Ask Any DBT or BPD Questions This Weekend!

Hi All,

Quick note.  This weekend I will do a Q&A on twitter.  Feel free to ask me any questions about DBT or BPD.  Tweet them @apazma, DM me to be anonymous, e-mail or leave them in the comments below.  I will re-post all questions (minus names) here after I am done.

Great way to get some professional information!

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**

Profiles of Borderline Personality Disorder: Tess Smith

Misdiagnosis and Invalidating Environment

Tess Smith was diagnosed with Borderline Personality Disorder in 2006 after 16 years of treatment for dysthymia, anxiety, and obsessive compulsive disorder.  A misdiagnosis that resulted from her lack of trust in adults as a child, and miscommunication with therapists as an adult. "In 2006 my primary diagnosis was BPD in addition to depression, anxiety and OCD. I started seeing a therapist when I was 14, it took many years for them do diagnose me correctly because I didn't trust anyone enough to admit I was a cutter.  Growing up mental illness was not anything we talked about in my family. When I was first diagnosed (with depression, anxiety, and OCD) my mother didn't want to discuss it or even look into it. She told me I was “in control of my feelings” and I “just needed to get better”, so for many years it was a dark secret. I hid it from everyone, I didn't talk about it, and I sure didn't look for others like me. There’s a lot of shame in a mental illness diagnosis."  

Tess's secret kept her sick and her environment growing up was very invalidating, "my father died when I was 12, he was sick for years so growing up I wasn't close to any adults. We weren't able to ever express how we were feeling, it was always very important to look perfect. There were several situations in which I felt I had been lied to and my trust betrayed. I never felt like I could trust my mom, and her reaction to my initial mental illness diagnosis made it clear she wasn't going to be very supportive.” Tess's secret mental health issues continued throughout her teen and early adult years, " In my teens I never felt like I could talk to anyone about what I was doing without them telling my mother... and when I became an adult, no one ever came out and asked me if I was a self injurer."  It has taken Tess a long time to get to where she is today, “22 years of off and on therapy and prescriptions for Prozac, Wellbutrin, Remerol, Ambien, Xanax, Clonazepam, and Trazadone."

BPD and Stigma

In 2006 Tess found little information about her diagnosis online, "I had never heard of it... and when I found out what little there was out in the mainstream media about it - it wasn't easy to wrap my head around.   The movie everyone knows is Fatal Attraction... no one wants to be that crazy chick... and accepting the diagnosis is one of the hardest things - but the first step I think in getting better."  

Treatment & Hope

When she was diagnosed in 2006, she was referred to Dialectical Behavioral Therapy.  Unfortunately, the first class was full, then there weren't any that met her work schedule, and then she lost her insurance coverage.  When she again had coverage to attend DBT classes, she couldn't get time off of work to go. At that point Tess took her treatment into her own hands, "I did my own research and thank gods for the internet in 2011 because it gave me access to self help and the DBT tools I needed to at least get going. This is a long term thing… something I will have to manage for the rest of my life. Has it improved? YES! Simple skills I was able to find online have helped me when interacting with everyone and in almost every situation. My personal relationships have improved and are more stable and I find myself willing to put a little more of myself out there, in order to improve life. I do continue to take Prozac to alleviate the symptoms of anxiety and depression, but use DBT skills to manage my Borderline Personality Disorder."

Relationships

Along with Tess's new coping skills, she is also developing friendships, "I'm very careful with whom I let get close... I've surrounded myself now with a handful of friends who I depend on.  I'm better with some distance though... I don't talk on the phone or hang out - I text, IM online... I don't go out.  I am more comfortable when I can control my environment and who I am with.  I don't seem to have conventional relationships...I've been married 4 times, and the longest relationship I've ever had is with my cat."

Ongoing Struggles

For Tess the hardest part of her BPD diagnosis is the emotional dysregulation, "my rapid and intense mood swings. I go from loving the ground you walk on to 'I can’t stand the sound of you breathing' in 2 seconds flat.  It’s hard for me to pin-point what I'm feeling, and then I have to figure out why I'm feeling it... every swing is an internal dialogue.  It’s hard to just 'be'… it seems like I’m always trying to figure out what I’m feeling and if it’s appropriate.  I feel tired a lot."  

Successes

For Tess getting the right diagnosis made a big difference, "it helped because I finally knew what I needed to do. My life was always on reset about every 4 years; a new address, new husband, and a new job. I didn't feel like I could be anywhere for very long without destroying everything. I had a stressful job, the diagnosis made me realize that maybe I liked what I was doing but not the position I was in, because it was just too demanding. I’m not built for that kind of long term exposure to stress. I now have a career in the same type of industry, but my day to day is very different. My interpersonal skills have improved, and I'm able to communicate what it is I want - instead of just being upset about not getting what I need. This whole time it’s been like being lost... and then getting a GPS.”

What would Tess like those without Borderline Personality Disorder to understand about those who do have it? "I’d like them to know that we don't mean to be cruel. It’s a protective mechanism that's a knee jerk reaction - we don't aim to hurt you.  We can seem distant or self-absorbed… if you get burned you pull away and it looks/seems like were lashing out. I think the main underlying issue of BPD is that we grew up in an environment we didn't feel safe in, and no one ever taught us coping skills - so we made our own."

"I used to think having a mental illness made me weak... I felt emotions more than other people and it made me different. I've learned now to look at it as a source of strength, my perspective has changed. With tools, friends, and willpower - I am strong enough to get better."

Hopelessness and Suicide

At the women's prison I work at they have a new job, essentially life sentenced inmates who have had specialized training are now "observing" other inmates who are in segregation due to suicide (talk of it, paraphernalia or an attempt.)  This is a controversial plan; inmates watching other inmates and when necessary calling for an Officer.  The inmates who have just started this say more than anything it is boring; lots of downtime, odd shift hours- but they get paid for it and these are "mentors," in our program.  I spent part of this week talking to one of these inmates about her shift last night which began at 2am and she told me about the training and what she had learned about suicidal risk factors.  She did not mention the #1 risk factor for suicide, which is hard to assess as an observer- hopelessness.

From this amazing documentary interviewing people who jumped

Hopelessness is the despair you feel when you have abandoned hope of comfort or success.  I often refer to hopelessness of being in a black box and being able to see a way out.  Hopelessness is the #1 indicator of suicide; more than age, gender or even past attempts.  When someone does not see a way out, or things improving they are more likely to hurt themselves.

The Beck Hopelessness Scale is a 20-item self-report inventory developed by Dr. Aaron Beck. It is designed to measure three major aspects of hopelessness: feelings about the future, loss of motivation, and expectations. The test is designed for adults aged 17 – 80.Individuals completing the scale are asked to answer the questionnaire based on their attitudes during the preceding week. It may be administered in written or oral form, and each item is scored with a true/false. Total scores range from 0-20 with higher scores indicating a greater degree of hopelessness. 

Beck’s cognitive model of depression focuses on a “cognitive triad” which includes negative thoughts about self, the world/environment, and the future. Hopelessness is the experience of despair or extreme pessimism about the future. As such, hopelessness is part of the “cognitive triad” of depression, but it also plays an important role in predicting suicide. [source]

Although I typically advise against taking any online quizzes to determine any mental health diagnosis, there is a copy of the "test" here if you are interested to see where you might be at this moment on the scale.  I would advise that if you feel you are at risk for hurting yourself you immediately call your local crisis line or go to the hospital to keep yourself safe.

I always tell client's who are suicidal, that by taking their own life they won't ever know if it gets better; their mood improves naturally, situation at home/relationship change or if new medications will hit the market.  They will never know what their life is going to be like in 2 or 20 years, if they end it right now.

DBT Handouts

Just a fast update, I am working on creating pdf handouts of all DBT skills and setting up a separate website just for that.  It is a lot of work and will update when it is complete.  I also had a great friend create a logo for me and have begun doing some advertising. 

I will also be giving away more DBT and/or BPD books the week of Nov 11-17th

BPD and Self Harm Syndrome

Working in a prison, the inmates wear short sleeves at all times (they do have coats they can wear outside and thermals for underneath their shirts at times), and due to my specialty with BPD I find myself often looking down at inmate arms for scars.  I haven't taken any kind of survey, but easily a quarter of the clients, whom are not necessarily mental health clients have scars.  They are quick to tell me the last time they cut, "it's been 2 years," "this was before I was locked up," mostly because they can be sent to segregation for these "dangerous" behaviors and suicidal actions (per the prison).  There is a huge rate of self-harm in those with Borderline Personality Disorder, as well as those with other mental health diagnosis.  There has been a push to create a diagnosis for those whom self-harm called Self Harm Syndrome. 

Favazza and Rosenthal, in a 1993 article in Hospital and Community Psychiatry, suggest defining self-injury as a disease and not merely a symptom. They created a diagnostic category called Repetitive Self-Harm Syndrome.The diagnostic criteria for Repetitive Self-Harm Syndrome include:

• preoccupation with physically harming oneself

• repeated failure to resist impulses to destroy or alter one's body tissue

• increasing tension right before, and a sense of relief after, self-harm

• no association between suicidal intent and the act of self-harm

• not a response to mental retardation, delusion, hallucination

Miller (1994) suggests that many self-harmers suffer from what she calls Trauma Reenactment Syndrome.As described in Women Who Hurt Themselves, TRS sufferers have four common characteristics:

• a sense of being at war with their bodies ("my body, my enemy")

• excessive secrecy as a guiding principle of life

• inability to self-protect (often seen in a specific kind of fragmentation of self

• relationships dominated by a struggle for control.

Miller proposes that women who've been traumatized suffer a sort of internal split of consciousness; when they go into a self-harming episode, their conscious and subconscious minds take on three roles:

• the abuser (the one who harms)

• the victim

• the non-protecting bystander

Favazza, Alderman, Herman (1992) and Miller suggest that, contrary to popular therapeutic opinion, there is hope for those who self-injure. Whether self-injury occurs in tandem with another disorder or alone, there are effective ways of treating those who harm themselves and helping them find more productive ways of coping. source

(Trigger Warning) It's the scars I don't see that worry me the most, the inmates whom have admitted they cut around their genitals as "punishment" for past experiences, which was not their fault.   Those that admit that even a man cat-calling them will give them trauma echo and their first thought it to hurt themselves, as they see themselves as to blame for the situation.  In my experience stopping someone from cutting is a lot harder than taking away the tool.  I meet with a 17 year old while working at a crisis center, whose mom told me he has not cut for a year, since she removed the knives and locked them away.  The young man then raised his shirt and told his mom that he had "found another way," showing her dozens of scars,  Without a new coping skill it is hard to leave an old stand by.  For that matter those who cut state "it works," it distracts from the pain they are feeling and provides temporary relief.  So rather than work on counting days without cutting, here is a list of DBT/CBT skills to do instead of self-harm.  I put my favorite in bold.

99 Coping Skills

• Exercise (running, walking, etc.)
• Put on fake tattoos.
• Write (poetry, stories, journal, etc.)
• Scribbling on sheets an sheets of paper
• Be with other people.
• Watch a favorite TV show.
• Posting on web boards, and answering others' posts.
• Go see a movie.
• Watch a movie from your childhood.
• Do schoolwork.
• Play a musical instrument.
• Paint your nails.
• Sing.
• Look up at the sky. (Night is especially beautiful.)
• Punch a punching bag (with gloves on.)
• Cover yourself with Band-Aids where you want to cut.
• Let yourself cry.
• Sleep (only if you are tired.)
• Take a hot shower or relaxing bath.
• Play with a pet.
• Re-organize your room.
• Clean.
• Knit or sew.
• Read a good book.
• Listen to music.
• Watch a candle burn (no playing with the flames!)
• Meditate.
• Go somewhere very public.
• Bake cookies.
• Alphabetize your CD's.
• Paint or draw.
• Ripping paper into itty-bitty pieces
• Hug someone.
• Write letters or email.
• Talk to yourself (or if that feels weird, buy a small tape recorder.)
• Hug a pillow or stuffed animal.
• Hyperfocus on something like a rock, hand, etc.
• Dance.
• Make hot chocolate.
• Play with modeling clay or Play-Dough.
• Build a pillow fort.
• Go for a nice, long drive.
• Complete something you've been putting off.
• Draw on yourself in red marker.
• Take up a new hobby.
• Cook a meal.
• Look at pretty things, like flowers or art.
• Create something.
• Pray.
• Make a list of blessings in your life.
• Read the Bible.
• Go to a friend's house.
• Jump on a trampoline.
• Watch an old, happy movie.
• Call a hotline or your therapist.
• Talk to someone close to you that knows [how you’re suffering.]
• Ride a bicycle.
• Feed the ducks, birds, or squirrels, etc.
• Color with Crayons.
• Memorize a novel, play, or song.
• Stretch.
• Search for ridiculous things on the internet.
• Hunt for stuff on Ebay or Amazon (you can find ANYTHING there).
• Color-coordinate your wardrobe.
• Watch fish.
• Make a tape of your favorite songs.
• Play the “15 minute game.” (You can't cut for 15 minutes, and when the time is up, start again.)
• Plan your wedding / prom / other event.
• Alphabetize your books.
• Hunt for your perfect home in the paper.
• Try to make as many words out of your full name as possible (then do your friends’ names.)
• Sort all your photographs.
• Plan a dinner party.
• Play with a slinky.
• Find yourself some toys and play.
• Start collecting something.
• Play video/computer games.
• Clean up trash at your local park.
• Go out and perform a random act of kindness for someone.
• Call up an old friend.
• Write yourself an "I love you because…" letter.
• Try to build something.
• Rearrange your house.
• Go through all your old stuff.
• Smile at least five people.
• Play with little kids.
• Go for a walk (with or without a friend.)
• Go to the mall.
• Clean your room /closet.
• Try to do handstands.
• Try to do cartwheels, bridges, backbends, and such.
• Teach your pet a new trick.
• Write a note to a very useful inanimate object thanking it for how useful it’s been.
• Move EVERYTHING in your room to a new spot.
• Get together with friends and play Frisbee, soccer or basketball.
• Randomly go up and hug a friend.
• Randomly search MySpace music for new music. Or use Pandora.com.
• Play the "If inanimate objects talked, what would they say?" game.
• Face paint.

My favorite skills I have utilized with clients is to freeze ice cubes (use red food coloring) and when you feel the urge grab an ice cube and melt it in your hands (over the sink or shower) and watch the red color drip down where you would want to cut. I try not to use foul language, but couldn't resist posting this gem.