Nadelson, C. C., & Notman, M. T. (1977). Psychotherapy supervision: The problem of conflicting values. American Journal of Psychotherapy, 31, 275-283. 42.
Cultural Intersections in the Psychotherapy of Borderline Personality Disorder
Nothing in the present state of knowledge leads one to think that this situation will end any time soon. It can be said with certainty, however, that BPD is also a type of cultural phenomenon. Although it originated in Europe (where it was mostly one of several labels ascribed to atypical psychoses),5 it was in the United States where serious efforts at the systematic description and characterization of the disorder were made.3,6-8As a result, when DSM-I11 first officially sanctioned this category,many psychiatrists abroad considered it an "Arnerican di~ease."~ The diagnostic criteria outlined for BPD reflected a number of characteristics well attached to the postmodern elements of social life embodied by the United States. Issues of instability, identity, or impulsivity were many times used by social scientists, particularly anthropologists, to describe collective happenings during the 1960s and 1970s. In the 80s and 90s, some of the same topics plus others, such as chronic emptiness, intense anger, issues of control and power, and real paranoia, populated the social stage of America. BPD was indeed an excellent example of the many interactions between culture and psychopathology, as outlined by recent studies.lo,'' The controversy around the diagnosis of BPD has not ceased. The increasing popularity of the term has brought forth the possibility of using it as a psychiatric "wastebasket," and has reinforced chances of calling a diagnostically confusing patient "borderline," by default.12Furthermore, as Reiser and Levenson point out,13the diagnosis of BPD may depend on the clinician's theoretical orientation and can often be misused or abused. The following example illustrates some of the ways in which the latter may occur: VIGNETTE 1 A third-year psychiatry resident was conducting therapy with a woman diagnosed as BPD. The presenting problems included rapid mood swings, occasional psychotic symptoms, a disruptive early family life with evidence of emotional abuse, hypersexuality manifesting itself in multiple sexual partners, and ongoing rage. The rage was palpable in the weekly therapy sessions, and the resident described how she could barely stand to be in the same room with the patient. In addition, the patient would bombard the resident with overtly sexual material, which was seen as a resistance to working on the very real issues of daily life. The resident discussed with her supervisor how she wished the patient would go away, and how she was coming to hate the patient and their weekly meetings. As time went on, the resident began to daydream during the sessions and missed some important
Cultural Intersections in the Psychotherapy of Borderline Personality Disorder medical training, such as "The appendix in bed 23." We submit that these attitudes are influenced by an alarming dehumanization of care, and an emphasis on reductionistic views about personality disorders in general, and BPD in particular. Needless to say, this type of interaction can set the stage for frustration and helplessness on the part of the psychotherapist, and create more negative, despairing experiences for the borderline patient. Much has been made of the unique set of difficulties in therapeutic work with borderline patients. Our intention is not to conduct an exhaustive clinical review, but to identify salient challenges for the therapist and highlight the social and cultural aspects of the conceptual and practical intersections between culture and the psychotherapy of this disorder. CULTURE AND PSYCHOPATHOLOGY There are at least five well-defined areas in which culture and psychopathology interact very c l o ~ e lAlthough ~ . ~ ~ ~ for~the ~ purposes of this paper, the therapeutic/protective role of culture in BPD will be highlighted, the other four are equally important. For instance, culture can be an interpretive/ explanatory tool of behaviors that otherwise could be mislabeled as pathological. In this context, the external circumstances of current life in urban areas generate a set of behaviors that often mimic the features of BPD. The recognition of such factors and the transiency of the behaviors attached to them should be duly considered in assessing young adults, particularly women, facing social exigencies and expectations that have multiplied in recent decade^.^^,^^ In these cases, issues of unresolved intrapsychic conflicts give rise to mood swings, impulsiveness, instability, ambiguity, unpredictability, intense anger and displays of temper that can be confused with BPD. Suicide-like behavior, such as wrist slashing, may be part of culturally determined rituals of bonding among Native Americans, Asian Americans, and Middle East person^.^',^^ The passivity of some individuals in some of these groups can be misperceived as a pessimistic outlook. Depersonalization, trancelike, and psychosis-like episodes are also well-known culturally determined events in the lives of people from many non-Western societies. Often fueled by deeply rooted religious traditions, these traits are exacerbated under the impact of a c c ~ l t u r a t i o n . An ~~,~~ interesting observation is that among Chinese people overt mourning is encouraged in spite of traditional discouragement from displaying strong feelings in public. This enhances the acceptance of loss through diminishing grief and resentment, and tends to ward off the development of pathological grief.2G28The temptation to see in this the shallow emotional exaggerations of BPD may be quite significant for the Western observer.
Cultural Intersections in the Psychotherapy of Borderline Personality Disorder Unfolding of the Psychotherapeutic Process
Once therapy starts, the psychotherapist needs to create a stable treatment framework for the patient in order to address issues, such as the boundaries of the treatment, and make decisions in reference to the flexibility of limit-setting. Once again, the patient's cultural background plays a critical role in these areas, and the therapist must be aware of the weight of such influences (culturally determined childrearing practices, for instance) in order to assure the effectiveness of his/her intervention. As the principles of psychodynamic psychotherapy have become truly embedded in contemporary Western culture, the use and identification of defense mechanisms, and the interpretation of current behaviors on the basis of unconsciously repressed experiences could face significant difficulties. For instance, the maintenance of a stable framework, as emphasized by Waldinger, to decrease transference distortions, increase direct communications and control impulsive behaviors with the borderline,3' may be arbitrarily deemed "irrelevant" because they are already assumed components of the surrounding cultural milieu. Similarly, establishing a soothingholding introject to better tolerate separations from significant figures12~'8 responds as much to cultural conditioning as it does to unconscious repressions. The therapist must conduct a continuous dissecting work in order to ascertain the true origin of these clinical events and manage them accordingly. The above applies also to the fostering of a therapeutic alliance. It is known that patients closer to the psychotic border will need a more supportive emphasis, and those with greater ego functions and psychological mindedness would benefit more from an expressive approach. Taking into account the cultural conditioning of the patient's attitudes, as perceived in psychotherapy, would help in this transition, encouraging a more open dialogue, and even preventing further clinical crises. The Issue of Boundaries
Defining the appropriate role for each of the participants in therapy is wrapped up with avoiding pitfalls in role violation. This is made more difficult in that what might be appropriate in one situation (nonintervention in the outside life of the patient) is inappropriate in others (the need to
write a letter to a patient's employer concerning side effects of medications that could interfere with job performance). Time boundaries provide structure and containment for session^.'^ Handling phone calls between psychotherapy sessions with a borderline patient brings up possibilities for time boundary violations. Decisions about these issues must be based on a 181
Cultural Intersections in the Psychotherapy of Borderline Personality Disorder
immoral b e h a ~ i o r .This ~ ~ ?is~one ~ more "eye of the needle" through which the therapist must thread. Defense Mechanisms
The defenses of splitting and projective identification must be understood by the therapist and managed in an empathetic fashion. One often hears nurses and therapists refer to a specific patient as a "splitter," as if the patient were a hardened crimina143!As Adler describes the phenomenon of positive aspects of the patient's psychological makeup are separated from the negative ones, and each of these is projected onto different people. On a psychiatric unit, different staff members may be recipients of different split parts from the patient. The staff d naturally tend to act toward the BPD patient as toward other patients, in ways consistent with the received "split parts" and the staff's particular cultural characteristics (individual backgrounds and "ward culture," or treatment philosophy and rules).45Another way to view splitting understands it as a universal mechanism arising out of normal development and its cultural context. The term's popularity arose with Kernberg's belief that splitting is the "key defensive operation" involved in BPD.46The elements of splitting are undoubtedly seeded by issues of "spoiling," ingratiating maneuvers, "early talents," sibling competition, and a number of other child-parents interaction^.^'>^^ Splitting may be enhanced by projection, which involves unconsciously attributing the bad qualities to another person in the environment while the good qualities remain ~ i t h i n . ~ 3 A related phenomenon is projective identification, which has been . ~ ~ 1 involves the clearly described as a three-step process by G ~ l d s t e i nStep projection of a part of oneself onto an external object. There is a blurring of self and object representations at this point. Step 2 involves the interpersonal interaction in which the projector actively pressures the recipient to think and feel in accordance with the projection. Step 3 is constituted by the recipient reinternalizing the projection after it has been psychologically processed. These steps and their strong cultural frame of reference can be highlighted in the following clinical example: VIGNETTE 2 A female therapist was seeing a female borderline patient in weekly therapy. The patient had been involved in prostitution and discussed how disgusting her male clients were. The patient continued the behavior in spite of her acknowledging the dangerous nature of prostitution. She saw herself as "bad and dirty," which reflected comments made to the patient by her father when he sexually abused her during childhood. As therapy
Cultural Intersections in the Psychotherapy of Borderline Personality Disorder
goes 011.~3 Therapists who work with these patients must be aware of their own needs and rights to a life of their own. Management of Suicidal Behavior
b
Suicidal behavior in the borderline patient presents one of the main therapeutic challenges to the psychotherapist. It is known that suicide can well be a "learned behavior," the result, among other factors, of massive media exposure to this type of e ~ e n t .Clinically, ~ ~ , ~ ~Kernberg56emphasizes the need to tease out suicidal behavior linked to severe depression from suicidal tendencies which are characterologically and culturally "anchored" and not indicative of clinical depression. The challenge here to the therapist involves a classic risk and reward decision: When and how to respond to the bulk of suicidal threats by borderline patients which are admittedly "feints" vs. when and how to respond to the more serious attemptshhreats. The former involves a mobilization for lifesaving maneuvers, and the latter demands a more relaxed approach. The dilemma involves an estimate of how to respond to a relatively rare event (completed suicide) but one which is catastrophic. StonS7 suggests therapists need to have a finely tuned "early warning device" with the suicidal patient. In order to operate effectively, this device would need to be sensitive to subtle shifts in ambivalence towards the therapist (or significant others) since shifts toward the negative can precipitate suicidal acts. These nuances have certainly a strong cultural component, as they respond to a cultural "training" on interpersonal transactions, including styles of emotional expressiveness and use of intimidating tactics. Complicating this task is the characteristic of certain patients to obscure moments of true suicidal intent by giving off "false-positive"gestures. This "risk thermostat" must not be set too low for this would lead to intolerable anxiety and overcautiousness on the therapist's part; too high a threshold risks doing nothing in a life-threatening situation. Some qualities that stand the psychotherapist in good stead include hisher ability to tolerate uncertainty and to accept risk, as well as the capacity to act quickly and decisively at the first hint of genuine suicidal intent. Adjunctive Therapies
Adjunctive therapies include group psychotherapy and family therapy. Group therapy allows borderline patients an opportunity to understand themselves and their defenses in a group context. The literature consensus is that borderline patients need individual therapy coincident with group therapy.44148J8 Dilution of transference in group therapy may benefit the patient and the individual therapist as the intense rage which can develop 185
Cultural Intersections in the Psychotherapy of Borderline Personality Disorder
significant cultural variability: different cultures around the world, and even within supposedly homogeneous societies, assign different roles to parents or spouses. The consideration of gender roles is also heavily influenced by culture. SUMMARY
L
Psychotherapy can be essentially considered a journey in which two individuals embark, each carrying a formidable cultural legacy. The psychotherapeutic enterprise then becomes a succession of stops and intersections as the two protagonists struggle to identify their culturally determined behaviors, using culturally determined procedures to take care of them. In this sense, cultural procedures are not a technical term but the appropriate combination of learned concepts, experiential modifiers, and common sense indicators of contemporary realities both at the individual and collective levels. The fascinating and challenging nature of BPD does have a significant cultural component encompassing explanatory, interpretive, pathogenic, pathoplastic, diagnostic/nosological, and service management aspects. It is in the psychotherapeutic arena, however, where both patient and therapist must face a multitude of culturally determined situations that may have a significant impact on the outcome of treatment. Culture can help the therapist to dispose of misleading clinical labels, with obvious advantages for the patient's well-being. Psychotherapy can correct the pathogenic elements of the patient's culture, recognize the pathoplastic clothing of the patient's symptoms, and provide culturally sanctioned and valued success experiences that may increase self-esteem, strengthen stability and, particularly, contribute to the patient's achievement of an identity with which he or she can feel comfortable. Finally, it must be remembered that it is not up to the therapist to offer infallible explanatory models of the patient's plight, but only culturally acceptable premises on which to build such explanations. On the other hand, it is up to the therapist to recognize the "idioms of distress," both physical and psychological, that the patient conveys in the psychotherapeutic context which is, as had been said many times here, totally immersed in the environment of culture. Two vignettes illustrate several of the issues under discussion. REFERENCES 1. American Psychiatric Association (1994). Diagnostic and statirtical manual of mental disorders, (Fourth edition). Washington, DC: American Psychiatric Association. 2. World Health Organization (1992). The ICD-10 classifiation of mental and behavioral disorders. clinical description and diagnostic guidelines. Geneva: World Health Organization.
Cultural Intersections in the Psychotherapy of Borderline Personality Disorder
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