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.
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].