Giving up on a Borderline before the first session

I saw the diagnosis on the intake form and I checked my malpractice insurance before I even looked at the client’s name. I am not proud of that fact, but I am also not going to lie to you about how I operate after fifteen years in this chair. The words Borderline Personality Disorder act as a professional containment notice. I saw those three words on a digital referral three weeks ago. I felt the familiar tightening in my shoulders. I did not think about how to help this person. I thought about how to protect my Tuesday afternoons. I thought about how many phone calls I would have to return between sessions. I looked at the history of three previous therapists in two years and I began drafting my referral out in my head before I had even cleared my throat to call her into the office.

I have watched this happen at every clinic where I have ever worked. I see the senior staff look at the folder and I see their eyes glaze over with a specific kind of fatigue. The diagnosis functions as a pre-authorization for clinical disengagement. I decided that this woman was going to be a problem because a piece of paper told me she would be. I did not wait for her to speak. I did not wait to see if she had any insight into her own patterns. I simply accepted the label as a fixed reality. I used the diagnosis to justify a lack of curiosity.

I told myself that I was being realistic. I told myself that I was managing my caseload. These are the lies I tell my supervisees when they want to avoid a difficult case. I call it boundary setting. I call it knowing my limitations. The truth is that I am often just refusing to do the work. I am deciding that the return on my emotional investment will be too low. I see a client who will likely challenge my competence, who will demand more than fifty minutes of my time, and who will eventually get angry with me. I do not want to be the target of that anger. I have grown comfortable with clients who appreciate me. I have grown lazy.

I remember a specific case from five years ago that still stays with me because of how I handled the intake. The client had a history of self-harm and a history of what the previous therapist called “intense idealization.” I read that phrase and I felt a wall go up. I decided I would be cold. I decided I would be the most rigid version of myself. I did not do this because it was clinically indicated. I did it because I was afraid. I wanted to make sure she didn’t like me too much. I wanted to make sure she knew I was not her friend. I was so busy building a fortress that I forgot to build a therapeutic alliance.

I sat across from her during that first hour. She was articulate. She was terrified. She told me she knew what people said about her diagnosis. She told me she could see the way therapists looked at her when they saw the label. I denied it. I told her I treated every client as an individual. That was a lie. I was already looking at the clock. I was already thinking about how I would explain to her that I might not be the best fit for her long term needs. I was managing my exit strategy while she was trying to tell me about her childhood.

I see this behavior in my peers every single day. I see it at the conferences where we talk about evidence based treatments for personality disorders. I hear the speakers talk about dialectical behavior therapy. I hear them talk about empathy and validation. Then we go to the bar and someone mentions they just got a new borderline client. The room shifts. The tone changes. I hear the sighs. I hear the jokes about keeping the phone off on weekends. I hear the subtle ways we dehumanize these people because their pain is inconvenient for our schedules.

I have used the diagnosis to ignore the client’s actual complaints. If a client with a standard anxiety disorder tells me I am being insensitive, I reflect on my behavior. I wonder if I missed something. I consider my tone. If a client with Borderline Personality Disorder tells me I am being insensitive, I write a note about “splitting.” I attribute their feedback to their pathology. I use their diagnosis to invalidate their experience of me. I make myself the arbiter of reality and I make them the broken observer. This is a power move. It is a way to stay safe in the room. It is also a failure of the basic requirements of my job.

I watched a colleague of mine receive a referral last week. He is a good therapist. He is experienced. He looked at the paperwork and he made a face like he had just smelled something rotting. He said he didn’t have room for “one of those.” He didn’t say “a person with that struggle.” He said “one of those.” He was referring to a human being as a category of labor he was unwilling to perform. I did not correct him. I nodded because I understood the feeling. I have felt that same repulsion. I have felt that same desire to shove the folder back into the file cabinet and pretend I never saw it.

The diagnosis has become a way for us to signal to each other that we are allowed to stop trying. I have seen therapists provide what I call “maintenance therapy” for years to these clients. They are not doing work. They are just keeping the person alive and out of the hospital until the client gets frustrated and leaves. They are waiting for the client to quit. They are performing the motions of therapy while they are mentally checked out. I have been that therapist. I have sat through sessions where I was just waiting for the clock to hit the fifty minute mark. I was not listening for themes. I was not looking for openings. I was just surviving the hour.

I think about the intake paperwork again. I think about the way I scan for certain keywords. I look for “suicidal ideation.” I look for “legal issues.” I look for “multiple providers.” If I see enough of those, I start to feel a sense of dread. I realize that I am not looking at a person who needs help. I am looking at a liability. I am looking at a potential complaint to the board. I am looking at a person who might ruin my reputation. I have prioritized my professional safety over my clinical duty. I have used the diagnosis of Borderline Personality Disorder as a reason to be less than human.

I recall a moment with a client who had been with me for six months. She had the diagnosis. She was doing the work. She was showing up and she was being honest. One day, she asked me if I liked her. I gave her a standard, clinical answer. I talked about the therapeutic relationship. I talked about our goals. I did not tell her the truth. The truth was that I found her exhausting. The truth was that I spent the hour before her session wishing she would cancel. I did not tell her that because I am a professional. But I suspect she knew. I suspect she felt the wall I had built.

I have started to wonder what would happen if we threw the manuals away. I wonder what would happen if I met a person without knowing their history of diagnostic labels. I suspect I would be a better therapist. I suspect I would be more present. I would not be looking for symptoms of a disorder. I would be looking at a person. I would not be managing an exit before I had even made an entrance. I would be forced to actually do the work.

I am tired of the way we treat this specific group of people. I am tired of the way I treat them. I see the burnout in our field and I know it is real. I know that some clients are more difficult than others. I know that some people require more of us. But I also know that we have created a system where a diagnosis is a death sentence for the therapeutic relationship. We have made it acceptable to give up before we start. I have done it. I will likely do it again. I will see those three letters and I will feel that familiar pull to disengage. I will have to decide, in that moment, if I am going to be a therapist or if I am just going to be a gatekeeper for my own comfort.

I sat in my office after that last intake and I looked at the notes I had taken. I had written down her symptoms. I had written down her history. I had not written down a single thing she actually said. I had only written down the things that confirmed what I already thought I knew about her. I had spent sixty minutes confirming my own biases. I had not learned anything new about her. I had only learned that I was still afraid of her diagnosis. I had wasted her time and I had wasted mine. I had managed the session perfectly. I had kept my boundaries. I had remained neutral. I had also completely failed to show up. I closed the file and I put it on the bottom of the stack. I knew I would not call her back for a second appointment. I told myself I was full. I told myself she needed a specialist. I told myself everything except the truth. The truth was that I had given up on her before she even walked through the door. I had already decided she was not worth the trouble. I had used her diagnosis to authorize my own apathy. I am a senior therapist with fifteen years of experience and I am still hiding behind a label.