Today's mystery: Blind spot as bright as the sun

 

Here I have “fun” trying to figure out how I’ve worked with this client for nine months, initially twice a week then consistently once-weekly, and missed diagnosing her now-obvious, stentorian, explicit, luminescent, egregious Borderline Personality Disorder. What brought it up? She diag­nosed herself from information on Facebook! Grandiose analogy: Imagine having the reputation, through your long career, as one of the pre­eminent piano virtuosi of the era, then suddenly one day becoming aware that through an origi­nal lapse of attention you had memorized a Beethoven concerto incorrectly, had been playing it with wrong notes, wrong phraseology and tempos for the last four dec­ades. A Twi­light-Zone-ish, Kafkaesque impossibility! A gaucherie beyond imagination! Such – at a commen­surately smaller scale – is what I am now feeling about this diag­nostic oversight: It is anti-stupendous!

Many of the symptoms and signs of BPD had been on display from the first minute: regres­sive imma­turity, several suicide attempts, enmeshment in conflictive dysfunctional relationships, hair-trigger angry sensitivity, no sense of meaning outside of work, alcohol and sex profligacy, and a baseline errant, “off” mood. And later, idealization then deval­u­ation. Strangely enough, three months earlier I had mentioned Borderline in a progress note in a detached referential way, and still didn’t land my damned head on it.

I am amused, surreally, by this neglect, partly as I realize that almost any first-year, nay, first-month counselor intern would have correctly guessed the client’s status.

There is no good answer. She intimidated me. So suicidal at the start. So full of toxic energy racing at top speed. And in months of sessions, so quickly and stably not-suici­dal, with brilliant bitter polemic about her mother’s abuses and absence of love, warm feelings about her work team. I think there was something peremptory about her per­sonality that masked her fragility. She accepted all my confrontations with at most mild alarm. Would a Borderline do that?

This shouldn’t have happened. There are quiet Borderlines, with subtle emptiness and brittleness as the main indicators. These I’ve been able to spot fairly soon. But this powerhouse? I need to know what kind of blind spot I have. If I don’t, I won’t see it next time.