Borderline personality disorder: Object relations perspective

Borderline personality disorder Object relation backs perspectiveThe term Borderline was coined by Stern in 1938 to describe a group of clients that exhibited primitive thinking and defense mechanisms, regressive transports, destructive styles, and acute countertransference reactions (Berzoff, Flanagan, Hertz, 2008 Gunderson, 1984). Today, Borderline Personality Disorder (BPD) is a well known and recognized diagnosing yet, it is still perceived to be a frustrating, perplexing, and complicated disorder for clients and clinicians to experience, understand, and cover up (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 primordial symptomatology associated with the diagnosis of BPD. One of the most prevalent characteristics of BPD is the presence of trigger-happy and un steadfast social 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 termination of a terrifying fear of abandonment and lack of endeavor 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 pull up stakes frequently oscillate between compliant and ego-importance-destructive behaviors in interpersonal relationships (Berzoff et al., 2008 Gunderson, 1984 Millon, 1992). Clients with BPD argon dependant on early(a)s to satisfy their needs of closeness and intimacy, and these individuals will very much exhibit contradict behavior in a desperate look for to pick up attention that ultimately takingss in the dissolution of relationships further perpetuating their fear of abandonment (Berzoff et al., 2008 Gunderson, 1984 Millon, 1992). Additionally, relationship boundaries atomic number 18 often perme equal to(p) and diff intent resulting in issues associated with engulfment or backdown (Berzoff et al., 2008 Gunderson, 1984 Millon, 1992). Individuals with BPD in any case frequently seek relationships with people that victimize or mistreat them, and reject hygienic partners and relationships (Berzoff et al., 2008 Gunderson, 1984 Millon, 1992).Clients with BPD be in like manner characterized by an un inactive and fragmented scent out of self (Berzoff et al., 2008 Gunderson, 1984 Millon, 1992). They frequently struggle with establishing a healthy guts of self-esteem, lack ambition, and experience difficulty in setting and attaining goals resulting in low achievement in various surveys of life (Berzoff et al., 2008 Gunderson, 1984 Millon, 1992). A number of self functions atomic number 18 in like manner impaired in individuals with BPD. Clients with BPD have difficulty regulating their affect and exhibit a range of intense and controvert emot ions including choler, 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 swelled head 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 ripping, 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 ar numerous theories regarding the etiology of BPD. However, this paper will focus on the significant contributions that purpose relation theorists William Fairbairn and Otto Kernberg have do regarding the etiology and trea tment of BPD.Theoretical Perspectives (Object Relations)Fairbairn Fairbairn made great contributions to understanding issues of dependence, 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). Fairbairns theory places an emphasis on attachment and ego organic evolution in accordance with object relations rather than traditional Freudian contract theory (Celani, 1993 Greenberg Mitchell, 1983). Fairbairn posits that personality disorders develop in early tikehood, and created a emergenceal model to explain how an infants interactions and relationships with objects in their early environment can influence dependency and future pathology (Celani, 1993 St. Clair, 2004).developmental ModelFairbairns model consists of three legs of development infantile dependence, transitional stage, and mature dependence (Celani, 1993 St. Clair, 2004). Of grumpy importance to t he development of BPD is the transitional stage, which is line up with Mahlers rapprochement stage, in which a kid struggles with the conflict of wanting to break open from the mother composition simultaneously desiring to remain connected to the mother (Celani, 1993 St. Clair, 2004). The transitional stage is critical in the developmental surgical operation as the mothers rejection of or qualification to connect with the child and satisfy their needs will ultimately determine the persona of the object relationship and aim 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 outlooks of the mother, opine 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 be futile 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 foreign desire to dumbfound connected to or dependent on the frustrating object (Celani, 1993 St. Clair, 2004).Dependency and AttachmentFairbairn described clients with BPD as suffering from severe splits in their ego resulting in a sense of omnipotence, a sense of detachment, and an unwarranted 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 hi s mother as a bad object but is dispiritedly 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 believelessly dependent on their mothers as both(prenominal) 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 akin f utile 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 DefenseOne of Fairbairns major contributions to the understanding of BPD was his proposal of the Moral Defense Against Bad Objects (Celani, 1993 Greenberg Mitchell, 1983). The virtuous defense is a childs 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 correct 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 a nd return to the exciting aspect of bad objects while rejecting the good and nurturing objects they desperately need (Celani, 1993 Greenberg Mitchell, 1983).Endopsychic StructureFairbairns endopsychic geomorphological theory provides an explanation for this paradoxical behavior by focusing on the central authority of the ego and the defense of splitting as a result of a childs 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 comp ints, 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 Gr eenberg 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 Freuds 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 wi th 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 disarticulate 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 systematically 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 individuals ability to experience and modulate a range of affects and control impulsivity (Clarkin et al., 2006 St. Clair, 2004). Let us now examine Kernbergs concepts and theories associated with the etiology of BPD more closely.Object Relation UnitsAccording to Kernberg, obje cts 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 defeat (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 broadly associated with pleasurable or frustrating interactions, such as when a mother satisfies or fails to satisfy a childs 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 individuals 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 importantly 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 InternalizationAccording 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 childs 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 relation ships which are activated to varying degrees in future relationships (Clarkin et al., 2006 St. Clair, 2004).Developmental ModelKernberg also proposed a developmental model of psychic structure formation that coincides with the internalization process (St. Clair, 2004). Kernbergs 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 Mahlers separation-individuation/rapprochement stages (St. Clair, 2004). The third stage of development occurs when a child is one and a half(a) to three years of age, and constitutes a childs 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 childs ability to view self and obje ct 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 DefensesKernberg 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 int ense 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 da ngerous 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 dis dictated 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 doctrine 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, 19 93).NeurobiologyMuch of the literature and research on the neurobiological etiology of BPD emphasizes the affiliation between abuse, damage, 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 worldly 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 inwardly the limbic system tha t 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 twist 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 f rightening 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) deals 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 re sult 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 individuals 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).DiversitySociocultural 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). each culture has a unique way of interpreting and goaling 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 ripening 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 failureinadequacy, 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).T he 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 enigmatical 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 confuse (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 dissocia tion, 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, interior(prenominal) 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 socia l 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).TreatmentFairbairn Fairbairns 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,