.)

I took a Psychology class my 2nd to last semester to fulfill a requirement and the more I thought about applying to Law School, the bigger the stack of unfinished applications sat.  I clearly had a lot of resistance to the path I had created for myself in Junior High School when I first thought about Law School.  The Psychology class had me hooked from day one; the professor was a PhD student studying Criminal Psychology and worked at Riker's Island, one of the largest men's prisons in the U.S.  I immediately choose my plan of attack; I cornered her after class and asked her questions about what she did.  Her job at the prison was to assess male inmates to determine if they could stand trial.  After 1 hour, in which I completely took over the conversation and violated her boundaries I decided that is what I wanted to do.  A few hours later I was at home googling what education I needed.  Within a month I told the boyfriend I was moving to Portland, Oregon (he did come with me-although it didn't work out,) enrolled in 3 extra psychology classes and had 3 very part-time volunteer jobs in order to meet the application requirements.

I currently work at the states only women's prison, as the Dual Diagnosis counselor in a unique intense 6-month program focused on addiction and criminality.  It is amazing to think to yourself "How did I get here?" and I am glad I took a leap of faith 8 years ago.

Here is a picture of me packing/driving/moving across country (again) to Michigan, where I am now.

What is it like to be a DBT Counselor?

When other counselors find out my specialty is Dialectical Behavioral Therapy (DBT) and Borderline Personality Disorder (BPD) I am often looked at with disbelief.  The stigma is still there and I have been told there is something wrong with me to want to work with "the hardest group of people there is in mental health."  I sometimes find myself having to explain that "Borderlines" are not bad people, the stigma isn't true and those seeking services are looking to change.  So, what is it like to be a DBT counselor?

First off I have done DBT groups for almost 2 years, as well as phone coaching, group consult and individuals, not all the clients have been identified as BPD.  Most of this is because BPD isn't covered by insurance.  The following is what it is like, both good and bad about running a DBT group. I understand each group is different and forms it's own culture.  Here is a list of my experiences as a DBT counselor.  The following is my opinion in it's most blunt form.

• Some DBT clients will hold counselors accountable.  The group was 2 hours long with a 10-15 minute break, the one time we (co-facilitators) were late we were asked to apologize by multiple members of the group.

• Some DBT clients are initial combative regarding "changing their ways."  I have been open about this in the first session of group.  DBT is hard to initially get into, first off what you have been doing is ineffective and here some tools to get you to be more effective.  Some clients get upset, over personalize and feel judged by this.  I have had 1 person cock back his fist to hit me (security guard grabbed him by his hood and pulled him back), 1 person curse me out then protest outside with a sign and 2 threatened lawsuits. Resistance is part of the norm for DBT groups, although it can be both uncomfortable and triggering for others.

• Some DBT clients have issues with the Zen Buddhist part.  I have had numerous clients have huge issue with the non-Christian base for DBT.  Even the idea of mindfulness or regulating your breathe has drawn criticism.  At one point we as co-facilitators had (per higher up staff) to allow clients to choose to be in the mindfulness exercise that took up the first 10-15 minutes due to a pending lawsuit.

• Some DBT clients often need concrete examples to understand DBT.  This includes a 2 hour session just to cover the definition of dialectics.

• Some DBT clients with addiction issues are often the "best" clients in group; the most engaged and the most honest.  I think part of this is due to how open 12-step groups are and how much they have shared in the past.

• Some DBT clients find it difficult not to get "stuck in the story," and it is often hard to re-direct back to the skills they used when discussing diary cards. 

• In 2 years we "graduated" 2 people; with 8-10 people in the group at the beginning and slowly people dwindling down this was a remarkably small number of people.  I would guess in 2 years we had a total 40 clients start DBT.  Some of this was due to people "dropping out" due to scheduling conflict, insurance issues and attendance.

• In DBT women outnumbered men, men were more likely to "drop out" of the group and need more examples to understand concepts.

• Rarely did anyone use the phone coaching, although it was strongly encouraged.

I am a huge fan of DBT and am still a firm believer in how great it can be for all people.  I also will say that most of the clients were not like the bullets listed above; completed modules, grew and gained skills.  I still enjoy doing DBT and working with those with BPD, although running the groups can be very stressful at times.  Part of the problem with the agency I did DBT groups was economic as all the clients were on state insurance and their coverage would get dropped for various reasons.  We also didn't have a DBT team (just the 2 counselors who co-facilitated) and some of the other counselors/case managers did not understand DBT, so they weren't getting the one-on-ones focusing on DBT.  I will also admit we did a quick screening process for new clients, meet with them for 30 minutes and made sure they understood what they were going to begin- I think a lot of clients has heard of DBT from someone or read an article and were quick to sign up without truly understanding what DBT is.  I do take responsibility for some of these issues as well as some of the bullet points, including some of the client's behaviors.

I still recommend DBT to a lot of my current clients (incarcerated females with substance abuse issues) and feel it is the best chance of a successful life if you have BPD.  Feel free to leave any comment about your experiences in DBT groups or any questions about DBT or BPD.

Bipolar vs. Borderline?

One of the joys of my job is that I diagnosis clients with mental illness, I find it necessary for someone to have the right diagnosis in order to move forward with treatment.  I often explain Mental Health diagnosis's as looking like a Venn Diagram with much overlap and often very little differentiation.

The tricky part is the past diagnosis's the clients have had.  There have been multiple clients that when I asked for current diagnosis they listed 5 contradicting diagnosis and the more I probed and speak with them the more it looked like 1 or 2 total.   This all brings me to a point regarding Bipolar  Borderline.  Most of the women that I have meet whom are diagnosed as Bipolar are not.  When I ask for mania symptoms they tell me things such as "I yell at my teenage son," "I blow up at my husband," "I get so angry I...." or "Sometimes I just don't want to talk to people and hide."  All of these are normal reactions for people with little/no coping skills.  I don't know anyone (even without a mental health diagnosis) whom wouldn't have at some point said yes to all 4.  I think this over diagnosis happens for a few reasons:

• Women are not suppose to get angry
• Anger in women sometimes feels like anxiety and a loss of control
• Psychiatrists don't know what Bipolar really is diagnostically
• Mood swings are viewed as "rapid cycling"
• It's easier to medicate a disorder than help someone with coping skills

For these reasons I take a lot of time and consideration into diagnosing women with Bipolar, especially those with trauma and abuse in their history.  Many of these women more likely have Borderline Personality Disorder (I am unable to "officially" diagnosis Axis II because of other reasons) and Post Traumatic Stress Disorder.  

Here are the difference between Bipolar and Borderline Personality Disorder (via Psychology Today article )

1. People with BPD cycle much more quickly, often several times a day.

2. The moods in people with BPD are more dependent, either positively or negatively, on what's going on in their life at the moment. Anything that might smack of abandonment (however far fetched) is a major trigger.

3. In people with BPD, the mood swings are more distinct. Marsha M. Linehan, professor of psychology at the University of Washington, says that while people with bipolar disorder swing between all-¬encompassing periods of mania and major depression, the mood swings typical in BPD are more specific. She says, "You have fear going up and down, sadness going up and down, anger up and down, disgust up and down, and love up and down."

*Do not diagnosis yourself-leave it up to the professionals*