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Dr. Bob is Robert Hsiung, MD,
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Posted by gardenergirl on February 2, 2004, at 21:01:44
I was wondering if anyone would be interested in talking about their feelings and responses to hearing a diagnosis from a T or a pdoc.
I just started with a new client who meets the DSM criteria for Borderline Personality Disorder. Her pdoc did not talk with her about a diagnosis. I would like to start DBT with her, but I feel it is only right to talk about my rationale for this type of therapy.
But there is such a stigma associated with BPD (unfairly, in my thoughts, as I love to work with this type of client) that I am concerned about how to tell her or if to tell her. I will process this with my supervisor, but I am also interested in hearing about real life responses to this situation.
I learn so much from this site. Anyone with any thoughts about this?
Thanks in advance,
gg
Posted by Karen_kay on February 2, 2004, at 22:01:23
In reply to How to tell someone about diagnosis, posted by gardenergirl on February 2, 2004, at 21:01:44
Uh, oh! When my Bubba (why do I keep calling him mine???) I was relieved at first to put a name to the things that I was feeling. Then, I did some research and I HATE it!!!! MAKE IT GO AWAY!!! Especially since I have a friend who is also dx and she is textbook case. I like to think I am nothing like that (sitting up straight, looking around proudly, nodding my head...). I wouldn't want to be the one to tell her. It's almost like dx someone with cancer. And I have it. I question my therapist every session about how to get that taken off my record. I want it gone!!! Does that answer your question????
Posted by Dinah on February 2, 2004, at 22:04:27
In reply to How to tell someone about diagnosis, posted by gardenergirl on February 2, 2004, at 21:01:44
From personal experience I can tell you that it hurts like h*ll to be told you have a "personality disorder". The phrase sounds so unpleasant. Like people should avoid you because you have a bad personality.
On the other hand, Marsha Linehan's explanation of borderline personality disorder is wonderful, and quite destigmatizing.
My only suggestion would be to preface anything you say with lots of explanation about what personality disorders *aren't*. And how there are biological underpinnings (see my post to Scott about the physostigmine challenge research) and a lot about emotional reactivity and slow return to baseline. If you can somehow downplay the label "personality disorder" to emphasize the empathy and understanding of what it feels like, that's what I *wish* my therapist had done. Actually, my therapist didn't tell me, my pdoc did, and I'd love to tell you how, but I'm afraid to on an archived message board. :(
Posted by Karen_kay on February 2, 2004, at 22:08:08
In reply to Re: How to tell someone about diagnosis, posted by Karen_kay on February 2, 2004, at 22:01:23
It could be because Bubba has a tendancy to hit me over the head with my diagnosis of BPD. After you inform the client of the dx, be sure in future conversations not to jump to conclusions.... If she (is she, right..) says her old man is a jerk, don't assume she's using black and white thinking. Maybe her old man really is a jerk..... My old man is a jerk, however anytime I say my old man's a jerk, my therapist claims, "Oh BPD this, BPD that..." rather than listening to why I think my old man's a jerk..... Just be cautious of jumping to conclusions because of a dx..... Letely though, he's come to realize that my old man really is a jerk :) I like that...
Posted by DaisyM on February 2, 2004, at 23:55:18
In reply to How to tell someone about diagnosis, posted by gardenergirl on February 2, 2004, at 21:01:44
I think you have to ask yourself the question: why, at this point in therapy, is it REALLY important to have this discussion? If you can answer it clearly and calmly for yourself, you are ready to have it. It seems to me that if a client is new to you, she might not trust your opinions of her yet. Not that you are wrong, just the age old question of "how could she know *that* after 2-4-6 sessions?"
My Therapist said he was dxing me with "adjustment disorder" something he does routinely with a lot of people at the beginning. It gives the insurance companies what they need, etc. When he had a write a treatment plan, he came in and said, "if I write what they really want, you will hate it. There will be a record of PTSD around...and you have political ambitions. What do you want me to do?" We talked about the DSM IV, possible other DXs, etc. It was a very open discussion, not HE knew what I had...I appreciated this very much. I was surprised that he completely refused to diagnosis depression. He said that insurance companies see that, want you to throw meds at it and be done in 12 sessions. Not that he was against meds, he is against insurance companies. LOL
I think gentle, sensitive and slow might be best. But lots and lots of explanation, like Dinah said. Labels can hurt, even if they are accurate.
Posted by alexandra_k on February 3, 2004, at 2:03:45
In reply to Re: How to tell someone about diagnosis » gardenergirl, posted by DaisyM on February 2, 2004, at 23:55:18
Hello. I have a diagnosis of BPD. I HATE IT. Initially my p-doc and T refused to diagnose me with it though there was pressure on them from other quarters. I didn't know why they were being so resistant.... I didn't understand.
When DBT became an option (for those with a diagnosis) they gave me the diagnosis. I soon discovered that when clinicians heard that label they would all but roll their eyes and they assumed some pretty nasty things of me. I couldn't understand what was going on so I read everything I could get my hands on, IT HURT LIKE HELL. And it was so not true, I thought.... I was so immensly hurt and thought 'I am not like that, I am not like that'.. And then I would panic and become suicidal because I started to think 'but I must be and everyone can see it but me I must be in denial' - but look at the stuff - if you had to take that on board as what you were like as a person could you handle it?...
I would say why? What's it for? Why put your client through that? What does it buy her? Why mention the name? Why not say that these are the specific symptoms that you would like to help her with (and tell her) and this is the way that you would like to approach those symptoms (and just work with her).
What will the diagnosis buy her - does she have to have it before you can justify giving her DBT?
Posted by justyourlaugh on February 3, 2004, at 5:29:53
In reply to Re: How to tell someone about diagnosis, posted by alexandra_k on February 3, 2004, at 2:03:45
i think the best thing to do is wait..
she will ask for her pdocs dx "opion" when she is ready to know and she will ask for yours soon enough..
j
Posted by Elle2021 on February 3, 2004, at 6:31:44
In reply to How to tell someone about diagnosis, posted by gardenergirl on February 2, 2004, at 21:01:44
At first I was convinced that if there was a diagnosis that my pdoc had come up with, I wanted him to tell me. I do not feel that way anymore. During my last session with Burt, I begged him to tell me what he thought. He said Schizotypal. Not only do I not agree with this diagnosis (neither does my therapist) but it really sent me into shock. I guess because to me that word "Schizotypal" sounds like Schizophrenic. I'm really afraid of having Schizophrenia. Anyway, my new therapist said I have PTSD, which fits better and wasn't as upsetting to me. Now, she mentioned something about Borderline traits. I think if she came right out and said your Borderline, then I wouldn't be shocked, but still depressed at the fact that she thought I were Borderline. Labeling has so many negative side effects, and if possible, I don't think you should tell this client of yours that is what you think she has. Just tell her what my pdoc originally told me, which was something to the effect of, "I think you have some negative coping skills and I think DBT might be helpful to you." BPD has such an ugly stigma.
Elle
Posted by gardenergirl on February 3, 2004, at 7:24:33
In reply to Re: How to tell someone about diagnosis » gardenergirl, posted by Elle2021 on February 3, 2004, at 6:31:44
Okay, I think I get the message about how painful hearing this diagnosis is. And I actually tend to agree that giving a dx is not always necessary for treatment, especially at my current placement. We do not have to worry about insurance needs, thank God.
If I am understanding you all correctly, I need to be quite gentle and empathic regardless of whether I give the "label" or not. And focus on the symptoms and use DBT (at least as much of it as I can do in my setting) to target the symptoms. If I do end up having to diagnose her, then utilize Linehan's explanations and perhaps wait until she asks or until more sessions have gone by.
I hope I am hearing (reading) y'all correctly. I'm sure that I would react just as strongly as others if I were given the dx. It DOES have such an awful stigma, which infuriates me. I am currently working with three who meet the DSM criteria who are as different as night and day (and night again, I guess ;) I think of BPD as a continuum from mild to severe. Not everyone with the traits or even the dx is the "typical" BPD. Arrggg! I feel myself getting on a soapbox which seems to already have enough advocates, so I'll defer to those who know best right now.
But thank you all for your input. It really helps in understanding what this must be like to hear and to experience. I'm so lucky to have such a great resource in y'all!
(((everyone))) Is that a group hug?Thanks again,
gg
Posted by dragonfly25 on February 3, 2004, at 7:28:35
In reply to Summing up, posted by gardenergirl on February 3, 2004, at 7:24:33
Posted by gardenergirl on February 3, 2004, at 7:36:55
In reply to what is DBT? (nm), posted by dragonfly25 on February 3, 2004, at 7:28:35
DBT is Marsha Linehan's Dialectical Behavior Therapy. It combines Cognitive Behavioral Therapy, which can be really invalidating, with validation and eastern philosophies like acceptance and mindfulness.
gg
Posted by alexandra_k on February 3, 2004, at 7:38:12
In reply to How to tell someone about diagnosis, posted by gardenergirl on February 2, 2004, at 21:01:44
Hi, sorry, more thoughts... Clinicians are starting to think that the current diagnostic categories or syndromes are a bit of a dead end with respect to research anyway. The DSM does not carve mental illness at the joints like biological taxonomy or the periodic table of elements. If the DSM V goes the way of the symptom I for one will sleep better at nights. If they consider symptoms to be on a continuim from mild to severe I may well have to revise my current opinion on diagnosis as a way of opressing people who provoke counter-transference.
My point (I am getting there I am getting there) is that most of the 'labels' that the diagnostic criteria provide do little more than promote stigma and encourage clinicians to assume rather than assess symptoms. Diagnoses can also be unhelpful with respect to predicted treatment outcomes and liklihood of improvement (what is the likely consequence of one believing they will not get better till they are in their 40's I wonder???) I found that in my case clinicians assumed symptoms I did not exhibit and I became paranoid and thought I was in denial for a long time until I met a clinician who told me that in their honest opinion - though I met the criterion - I did not seem to exhibit that particular symptom.
What are supposed to be the benefits of diagnosis?
1 - It leads to appropriate treatment.
2 - It can help people understand what is going on for them and help them access useful information and feel like they are not the only ones struggling out there with this.Why do this on the syndrome as opposed to symptom level I find myself wondering.... Why not assess her symptoms and address those symptoms with the best treatment for them that you can offer her. If that is DBT then so be it. What does the grand title 'borderline personality disorder' add to the equation other than prejudice and judgement of dinosaur clinicians with counter-transference issues?????
I don't see how the diagnosis would help one to feel less alone either. People with mental illness (even the dreaded borderline personality disorder) are not categorically different from the rest of humanity. Who does not exhibit borderline symptoms every once and a while, are we supposed to be such freaks of nature that we can only be understood by other such freaks? It is a difference in degree that is all (though I fully acknowledge that a big enough difference in degree CAN lead to a difference in kind I don't think BPD has evolved for long enough in isolation from adaptive functioning so as to be TOTALLY divorced from it).
Sorry this is a big long rambly rave.
Just a mad philosopher :-) .
Posted by alexandra_k on February 3, 2004, at 7:40:08
In reply to Re: what is DBT?, posted by gardenergirl on February 3, 2004, at 7:36:55
why does everyone just beat me to a post???? AAARG
Posted by dragonfly25 on February 3, 2004, at 7:50:41
In reply to Re: what is DBT?, posted by gardenergirl on February 3, 2004, at 7:36:55
Posted by Dinah on February 3, 2004, at 8:10:46
In reply to Summing up, posted by gardenergirl on February 3, 2004, at 7:24:33
It might be worth reading Linehan's introduction before speaking to her. She didn't actually invent DBT for borderlines. She was working with a group of people who exhibited suicidal and parasuicidal behavior. So if this person engages in any of that, it's 100% honest to say that this form of therapy was created to address that problem.
Posted by Penny on February 3, 2004, at 9:44:41
In reply to Re: Summing up » gardenergirl, posted by Dinah on February 3, 2004, at 8:10:46
> It might be worth reading Linehan's introduction before speaking to her. She didn't actually invent DBT for borderlines. She was working with a group of people who exhibited suicidal and parasuicidal behavior. So if this person engages in any of that, it's 100% honest to say that this form of therapy was created to address that problem.
To add to what Dinah said, I'm not diagnosed with BPD, but my T thought DBT might be useful for me - I don't engage in parasuicidal behavior per se, but I do tend to get 'over excited' or enraged or whatever, esp. when I'm feeling bad, and my mood can plummet from 'okay' to 'I want to die' in a fraction of a second. My T thought DBT might be a useful tool for me in handling these 'episodes.'
P
Posted by Penny on February 3, 2004, at 11:12:51
In reply to Re: what is DBT?, posted by gardenergirl on February 3, 2004, at 7:36:55
> DBT is Marsha Linehan's Dialectical Behavior Therapy. It combines Cognitive Behavioral Therapy, which can be really invalidating, with validation and eastern philosophies like acceptance and mindfulness.
>
> gg
Ya' know - I have never thought of CBT as 'invalidating' - but you're right, it absolutely can be (not that it can't be effective as well, but...). I had just never thought about it that way...Perhaps that's my beef with 'Dr. Phil' - my grandmother quotes him to me all the time and it drives me batty! My T doesn't like him, and I tell my grandmother all the time - "if only it were as easy as he'd like you to believe."
Hmmm....
P
Posted by Karen_kay on February 3, 2004, at 11:21:48
In reply to Re: what is DBT? » gardenergirl, posted by Penny on February 3, 2004, at 11:12:51
Oh no!!! I love Dr. Phil! But, I'm rather afraid of what he'd tell me if I were to be on his show!
Posted by Penny on February 3, 2004, at 12:05:00
In reply to Re: what is DBT? » Penny, posted by Karen_kay on February 3, 2004, at 11:21:48
Don't get me wrong - Dr. Phil makes many good points. BUT - he makes everything out to be easier than it really is. I mean, I've heard him say that he's not going to be able to fix someone's life in 15 minutes - but then he acts like once he says something to someone they are supposed to just be able to go "OH! THAT'S what I was doing wrong!!! WOW - thanks, Dr. Phil, for enlightening me!!!" The reality is, IMHO, that he doesn't say a thing that isn't pure common sense. Not that there's anything wrong with that - and perhaps it's the way he says it more than what he says that makes him so popular. But I'm having a real issue with him right now with the whole weight loss thing. I get O magazine (Oprah, for those who didn't know) and there was an excerpt from Dr. Phil's Ultimate Weight Solution book, and he was talking about the 'minimal effective response' to gain 'emotional closure' and my whole thing was that he didn't go into how you wouldn't necessarily know what was your 'minimal effective response' and how you can't base that on how others will react - the example he used had to do with someone confronting someone for past wrongdoing - well, that's great, but if that person hasn't changed, and you don't get the response you expect/want/need, then it's not going to be 'effective' is it? In which case, the minimal effective response doesn't work very well, or at least takes a heck of a lot longer than he would have folks believe!
I dunno - he just frustrates me. I mean, I wish I could just say "Okay, this isn't working for me" and change x, y and z. But it's not that easy. It might be simple, but it's not that easy. And I think he tends to equate simple and easy.
Of course, I'm sure I've offended all the Dr. Phil fans out there now! I could go on and on, but I won't. I just don't think he could do much for me, personally, in however much time he would spend with me on a show...
I'm sure he'd have some interesting things to say to all of us, though. He'd probably tell us to quit wallowing in our own self-pity. I heard a quote by him once where he said he stopped doing long-term therapy with clients because he was tired of hearing them whine and complain day after day. It goes back to what GG was saying about invalidating for me - that's invalidating. As though I don't have a right to whine and complain. Not that continual whining and complaining will get you anywhere, but it seems that if he was effective as a therapist he would have been able to guide his patients away from whining and complaining day after day. Just my thoughts...
sorry this is so long!!!
P
Posted by gardenergirl on February 3, 2004, at 13:08:42
In reply to Re: what is DBT? » Karen_kay, posted by Penny on February 3, 2004, at 12:05:00
I'm right there with you on this one, Penny. I can't stand Dr. Phil! I don't think he has an empathic bone in his body.
gg
Posted by Karen_kay on February 3, 2004, at 14:50:57
In reply to Re: what is DBT? » Karen_kay, posted by Penny on February 3, 2004, at 12:05:00
Now, don't get me wrong. I'm not arguing with you at all. I still like you very much :) I used to despise Dr. Phil with his "no nonesense" attitude. But, I think what he does is point things out to people (who BTW, aren't normally in therapy)
I think that with confronting someone with what they've done to you in the past gives a person a sense of empowerment, regardless of what the outcome is. Whether that person has chagned or not. You choose how you allow that person to affect you and by finally confronting them and saying, "Hey! You've done me wrong and I'm telling you about it finally!" it won't necessarily change that person, but it will give you a sense of closure in the situation. It allows you to finally say, "Hey, I'm not going to let that person affect me in any way that I don't want him/her to any longer. I've had my say in the matter and let him/her know how I feel finally." It gives you a chance to say that you won't let that person hurt you you any longer... I know, I know... Easier said than done. Sorry, not trying to spatter off advice or anything.... But, I don't really need to do that, as I don't feel that anyone's wronged me. I know my dad did, but at this point I don't have any feelings on the matter. And it wouldn't really do me any good because he's dead...
Maybe I'm just spattering crap at this point, because I honestly don't hold a grudge. But, imagine how nice it would feel to get it off your chest??? If it's there anyway. Maybe I shouldn't be talking, as I'm no expert. Or worse yet, maybe I have a problem because I don't have any feelings for anything.... Oh, bother, I'm starting to worry about that now.... Cripes!!!!
Posted by Dinah on February 3, 2004, at 16:33:37
In reply to Re: what is DBT? » Karen_kay, posted by Penny on February 3, 2004, at 12:05:00
I'm with you. I feel a similar way about Dr. Laura. I really like Dr. Laura and her message of personal responsibility and kids first. And a lot of times she'll say something that gives me something to think about re. how I look at things. But she's got that "just do it" attitude that I find depressing. I remember once she was talking about a book of holocaust survivors and how they managed to pick themselves up and make something of their lives. And she was basically saying that everyone could do the same, whatever their past trauma. And I drafted this whole letter to her about how everyone wasn't the same, that biologically we have different predispositions, and she needed to take that into account.
I dunno. That approach appeals to my logic, but it tends to end up just adding a layer of guilt to my other troubles.
Posted by fallsfall on February 3, 2004, at 18:26:41
In reply to How to tell someone about diagnosis, posted by gardenergirl on February 2, 2004, at 21:01:44
My therapist went down the list of BPD symptoms and told me which ones she thought I had. She presented the whole thing in an informative way - and I appreciated that because I am someone who wants to know what is going on. (I had just gotten out of the hospital, and had been seeing her for about 6 months at the time)
I went to a bookstore to find some information on BPD, and found Linehan's books. Those books were very comforting to me. I'm not a typical Borderline (I'm not impulsive, and I don't show anger - though I'm beginning to learn that I have it even if I don't show it).I do split (all the time), and I have major "self" issues - and those seem to me to be the basic building blocks of BPD. I could really relate to her descriptions of invalidation. This made me feel much more comfortable. I had felt like I had a problem that was different from everybody else's (I wasn't even "normal" among the mentally ill). Reading her books made me feel that finally somebody understood me. That gave me hope that someone could help me.
I attended 6 months of DBT Skill training (and that wouldn't have happened if I hadn't found Linehan's books and brought them to my therapist). It was helpful (though I was probably more proficient than many group members are to start - at least in some areas).
For me the diagnosis gave me an anchor. Something to research and understand. Hope that people were working on understanding what treatments work and don't work for us.
My current therapist doesn't think I'm Borderline. We haven't talked about what he thinks my diagnosis is. He's talking about how it might not be in my best interest to do so much "research". If he's right, then even though the diagnosis made me feel better, it might not have been truly in my best interest to know it. This issue is still up for debate.
When I was looking for a new therapist, I did a bunch of interviews. I would start the interview telling them that I was BPD, but not typical and explain what I did and didn't have that fit with BPD. One reason I did this was that I wanted to know right away if they were scared of a BPD patient. If they were, I knew we would never work well together. So, I used my BPD diagnosis as a useful tool for myself.
Posted by gardenergirl on February 3, 2004, at 19:49:49
In reply to Re: diagnosis - I never go along with the crowd... » gardenergirl, posted by fallsfall on February 3, 2004, at 18:26:41
Wow, I have a lot of respect for you to take something potentially hurtful and difficult and turn it into a tool or maybe even a strength. Are you like that with other things? I mean someone who researches things in order to understand more about whatever the topic is?
I'm glad this approach has been really useful for you. I admit it's hard for me to get a handle on the three clients I have who could be diagnosed BPD. I don't know how they will react. Well, I think I know how one would react, quite angry, hurt, and upset. But the other two...not sure yet.
I think the best approach then is to stick to symptoms and use Linehan's descriptions. She seems to be the queen (or goddess?) of validating.
I'm glad to hear skills training was helpful as well. At my site we are using a modified approach to this. I have the two junior members of my team (2nd year grad students) doing individual skills training with two of my clients. They are just getting started, and I am eager to see how it goes.
Take care,gg
Posted by badhaircut on February 3, 2004, at 20:39:40
In reply to Re: what is DBT? » gardenergirl, posted by Penny on February 3, 2004, at 11:12:51
> Cognitive Behavioral Therapy, which can be really invalidating
> gg> I have never thought of CBT as 'invalidating' - but you're right, it absolutely can be
> Pgardenergirl & Penny--
What do you mean by 'invalidating'? Like, "Your feelings don't matter!" or something like that?
Also, I've only seen Dr. Phil a couple times on TV, but from what I saw, I wouldn't call him a Cognitive-Behavior Therapist. (Or a very good one, period, but he obviously does something for a lot of people.)
-bhc
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