 HPN's interdisciplinary panel discussion on Borderline Personality Disorder. We have over two-and-thirty people logging into this webinar tonight. We have a very talented panel. I'll just introduce them all to you. We have Dr. Christine McCollough, who's a GP from Brisbane. She is a GP advisor to Primary Mental Health Care with the Australian Division of General Practice. And Chris has a strong interest in Primary Mental Health Care. The next person whom you'll see just down from Chris, who's just drinking out of his glass at the moment, is Dr. Chris Lee. He's a clinical psychologist from Perth. He's now a program chair in clinical psychology at Murdoch University. He's had extensive training from leading figures in DBT and has been accredited in schema-focused therapy by the International Society of Schema Therapists. The next person you'll see there is Jan McMahon. Jan is a consumer advocate. She's worked within the mental health area as a consumer advocate since 1997. She founded the Private Mental Health Consumer Care Network in 2002, which is a recognized national organization. She's appeared before six parliamentary inquiries and has been a member of a number of Australian government committees and expert reference groups, including that for borderline personality disorder. She's been awarded the Medal of the Order of Australia in recognition of her advocacy work. And next we've got, last but not least, is Dr. Andrew Shannon. He is a psychiatrist from Melbourne. He's a senior lecturer at Origen Youth Health Research Center and is attached to the University of Melbourne. He holds clinical appointments as a associate medical director at Origen Youth Health Group to help clinical program and is a consultant psychiatrist at the adolescent forensic health service in Melbourne. He is president of the International Society for the Study of Personality Disorders and was chair of the Organizing Committee for the 12th International ISSPD Congress. I'd just like you to welcome everybody. I will just go briefly through the structure of tonight's session. After the introduction we will be hearing initially from Dr. Christine, excuse me. After the introduction we will be hearing from Jan McMahon, who will give us her introduction from the viewpoint of a consumer. We will then move on to Dr. Andrew Shannon's input as a psychiatrist. We will then hear from Dr. Chris Lee, a psychologist with an interest in borderline personality disorder. And then to wrap it up we will have Dr. Christine McCall of the GP from Brisbane. We'll then go into a session where your questions will be put through me to the panel. And then we'll have it summing up at the end and we should be finished by 7.30. So I think we will ask you, I will just go through the introduction here, the introduction from MHPN. We have a number of learning objectives that we're hoping to achieve tonight. The first learning objective is to recognize the ways in which clinicians and or treatment teams may be challenged when providing mental health treatment and character borderline personality disorder presentations. The second learning objective is to acquire strategies to build individual and team resilience. Should you wish to find out more about your individual CPT, CPD recognition please visit the MPHN site. So we have a facilitated interdisciplinary panel discussion and then we have a Q&A from you good people who have joined us. We have now over 225 people logged in so I think that things have probably slowed down a little bit from when we first trialled this before the session. So I'll moderate the panel discussion and field questions from the audience. Submit your questions via the box in the bottom right hand corner. Ensure your sound is on and the volume is turned up on your computer. If you're continuing to have problems please phone the 1-800 number at the bottom of this page 1-800-733-416. Christine can you still hear me? I can hear you Michael but I've just dropped out sorry. Don't worry look at that. I'm a GP and this happened to the GP on the last session so maybe it's a plot. Okay we're ready to go into our panel presentations and are you comfortable there Christine with that video? I'll try and get it back on for you but I'm not sure whether we will be able to. Okay. Okay Jan. Thanks Michael. This is a very new frontier for me being able to be involved in something such as this so thank you very much. Look I've been advocating for folks with a BPD diagnosis so probably particularly so the last three years or so and in that course I've talked to many many people including their carers so what I'd like to focus on tonight if I could is just to look at sort of what makes people with BPD tick and I think one of the things that I really want to get across is that having BPD is not deliberate. People don't choose to have this disorder and part of the issues that people describe is having this ache, this internal pain that is constant so it doesn't matter what they do to ease that pain it becomes almost impossible or they can be contrary and feel absolutely nothing so people can go through their life not reacting to the death of loved ones or things such as that. I think another issue for folks that I've talked to is the inability to trust. I think for a lot of folks the boundaries have been bulldozed through so trust is a really major issue. Trust also is a really major issue in terms of the anger is so extreme that it and lasts for so long that physical symptoms come out of that you know the heart races the feeling of ill really feeling ill etc so anger is certainly part of the whole spectrum of BPD. Hightened overwhelming emotions you would be aware of all of these things so none of this is coming as any surprise to anyone I feel sure but in terms of a natural and a normal reaction to various things that happen in people's lives people with BPD it's heightened it's double it's quadruple the effects that we might have as a you know or that people might have as a normal response to things and their life is in complete turmoil the more severe the condition it relates to relationships to work where work really employment becomes almost impossible. Children living in this is sort of a chaotic environment are really at risk I think and if we talk to some of the experts we can quite clearly see that there's concern about the next generation. So Michael could you just go to the next slide please. No worries. I'll let you move the slides from now on if you like. Okay well I'll try. Good on you. So what do you folk as clinicians say and how are behaviours particularly challenging to you as clinicians do you see people that you don't particularly like or people that you feel great compassion for or people who are a real challenge to you. I think if we look at and I go back to this internal pain the actions around self-harm whether that's cutting or burning or other types of self-harm are in order to ease that awful constant internal pain or actually on the complete reverse to actually feel something there's something about needing to divert the feeling to actually a physical response to self-harm. Threat and suicide people feel as though life is just too overwhelming and too chaotic and often think and feel about suicide though not really wanting to die. This happens to many although we do know that the risk of suicide is very high for people with BPD. Those clinicians I'm sure that many misdepointments are the bane of your life in terms of when people are actually feeling okay and in control they feel that they don't actually need clinician support. Then something happens the old emotions flow and then they're in crisis that term at internal turmoil and they really require instant access. Bashing out is another really reasonable, well it's a response I'm sure that you all feel and have come against for many many times the anger issue and for our GPs who may be on this webinar there are many other health issues that people present to you. There we go. So why do people act this way? I guess the message that I'd like to get across is that people do whatever they need to just in order to ease that pain and I keep coming back to that because I'm not sure that people and clinicians necessarily have a sense that it is a pain, it's an ache, it's there and there's not an awful lot that people can do about it. And again actually feel something. So really we're looking at they'll do whatever they need to do to lessen these emotions that flood them, that overwhelm them in order to regain a sense of order and order in their life, in order in the moment, order in what they're trying to do at that particular time in order to feel back in control. I think that's probably what people do in the main. So in terms of my next slide. So how will you as clinicians respond to people with BPD? I guess the question and the plea that I would have to you as clinicians is please avoid perpetuating the fundamental feelings that people with BPD have. They feel fundamentally evil, fundamentally bad. The feeling of abandonment whether it's real or imagined is there. They have been invisible ignored and alone in many, many situations. So how will you respond? I would hope that you would respond with empathy and with understanding. I think something that is really important is that as clinicians you have firm but compassionate boundaries. And I think that recovery for people with BPD really does depend on choices and that can be choices of treatment modalities, choices of individual clinicians, choices of how, what and where that treatment might be delivered. So from... I'm just getting the next slide. So that there are three messages that if nothing else, if I can't get anything else across to you it would be that I would really ask that you have an understanding or at least the recognition that people don't choose to have BPD. And the second point is that people do whatever they need to do in order to survive. That's very real and that's a very real fact. And I think also people do recover. They do recover, I know many, many people out there with a BPD diagnosis. And whilst that pain is still there, they still go on to lead meaningful lives in the community. They have relationships, they work, they keep, they're okay. So I think it's really important to remember that when we talk about the BPD diagnosis that people can and do recover. So they would be the key messages that I'd particularly be pleased to get across. Thank you very much, Joan. That was a very eloquent presentation and I think it really sets the scene now. And I'll just go over our learning objectives again for tonight. We would like to come away from this tonight, recognising the ways in which clinicians and our treatment teams may be challenged when providing mental health treatment and care to borderline personality disorder presentations. And secondly, we would hope to acquire strategies to build individual and team resilience. I think that really sets the scene. Can everybody still hear me? We seem to have had a little bit of a glitch there. Yes? Yeah. Good. Okay, Andrew, you're on next. I'll leave you to go on to the next slide. You should be able to move it yourself. There's about a five-second lag. Okay. All right, thank you. Good evening, everybody. And it's a real pleasure to be here to be able to participate in this webinar tonight. What I'd like to do is go over some basics, assume that everybody knows what we're talking about, but go over some basics, and really give people the message that although challenging, there are basic things that every clinician can do that can actually improve the lives of people with borderline personality disorder. You don't have to be practising one of the major therapies in order to do good clinical work with people with borderline personality disorder. Just to remind people that there are nine diagnostic criteria, I'm not going to dwell on that. What I am going to dwell on for a minute is that clinically, it's very helpful to think of those nine criteria in four main domains, the affective domain, the cognitive domain, the behavioural, and the interpersonal. And although there is a lot of emphasis in borderline personality disorder these days on the affective domain, there is actually good evidence that all these domains are important in the understanding and treatment of borderline personality disorder, and that in fact there is also supporting evidence to suggest that it might be seen from any one of those perspectives as a disorder of interpersonal functioning, a disorder of poor impulse control, a cognitive disorder, or an affective disorder. It's also a common disorder. There are approximately 320,000 youth and adult Australians who have borderline personality disorder. The prevalence is highest in young people and then drops off with every decade. Overall, the prevalence is around about 1.5% in adults, but it's very common in psychiatric settings such that you see borderline personality disorder in around about 20% of outpatients. It varies according to the study, but some are as low as 10%, some are much higher, but on average around about 20% of psychiatric outpatients. These patients are already out there, they're already coming to see everyday working clinicians, and that's why seminars such as this evening are important in order to understand the disorder and to try and mount some kind of clinical response that is affective across the health system. We're not going to be able to ever deliver evidence-based psychotherapies to every person with borderline personality disorder. But on the same token, we also don't need to deliver the most intensive and expensive forms of treatment to every person with diabetes or heart disease either. Interventions need to be delivered according to the severity and phase of an individual disorder. IPPD is really a major public health problem and know that the functional impairments that are associated with borderline personality disorder are both severe but also more stable than the diagnosis itself. The diagnosis, the DSM diagnosis, is actually quite unstable, but that doesn't mean that people recover functionally from the disorder. The disability that is associated with borderline personality disorder is often for decades and there are now a number of high-quality longitudinal studies that have shown this. Borderline personality disorder lives persistently stable times even if they no longer meet the diagnostic criteria for the disorder. We also know that people with borderline personality disorder are not indestructible, as one of the clinical myths suggests. The suicide rate for borderline personality disorder is around about 8% to 10%, which is about the same as that for schizophrenia. We know that the disorder itself has a negative effect on the course of depressive disorders, that people with borderline personality disorder use treatments, not just mental health treatments, but physical health treatments, general practitioner visits, at very high rates and that this is a highly costly disorder to society at large. One of the areas that I have particular interest in and that we've published on extensively is that the diagnosis can be made in teenagers or from teenagers. It's been acknowledged for decades now that the disorder emerges during adolescence and young adulthood, but there's been tremendous reluctance to make the diagnosis. This is a demographically crowded period of life and there's a huge potential for ensuing developmental disruption if the diagnosis is not made and the disorder not treated. There has always been the capacity within the DSM to make the diagnosis, but there is a kind of myth about that it's prevented or precluded by the DSM. In fact, it is acknowledged that the diagnosis can be made, but there's been a wealth of evidence over the last 10 years to suggest that the disorder is no less reliable or valid in adolescence than it is in adults. And we also know that early intervention is possible and we've demonstrated a kind of proof of concept that this can be done. So I would encourage clinicians who are attending tonight if they want to follow up on this to make the diagnosis and to offer treatment when the disorder first presents itself. We also know that assessment is often done in a manner that is fairly rapid and the pressures of clinical work are very great, but it is important to remember that not every patient who gets under your skin has borderline personality disorder. So it is important to conduct a thorough and rigorous assessment. And really the primary task of assessment for borderline personality disorder is distinguishing stuff from trade. That is distinguishing the kinds of behaviours, particularly that you see in borderline personality disorder, that they occur in a person's usual manner of relating to others and relating to themselves. Not that it is confined to periods of depression, bipolar disorder, or psychosis for that matter. People who have or engage in the kind of interpersonal relationships that characterize personality disorder in an intermittent way that is confined to periods of mental state disorder don't have the disorder. It does need to be present in between episodes of mental state disorder. It clearly doesn't go away during episodes of mental state disorder, but it does get exacerbated by depression, anxiety disorders, and other mental state disorders. And I think the key message and I think everybody on the panel will be backing this up tonight, but the key message is that treatment is effective and that there are several specific forms of psychotherapy that appear to be beneficial for at least some of the problems associated with borderline personality disorder. All those in the field acknowledge that the treatments need to improve and need to be better. And one of the important pieces of evidence from literature is that meta-analyses and guidelines have recommended that there is no one specific form of psychotherapy that is more effective than another. It's likely that most of the evidence-based individual psychotherapies or treatment packages are effective and that there is no evidence to suggest favoring one over the other. There are certainly situations in which one might be more helpful than the other, but the NICE guideline in the UK, which is down the current international guideline for the treatment of borderline personality disorder, didn't recommend any specific treatment, and I think rightly so, because the evidence is limited and can't suggest that. Another important synthesis of the evidence is that there is very poor evidence for the effectiveness of pharmacotherapy as a primary treatment for borderline personality disorder, and most authorities would recommend that it should largely be avoided, and that particularly because of the risks of polypharmacy, that the use of medication as a primary treatment should be very limited. However, on the other hand, there is a strong case for using evidence-based treatments for co-occurring syndromes. Some patients with borderline personality disorder encounter a kind of clinical attitude that all the problems that they have must be due to the borderline syndrome, and so they don't in fact get evidence-based treatment for co-occurring mood or anxiety disorders or for that matter, bipolar disorder or psychotic disorders. So it is important that the message is clear that this is about pharmacotherapy for BPD as a primary treatment. Co-occurring syndromes should be treated at face value. So what are the general principles that people might take away this evening? You're going to hear later more about specific forms of psychotherapy, but what can working clinicians or teams in general mental health services do to provide effective treatment? And these are some of the principles that are effective across the range of evidence-based treatments and the principles that guidelines for the treatment of borderline personality disorder would endorse. The first thing is that patients need access to services. Denying patient services on the basis of behavioral disturbance or self-harm is of course the least helpful thing that you can do for someone with borderline personality disorder. All the key interventions have a model of borderline personality disorder. Now that might be as simple as understanding the disorder itself and applying the DSM diagnostic criteria. Certainly there are theories of borderline personality disorder. The standing of the disorder itself. Comprehensive assessment goes without saying, but as I've alluded to before, including co-occurring problems and making a full assessment of those is an important part of assessment. The next principle is that of non-judgmental acknowledgement and acceptance of the individual's experience, wants and needs. This is common to a range of treatments. Those familiar with dialectical behavior therapy will be familiar with the term validation, but it's a common principle across a number of treatments. The general attitude is that as Jan was suggesting earlier, people with borderline personality disorder are doing the best that they can manage, but the best that they can manage is clearly not enough to get by in life. So they need to make changes and to improve, but they're not doing this deliberately to get under your skin. The next is what kind of relationship do you need to have with someone with borderline personality disorder? This is clearly probably the biggest challenge, because the disorder itself mitigates against smooth, reciprocal relationships. The aim is for an open, empathic, and collaborative relationship, and importantly, optimism. People do get better from borderline personality disorder and, again, respecting the autonomy and choice of the individual with the disorder. Structure and consistency are really bedrocks of any treatment program, and the importance of structure and consistency is not just what you do, but also what you don't do, that people get into difficulties, particularly when they're highly reactive to crises and particularly self-harm, but also get into difficulties when transitions or endings are not anticipated and managed as part of the therapeutic relationship. Andrew, we're just a little bit time-constrained, so I'm going to have to ask you to expedite yourself through your next few slides, and then we'll have Chris. Okay. The other principles are that one needs to attend to case management needs and care planning. These are the practical issues that people with borderline personality disorder come with, and also clearly delineating the roles and responsibilities of individuals in a team. And then also to, as you can see, the slides seem to have slipped forward, but a common team approach, suit division and team support are, again, important principles of treatment. Sorry, they've gone back again now. It's going forward. It's a co-occurring psychopathology treating co-occurring syndromes at face value. The slides seem to have got stuck. That's okay. You can still talk. Okay. Well, if we're constrained for time... Yeah, we are a little bit constrained, so we might just pop on to your last slide, and then we can hear from Chris. But are you able to head on? The general psychiatric management? Yeah. If you're able to move it to the next one. I can move it to the next one for you. Thank you. Can you see it now? I can. Thank you. The last issue here is really what kind of structure does good enough treatment need to have? And John Gunderson has described general psychiatric management, which has been demonstrated in one randomized controlled trial to be equal to... I can only give you another minute, I'm afraid. I know this is distressing for you, but you will have to move on. Well, that's fine. That's...which has been demonstrated to be as effective as dialectical behavior therapy. And you can see there on the screen, I won't go through them, but the general principles, which are about focusing on the individual's priority, focusing on the here and now, and not just attending to emotions, but also attending to the relationship itself, and recognizing that hospital is not always contraindicated, the judicious use of hospital can be a helpful tool in the armamentarium. Thank you very much, Andrew. Dr. Andrew Shannon from Melbourne, is the character from Melbourne. And now we'll hear from Dr. Chris Lee, a psychologist with great experience in managing borderline personality disorder from Paris. And we'll just move you on to your first slide, Chris. Thank you very much. So what I'm going to talk about is one of the therapies that has been specifically designed for treating borderline personality disorder. Chris, could I just... Sorry, there's just a little bit of a fall-off with the distance, I think, if you can just speak a little bit louder. Okay. Or if I go down like that. Is that better? Yeah, that's lovely. Thanks. Okay. There are a number of psychotherapies that have been found to be effective in treating borderline personality disorder. I'm just going to focus on one, because it has a really interesting thing to say about multidisciplinary approaches. So, dialystical behavior therapy began about 23 years ago, and it began as cognitive behavior therapy. So Marsha Linnahan, a group of researchers, tried to apply CBT to borderline personality disorder. It's something that works effectively for depression and panic, but quickly found it didn't work in borderline personality disorder. So what they added, and Andrew and Jan have both mentioned, they found that they needed to add a more extensive validation emphasis. They found that when you try and do cognitive therapy with someone's borderline personality disorder, they've experienced that as invalidating. Someone who's depressed can be asked to maybe think about something differently. If you do it with someone's borderline personality disorder, they can feel that they're not understood or that they've been attacked for having their beliefs. And what Linnahan found in the histories of people with borderline personality disorder is extensive invalidation experiences. The next thing that her and her colleagues added is a dialectical philosophy. Simply, for every idea in the world, that's a thesis. There's always the opposite of that, the antithesis. And the dialectical processes when you synthesize these two. Now, those of you working with borderline personality disorder know that they think a lot in dichotomous ways. It's very hard for them to see the great. And having a dialectical philosophy can be really helpful to help them navigate through the problems that they're experiencing in life. To give an example of a patient from two weeks ago, she began the session by saying, all GPs are bastards. And by the end of the session, we're talking about how she'd fallen in love with her new GP. So the last thing that was added to dialectical behavior therapy is mindfulness and some skills that particularly deal with the problems that people with borderline personality disorder have. Mindfulness was borrowed from the Tibetan Buddhist approach, particularly useful in borderline personality disorder. Because unfortunately for most of them, they spend their lives... I'm sorry, Chris. We're just having difficulty in hearing you. I'm very sorry to interrupt you. Could you please just raise your volume a little bit? Thank you. That's much better. Thanks. It's really good. With the to add mindfulness, which is kind of like the opposite of what they're trying to do, which is normally to not experience emotions in their lives, to not experience painful thoughts. Now, as Andrew mentioned, there are four domains in borderline personality disorder. Dialectical behavior therapy as a slide suggests focuses a lot on the emotional dysregulation. Oh, the slides asked a lot. Maybe if I keep talking about it. There's actually a couple of things that seem to influence emotional dysregulation. There's a strong biological influence. The work of Bessel van der Kolk shows us that trauma has a direct effect on brain functioning, particularly the hippocampus. We know that people that have been traumatized have smaller hippocampuses compared to controls. And it's also true that for people with borderline personality disorder, that they have smaller hippocampuses matched to other patient groups. So there are things going on in the brain. There are probably some genetic components, and there's probably even intrauterine experiences that affect the patients with borderline personality disorder ability to regulate their emotion. So in addition to that biological arm, there's also the invalidating environment, or the environmental influences have a large part to play. And Linhan has focused a lot on the concept of invalidating environment. So I'm just going to explain briefly because it's important to adapt your treatment to take this into account. So what happens is an invalidating environment is one in which parents or the major caregivers don't necessarily mirror the child's responses. They often might be erratic or inappropriate or give extreme responses to situations. So I'll give you an example. If a child comes in from play and is crying and the parent says, shut up or I'll give you something to cry about, that would be an invalidating response. Or alternatively what they might say... Excuse me, Chris. I'm just having a lot of feedback that they're not hearing any sound. I was... that the attendee is not hearing any sound. I was wondering if you could just raise your voice really loud and see if we can hear that. I'm just not sure whether the sound's dropped out or whether it's... Right. Could you just raise your voice a little bit more? Okay. I will try. Thank you very much. The... I was talking about invalidating environment. So another example of invalidation would be to say to the child, you're never happy in response to their crying. So a validating response by contrast would be to say to the child what's wrong. That communicates a lot of things. It teaches the child that when they're upset, something has just happened to make them upset. It teaches them that when you're upset, a good thing to do is to talk about it. This is the opposite of the shut-up. You're never happy. I'll give you something to cry about, which punishes the child for communicating distress and never teaches them an association between things that are happening in the environment and the distress level. So it leads a lot to self-invalidation, which Jen mentioned. I'm going to click forward into the next slide. What are the effects of this invalidation? Well, people with borderline personality disorder often have difficulty labelling their emotional experiences. They just simply haven't had the learning trials to do that. We've already talked about they have self-invalidation. The other things that you can see is that often when they've been growing up, a lot of their communications of emotional distress are being not paid attention to, but really extreme displays of emotion were sometimes paid attention to. From behavior theory, this is the worst type of reinforcement. This is intermittent reinforcement of extreme emotional displays, and I think really can account for why some people with borderline personality disorders frequently display over-the-top communication behaviors when a simple request of needs can sometimes suffice. To sort of characterize some of the theory, according to Lina Hand, is that emotional dysregulation is central. The sort of things that are important in that is that people with borderline personality are very sensitive to emotional stimuli. They're very reactive to stimuli, and after they have been activated, they take a long time to return to baseline. So we've actually conducted some research to support this idea when we put people into four-hour heart monitors and looked at their activity levels. What we found is that they were, in fact, more reactive and more easily triggered and slower to return to baseline than other patient groups, including people with unstable panic disorder. So, Murray, are you still getting the sound? It's Michael, actually, but I'm still hearing Sam, but what I'm doing is I'm shutting down all the webcams so nobody will have any... nobody will see yourselves anymore in an attempt to increase the sound, and I think it has improved already. So I'll just leave my face up there. Okay. So everybody else has been... it's just an audio. All right, so let me talk about the... one of the things then that's taught in dialectical behavior therapy is emotional management. So patients learn to feel to better manage their emotions. What's important is opposite action. Opposite action means that you do the opposite of what feels natural. So someone who is depressed and has low energy will naturally feel like wanting to go to bed and pulling the cover over their head and not talking to anyone. Yet these are the very behaviors that will exacerbate depression. Someone who's agitated in your office will, in fact, pace. And if that's a pacing, it increases the agitation. They teach the client to learn to do behaviors that are the opposite of what feels natural. So they actually start to behave in ways independent of their mood. This is really important. They're then able to experience negative emotions without trying to numb them. Or if they experience positive emotions when they get a high, but they don't try and escalate that through drug views or through risky behaviors. So experience the negative emotions without numbing, and experience the negative emotions without trying to escalate them. And in that way, they'll get more of what they want from life. So going back to the model, the way we change emotional dysregulation is firstly we do a lot of teaching of mindfulness skills. That's not the... And the mindfulness skills are really helpful as I mentioned before, to improve self-identity, to change dissociation. We also teach emotional regulation skills, and these are designed to target the symptoms of anger and affective mobility. We also teach distress tolerance. Those skills are particularly useful when the person is experiencing a lot of distress, and wants to do something impulsive like spend money, gamble, self-harm, that they have other ways of managing that distress. And finally, we teach interpersonal skills as part of ZPT, to help manage the chaotic relationships, help them get more of what they need from their relationships, and change their feelings of abandonment. As Andrew pointed out, I think all of the psychotherapies that are designed to treat borderline have an extensive emphasis on validation, and this is really important for changing emotional dysregulation. So most of the therapies kind of say, you know what, it's amazing that someone with borderline personality sort of can get as far as they've got. And a lot of the kind of problematic behaviors make sense from the history, that they're angry in situations where they're meant to be trusting of other people, because in the past, when they trusted they got hurt. So we do a lot of validation of those kinds of behaviors. But a dialectical process is at the same time as doing the validation, we're also teaching skills. So we're saying it is true that you're doing the very best you can, and it's also true that you need to be more skillful in the situation of your life. And the final part about DBT is a special attention to the therapist's relationship. The DBT is a multimodal approach, as I've tried to talk about. It combines biological aspects, social aspects, and psychological constructs. It really emphasizes, as Andrew also said, the importance of supervision, because therapy with borderline patients, more so than in any other group, is a reciprocal relationship. You affect them, but they definitely affect you. And you need to have supervision to manage that if you're going to do weekly therapy with them. There's a lot about the therapist's style in DBT. Attention is paid to being warm, to being actually vulnerable sometimes with the client, and also an extensive use of humour to balance the warmth, the luminescent, and the vulnerability. And I think that's my 15 minutes. I did have one more slide, which I did, put up what I thought were the most useful references. I put up three, Linda Hand's original reference, for those of you that are really keen. A book by Ma, which is really handy for anyone who's working in a solo practice situation and wants to know more about things that you might be able to offer someone with dialectical behaviour therapy. And the last reference there that should come up shortly is about a study in Australia where dialectical behaviour therapy was applied in a multidisciplinary team's way and evidence of its effectiveness. Thank you very much, Chris. That was very exciting to have DBT explained so comprehensively and so expeditiously. It was really, really good and I'm sure everybody else feels the same way out there. We'll just move on now to Dr Christine McCall of the GP from Brisbane. Unfortunately, due to the number of people who have elected to join us tonight and due to bandwidth problems, we can't have everybody's video cam showing, so I have got the fan good now and I've got my video open. I'm really afraid to change it in case something happens. So if you can put up with looking at my face for the rest of this session, we'll just stick with that. Now, Christine, are you there? Yes, I am, Michael. I'm just not sure. I'm just moving into the slides again, but I'm not sure if I have any control over them. Would you like me to move them for you? Why don't we do that since that seems to be probably the most reliable. I'm just moving to the end of Chris's reference there to Mara MAARA, which she mentioned. Is that the beginning of yours or the end of...? No, that's the beginning of mine. That's great. Thank you very much. Great. Well, look, thanks very much. From a general practice perspective, I guess these are individuals who we see. In many situations, they are individuals who struggle to access any specialist mental health service and in cases have been told by specialist mental health services in the past that there's nothing that they can do for them and that they can't access their services. So you can certainly understand that, given what Chris has just described, the negative effect of that sort of information. These are individuals we might move to the next slide if we can, thanks. Individuals who have high levels of need and often present with quite challenging behaviors as has been discussed, they often find very difficult to describe what's happening for them or to seek help in a more normal routine sort of way. And that can present challenges at a number of levels for us, certainly in general practice, but I'm sure in other professions as well. We're certainly challenged at a professional level and as Chris mentioned, at a personal level as well. From a purely pragmatic point of view, we're challenged at a practice level. These are individuals who will often fail to turn up to routine appointments and at times seem to almost routinely present in crisis. Indeed, at times it seems they have a sixth sense for the days that are going to be most disruptive to your practice when they present, often extremely distressed. And that can be extremely challenging for the entire practice team from the people on the front desk, the practice nurses who often play a very valuable role in providing care to these individuals. And it can occur in a way which demands immediate attention regardless of what limits you've tried to put in place in the past. One distressed young individual, young woman who, if things really became completely intolerable, the first thing we knew about it was we had distressed patients coming into the practice saying that there was a young woman collapsed and bleeding outside the surgery. So her call for help was to lie on the ground outside the door of the surgery, which of course had a significant effect on people entering the surgery. So you not only had their distress to deal with, but distressed patients and usually, I think Jan's said their life is in complete turmoil. Usually your practice day has approached that as well. And that does present pragmatic problems about how you respond in a professional way in a time when you are under a fair bit pressure yourself from a number of directions. It's understandable that their behaviors will create significant anxieties and distress amongst their family and friends as well. And so you also may find yourself trying to juggle their needs in amongst everything else. Next slide if we could. So on the average practice day, when you're already fully booked, this can certainly seem overwhelming. Overwhelming in dealing with it pragmatically, but also the enormity of the need that sometimes these individuals seem to have. I think one of the key messages has already been made a couple of times and that is that it's important to first acknowledge their distress and react accordingly to that rather than to the distress that their behaviors might be causing to those around them. And to keep in mind that there are simple and effective things that you can do even when there really doesn't seem to be much time that you can sort of fashion to seek to attend to their needs. And we've talked a little bit about some of those simple things that you can do even in a short period of time in a busy day. Just trying to sort of acknowledge their distress, deal appropriately and compassionately with often what a self-inflicted wound and involve your team in providing them with care and practice nurses are often very valuable in providing just a calm, settling, compassionate response to their presentations. And that combines some time from a pragmatic perspective in just trying to juggle the needs of your other patients at the same time as dealing with an acute crisis. Michael, we might move on, I think. That's great. We have about two or three minutes left. We're already running a little bit over time. I'm very sorry. That's right. I'll speed up. I think one of the things that often present challenges in general practice is trying to keep people safe. And as we know, these individuals often do have a successful suicide. I'm sorry, they do. It's a suicide. It's not a successful suicide. And it is important that we do have some strategies of how we manage that. But really, ultimately, it's important as clinicians that we acknowledge that at the end of the day the safety is in their hands. And I think the development of a crisis plan is a really key step in trying to put some structure around how they might respond in situations where their distress really leaves them feeling quite helpless. And it's important that that is shared, if possible, with their family and carers because they can play a key role if they have some practical and constructive things to do. And if you're lucky enough to practice in an area where there are other mental health professionals who can add their expertise to the team caring for these individuals, it's important to share that plan across the team so that everyone's on the same page and they get a consistent and clear message about how to manage their safety. Michael, next one, please. It's really key that we do give a sense of health, but you know, you can either be the devil or the hero at times in their eyes depending upon what other aspects of their lives are intruding. And it's very important that you're really aware of your own response to their behaviours and don't fall into the trap of a rescuer. And that's not something that just happens to GPs. I've certainly seen it happen to quite experienced professionals and I guess back to Chris's point, it's important that we seek to work the team where we can and to support each other in providing care. And I think the last message is to take a long-term perspective when you're dealing with these individuals. It's amazing what can be achieved over time with consistent supporters and empathetic approach to supporting them and trying to meet their needs. Thank you very much. This is a really exciting webinar. We've heard from Jan from the consumer point of view. We've heard from Andrew as a psychiatrist. We've heard from Chris as a psychologist and we've heard from Christine as a GP. And I already have a greater understanding of how everybody sees the world from this thing to you all and I really do appreciate you attending tonight. Some common questions that came through and we're just going to go into our panel questions and answers session there. And you can still send in questions by typing into the bottom right-hand corner and I will relay them to the panel. A common question was differentiating between bipolar affective disorder and other affective disorders and borderline personality disorder. Chris Lee, would you like to comment on that? Between borderline personality disorders and other affective disorders. Yeah, I guess a key thing that I think about is the affect instability that happens with borderline personality disorder. What I look for is the mood for people with borderline personality disorder is often more like the Melbourne weather. It's dark and stormy in the morning. There's a bit of bright sunshine at midday and then it's drizzly in the afternoon so they have these intense affect shifts throughout the day. So they often don't... Well, sometimes, of course, comorbid diagnosis is common but they're not necessarily meeting the criteria of having sustained depressed mood present every day for most of the day for an entire two-week period and I guess that's the key... So it's the intent of the shift? Yes, that's right. And I like the comments as well. But the other thing with the... I think also the tricky part, of course, is the impulsive behaviors like the gambling and the, you know, sexual behaviors that they get into quite impulsively, the spending money, those kinds of things can also, of course, look like part of a manic episode and sometimes those different interactions I think are quite tricky. Thanks very much, Chris. That's really, really good. Thank you. Now, another common question coming through. Can you comment there, Michael? Yes, Andrew? Yes. I think one other comment to make is that specifically in differentiating bipolar disorder from borderline personality disorder, you don't get euphoria in borderline personality disorder and the elevated mood is quite rare, particularly sustained elevated mood in borderline personality disorder and differentiates the two. Unfortunately, the two disorders co-occur more often than chance, so you actually can get the bipolar disorder co-occurring with borderline personality disorder. The other means of differentiating borderline personality disorder from major depressive disorder, Chris alluded to this and I'd just like to reinforce, it's the pervasive depressed mood that you get in major depression that differentiates it, that you don't get the periods of perhaps just mild dysphoria or dysthymia that you get in borderline personality disorder. In major depression, you get pervasive depressed mood that's unrelenting going on for weeks. Again, you can get co-occurrence of the syndromes and that's why I emphasised in assessing the disorder that you need to distinguish state from tray. People who just engage in impulsive behaviours or self-harm during pervasive depressed mood and at no other time are unlikely to have borderline personality disorder. They're very, very good points, Andrew. Thank you very much. That's really good. So the euphoria is generally absent. Yeah. That's really good. Thank you very much. John, may I just ask you as a consumer what tips do consumers find... What tips could you offer on mitigating self-harm on attendance acutely? That's on attendance. Weasel without self-harm, Michael. Is this pre-self-harm? Well, basically it's more of a general question on general tips that clients find useful for mitigating self-harm. Okay. Look, clearly I'm not a clinician but in my mind self-harm is around trying to ease that pain or conversely trying to feel something and there is the release of emotion, I guess, in the act of self-harm. So in terms of being able to mitigate that, I think that as a clinician you shouldn't perhaps spend a lot of time in inspecting unless there, of course, it's in a surgery where actual suturing is required but to understand and try and reflect on what it is behind the self-harm that's actually causing that activity on that action. And I think if we can look at that and address some of those issues then I think that would certainly mitigate the self-harm. And I think too is really requiring the consumer to take a degree of responsibility for their actions and I think to use, often to use a suggestion that how would you feel if your daughter or your son came to you with self-harm? And I think that sort of puts it a little bit more in perspective and of course they'd be horrified. Usually the answer is they'd be horrified. That's a very good point, John. Thank you very much again for your input into the discussion. Christine, may I just ask you for some tips as a GP on working with the public system in relation to acute presentations? I'm not sure when the right person to ask. Well, from the GP's perspective. Look, in some places around the country there are now services provided through the public sector for people with a diagnosis of borderline personality disorder. But unfortunately... Sorry, Christine, can I just ask you to speak up a little bit, please? I said... Can you hear me now? Yes, thank you. There are some services in some places for people with a diagnosis of borderline personality disorder in the public mental health sector. Unfortunately, the reality for most GPs is they're still very difficult to access and it would probably be a minority of individuals that you would be seeing who would be able to access specialist mental health services publicly for borderline personality disorder. Thank you. Andrew, just going back to you, may I ask you a common question that we had was the management of the children of patients with borderline personality disorder. Could you give us some tips or hints on that? Sure. There is actually some work beginning to be done on this. Children of parents with any mental illness have often been neglected by mental health professionals and again the wider child protective field. And I think the principles for dealing with young people is to actually recognise the experience that they're having and to take steps toward offering both support and protection but also effective treatment for their parents. And I think that too often people in positions where they come into contact with children who have a parent with borderline personality disorder are at a loss as to what to do for the parent and I think directing them toward effective treatment services is the best thing that can be done as well as providing support and if necessary protection for the children. So what I'm hearing you say is using a multidisciplinary approach? Absolutely. It's important I think particularly across non-government sectors and across child protection and mental health for there to be coordination and unfortunately that coordination is not there as Chris McCollough has just said. You know services for borderline personality disorder are patchwork and often a child protective worker might be seeking assistance but get the brush off from mental health services because they either don't deal with the problem or if they do they might not see the parent's problem as being sufficiently severe for them to enter public mental health services. Thank you Andrew. Just getting back to you Chris Lee, a very good question that came through from one of the people tonight was the management in a rural area where you don't have access to good mental health services or any mental health services. Yeah indeed, that's quite a challenge. I think Michael in Queensland I'm aware they have quite some innovative ways of trying to deal with this One possibility that I know exists is that there are DBTs administered often in an individual and in a group. The person has to travel 150 kilometres for their individual session they don't want to come back two days later and have the 150 kilometres to have their own group session so they've actually been trialling on Skype and using that as a way to have the group experience of DBT in addition to the individual experience. I think that's a fantastic solution. That's good, that's good. So still using the multidisciplinary team, not taking all the challenges on yourself and using the tried and proved evidence based models. I noticed there was a question before about that one of the participants raised and said if you are going to do DBT can you just do it in an individual way? This we don't, there's actually no research to show whether or not just doing the individual component and not doing the group is actually effective or not. Although there's a very recent study that shows that you can in fact only deliver the group component and get a positive outcome for people as long as they're not really severe in the borderline personality disorder sense. Thank you very much, Chris. And just getting back to you, Andrew, getting on to pharmacotherapy. There were a number of questions coming through during the evening ranging all the way people were querying whether clotheapine, silicone. I realized from the tenor of everybody's talk tonight that pharmacotherapy should not be the first line of treatment but could you comment on pharmacotherapy with borderline personality disorder? Sure. I think that despite the evidence-based recommendation that pharmacotherapy is not indicated as a primary treatment there's an enormous amount of prescribing goes on and you mentioned ceroquil or cortiopine that's become particularly commonly prescribed for those who are old enough to remember thyroid, or melaril, it's really the new melaril and every second patient seems to be on it. There is no evidence to support the use of those medications as primary treatments for those core domains of borderline personality disorder and in fact there's evidence to show their lack of effectiveness. The largest pharmacotherapy trial to date was conducted with a lanzipine borderline personality disorder, a very well-conducted trial published in the British Journal of Psychiatry. It was industry-sponsored and normally there's a bias toward positive findings in industry-sponsored trials even that didn't come up with a positive finding. So I think that while there are some of the meta-analyses do suggest some I guess experimental type treatments I think pharmacotherapy is best conducted by specialists in pharmacotherapy for BPD as a kind of second or third level of treatment that on the whole as frustrating as it may seem, pharmacotherapy is really largely unrewarding and these days the harms are much more evident and we're much more aware of them. All those people on cortiopine are at risk of developing the metabolic syndrome and unfortunately the health status of people with borderline personality disorder is far worse than those of people without personality disorders or many other people with other mental health conditions. People with borderline personality disorder have particularly poor health. So what I hear you saying Andrew is that similar to some other therapies that actually using cortiopine is worse than placebo. It actually has negative effects. Yes I think in terms of the metabolic syndrome it certainly does. There are some small positive trials for atypical antipsychotics. There was some enthusiasm for fluoxetine or impulsive behaviors but the evidence has not really come out the more trials that have been published and the more meta-analysis that have been conducted. And the most extreme recommendation is just don't do it. But I think if you are going to do it review it regularly and call an end to it if it's not working. That's really good advice. Thank you very much. Well believe it or not we have reached the stage of the evening where I'm going to give everybody three minutes on the panel to sum up and then I will sum up at the end and so we might just go back to you again, Jan if you could give us your three minutes. Yes, thank you Michael. Look from a consumer perspective I understand that there are around 250 clinicians on this webinar and I'm very grateful that you've taken the time out of your busy days to dial into this webinar around this particular issue. I think that the points that I'd like to get across would be as clinicians to have an understanding that this disorder, borderline personality disorder is more than the person themselves. So in other words what I would ask is that you look past those challenging behaviors and you look to see the individual. You look to see that they are distressed. You look to see that their distress is real and you look to try and have some sort of an understanding that these behaviors that you see are certainly not seeking your attention but they are efforts, desperate efforts to ease either that pain or indeed to feel something. So I think that the other presenters have made some fabulous points. I found myself thoroughly agreeing with Andrew Channon on many of the points that he made. I found myself agreeing with Chris Lee on many of the points he made and I certainly understand the challenges for Chris D. McCulloch from the GP perspective. It's not an easy group of people to be able to treat and for many to actually even like I suspect. But I do thank you that you've at least shown the interest to be joining this webinar tonight and I think that all goes very well for future treatment and care for these folks who are finding it very difficult to be able to access appropriate and good quality treatments. So thank you for that, Michael. Thank you very much, Jenna. We certainly appreciate your skill and knowledge as well. It's certainly been very illuminating. Andrew, I might just turn to you now and ask you to present for three minutes just in summing up, please. Yeah. Well, again, I'd like to endorse the positive tone of this evening that I think the main points that I've got from this evening but also that I'd like to reinforce are that treatment is effective, that people should approach people with borderline personality disorder with a sense of hope and optimism. In fact, I think the first lesson is that once you stop arguing with people and trying to push them away from your practice that they're an extremely rewarding group to work with and that they do improve. I think that although there are evidence-based treatments and I conduct trials and evidence-based treatments myself, the number of people with borderline personality disorder is too great to ever be able to deliver those treatments to every person. And I'd like people to take away some of the general principles of practice that I think Chris McCall have also underlined that involve access to services, understanding the disorder itself, educating people about the disorder, assessing people thoroughly, being non-judgmental, validating in the terms that Chris Lee described and providing structure and consistency as well as attending to practical problems, problem solving as Chris McCall have said, treating co-occurring problems where they occur and getting support for yourself and then you engage in treating individuals with borderline personality disorder finding some way to get support so that you don't have to endure the burden of this yourself and where possible to work within a multidisciplinary team. Thank you very much, Andrew. I think that last point is a very important point that one needs to have support oneself if one is working with patients with borderline personality disorder. Now, Chris Lee, I'll just ask you to present for three minutes, Chris, in summing up. I've probably got three points to make, not necessarily summary, but I can three key things to say. One is the importance if you can and if you're going to do therapy to be part of the team. Sorry, Chris, you're just fading out a little bit there. I think it needs to speak up just a tiny bit. About now? Yes, that's much better. To be part of the team, this has been the most, the working with borderline personality disorder part of the team has been one of the most rewarding things that I've done in my career. You'll have team members who are really good at validating our clients and you'll have other team members that are really good at teaching mindfulness and other team members that are really good at teaching emotional regulation skills and the different disciplines seem to have particular strengths in some of these different areas. So I really do think that the combined team approach really has a benefit for those at the more severe end. As Andrew pointed out, not everybody kind of like needs the state of the art and the intent of the team, but it's fantastic when you get the opportunity to do that. The second thing I'd like to comment on is just one of the members of the audience ask about people with borderline personality disorder researching their own things on the web. I would like to make a comment like that. Mostly, I found that to be a positive experience. Unfortunately, some people find websites that are really very punitive about borderline personality disorder and based on way outdated information, saying things like nothing works, this can be extremely demoralizing for someone with borderline personality disorder. It's just not true. So sometimes when a patient is going off to do that, you might warn them that there is outdated and inappropriate information available. But for most of them, they get a greater sense of connection, understanding that there are a set of symptoms that a lot of people have, and they're actually part of a group which is great for their general sense of disconnection. And the final question I just saw that came up that I wouldn't mind commenting on is that one of the audience members asked about the therapeutic alliance and is that the most important part of the therapy? The therapeutic alliance is a very important part, but it looks like there are some things about the therapeutic alliance related to the model that's important. So in DBT, we actually know that, yes, it's really important that the patient feels understood and validated for sure. The other thing that's really important is that the therapist balances this continued validation with teaching skills. And people that just focus on trying to teach borderlines or only do validation don't seem to do as well. So I'll just have those commented. Can you just clarify that last point again from the Chris? So people who just do validation... Yeah. In one of the larger studies that Lina Hand conducted, they looked at the videotape of what happened in therapy. And therapists who were sitting there are only doing validation, but never actually teaching a person the mindfulness or how to regulate emotions or better communication skills. Those patients tended not to recover so much. People who focus the entire session on just trying to get the person with borderline personality to be more skillful and just keep teaching them those things and without the validation, those people also didn't do so well. So the optimal group had therapists to balance those two things. So what you're saying is that we really didn't need that multidisciplinary approach and it's either give it all or don't give individual parts of it on its own. No, I'm not saying that actually. You can give the individual part, but you have to pay attention to those validation and teaching the skills within your individual sessions. I think that is still a very effective thing to do. Yes, I can hear what you're saying. Thank you very much. Christine, would you like to spend three minutes summing up? Yes. The burden of disease with borderline personality disorder is firmly carried by the individuals themselves and their families. It presents challenges for us as clinicians, but I think it's really important that we have a very optimistic outlook as other speakers have spoken about with respect to engaging in their care. In an ideal world, it would be great to have access across the multidisciplinary team to meet their needs and these are individuals with high levels of needs and very genuine needs. I look forward to today when our system is a bit more validating of their suffering and more responsive to their needs right across the country. But in 2011, one big advantage has been the increase in access to special mental health service providers in primary care and I think that's been a huge boon in providing care to individuals. But it still remains that for most of these individuals, their primary caregiver will be their GP and they may not be able to access specialist mental health service providers for a whole lot of reasons. The message I'd like to leave with GP is this is something, despite the challenges, that is very rewarding to be involved with. Think about using your practice team if you don't have access to a broader mental health team to assist you in their care and don't underestimate the effectiveness of consistent approach to meeting their needs. There are simple effective things you can do in a busy general practice that really will make a big difference to these people and their lives and you will see good outcomes over time. And I think that's the key message that I'd like to leave with my colleagues that there's a very good outcome for many individuals with borderline personality disorder if they are able to access care. Thank you, Christine. So what I'm hearing you say is that in general practice, using the multidisciplinary approach, using the mental health care plan, using mental health nurse, OT, social worker, psychologist to refer to using the team approach is a better way of going than trying to manage it yourself. If you're fortunate enough to have access to those individuals and unfortunately these days they're more available in many communities and I'd encourage people to link in with their local service providers where they're available. But if you aren't fortunate enough to have those people supporting you and particularly in rural and regional areas sometimes that is less accessible, then don't feel like there's nothing worthwhile that you can do. There are some simple and effective things you can do even in the busy general practice. Thank you very much. Well listen, I would like to thank our panel and I'm going to get everybody out there. All 220 of you are still left to clap and we'll see if we can hear you. Thank you. Jan, thank you very much for your approach to presenting this and for providing the human experience of somebody who has experienced mental illness in the past. Thank you Mark, all pleasure. Andrew, thank you very much for your input. I particularly enjoyed the management principles that you're non-judgmental, the importance of access, assessment and being particularly non-judgmental. That's what I took away mostly from your talk and the care that we need to use with using pharmacotherapy. Chris, that was a marvelous exposition of DBT. It all makes sense now to me and I'm sure it was illuminating to everybody who is on broadband tonight with us. I think your point about people going on to websites was good and I think we need to accept that as practitioners and to work with it in developing the therapeutic alliance. Christine, your input as a GP was fantastic. You gave us all an insight to the problems that GPs experience with patients with borderline personality disorders and you also gave us an algorithm for dealing with it using the mental health plan and a multidisciplinary team approach. In summary, I'm going to finish off tonight by telling you that we will have all these assets available on the MHPN online at www.mphn.org.au and just follow the prompts to get to where they are. We had two learning objectives tonight. The first was to recognize the ways in which clinicians and or treatment teams may be challenged when providing mental health treatment and care to borderline personality disorder presentations and the second was to acquire strategies to build individual and team resilience. I do hope that you have all reached those objectives tonight and we shall pursue it further online. Thank you very much for your patience tonight and for logging in and thank you panel so much for your expertise, experience and presentations. Welcome. Thank you. Michael. Thanks. Take care now. Everybody drives safely home. Hello Christine. Yes, speaking Michael. Oh sorry, no, I don't know what's happened there. You just rang me so I'm not quite sure how that works. You rang me too. Okay, thank you. Take care, bye then. Bye. See you.