Abstract
This study uses a grounded theory approach to understand how borderline personality disorder (BPD) affects occupational participation. Environment, occupation, and internal experiences are discussed in the context of the lives of 18 participants with BPD. Affirming occupations provided escape from harmful environments and promoted positive internal experiences. By contrast, absence of affirming occupations resulted in problematic environmental challenges and distressing internal experiences.
Primary Author and Speaker: Emily Mokol
Additional Authors and Speakers: Kyra Jo Gaerke, Sally Wasmuth, Trevor Manspeaker, Karolina Szymaszek
Borderline personality disorder (BPD) is characterized by intense emotions, self-harm, low or unstable self-image, and risky behaviors, among other symptoms (American Psychiatric Association, 2013). The purpose of this study was to explore and better understand, through grounded theory analysis, the occupational lives of people with BPD to identify how occupational therapy (OT) may improve occupational lives for this population. There is limited research that specifically focuses on the impact of BPD on occupational participation, which is important for informing OT treatment planning.
This study uses a grounded theory design with existing data from a larger study looking at metacognition and function in people with BPD. Eighteen participants were recruited via convenience sampling from a Veteran Affairs Hospital inpatient/outpatient clinic in a urban midwestern area. Those receiving services for BPD who were over 18 and who provided informed consent were included.
Data were collected with the Indiana Psychiatric Illness Interview (IPII), a semi-structured interview designed to elicit illness personal narratives (Lysaker & Lysaker, 2002). Eighteen IPII transcripts were analyzed by four OT graduate students and their OT faculty research advisor, using the grounded theory steps including initial coding, focused coding, axial coding, and theoretical coding (Charmaz, 2014). Initial coding involved assigning a code to each line of data to begin establishing a code book. In focused coding the code book was edited to ensure the code book represented the data fairly. Axial coding was then used to synthesize and sort data. During the final theoretical coding stage, significant themes were examined in the context of participant narratives in order to identify how they emerged and their relationships with each other and life processes of participants to develop a final theory.
Findings illustrated a bidirectional interaction between the main themes of occupation and influencing environment. Participants’ environments contributed to their chosen occupations, which in turn continued to influence their environments in an iterative process. For example, a historical context of drug abuse led to drug use and choosing drug using peers and environments later in life. A bidirectional interaction was also evident between the themes of occupation and internal experiences. Internal experiences contributed to the types of occupations participants chose – feelings of shame and low self worth, for example, contributed to participation in relationships that reinforced these feelings. Finally, data in this study illustrated a one way interaction between the themes of environment and internal experience. Environmental contexts impacted participants’ internal experiences; however, while internal experiences impacted occupational choices which then contributed to shaping participants’ environments, internal experiences did not directly shape the environments of participants.
This research underscores how OT may powerfully impact lives of people with BPD; data illustrated how occupations affected both environmental contexts and internal experiences such as self-image and appraisal of relationships and events. This study suggests that people with BPD may have the ability to alter their internal experiences and their environments through intentional use of occupational engagement. This research is unparalleled because it looks specifically at the occupational lives of people with BPD and suggests OT may facilitate meaningful change through occupation-based intervention. Intentional efforts at occupational participation may beneficially address the centrally troubling features of BPD including problematic self-image, self-harm, and risky or disaffirming environments.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Charmaz, K. (2014). Constructing Grounded Theory. Thousand Oaks, CA: SAGE Publications
Lysaker, P. H., & Lysaker, J. T. (2002). Narrative structure in psychosis: Schizophrenia and disruptions in the dialogical self. Theory & Psychology, 12(2), 207-220. doi: 10.1177/0959354302012002630