Why are therapists hesitant to give a BPD diagnosis?

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GENERAL ANNOUNCEMENT This board is intended for general questions about BPD and other personality disorders, trait definitions, and related therapies and diagnostics. Topics should be formatted as a question. Please do not host topics related to the specific pwBPD in your life - those discussions should be hosted on an appropraite [L1] - [L4] board. You will find indepth information provided by our senior members in our workshop board discussions (click here).

[velvetfish]

Job Application

Have you ever been diagnosed with a mental illness? Yes____No____

The T may recognise that there may be severe ramifications to the diagnosee, if he/she checked the dotted line. No job, no entrance into certain things...and you can get caught if you lie.

This is the reason why I spent thousands of dollars on T's, as opposed to hundreds, and never declared seeing a mental health expert on my insurance. My uBPD mother 'diagnosed' me with NPD. 2T's have said that I am not. What an expensive relief. But I did get better clarity on what she probably is.

[Unreal]

My psychologist recently told me that only psychiatrists here can make a formal diagnosis. I imagine that if a psychologist's client wanted to be tested the psychologist would write a referral to a psychiatrist

This was mentioned in the context of Australia I believe.  I think we need to be careful as psychology and medical training vary greatly in different countries.  In some countries,  medical students go directly to med school out of high school.  In the US, to be called a "psychologist" one must have a doctorate degree.  Psychology, in the US, started as an assessment/diagnostic discipline.  It remains a strength.  I am a psychologist. . . all I do is diagnose/assess (clinically).  I don't do treatment. 

Not if you want to get paid...You have to ask yourself, are T's really there to help, or are they there to make a living? If they push too hard, the BPD will leave...If they treat them for something and it seams to be making a difference, why lable it? Not that I'm saying their unethical, I'm just sayng, they want to keep their clients...
       Doctors purposely mis-diagnonse...SO THEY GET PAID!
 Insurance companies are in the business of accepting risk, they and thier actuaries know that the chances of REAL RECOVERY are slim, none and slim just left town...So mant doc's will just label it something else because they don't want to work for free.

This is a complex issue.  To the former, thinking that way is unethical (if that were the motivation).  Diagnosis, and its impact, must be considered in the overall picture of helping the patient.   Regarding pay, it's not purposeful mis-diagnosis, but it is a delicate dance.  This is a major pet peeve of mine with the way the insurance industry/medicare/medicaid is currently setup.  Even for assessment, there are a lot of diagnoses that I will not get paid for.  Think about that.  I get a referral from an MD/DO (whatever) because they suspect a problem, or want to rule out a problem.  I work for 6-12 hours on assessing this person, analyzing the data, researching the results, and writing the report.  If I say there is nothing wrong (with respect to billling code, which is based on diagnosis), I don't get paid.  This is true for the MD crowd as well.  That's stupid.  So, we have to hire billing experts to navigate the system to figure out what we have to say to ethically get paid for our work. 

  I believe it is unethical for therapists to determine a dx and not disclose it to their client.

I think it depends.  If I believe the outcome to telling a patient they have BPD is suicide, it would be unethical to tell them. Also, as others have mentioned, there is a controversy with the Axis II system.  Many consider it to be an unhelpful diagnostic approach and don't use it.  There are plenty of other ways to describe a similar constellation of symptoms that have validity. 

[doc101]

This is a great thread... a very complicated subject matter...arguments can be made for so many variations of opinions and perspectives

My background...I am a board certified family practice doc...

Insurance Game:

As unreal mentioned above we get stuck with bills that go unpaid because insurance companies dictate to us what they will pay. Healthcare, I think, is the only system where the provider of a service can't demand their own fees. There are daily situations where I code things intentionally in an effort to receive payment...I don't lie...but I document things carefully

Client/patient perspective:

If a person enters into a therapists office to seek treatment the therapist is obligated to treat them in the best possible way to meet that client's needs. They should do so ethically and by professional community standards.

If they are following a therapy model the general direction of therapy may be the same for multiple diagnosis...thereby making a diagnosis not as important...the focus is on the client...and their  best interest..regardless of outside influences...not to mention these diagnosis are complicated, pervasive, branding, and take a realtionship between the provider and the client to make...the building of the relationship takes time and trust...they also tend to focus on a paticular behavior and modification of that behavior...so it's a one step at a time deal

Thereapist...those with midlevel professional credentials...are not really there to diagnose anyway... Hope that's not offensive to anyone...just my opinion

Docs outside of psychiatry:

A large percentage of my practice deals with mental health. Primary care providers (internists, OB/GYNS, FPs, pediatricians) see a dissproportionate amout of mental health. Usaully the patients needs don't require subspecialty attention. Often mental health patients carry multiple psychiatric diagnosis. There are multiple diagnosis I don't feel qualified to make or treat. The PDs are certianly in that spectrum. That's not to say I don't see them and recognize them it's just not a label I'd be willing to code...or even a possible diagnosis I'd mention to the patient... If they see me for their mental health I would code and treat their depression (a co-morbid condition)...or whatever co-diagnosis I could make and refer them out for diagnosis/treatment...

Psychologists (Phd training) and Psychiatrist...

Even here there are nuances that will be client specific. If a client wanders in off the street the obligation of the provider is strictly to help...doesn't necessarily require exact diagnosis...

However where referrals ore concerned...Diagnosis here should be as exact as possilbe because they are being asked for an expert opinion to help guide a team approach to therapy. Still would take time. The psychologists are going to be the professionals that do the testing and psychotherapy. The psychiatrists will be the people to guide pharmacologic therapy...


In General :

Any provider is ethically bound to help their patients and protect them. That is the nature of how we are trained. We should be very careful when we label someone with a diagnosis that can impact their lives whether its getting insurance, finding employment, or custody issues.

My own personal situation:

My X was diagnosed with Personality Disorder, NOS characterized as severe by her psychiatrist. That diagnosis was confirmed recently by a forensic psychologist who ultimately was an expert witness on her behalf. My litigation with my X has been helped by the diagnosis. Fair or not, I got her psychiatric records and used them for my gain in an effort to protect my children. Me nor my attorneys have argued that because of her mental illness she should be restricted from contact. Rather we have argued because of her behavior she shouldn't. The diagnosis has been used to strenthen that argument and argue potential future behavior...It's been something we have discussed to try and force her into theray...which has not worked...

I've been very thankful that her psychiatrist labeled her. The diagnosis gave me some peace...The paradox is the diagnosis was rendered for her and not intended for my use.

[GENERAL ANNOUNCEMENT]

GENERAL ANNOUNCEMENT This board is intended for general questions about BPD and other personality disorders, trait definitions, and related therapies and diagnostics. Topics should be formatted as a question. Please do not host topics related to the specific pwBPD in your life - those discussions should be hosted on an appropraite [L1] - [L4] board. You will find indepth information provided by our senior members in our workshop board discussions (click here).

[Mollyd]

BPD is "incurable" so they won't reimburse?

I'm not so sure that is exactly it.  From my perspective a personality disorder is perceived as a developmental disorder, noting that it is included in the same category as borderline intelligence.  It's a developmental disorder in that key components of the personality development were missing/not completed/don't exist. (E.G. in npd what is missing is empathy and a sense that they are equivalent to those around them ... in bpd what is missing is the development of proportionality and consistent sense of self.  These things are not there -they are missing or not developed fully). It is not seen as "curable", but more a condition that just is.  Treating it would be adding to the development of the person - which is different that Axis I treatment -where the person is seen as normally developed with a condition on top of that.

The reason it's not reimbursable isn't so much that it isn't curable, but more that it's a different axis/construct all together.  Reimbursement can occur (on axis I) if a therapist is using CBT/DBT etc. to mediate anxiety or mood disregulation - or other related symptom sets that also carry diagnoses.  A provider can diagnose/treat and include the axis II disorder. It's just that to diagnose ONLY the axis II disorder ... it's kind of like saying one is going to give therapy for the condition of borderline intellegence.  That's not therapy.  That's something else.

Aix II is for reporting personality disorders and mental retardation - and noting "prominent maladaptive personality disorder features". 

Axis III is for reporting General Medical Conditions.  We don't expect that therapists would be paid for treating medical conditions, right?

There is no cure for mental retardation and therapy isn't done for that specifically.  But, that's not to say that some services, therapy and otherwise aren't appropriate for those with this condition. 

I continue to think providers need to include the axis II diagnosis, or at least features if they are recognized.

My thoughts, anyway.

Molly

[Randi Kreger]

1. Ignorance, especially if the person is under 18
2. Belief that people shouldn't be "labeled"
3. So the person won't get stigmatized or refused treatment by other professionals who look in the chart
4. To get insurance coverage, especially when there is an Axis 1 disorder
5. So the person with BPD won't have their feelings hurt, see themselves as unloveable, use the illness as an excuse, etc.

Those are the main ones.

Randi Kreger
www.BPDCentral.com
The Essential Family Guide to BPD

[MagentaOrchid]

My T said she does give the dx.  She told me she gets one of two reactions.  One, they get upset and storm out and dont come back.  She says these type pwBPD are not able to be helped.  The other ones go ahead, read about it.  Admit that it is like them.  She says these ones can be helped somewhat. 

She has been in practice many years and I liked her explanation.  It helped me realize, my mom will not accept her diagnosis (she has been told).  And it helped me trust her further that she is not going to be keeping secrets from me about my own mental health. 

[dados76]

insurance.. can have something to do w/it.. my partners primary dx is OCD/PTSD bc those are covered by insurance for treatment.. 'secondary' dx are bpd/ppd.. even tho thats probably backwards to how he actually is.. his first dx was done in a correctional facility.. so they didnt care too much abt insurance and just ran down a checklist of whatever he 'probably' had.. his current doc explained that.. w/OCD as a primary dx.. he qualifies for a little more flexibility at work and is more likely to get his therapy covered by insurance.. which means he gets to stay in treatment.. and cant get fired from his job for having a panic attack and needing a break or something.. so.. depends on a lot of factors.. R tho.. also aint never had a doctor tell him he doesnt have bpd

[harmony1]

our marriage counselor told me that a therapist is not supposed to hurt the patient that is in denial..even tho a diagnosis would be helpful..if they are in deep denial it can do more harm than good

[nonhere]

"Why is a BPD diagnosis not given out more often?"  It's at the root of a great insecurity many have... is the person in my life "ill" or is it me?   What does it all mean when a person in our life fits many of the criteria of BPD or BPD traits (but not the obvious tangible criteria sch as cutting, suicide)and have seen a therapists and not been diagnosed or treated.

I very much liked reading what Skip wrote here: It's at the root of a great insecurity many have.  It certainly is for me.

Someone upthread suggested that therapists may be reluctant to diagnose because "you can't do with therapy with an empty chair".  I think that's an excellent point; and it parallels (horribly) how a non (e.g. me) in a relationship with a pwBPD can behave.  Is the other person "ill" or is it me?  I was never able to bring myself to say, clearly and definitely: "YOU are ill" or "YOU are impossible to deal with" or "YOU are behaving in a way I can't put up with - I'm out of here".  Precisely because, like a therapist, I knew that any chance to engage with the person depended on not saying that.  I think that with many kinds of therapy, there's a very good reason NOT to give an early diagnosis, if that'll prevent therapy from proceeding.  (I'd feel terrible if I went into therapy and the therapist simply pronounced "You are suffering from mental disorder X" - I'd say "so what?  It's a label.  How about helping me with it?").

The big difference, of course, is that I'm not a therapist.  It was wrong of me to hold back my "diagnosis", for the sake of continued engagement, because I wasn't competent (or in the right kind of relationship - therapeutic - with the person) to do any good.  But IMHO there are lots of good reasons why someone who is a professional, qualified therapist, and could do some good, to avoid making a clear "diagnosis".

Makes it hard as hell for us recovering nons. I'm back to the point from Skip I started with: wouldn't it be great if there was some undeniable, authoritative rubber-stamp from on high that told us (definitely, in the face of every doubt, and in the face of every protestation from the BPDex that they were behaving totally reasonably) no: this person is definitely ill?

[Major_Dad]

I think the T really has an obligation to tell the Non that their SO might be BPD. To not do so imo is akin to malpractice. The challenging part is how to coach them to deal with it.

The diagnosis of my BPDW has done much more harm that good. She simply projected it on to me and refuses to see another T or accept any notion that she has "issues".

[neil]

In the case of my ex, I believe her therapist is only interested in building up her self-esteem and her sense of self-worth.  My ex has a fair amount of abuse in her past, and I strongly suspect that the therapist is primarily concerned with protecting her from seeking out abusive figures in her life. All of which is a noble goal, but it probably obscures a lot of what is actually going on.

I very much doubt that the therapist understands how extraordinarily abusive she (my ex) herself is.  Of course, there's a strong possibility that she's not honest with the therapist about her behaviour...the things she's done to me, the things she's said...As we all know, pwBPD often make outrageous claims about things others have said or done.  I'm not sure every therapist will recognize that this a complete distortion of the truth. 

I believe that's probably one of the biggest issues in terms of lack of diagnoses...the lack of honest communication from the pwBPD

[Dera]

My therapist told me that psychologists are moving away from giving patients a label and toward describing them as having a collection of traits. He is a bpd and I am a non... what does that mean anyway? It makes a lot of sense to me to describe that he has these 6 traits and I have those 2 traits rather than just apply a label. I can't explain this well enough, and if someone can elaborate the point better than me I'd be interested to read it.

[GreenMango]

Dera

From my understanding there are a couple of reasons one of which the label is very stigmatizing.  Addressing behaviors, while isn't always easy, can be a more functional and less alienating approach to working with someone.  Not every person that displays traits qualifies for a clinical diagnosis, but the behavior is still dysfunctional or distressing and can be addressed.

GM

[Dera]

It seems to me that labels are useful in some contexts... how would we have all found each other here if we did not apply the bpd label to our loved ones?

However, on an individual basis it may be counterproductive to oversimplify someone has "a bpd". They have traits of bpd, and no doubt other issues as well, that do need treatment of course. Our brains like things to be black and white, and we want to interpret everything they've ever done as being bpd, which is an unhelpful oversimplification. Therapists are human too. Maybe it's better for them to move away from slapping a label on someone and treating them as "a bpd" instead of a complex human being.

[RUkidding]

I believe that it is. From what I have read the only way to be diagnosed with BPD is by a mental health professional. Thru a series of tests , sessions ect. I do know that there are MRIs and brain scans that can show abnormalities li the brain but they cannot give a specific diagnosis. PTSD and other mental illnesses show up also but to the best of my knowledge the diagnosis of a specific mental illness is done by a mental health professional and not a neurologist and therefore it in my opinion have to be subjective. The skill level of that person , the patient ect all would factor in . I believe this is true with most if not all mental illnesses. I also believe BPD would be one of the more subjective ones because of the wide varying of traits and the range of criteria needed for a diagnosis of BPD. This is just my opinion  ur I have not seen anything to make me think differently. If anyone does have anything I would be very interested to know. My r/s with my exbpdgf affected me in many ways. One thing it did was made me educate myself on BPD which is something I had never heard of . It gave me empathy for those who suffer from it and all mental illnesses. It made me grow as a person and appreciate my life even more. This women touched me in ways that I can't even explain. I have felt emotions with a deepness that I never have before. Those emotions include anger ,frustration , despair , but also joy and especially love . She was the cutest thing ever with cute lil soft feet so also lust :P she def rocked my world and despite all the crazyness I have no regrets !

[breathelife]

Thank you everyone for sharing.  This thread has helped me a lot.  Mainly it has helped me realize that I am not alone in this and I am not crazy.  I think that you are right in that it isn't sensical and I can go crazy trying to make sense of it.  My problem is trying to remember that it wasn't personal because I find myself asking all the time...if he loved me like he said he did then why...  I don't know why I find it so hard to get over when I was both miserable and lonely among other things towards the end of the relationship.  I didn't want to fight about him thinking that I didn't want to talk to him at midnight because I wanted to get off the phone to sleep.  I didn't want him fight anymore about me wanting to get off the phone to get back to work because he thought I wanted to call someone else.  I could not meet his needs and then he would complain that I didn't listen to him.  When I spent hours and hours texting him and talking to him.  I don't know why I am still pining over him.  So frustrated with myself.

[RUkidding]

Unfortunately but true it seems is the stigma that goes with mental illness. People are I believe very afraid to be diagnosed with a mental illness. I believe of they are smart enough they may be able to downplay some things when seeing a doctor. Or totally deceive them. I know the dr is trained to see through that ect bit the patient may be quite good at that also. As a society we do treat those with mental illness like lepers in some ways and most know that so they avoid any kind of diagnosis and this treatment. The compassion for them and others with disabilities that I have as a result of my r/s is something I am greatful I learned. I was a compassionate person I believe before but much moreso now . Breathelife I would advise u to just know u did ur best and nothing would of been right. You will in my opinion never get the answers to the questions u have. Let them go . Your ex doesn't know them no one does. I love her like I've never loved before and I now realize it wasn't what  I believed it was. She wasn't who I thought she was and I may not be to her what I thought I was. But my love was real that I do know and that's good enough for me.  I do hope that helps u and u find peace in it. I believe u will

[Want2know]

I think this is a good topic to discuss, perhaps using the term "inter-subjectivity" as a basis for what it seems you are trying to understand and relay to the group here.

Inter-subjectivity is how we can express ideas in a way that is necessary for communicating with one another.  Take for example the word "blue".  We all know what blue looks like, but do you really know what someone else's perception of the color blue is?

Inter-subjectivity allows us to agree upon a term so we can use it in a meaningful way.  Relating this concept to what I think you are saying about being subjective with psychological diagnoses, it is a way we can have some common discussion of our observations and express them in a way that promotes understanding and progression of thought, and can help with behavioral assessments and a courses of action.

[RUkidding]

Maybe I'm using the subjective incorrectly. I'm meaning that the diagnosis of mental illness and especially BPD is not an exact science. Two mental health professionals examining the same patient could both come to different diagnosis and neither would be wrong. What they consider meets the def of intense, risky, chronic ect would have determine their determination if the DSM criteria is being met. The reason I brought up this topic was in expressing my views how to help us best get thru our recovery from this r/s. which is that we should not look for the answers that many of us have and that we shouldn't play back this r/s in our mind and start to wellif I would of done this maybe things would have been dif ect. That by trying to do those things we are just wasting our time. Those answers will found. I also believe that if one wanted to we could actually shape those answers to put us in a better light. Many here seem to see a T to help us thru this period and possibly figure our role in it. I believe that many will do almost anything to have an excuse or proof that it wasn't simply that we're stupid , naive , stubborn ect and they we just got played or fooled which I believe is a possibility .  That's where the subjectivity comes in. Whether our SO is technically BPD really doesn't matter. They did things or said things that made it almost impossible to have a healthy r/s with them. Leave it at that. I've read many threads asking that ?(did they have BPD?). We will never know because there is no definitive way to know. Judge them by how they treated u and others. It is extremely tough to accept that you'll  ever really know it was mental illness, u got played , or a lil of both , or even something diff. If u dont accept that I believe the u will ended up in a sorta circular search for answers. Your doing the same things ie reading books on it or the posts here , seeing a T) and expecting to get a diff result then one you always seem to get which is u don't know. It's like our circular discussion with them. At some point u have to get off that merry go round and accept that will truely never now. So I say  get off it
now or you'll be doing those things forever. U have to totally stop. Because every lil tidbit u find leads to more questions we need to answer. Like a crack addict that more hit could get them back in it fully but with us that one lil tidbit gets us back in fully too . Just how I see it.

[Want2know]

"Why is a BPD diagnosis not given out more often?"  It's at the root of a great insecurity many have... is the person in my life "ill" or is it me?   What does it all mean when a person in our life fits many of the criteria of BPD or BPD traits (but not the obvious tangible criteria sch as cutting, suicide)and have seen a therapists and not been diagnosed or treated.

lasagna points out insurer issues. Lincoln points out that at certain types care providers do not have the education and background to diagnose these disorders.   lasagna points out the potential negative impact on the therapy... that patients often don't return (as a dx is telling an insecure, hypersensitive person that they are their own problem. geroldmodel point out that the "diagnosis" can't be made by a social worker, or non-MD therapist. All good points.

But it is also important to consider that even in the case of skilled, specialized psychiatrists, they don't have the equivalent of the low cost technical tools like blood tests and x-rays to diagnose patients like other doctors have.  

1. Clinical Process Psychiatrists are limited to what the patient tells them.  This communication is a function of time (appointments are under an hour), communication skills of the patient (remember, people often see a therapists when they are in crisis), patient self awareness and honesty, and patient follow up (coming in for additional appointments, reporting progress).

My understanding is that many clinicians work through a hierarchy of diagnosis and treatment - treating the more episodic, pharmaceutical responsive, and lower cost conditions first - they go after the "low hanging fruit".  Many of the Axis I disorders fall into this category. If this does not resolve the problems, they dig deeper.  The process is a little like peeling back an onion and dealing with each new layer.  If the patients heals or stop coming in, the pealing process stops. Insurance company reimbursement policies tend to encourage this approach.

Axis II disorders are far more expensive, complex treatments.  And they are often obscured by other comorbid conditions.

In a hospital setting, there is more time to analyze and diagnose a patient.  Outpatient treatment, however, is often very time limited.

Right now with the current medications and therapies that are available, a diagnosis of BPD (except in cases of suicidal ideation, or cutting) is likely to come later (rather than earlier)... the diagnosis of "high functioning" BPD is not obvious and straight forward.  

2. Subclinical The discussion also raises an obvious suggestion that many of the partners, parents, children here aren't  "BPD" by the clinical definition... they have some traits, or many traits, but not enough, or severe enough to be diagnosed.  They are extremely difficult people, nonetheless.  In many ways, the same tools, options, and thought processes are valid in subclinical situations... maybe even being more effective.

Anyway... "General BPD Topics and Questions" is an information exchange board... for me, this was a good exchange of information we have gathered.  Thanks.

Skippy

If you look at the diagnostic process, in practice , it's pretty clear that in the absence of a serious tramatic event (e.g., attempted suicide) that a personality disorder is diagnosed over time and based on non-response to therapy -- it's not a first line diagnosis.