OT - mental health diagnoses - really long and rambling

Yeah, even for me, it's long and rambling.  I guess I’m just venting.  This might be more appropriate on the mental health board but there’s not much activity over there and anyway, I know you guys on this board.  And yes, this is super long, and quite possibly boring to everyone but me.

I’ve been going back and forth for a little while about whether or not I wanted to post this here or if it was sharing too much personal information.  Yes, I know I update you all about when I poop, but… well, we all poop.  It’s generally not complicated or controversial or emotional.  At least my poop isn’t.

Today I saw my therapist again.  This is a fairly new therapist.  I saw her a few times back in the summer and saw her last week and then today.  Today she mentioned a change to the upcoming DSM-V, or the Diagnostic and Statistical Manual, the book by which mental health professionals diagnose clients.  I know lots of people here are familiar with the DSM but for those that aren’t, this is not like the ASMBS guidelines for vitamins, where it’s kind of like a suggestion but lots health care providers just ignore it.  Some do ignore at least some parts of it – like, there are some counselors out there that have been treating clients for homosexuality, as if it’s a disorder that they can cure, even though it was removed from the DSM back in 1970-something – but most don’t ignore it, at least not most of the time.  And the diagnoses in the DSM are important because in order for insurance to pay for mental health treatment, you have to have a diagnosis from that book.

Well, I have talked on here before about my depression and PTSD, and I have mentioned once or twice the fact that I have been diagnosed with DID, but I really don’t talk about that much with anyone.  Anyone but my partner and my therapist, that is.  I guess there is a stigma in a way.  Even though lots of people have mental health diagnoses, that’s a less common one and no one wants to look crazy, right?

So, OK, I have been diagnosed with DID, which is dissociative identity disorder, for those that aren’t familiar with the acronym.  I don’t want to debate the validity of the diagnosis here.  I know I usually like to debate things, or at least have… what’s the word?  Energetic?  Enthusiastic?  discussions, and I will discuss DID with anyone that wants to.  But I don’t want to argue about it.

DID has not been in the DSM for that long.  I think it was 1994, in the fourth edition, that it was listed.  Now, apparently, they are taking it back out.  Some professionals don’t believe it exists.  It kind of goes along with the whole repressed memories thing.  Some professionals believe clients make it up for attention, or that other (less competent and/or less ethical) professionals somehow create the disorder in their clients or encourage clients to begin faking the disorder.  And I’m sure it happens.  There are incompetent and unethical mental health care professionals out there.

Now, they’ve taken diagnoses out of the DSM before.  Homosexuality used to be considered a disorder, and then it was generally decided it was not a disorder and didn’t need cured, so it was removed from the manual.  But it was not because professionals said oh, gay people don’t exist.  Think you’re gay?  You’re just trying to get attention.  Or maybe your therapist convinced you that you’re gay but you’re really not.

At first I was thinking, who cares if they take it out?  I know I have it and my therapist knows I have it and she knows how to treat it.  Then I started doing some reading about the controversy.  And there are problems with it being taken out.  Insurance companies will not pay for treatment of it, if it’s not a diagnosis with a code in the book.  It’s never been a diagnosis to get a lot of time and attention in college for mental health professionals, but it will get even less now that it officially doesn’t exist.  So new doctors and therapists will have no idea how to treat it.  There are a few hospitals in the U.S. that have units specializing in DID.  Those won’t exist in the future if insurance companies won’t pay for its treatment.

And I guess I’m just baffled, really.  I know diagnosing mental health disorders is not the same as diagnosing physical disorders.  If I weigh 270 pounds, doctors know I’m fat.  They aren’t going to try to tell me that obesity doesn’t exist.  But what if you told doctors that you feel compelled to eat even when you’re not hungry or that you are addicted to eating and can’t stop, and they told you oh, there is no such thing as compulsive eating or food addiction?  You’re just trying to get attention, or that other doctor convinced you that you are addicted to food but you really aren’t.

I’m not sure I even have a point here so I’m going to stop now.  Thanks if you’ve read this far.

I totally get you. Insurance companies **** me off. They should have no say in whether a person does or does not have a diagnosis that's in a book, period! If a person has mental health problems and needs treatment, why can't that be enough? It's dreadful, as it is, that insurance companies don't pay psych. docs enough for them to be bothered dealing with insurance companies. I know this first hand, because my child has had a lot of problems lately, dx. OCD, depression and anxiety. There are 2 Psych docs under our plan that take insurance, one of which we have seen, and she's just awful, the other I called up and she can hardly speak English. Don't get insulted people, my husband is Asian and has a very heavy accent, I just feel that when a psych doc has 15 mins to dx. a patient, and listen to a patient, if there is miscommunication between patient and doc, then that's a problem, something I've run into in 22 years of living with my hubby, over and over again. We have had to go to "a great psych doc" that does not take insurance. Of course we can submit after we meet our $1000 deductible, but it's crazy, pardon the pun, that this should even happen. I get so angry that insurance companies dictate how health care is managed in this country. I work in health care and when a mother clearly will not deliver her baby vaginally, we still have to "pit a baby to distress", before we can take the patient to the OR! Insurance won't pay unless it's an emergency. So the baby suffers and is put in danger because of MONEY!!! A baby's life is endangered because this is the only way we can prove that the c-section is warranted. Insurance companies don't want docs doing unnecessary c-sections. I get that, but most docs are not going to cut a patient just for the sake of it, that would be so unethical. Why should insurance companies have so much power. I don't know if I'm making sense myself, but I feel for you and completely agree with you. I'll get off my soap box now.

I understand about the language issue.  You need to be able to communicate with your doctor well, any type of doctor, but especially a psychiatrist, I think.  If you have a heart disease, the cardiiologist will check your blood pressure and do an  EKG and base their treatment at least in part on the results of tests, which we'll assume they know how to read.  with a psychiatrist, they have to listen carefully and understand what you're telling them, and of course you need to be able to understand them.

I hate that it's so hard to get mental health treatment - good treatment, anyway - for kids because insurance won't pay enough.  My nephew that lived with me for a while last year is severely mentally ill and really needs some sort of long term residential treatment.  Unfortunately, no one in our family can afford something like that, and he has Medicaid, and they won't pay for it either.  They paid for one week in a psych hospital and it was a good hospital, too, but that wasn't anywhere near long enough.

I could've said it better myself.  Insurance companies suck !!

 Wow, Kelly.  I knew there was some controversy over DID, but didn't realize the DSM was going to remove it.  Do you know if their only reasoning is that it is controversial? Or, do they think that the disorder can be grouped with another listed one?  

You are right, though.  The liklihood seems low that future therapists will be able to treat DID patients if the DSM doesn't recognize it. 

As far as I know, they are not grouping it with something else, although I suppose at least most people with DID would also have PTSD so you could kind of treat it under that umbrella.  At least then insurance would pay for it.  but treatment is not exactly the same for PTSD and DID and therapists that are highly trained and very experienced in treating PTSD still may have no clue what to do with DID.  Geez, there are enough of them out there that don't know how to treat it now!

 Definately not a long & rambling post - one that deserves thoughtful attention! It's a larger problem of diagnosis vs treatment vs what will get paid. I'm of the ilk that has two minds in practice (not a pun on DID) - what I do for my clients is sometimes different from what I say to insurance companies. My loyalty is to the client so if I have to say that they came in for individual sessions when it was a couples' session but their insurance company doesn't recognize couples therapy, I bill for an individual session. It's ridiculous that third party protocol should block someone from receiving help. Now getting off my soapbox and addressing your issue on DID - you're right, not alot of people specialize in it. Is it due to the extra effort required to keep up on continuing education or extra training? Is it the nature of the work? I don't know why more clinicians wouldn't take interest in DID but I also respect therapists not trying to operate outside of their knowledge base. If someone with DID came to me, I'd work to the best of my ability with them for as long as they'd want me, but I also know that it's not my scope of practice and possibly others would be a better help for them, but sometimes SOME help is better than nothing at all. Sad to feel that way, when I live in a metro area that SHOULD have good acess to a variety of specialties & providers, but you'd be amazed what trouble some of my clients have had in finding providers. One recent one said a therapist wouldn't take her daughter on because she had "too many problems". Really? Who says that? On one level I can understand but would not say that to a client. I had another client who had a history of incarceration have a therapist literally lock the door behind him after their first and only session. Um, so maybe I have a higher tolerence for treating ex-cons, given I interned in a women's prison, but I feel part of this profession is to show dignity and honor to all who come in to my office.
I'd actually applied to be part of a review panel for the DSM-V but never heard back. If they're doing away with DID, I feel like it should only be in lieu of a more precise diagnosis. I'm not really a "label" person, so once I make a diagnosis, it's usually only for necessity or to give a general guidemap of how therapy wil go - not the more "person centered" focus that has to do with the whole person & their functionality. I've often felt that the current DSM ties my hands more than it helps. How do you put into a code all the complexities of the human existance? It often feels inadequate - a diagnosis can describe symptoms that we're working on, but I feel like my job is to work with the whole person, not just the disorder. Wish insurance companies could see that as important.

I understand treating the whole person, not the label.  And  on one hand, I feel like the labels shouldn't be important and everyone is unique so the treatment one client with DID needs may not be the same as the treatment another client with DID  needs.  But on the other hand, an accurate diagnosis provides a starting place for treatment, and it's a really easy way to tell a health care provider something about a client.  Like, if I had  multiple sclerosis, I might use a wheelchair, I might be unable to even feed myself, or I might look pretty normal and just need to walk with a cane once in a while.  Still, when I told people I had MS, it would be like a shorthand to let them know some basic things about  me and my body.

I don't know why so many therapists don't know how to treat DID or don't like to treat it.  It usually takes a long time and can be a difficult treatment process, so maybe if you don't want to deal with clients that seem non-compliant at times or suicidal or self injure or seem resistant to treatment sometimes, you probably wouldn't like treating DID.  And some professionals don't believe it exists, and of course you don't wanna waste time treating an imaginary condition, especially one you think your client is just faking to get attention.

I agree that therapists should refer clients to other therapists if they feel they don't have the knowledge or skills to treat them.  And I can understand it, I don't think it's reasonable to expect all therapists to be really good at treating all different disorders.  There are some general run of the mill kinds of issues people go to therapy for but things like eating disorders, substance abuse, DID, those require specialized treatment.

First, I would agree with much of what Nicole said.

Second, I can understand why many therapists prefer not to (or decline to) treat clients with DID. I think it is for much the same reason that many prefer not to work with clients with psychotic disorders or some of the Axis II PDs... they simply don't have a clue what to do.  Graduate programs -- even many PsyD programs -- don't cover treatment of some these disorders in any depth (not enough to be useful), and even finding post-grad training on them can be challenging, especially for those without the financial resources to cover a lot of travel expenses (and potential unpaid time off work).  Personally I think that there are a lot of therapists who should NOT treat clients with severe PTSD for the same reason... they simply don' know enough about what they are doing and therefore may do more harm than good.  Several of my clients initially gave up on therapy for a period of time (sometimes MANY years) because of a bad experience with a counselor who advertised themselves as experienced trauma counselors... and much of the time spent working with me was un-doing some of the damage caused by a previous therapist.

Because such a large percentage of my clients have PSTD (or Acute Stress Disorder after a very recent event) with dissociative symptoms, and because many of them experienced some level of depersonalization during the trauma, I would not have a problem with treating a client with DID... BUT I have also done a lot of post-grad trauma training and managed to find a CEU training that included some info on DID treatment.  I am not at all comfortable, however, with treating clients with psychotic disorders and many PDs (especially Cluster A and B disorders)... simply because I lack the appropriate training and my only experiences with such disorders was with during my internship (and even my supervisor was not much help regarding treatment).  I would refer such clients.

Lora

I definitely think therapists (well, all professionals, really) should refer clients they aren't comforable treating for any reason whatsoever.  If you dislike people with blue eyes for some reason, I'll think that's kind of dumb but please, please refer me.  And absolutely refer clients with conditions you don't feel qualified to treat.  When I was a social worker, I did intakes on clients for an anger management program and I did not admit those with significant substance abuse problems or those with suicidal thoughts to the program because those were things the program was not prepared to treat.  I did refer them to other services and did whatever I could to help them access those services - including paying cab fare for a teenage boy and his mom to get to the hospital because he was suicidal and they had no car and no money.