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Author Topic: TREATMENT: What to look for in a therapist?  (Read 6397 times)
leafygreens17
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« on: November 15, 2005, 12:18:27 PM »

My BPD husband is searching for a therapist. All the DBT therapists we've found are either full, or not covered by our insurance. Is there an easier way to track one down? His psychiatrist made recommendations, but they're not covered by insurance.  The previous therapist he was seeing was making real headway before we discovered that insurance wouldn't pay for it since she only had a masters degree. (Insurance requires a Psy D, Ed D, or MD.)  She recommended some other therapists, but they're all full.  Getting him to call new therapists is like pulling teeth, so having all of them fall through is really causing a problem.  Please, tell me an easier way!
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« Reply #1 on: November 15, 2005, 01:03:44 PM »

leafy:

I went to a therapist that came highly recommended by others (but not covered by our insurance) and asked that he recommend a therapist from the list of those covered by my insurance company.

Usually these people are familiar with each other either thru grad school or subsequent professional seminars.  It cost me $65 (half hour consultation which I gladly paid) and he recommended several good ones.

Good luck, T.P.
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« Reply #2 on: March 23, 2007, 03:05:28 PM »

It's frustrating when you run into therapists and doctors who are misinformed on BPD.

A friend of mine has a husband who exhibits all of the symptoms for BPD and has deep abandonment issues.  I gave her SWOE and she read some of it and took it to her therapist and asked her if she thought husband might be BPD. The therapist hadn't met him but from the wife's description she told her that he couldn't be BPD because BPD's don't get along with anyone.  And his only problem is deep abandonment issues and substance abuse.  Gee, since when is that criteria in the DSM-IV?

In another case I have a friend whose son-in-law has BPD symptoms and he himself agrees it sounds just like him.  His doctor said he couldn't possibly have BPD because he has a job!  Another new criteria in the DSM-IV that I missed?

Why can't they be honest and say, I really don't know that much about BPD.

Abigail
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Theireyeswerewatching
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« Reply #3 on: March 24, 2007, 12:13:55 AM »

It is true that a great number of mental health experts who are not specially trained in personality disorders such as BPd do not have an indepth understanding (workable knowledge) about how to treat this mental illness and the seriousness of it. It is also true that borderline personality disorder does not stand alone as a mental illness, it is accompanied with other issues making it a very difficult and life long process of treatment and recovery.

I'd also like to say, remember that some of these so-called experts in mental health (some posters on here have stated their spouse or SO with BPD and other personality disorders either work or have degrees in mental health) are simply people who usually come from problematic dsyfucntional and abusive backgrounds; it is not uncommon to find survivors of abuse or those still in the process of learning survival skills employed in the field of psychology and other helping professions.
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« Reply #4 on: December 31, 2008, 08:30:45 PM »

From tara4BPD.org:

WHY IS IT IMPORTANT TO SEE A TRAINED DBT THERAPIST?

DBT may be the most hopeful and helpful of any new therapy available for people with BPD. Many people with BPD have problems trusting others, have “failed in treatment” or have been dropped by former therapists. When DBT is not done as designed, the results may not be the same, causing the person with BPD to lose hope and trust and then be reluctant to ever try DBT again. If DBT is not practiced according to the research model that produces effective change but is practiced “my way” by a therapist without adequate training, it probably won’t produce the same kind of results as the research programs. Outcomes from this kind of DBT will not justify additional DBT training or new DBT programs in the community. Currently. Dr. Linehan is working on a way to certify therapists who practice DBT so that people can determine if a therapist is truly qualified to practice DBT.
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« Reply #5 on: January 01, 2009, 08:10:19 PM »

The  mental health is a complicated field that requires a good bit of knowledge for ethical/competent practice.  My opinion is that the letters are more likely to result in competence than trusting in a shoot-from-the hip person without the letters.  Yes, there are gifted, empathic counselors (masters level) out there.  I am not saying that not having a PhD or MD necessarily makes you an ineffective therapist or inferior to the doctoral level folks.  I am also not saying that having a PhD or MD guarantees competence.  What I am saying, once again, is that mental illness is complicated. I think in a lot of cases, a social work degree is fine.  Often, people just need to talk to an empathetic ear.  There's no real expertise needed with that.  It's about being a caring person.  But, on this site, we are talking about serious mental illness.  I wouldn't in good conscience rec a masters level person for this.  Ill-equipped. 

If I were recommending therapy to a friend, I'd recommend a PhD, ABPP psychologist because that is the clearest credential representing competence in the field.  It doesn't guarantee anything.  It's about probabilities.  A nurse might be able to function as a competent primary care physician if they've spent enough time in a hospital, but that doesn't mean that would always or even mostly be the case.  Experience is important.  But so is education, so are admission standards (better and brighter students), etc. . . If I was worried about a friend, I'm sending her to a board certified physician, not a nurse practitioner. 
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« Reply #6 on: January 01, 2009, 09:14:11 PM »

This is a really interesting discussion.   I think a lot of people don't have a very good road map for seeking mental health care. I often think people pick a resource based on cost or ease.

My experience, which qualifies as "one rat study", is that there is a huge range of competency continuum among mental-health providers.

I personally look at a DBT provider the same way I look at a surgeon -  their are a lot of general surgeons that can do the job, but picking a specialist, someone that does the same type of surgery day in and day out, really improves the odds that you'll get competent care. Especially if you have no other barometer to access someones skills.  DBT is pretty specialized.

A long the same lines,  I believe that a practitioner with active ties at the University, all things being equal, is also a good bet. It seems that the treatment of BPD is in an embryonic stage and there are still debates about which is best:

Cognitive-behavioral therapy (CBT)

Transference-focused therapy (TFP)

Dialectical-behavioral therapy (DBT)

Schema-focused Therapy (SFT) and

Mentalization-based therapy (MBT)

Although I understand that it is DBT that has the huge studies behind it now.

A few people I've talked to have recommended that DBT be done in conjunction with other methods - talk therapy being one, STEPPS being another, and, of course, the prescribing psychiatrist.   So a competent care plan probably has several mental health professionals involved each working out component of the care.

It's interesting discussion, guys.

Skippy
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« Reply #7 on: January 02, 2009, 09:47:57 AM »

Just to the comment of DBT being commercialized - I just perused ":)ialectical Behavior Therapy in Private Practice" by Dr. Thomas Marra, and the two things that jumped right out is how Dr. Linehan wants to "certify" DBT practicioners, and how DBT is now for all kinds of other PDs.

My limited experience with certificate of counseling from a divinity school is not positive. In general, the focus is spiritual verses mental, and the direction is that most mental disorders are manifestation of spiritual issues.

I am a firm believer of physical, mental and spiritual areas but with no hard boundaries, even major overlaps and influences.
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« Reply #8 on: January 05, 2009, 10:53:09 AM »

Excerpt
A few people I've talked to have recommended that DBT be done in conjunction with other methods - talk therapy being one, STEPPS being another, and, of course, the prescribing psychiatrist.   So a competent care plan probably has several mental health professionals involved each working out component of the care.



This should be reinforced.  A competent care plan might include a psychologist, psychiatrist, primary care physician, and social worker.  This may seem like a lot, but in concert, it can be effective.  The primary care physician is necessary to monitor general health factors.  There are many conditions that can affect mental health presentation.  Communication is key.  The mental health practitioners need to have access to medical records to stay on top of this.  The psychiatrist is necessary for any pharmacotherapy.  Though primary care physicians often handle psychoactive medications, they are underqualified for this.  A psychiatrist is the right specialist for this work.  The psychologist can be used for assessment, initially.  They are the most qualified for accurately diagnosing mental illness.  Then, the psychologist can be used for therapy.  The social worker can be used as a case manager and also to facilitate contact with needed services.  People with mental illness are often in need of multiple levels of intervention. 


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« Reply #9 on: January 05, 2009, 12:18:24 PM »

This is a good thread.  It seems to center on selecting an ideal therapist though.

I live in San Antonio, the 7th largest city in the US.  I have searched extensively, and have only found one therapist here that specifically mentions treatment of borderline, he is not trained in DBT though.

The only place in town I've found offering DBT is a center that specializes in treatment of eating disorders.
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« Reply #10 on: January 05, 2009, 01:33:12 PM »

This is a good thread.  It seems to center on selecting an ideal therapist though.

I live in San Antonio, the 7th largest city in the US... The only place in town I've found offering DBT is a center that specializes in treatment of eating disorders.

Your point is probably one of the most important - for any number of reasons, people often do not have the insight, the resources, the access, or all three to get into an optimal care plan. And of course, we don't want to forget the human elements, interests, compatibilities that also plays a significant role in the outcome. If the working relationship between the client and caregivers is not sound...   

Possibly the most pragmatic thing this thread can accomplish is to outline 1) ideal care models (which have been discussed), 2) outline models that would likely do more harm than good,  and then move on to discuss 3) the practical alternatives between. 

I'll start by saying that if you random or loosely recommended resource - you have as significant risk of "fouling" the person with the disorders acceptance of their illness and disorder.  I, personally, would research the field (both the type of care plans and referrals to specific providers) possibly starting with the nearest university, speaking to people at the best psych facilities in town, and if you can find a support group - inquire there too.

Skippy


PS: You may find these resources help in your search --

UTSW at Austin, has an active mood disorder program run by Robin B. Jarrett, Ph.D., Professor of Psychiatry, and Elizabeth H. Penn, Professorship in Clinical Psychology.  They may be able to direct to to resources a close to your home.

This is a self help group - they may be able to direct you to some resources:

Scarred Souls

San Antonio, TX

Contact: Laura (210) 349-7190 (*not* the church where meetings are held)

scarredsoul@hotmail.com
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« Reply #11 on: January 05, 2009, 03:23:08 PM »

william3,

I live in a major U.S. city, and our County Mental Health agency has DBT therapists and programs (with waiting lists).  Not that I recommend county agencies (I don't), but I just wonder if you have looked in the right places.

I found a referral for a private DBT therapist by calling my local county mental health agency.
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« Reply #12 on: January 06, 2009, 01:41:11 PM »

Skip & Bitzee -

Turns out the eating disorder clinic also treats BPD, but doesn't advertise it.  This is good - if they advertised BPD treatment, I doubt my uBPDw would be willing to attend.  In the past, telling her she has BPD and should seek BPD treatment has been counterproductive.  I guess I really don't care what her diagnosis is, as long as she can get the symptoms under control.  Now I just need to pick the right way to frame my suggestion for an appointment with the DBT therapist. 

Thanks for the other suggestions - I will check into those too if this doesn't pan out.
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« Reply #13 on: January 06, 2009, 11:16:03 PM »

 ... well, this probably goes without saying, but ...

ir'a not a non's job to select a therapist for someone with BPD, and that seems to be most of the content of this thread (and this conversation has been interesting!)

This is a non board, right?

So, selection of a therapist who really understands dynamics related to being in relationship with someone who has BPD ...

how does one find that?

thoughts?

Molly
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« Reply #14 on: January 07, 2009, 08:58:01 AM »



Mollyd,

I think Domestic Violence therapists understand these dynamics... they may tend to be a little low end, though, working for shelters, etc.  A private therapist with a background in Domestic Violence might be good.

I chose a DBT therapist for myself, thinking she would be knowledgeable about both the relationship dynamics and BPD.  I ended up being very disappointed with her, however.  Perhaps this was just a fluke.
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« Reply #15 on: July 08, 2009, 10:10:30 PM »

  My dBPDF is going to change Therapist's next week and has called a new one that I recommended that specializes in DBT and other BPD issues. Are there any specific questions  my F should ask the T before signing up or should she just give this new one a try? TIA
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« Reply #16 on: July 09, 2009, 08:54:17 AM »

 Maybe this could be made a sticky in case others ask :

From BPD Demystified , Robert O. Friedel, MD -

"John Gunderson described well the responsibilities of the primary clinician"

- Educate the patient about the nature and causes of Borderline Disorder

- Ensure that all appropriate evaluations are performed in order to determine the patients specific needs

- Develop with the patient a comprehensive treatment plan that best meets these needs

- Ensure the plan is implemented

- Routinely determine the patients safety and progress in treatment

- Implement changes in the treatment plan when indicated 

- Ensure communication among other therapists, if any , who are involved in the patient's treatment


And from Stop Walking on Eggshells by Randi Kreger and Paul T. Mason, MS  -

    Asking the clinician questions designed to evaluate the persons competence at treating patients with BPD -

1. Do you treat people with BPD? If so how many have you treated? Watch the therapist's body language and tone of voice to determine their attitude about BPD clients. We suggest you avoid therapist's who do not hav a lot of experience with borderline problems.

2. How do you define BPD? If the therapist knows less than you do keep looking. If the therapist thinks BPD is part of another disorder that you do not have, move on.  ( for example they may believe that BPD is really a form of Post-Traumatic-Stress-Disorder, yet you have no history of trauma.)

3. What do you believe causes BPD? If you are a non-abusive parent of a BP and the therapist believes all BPD is caused by parental abuse, we urge you to find a more compatible therapist. Also if the clinician does not mention possible biological causes, they are probably not up to date on the latest research.

4. What is your treatment plan for clients with BPD? Look for someone who can give you a clear overview of the treatment they provide, but who also says that treatment is modified for each individual. Therapist's who do not have a treatment plan tend to be diverted by BP's crises and never seem to get around to addressing long-standing issues.

5. Do you provide a specific treatment for self-injury? Substance abuse? Eating disorders? Loved ones of those with BPD? Substitute or add your own concerns here.

6. Do you believe that borderlines can get better? If so have you personally treated BP's who improved? According to Santoro and Cohen (1997), " what you want to hear is reasonable optimisim. No one can give you a guarantee( if they do, skip them). If they hedge their bets too much, it is probably better to move on to someone else." Make sure that you and the therapist share the same goals.

7. What are your views on medications? If the therapist is not a psychiatrist , ask who would prescribe them, if any are needed.

  Hope this helps others. I am going to give this to my dBPDF if she doesn't have me go with her.
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« Reply #17 on: July 09, 2009, 10:04:05 AM »

Good post - thanks!
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« Reply #18 on: September 08, 2009, 02:40:22 PM »

Hello,

I am looking for a T in my area, but when I get a list there are psychologists, psychiatrists, counselors, therapists, LCPC, LCSW etc etc.  I didn't realize it would be that hard.  I need someone that has a clue about BPD and can help me with PTSD.  So what do I pick?

Thank you for your feedback
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« Reply #19 on: September 08, 2009, 03:10:38 PM »

This might be a good source for help or recommendations in your area:

www.emp-dbt.com/index.htm
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« Reply #20 on: April 09, 2010, 08:01:58 PM »

Staff only

This thread about what we're looking for in a therapist is split off from another started by Randi Kreger about how therapists have helped/hurt: https://bpdfamily.com/message_board/index.php?topic=115997.40.

Without getting into details ( sorry I have not read all of the posts but some of them) I had the opportunity to speak to two T's recently that were my daughter's T's.  So the first one was phenomenal.  He was brilliant and perceptive and thought outside the box and was able to HEAR  and synthesize what H and I were telling him and he was able to see the possibility of BPD  in our D and then after talking to us ( h and me) HE felt validated by what we had told him.  He would have been the best T for our D.  But our D did not like that anyone was finding out what she was really like- being challenged so that was the end of him.  

Now- presently there is one who is exactly what I was afraid of- she is an enabler and to my D she is a keeper.  This is always the case- anyone who agrees is IN and if you see though her- and start to challenge you are out.  So I was telling T#2  the exact same things I told T # 1 (above) and #2  took it all differently and seemed to have a ONE TRACT MIND- and she used all of my very important information differently than #1 and kept defending our D as if I was TRYING  to use the information AGAINST  our D instead of informing the #2  of another side that my D is so good at hiding.  This T wasn't hearing a word I was saying.  She was like a broken record no matter what I said.  My aim was to help my D.  

It is about skills.  The ability to HEAR WITHOUT BIAS, SYNTHESIZE INFORMATION, THINK OUTSIDE THE BOX, UNDERSTANDING THAT THERE IS A GLOBAL PICTURE AND NOT JUST ONE SIDE...AND MORE!

Bleccchhh.  Speaking to this T#2 keeps me feeling so hopeless and my H too about our D.  I know it IS our D's own choice who she picked and I know what her schtick is all of the time- but besides what this thread is about I also wish there was a law that prevented BPD's to pick their own T's too.  That would be a miracle, eh?  Of course you need to have the diagnosis of BPD for that kind of magical thinking.  So many on these boards say uBPD...or they are too young for the psyche to "name" as BPD.  

Thanks

wtsp

oops- just saw that Randi had all of her answers necessary.  Well it felt good to vent anyway.  

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« Reply #21 on: April 10, 2010, 11:09:19 PM »

Excerpt
Experience is not enough.  There is a way of thinking that's important. . . the science of mental health

?

there are therapists/psychologists/psychiatrsits that are skilled and talented and there are those who are not ...

the point I was trying to make, which I don't feel is especially unique or controversial, is that a clinician who has a lot of expeience with a particular type of problem or disorder, like BPD, will possess more  knowledge and more expertise concerning that disorder, and therefore will likely be able to offer more help or assistance to someone suffering from that disorder, ... than would another equally skilled clinician that has little or no knowledge or experience of that particular disorder or ailment.   

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« Reply #22 on: April 12, 2010, 01:33:00 PM »

"there are therapists/psychologists/psychiatrsits that are skilled and talented and there are those who are not ... "

agree. . . but, they aren't equivalent levels of care therapist does not equal psychologist does not equal psychiatrist.  They are supposed to target different things.  Granted, there is significant overlap these days with the expansion of scope of practice of midlevels, but, even when performing similar tasks, you're dealing with very different experience/training/thought process among professions. 

"the point I was trying to make, which I don't feel is especially unique or controversial, is that a clinician who has a lot of expeience with a particular type of problem or disorder, like BPD, will possess more  knowledge and more expertise concerning that disorder, and therefore will likely be able to offer more help or assistance to someone suffering from that disorder, ... than would another equally skilled clinician that has little or no knowledge or experience of that particular disorder or ailment.   

"

I agree, with the caveat that experience without proper frame of reference is nearly useless.  Meaning, I would tend to prefer a less experienced (with BPD) doctoral level practitioner than a masters practitioner who has lots of exposure to BPD because in my view treating BPD should be outside of the scope of practice of a masters level therapist. 


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« Reply #23 on: April 12, 2010, 10:11:13 PM »

Excerpt
I agree, with the caveat that experience without proper frame of reference is nearly useless.  Meaning, I would tend to prefer a less experienced (with BPD) doctoral level practitioner than a masters practitioner who has lots of exposure to BPD because in my view treating BPD should be outside of the scope of practice of a masters level therapist.

 

I see it differently.  I would rather work with a skilled and talented cinician(s) who has expertise in a specialized area if I were dealing with a difficult and specialized disorder such as BPD, regardless of the PhD v. Masters level of education. I've seen way too many genuinely talent people from the 'lower eschelons' of life work wonders and way way too much inflated pseudo brilliance from supposedly 'higher degreed' individuals... to assume or expect the degree or even the school (Harvard v. a State School) necessarily means squat

A psychiatrist is of course a medical doctor and therefore can treat medical issues and perscribe medication, whereas a psychologist and MFT or other master's level clinican cannot.   A psychologist can administer and interpret a variety of psych tests.  Someone w/ a PhD level education may also be invovled in teaching/research endeavors.  While perscribing drugs and administering (certain) psych tests are beyond the scope of practice of a master's level clinican...Neither of those targeted skills, nor teaching or research endeavors, necessarily make an individual a better therapist.  I've worked with way too many physicians and other 'supremely degreed' individuals whose people skills and common sense were absolutly atrocious and whom caused many more problems than they ever helped.  I am not personally automatically enamoured of  or even trusting of a professional based on the degree.

I would never personally choose to do ‘therapy’ with a psychiatrist.  This is an individual who has focused most his/her adult life on the study and application of a classic medical model, and gaining expertise in prescribing drugs for specific mental health issues.  They are usually over extended and stressed-out and typically  have way too large a patient load.   They can barely keep up with seeing their patients 1x every 2 weeks to check on how the medication is doing and are of course immersed in all sorts of insurance issues and hospital paperwork.  This is the person I want to see for medication, this is  NOT the person I want to see for ongoing  ‘therapy’.   

In any event, what I've seen in practice are 'treatment teams' with a psychiatrist taking the lead on dx and medication even though they have the least 'face time' with the patient...and maybe a psychologist for testing...but the people working daily in the trenches in group and individual therapy, including DBT therapy targeted for BPD symptoms, are mft's and/or lcsw's.  Further rounding out the team are psych. nurses and in some cases even case managers.   

I don't see too many psychiatrist's or psychologists leading dbt therapy groups or any kind of therapy groups w/ significantly mentally ill individuals. In fact I've never seen that.  Ever.  At least not in out-patient or partial hospitalization programs and / clinic programs that I've been exposed to. Not even once.  Maybe that's just the case in  my state or my area, but that's what I see.  In support of family members of those who suffer w/ BPD, it is my understanding that some Family Connections type support groups are led by lay people; family members who have lived with this disorder and gone through their own skills training and are trained to help lead groups of family members who are eager to learn similar skills, with positive results.

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« Reply #24 on: April 12, 2010, 11:25:39 PM »

continued...

The overlap is that all three are involved in psychiatric patient care to one degree or another.  But there is less and less overlap, and more specialization in each role, specifically…

Psychiatrists are medical doctors and their expertise usually lies in hospitalization and medication issues of patients with acute mental health problems.

Psychologists are relied on by schools, hospitals and other social institutions to administer and interpret psychological tests, and some also perform  therapy.  Many psychologist programs can be entered from directly after the undergrad level of study has been completed…meaning you do not have to move from undergrad to masters to PhD level study.  Indeed,  if you want to ultimately become a psychologist, it is recommended that you not take a  masters course of study such as an MFT undergoes, because you will have to start from scratch and go through many of the same hours of onsite training that you did while getting your MFT.  

MFTs are Marriage and Family Therapists, they are trained and licensed exclusively for the purpose of performing therapy with men, women, children and families regardless of the diagnosis.  They work either in private practice or in mental health agency’s and clinics and/or hospitals in tandem with a ‘treatment team’ that will include consultation with and referral to a psychiatrist if medication or medical issues are assessed.  They undergo a total of 7 years of total undergrad/post grad schooling and another 3000 hours of supervised onsite training as a therapist intern doing one on one, group, family and couples therapy supervised by a licensed MFT or clinical psychologist before they can sit for the state board and become a licensed therapist in private practice.  MFT’s along with LCSWs are relied upon almost exclusively in hospital settings by psychiatrists to perform hours of client individual and group ‘therapy’ , they are relied upon to peform assessment, diagnosis and treatment planning, and their scope of practice is NOT limited by law or ethics to any particular type of client or diagnosis.  Meaning…it is fully within the scope of practice for MFT’s to be working with individuals with BPD or any other diagnosis.  As with any clinician, if they feel they do not possess the knowledge or expertise to address a client’s presenting problem, they are legally and ethically mandated to refer the client to a practitioner who can and they most cetainly cannot perscribe medicine though they monitor and consult with a psychiatrist and other team members regarding medication issues.

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