This study explored how patients in TFP experience and make sense of receiving a PD diagnosis, with particular attention to how it shapes therapeutic engagement, self-understanding, and the therapeutic relationship. Overall, six themes were identified, capturing different ways in which patients understood and integrated the diagnosis into their therapeutic experience. In general, participants described diagnostic disclosure as a complex and emotionally charged experience, evoking reactions such as surprise, fear, relief, gratitude, and curiosity. Most reported an ambivalent relationship to the diagnosis, with its meaning evolving over time through therapeutic work and reflection. These findings suggest that receiving a diagnosis was rarely experienced as a one-time event, but rather as an ongoing process of meaning-making unfolding within therapy.

Since, within the TFP framework, diagnostic disclosure can be understood as a relational intervention that activates dominant object-relational dyads (Caligor et al., 2018; Felici et al., 2025), the quality of the transference relationship may shape how the diagnosis is experienced and integrated by the patient. Indeed, our findings indicate that the experience of diagnosis was fundamentally relational (Theme 3: The Relational Context of Diagnostic Disclosure). The way in which the diagnosis was communicated shaped how it was subsequently understood and integrated: when discussed within the therapeutic relationship, it was more often described as tolerable, meaningful, and integrated into an ongoing process of change, in contrast to diagnoses processed in isolation, such as through online searches. Nevertheless, for many participants, the initial diagnostic encounter disrupted self-narratives and created cognitive dissonance between long-held self-concepts and clinical categorization (Theme 1: The Diagnosis as Verdict). Rather than providing clarity, the diagnosis was experienced as an external verdict that intensified feelings of difference, activated stigma-related meanings, and temporarily undermined self-esteem. This pattern appeared across narratives of participants who reported different diagnoses (e.g., borderline and narcissistic personality disorder) and suggest that diagnostic disclosure may function not only as clinical information but also as a symbolic event that can reshape identity, sometimes in constraining ways. Two clinical factors may contribute to experience the diagnosis as threatening or destabilizing. First, patients at different levels of personality organization may respond differently, with more primitive defenses based on splitting and projection increasing the likelihood that the diagnosis is experienced as a threat, criticism, or external attack on the self (Clarkin et al., 2007). Second, the transference relationship may substantially influence this experience: patients with more paranoid or narcissistic features may be more likely to experience the diagnosis as a source of threat or shame, whereas those with more neurotic organization may respond in a less persecutory way. Future studies should examine whether the experience of diagnosis disclosure differs across specific PD presentations.

As therapy progressed, participants came to experience the diagnosis as more than a descriptive label, using it as a practical framework that helped translate diffuse distress into identifiable and workable therapeutic targets (Theme 2: Diagnosis as Frame of Reference) and as a reference point guiding efforts toward change (Theme 5: Diagnosis as Tool for Change). For many, naming their difficulties ultimately brought relief, greater self-understanding, and a sense of agency. However, some participants struggled to move beyond the diagnosis—becoming overly absorbed in diagnostic information or increasingly defining themselves through the lens of having a disorder. Rather than serving as a framework for understanding, the diagnosis became a fixed lens through which the self was perceived. From a TFP perspective, such reactions may reflect the activation of internal object relations and defensive patterns that organize the patient’s experience of the diagnosis within the transference (Caligor et al., 2009, 2018), such as perceiving oneself primarily as the victim of “bad” parental objects and earlier adverse relational experiences.

Although a diagnosis of PD may initially be experienced as stigmatizing, participants’ accounts suggest that stigma is not a fixed or inevitable outcome (Theme 4: Digital (Dis)information and Diagnostic Stigma). Our findings indicate that stigma may be mitigated when diagnostic information is communicated within a reflective therapeutic relationship and accompanied by collaborative discussion and psychoeducation. Studies drawing on lived experience perspectives showed that when clearly communicated contextualized within patient’s history and linked to meaningful treatment options, a PD diagnosis has been described as a turning point supporting insight, autonomy, and hope for recovery (Perkins et al., 2018; Tedesco et al., 2024). In contrast, participants’ narratives suggest potentially iatrogenic effects of seeking diagnostic information independently, particularly online, where oversimplified, decontextualized, or pathologizing portrayals of PDs may intensify self-stigmatization or diagnostic foreclosure (Monteith et al., 2024). Overall, our findings suggest that patients do not remain passive recipients of a PD diagnosis; rather, they actively engage with it, interpret its meaning, and integrate it into their evolving self-understanding (Theme 6: Living with the Diagnosis Over Time). The present study therefore shifts the focus from whether a diagnosis should be disclosed to how patients engage with diagnostic information—how they negotiate its meanings, resist or reinterpret stigmatizing aspects, and use the diagnosis as a resource for self-understanding and change within and beyond therapy.

Overall, our findings align with recommendations that patients with PDs should be actively involved in collaborative discussions about diagnosis and treatment, including psychoeducation tailored to the disorder (Keepers et al., 2024). Within Transference-Focused Psychotherapy, the explicit sharing and ongoing discussion of the diagnosis is strongly emphasized as a foundation for treatment planning, contracting, and therapeutic focus. At the same time, our results also resonate with concerns raised by individuals with lived experience, who have noted that the impact of diagnostic disclosure depends critically on the conditions in which it occurs and the meanings patients subsequently attribute to the label (Renneberg et al., 2024). Importantly, in psychodynamic treatment these processes unfold not only at an explicit, reflective level but also within the transference relationship, where the diagnosis may become embedded in ongoing relational patterns and unconscious meanings that shape how it is experienced and integrated over time.

While these six themes emerged independently, they may be seen as reflecting a temporal process: initially the diagnosis is experienced as a verdict—difficult to accept and disruptive, particularly when explored independently online; subsequently it becomes a framework enabling self-definition and motivating therapeutic engagement; and ultimately it may be transformed through reflection and meaning-making into an integrated experience. The therapeutic relationship appears as a central element throughout, functioning as a holding environment that allows various emotions to be experienced safely. Consistent with work on collaborative diagnosis (Hackmann et al., 2019), our findings suggest that patients attribute particular importance to the relational context as shaping whether the consequences of disclosure are experienced as supportive or harmful.

The present findings underscore that patients’ experiences of diagnosis are highly individual, dynamic, and subject to change over time. Diagnostic communication may be most helpful when approached as a collaborative process: in TFP, although the clinician holds responsibility for establishing the diagnosis, linking the diagnostic formulation to the patient’s personal history and the function of their symptoms may reduce shame and support reflective understanding, with strong emotions addressed through ongoing dialogue. Moreover, working with a diagnosis should be understood as an ongoing process, with clinicians revisiting its meaning and relevance over time.

Clinical attention should be paid to patients’ independent searches for diagnostic information online. It may be helpful to explicitly acknowledge that internet-based descriptions can be simplified or stigmatizing, and to support patients in maintaining a clinically grounded understanding of what the diagnosis means in the context of their own experience and therapeutic work. Therapists should actively explore what meaning the diagnosis holds for the patient, as pre-existing beliefs may be shaped not only by online information but by the broader socio-cultural environment. In many cultural contexts, narcissistic and borderline PDs carry particularly heavy stigma; when communicating such diagnoses, clinicians should emphasize the psychological suffering inherent in these conditions, framing them as sources of distress rather than character flaws. This approach helps ensure that the diagnosis strengthens rather than undermines the therapeutic alliance, fostering collaboration and hope instead of shame and resistance.

This study has several limitations. A key limitation concerns sampling. Participation was voluntary and based on self-selection, and for ethical reasons therapists informed only patients for whom participation would not be emotionally burdensome or disruptive to therapy. Moreover, in Poland, TFP is practiced mainly in private settings, so patients are typically functioning well enough to afford treatment. Most participants were highly educated and recruited in a large academic city, and may therefore have been more familiar with psychological concepts, more comfortable reflecting on their experiences, and more willing to participate in research. As a result, the sample likely overrepresents relatively well-functioning patients willing and able to articulate their experiences, while those with more negative or paranoid transference, greater distress, or more negative views of TFP may be underrepresented. The findings therefore do not capture the full range of possible responses to diagnosis disclosure in TFP.

Another limitation is that the material consisted solely of written responses. While this may have supported concise and reflective accounts, it did not allow probing, clarification, or exploration of emerging meanings as interviews would. Interview-based data might therefore have yielded more processual, affectively nuanced, and contextually elaborated findings, pointing to an important direction for future research. The study also relies exclusively on patients’ retrospective accounts of how the nosological diagnosis was discussed during TFP. We had no independent or objective information about the diagnostic communication itself; thus, the findings reflect patients’ subjective experiences and interpretations rather than verified descriptions of how the diagnosis was conveyed. Fourth, all members of the research team were trained within a psychodynamic framework. While this facilitated interpretive coherence, it may also have narrowed the analytic lens and limited engagement with alternative perspectives. The dual roles of researchers as clinicians and analysts enriched the analysis with clinical sensitivity but also risked projecting therapeutic assumptions onto the data; we sought to mitigate this through a continuous reflective stance throughout the analytic process.

Fifth, the analysis was conducted in Polish with findings reported in English. Although care was taken to preserve semantic integrity, subtle shifts in meaning cannot be ruled out. The use of Microsoft Excel as the main tool for coding ensured transparency but offered fewer functionalities than specialized qualitative software; however, this solution was adequate given the modest size of the dataset. Finally, the findings are situated in the Polish psychotherapeutic context, where practices of communicating nosological diagnoses have changed considerably over the past decade. This may limit transferability to settings where diagnostic practices differ. At the same time, it does not alter our central point: communicating diagnosis is a significant part of the therapeutic relationship and extends beyond therapy, becoming part of the patient’s lived reality and its ongoing transformations.