But what if the patient truly has a Borderline Personality Disorder? I have been asked this often whenever I speak on this subject to colleagues, students and consumers. My answer is so what if he or she does? What doers that truly add to the question of whether the patient’s or the therapist’s claim is just. Let’s suppose for the sake of argument that the patient is borderline, nuts whacko daffy or whatever term suits our fancy. Is that prima faca evidence that the client is lying or making things up against the therapist and therefore not to be believed so their claims should be dismissed out of hand? Ironically mental health professionals would be among the first to defend their clients no matter the diagnosis if others wanted to assume some form of guilt or culpability based on the diagnosis alone. In fact if it not accusations directed at the therapist him or herself therapists can be all too believing of their patients claims of abuse often without even any shred of corroborating evidence. We need go no further than the accounts of therapists totally accepting claims of sexual abuse on the bases of recovered memories. 2
So is a diagnosis of Borderline personality Disorder ever relevant in disputes between patients and therapists? It can be under some conditions. If the diagnosis is genuine and not merely used by the therapist as an ad hominen retaliation and attempt to defame the character and reputation of their disgruntled patient it could demonstrate that there may be a pattern of distortions and making things up and would be one but not the only factor in determining credibility. Remember the proverbial story of the boy who cried wolf. This is a cautionary tail not only about the dangers of crying wolf when there is no wolf, but also it cautions us not to emphatically declare there is no wolf simply because our source is not totally reliable. Put another way even a broken clock tells the correct time twice a day.
So what can we do?
My advice to practitioners is the same whether the disgruntled client is borderline, nuts crazy or just plain angry and upset. Try not to let it get personal and react as if it is your ego is that injured. It’s business. Keep it business like. That difficult of course especially when they are threatening or actually filing complaints with licensing boards or ethics committees or are going for blood i.e. malpractice.
First, ask yourself as objectively as possible if the patient could have a point. Could their complaint have at least some merit? If there is a reasonable possibility that they do and if you have eroded in some way consider admitting it and apologize. There are studies that suggest that patients will often accept an apology if we have made a mistake and formal complaints and litigation are as often as not the result of our attitude toward the patient and not any particular error we made. 3
Consider offering a refund. Yes, a refund! On occasion I have offered to refund fees to clients who for whatever reason were dissatisfied with something said or did in a session if they expressed it in a timely manner before too many sessions past. If other merchants can offer refunds for products why can’t professionals. I would much rather eat a hundred or even a couple of hundred dollars than spend hours and perhaps thousands in legal fees in a business dispute with a patient that even if you win the cost is staggering in money and aggravation. Of course in such a situation a documented offer of a referral to another therapist might be in order rather than continuing with the same patient to only be dissatisfied again.
But some of my colleagues might argue if it’s a true borderline offering a refund would show weakness and it is like bleeding in front of a shark. Perhaps but willingness to negotiate from strength is not a weakness. A refund is simple one of the possibilities to avert unnecessary and costly conflict.
That brings us back to the question of whether the patient meets criteria for a true borderline personality disorder or the term is merely name calling on the part of the practitioner out of their own frustration. If it’s a true borderline diagnosis one might expect that the diagnosis predates the dispute with the patient. On the other hand if the original diagnosis only began to emerge after the patient was making demands that the therapist did not like it could mean that the true borderline features took time to emerge. But it could also mean that the therapist is attempting to convince colleagues and possibly themselves that it’s all the patient’s problem. What would be even better than the practitioner in question diagnosing the patient as borderline would be if there were previous therapists and all concluded that the diagnosis was Borderline Personality Disorder. Again this would does not prove that the patient is making up the allegations but it would lend some credence to the possibility.
The key in whether we are dealing with a borderline or any other patients is the patient’s record. There is the old maxim, “If it’s not written it did not happen”.
What indicators were used to make the diagnosis whatever it may be? Are there any indications that the therapist deliberately incorrectly diagnosed the patient? Regrettably incorrectly diagnosis of patients occurs with some frequency. Most often it is a form of “up-coding” 4 to help them obtain benefits from their party payers that a more accurate diagnosis would not make them entitled to obtain. However If a therapist would deliberately misdiagnosis a patient for one reason say to help get 3rd party payments it is just as possible that they would deliberately y misdiagnoses for another i.e. to try to quash a ethics or licensing board complaint. In both cases it is the therapist who benefits. In one case by getting payment that they might not get if the patient had to pay out of pocket and in another they save their save a reputation.
One criticism I have encountered when I have talked about these issues be it online or in person lectures to colleagues and students is that it’s too “medical model”. The medical model many therapists argue is not really conducive to the practice of psychotherapy which they would argue is more about the relationship than anything else and more of an art then a science. And there is a lot of truth to those sentiments. Many of us, including myself, are not totally comfortable with the medical mode; some of us not at all.
However it was Brandt Caudill, a mental health malpractice attorney who said it best.
“Faced with the complexities of informed consent, standard of care, note taking, etc., some therapists have tried to opt out of these requirements by simply taking the position that they do not believe in, or endorse the medical model, and therefore they should not be held to it. This has the same effectiveness as reporting to the Internal Revenue service that you do not believe that the tax laws are valid, and that you should not have to comply with them. While this may lead to making the acquaintance of interesting criminal defense and bankruptcy lawyers, it will not cause any change in the IRS's view of the applicability of the tax laws. By the same token, for a psychotherapist to assert that he or she should not be subject to the medical model will be ineffective. The medical model will generally be imposed with or without your agreement.”5
The reality is it is just a little too late for us non physician mental health professionals to be opting out of the medical model even if we don’t think we should be held to it. For too many years many of us fought for the status of certification and then licensure. We wanted to be held in similar respect as our physician colleagues. If we had PhDs we wanted to be called Doctor just like physicians. We fought hard to have our serviced reimbursable by our patients medical health insurance. We are currently fighting very hard for full parity so that mental health conditions will be reimbursed on a par with other medical conditions.
It’s just a little late and it’s also just little disingenuous to at the same time claim the medical model does not apply to us. And even if we can convinces ourselves of that, few if any other will buy it. We are stuck with the medical model and we have no one to blame but ourselves for it.
Therefore since we are stuck with the medical model whether we like it or not the best way to deal with patient complaints is to follow the medical model at least to the extent of accurate and detailed record keeping. In a dispute wit ha patient whether it is at an ethical committee hearing, licensing board or court room no matter if the patient is borderline crazy or whatever our best ally or worst enemy is the record. If our records can support our actions it should not matter what the patient’s diagnosis happens to be borderline or not. If our records are sloppy, slipshod incomplete, inconsistent or cooked it will not matter if the patient is mad as a hatter. We will most likely lose.
1 See Retrieved from Psychotherapy Finances, May 2004 http://www.psyfin.com/articles/050402.htm
2 See Recovered memory Series by John Riolo http://www.youradvocateonline.com/questionable_therapies_intro.html
3 See http://www.nytimes.com/2008/01/01/health/views/01case.html?_r=1&th&emc=th&oref=slogin
4 See http://findarticles.com/p/articles/mi_m3257/is_12_56/ai_95967049
5 http://www.insiderlawethics.com/malpractice_pitfalls.html
