When I was in my freshman year of undergraduate, I watched the Angelina Jolie and Wynonna Rider movie called Girl, Interrupted that is based on the real-life experiences outlined in Susanna Keysen’s book of the same name. I jumped on watching the movie because Wynonna Rider is a goddess on this Earth (as her performance in Heathers so kindly convinced me). I had briefly heard of the content when I was in my senior year of high school and girls in the Speech and Debate (S&D) circuit liked dark topics to perform in the Dramatic Performance competition.

Granted, I was already too insistent that no one else could understand mental illness to give much of the performances any credibility in my mind. My constant feedback on my ballots was “You’re too happy.” This is nothing more than a dodgy attempt at an excuse to not have to actually say “You were at least as good as, if not better than, the best, but because you are a bigger dress size, we have to knock you down several points.”

I could write pages on how S&D killed my confidence as a performer, but would be remiss if I didn’t first acknowledge that ALL high school theater and theatre-adjacent programs are fatphobic. But that’s actually not today’s topic of discussion. It is saved for a time when it doesn’t impede on the main crux of a mental health issue at hand.

I have Twitter. And this means some mental health news I see is rampant and often wrong.

In today’s circuit, borderline personality disorder (BPD) came under the focus of the client lens for scrutiny toward mental health discrimination from professionals. And what’s even more depressing for me to admit is that those clients, by and large, are absolutely right in their claims. BPD is one of the most misunderstood diagnoses to treat, and there are a lot of reasons. But I wanted to make this post as a resource for people diagnosed rather than people treating.

Here are five main things ALL clients should/can do. I’ll explain them BPD-relevant, though!

1. Be picky about your provider.
2. Don’t be afraid to switch up scheduling.
3. Ask about modalities.
4. Give the tough questions upfront.
5. Your treatment = you should be satisfied.

First, be picky about your provider!

As with alll diagnoses, clinicians/providers/practitioners (“therapist(s)”) have specality areas or focus areas in which they are better equipped to help. This means that you can ask right away if the therapist you are meeting with specializes in your symptoms or diagnosis. While not all therapists have a comprehensive list available, they should at least be able to answer if their training will help, or if they would refer you out. Also ask for referrals if you need!

Mind you, BPD often is harder for therapists to determine if they can help with because BPD is sometimes used as a “filler” diagnosis, like some Z-codes out there. I’m NOT saying BPD isn’t real, and am NOT asserting all BPD diagnoses are false. Rather, I AM saying that if BPD doesn’t seem to fit you and you’ve read up on the symptoms, it is YOUR RIGHT to ask for an updated assessment. It’s sometimes much better to have a diagnosis with meaning to you, the client.

What a “filler” diagnosis is, in case that’s not really a term outside of me, is a diagnosis that allows the therapist to get insurance approval quicker. This is often the most ethical way therapists can “diagnose” you in one session but also ensure you get continued covered care. A “filler” diagnosis is given when the therapist knows that your concern is treatable and they can treat it, but also that they may need a bit longer to adjust your specific diagnoses to the insurance company.

Granted, if your provider refuses to discuss your diagnosis or gets defensive about you questioning it, that is reason enough to switch. Part of ethical therapy is psychoeducation. If your therapist seems more concerned that you know yourself than that a human error could have been done, I’d encourage you to find a therapist who can work through the issues surrounding being diagnosed and how to continue self-care through not thinking it was the right diagnosis.

Second, don’t be afraid to switch up scheduling.

The average therapist will be able to tell you upfront how they schedule people. There is a slew of options – it can be from pro ro nata (PRN), or as needed, all the way up to twice a week. It might take some finessing to figure out which frequency is for you. Often a therapist will know upfront how they like to and prefer to schedule clients. BPD as a diagnosis often means you want to have a therapist with flexible scheduling or who doesn’t need you to have a set opening in your week.

Why? Simple – with common symptoms of BPD including constantly changing life dynamics (all to do the good work of discovering yourself), it means that while having the same therapist may be helpful or desirable, thinking upfront about how often you like sessions can help your therapist consistently be able to meet your scheduling needs. (Knowing ahead of time when job changes are coming is also a lovely thing to bring up when scheduling, as most therapists are used to people changing schedules.)

When scheduling, the one recommendation I have is to keep something consistent.

This isn’t because it’s impossible to have changing meeting times, but rather because therapists, like professionals with scheduling, are more likely willing to work with a changing schedule that is more along the lines of – “sometime in the week, around 4 PM” or “preferably on Tuesdays” – as these give ways for a therapist to easily try and reserve you a spot each week, whether or not you need it.

Third, ask upfront about modalities.

Marsha Linnehan is quite a triumph in the field of BPD studies. She is the mastermind behind dialectical behavioral therapy (DBT), which has become somewhat of a more popularized phenomenon in treating BPD and trauma, at least in recent years. But before I explain a few modalities*, let me insist this: if you do/don’t like a modality, it is OKAY. Therapists themselves have least/most favorite intervention methodologies. It’s only fair that you, the client, do as well.

DBT is essentially a therapy about learning to hold opposite ideas as true simulatenously (dialectics). Traditional DBT has a weekly group session and a weekly individual session. Group sessions go over specific coping skills, often in Linnehan’s recommended order. Individual sessions tend to focus more on how the skill is utilized/or not, and then why. It’s in the field of cognitive-behavioral therapy (CBT) and so many coping skills include a component of intellectualizating emotions/verbal emotion statements. Things like “I feel” or “When this happened, I experienced” are common.

Cognitive processing therapy (CPT) is also one to consider utilizing for BPD since CPT is mainly used in trauma processing. BPD has a high co-morbidity with anxiety/related disorders, and it may be a good idea to conisder working through the surrounding symptoms while also recieving deserved help for a primary diagnosis. CPT tends to take the form of slowly going through the client-written narrative of a startling or tough event. The narrative is often flexible in format, meaning clients can use CPT through prose, poetry, or even scripts/diaglogues. This allows more people an ability to write down an event without being confined by traditional styles.

To not mention EMDR would be somehow rude. EMDR is eye movement desensitization and reprocessing therapy. If it sounds like a mouthful, it is. EMDR is often solely for trauma processing and would be done with an independently licensed therapist, for best results. EMDR often requires a lot of background work. Clients can spend up to a year building a therapeutic alliance with an EMDR provider before the therapist determines EMDR is safe to begin. EMDR can help with trauma, and as stated earlier, BPD is commonly co-morbid with trauma. However, if there really isn’t a trauma at the heart of the issue (which is also fine), EMDR may end up exhausting the client out as they search for an event that will blend with the proper techniques needed from EMDR.

Family systems therapy (FST) is one that some people may not consider for BPD, but it could allow the client to better see how they are percieved. This may sound daunting. FST is focused on the idea that the family is a system, meaning interwoven and interconnected. The principle is that all members of the family interact together to both create and solve issues. By allowing a more FST approach to BPD treatment, there is room for extra support within the family as well. This calso be an approach to look for in a couple’s therapist when one partner has BPD. Since FST includes different theroetical orientations (which is a whole different can of worms), looking for specific therapies within FST can also be enlightening and encouraging to an individual desiring extra support.

*These are not exhaustive, but are good places to start.

Fourth, give the tough questions upfront.

Therapists are professionals in the field of helping people get their lives back on track. While that is oversimplyfying the job a little, the point still remains that a therapist is trained to answer the tough questions and the stupefying ones, as well. The catch is that not all therapists will give you the correct answer you are hoping for. In that case, no worries. You didn’t fail at therapy. You simply didn’t connect with the right therapist (which admittedly can feel like a failure).

Over time, you’ll learn what issues you will and won’t be pushed on in the therapeutic space, and finding a therapist who understands that boundaries can be as flexible as the relationships we pretended to be in back in middle school, is actually somewhat difficult.

Most therapists who are trained to work with BPD would be more than happy to answer treatment and diagnostic questions during a consultation call. Don’t hold back. Ask the hard hitting questions that can give you and the therapist the best shot at getting you the best care possible.

Fifth, your treatment = you should be satisfied.

Like the earlier point hints at: therapists are professionals. If you, as the client, are not happy with your treatment for any reason, talk to the therapist. And if that is not a viable option, then request to be transferred to another therapist (also called “referred out”). Your therapy is yours.

You deserve to get the treatment anyone else would get.

XOXO,

Dorothy B