Cultural Factors Psychology

Cultural factors in diagnosis and treatment are highly imperative. This paper includes critical thinking on the perils of using mainstream methodology with non-Western cultures.

Cultural factors have deep roots in the clinical psychology. Cross cultural psychology has now become an inseparable idea in clinical psychology. Culture cannot be avoided in order to make a precise judgment on mental problem. The paper is based upon literature review on various academic articles and books written to cover the significance of culture in clinical psychology. It offers systematic review based upon authentic basis regarding psychological treatment considering the cultural factors involved in diagnosis. Efforts are expected to focus on accurate judgment, suitable therapeutic process and an eventual release of the painful feeling. The capable psychoanalysts must be devoted, and eager to understand the cultural backdrop, past experiences and its correlation with the psychological diagnosis and handling of the case. Also a patient from non-western cultural background must be treated with extreme care while considering his cultural beliefs as important indicators to achieve optimum output; an ultimate relief for the patient. Respecting the consensus developed by historic and contemporary professionals, a psychologist can enhance efficacy of the treatment and avoid the perils of the mainstream methodology in treatment of non-western cultures.

Cultural factors are one of the most significant variables in the field of clinical psychology. A clinician cannot aim for precise diagnosis and appropriate treatment without considering the culture of the patient as a guiding principle, as many of the psychological behaviours are directly influenced by the cultural norms.

The paper presents a review of different cultures and their requirement for the diagnosis of treatment on mental health problems. It will also highlight potential harms of applying mainstream methodologies on a non-western client. A detailed literature review will explain the main aspects of non-western culture and culture related attitude on mental health. While treating the mental disorders, it will be useless if a general method is applied on everyone, without studying the socio cultural background of the client and salient features of the specific culture. We can explain its importance through an example; drinking habit may be a serious issue in a culture and may demand psychotherapy to get rid of it, but it is possible that it is considered as a normal thing in another culture. Also shyness of a female towards the males can be considered as a psychological problem in the western culture, though it may be considered as a normal behaviour in non-western traditions. Any diagnosis cannot be appropriate unless it is seen through the lens of the culture. Every psychological disorder has a deep connection with religious beliefs, ethnic norms, and native environment. An expert clinician has to identify that root first before making a professional judgment on the problem, type of treatment and therapeutic process required, and mannerism of the sessions, and required cultural sensitivity aspects during the therapies. The need of cognitive testing can only be identified after thorough analyses of the cultural factors behind the problem.

Cultural factors in psychological diagnosis and treatment; an overview

 Psychological diagnosis is very much dependent on the symptoms in human behaviour. Talking about the general perception on mental illness or disorder, anything different from a usual behaviour is referred as a psychological disorder. These perceptions are closely related to the culture possessed by the patient and also the interpretation of any behaviour as according to the cultural norms. We can understand this phenomenon by an example of some sort of mania. Mania is almost a common problem found in almost all the cultures, but the clinician must be very careful in diagnosis, as there is a probability of confusing the culture related expression of distress as wrong diagnosis of mania. We can observe cultural diversity in stating the depression, but it may be under diagnosed, usually on initial stage and careful measures are not taken. It is true that somatic characteristics may be identical in all the cultures, yet, it is critical to differentiate physical descriptions of a sentimental situation. Generally ways of expressing depression are different in all the cultures, however, sad mood, unwillingness in enjoying something, nervousness, and feeling energy less are common symptoms of depression. Culture cannot be neglected for any sort of psychiatric treatment like, while classifying depressive disorders, for example, we have to consider both internal factors within the individual and external factors related to the culture of the subject (Cowen P. et al. 2012. p212).

In the discussion, as it follows, various culture factors will be elucidated as they influence psychological diagnosis and treatment in various situations. It is also important to know how the treatment can cause harm instead of healing the suffering if a client from non-western culture is dealt in mainstream methodologies of diagnosis and treatment.

Cultural diversities and mental health

Culture is an inherited asset which travels from generation to generation. This is a factor which has direct influence on all aspects of the lives of human beings. As far as the approach on mental problems is concerned, it varies from person to person, family to family; various ethnic groups, culture to culture and country to country. It has been observed that culture and religion have a strong influence over the mental health of a person, and initiation of mental illness. Also cultural mannerism of responding towards such problems, determines the extent of agreement of the patient for mental sickness treatment and consistency in this regard. It is very important to understand that representation of mental wellbeing service demands cultural sensitivity for improving acceptance and awareness on the use of these services. This will help to reform approach about mental illness, as it is different from the one customary in the west. We can review a case study to understand this difference. This comparative study was conducted by universities in India and America, to compare behaviours in India and USA. It was found that the students from India perceived depression as an outcome of the factors like, being unsuccessful in achieving goals, or else which can easily be controlled by them individually, and felt that only way to manage depression is to ensure social facilitation and religious practices. They suggest that understanding and treating depression must consider diverse point of views on mental illness for enhancing the efficacy of mental wellbeing plans (Nieuwsma, J.A.et al. (2011). p 539-568).

Relationship of psychology and culture has been discussed by many expert psychologists, according to Triandis H.C. quoted by Kitayama S. and Cohen D. (2010), history of psycho-cultural tendencies have shaped the contemporary approaches of cultural psychology, and the future of this field is also based upon the same. He emphasizes on the close connection of the language; a salient feature of each culture, and psyche. He believed that language is the key to understand the thoughts of the speaker. Due to interaction of various people within the same culture, many agreements are found on the ways to behave collectively. These practices by the time shape the mind accordingly, thus we can say, an individual expresses his culture which he has been brought up (Kitayama S. and Cohen D. 2010).

Mental illness as a stigma in various cultures

Perceiving mental disorder as a shameful fact may be due to many reasons, for example, any of the apparent reason of the sickness. Many studies have reported other major distinctions in behaviour towards mental illness amongst cultural groups in the USA. Carpenter-Song et al. (2010) performed a thorough, one and a half year long culture based study. The subjects for the study were 25 patients with critical mental illness. These were European-American patients engaged in regular treatment by expert psychiatrist, inclined to state convictions about mental sickness associated with medical viewpoints about the illness. Contrary to this, people belonging to Africa, America or Latin patients were more liable to highlight non-medicinal explanations about the signs of mental disorders. Though, all the subjects from 3 cultural clusters shared about some sort of stigmatization because of their mental problems, this very shamefulness sentiment proved to be a main part of the African-Americans reactions, hence it was not focused in case of European-Americans, instead they inclined to consider mental problems as major and most important side of the human requirements on health. As far as African-Americans were concerned, they were frustrated when the clinicians emphasized on the need of medication. In case of Latin persons, they generally considered diagnosis of mental sickness to be a severe damage to their social image and status; they focused on stating the sickness on a very low severity to stay safe from extreme stigma (Carpenter.S. E. (2010) p 224-251).

As argued earlier, when we talk about stigma, its severity may be different in different individual cultures, which refers to a diverse nature in western and non-western cultures. In the non-western culture, sentiment of dishonour linked with mental disorder is very high. In such cases a mental situation, in which the patient thinks as if he is humiliated or not cared by anyone, leads to extreme loss of self-belief; thus the symptoms of mental sickness may even enhance. Another evaluation of the association between ethnicity & cultural beliefs and mental disorders is conducted by Abdullah et al. (2011). This study illustrates thoughts on broad diversity of culture related ideas embedded in mental condition. For instance, a number of the cultures may not regard mental disorder as a cause of disgrace, some of those only focus on the extreme problems but others may feel shame on disorders of any level of problem. Generally, non-western people are highly anxious about their traditions, self-control, individual associations and expressive connections, mental illness is taken as shameful dilemma, not only for the specific person, but for the whole immediate and extended family. (Abdullah et al. 2011)

Resistance from the patients

Bailey et al. (2011) have shred about reluctant behaviours regarding mental treatment. He notes that sense of being ashamed, religion related misconceptions, lack of trust on the clinicians and language barriers & communication issues may be the reason behind this resistance in opting for mental health treatment as required (Bailey, R.K.et al. 2011 p 548-557.) In certain cultures clients show a lot of resistance just to satisfy their self-respect that they are normal and it will be real dishonour if they admit and accept need for mental treatment. That is the main reason behind the concept that understanding culture of the client is very important, so as to understand the root causes of the resistance and reluctance. During the therapies, the clinician must develop a good rapport with the client, which is only possible with some awareness on the culture of the client. An expert clinician must focus on building a good relationship with the client during a few initial therapeutic sessions. It may be performed through friendly discussion demonstrating interest in getting awareness on the client’s culture, which must be complemented through attempts to gain knowledge on the same through books and other sources, such as, friends and family of the client, other members of the same community and other internet sources. This way the client will share many thoughts from his subconscious, and the root may be identified, along with a great control over the expected resistance from the client. Especially when we talk about non-western culture; as argued earlier; their stigma may be a great source of resistance. This can be overcome, if the client receives friendly signals from the clinician, and a sense of trust worthiness for thought sharing.

Cultural sensitivity while treating non-western clients

Generally, Non-western clients, especially Muslims adhere to their religious beliefs; therefore, it is crucial to be aware on the cultural heritage, and religious background of the Muslims for the contemporary psychologists, so as to ensure efficacy of the treatment, as this group of clients is rather difficult and needs to be understood properly. We have a discussion about the Muslim cluster in the non-western culture as it the biggest majority group in the non-west representation. Considering religion, as a central point of the human life, makes it possible for a practitioner to manage therapeutic process with a high level of skill and anticipation of the optimal output, when tackled in religious framework. Religious beliefs, spiritual thoughts and mental health have an interesting correlation to apply for treating several mental disorders efficiently. Keshavarzi H. and Haque A. (2014) in an article highlight the need of improving the psycho-treatment procedures with the help of its integration with the culture and religious values, while treating Muslims for psychological disorder. Religious faiths about the reason of mental sickness are typically unconnected to biological systems. Most of these are considered as a curse due to any bad deed in the past, or due to some spirits. However these symptoms may be different in the young and old generations. Also the nature of sickness differs in the native non-western client and second generation borne in a different culture. (Keshavarzi H. and Haque A. 2014)

Keshavarzi H. and Haque A. (2013) also quote Veling et al., (2008) who have highlighted non-western tendency of community based culture. It is a general norm that Muslim are fond of replication of a community environment similar to the native culture, wherever they live, such as community centers, caring for right of neighbours, selfless attitudes, mutual reliance and family values. These strong bonding practices generally tend to reduce chances of mental problems.

Cultural Factors Psychology
Cultural Factors Psychology

Lack or absence of cultural knowledge, especially on religious faith, norms and practices by non-Muslim therapists may be a hurdle in creating a remedial association with the client. It is important to be aware of certain practices which are extremely conflicting with Muslim cultures as observed in the west. Male and female interaction can be one of the examples, which is extremely prohibited in Muslim culture, though considered a normal matter in other cultures. This can lead to a serious problem during the sessions, if not understood according to the cultural requirements. For the therapist, it is also recommendable to make collaboration with religious leaders, so as to enhance religious understanding on the Muslim psyche and Islamic modes of treatment (Keshavarzi H. and Haque A. 2013).

We see that there is lack of sufficient materials on culture specific treatment methodologies for non-western clients. Many therapeutic concepts cannot be applied on the non-western client the way these may probably be efficient for the western client. Treatment of non-western client, though complicated, it also holds many helpful resources within its roots. As we see that in the non-western culture, family values and social relationships are highly cherished. These may a helpful tool for resource mobilization. To cope with language barriers family members can be a helpful resource. Another precaution is also recommended by Cowen P. et al (2012) that assigning a translator during sessions also demands special care about the selection of the person to interpret. As a general observation it is a fear that involving a translator, other than the therapist himself, may cause difficulty to achieve specific results, besides ever-increasing the duration of the meeting. Mare transformation of the language may not be helpful while the person is not a health expert, sometimes the spirit of the conversation is lost while translation process. This problem can only be conquered with the help of same community members, close family relation, or assigning a professional psychologist, the responsibility to communicate and interpret with the non-western client, and then be a part of diagnosis and therapeutic process. These dissimilarities are not exclusive for Muslims only; the other representatives of the non-western culture, such as Hindus and Buddhist are also different in terms of their traditions, norms and their approach towards mental illness, from the western culture. The same requirement of studying the specific culture persists for the therapist for a patient who belongs to any of these cultures (Cowen P. et al 2012).

All these arguments on the study of clinical psychology elucidate that dealing mannerism must represent adaptability according to the requirement of the culture when handling patient from a culture, which the therapist does not belong to. It must be understood that mainstream psychological methodologies might not fulfill the extraordinary needs of the situation. It is also quite natural that a single person may not possess the knowledge about each and every culture in the world, which makes things more complicated for the psychologist to have the anticipated outcomes. In some cases patients may even assume biased behaviour from any person or a group, financial stress, and a feel of inaccessibility to services if he is uncomfortable in any other culture, this might transform into the symptoms of mental illness later on. As a general observation, most of the cases of migrants emerge due to adaptability issues and may become severe if not handled on time with due diligence (Cowen P. et al 2012. p. 26. Ch 3).

As argued earlier, mental health issues with the systematic application of connection with the clients may notably increase because, most of the issues come forward because of cultural intricacy. Even the best knowledgeable practitioner may not be able to ascertain mental wellbeing of a patient, if, he does not make himself well aware of the culture; the patient is coming from, and all probable cultural approaches which may be contributing in increase of mental illness motives in the subconscious of the patient. The contemporary studies emphasize that culture has unambiguous connection with psychological problems. A psychotherapist must not stress on conservative systems of treatment, and bring in inventive thoughts in accordance to the requirement and judge diverse features of cultural psychology (Tseng W.S 2008).

As we learned from Keshavarzi H. and Haque A. (2014), that initial effort for applying the psychological approach is the precise judgment of the issue and the performance level of the patient. In this regard, the therapist has to collect information which is essentially required for treatment. If the judgment indicates a high tendency of the client towards religion, the therapist must take that into account. This may be evaluated during initial informal discussions through the use of terminologies and his general approach. The clinician must have an intention to develop an understanding with the patient on how the objective of the treatment is set. Later, a detailed session should be conducted to assess how he expects the improvement as a result of the therapeutic process. If the patient does not take interest in self-actualization, and wants focused attention to the specific problem, therapist must not resist, and make the client comfortable, removing discomforts of cultural difference (Keshavarzi H. and Haque A. 2014).

When we talk about the cultural beliefs in Arabian culture we cannot exclude religious and traditional methods of the psychotherapies. The majority of the Arabs rely on conventional healers, also referred as faith healers, such as experts of herbal medicines, religious elders of the region, healing through rituals. Unfortunately the initial level of mental disorder is assumed to be an assault of evil spirits such possession of the body, which can just be treated with the help of rituals. Treating the mentally ill person is believed as a punishment for the patient, that might mark him as a crazy or abnormal person forever, thus restricting hi normal movement in the in the society for the rest of his life (Parekh R. 2013).

The most complex idea about this subject is the command of a clinician about the features of every culture. Though it is not simple but the clinician must be open to learn about the cultural features which truly have an effect on the healing procedure. Cultural knowledge compliments the success of the healing procedure by demonstrating respect for the patient and the culture. The most important aspect of the point is that a proficient psychologist must be impartial, enthusiastic, and considerate on the cultural surroundings, the history and its link with the course of analysis and therapy.

The whole discussion stressed over an idea that culture and psychology cannot be viewed in isolation; we cannot suppose on the performance of brain and a culture bound psychosomatic approach, linked with one culture and expected to apply in any other culture, these aspects must be taken into account during therapeutic process.

While treating non-western clients, we must be clear on a few general distinctions in the culture, Such as:

  • Adaptability issues
  • Effect of religious beliefs on psychological beliefs
  • Strong family bonding
  • Reluctance of women on open communication with a male therapist,
  • Entirely different social environment
  • Less preference of psychological treatment as compared to physical issues.
  • Language barrier

Keeping all these aspects in mind, a clinician has to show respect for that cultural characteristic to develop outstanding professional relationship with the patients. Talking about sentimental problems in a responsive manner may help in this regard, because, general tendency of the non-western clients demonstrates shyness in discussing personal events, which may point towards the roots of the problem which may be linked with the cultural beliefs. Thus, to discover secrets of the subconscious, information on the patient’s culture is unavoidable.

As we have already discussed that family bonding and social relationships are very strong in the non-western culture, these may also give rise to some problems related to the expectations associated with these values. These false expectations may give birth to a feeling of disappointment or betrayal from a close person. It also makes them feel that those people have wasted their sacrifices and have not cherished their support. This leads to anger and fury for their own selves as well as for others. This also gives rise to hopelessness, and trust over others including their psychologist. It can also result into discontinuation of constructive attitude; which generates dire need of family support, counselling and cognitive therapy with individual. A feel of being deprived regarding marital rights can be an example of such cases. These sort of cases are culturally sensitive and may be dealt with high care, after acquiring sufficient knowledge of the specific cultural values and norms (Keshavarzi H. and Haque A. 2014).

Mainstream methodologies: Benefits and Perils

Before concluding the paper, we must focus on the perils of the mainstream methodologies when applied in non-western culture. During our argument, one thing has been concluded that we cannot study psychotherapeutic treatment in isolation; culture must be included in the analytical process. We can classify the type of clients in two culture specific groups:

  • Western culture
  • Non-western culture

Both have very clear dividing lines for general understanding on cultural beliefs. As we conclude that cultural beliefs play a major role in psychiatric diagnosis and treatment. The very first step involves the basic understanding on the culture of the patient and to what extent these beliefs and norm influence his cognitive behaviour. Though these are the two basic cultural groups, the non-western cluster may further be divided into more clusters based on religion and geographic trends. Muslims; the largest group in the non-western culture are more influenced by the religious education, rituals, spiritual treatment and other limitations. The beliefs of the patients may not be agreed by the practitioner, however it is important, not to argue with the patient, and give him a feel that the practitioner believes him and respects his point of view. Other clusters within the non-western cultures should also be dealt accordingly. Suspicion on the clinician, being afraid of the treatment, being afraid of racist of discriminatory approach, language and communication barriers, and cultural & religious issues may hinder the successful treatment (Keshavarzi H. and Haque A. 2013).

This reaches the following understandings:

  • Considering culture is the most important aspect in psychological treatment.
  • Initial meetings should be focused on gaining awareness about cultural and religious tendencies of the patient.
  • Physical interaction between male and female is strictly prohibited in non-western culture; this must be avoided at any condition.
  • General methodologies may not be applicable to all the patients. In the study of psychology, every client has his unique identity, he must be dealt individually. The approach that proved to be successful for treating depression of a western women, may not work for exact replication for a non-western woman.
  • The clinician must not try to influence patient’s cultural beliefs.
  • The clinician must show respect for the culture to develop mutual trust and good professional relationship.
  • Mare translation is not enough for the sessions, the interpreter must be a professional therapist, or a family or community member of the patient if the first option is not possible.
  • Consultation with the family is also recommended when possible. This may also help to overcome stigma and seek early healing of the problem rather that making it worse due to delayed treatment.
  • Depressive disorders may be similar in different cultures, however, the therapist must study, what is hidden behind the symptoms, inside the cultural context.

Conclusion

As a concluding note we can easily claim that psychiatric diagnosis cannot be made leaving the cultural factors behind. Making an attempt to do so may lead to commit wrong diagnosis and ultimately a wrong treatment. In advanced clinical psychology, wrong diagnosis and treatment is as dangerous as an unnecessary medicinal injection. A clinician has to demonstrate high level of professionalism and skill to handle the case with careful cultural sensitivity. There may be chances to disagree with the client belief, and also his cultural belief may be opposite from the therapist’s cultural norms, yet, he must not mention so in front of the client. There is high probability for resistance from the client and he also may show distrust on the treatment, however, the therapist has to be unbiased and temperamental. He has to make the client feel that his opinion is respected; being a leader or teacher may not be an appropriate approach, rather than being a facilitator.

As any unnecessary medicine may cause harm, in the same way, wrong approach towards cultural psychology may be equally harmful. A uniform methodology may not be applicable in all cases. If the client is under strong influence of religion and other features of the culture, it may not be ignored. A good rapport with the client is a half way towards the successful psychological treatment, and understanding the Cultural Factors is the map to reach this destination. .

References

Abdullah, T., Brown, T.L. (2011). Cultural Factors, Mental illness stigma and ethno-cultural beliefs, values, and norms: an integrative review. Clinical Psychology Review, 31: 934-948.

Bailey, R.K., Milapkumar, P., Barker, N.C., Ali, S., Jabeen, S. (2011). Cultural Factors and Major depressive disorder in the African American population. J Natl Med Assoc.,103: 548-557.

Carpenter-Song, E., Chu, E., Drake, R.E., Ritsema, M., Smith, B., Alverson, H. (2010). Ethno-cultural variations in the experience and meaning of mental illness and treatment: implications for access and utilization. Cultural Factors Transcultural Psychiatry, 47(2): 224-251.

Cowen P. Harrison P. Burns T. (2012). p.621. Ch 21. Shorter Oxford Textbook of Psychiatry Cultural Factors. Oxford University Press.

Keshavarzi H. Haque A. (2014) Integrating indigenous healing methods in therapy: Muslim beliefs and pract ices, International Journal of Cultural Factors and Mental Health, 7:3, 297-314.

Keshavarzi H. Haque A. (2013) The International Journal for the Psychology of Religion and Cultural Factors, 23:230–249.

Kitayama S. and Cohen D. (2010). Handbook of Cultural Factors psychology. Guilford Press.

Nieuwsma, J.A., Pepper, C.M., Maack, D.J., Birgenheir, D.G. (2011). Cultural Factors perspectives on depression in rural regions of India and the United States. Transcultural Psychiatry, 48(5): 539-568.

Parekh R. (2013) The Massachusetts General Hospital Textbook on Diversity and Cultural Factors in Mental Health Springer shop

Tseng W.S (2008). Cultural Factors and Psychotherapy: Review and Practical Guidelines Sage Publications.

WonPat-Borja, A.J., Yang, L.H., Link, B.G., Phelan, J.C. (2012). Cultural Factors Eugenics, genetics, and mental illness stigma in Chinese Americans. Soc Psychiatry Psychiatr Epidemiol., 47(1): 145-156.

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Borderline Personality Disorder

Borderline Personality Disorder

According to DSM-IV-TR (the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision) personality disorders are defined by maladaptive personality characteristics which begin during early years of life and have serious and consistent effects on functioning (Diagnostic and statistical manual of mental disorders, 2000). Borderline personality disorder (BPD) is a common reason to visit a psychiatrist (Skodol, Gunderson, Pfohl, Widiger, Livesley & Siever, 2002). BPD affects 2 percent of adults (mostly young women) (Swartz, Blazer, George & Winfield, 1990). Patients with BPD present a high rate of self-injury (without intent of suicide) and a significant rate of suicide attempts and completed suicide (Soloff, Lis, Kelly, Cornelius & Ulrich, 1994).

The patients of BPD are many times in need of mental health services and approximately 20 percent of hospitalizations in the psychiatric department are of BPD patients (Zanarini, Frankenburg, Khera &. Bleichmar, 2001). A patient with depression or bipolar disorder mostly endures the same mood for weeks while a patient with BPD may experience angers (intense bouts), anxiety and depression that may endure for only hours or at the most for a day (Zanarini, Frankenburg, DeLuca, Hennen, Khera & Gunderson, 1998). A study performed by Zanarini & Frankenburg (1997) showed that most of the patients with BPD report a history of neglect, separation (as young children) or abuse. Another study performed by Zanarini (2000) concluded that 40 % to 71% of Borderline Personality Disorder & Attachment Theory.

Origin of Borderline Personality Disorder

Children who have been exposed to psychological and physical neglect, sexual and physical abuse and maltreatment are at risk of developing BPD. The mental trauma faced by these children is due to neglect and abuse by a primary caregiver. This trauma disrupts the normal and healthy development of secure attachment. And as a result these children develop disorganized attachment (anxiety and depression). The children who are neglected are at risk of social rejection, incompetence feeling and social withdrawal. Neurobiological dysfunction can be caused because of abuse and neglect by primary caregiver. In order to develop a capacity of regulating emotions and developing a coherent sense of self the child has a requirement of attachment from the primary caregiver.

Attachment Theory and Borderline Personality Disorder

As per the ethological perspective of John Bowlby (1977, 1980, 1991) BPD can be considered as a condition of significant insecure attachment (with significant oscillations between detachment and attachment & between yearning and longing). The working models present in affect regulation and a lack of coherence (mainly in relationships with others) (Bowlby, 1973). The sorrow of detachment faced in early childhood negatively impacts the psychology of the person and this result in heightened sensitivity to loss and separation. It is also important to note here that since these feelings and thoughts are disconnected to the happenings in early childhood these individuals are unable to understand the reason behind their reaction. Research scholars (Melges & Swartz, 1989) have compared the fluctuations in the behaviour of BPD patients to prickly porcupines – they are of the opinion that patients with BPD are in need of someone but when someone comes close to them they drive themselves away as a result of fear. Thus BPD patients are looking for secure attachment but they fear rejection, anxiety and anger that could result (Bowlby, 1979). Melges and Swartz (1989) are also of the opinion that patients with BPD are preoccupied with regulating space. They do not feel the “invisible elastic” of attachment (Bowlby, 1969, p. 45). Also they are unable to protect themselves from anxiety of separation (Adler & Buie, 1979). The influence of certain types of experiences as related to family can be the cause of separation anxiety (Bowlby, 1988). John Bowlby’s “The seminal developmental theory” for treatment of BPD patients (Bowlby, 1969; Bowlby, 1973; Bowlby, 1980) has gained great attention. Bowlby proposed that human beings face pressures of natural selection in order to evolve behavioural patterns (example, clinging, smiling and proximity seeking ), that evoke in adults the caretaking behaviour (example, soothing, holding and touching).

These behaviours are reciprocal and encourage the development of an affective and enduring tie between caregiver and infant, which forms attachment. It is the result of these parental responses that internal models of the self and others are developed in infants which act as templates in the functioning of relationships later in life (Bowlby, 1973).

The Findings and Proposals of Bowlby the Following Is True In Case Of Attachment (Bowlby, 1973)

1. Model Of Self: The Internal Working Of It Is Related To The Degree Of Acceptance And Love One Has In The Eyes Of Primary Attachment Figures.

2. Model Of Others: The Internal Working Of It Is Related To How Available And Responsive Attachment Figures Are Expected To Be.

Attachment plays a very crucial role in the development of an external environment from which the child develops a safe and secure internal model of the self. Security on the grounds of attachment as perceived by the child results in his or her exploration of the world with confidence; this confidence springs by the availability of the caregiver. Security in attachment thus promises consistent, coherent and positive self-image. It also provides a feeling of being worthy of love and expectation that the important ones to him or her will be responsive and accepting. We here note that Bowlby has presented to the scientific mind the importance and need of attachment as essential to infants and children. Thus, attachment can be considered as an essential ingredient in the production of a psychologically healthy life. Now let us consider BPD patients, it is a case where the security in attachment is absent and there is a split and malevolent representation of self and others (Kernberg, 1967). In the life of BPD patients we usually observe angry, manipulative and needy relationships (Benjamin, 1993).

A number of scientific studies and intellectual thoughts have considered that intolerance of aloneness is the main defining characteristic of BPD and it is essential to note here that the descriptive criteria of DSM are also of the same opinion (Adler & Buie, 1979). Thus, the concepts and theories of attachment in many ways relate to DSM diagnostic criteria. Gunderson (1996) proposed that the early attachment failures actually constitute the cause of intolerance. He noted that in times of distress and sorrow patients with BPD are unable to invoke a “soothing interject” and this is due to unstable and inconsistent attachments to early caregivers. The above proposed scientific thoughts of Gunderson (1996) are same as that of Bowlby’s concept of insecure attachment.

The Scientific Observations Of Gunderson (1996) The Following Points Are True In Case Of Patients With Borderline Personality Disorder:

A Feeling of Insecurity on Grounds Of Attachment, Especially Pertinent To:

  • Plea for Attention
  • Pleas for Help
  • Checking For Proximity
  • Clinging

A Feeling of the Following in Borderline Personality Disorder Patients:

  • Denial Of
  • Dependency Needs
  • Fearfulness About

Based on the comparison of theories of object relations and attachment (Lyons-Ruth & Jacobvitz 1999) distinguished between normal processes (in early development) of separation individualization from the disorganized conflict behaviour (for attachment figures) by toddlers who are at significant risk for development of psychopathology. She identified that in infants the disorganized insecure attachment as a risk factor in the later development of BPD. Thus, we can state that as per the findings of Lycos-Ruth those infants who are victims of insecure attachments during the early years of life are at risk of developing BPD during later years of their life.

Borderline Personality Disorder
Borderline Personality Disorder

Attachment Therapy

In 1990, ATTACh (Association for Treatment and Training in the Attachment of children) was created in order to address the need of society and families to deal with critical attachment and bonding issues. ATTACh has cited important principles of attachment therapy and this includes the following:

1. Attachment therapy can be defined as a therapeutic process that is designed with the aim to define, develop and promote reciprocal attachment relationship and that which completely meets the criteria of that therapeutic process as defined and developed by ATTACh.

2. The aim of treatment by attachment therapy is to address the attachment problems and enable patients with healthy attachment relationships.

3. The emphasis in attachment therapy is laid on touch, physical and emotional closeness, reciprocal behaviours, empathy, atonement, communication, playfulness and humour. The attachment and bonding therapists are therefore required to treat with attention to the physical and psychological safety and wellbeing of the children and adults.

4. Family systems approach is of prime importance in attachment therapy. Thus there is need to correct child’s relationship with his or her primary caregiver.

5. It is essential to assess and study the following;

  • Psychological history
  • Educational history
  • Treatment history
  • Medical history
  • Attachment & Social history (including breaks in attachment)
  • Developmental history (including prenatal and birth)
  • Intellectual and Cognitive skills and deficits
  • Family functioning
  • Differential diagnosis (including DSM and ICD diagnoses)

6. Parents and children form the most active group of treatment regimen. Attempts are made to develop healthier patterns of interaction and communication.

7. To assist parents to develop parenting strategies in order to support positive attachments.

8. Description of any shortcomings attachment therapy might have for treating this issue and what else could be fused with attachment therapy to meet these needs.

Criticisms of Attachment Therapy

1) The application of attachment therapy for treatment of patients with BPD is equated with rebirthing or holding therapy and the techniques used to achieve the results are dangerous.

2) During the treatment of patients with BPD the attachment therapists make use of criteria that are even beyond those provided by the DSM-IV-TR (Zeanah 1996; Boris et al 2004). The strong correlation between insecure attachment and pathological parent-child interaction as shown by attachment therapy are beyond the symptoms listed in the DSM criteria (Bowlby 1944, 1973).

3) The attachment therapists many times over diagnose BPD.

  • Almost 87% to 96% of the children, who experience abuse, neglect or both, show an insecure attachment (Crittenden, 1988).
  • Between 50% and 80% of the adopted children have attachment disorder symptoms (Carlson, Cicchetti, Barnett & Braunwald, 1989).
  • Approximately 20% of children living in homeless shelter and nearly two thirds in foster care are identified with attachment disorders (Boris, Wheeler, Heller & Zeanah, 2000).

4) Attachment therapy is not supported with “empirical evidence” While attachment therapy can provide treatment of BPD, studies have revealed the effectiveness of other therapeutic methods as well. These methods have been briefly described below:

1. Psychotherapy

Randomized controlled studies have presented the efficacy of dialectical behaviour therapy and psychodynamic / psychoanalytic therapy (Bateman & Fonagy, 2001). The treatment provided in these trials comprises of three key features;

  • Meetings with an individual therapist (once a week)
  • Group sessions (one or more in a week)
  • Meetings of therapists for supervision or consultation

The psychotherapist’s approaches include a building of a strong therapeutic alliance and monitoring the suicidal or self-destructive behaviours. Other essential component of effective treatment plan for patients with BPD includes managing feelings, promoting reflection action (and not impulsive action), reducing patient’s splitting tendency, and limiting the behaviours related to self-destruction. There is some empirical data that supports individual psychodynamic psychotherapy.

2. Group Therapy

Group therapy for BPD patients is supported with research findings that indicate that it can be helpful (Greene & Cole 1991). Note: However, the benefit of family therapy in the treatment of BPD patients is not evaluated yet with research studies.

Descriptions of how dimensions of cultural context impact the issue you are discussing. How might this inform your treatment? I strongly believe that psychologists should not be racists. Today we are required to treat patients of different ethnic groups and countries during our clinical practice. Even an expression of detachment or neglect can hurt hard the patients with BPD. As discussed above the patients with BPD are in need of love and acceptance, care and attachment, understanding and touch, soothing approach and closeness. If a psychologist will distinguish on the grounds of colour, race, region and country then s/he won’t be able to perform well because for the treatment of BPD patients with attachment therapy it is essential to shower true attachment. Roentsch (1985) defines racism as: “Let there be no misunderstanding. A racist is anyone who accepts the existence of racial collectives”. Amongst doctors there is a belief in the a priori inferiority of non-white (Eysenck, 1990: pp. 215-220). The facts on racism reveal that we divide the world into ‘in-group and out-group’ or ‘us and them’ (Baron and Byrne, 1994: pp. 228-229). An important study first conducted by Clark and Clark (1947, in Baron and Byrne, 1994: 256) showed that a significant proportion of non-white children had internalized the attitudes of white racist. Thus the reaction of non-white adolescents towards white psychologists can be considered to be different from the reaction towards non-white psychologists. These racists’ feelings need to be addressed with maturity and patience. The dealings, behaviour and communication need to be such monitored that the feeling of racism is absent.

Self-issues that may impact a clinician’s conceptualization and treatment of this issue from an attachment perspective. How might one’s cultural context inform what they see and how they see it? What should clinicians be cautious of? Bonus points for examination of your own “self” in relation to treating this issue from an attachment perspective.

During my school times I lost my best friend because of racial differentiation attitude of a teacher. I was very much in harmony with my non-white friend. We had a high level of understanding and we loved spending time together. We were best friends for 3 years. However, my teacher did not like us being friends. She was white and disliked non-white people. Though she did not show it openly but it was obvious by some of her remarks at different times about non-white people. My teacher asked me to quit my friendship with the non-white girl. At first I was very much hurt by my teacher’s approach but then I agreed to it. This is because my teacher said that she will assure that I will get better grades in school if I agreed to what she said. My friend was very much hurt when I broke friendship with her. And after doing this I felt guilty for doing something really wrong. Even several years after quitting friendship with her, I feel sorry for my decision. Actually for some part of my life I had started thinking the way my teacher thought. I use to respect my teachers and had a feeling that they are always right. This is the reason why I started feeling that my teacher’s attitude towards non-white people was right. However, my thoughts have changed to good after leaving school. Now, I am equally friendly towards both non-white and white. I have both non-white and white as my friends. But sometimes the thought that I was once a racist makes me feel guilty. When I recollect that I was once a racist, I lose confidence in dealing with non-white people. I noted this when I was working on the treatment of a BPD patient who was non-white. I need to be more confident in my dealing with non-white people. I need to feel sure that I no more differentiate between non-white and white. I think I will gain this confidence when as a result of my sincere work several non-white BPD patients will get healed.

Describe what the early, middle and ending phases of therapy might look like for treating this issue based on what you have learned. Please also include some possible interventions and assessment methods. Attachment theory has been applied to both children and adults suffering from detachment. Bowlby (1969) formed a lifelong attachment behavioural system which encourages secure attachment. The attachment thus begins with the child’s requirement of secure attachment from the primary caregiver. The behaviour of attachment is organized and revolves around primary care giver. The feelings of attachment are elicited during the period of mental or physical discomfort or stress (1969). As per Bowlby’s (1969) perspective BPD can be considered as a condition of significant insecure attachment. There exists number of oscillations between detachment and attachment. The early childhood experiences of BPD patients are that of detachment, neglect, abuse, separation and loneliness. Thus the systems that mediate the feelings of attachment and positive behaviour are distorted and deactivated. In addition to this BPD patients have intense fear linked with loss and separation. However, since BPD patients do not remember their childhood time when they were neglected and abused they are unable to understand the reason behind their behaviour. I think a therapist is required to develop a secure and genuine attachment relationship with the BPD patients. The patient should feel completely secure in his or her relationship with the therapist. S/he should have no fear of loss or separation as related to relationship with the therapist. Development of a ‘secure’ attachment can help establish happiness in the life of the patient.

BPD patients are in need of love but the fear of loss and separation drives them away from people. It is therefore crucial that this fear of loss and separation should be dealt in the first phase of treatment. The patient with BPD should be counselled in such a manner that s/he starts gaining confidence in building secure relationships. The approach of the therapist should be driven by ‘attachment’ and ‘love’. Thus, while attempting to heal the BPD patient of the fear of separation, the therapist should try to build his or her own place in the heart of the patient. The approach should not only aim to heal the fear but also to open ways for love and attachment. The therapist should make the patient feel that s/he really cares for him. That it is not just a routine responsibility or duty to address the need of the patient. The therapist should show that s/he has started loving the patient and has become attached with him. S/he has started caring for the needs and essential requirements of the patient. A feeling of attachment should spring from within the heart of the therapist and should touch the emotions of the patient. Parents of the patient should be educated on the basics of attachment.

They should be taught the need of touch, eye contact, motion, love, compassion, care and attachment. The issues related to behaviour should be addressed and the pitfalls should be examined. The treatment should include a review of the attachment issues of the parents’. The parents should be educated on good ways to bring up the child. The attachment from parents and primary care taker are essential for answering the need of BPD patients. Gregory C. Keck states that holding the child or adolescent gives rise in an emotional response and intensity that cannot be achieved by any other medicine or therapeutic regimen. Therapist should educate the parents or the primary caretaker to hold the child or adolescent. The therapist should work to build in attachment between the child/adolescent and the parents/primary caretaker. Building of relationship and providing security and affection from parents or primary caretaker should be assured.

The therapist should also spend time to build in attachment between the child/adolescent and himself

The therapist should also work to repair the relationship that has been broken. S/he should try to develop more peaceful and lovable feelings between the child/adolescent and the parents/primary caretaker. The therapist can also do the holding of the child/adolescent and then s/he can transfer the responsibility to the parent or primary caretaker. The therapist is also required to make an important clinical judgment with regard to the suitability of the primary caretaker or parent for such an attachment. Guidance and education as related to the attachment should be provided by the therapist. In addition to holding ‘eye contact’ is an important part of attachment therapy. Eye contact opens the door to the heart of the person and builds attachment.

In conclusion, the therapist should believe in building relationships of attachment. A feeling of security should be the base of such attachments. Broken attachments should be repaired and new attachments should be built-in. The therapist should form attachment of the patient with himself or herself. In addition to this attachment should be built between the parent/primary caretaker and the child or adolescent. Education should be imparted on developing attachment. Today, in the modern days parents find little time for their children. Many times they forget to care for their own child. The child gets hurt each moment by a lot of anxiety, depression, neglect and loneliness. The child loses the charm of attachment and feels that s/he won’t get attachment from anyone. I believe that in order to begin with attachment therapy it is essential for the therapist to first build attachment between himself and the child/adolescent. Therapist should also build in attachment between himself and the parents of the child/adolescent. This is because the parents who feel attachment from the therapist will be more responsive and agreeable to treatment.

Attachment Can Create Wonders in the World of Therapy and Therapeutics

Attachment speaks to the heart and touches the emotions to bring forth a feeling of recovery. I strongly believe that attachment therapy is the best suit for patients with BPD. This is because attachment can repair the broken hearts, the fading hopes, the dying relationships and the detached home. I would strongly recommend attachment therapy as a method of choice for the treatment of patients with BPD. Children and adolescents want someone to speak to their heart, someone who understands their need of attachment and addresses to their requirement of love, touch, care and affection. During all the phases of treatment this should be kept in mind and should be reflected in approach and practice of the therapist.

Conclusion

Attachment theory is a good addition to the knowledge of psychology and its application can be beneficial for the treatment of BPD patients. While dealing with patients of BPD the psychologist should not have racist attitude and his or her approach should be confident.

References

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C. H. (2004). Comparing criteria for attachment disorders: establishing reliability and validity in high-risk samples. J Am Acad Child Adolesc Psychiatry, 43(5), 568-77

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Childhood Obesity

Physical inactivity, nutrition, genetics and psychological factors are the main causes of prevalence in childhood obesity

Sources: Langwith, J. (2013). Childhood obesity. Detroit: Greenhaven Press

This book by Jacqueline gives an overview of what childhood obesity encompasses. In the book, she talks about childhood obesity being a global health concern and health risk factors associated with childhood obesity. She also talks about the various causes of childhood obesity. They include Type II Diabetes, cardiorespiratory diseases, cancer, and hypertension, stroke, and sleep apnea and liver disease. She argues that children who are obese have a high risk of having a shorter life expectancy and also the controversies surrounding childhood obesity.

In her book, she talks of two main causes of childhood obesity which are genetic factors and stress, the effectiveness of anti-obesity programs, and whether bariatric surgery is appropriate for children the role government should play, focusing on contributing factors, and personal stories of people dealing with childhood obesity. This book is a credible source that will prove useful in the final research paper since it gives detailed information on the issue of childhood obesity. Jacqueline provides general views and clear evidence, and she is not biased in any way. This book will be useful in putting up a strong argument on genetic and psychological factors being causes of childhood obesity. (Langwith, 2013)

Jimerson, M. N. (2009). Childhood Obesity, Farmington Hills, MI: Lucent Books

The author of the book touches on childhood obesity, by talking about what it is its causes and the effects it has on the affected kids, its health risk factors, how it is to live with it as a child and future prevention measures. He says that childhood obesity could be prevented if parents carefully determined the environments they bring up their children. By parents and guardians encouraging their kids on healthy eating habits and an increase in participation in physical activity, cases of childhood obesity will be reduced. He urges parents to maintain their kids body weight, reduce the number of adverts promoting unhealthy food.

To support the suggested preventive measure, he provides information about medical issues of childhood obesity such as diabetes, emotional problem. This book is a credible source in the research as it talks about the main causes of childhood obesity. The book’s details are based on evidence making it of undoubted quality. The book having discussed diet and physical inactivity as the main causes of childhood obesity will help me in arguing out my case (Jimerson, 2009).

Juettner, F. B. (2010). Childhood Obesity. San Diego, CA: Reference Point Press

This book is a reliable and provides unbiased information on the issue of childhood obesity. Source to research on whether physical inactivity, nutrition, genetic factors and psychological factors are the main causes of prevalence in childhood obesity; The books discusses in depth on the origins of childhood obesity, how much of a problem childhood obesity has been all over the world. It also focuses on the causes of obesity which the author discusses in depth. He also tries to answer the question: can obesity in children be prevented and can it be reserve. It also discusses a few controversies that exist on the issue of childhood obesity. The information in the book goes a long way in helping one understand childhood obesity better and what exactly it entails. This source is credible and can be used towards the final projects. The book will provide information to strengthen the argument that the main causes of childhood obesity are physical inactivity, nutrition, genetic factors and psychological factors (Juettner, 2010).

Smith, J. C. (1999). Understanding Childhood Obesity. Jackson: University Press of Mississippi

The author of this book talks of physical inactivity as the main cause of childhood obesity. He urges growing children to exercise daily to help them grow healthy and avoid cases of childhood obesity and the health risk factors associated with it. He outlines the type of physical activities that kids need to undertake, through the help of their parents to remain physically fit. By parents acting as role models to their children in terms of physical activity, obesity in children will be reduced. This will act as a source motivation and could influence the child to do the exercises by themselves at a different time to help reduce some of the weight they have. This book is a reliable source to the research paper as it will because it in figuring out what motivates the child to exercise; is it an incentive by their parents? It will give an understanding on the causes of childhood obesity or is it through only bad eating habits. The information quality of this book is great though it does not focus on all the causes of obesity. This source is supportive to the argument that physical inactivity is associated with childhood obesity (Smith, 1999).

Childhood Obesity
Childhood Obesity

Institute of Medicine (U.S.). Koplan, J., Liverman, C. T., Kraak, V. I., Institute of Medicine (U.S.). & Institute of Medicine (U.S.). (2005). preventing childhood obesity: Health in the balance. Washington, D.C: National Academies Press

The authors of this book talk more on the extent of childhood obesity and the consequences it has on children with it. It also develops an action plan to fight with childhood obesity and make it a national public health priority. The authors also try to create awareness on the existence of childhood obesity through advertising, public education, through the media groups. This information passed to the local communities, homes and schools to help them eradicate the issue of childhood obesity in the society. This book is a credible source in the research paper as it talks about of the preventive measures of childhood obesity. The book mainly looks at childhood obesity in the United States and may seem biased to other areas in the world. The book will only help in arguing out what the consequences of childhood obesity are (Koplan, Liverman and Kraak, 2005).

Dehghan, M. Akhtar, N. and Merchant, A (2005) Nutritional journal: childhood obesity, prevalence and prevention

This article talks more on the causes of childhood obesity such as physical inactivity in that, children prefer playing video to having healthy activities such as swimming or playing in the playgrounds, poor dietary such as high caloric intake, foods with a high level of sugars, genetic factors, how cultural environment influences obesity among children and psychological factors. Impact of advertising junk food and also the preventive measures towards eradicating childhood obesity such as Parents being role models to their children on healthy eating and exercising at an early age. The article has a lot about the health risk factors associated with childhood obesity like type II diabetes, cardio respiratory diseases and stroke. It is a credible source as it has detailed information on the causes and prevention of childhood obesity. The information in the article will strengthen the argument on how poor diet or nutritional habits cause childhood obesity (Dehghan, Akhtar and Merchant, 2005).

Donahue, E. Paxson, C, Haskins and Ron (2006) Future of children: fighting obesity in the public schools

The article acknowledges how childhood obesity has increasingly grown the United States. It recognizes efforts schools are making toward fighting childhood obesity and encourages that more should be done such as including physical activities in the schools’ curriculum and making it mandatory as it will increase the chances of every child being physically active. Also, the article gives detailed information on how and why the government should take part in fighting this pandemic of childhood obesity. Information on the call to take action from congress to put more restrictions on the diet program in the school system; It gives more detail on setting up detailed goals and objectives for change in public school thus making it a credible source (Donahue, Haskins, Paxson and Ron, 2006).

Clinic, M (2006) Child Obesity

In the article, it is clear that childhood obesity is a serious problem globally and especially the industrialized nations. The article continues to give an explanation on the main causes of childhood obesity such as eating fast foods, foods with a high level of sugars and the e health risk factors associated with childhood obesity. It explains the processes of diagnosis and screening, effects it has on children and preventive measures that can be taken. This article is a very credible source in the research paper as it has detailed information on the causes of childhood obesity. Though it has great information, it lacks to provide enough supporting material of their conclusions (Mayo Clinic, 2006).

Centers for Disease Control and Prevention. (2010.) Childhood Obesity

This source states the many facts which have accrued as a result of childhood obesity. It shows how cases of childhood obesity have increased over the past thirty years with a higher percentage of children in the United States of age6- 11years being obese. This source defines obesity as having excess weight for a particular height. The causes of obesity Are also given in this article such as high caloric intake, environmental factors, genetic factors, behavioral factors and physical inactivity. It is clear that kids are the most affected and fall in this unhealthy balances and standards. This is a very credible source as it has information on the causes of childhood obesity as it also gives the preventive measures of this disorder among children. This source is very credible since it provides statistical evidence on issues relating to childhood obesity. The article looks at childhood obesity in the United States and may be questionable in terms of quality when talking about obesity globally. The source will support the argument that childhood obesity is on the rise (Centers for Disease Control and Prevention, 2010).

Centers for Disease Control and Prevention. (2006). Nutrition and the Health of Young People

This is a helpful source as gives more information on healthy eating, associated with the reduction of diseases associated with poor diet such as heart diseases, diabetes, cancer and stroke. Information on healthy eating among kids is given in order for the proper growth of children and prevents cases of child obesity. The article gives detailed guidelines for a recommended diet rich in grains, low fats dairy products, fat free for children. Schools are also are able to promote healthy eating among children by ensuring that only nutritious and the. The school food programs should provide appealing foods. Also, physical activity and nutrition program should be included in the school curriculum. The source will be supportive in the argument that poor diet causes childhood obesity (Centers for Disease Control and Prevention, 2006).

Did you find any useful knowledge relating to childhood obesity in this post? What are the key facts that grabbed your attention? Let us know in the comments. Thank you.

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