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THE PSYCHOLOGY OF PERSONALITY DISORDERS
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Author Topic: Why are therapists hesitant to give a BPD diagnosis?  (Read 57448 times)
Major_Dad
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« Reply #10 on: January 15, 2008, 01:58:32 PM »

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.
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« Reply #11 on: January 20, 2008, 11:26:53 PM »

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.
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Major_Dad
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« Reply #12 on: January 21, 2008, 09:32:44 AM »

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.
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Mollyd
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« Reply #13 on: January 21, 2008, 01:47:41 PM »

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

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flamingo13
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« Reply #14 on: January 21, 2008, 07:41:54 PM »

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.
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Bricolage
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« Reply #15 on: January 23, 2008, 05:38:52 AM »

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
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SOOOdone
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« Reply #16 on: September 18, 2008, 12:14:09 PM »

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...smiley

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« Reply #17 on: September 18, 2008, 02:33:48 PM »

Job Application

Have you ever been diagnosed with a mental illness?

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.
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« Reply #18 on: September 19, 2008, 08:10:58 AM »

Quote
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. 


Quote
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. 

Quote
  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. 

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doc101
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« Reply #19 on: September 19, 2008, 01:32:25 PM »

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.

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