Second year is proving challenging for maintaining an occupational balance that includes time for blog-writing. However, I find myself with a rare window of both time and motivation so will consider a few thoughts. After my frustrations of the first week of term I’ve found the content of the course so much more engaging and well delivered. We’ve had lectures on a range of topics including; learning disability, the Recovery Model and implementing evidence-based practice. We also had an lecture on working with individuals with Personality Disorder, which was thought provoking, honest and well-delivered. Interestingly it was not this lecture that had the most resonance for me, but rather the lecture on Occupational Therapy in forensic settings.
I have never been a patient in a forensic setting, but it was one of the first clinical settings that I visited when researching Occupational Therapy as a potential career. However, I have spent long periods of time under very high levels of observations on both acute wards and psychiatric intensive care units (PICUs). Previous blog posts have explored the effect of Borderline Personality Disorder (BPD) on occupational engagement, but this post will consider the effect of ‘high restriction’ environments on the occupations I engaged in.
I’m keen to understand my occupational engagement from an Occupational Science perspective, in particular relating to concepts of occupational deprivation, that is “a state of prolonged preclusion from engagement in occupations of necessity and/or meaning due to factors which stand outside of the control of the individual” (Whiteford, 2000, p201). I will also explore positive consequences of hospitalisation, in terms of the self-defeating occupations I was prevented in engaging in and the extent to which ‘replacement’ occupations held meaning.
The above definition highlights that occupational deprivation is caused by factors external to the client, and involuntary admission to hospital, understandably, involves many factors relating to the procedures (most often risk management), routines, length of admission, staffing levels, even choice of bed location that the detained person has no control over. My admissions were designed to protect me from myself, and the risk assessments conducted prompted higher and higher levels of observation/removal of possessions/imposition of restrictions. Being ward-based on a PICU would mean all of the occupations I valued (they were almost all ‘outdoor’ occupations, other than the self-harm/eating disordered behaviour) could not happen, but the setting also influenced other occupations.
I have always enjoyed writing. While my background makes creative writing a challenge, I relied on being able to write about my experiences when in hospital. The only problem was that my spiral bound notebook was not allowed on a PICU. It was only a few days until visitors brought me a safer replacement, but in retrospect I do wonder if I could have been given some paper to write on.
Being on a PICU also removed my opportunity to use the hospital gym. At this point in my admission I was still severely eating disordered and this removed a vital coping strategy. The desperation increased my hopelessness and I began to binge eat, encouraged by the lack of stimulation or opportunities to self-harm on the ward – it became my new self-destruction. The staff saw only an improvement in my willingness to eat, whereas I felt out of control.
Other aspects of the PICU environment are difficult to adjust from when transferring back to an acute ward. My first transfer back happened in the middle of summer. As I had been on a first floor PICU that had air conditioning, no outdoor space and no opening windows, I had lost my ability to cope with heat. This, combined with an increased level of noise and other stimuli, made the transfer back almost overwhelming. Now this seems like a perfect opportunity for some grading, perhaps short periods of time escorted outside, to ease the transition.
PICU admission was intended to deprive me of the occupations that were a risk to my life (See here for a post on the topic of self-defeating meaningful occupations: http://wp.me/p2rK3N-P ). To some extent this worked. However despite high levels of observation, searches, and all of my possessions being in a locked wardrobe I always managed to have access to self-harm implements, ‘stored’ on my person. I did still self-harm, although this was done with an unusual level of restraint (I was terrified that if caught my means of self-harm would be removed and my admission extended indefinitely or moved to more secure services (as had been threatened)).
Occupational engagement was also very heavily influenced by situations on the ward. If another patient was in crisis staff had to respond to that individual – often meaning OT sessions were cancelled or the rest of the patients were confined to the bed area, meaning no access to TV, music or writing materials for periods of time.
My long periods of hospitalisation did not have much therapeutic value, they were simply attempts to save my life. Admissions to acute wards were intended to prevent self-harm and eating disordered behaviour, while attempting to improve severe symptoms of depression with medication. When this level of support was insufficient one-to-one observations were designed to reduce further the risk to myself and ensure my safety. This again wasn’t enough and so transfer to a PICU was implemented to reduce my arousal level as well as opportunities to hurt myself. Again, this did not have the desired effect and further ‘protection’ was implemented by physical/chemical restraint and higher observations. While I understand their desire to find ways to reduce my engagement in self-defeating meaningful occupations the increasing level of restriction only served to increase my distress. It also prompted me to become more creative and ‘test’ their procedures. I’m not going to share some of the things I did, in case they were to be copied by other people, but a frustrated, occupationally deprived, distressed young woman will find every loop-hole and determinedly find ways to continue self-destructive behaviours, especially when meaningful occupations are prevented/withdrawn. Did hospitalisation save my life? Most probably. Did it reduce the self-defeating occupations I engaged in? Yes, although possibly not anywhere near the reduction that those involved in my care would have expected/desired. Did it protect me from myself? Possibly, although the level of restriction seemed to prompt more creative and desperate attempts at self-destruction as well as a diminishing consideration for the effect on other people.
I have always been a very active person, and so finding meaningful occupations for me that could occur in the tiny occupational therapy room attached to the PICU was always going to be a challenge. However, simply having access to materials to be creative with seemed very appealing when the rest of the day was spent on a ward where all of my possessions were locked away and even those deemed ‘safe’ could only be used for short periods of time in the area directly outside the nurses’ station. Was making ‘bead art’ (that the OT had to take away to set using an iron) particularly meaningful for me? It’s not an occupation I would engage in now, but it did give me some sense of accomplishment at the time.
In fact, thinking about the bead art I made reminds me of many of the products of my OT interventions. I made many items, some were things that had I produced them today I would be quite proud of, however due to the associations the items have with a time in my life of distress, despair, restraint and lack of control, they are all items I would find very difficult to keep/display. Part of my academic programme has involved mock facilitation of groups and some of the facilitations I observed seemed keen to have a tangible product that the client can take home with them on discharge. While I don’t question the importance of there being a concrete outcome to interventions, I think it is important that OTs remember that for some (not all), items produced in OT sessions are actually very painful reminders of a difficult time of life. The value of OT sessions is often the skills learned (both surrounding the task but also concepts of occupational balance/using structure), the self-understanding gained and an appreciation and awareness of meaningful occupation for the person, not the random nik-nak produced in the session.
The challenge of replacing my very powerful (self-defeating) occupations was one of the biggest barriers to my recovery. As this blog has previously explored, the reasons why I found myself engaging in such occupations were compelling. The environment of a PICU, or being confined to a ward under observations, not only removed my freedom but also left me with only contrived ‘activities’ to engage in. It was very hard to imagine that the options for replacing my self-defeating behaviours were desirable or a viable alternative to manage my life. It was only when a longer-term plan was implemented at the therapeutic community, which involved transference of the skills ‘into the real world’, that I was able to begin to believe that I could have a different experience of life.
I am in no doubt that the high level of restrictions imposed on me saved my life, but understanding how they reduced, disrupted and deprived my engagement in occupation helps me understand why the experience was so difficult to endure.
Whiteford G (2000) Occupational deprivation: Global challenge in the new millennium. British Journal of Occupational Therapy, 63(5), 200-204.