Case Study

Case Study

“You Have Borderline Personality Disorder”: Sharing a Difficult Diagnosis with a Client

By Jill Sammak

November/December 2021

It might feel intuitive to give your client a diagnosis when you spot the symptoms of a problem that’s causing them distress. After all, once the therapist and client are on the same page about the issue, they can get to work, right? Not necessarily. Sure, for some clients, a diagnosis provides clarity, giving shape to problems that may have long felt mysterious and made them feel alone. But when it comes to more stigmatized diagnoses, like borderline personality disorder (BPD), it can not only alarm clients, but provoke defensiveness, elicit shame, damage the therapeutic alliance, and even threaten to derail therapy altogether.

The notion that some clients may be blindsided or offended by a BPD diagnosis is understandable. Mental health professionals have called clients with BPD difficult, erratic, antisocial, delusional, and hostile. Media portrayals don’t help either. Characters like Alex Forrest, played by Glenn Close in Fatal Attraction, and Annie Wilkes, played by Kathy Bates in Misery, have BPD. While there’s much, much more to BPD and clients who suffer from it, I get it. From the client’s perspective, if you’re going to be stigmatized or rejected because of a label, why would you want it?

As clinicians, we don’t usually have a choice about whether or not to diagnose a patient: for insurance and bureaucratic reasons, it’s required. But we need to consider not only what diagnosis to give—in essence, how to diagnose on a case-by-case…

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