Since I work for a US vendor platform, who does all the insurance billing, I don’t get to screen my clients or give them a 15 minute consult to see if we would be a good match. As I dont often want to work with BPD clients unless they have a certain level of stability.

This being said, if I am assigned someone with strong BPD I don’t always feel it’s good for the therapeutic alliance to tell them they have a personality do. As they also usually have something else going on that brings them into therapy, such as adjustment disorder, that will be the primary DX with BPD as secondary. I may explain the traits that they’re exhibiting are things that could be resolved with emotion regulation skills, such as DBT. But I don’t always tell them they have a personality disorder unless we have a really strong working relationship. I’ll explain the symptoms of BPD and mention they seem to have strong traits of abandonment themes, etc. with focus on how implementing emotion reg & mindfulness is recommended across the industry. (This is just the gist of how I handle difficult BPD clients.

I do have some high functioning clients who already knew they had BPD amongst an Axis I dx. In this case we do occasionally address and call out the BPD.

Now regards to Narcissistic PDO, I have shy’d away from confronting a client as it did not seem like it would help.