‘Apparent Competence is Going to Kill Me’

This is a topic that I have wanted to write about for a while, as well as receiving requests from followers to explore it after brief references to the concept in other posts. It’s also highly relevant at the moment as I continue to question whether I still slip into apparent competence, rather than genuinely being a competent person. As per the usual format of this blog, I will apply this reflection to the effect of apparent competence on engagement in occupation and performance capacity.

Firstly, some definitions and explanations. Apparent competence is a common ‘trait’ for some individuals who have Borderline Personality Disorder (BPD) and is thought of as the opposing dialectic to ‘active passivity’. Linehan (1993a) provides an excellent explanation of the concept in ‘Cognitive Behavioural Treatment of Borderline Personality Disorder’. (Other dialectics are explored in ‘Skills Training Manual for Treating Borderline Personality Disorder’, I’d recommend reading both.) Linehan’s text explains that an individual exhibiting apparent competence may have varying levels of competence and this competence is highly dependent on the situation. For example a person could be easily able to manage work demands and roles, yet struggle with personal relationships or interpersonal interactions. Apparent competence can also emerge in the form of incongruous communications. The person may state a problem or talk about a subject that evokes high levels of emotion, but without the ‘matching’ level of non-verbal communication. The theory explains that this way of behaving could be derived as a learned response to an invalidating environment, where negative emotions need to be suppressed. The consequence is that the person is unable to communicate their distress, or needs, and the invalidating environment repeats, albeit unintentionally. The problem with apparent competence is that the person, or indeed the professional working with the individual, being aware that it can happen is not enough to prevent it. To further explore the challenge of apparent competence I will reflect on some of my own experience of being ‘apparently competent’.

Can Apparent Competence Really Kill?

The title of this blog post comes from a piece I wrote at a time when my apparently competent behaviour was leaving me feeling very isolated and distressed. I was in treatment in a therapeutic community and while, by virtue of being an NHS funded client in a unit for people with very high levels of problems, people knew the level of difficulty I had I felt my distress wasn’t being understood, or communicated. When apparent competence was discussed in groups I began to understand that this limit on my communication was understandable given my background, but I still felt at a loss as to how I could communicate in a way that would leave me feeling ‘heard’. I often felt, and probably still do feel, more comfortable communicating via written media. It affords the luxury of the recipient only being able to ‘hear’ what I intend them to, without being confused by non-verbal communication that doesn’t support the statements being made. For example, I truly felt that apparent competence would kill me, by increasing my distress and despair and leaving me feeling totally alone with my problems, and I was able to convey that in a letter that I showed my key-worker. However, I would have struggled to say the same words in a tone that communicated that distress for fear of someone being able to see that I wasn’t ‘ok’. This paradox sums up apparent competence: I wasn’t ok, I was desperate for someone to realise I wasn’t ok and I was also terrified someone would realise I wasn’t ok and tried to make sure they thought I was absolutely fine.

Apparent competence is highly frustrating for both service-users and professionals. Awareness that apparent competence is an issue for the person helps, especially in highlighting the need to remember that observed performance in one area does not imply transferable capabilities, but it is often not sufficient to ‘override’ incongruous communication.

Apparent Competence and Occupation

In my experience apparent competence both enables and disables performance capacity in relation to participation in occupation. The following are examples of my own experience.

Facilitating Engagement

While this post has mostly focused on the frustrations, I was actually very grateful for apparent competence and often felt it was a useful starting point. Apparent competence alone is not sustainable as it can be isolating and disingenuous, the latter I feel prevents mindful participation in meaningful occupation, however apparent competence let me participate and provided me with access to environments and situations through which I could gain skills and become genuinely competent.

‘Appearances can be deceptive’ – I’ve lost count of the number of times people have said they had no idea as to the struggles I’ve faced. Currently, this may be because I am in a very different place to when I was in treatment. However, when I was just discharged from several years in hospital and a therapeutic community I am grateful that I was able to blend in to salsa and college as if I had no issues.

‘Fake it until you make it’ – I remember doing my first university presentation and receiving feedback about how confident I was. I wasn’t, at all. However, once I realised that no one could see my anxiety I was able to become genuinely confident and enjoy presenting to my peers. I recently presented at a learning network while on placement, with possibly less anxiety than the qualified staff.

I often find that for me, my apparent competence is ‘switched on’ when in the presence of others. While I don’t believe this is a sustainable way to live it does have benefits. For example, if I had periods where things were a real struggle and I was barely functioning at home, I knew I would manage when out. This means I can still access the things that help, for example attending university or college, meeting friends, engaging in exercise. Often I would then feel better and be able to manage self-care tasks on return home. Unfortunately this is not always true and if the disparity between my inner-world and my perceived presentation grew too wide my level of distress increased and engagement in occupation was limited.

Limiting Sustainable Engagement

As mentioned above apparent competence can increase distress, and often made my engagement in occupation feel unsustainable. While it can be a useful ‘skill’ that allowed me to participate, the level of ‘performance’ required meant there was generally a pay-out or delayed impact on my well-being. For example, ‘competently’ planning a shopping list, going to the supermarket and chatting with the checkout staff would have required such composure and masking of difficult emotions that on return home I would sit on the kitchen floor, unable to move, totally overwhelmed with all the food I had bought. At that moment I felt like a child who had no idea what to do next, 30 minutes before I looked like someone completing their weekly shop without a care in the world.

This also limited my engagement in occupational therapy (OT) kitchen assessments. I could do all the right things, with only limited reassurance needed, when cooking in the OT kitchen. When I returned home and had to face the reality of nurturing myself, in my own environment, the emotional demands of the task prevented my engagement. What was the difference? In the OT kitchen I was performing and this meant I could put my emotions on hold – the task may have appeared the same but the difference in cooking a meal for myself, out of my own volition, compared to doing it because it was an OT session and ‘that’s just what you do’, was vast.

A further example of where my skills weren’t transferable was my engagement in group psychotherapy. In the other groups in the therapeutic community I happily gave feedback to others and took my turn to speak about how I was (albeit reasonably briefly). As soon as I was in a group that didn’t have a set order to speak (in community meeting we went around the circle) I found I dissociated or just remained silent. I still struggle to claim my space today and this is something I am trying to address. I feel much more comfortable addressing the needs of other people and find myself repeating the pattern of ‘if we discuss your stuff I can hide that I’m not ok, and I’m not ok but I’m terrified you will see that, and I’m frustrated that you don’t see I’m not ok’. This also has been an issue when interacting with university with regard to placement. It felt so terrifying to say ‘I need help’ and so my communication was confusing, and then I felt more alone and unable to manage. While I haven’t completely solved this problem I do find that I am managing to ask for my needs to be met, eventually (usually at the point that I realise I feel more alone I am able to think ‘I’m doing that thing I do again, now time to go back and have another attempt at saying what I need to’), and with the help of educators and university tutors who attempt to ‘figure out’ what it is I’m saying. The next step is to get directly to the point, and cope with how that feels.

What helps?

I think this post highlights the complexity of apparent competence. I believe awareness of pattern of behaviour is useful for the person and those who work with them. With respect to the example of OT kitchen assessment above, my OT suggested supported cooking in my own home when I spoke about the challenges I was experiencing. This helped, the situation was more real and less of a performance (although not entirely), phone support while cooking alone also helped, although still there was an element of ‘I’m on the phone, must put on calm, composed phone voice’. For me writing helps, as I mentioned above I seem able to convey the facts and explain how I feel, with the conflicting non-verbal cues removed. Mindfulness also helps, particularly just noticing how it feels to let my guard down and ask for help. Other people have prompted me to notice that nothing bad happened. Another application of mindfulness is noticing the times that I am being competent, and not writing it off as apparent competence, as I used this to invalidate the skills I had.

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References

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

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

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Mindfulness and Occupation

This blog post is inspired by the forthcoming #occhat on Mindfulness and Occupation (Tuesday 28th August, 8-9pm BST, follow #occhat on Twitter) as well as numerous discussions on Twitter, particularly in #BPDchat, #OTalk and #occhat, on the nature of the relationship between Mindfulness and Occupation. The first part is designed to suggest some related reading and a list of questions to prompt reflection on the topic before the #occhat, the second part in my personal reflection on Mindfulness and Occupation.

Related reading (this list, books in particular, is by no means exhaustive) :

Books

Kabat-Zinn, J (2004) Full Catastrophe Living, How to Cope with Stress, Pain and Illness using Mindfulness Meditation. London: Piatkus

Linehan, M (1993) Skills Training Manual for Treating Borderline Personality Disorder. New York; The Guilford Press.

Journal Articles (with great thanks to @clissa89 who supplied many of these)

Davis, D; Hayes, J (2011) What are the benefits of mindfulness? A practice review of psychotherapy-related research. Psychotherapy 48 (2), 198–208

Elliot, M (2011) Being mindful about mindfulness: an invitation to extend occupational engagement into the growing mindfulness discourse. Journal of Occupational Science 18(4), 366-376.

Gockel, A (2010) The Promise of Mindfulness for Clinical
Practice Education. Smith College Studies in Social Work 80, 248–268

Grossman, P (2011) Defining mindfulness by how poorly I think I pay attention during everyday awareness and other intractable problems for psychology’s (re)invention of mindfulness: comment on Brown et al.(2011). Psychological Assessment 23(4), 1034–1040

Gura, S (2010) Mindfulness in Occupational Therapy Education. Occupational Therapy in Health Care 24(3), 266-271

Hill, C; Updegraff, J (2012) Mindfulness and its relationship to emotional regulation. Emotion 12(1), 81-90

Reid, D (2008) Exploring the relationship between occupational presence, occupational engagement, and peoples well-being Journal of Occupational Science 15(1), 43-47.

Reid, D (2009) Capturing presence moments: The art of mindful practice in
occupational therapy. Canadian Journal of Occupational Therapy 76(3), 180-188

Reid, D (2011) Mindfulness and flow in occupational engagement: Presence in doing. Canadian Journal of Occupational Therapy, 78 (1), 50-56

Stew G (2011) Mindfulness training for occupational therapy students. British Journal of Occupational Therapy, 74(6), 269-276.

Wright, J; Sadlo, G; Stew, G (2006) Challenge-skills and mindfulness: an exploration of the conundrum of flow. OTJR: Occupation, Participation and Health, 26(1) 25-32

Mindfulness Defined

Mindfulness refers to a person having total awareness of their environment, and requires a person to full participate in and experience life (Kabat-Zinn, 2004). Mindfulness meditation is based on this and involves a determined effort to engage in mindfulness. Such exercises can help develop an automatic mindful awareness of self and environment.

Mindfulness is now a common feature in psychological therapies. Jon Kabat-Zinn created Mindfulness Based Stress Reduction (MBSR), from which Mindfulness Based Cognitive Therapy (MBCT) was derived for people with recurrent depression (MBCT, nd). Dialectical Behavioural Therapy (DBT) is a therapy derived from Cognitive Behavioural Therapy (CBT). It is modified, primarily to suit a client group diagnosed with Borderline Personality Disorder (although has subsequently been applied to other diagnoses), in a number of ways. One of the key points is that DBT focuses on acceptance and validation in the present moment, additionally DBT uses mindfulness as a core skill set, and those engaged in group DBT skills training will repeat the mindfulness module at the end of each other module (Linehan, 1993). For further reflection on the fit of Occupational Therapy with DBT you may be interested to read https://pd2ot.wordpress.com/2012/06/22/dialectical-behavioural-occupational-therapy/ , it also explores the role of occupation to the specific mindfulness skills used in DBT.

Points for Reflection

When I read through the articles listed above I noted a few key points or questions for my own reflection. They might be a useful prompt for pre #occhat reflection.

Focussing on Occupational Therapy Intervention, which incorporates Mindfulness Practice.

Potential Benefit to the Professional

1. A professional who is able to apply a mindful approach to their interventions will be able to ensure they are fully present in the session, aware of the imposition of distracting thoughts and also able to contain and acknowledge their own emotional reactions to, or prompted by, the client.

Potential Benefit to the Client

2. As well as the benefits to the client of having an OT who is fully ‘in the moment’, mindfulness could increase their awareness and understanding of the issues they are facing and communicate this to the OT.

3. A client who can utilise mindfulness practice may maximise the benefit of an OT session. For example, a person who has recently had a traumatic or life-changing illness/injury would be able to recognise that their thoughts were drifting to distress over lost skills and be able to validate the related emotion while bringing their attention back to the task. Similarly, if an occupation resonated with a traumatic experience for a person, implementing mindfulness may mean they are able to have a different, more helpful, experience.

Limitations of incorporating Mindfulness into OT interventions.

4. Mindfulness may not suit every individual and, as with any OT intervention, a client-centred approach needs to be adopted. That said, I considered some client groups that may struggle to engage as a whole. A person experiencing psychosis may find it incredibly challenging to be aware of their thoughts. Reid’s (2009) article discussed the relationship between the Middle Pre-frontal Lobe and appreciation of emotions and feelings, which is inherent to mindfulness. Consequently a person with brain injury to that region would be struggle to engage with mindfulness.

5. Mindfulness is not an easy skill to learn, and it requires frequent practise to become an automatic process and a client must be motivated and choose to engage with this approach.

6. For some clients mindfulness can verge on being a traumatic experience. I have known people who find the experience of not-dissociating from resonant occupations to be painful and prompt extreme self-defeating behaviour. Risk may need to be assessed along with multi-disciplinary team working to have a consistent and contained approach.

7. Training – the OT needs to develop their own skills through appropriate training. As there is little evidence available as to the value of incorporating mindfulness into OT intervention, there is likely to be little funding for such training.

Could the application of Occupational Therapy Theory facilitate greater benefit from Mindfulness Exercises?

8. Will a client find it easier to engage in a mindfulness exercise based on an occupation that holds meaning for them?

9. Conversely, could the meaning of an occupation make the task of engaging in mindfulness too much of a challenge?

10. Could increased levels of mindfulness skill be encouraged by ‘graded’ mindfulness practice, from benign exercises to those which might evoke stronger emotional reactions?

Final Point for Reflection

11. I found myself imagining facilitating an OT intervention and wondered how a mindful approach would compare with implementing Schön’s (1983) ‘Reflection In Action’. I think my initial reaction was to feel that the concepts aligned well, until I considered that thinking about the present moment and what was occurring in it (as in reflection in action) was the antithesis of being fully involved in the moment. So, where does that leave the compatibility of the mindful approach with reflective Occupational Therapy?

Service User Perspective (Mine)

There is a sign in a venue I dance in that states, ‘Please be mindful of the stairs.’ I always chuckle internally and imagine myself sitting down in front of them to observe or describe them, in a true ‘DBT Mindfulness Style’. In many ways, we all are familiar with the concept of ‘paying attention’ or being mindful, just as the creator of this sign wanted people to not have accidents on the stairs due to inattention. As those who have read the rest of my blog posts will be aware I was, initially, a reluctant recipient of both OT and DBT. My lack of engagement also extended to the Core Mindfulness incorporated into DBT. In reading the above articles and reflecting on the points I raised I also considered how I felt about the role of Mindfulness in OT interventions.

As my OT was also my DBT therapist, mindfulness was utilised to manage difficult situations. For example, in supported cooking sessions the OT would encourage me to bring back any thoughts that were disappearing off into ‘judgement land’ and to focus on the task. I also remember struggling with feeling overwhelmed with tasks such as hanging my washing out when I returned to my flat as a day patient. The OT suggested that I mindfully hang out socks, instead of judging myself for racing through the task and ‘performing badly’. It sounds simple, but this approach helped greatly.

I feel quite clear that mindfulness facilitates recovery-focused meaningful occupation. As for the reverse? As part of my individual DBT interventions we started every session with a mindfulness exercise. I believe I found these to be, simply, exercises. It didn’t seem to matter whether I liked the task or not, or if I would choose to do it outside of the session, my ability to engage was more determined by other factors such as mood or events in the Therapeutic Community (TC). I do remember that I found some of the group exercises difficult if they carried specific resonance. For example a game called ‘warp speed count’ had associations with childhood and I found the task of remaining mindful to be too large. However, I can also see a progression, or grading, in both what I could engage with and also what I could contribute to mindfulness. Eventually I was able to fully participate, mindfully, in ‘Warp Speed Count’, so much so that I felt able to lead a mindfulness training session for professionals, using the game as my example. The gradation to this point involved coping with more challenging mindfulness exercises in sessions and taking the lead in individual mindfulness sessions before leading group mindfulness.

References

Kabat-Zinn, J (2004) Full Catastrophe Living, How to Cope with Stress, Pain and Illness using Mindfulness Meditation. London: Piatkus

Linehan, M (1993) Skills Training Manual for Treating Borderline Personality Disorder. New York; The Guilford Press.

MBCT (nd) Mindfulness Based Cognitive Therapy [online]. Available at: http://mbct.co.uk/ [accessed 12 August 2012]

Schön, D (1983) The Reflective Practitioner: how professionals think in action. London: Temple Smith

#worldsmaddestjobinterview

The (UK) Twitter world has been full of discussion about Channel 4’s recent ‘4 goes mad’ season, a series of programmes about mental health stigma, particularly in the work place. It culminated last night with ‘The world’s maddest job interview’ (http://www.channel4.com/programmes/worlds-maddest-job-interview/4od) in which a number of candidates, some with, some without, histories of mental health problems were put through a series of tests and assessed by psychiatrists/psychoanalysts and potential employers for both traits of mental health problems and their aptitude for work. I’ve just caught up on the programme, given that last night I was engaging in my own favourite leisure activity of salsa dancing (with some great friends and a very special, talented teacher who has been both a great support as a friend and also a fantastic teacher who has facilitated the recent salsa opportunities, see https://pd2ot.wordpress.com/2012/07/25/116/ ‎ for my reflection on the role of salsa in my recovery).

I have to say I was a little anxious about watching, given the response I observed on my Twitter feed, and many of the objections seem valid. This blog post is not intended to be a review of the show, but more a personal reflection on some of the key points that I took from it. I suspect some of the issues will develop into more in depth blog posts in the future.

The power of label

I suppose the first thing that struck me about the whole #4goesmad concept was the use of the word ‘mad’. Like many, I questioned the appropriateness of a supposed ‘anti-stigma’ campaign being based on a word that was stigmatising, in itself. Initially I had that ‘ouch’ feeling every time I saw a trailer or read the hashtag, but perhaps on reflection is it such an issue? If, for example, channel 4 had named the series ‘4 challenges the stigma of mental health problems’, would it have captured our imagination in the same way? Would we have had so many discussions on social media about the complexities of labels and societal judgements? Would the person with little understanding of mental health problems have paid any attention to the series? I suspect not. Channel 4 has always been a broadcaster that takes risks and sometimes steps over the line. While I’ll never be comfortable with the use of words like ‘mad’ or ‘crazy’, I can understand why it was branded in such a way. I also think the programmes did a reasonable job in highlighting mental health problems in a serious and fair light. Perhaps a feature on the power of labels and their contribution to stigma would have been the ideal compromise.

Another aspect that caused me to reflect was the frequent use of the word ‘suffering’ by both professionals and those with the mental health problems. I recently started a discussion on Twitter about my intense dislike of the description of people to be ‘suffering from OCD/depression/bipolar/personality disorder/psychosis etc.’ I am a pretty placid person, but both the attribution of the word ‘suffering’ to a person’s experience of ill health, as well as describing someone as ‘anorexic/schizophrenic/autistic’ are things that I will step on my soap box about. I was relieved to find a number of service-users and professionals shared my view that this use of language was unhelpful. It feels far too reductionist to see people as only their diagnosis, and puts them into a helpless ‘victim role’ to assume they suffer with their illness. I suppose the aspect that prompted further reflection was how many of the candidates on ‘The World’s Maddest Job Interview’ said that they had ‘suffered from bulimia/OCD/clinical depression’. I wondered how much of this was almost conditioned into them by society and medical professionals, that they used the term without thinking about how it felt for their identity. I also wondered how many of them felt that their illness was something they suffered. I believe it is a very fine line. Mental illness can be some of the most extreme torture that a person will experience, and the person does suffer. However, I don’t think it is helpful to give all the power to the illness and adopt a powerless victim role. I’ve talked before about how much I value Dialectical Behavioural Therapy (DBT) and one of the key, founding, assumptions of the therapy is that the person engaging with DBT is not responsible for the problems they have or the events that caused them, but they are responsible for how they respond and manage those problems. I think this is a much healthier approach to both Personality Disorder and also other health conditions. The person with the illness did not cause it but they can do all they can to manage it. I felt cautious of applying this logic to something with a very biological origin, like cancer, especially as a person can’t have full control of determining if a tumour grows, but feedback I got from the Twitter conversation is that there are few areas where it helps to adopt a helpless victim role.

The role of productive occupations

I think, on reflection, that this part warrants its own blog post with a little supportive reading and findings from relevant studies. However, like many, I was very pleased to hear the statement about work helping people get better. I do believe it is a far more complicated process than that. For example, a graded process building up to a goal of paid employment is more likely to be successful than simply jumping from hospital into a job. Similarly the job needs to be right for the person, finding the right balance of demand and personal growth with stress levels for each person. As with many areas I also believe that there are exceptions. Work will not help everybody. I think Occupational Therapists (OTs) have a fantastic opportunity, approach and skill-set to finding the right balance of occupational demands, collaboratively, with a person recovering from a mental illness. I think occupation is the key to recovery, and would like to explore the extent to which productive occupation facilitates recovery.

‘You wouldn’t know’

A common statement in last night’s programme seemed to be this expectation that mental health problems would be evident in some way. I suppose it caused me to reflect on how my understanding of mental health is different to the ‘average joe’. I’ve had the fortune of knowing a great many people who have had a variety of mental illnesses or recovered from them and so never had to challenge a misconception that a person with a mental health problem will be unable to function or not have any notable skills or positive attributes. I’ve also been aware of how easily hidden mental health problems are. I’ve lost count of the number of times I’ve been told that people had no idea of the extent of problems I had. From colleagues being shocked that one day I was at work, ‘fully’ functioning and the next sectioned and starting what would become a hospital admission lasting 16 months. I think it frustrates me that understanding can be so limited that people expect a person with mental health problems to appear ‘mad’. It also prompts me to think about the nature of mental health problems. Many people with such problems have difficulty displaying emotions, or perhaps developing trusting relationships in which they allow friends to know ‘the real them’. I often was frustrated by a trait of mine that was to show ‘apparent competence’. In the world of DBT this feature is assigned as the opposing dialectic to ‘active passivity’. I often struggled to relate to this particular dialectic but did feel aware that apparent competence made my life very hard. I was skilled at appearing fine, in control and competent as it protected me from people getting too close or understanding me. It also blocked all help, even in hospital I found it hard not to appear ‘ok’, even when in deep distress.

Stigma

I suppose the other element that surprised me was the employers shock at hearing a person’s diagnosis or past experience. I suppose I am very accepting of the fact that I have had significant mental health problems and nearly not survived AND I feel that I am a stronger, more resilient and highly skilled person as a result of it. Perhaps I am a little naive to believe that my potential employers would not be put off if they were to know my history, but I also think they have no need to know. As things stand I have needed no adjustments to my course and passed a demanding placement with distinction, my needs are no different to a student without a history of mental health problems. I have been fortunate that my university have been supportive, and on the whole, value the experience I have. I suppose that is the point of this blog; to increase my own understanding of my limitations and strengths due to my history, and to make others aware of the contribution ex-service-users can make to the profession. I suppose I felt that the 4GoesMad season could have benefited from a broader inclusion of mental health diagnoses. While many of the people featured had experienced severe levels of mental illness, the absence of participants who had recovered from or were managing psychotic illnesses or personality disorders felt a little stigmatising. Perhaps the main focus was given to OCD and depression as they are illnesses that most people can attempt to understand the traits of. Given that a person diagnosed with Borderline Personality Disorder (BPD) may be a similar spectrum, in terms of the diagnostic criteria, with a person who considers themselves to not have a mental health problem, it would have been most beneficial to include some of the more ‘scary’ diagnoses in the programmes, in order to maximise the potential to challenge stigma.

As I said, possibly some of this needs more time and exploration, but that’s just a summary of some key reflections for now.

Summer of Salsa

The Summer seems to be a time of anniversaries/reminders for me. Some positive, some less-so. In fact, as the London 2012 Olympics are about to start it prompts me to reflect on how things have changed since the Beijing Olympics of 2008.

In the Summer of 2008 I remember watching hours of Olympic sport, not because I was a fanatic, but because I was a patient on a Psychiatric Intensive Care Unit (PICU) and not allowed access to any of my possessions due to the level of risk I was at. I don’t remember any key events of that Olympics, I suspect while I was watching I wasn’t really taking much of it in.

In the Summer of 2009 I was still an inpatient in a psychiatric hospital, as I had been for 16 months at this point, but now on an acute ward on 1-1 observations. I was considering, reluctantly, transfer to a residential therapeutic community (TC).

In the Summer of 2010 I was nearing the end of my TC admission, I had spent 8 months as an inpatient and was finding my feet in the real world. As part of this I embarked on salsa classes to help build up social contacts in the new area I was living in.

In the Summer of 2011 I had completed an Access to Higher Education Diploma, to help get me back into the world of academia and had built up a great network of friends, as well as enjoying salsa dancing and voluntary work.

Now, in the Summer of 2012, I’ve completed my first year at university and loved my first practice placement.

Anyway, after that nice little timeline I’ll get onto the main point of this post, salsa! As a self-confessed #OTgeek the other incredibly meaningful occupation in my life is salsa dancing. Consequently I was thrilled to see on Ruby Wax’s Mad Confessions (http://www.channel4.com/programmes/ruby-waxs-mad-confessions/4od ) that salsa features as an activity for people receiving treatment at The Priory. During an OT intervention when I was in the TC the idea of finding leisure occupations that would be meaningful and also not self-defeating (as many exercise/sporting occupations had been for me) came up. The OT and I felt that I needed to explore a hobby that could be fun and that would help me make friends in the area I was living. As a child I had done some ballet and modern dance and really quite enjoyed it, but I was wary of this type of activity for someone who had a slightly shaky body image. I did some research and found a local streetdance class and decided to attend. While I enjoyed the class I found that most of the participants were 16-18 years old, despite it being an adult class. I then decided to try salsa, simply because there seemed to be a multitude of classes and I believed I was likely to find a wider age range of participants.

I picked a local salsa class that seemed to have a good structure format and a separate class for those who were attending their first class. While I was nervous about attending the first experience went well. The format was as I expected and being in a separate class was really helpful as it reduced the number of social interactions I needed to have.

The first few months were probably a little challenging and I don’t seem to have the energy (or possibly the desire) to reflect in detail on that but I will summarise in terms of the benefits and challenges I experienced as I started.

Benefits

  • Enabled me to explore my identity as someone who was functioning and competent.
  • Helped me develop a healthy body image and discover how to use my body in a good way, rather than abuse it.
  • The structure of classes meant that the occupation was the main focus, taking the pressure off the social interactions and allowing me to increase my confidence with those, little by little.
  • It’s fun! Still after some really special nights I’ll find that I have such a buzz that it can be hard to wind down.
  • It doesn’t feel like exercise, therefore I get to be active without it slipping into eating disordered behaviour.
  • It’s difficult, so I don’t get bored and have to work hard to improve.

Challenges

  • I did find it very hard to dance with, and be in close proximity to, lots of men. Often I wonder why I picked this sort of activity but I know it’s been a useful challenge to work through in therapy.
  • At the start I was still a member of the TC, inevitably small talk usually got onto questions about where I worked/what I did during the day and I found these awkward. It was so much easier several months later when I could say ‘I’m a student’
  • You get hot! I still wear long sleeves when I dance as I don’t feel comfortable with people, perhaps, making snap judgements about my arms. While I now do many other activities in short sleeves I don’t feel comfortable doing it at salsa, perhaps because it would involve ‘coming out’ to so many people who have known me for some time.
  • As mentioned in another blog post, wearing nice, feminine clothes was almost traumatic at times.

As time has gone on I am so much more comfortable in the salsa scene and have made some incredible friends. Including some close friends who I can rely on for support, should I ever need it. It has also brought great opportunities. In the past year I’ve attended salsa congresses and danced at lovely venues like the Blackpool Tower Ballroom. I’ve also recently joined a performance team, that will mean I get to perform all over the country, and even abroad. I don’t think I could ever have imagined that my first class would lead to my current situation.

I do believe that salsa has a very important role in keeping me recovered. It gives me energy and enthusiasm for life and has increased my confidence in so many areas. Many of the skills I developed through salsa have been transferable to other occupations.

While on placement I reflected on how easy I found it to build therapeutic relationships quickly. Much of this I attribute to salsa. Every time I dance with someone, myself and my partner has to work collaboratively, adjusting to each other’s strengths and weaknesses, to make the dance work. I also have got more comfortable chatting to and working with such a variety of people, and even getting on with those whose behaviour/manner I find difficult.

So yes, for me dancing and really participating (in terms of the DBT mindfulness skill, ‘participate’) in salsa helps my sense of self and is now an integral part of my identity. I think part of the value of salsa for my recovery was that while it linked to areas I had previous experience of, ie. a dance class, it was not something that had any real connections to difficult stages in my life.

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].

‘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.

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