I had intended to explore the topic of how I moved from a disdain of OT to training to become an Occupational Therapist as my next blog post, but I discovered some literature relating to a topic I’ve always been interested in and decided to explore it first. I also have created a page with my intended future blog posts to help keep track of them.
This is a concept I’ve given thought to for a long time, including several years before I understood the importance of meaningful and purposeful activities to the practice of occupational therapy. For the purposes of this post I will refer to ‘self-defeating behaviour’ as SDB and define them to include behaviours I exhibited when diagnosed with Borderline Personality Disorder (BPD), namely: self-harm (primarily cutting/burning), suicidal ideation/suicide planning and eating disordered behaviours of over-exercise, restriction, bingeing and purging.
I recently read a paper by Elliot (2012) that explored the concept of ‘Occupations of Illness’, in particular relating to the effect of eating disorders on daily occupations. I found I could relate many of my own SDBs to constructs discussed in the paper, particularly to the ideas that eating disordered behaviour can turn previously neutral occupations into ones of significant meaning, and the role of such occupations influencing identity.
The Role of Self-Defeating Occupation, for me.
With regard to BPD I’m never terribly sure about whether I should refer to it as an ‘illness’, or something that happened at a certain age, due to being aware that I always had the issues that escalated to become what was diagnosed as BPD. However, for the purposes of this blog I am considering the time I had BPD to be the period of my life where it became all-consuming and significantly limited my engagement in occupation.
On reflection, I feel my goal at the time was self-destruction. I was not particularly aiming for death but more behaving in a violent and aggressive way against myself. I do remember hoping that death might occur, but didn’t feel worthy of releasing myself from the chaotic life I was living. I am also aware of just how ‘all-consuming’ the SDBs were for me. It was only later in my recovery that I was able to acknowledge that the behaviours themselves were not the issue, but the emotions and experiences that drove me to try and manage by engaging in occupations that were detrimental to my health.
I also remember feeling that there was nothing that could ever replace the power of a binge/purge to suffocate difficult emotions, or the release and calm from seeing blood flow. For this reason I decided to attribute the components of my self-defeating occupations to the occupational needs defined by Doble and Santha (2008):
Accomplishment: It is often cited that people with eating disorders feel accomplishment with seeing lower numbers on the scales or clothes becoming too baggy. While this was true for me, I also felt a sense of achievement and power for every person I could hide my problems from, becoming sicker, and weaker, almost invisibly. Similarly, being able to create huge wounds on my body ‘proved’ that I had the power to destroy and make myself more ugly.
Affirmation: My cognitions told me that engaging in SDBs and the occupations that supported them were the only thing of worth in my life. I obtained tangible results, but possibly more importantly I had a way to manage and survive. On reflection now, I do believe that while I nearly didn’t survive BPD, the behaviours kept me alive for long enough to engage in recovery.
Agency: The role of ‘control’ in eating disorders is often recognised. I think I also, mistakenly, felt that the ‘control’ of being able to put in, and remove, vast quantities of food from my body was my evidence that I had power over everything.
Coherence: For me, the coherence of SDBs with my sense of self and internal world was one of the key driving forces. I felt worthless, scum-like and evil. Therefore, abusing the body of the person that housed such a disgusting ‘person’ (I really didn’t even feel human) felt entirely appropriate. At that time, the concept of ‘being kind to myself’ would have been impossible to entertain but finding newer and more serious ways to hurt myself aligned completely with the value I attributed to my existence. My goal was punishment and destruction and repeated SDBs felt like the least I could do.
Companionship: SDBs are isolating. However, before I started using them my internal world was incredibly isolated from the rest of the world. For this reason the behaviours gave me structure, and almost a sense of ‘company’. Self-harm and eating disorders felt like part of me. While in the early years my behaviour was disclosed only to myself, latterly I did use self-help/recovery websites, and also even ‘pro’ self-harm/eating disorder websites. These forums provided the companionship of some great people, who didn’t judge but listened and just understood.
Pleasure: While I would never say that I enjoyed engaging in SDBs or say I was ‘happy’, I know that there was a real sense of contentment provided by having occupations to engage in that were ‘mine’, I did not rely on anyone else for them and I was ‘safe’ while I was occupied with them. SDBs also fought off boredom and chaotic emotion, meaning I didn’t have to engage with the ‘real world’ and was protected from it.
Renewal: I often described bingeing and purging as a sense of ‘oblivion’. Once I started into the cycle all other emotions were forgotten. The binge squashed difficult emotions while the purging felt like letting them go. I followed almost every binge/purge with self-harm, I was numb but found the sensation of the blood grounding. After both behaviours I had a sense of calmness and peace that wasn’t afforded to the rest of my life. It was temporary, often nearly fleeting, but it did provide the sense of renewal.
Replacing Self-Defeating Occupations with Occupations Facilitating a ‘Life Worth Living’.
It is understandable why, after exposing the multi-faceted nature of self-defeating occupations, replacing these occupations with new, healthier occupations was never going to be straightforward. I believe there had to be a series of stages to the process, probably even involving the stage of being contained and ‘kept safe’ in hospital for many months/years before the process could begin. I doubt I ever could have just given up the SDBs and have found new ways to manage my time without significant therapeutic input from dialectical behavioural therapy, psychotherapy, a therapeutic community, medication AND occupational therapy. However, I do believe the latter is the key to my continued recovery and successful rehabilitation. For me, finding meaningful, yet health promoting occupations to engage in was challenging: I had little experience of letting myself have ‘fun’ and enjoy things. So, while it might have seemed easy for someone like me to go shopping, or take part in leisure activities, there were so many issues surrounding this. For example; I was a competent cook and could happily create a meal for a group of 10 people, yet cooking a meal for myself left me in a state of high distress and unable to engage. Even the small things like making a cup of tea or having a bubble bath were so tied up with SDBs that it felt impossible to separate them, never mind challenge the cognitions with regard to not punishing myself.
I’m happy to say that my life now is full of meaningful, health promoting, and even ‘fun’ occupations. I hope to explore more the role of OT in recovery from BPD, particularly relating to the challenges surround doing ‘nice things for yourself’ and the role of SDBs in making neutral occupations self-defeating.
Doble S, Caron Santha J (2008) Occupational well-being: Rethinking occupational therapy outcomes. Canadian Journal of Occupational Therapy 75(3) 184-190
Elliot M (2012) Figured world of eating disorders: Occupations of illness. Canadian Journal of Occupational Therapy, 79(1) 15-22