Borderline personality disorder: Object relations perspective

The term Borderline was coined by Stern in 1938 to describe a group of clients that exhibited primitive thinking and defense mechanisms, regressive transferences, destructive behaviors, and intense countertransference reactions (Berzoff, Flanagan, Hertz, 2008; Gunderson, 1984). Today, Borderline Personality Disorder (BPD) is a well known and recognized diagnosis; yet, it is still perceived to be a frustrating, perplexing, and complicated disorder for clients and clinicians to experience, understand, and treat (Berzoff et al., 2008; Gunderson, 1984). Clients with BPD can present with a number of different characteristics and symptoms. However, clinicians and theorists have identified key symptomatology associated with the diagnosis of BPD. One of the most prevalent characteristics of BPD is the presence of intense and unstable interpersonal relationships (Berzoff et al., 2008; Gunderson, 1984; Millon, 1992). In this realm, individuals with BPD struggle to develop and maintain close and intimate interpersonal relationships as a result of a terrifying fear of abandonment and lack of object constancy (Berzoff et al., 2008; Gunderson, 1984; Millon, 1992). Clients with BPD frequently experience ambivalence in relationships with a desire for attachment coupled with a simultaneous need for distance, and will frequently oscillate between compliant and self-destructive behaviors in interpersonal relationships (Berzoff et al., 2008; Gunderson, 1984; Millon, 1992). Clients with BPD are dependent on others to satisfy their needs of closeness and intimacy, and these individuals will often exhibit negative behavior in a desperate attempt to garner attention that ultimately results in the dissolution of relationships further perpetuating their fear of abandonment (Berzoff et al., 2008; Gunderson, 1984; Millon, 1992). Additionally, relationship boundaries are often permeable and diffuse resulting in issues associated with engulfment or detachment (Berzoff et al., 2008; Gunderson, 1984; Millon, 1992). Individuals with BPD also frequently seek relationships with people that victimize or mistreat them, and reject healthy partners and relationships (Berzoff et al., 2008; Gunderson, 1984; Millon, 1992).

Clients with BPD are also characterized by an unstable and fragmented sense of self (Berzoff et al., 2008; Gunderson, 1984; Millon, 1992). They frequently struggle with establishing a healthy sense of self-esteem, lack ambition, and experience difficulty in setting and attaining goals resulting in low achievement in various aspects of life (Berzoff et al., 2008; Gunderson, 1984; Millon, 1992). A number of ego functions are also impaired in individuals with BPD. Clients with BPD have difficulty regulating their affect and exhibit a range of intense and negative emotions including anger, hate, and bitterness (Berzoff et al., 2008; Gunderson, 1984; Millon, 1992). Individuals with BPD also tend to lack impulse control resulting in unpredictable, self-destructive, and ego dystonic behaviors including self-mutilation, sexual promiscuity, and substance abuse (Berzoff et al., 2008; Gunderson, 1984; Millon, 1992). Clients with BPD also utilize a number of primitive defenses including “splitting, projection, projective identification, denial, primitive idealization, and devaluation” (Berzoff et al., 2008, p. 331). Lastly, individuals with BPD may occasionally suffer from psychotic episodes and dissociative experiences despite a relatively stable sense of reality testing (Berzoff et al., 2008; Gunderson, 1984; Millon, 1992).

There are numerous theories regarding the etiology of BPD. However, this paper will focus on the significant contributions that object relation theorists William Fairbairn and Otto Kernberg have made regarding the etiology and treatment of BPD.

Theoretical Perspectives (Object Relations)

Fairbairn: Fairbairn made great contributions to understanding issues of dependency, the use of splitting, and the inexplicable desire to continuously seek out and attach to frustrating and rejecting objects commonly seen in clients with BPD (Celani, 1993). Fairbairn’s theory places an emphasis on attachment and ego development in accordance with object relations rather than traditional Freudian drive theory (Celani, 1993; Greenberg & Mitchell, 1983). Fairbairn posits that personality disorders develop in early childhood, and created a developmental model to explain how an infant’s interactions and relationships with objects in their early environment can influence dependency and future pathology (Celani, 1993; St. Clair, 2004).

Developmental Model

Fairbairn’s model consists of three stages of development: infantile dependence, transitional stage, and mature dependence (Celani, 1993; St. Clair, 2004). Of particular importance to the development of BPD is the transitional stage, which is aligned with Mahler’s rapprochement stage, in which a child struggles with the conflict of wanting to separate from the mother while simultaneously desiring to remain connected to the mother (Celani, 1993; St. Clair, 2004). The transitional stage is critical in the developmental process as the mother’s rejection of or ability to connect with the child and satisfy their needs will ultimately determine the quality of the object relationship and level of dependency a child has on the mother (Celani, 1993; St. Clair, 2004). Successful completion of this stage results in the ability of a child to integrate positive and negative aspects of the mother, view the mother as a whole rather than partial object that is separate from the child, and develop a healthy object relationship with the mother (Celani, 1993; St. Clair, 2004). Clients with BPD are unable to successfully complete this stage of development due to an inability to differentiate from the maternal object resulting in increased dependency (Celani, 1993; St. Clair, 2004). This pathology is later replayed in adult relationships when clients with BPD exhibit a desire to separate from a frustrating object coupled with a conflicting desire to stay connected to or dependent on the frustrating object (Celani, 1993; St. Clair, 2004).

Dependency and Attachment

Fairbairn described clients with BPD as suffering from severe splits in their ego resulting in “a sense of omnipotence, a sense of detachment, and an excessive focus on the inner world” (Celani, 1993, p. 6). Fairbairn believed that these personality deficits were a direct result of an unnurturing environment that forced a deprived and frustrated infant to split the mother into part objects in order to preserve the need satisfying aspect of the mother (Celani, 1993; Greenberg & Mitchell, 1983). According to Fairbairn, over time the rejected and frustrated child comes to view his mother as a bad object but is hopelessly attached to and dependent on her (Celani, 1993; Greenberg & Mitchell, 1983). Fairbairn developed the concept of “stubborn attachment” to explain why rejected children become increasingly attached to the frustrating object (Celani, 1993; Greenberg & Mitchell, 1983). According to Fairbairn, rejected children come to understand that their mothers do not love and value them resulting in feelings of deprivation and inferiority that lead children to become fixated and hopelessly dependent on their mothers as both frustrating and exciting bad objects (Celani, 1993; Greenberg & Mitchell, 1983). In essence, Fairbairn asserts that the more neglectful and depriving a mother is, the more a child will cling to the mother in an attempt to win her love and affection (Celani, 1993; Greenberg & Mitchell, 1983). This behavior is seen in clients with BPD who repeatedly attach to rejecting and frustrating bad objects continuously replaying the same futile attempt to win the love and nurturance they were deprived of in childhood (Celani, 1993; Greenberg & Mitchell, 1983). Fairbairn asserts that the lack of a nurturing and loving environment results in reactive hate in which the child feels they are innately bad and reflect this belief onto future relationships (Celani, 1993; Greenberg & Mitchell, 1983). This is evident in the behavior of clients with BPD who often respond to interactions with objects in their environment with anger and hostility reflecting their own internal feelings of badness (Celani, 1993; Greenberg & Mitchell, 1983). The paradox of this behavior is that individuals with BPD are desperately seeking a loving and nurturing relationship, but their hostile and destructive behavior often results in further abandonment and abuse (Celani, 1993; Greenberg & Mitchell, 1983).

The Moral Defense

One of Fairbairn’s major contributions to the understanding of BPD was his proposal of the “Moral Defense Against Bad Objects” (Celani, 1993; Greenberg & Mitchell, 1983). The moral defense is a child’s ego defense against the dilemma of being attached to and dependent on a frustrating object (Celani, 1993; Greenberg & Mitchell, 1983). This ego defense allows children to stay attached to a frustrating or rejecting object by repressing memories of abuse or abandonment and the rage associated with those memories, and developing a view that the child himself is the bad object and responsible for and deserving of the behavior of the parent (Celani, 1993; Greenberg & Mitchell, 1983). In essence, the child internalizes and represses the negative aspects of the frustrating object allowing the child to view the parent as a good rather than bad object (Celani, 1993; Greenberg & Mitchell, 1983). Unfortunately, the moral defense results in a child learning to introject bad objects and reject good objects which ultimately influences the development of BPD (Celani, 1993; Greenberg & Mitchell, 1983). Borderline adults continuously seek and return to the exciting aspect of bad objects while rejecting the good and nurturing objects they desperately need (Celani, 1993; Greenberg & Mitchell, 1983).

Endopsychic Structure

Fairbairn’s endopsychic structural theory provides an explanation for this paradoxical behavior by focusing on the central role of the ego and the defense of splitting as a result of a child’s inability to mask object failures (Celani, 1993; Greenberg & Mitchell, 1983; St. Clair, 2004). Fairbairn asserts that children must split off the negative aspects of the bad object and focus on the exciting aspects of the bad object in order to survive abuse and deprivation (Celani, 1993; Greenberg & Mitchell, 1983; St. Clair, 2004). Fairbairn postulates that the endopsychic structure is composed of a central ego and two subegos: the libidinal and antilibidinal egos (Celani, 1993; Greenberg & Mitchell, 1983; St. Clair, 2004). Each aspect of the ego associates with a different part of an object (Celani, 1993; Greenberg & Mitchell, 1983; St. Clair, 2004). The antilibidinal ego is home to the rejecting aspect of the bad object, and the libidinal ego houses the exciting aspect of the bad object which promotes hope for future gratification (Celani, 1993; Greenberg & Mitchell, 1983; St. Clair, 2004). In the normal developmental process, the central ego connects with a good or ideal object and grows in response to a nurturing environment that contributes to stable ego functioning and a healthy sense of self (Celani, 1993; Greenberg & Mitchell, 1983; St. Clair, 2004). In a frustrating or rejecting environment a child internalizes the bad object, splits the object internally to reflect the satisfying and unsatisfying components, places these aspects respectively into the libidinal and antilibidinal egos, and aggressively represses these aspects of the ego (Celani, 1993; Greenberg & Mitchell, 1983; St. Clair, 2004). This ego split allows the child to view a bad object as both frustrating and exciting (Celani, 1993; Greenberg & Mitchell, 1983; St. Clair, 2004). The libidinal and antilibidinal egos dominate the world of an individual with BPD, and are constantly in conflict with one another (Celani, 1993; Greenberg & Mitchell, 1983; St. Clair, 2004). This internal conflict explains the sudden shifts in mood that clients with BPD often experience as well as the continuous return to the exciting aspect of the bad object in interpersonal relationships (Celani, 1993; Greenberg & Mitchell, 1983; St. Clair, 2004).

Kernberg: Kernberg created a theory underlying the development of BPD that integrates object relations theory with aspects of Freud’s drive theory (Clarkin, Yeomans, Kernberg, 2006; St. Clair, 2004). Kernberg asserts that the mind consists of psychological structures (ego, superego, and id) that are formed by internalized object relationships in early development, particularly that of the relationship with the mother (Clarkin et al., 2006; St. Clair, 2004). This primary object relationship is correlated with the drives of libido and aggression, and lays the foundation for ego development and the establishment of a stable, integrated, and cohesive sense of self and objects in the environment (Clarkin et al., 2006; St. Clair, 2004). Kernberg emphasizes the important role affect plays in object relationships, and asserts that affects result from both biological and environmental influences (Clarkin et al., 2006; St. Clair, 2004). According to Kernberg, BPD pathology results from innate or genetic pregenital aggression and/or frustrating object relationship experiences in the developmental process (Clarkin et al., 2006; St. Clair, 2004). Kernberg asserts that these feelings of intense aggression inhibit a child from integrating positive and negative self and object representations, and results in the use of primitive defense mechanisms to protect and dissociate the positive image of the self and the object from aggressive feelings associated with negative self and object representations (Clarkin et al., 2006; St. Clair, 2004). In essence, primitive defenses are used to separate contradictory views of the self and object in an attempt to resolve feelings of intense anxiety associated with intrapsychic conflict (Clarkin et al., 2006; St. Clair, 2004). Kernberg also draws a correlation between attachment, affect, and the development of BPD by asserting that children with consistently frustrating and distressing self and object experiences in early development have increased negative affect or aggression which contributes to intrapsychic conflict (Clarkin et al., 2006; St. Clair, 2004). Kernberg also asserts that early failures in attachment contribute to the development of BPD by decreasing an individual’s ability to experience and modulate a range of affects and control impulsivity (Clarkin et al., 2006; St. Clair, 2004). Let us now examine Kernberg’s concepts and theories associated with the etiology of BPD more closely.

Object Relation Units

According to Kernberg, objects are internalized as units which include an image or representation of the self, an image or representation of the object, and an affect associated with a drive (libido or aggression) that connects the internalized images of object and self (Clarkin et al., 2006; St. Clair, 2004). In short, an individual internalizes an object relation unit which represents aspects of the self and other that are connected by an affect of pleasure or frustration (Clarkin et al., 2006; St. Clair, 2004). Kernberg referred to these internalized units as object relation dyads that correspond to specific moments of interaction with objects in early development (Clarkin et al., 2006; St. Clair, 2004). Kernberg asserts that infants experience and internalize multiple object relation dyads with varying levels of affective intensity throughout the developmental process (Clarkin et al., 2006; St. Clair, 2004). Experiences associated with high affect intensity are generally associated with pleasurable or frustrating interactions, such as when a mother satisfies or fails to satisfy a child’s needs (Clarkin et al., 2006; St. Clair, 2004). Kernberg posits that these high affective experiences are internalized and become part of “affect-laden memory structures in the developing psyche” (Clarkin et al., 2006, p. 5). Kernberg asserts that an abundance of intense frustrating or negative affective experiences interferes with the development of a stable ego and sense of identity by inhibiting an individual’s ability to integrate these experiences in later development (Clarkin et al., 2006; St. Clair, 2004). Thus, the interactions a child has with early object relation dyads significantly affects the development of their personality structure, sense of self, and views of others in their environment, and can lead to BPD pathology in adulthood (Clarkin et al., 2006; St. Clair, 2004).

The Process of Internalization

According to Kernberg, an infant progressively internalizes object relation units in early development, which provides the foundation for psychic structures, through the process of introjection, identification, and ego identity (Clarkin et al., 2006; St. Clair, 2004). Introjection is the earliest and first stage of internalization where self and object images are fused and associated with intense and primitive affects (Clarkin et al., 2006; St. Clair, 2004). If infants are inundated with feelings of frustration and aggression during this stage of internalization it will result in the development of negative self and object representations which adversely affects ego and personality structure development (Clarkin et al., 2006; St. Clair, 2004). Splitting is generally used adaptively in the introjection process to help a child separate positive and negative self and object representations; however, the continued use of splitting in the internalization process can lead to BPD pathology (Clarkin et al., 2006; St. Clair, 2004). Identification is the next level of internalization and encompasses a child learning social roles through interaction with objects in their environment (Clarkin et al., 2006; St. Clair, 2004). These object relationship interactions are also connected by libidinal or aggressive affective states that influence a child’s interpretation of social roles (Clarkin et al., 2006; St. Clair, 2004). The last step of internalization contributes to the development of a healthy and stable ego that is able to differentiate and organize self and object representations and affects in a coherent manner that supports identity development (Clarkin et al., 2006; St. Clair, 2004). According to Kernberg, individuals with BPD are able to complete the process of differentiating between images of self and object, but are unable to effectively integrate libidinal and aggressive self and object representations as a result of pregenital aggression (Clarkin et al., 2006; St. Clair, 2004). Thus, children internalize both positive and negative aspects of early self and object relationships which are activated to varying degrees in future relationships (Clarkin et al., 2006; St. Clair, 2004).

Developmental Model

Kernberg also proposed a developmental model of psychic structure formation that coincides with the internalization process (St. Clair, 2004). Kernberg’s developmental theory consists of five sequential stages (St. Clair, 2004). Of particular importance to the development of BPD are the third and fourth stages which align with Mahler’s separation-individuation/rapprochement stages (St. Clair, 2004). The third stage of development occurs when a child is one and a half to three years of age, and constitutes a child’s ability to differentiate between positive and negative self and object representations, and the use of splitting to protect positive self and object representations from negative object relation units (St. Clair, 2004). The fourth stage of development occurs between the ages of three to six and is defined by a child’s ability to view self and object representations as whole, and to integrate good and bad aspects of the object relation dyads and their associated affects into a realistic view of self and object (St. Clair, 2004). Clients with BPD are generally fixated in these stages of development resulting in an inability to integrate good and bad self and object representations, a primitive use of splitting, a weak and dissociated ego, a lack of object constancy, and the development of a diffuse and unstable identity (St. Clair, 2004). Kernberg believes that the inability to integrate positive and negative object relation units results from overwhelming feelings of frustration and aggression as a result of negative self and object experiences in early development (St. Clair, 2004).

Primitive Defenses

Kernberg asserts that much of the pathology associated with BPD results from the rigid and excessive use of primitive defense mechanisms to protect and separate the ego and imbued positive self and object representations from intense aggression associated with negative object relation units (Clarkin et al., 2006; Clarkin & Kernberg, 1993). Although many of these defenses are used adaptively in early development, the continued use of such defenses in adulthood as a result of an inability to integrate positive and negative object relation units frequently contributes to the development of BPD (Clarkin et al., 2006; Clarkin & Kernberg, 1993). Splitting is the primary defense used by clients with BPD, and involves separating good and bad object relation units in an attempt to avoid intrapsychic conflict (Clarkin et al., 2006; Clarkin & Kernberg, 1993). Splitting is frequently used in conjunction with idealization and devaluation in clients with BPD (Clarkin et al., 2006; Clarkin & Kernberg, 1993). Idealization complicates the process of splitting by imbuing either the self or external objects with faulty or unrealistic qualities of power and omnipotence (Clarkin et al., 2006; Clarkin & Kernberg, 1993). Idealization is dangerous for clients with BPD because it creates further contradictory experiences for the client when the self or object is unable to fulfill the unrealistic expectations; this phenomenon generally results in an abrupt shift to devaluation or degradation of the self or the previously idealized object (Clarkin et al., 2006; Clarkin & Kernberg, 1993). The process of splitting and the concomitant use of idealization and devaluation also make the therapeutic experience difficult and emotionally draining as a result of intense transference and countertransference issues (Clarkin et al., 2006; Clarkin & Kernberg, 1993).

Clients with BPD also frequently rely on the defenses of projection and projective identification in an attempt to rid themselves of feelings of intense aggression (Clarkin et al., 2006; Clarkin & Kernberg, 1993). Projection occurs when an individual places their own negative feelings onto someone else and views these displaced feelings as emanating from that person as opposed to themselves (Clarkin et al., 2006; Clarkin & Kernberg, 1993). Projective identification takes this process one step further and results in an individual depositing negative feelings into another while simultaneously eliciting those feelings out of that person (Clarkin et al., 2006; Clarkin & Kernberg, 1993). Unfortunately, the use of projection and projective identification often results in a desire to control the person that carries the projected feelings or the development of fear associated with the projectively identified object (Clarkin et al., 2006; Clarkin & Kernberg, 1993). Lastly, the defense of denial allows individuals with BPD to negate and separate past feelings of aggression and frustration from their present emotional state (Clarkin et al., 2006; Clarkin & Kernberg, 1993). Consistent reliance on these defense mechanisms in adulthood leads to significant difficulties in the realm of interpersonal relationships for clients with BPD (Clarkin et al., 2006; Clarkin & Kernberg, 1993).

Neurobiology

Much of the literature and research on the neurobiological etiology of BPD emphasizes the connection between abuse, trauma, and attachment in early childhood (Applegate & Shapiro, 2005; Cozolino, 2010; Teicher, Ito, Glod, Schiffer, Gelbard, 1994). Studies have indicated that nearly 81% of clients diagnosed with BPD have suffered some form of abuse or trauma in their childhood (Teicher et al., 1994). The presence of trauma and/or abuse in early development frequently results in the dysfunction of the limbic system, cortical region, and frontal and temporal lobes of the brain (Cozolino, 2010; Teicher, 1994). The limbic system develops in early infancy and is considered to be the social and emotional aspect of the brain which includes the orbitofrontal cortex, anterior cingulate, amygdala, and the hippocampus (Applegate & Shapiro, 2005; Cozolino, 2010; Teicher et al., 1994). Abuse and trauma often have deleterious affects on neural regulation within the limbic system that adversely affects emotional and behavioral aspects of personality development (Teicher et al., 1994). For example, an excessive release of norepinephrine in response to stress can impair the hippocampal memory networks resulting in the formation of dissociative symptoms commonly seen in clients with BPD (Teicher et al., 1994). Additionally, trauma often increases kindling, or the repeated stimulation of neurons resulting in increased excitability, in the limbic system which can adversely affect behavioral inhibitions (Teicher et al., 1994). Limbic kindling is associated with the expression of inappropriate and excessive aggression and/or sexual promiscuity frequently seen in clients with BPD (Teicher et al., 1994). The lack of integration between the right and left hemispheres of the brain is also thought to contribute to the formation of intrapsychic conflict and splitting associated with BPD (Teicher et al., 1994).

Cozolino postulates that BPD results from negative, frustrating, or frightening interactions with early caregivers resulting in an inability to regulate affect and integrate experiences as a result of insecure attachment (Applegate & Shapiro, 2005; Cozolino, 2010). From a neurobiological perspective, insecure attachment occurs when an infant is exposed to negative interactions with the primary caregiver which increases the production of cortisol in the brain and induces feelings of fear and danger within the amygdala; this affective response is then processed by the orbitofrontal cortex and stored as implicit memory in the right hemisphere of the brain (Applegate & Shapiro, 2005; Cozolino, 2010). Cozolino (2010) argues that the characteristic fear of abandonment and aggression associated with BPD stems from implicit memories of real or perceived abuse, abandonment, and frustration in early development. Cozolino (2010) also asserts that frequent and abrupt shifts in mood and the oscillation between positive and negative views of the self and objects may result from dissociation within the orbitofrontal cortex impairing the brains ability to adequately process information (i.e.: right-left/top-down). Cozolino (2010) further argues that increased levels of cortisol in the brain may impair hippocampal and amygdala functioning resulting in the experience of intense affective states and a reduction in an individual’s ability to appropriately modulate affect. Lastly, Cozolino (2010) argues that insecure attachment can result in a reduction in the level of serotonin in the brain increasing the risk of “depression, irritability, and decreased positive reinforcement from interpersonal interactions” (p. 283).

Diversity

Sociocultural factors play an integral role in the process of personality development (Miller, 1996; Millon, 2000). From a young age, children are influenced and guided by cultural values, traditions, norms, and expectations that contribute to how they view themselves and the world around them (Miller, 1996; Millon, 2000). Every culture has a unique way of interpreting and addressing issues of anxiety, distress, depression, and emotional upheaval (Miller, 1996; Millon, 2000). Some cultures value these symptoms and view them as a natural means of growth and development, while others perceive the presence of these symptoms as pathology (Miller, 1996; Millon, 2000). Paris contends that many traditional cultures provide protective factors that inhibit the development of BPD and other personality disorders, while others argue that individuals from virtually all cultures suffer from symptoms similar to BPD due to a “perceived sense of social failure…inadequacy, marginality, and powerlessness” (Miller, 1996, p. 194). However, each culture differs in how they view, express, and treat these symptoms; thus, it is imperative that clinicians consider the influence of sociocultural factors on personality development and/or pathology in order to accurately diagnose and treat clients (Berzoff et al., 2008; Miller, 1996; Millon, 2000).

The prevalence of BPD and other personality disorders in American culture provides a unique understanding of how sociocultural factors influence personality development (Miller, 1996; Millon, 2000). Millon (2000) argues that American culture is filled with ambiguous and contradictory values, beliefs, and expectations that contribute to identity diffusion and interpersonal conflicts. American culture also places a strong emphasis on achievement and encourages competition in various aspects of life placing intense pressure on individuals to continuously strive for excellence while inadvertently setting the stage for failure and feelings of guilt and shame (Millon, 2000). The presence of conflicting demands and expectations, an emphasis on competition and success, and harsh sociocultural conditions such as poverty, prejudice, and racism in American culture complicate the process of personality development and perpetuate symptomatology commonly associated with BPD including dissociation, intrapsychic conflict, and a fragmented identity (Miller, 1996; Millon, 2000).

There is also debate surrounding issues of gender bias in the assessment and diagnosis of personality disorders (Becker, 1997; Berzoff et al., 2008; Widiger, 2000). Many scholars argue that the Diagnostic Statistical Manual (DSM) defines and describes personality disorders in a way that is biased toward traditional male or female characteristics (Becker, 1997; Berzoff et al., 2008; Widiger, 2000). As a result, personality disorders that are associated with dramatic emotional responses, dependency, and masochist qualities such as Histrionic and Borderline are often over diagnosed in women (Becker, 1997; Berzoff et al., 2008; Widiger, 2000). Scholars argue that this bias pathologizes female traits without consideration of the impact that societal, familial, and cultural pressures and external influences have on these behaviors (Becker, 1997; Berzoff et al., 2008; Widiger, 2000). Women are generally socialized to be more in touch with and expressive of their emotions, compliant or submissive to others needs, and dependent or reliant on others to varying degrees (Becker, 1997; Berzoff et al., 2008; Widiger, 2000). Yet, these very characteristics can be viewed pathologically when they are incorrectly or incongruently expressed in accordance with social and cultural norms and expectations (Becker, 1997; Berzoff et al., 2008). Additionally, the DSM criteria fails to account for the relevance of the psychological distress that many women experience associated with trauma, sexual abuse, domestic violence, and oppression which results in women being frequently misdiagnosed with BPD as opposed to post traumatic stress disorder (Becker, 1997; Berzoff et al., 2008). It is important for clinicians to be aware of gender biases within the DSM, as well as personal gender biases, when assessing pathology in a client, and to ensure that a diagnosis accompanies adequate consideration of the social and cultural norms placed on women as well as the influence trauma, victimization, and oppression have on personality development and pathology (Becker, 1997; Berzoff et al., 2008; Widiger, 2000).

Treatment

Fairbairn: Fairbairn’s treatment model was designed to address the needs of what he termed “dependent borderlines” who express an obstinate attachment to frustrating-exciting objects within their environment that perpetuate ego splits and intrapsychic conflict (Celani,