Dissociation and Occupation

winter-tree-and-fog-1355740795GPD

This blog post will endeavour to explore dissociation and its effect on occupational engagement. In terms of my own personal experience dissociation was the last ‘symptom’ I was willing to admit to as I felt great discomfort admitting to engaging in something I had so little control over or understanding of. Dissociation is a challenging topic to write about, not least because everybody’s experience of dissociation is different. It also is difficult to write about something that involves losing touch with reality because the very nature of the experience is difficult to understand/describe when not dissociated, so I apologise if this post lacks the clarity of previous efforts.

*Additional note – September 2015* –  I started writing this post over 2 years ago and it has languished in my ‘drafts’ folder for a very long time. I think this is indicative of my own struggles to fully process my thoughts about dissociation and its effect on occupation.

What is Dissociation?

‘Everyone Dissociates’

The ‘Dissociative Experiences Scale’ (DES) is a 28 question screening test for Dissociative Identity Disorder (DID). I suspect very few people would take the test and score a ‘0’. It is expected that the non-clinical population will score below 30 (this equates to a percentage of time that people experience different dissociative experiences) and is noteworthy. The test expects everyone to relate to some experience of dissociation. The example most often quoted is about completing familiar actions on ‘automatic pilot’, for example driving a familiar route. How many times do you find yourself having completed a task, but not actually able to remember the steps you took to complete it because your mind was on other things? On a simple level, this is dissociation.

Mind have a simple but clear explanation of dissociation, including the different types of dissociative behaviour a person can experience, furthermore the Healing from BPD blog provides a valuable account of the personal experience of dissociation in  ‘what does it feel like to dissociate?’

Dissociation in Borderline Personality Disorder (BPD)

While the DES screens for dissociation as a diagnostic tool in DID, the occurrence of dissociative symptoms in BPD is common. The ninth diagnostic criterion in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) (American Psychiatric Association, 2013) for BPD (of which a person must have five of the nine symptoms to be diagnosed with BPD) is listed as; ‘transient, stress-related paranoid ideation or severe dissociative symptoms’. Certainly in my experience of receiving treatment in a Therapeutic Community (TC), dissociation was a significant and problematic symptom for many people.

Dissociative Identity Disorder (DID)

I have also known people dually diagnosed with BPD and DID. The DSM V (2013) defines DID as being diagnosable  when a person experiences recurrent dissociative episodes, in which behaviour is modified by appearance of a minimum of two separate identities. This can now either be observable by others on self-reported.  For the purposes of this post, the dissociative experiences will be considered from the perspective most often associated with BPD, but I wished to acknowledge DID.

Dissociation as an Occupation

This feels like an uncomfortable statement to me. And further reflection on this concept lead me to wonder about the types of dissociation experienced. For me, much of my dissociation involved a modified participation in occupations that exist ‘in their own right’, such as self-harm or shopping. The dissociation itself was not the occupation, but it really changed my experience of it. It possibly indicated the complexities of that ‘base-occupation’ for me as it was eliciting such a dissociative response. But what about the experience of being dissociated and re-living trauma? Is that an occupation? Often there is no decision to engage in it. But it can certainly be functional, purposeful and packed full of meaning. While incredibly different in cause and experience, there could be some parallels drawn with the experience of daydreaming – and daydreaming feels like something that could be thought of as a discrete occupation to some. This concept needs more exploration before I finalise my views.

Enabling Participation

While dissociation as an occupation is something I’m uncertain about, I’m much clearer about the effect of dissociation on occupation. In my post on apparent competence, Sue (@BPDFFS)  made a very interesting comment that prompted me to reflect. Her feeling was that apparent competence is a mild form of dissociation. As I considered the concept I quickly realised I agreed, there was a certain compatibility with my experience of being able to ‘perform’ in certain situations. I can also relate to the experience of ‘derealisation’ in stressful situations. Often, in high states of arousal I would experience the world as unreal, sometimes like viewing it through a thick fog. This detachment from reality was my way of managing to remain in an environment I found challenging. While derealisation limited full, mindful participation in the occupation occurring, I also believe it provided the opportunity to remain in the situation long enough to allow arousal levels to recede and for participation to occur. I experienced this at college, and salsa, both in the first few sessions. The derealisation ‘bought me enough time’ to stay with the activity and for it not to become something I found too overwhelming. On a similar level, depersonalisation was something I often experienced. I would ‘watch’ myself engage in activities as if it was someone else. Again, this does not allow mindful, integrated participation in occupation but was a sophisticated means of managing high-stress situations.

Disrupting Occupation

As analysed above, dissociation can have an enabling effect on occupation. It is an important coping strategy for people experiencing high-states of arousal. When in treatment, dissociation was, perhaps controversially (due to the automatic nature of it), called a ‘self-defeating behaviour’ and it is difficult to deny that it prevents integrated, cohesive and meaningful participation in occupations. However, I believe the power of dissociation to provide a means of survival, particularly when used to cope with abuse, must be respected. I can certainly also understand the negative aspects.

For me, the vast majority of my self-harm occurred while dissociated. This increased the risk to myself as I was not fully in touch with reality and simply ‘observed’ myself hurting myself. I also had a reduced awareness of pain, and did not have the same protective responses as I might have in a more connected state. Dissociation was also incredibly disruptive when I’d lose large chunks of time when I was trying to study at university – it also felt very hard to explain to my department when I didn’t understand what was happening or why.

For people who dissociate in response to situations that replicate traumatic events, dissociation can happen when related perceived threats occur. This can disrupt occupations occurring in a safe environment. For example, a scene in a film may prompt dissociation and re-experiencing of trauma. In this situation the person has responded as if there is danger, despite being entirely safe. Awareness of the potential for dissociation or re-experiencing of trauma can reduce confidence and pleasure in engaging in such activities, leaving a limited number of safe occupations for the person.

Using Occupation to Reduce Dissociation

I’ve previously written about mindfulness and occupation and while I am not a big fan of ‘minfulness for mindfulness’ sake’ I find mindful participation in activities that truly are purposeful and meaningful to me to be very helpful when I am struggling. In the same respect I find participation in occupations that meet my occupational needs (Doble and Santha, 2008) particularly valuable in reducing dissociation. For example, when I feel accomplished and in control of the occupation it is highly unlikely I would dissociate. However, if the occupation lacks a sense of coherence with my identity, it is much more likely I’d experience some element of dissociation. That said, much like my thoughts on mindfulness, I can also see value in use of mindfulness as an emergency ‘band-aid’ to manage dissociation. If completed ‘well’ (which can be difficult when experiencing the level of distress and detachment associated with dissociation) it comprises such an element of being present that makes complete dissociation and the related detachment from reality very difficult. But as I said, that can be hard to achieve during the onset of dissociation and ultimately I’ve found a longer-term approach to living a life full of congruent, satisfying and meaningful occupations to be a better ‘cure’. I also don;t think occupation is enough to reduce dissociation to a manageable level. It is a powerful coping mechanism that has been developed as a response to life events. So for that reason some other type of therapy is needed to process the feelings, thoughts, emotions or memories linked to the need for a dissociative response.

So, yes, possibly the longest I’ve ever taken to write a blog post and it’s far from a complete consideration of dissociation and occupation. However, it’s a start, and I hope I might be able to explore the topic in more depth now that I’ve gotten over the initial hurdle.

Reference
Doble S, Caron Santha J (2008) Occupational well-being: Rethinking occupational therapy outcomes. Canadian Journal of Occupational Therapy 75(3) 184-190

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

‘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.