From a woman in the U..S.: I have some of the symptoms of ASPD. I was diagnosed with BPD. I haven’t told my therapist about my ASPD symptoms. I don’t know if they’ll even believe me. I have a tendency to lie. I lack empathy most times. I find myself manipulating others for my own personal gain. I have a gnawing yearning for attention and control. But BPD explains these. What it doesn’t explain is the obsession with blood, constant visions of harming others, a lack of remorse, and dreams of violently killing people I know and strangers. I need to know if this is even safe to tell my therapist.

Thank you for writing. Here’s the truth: If you don’t trust your therapist enough to tell her what is troubling you, your therapy will not be successful. The “safe” way to tell your therapist is to start with a discussion about your level of trust for the therapist and the therapeutic process. Trust does take time. It takes being honest. It takes venturing into areas that are anxiety provoking to see how the therapist handles them and then talking about any worries you have about what happened.

Over time, you and the therapist will build a relationship where you feel free to talk about your history and anything that is upsetting you. Your therapist will help you deal with your concerns. Most important, therapy will become a “laboratory” for discussing how trust issues impact other areas of your life. With support, you will be able to have more honest and richer relationships with other people in your life as well.

As far as your apparent symptoms of ASPD: A credible therapist will help you feel safe when you talk about things that might be shocking or upsetting to other people. An experienced therapist has heard such stories before and knows how to handle the subjects with respect and compassion. It’s the therapist’s job to help the two of you make an environment where sessions feel safe. If you can’t develop enough trust with your therapist to share such things, it may mean that you need another therapist.

On the other hand, (this is very important) since you also have a diagnosis of BPD, be careful about fleeing a therapist when things get difficult.

As you know, BPD is characterized by unstable relationships. Often people with that diagnosis can’t tolerate conflict so they find a way to minimize the importance of the relationship or to fault the other person to justify leaving. Often they form a harsh criticism of the other person while being blind to the  ways that they themselves may have damaged the relationship. The challenge is to both think about your own part in a conflict and to find ways to have a constructive conversation with the other. When that kind of conversation happens, relationships not only stay but also grow.

Staying in therapy when your relationship with the therapist is challenged may be one of the most important things you can do. An important part of your healing is to resist your instinct to write someone off or to leave and instead to talk it out. Working through conflict with the therapist can be a powerful and positive rehearsal for doing so with others.

I wish you well.
Dr. Marie