 Good evening and welcome to this evening's webinar. It's a webinar which is the first of a series towards the national borderline personality disorder training and professional development strategy. My name is Lynna Grady and I'm a community psychologist and I work typically with the Australian Psychological Society that facilitates some of these webinars for NHPN and really enjoy the opportunity and welcome you and our panel for this evening's webinar. I'd like to begin with an acknowledgement of the traditional custodians of the land and on behalf of NHPN and Spectrum and the Australian BPD Foundation Limited acknowledge traditional custodians wherever we are around the country and pay respect to elders' past, present and future for memories, traditions, culture and hopes of indigenous Australia. I work with the Australian Psychological Society managing some projects and have been managing the kids matter of projects most recently and I'm really pleased tonight to be able to facilitate this session and to have a panel of experts who are really specialists in the borderline personality disorder area with lots of experience and work in that space as well as an advocate who's joining us as well. So hopefully you've had a chance to have a look at their bios and also have a look at the case study so that you've got a chance of really keeping up with the conversation tonight and knowing that's what we're aiming to be doing. I also said this is the first of a series of webinars and the funding is coming through the Australian Government and other webinars in this series which will be happening early next year are listed here so you can see that there's a series of sticks so there's lots of content to cover in this area and tonight is really a starting point and an overview and we're going to give you lots and lots of information but you can see there that there's going to be a lot of other topics that will be covered and a lot of other information will be shared in coming months so hopefully you'll be able to join us for those as well. We have lots and lots of interest in this webinar and we have many people who are joining us and many people who will be watching this later as a podcast on various websites where they're available. We're also mindful that this topic, as many of the mental health topics that we do deal with can be quite tricky sometimes and it can be quite hard for people to hear the symptoms and signs and can be really find it quite triggering at times and we know that we'll have some people who do have their own experience, live experience, borderline personality disorder or a caring for people with borderline personality disorder so we're really wanting to make sure people are very mindful of that, are able to look after themselves have a bit of a plan for yourself and that might mean that you're not necessarily going to watch the whole webinar tonight you can watch it as far as you feel like you're comfortable doing and then you'll get a recording and look at it later if you want to do that as well or other strategies that you know work for you and that might mean people that you can talk to or your own self-care plan that you have in place so I really wanted to, I guess, remind people about the importance of that and really get you thinking about that right from the start. I did mention the panel and I skipped over them this is a panel that I think is going to bring us a whole lot of information as always they come from a range of different groups and bring range of experience with them and going to hear from each of them in a moment so I'm very pleased to have them as part of this the way that we work in these webinars is that we will hear from them each we'll do a presentation and then we'll actually have some time for questions and answers and that's where we would like you to participate in whatever way you can we have a question and answer session rather than a panel tab this evening and we have lots of questions that have already been sent through so we're doing our best to answer those in the presentations and to build those into our question and answer planning so we're hoping we'll get to answer lots of those questions we'll also have the resources that will be available for you later on the Spectrum website and of course we've got the whole series where lots of questions that we don't get to tonight can be picked up and answered there as well. Alright so you've had the bios already and we've talked a little bit about the sort of process that we're going to be going through and really wanting to make sure that if you need technical support that you can use the tab but that's Mark's technical support we have Redback help desk phone number there as well so if you're really struggling with the technical side of that there's good support for you we have people moderating so if you do put some questions in the Q&A there might be some people who answer you there as well but I'll keep an eye on that as well that's our house keeping and our way that we're going to be working together you would have read the case study and in registering you're probably very familiar with the learning outcomes of what we're aiming to achieve in this webinar and because it is the first one we're really looking at what are we talking about when we're talking about borderline personality disorder underlying causes we're looking at the diagnosis of borderline personality disorder and what that might mean in terms of the discussion with patients, clients and families and then really looking at some of the I guess some of the past understandings and ways that people have been thinking about borderline personality disorder as well so I'm going to introduce each of the panellists to start with and then we're going to jump into Jo's presentation first off so I've got a question for each of them we're going to put them to work very quickly because we do have so many questions that we're wanting to answer so I'd like to introduce Associate Professor Josephine Beatson Jo is a psychiatrist and does some work with spectrum and welcome Jo and thank you for being here this evening and I've got a question for you straight away what age can we now diagnose borderline personality disorder? Well very young now we can diagnose it legitimately in adolescence even from some people say 12 most people would suggest 14 and all the features of the EPD are there it is diagnosable in adolescence OK and there's quite a change to in the past perhaps where people had to wait until they were well it was well that's true but also people didn't like to diagnose it in adolescence because of the worry that they were then labelled but the modern thinking is that it's actually better to diagnose it the features are there and get on to treatment straight away better outcomes when that happens OK great thank you looking forward to hearing some more for you in a moment next in line is Dr Christopher Worm and Chris is a general practitioner and has also done some other studies and has an interest in alcohol and other drugs dependency so Chris again putting you on the spot straight away welcome can you tell us a little bit about your interest in borderline personality disorder please yeah I particularly like the approach that Professor Victor Frankl developed there was an Austrian psychiatrist wrote books including one called man's search for meaning and as I got more and more interested in what it's like for people who are looking for meaning and purpose in their lives for borderline for BPD to have feelings of emptiness as one of the characteristic symptoms that seem to be a particularly good match and I suppose as I talk to people and I was curious and I might not have known exactly what to do but I think people appreciated that I showed some level of interest and yeah it seems to be a reasonably big part of the work I do which probably is not a particularly typical regular general practice work these days but thank you okay thank you and again looking forward to your your perspective is a GP it's always important that we have a GP because often DPs are the first protocol for people when they're looking at what's happening so we'll be interested to hear from you as well so thank you and now to Jan, Jan McMahon OAM is our advocate for our panel this evening so Jan again welcome and thank you for being here with us and another question throwing you in as well so your question to start with post diagnosis some people find it difficult to remain positive about their future what could be your message what would you say to people who might be concerned about it yes look very quickly people can and do recover there's a great deal of hope with the BPD diagnosis these days the different evidence based treatments that are now on office I think there's a great deal of hope fantastic thank you a really important starting point for us I think tonight as we're exploring this to I guess to be really thinking about hopeful messages and perhaps how things are being seen these days which might be important for people so thank you and looking forward to you as your presentation as well and last on our panel tonight but not least by any means is Julian Brown Julian you're a psychologist and you've been doing some work with Spectrum for a while now so thank you for joining us and the question for you is kind of psychologists diagnose borderline personality disorder oh yeah hi Lynn hi everyone you look absolutely part of a psychologist role to diagnose of course one has to be careful and thoughtful with regards to diagnosis and the meaning that that might hold for a particular client it's most important to be sensitive about that but also very clear a nice way of managing that is to really share the criteria with the client and ask the client is this these symptoms that you experience and so the client might at times identify with that and that might assist in the diagnosis so starting with the client first has made sense rather than the other way around fantastic so that's just given everybody a little bit of a taste I guess of the sorts of things we're going to be talking about and the different I guess the different perspectives but also really focusing as we always do with MHP and webinars on the connections and the collaboration that can happen between and I think the idea of working together as much as possible so that we we're really getting the benefits for clients and patients now just a reminder as well for people who are perhaps familiar with our MHP and usual way of working is that we usually have a chat that's quite active and some people love it and some people don't we've got lots and lots of numbers that are joining us this evening so we've actually changed that format so if you're looking for it wondering where it is or you're really missing it we don't actually have it tonight but we do have a question and answer so we can actually get any questions that you do have that you really wanted to come through to us that will come through to moderators and to myself so we will monitor that but we don't have the usual chat function so if you're looking for that it's not there for this evening let's move into our presentation our case study hopefully you have had a chance to talk about and we'll be giving opportunity for general information but also tapping into the case study so when people are joining us sometimes they're thinking about their own cases or themselves but we really like to have a case study that we can we can draw upon and really have this kind of made up example that we can really talk about in a really appropriate way so you'll see the presenters will be coming in about general information but then also touching on the case study and hopefully you have had a chance to read it it's about Rachel is a case study who has quite a detailed list of things that have happened over the course of her life that are suggestive of borderline personality disorder and that's what we'll be referring to so hopefully you can access that and you've had a chance to read it and see what you're doing alright I think it's time to hear from the panel so let's begin with you Jo and you're going to give us a bit of an overview of what borderline personality disorder is so thanks thank you good to be here what is borderline personality disorder it's a serious mental illness with the following core features relating, trolling, emotions and impulses unstable and intense interpersonal relationships an unstable self-image or sense of one's own identity and also going along with that an unstable sense of the identity of others importantly in addition an insecure attachment to significance suicidal and self-adjurious behaviors often occur in stress in particular but they tend to remit within a year or two of effective treatment and that's a terribly important recognition the prevalence of borderline personality disorder is 1-4% in the community it's up to 30% however of psychiatric inpatients and 15-23% about patients in psychiatric facilities so we see how highly represented it is in psychiatric services what causes this serious illness well very complex causation it's the outcome really of an admixture of several things one's inborn temperament difficult childhood experiences and insecure attachment some people with any authorities consider that insecure attachment can be used very effectively to explain all the phenomenology in other words all the symptoms all the behaviors that occur with people with BPD now the inborn temperament in this disorder is usually over sensitive anxious and has a preponderance of negative emotions however my question about preponderance of negative positive emotions is how much is that an outcome of difficult very early childhood experiences because difficult infant experiences can result from parents difficulties with soothing a very anxious sensitive baby very hard for parents very extremely much harder of course for the poor baby but this is a fact of what happens between parents and mothers in particular perhaps and babies and difficult experiences feelings of invalidation we don't like to call it that in infancy but babies sense things very early and they will know if mother is or father anyway the principal caregivers are actually not able to get them if you like to tune in to what they're feeling and their distress and to help soothe it abusive experiences of course could also contribute but they're likely to be much rarer in very early life now the insecure attachment in borderline personality manifest in adulthood in the severe anxiety about abandonment that is really all that is inevitable in people with the early childhood trauma or abuse is by no means always present of course is present child but by no means what's the word always there now when do you consider a diagnosis when do I consider a diagnosis of BPD well you look to the following when there are frequent presentations to emergency departments priming health services like GPs mental health services with self harming or suicidal behaviors you need to think of BPD that doesn't mean that BPD is necessary for a diagnosis like any other but if it's a frequent competitive presentation you must think of it presentations in crises with severe emotional distress sadness anger unmanageable anxiety in the context of a crisis is a very common mark crises in particular tend to occur in interpersonal relations relational context I'm getting my words mixed up or when abandoned and threatened felt to be rejecting or highly critical or invalidating that sort of thing is likely to occur to trigger sometimes the sense of crisis and major major distress frequent occurrence of dysregulated emotional states and or impulsive stress related behaviors again consider this diagnosis um now if you think the diagnosis is actually present you would only communicate when you're sure don't communicate the possibility because that's not helpful at all but when you're sure that this is probably what your patient has uh describe as Julian was saying earlier describe it in terms that the patient has already talked to you about particular symptoms look my moods up and down all the time and uh when I want to self-hyme I just can't stop myself it's the only way blah blah blah of relieving stress all that sort of thing you use what the patient has actually told you then you name borderline personality disorder and you say treatable illness it responds very well to treatment and there are now very effective treatments available be absolutely sure to say that the internet is a an unhelpful source of information it's often misleading it's often frankly inaccurate and it's often grossly exaggerated give the patient a written account of BPD or refer them to a reliable website the borderline personality disorder foundation has a very good website Soda Spectrum and Soda's Project Air in New South Wales worth asking your patient if they want to discuss the diagnosis with their doctor or their family or their carer and if they do is there any help they'd like from you in doing what to say and so on all worth doing now the next slide I'm having trouble with this being I'll just go down is the treatment psychotherapy either individual or group psychotherapy is the principal form of treatment for BPD absolutely across the board is the principal form of treatment however if a patient is in crisis they're not going to be able to engage in psychotherapy if a patient is in crisis then you need to ensure safety and containment before you do anything else how do you provide safety in a crisis well in my view safety in a crisis is best offered through developing with your patient a safety plan or a crisis plan whichever you want to call it and that involves trying to soothe themselves when they're distressed in a crisis situation what if they found helpful in the past and what do they tend to do to try and self-soothe write that down there's to be a written thing because people in a crisis need something to look at sometimes they need something on their fridge to go to you might but then important to also put down is unmanageable and they've done all the things they have agreed to do to try and manage the stress then who do they contact what do they do write the phone numbers in the names of the people where ever possible so that they have got something actually structured to do in a crisis that's the most important thing containment is a different kettle of fish but similar ends containment is helping the patient to deal with their own distress you've already written down and discussed with them what they usually do in a crisis situation or when they're distressed to manage the distress yep, you've written that down but you want to help them with other strategies when their own have not been adequate through their breathing techniques with them deep breath in and a very slow breath out distraction techniques taking the dog for a walk all things that they may not have come up with or even know about for themselves and you can suggest but always in a very collaborative cooperative way those are the best means of containment and once a person is able to manage her distress then different forms of psychotherapy I'm not going to go into all the different forms that are available can be introduced psychotherapy must be a collaborative endeavour with an active therapist you know, you're active you're in there, you're interested, you're curious you want to understand you want to understand what it's like for this be respectful, be flexible you're with them in their emotions at the same time you're able to step back in order to acknowledge and think about them you're able to acknowledge your own mistakes misunderstandings, we all make them sadly too often I sometimes think in my case and take responsibility for them validate their distress always validate it's so important because too often these people have not been validated or had their distress validated in childhood focus on their thoughts their feelings especially at the time of self harm or risk taking behaviours because you want them to become able to link feelings of emotional distress with the urge to self harm that linking of emotions and impulses is a profound importance to them becoming more able to resist impulses to action and focus on their own feelings consistent session times duration agreed goals clarity about the treatment approach and as I've said responses to crisis are all critical to treatment outcomes however, I want to stress this the quality of the therapeutic relationship the relationship, the connection the emotional connection between you and the patient is the most important aspect of all treatment not just psychotherapy for BPT I'll back to you, Liz Thanks Jo and what a fabulous overview I think for people and moving into what it is and treatment and I think what I really appreciated was your language was very respectful around really appreciating what's going on to people who are coming to see you so I think you would really got a lot already out of that session just been through so thank you very much to you Jo and we're going to move on to Chris now but we'll be back to you with some questions I'm sure people are just keeping an eye on the questions as well if people have got any particular questions as Jo feel free to use that Q&A function so that we can get those so let's move on to you now Chris and I know you've got some thoughts you're going to take us through in terms of perhaps the older ways and ways that people have perhaps talked about and understood borderline personality disorder in the past so you're going to take us a little back way back before we can come forward again Okay Well certainly there was a time that BPD was a diagnosis that people were sometimes even reluctant to accept that that was the diagnosis because they may well genuinely have heard people speaking without respect, without understanding there was a time that BPD was seen to be well all of the personality disorders were seen to be different from real illnesses there was this sort of the DSM had access one, access two, access three and there were some areas where people would say we won't take on this client because everything's access two that's not the way things are done now BPD is recognised as a genuine and specific psychiatric illness and a very treatable one so the outlook is much better now and there were some really old definitions that we have to completely confide of the history books that were quite pessimistic really the treatment for BPD is very good and even some people who embarrass us clinicians by improving with little or no treatment I want to really highlight the good things in the present and not bog down with things in the past now if we're going to talk about how to approach getting to no Rachel typically people often think or taking history you really need a lot of information but exactly as Joe said you really want a good therapeutic relationship and even in general practice where you're not necessarily all setting out to be therapists it's still good if you can bear in mind that what you really want is rapport a therapeutic alliance and you might want some information you might want some details but it's even more important to get that working together in a sense of understanding each other certainly one of the things is you've got to work out what is urgent there are some things that can wait and some things that can't wait and that whole notion of if it's a really serious crisis and if the person has already gone through their self soothing and their other strategies and it's getting worse and they don't feel safe you've got to know sometimes clinicians have to be the person that bears hope on behalf of the client but sometimes we even may need to work out and we handle a genuine emergency but before we get to that I think it's also really valuable to set aside enough time and in general practice historically that's been rather difficult but bit by bit the way GPs are set up the way GPs are funded it is possible to do extra training and get additional Medicare rebates for longer consults sometimes it may work out that if you've got something with BPD instead of waiting for them to have a crisis and then having to spend 30, 45 minutes with them it may be more practical to actually say let's plan that I will see you every fortnight or every three weeks and it'll be for 20 or 30 minutes or maybe even longer certainly we've got to make sure that we're aware of what to do if there is a serious emergency sometimes you even have to think is it time to say this person's safety really requires them to be in hospital I think that's very much a last resort and something that people appropriately try to avoid but if you need to do it you need to know how and your staff need to know what numbers to ring you need to know where are the forms and how I think we've lost your sound is that just me or is that no I can't hear either I can't hear it's dropped out still talking away we can't hear we'll get read back to have a look at that and see what's happening maybe the phone line dropped out still talking and none of us can hear him we've got some while we're waiting for that to be sorted out I can let people know that we've got about 1900 people joining us live sorry that's a a so realist number and we knew there was a lot of interest but that's the number that people were out there so it is important that everybody gets to hear what Chris has to say and I know he had a lot of important things that he was going to share with us I have had a question around clinicians attitudes and judgments around working with people with borderline personality disorder and I'm hoping that Chris's introduction there just talking about the changes answers that question but I guess also the fact that we've got 1900 people and many of them will be practitioners and a panel of people who are committed to doing this work and helping people to understand and do it better hopefully that's kind of covered off on that question but if you do have other questions I am keeping an eye on it so please please send a through to give us that question that you really wanting to talk to us about or make sure that we do cover so Jo while you're waiting there any reflections on things that Chris was talking about that you would like to pick up on I was thinking how important all the things he has said are I think it's his recommendation that rather than wait till a crisis with these patients it could be very helpful for a general practitioner to offer to see the patient every two or three weeks whatever on a regular basis because that could often give them some way to go they don't get to crisis point because hopefully they'll feel a sense of connection with their GP and be able to talk to them about whatever is on their mind I think that's a really excellent suggestion on Chris's part I don't know how many GP's are able to provide it or offer it but very helpful I think I guess one of the challenges is the time that GP's have to be able to provide that kind of support but I guess for you as a psychiatrist as well knowing that the GP is available you can be working kind of in collaboration together to support the patients is fantastic. Well it's great when there's a good GP because it makes so much difference through our work as a psychiatrist and psychologist it's an enormous benefit and sometimes I think another thing is the GP is in sometimes for the whole patient the patient's whole life you know they are the longest you know what I mean the long-term contact and terribly important support people of course but not just that an attachment figure in the band it's really important meaning of that term alright we've heard that Redback are trying to get back on to Chris but not able to so there's something going on with telephones wherever Chris is tonight so I think it's because time is really important to us let's move on to you now Jan and you can start yours and then we'll try and find Chris he's there somewhere I'm sure thank you look firstly I'm not a clinician so you need to take my comment as non-clinical that's a really important thing I'm also an advocate bringing a consumer perspective to the webinar this evening so look what I'd like to do is to say well let's try to touch base with Rachel's feelings Joe mentioned abandonment but I think the textbook say real or imagined but it's that awful ever present internal pain you know the thing that just sticks here in your throat Rachel was expelled from school she had a violent episode at home and then her parents refused to let her return and she lost a significant friend then think about your own experience when you've lost someone who was perhaps very near or very dear to you and try and connect with that feeling and and try and think about Rachel and others that have BPD in terms of the distress in the pain that these feelings bring to Rachel they're probably compare them to yours and it's probably about ten times more serious than perhaps you may think yours is so you know it's sort of expand almost like she's overwhelmed by emotion she says many times that she just wants to die or is it that she just wants that distress to stop she finds that as do many people with BPD very hard to live with that pain as a teenager she was unmanageable at home now she moves home frequently with frequent ed presentation she's on and off with friends too in other words she tends to drown them her life is in chaos she's highly anxious and she needs to be contained which is the word that Jo used very effectively so she needs to be contained both within herself and with the help of clinicians it's that containment as Jo talked about that helps with that overwhelming sense Rachel doesn't feel as though she deserves help she's very difficult to engage and she certainly doesn't feel very highly of herself she certainly doesn't have that stable or good self image that many people with BPD talk about so in her early years she disengages with case management she has very sporadic attendance to counseling she's poorly engaged with the case manager and she stays in a violent partnership for three years she's now looking to move on and with the regard to her sexual assault she refused to discuss this with the professionals it's people with BPD often feel just bad about themselves they are a bad person and they just don't deserve to receive any help or any support and that is as we talked about earlier she's been utterly overwhelming for them Rachel's coping mechanisms are cutting she often takes overdoses and she continues with risky behaviour now this is all part and parcel of her coping mechanisms I don't believe for one second it's about seeking attention people don't cut or take overdoses on a continual basis and they don't continue with risky behaviour but certainly in terms of cutting many people that I know with BPD who are my friends and my colleagues they will wear the long sleeves they will wear the jeans so I don't believe for one second it's about seeking attention this is the very thing that people hide people with BPD hide now if we look at stigma I think this is an area that I would like to speak about I think it's changing and I think the fact that you've joined in this webinar tonight and there's 1900 or something people on this webinar I just think that that's wonderful and I do think that the culture is changing that I do think that clinicians are seeing people with BPD are far more respectful in their association with them but if we look at stigma people with BPD have enormous self shine as I said they just feel bad they feel bad about themselves bad about everything they do people with BPD are hardest on themselves they are their hardest critics Rachel certainly feels she deserves she deserves in some way to be treated badly so when she actually is treated badly so when she has those verbal put-downs and those discriminatory practices shown by some clinicians she absolutely believes that you know she says well I'm not worthy of this however there is absolutely no reason in the world for verbal put-downs by health or mental health clinicians or anybody else people in the community family friends there is absolutely totally no requirement and I think that if you are in a culture where there is blame and shame and everything else then you need to step in and say this is all about those overwhelming feelings so finally to the diagnosis itself we heard Joe talk very clearly about how a diagnosis should be given and it should be given sensitively the diagnosis itself can certainly be distressing and it can evoke anger and if it's not done sensitively it can certainly break down that therapeutic relationship which is so vital for the clinician in the treatment of people with VPD so as Joe said identify the symptoms that Rachel or others are feeling and then ask them do you think this makes this and this and this and the answer would probably be yes or then that relates to the diagnosis of borderline personality disorder what do you think about that so getting a diagnosis can be absolutely one of two things it can be the worst thing ever because people are aware of the consequences of what this diagnosis may mean for many in the adult mental health services in Australia as I said things are changing thankfully but we still have a long way to go it could also be the absolute best thing for someone who is struggling it can provide a reason for why people are feeling the way they do and it can provide a reason why people are acting like they do and it can be an enormous relief to know that you they have a mental illness and then that explains why the things we talked about the feelings of abandonment and the overwhelming feelings so there is a great deal of hope there is a huge amount of hope there is hope for Rachel she is now receiving the appropriate treatment and support she has a consistent GP and before we lost Chris he was talking about his relationship with his patients with BPD very often the GPs are the first port of call in the mental health system aren't they they have a source of referral Rachel has a good psychotherapist we heard Joe say that psychotherapy really is the best form of treatment for people with BPD and Rachel has completed the DBT course many people who go through the DBT course talk about how useful and helpful it's been but some people find a group type setting difficult so there needs to be some rules and boundaries around that and some people may need to go to the DBT course a couple of times if that's possible but there is a great deal of hope for people with BPD and I think that therapeutic relationship with you as a clinician whether you're a psychiatrist, a GP a psychologist a mental health nurse and other allied health if you're a service provider there's a huge amount of help now for the diagnosis so thank you Lynn and that's all from me fantastic thanks Jan and again continuing that theme of hope which I think is really important I can see from some of the questions coming through that people often haven't felt that sense of hope or getting that feeling so I think it's really important for people to hear those messages so we'll appreciate that we've got Chris back online now so let's go back and find Chris I'm going to whip back to your slides Julian's waiting very very patiently and we will get to you Julian I promise now Chris it's a bit hard to know exactly when you dropped out but I think it was when you were talking about that Rachel and this experience with trauma so I think you slide and the next couple we should just do a recap you were talking beautifully but we couldn't hear you thank you what would we do with that technology now so this slide is really getting us to think about how to talk about trauma when to talk about trauma I think even Joe would say whether to talk about trauma and certainly it's not what you do in the middle of a crisis and certainly the GP role the GP doesn't necessarily in most places the GP doesn't necessarily have to do everything and certainly looking for the underlying trauma is it's not always important it's not always helpful and certainly these next few points are from a website put together with people from the Royal Australian and New Zealand College of Psychiatrists and they say talking about trauma should only happen when you are feeling strong and obviously talking to Rachel when you are feeling strong when you have already started psychological treatment and your problems and symptoms have improved and when you trust your treatment provider and I think that's already being covered but the whole idea of trying to get to the bottom of the underlying trauma when somebody is in the emergency department or already in an acute inpatient setting that's probably not the most practical, most logical time to go exploring issues about trauma and not everyone with BPD has a history of trauma and even those who do it may not always be the most appropriate or essential starting point now I have a particular interest in the alcohol and other drug area but I also have a particular interest in how do you get people to talk about what they do and I think it's really important that we normalise it that we don't sort of ask in a really sort of judgmental pejorative way but we say how many days a week do you have alcohol and ask some questions about not just alcohol and other substances but gambling can also be a way people try to let off stress obviously can leave people with more stress as well and another sort of gentle realistic way of approaching that subject is to say do you ever have a bet on the horses, you play token machines or buy lottery tickets and sometimes you want to know whether people use over-the-counter medications and I guess especially people who might also have concerns about body image and their weight they might be wanting to use diuretics or things like the the old tablets used for getting rid of constipation, forward pills and so forth and the people that have lots of headaches they'll often end up using codeine and sometimes they'll end up with even more headaches as the codeine wears off so lots of things to think about and in the alcohol and other drug area sometimes and seeing as Rachel found she was actually already involved in this part of life at the age of 14 sometimes people aren't about to change and then if someone's going to keep using alcohol it's good to keep them well nourished, it's good to see if we can help them at least get places without being at the wheel of the car can we also offer people Simon to protect them against vitamin deficiency, people who are involved with injecting drug use obviously if they want to stop then we offer whatever help to help them with a substance free life but sometimes people aren't ready to give up their use and then if we can at least talk about clean needle programs perhaps immunization against hepatitis B if they've already got hepatitis C you can treat that quite well now some people do very well with suboxone or methadone to help overcome the urge to use opiates and when people are on any other kind of prescription medication if the person's got a temptation to take a lot of things all at once another safeguard might be that you don't send them off with a prescription for a month's worth of medication that someone might take all at once some people it's good to have some reduced intervals and perhaps only collect a supply of a week's worth or even go to the pharmacy every day naloxone is something that if somebody's had too much opioid whether it's codeine morphine or heroin that gets people back to consciousness and breathing and you still need all the other first aid and things but that's a helpful thing that I think increasingly we'll hear more about in Australia and another part of sort of general health when BPD coexist with eating disorders it's worth just double checking because BPD is a woman still having her period has her diet become so abnormal that we've got to watch out for potassium changes got to look at kidney function lots of things to keep track of but hopefully always bearing in mind respect, support and helping the person get back to their own strength my last slide is one where in fact I was going to talk specifically about therapy from some material that people studied, people attending a UK mental health service in the public sector and ultimately what they found was that people attending that service what they really wanted was help with housing with their money, with their social networks and their physical health they also wanted to come to terms with having a mental illness traditionally professional people are more inclined to focus on treating the mental illness which obviously is a very good thing too but if somebody's homeless and they've got psychological symptoms it may be more practical and more helpful to deal with the homelessness and once you've shown them that you care about what they think is the most urgent and important thing they're going to do an awful lot for rapport and therapeutic alliance I'll stop there and look for the question and answer and I hope my technology holds out thank you Thanks Chris, much better when we can actually hear what you're saying, that was really helpful and I think just looking at the questions coming through and there's quite a lot of them as you would expect we've got so many people online I think some of the things we're touching on terms of home morbidity and the complexity and including this last slide some of that will answer some of those questions but I think it's very good we've got several other webinars coming up because we can pass these questions on the news because it's obviously an area of great interest and complexity for people so hopefully we're answering the questions as we go but we do know that there are many more now we need to move on to you Julie and you've been waiting incredibly patiently it's always a risk of being the last person but we wish you now and looking forward to what you've got to add to the mix tonight I think. Thanks for that Leanne, I'll just skip forward there last slide OK, hi everyone so it's important that we think of this idea of BPD as developmental in origin but also it's important to bear in mind that it is we can think of it as a relational disorder and there's a reason for that of course some of the other speakers have spoken about this notion of a lack of caregiving or attunement through no fault of the parents or the family this notion of lack of attunement or validation but we also have histories there obviously high rates of frank developmental trauma and we think about this notion of a personality structure which is inherently developing as unstable and many people with BPD will talk about the sense of their mind as being very much locked in emotion and memory and this notion of repetition in their thoughts and the feeling of the experience of the thoughts racing not going away and attempting to control these overwhelming internal states but we want we want people to really start to think of the symptoms of BPD as actually adaptive adaptive to an environment perhaps developmentally often through no fault of the family at all where the child's basic needs aren't being met around being seen being validated and sort of having a caregiver who is attuned so we think of the BPD symptoms in a sense as coming into play for an individual to actually cope in a world where there's a sense of either dangerousness or needs aren't being met so with this sense of an unstable structure we think of the idea of an individual like Rachel beginning to look to the environment for stability an internal sense of instability looking to the environment for stability and also hyper vigilant to the environment especially in primary relationships for the signs of danger and the signs of danger might mean for example signs of abandonment signs that you might be leaving etc etc and of course we are in relationship with the client aren't we so the BPD client might come into relationship with us also with heightened states and really looking for the signs of danger looking for the signs of abandonment so because we think of this idea of BPD or the word of border as perhaps describing the boundary between the self and the other the system then around the client the health system the family and so on is also affected by the disorder and so we need to take into account the system around the client and therefore any work with Rachel must be absolutely holistic systemic but also individual to her we don't come in with a sort of a template for BPD treatment it is individual to her so we think of the system the family and the health sector perhaps at times especially in cases of moderate to be severe BPD requiring treatment and that is containment and stabilisation prior to Rachel's treatment many people would have seen payoffs around clients with BPD and where that is the case treatment really I think as Joe said earlier treatment really has limited facility for success so we need to look at containment and stabilisation before we think about systemically stabilisation so Rachel's part of the picture Rachel's family etc good effective communication and the ability to take all perspectives in the system into account because people with BPD can often present different parts of the system in different ways and you think of that as context found behaviour really once again it's about getting a need met how do we get needs met and we get needs met in different ways in different environments so we need to include all perspectives in the system especially in cases of moderate to severe BPD we really need to think about treatment plan a thoughtful treatment plan which is inclusive and collaborative with Rachel and her family and to take what we think of as a clinically indicated risk tolerant approach in terms of the direct treatment for Rachel and you can see you longitudinally of course we know the picture but of course we can imagine that we could enter into treatment with Rachel and a relationship with Rachel at any point along that picture so we must commend in a sense because we think about this as a developmental disorder we think about immediately a developmental assessment we use wherever possible multiple sources for that assessment we then develop a thoughtful formulation with ongoing review and that underpins both the systemic and the individual work now that in a sense guards against short term reactive type treatment which can often lead to burnout and also lead to unhelpful unhelpful approaches with Rachel and the possibility of stigma now a focus only on symptom remission remember the symptoms are secondary so if you think only on symptom remission we can actually end up having a kind of in a pattern of treatment that is unhelpful and becomes quite reactive and ineffective so what we're doing in a sense is we're treating the BCD rather than really just focusing on the symptoms we need to be non-reactive we need to think long term and proactively and that helps all treatment providers remain thoughtful and of course we must keep in mind that this in a sense our frontal lobe our reflective function is really all we have for the client so we need to maximise that our ability to remain calm and reflective so the principles that might underscore the treatment for Rachel we need obviously an ongoing process of understanding now we would argue perhaps even this process of understanding that is understanding Rachel's lived experience is the treatment that is an unfolding process without necessarily an answer at the end of the day but an unfolding process of attempting to understand and helping Rachel to also understand her lived experience and of course maintaining a collaborative relationship as it's very foundation and a focus on the relationship as we've heard from all the speakers tonight autonomy for change we can take up responsibility for change for clients with BCD but we need gentle and continual returning to Rachel her autonomy for change what is it that she wants how can she get there and so on because we think about this notion of attachment trauma et cetera and that often the body is used in particular ways to in terms of the symptoms and so on there's a focus on putting words to internal experiences and use of language rather than acts on body and otherwise at the same time what we see is the client develop the language for their own experience we see a softening and decreasing of the severity of the symptoms now with Rachel we know that she's had an eating disorder in the past and she's experienced trauma some frank trauma so we need to check carefully for the symptoms of PTSD but also the the possibility of deafness in this client group which and the rates of that are quite high Rachel has a family her family are very important to her and having worked a lot with families I'm aware that parents can experience considerable blame and stigma in the health systems around BPD and of course providing that there is no kind of frank perversity in the family the parents can offer us a great deal of expertise and developmental picture that we wouldn't perhaps otherwise know they're going to be around long after where we've left the scene so it's important that we include them and we collaborate with the family of course with Rachel's commission working with Rachel's family and parents separately is going to be very important to support them and to support them to understand the principles that the treatment that underpins the treatment so that they can then collaborate and be part of the team as well the parents are likely to have a great deal of guilt anxiety and anger and frustration and along with profound feelings of grief that can be associated with the loss of the daughter that they hope for the life that they wished for for their daughter but also the loss of the life that they might experience as well parents can be highly traumatised and quite highly vigilant to risk as well the parents input can greatly assist our work as they begin to collaborate many times with families that can work wonderfully Lastly it's important to be able to look after yourself because really you need to attend to your work and you need to be the best possible clinician you can be for your client and we're exposed to a great deal of raw emotions and raw materials often related to trauma and it can take its toll we have, all we have for our clients as I said earlier is our ability to reflect and when we're stretched when we're anxious, when we're reactive when we're burning out this function can absolutely be compromised so it's important that we process that raw material outside of the session and then we can come in with the client in session in a thoughtful way and be as therapeutic as we possibly can we always get caught in enactments with this client group we can't avoid it in a sense so it's important that we also have space and time to process that we must be aware of our own limits that is our own personal limits and attend to that and the limits of our role and remain within our role to prevent overreach and burn out of course lastly work structures that support a thoughtful engagement with this client group are absolutely critical and we would argue that advocacy for this in the workplace where you see some unhelpful structures that actually work against the best possible treatment for people with BPD is also advocating for the client group so we would support people to absolutely advocate for better structures in the workplace to support their best practice with BPD so thanks for your time Fantastic, thank you for your time Julian a lot of information there and it felt like at any one of those points we could continue the conversation but I do think a lot of the questions I've been looking at were about family particularly around supervision and support and the links I guess when people and young practitioners coming through and negative attitudes sometimes and people having to provide support so hopefully people are seeing their answers in your slides and the other slides so thank you very much and it does highlight there's much more we could be talking about we are running out of time though and normally we would be moving on to the Q&A and I did say we'd get there but because our presentations have been so expensive we took a little bit of time finally Chris when he disappeared on us I think we need to move pretty quickly into our more kind of reflective past and comments really or take home messages I did say so I'll get the panellists just to think about what your take home message is because that's what we're going to be doing now but just so that people are aware I did talk earlier about the resources and further information I think that is important because it's a while before the next webinars come next year but no they will come and these questions will all be forwarded on and really help with the planning of those webinars but there's a range of resources available on this link these slides are available for you so there's a folder that you should be able to access now that do have the slides so you should be able to access those but I do want to hear from each of the panellists just with your kind of take away message and you might have planned it beforehand or there might have been something that's come to you that you really thought you'd get to answer so maybe it's one of those answers without the question who'd like to go first we'll go back to you Joe I was just thinking what an earth will I say I think I guess what I want to say is that when I first graduated as a psychiatrist in 1983 I was told oh no we don't treat people with BPD it's untreatable and what I want to say is that in the lab or however many years there is since 1983 things have changed totally and dramatically it is an eminently treatable illness there is no question that it must be treated these people need treatment and they respond extremely well to effective treatment for BPD always keep on looking for that connection with someone a clinician, a GP a psychiatrist or a psychologist that you feel safe in and make the commitment to work with that person through all the ups and downs but really are quite inevitable because you'll get better you'll get better if you do that so that's really what I want to say okay great thank you and thank you for your time tonight let's move on to you Chris have you got to take home message for us yeah I think in addition to Joe's whole message of hope I think there is also hope in that there are more and more places there was a time perhaps a person that I've worked with for a number of years who was in a fairly bad way in the beginning he's given me permission to talk about him and he came to me when he was referred by the court diversion program and he was harming himself but really getting into trouble with other people in the community and partly after a local community mental health team said oh no you're not suitable he wound up admitted to hospital and he had a bit of attention during that inpatient stay it was possible to help get through the alcohol withdrawal to get on some treatment for some substance use and later on he did get into a DBT group and he's flourished and he's just one of many people I've seen do remarkably well so keep on keeping on okay another good message and I guess for people who are listening tonight to be able to go away with some of these ideas and so if they're hearing attitudes that are not current and consistent with what we're talking about to be able to challenge them and refer them on to this webinar and to the rest of the series would be a great way of continuing to challenge I guess some of those outdated ideas that we still take a long time to change Dan let's hear from you have you got to take home message for us yes Lynn I've got a couple anger is that shown to you it's not personal just remember that and just be aware of that internal pain that people are suffering and are feeling very very much and just remember that people do recover and as clinicians you have a real part play in this and what a rewarding journey for you people with BPD really are worth investing your time and your energy and BPD is now seen as a legitimate mental illness and it's certainly a legitimate use of mental health dollars thanks Lynn thanks Dan and it's been great to have your voice because I know when we do webinars and other activities we don't always have the voice of the evidence so I think that's really given us another perspective and really appreciated that thank you and back to you Julian last again you get the final say that's a good thing sure I think it's important for people to keep in mind that the treatment for BPD is actually some way counter-intuitive the treatment as usual the kind of normal medicalised or recovery models really don't work so well and so what we tend to do is because we're presented with someone with a great deal of suffering and very compelling symptoms we tend to jump in very very quickly and get very active and attempt to get rid of the symptoms and we want you to really think about coming back to this notion of attempting to understand the person's experience remaining calm and collaborative so and when that occurs when we begin to actually work in a different way with BPD in a way that can be enjoyable be interesting and your client will start to get better and I think that's a very important message that people with BPD get better when they're actually engaged in the right treatment in an evidence-based treatment very very important and if you feel like you've got clients with BPD and you're really struggling in the work it's important to go and get supervision and training so that you've got a treatment that you can actually offer people with BPD yeah great thank you and again why we need some more webinars to explore that further so that people are really I guess using that as their training and support and looking at just in more detail so hopefully tonight has given you a really good overview of what it is that we're talking about and some challenges to way we might think about it and I think there's a lot of information that people will certainly take for tonight. We do want people's feedback and so there should be a survey that's coming up on your screen now and we would like you to fill that out it's always important for us and also with Government funding we have accountability and we need to report back but we all always want to feedback and want to hear what you think and what's been helpful and what else we could do to improve particularly when we do have these other webinars coming up while you're doing that so it's important to look at HPN and there's the website there that you can join a local practitioner network and there are forums that are being established for practitioners who have a shared interest in BPD so again another avenue to get some of the support from other colleagues who are interested in BPD and are really wanting to learn together and continue the learning so there's an opportunity there to contact MHPN to find out more and put your name there so thank you to everyone for your participation and we're really pleased that we've had such fabulous numbers it's a lot of people who are joining us we've had a panel that you can see have given us an enormous amount of information and shared a lot of their expertise and experience we've really enjoyed that you will get a certificate for the webinar as a sort of attendance within the next four weeks you'll also receive a link to the online resources that come with this webinar within the next two weeks and please look out for the next webinar in the series which will be held in early 2018 so we're really hoping that you can join us then and continue this series and have some of those many questions answered in follow up webinars so thank you very much everybody thanks to the panelist again for your contribution and everybody else at home who's been participating and sending the questions and they will be answered in other webinars so good evening everyone see you next week