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.

Boundary Garden

Those with Borderline Personality Disorder struggle with healthy boundary setting.  From my perspective this is part of their black/white, all/nothing thinking.  Sometimes it's obvious when someone has poor boundaries. The story I always tell to describe what poor, or low boundaries look like is this personal one from when I was 15 years old.  I had just walked off the city bus to walk to go home, as did another classmate I had not seen before.  It was the first week in school, so I guessed she might be new.  I began talking to her, figuring if nothing else it would give me someone to walk home from school with.  Our walk and only conversation lasted 8 minutes and in it she told me her mother had killed herself, she was now living with her father, he didn't know how to cook, was "icked" out buying her tampons, she had an array of mental health issues, told me what medications she was on and showed me scars from when she tried killing herself a few months back.  My radar went into the red danger zone and I immediately knew this was not someone I would want to be friends with, even if it was 16 minutes a day round trip.

Those with all/nothing thinking struggle with making, having and often keeping friends for this primary reason; "they are either my all-time best friend or my worst enemy."  This was a quote from a client, whom I didn't at the time know much about BPD to diagnosis.  I have my clients create boundary gardens to illustrate this point and have a visual for where their friends lay.  Below is the outline of the garden I have them fill in.

Here is an example of one filled in for someone who has low boundaries,

After I have the clients fill in the garden I ask a few questions; which section has the most people in it? Why are people in old brush and not out of the garden? Is there anyone who has been moved towards the old brush or into roses since starting therapy/group/recovery?  It's a great starting point for creating and enforcing boundaries.  I also have the clients put lines where they would like to move people, for example, "my step mom and I have had a better relationship the last few years since she stopped drinking, so maybe it's time to have her as a violet," or "My brother is a close friend now, but I think he has been stealing money from my purse, so maybe we need more distance and he needs to be moved to Geraniums."

It doesn't solve their boundary issues, but it gives them a starting point and a nice visual to begin working on.

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.

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.