How to choose a BPD therapist

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For national referrals:

To find a therapist trained in Dialectical Behavior Therapy, go to: http://www.behavioraltech.com/resources/crd.cfm, e-mail them at info@behavioraltech.com, or phone their office at 206-675-8588.

Choosing the right therapist is crucial. While many wonderful therapists are knowledgeable about BPD, many aren't.

A therapist on the Net warns, "Therapists who work with BPD patients must be absolutely committed to the process of working with the patient and the family. This is not short term therapy, and anyone looking for short term solution focused therapy quick fixes is not going to accomplish it with this type of client. (Speaking of the therapist here.) The therapist must be absolutely committed to long term therapy with both the client and the family if any help or change is to be obtained."

We chatted with a psychologist in California who specializes in treating BPD and related disorders. He also has provided many professional workshops on the subject, and he supervises therapists and consults on these cases. He said,

"One of my principal concerns is the absence of adequate training in the recognition and treatment of BPD, which results in bad outcomes for many. Most of my current clients ended up with me after multiple prior treatment failures, often because the therapist, while well meaning, did more harm than good...Much of the damage occurs because the therapists have lousy boundaries, either because of their own issues or because they are inadequately trained.

"The 'harm' results when the therapist recognizes the boundary violations and suddenly changes the rules, even blaming the BPD patient. Since issues of trust, rejection and safety are so important to the BPD client, this therapist behavior can be very destructive.

"The second type of harm often occurs when patients requiring long term treatment are invited into a short term process, only to be dropped when money runs out. BPD patients need to understand what they are undertaking, up front. Most of the other problems occur via simple therapist incompetence."

Therapists tend to work in one of three ways (or they may use a combination):

  1. Psychotherapy: The therapist explores the patient's early childhood and develops a healthy relationship with the patient in an attempt to resolve interpersonal issues. This type of therapy may be appropriate for people with mild BPD.

  2. Supportive Counseling: This is less intensive than psychoanalytic. The therapist helps the patient with problems that are more current rather than trying to resolve early childhood issues. This type of therapy may be more appropriate for people with more severe BPD.

  3. Cognitive Therapy: The goal of this type of therapy is to reduce immediate behaviors that are either life threatening (suicide threats, self-mutilation) or interfere with quality of life (rages directed toward others).

When trying to find a therapist, ask many questions. Determine the person's attitude toward BPD and their knowledge of the subject::

  • What percentage of their patient load is people with BPD?

  • What treatment approach do they use?

  • What is their philosophy about calls between visits?

  • Read up on BPD and visit the therapist.

  • Ask insurance questions as well.

A California therapist says:

"Regarding my approach, I spend a good deal of time early in treatment just outlining and reinforcing the rules and structure of treatment. It is important to have a clear model in one's head that can be articulated simply to the BPD patient, so much of what I am doing is behavioral (i.e., it's okay to feel suicidal and it is okay to think about suicide, but it is against the rules to do it). I also make certain that I follow through on everything I say that I will do. Third, it is useful, I think, to predict struggles for the BPD patient, but this is a bit complicated to describe at this point."

 

My book The Essential Family Guide to Borderline Personality Disorder has an entire chapter on finding a therapist. Following are some excerpts from that chapter. Normally, I would not put so much from a book on a web site. But this information is so badly needed I am making an exception.

 

Why It's So Hard to Find a Therapist

If you want to hear a lively and revealing conversation, listen in to a group of mental health professionals talk about patients with BPD. June Peeples, a producer of the Infinite Mind radio show, did just that. It happened at a cocktail party attended by social workers, psychologists, and psychiatrists—"smart people and concerned, caring therapists," Peeples says.

Over hummus and veggies, the group started to talk about patients who, it seemed, were a therapist's worse nightmare. One therapist said that she was careful to make sure she wasn't treating more than one of them at any given time. "I won't treat them at all," said another, and a heated discussion ensued about the importance of a rapid and correct diagnosis of these patients—not for therapeutic reasons, but to make sure you don't get stuck with them.

Therapists develop this negative mind-set for two general reasons. First, BPs are one of the most challenging types of patients to treat—if not the most challenging. Second, treating borderline patients can be emotionally draining for the therapist. Each of these factors feeds into the other.

Borderline Patients Are Professionally Challenging

BPD is more tightly woven into the fabric of a person's being than other types of brain disorders. The disorder alters the process by which a person thinks, feels, and acts. You can't get any more fundamental than that.

Lower-functioning conventional BPs often come to therapy with a defeatist attitude—understandably, after all the time they've spent in the mental health system without feeling better. Psychiatrist Richard Moskovitz says, "Even during the first therapy sessions, patients make remarks like, 'You can't help me,' 'Why should you be any different from the people in my past who betrayed me,' and 'I am too defective to ever be repaired.'

What all this comes down to is that borderline patients are probably the toughest clients a clinician will ever treat. They test the skills of even the most experienced and well-trained therapists. One common dilemma is finding time to explore deeper issues when the BP is always in crisis. Another is that some therapists (especially those inexperienced in treating borderline clients) have difficulty observing their own limits, such as keeping after-hours phone calls to a reasonable number. Once problems begin, it's tough for the therapist to reverse course without seeming critical or abandoning. In situations like these, an untrained therapist can be worse than none at all.

Borderline Patients Are Emotionally Challenging

Mental health professionals are human beings. As such, they have many of the same gut reactions that you do when they're faced with rage and blame—even though they know intellectually it's not personal. "Borderline patients can be hostile or attack," says Marsha Linehan. "Therapists can feel so scared, angry, frustrated, or helpless that they pull back. And that is harmful to the patient."

Kathleen, a woman with BPD, agrees. "A lot of the therapists I saw were frightened by my rage and my inability to engage or form an alliance with them. I didn't want really to get better. I just wanted to express rage. I always felt that the people who were treating me were disgusted by me." On the other side of the spectrum, it can be scary if borderline patients go overboard in the other direction: idealizing their therapists, fantasizing about having a relationship with them, and making them the focus of their lives.

Mental health professionals go into the field because they want to help people. When a client doesn't get better despite the therapist's best efforts, it's tempting to blame the client for the lack of progress and to view their attempts at trying to get what they need as manipulation, rather than to question whether the treatment they're providing is effective.

Of course, all of this is only a problem if your family member is willing to walk through a clinician's door.

How Do I Motivate My Family Member to Seek Help?

Before you start the search, make a realistic assessment of whether your loved one is willing or ready to enter therapy. If not, therapy may be an expensive waste of time. Nearly everyone in the WTO community has made numerous attempts to compel their family member to see a therapist. Common methods include

•     manipulation

•     bribes

•     crying

•     pointing out the person's flaws

•     logic and reasoning

•     begging and pleading

•     leaving self-help books around the house

What happens next is as predictable as the change of seasons.

Stage 1: The BP says it's the non-BP who needs therapy, not the BP. If the non-BP has unwisely put forth BPD as an explanation for their BP's behavior, the BP accuses the non-BP of being the one with BPD. For good measure, the BP also accuses the non-BP of being abusive, unreasonable, and controlling.

Stage 2: In desperation, often during a crisis, the non-BP finally resorts to an ultimatum such as, "Go to a therapist or I'm leaving you," or some other consequence. The non-BP hopes that once the BP is in therapy, the clinician will force their family member to see the light.

If you are serious about limiting or leaving the relationship and and your family member knows this is true, this is the only thing I have seen really work to pursuade the disordered person to seek help.

Stage 3: Apprehensive that their loved one might actually carry out their threat, the BP agrees to see a therapist, perhaps with the partner or other family members. Therapy, however, goes nowhere. That's because even the best BPD clinicians can't help a patient who doesn't want to be helped.

Stage 4: Once the immediate threat dissipates, the BP finds some reason to drop out of therapy. This is especially true if the therapist is a good one, skilled at bringing the focus to the BP's core issues instead of reinforcing the BP's feelings of victimhood. However, if the therapist takes everything the BP says at face value without probing further—and this is not uncommon—the therapist may inadvertently reinforce the BP's twisted thinking, making things worse.

Stage 5: Eventually, the non-BP realizes that forced therapy is not going to work and that no one can "make" anyone do anything (a good life lesson, by the way). Sometimes the whole process needs to be repeated several times before this truism becomes evident.

Stage 6: Months or years later, the non-BP realizes that her efforts to change the other person simply added a thick second layer of conflict on top of the original issues. She becomes even more disillusioned, depressed, angry, and hopeless. As one Welcome To Oz member noted, "My attempt to invade his world with facts only caused more pain."

Life-Changing Therapy Requires a Major Commitment

Therapy is hard work. Transforming the way you think, feel, and act while taking responsibility for things you've always blamed on someone else is a tall order. People with BPD who are serious about treatment will pursue it, perhaps with your help, and make a commitment to it. They will make their own appointments, be honest with their therapist, and complete any "homework" the therapists give them. Life coach A. J. Mahari says, "The truth is relative, and each person with BPD must come to their own truth in their own time and way."

That said, for the sake of readability, in this chapter the term "you" (as in, "When you call the therapist, leave a voice mail) could mean either the family member (parents, especially) or the individual with the disorder.

Rock Bottom as a Motivation to Take Therapy Seriously

Some BPs will only concede that they need help after they have hit rock bottom—after someone they love does end the relationship or they wind up in jail or under psychiatric observation.

Rachel Reiland, a woman recovering from BP and the author of the BPD memoir Get Me Out of Here, says:

I believe that there needs to be some kind of major upheaval that serves as a catalyst for a borderline to face the truth. Not wanting to lose something, perhaps. They can no longer blame the power-hungry boss or the bitchy spouse or the scores of people who have it in for them.

But denial is a funny thing. What some of us may see as shocks or the bottom isn't necessarily going to be viewed that way by the BP. So they've destroyed a relationship? They move on to the next one, and so on. They get fired from a job they liked? Blame it on the boss and get another one. Lose custody of the children? It's the damned court system.

The fear of change, the compelling fear of the unknown, is so intrinsic, so vast, so encompassing and overwhelming, that it's greater than the tragic events that would send most people down to their knees. The shock cannot be predicted, nor contrived. It can't be provoked by the greatest of efforts or good intentions on the part of another.

Mahari advises family members to let go of any desire to control what's going on in therapy. "This is their journey, not yours," she says. "You can support them, but it can't be your life plan." She suggests that family members do the following:

•     Emotionally disengage from the outcome of the person's treatment. The less you're involved, the better able they will be to take care of themselves and observe their limits.

•     If your family member talks about what goes on during therapy, take a neutral stance, neither agreeing nor disagreeing with their judgments, complaints, anger, or devaluation. Be positive, but beware that making too much progress can be threatening to your family member. If they enter recovery, the thinking goes, they might lose your intensive support. Plus, if they relapse, you might be disappointed in them. So be encouraging and optimistic, by all means, but be sensitive to this as well.

•     Recovery from BPD (or anything else, for that matter) is a long, winding road, and sometimes it doubles back. The speed limit changes and there's a few stop signs, too. Mahari says, "There are no simple rules here. This is not the rehabilitation of a physical injury. This is the rehabilitation of the entire self."

Preparing for the Search

Whether you're a BP or a non-BP, going into full-throttle search mode for a therapist can help overcome feelings of hopelessness and helplessness. There are some things that you can't do. But searching for a therapist is one thing you can do.

Become an Informed Consumer

Learn everything you can about BPD from recent and reputable resources. You'll come across contradictory information, especially in the area of causes and treatment. So the more research you do, the firmer your foundation will be and the better you'll have a handle on which therapist can best meet your needs. Let a potential therapist know you've done research and the descriptions of BPD symptoms seem to match your family member's symptoms.

Create a Medical History File

Document your own (or your family member's) struggle with the disorder. Write a short medical history that includes the following:

•     Signs and symptoms by age and any special circumstances, such as self-harm occurring after a bad break-up

•     Previous treatment (if any), including the name(s) of the clinician(s), diagnoses given, whether the treatment was beneficial, and anything else that strikes you as important. List all medications currently being taken, their dosages, what time of day they're taken, and what they're for. (It will come in handy when you fill out forms.)

•     A list of the medications (and dosages) that have been tried and discontinued. Explain why, such as it wasn't effective or produced undesirable side effects. This will help during the trial and error process. Perhaps a different dosage may produce better results or fewer side effects.

•     Anything else that you think a therapist should know, such as family stressors like a divorce, a move, or the loss of an important person in the BP's life. You might also talk about the impact the BP's behavior has had on family members.

Having this information at your fingertips will be useful in many ways. For example, it will help with continuity of care and remind you of questions you want to ask. Once therapy begins, this record will help the clinician obtain the most information in the shortest amount of time. Many people find it a validating and healing exercise to see it all laid out in one place. Feel good about yourself; you've made it this far!

Read Up on Your Health Insurance Benefits

Get up close and personal with your health insurance documentation. Call the company if you don't understand the plan. Pay special attention to what they pay for and what you must pay for. Assess your finances to determine whether you can pay for co-payments and services that aren't covered.

Once you do settle on a therapist or treatment program, talk about fees right away. Bring up matters such as co-payments and how you're supposed to pay them. (Some want payment at each session). Find out whether the provider offers a discount for private-pay patients. Some providers will offer discounts for payment with cash or check because health insurance has so much red tape. Ask about a monthly payment plan.

Parents, Anticipate Being Blamed

If you are a parent looking for help for your child of any age, mentally prepare yourself for running into at least one clinician who assumes you caused your child's disorder.

Some may be explicit about this; others just imply it or treat you in a disapproving way. This is one reason why it's so important for you to do your own research, especially on the chemical and genetic risk factors of developing BPD. The father of a borderline child who is a member of an online support group for parents says:

Despite all the new information about what causes BPD, we parents still come across clinicians who automatically assume that we've mistreated, abused, neglected, or invalidated our children. This is harder to endure than my daughter's outbursts and even her punching and kicking. It's like screaming for a lifeguard when I see my daughter drowning, then running out to save her, and when the lifeguard gets there he punches me in the gut for deliberately trying to drown my own daughter. And the tragedy is, while he's hitting me, she's still sinking, crying for help.

If you are accused, pretend you have a rubber shield around you so the hurtful words bounce right off you. Do not take them personally. They are no reflection on you, and the next parent who walks through the door will probably get the same treatment.

Making Contact

Here's another way that looking for a good therapist is like searching for a job: networking produces some of the best leads.

Find Referrals

•     Ask friends and family. Ask them if their friends and family might know of anyone.

•     For schema therapy, see www.schematherapy.com

•     For a dialectical behavior therapist, see www.behavioraltech.com

•     Try contacting the NEA-BPD at NEABPD@aol.com

•     Check with your primary physician and other health care specialists you see, from your allergist to your dentist.

•     If the BP is a child, ask your pediatrician.

•     Phone the psychiatric department (often called "behavioral health") of the hospitals in your area and ask the nurse-manager whom she would recommend if someone close to her needed a psychiatrist or a therapist. You don't have much to lose if you also ask her whom she would not recommend.

•     Consult online "find a therapist" databases. They can contain a great deal of information about the therapist—orientation, interests, philosophy, background—and it's easy to hone in on the ones who most interest you. You may want to begin your search process by looking at these to see the type of information the therapists give.

•     If you already have either a psychiatrist or a therapist, the psychiatrist should have names of therapists to recommend, and therapists should be able to recommend psychiatrists.

•     Inquire with people you know who are employed at a hospital or clinic, even if they work in a totally different area. The grapevine is long and thick, and they may have a good buddy in a relevant department. If you know a psychiatric nurse or aide, you've hit pay dirt.

•     If your family member has a serious co-occurring illness, you may want to start with a specialist in that area. A therapist who treats depression is easier to locate and may know of a peer who works with borderline clients who have that co-occurring disorder.

•     Look up local mental health agencies. Some local mental health services are listed in the phone book in the blue government pages. In the "County Government Offices" section for the county where you live, look for a "Health Services (Dept. of)" or "Department of Health Services" section. In that section, look for listings under "Mental Health."

•     Call your local state psychological association.

•     Find the most respected medical clinics in town that have a behavior health department. Top clinics like to become associated with top people.

•     If you have a local university, call its department of psychiatry. These psychiatrists are often on the cutting edge of research. Also, ask for recommendations of people trained in that university's psychiatry or psychology program.

•     Contact the National Alliance for the Mentally Ill (NAMI), both state and local branches, as well as any other mental health organizations.

•     Look in the Yellow Pages or Internet databases, particularily the one at www.PsychologyToday.com. Mental health professionals are listed under "counseling," "psychologists," "social workers," "psychotherapists," "social and human services," and "mental health." Look for certifications such as Board Certified in Psychiatry or Board Certified in Pediatric Psychiatry.

•     Make use of the information and referral services of the United Way—particularly if you are in need of financial assistance. Look into low-cost or sliding fee clinics.

•     Check if your company offers a employee assistance program, which may be able to provide the names of psychiatrists.

•     Talk with your pastor, minister, priest, rabbi, or other religious leader.

•     Take a look at local magazines that may put together lists of top professionals in the area.

•     Keep your eyes open for the names of professionals used as sources in the local media.

•     After each interview with a potential candidate, ask if they can give you any names.

Evaluating the Candidates

Before you contact your candidates, search for them on the Internet. These days, many clinics and practitioners have Web sites that can give you insight into their treatment methods, interests, and philosophy.

Remind yourself that if you were getting your house painted, you would ask for references and check them out. And your loved one's mental health is a lot more important than the color of your house! Call or email the offices of the best candidates. Introduce yourself and explain the reason for the call. Leave a voicemail and suggest good times to call you back.

Once you connect, ask if they have time to chat with you on the phone for a few minutes. The way the therapist answers the questions is also revealing. A good one should encourage you to shop around for the right therapist and not be offended that you're asking questions.

Consider whether you want to use the actual term borderline personality disorder, especially if your loved one hasn't been formally diagnosed. If you do, the image of suicidal, self-harming, lower-functioning conventional BP will most likely come to the clinician's mind. If that doesn't describe your family member, be cautious about using it. Even if you do have a lower-functioning conventional BP family member, you may wish to just describe the traits themselves first to help the therapist keep an open mind. Experiment.

Medical professionals can sometimes loom larger than life. Remember, you're paying them, and, depending upon your circumstances, that could run into the thousands of dollars. Don't be intimidated by their degrees or the cost of their office furniture. Be open-minded, but trust your instincts. (Few people ever say, "I wish I hadn't trusted my instincts.")

You'll be evaluating prospective clinicians in three areas: hard factors, soft factors, and attitudes and beliefs about BPD.

Hard Factors

Ask:

•     Are you taking new patients?

•     How much do you charge? What insurance plans do you accept?

•     Do you have a particular focus or interest? (Some therapists work closely with particular populations, such as Christians, gay men, or ethnic minorities.)

•     Are you available after hours for emergencies? (For lower-functioning conventional BPs, this is critical.) Who covers for you when you're unavailable?

•     What is your education and training? (The clinician's credentials should be from a nationally recognized, respected organization or an accredited school of higher learning.)

•     Do you have a license? (This assures you that the clinician has met at least minimal standards in his education and abilities. Call—or check online—the state licensing board to make sure there's no history of legal or ethical complaints.)

•     (If your family member is a child) Have you been specifically trained to treat children and adolescents? (Some clinicians have not been specifically trained; they just prefer working with younger patients. There are fewer therapists who specialize in working with children, so you may have to look harder.)

Soft Factors

You will probably feel comfortable asking some of these questions over the phone. Getting answers to a few of the following requires at least one visit to the office. Or, the answers may reveal themselves over time. If you're evaluating a clinician who practices within a standardized therapy program, you may find the answers to most of these questions in the program materials.

•     How do you see your role in therapy, or what is your style of working? (This is a significant factor that prospective clients often overlook. Some clinicians offer "supportive therapy," which means working on reducing stress and talking about problems in the here and now. Other therapists do deeper work that has the potential to give clients insight into their behavior and effect real change, such as exploring negative patterns in the client's life or ways in which the client may be unconsciously sabotaging herself.)

•     Clinicians who have confidence in themselves do much better with borderline clients. Being able to say, "I don't know," and answering questions without becoming defensive are signs that the therapist has confidence.

•     Ask yourself if this person listens, puts you at ease, and creates a general environment of acceptance while still challenging the client when necessary for his or her own growth. Look for personal qualities such as empathy, flexibility, patience, and a sense of humor.

•     Studies show that sex role stereotypes already play a part in the way BPD is diagnosed. They may also play a hidden role during therapy; watch out for it. For example, women in WTO have said that when they've expressed deep resentment at their BP husband, they've been dismissed as being overemotional and angry. It works the opposite way, too. Some men find that no matter what's going on in their relationship, they're assumed to be the aggressors or abusers and their female BP is presupposed to be the victim.

BPD-Related Factors

Ask open-ended questions such as the following:

•     What are your thoughts about BPD and treating borderline patients? (Don't interrupt, agree, or disagree; rather, jot down anything you want to follow up on later. This will tell you what the therapist considers important. Hesitations and tone of voice can be revealing. Make sure the therapist touches upon the definition, causes, and, most important, treatment of BPD.)

•     Do you believe that both medications and therapy are necessary in treating someone with BPD? (While meds aren't for everyone, in general the answer should be "yes." A clinician's answer to this question can often clue you in to what she believes are the causes of BPD.)

•     Do you have experience in treating borderline clients? Or, if you're not using the term borderline, Do you have experience in treating clients (insert traits or patterns of behavior at issue)? (If "yes"), how long have you been doing so? (Naturally, if the BP in your life is a child or adolescent, you'll want someone with experience in that age group.)

•     Do you have time to keep up with the latest BPD research? (It's vital that psychiatrists, especially, be aware of the latest studies about medications. BPD is an active area of research, with hundreds of studies published each year. Pick a psychiatrist who stays current. With psychiatrists, you do want to use the correct diagnosis.)

•     How do you view family members as being affected by their borderline family member? Do you do family therapy as well? (Whether the therapist involves the family in therapy is not the point; ideally, you at least want someone who understands how the entire family is affected.)

•     (If your family member has a co-occurring disorder) Do you have any experience treating someone with this co-occurring disorder? (If not) How would you address both illnesses?

•     Do you believe that recovery from BPD is possible, and if so, to what degree? (The clinician's attitudes are influential. Innumerable studies have discovered that people tend to live up—or down—to people's expectations of what they can accomplish. Even those who are optimistic may tell you that a complete recovery is unlikely. However they respond, remember that they're probably speaking about lower-functioning conventional BPs, those who are often suicidal and practice self-harm. And if they're negative, don't take this for a fact and lose hope. They don't even know you or your family member, and they're not up-to-date with the latest treatment information.)

The Client-Therapist Relationship

Now that you've asked the therapists all these questions, there's a big question you need to ask yourself; "Of all the people I've spoken with, which ones do I like the best, trust the most, and have the most confidence in?"

Although choosing a therapist who uses an appropriate method for treating BPD is important, mental health experts are beginning to realize that only 15 percent of therapy success is related to the orientation of the therapist. The other 85 percent is the therapeutic relationship between the client and a therapist experienced in treating BPD. Data show that even the placebo effect plays a far greater role than the method used. This is probably even truer for patients with BPD, who have major issues with trust, low self-worth, fear of abandonment, and forming close bonds.

In mental health-speak, a good relationship is called a therapeutic alliance. A therapeutic alliance is one in which the therapist offers empathy, genuine, unconditional caring, and validation, and who builds a sense of trust. Clients, in turn, feel safe, respected, and understood. Once clients feel safe, they can calmly and noncritically observe their own behavior, which leads to insight and personal growth.

This fact can bring much hope to BPs and non-BPs alike, since it is so difficult to find clinicians as knowledgeable about BPD as you would like them to be, let alone meet the rest of the criteria. A therapist can always learn more about BPD (many would be interested in any material you can give them), but neither party can do much if that "click" isn't there.

Obtaining a Diagnosis

Why is it so hard to make a psychiatric diagnosis? Widely published psychiatrist Edward Drummond, MD, says it's because unlike some physical illnesses, "Mental illness does not offer up an obvious villain; no rogue bacteria we can scour with an antibiotic or cancer cells we can see under a microscope." This means that while we wish the process of obtaining a definitive diagnosis were more scientific and consistent, we just aren't there yet.

As you go through the process of getting an accurate diagnosis, you'll find that clinicians have different belief systems. Some mental health professionals believe that diagnoses are of minimal value and are too subjective. In therapy, they usually prefer to focus on specific issues and concerns—unless, of course, there are specific treatments (medications or therapies) shown to be effective with this particular problem. In other words, no effective treatment, no diagnosis.

The problem with this point of view is that it doesn't take into account that effective treatments can and do become available, as they have with BPD and a host of other brain disorders. Clinicians who adhere closely to the diagnostic literature find making a proper diagnosis of value because they believe it aids them in developing a deeper understanding of the condition, addressing specific problems, and developing individualized treatment plans.

Treatment Plans

In most cases, the discussions in therapy sessions are somewhat free flowing or flexible. But the patient and therapist should have a plan that outlines the goals of therapy and how they're going to get there. Treatment plans generally include things such as

•     The problems that brought the client to therapy, from "stress" to "feelings of emptiness" and how much they interfere with having a normal life (mild, moderate, serious, severe)

•     Specific goals for treatment and the steps that need to be taken to reach these goals, such as treatment methods, their frequency, and medications

•     The role of any other health care providers who may be involved in the patient's care. The intervals when the plan will be reviewed and adjusted if needed.

Diagnosing Children

Because a minor's personality isn't fully formed, clinicians tell parents to defer a formal BPD diagnosis until and unless the traits persist into adulthood. But that can be a long wait, and this reluctance to diagnose can have unintended consequences by depriving the child of help that he or she needs.

Robert Friedel, MD, believes that if parents see that their child has BPD-like traits, they should take the child to be evaluated as early as two years old. He also points out that the DSM allows for a BPD diagnosis in childhood if the patient has had symptoms for more than a year.

"If you get them evaluated, you can at least help them though a number of years before a clear diagnosis can be made," he says. "Just as it's possible to taste a spice and then add it to a soup without knowing what it is, it's possible to treat a child who displays BPD-like symptoms without first formally diagnosing BPD."

A major issue is divining what is typical adolescent acting-out behavior and what is indicative of BPD. The answer lies not in the behavior itself, but the reason for the behavior.

Blaise Aguirre, MD, says, "Like typical adolescents, adolescents with BPD may drink, drive recklessly, use drugs, and defy their parents. However, adolescents with BPD often use drugs, self-injure, and rage against their parents as a way of coping with profound misery, emptiness, self-loathing, and abandonment fears."

A comprehensive psychiatric evaluation usually takes several hours and may be spread over more than one visit. The professional interviews the child or adolescent, the parents or guardians, and other professionals involved with the child.

The evaluation frequently includes the following:

•     A description of the child's present problems and symptoms

•     Information about health, illness, and treatment

•     Parent and family health and psychiatric histories

•     Information about the child's development, school performance, friends, and family relationships

•     If needed, laboratory studies such as blood tests, X-rays, or special assessments (for example, psychological, educational, speech and language evaluation)

The psychiatrist develops a report that describes the child's problems and provides a diagnosis. This report becomes the foundation for the treatment plan.

 

 
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