 Good evening. Tonight's webinar is the Management of Borderline Personality Disorder in Public Mental Health Services, Private and Primary Health Care Sectors. And I would like to begin with an acknowledgement of the traditional custodians of the land and acknowledge all those lands across Australia where our webinar presenters and participants are located. And in Melbourne where I'm based, the run three people of the Kulin Nation, we wish to pay respect to the elders past, present and future, to the memories, traditions, culture and hopes in Indigenous Australia. My name is Lino Grady and I'll be for someone that's facilitating this webinar as I have facilitated the previous ones. I'm very pleased to be here and as always joined by a fabulous panel who I want to be with you in a moment. So if you're not aware of the series, this is the sixth webinar of this National Borderline Personality Disorder project that's funded by the National Mental Health Commission. And if you haven't attended the first five webinars, well know that some people haven't because some of the questions that have come through would have been covered in those other webinars. So I'd like to encourage you to go to the Australian BPD Foundation website and have a look at those other webinars because they'll cover a lot of interesting information for you. In my day job, I work at the Australian Psychological Society Managing Strategic Project. I also supervise some interns. So this series has been of great interest to me as well. As always, we have a panel and we have a lot of you at home. We have over 650 people now joining us and we know that there are a lot of people who will be joining us with their own experiences as well. So wanting to just, I guess, remind people to look after your own self-care. And I say this at the start of every one of our webinars, but we're really mindful of the need for us to have good self-care for ourselves and just display that at the start of the webinar. So of course, if there's any distress or concerns that you're feeling for you to plan for, what you might do to look after yourself, of course, beyond blue, phone number 1322463-6. But you may well have your own plans of what you need to do and how you will take good care of yourself. You can always watch this webinar tonight or you can stop and pause and come back to it or you get a recording later on. So you can always watch as far as you'd like to and then join us for a podcast later on when you get the recording. And of course the Suicide Callback Service is 1300-659-467. Just a prompt to have those numbers there. So here's our panel for this evening and this is again another really interesting group of people I think. And you would have seen the bios. They were disseminated with the webinar invitation. So we won't go over those again, but I will introduce each person one by one. So let's begin with you, Kerri-Ann. Kerri-Ann Chapman is here as our lived experience advocate. And I've got to welcome to you, Kerri-Ann. And I've got a question for you. What's something you want people to know about recovery? Thank you, Lynn. The one thing I would want people to know about recovery from BPD is that it's always possible with the right treatment and right support. Right. Thank you. A really important message up front. And this series we've always had lived experience person advocate with us and people have really appreciated it. So I know people are going to be really looking forward to what you've got to see with us tonight. And we really appreciate you being here. Jillian. Dr. Jillian Singleton is a general practitioner. Hi, Jillian. Welcome. The sun's starting to set where you are now. The sun before it was very dry and the sun's starting to go down a little bit. We were graced with Jillian's cat early on. So I think everybody should watch out for when Jillian's speaking to see whether there's a little black cat that appears again. We may have locked it out by now. So let's ask you an introductory question. As a GP, why did you become interested in borderline personality disorder? Sure, Lynn. I've always had an interest in mental health. And that's what I really love about general practice is you get a whole list of your patients. And a number of years ago, I got completely burnt out. And when I looked back at my patient list, as to who was going to hand over and I decided to take some time off two thirds of my patients actually had either a borderline diagnosis or borderline trades. And that really was an aha moment for me. And it really made me realise importance of self care and actually having some strategies to look after myself so I could be there for my patients. That's what I'm passionate about. All right, okay. Thank you. Thank you for sharing that story and look forward to hearing from you as well. Let's move on to you now, Paul. So Dr. Paul Camel, I'm not sure if I've said your surname right. I should have checked that earlier on, but hopefully that's okay. Paul's joining us. He's a psychiatrist and I've got a question for you as well, Paul. What role do you play as a psychiatrist when working with people who have borderline personality disorder? So just a little question to get started. A little bit hard to hear you, Paul. You're cutting in an hour. I'm not sure if Red Baths are able to help us with that. Maybe start again. Better, can you hear me now? Yeah, he's better. That's much better. Okay, I've just adjusted my microphone. Okay, I was just saying that I work in public and private practice. I work in a large hospital or Melbourne Hospital and Emergency Mental Health and inpatient work as well as in a private clinic. So I can see these kinds of conditions in both of those sectors. And I think there's a lot of messages we can get across about how to work as a psychiatrist in the field. Thank you. So you're perfectly placed for tonight's tricky questions around navigating both of those systems as you're in Goat. So those hard questions can come to you. So thank you. And yep, Downey, not better now. Sorry, you have to repeat yourself. Let's move on to our last panelist for this evening, certainly not living last, not least, but last for the moment, Professor Brynn Greiner. I'm having trouble with surnames tonight, Brynja. Psychologist, sorry Bryn. What's your involvement in public mental health services treating borderline personality disorder patients? Yes. Thanks, Lynn. And welcome, everyone. Look, about 20 years ago, we started a collaborative training program and to treat really borderline personality disorder as a collaboration with our mental health partners and really have developed that training program and that treatment that we've developed in a lot of different public mental health services. So it's a real pleasure to be here this evening. Thank you very much. And it's been a long, long time that we're drawing on. So it's 20 years is a long time to be doing that work. So thank you. Thank you very much. So as you can see, we have a fabulous panel. And I think you're going to see the part of the discussion that we're going to be having and the information that they're going to be sharing with us. We have over 750 people joining us now. So we're just moving, moving right along, but lots of people will be, will be continuing to join us as we go, go forward. Given that this is our last in the series, we're wanting to, I guess, help people who've been joining us for quite some while who might be having some withdrawals after this one to know that there are other opportunities to use network. So there are seven practitioner networks that provide a forum for practitioners with a shared interest in borderline personality disorder. So you can go to the mhpn.org.au news section or contact mhpn to learn more about those networks. So we want you to continue this learning. We know that this is something people are very interested in and we want to want to continue to support you with that. So we encourage you to do that. And let's have a have a bit of a look at our ground rules. And people will join us. We'll be very familiar with these, of course. So we will have an opportunity for you to ask more questions and comments. We don't have the live chat that you might be familiar with because we just have so many people to discuss this morning. So you can ask us questions and comments and we really encourage you to do that. And I'll remind you to do that as well. And when you're asking those questions, comments, of course, be respected by the participants and panelists that's professional development events. So of course, we can only look at professional development type questions and comments. We have a case studies that we review so that we've got something to focus on and behaviors you would interface to face activity. We're well supported, as you know, by technical support, the people from Redback as well as people behind the scenes from mhpn as well who are there to support you. So if you have any technical issues, you can refer to the technical support frequently asked questions tab at the top of the screen. Or if you still need further support from that, there's a help here phone number there that you can ring and get some immediate help with these people. And if there's any major issues, there'll be an announcement. But we hope that won't happen. At the end of the webinar, we will have a feedback form for you. And we really would like you to fill that form out. We find it very, very helpful. We do report on each webinar and on the series. So we really value the support and information that we can get from the feedback form. And obviously reporting to funding bodies is also really very important. So please take a few minutes at the end to do that. All right, let's move on to our learning outcomes for tonight. So you would have seen these when you registered as well. So through an exploration of borderline personality disorder, the webinar will provide participants with the opportunity to do these three things. Identify challenges in the management of borderline personality disorder in public, private and primary sectors. Describe how borderline personality disorder is best managed in public, private and primary care settings. And outline how best to collaborate between public, private and primary care settings to get optimal treatment outcomes for people with borderline personality disorder and their families and parents. Oh, I just want to remind you of the case study. Hopefully you've had a chance to read it, but just in case you haven't or you've forgotten, I'll just do a brief, as I can, recap so that we're all familiar with what we're talking about and just to set the scene so that then we can move on to Kerri-Ann and hear what she has to say about it. So the case study is a pixel case study that's been made up by the group about Tina. And Tina is a 30-year-old woman. She's a single mother of a five-year-old child called Joshua. And she lives with her mother, Jane. Tina is unemployed. She's on a disability pension. She meets criteria for borderline personality diagnosis. Frequently overdoses on medication, clicks cuts on her limbs, has a hospital emergency department of tendences, then leads to an ongoing cycle of crisis-prone symptoms, has a history of violent relationship, very few friends and has angry upbursts with Jane, her mother. And she also has disordered eating since the 16-year-old age. And the situation we've put ourselves in to talk about tonight is three days ago. She's admitted to a local public hospital. She's been case-managed by local mental health service and then advised that she will be discharged shortly. So the case management has also advised that she's about to leave. So she's been referred back to the DP. And she's very lucky she's known the DP since the 15-year-old age. And Jane, her mother, is worried about this and wants a private psychiatrist to be involved. But Tina has no private health insurance. So you can see already the systems are at work and getting involved there. So that's what we're going to be exploring this evening. So without any further ado, I think we should hand over to you, Keri Ann. Let's see what your thoughts are about this case study. Thank you, Liz. I want to acknowledge the individuals who have a lived experience of borderline personality disorder and their carers who support them through this difficult journey, as well as the clinicians who provide individual and group support to consumers on their healing journey. In this case study, it's important to remember that Tina is first and foremost a human being. And she is someone who has a lived experience of borderline personality disorder as a secondary statement. Consumers are not their diagnosis. They are individuals who have experienced significant pain and distress and need to be treated with humanity and compassion. When given the diagnosis of borderline personality disorder, it can be very confronting for consumers and their carers due to the high level of stigma around this diagnosis that still exists today. As a clinician, supporting someone through their diagnosis, it's essential to promote hope and self-empowerment with that individual. This can be through sharing success stories of consumers who are in recovery and doing well that you have supported previously. By doing this, you're showing that recovery is possible and also that you have belief in the person you are supporting that they too can recover. It can be really difficult to find clinical support that best works for the consumer's recovery and it can take a lot of time. Don't be afraid to see a few clinicians before making a decision about which clinician you'd like to continue seeing. Another challenge with accessing support is that you can be on a very long waiting list, which can cause distress and uncertainty. During this period, it's important to find strategies and supports that can alleviate some of this stress and to keep the consumer safe. At many points, this somehow happens to be the GP when someone's waiting to get an appointment with a clinician, they go back to their GP to find that support. Other challenges that consumers face when accessing support in the public sector are long waiting lists for DBT group therapy or short DBT group therapy programs and the fact that long short-term group therapy programs do not provide long-term care so it might not be the right fit for that consumer. There's also misdiagnosis and disrupted continuity of care through seeing different clinicians with short appointment times. In the private sector, challenges that consumers face are very expensive out-of-pocket costs for private treatment and increasing annual health insurance premiums, long waiting lists for DBT group therapy and also the difficulty of finding a DBT specialist who does not have their book shut. Slide please. When a consumer is engaged with several different service providers, oftentimes information is not shared openly with all parties involved in the consumer's treatment, which can impact significantly on the consumer's recovery as not everyone is on the same page. When a consumer has been provided a case manager, like in this scenario, it's important to provide regular updates to the case manager with the consumer's consent so that there is a continuity of care and the best outcomes of recovery for the consumer. Feedback mechanisms need to be established so that the dialogue remains open and wellness plans need to be consistent throughout each service that the consumer is accessing. These wellness plans need to be living documents that are flexible and grow and change as the consumer does at different points in their recovery and it must be led by the consumer. A positive aspect of accessing the public system as a consumer with BPD is that you may be eligible to access peer support in patient treatment facilities and while transitioning to community care settings. This support can be invaluable as it's built on mutual understanding, shared experience and role models recovery to the consumer. It also assists the consumer with reducing their likelihood of readmission in that critical 28-day period after being discharged from hospital. A peer support worker can purposefully share their story of recovery, which promotes hope and self-determination. And regardless of whether a consumer is accessing public, private or primary care support, it is best practice to give the consumer options for their treatment. Allow them to make decisions by giving them information to make informed choices and the choice it is best for them. Involve their care into planning wherever possible for the consumer's consent to do so. Ensure consumers are able to complete wellness plans in each service that they are accessing, where their needs and preferences are identified, so that if the consumer becomes unwell, there is a plan for what support they'd like to access and who they would like to be notified at that time. Goals need to be collaborative between the clinician and the consumer and the consumer needs to lead their own recovery with autonomy. I'll pass it back to you now, Lynn. Thanks very much, Kerri, and there's so much information now, I'm sure people are already thinking we're covering lots of ground and we could pick up on a lot of those points and I know there's some of the things that people started asking questions about already, so thank you very much and we'll return to some of those later on. Just a reminder too, if you do have any questions or comments, please pop them in the appropriate place and we'll get to those as we go through, so we want to have them streaming through as we go through tonight's session. If there's a particular issue you'd like one of the presenters to talk a little bit more about, you can focus to ask that person. So let's move on to you now, Gillian, and let's hear your perspective from the general practitioner. Thanks so much, Lynn. So my aim now in general practice is not to end up looking like the guy on the left at the end of the day. And so as I mentioned before, self-care and self-reflection is so incredibly important. I think there are lots of challenges, say five GPs in both identifying and getting consistent management through these vulnerable individuals with a BPD diagnosis. You're probably already aware that it is incredibly common in general practice that five per cent of individuals to get presented to primary care actually meet criteria for BPD. And sadly, many of those are not recognised. Due to the presence of comorbidity, about 94 per cent of these individuals have significant other comorbidities, often other mental health diagnoses, which cover up the BPD diagnosis, which prevented from accessing the care that they need. And I'm wondering if this is what's been happening to Tina. So we know that, based on those stats, every GP in Australia has between five and 27 patients with BPD. And so I'm really passionate about educating GPs about the fact that it's really important that we play a management role, particularly in individuals in the left at the end of the spectrum, for the people at the most severe end can access the specialised services. There's a lot we can do as GPs to just using simple basic strategies and carry on then to deal with those before, just being consistent and being there, having boundaries, having a safe, therapeutic environment. What individuals like Tina can come through on a regular basis. We all know that there's a lot of stigma and dissemination associated with BPD. And I'm wondering when Tina's diagnosis is made. I'm wondering if it was picked up when she was in adolescence with her GP or whether it's come much later, because we know that early interventions make a big difference. I think GPs are incredibly well placed to intervene early and provide really good psycho education and some simple strategies to support people until they may need to access more specialised services. So in this particular case, we have a GD appeal, obviously for Tina, but also to Josh and Jane. And I've got lots of questions. Jane doesn't sound like she's getting any support. And so for me, as a GP's family, I'd be wanting to make sure that she's linking with some really good support networks and get access to the information she needs so she can be there for Tina. And Josh, sure, but is he at risk? Certainly with Tina's history of tumultuous relationships exposure to intimate partner violence. I'm concerned that he might be at risk and also how Tim's going with her parenting and looking at whether she needs some supports in our Madeline Victoria, whether we need her for her child first or another service that can give her some extra help. In terms of risk reduction, obviously there's lots of complexity in Tina's case, being a type 1 diabetes with an eating disorder that's huge in itself and puts her at significant risk. Both of Obovadose is certainly developing complications of her control as in good. I'm concerned about her medications. I mean, does she need to be on therapy? I'll be talking to her psychiatrist about that and wanting to make sure that we had a clear plan. Now, moving on to the importance of foundry in general practice. And it's an easy word to say, but really hard to implement in an individual like Tina. There are some significant physical health issues that need to be managed. And so saying, I can only see her every fortnight. You know, I don't think that will work with her because she has other needs and so developing a really good long-term contract in the management plan with Tina around shared decision making and helping both of us together working as a team with the other professionals to come up with who's doing what and what can we do to support her best to be both physically and psychologically and socially well? As I was just said, having a whole physical approach is incredibly important. And we all know that some individuals on disability support pensions are difficult to access, especially as care that they need. All psychological sessions a year is not enough, but nowhere near enough for most individuals with BPD. And so it would be wonderful if you could link him with specialised services, but not a lot of the cases I see in my practices can't afford it until they get so unwell that they need to admit it to a public nurse or access case management through community mental health. And focusing on collaboration being absolutely essential. So working as a team with Tina at the centre of that team involving Shane and Joshua, her psychologist and her psychiatrist, communicating regularly, figuring out who's doing what and who's defining those responsibilities. In my last 20 seconds, I just wanted to touch on self-care. As I mentioned before, it's incredibly important. As GPs, we're not good at debriefing. We're not good at talking about how we're going. And so it's incredibly important to recognise compassion for Teague and burnout and vicarious trauma in ourselves and our colleagues. And to develop some structures around boundary and time management that debriefing regularly about maybe joining a valent group, finding what works for you to ensure that you're in a good space, a better space for a person's environment for your patients. Thanks, Wynne. Great. Thanks, Gillian. And I can see you really trying to get through all that information in the timeframe. So thank you for that. And I think the message around self-care is a really important one. And I'm sure close to DPs but also other mental health professionals as well. And the quote there, if your compassion does not include yourself, it is incomplete. So that's a really important message as well. So thank you very much. And we'll come back with questions. I can see a few questions starting to come through now, which is great. So keep them coming. I'm keeping an eye on them. So thank you. Let's now move on to who we have next. Brynne. Now, Brynne is a one-slide man, which is very impressive. So over to you now, Brynne, to take us through all of the information you're going to share with us. Thanks, Wynne. Look, I think this case is a very important case and that it highlights, I think, a number of critical issues we need to be thinking about. And to me, the major issue here is how do we manage transitions a lot better? Carrie Ann's already talked about the problem of long-waiting lists and it is a significant risk for people with personal disorder. But also it's a risk for the way the health service understands and works with the person who's seeking care. Ultimately, we need to have it a compassionate approach and I'm sure that everyone understands that, you know, compassion means that we don't necessarily always have to understand or agree with everything that's going on around us, but at least we can try and put ourselves in the shoes of the person and try and understand and have compassion towards the struggles that they have. And one of the best ways of doing that, really, is also to be thinking about, you know, being human ourselves and that all of us at any time, you know, can get emotionally dysregulated and can have challenges. And I'm sure all of us at some stage in our lives have had struggles and understanding that in many ways, people with BPD are asking for help when they're in crisis. They expect a human and compassionate response and really are asking for somebody to talk to them about what's going on for them and ask questions about what's going on. We know that psychological treatment is the treatment of choice for BPD and so in many ways we need to work out, well, what's the best way of actually ask all they are to communicate in a much more effective and helpful way that really bridges that gap. Now, Tina's in a very difficult situation. She's just been admitted. And the problem that she has, of course, is that she keeps getting into a cycle of readmission to emergency departments. And so one of the big challenges there is really multi-discipline recommunication and how do we all make sure that we understand each other and are on the same page. Considerations on the inpatient ward, we know in the here and now that very much Tina will want to be connected with us and she'll want to know what's going on. So we need to communicate clearly and give her clear expectations about what's going to go on and also to be expecting that discharge from hospital can be challenging for people with BPD. It can activate abandonment anxiety. It can make them feel very uncertain about whether they're going to get the help that they're asking for. And therefore, we really do need to have some kind of stepped care or rapid access to psychological care that really does provide a way of making sure that there is a good transition to psychological care after an acute presentation. The problem, of course, with Tina at the moment is that's not in place. And I think all health services need to think very carefully about the opportunities for building more stepped care programs. I think the other issue for Tina here really is also that she has a five-year-old son. When she's in hospital, there's issues there around his care. And it really brings in a whole bunch of issues, I suppose, around Tina's mum, Jane, and what family and care of support is she getting? At the moment, she doesn't seem to be getting any support, so nobody's talking to Jane about Tina's struggles or about the diagnosis or about some of the really good family skills and psychoeducation programs that are available. And similarly, Joshua, you know, there are definitely some parenting kind of strategies that we could be working with Tina around to protect him, to make sure that he's well looked after when she gets unwell, and some additional parenting skills. I think also, in terms of discharge, the first 30 days are very important. Kerry-Ann's already talked about, you know, a really important role for peer support workers. We also, in New South Wales, are developing these transitional clinics called Gold Card Clinics or Step-To-Care Clinics to really ensure that there's rapid follow-up when people are discharged. And there's really, I think, opportunities for health services to think a lot more about what happens in those first 30 days, because really, that is a high-risk period, and people do want to be able to talk about and get the skills that we know are based on evidence. I think evidence-based therapy for Tina is always the primary goal. Obviously, we've talked a lot about the challenges in accessing that. We do need to build more evidence-based programs across Australia. And also, we need to be wise in the way we use that. So people do need to have access to Step-To-Care, where they can get help rapidly when they need it, and also to be able to have opportunities for longer-term programs that we know are going to be effective. So there are some of the kinds of considerations I think we need to be thinking about in terms of working with Tina. It really is multidisciplinary, and it really is an opportunity for us to think more broadly, not only about her, but also family support and carer support for her mum, and also be very mindful of Joshua as well. Thank you. Thanks very much, Bryn. You've covered a lot there, and you're picking up on some of the comments that are coming round around sent an abandonment, and you did touch on that in terms of the follow-up and that need to recognise that and acknowledge that and follow-up carefully. So we might pick up on that again a bit later on. And also, the evidence-based treatment is something we've talked about in previous webinars. So if people haven't seen those and are wondering what are those treatments, we're not going to have time to talk about the treatments themselves tonight. We're talking more around the systems in the process of clean systems, but we do have webinars and information that's available on those evidence-based treatments. And I think a lot of messages in the past have been around the sorts of things we've been talking about around family and the hopefulness, I guess, and the treatment, or our treatment there that can be less interesting. So look out for the other webinars to find out some more about that. So thanks, Bryn. You've covered lots of ground there. Now, let's move on to you, Paul, who's been patiently waiting for us. So let's move on and hear your perspective on psychiatry. Very good. Thank you very much, Lynn. So I've really appreciated all the contributions of the other speakers so far, and I think I can go a lot on potentially what they've already had to say. I think I really like what Carrie-Anne had to say about really, I suppose, being first and centred in your approach, not thinking about a diagnosis and the importance also of information sharing and being collaborative. And I also was very impressed by what Julian had to say about her comprehensive and thoughtful approach as a general practitioner to how she would work with an individual like Tina. And then I think Bryn covered very thoughtfully and comprehensively how health systems need to engage and think very carefully about these transitions and to be collaborative and compassionate and to communicate very well. And so when I work as a psychiatrist and if there's a sense that someone like Tina needs some kind of specialist involvement, a psychiatrist involved or specialist therapy, often the most important thing to do, building on what Carrie-Anne is saying, is first just to meet the individual and see where they're at currently and see what their needs and expectations are and what that like. So really that's the basis of building some kind of therapeutic alliance or therapeutic rapport initially. You're seeing the person engaging with them and seeing what they want before you start to think about all of these complexities behind that, to see what Tina wants. And then, of course, there is a lot that a psychiatrist can offer just simply initially by assessing and coordinating so building on what Julian was talking about. There's already someone I'm new to the scene and I'm just seeing Tina for the first time. But I know since Tina, she's there now, since she was 16, she's had a very involved general practitioner. So we'd be collaborating on all of these complex issues around her, diabetes and insulin use and issues with her mother and son that she lives with and all of her engagement with other services in the past and in the present and issues managing her. Eating disorder that's been very significant in the past and it's still active. There's all of those things to initially engage with and, of course, stakeholder engagement is really important. So seeing what the Tina's needs and expectations are in terms of working with her mother as a support and also seeing how she's coping with the parenting role and all of those kind of things. So all of that engagement in communication and involvement occurring right at the beginning as a psychiatrist or then begin to think about what kinds of specialist psychotherapies can be made available. They could be something I could potentially offer. My training and interest or I can be someone who's almost like an advocate, someone that can help Tina troubleshoot how she accesses other supports and services and therapies and I can play a, almost like a case coordinator, like role overseeing those kinds of issues as well as related issues like the medication treatment that she's been on assessing, but the role of medication if there is any and what benefit that's had and how she's going with all of the other supports that are coordinating the supports because really we can see that for Tina to this point there's been lots of different services and supports involved and there can be this feeling a bit like Rin was saying that there's issues of abandonment that might be activated or a sense that there's chaos and a lack of coordination and really a psychiatrist role can be to communicate and try to end of thinking about the principles of care for personality disorder, getting the different services and then the different people involved in some kind of cohesive and containing system of support around Tina. As I said, that begins with having a conversation with Tina about where she's at and what she wants before we start to build on that. So I think that's what's a key role that a psychiatrist can play in this kind of case. Everyone can, like Carrie-Anne, can readily access a psychiatrist sometimes as a wait and sometimes there's a lot of open expectation built on that initial lump encounter with the psychiatrist. So the psychiatrist has to be very flexible and adaptive to the situation and think about the different kinds of things he or she can offer, someone like Tina and off all of the people around Tina who might be very concerned about how she's progressing. So hopefully that conveys some of what a psychiatrist in this kind of real and practical situation would have to offer women. Okay, great. Thanks, Paul. I think one of the things that was important from what you said was that you're working together, but you also have distinct roles. So what is it that you could do that a psychologist might not do or the DP might not do? I think that's really important and also to the workers, but also to the clients to say that there are just these roles that people can role. So thank you very much for that. Do you want to talk about this one, this slide at all? Before I move past this. I think that was just really for the audience, some of the content there to look at afterwards in terms of some of the ideal models of care that we need to try to apply into these real-world settings. Right. Okay. There's lots there, isn't there? And I guess people starting to think, where do I fit in this? Where am I in this space? And what can I continue to do? We can come back to that if some of the questions lead us to that. So let's get on to our Q&A session because I know people are asking some questions already, which is great. One of them that I thought is perhaps useful to start off with, and this could be a question that has hurt anyone to answer, and asks us, as a mental health triage clinician, I find that many services and professionals refer to acute mental health and emergency departments in a fear reaction to risk when de-escalation, support and reassurance may be more appropriate. So any comments on how we might be able to educate regarding managing and de-escalating risk and understanding why it is there in that moment? Now, I've tried to read that slowly, and I've hopefully captured that. So it's really the professionals being able to manage their own fears and worries when things are escalating for the client. Would anyone like to pick us off with an answer to that one? Yeah, I'm happy to say a few words on that then. Right, thanks, Spring. Yeah, look, I think it's a very important clinical question in treating BPD is to differentiate between acute risk and chronic risk. It's true that people, early in their journey, their recovery journey with BPD often feel quite helpless and hopeless and can have suicidal thoughts, and yet at the same time, may have active factors around that. But there's never, ever a time when a person can be considered to be completely not at risk. And I think it's very important as a clinician to differentiate between acute risk when a person has a sudden change in their mood and becomes much more risky because of some kind of breakdown in their relationship from, I suppose, what we might call chronic risk, where actually we can do very good work in the community and keep people safe if we ensure that they get the treatment that they need in the psychological care. So just in a sense to be effective with BPD, we have to tolerate some degree of risk in order to be able to make sure people get evidence-based therapy. Great, thanks, Spring. So we have to tolerate some degree of risk and I guess be supported in that as practitioners. So that's important. Anyone else like to comment on that? Yes, I can see that people do. So Paul, over to you. What would you add to that? Just building on what Bryn had to say, I think that anyone working in this space has to tolerate risk, like Bryn was saying, and I think that always becomes a collaborative point with the individual that's expressing a sense of lack of safety or suicidal thoughts or impulses or a sense of loss of control. Actually, entering into dialogue with them about that and frequently, I suppose we've got the questions of someone that works on a triage line. Sometimes someone living with personality disorder might describe really mixed responses. They get from someone on the triage line at one moment that feels like it's dismissive or minimising of their problems. That's held to the stamp self-sues or have a warm bath when they feel a lot more unsafe than that. But at other times, they might feel the triage person escalates things too rapidly and might call an ambulance on them and they just needed to talk for 15 minutes and help themselves get control of the situation. So I think the thing to learn is that a person might have an acute sense of risk and just engage in that kind of therapeutic conversation where you can help them come to terms with their sense of loss of control or lack of safety and kind of straddle those two kind of opposite the sense of the person as it really an acute change and needs to go straight to hospital or there's nothing much wrong with them at all. You need to kind of empathise and validate and help the person work through what they're dealing with and that's the most important thing. Great. OK, thank you. And I guess some of that conversation happening when the person is not in that stress state as well. So they've got a bit of a plan agreement beforehand. So this is kind of part of what might happen. So planning for that. OK, thank you. That's great. And Gillian, you'd like to add something as well? Yeah, it's just adding to what you just mentioned, that I think people can play a really important role. Often we do have the long view of patients over time and we see people between crises when they're dealing OK. It's really important to develop those crisis plans with the other professionals on the team and the individual at the centre, obviously. So if this happens, what shall we do? And coming up with the strategies which to cope that the individual has helped you develop, I think that can be really useful. And I think a lot of GPs are quite scared and don't feel that they have the skills. And I just encourage the GPs out there to... This is a really important area to develop confidence and develop skills, because instead it is so common. And so I think we all need to have those skills to provide these individuals with the best quality care that they can access. Great. OK, thank you. So pretty comprehensive answers to that question. We did have a webinar. I feel like I'm just like this walking advert, really, because we did have a webinar that did look at self-harm and suicide because it is something that comes up with people with borderline testimonial disorder. So it looks back to the previous webinar and that might give you a bit more information as well. Now, let's have a look at some of the other questions that are coming through as well. The question around abandonment has come up quite a bit. And I think if the case study got us thinking about that in terms of being discharged and then the case management plan, not sort of happening, and then where is the person going to be left? So would anyone like to comment a little bit more on this question around all this sort of issue of abandonment, the sense of abandonment or the sense of being rejected? Would anyone like to comment in terms of what can we do as individuals all together? So how can systems maybe recognise that this can be something that we might be able to understand better and distance the work on? Anyone like to comment on that one? Well, then I can say something again. Thanks, Breen. I can always rely on you, I'm noticing, to get us started at least. I think it's important to understand one of the core criteria of BPD is a real difficulty with relationships, which can include intense sensitivity, attachment neediness, attachment fears around trust and suspiciousness and so forth. And that really does require the mental health clinician and also family members and carers to recognise that actually people with BPD want to stay connected. They actually need people to feel... They need to feel like people are around and that they are being held in somebody's mind. They can often have a great sense of emptiness and that can mean that actually what they're reaching out for is connection. And so obviously, in the case of Tina, when she has been transitioned from service to service, we need to be thinking very carefully about how can we make sure that she understands what's going on, that we talk to her about that and we open the opportunity to stay connected and to ensure that her mother, Jane, and so forth are well connected also with what's going on because they are often the most important people in their lives. And so if we can help Jane as the mother of Tina to understand the nature of that kind of attachment neediness and abandonment anxiety, then that can really help Jane to understand some of Tina's needs. Great, thanks, Brim. Anyone else like to jump in to add anything today or other thoughts about that? Or we can move on. Moving on, I think. OK, so there's a question specifically for you, Gillian. And Julie has asked, what is the Balint group? Now, I don't actually remember you saying that, but did you mention a particular group? A Balint group. Structure groups where any health professionals can get together and talk through complex cases and their reactions to those cases and talking about transplants and countertransplants. It's just a structure, a de-pleasing. It's a particular theme of structure, yep. OK, and where would people find out about that? Oh, my goodness, there is a website. Can I get you on that one? Yeah, yeah, we can do it at a website. Or people could maybe Google and see what they can find as well. I'll come back before the end of the webinar. All right, fantastic. And I've just heard that MHPN actually has these groups. I'm not going to say the word, because I'm sure I'll pronounce it wrong again. So MHPN has some that you might have a website for us as well before the end, so people can stay tuned for that. I've got a question around limited services in rural areas. So I don't know if anyone, this is always a difficult question and we always have this as one of the questions that come up in any MHPN webinar that I facilitate. Would anyone like to have a go at what can we do in rural areas when perhaps the systems that we're talking about aren't able to connect up as well, or there are perhaps some gaps? Would anyone, and Carrie Ann, I know that... I haven't heard from you for a little while. I don't know if you'd like to answer that question or any comments on any other things that we've been talking about. Give you a chance to tell us what you're thinking. I'm from a rural area, but when I was accessing DBT, Group DBT, there was only one hospital in my local area or in the hour and a half in which I live that accessed DBT. So that was quite challenging for me. The biggest challenge I experienced was being on the waiting list for seven months and never knowing when I was going to start. So that was quite difficult for my family to manage, but we had plans week to week about how I was going to get through it. I had an appointment with my GP every four days. I was seeing an interim psychologist at that time, and we had skills that I could start building around distress tolerance and self-care, which enormously helped me in terms of waiting to access that treatment. Wow, so a really comprehensive plan and support around that while you're waiting, because it's a really long time, isn't it? It is, yes, especially when you don't know how long you're going to be waiting for. It seems even longer. Yeah, yeah. So it doesn't have to be rural areas for that to happen, either, which is what I'm always concerning. Anyone like to comment on the rural question, no? Anyone with a particular perspective on that or no of anything that's kind of working well in rural areas? I can say a few words on that if you like them. Yeah, thanks, Brink. I think the issue for us, really, in terms of rural care is how important the GP becomes, because, and also not only the GP, but also, I guess, those really core community-based services and the communication between them, the GP, and sometimes also the school can be the centre of a community. And really, we need to think very carefully about communication, again, and relationships and to be prepared to adapt evidence-based therapies, like it can be very difficult to run groups, but you can do lots of good work individually as well. So, certainly, the work that we've done with Project AIR in terms of our work with regional and rural areas has certainly looked at the way we can try and build together a treatment team. And often, the GP's very important with that. OK, so, the GP stands out again. So, let's hear from you, Gillian, and you've worked in a rural area, so you've got something to add, but it certainly sounds like the GP's often the leach pin for this, when other things have been put in place, the GP's there. Yeah, I was just saying, I mean, Brink's actually covered most of the issues, and I was going to cover my work in a little area for six years, and, certainly, I think access to the right kind of mental health services is a problem across the country, but, as Cary Ann and Brink was saying, it is exacerbated in rural areas, and the GP's still needing it to carry a lot more of the, I'll just call it low, that's one of the right words. And so, the importance of accessing those amazing resources throughout, like, Project AIR, which Brink's been involved in, that the resources that package us in access now compared to 10 years ago are very much better, that the importance of collaboration is emphasised, and the importance that I was saying before, to fit in those simple strategies, so providing that consistency over time, and as Cary Ann mentioned as well, there's regular visits with the GP in that safe space, having those clear boundaries, and just doing some simple work can actually be really effective for a lot of people. Right, thank you, and I think one of the things we've been covering in some of the other webinars as well is that people can't, you don't have to have entirely specialist skills and knowledge. Some of the things that people can do can be part of what they might do anyway, so that's something that we have talked about and created these webinars as well. So that's something that you spoke to bear in mind, I guess, for people to feel confident in doing this work. Now, Paul, I think you had something to add, but I think that was a little while ago. People may have covered the ground, but anything else around the rural issue? I think it was largely covered by Brendan Gillian, but just really emphasising that community health centres, community mental health centres and GPs ruraly can innovate locally and access training from places like Project Erin and Spectrum and come up with their own individual and group programs and also that there are a range of psychiatrists that can offer remote input, either case consultation, supervision or through video conferencing platforms. There are Medicare items for psychotherapy to be available remotely and the R&ZP college websites where you can search for psychiatrists, you can find which ones offer those kinds of services. Yeah, great. OK, that's really helpful, I think. All right, I've got some questions that came in a bit earlier that I think we might go back to, and I think this is something that everyone will have something to say about. And this one is around the importance of discharge care planning and follow-up. So we'd like to, Terri Ann, perhaps let's begin with you in terms of the idea of being discharged from hospital and the follow-up that we've talked about a little bit. But would you have anything to say about that in terms of the importance of it or what can set that up or what it's like for people to have that to know that that's coming? Or have you got any thoughts about that? Usually in acute settings, this is extremely last minute or right before someone is about to leave the unit and no meaningful plans are made to make sure that they remain safe once they leave hospital. So it's important to have these discussions, usually at least 48 hours before the individual is going to be discharged. In terms of discharge planning, you need to make sure that you're having these conversations with the consumer and if they have any family involved and want that family involved, to ensure that they're part of those discussions as well. I'd say that it has to be meaningful so that the consumer feels that they can stay well outside and that they have a good plan in place to make sure that should something happen, they know what they can do. Right, okay, thank you. So Carrie-Ann has really set that up that this is something we need to do better, I guess, is that first message. So would any of the other panelists like to comment on that or talk about what we could do in terms of doing this better and what gets in the way of us doing better? What's your think about that? I could add something there, potentially. I think I'd agree with everything Carrie-Ann had to say, which is often the whole point of the brief hospitalisation and often it's felt to be limited or time limited and inadequate in some ways and there's anxiety about discharge. The whole point is really to look at that system of support for the person when they leave hospital and existing family members or carers who are involved but also giving the individual a meaningful sense that they've got active follow-up supports being arranged and talking about all of the relationships that they have or want or need in their lives, including potential therapy options and community and mental health options and really what's available and how to use them and some of them might not seem ideal in a sense but they're also there as crisis option supports as well, like emergency departments and triage lines and just giving the person a sense that there are all sorts of things available to them and not the doors are being shut in their face or they're being rejected or abandoned that there's a system of support around them and making this and feel that it's cohesive and available for them. That's really important. Okay, thanks Paul. I can add something there too then. Yeah, thanks Ben. I think the issue to me is also it's a system issue for health services to think about. Discharging a person from hospital to a waiting list is really not acceptable. At the same time, we have health services, there's very experienced staff who have the capacity to do rapid follow-up and unfortunately sometimes health services have people with such long kind of case loads but they don't have any gaps. So it really comes about how do we work with the staff that we do have and how can we ensure that we have opportunities for rapid follow-up clinics so that people are discharged to a service and get followed up within one to three days. That's what we're aiming for in the Project Air Strategy Step-To-Care Clinics that we're setting up in New South Wales is to have that opportunity and it's really about health services working on how they use the staff that they have to ensure that they can do both brief interventions and longer-term treatments. Okay, all right, thank you. So the communications, they're having ideal plans but working with what we've got, I guess, is the important message there, but communicating is a common theme that we're hearing about, people communicating and including the client, the patient. Julie, and anything to add to that? I guess it comes right to be about communication, really, but often I find out once the patient arrives in my waiting room that they've been discharged from hospital. I think things have increased a lot in the last couple of years. I don't mean to be critical to health services, I know that everyone was under a lot of pressure, but I think communication is absolutely essential and making sure that the team is working as a team and I think we're doing much better at that. Okay, and we're very happy to meet you guys, yeah. Yeah, good, and I think throughout all of these webinars, we're hearing much more hopeful messages, so obviously, still more work to be done and more research and more services and funding, but I think there's a lot of hopeful messages that I've been capturing as it comes through all of these webinars. Now, Gillian, you've followed up on that group and you've given us the name of the website, so www.baylintastraliannews Zealand.org slash. So that's the website, so I think we can probably share that with people as well. So people are interested in that. I've also got a reminder that Spectrum have great training for GP, so another link, and there will be resources that I'll talk about in a moment that people can look at as well. So our time is getting to the end of our question and answer time and I know there's lots more that we could be talking about, but I think there's been some call messages and we've covered lots of the questions that have come through, so hopefully that has given people quite a good idea in terms of communication ways as collaborating. And some of the questions will be answered in previous webinars, which you'll be able to find here. So here's the website for resources and further reading that people can pick up on and get some more information about. But I would like to ask the panel, it's the panelist now, to give us a take-home message. So after all the things we've been talking about and all the planning that you did for the presentations this evening, I'm going to invite you each to take home message that you'd like the audience to take away with, one of the most important things that you think you'd like them to be thinking about when they finish off shortly and go and have their cup of tea or put the tally on. So let's start with you, Bryn. You've been jumping in first a lot, so let's start with you again. Well, you just mentioned going and having a cup of tea, so my take-home message would be to keep calm and make tea and really be thoughtful about the work, not be reactive and not jump in and panic. And to remember the difference between clinicians and patients is quite small. We can all get it dysregulated, we can all become emotionally unhinged at times, and so, I guess, maintaining compassion. Compassion for ourselves is a really important message. You've said that a few times now about us becoming dysregulated and that reminder that we're all going to have this experience. So thank you for that. Important messages there. Gillian, let's hear from you now. What would be your main takeaway message to people tonight? It'd be unfair following on from Bryn. I was going to talk about compassion, but I just encourage all GPs out there, or those of you who have colleagues who are GPs, to encourage GPs to get out there and develop skills and confidence in what is really really effective care for the individuals with DPP, because it's such rewarding work. And I love it. And coming from the social being completely overwhelmed and burnt out a few years ago, I've learnt a lot about self-care. I encourage all of you to make sure that you look after yourselves first as you sit down and we'll actually measure you to check your own concept. Just reflect on how you're feeling and how you're coping. Make sure those boundaries are in place and then you can do really effective care that really makes a difference for people. Yeah, that's good. Thank you. And I think you've provided us with a great model tonight in terms of your story around that's burning out risk and not necessarily feeling like you're managing so well and then learning how to do this better and promoting that message. So thank you for sharing that with us. I think it's been a really, really important message. I'm a bit disappointed that the cat hasn't made another appearance, so I'm not sure whether what you've done with the cat would be included the cat out, but the cat hasn't come back again. I did it. I did it. Turn the volume off. Let's move on to you now, Paul. What would your take-home message be for us? Well, I guess building on from what other people have said, it's really about being mindful and compassionate and engaged. And then just really, we can say that lots of parties involved in these situations are just for everyone involved to feel that they're doing something and they're engaged, so they're not being avoidant or feeling like the solution somewhere else, but they've got something to offer and really then engaging with these kinds of issues and still in the same, forming yourself and equipping yourself and being willing and interested in being involved and knowing that everyone, if they chip in and do that, it makes an enormous difference. So that would be my message. Yeah, okay. Fantastic. So seeing yourself as part of a team rather than in isolation. Part of the solution, yeah. Yeah, not the only one. Okay, great. Thank you. And Carrie Ann, let's move on to you. We began with you and now I'd like you to give us your final takeaway messages so that we're really wanting to hear from you. What do you think is the most important thing for people to take away? Very often people with BPD are portrayed as being very sensitive and vulnerable people, but I want you to remember that they are amazing, resilient and strong individuals who have experienced significant distress in their lives. Remember in your role to do no harm. In your role, please believe wholeheartedly in the people that you support so that in time they can start to believe in themselves. Recovery takes a lot of time. Please be patient and hold space for healing and meaning making and stay on their journey with the consumer so that you can hold onto the hope for them while they cannot. Well, thank you so much and I know you really thought about that and it's something that is really powerful coming from you and really appreciates you sharing that with us and some really clear direct messages for us. And I think this series of webinars has really been about understanding and thinking about people with borderline personality disorder in ways that haven't always been the case. And I think what you just said captures that really, really beautifully. So thank you very much. I know we've lost your image, but I know you can hear us. So thank you very much for that and thank you very much for all of our panellists for joining us tonight and for all of these messages that are here and are really important to people to take away and do the work and keep doing the work and feel positive about the work as well. Well, there are practitioner network opportunities to continue this work. I think the message tonight has been don't do this work alone, that it can be challenging, that there are challenges that come with the work and there are ideals of what we want to do and sometimes the systems don't always work as well as we would like. We've also heard messages around the need to self-care and to look after ourselves. And of course, one of the ways we can do that is to connect with others and to not be alone in doing this work. So mhpn.org.au is a place to go and look for local practitioner networks. As we said earlier, some of them are specific to borderline personality disorder. Some of them are general ones in the local area. So have a look and reach out and get the support that will be obviously beneficial. So you can be doing this work for the long haul and recognising it's been very eloquently told us that we all need support sometimes or at managing our own distress as well. Now, this is the final webinar in the series and it's important that we do remind everyone to continue to do this work, to look at the resources that are available already. So go back and look at the resources, the website that was given you before and the webinars that have been there before. There's been a number of different webinars on different topics. Some of them have been looking at the principles around borderline personality disorder and working with people. And some of them have been the most current evidence-based treatments that we've talked about and some of the other webinars have looked at working specifically with young people and self-harm and suicide risks that we've also talked about. So a whole range of them are available for you to look at and to go back and have a look at those and continue to do the work. We have a feedback survey that we'd like you to complete. When you do go to log out in the moment, you will see that that feedback survey will come up and we would like your feedback. As we said, you click on the feedback survey tab at the top of the screen to open the survey. As I said, we do report on the results and we do value your input and what you have to say it can help us to continue to do the webinars that will be held in the future that MHBN will be doing. And it obviously is provided to funding bodies as well. Certificates of attendance for the webinar will be issued within the next four weeks and each participant will be sent a link to the online resources associated with this webinar within the next two weeks as well. So you'll get access to all of that information. I would like to thank everybody that's been involved in the whole series for the webinar as well and people who've joined us throughout this last year that we've been running these series. But particularly for our panelists for this evening, thank you for your input. It takes a lot of behind the scenes work and preparation to run a webinar like this. So thank you very much for your time and effort in doing that and answering some of those very difficult questions tonight. And for all the people at home who are joining us as well, thank you for your ongoing support and interest in the topics as well. So before I close, I'd like to acknowledge the consumers and carers who've lived with mental illness in the past and those who continue to live with mental illness in the present. So thank you to everyone for your participation this evening and good evening.