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).

[karategrrl]

This took me a while to figure out, but based on what my ex's therapist has told me, here it goes... My ex is high functioning...She can hold down a job, pay her bills, etc. She meets 7 out of the 10 criteria...So it bothered me when her therapist refused to give a BPD stamp...going as far as saying "If I was to diagnose, it would be BPD...I won't do that, but I'll treat you for BPD"... So here's the thing...If a therapist or Dr. gives the actual stamp of BPD, the person is now qualified for SS benifits, or other compensation...This really bothered me because Ex would use her lack of diagnosis as a fighting tool, "see, even my therapist doesn't agree that I have BPD"...So now I'm more accepting of this descision...

[lasagna]

To my knowledge, insurance companies don't cover treatment for BPD because they are not convinced that any tools work. so most therapists stick with diagnoses more in the anxiety/depressed realm.       Also, it might show up during a custody investigation I am speaking in the broadest parameters here. I have no knowledge of your particulat situation.

I'm surprised the therapist broached the subject of BPD at all. That causes a lot of patients to never return, so it is gingerly discussed way into treatment.       I am unaware that BPD automatically qualifies one for SSI.  Perhaps you have some specialized knowledge in that field. Many BPDs are able to have successful careers.        I wish you the best. 

[karategrrl]

My friends brother got SS benifits because of his personality disorder...

[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).

[Abigail]

 In my opinion, that is unethical.  Imagine saying to someone, "If I were to diagnose him or her, I would say diabetes, but I'm not going to say that.  However, I will treat him or her for diabetes."  I believe we have a right to know the truth even if it isn't what we want to hear.  I may not be very happy if I were diagnosed with diabetes but I would rather know so I can educate myself and learn what I need to do.  I might make the choice to be in denial, but that would be my choice.
  I do understand that there is still a stigma with the BPD label and that many individuals do not want to hear it.  But you can never get any better if you deny the truth.

  Abigail

[Lincoln]

I don't know for sure, but it may also be that most therapists simply aren't qualified to offer a diagnosis of BPD.

It's kind of like getting diagnosed with diabetes by a podiatrist. 

But then again, if the therapist suspects it, they should refer you.

[geroldmodel]

Diagnosis and classification of personality disorders or even health in general,
differs all around the globe.

In USA the DSM-IV-TR is used to diagnose.
In Europe the ICD-10 is used.
But THEY ARE ONLY TOOLS to diagnose.
Other factors -such as a job- has to be taken into consideration.

In Europe most countries have universal healthcare.
When BPD is diagnosed treatment, therapy and a possible loss of income because of the inablility to work,
will be repayed by the social security system.

In the US it seems that insurance companies do not cover anything when diagnosed.

In my country psychiatrists, forensic psychologists and general practitioners can diagnose a personality disorder officialy. Only psychiatrists and general practitioners can prescribe drugs.
Therapists, Councerlors or even standard psychologists cannot officialy diagnose. They can only refer.

"If I was to diagnose, it would be BPD...I won't do that, but I'll treat you for BPD"...

So imo this is a very reasonable statement.
She has all the emotional issues of a BPD, but she can hold a job and is high-functioning.
He will deal with the emotional issues in the same way as if she was low-functioning.

What does it matter to you karategrrl ?

[Skip]

"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

[lasagna]

karategirl; If the therapist is recognizing that your SO had borderline, then I'd be grateful for that.  The medical coding doesn't really amount to a hill of beans. My BPDd had a therapist who scapegoated me for two years; until my BPDd lied about her.    It sounds like the therapist actually made the BPD statement (in your initial post) directly to your BPD SO.   That is a very astute therapist. We cannot ask for more. Of course, your SO will deny the BPD label. That's illustrative of the illness.       

In the US, therapists can diagnose. social workers, nurse practitioners, psychologists are all legally allowed to diagnose a psych pt. That doesn't mean that any of them- including phsicians- make the correct diagnosis.

Skip, you make a lot of really good points. I'd be doing a jig if my BPDd's initial therapist had called it for what it was.        My best to you. 

[lasagna]

If I were a therapist and I was treating my BPDd, I would #1 insist on getting a history from previous therapists (why re-invent the wheel?) #2 have every session recorded for when I face false accusations and #3 be very grateful to the mom(me) who sends me accurate accounts of events to read and discuss in therapy.    But I would charge so much that no one could ever afford me!

[ocean401]

My ex's therapist coddled her to no end.  I remember asking her therapist about BPD and she said to me, "I can see how you'd think that but I'm not ready to go there."  I think her therapist simply knew that she couldn't push her too hard and so she seemed to never push her.  I mean, come on, after meeting every week for over a year you gotta push the client at some point!

[karategrrl]

My ex's therapist coddled her to no end.  I remember asking her therapist about BPD and she said to me, "I can see how you'd think that but I'm not ready to go there."  I think her therapist simply knew that she couldn't push her too hard and so she seemed to never push her.  I mean, come on, after meeting every week for over a year you gotta push the client at some point!

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...

[lasagna]

Here's the therapeutic view as I understand it. BPD need a connection to a T that is accepting, not rejecting.  Labeling a pt as BPD certainly can be perceived as very rejecting.   Instead, the therapist acknowledges the very real emotions (fear, sadness) that drive BPD behavior and validates those feelings.  Alternative, healthier reactive  behaviors are discussed in a non-judgemental tone. You cannot do therapy with an empty chair.

[Major_Dad]

A couple of things I have learned from T in the past few weeks:

1) Most T's will only treat a few BPD's at a time because they are VERY high maintenance.

2) Making a formal diagnosis usually occurs when law enforcement or civil authorities are involved. This ties back to what was said earlier, a BPD will likely feel threatened and leave if they are faced with a diagnosis. Unless they are compelled to stay by the system.

[Malachite]

I asked a T who specializes in treating BPD's exactly this question. Her response was kind of scary to me. One: all therapists worth the paper their degrees are printed on *recognize* BPD when they see it (which can occur YEARS before any formal Dx happens, if it does at all). and Two: they also have a healthy fear of diagnosing it, due to it being counter productive in whatever modality of treatment they are applying. Three: only a psychiatrist can diagnose.   The other things were a compilation of other poster's replies: but seemed to boil down to fear on the part of the therapist.

[Major_Dad]

I asked a T who specializes in treating BPD's exactly this question. Her response was kind of scary to me. One: all therapists worth the paper their degrees are printed on *recognize* BPD when they see it (which can occur YEARS before any formal Dx happens, if it does at all). and Two: they also have a healthy fear of diagnosing it, due to it being counter productive in whatever modality of treatment they are applying. Three: only a psychiatrist can diagnose.   The other things were a compilation of other poster's replies: but seemed to boil down to fear on the part of the therapist.

Your third statement is incorrect. Any certified psychologist can render a diagnosis. Only a Psychiatrist (MD) can prescribe psychotropic drugs. However, since there are not many Psychiatrists in some areas, a psychologist will make a recommendation to you Family Doctor, who will write the script.

[Mollyd]

FWIW -

Many are making a huge assumption - that most therapists who know of a dx of bpd chooses to either not document it officially, or not tell the client of their findings.  I don't know if either of those scenarios is true, though it may be the experience of people on this board.

This, to my mind, is a multifaceted issue.  There is the issue of therapist training, ethics and diagnositic consistency.  There is also the issue, mentioned previously, of insurance reimbursement (It is true that an axis II disorder cannot be the primary dx - for many insurance companies to reimburse). And there are the good points that Skip makes.

I believe it is unethical for therapists to determine a dx and not disclose it to their client.  Clients have the right to choose the treatment of their choice.  To not disclose a dx, in essence, prevents a client from considering the different choices in front of them.  For example, if a doc didn't disclose a patient had cancer, that would obviously be unethical, as the patient has the right to know what they are dealing with, and then, make appropriate choices. 

I think a therapist who "knows" of a dx and withholds it, has to have some darn good reasons, past personal discomfort ...  and I can't really imagine any reason that justifies withholding.

That said, therapists, like all of us, are people.  Some are smarter than others, some more ethical, some are embedded with issues that interfere with their ability to do their jobs - just like everyone else.  There are crappy cops, crappy politicians and religious leaders, etc.  Therapists are certainly not immune from their own barriers.

Are therapists adequately trained to appropriately diagnose pd's out of grad school?  Based on my knowledge of master's level psych programs - generally, I'd say no. I believe the training is inadequate in that area.  And, I don't know if that particular thing can be trained, really.  I believe what can be trained is to know what one doesn't know - new grads can be taught when they are over their head - outside their scope of expertise, what to do then.

Another aspect of the problem, in my opinion, is that the broader field of mental health does not agree about pd's.  As has been mentioned in other threads, there are groups of folks in the "field" who don't like the organizational criteria of PD's altogether.  There are folks who "view" bpd as linked to bipolar and ptsd, and others who don't at all, but see pd's as a distinct category - much like it's presented in DSM verbage.  There are folks who find the pd criteria as needing much, much, revamping in terms of diagnostic criteria and dimensionality.  And so on. 

I understand why there is the perception that "most therapists don't ... ", but, I think the reason is complex, and the perception is generalized.

There two final thoughts.  First, therapists may well discuss a diagnosis of bpd with someone who has it - and the person with the pd may deny the dx was discussed, distort what was said, or refuse to acknowledge the conversation ever occured.  What happens in real life also happens in the therapy room.  Second, also as in real life - many people on this board hold the position that "telling" the person with bpd that they have it is ill advised - because ... it makes things worse.  The same can be true in the therapy room, I'd imagine.  If a therapist documents their dx (which they are obligated to do) and does all the things they would do (treatment interventions, referrals) what difference does it make?

Now, personally I don't advocate not telling - not from family members or therapists - but, it is the actions and behaviors that really are what it's all about.  If a person is willing to do all the treatment interventions and healing - what they call themselves, really doesn't matter - or does it?  And, to whom does it really matter, and why?

Always, fwiw

Molly

[flamingo13]

Your third statement is incorrect. Any certified psychologist can render a diagnosis. Only a Psychiatrist (MD) can prescribe psychotropic drugs. However, since there are not many Psychiatrists in some areas, a psychologist will make a recommendation to you Family Doctor, who will write the script.

Yes, except that in the States or at least this one, any MD or DO (MD and DO are equivalent regarding scope of practice in the USA) can write an Rx without a recommendation/referral from anyone. My family practice doc writes for all of mine as well as Dxed me. Doc's Dx concurred w/ T perhaps a year or more after the fact -- doc was first and already writing for me.

[lasagna]

The whole issue of "labeling" patients is disputed within the mental health community.   

My BPDd was told by two different therapists that she was BPD. She made up a horrible lie about each of them and never returned.  She was 17 in one of those instances. The respected therapist felt she needed to tell my BPDd that she had BPD.  In response, my daughter created a terrible lie that the therapist had told her that "it was time for her (my daughter) to become sexually active."  I knew it was a lie. But what if I didn't? My daughter was a minor and I could have filed a complaint with the state board of Psychologists.

My BPDd had several years of successful therapy with a subsequent therapist who never discussed diagnosis.  And the diagonostic code (easily googled) was Depressive Disorder, Generalized Anxiety Disorder and Panic Attacks(all Axis 1 and all insurance reimbursable).   My daughter's extreme feeling states (anxiety, anger and sadness) were the targets of therapy.  My daughter stayed with this therapist for years and learned a lot about controlling her BPD symptoms.

It is not like a cancer diagnosis, where the patient needs to know so they can take responsibility for their illness. I am a cancer survivor. It would be malpractice if I was not told.   I need to know how important it is to keep up with my follow-up testing for years.     

Many good therapists don't get into the borderline labeling. There is no secret therapy path that begins with that diagnosis. the patient needs to safely re-learn in therapy what they did not get at age-appropriate times.  Even with the best parenting, some borderlines just didn't successfully complete certain developmental tasks.   

You do not need a medical degree to diagnose in the US. You need a master's level licsence. I diagnosed and I am not a MD or DO.  I can prescribe medication (as a psychiatric nurse practitioner) but only under the supervision of a medical doctor.

Therapists have to provide proof to insurance companies that different therapy techniques work. They gather for conventions to hear and discuss the results of research. It's called evidence-based practice. Recently, studies were reviewed in the area of cognitive therapy causing visible brain changes that help with depression.     

Insurance companies would deny payment for therapy for PDs unless there was an Axis 1.  And I myself never wanted to put down a BPD diagnosis that could eventually cost the patient their insurance policy. Not to mention custody issues of children who hadn't been born yet. The diagnosis becomes part of their permanent file that can be easily accessed down the road.  So it wasn't a cop-out. I believe it was best practice. 

[Bricolage]

It seems to me that different countries probably have different regulatory procedures as to who is legally entitled to make an official diagnosis of BPD.

I am in Australia. 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.

In Australia psychologists can't prescribe medication, psychiatrists and GPs (our term for medical doctor - it stands for 'General Practitioner') can.

Our health insurance system is very different to the US model. It has changed somewhat in recent years, but is largely still based on the 'universal health care' model, with an optional private insurance system alongside. The choice of private insurer is the individual's, not associated with their place of employment.

I don't know how a person diagnosed with BPD would fare. I know the government funded Medicare system would be obliged to treat such a person, regardless of their income. How appropriate or frequent the therapy would be I don't know. I'm not sure how things would go with the private insurers. It might depend on the insurer and type of cover.

Soar

[SOOOdone]

I am a therapist. The ONLY reasons why I even bother to diagnose is so my clients can get reimbursed from insurance. My thoughts are that the DSM IV is a tool. I also don't see mental health the same as physical health but interconnected. So I see a Dx of diabetes to be much different from a diagnosis of a mental issue. Also, a person can present one mental issue at age 20 and a different one in their 40s. I see psychology as a combination of craft and science, intuition and relationship. A medical doctor doesn't need to be particularly empathetic while performing open heart surgery.

The whole Dx of BPD is also variable...some would say women have BPD and men NPD more often than not...I see them as very much the same, splitting, rage, fear of engulfment/emeshment, control...etc...childhood abuse/neglect/trauma.

I just assume that if anyone has severe neglect, alcoholism in the family, abuse, trauma, etc...I have to RULE OUT BPD first. Since I adopted that approach, I have much better results and happier clients.

I am not afraid to discuss BPD characteristics with my clients. I have to model honesty, trust, integrity. I have to be careful how and when I do this, sometimes its years into therapy. I start by saying that if I were them, I'd feel ________ in a given situation. When they are amazed that I know how they must feel, I start introducing the BPD concepts to them. When they do the push=pull dance in Tx, I ask them where else this has happened to THEM in their lives. I actually enjoy working with BPDs, the high functioning ones at least.

Also a lot of therapists hate working with them because they tend to call all the time. I cured that. I MAKE them call me nightly on a special line I don't pick up. Being oppositional to control, they rarely call then...