Tuesday, August 6, 2013

Disturbed Sense of Identity in Borderline Personality Disorder: Part 5

Final installment time. So what have you thought about this series? Enlightening? I’ll definitely try to find some things on how to strengthen identity in BPD, because there have been inquiries, but don’t be surprised when some of it is going to be…. Talk to a therapist and battle out those demons!

Carsten Rene´ Jørgensen, PhD


Personal identity is ‘located’ at the crucial interface between the individual and society and, as argued by Erikson (1968, p. 23), we cannot separate “the identity crisis in individual life and contemporary crisis in historical development because the two help define each other and are truly relative to each other.” Nevertheless, much of the theory and research about BPO and BPD has severely underestimated or even ignored the influence of social organization and

culture. Traditional psychoanalysis and clinical theory cannot fully grasp human identity and identity disorders because they have not developed profound models to conceptualize culture. Early on, Horney (1937) claimed that some of the typical problems recurring in psychopathological individuals are not qualitatively different from the problems experienced by smoothly adapted individuals living in contemporary culture. What is normally interpreted as manifestations of individual psychopathology must also—in part—be understood as a reflection of societal dynamics. One of the remaining questions is of course, as Horney writes, why certain persons develop psychopathological symptoms while others, living under similar conditions, are able to cope with the difficulties they experience. Similarly, in their early investigation of ‘the borderline syndrome,’ Grinker et al. (1968, p. 171) concluded that it is highly likely that ‘the sick borderline’ “represents an exaggeration of a contemporary problem in all civilized mankind.” Thus, from a social psychological perspective, the identity diffusion often found in borderline patients can be interpreted as an illustration—albeit in a radical and pathological form—of the impact the momentous social changes in western culture have on the human psyche. “As the pace, extension, and complexity of modern societies accelerate, identity becomes more and more unstable, more and more fragile” (Kellner 1992, p. 143) and the syndrome of identity diffusion in part reflects problems and discourses in late modern culture. Thus, identity diffusion cannot be reduced to an individual psychological problem alone.

Hmmmm. While I definitely think personality is influenced by society and culture I’m not sure I would go so far as to say it wouldn’t exist without it (in regards to where it’s located.) However the drawing a cultural parallel between BPD identity diffusion and the potential impact of momentous social changes in western culture on the human psyche is interesting. Limiting, but interesting. I say limiting, because clearly BPD is found all over the world, and is not limited to western societies.

Even though sociology and social psychology, on the one hand, and clinical psychology and psychoanalysis, on the other, focus on different parts of identity and identity development, representing different perspectives on issues of identity, it is interesting to note the significant similarities between the descriptions of ‘late modern man’ in contemporary sociology and what has been described as the core—and primary manifestations—of borderline personality disorder. The point is not that there should exist something like a direct cause and effect relationship between contemporary culture and borderline disorders, including clinical cases of pathological identity diffusion, rather that in order to arrive at a satisfactory conceptualization of borderline disorders our established clinical models must integrate an understanding of late modern culture and how trends in contemporary culture affect human psychology. In particular, focus should be given to how identity diffusion is related to the prevailing zeitgeist and cultural change (Jørgensen, 2006).

DSM-IV emphasize that the essential feature of borderline personality disorder is “a pervasive pattern of instability of interpersonal relationships, self-image and affects.” Similarly, Bauman (2005, p. 33) has suggested that what will result from contemporary culture, characterized by continuous change, is a “permanently impermanent self.” “Identity building has taken the form of unstoppable experimentation” (Bauman, 2004, p. 85) and has become a never-ending process, characterized by instability and perpetual change. In modern societies self-chosen identities and commitments predominated, whereas some form of ‘adaptive’ identity diffusion (lack of stable, long-term commitments) appears to be emerging as predominant in late-modern societies (Cote, 1996, p. 421). Identity problems have become “more than a rare condition of mental patients or a passing condition of adolescence” (Bauman, 2001, p. 148). And some of the identity problems we observe in our borderline patients reflect experiences that are relatively common (though in moderated forms) among people living in late modernity.

            I like that – a permanently impermanent self. A walking, talking contradiction.

Breakdown of the cultural mechanisms that formerly provided individuals with prefabricated, culturally constructed, and a priori validated and recognized identities is part of the process that has made identity a problem in late modern societies (c.f. Westen & Cohen, 1993). Social structure that formerly provided a buffer against psychopathology has been weakened and the risk of developing psychopathology, including identity disturbances and borderline disorders, has increased. In some cases the weakening of social institutions and structures presumably contributes significantly to the borderline patient’s characteristic identity problems.

Too much choice and freedom is apparently the problem. Back in ye olden days when the oldest ran the family business, the middle child went to seminary, and the youngest went into the military it was all easy and shit. You didn’t have to think. You knew exactly who you were supposed to be. If you were a woman even easier! Parents picked you out a husband, you shut up and let your husband do all your thinking. It’s these modern time freedom shenanigans that are causing all these problems.

Rapid social changes, intergenerational discontinuity, unclear and rapidly changing social roles, and decreased family and community cohesion (Paris, 1998), which characterize modern western culture, constitute risk factors for identity diffusion and the development of borderline pathology.

Okay, look, I get the impetus behind this, but we only live one life at a time. I wasn’t even alive when all that stuff happened or these traditions were in place, so I was programmed to respond to things that way. The freedoms of my modern society aren’t shifting rapidly for me. It’s just how they are. It’s a cute analogy, and I get that social change is upheaving, but social change is also radically necessary. I for one like not being discriminated again and having the vote. Bleh.
Additionally, borderline personality has been conceptualized as an impulsive spectrum disorder associated with under-controlled emotions and dysregulation of the self. Even though affective instability/dysregulation and impulsivity is partly constitutional (Stone, 2005) and has been related to significant others repeatedly invalidating the self (Linehan, 1993), the unfolding of personality traits related to instability and impulsivity is probably sensitive to the prevailing relative absence of external structures (Paris, 1998), invitations to almost limitless self-expression and self-realization, unstable and unclear social roles and unpredictable, rapidly changing social expectations. In all likelihood, cultural changes intensify the development of maladaptive behavior in brittle individuals. This possibly leads to the establishment of malignant vicious circles where maladaptive behavior is followed by social exclusion, shown to enhance anxiety and proneness to regressive and maladaptive behavior. In addition to this, social exclusion and marginalization deprives the borderline patient of important sources of identity building and the means to stabilize a fragile identity (work, resource-full, and enduring social communities, etc.).

I think cultural norms and stigmas that are forced on us based on race, religion, gender, sexual orientation, etc. that go against how we feel and would like to act or be perceived are enough to make anyone that acts against them in any way be perceived as impulsive or odd. That’s before you add even a little bit of BPD into the equation. Cultural and societial norms when a person doesn’t feel they apply appropriately to who they are can be oppressive and fighting against them is stressful especially when you’re trying to get people within the norm to understand and accept you though you may be a bit different. Going against the grain creates negative feedback from a person culture. Many people (myself certainly included) have very little interest in following the preordained societal norms of expression not because of BPD, but because that’s just not who we are. So yeah that leads to social exclusion, and anxiety, etc, but is that because of BPD? Or is that because of the culture and society being unaccepting?

Lifton (1993) describes how people living in late modern culture develop a protean self, a sequential and fluid self-characterized by ever changing involvements with people, ideas and activities. Similarly, Bauman (1997, p. 24) has suggested, “instead of constructing one’s identity, gradually and patiently, as one builds a house” late modern man constructs a palimpsest identity; “a series of ‘new beginnings,’ experimenting with instantly assembled yet easily dismantled shapes, painted one over the other” (p. 24). The restless late modern culture, ruled by short-term goals and commitments, threatens to corrode psychological character, “particularly those qualities of character which bind human beings to one another and furnish each with a sense of sustainable self” (Sennett, 1998). Flexible or short-term capitalism (p. 27) emphasize flexibility and people are “asked to behave nimbly, to be open to change at short notice, to take risks continually” (p. 9). “Failure to move is taken as a sign of failure, stability seeming almost like a living death” (p. 87).

In a world that demands flexibility in self-presentation and behavior “the most adaptive form of selfhood may be a loose confederacy of multiple self-conceptions” (McAdams, 1997, p. 51). “The hub of post-modern life strategy is not making identity stand—but the avoidance of being fixed” (Bauman, 1997, p. 89) and the most adaptive life strategy is probably a moderate and controlled form of the protean self. Some of the requirements of classical identity theory, notably the ideas of inner sameness and continuity over time and across situations, are partly at odds with the fluidity of predominant culture and experiences (Lifton, 1993, p. 26). “In our age of hyper-individualism—which stresses instant transformation, flexible reinvention and creative renewal—conventional assumptions regarding the solidity and durability of identity are increasingly disrupted” (Elliott & Lemert, 2006, p. 31). Inner plurality has become an adaptive answer to contemporary plurality of values, forms of life, and social contexts where the individual is expected to navigate competently (Bilden,1997). The essence of the protean self “is a linking—often loose but functional—of identity elements and subselves not ordinarily associated with one another,”(Lifton, 1993, p. 50). Similarly, post-modern theorists (Cushman & Gilford, 1999) have claimed that western society is moving towards a state of mind where the individual, in order to survive, must contain ‘multiple selves’ or have multiple identities. Gergen (1991) has described how late modern man develops a ‘pastiche personality.’ He becomes “a social chameleon, constantly borrowing bits and pieces of identity from whatever sources are available and constructing them as “useful” or “desirable” in any given situation” (Gergen, 1991, p. 150).

As pointed out by Lifton (1993, p. 190), the protean self is always confronted with the danger that the combination of identity elements will not cohere and there is an “ever-present danger of diffusion, to the point of rendering the self-incoherent and immobile.” ‘Negative proteanism,’ as described by Lifton (1993, p. 190), is characterized by “fluidity so lacking in moral content and sustainable inner form that it is likely to result in fragmentation.” Lifton hypothesized that commitment to proteanism may cause the person to respond to emotional problems by accelerating the shifts between fragments of identity “while clinging to an illusion of salvation via perpetual transformation.” It is interesting to note, how descriptions of contemporary social character and life strategies resemble those we find—in more maladaptive forms—in borderline patients. Some of the severe identity problems found in borderline patients can be understood as pathological forms of prevailing life strategies and strategies to handle important identity themes that have become out of control. Identity diffusion can partly be conceptualized as a radicalization of the protean self or pastiche personality where flexibility and perpetual shifts between different identity elements have become maladaptive and pathological.

This idea of the Protean Self I find interesting. The concept of being different people in different situations; mirroring or projecting but they make it seem like it’s a conscious effort. I’ve never noticed any real conscious thought going into things when I’ve found myself mirroring or projecting (which is what this reminds me of but to a more extreme degree). Being in character(s), for different people, in different places.

One of the things that differentiate pathological identity diffusion in borderline patients from ‘normal’ identity problems in late modernity is the borderline patient’s inability to integrate the multiple identities and assemble the many identity fragments in a coherent identity or self-narrative.

In conclusion, one must assume that dynamics in late modern society will contribute to a rising prevalence of borderline personality disorders. (Or simply the fact that we have a booming population and more dysfunction families.) Additionally, cultural changes have made it increasingly difficult for people with borderline disorders to navigate and act competently in daily life. (I’m not sure I entirely agree with this statement either. BPD is a spectrum of lower-to higher functioning and it’s the higher functioning of us that don’t always come out of the psychological closet to get help so how do you know? When would it have ever been easy for someone with BPD to navigate daily life?) Contemporaneous with the weakening of outer structures that hitherto stabilized and gave meaning to life, the need for a strong, stable and mature personal identity has been radicalized. As a consequence of this, borderline patients and others with identity deficits will experience difficulties of increasing severity. They have not developed the inner psychological resources, which ‘normally’ compensate for the consequences of liquidation of social institutions and those cultural practices that generate meaning. Therefore, they urgently need durable social structures and normative social roles to stabilize the self. (Normative social roles? No. Stable social roles. Yes. Sometimes I think that people that have never lived outside of normative society shouldn’t write about cultural pressures.) When the access to such stable outer structures is limited, they will experience more serious difficulties in navigating and making necessary choices of daily life than hitherto experienced. The German sociologist Niklas Luhmann (1968) has argued that trust is an important psychologically founded mechanism to reduce social and societal complexity. In order to live and flourish in late modern societies one must be able to rely upon more or less anonymous others and social systems, and its representatives. The conception of the world seen in borderline patients, however, is typically based on mistrust. Because of deficits in basic trust and fundamentally insecure attachments, borderline patients do not have access to essential psychological resources in their attempts to handle social complexity. Instead, they are overwhelmed by the complexity they experience and recourse to primitive defense mechanisms and invalid attempts aimed at reducing complexity (idiosyncratic understandings of the self and interpersonal processes, simplistic models of the world, etc.).

As if it were a choice ::sigh::. It is often very overwhelming.

In order to understand borderline pathology and identity diffusion in particular, we must operate on at least three different levels. In our future investigations we must focus on how borderline pathology is related to:

(1)   individual vulnerability and resilience (rooted in genetic, temperamental and historical factors);
(2)   current strains, including traumatic experiences, loses and normal developmental transitions; and
(3)   tendencies in contemporary culture that affect human psychology and impede the normal development of human identity.

Hitherto, our understanding of borderline conditions have focused almost exclusively on the first two levels, while our understanding of possible connections between elements of contemporary western culture and identity diffusion have either been ignored, or confined to theories of limited specificity. Given that modern psychoanalytic theory (and psychology in general) represents a sustained endeavor to understand human experience and psychopathology in specific social and cultural contexts, it is essential for our ongoing attempts to understand borderline pathology that we try to appreciate how borderline pathology is related to elements of contemporary culture. We must look beyond the problems of the individual borderline patient to the social structures that aggravate or even contribute to the creation of his or her problems. This will inevitably imply that clinical theory and psychotherapeutic practice acquires/reacquires a distinct moral and political dimension (Jørgensen, 2002). In addition to this, some of the symptoms and dysfunctional behaviors seen in borderline patients reflect elements of late modern culture and could be of significance for our ongoing attempts to understand the problems and experiences which confront humans living in late modern culture. Therefore, we should not only try to integrate theories of contemporary culture in our understanding of the borderline conditions, but also acknowledge the invaluable information concerning contemporary culture that we have access to when we work with borderline patients.

Well I think it’s pointless to only study the impact of Western culture when people in Eastern, Middle Eastern, African, Asian, Australian, Southern Hemisphere, etc cultures experience BPD as well. Egads. BPD is not just an American and European problem.

Don’t get me wrong, I do think culture does have an impact but I don’t think you’re going to get an accurate representation of how it’s affected by culture if you limit your cultural representation. I would think that you would want a cross cultural representation to find similarities between cultures that could contribute. Something along those lines.

So I’m not sure how I feel about this last installment. I think it’s seriously underwhelming and a lot more research and care in the research needs to be done. And no more of this needing Normative stability crap. There is no norm, no normal, no normative. Get rid of that concept. I think that concept of “normal” is part of the problem. 

Snarky Haven is snarky today. 

1 comment:

  1. "Too much choice and freedom is apparently the problem."

    This is a great talk on what you're talking about.



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