 Good evening and welcome to tonight's webinar. I'm Lina Grady and I'll be facilitating tonight's session. This is a third webinar in the series of Borderline Personality Disorder. And tonight's topic is evidence-based treatments for people living with Borderline Personality Disorder. I'd like to begin by acknowledging the traditional custodians of the land across Australia where webinar presenters and participants are located. We should pay respects to the eldest past, present and future for the memories, the traditions, the culture and hopes of Indigenous Australia. So this is an important series. Hopefully you've been aware of the previous webinars that we've had and that we also have a number of webinars yet to come. So tonight is one of the opportunities to answer some of your questions and we know there are lots of questions. We have about 700 people joining us live at the moment. So welcome to all of you and welcome to our panellists as well. I usually work with the Australian Psychological Society in my day job. So I manage strategic projects at the market and I really enjoy the opportunity to facilitate these webinars with MHPN and find their very useful opportunities for people to undertake professional development. We do have, as I mentioned, a panel tonight. So we have a panel of people, as we always do, if you're familiar with MHPN webinars, you'll know that we have a panel and these are people who represent, as you can see, a range of different perspectives and that's one of the real benefits, I think, of the MHPN webinars is that we do have an opportunity to bring some different perspectives together. We have a case study that hopefully you've had a chance to read. The bio is of the panel members as well and hopefully the case study, but I'll do a bit of a recap of the case study before we move too far along. So this is webinars that are funded, as you can see, by the Australian Government and these are the webinars that are coming up. So the first two webinars covered what is borderline personality disorder and some of the statistics and some of the current thinking around that and the last webinar, if you didn't join us, covered some of the general principles around treatment and the importance of the relationship. And you can see there that after this one, we've got webinar four coming up in July and I'll give you the date at the end, which is going to have a focus on youth and early intervention and then you can see webinar five around self-injury and suicidality and then webinar six, management in mental health services, primary and private sector. So I know that a lot of you will have questions around some of those topics, but I can do to hold on to those and come back to future webinars to get those answered. And if you've got questions relating to the first couple webinars, it would be great for you to have a look at those. They're available on the MHPN website as well, so you're able to tap back into those and get that information. So we want to really keep focused on what it is we're talking about tonight for our particular topic. I'm also really mindful when we do webinars, our fabulous professional development opportunities, we can get a whole lot of you together to get the opportunity to hear the panel and engage with us. But we do also acknowledge that you are on your own. We can't see you out there. So we really want to remind you around your own self-care and we know that whenever we're doing any kind of webinar or any kind of professional learning around mental health issues, that it can impact in lots of different ways for us. It is a professional development event, but that's not to say that we don't need to look after ourselves as well. So remind always that you think about your own self-care plan that works for you, but also lifeline, of course, 13114 and below is necessary and beyond blue, 13224636. So it's really important that you sort of compare to that. If you're finding tonight's session gets a little bit too much, you can always come back. There'll be a recording that will come later, so you can always follow up with that. You don't have to sit through the whole lot tonight if you're finding it's a bit hard going. We will now introduce the panel, I think. So you can see them there and without further ado, I think it's time to introduce them. So let's begin with you, Martha. So Dr. Martha Kent is a psychiatrist and she's from South Australia. Hi, Martha, and welcome. Hi, Nen. Thank you. We've got a question for you. So you were telling us last week when we had a session to prepare for tonight about some recent developments in South Australia in relation to borderline personality disorder services. Would you like to quickly fill us in on what's happening over your way? Yes, certainly. For the last ten years, we, a small group of advocates in South Australia, have been protesting the state of services here for borderline personality and pushing for an improvement in those services. And then, fortunately, and possibly fortuitously, late last year, with a combination of a coronal inquest, an election coming, and Kelly Vincent doing a hard deal with concuits and toners, we have been offered, and of course we have accepted, $10 million, $10.25 million in the state of South Australia to develop a statewide South Australian borderline personality disorder service. Wow. That sounds amazing. That sounds fabulous. But hopefully it's a good opportunity to say, well, South Australia are doing it. What about other places? Great work. It sounds really promising. And I guess when we're talking tonight, knowing that's coming makes it more hopeful, I guess, in terms of services that can reach people. So that's great news. Thank you for sharing that, and thank you for joining us tonight. We'll be hearing from you very soon. Let's move on to Pip now. Pip Bradley is a mental health nurse and Pip, you've been doing, as Martha has, you've been doing this work with borderline personality disorder clients for quite some time. What is it that you find satisfying with working with people with borderline personality disorder? Oh, well, Lynn, and good evening, everyone. I come from a background of nursing and general nursing, actually, initially, and when I moved into mental health nursing, I immediately found that I enjoyed borderline personality disorder. I liked the way that I could make a difference to them, and they're not only their daily lives with their struggles daily, but also with their longer-term kind of emotional difficulties and helping them to establish a life that was meaningful for them. I think that we think about borderline personality disorder as featuring emotion and relationship difficulties, and really, they're the same problems that we all have to varying degrees in our lives, and so their issues are really relatable, and I kind of enjoyed that, found that I could understand it and work well with it, and so I continue to do the work. Yeah, fantastic. Thank you. Thank you. I'm really looking forward to you sharing some of those ways of working and, again, some of the things that you've found over that time. I'm looking forward to hearing from you soon as well, so thank you. Thank you. And last but certainly not least, Fred Ford. So, Fred is a carer, and one of the things about this series is that we have had consumer and carer representation on each of the webinars so far, and that's a really important part of the way that we work, and really important to have the voice of people like you, Fred, to keep us, I guess, focused on that as well, and to make sure that we're being aware and holistic in the way that we work. Thanks for caring for your loved one. What are some of the things that you've been doing in the broadline personality disorder space? Well, one of the things I've done, I was actually the carer representative on the National Mental Health Research Council's Guidance Lines Committee for BPD. I've also been a keynote speaker at the Victorian BPD conference. I've done BPD training of also trained as a family connections facilitator, as well as some other sort of local work as well. Yeah, fantastic. It's kept you pretty busy then, which is fabulous, and again, great that you're joining us tonight to bring that particular perspective from a carer's point of view. You mentioned the guidelines, and we'll probably come back to those again, but the documents that I'll give you a link later on for people to connect with are really important, and particularly with those questions that you might have that we know we're not going to get to answer all of them tonight. Those guidelines are really useful documents for people to get information. It has quite a lot on the evidence base and a lot on practical kinds of information that I think people will find really useful. So great work being part of that group as well. All right, so thank you, Freddie. We'll get to you soon as well. So let's have a bit of a look at our ground rules. This is always important when we're talking about webinars and how we run. If you're familiar with webinars and with the MHPN webinars, you'll know this because they're important, but they're also quite standard. We don't have our chat function that we often have. So often when we have events, we do have a chat function that people can see each other's conversations, and in that case, that's where that part, that first point is really important. We have a question opportunity, so people can ask some questions, and that will be sent through to me to look at as much as we can in the time that we have. But because of the large numbers, it's a bit difficult to manage such a big chat. We have over 1,200 people who are joining us now, so that number, as you can see, is increasing. So, you know, just be mindful. There are people there who do have questions. You can ask those, and obviously being respectful is always good. In technical difficulties, if they arise and we've got great support from Redback to help desk, you can see that there is a technical chat button that you'll be able to see, and also a phone number there. So if there's any kind of technical problems, please make sure that you use that, and they will do their very best to help you. And most importantly, they can be resolved. So, yeah, we're really well supported by people who are there to do that. As I said, we will talk about some resources at the end so that you make sure you've got access to information, and if you do have questions that we haven't been able to answer, you'll have information to go away with. We'll also ask you at the end for some feedback, so we do really value your feedback. We use it. Obviously, we've got three more webinars to prepare for, so we really take on board what you have to say, and obviously for funding purposes, it's also really important, so that will come up a bit later on. Our learning outcomes for this evening, and you would have seen this when you registered, but just as a bit of a recap and just to keep us all focused, including me, what we'll be doing tonight is through an exploration of Borderline Personality Disorders. The webinar will provide participants with the opportunity to identify the evidence-based treatment for the Borderline Personality Disorder, outline the limitation and the lack of available services to access evidence-based treatment. So, we're already flagging that that's the case, except in South Australia when that project rolls out. And to identify the core principles and example of an evidence-based treatment for BPD and dialectical behaviour therapy, we pre-empted that by mentioning that, so we'll be focusing on that. We know that people really like to have some really clear ideas to go away with and to really make sense of in these webinars, so we will be doing that. You can see there in the little writing, there's an audience tip, the PowerPoint slideshow and case study can be found in the resources library at the bottom right, I think that says. So, make sure you access that and you can follow along with us. I will just do a brief recap of the case study though. Hopefully you have read it, but just as a bit of a recap of that, we're going to be talking about a case study that's been made up but based on people's experiences. The person we'll be talking about is Liz and she's a 27-year-old woman. She lives in a rural country town and she's lived there for three years and she went there three years ago for a fresh start when things weren't going so well. There's a history of having a poor relationship with her mother and her brother and she's been seeing a psychologist for some months. She's got some difficulty sleeping, she's got some medications for that. There's some alcohol use, there's some self-harm, there's been a recent argument with her family. So, that's the situation that we're going to be focusing on where we're appropriate tonight and I think we should get into the presentation. So, let's kick off with you, Martha. So, let's hear from a psychiatrist. Hello everyone. Over the past 20 to 30 years, the treatment of borderline personality disorder has swung between two extremes. For many decades in the 1900s, it was thought to be treatable only by psychoanalysis, which put it out of the reach of most patients and many clinicians. It was long, it was expensive, it was very specialised and essentially borderline personality disorder developed a reputation then for being untreatable. But then in the 1990s, Marsha Linnahan burst onto the scene with her innovative, pragmatic, eclectic approach to the treatment of borderline personality disorder, namely DBT or dialectical behaviour therapy. And since then, there's been a plesera of talking treatments which have become available and all have proved approximately equivalently effective. And on that slide, you can see the first four which include dialectical behaviour therapy, mentalisation-based, transference-focused and schema-focused therapy. And then, but there are others, weight there are others. There's something called STEPPS, which you can see is Systems Training for Emotional Predictability and Problem Solving, CBT, Cognitive Analytics Therapy, ACT and the Conversational Model, which was developed by Russell Mears in Sydney and is used predominantly on the east coast of Australia. The asterisks in these slides refer to the psychotherapies which are considered to be evidence-based according to a recent review. And I've put the title of the details about that recent review on the final slide. It's a recent review of treatment approaches to borderline personality disorder over the past five years, and I recommend it to you. There's really no real difference between the outcomes in all these treatments, so we've gone from not much to an awful lot of treatment effects. People describe DBT as it relates to Liz and her situation in more detail, and I would like to just briefly describe the principles of MBT, or mentalisation-based therapy. So mentalisation is defined as the capacity to recognise and accurately label, that is to interpret accurately the inner thoughts and feelings in one's own mind and in the minds of others. The conceptualisation of MBT is rooted in attachment theory, and the focus of MBT is to strengthen the patient's capacity to mentalise, particularly when she's feeling stressed, particularly when there are threats to her attachment system or there are relationship challenges going on in her life, whether it's in the therapy room or whether it's in real life. Because when patients feel under threat, they become emotionally aroused and they often lose the capacity to mentalise. Now in order to facilitate mentalisation, the therapist is trained to adopt the stance of curiosity and of not knowing, which can be unfamiliar to many of us, to encourage the patient to assess and interact in any interpersonal situation more flexibly, more kindly, and in a more grounded way. So with Liz, she was tending to mentalise her mother's motives and other delayed responding to her needs, narrowly and harshly, and she was quite certain that her mother's motives and intentions towards her were negative and rejecting, unloving and uncaring, and this was based around her interpretation of her mother's behaviour. Now time does not allow me to explore all of the other forms of specialised therapy that you saw on the slide, but it is very clear that all of these treatments require considerable training, expertise and ongoing supervision and support. This is a very expensive process and therefore when you think about it, it's not really applicable or able to be accessed by the wider community or the Australian population as a whole. We know, don't we, that drugs have not been shown to be effective in changing the core symptoms of borderline personality disorder and multiple studies have attested to that. They can assist in ameliorating some of the more intense symptoms of BPD and are often used to treat comorbid illnesses, but that is recommended as a short-term option only, at least theoretically. So how can we address the need for good enough population-wide treatment of BPD? Well, happily, there are a couple of more generalist developments in this area which offer hope in this regard and have shown significant clinical promise and the one that I think is most popular is called GPM or Good Psychiatric Management for BPD and it was developed by John Gunderson in the USA. And the model that it's based on is a model of BPD as reflecting heightened interpersonal sensitivity, especially in emotionally charged interactions with social situations. It fits nicely into a case management model and therefore it has wide applicability in public mental health settings. It focuses on the patient's life outside therapy rather than exploring in detail their inner dynamics of the nature of the therapeutic relationship, but it does aim to provide a good enough holding environment in the relationship with the therapist. It overtly focuses on the expectation of change in life with improvements in social and work functioning, thus it prioritises work and better relationships in general across the board over love and romance. It's very flexible. It can be as short or as long as needed. It's very pragmatic and it includes psychoeducation for the patient and the family and group therapy. Any group therapy will do. So this approach offers considerable promise, particularly for public mental health services in Australia. There are other approaches that are being developed as well. Another way forward in terms of affordability and accessibility is to simplify the more specialised forms of treatment which already exist and to make them more user friendly and simple and cost effective across the board. And this approach is also showing promise in clinical trials. So I suppose the approach this generates is to start with the more general types of therapy initially and if and when they fail to move on to the more specialised ones in an ideal world. So thank you for your attention and concentration. And the last slide that I have showed some references for you if you want to pursue these ideas in more detail. Thank you. Fabulous. Thanks Martha. A lot of information there that you covered in a really short timeframe and I'm sure people have got lots of questions as well and would love to hear a little bit more and people will pick up on some of those. But we do have one quick question that Ty has asked which is specific to your presentation. Can Martha please outline the difference between standard DBT and DBT with case management? Is that something you can give a fairly quick response to? Well I think the usefulness of DBT is that it can be applied in many different clinical situations theoretically. So for people in private practice or patients in private practice they would presumably access private therapy with a psychiatrist or a psychologist but be referred to a DBT group and that would be standard DBT group and then the therapist would arrange their own supervision and support and look at crisis management. But in the public mental health service generally where they tend to care for people who have the more severe end of BPD then clearly DBT can be tailored to fit into a case management model and that would include DBT trained therapists supervision in the public service crisis management pathways often articulated in a crisis plan as well as support for the therapists involved. So I think it's really the same process just different locations with a bit of tweaking here and there depending on what is the need. Yeah. Fantastic. And you pre-empted another question which is around short-term crisis admissions still considered in appropriate intervention. So there seems to be people kind of starting to think about what might this mean. So you did mention that sometimes crisis response might be part of that. So we might move on to Pip and we might come back, hopefully we'll have some time for some questions now so we might be able to pick up on some of that a little bit more as well. So thank you very much Martha for that really great affirming message I guess in terms of the range of evidence-based treatments that are there now. So it hopefully gives people a real sense that there are ways for them to find a place for themselves and their own work and opportunities to do this work as well as they can. So let's move on to you now Pip. You're going to give us a perspective from mental health nurse. Yes. Great. So I'm using DBT dialectical behaviour therapy as an example of an evidence-based treatment to use whifflers. And I'll kind of intertwine explaining little bits about DBT and also how I would use it whifflers throughout my talk. Just briefly starting with what DBT is about. Well DBT basically understands borderline personality disorder as an emotion dysregulation disorder. Emotion dysregulation is the core problem and we've done a biopsocial theory of understanding what causes this biopsy, the emotion dysregulation. The biological part of the biopsocial theory though in DBT, thinks about a person having an emotional vulnerability, an innate emotional vulnerability that they were born with. And that vulnerability can take three different forms. It can be they have a heightened sensitivity to emotional stimuli. They notice more emotional stimuli. They perceive more. That means they have more frequent and they experience their emotions. They react more frequently. The next type of vulnerability is a heightened arousal once they do notice an emotional stimulus. So their arousal can go up quite high, higher than for a person who wasn't sensitive. And then the final type of vulnerability is a slow return to baseline. So once they do have a state of emotional arousal it can take quite a long time to return to baseline. Now there's nothing wrong with any of these per se but the combination of them is difficult for a person especially when they may have had the social part of the biopsocial theory. There were difficulties for them in learning skills and having their emotions regulated during their development. Many of us as mental health clinicians may come into this work with a sensitive nature that's often what brings us in but generally we don't also have the heightened arousal and the slow return to baseline. So when we have the social and biological vulnerabilities the transactions of these over time influence both the child and the parent that makes the child more sensitive, more withdrawn, perhaps more difficult to see and over time their caregiver gets more withdrawn, more critical, even more abusive if that's the initial problem. So the person in their childhood isn't developing skills to manage the things that we have to learn how to manage particularly emotions and relationships in their childhood because for one thing their emotional arousal is generally quite high and they're not getting those skills taught to them within an invalidating environment. None of us can move skills in our emotional arousal is too high. So in starting work with Liz, I would actually explain, if this is biopsocial theory to her, I would communicate that the things that she is struggling with makes sense to me in terms of her past experience and her nature. Taking care to explain is nothing actually wrong with her nature, there's nothing wrong with being sensitive. It's a common trait to have but when it's combined with difficulties in learning how to manage the resulting emotions and stresses that a person has then it can cause a lot of difficulty for the person through life. Do this in a very non-blaming way so that Liz can understand that she has to work on her problems herself. I always also communicate this in a very compassionate and validating way so that she's understanding that I'm on her side throughout. So moving on to the next aspect of DBT I want to talk about, dialectical behaviour therapy, dialectical just means that we're synthesising apparent opposites finding balance between positions and the main dialectic we work with or the main balance in DBT is between validation and change or acceptance and change. So the acceptance side, we provide through validation, you are okay the way you are to change sides and yet you still have to make changes in your life, you have to do something differently and starting work with Liz the focus would need to be on validation to help it sustain the treatment. So how would I validate Liz? I can talk with her about how she has tried so many things herself. She's worked on she made civil changes in her life she moved locations to go to an area, a rural area, she's seen the GP, she's seen the psychiatrist, she's taking medications she's trying really hard to work on her problems, just hasn't been changing for her. I also validate that I accept and listen to everything she says and I'm trying to communicate that I'm on her side, I'm not here to criticise her, I'm here to actually help and make a difference for her. And then how to help using DBT? Well the ultimate goal in DBT is for a person to develop a life worth living. We're very target and goal oriented in DBT the theory is that what we target does change. So if we target self harm and addiction and other problem behaviours they will change over time and if we establish with a person at the start of treatment that they need to have goals to be working on themselves then for the life that they want then it helps them to understand why we work on the targets. So if Liz wants to have meaningful relationships in her life if she wants to have a partner or a family she needs to learn how to manage her work on relationships with people even at work in her workplace. The skills and the individual therapy that we do in DBT help her to move towards those goals. So in her case verbally attacking her co-workers isn't appropriate but I would validate her emotion underneath that. It sounds like you're feeling very angry or frustrated or maybe she was feeling hurt. But I would also, so initially I would start with the validation. Just to make a mention here that full DBT does include a comprehensive program but in rural and remote areas often people have to do just aspects of DBT or DBT informed therapy and that's very common. But the full DBT includes the modules of emotion regulation and interpersonal effectiveness to stress tolerance and of course mindfulness. So moving on again the main tool that we have, one of the main strategies in helping a person to make progress within DBT is the chain analysis. It's a moment by moment step by step analysis of what's led up to a problem behavior for a person. Each little step or link on the chain becomes an opportunity to develop alternative skills and it helps to increase the person's awareness of their own patterns by looking at all the steps that have been involved. So it's important to know that the therapist is using change and validation throughout chain analysis. Chain analysis itself is a change strategy. We're working on identifying what's going wrong, seeing where the person needs new skills and new strategies and trying to get them to develop those. So it's very much a change strategy but if we're not also working on validation throughout the change we'll lose the client's focus, engagement and treatment. As a beginning stage of treatment it's going to need a lot of support to understand why she should keep feeding me or keep doing this hard work. This is what a chain analysis might look like. Now I hope you can actually see that slide on your screen. The font is quite small but at least you can get the idea I often do it like this with clients on the whiteboard showing kind of bubbles with different steps or different chains on the link and you can start with the actual problem behavior. So this is a hypothetical chain for Liz starting with the problem behavior of yelling at her colleagues. The prompting event which is at the beginning of the chain is that she saw her co-worker, the one who was promoted above her, laughing with her employer. She immediately felt hurt and had thoughts around I'm not good enough I get overlooked all the time but it's hurt is a difficult feeling to feel and it often diverts to anger for people she quickly changes to anger and then has anger thoughts they don't care about me, they don't like me. As she thinks these thoughts the anger gets worse and as the anger gets worse she gets a strong urge to lash out which is the urge that goes with anger and her way of lashing out is to yell at her colleagues or to communicate verbally attacking them so she might yell out something like some of us are trying to work out can you keep the noise down and then immediately she feels better after it because the acting out, the lashing out kind of relieves the emotional distress but in time she feels worse as she realizes that she's done it again, she's got herself into more difficulty and she might just probably even worry that she might lose her job so NDBT would be using all of the skills to help her on this chain to identify links or places where she can do things differently. Mindfulness would help her to be more aware of how she's interacting more aware of how she gets distracted onto what her coworkers are doing and help her to stay focused on herself so that she can calmly work on her own work. Also mindfulness would also help her to manage her ruminating thoughts at night which are interfering with her sleep sleep's a major problem for Liz one of the reasons why she's taking medication and possibly even drinking alcohol at night so if she can work on skills to manage rumination and to improve her sleep that would help. Distress tolerance helps to get the higher razzle down and we have numerous skills we use intense exercise we use pace breathing, we use distraction and self soothing skills to get a razzle down and then emotion regulation skills would help her to stay with the hurt rather than diverting onto anger it's actually the underlying emotion that needs to be heard and expressed and validated. The hurt is really sorry the anger is really a distraction from her feeling of hurt and teaching her that the emotions do pass, they're like waves of waves of emotion and act opposite of my favorite emotion regulation skills so when she feels like letting out do something different, go for a walk get out of the office or distract herself with something else on her computer the final set of skills we would use to help her on this chain is interpersonal effectiveness however to start with her, Liz's razzle is so high that she can't really even recognize what she wants to get out of relationships and work on how to communicate effectively how to validate the other person how to be fair to others as well as herself so the first step in managing her relationships is to get that a razzle down using distress tolerance and that way so at every link in the chain we can work on places she can do things differently and sometimes just changing one link can make a difference to mean that she isn't going to end up doing the problem behavior I think I'm out of time but as in finishing with Liz and our early sessions I would make a plan with her I want to keep seeing her I want her life to help her to change her life but so I'd be working on her commitment to engaging in DVT treatment discussing practicing initial strategies and session that she can use working through her breathing exercise if she finds that helpful planning further sessions so doing family work and support from her mother perhaps through family connections or whatever was available in the local area so that feels like a quick race through DVT but it's enough at the moment and I'll hand back to you, thanks Liz thanks very much there's so much to say in such little time and I called you Liz as well I'm sorry Liz you were not so patient that's our case study we have a lot of staff thank you, there's lots to cover and I think what you've given is that overview going a little bit more deeply into DVT and I think that chain image I think will be really helpful to people to kind of see that pathway and the link between those sorts of things did you mention at the end family and working with the family and that's really timely because here we are now with Fred and the CARA perspective we've also had a question from Ryan into that CARA role as well given that the CARA CARAs are the people that are there 24-7 when practitioners and clinicians might see people for a shorter period of time so I think that Fred you'll be picking up on some of those points now so over to you good evening everybody I'd like to start off by saying that personally I don't like the term CARA when it comes to mental illness or borderline personality disorder CARA gives over the connotation of doing for whereas our role is supporting our loved one and that's very important because sometimes we do need to do things for our person but it's also very important to give those responsibilities back as soon as possible another thing emotion can and will play a part in how CARAs react and this could be for a number of reasons and probably the biggest one coming from a rural area myself is difficulty in accessing and maintaining services as I say particularly in our areas another is frictions within the relationship and we see this in the scenario with Liz and her mother and her brother it's something that seems to be goes with BPD whereby particularly families who don't have an understanding of the illness can sometimes also misinterpret the reactions of the person they're supporting and thirdly the self harm it can be very difficult for families to deal with and to witness and to accept and I know in my situation that was probably the hardest thing of all was standing by seeing this happening and the feeling of helplessness CARAs need support also and it's important to refer CARAs to support services and in most areas you have CARA advocates or support workers also there are other services CARA services that you can refer to for support and things like that as well CARAs need time out to look after themselves research has shown that between 60 and 80% of all CARAs develop mental health issues it's important that CARAs have their own time away from the CARE role and what I usually encourage CARAs to do is to set aside some time in their week which is their time so a set time whether it's go out with friends for a coffee or what may play golf read book or whatever but that time is their time and sometimes they need services to support them in doing that as well sorry I forgot me quick CARAs need specific education such as family connections as well and it helps them to develop appropriate strategies to support their loved ones our family connections is based on DBT so they're learning the strategies that are being taught to their first to their person but also it helps them to develop strategies in appropriately supporting their loved one CARAs can feel guilt and blame for their person's illness which is usually baseless you might have a situation where say a CARA has had to go into hospital there's been nobody else to look after their person the person's been put into care they may have been assaulted while they're in care and that CARA can carry that guilt around with them so it's important to emphasise for them that it's not their fault and to show them what was the other thing that they had and the fault lies with the perpetrator not with them CARAs an integral part of the person's care team and this is important to remember that we're the ones that are on the front line and where appropriate they need to be involved in care planning and know the basics about the person such as diagnosis medication and care plan these are the things that help them work with you as professionals along the same lines so that everybody's working together some professionals have asked me about confidentiality and how they can overcome this as a clinician to involve the family more probably one of the most important things is if the person you are working with is saying they don't want their primary care or those closest involved is to not to much argue with them but revisit that over time because while consumers have rights they also have responsibilities and this is something also to say if John wants to hand to support them then they have a responsibility for those three areas so that they can support them appropriately such as being involved with the care plan knowing the diagnosis and knowing what the medication regime is as well another important thing is develop a care engagement plan while the person is well because that like in my situation when my loved one became unwell then I would become public enemy number one and what we did was simply sat down while they were well we wrote how to plan of what my care role would be also my involvement with the professional team how that would look how my person was involved with that and the fact that they would be aware about everything that was happening in that situation this is something all through the sign the case manager myself and my person and it worked very very well particularly when they became unwell there may be need for family interventions or maintain to repair family relationships and this is something that would probably happen in Liz's case with her family and a brother particularly if that was what she wanted because as we know when people at BPD these personal relationships can and often do become strained another area is that if there's small children within the household often or at times family services can become involved and some families actually have to make a decision between the other children and they're supporting so it can become very difficult if carers become angry try to find the cause of the very anger or their frustration because quite often what they're presenting with is not actually the cause and you could think of a situation like where parents their sons at home he's unwell they're trying to get him to hospital he becomes angry and they call the police just to get him to hospital police come the parents say they don't want their son charged the officer happens to get one of the parents to sign their daybook which then in turn gives him the right to then have charged so in the situation you might have to go and speak to the police liaison officer and what I've found situations like that once they're resolved then the relationship with the workers and the service also improves so again quite often they might be angry but what they're angry about is not necessarily with the service but with something that's happened so it's important to find out exactly what it is what can carers do if their person is resisting or refusing treatment this is very difficult really we can only encourage the person to get support support them in intending appointments without overdoing it and working in conjunction with with the service to try and get them to actually go to their appointments what if they're talking about threatening or self-harm this is probably the hardest thing and it was the hardest thing for me to deal with was this really an act for self-harm or for suicide or was this about trying to get my attention and the thing that I learnt was it was important for me to listen to my gut and if I felt that the situation was serious to do something about it and there's one thing my person told me and I'll never forget was that they said to me if you think I need help get me help I might abuse you for two or three weeks and then I'll say thank you so it's about learning and we all know our person as in family carers so it's about using that sixth sense to really ascertain what's happening there and the thing I'd like to leave you with is a well nurtured family or carer and actually be your greatest asset because they're there 24 hours a day seven days a week and if you have a good relationship they can give you another insight as to what's happening for the person because as we all know when someone gets into their therapeutic relationship they don't always say exactly what's happening so where there's a good relationship with a carer you can get that other perspective and I've often said it helps workers to sort the weight from the chaff. Thank you Thanks very much Fred and again lots of information covered in a really short time so thank you and I guess for me there were a number of things that jumped out one of them is that last point where the carer and family members can play a really important role in supporting the patient the client by sharing information and being able to give some insight that can be really useful to the practitioner who's treating the person but the need for the carer and the family members to have the support as well so could you just maybe touch on that and how that like what you might say to carers around what support they might get to themselves he talks about having some time out but what about some professional support if that's something you'd be talking to carers about as well Yeah and as I said in a lot of services today they do actually have family carer they just support workers or carer advocates as they have or carer advocates as they have in Victoria New South Wales largely that's done via a community managed organization which is called Carer Assist but it's important that that carers get that support as well and what those services or those workers can do is sit down and hear the carer's story and give the carers an opportunity to actually talk through what's happening for them quite often these workers have a lived experience as well as carers so they're able to empathize with them one thing I did forget was that workers have often said to me about the confidentiality side and said to me how do we identify a primary carer and usually as a rule of thumb I usually say it's the person they turn to when the proverbial hits the fan and that's generally their primary carer Yeah okay and you made the point of doing some of this planning before things hit the fan so during the planning early on yeah the other point and I'll open this up to the other panelists as well is around a question that Miss Rache I think you spelled that one sorry if I haven't said that right but what do people think of the parentification process so this is the idea and you did mention that children are young people looking after their parents rather than the other way around so you did flag that as something that can happen but I guess I'm interested also in Martha and Pip's perspectives around that in terms of practitioners looking out for that and what sort of suggestions they might have around that or Fred if you want to kick off and talk a little bit more about that and what you might say to carers as well about supporting their kids protecting their kids while also acknowledging the role that they play Yeah well I think it's very important because like we spoke about a lot of relationships become fractured around BPD so in my area, in the rural areas there are a lot of parents who suffer BPD only have their children there and they're their main supports so it's important that they're included in what's happening as well and that they have an opportunity to be able to learn about what's happening for their parent or their sibling and again sometimes there are there are a young carer supports out there and that varies greatly there's more available in capital cities and there are in rural areas which is something I've tried to get going in my area but it's just important that they've recognised and they also have the opportunity to talk about how they feel Right OK thank you Martha Pip would you like to add anything to that or are we happy to move on to some other questions You've got a few I'd like to make a couple of comments Unfortunately this situation is all too common but I think most therapists would agree that it's not particularly in the best interest of the development of the minor of the child because while the child is so anxiously caring for the parent they're not able to attend to their own spontaneous and necessary development processes and they pick up a lot of best responsibility and possibly anger and frustration and fear along the way none of which is good for their own personal development so we recognise that this is common but it does leave a legacy of conflict and difficulties for the child as they mature into adulthood OK thank you for that perspective Pip have you got anything to add Well I think just to add I've gone from what from what Martha just said around the legacy can be carried into adulthood so I generally am working with adult clients and they can still feel a sense of duty and responsibility to their parents even well into even middle adulthood and so I think sometimes you do have the opportunity to work with both the adult and their parent but sometimes you just have to work with your client on their own around establishing how this is getting in the way of them living the life that they want and then trying to find a way now to focus more on their goals, their values what they want their life to be and using mindfulness and other strategies we use in DBT kind of starting to get a sense of how they can be more present to their life as it is now and focus on the relationships that are really meaningful for them Yes Alright thank you we do have some time to look at some of the other questions that have come up so we do have one around medication and I guess this is back to you again Martha you did mention medication is not necessarily going to solve a lot of problems for BPD particularly but may be useful for some of the comorbid conditions and we've got a question from Nimai Garda I think he's saying that right, the role of medications such as Lama Trudine I don't know if I said that right for mood stabilizing before commencing DBT is that something you can comment on? Look I think it is, it can be commonly used in order to stabilise labour, intense mood swings but it has not been shown specifically beneficial for core symptoms of BPD and we must remember this added to which Lama Trudine has all thoughts of well described possibly serious side effects so I guess as always it's a balancing process but I think we need to remind ourselves that the core evidence based treatment for borderline personality disorder it's fundamentally psychotherapy and group therapy rather than medication Okay Thank you, we also had a question about groups it's like all these questions are linking together which is really nice so Blythe asked about it would be interesting to know how you manage borderline personality disorder people people with borderline personality disorder might be a good way to say it in groups so Martha you've mentioned that but Pip you might do some work as well and whether or not Fred you've had a chance to join any groups or your experience with that so Pip do you want to kick off with that and then we'll go round Yes, thank you so DBT it structures its groups quite well and we explain the structure of the group really well to our clients and also our clients we have the luxury of providing full DBT treatment and we're able to do some pre-treatment sessions before they actually join a group and those pre-treatment sessions can kind of prepare for being in a group start them developing some ways of managing their arousal even before they join the group and then within the group there's a real structure so the first half of the group is reviewing homework that was given the week before then there's a break and then the second half of the group is teaching new skills so the whole focus the group tends to be two hours long and the whole focus for the two hours is on using skills and if a person does present in a group with a difficulty or they start to have some emotional arousal tension within themselves and apparent within the group we use skills to manage that even in the group and so kind of everything is seen as an opportunity for using skills but the structure of the group really helps and then people get the sense of people attending the group get the sense that this is about learning skills it actually seems to help them to step into a more functional way of talking about their life and how they can improve it Fantastic, so the preparation leading up to it sounds really important and the structure and careful Yes, I am aware there's a lot of services do just provide groups and might not have the opportunity to do preparation beforehand but it is always good to have some form of assessment, some kind of a plan with a person around how they would manage their distress if they found it difficult to be in the group people can just leave too, just leave quietly saying just giving a reason that they just need to take some time out where we would encourage people to do that as well Yes Alright, so you said something that you would have experience of or people that you care is talk about groups or were they useful what helps them work any comment about that? I think you need to unmute yourself Sorry In my experience with my person they had a combination of group therapy and individual therapy and that was a spectrum Both were very useful from two perspectives in the group that gave the opportunity for them to have that relational work as well whereas in the individual there was more intense sort of personal work if that makes sense In the country it's a lot different, most of them are actually groups as Pip was saying with not a lot of pre assessment because generally it's your public mental health services doesn't and it's clients that are already within the service so they'd have a bit of a run through from their case managers then they would go into the group after being assessed if they're suitable for the group if that makes sense they are also useful for a lot of people but then those that struggle with groups they miss out because they don't get that individual so to me that's probably the biggest difference Okay, thank you for that and Martha would you have anything to add about group work and benefits or things that people be aware of? Well look I think the dismantling studies of Marsha Lena-Hanne are quite interesting in this regard I mean what she did was she compared standard DBT which is one on one with groups fundamentally to groups alone or to one on one school development alone and they still showed some promise so sometimes I think we have to be pragmatic and be grateful for whatever therapies are available even if they're not quite the full package. That sounds like a really important point and we said one of our learning objectives for tonight was around limitations and we're hearing throughout the presentation some of the limitations in terms of what's available in different places and different circumstances so that sounds like a really important part of our thinking and our work is to be open to possibilities and I guess to look at what the research says because there's quite a lot there that can give us some hope that there's not just one pathway. So thank you one of the comments that Margaret's made that I think is really important and a really important part of the work of MHPN and whenever we do these panels I mentioned earlier that we always have a range of people from different disciplines and of course we can't have all disciplines represented in one webinar but Margaret makes a comment that mental health social workers are not included in tonight's discussion and but she wants to make the point that it's good to mention this and as I asked us to talk about this because they are allied health professionals who are referred by DPs to work with people under Medicare including people with borderline personality disorder so letting people know about that because people might not be aware of it is something that Margaret wanted us to mention so but be interested in hearing from each of the panellists as well around this sort of idea around collaboration having perhaps working with others not necessarily seeing our own particular discipline or our own way of working is the only way and how we might collaborate with other people so maybe we'll just go around maybe we'll start with you again Pip. How do you see that or what it might look like for you? I've always worked in public mental health services and in community mental health teams and they contain a variety of disciplines, social work, nursing, psychology, occupational therapy and really the work that we do tends to be similar like we don't kind of we bring a different we may bring different approaches to the work but we're really very much doing the same standard of work so in our DBG team at the moment in the spectrum we have a couple of nurses and the rest are psychologists that I've definitely worked with occupational therapists and social workers and the team before and and really it's about the person, it's about the clinician and the type of therapy that they, that works for them that suits their personality and the way they use it to work with their clients but I think collaboration between all disciplines there's so much work to do and we all do need to work together and I know that outside of public mental health services and even between the public and the private sector and the with Medicare there needs to be a lot of collaboration and there are a lot of clinicians and therapists in the community who are really well trained and working with good line personality disorder. Okay, that does. And Fred, what about you? Is that something that carers would be aware of and what helps that if you do have a number of different professional workers working with your person and family, what helps with that or what might people want to be thinking about that can make it work best? I don't think a lot of carers would be aware of the different disciplines within a mental health team but in my experience both working as part of a public mental health team and as a carer the main thing that they're looking for is that their person is looked after and the progress is made. I'd like to corroborate everything Pip said there before and another area that's going to become more prevalent as you go by is also peer workers. They're starting to become part of the workforce more and more as well. Okay, yeah, that's a good point. Okay, thank you. And Martha anything to add to that just around that collaboration between different professional groups? Look, I think borderline personality disorder is a classic example of multiple forms of therapeutic approaches can be equally effective and I think it's important working in this area that we remember that and that even if somebody some of our colleagues uses a different form of therapy the temptation of course is right for splitting but provided we can communicate clearly and respectfully and remember that there's not just one way to deal with this then it can only be for the good. Yeah, fantastic. Thank you. And that's a great place for us to kind of finish our Q&A. Unfortunately our time for that is coming to an end but that was kind of where we started with you Martha in terms of the different types of evidence based treatments that there's more than one now that we can be looking at so we've kind of come full circle. I can see there's still lots of questions that are outstanding that we're not going to get to unfortunately but I do want to give each of the panellists a moment just to perhaps share their take home message what is it after sort of having been through the session that they would really like people to take away so Martha you're okay if I start with you things you're still there for everyone to see. Of course, happy to I think it's very important for us to remind ourselves that there are many different forms of psychotherapy that really do make a difference for borderline personality disorder so improvements in recovery can be expected it's a good news story not a diagnosis of despair or hopelessness or nihilism and that's good for patients and therapists alike because typically at least there's so much scope for different approaches we have the generalist model which is a good place to start and then moving on to the more specialised model if that's available so it gives clinicians patients alike so much scope provided the training is to yeah fantastic thank you and that's a very consistent message we've been hearing through the previous webinars as well that there is something that everybody can do and certainly being trained and aware as possible that messages of hope I think have been coming through the last couple of webinars as well so that's very affirming and hopefully does give people a sense that we can look at this in lots of different ways so thank you for that Fred let's move on to you and your takeaway message what would that be for me it's two points first one being that families and carers are an integral part of a care team and they need to be included I'm not saying that it's the same in every case there would be a small percentage of carers who should not be carers but in the main if you nurture your carers and you make sure they're supported and that they get some education as I said before they can be your gracious asset as a clinician in finding out exactly what's happening with the person and what progress they're making or not making fantastic thank you that's really an important point and I think you gave us some really good advice to help people to see some of the things that we might need to be thinking about in order to do that work well and to set that up and even your beginning point around carers and what that might mean and how you kind of think about that role and then how practitioners might set that up as well so to challenge some of those ideas around what caring, what that role might look like so thank you for that and what about you Pitchlet let's get on to you in your last parting comments so to follow up on what Martha said about there are many therapies that work and that their message really is one of hope for treatment I think across all treatments all evidence based treatments for borderline personality disorder there's a core key factor common factor of validation or some term that may be different from validation but something that means that you're communicating to the client that you understand or that what they're saying makes sense in some way and I do really want to emphasize that because sometimes we can focus more on the change side of the treatment and not as much on the validation we have to have the balance and sometimes it can be difficult to validate clients because sometimes the content of what they say can be very exaggerated or judgmental but underneath your words and that's what we're looking for with validation we look for what's underneath your words and it can be quite hidden sometimes but often there's real pain real fear or anxiety about something there's real feeling and when we validate the feeling it's kind of like for the client it can be give them an enormous relief it can be transformative if they've had minimal experience of validation in their life previously I also just want to make a comment about for clinicians working doing this work and thinking about those who we had in the case study she was bringing a lot of she was bringing anger into the room not only with her colleagues but also with therapist she was also bringing in her desperateness and her hypelessness and so how do we as clinicians or therapists manage ourselves with those strong emotions it's really important to keep having awareness of how we are ourselves in doing this work because it can be really hard work with pain or with anger so the most important thing initially is just to be aware of yourself aware of how you're feeling so that you're mindfully aware rather than reacting or acting on your emotion without realising what you're doing and the usual means of helping our awareness and helping us to manage our feelings are important such as validation such as supervision reflection and other ways of getting support that's my finishing note thank you that's my dog we're supposed to be a dog so he has that's a really important point we normally do finish up with that message around self-care so thank you for reminding us about that because we have heard that there's complex work and there's lots to it and it is important that we do care for ourselves when we are doing the work as well as the time it's validating ourselves actually as well as validating our clients thank you well thank you very much for that we've got a few minutes just to wind up really now and it's always difficult to get to this point because there's still so much more I know people want to know but we do have more webinars coming up for you there's also some resources I said that there'd be some resources that we would talk to you about and here's the website for you to go through so the Australian Borderline Personality Disorder Foundation put together some resources for you and the practice guidelines that we talked about earlier on that Fred mentioned will be available there the previous webinars you can look at on the MHPN site so there is the information out there is important so hopefully you've got some answers to the questions tonight and now you've got a chance to get more information if you need it and also more information from our next webinar which will be held on Monday the 23rd of July 2018 and that's the one that's going to be on youth and early intervention there's always other MHPN webinars as well so you can always look at those and make good use of those as well MHPN also have Practitioner Networking Opportunity so you can look at that website to join your local Practitioner Network and a number of being established to provide a forum for practitioners with a shared interest in Borderline Personality Disorder so you can visit the website to the news section or contact MHPN to find out more so when we talk about some of the limitations or some of the constraints by having forums for you to share your interests with others will be really helpful your feedback is really important to us as we keep saying so it is important that you do look at the survey and take a moment to fill that out so that you can do that so click the feedback survey tab to open the survey and that's really really important feedback for us you will get a certificate of attendance for the webinar within the next four weeks and you will be sent a link to the online resources associated with the webinar within the next two weeks so look out for those as well so thank you everybody for joining us this evening thank you for the contribution and the work that's gone in behind the scenes for tonight's webinar to the panellists and to the Redback people and the MHPN people as well and for you for joining us and the really helpful useful questions that came through as well it really adds to the experience so I hope it's been useful experience for people but you've got more opportunities to find out more through those ways so I'd like to just close by acknowledging the consumers and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present so thank you everyone for your contribution and good evening and look forward to seeing you next time good evening