Dialectical Behavioural Occupational Therapy?

It is clear to those that have read this blog that I attribute my recovery to a variety of components that each contributed to my improved well-being. However, I feel that the role of Dialectical Behavioural Therapy (DBT) and Occupational Therapy (OT) were both equal and central to my recovery. I personally feel the two therapeutic approaches are quite complementary; at times DBT requires participation in meaningful occupation to implement DBT skills, whereas engagement in meaningful occupation can be enabled by utilising DBT skills to manage the task. As I was in the fortunate position to have a key worker who was an Occupational Therapist and also my DBT therapist, I felt it was important to reflect on my observed link between the two therapies to gain further understanding into my experience of the therapies. I feel it would be an interesting, but giant, task to consider where DBT and OT theory aligns and diverges.

As I mentioned in a previous post I was unable to find significant literature on Borderline Personality Disorder (BPD) and Occupation, when I searched for DBT and Occupation I got even fewer results. I did read through the National Institute for Health and Clinical Excellence (NICE) Guidance for Borderline Personality Disorder (2009) to see what was recommended in terms of OT intervention, and also noted the absence of clear recommendations for the therapeutic value of OT for BPD, while DBT was recommended as a consideration for women diagnosed with BPD. Interestingly, the guidance recommends that when a person with BPD is assessed that their occupational functioning is included in the assessment, yet does not recommend OT other than encouraging multi-disciplinary team intervention in which, conceivably, OT could feature.

As mentioned above I believe the two therapies are complementary although most definitely distinct. In order to understand if there is any substance to my belief I thought I’d use Linehan’s (1993) list of DBT skills, and my understanding and experience of implementing the skills, to explore the role of OT, or perhaps more simply occupation, in DBT and DBT in occupation, for a person recovering from BPD.

DBT Skill Area 1: Core Mindfulness

Linehan’s use of therapeutic mindfulness involves 3 ‘what’ skills, suggesting that you can be mindful in any situation by observing the experience, describing it or fully participating in it and this can be achieved by using the ‘how’ skills. Participation is considered a core belief by OTs (Finlay, 2004) and so this link may be easy to understand. But what about observing and describing? Do they link to engagement in occupation? In my opinion, absolutely. When I have provided teaching on DBT to Clinical Psychology students I often explain the purpose of mindfulness in relation to paying attention in a lecture, if you are able to control your mind and just notice when your mind wanders, and successfully bring it back to the topic being discussed, without judgement, then it is much easier to participate in the lecture.

DBT Skill Area 2: Interpersonal Effectiveness

Linehan’s Interpersonal Effectiveness (IE) Skills provide strategies for ensuring effectiveness that enables a person to achieve their objectives, maintain balanced relationships and importantly that promote self-respect. In developing the skills Linehan suggests a variety of occupations that require the use of IE, such as asking for information about a product or inviting a friend for a meal. It is very easy to see how a person who can competently and confidently ensure that they can get their needs met and interact with people in a way that leaves each party feeling understood and respected, will find it easier to engage in meaningful occupation. Conversely, I would argue that a person is more likely to take the ‘risk’ to develop the IE skills in situations where the occupation is meaningful to them. For me, while starting dance classes was scary and, at times, overwhelming, because it was something I was interested in I was more motivated to increase my DBT skill level to manage the situation, compared to the Tennis Club I joined because it was near by but didn’t really desire to become a competent Tennis player (and subsequently dropped out of after a few weeks).

DBT Skill Area 3: Emotional Regulation

The Emotional Regulation (ER) Skills are possibly the most ‘psychotherapeutic’ as they deal with understanding and tolerating a variety of emotions, any of which can feel overwhelming to a person with BPD (some of my most serious self-harm was after feelings of excitement or elation). However, the skills included in ‘Please master’ deal with reducing vulnerability to emotional dysregulation and rely on engagement with healthy occupations such as eating well, getting enough sleep and exercising, as well as engaging in activities that make you feel competent and in control. The occupations for ER can be quite challenging, for example for me sleep was a pretty torturous experience and I would have chosen not to engage with it, could I have managed it. Similarly, balanced eating felt impossible, never mind being contrary to what I desired to engage in. I feel that some of the occupations for this skill-set are not what will be easy, or even meaningful, for the client and at times they may have to be engaged in with a mindset of ‘this doesn’t feel ok AND I believe it’s the right thing to do and will do it anyway’. While I’m sceptical about the use of meaningful occupation to achieve ER, I firmly believe that reducing vulnerability to emotional dysregulation actively enables participation in occupation. I know that to function at my best I need to eat well and engage in physical activity, I also am aware that my sleep is still inadequate and limits my functioning. It’s important to note that most of the reducing vulnerability skills are not unique to DBT; most people are aware of advice to eat well, exercise and rest for not only physical health, but also mental health. The emotional regulation skills that focus on building positive experiences suggest a variety of means of achieving this, in fact of the 176 listed ‘adult pleasant events’ most involve actively participating in leisure occupations (a challenge in itself, see ‘BPD’s influence on fun occupation’ https://pd2ot.wordpress.com/2012/06/02/bpds-limit-on-fun-occupation/ )

DBT Skill Area 4: Distress Tolerance

Distress Tolerance (DT) Skills are designed to help the client manage period of intense distress and despair, without resorting to self-defeating behaviour. DT utilises mindfulness skills to manage the period of intense emotion and also encourages meditative activities like observing breathing and therapeutic thought processes such as ‘radical acceptance’ of a situation and diverting the mind away from difficult thoughts. While DBT does not endorse distraction as a long-term solution, it does value it as a short-term ‘bandage’ for a situation, and encourages participation is household chores, exercise and social activities. In my experience I have done a lot of distracting from my situation, and particularly when in hospital I used to fill the endless hours with Sudoku puzzles, Nintendo DS games and card making. Now however, I would never choose to engage with any of those activities, but if I do feel distressed I’ll distract with occupations that are meaningful to me, often this will shift it from being a temporary fix to building a positive experience that encourages emotional regulation. I believe that DT skills have been vital in my increased engagement in occupation; many of them are discrete and involve thought processes, meaning I’m able to manage demanding situations and utilise skills, while those around will be unaware of my ‘actions’.

In summary, I feel DBT and OT each have an equal role in facilitating the other. For me, learning DBT skills, while engaged with occupations that were a little more contrived, than meaningful, did not prevent benefit from DBT, but this benefit was maximised when the occupations used were meaningful to me. I suspect that without DBT skills I would have been unable to manage the occupations that I currently participate in, and that I attribute to the sustainability of my recovery. So, yes, I’m a big fan of both approaches and believe they work best when implemented together.

References

Finlay L (2004) The Practice of Psychosocial Occupational Therapy (3rd ed.) Cheltenham: Nelson Thornes.

Linehan M (1993) Skills Training Manual for Treating Borderline Personality Disorder. New York: Guildford Press

National Institute foe Health and Clinical Excellence (2009) CG78 Borderline Personality Disorder: Treatment and Management. Available at: http://publications.nice.org.uk/borderline-personality-disorder-cg78 [Accessed 22 June 2012].

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‘Fitness’ to Practise

I’ve been struggling to find time to blog due to being on placement, and yet I have so many areas I want to explore. I’ll leave the more academic stuff until I have time to do it properly, but for now a reflection on the process of my recovery, prompted by experiences on placement.

A Graded Recovery

When I look back on my recovery I can see a very clear gradation; some of the latter parts were planned in a nice ‘OT way’ and other parts occurred more naturally because I was able to improve and require different levels of support. A brief summary from the point where I was requiring the highest level of support is as follows:

Psychiatric Intensive Care Unit (PICU)

Acute Ward (24hr 1:1 Observations)

Acute Ward (1:1 observations, being gradually reduced)

Acute Ward (ward based)

Therapeutic Community (In-patient)

Therapeutic Community (Day-patient), beginning voluntary work (in a fairly low demand setting), starting leisure activities.

Discharge from Therapeutic Community. Increasing voluntary work commitment (increasing both the challenge from the setting and duration), starting a college course and becoming more involved in leisure activities.

More demanding voluntary work, starting university, increased involvement in leisure and social activities.

First practice placement (decreasing voluntary work and leisure activities in order to try and preserve some restful time).

The time spent at each of the levels was not equal, but I am fortunate that while I have, at times, felt ‘stuck’ in terms of my progress, I never had to drop back a level. This is not true of the period before, as I tended to bounce between being able to be ‘managed’ on the acute ward on 1:1 observations and requiring treatment on the PICU. The purpose of the summary was to consider the many, and fairly significant, steps I have had to take to reach the point of being able to go out on placement.

The Challenge

I remember clearly a lecture earlier this year that included statistics about the poor relationship between the length of time off work due to illness and the chances of returning to work. The lecturer quoted the study by Waddell and Burton (2006) that stated that those people off work for more than 2 years are more likely to retire than they are to return to work. I remember thinking, ‘Yikes, that’s me, in fact my last hospital admission was almost that length alone’ and I wondered what challenges lay ahead of me. Of course, I’m not there yet, but as I’m currently engaged in a full-time placement I thought I might reflect on some of the challenges I’ve encountered.

‘So, why do you want to be an OT?’

It’s funny, during the year at university this question hasn’t cropped up nearly as much as I thought it would, and when it did it was very easy to give a fairly superficial answer that felt comfortable given the level of familiarity I had with the person who was asking. On placement however, I seem to have been asked this by professionals almost every day. With some I can give a nice vague answer about wanting to work with people and liking the approach used in occupational therapy, I’ll also talk about how I’d done various types of voluntary work and discovered it that way. Other people seem to want more concrete examples, like wondering how I discovered about the role of an OT and wanting to know whether I came to the place I now live to study. Now, you could argue that a lot of this stuff is none of their business, but as I am an honest person and because they are only asking to get to know me I find it difficult to be too evasive. Equally, I don’t feel replying with ‘well, I was a nightmare patient, sectioned and unmanageable who was sent for treatment here and when I realised the value of OT in my own recovery I decided to research the profession further and get experience in related settings before applying to study it’ is quite the answer I want to give. Of course, part of me feels like perhaps I should stand up and challenge the stigma surrounding mental health problems, especially personality disorder, but I’m also aware that I have the choice to manage my personal boundaries the same way anyone would on first encounters with people.

The Shadow of the Past

I feel like I am incredibly fortunate to be able to say ‘I have recovered from BPD’ but to not acknowledge that it has left its mark on me would be unrealistic. So, not only do I feel like I have 6 years of ‘crisis’ to try and account for I am still very much in a process of rehabilitation; it is not yet two years since I left full-time treatment. On a very practical level working a 5 day week is a bit of a shock to the system, not least because the one area of my recovery that still requires work is my sleep pattern. I have always found the night to be a very distressing time and while the quality of my day has improved significantly, I still struggle with lack of sleep, nightmares and dissociation throughout the night. University were very happy to discuss my needs regarding placement and we agreed the practical arrangements that would be helpful for this first experience. However, while I did move towards this point in recovery in stages I do feel a little like I’ve chosen to run a marathon while having only trained for a 5k race.

Everyday Reminders

The locality that I am on placement is not one I’d had much experience of. Bar one, slightly significant, incident involving quite a lot of blood and an ambulance. Obviously being in that area brings back some challenging memories and it can feel quite isolating as those memories are not ones I’d choose to share with current colleagues. On balance though, it feels like a great opportunity to be able to face up to some demons and create a new, more positive, experience of the location. Yes, it is a stark reminder of how difficult my life has been AND also a very clear reflection on the progress I have made.

‘Fitness’ to Practise

This post has possibly focussed a little more on the negative consequences of my life experience than is normal for me. However, I wanted to use the post as an honest reflection on how my past influences my present. I am aware that there are areas of my life that still need to be improved and that this placement is quite an increase on the demands I am putting on myself in terms of both physical and emotional energy. I think this self-awareness is vital; it’s allowing me to try and balance up other areas of my life, perhaps temporarily scaling back the leisure activities I do, replacing them with less energetic options and ensuring that I make time to rest, even if my sleep is still atrocious.  I’m also conscious that I still have work to do; that I am still very much on a journey and while I believe I am able to be a responsible and competent student I have to keep building these new, positive experiences. I also value this blog because I have a tendency to come across as incredibly competent to others. In the past I have found the trait of ‘apparent competence’ to be incredibly limiting and this has left me feeling very isolated and overwhelmed, in fact the concept of apparent competence and its influence on occupation is something I wish to explore later, but for now I feel that I’m not falling into the old trap of ‘performing’ for others while internally collapsing. This time, I am managing, and managing quite well thanks to a big chunk of mindfulness and honesty about my current situation. So yes, I am fit to practise, even if it is leaving me feeling a little out of breath!

Reference

Waddell G, Burton A (2006) Is Work Good for Your Health and Well-being? Norwich: The Stationery Office.

Don’t Handle Me with Kid Gloves.

When I created this blog I didn’t really imagine anyone reading it, never mind finding it useful. So, I’ve been very surprised by the response it has gotten on here, Twitter and Facebook. I suppose I was perhaps projecting judgements about my suitability to practice onto others, expecting that if anyone did read this they would be telling me I was too damaged or fragile to be an OT. Consequently, I have been reflecting on two loosely related areas; one, the extent to which stigma about mental health issues still causes an uncomfortable silence and two, how helpful is it to be a professional with extensive experience as a service-user and does it make me ‘different’.

Breaking the silence

I’ve embarked on this exploration of the experience of turning from service-user to service-provider under a blanket of relative anonymity. So far I have only given quite broad identifiable information, however I am not concerned about people who know me discovering this blog, in fact I suspect that one day soon I’ll be much more open and actively join up the facets of my life experience, due to the positive response I’ve received.

So, why have I felt the need to be so tentative in putting my story out there? Especially as I have had extensive, positive, experiences of being a ‘professional service-user’ providing training for a range of professionals and contributing a narrative on my experience as a service-user to mental health texts under my real name? I suspect it’s a combination of my own insecurities and a very real stigma in society. While I am very accepting of the path my life has taken, I think at times I get tired of having to explain myself to others. Most people see me as a competent and interested student but when the conversation, inevitably, gets on to what brought me into the profession and what I’ve been doing with the preceding years of my life, I groan inwardly. How much do I tell people? How much do they need to know? Will they judge me? Are they actually interested? Is it appropriate? All these thoughts, and more, go through my head. I often wonder if I had spent several years in hospital for a physical illness, how much would I say in the same situation? The answer is that I can’t know how I would respond, as I haven’t experienced it. I suspect though, that if the situation was right, I would be much less hesitant, while acknowledging that it’s probably not easy for anyone to disclose personal details early on in encounters.

I have experienced a range of responses to people who discover my background. The only response that I find entirely unhelpful is that of pity and sympathy, and I am sad to say that has happened in my recent experience. Pity ensures that any professional working relationship is certain to fail, and leaves me feeling assigned to a ‘patient-role’. While people who respond in a way that suggests I have reason to hide my background are not the ideal, their attitude has helped me reflect on my own sense of self. When I was applying to university my tutor at college suggested that declaring mental health problems on my UCAS form might result in rejection. I gave this some thought, and while being aware that such a response would be illegal, I also concluded that I wouldn’t want to study somewhere that would only take the ‘undamaged’ version of myself, as well as feeling it was important to be congruent with my own values of honesty and integrity (as far as I can tell, the declaration had absolutely no effect on my application).

In general I find people are very positive when I disclose my history. From friends who are comfortable enough with me and my past to make jokes about it (while, very sincerely acknowledging that out of our group of friends I am the most ‘sorted’), to tutors and professionals who respect the extent of a journey that I have been on, as well as the valuable experience I’ve gained along the way.

Don’t wrap me up in cotton wool

Being an OT student I regularly am involved in conversations regarding people with mental health problems. Those who know my background may say something that is insensitive and then realise, with embarrassment, what they have done. Others who don’t know may talk about ‘these clients on the psychiatric ward, like, well they were a bit scary, but actually quite nice people’. I think it still surprises me that the stigma is present. However, on a personal level it does not upset me to hear conversations that contain judgements or ignorance, it simply provides me with an opportunity to introduce a slightly more accurate perspective and challenge some of their beliefs.

So while the above shows that there is still some very real stigma surrounding mental health problems. I do wonder if it is my own belief that I am in some way a weaker or less able person that causes me to question why it isn’t easy to stand up and say, ‘I’m pd2ot, I’m lucky to be alive as I used to be so self-destructive, and I have recovered. The ‘old’ pd2ot has not disappeared, but simply understood themselves and grown into the person you see today’. While I believe that statement to be entirely true, I have been thinking about whether I am, in fact, damaged and broken.

I remember a psychiatrist I was once under the care of saying, ‘you know, people with your background and extent of problems are usually either dead or in prison.’ While I found this statement validating of my experience, it did leave me feeling hopeless that I could ever be ‘normal’. I also have had various nurses and care staff acknowledge that they couldn’t foresee a future for me that didn’t involve hospital or serious self-harm. It’s understandable that with these external reinforcements that I have ingested some belief that I would always have to be a ‘disordered personality’. However, the reality of my current experience has proven these people wrong. I have recovered.

I also feel that my experience has given me a great deal of strength. In being a member of a therapeutic community (TC) I have had to sit with anxiety for others exhibiting dangerous behaviour, other clients running away and attempting suicide and been on the receiving end of intense anger and hatred directed, perhaps unfairly, onto me by struggling clients. I have experienced being pushed away, or even being put on some unachievable pedestal by the same clients. All of these experiences must be so common as a professional, and I’ve discovered that I can manage them even at the time when I was still engaged in my own therapy. Being part of a TC also exposes you to details of horrific abuse and violence. While some of it was traumatic to hear, it can only have increased my awareness and understanding of some of the terrible things experienced in the world and the consequences for those involved. I also have gained some incredible insights that only clients can share, such as how people can ‘con’ the staff and hide things from prying eyes, to understanding a range of people’s attitudes to services, what has helped them and what has happened.

I feel there is a real balance to be achieved between ensuring that my recovery is maintained and not overly protecting me from the real world. For example, my placement locations and settings are discussed regarding uniform, distance of commute, and to a lesser extent the client groups encountered. I don’t want to be held with kid gloves, but we might agree that placements that might have more impact on a personal level could be encountered later on in my study. The reality is, I think I’m more resilient due to my life experience; not only from what I’ve been through but also the skills and understanding I’ve gained along the way. On my first day of my first placement I went on a home visit to a place that my only previous experience of was being scooped up in an ambulance and taken to hospital for treatment for serious self-harm and prevented from attempting suicide. I was aware of the significance of the location, and also able to mindfully acknowledge this new experience at a different stage of my life.

Once again it’s all about the balance! I have no reason to be ashamed of my past and while I would never, ever, wish to repeat my life so far I am actually glad I’ve been through it. I believe I’m a more resilient, compassionate, resourceful and reflective person as a result, and for that I’m grateful.

BPD’s Limit on ‘Fun Occupation’

It is no coincidence that at the start of a four day weekend (we’re having an additional public holiday for the Queen’s Jubilee, as well as a Spring Bank Holiday, in the UK this weekend) that I have spent my Saturday reading journal articles, and now typing this blog post. I really dislike holidays, especially official ones where there is an expectation to ‘have fun’ or at least do something special. I have gotten better at managing them but I doubt that I’ll ever be a fan of Christmas. I know many people find holidays stressful, not least because of the change in structure to our daily occupations, but it got me thinking about the effect of Borderline Personality Disorder (BPD) and engagement in ‘fun’ occupations (often leisure activities), as well as the different perceptions of things society often considers as a good thing, like holidays from work.

(Quick disclaimer; my thoughts are based on my own experience and that of the other clients I had the privilege of sharing therapy with in a Therapeutic Community (TC). I know that everyone’s experience will vary, but I am also aware that I’m in the fortunate, and relatively unusual, position of having discussed such matters with a number of reflective clients and shared in their engagement in therapy over a considerable period of time).

What is BPD’s limit on ‘fun occupation’?

I did a quick search using EBSCOhost on Personality Disorder and Occupation and retrieved limited results. Perhaps my own experience is influencing my perspective, but I believe understanding the limitations of BPD and engaging in meaningful occupation could help people with BPD to achieve the often quoted, ‘life worth living’ (Linehan, 1993a, p99). I also think there is a role for joint intervention using an OT and a dialectical behavioural therapy (DBT) approach, because in my experience, the DBT skills of mindfulness, emotional regulation, distress tolerance and interpersonal effectiveness (Linehan, 1993b) not only are often best implemented through occupation, but they also facilitate engagement in meaningful occupation that was previously impossible to achieve. That feels like another blog topic: the link between DBT and OT in recovery from BPD!

In the limited literature I found, the link between DBT and occupation was acknowledged (Falklof, Haglund, 2010) alongside explanations of how the symptoms of BPD can negatively influence components of occupation (Lee, Harris, 2010). As the skills areas of DBT are able to overcome these occupational performance limitations (in my experience, although there is evidence of the efficacy of DBT in reducing behavioural symptoms of BPD such as suicidality, depression and anger (Neacsiu, Rizvi, Linehan, 2010), which will reduce occupational competence), I feel the joint role of DBT to facilitate engagement in occupation is an area that would benefit from increased research.

Anyway, I digress. However, the above is not in vain as my thoughts on the challenges of fun occupations will include the limitations of BPD on engagement in occupation. I’m going to illustrate this discussion with a series of examples from my own life.

New Year’s Eve

I mentioned above that I’m not a fan of Christmas, but when I was ill New Year’s Eve was even more challenging. I know this can be a lonely time of year for many people, but when your whole life had been a period of chaos, distress and dissociation it was intolerable to be surrounded by people reflecting on the past year and setting out goals, full of hope, for the year ahead. I generally managed the 31st of December with quite serious self-harm and a feeling of dread of having to endure another hour, let alone another year.

Other Public Holidays

Bank/Public holidays were mainly challenging due to the interruption to my daily structure. Things like appointments with professionals would be cancelled, and when inpatient, the wards ran a weekend schedule so no OT (even though I hated it!), physiotherapy gym sessions or even ward rounds to break up the day. There would also be more visitors, often children, the presence of whom I found quite stressful. Basically, holidays changed my routines and left me feeling exposed and vulnerable. No matter how rational I was the BPD ‘fear of abandonment’ went into over-drive and I spiralled off into destructive behaviour, just because my psychotherapist was taking his statutory holidays. I hated this bit, because I could never reconcile how my emotional world would react this way when I felt I truly understood why he wasn’t in. I suppose that’s just the nature of BPD. Even the ‘little things’ during holidays scared me, I could no longer conduct my safe routine of visiting 24hr supermarkets at quiet times to buy binge food and blades, having instead to cope with the reduced opening hours and hoards of people.

Enjoyment of sunny weather

We’ve recently had some hot weather in the UK and it most definitely lifted my spirits. However, when I was ill I dreaded the warm weather, my secret self-harm and often disguised thin body were suddenly under pressure to be exposed. I hated the attention of people asking ‘are you not hot in long sleeves’ and avoided situations like foreign holidays, swimming with family/friends or simple garden parties/BBQs. This issue still remains with me, while there have not been any new scars for several years I only expose my arms around people I feel very comfortable with, I rarely swim and get so frustrated when clothes shopping.

Going to the cinema

This is an example of a fairly ‘safe’ leisure occupation that was far from straightforward. At times when I was managing to function enough to go out and fill time I would often go to the cinema as it was a place to hideaway, unseen, with a giant ‘bucket’ of diet coke and avoid food for an afternoon. Often I’d choose films that I knew had content that I’d find upsetting, simply to punish myself and cause dissociation. Even now, the cinema is something I have to be feeling pretty good within myself to manage, because even though I’ll now be there with friends, eating popcorn and watching a funny film, the memories of that time in my life are quickly evoked.

Anniversaries

Anniversaries of significant events can be problematic for people with BPD. Quite often the memory of either difficult events would result in me using serious self-harm to manage, or commonly self-harming on an unrelated important day then compounded the memory in subsequent years. Now, when certain dates appear, such as anniversaries of deaths, or dropping out of university, or even something as simple as Hallowe’en, I’ll have intense regret over the way I used to manage them. This often means I’ll have to use high levels of mindfulness to remember that I now have a different experience of the dates and that I manage my life differently.

Summary

While the discussion explore the challenges of occupations often perceived as fun for a person with BPD, it also highlighted the lasting conversion of occupations often considered neutral or benign, to evoke memories of difficult times and remain less fun than desired. For me, I’ve achieved a balance between engaging in some occupations that are completely new, and therefore have few difficult associations (but still requiring the use of DBT skills), and managing to engage in occupations I previously did, but with a new approach facilitated by high levels of DBT skill use.


References

Falklof I, Haglund L (2010) Daily occupations and adaptation to daily life described by women suffering from borderline personality disorder. Occupational Therapy in Mental Health, 26(4) 354-374

Lee S, Harris M (2010) The development of an effective occupational therapy assessment and treatment pathway for women with a diagnosis of borderline personality disorder in an inpatient setting: implementing the Model of Human Occupation. British Journal of Occupational Therapy, 73(11), 559-563

Linehan M (1993a) Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guildford Press

Linehan M (1993b) Skills Training Manual for Treating Borderline Personality Disorder. New York: Guildford Press

Neacsiu A, Rizvi S, Linehan M (2010) Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behavior Research and Therapy, 48(9), 832-839