"Finding a QUALIFIED Clinician"

(From Stop Walking on Eggshells, 1998, New Harbinger, Randi Kreger and Paul T Mason, MS) New material by Randi Kreger; this reflects her opinion only.


Start with a Psychiatrist

When choosing a psychiatrist, we strongly suggest asking if the person has  experience in treating people with BPD. Make sure that the person keeps abreast of the latest advances in research in this area. For example, ask if they've read articles showing that SSRIs may help with impulsivity. 

NEW MATERIAL BY RANDI KREGER: One way to find a good psychiatrist is to call the nurse-managers of inpatient psychiatric units. Simply look in the phone book, look for an inpatient unit (either part of a regular hospital or a standalone psychiatric hospital), call the appropriate unit, and ask to speak with the nurse in charge. Tell him or her you are looking for a good psychiatrist  FOR PERSONALITY DISORDERS and ask who she or he might recommend. 

Make sure you specify personality disorders and mention any other behaviors that apply, such as self-injury, substance abuse, eating disorders, etc. 

If the psychiatrist is for a non-BP, you would ask for a psychiatrist who is  most familiar with personality disorders because they will know best what you're going through. 

The nurse manager will know whom he or she likes; the challenge is to get the information. They will have opinions about who truly seems to care, who seem to be up-to-date and highly qualified, who responds to calls quickly, etc. 

Don't expect NEGATIVE information, such as, "I think Dr. Jones is a really bad doctor." However, there is no reason why he or she shouldn't feel free to give a good opinion about Dr. Smith. If you ask about Dr. Johnson and all you hear is silence and a vague answer, you can assume that his or her opinion of Dr. Johnson is one he or she would not like to talk about on the record. 

The key is to be personable. Act like the nurse is your best friend. Pretend he or she is a friend and already on your side. People want you to get the best care; they just don't want Dr. Johnson to come back and sue them if they say, "I wouldn't see Dr. Johnson if my life depended on it."

If this person will not talk to you, try another hospital. Or call the same place during a different time and try to talk with someone else--even someone who has been there a long time but is not a manager. 

Be cautious about calling during busy times. Ask beforehand if it is a good time to talk. You may wish to call at night (after 11 p.m.) because usually patients are asleep and things are more quiet. Make sure the hospital itself has a good reputation; usually newer, for-profit hospitals do not have as good a reputation as long-standing units. 

You can ask other health care professionals (therapists, social workers,  etc.) about psychiatrists in the same way. Expect good information only;  silence is a bad sign. Get opinions from many people because one person's opinion is simply one person's opinion. If five people all speak highly of Dr. Kim, you can be reasonably sure that Dr. Kim is better than a random selection from the Yellow Pages. 

Be aware that just because a clinician is well known for their work in BPD, that does not necessarily make them a good psychiatrist. They may be a good researcher, but not-so-great one on one. Some people may have pet theories and they may discount any new information that doesn't fit their published theories. They may have their own agenda. 

One woman reported to the author of this section that she called a well-known psychiatrist and the first words out of this person's mouth were, "What makes you think you can afford ME?" When many other people also reported negative experiences with this psychiatrist, this author finally took this person off her referral list. This person may be a great researcher, but basic respect is a must. 

Trust your instincts. If you don't feel respected or listened to, seek out  someone else. If the person's pet theories don't fit what make sense in your case, seek out someone else. If the person doesn't want to deal with BPD and hasn't kept up with the research on BPD, go somewhere else. 

For example, this author also spoke to one psychiatric nurse who insisted on The Truth about old information about BPD. She said "I've been a nurse for 20 years and THIS is what they taught me."

Research on BPD is going on all the time. Would you trust your body to a brain surgeon who was going on 20-year-old information? In the same way, don't trust your mental health to someone who hasn't kept up with the research. 

This is not to put down clinicians. There are more than 300 different types of brain disorders in the DSM-IV; it is not reasonable to expect every clinician is going to be equally qualified in all of them. Everyone has his or her interests, biases, and so forth, and many clinicians are taught in school to stay away from patients with BPD and start out on the wrong foot.

In other words, clinicians are human. Just like you are not an expert in  everything in your job, they are not an expert in everything and all topics dealing with mental health. Your challenge is to find the clinicians whose  interests coincide with yours and whose attitudes have not been poisoned by the "system." 

The high suicide rate, extreme moodiness, and intense neediness cause many clinicians to fear working with BPD patients. On the other hand, many clinicians LIKE working with BPD clients; this author personally knows many of them. These clinicians find it extremely rewarding to really make difference in these patient's lives. As someone writing about this topic, this author understands completely. Any clinician is trained to work with someone who is stressed or depressed. Not everyone can work with someone with BPD or someone who loves someone with the disorder. The rewards can be very great. END NEW MATERIAL

Therapy

It is important to realize that medication alone is not enough. Therapy is  also needed to help the person with BPD. 

Nevertheless, finding a mental health professional who is experienced in  effectively treating BPD clients can be very challenging. Common problems reported to us by BPs and non-BPs include:

• Clinicians who are not educated about BPD and fail to appropriately  diagnose it.
  

• Clinicians who diagnose BPD but are not experienced in treating it, and who do not know how to effectively work with borderline clients. They may give clients incorrect information such as, "there is no way to treat BPD" or "people with BPD never get better."
  

• Clinicians who bring negative expectations and attitudes about BPs into treatment, and thus unconsciously pass along this stigmatizing attitude to their clients.
  

• Clinicians whose beliefs about BPD are so rigid that when clients present information that conflicts with their theories, they tell the client that they must be mistaken. For example, some clinicians believe that all people who cut themselves or who have BPD were sexually abused. This is untrue.
  

• If you are a parent seeking treatment for your borderline child and the  therapist continually treats you with suspicion instead of respect, we  suggest switching therapists. 
  
  It is also common for people with BPD to enter treatment, but then  consciously or unconsciously sabotage the process. For example, the BP may:
  

  • Enter treatment to please a family member (or because of an ultimatum or  court order) but not really work at it. This can be a significant waste of time and money.
    

  • Discontinue therapy when faced with issues that make them uncomfortable, accusing the therapist of incompetence. These BPs may see clinician after clinician until they find one who will validate their belief that all their problems are someone else's fault.
    

  • Continually test the clinician and push against their limits until the  clinician discontinues treatment. This is usually devastating for the client.  Effective BPD clinicians anticipate this possibility and set firm but caring  limits when therapy begins. This is one reason why it's crucial that  therapists be experienced in treating borderline patients. 
    

  • Put up a false front to the clinician, who then refuses to believe that this model patient would ever go into uncontrollable rages. In our experience, this happens most frequently in couples therapy.

The book "How to Live with a Mentally Ill Person" by Christine Adamec (1996) is a good resource for choosing a qualified clinician. Her topics include getting referrals, understanding different types of therapies, conducting an interview, dealing with insurance matters, switching professionals, and overseeing the case of a child.

It's also crucial that you ask the clinician questions designed to evaluate the person's competence at treating patients with BPD or patients who are greatly affected by someone with BPD. These questions include:

1. 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 therapists who do not have a lot of experience with borderline problems.
   

2. 2. How do you define BPD? If the therapist knows less than you do, keep looking. If the therapist believes that BPD is part of another disorder that you (or the BP in your life) 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 the non-abusive parent of a BP and the therapist believes that 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 general overview of the treatment they provide, but who also says that treatment is modified for each individual. Therapists who do not have a treatment plan tend to be diverted by BPs' crises and never seem to get around to addressing long-standing issues.
   

5. Do you provide 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 BPs who improved? According to Santoro and Cohen (1997), "What you want to hear is reasonable optimism. 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 onto 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.

Researcher Marsha Linehan's cognitive-behavioral method of treatment, called Dialectical Behavior Therapy (DBT), has been shown in empirical research to
help BPD patients experience less anger, less self-mutilation, and fewer  inpatient psychiatric stays than patients who received other forms of  treatment. 

Many BPs we met were very enthusiastic about this treatment and recommended it wholeheartedly. Melissa Ford Thornton (1998) says, "DBT gave me a set of tools to take with me and use forever when I am feeling hopeless." To locate a clinician who specializes in DBT, try contacting Linehan's office: Marsha Linehan, Ph.D. Dept. of Psychology, University of Washington, Seattle, WA.  98195, phone 206-543-9886 

NEW MATERIAL BY RANDI KREGER: To find a DBT Therapist you may also see the Websites http://www.behavioraltech.com  or http://brtc.psych.washington.edu (click on "Clinical Services"). If you would like information on a  DBT-trained clinician in a specific location and can't find it on the site, e-mail info@behavioraltech.com and she will research therapists in that area.  In some cases therapists may not be found in all areas.