How, but in custom and ceremony, are innocence and beauty born? – W. B. Yeats
The purpose of this study is to compare and contrast certain prevalent contemporary pathological symptoms--parasuicide (especially impulsive "self-cutting" or wrist cutting and other forms of self-mutilation), anorexia/bulimia, substance abuse, and a predisposition to frequent transient psychotic episodes, all of which, as a constellation, combination, or in some cases individually, are identified by clinicians as presumptive signs of "borderline personality disorder" (BPD)--with those same behaviors in tribal societies. The focus is anthropological and cross-cultural; it is a study of rites of passage, many of which involve food deprivations (fasting and purgations), body mutilations (circumcision, scarification), accompanied by episodes of altered or nonordinary states of consciousness (visions, loss of boundaries). It is argued that there is a relationship between BPD and the failure of Western culture to provide context and myth for meaningful rites of passage. The typical symptoms of borderline disorder have neither an appropriate cultural channel nor symbol system to provide direction and consequently are not fully appreciated by clinicians. However, these "symptoms" may actually be attempts at self-healing gone astray in a culture bereft of an integrative spiritual and ritualistic context, and therefore without an education for transcendent states of consciousness.
Every culture provides a model for the expression of psychopathology. Linton (1956) speaks of "patterns of misconduct," Devereux (1956) of the "ethnic psychoses," Yap (1969) of "cultural bound reactive syndromes." Over 150 have been identified in the ethnographic literature (Hughes 1985). Tseng and McDermott (1981) define a "culture-related specific psychiatric disorder" as having three aspects: (1) a specific set of symptoms not seen in other mental illnesses; (2) commonly observed in some cultural areas but not in others; and (3) manifested in a manner closely related to culture. CBS as a concept is descriptive and not explanatory (Prince 1985). Thus, in this paper I will not focus on theories regarding the etiology of mental disorders, whether these be biomedical, infantile trauma, or by level of personality development. Rather, my focus is on observable behaviors within socio-cultural context. Classic examples of CBSs include koro (impotence panic) in China and Malaysia (Yap 1965), latah (startle reaction) in Indonesia (Kenny 1985; Simons 1985), susto (fright, soul loss) in Central America and Mexico (Rubel et al. 1985), wiitiko (cannibalistic frenzy) among Native Americans in Central and Northeast Canada (Parker 1960), and "possession-trance" found in numerous cultural areas. The type of possession identified as a CBS is anthropologically referred to as "negative possession-trance,"which is an involuntary, dissociative, uncontrolled, spontaneous experience and is contrasted with voluntary, controlled, ceremonial, shamanic, non-disordered "positive possession-trance" (Bourguignon 1968; 1976; Lewis 1989; Oesterreich 1966; Peters and Price-Williams 1980).
The West also has cultural bound syndromes, as Littlewood and Lip-sedge (1986; 1987) attest. CBSs represent tensions basic to a society, whether traditional or modern. Many of the non-Western CBSs have been equated to western pathological syndromes. For example, negative possession-trance has often been thought of as a cultural variant to multiple personality disorder (MPD), the latter being a Western CBS (Kenny 1992) shaped by Western cultural and psychiatric beliefs (Hacking 1992) but psychologically similar to negative possession because both involve alterations of identity, parallel types of dissociative amnesia, and splitting of consciousness (Ellenberger 1970; Ken-ny 1986; Spanos 1986). While there is a certain plausibility to this argument, there are also differences between the two categories. Possession, a less precise traditional category which may include any number of heterogeneous western psychiatric conditions (Bourguignon 1992), is nevertheless considered by most ethnological researchers to be a less severe neurotic disorder, a "pseudo-psychotic hysterical reaction" (Yap 1960) or "hysterical psychosis" (Langness 1976), the symptoms of which are amenable to short-term therapy (Kennedy 1967; Kiev 1964; Peters 1978; Wallace 1966). MPD, on the other hand, is a severely damaging chronic dissociative disorder in which each personality is complexly integrated with enduring patterns of behavior in a wide range of personal and social contexts, giving it a distinct clinical picture from possession which is much less global and pervasive to the personality (Cardena 1992; DSM III; DSM III-R).
The hysterical psychosis is marked by the inability to deal effectively with psychosocial stress. Symptoms include brief psychotic episodes with hallucinations, delusions, depersonalization, derealization, and grossly unusual behavior. These symptoms may last a few hours to a few weeks (at most) and recede as dramatically as they appeared, leaving no residual psychotic deficiency. It is not a schizophrenia. The episodes may include suicidal gestures. Second or third episodes are likely to occur. There may be amnesia but not necessarily. The hysterical psychosis is the end point of severity on a continuum of hysterical disorders. Psychoanalytically speaking, the transient episodes are interpreted as an over-whelming of the ego by the id, a temporary ego annihilation (Hirsch and Hollender 1969; Hollender and Hirsch 1964; Langness 1967). The likelihood of experiencing periodic but reversible psychotic episodes are also a primary feature of BPD (Easser and Lesser 1965; Millon 1981) and are sometimes referred to as "borderline states" (Knight 1953). As will soon be discussed, this and many other of the disordered hysterical psychosis characteristics overlap with the DSM III-R criteria for BPD, albeit BPD is a chronic disorder and not treatable in short term therapy as is the hysterical psychosis.
In the Western CBSs, as well as non-Western CBSs, there is projection of accountability for acting-out behavior onto agencies that are beyond the patient's control (mystical symbols in traditional societies, psychiatric and bio-medical in contemporary cultures). This explains why CBSs are seen in the West as "disorders" (Littlewood and Lip-sedge 1986; 1987). However, in non-Western contexts, there have been many investigations that indicate that the hysterical psychosis may actually be beneficial to adaptation, and therapeutic. Among the Bena Bena of New Guinea, for example, "wild-man behavior", an episode of antisocial violent behavior which is explained as being due to a spirit possession, is quickly forgotten and leaves no social stigma (Langness 1967; 1976; Salisbury 1968). A brief episode or two occurs in adults who have delayed assuming full, mature, culturally-defined responsibilities. This apparently psychotic behavior, however, leads to psychosocial reintegration and is accepted indigenously to be a prelude to the necessary transition to adult life (Langness 1965: 267). In another New Guinea group, observed by Newman (1964), such wild-man behavior leads to a permanent loss of status, chronic reoccur-ring episodes, and the person is not allowed and/or expected to fulfill normal adult obligations. It is not valued as transitional behavior. This ethnographic distinction is important because it demonstrates how differently the same behavior is responded to in two similarly "primitive" cultures, and the psychosocial consequences for the individual because of cultural beliefs and values.
Nonetheless, in almost all of the examples of the non-Western CBSs, the behavior is a culturally prescriptive means to communicate distress. In Haiti, for example, negative possession-trance is considered a disorder by Western researchers. However, Haitian "negative" possession is the precondition for admission into the possession cult. Initiation into the cult is concomitant with ceremonial control of the possession state. Negative possession-trance is thereby transformed into positive or ceremonial possession-trance. This process is described by Bourguignon (1965:55) as a "dissociation in the service of the self" that "enhances the field of action for the self." In other words, the appearance of "symptoms" begins a process of initiation leading to psychosocial transformation. Thus, " . . . negatively valued trances," Leavitt (1993:54) writes, "are just as religious, just as culturally defined, as positively valued ones . . ." He contends that it seems arbitrary to separate out the negatively valued aspect of a total process, in which both positive and negatively valued trances are the different parts of one experience, and label only one part non-pathological. It was from a similarly erroneous perspective that the initial "calling" experiences of shamans often reported as due to a negative (unsolicited) possession became inaccurately labeled by Western psychiatrists as schizophrenia (Silverman 1967).
Thus it is ethnocentric bias to interpret many of the non-Western CBSs according to our categories of illness outside of their socio-cultural context. In the West, however, behavior such as seen in the hysterical psychosis is not initiatory and instead leads to labeling, social stigma, and intra-psychic guilt and shame. Symptoms of the hysterical psychosis as documented in Western contexts include chronic "impulsive" acting-out such as self-cutting episodes in which patients are dissociated from feeling any physical pain (Pao 1969; Siomopoulos 1971; 1983:100ff). Similar chronic impulsive behavior is considered a "presumptive sign" of BPD (Grunebaum and Klerman 1967; Kernberg 1975; 1977; Tupin 1984).
The discussion of CBSs began by defining them as belonging to specific cultures. They are more prevalent in tribal and third-world cultures in their non-chronic form. They are distinct from Multiple Personality Disorder. It was also suggested that it might be unwarranted to equate many of the non-Western CBSs with our mental disorders in that they initiate cultural processes that further adaptation, and may be a means of resolving conflict, acquiring social support, and are part of a religious initiatory system (Boddy 1992). Although the non-Western CBSs are considered to be illnesses by Western observers, the supposed illness becomes a means of reducing social inequalities (Peters 1978), becoming a member of a new social organization (e.g. a culturally sanctioned possession cult) (Kennedy 1967), is a means of transitioning to new social responsibilities, is a "calling" to a new vocation as in shamanism (Lewis 1989) and consequently, as discussed above, "an enhancement to the self." More than this, these so-called and misidentified "illnesses" carry relatively little social stigma. Thus it is important to keep in mind that the psychiatric terms utilized in much of the cross-cultural research belie a cultural prejudice for equating our categories of mental disorder with the relatively non-stigmatizing "idioms of distress" of other cultures (Nichter 1981; Obeyesekeye 1969).
Consider the "ataques de nervios" among Puerto Ricans and other Latin Americans, also known as the "Puerto Rican Syndrome" by Western psychiatric researchers. First of all, the attack of nerves is not natively considered to be a mental illness and thereby avoids the consequent stigma. It is believed to have "material" (medical) or "spiritual" causes. Symptoms include a transient altered state of consciousness, and possibly convulsive movements, hyperventilation,moaning and groaning, profuse salvation, aggression toward self and others, impulsive suicidal acts, hallucinations and delusions, derealization and depersonalization, i.e. psychotic manifestations according to Western prejudice. There is a sudden onset and termination lasting a few minutes to a few days (Fernandez-Marina 1961; Rubio et al. 1955; Trautman 1961); in other words, a transient psychosis. When medical problems are not found, the attack is natively attributed to a spirit, possibly through malevolent witchcraft. 76% of the cases reporting to an estpiritista in New York City for treatment were diagnosed as Being spiritually caused and, in a majority of cases, especially among adolescents and young adults, the episodes were interpreted as spiritual evidence (i.e. a "calling") to develop one' s transic faculties for mediumship (Garrison 1977). Thus, in most cases, the attack is initiatory and, while seen as critical by the culture, is a prelude to initiation into a new social organization and the development of a socially honored profession. Still, even in the cases that were not seen as evidence to begin training for mediumship, they are indigenously understood as socially acceptable means of alleviating stress, pent-up anger, and frustration (Rothenberg 1964). It is cathartic and therefore psychotherapeutic according to Garrison (1977), a "regression in the service of the ego" according to Fernandez-Marina (1961), and a culturally honored means for asking and getting care and support from others who are demanded by the norms of good behavior to rally to the aid of the victim (Garrison 1977). Thus, as Leavitt (1993) suggests, what may be involved in such non-Western cases, is the misappropriation of psychiatric nosology.
According to Valliant and Perry (1980), personality disorders fall on a continuum between neurosis and psychosis. They are distinct from neurotic disorders in that they are ego syntonic. They are pervasive and much more like maladaptive life patterns than the isolated symptoms of a neurosis. Personality disorders affect the individual's long term functioning by creating social impairment and distress. One of the crucial concerns of transcultural psychiatry is to illuminate the role of cultural factors in the etiology, expression, course, outcome, and epidemiology of mental disorders (Marsella 1984). Cultural bound disorders are culture bound because culture both shapes their manifestations or symptoms and influences their course, outcome, and severity. For example, there are numerous significant studies that indicate that extreme and chronic forms of mental illness, including schizophrenia, depression, as well as MPD, are much more prevalent and/or chronic in the West than in third world or tribal communities (Coons et al. 1991; Fabrega 1989; Kennedy 1973; Marsella 1980; Murphy 1968; Prince 1968; Ross 1991; Sartorius 1973; Sartorius et al. 1978; Torry 1980). Similarly, it is my hypothesis that BPD is an insidious breakdown of social cohesion, norms, values, and families. Paris (1991), a transcultural psychiatrist, believes BPD may be a universal reaction to social disintegration and it has indeed been reported in non-Western developed and developing cultures like Kuwait (Suleiman et al. 1989), Chile (Cardenas 1985), Korea (Lee and Lee 1982), and Egypt (Okasha and Lotaif 1979). However, this severe and chronic disorder is much less prevalent in non-Western contexts (Paris 1991).
BPD is a mixture of psychotic, neurotic and characterological disturbances combined with healthy personality aspects. There is a weak ego that creates an unstable clinical picture in that patients under stressful conditions may experience a "temporary psychosis" (Grinker 1977; Grinker et al. 1968). Gunderson and Kolb (1978) and Gunderson and Singer (1975) identify as criteria for BPD: lowered achievement or work capacity; impulsivity, especially in areas of drug abuse; manipulative suicidal gestures like wrist slashing (see Graft and Mallin 1967); brief psychotic episodes; rapid shifting identifications; disturbances in interpersonal relations. Carpenter et al. (1977) emphasizes the borderline's intense affects, frequent dissociated states, and lack of stable interpersonal relationships.
However, BPD is not "borderline schizophrenia," although patients may describe psychotic experiences that appear like "acute schizophrenia" (see DSM III). The overall symptom pattern more resembles anxious and irritable depression. It is an affective, rather than "thinking disorder" (Spitzer and Endicott 1979). Borderline patients, unlike schizophrenics, do not deteriorate over time; there is no residual damage of cognitive disorganization. After episodes, the individual rapidly returns to usual levels of functioning but remains vulnerable, easily agitated, and prone to rapid mood swings and recurrent psychotic episodes (see Carpenter et al. 1977; Grinker 1977; Gunderson and Kolb 1978).
BPD is considered a self disorder (Kohut 1971; Rinsley 1982) characterized by a developmental failure to achieve a coherent self structure or identity, i.e. an "identity diffusion" (Kernberg 1975). Grinker (1977) separates those individuals closer to the "psychotic border" from those with a better prognosis and a less brittle ego who are closer to the "neurotic border." Yet the susceptibility to be overwhelmed by unconscious material (i.e. borderline states) and the absence of a consistent self-identity are clinical factors in both borderline groups, while a greater capacity for positive affect with less withdrawing and distancing defenses, i.e. an "anaclitic depression," predominates at the neurotic border (Grinker et al. 1968).
Psychoanalysts call attention to the role of "splitting" in BPD, in which contradicting "ego states," i.e. constellations of perceptions, thoughts, and feelings, vacillate between extremes of good and bad, and idealization and devaluation (Kernberg 1967: 667-670). That is, BPD patients are split and their attitudes may shift between remorse about acting out, at other times rationalizing the same behavior, making it ego syntonic (Kern-berg 1967:648). Searles (1977) speaks of "multiple identities" supported by splitting defenses. Fairbairn (1952) states that splitting is a manifestation of "separate dissociated subpersonalities." The characteristics of splitting in BPD include conflicting feelings and identities, and acting-out episodes where the individual is dominated by uncontrollable impulses. The latter may involve dangerous self-destructive behavior and may reach psychotic proportions. Given the overwhelming nature of the borderline's autonomous split-off complexes or "internal objects," it is not surprising that psychoanalytic investigators draw a parallel between BPD and "possession" states (Grotstein 1979; 1981; Taylor 1978).
In an earlier paper (Peters 1988), I proposed that the "possession" state identified by these Western analysts is a more severe, chronic, and pervasive variety of the "possession syndrome" than is prevalent in most third world and indigenous cultures. Yap (1960) reached a similar conclusion regarding chronicity, and epidemiology of the severe-pervasive type in his comparison of the possession syndrome in Chinese and French contexts.
Of interest are the variations and reversals in male vs. female epidemiology for BPD cross-culturally which may parallel distinct social tensions (Paris 1991). In the West, for example, there is a prevalence of women over men diagnosed as BPD (DSM III-R), a ratio as large as 3:1 in one study (Stone 1980). This may be due in part to cultural bound factors such as the stress for women to be thin, leading to high rates in women with anorexia/bulimia (Newman and Halvorson 1982), considered by numerous clinicians to be a borderline-associated condition (Grotstein 1981; Masterson 1977; Stone 1980; 1983). Another factor may be the overwhelming ratio of male over female suicide completion: 70% vs. 30% (Schneidman and Faberow 1983), as compared to suicide attempts ("parasuicide") (Wekstein 1979). Further, as some scholars of Western psychiatric history for the last few hundred years have pointed out, women make up the preponderance of mental patients, including diagnosis of such disorders as demonical possession, hysteria, schizophrenia (Chesler 1972). They especially call our attention to "dependency" personality disorders, like BPD and the hysterical personality disorder, and the recent craze over "codependency," all of which, in many ways, are a reflection of Western feminine social reality (Nuckolls 1992; Ussher 1991). As Chesler (1972) indicates, madness in our culture functions as a mirror image of the feminine social experience and the penalty for being feminine.
Unlike the non-Western CBSs discussed above, the borderline syndrome, although primarily affecting young individuals who are having difficulty making the transition to adult responsibilities, goals, identity, values, and career choices (see DSM III~R), does not initiate a cultural rite of passage and is instead a severe form of mental illness with chronic reoccurring psychotic episodes and impulsiveness lasting for years, even decades, until they eventually "burn out" with age (Paris 1988). The borderline state, unlike the ataques de nervios or negative-possession states in tribal cultures, is not a culturally legitimate means of coping with overwhelming stress nor is it a "calling" to initiation. Rather it is a socially isolating mental illness.
In small scale societies, labeling someone ill is a precondition for effective social action (Edgerton 1980). The penalties which one might accrue are not significant in the light of the care and support offered (Westermeyer and Winthrob 1979). The New Guinea example and the Puerto Rican Syndrome cited above can best be understood as "transitional" experiences. In New Guinea, the hysterical psychosis (wild-man behavior) was occasioned by a failure to assume normal adult roles and, in the Bena Bena example, as a means for making that transition. The ataques de nervios was typically treated as a "calling" to develop spiritist-mediumistic faculties. This is a transition to a spiritual vocation and is similar to becoming a shaman (Hastings 1991; Kalweit 1988; Lewis 1989; Peters and Price-Williams 1980; 1983). They form an initiatory scenario.
There is, of course, a distinction between transitional experiences and a pathological syndrome. But, in the West, labeling and consequent stigma have been implicated in the chronicity of mental disorders (Foucault 1965; Scheff 1966; Szasz 1961; Waxler 1974; 1979). Cross-culturally, there are distinct ways in which unusual states of consciousness are labeled and treated. As mentioned above, many of the non-Western CBSs are not indigenously considered to be "mental disorders." In Western societies, practically any radical alteration in consciousness is considered a sign of "craziness" and "so usually induce great fear in people when they begin to experience them" (Tart 1971:119). In non-Western cultures, CBSs are generally recognized as spiritual crises, analogous to "spiritual emergencies," a concept of significance to transpersonal anthropology and psychology, as well as to the cur-rent-day psychiatric nosology, treatment, and conceptualization of spiritual experiences (see Grof and Grof 1989; 1990; Lukoff 1985).
Cultural rites of passage occur during crisis situations in the life cycle of an individual. They are periods of transition in cultural expectations, in social roles and status, in interpersonal relations, in psychological state and way of being-in-the-world (Chapple and Coon 1942; Turner 1967; van-Gennep 1960; Wilson 1967; Young 1965). The typical rites of passage relevant to this study are male and female tribal or puberty rites and initiations into sacred vocations (e.g. shamanism). Rites of passage have three phases: separation, transition (liminal), and worldly return. Separation is from one's familiar surroundings, life style and identity. Australian aborigine children are taken to sacred huts or clearings away from their homes by initiation masters masked and clad like the eternal ancestors of the dream time, to make contact with the sacred (Eliade 1958). Native American youths traditionally make contact with the sacred through fasting and "vision quests" in the wilderness (Foster and Little 1987). Shamans seclude themselves during their "calling" (Rasmussen 1929) or are chosen due to near fatal illnesses (Myerhoff 1974), or near-death experiences (Ring 1988), in some cultures running off naked into the forest for days (Peters 1981), in others immersing themselves in icy water for long periods (Blacker 1986), or cutting themselves with knives (Crapanzano 1977), or quite commonly having visions of body dismemberment ("skeletonization" ) (see Eliade 1964), all of which result in spiritual awakening (Harner 1990; Kalweit 1988; Peters 1989; 1990). On the other hand, Western psychiatrists note that dreams of body fragmentation, dismemberment, and mutilation occur frequently to individuals with BPD and are often indicative of the borderline disorder (Stone 1979).
The second phase, transition or liminality, is "betwixt" and "between" social categories and states of being. The novices are "travelers in a transitional area" (Turner 1962). The individual, now separated, is no longer what she/he was before, but not yet what will be once passage is achieved. The process is comparable to gestation; the old dies and gives way to the new (death and rebirth). Herein the candidate acquires sacred knowledge; the new life is explained through the means of sacred myth and object (sacra) or received through a vision. The neophytes are typically referred to as "dead" or "being in the womb, " symbolic of "dying" and "resurrection," the completed passage (Campbell 1968). In puberty rites, a sacred operation is performed by the initiation masters, typically a form of body mutilation like circumcision, scarification, symbolizing the transition to a new form and way of being.
Once the new state of being is imprinted, the novice is reintegrated into the community, expected to fulfill the new role of adult or shaman, etc. There is a resumption of ordinary reality, but now others are treated in a new way and new types of interactive patterns emerge, as when the aborigine mother performs a bereavement ritual for her child when he returns to the ordinary world as a man (see Eliade 1958). The person has been reborn, transformed as the chrysalis becomes the butterfly, the child the adult, the adult a shaman. The cognitive function of rites of passage is the "transformation of the model of reality" (McManus 1979).
The period of transition is paradoxical; within it the symbols of life and death both dominate. Eliade (1958:21ff, 72) considers the existential state of consciousness created during initiations to be one of "dread," "awe," and of a "belief in impending death." Everything is done to cause a "disintegration of the personality." In other words, there is a nonordinary state of consciousness created, typically through fasting, ingestion of psychoactive drugs, and physical deprivations and mutilations, all to aid the process of passage: disintegration, transformation, and psycho-social reintegration.
The Latin term, transitio, means "the act of going across," the passage from one state to another. Initio is to go back to the beginning, to re-connect with the origin of life, the eternal and sacred, i.e. to transition by "regressing" to initial conditions (Eliade 1954). Such are the goals of rites of passage and, in my opinion, the symptomatic acts of the borderline patient. Because transition involves a death and rebirth, the initiate's food and blood, necessities for life and the integrity of the body, are challenged. These procedures bring the individual, contemporary and tribal, to the "threshold" of transformation.
As documented earlier, fasting, body mutilation, and/or the use of psychoactive drugs are often pans of rites of passage. Yet these same behaviors, albeit from a distinct psychiatric and pathological perspective, are all highly implicated in BPD. As regards anorexia, it is now generally accepted to be a Western CBS and has not been reported in small scale societies (DiNicola 1990; Prince 1979; 1983) while fasting, as stated above, is a typical part of a rite of passage in tribal societies. Likewise, the border-line traits of addiction and substance abuse are uncommon in small scale tribal societies (Fabrega 1984). In these societies, the use of intoxicating substances are pan of the sacred ritual context and quite commonly part of rites of passage into adulthood (Grob and Dobkin de Rios 1992). In such a context intoxicants seldom produce disruptive behavior (Marshall 1979). Such is also the case with body mutilations in "primitive" cultures (see Favazza 1987).
It is my contention that the para-suicidality and other life-threatening borderline symptoms are "ritualistic" attempts to provoke an encounter with death. As the Jungian analyst, James Hillman (1965), believes, the underlying meaning of suicidal behavior is that the psyche needs the "death experience" in order to undergo radical change. These self-destructive symptoms are thus actually attempts at self-transformation of "rites of passage," as Reeves and Tugend (1987) say, that have "gone wrong." Similarly, Bateson (1961) has argued that the psychotic episodes, which he sees as an attack upon the self, have the function of "endogenous rites of passage," but without exogenous social support and validating belief system and are therefore failures at healing. In other words, these regressions to the potentially tranformational "prima materia" (to use Jung's  term) become stigmatizing and culturally isolating. And, seeing that the person is in crisis, this influences the course of the experience and predisposes the person to a chronic mental illness.
Rites of passage in traditional societies are culturally sanctioned "spiritual emergencies" (Grof and Grof 1989; 1990). Spiritual emergencies can be triggered by physical factors (disease, accident, lack of sleep or food, the birth experience in women). They may be started by psychosocial stress or loss such as a death or divorce. They can be the result of "hitting bottom" due to alcohol or drug addiction. In essence, these are all "peak" and "nadir" type trans-personal and transformational experiences (Grof and Grof 1989; 1990; Maslow 1962). Spiritual emergencies follow a trajectory of death and rebirth, the paradigmatic scenario of a "rite of passage." As Grof and Grof (1990) write, "ego death", that is, being reduced to nothing but one's "essential core," is the precondition for a "spiritual emergence." The nearness to death experience is a prerequisite part of the tranformational experience, and is recognized in nearly all the great mystical traditions of humankind including alchemy, shamanism, and the mystery religions (Metzner 1986). The transitional and sacred symbols of the ritual process help negotiate the major psychological transformations--the deaths and rebirths--life demands. If handled with understanding, these become unique moments of growth and re-structuring of consciousness (also see Grof 1985; Grof and Grof 1980).
Borderline patients, as has been discussed, have a propensity to anorexia, addictions, and suicidality; i.e., to a cycle of self-destructive behaviors. Further, these are "framed" as psychiatric disorders and therefore stripped of spiritual purpose. It is highly prevalent in contemporary society. However, in traditional cultures where "hysterical psychosis" or borderline states are treated in the context of the sacred, they are typically acute and transitory. It may well be that social stigma and rejection consequent upon labeling is one of the causal factors, as is our lack of viewing these experiences from the context of the sacred. In other words, CBSs are successfully treated in traditional communities whereas the Western individual is more dependent on his or her own resources in order to successfully complete a spontaneous endogenous rites of passage. Thus the lack of sacred community rites of passage that aid individuals in critical and transitional life phases is an important implicating factor in BPD.
During rites of passage, according to Turner (1969), "communitas," an existential state of oneness with others and the sacred, is established in the novice. Communitas is "anti-structure," an ecstatic feeling of unity beyond all categories and hierarchies. Occurring during the transitional or threshold period, it is a relatively undifferentiated "living together." It is the precondition of community and social structure. From it, the differentiations of status and role which is society emerges. Anti-structure or communitas is the existential base of society that transcends all psychosocial boundaries. Communitas is the feeling of our "common humanity" stripped of all differentiating qualities. The social function of ritual, according to Durkheim (1957) is to create such social solidarity, i.e. to bring people together in an "effervescent" state of consciousness to celebrate and commemorate their unity. This communal social experience is, in many ways, analogous to Wilber's (1979: 134) description of "no-boundary" transpersonal and therapeutic experiences in which we learn through ego transcendence to care for others, not because they respect, love, secure, support, or reflect us, but because they "are us".
These transpersonal experiences of community and oneness are, in my opinion, what borderline patients are attempting to achieve through drug use and abuse, mutilations, and other self-destructive behavior but which, however, become isolating and labeled. Like rites of passage and spiritual emergencies, borderline states may be ego annihilating crises in which acts and symbols of life and death are evoked. But they, unlike traditional rites of passage, are bereft of cultural value, spiritual context, and an education for transcendence, which hinders their transpersonal potentiality.
In the Western contemporary world, we separate psychology from religion. Emotional problems have to do with personal trauma in the family or in childhood, and not with the cultural loss of spirituality or our sense of interconnectedness to each other and to the whole. We don' t diagnose the absence of personal and/or cultural spiritual sensibility or deep meaningful myth and rite. Through ritual, we access the spirit and move closer to what our souls aspire (Some 1993). Yet, when culture does not fulfill a human "need for myth, ritual and a spiritual life, " a person is deprived, suffers and, according to Moore (1992:203), becomes symptomatic. The symptoms of BPD are, in themselves, impulsively ritualistic and, while not culturally sanctioned, replete with cultural meaning. As Moore (1992:205) writes, persons who are starving themselves anorexically evoke in their ascetic ". . . food rituals, vestigial forms of religious practice . . . [and] as [our] society's symptom, anorexia could be trying to teach us that we need a more genuine spiritual life. . ." (parentheses mine). Thus we are starving ourselves spiritually rather than fasting in a sacred way from a vision or a transcendent experience.
Paris (1991) has suggested that borderline disorders are rapidly increasing in Western societies. As indication of this, he asserts that suicide attempts (parasuicide) have more than doubled in the United States, Australia, and Great Britain in the last ten years. High suicide rates among youths are found in cultures undergoing rapid change, loss of traditional and spiritual mores and values, and other situations of cultural disruption (see Jilek-Aall 1988). Although suicide attempts are not exclusively part of BPD, appearing in other diagnostic categories, especially depression, they are also quite prevalent during the depressive swing in BPD and are worthy of mention in this regard.
May (1991) believes that suicide and major personality disorders like BPD stem from a lack of meaningful sacred myths. In our age of "ruthlessness, " "narcissism," "individuation," and "scientific rationalism," he contends, the divine is absent to many. Without myth, we are without soul. Myths and the rituals they explain guide the formation of cultural identity. As Geertz (1973) writes, they are models "of" and "for" identity and reality. Models of in that they provide a blueprint of what culture maps as real and valuable; a model for in that they form charters with which individuals identify and are thereby guides for behavior, identity, and reality.
According to Eliade (1954), reality and identity are established for "primitive" peoples through "participation" and "repetitions" of the mythological paradigms. In other words, an action, event or person acquires meaning only to the extent that there is an identification with what was revealed in the sacred mythos. Through myth and rite, we learn of our identity and bring value to the world. The lack of sacred myth and rites in our culture has led to an erosion of meaning for both sexes (Bly 1987; Woodman 1987). In the extreme, this "identity diffusion", i.e. the lack of the goals and values that form personality and community solidarity, is a principle feature in BPD (Kernberg 1975).
In a seminal article on the !Kung Zhu/twasi of South Africa, Katz (1973) writes about their "education for transcendence." The transcendent state of consciousness described as !kia involves a "death" to normal identity and leads to the activation of a powerful and mysterious energy (n/um) that is used by half of the adult males and one-third of adult females for religious and healing functions in rituals in which the entire band, including children, participate and learn about transcendental experiences. Katz (1973) believes that, analogous to the !Kung youths, Western young people are looking for the experience of transcendence and transformation, but many are instead left in a state of "identity diffusion." According to Katz (1973), "education for transcendence" is a principal factor that distinguishes !Kung trancers from their contemporary counterparts who have little sense of place in the universe. That is, there is no identity forming spiritual base or mythological system to support the psychological death experience necessary for transformation and spiritual rebirth, nor rituals that create communitas. Unlike the !Kung, we do not have meaningful myths and rites of passage to aid in the formation, transformation, and, on a higher transpersonal level, the reformation of identity.
From the perspective of cultural psychology, rituals heal because their purpose is to create social support and thereby decrease alienation, encouraging hope and faith which, in turn, reduces depression and anxiety (Frank 1979). Achterberg (1992: 158, 162) suggests that rituals are "the foundation for transpersonal medicine" in that they increase well being because, "though ritual one can gain access to the transpersonal forces of community and spirit . . . a sense of knowing that we are intimately connected to all that is." Charlene Spretnak (1991:22) asks, how can we expect to achieve a fundamental deepening of our modes of being without ". . . cultural practices that encourage us to grow in awareness, to come to realize we live in a participatory universe."
Borderline "psychotic" episodes are attempts to achieve identity, transition, and rebirth through ego death. The borderline is fixated in transition--betwixt and between, repetitively reinvoking symptomatic concrete "ritualistic" acts of self-destruction unacceptable in contemporary culture, yet at the same time symbolic of the necessity to psychologically die to the old before worldly return and reintegration to complete the cycle of transformation. All too often therapists fail to appreciate the initiatory nature of many borderline addictive and impulsive behaviors as ecstatic and agonizing attempts to achieve healing and transformation through a "dark night of the soul," which may become, in a milieu of sacred myth and rite, a healing experience (Bragdon 1988; S. Grof 1987; Grof and Grof 1989; 1990; Small 1991).
BPD and borderline self-destructive "acting-out" behavior has been investigated extensively by psychoanalysts and described as being akin to "trance" and "dream states" and, while seen by many as pathological (Greenson 1966; Grinberg 1968; Stein 1969), there are other psychoanalytical clinicians who interpret acting out episodes as providing "relief of tension" (Rexford 1978: 323), as "experimental recollection", and a "necessary detour" that is potentially therapeutic (Ekstein and Friedman 1957; Khan 1964). Limentani (1966) believes that acting-out is a cry for help and an indication of hope which therefore should not be censured in therapy unless the patient's vital needs must be safeguarded. Acting-out is therefore not necessarily a disturbance, but may be a means of gaining insight and integration (Kanzer 1957). Angel (1965:79) maintains that the borderline patient's acting-out is an attempt to separate and achieve identity. Blos (1978: 166-167) posits that acting-out during the "second separation-individuation process" in adolescence is adaptive, "in the service of progressive development," and that the individual could not go forward without first regressing temporarily. Thus acting-out is potentially "transitional phenomenon," a necessary temporary regression which aids passage from one developmental level to another. As Limentani (1966:280) says, it should be expected in therapy with the borderline patient and is part of the process of "working through" feelings of envy and hatred. Milner (1952) maintains that such temporary regressive experiences of "merging," "fusion," and "loss of boundaries" are necessary for psychological change and should be fostered in therapy (see Kris 1952). In these studies, there is an underlying recognition of transitional processes; that destructuring precedes restructuring, and that the destructuring symptoms are part and parcel of the total healing experience, as fever is the body's curative reaction to infection.
The psychological value of such critical processes has of course been recognized in humanistic and trans-personal literature for many years (Jung 1969; Laing 1967; Maslow 1962). Still, in our culture, the patient is thrown upon his/her own resources again because of our lack of sanctioned sacred rites of passage (Bernstein 1987). As Achterberg (1985) suggests, the symbols and rituals that hold power culturally appear to be necessary with many patients to open the healing mechanisms. Myth and ritual are pathways to the transformative and the transpersonal. The term "ritual" stems from the Indo-European root which means "to fit together" for the purpose of creating order (Combs and Holland 1990). The ritual process represents a movement from "chaos to cosmos" (Eliade 1954; Turner 1969). In tribal cultures, there is ritual support for change and life transitions, i.e. to help fit things together anew, ordered and balanced socially and psychospiritually. As Arrien (1993:6) affirms, our loss of myth and rite contribute to mental illness by making it necessary for individuals to accomplish their transitions alone and with private symbols (also see Kimball 1960).
In a previous article, I reported a clinical example of a case I anthropologically followed of a borderline patient whose acting-out episodes of self-cutting and deep depression oscillated with periods of high functioning as a licensed psychotherapist (Peters 1988). This patient's mental condition was rejected by her psychiatrists and by society. She was advised not to continue her work as a therapist. Indeed, it seems appropriate to us that a disturbed individual should not be employed in treating other disturbed individuals. Yet it was only after nearly a decade of parasuicidal behaviors and intermittent hospitalizations that the patient decided to leave her native state and resume her profession in another (against psychiatric advice). Today, she is a therapist of adolescents and youths, married and a functioning mother without episodes for nearly four years. One is reminded of the archetypal theme of the "wounded healer" who returns from near-death, after skeletonization and dismemberment, transformed with new purpose, value and way of being (Halifax 1982). The patient described her transformation retrospectively as having been catalyzed by the realization that, contrary to what her doctors said, she felt she was better qualified to be a therapist because of her own inner journey. Her encounter with madness had made her able to understand others who had embarked upon a similar course; that is to say to find empathetic communitas with them. Thus she came to believe in the inherent value in her "illness" which set her on a renewed path of service.
In traditional societies, such experiences typically lead to initiation. Shamans, for example, are thought to be "healed madmen" (Ackerknecht 1943). Their so-called "psychotic episodes" are indigenously framed as a "calling" from which recovery is expected and a signal to begin an apprenticeship (Peters and Price-Williams 1980; Walsh 1990). They are "creative illnesses" (Ellenberger 1970). Such experiences are a socially acknowledged stage of a spiritual discipline (Peters 1989; 1990) and are analogous to the cross-cultural experiences discussed earlier.
Clinically, it seems necessary to learn from the past and become more sensitive to the potentially progressive function of many hysterically psychotic or borderline experiences. While such states of consciousness may be uncomfortable to both patient and therapist, as the transpersonal psychology literature indicates, loss of identity boundaries possesses value and may be healing. From this perspective, the role of a psychotherapist is possibly closer to that of initiation master, a creator of communitas, than to a medical doctor (see van der Hart 1983). Such a temporary regression might be initio for psychology and psychiatry--a going back to our shamanic medicine and healing roots, a reincorporation of spirit and community into psychiatric ritual. In tribal cultures, the weights of a whole society and its belief in myth, ritual, and united community spirit (communitas) enters into the healings. The power of such rites far overshadows modern psychiatric methods. Tranquilization and insight oriented psychotherapies pale in comparison to the emotionally evocative community healing rites of shamans. Thus the job of even the best neo-shaman therapist is more difficult in our heterogeneous community which has no relation to myth, ritual, and communitas. Likewise difficult is the task of present-day psychiatric patients who must navigate a virtual Sea of Dragons of psychotropics, hospitalizations, stigmatization, isolation, and disconfirmation, in contrast to our tribal brothers and sisters who receive education in transcendence and transformation through sacred myth and ritual.
In tribal societies, "soul loss," "spirit possession," and other typical CBSs are not considered individual problems per se. Rather they are seen as problems involving the whole social network, and the balance and relationship to the spiritual forces of the cosmos. That is, because "illnesses" are considered transpersonal and sacred crises, they involve the intense participation of deity, family and social network. Thus treatment is simultaneously psychosocial and spiritual.
Spiritual and religious experiences are all too often considered negative by psychiatry. Yet there is a significant and positive relationship between religiosity, spirituality, and psychological well being. For example, consider the superior efficiency of the 12-Step programs (all modeled after Alcoholics Anonymous) and other treatments for addiction which involve relationship to a transpersonal "power greater than ourselves" (Lukoff et al. 1992), as well as strong supporting social network of other members. There are also analogies to "rites of passage" through emotionally cathartic "testimonies," and to the mentor-initiate type relationship with the "sponsor." As Lukoff et al. (1992:5) write, "The founders of AA did not ponder whether religion or spiritual factors are important in recovery, but rather if it is possible for alcoholics to recover without the help of a higher power." In another study, Christian psychiatrists reported that, in cases which included such borderline traits as "suicidal intent" and addictions, the Bible and prayer scored as the most effective modality of treatment (see Lukoff et al., 1992: 53). Spiritual, religious and communitas experiences may also explain such cases as the one reported by the psychoanalyst, Rinsley (1982) of a long-term hospitalized borderline patient who improved markedly following a "possession" by the Holy Spirit, which the patient experienced when she began attending services at a charismatic church. Or the possibly borderline patient discussed by Waldman (1992) who explained her own experience of "healing" as being due to her new found faith and church membership.
Engler (1986:34,39) believes that there is a special attraction for individuals with self pathologies (borderline and narcissistic characters) to meditation practice and Buddhist doctrines such as anatta (or no-self), basically because the doctrine legitimizes and rationalizes their lack of self-structure and integration. He warns of the dangers and contraindications, and basically cautions against the practice of meditation or any unconscious uncovering psychotherapies by the borderline patient because of their lack of stable self structure. In other words, one needs an ego or non-diffuse identity before beginning the process of discarding it (Epstein 1990; Wilber 1986a; 1986b; 1986c). However, it may also be that, in our society with its high prevalence of self pathology, a spiritual discipline or education for transcendence is needed to help such individuals find identity, wholeness, and healing. It is not that the borderline patient is without ego. Rather, the borderline condition is a mixture of healthy and pathological characteristics. And, it may be that the borderline person is drawn to meditation and other spiritual practices because he/she is seeking transitional experiences, to transcend in order to reform the ego. Culturally sanctioned rites of passage typically elicit unconscious dynamics and altered experiences of consciousness that are at variance with the ego structuring therapies suggested for unstable self pathologies. These rites, however, are the very means of achieving identity and acquiring community in traditional cultures and are, in my opinion, fundamental psychotherapeutic goals in any society.
If people need a strong or stable ego in order to undergo healthy transformation, then there couldn't be any psychological development in the first place. Children and adolescents do not have, nor do they seem to need, a stable ego identity to undergo radical change. Consider the writings of Erik Erikson (1980:143-144), the psychoanalyst who developed the concept of "identity diffusion" and who, in discussing therapy with dangerous regressed acting-out borderline characters, speaks of a mechanism which he calls the "rock-bottom attitude" that consists of a tremendous pull toward ". . . both the ultimate limit of regression (which is at the same time) the only firm foundation for a renewed progression" [parenthesis mine]. Thus, an extreme regression in the service of the self may lead to a recovery that often coincides with the discovery of previously hidden creative gifts.
Chronic borderline states are attempts to achieve healing change, but failures in that they haven't completed this progressive function. It is in this area that culture, with all its multifaceted complexity, either supports the transition or contributes to the problem, by failing to provide meaningful transpersonal symbol systems for identity reformation or education for transcendence, and thereby fosters chronic transitional illnesses like BPD.
The healing power of rites of passage foster an awareness of the presence of the transpersonal, however this is understood cross-culturally, and this, in my opinion, is the missing element in our psychiatric understanding and treatment of the borderline patient. The loss of rites of passage and their sacred context could be one of the principle factors in the West's transformation of an endogenous healing mechanism--which, in tribal societies, is a culturally sanctioned, sacred, transitional process--into the chronic and insidious medical/secular/profane/unfit for spiritual practice borderline disorder that has become an endemic public health problem. In other words, the borderline syndrome, as mentioned above, like most other chronic and severe psychiatric disorders (e.g., schizophrenia and depression), is less prevalent in cultural contexts with meaningful rites of passage that aid individuals, by evoking communitas and other transpersonal experiences, to successfully traverse life's critical transitional periods. It is not the borderline state itself that is the problem, but cultural and psychiatric phenomenology if it views such radical alterations of consciousness with fear and trepidation, and labels as crazy what may well be endogenous attempts at healing and transformation in need of exogenous social, familial, and psychiatric support, validation, and guidance.
The psychotic episodes of BPD do not have a channel or cultural "container" that is provided by indigenous rites of passage in which chaotic feelings are shaped and thereby become manageable (Plaut 1975). It is this cultural channel, illuminated by the myths and symbols of initiation, that help form identity by providing a transpersonal meaning and context to critical life periods. Without such cultural practices that educate for transcendence, it is difficult to build the self structure that can utilize and integrate experiences of non-ordinary I consciousness. Thus, even the natural healing mechanism of the best "psychotic experience," which Bateson (1961) calls an endogenously orchestrated rite of passage that, in all too many cases, is insufficient to catalyze transition and reintegration.
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Peters, Larry G., Rites of passage and the borderline syndrome: Perspectives in transpersonal anthropology., Vol. 17, ReVision, 06-01-1994, pp 35.