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 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.
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.
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