Pd2ot Becomes an Occupational Therapist.

IMG_20150323_223948I miss blogging. I could make excuses about my lack of posts being due to being busy at work, but that wouldn’t fully explain it. When I first started writing I had so many ideas to explore and I made time for the blog. Now it’s dropped into that rather full  category of “things I’ll do when I have some free time/am not so tired/am bored”, which has a very low probability of being the chosen occupation if/when any of those situations arose. Why am I not blogging any more? I suspect it’s a combination of feeling a little like I’ve moved on a lot from ‘needing’ to explore pd2ot-type topics and a less conscious disconnection from pd2ot. However, in recent weeks I’ve had a little more time for all things pd2ot, which has reminded me how much I enjoyed writing.  So, this is going to be a pretty basic ‘catch up post’ to get me writing.

This week actually marks the beginning of my PhD. I’ve spent the last six months working full-time in my clinical role to have time to embed my skills as a newly-qualified occupational therapist and develop a better understanding of the client-group and service my research will be focused on. It’s been great. Tough, challenging, I’ve learned a lot, AND I’m really ready to start work on the research. I’ve always struggled a lot with routine and getting bored, and although my clinical work is so varied and without time to breathe,never mind get bored, I do find that I’m grateful for a new dimension to my weekly routine. I’m really excited to have 3 days every week to just focus on research.

It’s probably good timing that I’ve just returned from the College of Occupational Therapists – Specialist Section: Mental Health’s (COTSSMH) Conference at the University of Liverpool. I’m feeling motivated and ready to start my study. As I first discovered at Emerging2OT, live-tweeting added a valuable dimension to my participation in the event. I always enjoy reading other delegate’s perspectives and thoughts on the session they are attending. The only downside is when you’re following the hashtag you may read tweets from a different session that sounds unmissable. At least with tweeting you still get the opportunity to read the tweets even if it can feel like you missed out!

The live-tweeting may not have been a new experience for me. However, presenting at the Conference certainly was. I was fortunate enough to have an abstract accepted for a 45 minute seminar on self-defeating occupation, a concept I developed from this blog post. I’ve always been a little ‘last-minute.com’ with my preparation for assignments/presentations, however I was probably pushing it to the extreme with this paper as I was frantically trying to decide what to say and scribble some notes in the break immediately before the session. Fortunately it all seemed to come together in the minutes before and I actually really enjoyed presenting my work. Who knows, maybe I won’t avoid thinking about it so keenly before the next one…

Public-speaking and presenting is not something I get too worried about normally, however I suspect the content of this presentation meant I was more concerned about its reception than a piece of assigned academic work. It was my original thoughts and ideas, rather than an answer to a question set by others. I’d debated whether to include my Twitter name on my title slide and to explain where the concept originated from during my preparation. In the end I didn’t include it, but actually felt quite sad that I didn’t ‘join things up’ so fully in the end. The paper was received well and the live-tweeting that accompanied it allowed for pd2ot to be joined up with Sarah, the presenter, which felt really positive and congruent.

My experience at the COTTSMH Conference prompted me to reflect on how I feel about the ‘pd2ot’ side of me. At times I almost forget that that side ever existed. I think in my current line of work it’s quite easy to forget. So how have the first six months of being qualified occupational therapist been given my history of mental health problems? To answer that I’ll explain a bit more about what’s been happening in that time. I work in a service that is in the early stages of becoming an integrated care team, but at present the physical health side of the job dominates. I work with a great team of people, including a large team of district/community nurses. However there’s minimal formal mental health experience within the team. I think this leaves me wondering ‘how much do my colleagues understand about mental health’.

Unlike when I was a student I haven’t needed to disclose much about my mental health history as I am well and don’t need significant adjustment to my work pattern. I do, however, where a uniform that exposes my arms which are very scarred from previous self-harm. As I student I was absolutely terrified of this, and generally agreed with educators that I would wear long sleeves other than when it was necessary for infection control reasons. So in general I’d have a cardigan on when I was in the office. In fact, my university supported me to have a first placement that didn’t require me to be bare below the elbows at all, and allowed me to gradually develop the confidence to expose my arms. On my first day in this job I decided I’d just make sure I was in my short sleeves even when in the office so that I stopped needing to be self-conscious about it (fortunately my office is very warm, so that became a promise I was very relieved to keep!). In terms of reactions from colleagues it has been minimal. One person said “that looks sore” and another asked “Sarah, what happened to your arms?”. Out of the two approaches I prefer the latter. It allowed for a brief, yet honest, discussion about it. Most people, however, have not commented. Partly it feels like it’s a difficult thing for people to talk about and I’m left wondering if people actually know the cause of the scarring – I find it difficult to appreciate how much awareness of self-harm people have if they don’t work in mental health or have personal experience of self-harm. Mostly, though, it feels that my colleagues simply accept me as I am. I’ve always wondered how I’d feel if a patient commented on them. I suspect it will happen at some time but my experience to date would suggest that most people I visit have far bigger things to worry about or even notice, than some old scars on my arms.

As many people with be very conscious of, mental health problems are often invisible. Given that my mental health is pretty good at the minute, the only indicator of previous problem is the scarring. I think this probably explains why the ‘pd2ot-side’ can feel very distant at times.  As ever, I feel grateful for my experience as a service-user. There are numerous skills/experiences I wouldn’t have without it. I’m also really glad that it is not a defining feature of my experience as a clinician. I feel like I’m a BETTER occupational therapist due to my experience as a service user, but that it is not the only thing I offer the profession.

Checking in – pd2ot and the brain.

brainIt’s been quite some time since I blogged. The dissociation post remains a 70% complete draft and my list of blog topics I want to write about is growing, yet I have been pretty silent on here and Twitter (except for much needed #teamduvet chats at the weekends). So I thought this post could be a brief update and pave the way for more regular blogging.

At the moment I’m getting to grips with unstructured time again. I’ve just finished an 8 week placement in neurosciences and now have some assignments to do before I break up for the summer. A big part of me is terrified of the thought of several months with no placement or assignments, so I’m noticing I’m having problems engaging with my work for fear of finishing it. Mindfulness is helping and I know I’ll get there in the end.

Placement itself… Possibly my most challenging placement to date, and also probably the first one that I could see myself working in as a qualified occupational therapist. I think the variety appealed to me. My youngest service user was in their teens and my oldest in their eighties. I worked with people with a wide variety of conditions (in fact most of my preparatory reading about Parkinson’s Disease and Multiple Sclerosis was in vain as we experienced a series of referrals for people with much more uncommon neurological conditions). The interventions used ranged from work on personal activities of daily living and equipment assessment to work on leisure occupations and vocational rehabilitation. The settings included inpatient wards, outpatient appointments and community work. Needless to say this variety prompted me to feel a little(!) overwhelmed at the start, AND I loved it – because I wasn’t going to be bored or unchallenged.

Before starting the placement I was worried about a number of things. Firstly, this was going to be a ‘properly physical’ placement. My comfort zone is mental health and while I enjoyed my first placement in a physical setting (social services) I was still afraid that I wouldn’t be any good at the ‘bread and butter’ occupational therapy required in this setting. Fortunately my fears were unjustified and the combination of university work, previous experience and transferable skills from other settings made this nothing other than a manageable learning opportunity.

My other worry had been about the requirement to be ‘bare below the elbows’ when working with patients. My arms are scarred from past self-harm and it is only within the last year that I have done any, literal, ‘exposure work’ of having them uncovered when exercising, I also have not yet had a placement that required me to be bare below the elbows. I was worried it might cause judgment from others or prompt me to feel insecure and exposed. Mostly, I feared it would be a barrier to my usual ‘apparent competence‘. The reality? I didn’t experience any overt negative attitudes from others and mindfulness prevented me attempting to mind-read their thoughts. However, the internal fallout, initially, was huge. I spent the first two weeks cycling home from placement at high speed, as an attempt to escape the discomfort of being there. I drafted many an email to my tutor and the placement co-ordinator saying that I couldn’t cope and wanted to quit. But, like in other placements where there were challenges I also knew that I didn’t want to give up, and this particular placement experience was not an opportunity I wanted to lose. I think I knew the emails would never be sent and were simply a way of validating the experience to myself. I’m also grateful that I tend to be incredibly stubborn and it takes a lot for me to stop doing something. Gradually, as I became more confident in my work being bare below the elbows was easier to manage. I don’t think I ever became less aware of it but I did become much more secure in my role as a competent occupational therapy student.

While the personal and professional challenges of this placement were probably the biggest I’ve encountered to date I know I benefited from the time of year of the placement. Like many, I really struggle with the winter. Although we had several weeks of bitterly cold weather at the start I found my energy levels were helped by the increasing daylight. I also found being able to cycle to placement so helpful, not just in the reduced journey time compared to previous placements but also starting and finishing the day with physical activity. I also found myself able to get to the gym several nights during the week, which I find so helpful for my mental health but just hasn’t been possible during my placement experience up until now. Fortunately my final placement falls at the same time of year next year, so I feel confident that I can manage it with similar success.

Self-defeating Occupation

I had intended to explore the topic of how I moved from a disdain of OT to training to become an Occupational Therapist as my next blog post, but I discovered some literature relating to a topic I’ve always been interested in and decided to explore it first. I also have created a page with my intended future blog posts to help keep track of them.

‘Self-defeating Occupation’

This is a concept I’ve given thought to for a long time, including several years before I understood the importance of meaningful and purposeful activities to the practice of occupational therapy. For the purposes of this post I will refer to ‘self-defeating behaviour’ as SDB and define them to include behaviours I exhibited when diagnosed with Borderline Personality Disorder (BPD), namely: self-harm (primarily cutting/burning), suicidal ideation/suicide planning and eating disordered behaviours of over-exercise, restriction, bingeing and purging.

I recently read a paper by Elliot (2012) that explored the concept of ‘Occupations of Illness’, in particular relating to the effect of eating disorders on daily occupations. I found I could relate many of my own SDBs to constructs discussed in the paper, particularly to the ideas that eating disordered behaviour can turn previously neutral occupations into ones of significant meaning, and the role of such occupations influencing identity.

The Role of Self-Defeating Occupation, for me.

With regard to BPD I’m never terribly sure about whether I should refer to it as an ‘illness’, or something that happened at a certain age, due to being aware that I always had the issues that escalated to become what was diagnosed as BPD. However, for the purposes of this blog I am considering the time I had BPD to be the period of my life where it became all-consuming and significantly limited my engagement in occupation.

On reflection, I feel my goal at the time was self-destruction. I was not particularly aiming for death but more behaving in a violent and aggressive way against myself. I do remember hoping that death might occur, but didn’t feel worthy of releasing myself from the chaotic life I was living. I am also aware of just how ‘all-consuming’ the SDBs were for me. It was only later in my recovery that I was able to acknowledge that the behaviours themselves were not the issue, but the emotions and experiences that drove me to try and manage by engaging in occupations that were detrimental to my health.

I also remember feeling that there was nothing that could ever replace the power of a binge/purge to suffocate difficult emotions, or the release and calm from seeing blood flow. For this reason I decided to attribute the components of my self-defeating occupations to the occupational needs defined by Doble and Santha (2008):

Accomplishment: It is often cited that people with eating disorders feel accomplishment with seeing lower numbers on the scales or clothes becoming too baggy. While this was true for me, I also felt a sense of achievement and power for every person I could hide my problems from, becoming sicker, and weaker, almost invisibly. Similarly, being able to create huge wounds on my body ‘proved’ that I had the power to destroy and make myself more ugly.

Affirmation: My cognitions told me that engaging in SDBs and the occupations that supported them were the only thing of worth in my life. I obtained tangible results, but possibly more importantly I had a way to manage and survive. On reflection now, I do believe that while I nearly didn’t survive BPD, the behaviours kept me alive for long enough to engage in recovery.

Agency: The role of ‘control’ in eating disorders is often recognised. I think I also, mistakenly, felt that the ‘control’ of being able to put in, and remove, vast quantities of food from my body was my evidence that I had power over everything.

Coherence: For me, the coherence of SDBs with my sense of self and internal world was one of the key driving forces. I felt worthless, scum-like and evil. Therefore, abusing the body of the person that housed such a disgusting ‘person’ (I really didn’t even feel human) felt entirely appropriate. At that time, the concept of ‘being kind to myself’ would have been impossible to entertain but finding newer and more serious ways to hurt myself aligned completely with the value I attributed to my existence. My goal was punishment and destruction and repeated SDBs felt like the least I could do.

Companionship: SDBs are isolating. However, before I started using them my internal world was incredibly isolated from the rest of the world. For this reason the behaviours gave me structure, and almost a sense of ‘company’. Self-harm and eating disorders felt like part of me. While in the early years my behaviour was disclosed only to myself, latterly I did use self-help/recovery websites, and also even ‘pro’ self-harm/eating disorder websites. These forums provided the companionship of some great people, who didn’t judge but listened and just understood.

Pleasure: While I would never say that I enjoyed engaging in SDBs or say I was ‘happy’, I know that there was a real sense of contentment provided by having occupations to engage in that were ‘mine’, I did not rely on anyone else for them and I was ‘safe’ while I was occupied with them. SDBs also fought off boredom and chaotic emotion, meaning I didn’t have to engage with the ‘real world’ and was protected from it.

Renewal: I often described bingeing and purging as a sense of ‘oblivion’. Once I started into the cycle all other emotions were forgotten. The binge squashed difficult emotions while the purging felt like letting them go. I followed almost every binge/purge with self-harm, I was numb but found the sensation of the blood grounding. After both behaviours I had a sense of calmness and peace that wasn’t afforded to the rest of my life. It was temporary, often nearly fleeting, but it did provide the sense of renewal.

Replacing Self-Defeating Occupations with Occupations Facilitating a ‘Life Worth Living’.

It is understandable why, after exposing the multi-faceted nature of self-defeating occupations, replacing these occupations with new, healthier occupations was never going to be straightforward. I believe there had to be a series of stages to the process, probably even involving the stage of being contained and ‘kept safe’ in hospital for many months/years before the process could begin. I doubt I ever could have just given up the SDBs and have found new ways to manage my time without significant therapeutic input from dialectical behavioural therapy, psychotherapy, a therapeutic community, medication AND occupational therapy. However, I do believe the latter is the key to my continued recovery and successful rehabilitation. For me, finding meaningful, yet health promoting occupations to engage in was challenging: I had little experience of letting myself have ‘fun’ and enjoy things. So, while it might have seemed easy for someone like me to go shopping, or take part in leisure activities, there were so many issues surrounding this. For example; I was a competent cook and could happily create a meal for a group of 10 people, yet cooking a meal for myself left me in a state of high distress and unable to engage. Even the small things like making a cup of tea or having a bubble bath were so tied up with SDBs that it felt impossible to separate them, never mind challenge the cognitions with regard to not punishing myself.

I’m happy to say that my life now is full of meaningful, health promoting, and even ‘fun’ occupations. I hope to explore more the role of OT in recovery from BPD, particularly relating to the challenges surround doing ‘nice things for yourself’ and the role of SDBs in making neutral occupations self-defeating.

References

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

Elliot M (2012) Figured world of eating disorders: Occupations of illness. Canadian Journal of Occupational Therapy, 79(1) 15-22