 Good evening and welcome to this evening's webinar. This is a webinar in Borderline Personality Sorter Series, it's number four in the series as webinars that we're having and I'd like to welcome you all this evening. My name's Lina Grady and I'll be your facilitator tonight, working with a panel who I'll introduce in a moment. I would like to welcome the 1,251 participants that we have joining us live this evening. We know that there'll be some more joining us as the evening goes on and there'll be more watching in the podcast later on. And welcome to all of you, welcome if you've joined us before, welcome back. And this is the first one that you're joining us for, welcome as well, and please have your... I'd like to begin with and discuss where the traditional custodians of the land and acknowledge the many lands from Australia where our webinars have been located. We should pay respect to the elders past, present, future, for the memories, traditions, culture and culture. So I'm always pleased to facilitate these webinars. I find they're very interesting to me as a community psychologist. I work typically in my normal day-to-day work. I work at the Australian Psychological Society managing specific projects and I also supervise some psychology interns. Then online personality disorders, something that comes up as a concern quite often in terms of the interns that I'm working with. And I guess one of the concerns is how do we know and what's the best way forward. So this series has been really helpful, I know a lot of them are joining us this evening as well. We do have a panel who I'm really pleased to have with us this evening. And I want to begin with it's great for acknowledging the generous and significant contribution of staff from Origin, the National Centre of Excellence in Youth Mental Health and the Development Commission of the content for this webinar. So you'll see a number of our panellists working at Origin and they'll be talking about some of the work that they do and really pleased that they're here with us, particularly for this one that we focus on on young people. We also know from the previous webinars as well that people have been very interested in this topic and you can see here that it's enforced, as I said, funded by the Australian Government and you can see that we still have some more to come. So this webinar will focus on youth and early intervention. The previous ones are focused on what is borderline personality disorder, what are some of the treatment principles, what are some of the evidence-based treatments. At the moment, we've often had questions in those webinars about young people and tonight's the chance it gets holding off today, we'll get to those. You'll see the next two webinars will be looking at self-injuring suicidality as well as management in mental health services, primary and private sectors. So questions about those topics will be holding off on tonight but we'll certainly get to answer some of the questions in relation to and that will be a really important part of the evening and fit in. If I could, I guess you mind people, and if you've joined the webinars before, you'll be very aware that this is something that we talk about all the time and so my camera's going in with honey at the moment. This is a webinar, it's a professional development event. We're aware that people are coming to this event with their own various experiences. So some people, that might mean experiences, it should be experience of borderline personality disorder or experiences of practitioners that can sometimes be challenging. So we do ask that you take care of yourself, your self-care, and if any content tonight does cause stress, cause this lifeline, 13114 to below, Beyond Blue, 1300, 224, 636, or your GP or local mental health service of course, and I'm sure that many of you will be aware of that but we do like to remind you that we are here as practitioners that we also need to be mindful of our own needs and our own self-care as well. Of course these webinars are recorded and you will have the chance to look at it later. So if you're finding throughout, you sort of want to have a break from it, you will get the recording in the wake of those times. So you can always pick up on it again then. We don't have a chat function in this webinar because we have over 1,300 people now online with us this evening. It just makes a chat function very difficult. So if you've joined us in other webinars and we have had a chat that's where you've been able to participate a bit more, be more fully there, we do have the opportunity for you to ask questions. So if you do have some questions for us, we do have a lot already, so when you're registered, but if you do have some burning questions that you would like us to consider, we'll look out for some of the themes and I'll keep an eye out for those and we'll do what we can in the questions. As always, if you do have any technical difficulties we're well supported by Redback. We have a team of people behind the scenes from MHPN and we also have a team of people from Redback. So there are lots of opportunities for you to get some help if there are some things that are not working quite well with your technical issues. So I might need some help as my camera keeps going off. There's a help desk number there and it's on the way's ringing and they'll call you through some of the necessary. If there's anything major that happens, there'll be an announcement. So we're going to be up to 1500 people now, so our numbers are really increasing. All right, so you've seen the panellists bio already. So hopefully you've had a chance to read those and you will see who these people are who are going to join me this evening and talk about our case study that hopefully you've read as well. So we're not going to read over the bios but I'm going to introduce each of our panellists now and have a very brief chat with them just to give you a sense of who they are and what they're going to be contributing this evening. So I've mentioned already Oregon and we do appreciate the support of Oregon, the National Centre for Excellence in Youth Mental Health and they've played a very important role and of course do a lot of important work in relation to youth mental health. So I'm going to begin with Professor Andrew Cannon and Andrew, you're a psychiatrist from Oregon in Victoria. I've got a question for you to kick us off, really. Why might people, practitioners that is, be reluctant to diagnose borderline personality disorder in young people? Well, hi, Lynn and hello to everybody and thank you for inviting us to participate in this webinar. I think that the main reason that we encounter nowadays because the science is pretty clear about the validity of diagnosing the disorder, the main reason is stigma and discrimination that people are reluctant to let young people be exposed to the stigma and discrimination that is right throughout the healthcare system. And so we hope to address that in the webinar this evening. Fantastic. Thanks, Andrew. And that's certainly a theme that's come through in the previous webinars as well. We certainly talk about some of the stigma and that really the series is really about trying to break through that stigma and I guess it's particularly in relation to young people and some of the perhaps thoughts or some of the advice people have received in the past about young people. So we'll really tackle that tonight. I know that's something. So thank you very much for joining us Andrew and you're not a newcomer to MA2 field webinars because you've been involved in quite a few before. So an old man. Yes, so welcome back. Nice to be back. Let's move on to you, Karissa. Karissa is a young person from Western Australia. So it's a very different time. Western Australia people can probably see my background is the lights of Melbourne. So I guess you see your background. You've got some sunlight still, which is nice. So thank you very much for joining us. It's really important and it's been a really important feature of these webinars the series that we have had people's lived experience. And this is really important because what you do is help health practitioners to really become more aware and more tuned in to what's actually happening to people they're working with. So we really appreciate what you're doing. When we had a briefing a couple of weeks ago, you mentioned Safe Space Cafe and we thought that sounded really interesting. So can you tell us a little bit about that and what it is and what you do there? Yeah, I can. Thank you, Lynn. And thanks, everyone, for having me tonight. It's been a year-long project and we... So we have a group of lived-experienced people who have co-designed a Safe Space Cafe in Western Australia and we just recently sent off our application for funding. So hopefully Western Australia will have a Safe Space Cafe by next year. So the concept of it is for people who have... who are suffering distress from a mental illness or having mental health issues can present themselves to the Safe Space Cafe instead of going to emergency departments. And it's going to be peer support-driven as well. So you're going to have peer support workers on board straight away. So they have someone to support to who... Yeah, I can't say too much, but that's what's been happening. Fantastic. Thank you. That sounds really interesting. And I'm sure people around the country will be looking out for how that goes and finally ways that they might be able to do something as creative in. And I guess you guys are thinking and working. So thank you for joining us. We'll be back to you shortly. Let's move on to you now, Susan. Susan Priest is a carer family friend. Bringing a carer family friend perspective from Victoria. I'm sure you are a carer family and a friend, but you're bringing that perspective today. So I've got a question for you. How long have you been working with families who have a young person who's got a diagnosis of borderline personality? Good evening, everyone. I've been working for over seven years with families and friends of young people who have borderline personality disorder. And it's a real privilege to work with those families who are often extremely resilient as are the young people. So it's really good, again, to have you as Carissa, to have that perspective because it's a really important part of... part of the work of practitioners is to supporting the young person, but also be aware of who are the people who support people around them that may be parents' friends. So it's really important that you, again, bring that awareness to us and keep us in check and be really good at doing that in terms of reminding us of the perspective of parents in Carinel. So we're looking forward to your inclusion tonight as well. So thank you. Thank you. And moving on to you, Louise. So Louise, Dr Louise McCutcheon is a psychologist from Oregon in Victoria. And the question for you is, what do you find rewarding about working with young people who are living with borderline personality disorder? Hi, everybody. I think that one of the things to say about young people is that often their patterns are less entrenched and they've been left tossed around by the system. And so often their difficulties are more responsive to small amounts of treatment. Now, it might be something to do with young people anyway, but I think it's really inspiring working with young people who want to make their lives better, who don't want to be able to care for themselves better and to be part of that process. And often it's more simple than people think. Okay, well, that's good. That's a great starting point. And I'm sure that a lot of people that are joining us tonight are working with young people and maybe working with young people and seeing the things that you're talking about, but maybe be challenged by ideas around borderline personality disorder. So I guess the audience will have lots of different perspectives. But I think if you have worked with young people, there's lots of great benefits and energy that comes with that, that I've always enjoyed in my work. So thank you very much. And it's great to have people with such diverse experience in lots of ways, but it will bring a depth, I think, to our session this evening. I'm not sure if I said that this is a joint. I've talked about origin being part of tonight's session, but the overall series is Australian Borderline Personality Disorder Foundation and Spectrum, and funded within HPN and funded through Departments of Health as well. I'm not sure if I mentioned that earlier. So I've mentioned it now. So let's get on with our case study for this evening. This is our learning outcomes, which you would have seen as well. So we're going to be talking about borderline personality disorder as kind of the main theme, but looking at it in relation to young people and how we might be understanding what borderline personality disorder might look like in young people, we're looking at age-appropriate therapeutic interventions and treatment principles for young people, and we've covered off on a lot of those in other webinars, but really thinking about what is it with young people and what might be the same, what might be different about that, and outline how to work appropriately with a young person and their family. You can see there that the PowerPoint presentation is available and can be found in the resources section of your platform. So hopefully you can see that there. I do want to just recap a little bit about the case study. Now, hopefully you've had a chance to read it, but if not, it might be good just to give you a bit of a reminder. So we're going to be talking about Michelle, and Michelle is a fictional character and drawn from experiences, people on the panel. So Michelle's a 17-year-old female student, lives at home with her parents and her younger siblings. A few months ago, she's referred after having an overdose and spent some time in the adolescent patient unit. She reported feeling hopeless and sad about her life, no friends at the moment and couldn't see a point in living. She thought that things had been going OK until she started secondary school. So she's 17 now, but she's able to reflect back on issues that arose at secondary school. She talks about moods being intense and feeling four different moods in a day and it can be overwhelming. She's self-harmed since the age of 14 and can frequently feel angry about small issues. She's been suspended from school for assaulting a PS six months ago. Parents reported feeling often moody, frequent anger tantrums and having short feuds. She's doing well academically and could put it basketball, but gave that up a couple of years ago. So now she's a new 11 and just tripping away from school, so failing to do two absences. So when, and this is interesting, I think, in terms of what a number of our speakers are going to be talking about, Michelle had been referred to CAMHS by her GP for treatment of depression when she was 14. Didn't like her counsellor at that time and so offered the family, offered some family appointments, but it was quite difficult to make those happen. So most recently, she's been spending a lot of time on her own. Self-harm has increased, missing appointments. So we're thinking about it from a practitioner's point of view, maybe missing appointments with you. Not quite sure what goals are. A 17-year-old wants to finish school year, but doesn't want to be discussing how she might do that. And it's a difficult place for her. Parents came along to the first joint session a couple of months ago, saying they didn't know what to do. They've been trying to manage the situation for a number of years now and been in touch recently, saying they're feeling upset and frustrated because she's been to herself. There's been some family illness with the grandmother and father working quite hard and some financial issues that are starting to impact on the family. So the family's feeling quite overwhelmed at the end of their tether. While on the adolescent inpatient unit, Michelle reported symptoms of depression and was described as antidepressant. We're sure they'll be interested tonight in medications and we'll ask Andrew for questions about that. It's been seen since that time by the GP, but since the medication's not helping, makes her feel numb, so she's reluctant to be taking it. And when you're trying to talk with her about that, she becomes angry defensive. She can't sleep. I'm wondering about some medication to help her sleep. So these are some of the examples of the sorts of things that Pappasie might be talking about in terms of what might be going on for a young person with borderline personality disorder. So let's move on to our first speaker. So let's move on to you now, Andrew, and get your psychiatrist perspective. Thanks, Lynn. So what I would like to do is set the scene, really, for this evening's webinar about why we should be intervening early for borderline personality disorder. One of the features of borderline personality disorder is that clinically significant disorder usually comes on, as it did in Michelle, sometime after puberty and before the mid-20s. And it's a very common problem in mental health practice, in specialist practice, it's about one in five psychiatric outpatients. And really one of the key messages from this evening is that BPD in young people shows continuity with personality disorder and adulthood. This is the same disorder when we talk about it in young people as it is in adulthood. But what's really been interesting over the last couple of decades is the discovery that personality and personality disorder remains dynamic across the lifespan. It's not something you're branded with for life. In fact, it's quite a relatively unstable disorder. And despite all the evidence that's been published, and there's now really a very strong scientific literature about the validity of borderline personality disorder in young people, there's a very strong taboo among the clinical community against diagnosing the disorder. However, we know that borderline personality disorder is a legitimate differential diagnosis of common mental disorders in young people. That is, when someone presents with a common mental disorder, you should be thinking of borderline personality disorder as one of the possible differential diagnoses. And what hampers are thinking is this spurious distinction between personality and mental state pathology when more recent evidence really shows us that they are actually part of a larger structure of psychopathology and that we can understand them as being related. And one of the reasons that they're related is that many of the common disorders in young people are underpinned by traits like impulsivity or affective instability or hyperaggression. And like all mental disorders, borderline personality disorder is kind of messy when it first presents. It's overlapping, it's nonspecific. You get lots of symptoms presented. Young people don't read and certainly don't respect the DSM and present like adults with the disorder who had it for many years. And we also know that borderline personality disorder is not part of normative development that they have increased levels, dramatically increased levels of impulsivity, substance use, harmful sexual behavior, and self-mutilation and suicide attempts. And it really importantly, and we'll talk more about this, high levels of interpersonal and vocational dysfunction. And the reason we focus on borderline personality disorder is that it is equivalent to severe personality disorder. There's a lot of interesting evidence coming out now showing that borderline is really a marker of severity for personality disorder. And our interest in borderline personality disorder is not really the narrow syndrome itself. It's actually that people who have ever had any borderline features, young people, are at risk of very poor outcome. It's like a red flag that says, this is a person who is at risk of poor outcome in their life. And those poor outcomes include high mortality. This is a disorder that has an 8% suicide rate and people with borderline personality disorder live two decades from the rest of the population. We know that there's also high morbidity in terms of mental disorder, poor physical and sexual health, and again, severe and persistent functional disability. So if all these harms emerge early, which we know they do, then perhaps we should be intervening early. But late intervention, as you probably gathered from the previous webinars in this series, is the norm in personality disorder. We delay diagnosis, which has a number of harms. One of them is that it decreases the likelihood of appropriate intervention, but it also increases the likelihood of inappropriate or harmful intervention, particularly inappropriate prescribing. And we know that specialized treatments, although effective, are usually delivered very late in the course of the disorder, usually when disability is entrenched, and often when people have already been harmed by the health system. And the evidence over the last decade or so has shown that timely diagnosis and structured treatment leads to clinically meaningful improvements in young people. What we can say about the evidence base is that structured psychosocial treatments are more effective than treatment as usual, but there is no evidence of superiority of one treatment over another. And we know that structured clinical care is actually as effective as the brand name psychotherapies, and that probably the most important element of care is actually the structured care. So there are a number of principles of early intervention for borderline personality disorder. Firstly, we see borderline personality disorder dimensionally. We don't use a rigid cutoff of five out of nine criteria. In fact, if you've had any borderline criteria, that's a marker of difference from your healthy peers. So we include sub-syndromal cases, that is people who have only one, two, three, or four create DSM criteria in early intervention. And of course, we include people who meet the diagnosis for the full syndrome. We also have very broad inclusion criteria, and we rarely limit people from attending the program, including problems like depression, anxiety, substance use, antisocial behavior, because we know that these problems can't be separated out from borderline personality disorder, and in fact, they occur more commonly among people with borderline personality disorder. And a really important aspect of early intervention is that this can't be done in isolation from other problems in mental health. Borderline personality disorder co-occurrs with the whole range of mental health problems, and so we need early intervention programs to be able to cater to the young person and their family who are presenting, rather than having rigid selection criteria that leave many people without a service. So thank you. Great. Thank you. Thank you, Andrew. You covered an enormous amount of information there, and I can just imagine people wanting to gather some more information. One of the questions that came through was Walden asking about how borderline personality disorder can be discerned or differentiated from anxiety, depression, hyptomatology, coupled with general adolescent behavior. So I don't know if there's a quickish answer to that one, but you kind of touched on it, but what are you thinking about that? So in terms of depression and anxiety, one of the helpful techniques that we use is to actually draw a timeline, and depression and anxiety, mood and anxiety disorders will usually follow an episodic time course, whereas borderline personality disorder tends to follow a longer time course, and you can trace its roots usually back before puberty to early childhood difficulties with impulsivity and unstable effects and hyperaggression. And then differentiating it from normal development is really important because that's a really common question that we get. And the key issue is that each of the criteria in their mild form might look like some of the changes that happen with the onset of puberty, normative changes, but it's the extent and the number of problems that make it personality disorder. So people will get unstable moods with the onset of puberty, but the extent of instability is much greater in borderline personality disorder. Great, thank you. And I guess one more quick question. The question that everybody will be dying to ask is what's the earliest age? And I know you talked about this as well, but I know this is a question everyone's asked. It's every webinar with this question, so I just have to ask you. So it is a really good question. I think where the field is at the moment, people are confident with making a diagnosis from puberty onwards. In children, you can identify abnormal personality traits in children, but I think there needs to be more work done to establish whether we can in fact make a diagnosis of borderline personality disorder and really the kind of switch for the disorder gets switched on with puberty. So even though some of these problems in retrospect, you can see that they were there. It's the increase in drives that come with puberty and the capabilities that come along with that developmental age that really bring borderline personality disorder into the clinical realm. OK, so it does sound like careful assessment and gathering of history and information is really important so that we can figure out what can be very similar behaviours or characteristics that are happening. So it's complex, but we're working our way through it to hopefully make it clearer for people and I guess to make sense of it in some different ways than perhaps we've thought about in the past. So thank you very much and hopefully that's put that question to bed for a little while about the age and people will start to take it into account but sort of look at the whole lot of things that are going on. So thanks, Andrew. Let's move on to you now, Carissa, and you're going to share with us positive approaches towards addressing borderline personality disorder and youth from a lived experience. So thank you. Thank you, Lynn, and thank you, Andrew, as well. Today I'll just be addressing some things that, in Michelle's story, that I think would have kind of focused on long-term recovery for Michelle, even though she hadn't been given a diagnosis and I'll explain at the end of this slide why I think it was... So first off, I'll talk about appropriate borderline personality disorder language. Not that it says in the case study that the worst manipulative attention-seeking will are being used, but it's a past experience. I know that has been used throughout my recovery. So just making sure you use positive borderline personality disorder language around when you're dealing with distress. So I kind of... So I think for Michelle to be able to respond well, kind of steer away from clinical use of language just so she can understand, because I feel like she's at the beginning of her journey with this disorder, and making sure you reflectively listen to Michelle when she is talking about her experience. So obviously validating Michelle when her self-harm has presented itself is very crucial for recovery, especially with someone who is experiencing borderline personality disorder. Using validating language when this does happen without kind of rewarding the behaviour, but just trying to understand that this is part of the disorder and this is how we express the pain we are feeling internally. So just saying it's okay to feel that way and not getting angry at someone when they do self-harm. Recovery-based approaches, so rather than speaking short-term solutions, as you can see, the carers for Michelle were quite frustrated as they reached a point where they didn't really know how to handle Michelle's behaviours. So I think the first priority that should be addressed is suggesting therapy. I know Michelle's on some medications that she feels are working at the time, and I don't want to invalidate anyone's experience, and they have taken medication, but something personally in the past, medications didn't work for me. And when someone suggested some therapies, I was able to find the one that helped me and I feel like that could be vital for Michelle as well. And also maybe suggesting to Michelle a peer worker, so someone who has had a good experience with borderline personality disorder and is in their recovery journey. I think the most important thing out of this case study is to know that if she does get a diagnosis of borderline personality disorder, that this can be a very positive thing. For my lived experience, what a view when I was given a diagnosis, it helped me navigate the symptoms that I was presenting and made me able to seek recovery. And we know our rights and needs, so that I shouldn't get in the way of early intervention. I know I would have liked to have early intervention when I was younger. I was diagnosed until I was 18, and then when I was 28, I finally started dialectical behaviour therapy, so it took a long time for me to be able to recover. That we deserve to be heard and we deserve our recovery-based treatment, and that I lived with. Thank you. Thanks, Carissa. I really appreciate your comments there. I guess language is something that we do hear a lot about, and you've reminded us that some of the language that people use can be really dismissive, disrespectful, and unhelpful, and you've used language-like manipulative behaviours as one of those terms. Is there any other language that, in terms of practitioners, and on thinking perhaps jargon and things that health practitioners sometimes don't... We don't always realise what things we're saying, and it makes sense, and we're sort of thinking we know what people know what we mean, but any other sort of language that you think people could be aware of just to alert us a little bit more? I just think it's like... Obviously, if you are explaining, for instance, to someone as well, is actually explaining what they mean, like just association is quite a complex word and not a lot of things. The language is quite broad, so just if you do have words that we probably have not heard ourselves before, especially at a young age, trying to just like emphasising on what it actually means and just kind of simplifying it to other people. Yeah, fantastic. Thank you. And maybe checking out, are there any questions and not assuming that what we were saying is actually making sense to anyone other than ourselves. So, yeah, that's great. Thank you. It's a really good example for us, as well. So thank you and really appreciate those comments. Let's move on to you now, Susan. So you're going to bring the CARA family-friend perspective, and you're going to talk a little bit about the Shells experience and help us to think about this from a different perspective again. Thank you. Yes, well, a lot of the things I was thinking of saying, too, actually reflect what Carissa has just said, because a lot of the suggestions she's made can also be made for the family in their recovery, because often there's a family and a CARA recovery. Most people hate the word CARA, by the way, as well as talking about language, but that's in the literature and in government sources, et cetera, that's often the word for you. So, and there are quite a few, in my experience, partners as well who are involved with someone who has a diagnosis of borderline personality disorder. But tonight we're looking at more of a family and at Michelle. And I think the social isolation is something that families really worry about. Families report to me all the time that they're worried about their young persons like their friends or their social isolation being in their room all the time, not wanting to go out, not wanting to come out for family meals. And so it's very understandable that they do fret and worry about the young person. And so that's obviously Michelle's case. It also moves swings and angry out, but this can sometimes feel the families like they're on a roller coaster. And the sort of language that families report are things like that they feel like they're always on guard, that they're always sleeping with their mobile phone on their chest, walking on eggshells and not knowing what to expect in a very hypervigilant. And they just don't know where they stand from one, sometimes one out of the next with the young person in their life and it makes them quite anxious themselves. Self-harm is also very confronting for parents. And I think parents really want to protect their children. That's what we, as parents, we always want to make sure that we're looking after our children. And I think when there is self-harm involved, families get very, very anxious. And of course, some of them might be on 24, 7 watch trying to keep their young person safe. And I think for clinicians, it's a sobering thought because clinicians often have a long-term view of the young person's recovery in their sites. But for parents, it's a day-by-day proposition. In fact, sometimes as I said, an hour-by-hour proposition and it can be very distressing. So often we have to reassure families that we do have a plan, that we're working on working forward and that some of this stuff can't be rushed. So I know that for myself and the other families that would have been very comforting to someone to have said that rather than thinking it would be like the recovery, for example, of a physical illness which can be a fairly predictable trajectory. And I think grief and loss is a big issue for families and they often don't recognise it at first. And I think the thing about BPD is that often there's been a sometimes a slow and gradual worsening of the young person's condition. So families often just don't quite know where they're up to with diagnosis, et cetera. And when they land in an emergency department, they can be very traumatised. And also they report, a family's report to me, the waiting in the emergency and always being put to the bottom of the list to go in and see a psychiatrist and also the revolving door where the young person may request or not request to go down to the emergency department. And they're just not feeling that that's the right place for them and that it's just going to end the same way. And I think that Carissa's concepts about the cafe sounds to be very helpful. In fact, it'd be really nice to also have a cafe for families who are struggling with this sort of thing because that's the sort of work I do at Origin where we support families whether or not the young person wants to be involved. We still let us support the family. Of course, we don't talk to them about the treatment of the young person, but we support them because they have a right also to be heard and they certainly often want to be heard. The Guild families often feel particularly parents. Their parents are particularly good at Guild. They, it's very powerful and this can sort of see in Michelle's situation where it says, you know, her father has a short fuse. And so there's a sense in which, you know, families feel responsible and not sure whether it's just a bad family failing or whether it's actually a diagnosis or a symptom of having borderline personality disorder. I think in the case of Michelle, it sort of shows us that families are often not available in business hours. And even though I know this is really difficult and may not be viable for most clinicians, flexibility in seeing families could be really helpful as it is for often young people. So phones, type, face time, after hours work, trying to be as available as possible for people because often there's a whole, there can be many crisis or big crisis and it really is looking at ways of keeping people out of the emergency department and trying to work with them when these crises happen. And also I think it's really important to, as much as possible, train families in the strategies that would be helpful to the young person. And families report to me being able to help the young person feel safe and supported because they're actually practised, they're actually reminding them of the strategies that the young person's being taught and supported in learning by the clinicians. So if you like, you have, you know, the, at home is mirroring the, what's actually being talked about in the clinical situation. The family being burnt out is a very common sort of situation in any sort of mental ill health with young people. But you often find it with families where there's a sandwich generation of looking after elderly parents. You have relational burden on the family in different ways and for me, I always thought, I felt like an emotional traffic cop in the family in trying to get everyone in the house happy and sorted. And it was a very, very challenging time and the walking on eggshells again is very common. So families can get burnt out and also because borderline persons now they just thought it can be like a slow burn. It's been going on for quite some time even before, even though the young people are young, often by the time we see them, there's already been quite a bit of family damage done within relationships. So I think often it's really important to remember that some families are burnt out and may not even want to engage in the treatment for the young person, which is sort of sad, but sometimes if you can bring them around by listening and acknowledging their distress and validating their distress in this. And so I think for clinicians and people working with families and carers and friends and partners, all of those, that looking at self-care strategies is really important. And if that family's been on this journey for a while, they obviously got some strings for their still standing. So trying to build on the strengths and resilience that are within the family and then building that up and giving them a professional and personal team around them that and encourage them to reach out to whatever supports are in your community because families need a team as much as the young person also needs a team around them. And that's part of what we do in peer support as well. Thank you very much, Susan. Lots and lots of information there. And I think you've really captured very well the many challenges and difficulties that families go through over a long period of time that we did see in the case study going on for years. Families and friends and carers are there for a really long time. I think you've done a great job of talking about the different, what that can look like in different ways, but also there's the need for them to look after themselves and reach out for support. And I guess that's what your role at Origin is about. But are there other sort of roles around the country? Do you think there's quite a unique one? Or are there other... No, actually... Actually the lived experience workforce both for people who are unwell and also people who are carers is a burgeoning area. There's a lot more government funding going in at different levels and in communities as well. So certainly I would ask, often people don't know it's a service that someone who's been through a journey that you've been through could be around to chat. It's always worth asking. And also if you are a person, a family member, but also for clinicians and doctors, et cetera, to know those services in the local area because they are popping up everywhere. And they're in headspace. They're in the adolescent mental health units all around the place. And also there's support groups sometimes that could be accessed as well as online supports as well. So there are different supports. Thank you. Okay, yeah, fantastic. I think really important for the workers to be thinking about that, particularly if you're focused and your funding might mean you're working with a young person, but to be thinking about, well, I might not be able to do the work, but there are people that care. Thank you for that. All right, let's move on to you now, Louise. You're going to bring a psychologist perspective to our case study. Yes, I wanted to focus more on what Andrew referred to as structured clinical care. So that's a generalist approach, which is less about using a specialized therapy like DBT or MBT or any of those other three-letter names that you've heard and more about general principles that anyone working with a young person might be able to apply, whether you're a school counsellor or a community worker or a youth worker or a clinical psychologist in a mental health service. So we call our version of that relational clinical care because we want to think about our relationship with the young person while we're doing these practical things. So the first thing in Michelle's case that I think would be really important would be to check that we had actually gone through and given her a diagnosis that was appropriate and given her appropriate feedback and psychoeducation. So I would have hoped that that had been done really at the very beginning in Michelle's case that you don't want to commence working with somebody without knowing what you're working on and you want the young person to know what you're working on as well. So our recommendation is to go through the DSM-5 criteria and confirm the borderline features with Michelle's help, so tailoring what you're talking about to her experiences, giving her psychoeducational material about BPD and the sorts of problems that she's endorsing. You want to provide a realistic and optimistic view, but not be unrealistic about it because we know that people with BPD can get better, but it also might take a bit of time and it might also depend on how engaged in the treatment they are. So we also warn young people about stigma and misinformation because as soon as you Google BPD, you get exposed to a whole lot of different points of view and some are helpful and some are not. So we would want to warn the young person and their family about those kinds of experiences so that they can become discerning about what they read. And I think the final point about diagnosis, feedback and psychoeducation is that you don't want to just have that conversation at the beginning. You actually need to revisit it because young people will have a changing understanding of their own problems and how they're being affected and their progress. And so we would want to go back and discuss those things over time. One of the things that really struck me in the case study was that Michelle was not really very engaged with the process of coming in. So my guess would be that the relationship is not terribly strong yet. So she's not attending regularly and it also seems fairly clear that we don't really know what she wants from the treatment. So I think those two things would be really important to address. We need to engage Michelle in a way that she feels supported and understood and listened to, that she feels her experiences are validated, that she understands that what we're trying to do is work towards change. And you need to have some trust in order to be able to challenge gently when people are feeling less motivated or maybe engaging in repeated sort of self-defeating behaviours because all of that is working against her, having a life that's satisfying and engaging for her. So we need to keep an eye on motivation and keep working towards that. And of course, that might mean that we have to be really clear and open and transparent about confidentiality and who's involved in the treatment. We try strongly to involve families in the young person's treatment, but that's not always something they want to do at the beginning. So it might be also another conversation that we revisit over time and have to keep an eye on. I think it's important to think about ideas like structure and flexibility and consistency. So we know that consistency is really important in the work that we do with young people or with anyone with complex problems. So we want to have shared language and share the plans that we make. And so everybody's always on the same page or is close to being on the same page as we can get them. If we think about structure, structure, it can be something that you vary through the treatment. So it might be that when the risks get higher if Michelle or a young person is having a difficult time at some point through the work you're doing and risks increase, or they're becoming more suicidal, for example, it can really help to apply more structure. So being clearer about when and where you see the person, maybe providing more appointments or something like that. But we do want to be careful with structure because as soon as you give too much structure or unnecessary structure, then young people often fight against that. So reading out rules, for example, people who want to challenge those rules. So I think it's also important to balance any structure with some flexibility. Is that actually young people want to have a say in what they're doing and want to feel like we're trusting them to make their own decisions? That it also needs to be said that sometimes they may not be very good at making decisions that are good or healthy for them. So we want to do that within the bounds of what we think we can manage. And we want to be aware that young people are doing the best they can. So are the families, actually. And so we want to be able to encourage as much as we can towards the sort of outcomes that we want. So we also want to have a good think about making a collaborative management plan with the young person and preferably with their family involved as well. I think Andrew has already said that we want to really focus on like a social goal. So in Michelle's case, keeping her engaged in school and really facilitating the communication with the school, doing what we can to keep her having some good relationships with school so that that process can be going as well as it can. It sounds like Michelle is struggling a lot with her relationship, so we might want to talk with her about how to facilitate her to having better relationships with her peers as well as with family members. And then of course, we want to have some thought about crisis management and safety planning. And if we're going to work on self-harm with Michelle, it would be really important to know what the function of her self-harm is. So why is she engaging in self-harm is it about managing her negative affect or mood? Is it a form of self-punishment? Is it a way of communicating with others? So there might be a number of reasons why Michelle is engaging in self-harm and it might be quite unrealistic to expect her to reduce her self-harm very quickly. So we would want to have conversations with her about how to help her ask for care or support in more adaptive ways. We'd also be interested in thinking about whether there are some other issues that we could work on at the same time. And I'd be particularly thinking, is she depressed at the moment and do we need to help her manage that? And I think that in any short-term or brief or time-limited treatment, we have a time-limited model. And so most of the work we recommend with young people should be, you know, at least episodic in nature, so that we work in contracts or we work in time limits and we review how we're going. So we think that it's very important to talk about those endings, plan for those endings, review our progress as we get closer to those endings. And that allows people to manage the endings in a more helpful way. Having an unlimited time then means that actually managing the ending can be really challenging and difficult for young people. So coming back and reviewing progress on a regular basis helps young people understand and think about how stressful endings can be and helps them learn how to negotiate and better. I think I've come to the end of my bit. Yes, you have. Thank you, Louise. And lots and lots of information in there as well. One of the questions that came through as you were talking around confidentiality, one of the questions that came through was about a young person who doesn't want to disclose the borderline personality disorder diagnosis or perhaps understanding the possible diagnosis to family. So as a health practitioner, what might you be thinking in terms of how to handle that situation, in terms of managing confidentiality, in terms of understanding perhaps what the young person might be concerned about and any thoughts about that? Yeah, I think one of the things that I think is important is that really a diagnosis is about helping us all work with a young person the most effectively we can. So it's not really about giving somebody a label and that being the point. It's about making sure we all work towards the same end. So whether we call it borderline personality disorder with her family or not, it's probably irrelevant at the end of the day as long as we can describe the kinds of problems we're working on together. And it depends a lot on how old the person might be. If it's a particularly young person, then you have a bit more leverage, if you like, to disclose things when it's appropriate or to push a little bit more. With somebody in their early 20s, you may compromise and say, actually, it doesn't really matter. Let's not tell your parents that or you tell your parents when you're ready. I think the most important thing is that we find ways to work together to solve some of the problems and for the parents or the family members and the young person to get on better. That would be my own. Yeah, great. Okay, thank you. And I think that's a good reminder for us when our whole series is about a diagnosis but to actually come back to what does it actually mean and how do we use that to be helpful? We are now at our question and answer time. So we're going to just kind of open up a few questions that have been coming through and open this up to the panel again. There's one that I'm going to pick up with Andrew because it's been coming through quite a lot and there's various questions around trauma and people have been asking about trauma and trauma in early childhood, to post-traumatic stress disorder, a whole range of questions. So, Andrew, could you just maybe give a very succinct kind of comment on the impact of trauma where it might fit in borderline personality disorder? I'm asking you hard questions. I know, you know, with some circumstances. Look, it's actually a really good question and it's a common one that comes up. And the most succinct answer is that trauma is a risk factor for virtually every mental disorder and it doesn't really have any specificity for any one disorder. And so unsurprisingly, trauma is involved in the etiology of borderline personality disorder. But when you actually look at people with borderline personality disorder and ask them, it's involved in young people in around about 50% of young people. And there are many roads to roam. One of them is through trauma but the other is through other means. And there are many ways to develop borderline personality disorder and it's important that we acknowledge and validate the developmental experiences of everybody with borderline personality disorder. So those who've had traumatic histories, you will always address that in the treatment. But for the many people who haven't, it's important to validate that they took another road to get there and that we shouldn't be narrow and blinkered and just look at it as being related to trauma. And I think the problem with focusing exclusively on trauma is that people stop looking at other issues. You can see in Michelle's case that actually she's got a short fuse like her father which speaks actually to the heritability of the disorder. And you might be surprised to know that borderline personality disorder is actually highly heritable. It's much more heritable than depression, for example. And so it's important to recognize that the development and the etiology of it is complex and a subgroup of people do have post-traumatic stress disorder co-occurring and that tends to run a different course. It tends to run a different time course to the borderline personality disorder and when it's present, it does need specific treatment. Okay, fantastic. Thank you. And I think we're doing a fair bit of misbusting tonight because perhaps there are people thinking about, you know, there has to be trauma in early childhood or you know, it's one or the other. So there's perhaps this is clarifying, I think a lot of some of the assumptions that people might be making. So thank you for that. But again, highlights, this is complex and we need to make sense of a whole lot of things and rule things in and rule things out or look at what might be sitting beside a diagnosis as well. So thank you. I'm going to come to a question that's come up prior and again tonight as well. So previously people have sent through questions and this is one that I think probably everybody can maybe comment on. And it's around the role of a school counsellor and school psychologist perhaps or somebody working in a school and maybe even teachers. But what is it that people working in schools can do to help a young person who might have borderline personality disorder? So let's begin with you, Carissa. If you're a young person in a school, what do you think would be most helpful from a counsellor of teachers? I mean, people are going to go and see counsellor. What do you think teachers would like if you think teachers should be doing something that would be helpful? I think first is actually educating people on the different disorders in health education because when I was in high school, all I knew about that existed was depression and anxiety. I'd never heard of borderline until I actually got the diagnosis. So probably by implying that into classes from the beginning would be helpful. And obviously when someone does come to them with this information that they may be presenting systems or do have the disorder, is to approach it in a way where you don't... In the past, I guess it's sort of stigmatised that they would be like, oh, well, you're too difficult to deal with kind of thing and kind of embrace it with open arms and be up for the challenge. Not that it's... Not that it is challenging, but it is like a very... What's the word? It is very enriching when you do work with someone with AC&D. So hopefully they can take that on board Yeah. OK, thank you. So more awareness amongst the whole school staff and the whole community being able to understand and break through that stigma. OK, thank you. Great. No worries, thank you. Who would like to comment next? So, Louise, what are your thoughts around that? You did mention school in there in terms of being part of planning. It's not just being part of young people's lives. So what are your thoughts around a school council or other people working in school? What would help most? Yeah. I think quite strongly that actually there's lots of things that people in schools can do, school councillors or teachers or others. The Australian guidelines are a place to start if people really are not knowing what's important and just simple crisis planning and goal-setting with young people can really be very helpful. I think that probably one of the important things to say is that if you start with doing some of those activities and you feel like you're getting stuck, then I think that that's a good point at which to either get some more training or to seek some supervision that sometimes people with interpersonal problems can be tricky to work with. And, you know, the problems of BPD can get in the way of people asking for treatment and actually using treatment effectively. And so I think that supervision and further learning are really helpful ways of doing some simple things with young people. Yeah. Okay. And to get you get stuck, yeah. Yeah, okay. And I think that's a really important message because, again, when things get complex, we can sometimes look for complex answers. So going back to what we know and what to be basic and seeking some extra help can be really good things to do. Yeah, thank you. And I think just even simple kind of coping strategies for managing stress, things like that, that lots of different councillors know, know really well, that all of those things can be helpful. Yep. And it could be helpful for all young people. Yeah. As well, which can then go a bit of a way to break and go in that stigma that this is something for everyone that can be useful. Okay, thank you. So, Susan, what about parents in this mix, Sam? What about parents in school? What could school councillors and teachers be doing that's going to be helpful to parents? I think actually having families involved is really important. And the thing is that if you do not involve families, and that goes to school staff or clinicians, whoever it is, if you do not, it doesn't go away. They will, in fact, start to cause a lot of noise with a lot of people in the community. They are not seeking support somewhere, someone to listen to them. So, if it can be nipped in the buttocks of schools, one of the very first ports of call, if it can be nipped in the blood and that distress acknowledged and heard and they are engaged as allies in this process, even if there's confidentiality issues. So, I'd like to reiterate what Louise said about the fact that even if a young person says initially they don't want their family involved, that is a question to keep asking regularly as the treatment goes on, because people do change their minds and young people can be very fluid about how they're feeling about their families. So, I think in a school context, if the school can't give that support to the family, separate from the young person or with the young person, they need to intentionally outsource that or bring family therapists or family work into the school to work with the young person and the family or just to work with the family by themselves, because the dividends is that there'll be a lot less than collateral for the community to pick up from the family who is so interested. Yeah, okay. Thank you. A very strong message there around the role of families and the importance of school and parent engagement and working proactively and waiting for things don't go so well. Now, time is running out, but Andrew, you've got something you want to say about that family which is really important and then I've got one more quick question for you as well. Sure. I just wanted to underscore what Susan has been saying because there's good evidence to show that actually among families caring for young people with any mental health problem, that actually those with a family member with borderline personality disorder have the greatest level of burden. And I think people often don't appreciate the extent of that burden. I think Susan, she presents it so calmly and articulately that it, but I think it really needs the emphasis that this is incredibly burdensome for families and ignoring them and leaving them out of treatment is probably the worst thing that you can do. They are your allies, not the enemy in this. Yeah, fantastic. As you were saying that, I was thinking it's about bringing them in and working with them as a support and working together, really important message. Yeah. So thank you. I'm really conscious we need to start wrapping up and have our last sort of take home messages from everyone, but I do want to touch Andrew briefly on medication because it's coming through as another one of these really important questions. So have you got a very quick couple of sentences on medication? Okay, well the quick answer is don't do it for borderline personality disorder, that there is no medication that is indicated for borderline personality disorder, but the longer answer is that young people with borderline personality disorder present with a whole range of other mental health problems and that you should play a straight bat to prescribing for those problems. So for depression, for anxiety, for psychotic symptoms, whatever it might be, that conventional treatments can be used. So people shouldn't get stingy, but they should also be clear that why they're prescribing. In severe borderline personality disorder where the evidence is really absent, there isn't anything to guide us, there's not good studies. If you are going to prescribe, then it's important to do it with the young person to have clear goals, to have a clear review plan and to provide single agents in safe quantities and to review the effectiveness. Agree on what you're going to evaluate. At the end of that period, evaluate whether it's worked and if it hasn't worked, stop it because one of the problems is that when a medication doesn't work, often people will just add another medication and so people end up on three, four, five medications. In fact, 38% end up on three medications or more. So, and that's when we start to harm people in the health system. Great. Okay. Thank you. Obviously, these are hard questions to answer quickly because they're complex and people need to kind of get some advice and support. Look at the research. So thank you, thank you for that, Andrew. Now, let's just go around the panel one more time and have a take-home message. So what is it that you would like the people listening tonight to take away from something that you've been thinking about or talking about or something from out of stuff this evening? So let's kick off with you. Let's start with you, Susan. What would your take-home message be? And I suspect you may have already said it, but what would it be that you'd want people to really read for? I'd say that most mental health acts acknowledge that families deserve support and that they are allies in the whole process. And that it's important that people working with young people with borderline personality disorder always assume the best about the family, not the worst, and assume that young people in their families do want to be together in a team and that to keep asking a young person if that's not initially given that permission, to keep asking that question in a gentle and encouraging way throughout the process. Great. Thank you. Louise, what about you? What's your take-home message for people? Well, I think what I've tried to talk about today is the idea that simple treatment approaches can be really helpful for young people. And we know that many people read up on specialised treatments or do a small amount of training in specialised treatments. So they may have special skills as well to add into that and that's fine. I think that the big take-home message would be if you feel stuck or you're feeling pulled to respond in particular ways, it's really important to step back and try and be objective and sometimes that involves getting some supervision or getting some peer supervision even to be able to stay objective about what you're doing because sometimes when we get really stressed or we're trying really, really hard to work with people who are finding a bit challenging, we don't realise that we're kind of straying off the path and I think it's really important to try and catch yourself when you are straying because that is usually unhelpful. Mm, yep. And I think you do some training around specific focus. Is that available sort of only in Melbourne or is it available to people who are in other places? Is that, how accessible is that at the moment? That's a really great question actually. We run training courses here, but we also run packages of training for other services interstate and even internationally. So if anybody is in an organisation or in a team or in a small group where they would like some training and they're outside of Melbourne, please, you know, give us a call and you can access great information through our website. Okay, fantastic. Thank you. There's lots of online training as well. Great. Online training too. Great. Fantastic. All right, thank you. Andrew, your take-home message, what would that be? Well, I have two parts to it, really. One of them is to back up what Carissa said and to really to stand up to bigotry and discrimination, to use respectful language, to be respectful of people with borderline personality disorder. And if one of your colleagues is bigoted and discriminating against a young person, to stand up and advocate for that young person. And then the second part is to keep your eye on the ball. And the ball in all of this is relationships and functioning. That is vocational and educational outcomes as well. And they're the things that suffer in the long term. A lot of the behavioural problems will settle down fairly quickly, but unless people's lives are kept on track, then they will suffer long-term harms. Great. Thank you. And Carissa, the final word goes to you. Is our young person representative on the panel? What's your take-home message that we're all going to remember? For anyone who's experiencing BPD that may have listened to this webinar, that recovery is not a linear line, so it's not a straight line. So be patient with yourself and navigate to the best of your ability and what's with your experience, no one else's. And also remember that there is clinicians and carers out there such as Andrew Louise and Susan are prime examples that are working hard to de-stigmatise its illness and work with you so you can have a very well-recovered life and it's not a lifespan. So there is help. Fantastic. Thank you. And I think this series of webinars, that's been a really consistent message that we've had throughout, so hopefully that really does carry that home with people tonight, that there's treatment, there's hope, there's things that we can do as practitioners as well as people who are experiencing borderline personality disorder to feel like it's serious and hope as well. We are running out of time and it feels like we could have kept this conversation going for way, way longer, but we do have two more webinars, so we will be able to pick up on some of these issues again. We also are very aware that when we have lots of information that's shared, there might be still lots of questions. I know there are some questions we haven't been able to answer, but there might be some questions that have come out of this that you really want to continue. So we've heard from Louise around some training that's available. We've also heard Louise talk about the guidelines and we've talked about them before and they'll be available on this website. So there's a list of resources that have been gathered by Spectrum and the Australian Borderline Personality Disorder Foundation for you to be able to pick up and to have a look at and to continue your journey in understanding and learning and working out what this might mean in your particular workplace and what it is that you can be doing. But I guess those messages we've been hearing tonight hopefully give us a sense of what we can do with our existing skills as well. There's also networking opportunities and here's a conference that's coming up in Brisbane. This sounds pretty nice when you're in Melbourne and it's pretty cold and miserable in September, so it's not too far away and there's information there about the website to visit. So that would be something that you could have a look at as well. And MHPN also have a range of local practitioners' networks. So instead, as well as doing fabulous webinars, they also have local, on-the-ground, face-to-face networks. And so there are some that are being developed as a forum for practitioners with a shared interest in Borderline Personality Disorder. So you can visit the website in the News section or contact MHPN to find out some more about those particularly. So we are about to wind up in closing. I would like to again acknowledge the expertise and the contribution tonight from the staff of Origin, National Centre of Excellence in Youth Mental Health, in developing and contributing a lot of the content to tonight's webinar and to bringing their expertise. And this is obviously an area of great passion and expertise that they bring. It's fairly unique, I think. So I really do appreciate that. So thank you very much to everyone for that participation. Thank you to the many people at home. I think we've reached over 1,700 people live tonight. So thank you to everyone for joining us this evening and hopefully you have got some new ideas and can go away. At least knowing where else you can get some information if you need some more. We do have a feedback survey just before you log out. When we close, this will just pop up. So it would be great if you could take a moment to fill in the survey. The feedback survey tab will pop up at the top of the screen to open up the survey. Certificates of attendance for the webinar will be issued within four weeks and you'll have a link to the online resources associated with this webinar within the next two weeks as well. Before I close, I'd like to acknowledge 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 again to everyone for participating in tonight's webinar. We look forward to seeing you next time. Thanks, everyone.