Cultural intersections in the psychotherapy of borderline personality disorder.

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.