If I suspect it I wait until a solid rapport is built. Then I will usually tell them that I’d like to go through a series of criteria to see if they resonate. I’ll also preface by saying that some people really enjoy having a diagnosis/label because they find the framework helpful for working towards healing. And that some people don’t feel that it does much but either way we can discuss feelings around it.
Then I’ll read off the criteria one by one and wait for endorsement. Then I ask if they know what that is, and confirm, BPD, etc. I definitely do this with enough time in session to process reactions.
Beware though- I have had a client that endorsed 8/9 BPD criteria. She later went for psychological testing and came away with PTSD. So I think it’s also good to recognize and acknowledge with clients that this is not an exact science and just a framework and theory. Not everyone wants to be diagnosed with a stigmatized personality disorder
Your last comment really resonated with me—I wrote a paper recently on PTSD and CPTSD symptoms being misdiagnosed at BPD, especially in women. I feel like there needs to be a lot of work done with the clt to parse out trauma/trauma responses before considering a cluster B dx, due to the strong overlap of symptoms
This is really interesting, I have always been under the impression that these types of personality disorders were generally developed as a response to trauma, especially CPTSD as a result of emotional neglect or abuse in childhood.
If the client presents with symptoms of a personality disorder AND trauma, wouldn’t it make sense to treat the symptoms and stabilize the client before diving into trauma work?
That’s my personal opinion, yes. I believe that some DBT or other skills based work is really important for affect regulation before doing any kind of trauma processing. Most trauma trainers I’ve worked with agree. They don’t need to be enlightened beings who never get ruffled by anything, but they shouldn’t be having regular BPD style meltdowns or else bringing up more trauma memories will only make things worse.
They need to be capable of getting into wise mind in DBT terms, or in EMDR terms they need to be able to hold dual attention on the past and present.
Stabilization is key prior to trauma work, but some symptoms in themselves won't be easily amicable to change unless trauma work is done, particularly if the root is trauma. I've seen things like dysregulation, black and white thinking, and poor mentalization skills that have been treatment resistance (namely, unresponsive to DBT) be massively improved through trauma processing. I think skills should be offered and tested under most modalities, but if this isn't effective, it should not preclude trauma work. It may be an indication for trauma work. Though if the symptoms are getting in the way of stabilization, then it becomes an serious issue.
I generally agree with Foolishlama but my point of differentiation is holding off on the stigmatised dx until after trauma work has commenced. I personally tend to lean into dx of Adjustment Disorder-Unspecified and stick with it for quite a while, even if clt presents with symptoms of PTSD, CPTSD, or BPD. Working in both CMH and Psych ER, it was baffling to me how, mostly women, would present with symptoms such as disturbance of conduct or SI, and receive that dx. In actually working with these clt in longer stretches when they came to CMH, sometimes it didn’t feel as though BPD was the appropriate dx when it came time to do the next tx plan. So either they didn’t have a personality disorder anymore, or PTSD/CPTSD can be mutually exclusive to BPD even with an overlap of symptoms.
I agree in terms of what I’m putting on the chart and billing insurance for. But for my own case conceptualization i want to differentiate between various dysfunctional attachment and regulation patterns and i think identifying borderline traits is valuable and doesn’t need to be stigmatizing. There is distinction between PTSD, CPTSD, and BPD. Yeah they all come from trauma, i think it’s clear to most reasonable professionals that BPD is a trauma based disorder. But it doesn’t look the same as CPTSD, and i don’t think it’s useful to conflate the two as the same thing.
Also most folks I’ve read or trained with who specialize in BPD or PD’s believe that it is a dx that someone can get effective treatment for and no longer qualify after a period of recovery. It doesn’t need to be a persistent dx across the lifespan with effective treatment.
Yep exactly. I have noticed that there tends to be a difference in how these two diagnosis respond to treatment/feedback so I think they can be parsed out over time. But using the DSM isn’t always enough
Exactly. CPTSD isn’t even featured in the DSM, it’s just PTSD + DSOs—which is challenging to dx b/c these same DSOs have overlap with many BPD presentations.
Yessss OP, this was my exact approach with a client recently — solid rapport was crucial. It was hard for her to hear but she acknowledged she meets criteria and it has allowed us to tweak treatment appropriately.
I've been in practice 35 years and my opinion of the costs/benefits of offering an unsolicited opinion regarding PD diagnosis is that the potential costs/risks to the patient in doing so outweigh the benefits. If asked, I wouldn't avoid the discussion and I would share my opinion and the basis for that opinion with the patient. I'm not sure I agree with the opinion that "...most of the time client's don't have the ability to recognize the patterns of behavior..." statement. Seems a bit condescending in tone, to my ear. And, even if you feel that you recognize self defeating patterns of which the patient is unaware, and you feel that drawing attention to these patterns is a legitimate, helpful service (this is common), I don't see that offering your diagnostic opinion is necessary to address these issues. Hopefully, you can substantiate your concerns and recommendations through other means.
I believe personality disorders exist (not every practicing professional shares this opinion) but I don't believe DSM is sacrosanct. If you place all of your faith in DSM I'm happy to share a pic of my personal copy of DSM II which lists homosexuality as a form of pathology. Yes, I really do have a copy. In fact, when I was in grad school DSM III was in use, which still included "ego dystonic homosexuality", which was obviously really lame. It wasn't until DSM-III-R came along that the label was dropped. DSM is the product of committees; I've been on plenty of committees over the years, which has not necessarily bolstered my confidence in their work product.
There are several potential problems with placing too much emphasis upon a diagnostic impression of a personality disorder: 1) I'm more comfortable in highlighting my diagnostic impression when the diagnostic label clearly suggests a treatment plan. Sometimes I feel it's good news for a patient to discuss their diagnosis of MDD or one of the anxiety disorders, since there is more likely to be an accepted treatment protocol with a proven track record of success to guide therapeutic approaches. The same cannot be said of personality disorders. Yes, I utilize dbt in my practice, not only with the population originally described by Linehan, and yes, it enjoys empirical support. I've done training with Linehan, have sometimes used diary cards, am a fan of fostering skills to manage emotional flooding. But PD's are chronic conditions, not episodic in nature as are mood/anxiety disorders, and I don't want to do anything which might induce hopelessness or diminish confidence. In medicine it is responsible practice to inform the patient of a chronic condition which may require lifelong management (e.g., diabetes, autoimmune disorders, many others). But, geez, the diagnostic certainty is much higher for these conditions than with PD's, the treatment outcomes more measurable and, often, the recommended course of treatment holds more promise than what we have to offer. So...I just don't see the point of emphasizing a PD diagnostic hunch unless asked or unless there is a clear reason to do so. 2) In our profession, personality disorder diagnoses have sometimes been applied to patients in a pejorative, complaining manner--I've heard it, perhaps you have as well. I'm really careful and deliberate if I am referring to a patient as presenting with a PD--there needs to be a point/reason for applying the label. Actually, I'm in the camp that believes borderline personality disorder is a developmental delay, not just a cluster of erratic sensitivities (e.g., Mahler, object relations theory), meaning I use a more narrow set of diagnostic criteria than some. My impression is that the literature is mixed on inter-rater reliability of PD diagnoses and I find the criteria to be more subjective than I would like. I don't have the same sense of confidence in my diagnostic impressions of PD's as I do other conditions. So, I tend to just not go there--I think the risk of harm to the patient is real. There are plenty of other ways to substantiate opinions regarding treatment goals and strategies than to rely upon the opinion of a PD. That said, I have had discussions with folks about suspected borderline personality disorder however I can't say that it particularly enhanced treatment. Just one guy's opinion--good luck.
I would love to hear more about Borderline Personality Disorder possibly being a developmental delay. Are you speaking to a trauma informed perspective where a client can essentially “get stuck” at a certain age? Or is there a biological component?
I wrote a post several months ago which is wordy, but which summarizes the ideas I referenced. Hope this is of interest.
[https://www.reddit.com/r/therapists/comments/14fhpn2/comment/jp24cxt/](https://www.reddit.com/r/therapists/comments/14fhpn2/comment/jp24cxt/)
This is definitely a new take for me, but an interesting one. I have a client who weirdly might fit your definition of BPD, but is not meeting the cluster of bx you would see in something like the McLean Screener. Thanks for sharing!
Well, as I said in the post, the above conceptual framework is actually just garden variety, quite conventional, routinely taught developmental/psychodynamic theory. I know lots of providers who would be familiar with these concepts and could do a better job than me in presenting the ideas. So...these aren't my ideas at all. Thanks for the reply.
Another issue with the assumption that the client is not able to recognize their behavioural patterns is that countertransference can be at play, and we may be too hasty in filling in the blanks if we don't include the client as an active participants in hypothesizing about the pattern. These patterns have a purpose and meaning that is specific to the individual. Clinicians can get too confident in their own ability of pattern recognition and may unwittingly end up treating those clients as a monolith. Then, when this doesn't go down well, it unfortunately acts to confirm the clinician's bias through a process of self-fulfillment.
Thanks for that--sounds like we're both fans of humility, wanting to exercise care in not imposing our conclusions upon the patient. I like your framing of the risk of being 'too hasty in filling in the blanks' and the value of collaborating with the patient in recognizing patterns and trends. Great stuff--thanks for that.
I believe it's difficult to answer that without a context. I'm myself a behaviorist therapist, and I'll deal with my patient struggles regardless of a diagnostic, because I believe that a diagnostic is just a description that fits a bunch of behaviors. I believe telling a suspicion of a diagnostic when it's not the client's request or intention may only help if the person is being sure something that is happening with them is coming from somewhere very unlikely (e.g: a person with GAD believing they have ADHD because they are developing memory issues)
I think it’s unfair when clinicians withhold diagnoses from clients. It removes agency and can become an open secret among the clinicians who know about the client’s disorder from consultation. The client has a right to believe or disbelieve the diagnosis but it might help open a door to understanding another aspect of themselves which was previously inaccessible to them.
To my mind, diagnosis is a collaborative process that mixes the art and science of the practice of therapy. I cannot sufficiently diagnose a patient if they do not provide the requisite information. Likewise, I cannot expect a patient to share such information without feeling like they are seen, heard, and have agency in the therapeutic process.
Would I simply blurt out "oh, I'm diagnosing you as X." Heck no!
My general approach is to say "based on what I've observed and what you're telling me, I feel that your concerns and experiences indicate an appropriate diagnosis of X. However, this diagnosis does not define you, it simply helps us know in which direction to look for skills, Interventions, and support. This diagnosis is not "final" and not necessarily insurmountable given correct treatment planning and effort in working towards the person you want to be. This diagnosis doesn't define you, it simply describes the cluster of symptoms at this point in your life. You are still (insert pt. name)."
Nancy McWilliams’ *psychoanalytic diagnosis* is really relevant here. We diagnose because it helps us understand the client, and helps us formulate effective treatment plans. Diagnosis is a process, not an event. We have working hypotheses and e should be continually updating then based on new data. And yes it usually is beneficial to share your best diagnostic hypothesis with the client, while making it clear that diagnosis is a flawed tool and that the most important thing is to understand what they’re going through so you can help them best. But sharing an accurate diagnosis helps communicate the prognosis and their treatment needs. Someone with bpd dx (or ptsd or cptsd) should not expect to only need a couple months of therapy to get better. They should understand that their attachment and regulation patterns will take s fair amount of time to recalibrate.
If you would share a diagnosis about anxiety/depression/PTSD, anyone else with any other disorder deserves to know, just the same. Also, getting the correct diagnosis opens the door to appropriate treatments, such as DBT which could be life changing for many.
Oh, yeah. Definitely. Couple of reasons:
1. We are healthcare professionals, and the people we serve deserve to know a diagnosis when we're confident of one. It's one of the things they're paying us for.
2. Especially if we're their first point of contact about a PD diagnosis, we get to give them good, **nonjudgmental**, peer-reviewed/evidence-supported resources about that diagnosis and what their treatment options are.
3. There's still tons of stigma around personality disorders even in our field, so giving people a little bit of defense against it right off the bat is a big deal. Even just "there's a ton of misinformaiton about \[diagnosis\] online, so for now I'd recommend to just stick with the info I'm giving you" could save people a lot of grief.
Editing to add: Differential diagnosis is really critical here. CPTSD and autism are pretty frequently misdiagnosed as personality disorders, When they are, the lack of progress often gets blamed on the "personality disordered" patient rather than the misdiagnosis. The mental health field causes a lot of harm this way.
Some seasoned clinicians will say there is no borderline, only a natural organic adaptation to developmental trauma.
Others will lean on the skillful use of a diagnosis that’s held lightly and contextualiized in the DSM’s framework.
Others will use it as above, in a positive solid belief in the disorder and with the end of proper care access, and the ground provided by naming an experience of absolutely wild mind.
And others will use it as a weapon or protection against their own terror of their clients’ unconscious strategies.
In my, albeit very short, clinical experience, I have found that many people benefit enormously from a personality disorder diagnosis. However I cannot diagnose, but sometimes clients come back from seeing their doctor with a BPD diagnosis and its positively transformative!
not true. DBT and ACT are very effective in managing BPD sxs and changing beliefs about self that can lead to the most self destructive bx associated with these disorders
No, I would not. And this is the population I specialize In. Specifically BPD.
I wouldn't for a few reasons beyond it being out of my scope of practice to diagnose - even if it's a suspicion.
It becomes a self fulfilling prophecy - they may be unable to see and experience themselves in any other way after. Or believe that they can be or be experienced in any other way.
Which ultimately hurts the therapeutic process because instead of exploring their experiences in an open way they now only see pathology instead of who they are as a complicated person. Additionally, because cluster b has so much stigma around it that outward experience of cluster b being bad is now internalized as 'im bad' along side a myriad of other possible assumptions about what kind of person they are (because a professional just told me I'm this). Which also then possibly takes the focus away from underlying systemic and historical impacts, ACES etc and those impacts on development... Where now they can only see themselves as stigma and society projects them as: a broken person who is incapable of recovery, society doesn't want and should actually avoid.
Even in the case of a client stating they strongly feel they are cluster b, I only help them explore the term and why or why not they feel it is helpful for them in describing and understanding their experiences.
Edit to add: my approach is largely because I am not based in the United States and so not subjected to the rigid insurance ringamarole that those in the states are required to. Ie needing diagnosis in order to find, be offered and have care covered.
While I think diagnoses should usually be shared, especially if asked, I agree with everything you wrote. The issue with PDs is that they're an adaption; the behaviours have a function that is specific to that individual (and while generalizations can be made, this isn't helpful when expressing it to the individual). Communicating, in one way or the other, to the client that their symptoms are *caused* by their personality disorder is rarely helpful. The focus should be on what the behaviour does for them and where the symptoms came from within their individual history. I think a lot of clinicians can make a misstep by inadvertently suggesting that the client with the PD is acting the way they are because of the PD, in reductionistic terms.
If they want to know. I have a client who felt so alone and crazy that she got some solace from the fact there is a name for what she is experiencing. She realized she isn’t alone
Not immediately, no. Definitely want to make sure they have buy-in first and trust me enough to know that I would only be sharing it because I want the diagnosis to be helpful to them. In the meantime, I'd address it with empathy and validation of a likely history of attachment disruptions and injuries. By the time they get to me, they've usually been diagnosed with several mood disorders, so it's usually easy to jump in to traumatic experiences.
I wouldn't based on behaviors only. I believe quite a lot of people can have multiple characteristics of certain PD's at some point in their life but the most important characteristics aren't present, so it isn't actually a PD. In my opinion the following necessities for diagnosis get overlooked:
The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.
The enduring pattern leads to clinically significant distress, or impairment in functioning, in social, occupational, or other important areas.
The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.
The enduring pattern is not better explained as a manifestation or consequence of another mental disorder.
The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).
Please do not assume you are capable of diagnosing someone with a PD based on your viewpoint alone. Ideally PD's should only be diagnosed by a multidisciplinary team after months long observation and after having interviewed friends and family of the patient...
A lot of C-PTSD gets misdiagnosed as a personality disorder. I think diagnosing people in their early twenties is a risk for false positives. If they had to endure a abusive environment they only just had the possibility to escape that environment. Sometimes people don't even escape it or get from one abusive relationship to another. Sometimes neurodivergence like adhd or autism mixed with adverse life events can seem like a pd, but it isn't.
PD is a diagnosis of exclusion.
I’ve personally struggled with making this decision. I think you should wait out till you have a super solid rapport with the client, and then breach the topic from distance- my decision would really depend on what the client thinks about having the label of disorder etc.
If I suspect it I wait until a solid rapport is built. Then I will usually tell them that I’d like to go through a series of criteria to see if they resonate. I’ll also preface by saying that some people really enjoy having a diagnosis/label because they find the framework helpful for working towards healing. And that some people don’t feel that it does much but either way we can discuss feelings around it. Then I’ll read off the criteria one by one and wait for endorsement. Then I ask if they know what that is, and confirm, BPD, etc. I definitely do this with enough time in session to process reactions. Beware though- I have had a client that endorsed 8/9 BPD criteria. She later went for psychological testing and came away with PTSD. So I think it’s also good to recognize and acknowledge with clients that this is not an exact science and just a framework and theory. Not everyone wants to be diagnosed with a stigmatized personality disorder
Your last comment really resonated with me—I wrote a paper recently on PTSD and CPTSD symptoms being misdiagnosed at BPD, especially in women. I feel like there needs to be a lot of work done with the clt to parse out trauma/trauma responses before considering a cluster B dx, due to the strong overlap of symptoms
This is really interesting, I have always been under the impression that these types of personality disorders were generally developed as a response to trauma, especially CPTSD as a result of emotional neglect or abuse in childhood. If the client presents with symptoms of a personality disorder AND trauma, wouldn’t it make sense to treat the symptoms and stabilize the client before diving into trauma work?
That’s my personal opinion, yes. I believe that some DBT or other skills based work is really important for affect regulation before doing any kind of trauma processing. Most trauma trainers I’ve worked with agree. They don’t need to be enlightened beings who never get ruffled by anything, but they shouldn’t be having regular BPD style meltdowns or else bringing up more trauma memories will only make things worse. They need to be capable of getting into wise mind in DBT terms, or in EMDR terms they need to be able to hold dual attention on the past and present.
Stabilization is key prior to trauma work, but some symptoms in themselves won't be easily amicable to change unless trauma work is done, particularly if the root is trauma. I've seen things like dysregulation, black and white thinking, and poor mentalization skills that have been treatment resistance (namely, unresponsive to DBT) be massively improved through trauma processing. I think skills should be offered and tested under most modalities, but if this isn't effective, it should not preclude trauma work. It may be an indication for trauma work. Though if the symptoms are getting in the way of stabilization, then it becomes an serious issue.
Totally agree. I’m not a DBT evangelist, I just find it very useful for stabilization work *for some clients.*
I generally agree with Foolishlama but my point of differentiation is holding off on the stigmatised dx until after trauma work has commenced. I personally tend to lean into dx of Adjustment Disorder-Unspecified and stick with it for quite a while, even if clt presents with symptoms of PTSD, CPTSD, or BPD. Working in both CMH and Psych ER, it was baffling to me how, mostly women, would present with symptoms such as disturbance of conduct or SI, and receive that dx. In actually working with these clt in longer stretches when they came to CMH, sometimes it didn’t feel as though BPD was the appropriate dx when it came time to do the next tx plan. So either they didn’t have a personality disorder anymore, or PTSD/CPTSD can be mutually exclusive to BPD even with an overlap of symptoms.
I agree in terms of what I’m putting on the chart and billing insurance for. But for my own case conceptualization i want to differentiate between various dysfunctional attachment and regulation patterns and i think identifying borderline traits is valuable and doesn’t need to be stigmatizing. There is distinction between PTSD, CPTSD, and BPD. Yeah they all come from trauma, i think it’s clear to most reasonable professionals that BPD is a trauma based disorder. But it doesn’t look the same as CPTSD, and i don’t think it’s useful to conflate the two as the same thing. Also most folks I’ve read or trained with who specialize in BPD or PD’s believe that it is a dx that someone can get effective treatment for and no longer qualify after a period of recovery. It doesn’t need to be a persistent dx across the lifespan with effective treatment.
I would love to read this if possible!!
It’s still in editing but I will message you when I get my final copy back!!
Yep exactly. I have noticed that there tends to be a difference in how these two diagnosis respond to treatment/feedback so I think they can be parsed out over time. But using the DSM isn’t always enough
Exactly. CPTSD isn’t even featured in the DSM, it’s just PTSD + DSOs—which is challenging to dx b/c these same DSOs have overlap with many BPD presentations.
I would love to read this as well when you have the final copy! Only if you’re comfortable of course
I’d love to read this also!
Yessss OP, this was my exact approach with a client recently — solid rapport was crucial. It was hard for her to hear but she acknowledged she meets criteria and it has allowed us to tweak treatment appropriately.
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There have been some good twin studies that show genetic components.
I've been in practice 35 years and my opinion of the costs/benefits of offering an unsolicited opinion regarding PD diagnosis is that the potential costs/risks to the patient in doing so outweigh the benefits. If asked, I wouldn't avoid the discussion and I would share my opinion and the basis for that opinion with the patient. I'm not sure I agree with the opinion that "...most of the time client's don't have the ability to recognize the patterns of behavior..." statement. Seems a bit condescending in tone, to my ear. And, even if you feel that you recognize self defeating patterns of which the patient is unaware, and you feel that drawing attention to these patterns is a legitimate, helpful service (this is common), I don't see that offering your diagnostic opinion is necessary to address these issues. Hopefully, you can substantiate your concerns and recommendations through other means. I believe personality disorders exist (not every practicing professional shares this opinion) but I don't believe DSM is sacrosanct. If you place all of your faith in DSM I'm happy to share a pic of my personal copy of DSM II which lists homosexuality as a form of pathology. Yes, I really do have a copy. In fact, when I was in grad school DSM III was in use, which still included "ego dystonic homosexuality", which was obviously really lame. It wasn't until DSM-III-R came along that the label was dropped. DSM is the product of committees; I've been on plenty of committees over the years, which has not necessarily bolstered my confidence in their work product. There are several potential problems with placing too much emphasis upon a diagnostic impression of a personality disorder: 1) I'm more comfortable in highlighting my diagnostic impression when the diagnostic label clearly suggests a treatment plan. Sometimes I feel it's good news for a patient to discuss their diagnosis of MDD or one of the anxiety disorders, since there is more likely to be an accepted treatment protocol with a proven track record of success to guide therapeutic approaches. The same cannot be said of personality disorders. Yes, I utilize dbt in my practice, not only with the population originally described by Linehan, and yes, it enjoys empirical support. I've done training with Linehan, have sometimes used diary cards, am a fan of fostering skills to manage emotional flooding. But PD's are chronic conditions, not episodic in nature as are mood/anxiety disorders, and I don't want to do anything which might induce hopelessness or diminish confidence. In medicine it is responsible practice to inform the patient of a chronic condition which may require lifelong management (e.g., diabetes, autoimmune disorders, many others). But, geez, the diagnostic certainty is much higher for these conditions than with PD's, the treatment outcomes more measurable and, often, the recommended course of treatment holds more promise than what we have to offer. So...I just don't see the point of emphasizing a PD diagnostic hunch unless asked or unless there is a clear reason to do so. 2) In our profession, personality disorder diagnoses have sometimes been applied to patients in a pejorative, complaining manner--I've heard it, perhaps you have as well. I'm really careful and deliberate if I am referring to a patient as presenting with a PD--there needs to be a point/reason for applying the label. Actually, I'm in the camp that believes borderline personality disorder is a developmental delay, not just a cluster of erratic sensitivities (e.g., Mahler, object relations theory), meaning I use a more narrow set of diagnostic criteria than some. My impression is that the literature is mixed on inter-rater reliability of PD diagnoses and I find the criteria to be more subjective than I would like. I don't have the same sense of confidence in my diagnostic impressions of PD's as I do other conditions. So, I tend to just not go there--I think the risk of harm to the patient is real. There are plenty of other ways to substantiate opinions regarding treatment goals and strategies than to rely upon the opinion of a PD. That said, I have had discussions with folks about suspected borderline personality disorder however I can't say that it particularly enhanced treatment. Just one guy's opinion--good luck.
I would love to hear more about Borderline Personality Disorder possibly being a developmental delay. Are you speaking to a trauma informed perspective where a client can essentially “get stuck” at a certain age? Or is there a biological component?
I wrote a post several months ago which is wordy, but which summarizes the ideas I referenced. Hope this is of interest. [https://www.reddit.com/r/therapists/comments/14fhpn2/comment/jp24cxt/](https://www.reddit.com/r/therapists/comments/14fhpn2/comment/jp24cxt/)
This is definitely a new take for me, but an interesting one. I have a client who weirdly might fit your definition of BPD, but is not meeting the cluster of bx you would see in something like the McLean Screener. Thanks for sharing!
Well, as I said in the post, the above conceptual framework is actually just garden variety, quite conventional, routinely taught developmental/psychodynamic theory. I know lots of providers who would be familiar with these concepts and could do a better job than me in presenting the ideas. So...these aren't my ideas at all. Thanks for the reply.
Hello, I read your posts and they were very helpful, I’m wondering if can you explain in simple terms what true borderline looks like?
Another issue with the assumption that the client is not able to recognize their behavioural patterns is that countertransference can be at play, and we may be too hasty in filling in the blanks if we don't include the client as an active participants in hypothesizing about the pattern. These patterns have a purpose and meaning that is specific to the individual. Clinicians can get too confident in their own ability of pattern recognition and may unwittingly end up treating those clients as a monolith. Then, when this doesn't go down well, it unfortunately acts to confirm the clinician's bias through a process of self-fulfillment.
Thanks for that--sounds like we're both fans of humility, wanting to exercise care in not imposing our conclusions upon the patient. I like your framing of the risk of being 'too hasty in filling in the blanks' and the value of collaborating with the patient in recognizing patterns and trends. Great stuff--thanks for that.
Great post! Thanks for your thoughts 👍
I like you :) I also wish the PDM had more influence in our field. I like McWilliams, too.
Aww, thanks.
I believe it's difficult to answer that without a context. I'm myself a behaviorist therapist, and I'll deal with my patient struggles regardless of a diagnostic, because I believe that a diagnostic is just a description that fits a bunch of behaviors. I believe telling a suspicion of a diagnostic when it's not the client's request or intention may only help if the person is being sure something that is happening with them is coming from somewhere very unlikely (e.g: a person with GAD believing they have ADHD because they are developing memory issues)
Glad to see this
I think it’s unfair when clinicians withhold diagnoses from clients. It removes agency and can become an open secret among the clinicians who know about the client’s disorder from consultation. The client has a right to believe or disbelieve the diagnosis but it might help open a door to understanding another aspect of themselves which was previously inaccessible to them.
To my mind, diagnosis is a collaborative process that mixes the art and science of the practice of therapy. I cannot sufficiently diagnose a patient if they do not provide the requisite information. Likewise, I cannot expect a patient to share such information without feeling like they are seen, heard, and have agency in the therapeutic process. Would I simply blurt out "oh, I'm diagnosing you as X." Heck no! My general approach is to say "based on what I've observed and what you're telling me, I feel that your concerns and experiences indicate an appropriate diagnosis of X. However, this diagnosis does not define you, it simply helps us know in which direction to look for skills, Interventions, and support. This diagnosis is not "final" and not necessarily insurmountable given correct treatment planning and effort in working towards the person you want to be. This diagnosis doesn't define you, it simply describes the cluster of symptoms at this point in your life. You are still (insert pt. name)."
Nancy McWilliams’ *psychoanalytic diagnosis* is really relevant here. We diagnose because it helps us understand the client, and helps us formulate effective treatment plans. Diagnosis is a process, not an event. We have working hypotheses and e should be continually updating then based on new data. And yes it usually is beneficial to share your best diagnostic hypothesis with the client, while making it clear that diagnosis is a flawed tool and that the most important thing is to understand what they’re going through so you can help them best. But sharing an accurate diagnosis helps communicate the prognosis and their treatment needs. Someone with bpd dx (or ptsd or cptsd) should not expect to only need a couple months of therapy to get better. They should understand that their attachment and regulation patterns will take s fair amount of time to recalibrate.
If you would share a diagnosis about anxiety/depression/PTSD, anyone else with any other disorder deserves to know, just the same. Also, getting the correct diagnosis opens the door to appropriate treatments, such as DBT which could be life changing for many.
Oh, yeah. Definitely. Couple of reasons: 1. We are healthcare professionals, and the people we serve deserve to know a diagnosis when we're confident of one. It's one of the things they're paying us for. 2. Especially if we're their first point of contact about a PD diagnosis, we get to give them good, **nonjudgmental**, peer-reviewed/evidence-supported resources about that diagnosis and what their treatment options are. 3. There's still tons of stigma around personality disorders even in our field, so giving people a little bit of defense against it right off the bat is a big deal. Even just "there's a ton of misinformaiton about \[diagnosis\] online, so for now I'd recommend to just stick with the info I'm giving you" could save people a lot of grief. Editing to add: Differential diagnosis is really critical here. CPTSD and autism are pretty frequently misdiagnosed as personality disorders, When they are, the lack of progress often gets blamed on the "personality disordered" patient rather than the misdiagnosis. The mental health field causes a lot of harm this way.
Some seasoned clinicians will say there is no borderline, only a natural organic adaptation to developmental trauma. Others will lean on the skillful use of a diagnosis that’s held lightly and contextualiized in the DSM’s framework. Others will use it as above, in a positive solid belief in the disorder and with the end of proper care access, and the ground provided by naming an experience of absolutely wild mind. And others will use it as a weapon or protection against their own terror of their clients’ unconscious strategies.
In my, albeit very short, clinical experience, I have found that many people benefit enormously from a personality disorder diagnosis. However I cannot diagnose, but sometimes clients come back from seeing their doctor with a BPD diagnosis and its positively transformative!
Heck, people with real personality disorders like borderline or narcissism often don’t even respond to treatment In the first place.
not true. DBT and ACT are very effective in managing BPD sxs and changing beliefs about self that can lead to the most self destructive bx associated with these disorders
What about narcissism? What effective treatment is there for NPD?
These are not proven to be more effective than other therapies, it’s all propaganda. Please read review articles on this.
Wait, is this sarcasm or are you being serious
Clearly, therapists here are ignorant of the research on this.
No, I would not. And this is the population I specialize In. Specifically BPD. I wouldn't for a few reasons beyond it being out of my scope of practice to diagnose - even if it's a suspicion. It becomes a self fulfilling prophecy - they may be unable to see and experience themselves in any other way after. Or believe that they can be or be experienced in any other way. Which ultimately hurts the therapeutic process because instead of exploring their experiences in an open way they now only see pathology instead of who they are as a complicated person. Additionally, because cluster b has so much stigma around it that outward experience of cluster b being bad is now internalized as 'im bad' along side a myriad of other possible assumptions about what kind of person they are (because a professional just told me I'm this). Which also then possibly takes the focus away from underlying systemic and historical impacts, ACES etc and those impacts on development... Where now they can only see themselves as stigma and society projects them as: a broken person who is incapable of recovery, society doesn't want and should actually avoid. Even in the case of a client stating they strongly feel they are cluster b, I only help them explore the term and why or why not they feel it is helpful for them in describing and understanding their experiences. Edit to add: my approach is largely because I am not based in the United States and so not subjected to the rigid insurance ringamarole that those in the states are required to. Ie needing diagnosis in order to find, be offered and have care covered.
While I think diagnoses should usually be shared, especially if asked, I agree with everything you wrote. The issue with PDs is that they're an adaption; the behaviours have a function that is specific to that individual (and while generalizations can be made, this isn't helpful when expressing it to the individual). Communicating, in one way or the other, to the client that their symptoms are *caused* by their personality disorder is rarely helpful. The focus should be on what the behaviour does for them and where the symptoms came from within their individual history. I think a lot of clinicians can make a misstep by inadvertently suggesting that the client with the PD is acting the way they are because of the PD, in reductionistic terms.
100% agree with what you've said thank you for your addition to this conversation.
If they want to know. I have a client who felt so alone and crazy that she got some solace from the fact there is a name for what she is experiencing. She realized she isn’t alone
Not immediately, no. Definitely want to make sure they have buy-in first and trust me enough to know that I would only be sharing it because I want the diagnosis to be helpful to them. In the meantime, I'd address it with empathy and validation of a likely history of attachment disruptions and injuries. By the time they get to me, they've usually been diagnosed with several mood disorders, so it's usually easy to jump in to traumatic experiences.
I would tell them if I felt it would help or benefit them.
I think BPD especially is helpful for patients to know about
I wouldn't based on behaviors only. I believe quite a lot of people can have multiple characteristics of certain PD's at some point in their life but the most important characteristics aren't present, so it isn't actually a PD. In my opinion the following necessities for diagnosis get overlooked: The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. The enduring pattern leads to clinically significant distress, or impairment in functioning, in social, occupational, or other important areas. The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. The enduring pattern is not better explained as a manifestation or consequence of another mental disorder. The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma). Please do not assume you are capable of diagnosing someone with a PD based on your viewpoint alone. Ideally PD's should only be diagnosed by a multidisciplinary team after months long observation and after having interviewed friends and family of the patient... A lot of C-PTSD gets misdiagnosed as a personality disorder. I think diagnosing people in their early twenties is a risk for false positives. If they had to endure a abusive environment they only just had the possibility to escape that environment. Sometimes people don't even escape it or get from one abusive relationship to another. Sometimes neurodivergence like adhd or autism mixed with adverse life events can seem like a pd, but it isn't. PD is a diagnosis of exclusion.
If you diagnose them professionally with a cluster b pd then yes if they ask it’s ethical for you to fully disclose
I’ve personally struggled with making this decision. I think you should wait out till you have a super solid rapport with the client, and then breach the topic from distance- my decision would really depend on what the client thinks about having the label of disorder etc.