 and welcome to the around 1,400 participants that we have on already this evening from all over Australia and possibly overseas. We would like to acknowledge the traditional custodians of the land across Australia upon which our webinar presenters and participants are located. We pay respect to the elders past, present and future, for the memories of traditions, the culture and the hopes of Indigenous Australia. I'm Mary Amalaeus and I'll be facilitating tonight's session. I have a background in general practice and psychotherapy, and I am now training as a psychiatrist. I have been based in North Queensland for almost all of my professional career and have also enjoyed being a medical educator for rural DPs. I'm particularly pleased to see so many people from rural and regional centres. I'd like to also introduce the webinar host for tonight. So this is a collaborative partnership between Project AIR, Strategy for Personality Disorders and the MHPN. So we have engaged in a partnership to plan, produce and deliver this webinar around NPD. And if you would like more information about assessing, treating and or living with a personality disorder, go to the Project AIR Strategy for Personality Disorders website, which is projectairstrategy.org. Now this is a good point to draw your attention to the resource box. In the bottom of the screen there's a little file icon, and in there will be the resources relevant to this webinar. I'd like to introduce our panellists for this evening. So we have a bit of an East Coast panel tonight. First of all I'd like to welcome Monica Moore, who's representing general practice on our webinar this evening. Now Manika, you're based in Sydney, and I can see that you've been involved with the mental health professionals network. I think it must be pretty much since it started. Could you just tell us a tiny bit about that? Yes, yes. So when it started, you know, GPs who had a special interest in mental health, of which I'm one, I've been interested in mental health since I had some CBT training in 1996. So we were invited to run some groups, and our area was quite successful, and so we've just kept it going since then. And so we have monthly meetings. We have 41 people enrolled for tomorrow, tomorrow night's meetings. So it's quite a popular activity and a very helpful one across the different disciplines. Yeah, it's really good. Thank you Manika, and it's great having you on the national panel for the webinar tonight. Now I'd like to welcome Andrew Staniforce, who's a clinical psychologist. Now Andrew, you're in Canberra, and I noticed that you have quite an involvement with working at the university and also some teaching. Do you want to tell us a little bit about the kinds of things you do with ANU? Yes, so I've been at the ANU for a couple of years in my current role, which is at the counselling centre. And so I have a number of roles, counselling students that are studying here and seeking help for various things. I provide supervision to clinical psych registrars as well as within the team. And for the last more than five years, I've toured into the clinical psychology program at ANU as well as a casual lecturer. Thank you, and it's great to have you on the panel tonight. And I know you have a particular interest in working with clients who have long-term kinds of problems like personality disorder. Great to have your expertise. And Tom O'Brien is a social worker and psychotherapist from Brisbane. Now Tom, I'm just going to declare here that Tom has also been a teacher of mine in my master's degree in psychotherapy a long time ago, and it's a pleasure to work together on this panel. Now Tom, I noticed that you have 32 years in private practice. Do you want to comment on that? Fine. But it's an exciting time. I mean, and just in narcissistic personality disorder, it's almost one of the places that you do deal with people with narcissistic personality. And it's been one that's given me a great deal of learning as well as significant moments of pain. But I've enjoyed it. And I'm sure that the people that have come to see you over the years have greatly valued it too. It's one of the lovely things about these MHPN webinars is that the panels often have such a diverse group of clinicians. And we have people from the public sector, the private sector, NGOs. So I'm sure the audience really appreciates your experience and everyone on the panel. I just wanted to mention tonight we're using a slightly new space, which has been the case since February. So there's currently 1,600 people in the participant room. So because we've had such high numbers, we had 4,000 people register for tonight, which is amazing. And about 350 people are currently using the chat box. So there's some improvements that have been made to the platform. It has the same functions as before, but it just looks a little bit different. So if you would like to use the chat box, there's an open chat tab at the bottom of your screen. And the chat box will then open on a separate tab. I've mentioned the resources down in the bottom right-hand corner there. And if you have any problems that are technical in nature, you'll see there is a tab that says technical support. And you can click on that for frequently asked questions and also if you need technical support. Now, you have also received the case study in advance for predisposing activities. And the ground rules have been disseminated beforehand. Essentially, just remember that this is a public forum. So things you type in the chat box can be seen by hundreds of people. And then on the webinar library in the future, people who record it, actually, I'm not sure if they see the chat. But anyway, don't put anything in writing that you wouldn't want on the front page of the paper. Now, each panelist is going to give a short response to Gary's story and then followed by questions and answers between the panel and between the panel on the audience. And we have registered the questions that you put in at registration and we will make sure that those get acknowledged. But the learning outcomes just to remind you is we're going to be looking at the prevalent distinguishing features of and prognosis for NPD, including its impact on families and carers, looking at some evidence-based approaches that are most effective and to look at how different disciplines, as well as families and carers, contribute to supporting and managing people with narcissistic personality disorder. Now, I certainly had some of my own responses to Gary's story and I thought about if I met Gary as a psychotherapist where I had maybe 50 minutes just for the initial conversation and then the difference between where I might meet Gary as a general practitioner for the first time, maybe there's 10 minutes and five people in the waiting room. And I had different responses. So I'm sure all of you, and some of them weren't very polite, to be honest. I'm really interested to hear how the panelists respond. So first of all, I'm going to invite you, Monica, to have a look at how you might think about Gary when you met him. Thank you. And thank you for inviting me to participate in the webinar. I must admit when I saw this case, I was thinking about how could I have got that much history in one consultation? And I think it's because I would have ended up extending the consultation and felt a bit steamrolled, which is not unusual. And that's part of the diagnostic process. And I suppose if I think about the red flags, like the things in the consultation that make me think that perhaps this person has a narcissistic personality disorder, is that concept where everyone else is less than me you know, he's better than everyone else. And he doesn't have a problem. And that, you know, if I talk to Jesse later, you know, that he's charming and romantic, and then he's changed when the baby's born and doesn't get enough attention. And there are multiple problem areas with substance use, with alcohol, with his employment, his wife, with his child, family of origin, and friends. And just the gut feeling that I would have had of being steamrolled, feeling devalued and irritated and just a bit bored with his story of, you know, how good he is and how everything is just not good enough for him. So as I was thinking about it in general practice, about how I might want to behave, this is the aim, is once I sort of get that sense in me, is to just try and hold my patience and be really interested to the person inside to see what it is that he needs and just let those grandiose statements pass unchallenged. And, you know, he's complained about the receptionist just saying, oh, of course, you know, receptionists are people too, we all have our off days, and just normalising that being good enough. And then perhaps making a decision to model some good boundaries myself. And talking about good self-care, you know, that validating that it's good that he's here, that looking after his self is really important, that I'd like to be able to help with that. I'd introduce, you know, the concept of stress management is clearly under a lot of stress if nothing in his life is ongoing according to how he'd been hoping and would you like to go and see a psychologist that can be very helpful? I know that your boss has told you you've got to do something, but for yourself, you know, you would do this for yourself. And being curious about alcohol use and gently expressing my concern on his health, maybe, you know, some people use it to self-medicate, just being a little bit gentle and curious about it. And that if I really focus on his physical health care, it might be a way of getting him back perhaps for some blood tests and engaging him. And definitely making sure that when he comes back, I would book a longer appointment. And then if he, you know, in ongoing appointments, hopefully building up a relationship with him where I could gently guide him back to what he actually needs because, you know, he might want to talk about other people and how other people do this and other people that and allowing him to say it and he feels heard and then say, but what can we do for you in this consultation? And trying to avoid that special treatment that sometimes they want, you know, the bulk billing, the longer appointments, the contact in between appointments and just being aware that at the moment he's quite unsupported in terms of his social network. And he has got a wife, but she's expressing some degree of concern about, you know, the relationship and she's going to see her own psychologist and it may well be that the relationship may not survive. And so people with narcissistic personality disorder actually have a high risk of suicide. So it's important to be, you know, gently curious and to screen for it regularly. And in terms of, you know, in my situation as a GP, because I do do psychotherapy, but when I'm thinking of the general practice sort of setting, just remembering that inner patience and when he complains about my treatment and how I'm not good enough and I'm not doing it well enough and where was I trained? Not to take it personally and keeping a sense of humour and really discussing the case with peers and with a supervisor is a really good idea. You know, it's something that keeps us on a focus and acceptance that sometimes they will come to the GP for a long time before they'll engage with a clinician who's going to help them. And often it's only after a major loss, like a divorce or they do their job or something like that that they will actually engage. And, you know, so in terms of what I would recommend, I think a sense of humour and patience and supervision and peer support, these are the things that I think in general practice I found helpful when this was happening. So those are the ideas that I've had and it's a complex case, it's quite difficult. So I'm keen to hear what the others have to say. Monica, I think you're a very patient GP because I must admit I read the story and I thought maybe Gary could see another GP. Anyway, so now it has been pointed out and it's very appropriate at this moment that actually there's many people in the MHPN and under the Medicare system there are a number of different clinicians that we can refer to including mental health social workers. And in my referral network in Cairns I refer a lot to people like mental health social workers and I have the option of some mental health nurses also through ATAP. So it's important to remember that lots of the counselling and psychotherapy clinicians are not only social workers and on that note I'd like to introduce Tom to talk about how he might respond to Gary. Thanks, Tom. Thanks, Mary. Working with Gary in his world is, you know, a complex art. It's a difficult presentation. It's not one that's very... His motivation I think is quite questionable. It doesn't seem to come from him. It's a relatively external one. His work situation is vulnerable. He's had a long history with the firm but hasn't been able to rise from a base level. There is, I think, significant vulnerability within the family context. He's got a serious alcohol problem. I mean that amount of drinking is such that I think it's certainly one of the major priorities and makes him increasingly vulnerable. We don't know much about his personal history. Some brief notes. But we did see a pattern of him feeling that he was lesser and treated as lesser than his brother, who I think is a significant player in this world. I think she clearly has more motivation but I think that's still to be tested. I thought that there was real concern about safety. I wondered about what her understanding of her own safety was but I thought that there was enough signs from Gary, about Gary, that especially if there was some breakdown in his work or breakdown in the family or even the threat of breakdown in the family that sense that he felt that his wife was really focusing mostly on the child and leaving him feeling vulnerable. I would be concerned or I'd want to investigate further about any safety risks that there may be from Gary towards other members of his family and perhaps towards himself. I think the boss, his work situation is one that we would need to investigate. I think it would be a key part of stability for Gary. Okay. Now, how do we start to think about what's going on? Well, I thought the three major issues were a serious alcohol problem that will be limiting his functioning at present, has the risk of getting worse and alcohol may complicate his response to any further problems. He's got significant narcissistic functioning. He's arrogant, contemptuous and he really has had limited achievement but his presentation on just the words is of looking down on everyone and I am concerned about safety for Gary and his family. So, what do we do and who does what? I think in this kind of presentation, I think there is a question, which comes first? Do we start to look at doing something, encouraging Gary to pay attention to his alcohol use and perhaps look for some kind of treatment or support in that area? Do we attempt to take on the very big task but the central task of his narcissistic relationship with the world and all the time, of course, but is it such that it comes first? The safety for Jesse and his child. So, who does what and when? By timing, I mean, which do we attend to first? I think it's a really open question. The second is, who does this task? What is the role of the split between some specialist role attempting to treat either both the alcohol or the narcissistic personality or the role for a general practitioner and I see a very key role for a general practitioner and I really liked what Monica was saying. I think that I suspect that a focus on health might be a way to get into Gary's world and then a mental health clinician and as Mary was saying, what kind of mental health clinician? Okay, how to work with him? Well, in the end, I think relationship is the main thing that we can influence. We know that the research is in. It's very clear that relationship is key in all forms of mental health practice, especially in any kind of psychotherapy. But how do we do that with someone like Gary? Using the work of Rosenfeld, I think of Gary as a thin-skinned narcissist in contrast to a more thick-skinned person who just has no sense of their impact on other people and who needs a fairly robust engagement with them to try and get through that hard shell. I think Gary is very thin-skinned and very hyper-sensitive and any engagement, you need to have to be very careful not to have Gary feel humiliated. And the final thing is keep working, no matter what happens. And I think Monica was onto that. If he starts to diss you in terms of your capacity or your training or any other characteristic or whether you're bald, whatever it is, you need to somehow keep engaging with Gary. What is happening? Why is he talking like this now rather than kind of respond with some kind of limit-setting? Thanks, Tom. Thank you, Marion. Now, it's really one of the things I always enjoy is people submit their questions in advance. And it's interesting how often the questions get answered in the presentations by the different disciplines. And I know that someone particularly asked about that spectrum and the thin skin versus the really grandiose narcissist and I think you explained that really beautifully. And I'd now like to welcome in Andrew to talk about Gary from a psychologist perspective. Thanks, Andrew. Yes. And thanks for inviting me to be part of this tonight. The GP, I think, has just done a wonderful job to initially engage Gary. And the beginning of the vignette really helps us know that there is a bit of leverage, I think, that the GP can use to try and get the... to Gary in with the psychologist as it's deemed necessary for his return to work. So I think it could be really pivotal for both him and his family that, really, the GP's able to help that move that way. So the first point that I want to make is that Gary... When Gary presents the therapy with us, the psychologist or other mental health clinician, it's likely he'll be assessing us as well as us assessing him. We already know his high expectations about what he wants from us and that he believes he's more likely to encounter incompetence than not. I'd expect that alongside hearing about the presenting issues, I may be challenged at various points in the first appointment and beyond that, too. I believe our response is really important here. Ideally, we want to be open and curious to what is said or implied and demonstrate our ongoing focus on the client on Gary. If Gary did this, if he was challenging, I probably would attempt initially, maybe quite a while depending on how it goes, to sidestep the challenge and instead attempt to open up the discussion to explore the commoners reflecting something else that might be going on somewhere else in his life, such as at work. Our focus and the more important task, I think, is to develop the working therapeutic relationship and our shared understanding of the presenting issue. The emerging personality information, I would take as information that I'll observe and gather as I get to know him a bit better. And as with any new client, developing a clear understanding of the presenting issues is really important. We know from the vignette some information. We've got an idea of the picture of what he's coming in. Of course, there's going to be much more detail. We understand that there's stresses at work, change at family with his new baby. We want to understand these things. I'd also initially explore alcohol as how he's using it to cope, what he might be thinking around his alcohol use, but I guess I'd just kind of continue to flag that, but maybe not dive into it too much. It is vital our initial approach to choose direct challenge and verges much closer to a curious stance that demonstrates our ongoing genuine interest in the reported experience, Gary as well as our emerging experience in the room. As the GP is all ready, it is vital we create an experience with Gary that is likely to buttress the emerging collaborative therapeutic alliance. We want to hear him talk to the situations that are grieving and continue to be strongly empathically present, validating of experience and genuinely open to collaborative exchange that's focused on his goal, returning to work. For a moment with the referral, I want to imagine we don't know that narcissism is a presenting issue. From my experience, this is probably more likely. Rather, I would expect to find other factors like relationship trouble with his wife after the birth of the baby, ongoing disputes, increased drinking, conflict interpersonal things at work or perceived bullying alongside things to do with risk. And as I indicated earlier, the primary focus is the development of the relationship and assessing those initial presenting issues. The other areas we may want to assess like developmental history will need to wait because we must be finely attuned to his emerging presentation in the room and being really curious about what that is. The experience I'm referring to in regard to the my emerging experience in the room is that I'm attuned to what's going on in me, my counter-transference, as that could be the first key as to how I'm encountering a narcissistic presentation. So without the referral, this is the experience to which I would be open to listening to. I mentioned at the start he would be assessing us. I would be open to his comments and meet them with curiosity and interest. I would want him to tell me about his comments as best he can. Here we can build our shared understanding and the unspoken experience what's emerging in me and perhaps in him too will also develop. Hopefully he'll likely begin to show us his character as it's experienced and hacks upon him. The advantage we have in this then yet is we get a sense of who Gary is now but we also have some reported history which enables us to develop empathy towards him. It might be easy for me to say but being empathically present with someone with a narcissistic personality disorder or any other personality disorder can be challenging. And so for treatment, a primary challenge is keeping someone with an NPD presentation in treatment. We want to keep them there so they keep coming in and we form our relationship. Then we can start to understand the maladaptive coping mechanism. The steadiness and consistency in which we can orientate and respond to Gary is likely to be fundamental in both our ability to sustain a working relationship and focus on helping Gary with his experience. Over time in therapy with a consistent empathic connection has been formed. Some of those narcissistic defence might become more permeable and then create an opportunity for us to explore them. But it's unlikely Gary will show any sign of vulnerability early. We need to do this through establishing a very strong empathic relationship that is focused on understanding him and to help Gary understand himself. Thanks, Andrew. Yeah, it's really interesting what you're talking there about the dual assessment and it does feel like that. You immediately feel as a clinician that you're under the microscope yourself and it can be quite hard quite an unpleasant place to sit. So we'll continue to explore all of these issues. What I'd like to do now is just move on to our audience poll. So a number of...now first of all I would like to say there are around nearly 1800 people online which is wonderful and I hope you're enjoying talking to each other in the chat box as well. Remember it's there if you'd like to. Now people submitted some questions, about 350 people put in questions at the beginning. So there are a number of points there on the screen. What we're going to do is poll the audience and give you the opportunity to say which of these things you really want to address in the panel discussion. Now it is very organic so I can't make any promises but we would be really interested to see what this particular audience would like to focus on tonight. So I wonder Redback if you could activate that poll for us please and we'll give the audience around 30 seconds to respond. So hopefully people are getting the opportunity. Not seeing any numbers yet, Redback I wonder if it's... Oh yep, no. Let me know if I should just keep it open. Yes, great. Okay so there's people quick off the mark there. We'll just have about another 15 seconds if you've still got time. About 300 of you have responded so far. 900 the numbers are going up. That's about half. If anyone else wants to you've got about 10 seconds left. We're looking forward to seeing where we go. Okay we might close it there. Thanks very much Redback. So just run through the results there. So the theme that people most want to talk about and I must admit I'm not surprised is the transference and counter-transference. This is the hardest thing working with narcissistic personality disorder and then the next question is around engagement. So how do you actually engage with someone? How do they even come to therapy? And then we're pretty close there around the overlap or the differences and similarities with other personality disorders and then narcissism's relationship with things like ego, age, personality, mental health, other diagnoses. So I think that just helps to inform the panel when you're answering your questions that we're particularly interested in the transference issues and the engagement issues and no doubt we'll cover some of the other as well. So thanks very much for that Redback and I might go on to the discussion. So I think first of all there's been some interesting questions in the chat box around formal diagnosis and perhaps tangentially related to engagement. So I might go to Andrew. If Gary did come back a few times at what point if ever do you think it would be helpful to say to him Gary do you meet the diagnostic criteria for narcissistic personality disorder? Can you comment on that? I think it's a great question and a conundrum I've faced before as well. I don't play down the middle. I don't think there is a right way to answer that question. I think it really depends on what you're forming with that client and I might urge towards letting him know what I'm thinking or letting a client know what I'm thinking if we've already started to establish a discussion around grandiosity, self-esteem interpersonal wounding emotion dysregulation and how they might try to manage that in the way they interact with others if none of those things were coming up I wouldn't probably be going near it. I'd also probably not really want to go near it too early in our treatment because I think it probably will just create another barrier or even a whole other thing to debate and argue and I think that's going to keep moving us away from the client's experience or Gary's experience. Thanks, Andrew. Monica, I'd like you to perhaps respond to the same thing. Sometimes when you're GP you might have a sense that this is what's going on and you're trying to encourage someone to seek some psychological support would diagnosis be part of that and what other ways might be effective to encourage someone like Gary to seek psychological support? I have never found I mean I've never done it I've never said to someone I think you have narcissistic personality disorder and you should go and see someone about it because in my imagination that would be just something that would make them feel so wounded and so got at and I don't know that it would be a positive thing but my encouragement about him going to get psychological help would centre more around the issues that he's presenting with that would motivate him and so within that context I would hope that down the track you know if it's helpful I mean sometimes people look it up and then they come in and they say do you think I have this disorder in which case I'll go well what do you think and what makes you say that and if it was true that you did what would you do about it that would be as far as I go I would never diagnose someone with a narcissistic personality disorder because I don't think it would be helpful Just out of curiosity Monica do you think is that specific to narcissistic personality disorder because there might be other kinds of personality disorders where people find it helpful I wonder about that Yeah I think it's true I mean it depends I think sometimes people with borderline personality disorders especially now that more information is coming out in terms of it being related to complex developmental trauma that might actually be helpful and they'll understand why it is that they have emotional storms and difficulties and that might be helpful but my so far my understanding of what's available widely of what people know about narcissists is that it's a really derogatory term and I don't know that they'll be helpful it's not I mean sometimes when people have ADHD or autism that's an actually a helpful diagnosis to say look this is what's happening I would feel uncomfortable other GPs might have done it and feel that it works really well but I don't know that it would help them to engage in getting help for themselves Thank you very much for that and I think they are their questions where there's no simple answer which we keep saying it's very complex and Tom I'd like to invite you to come in and I want to think about this question of you know let's say Gary does accept the advice from his GP who he currently thinks is very confident and comes to see you and being an experienced clinician he's not going to walk in the door and say I've got narcissistic personality disorder but you're probably going to feel that quite quickly so I just want to talk about what it's like as a clinician how you can be in the room with someone I mean I just found reading the case study about Gary the things that he said really confronting and he wasn't even a person in the room with me how do you Yeah look it is complex and I'm just bringing to mind someone that I thought just seen the last week or two that who's you know saying sort of quite ridiculous or repulsive almost things not not anything that was you know stomach churning repulsive but that kind of arrogant way of dealing with the world and I I felt it quite strongly and I thought oh this is you know where's this going to go and but I just managed to just wait a little and go I wonder what's going on for this person why are they talking like that what needs to be happening for you what's your experience of the world that you see it this way and with Gary I mean you know you really run the company I'm the only one who knows what's going on and yet I'm in a base grade job and have seen in the same or similar I think base grade job for 10 years there's that's just an inherent conflict that anybody with any degree of intelligence could understand is a problem that something prevents him from using his intelligence to recognize that there's something wrong with that story so why does he think like that what's why is it so important to him that he thinks he is a superstar that he is knowledgeable where everyone else is lacking you know it doesn't take a you know psychological genius to suggest that it's related to feeling that he hasn't got those things so how does he deal with not having and knowing somehow that he hasn't got those capacities that he claims and feeling that he has to proclaim to the world that he is a central figure a significant business owner or manager the smartest person in the world I mean he's so that kind of thinking in myself I think helps me to see a guy who's struggling and Andrew you know at the same time as we're able to think about how he might be feeling we also can feel you know integrated belittled not valued and those feelings can be really hard to sit with you've got any you know because you're talking about making an empathic connection is being really important so how do you keep an attitude of empathy and openness and curiosity when someone is telling you that you're a fool I think it is a really difficult thing as Tom was talking I was thinking we're attending to the client we're attending to our own thoughts about what we want to do about an assessment and attending to our internal experience and trying to keep all of it in check and when I sit with people that may be provocative and really pushing buttons or being critical or challenging me I guess I try to orientate to what's going on and be curious about what is happening for them and try to find a way that I could maybe phrase something or say something that could help us understand their internal experiences what I want to do while at the same time trying to notice if in me something is coming up that makes me angry or upset or like I want to defend myself and just trying to notice that really and watch that and as best I can and of course I don't do this well all the time but as best I can trying to stay steady within myself trying to provide this consistent way of responding which still maintains boundaries but also I guess let some of those things go through to the keeper whatever different way of saying it Thanks Monica just coming back to you I mean often when you refer a patient to a counselling professional of some description the patient will come back and report into the GP so how do you you know what's your experience about whether people with this level of narcissistic personality disorder actually engage how many of them actually stick with it how many of them can tolerate it what have you seen work what's effective to keep them in therapy So I'm thinking of the various people thinking of this particular woman who who was a woman in her 70s and she actually tried a variety of people and she'd always come back and say no there's always no good because of this and that was no good because of that and but my focus was more in managing my own sort of reaction of not losing patience and keeping my sense of humor and also I would I suppose with Gary it might be a little bit more difficult being female to banter with him and that's sort of a little bit that's something to take into account but to just keep a sort of a gentle thing oh well you know how about trying it again because sometimes the first time it doesn't work but how about going another time just being patient with the clinician maybe you need to explain what you actually need a little bit more and how they could be thoughtful but just also accepting and not arguing not entering into an argument about you know how they could sort of do it better I also wonder about the the concept of really recommending someone I mean because sometimes they find someone this is the best of the best of the best and this is the you know the really the expert on someone who might be you know my condition which is stress management in a business world okay well let's see how that goes and to allow them to choose the clinician based on their assessment and sometimes that's helpful and they will engage with someone merely because they feel that this person is a person of authority but it's very variable and they sometimes come back and you know it wasn't good enough so you just have to play it by ear I don't have the answers to that one I'm sorry and coming back to you I mean communication between the different clinicians involved in somebody's care is that important in this kind of situation it's obviously a central issue you know no one has got capacity to be across those three central issues that I suggested you know the alcohol the safety issues and the you know engaging with you know the complex task of trying to help someone negotiate their narcissistic relationship with the world so no single person can do all of that so communication is important I think you need to be clear to the patient that you are communicating with other people you don't want to find you know for them for any particular reason they come across that you are communicating with someone without their knowledge so I certainly do that I'd you know pictured as our concern for that we work together to meet their needs but it's always going to be on the edge it's always going to be a risk of breakdown and it's you know I think I think this story would be given is a complex one because I think there are urgent issues but at the same time somewhere in the system we need to be able to say okay we'll get there don't worry these are these are problems but I think as Monica said have another go go back try again you know try and negotiate with work try and talk to your wife try and keep going and so how to balance urgency and the need not to have over much pressure on anybody the problem and some of you got with your because you've been a private practitioner for such a long time what kind of practical tips have you got around communication with people like referring doctors so you would probably get referrals from psychiatrists and from DPs are there any things that that work you know how do you I mean I think relationship again is key I think that you know I know it's difficult in busy schedules but I like to talk to the colleagues that I'm working with especially in complex cases like Gary's you know I think in when they're relatively straightforward it probably can be handled by just written communication but I think because Gary is going to go from practitioner practitioner dissing everyone else and you know it can be hard if you're going okay with a Gary to hear and say oh GP is like this and you go oh yeah no you know internally I hope oh yeah GPs can be like that sometimes oh the last psychologist I saw he she was like oh yeah well that can happen you know so it's easy to get a sense that you know I'm doing okay with this person so you know if the report is that someone else isn't then maybe that's accurate you know a verbal communication with a specialist of some kind whether a clinical psychologist or a psychiatrist or somebody else and the general practitioner will go a long way to keeping that communication open and Andrew I wondered whether I suppose we might move on to thinking about particularly the sort of pointy and safety kind of issues I mean sometimes people do become suicidal or you concerned their you know jealousy about their partner is reaching a crisis kind of level have you had um approaches to those I guess let's start with the suicidal situation so any experience in that area with I think it's really important as I've been saying I think we're all saying to be consistent and to maintain a clear way of what we're going to do and then following through with action so I guess with anyone where I says risk and risk is part of the picture I would continue to assess just as Monica was saying and look at it and if risk was increasing I'd hopefully would have established with someone like Gary the way that we're going to manage that together so I'm assuming we've been working for a little while hopefully without some understanding but around what my responsibilities will be to him or to his family and that might be referring to the acute mental health team in the area definitely with communication with the GP or any other treatment providers I agree with what Tom was just saying earlier about it's so important really that we're all collaborating particularly with someone that is complex and challenging for us to stay in the picture and I think sometimes with some clients and with people with nurses at times they might try to want special treatment or negotiate things and I think for us it's so important to have a clear idea of how we're responding to risk and what those acute in particular those acute factors are that will compel us to do things and how we then talk about that with a client regardless of maybe protests or they're challenging of us or getting really upset remember a few occasions where that's happened but I think over time we've been able to repair those ruptures that occur when maybe we do something that they don't like because we start to understand I guess the bigger picture and I think Tom and Monica were talking about the bigger picture within all these microcosms of what we're trying to do each session as well. Thank you. Monica did you have anything to add around that issue of risks in particular when people become suicidal any tips or reflections? Yeah, I suppose just keeping trying to preserve relationship by saying that it's my role as your GP to look after you today you look really down and I asked you about how you were and you said that you were contemplating suicide so I'm going to have to ask you these questions and then we're going to have to establish safety and so I'll take your risk step of the way and if he has engaged with a clinician, a psychotherapist or a psychologist that I'd say I have to get in contact with them as well and let them know and depending on what it is I'll say my job is to call an ambulance or my job is to do this so it really would depend but trying as much as possible to engage with them and the other thing is that sometimes as a GP when they don't get their own way they threaten suicide so again this elderly lady who no one else in the general practice would see they would say you know Monica she's wanting a house call straight away in the middle of a session and if you don't go she says she's got a gun and she's going to kill herself and so I just think you know I said okay in between sessions I'll ring her up and I said look I'll miss you I really miss you if you kill yourself so how about we organise a home visit for tomorrow and so that's what I mean about that sort of gentle sense of humour but not necessarily giving into their request and that's something I could do with her because I had relationship with her it wasn't the first session but it really does need to be taken seriously I think as a GP because I'm not limited by the Medicare item numbers I can sort of just have that contact with her and maybe make a regular appointment to support Gary you know let's make a regular appointment see how you're going check things like your blood pressure you know maybe I could be working around that but it is a really difficult thing and also domestic violence I mean I'm glad that his wife is seeing someone because I guess from my point of view she's having the support she needs there and I'm not going to have a discussion with him unless you know there is evidence of this in which case I have to say you know I may have to make a report with that too those are the sorts of things I'd be thinking about and then having a discussion with the clinician if they're seeing someone and yeah what do we do now Thanks Monica Now Tom as you have pointed out a few times this is a very complex case and one of the issues in here was that he partly has come because his boss said he had to get some help before he'd have him back at work now what's your experience about compelling people I mean Monica said you know often people like this don't even go near therapy unless there's a major narcissistic wound like a divorce or something people do get compelled what's your experience of having My experience is I think that there's always even if they claim to be frog-matched into the room with you know their one arm being twisted at the back as they walk in there's always some percentage of them that knows that there's a problem even if that's two percent ten percent you're shooting for a bit closer to forty or fifty but I try and work with that percentage whatever it is whether it's two or forty you know in fact the person who comes in and says I'm really keen on help in reality they're probably only operating on forty or fifty percent willingness to change and have something new happen in their life mostly they just want their problem to go away especially if it can be done without any change in them so I think this kind of person is in fact no different from anyone else in that impulsion especially this isn't a legal compulsion it's not a child in care of the department or something like that this is a person whose boss told them to come along and get some help well I don't know about you but that wouldn't be enough to get me along to see some help unless there was enough in me to say I need something so that's what I'd be searching for Andrew's term earlier curiosity I'd be trying to get to that base in them the practical level is that something you're looking for it you're observing it, you're estimating it it's about ten percent or whatever would you observe that to the person themselves it seems like there's a part of you that wants to be here I think I would definitely as part of saying where are we going from here you know after you know as the session goes on even after a couple of sessions you know there is no compulsion I'm not in a position to insist that they be here so in the end each time anyone sits in a room sits down starts talking they're indicating some kind of some kind of collaboration now we have 1800 people in our participant room at the moment which is great Andrew I wondered whether you had any comments there around that sense of compulsion but then there's a part of them that does actually want to come yeah I agree with Tom and I think trying to attune to and then align with that part even if it's a small part I would really try to elaborate that with the client so two percent or forty percent and I would also just as Tom said respect that I would talk about I know you know part of you might be feeling like this and part of you is compelled to be here I wonder what else is going on I wonder what you're finding within yourself how can we still make use of this time and space that we have to see what you want to get out of it and going back to this being yet we do have you know he thinks he contributes a lot to the company so could that be a way to help increase his motivation and identify more with there are some internal things that perhaps he could get from being there particularly if he does want to retain his work thank you and actually while I still got you Andrew I know that you actually with Tom at the beginning but I suspect you might have some thoughts on it too around the different sort of spectrum around narcissism so some people are actually very vulnerable whereas other people are very thick skinned yeah how do you sense that and what different approaches might you have I I guess from my experience from what I've read as well they might present like that in the room someone might be more aggressive or particularly challenging about qualifications or experience or anything like that and someone might present on the other spectrum be more easily wounded but underneath I think both are facades of some internal pain that we really want to find a way to connect with and maybe create some interest in the person in Gary in this case getting them to look inside and so like with other presentations borderline clients can look differently at different times but there's something going on internally to do with the developmental attachment experience perhaps with depression it could manifest lots of different ways we want to find out what's going on inside for someone and I'd say the same the outside is maybe these different defenses that can keep people away from them and it keeps them safe but at the same time it keeps them feeling this disconnect and loneliness that they never really have a chance to repair and if we can be steady enough to find a way to persevere through some of those attacks then maybe we can get inside and start to notice and attune to and then maybe create some interest in the client to look at that experience and so Thank you and Monique who I'd like to bring you in now just thinking about you know people live with Gary so he lives with Jesse and they have a child who at the moment is a baby and we acknowledge that Gary struggling with that because Jesse doesn't have as much time for him anymore and he seems like he's a bit jealous of the attention the baby at some stage that baby's going to be a teenager and I just wondered whether sometimes you know as a GP you see a young person who's distressed and you quickly can ascertain from their story that they actually have a parent with a personality disorder have you you know how would you support Jesse sorry Jesse and Gary's child when you know he's 14 and coming in in distress that's a really common story especially because that child will have come in over time and it depends I mean a 14 year old you know the may be developing not just the stress you know that's manifested in terms of clashing with Gary so the you know there may be clashes and Jesse might say you know because rather than Gary being identified as the person with the problem the child might be identified as the person with the problem at which point it might be a time to refer that child to a clinician of their own but also sometimes just normalising that you know parents when they're stressed they don't do a good a job as they could and it is interesting that with teenagers I mean they're still living at home and so it makes it hard to have a really deep discussion with you know your father has a personality disorder I mean I don't know that it would be really helpful but I have engaged with teenagers where you know just even talking about the fact that when parents are stressed they're not doing a good enough job and how can you how can I support you how can I help you what would be the most useful thing I mean there's headspace there's all sorts of things you know liaising with the school and finding out you know whether there is support there and I think also with peers you know that teenagers might have peers that might support them as well in terms of their network and one of the things that sort of came up with Gary's loneliness that sometimes with people like this they will join groups where they feel they can you know feel that they're contributing something and that will contribute something towards their peers support and get them out of the house so that they're not necessarily with Jessie and their child but it's a really complex thing but it's actually true there's an intergenerational trauma that continues and I'm not clear about what to do except mop up as we go thanks Monica now Tom I would like to bring you in because I'm sure you have some thoughts around the family here his wife, his child have you been thinking anything particularly you wanted to say yeah I'm concerned when I read the story I was concerned she is increasingly scared of his rageful thoughts now I imagine she's not managing to read his thoughts she's hearing his words and his gestures I I think I feel like a cranky old wouter but I think the combination of alcohol and his feeling excluded within the family is a potentially nasty combination I would think that perhaps Jessie and the general practitioner working with Jessie and Jessie's mental health condition too may be able to help her explore questions of her own safety and make an assessment at the very least about her capacity to judge what's going on I would say as anybody who was involved with Gary I would talk to him about safety I'd put it front and centre and say that this was an issue that I feel that I can see the difference about and I'm wanting to work with him for him to protect himself but also to protect his child and wife Thanks Tom I just didn't mention before but Project AIR has got some excellent resources on the website for supporting family members and even parenting as well COPME, the Children's Parent with Mental Illness has resources for parenting with different kinds of mental health problems but do look at the resource box and the Project AIR website has got some great things particularly if you're someone like a GP and you're not spending a lot of counselling time with a patient but you want to give them good resources I recommend that now we're just approaching the end of our time it goes so quickly I'd like to invite you Andrew first of all to just if there's anything that you'd kind of like to say to leave the audience with there's probably a couple of things I could say but I guess it's to persist as clinicians when we see people with this kind of presentation it can be pretty tempting to refer on if we can try to persist through that initial difficulty or the ongoing emerging difficulties underneath it all these people that have experienced loss or trauma or pain and have developed this way of coping and adapting through their life they need our help and I think it's really important we try to to look inside look to that internal experience that being said it's crucial we're taking care of ourselves and we've got good support and supervision and you don't want too many people on your caseload like this I think a few is good too many and I think it could start to weigh on us you usually could get burnt out and I don't think that's going to be good for them or for ourselves and I just want to emphasise I agree with the ongoing assessment around the need around suicide and I think as best we can as I've said before I think we've all been saying trying to be as upfront and clear and respectful and transparent as possible to be that consistent person in this world so at least they start to have that sense of okay I know perhaps where I can stand with this clinician Thanks Andrew this is really really wise advice there I think Monica I might invite you back in is there any sort of final things that you that you wanted to say yeah I mean I think you know the same as Tom and Andrew is that thing about maintaining a sense of patience and understanding that the person inside is really suffering otherwise they wouldn't be behaving like this and that it's about them it's not about me and so and I suppose I'm thinking of the rule and isolated sort of clinicians who are watching this webinar and wondering you know what support do you have how do you get support for yourself I mean I know that I can talk to colleagues I have supervision but you know there are also things you have case consultation meetings via Zoom we run them through the Australian Society for Psychological Medicine but it's about sort of having a balanced life yourself so that you actually have the support that you need to then allow for the fact that they're going to push against you they're going to push your boundaries and I really like you know what Tom said about being upfront and really clear you know these are the boundaries this is what we do if you say this what's going to happen if I hear that you're beating your wife and I'm going to report this like it's all those kinds of things that are helpful and just and just being present just trying to maintain the relationship as Andrew was saying. Thank you Monica and then Tom I imagine you guessed that you would be next is there anything else that you'd like to say in No you know both the other speakers have really talked about the things that I think are important it's this balance between the hot issues crisis danger you know breakdown of you know in even if not a psychological breakdown for instance a breakdown in work would be a serious difficulty for this family so trying to pay attention to those significant active issues whilst in a sense the main thing we're trying to do is keep in the game somewhere in the system between general practitioner specialist other practitioners involved we need to keep Gary or need to keep working with that part of Gary that wants to do something about his life and that's not going to happen quickly Thanks for that Tom and yeah look I think everyone's contributed so much tonight and I was just reflecting even for myself like just being part of this multidisciplinary panel has helped me to see that the reason I had such a strong response to reading Gary's story is because I'm working in an emergency department and I'm seeing pointy end people all day every day so imagining myself as a GP with a Gary was just too much and even just a conversation of this length is so valuable so I encourage everybody to make sure that you have good peer groups and good professional supervision if you're doing this kind of work so I'd like to just thank all the panelists again it's been a really rich and interesting discussion so thank you all very much for your individual and collective contribution now just to the audience please make sure that you don't leave without completing our exit survey so there's a feedback survey tab which you can open to complete the survey and you will receive an attendance certificate within a couple of weeks and you will also receive an email with a link to the resources from the webinar and that will include a recording of the webinar you may not all be aware that all of the MHPN webinars are in a library online and you can log in and access those for free and there are many 40 to 50 I don't know the exact numbers but thank you so much to the audience for your participation tonight we've had such a great number of people participating over 1800 which must be close to a record and hopefully the new platform has well for you too so if you wanted to say anything about how you found that please go ahead and also to once again thank Project AIR for their collaboration with MHPN on this webinar so thank you all very much and I hope you have a pleasant evening good night