by Randi Kreger
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 WTO 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 therapists, and complete any “homework” the therapists give them. Recovered BP 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 you, 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 ends 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 shocking or rock 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.5
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. There are no simple rules here. This is not the rehabilitation of a physical injury. This is the rehabilitation of the entire self.”6
Psychiatrists John G. Gunderson and Cynthia Berkowitz caution that 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. Gunderson and Berkowitz say, “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.”7
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. Start with “Finding Qualified Professional Help,” which is chapter 11 of the Stop Walking on Eggshells Workbook, as well as the other material you’ll find listed on bpdcentral.com.
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 breakup
• 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 your BP’s life. You might also talk about the impact your 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 the company pays 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.
Make Contact
Here’s another way that looking for a good therapist is like searching for a job: networking produces some of the best leads.
• Ask friends and family. Ask them if their friends and family might know of anyone.
• For schema therapy, see www.schematherapy.com.
• For dialectical behavior therapy, see www.behavioraltech.com.
• Contact the Borderline Personality Disorder Resource Center (www.bpdresourcecenter.org) or e-mail info@ bpdresourcecenter.org. Most referrals are in the major metropolitan areas.
• Check with your primary physician and other health care specialists you see, from your allergist to your dentist.
• If your 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 databases 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 a co-occurring illness 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 behavioral 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 on Mental Illness (NAMI), both state and local branches, as well as any other mental health organizations.
• Look in the Yellow Pages. 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 an 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 he or she can give you any names.
Evaluate 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 e-mail the offices of the best candidates. Introduce yourself and explain the reason for the call. Leave a voice mail 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 a 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 on your circumstances, that could run into 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 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
Getting answers to a few of the following questions 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.)
• Does the clinician have confidence? 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
may be signs that the therapist has confidence.
• Does this person listen, put you at ease, and create 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.
• How does the clinician view sex role stereotypes? 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 on 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.)