‘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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The Power of the Pie! (2nd Annual Blog Carnival for World OT Day (27th October 2012): Exploring Balance)

Time-Use Analysis and Occupational Balance

Click to see my Time-Use Pie Charts created when in the Therapeutic Community

One of the most helpful parts of Occupational Therapy, for me, was time-use analysis. Initially we used a diary sheet to note down what we had been doing in each thirty minute section of one twenty-four hour period, and used it to reflect on whether we felt we had ‘occupational balance’.

After attending a Learning Network for Personality Disorder and Occupation I, and occasionally other clients, would transpose the results into a pie chart. I’d attended a talk from another PD service that advocated the use of pie charts to document change and progress, with respect to occupational balance. My ‘inner geek’ (this quality I now understand and share with many #OTGeeks on social media sites) embraced the idea and enjoyed producing the chart and trying to devise an Excel spread sheet that automatically produced the graphs. This was easy for the pie charts that showed the split of occupational domains, but less straightforward for the charts I liked that displayed time-use, by domain, on a donut that illustrated where in the day I was engaging in the occupation types. I never did create a formula to automatically create those ones!

As a service-user it was quickly apparent that dividing occupations into 4 ‘simple’ domains was a challenge. Could an hour spent cycling to quieten the eating disordered thoughts really be called ‘leisure’? What about time spent planning for suicide, was it a productive occupation as it provided issues that kept professionals employed, self-care by finding a way to reduce mental suffering, or something I was engaging in to provide some renewal from real-life stresses, akin to a leisure activity? Often, making plans was sufficient to stop me trying to act on the impulses, so while suicide planning would be unlikely to be considered by many people as a positive occupation it did improve my mental well-being (on a relative level), it also kept my mind occupied and provided relief from reality. So, not only did I struggle to assign ‘negative occupations’ to the OT domains I was presented with, I also struggled to just assign them to one category. When I started my OT degree I was interested to read Karen Whalley Hammell’s Paper, ‘Self-care, productivity, and leisure, or dimensions of occupational experience? Rethinking occupational “categories”’ (2009b) as I found myself in agreement with many of the key messages of the paper. Despite being white and middle-class, which Whalley Hammell argues is the background the traditional occupational domains is exclusively suited to (2009a), I found I was aware of the function of my occupations on a much broader level. Had I read the papers when I was in therapy I may have decided to try implementing some of the categories suggested by Whalley Hammell. However I would suspect that at the start of my therapy, when I was still very distressed and hopeless, I would have struggled with applying the suggestions of ways people experience occupation;

“as restorative;

as ways to contribute and achieve a sense of connectedness;

as ways of fulfilling duties, responsibilities, and interests;

and as ways to connect the past and present to a hopeful future”

(Whalley Hammell, 2009b, p112),

However, I did gain significant benefit with persevering with the common domains of productivity, leisure and self-care, with an additional category for rest, but perhaps not in the way people might expect.

When I presented the first pie chart to my OT, showing fairly equal divisions in time-use, I remember feeling almost judged by the statistics. I felt like it was proving, ‘look, there’s no issue, lots of leisure, lots of everything, perfectly balanced’, whereas my own experience was ‘everything I do is torture, I get no pleasure from anything’. And that was the point. Almost a quarter of my day was ‘leisure’, experienced as compulsive exercise I had to do to punish and protect myself, and the same figure of ‘rest’ involved no sleep, but instead anxiety and dissociation. Feeling so misunderstood by these categories prompted me to speak honestly about my engagement in occupations.

Several months later my pie chart looked very different. It was recorded over the 24hr period that had the same structure, and therefore similar productivity, as the first pie. While leisure only made up 13% of my day the difference was significant, it was leisure that I enjoyed and wanted to participate in. My self-care had increased, as I was taking more pride in my appearance and exploring the challenges in living independently as a day-patient and cooking for myself. In those early days cooking an evening meal took several hours and a lot of support and encouragement(both internal and external). I divided ‘rest’ into sleep and ‘activities designed to promote rest’ when I couldn’t sleep. This helped me feel that people could understand how little sleep I got and how hard I was trying to rest and let my body cope.

So, time-use was very important for me. For making me reflect and think about the function of my occupations and for the value of its limitations in providing me with the opportunity to have an emotional reaction to what I felt the theory implied. I still analyse my time-use today and find it a really useful reflective tool, as well as a marker of my progression as I realise how my daily occupations are now largely meaningful and incredibly positive.

References

Whalley Hammell, K (2009a) Sacred texts: A sceptical exploration of the assumptions underpinnings theories of occupation Canadian Journal of Occupational Therapy 76 (1) 6-13

Whalley Hammell, K (2009b) Self-care, productivity, and leisure, or dimensions of occupational experience? Rethinking occupational “categories” Canadian Journal of Occupational Therapy 76 (2) 107-114