 Good evening everybody and welcome all to this webinar tonight Personality disorders and substance use tips on effective treatment approaches I'd like to welcome the over 1,000 participants who've joined us for tonight's webinar and the viewers who are watching the podcast later There are actually over 4,000 people have registered for this webinar Which is a record as far as I know and it is a stark contrast to the beginning of MHP and webinars I can remember facilitating to 60 people. That's very exciting to have you all with us tonight I'd like to begin by acknowledging the traditional owners of the land in which our webinar presenters and participants are located I would also like to pay my respects to elders past and present I'm Mary MLAF and I will be facilitating facilitating tonight's session I have a background in general practice in psychotherapy and now I am a psychiatry trainee in Final Queensland and I would like to give a particular welcome tonight to all the people who are watching the webinar from headspace Ken and as you can see I have a different background to normal and I'm actually at headspace kens in a private room So I'll join them later on now. I would like to Introduce you to the host for tonight So project air strategy for personality disorders and MHP and have engaged in a collaborative partnership Plan produced and delivered this webinar, which is exploring substance use and personality disorder For more information or resources about assessing treating and or living with a personality disorder or someone who has one Go to the project air strategy for personality disorders website In the bottom right hand corner of your screen You can see a small file icon and that has the resources for tonight's webinar. So there's some recommended articles and other things which the presenters will mention tonight and project air strategy is project air strategy org and I really recommend their resources one of the great Privileges to me and doing this job is that I get to meet interesting people and find all the best resources in the country And I the project air personality disorder resources are fantastic So I'd like to next introduce to you our panelists for tonight so in no particular order Hester Wilson is a general practitioner based in Sydney, but Hester you also have I understand a Fellowship in addiction medicine now. I just Wonder if you could just tell us a little bit about how you became interested in addiction medicine from the background of general practice Look, it was pretty serendipitous, but I have to say We see a lot of drug and alcohol and mental health issues in the general practice setting And what I was aware of for myself was I actually didn't have the skills or the tools I needed to actually assist my patients particularly with their drug and alcohol issues and so got interested in In doing that better and ended up becoming an addiction specialist as well as a GP Thank you, it's great to have you on the panel tonight and it looks a bit colder in Sydney than it is in terms It's very cold So then I think we might move to Perhaps we'll go in order of coldness. I don't know whether it would be Canberra. Let's go to Canberra next so Jeff Like to welcome Dr. Jeff Ward who's a clinical psychologist in private practice in Canberra and Jeff I noticed that you had a really significant career also in teaching and research and and now you're more in private practice I was wondering if you could tell us what was the most interesting piece of research in Substance use that you did that's a bit of an on-the-spot question Yes, I think early on I did research at the National Drug and Alcohol Research Center on HIV risk-taking behavior and that to me at the time Before we had medications for AIDS was a very significant problem in Sydney and there was a sense of urgency about Trying to understand What the causes of that behavior were and so I was involved in a number of research projects That looked at that and so that seemed to me very important at the time and And also Had me going out interviewing hundreds of people who use drugs and Talking to them about their risk-taking behavior, which was a very interesting experience at the time Thank you, and I can say that you've had a really interesting and varied clinical career And so really excited to have you on your expertise on the panel tonight, and then I think we'll move down to Tasmania so Trevor We're about in Tasmania. Are you and I can see that you've also had a lot of of interest in In teaching as well. So what what are some of the I can do that? You've been teaching, you know families and recovery to people with lived experiences mental illness and substance use problems What's one of the most interesting sort of things that you that you or the group that you've enjoyed teaching? Well, that's your first question down the south of Tanzia. We're about an hour south of Hobart. So it's Probably done zero out there this morning tonight We've been getting some frost so yes, it's done in turn Teaching I was teaching Psychologists at uni last prior to that was it was the recovery work and so that involved kind of traveling around the country and working with mental health teams and Talking about how What are some of the challenges in supporting an overall recovery for people and not not just come treating symptoms? And that that includes the families as well as, you know, you know consumers And as well as the practitioners. So, you know a good mix of those and I think the thing that kind of stands out for me in terms of What was most interesting was? Hearing people's actual stories and the meaning the narratives that people bring because I think that's always more from there at least it's more alive than then Auditative data and kind of looking at stats actually the the meaning that people kind of give in their story Thank you, and we're really looking forward to your contribution tonight as well And I'll just point out which is a little unusual for us to have two people from this Ostensibly the same discipline so we have two psychologists night Are they are coming from different kind of theoretical and therapy models in their approach to the case? And I'm sure it's going to be a really rich and interesting Welcome everybody just like to run through a few ground rules and for those of you who haven't used the webinar platform before and There is a chat box in the bottom of your screen, and if you'd like to open the chat box You can you can see the little button there, and it'll open on a different tab I've mentioned the supporting resources that will include the slideshow the ground rules The vignette that we're going to talk about and other resources in the resource library there if you have any technical problems you can click the Technical support FAQ tab for help and there's a number that you can call as well So currently we have nearly 1,300 people online, and I know that there is more than one person on some of those links They welcome to everybody at the end of the webinar there is going to be an exit poll And it's a survey for you to just let us know your experience of the webinar and gives the opportunity for Suggestions for other topics, and it's really important to provide that information to both project air and MHP and There are some predisposing activities which was sent to you and for the GPs in the audience you need to do those BPD points so explain that Story there you received beforehand and also the ground rules about using the platform But if you need them again, they're all down in the supporting resources tab The way that we're going to work this tonight is that each of our panelists will give a short response to David's story From their sort of discipline perspective and then there will be Questions and answers between the panel and between the audience and the panelist So many of you have submitted questions Beforehand when you registered and I have been provided with all of those in themes. You also have the opportunity to Type into the chat box. Just remember that the chat box is a public space So anything that you type in there is going to be read by 1300 people They just keep it as a professional Discussion you may find that some of the other audience members might answer some of your questions and I Think that's probably about all the ground rules. We need to go through so we're just going to quickly remind ourselves of the learning outcome So we're going to have a facilitated panel discussion about David and at the completion of the webinar participants participants will be able to describe the prevalence distinguishing features and prognosis people with personality disorder and substance use Demystified challenges myths and constraints of providing treatment and support to people with personality disorder and substance use and Identifying prioritized evidence-based approaches, which are most likely to be effective So there is no way in which we can give you all the answers to all of your questions But hopefully this opens up a space for discussion and thinking about things in some ways that you may not have done before so I Think without further ado, I'd like to just Remind us a tiny bit about David. So he's a 24 year old engineering student and Being a GP by background his initial presentation makes me slightly anxious So he missed his schedule appointment and then turned up later in the afternoon needing to be seen and then the second time the same thing happened However, this GP who saw him was very dedicated and rather than us rescheduling him and Decided to take the opportunity to see him feeling that he might be a vulnerable young person now This evening just to let you know because each of our Panelists comes from a different kind of theoretical model I'm just going to kind of let you know in advance the kind of Framework from which they're responding so Hester is kind of taking a medical model approach to how she might think about David So I'd like to welcome Hester to respond from the GP perspective. Thank you Thank you So, you know the first thing is yes This is a young man who was turned up at the GP practice outside his appointment time And we have a fabulous GP who's hopefully got a bit of space so that they can see him because they've recognized Vulnerable but it is a real challenge for us working in general practice if people don't turn up for appointments And then turn up at a time when they don't have an appointment and you've got a waiting room full of people screaming babies usually You know and so for us in general practice First thing I would say is general practice It's okay to say that they're too busy and that they need to come back at this schedule time But understanding at the same time that if it is possible that you may lose someone if you do that It is interesting that this is a young 24 year old bloke now I don't know if it's just me, but I don't see very many men between the ages of kind of 16 and 40 There are a group that don't attend general practitioners as much and he's presenting with physical symptoms So it's it's it's an interesting presentation and then this age group immediately starts me thinking what is happening For him in a biofucker social kind of model He's a new patient. Do we know him? Do we understand the family background because we are in a fantastic place with GP's quite often to have really valuable information about that the patient's background And I think it is important from the medical model to always consider is there a physical cause to this? You need to exclude that we can't assume that everything is to do with mental health issues So we do need to do as the GP did and check that there aren't other physical issues going on But do be aware of mental health and drug and alcohol use that may be driving this presentation Now we are in the general practice setting ideally placed To assist someone like David we see more 86% of the community in any one year will see That much of the community. We're really fabulously well-paced. The issue is that busy Time-poor may not feel that we have the Skills to actually manage someone like David and I have to say when I read through it I think or Jesus so much going on here. What do I adjust first? I think one of the things in the general practice setting is to remember to ask the commission You know so that he's coming with physical symptoms So he's expecting you to focus on the physical symptoms but explaining look sometimes this can be the way that we express Humans we express our psychological distress and so it's a good GP. I want to ask The head's assessment which many of you may have heard of that has a great deal many more letters than that But it's about the home environment. It's about education. It's about eating. It's about anxiety It's about drugs about depression. It's about suicide. It's about psychosis So it's a really useful assessment that goes from the less tricky areas to talk about To the more tricky areas and does include drug and alcohol use It's really important for us in general practice to be asking those questions So coming to the drug and alcohol issue really how old was he when he first started drinking? It's a really good indicator. The other really good indicator was how old was he when he first started smoking cigarette He's a cigarette smoker quite often That's the first indicator and people will start that at age 10 11 12 and it's a good indicator of psychological distress and environment And the fact that this guy's drinking daily six to eight standard drinks and he's having eye-opener He's having a drink in the morning and as well as that he's drinking but hasn't level Hasn't levels is anywhere above poor standard drinks on any one drinking occasion in the social setting And he's actually had some harm come off that in terms of at least his driving under the influence charge But also perhaps relationship issues and we know there's been a history of interpersonal conflict including physical violence I'm risky drinking or hazardous drinking is not uncommon But this is a little bit different because there's also the daily drinking in it and the drinking in the morning and to me This looks like someone who may well have alcohol dependency and self medicating there to stress He's also using other drugs for the cannabis Also some ecstasy and he takes whatever's going so there's some risk taking care of someone who is Happy to take whatever's around and so that's another really important indicator of risk and what's going on for them So, you know, there's so much here There's so much here when he talks about being anxious those social difficulties his low moods the suicidal Presentations the impulsivity which is you know, I will take what's ever there. I just I'll take whatever I can get hold of because I just done this bungalow move We have the family background for him, which is really really important in the way his life experience has been The relationship issues with the recent stressor of the relationship they break up and also his emotional Management is the guy who gets angry who struggles to manage his emotions I'm moving on to the next one. Do I go back or what do I do? No, that's that's fine. Yes. Yep Thanks very much for that. So we will be we'll be coming back to you later on as part of our panel discussion But it was it was fantastic to just see the kinds of things that a GP would be thinking about if they had time as you pointed out But I ideally would be thinking about that very holistic perspective about what's going on for him So thank you for that and then I'd like to bring in Next Jeff so dammit in Canberra And so Jeff you're coming at this from a model which has a strong central focus on Empathic understanding as the necessary basis for any therapeutic relationship and an integrative modular modular approach To assessing his specific problems. Thanks Jeff Yes, that's right. So if I think about the case history as I've received a letter from the GP and David's going to come and see me. I want to talk about What how I'm going to think about David how I'm going to try and engage him So first of all, I just like to make a few remarks about My general approach to David's problems and treatment The first one is that I would assume that David has excellent reasons for everything he's doing Even though those reasons even though the behavior itself might be maladaptive My job is to understand what those reasons are and to help him understand them that is I'll take a strong validating empathic stance and Also help David to relate to or begin to relate to himself in this way more broadly, I would see David's problems as making sense in terms of his life history and Help him to understand himself in this way. There's general question. I would hold in mind here Is how did David come to be this way? The third point on the slide here doesn't really fit anywhere else, but it came up in in the GP's letter That there was an anxiety about dependency and this anxiety quite commonly comes up With in the treatment of people with Mortaline trade So what I would say is David may develop a dependency on me as he hasn't been able to depend on anyone yet and Any dependency he develops I would see is provisionally stabilizing and transitional and then it would become an aspect of the treatment process to be worked on at some stage and to help him to move to a more autonomous position So what I want to talk about tonight is what is known as integrative modular treatment This is recommended by Liversley and colleagues and you can find the reference in the materials that have been provided So we have evidence-based psychotherapists for borderline personality disorder And these are mainly cognitive behavioral treatments like DBT or schema therapy or their psychodynamic treatments like Mentalization based treatment transverse to focus treatment and in Australia. We have the conversational model But we don't have much evidence for the treatment of other personality disorders and the different Therapies for borderline personality focus on different areas of dysfunction and have different Conceptualizations about what the problems are, but there's no substantial difference in their outcome So in the integrative modular approach to treatment We do two things One is we acknowledge that there are common problems across the different personality disorders in The person's relationship with themselves and with other people and the DSM 5 includes this in in the current criteria But then we also identify specific problems that a person may have with the particular personality disorder or Even within the same personality disorder people can have a range of different problems And it's recommended that we incorporate modules of treatment to address those specific problems And we can take these from different therapies There are three general phases of treatment that we talk about First of all, we want to develop a therapeutic relationship with the person engage them in treatment Help them to stay in treatment We want to then look at the most distressing symptoms and address them And finally If the person stays in longer term treatment, we want to deal with the underlying personality disturbance So in terms of the first phase engaging David and holding him in treatment I would ask myself a question. What do I need to do to increase the likelihood that David will engage in treatment from the letter? We can see that David has problems engaging So the main question here would be how can I understand David and communicate in a way That ensures David understands that I get it at least to some extent I want to put myself in his shoes and see things from his perspective And I want to put this into words and communicate it to him in doing this I'll use a wandering collaborative style of empathy Understanding empathy as a co-constructive process. That is we David and I will do this together. So I'll do a lot of checking asking if I got this right if I understood you Am I getting the sense that it's like such and such or I'm getting the sense. It's like such and such is that right? Now this understanding does a number of things that creates connection It reduces the stress It generates hope and it begins the process of enhancing David's self-reflective capacity Due to Indications that David can become overwhelmed emotionally Initially, I would attune to David and probably keep the conversation at a cognitive and general level Second question I've got in mind is how can I generate a sense of hoping David that I might be able to help him And the first thing I want to do is I just outlined is understand him But the second is that I want to provide a problem a problem summary A formulation of those problems and a treatment plan that makes sense to him so that he can have some sense that His problems might be addressable So David's problems area problem areas if we look at likely diagnosis We have a likely diagnosis of borderline personality disorder and of an alcohol use disorder And if we look at the specific problems that I was talking about Then we have a poor capacity for self-reflection and interpersonal understanding We have attachment and interpersonal difficulties There's social anxiety self criticism anger and aggression suicidality identity confusion You just know who he is emotion dysregulation Low mood and there's alcohol and another drug use there so Having seen David for two or three sessions if I can engage him I would then provide him with a provisional case formulation I would summarize David's problems as he has described them and I would invite his additions and corrections to that I provide a provisional developmental account of how these problems develop We know already that he had an absent father a critical mother grew up in a drinking culture and so on Uh, and then I would provide a treatment recommendation. I would tell David that We should meet weekly Focus on what David sees as the most important problems first Make sure there's agreement. We want to make sure in this way that there's agreement about the tasks and roles of treatment And examples of treatment modules that might be used in response to specific problems and these are only Just recommendations off the top of my head But we would want to incorporate early on Probably immediately we would want to address his suicidality and here you could use dbt style interventions or any other evidence-based intervention We might want to address his self criticism and we could use modules from emotion focus therapy schema therapy or psychodynamic therapy Uh, his social anxiety if you're going to address that for example, you could use dbt intervention Or again psychodynamic intervention priest romantic difficulties Uh, there are a range of approaches you could use from interpersonal therapy schema therapy or psychodynamic therapy And for example, holland drug use you could use motivational interviewing Or if Hester was the gp and she has expertise in that area I might communicate with her and see if she would manage those problems Well, I manage his psychological problems and we could keep in touch with it with each other around that And finally if david does say in treatment for the longer term We would try to address his underlying personality pathology. Uh, that is uh, you schema therapy and psychodynamic therapy are both designed to do that Um, yeah, so that that's uh Thanks very much. Yeah, my slides. Yeah, just um fantastic Introduction and I was I found this modular approach to therapy and personality disorder really refreshing I think it gives a name to something that a lot of us just intuitively do And maybe feel a little bit dubious that we're doing it But um, it's great that it's actually something that has a really good theoretical basis And I also really appreciate it. Yeah If I let you say something quickly about that sure that That's where I wanted to go up to say I would encourage people to use what they know If they don't have specific training in a in a personality disorder approach Thank you really encouraging And I think also that the idea that his behavior and his um approach to life actually does make sense Even if it might be not not healthy, it's it's in some way making sense for him So we'll come back to those kind of things in the panel discussion and thank you again very much for that and then um Trevor is going to give us his response again his background in psychology, but he's coming um to see david In a response that's informed by trauma and attachment theory Motivation theory and mental health and addiction recovery models Thanks very much Thanks, mary um Hey everybody just just to give you a sense of what we're talking about here. We're talking personality disorders. We're talking about approximately 25 percent of presentations at emergency departments and about the same figure in terms of those that are admitted to psychiatric facilities have a diagnosable personality disorder overall population you're looking at around six and a half seven percent of the population could meet that criteria But I must say I think I think that's probably an underestimation Particularly when you look at co-morbidity and in this case we are when there's a substance issue as well the overlap between those symptoms make make diagnosis quite quite difficult um But generally in terms of david I want to have a conversation Straight up around, you know, what what what his experience Reflecting a lot of what jeff has just said also, but then thinking about the broader picture in terms of what is recovery Often people will come in with a um understanding that recovery is really defined in terms of symptoms and function management So it's kind of looking at that through a medical perspective and as we've seen from the start of this the starting point But also encouraging a conversation about psychological recovery and this this draws on what what People with lived experiences the teams who come out of their stories around recovery include recoveries marked by increased hopelessness It's marked by increased meaning changes in identity to incorporate the experiences of mental and and substance abuse And taking personal responsibility for making recovery work. So these are particularly challenges for for for both populations of personalities Substance abuse because the avoidance of responsibility or making other people responsible for what happens next is is pretty symptomatic of But these both of these presentations. So so understanding that's really important from the get go But also then extending that into what is recovery has recovery what they look like in in oneself in in terms of one's relationships and in terms of community And therefore kind of we're necessarily tapping into attachment issues and How is this how is this person? Attached to new early relationships and how's that reflected in your adult relationships? What are the core relational themes that are showing up and how to how do people Elicit certain responses from from loved ones that that may reinforce those those experiences of being perhaps a victim And part of and again, this is Part of what Jeff was getting at I think is Being able to create a safe haven a firm attachment reliable attached in space for these clients to Basically Very briefly in trauma and attachments a really rich field that covers since that's really is implied implicated in in both personalities and Substance abuse history it may not be identified within all of those but it's certainly represented in the vast majority in this case Father was absent. He had a critical mother that might be considered an unreliable kind of attachment system And he was adapt some of his behaviors might be might be understood in terms of his adaptation to those Those experiences and in repeating those through his adult romantic relationships He might be described as having an anxious attachment. He has this kind of profile Particularly in that last case where he's talking about his recent relationship where he pushes for more intimacy wants to be close And just for whatever reason that his partner's experiencing Much and they threaten to leave him so they'd push they reject him and he threatens That's the cycle He kind of gets locked into an alcohol is kind of and other drugs are a big part of that cycle Um So, um, he's he's also saying is your first person he's ever he's ever opened up to um, I'd be I'd be cautious around that What does that actually mean? What are the implications of that in terms of you know becoming very quickly attached and And and repeating some of those same signs in therapeutic relations Um Other things that we don't haven't really got from the profile But things I'd really like to kind of unpack more and get a get a sense of would be to do with His his fracturing himself. How does that show up? How does he play different parts? Against other parts with himself like the critical pair and this disreactive emotional side And you know and anxiety is clearly a part of his profile and you know, so part of part of recovery from trauma and anxiety and Basically sit with a notion is learning how to actually be present to those experience Learning how to tolerate his his level of distress and not turn away from it so readily And there will be there will be Unfinished business that kind of comes in there and then looking how he shows up physically his His gestures his movements his bracing his fight flight responses the thoughts processes It's a reverent or maybe unpacked and any any evidence of any form of dissociation would be useful Um Trying to understand the function and the meaning behind um, David's substance abuse is critical because if if if in fact This is um primarily and I'm not saying it is but one one theory might be that he's um He's self medicating his psychological distress and he's using alcohol and or other drugs to do that and um, first of all My experience of working in the addiction field for 25 years The accuracy of which people report their their substance use is usually questionable in the first instance So there's ways of trying to get around that to kind of open open the open space up to get more information more information It may be seen that his his seeking security answer the in both his substance abuse and and in his social connections and his relationships So it's all externalized It's all taking something outside of himself to make himself feel better And he keeps his boundaries nice and kind of loose and blurry and you know, that's seen in his his attendance of um, or his lack of attending at the right times in Appliance with his pp and that's down to kind of roll over incident. He's psychotherapeutic intervention as well He's trying to numb his pain um Is presenting in a stress state Is using alcohol to feel strong who referred to that in his younger alcohol use and certainly to escape and avoid So really in terms of engaging him We don't want to just say stop doing that because it's serving a purpose We want to understand what that purpose is and and explore other ways that may be More helpful in terms of meeting that need so that it frees up some of the energy energy to kind of Turn some of that motivation towards change and moving forward So we don't want to get into this process of convincing him It's really using motivational interviewing skills is very useful in this regard Kind of help him activate his own motivation particularly when when his um, whole nervous system is fired up and he's ready to kind of go into Other other So I I feel that it came to me as I was thinking about David's In cases that David's relationship with his substance is substances resembles and mirrors his relationship with His life seeking security seeking soothing And that is I guess an underlying attempt to kind of Work through some of these original attachment injuries um Again, Trevor can I just just in the in And we will get to a lot of this in the chat box. So I was wondering if you wouldn't mind just just covering the last two slides really Briefly. Yeah. Yeah. I was just going to say that Jeff's covered some of this already anyway in terms of these key features Pulling different pieces from different models. Most models will be using various Maybe slightly different kind of emphasizing different parts, but there'd be elements of that in there anyway so so looking at symptom management as well as in terms of people's definition and orienting to the overall future direction of their account brief And lastly then looking at what gets what gets in the road the things that it's already showing up here for David in terms of activated and unhelpful relationship dynamics Exploring his boundaries his his insecure attachment dynamics are showing up. These are all risk that's risk Features and as well we need to look at clinicians responses in terms of pushing them away repeating those patterns and increase You know increasing the market And slipping into these these these roles or somebody's likely to reinforce that So again, just trying to try to avoid those things is really important and to be aware of Thank you. That's fantastic Trevor and look really everybody I would encourage you to revisit these slides afterwards and actually go and look these things up if you're not familiar with them Trevor actually while you're still there I actually wanted to bring a question from the audience and so I noticed on your Um perspective there about recovery and appearance one of the things is clinician burnout And um, there's a question that actually it just says our personality disorder is curable And I just wondered if you wanted to comment on that Can people actually get better? Yeah, absolutely they can the evidence is still in some respects to one's infancy Um, that the randomized controlled trials are showing and Jeff pointed to this before too that um, particularly things like Um, dbt and some of this psychodynamic approaches There's there is evidence that people can improve across a whole range of different symptoms Um, complicated in that though is the substance abuse stuff and we know that people can recover from Recover from substance abuse. So it's kind of how do you manage both of those things things at the same time is where the evidence is Integrated treatments rather than a serial of treatments. Um, it's the best way to go But we're looking at long-term treatments. This there's no there's no short fixes for this It's it does require usually if A a single relationship that's a reliable attachment frame and probably that'll be the core therapist Um, and often that will also be integrating other other services into the into the um into the mix Thank you, but it is yeah What I'll do I I think what you're saying there is really important and I know we've got a lot of Participants in the audience who work under the better access scheme and I have 10 sessions per year with the patient So I'm actually going to go over to hester now and hester as the gp the audience have been The psychologists that have presented to us have been quite comfortable with the idea of a long-term relationship in some therapeutic dependency kind of In the relationship That may be helpful for this young man But I know a lot of gps are really anxious about patients to say you're the first person that's ever helped me And you know you're already finding yourself making special exceptions to fit them in and it's only the second appointment And we're quite fearful of people becoming dependent on us So I just wondered if you wanted to comment on that how you might think about that as a gp But I think this is really really fascinating And and certainly I I've had that experience where someone has said, oh Hester you're the best gp nobody else understands me like I like you do and I think See what have I done wrong? What what boundary haven't I held? Look and in general practices I was saying before many of us have been in our practices for a considerable period of time We may well have the capacity And the knowledge and the history of that person But we also have the capacity to have a longitudinal relationship Unlike our our colleagues who are doing therapy under the better access scheme where they've got 10 appointments a year We can see people as often as as as we want as we need to But it is really being clear on those boundaries and what you can and you can't do And this certainly goes back to the point that was made before about how you integrate the care How you work with other people to ensure that everybody is on the same page The other thing I think for us the gps is around our anxiety at their distress Our distress at their distress and wanting to fix that and and the way it plays into us as practitioners who want to help who want to relieve suffering and understanding that we can't Do it In the way perhaps that we automatically would like to by offering extra appointments by doing things beyond what is okay So maintaining those boundaries is actually really important and it's hard to do I'm certainly for us the gps not many of us actually do supervision But I think that if you're seeing patients that that are as complex as David is That is really important for us to get some support around our own psychological space as well Okay, that's great. And I know that the the audience has been discussing self-care a lot in the chat box as well Thanks very much for that Hester and now Jeff. I wonder it was actually your um slides that introduced the idea about dependency And I I could could you comment to us about whether it's possible to actually avoid that kind of dependency and yet still be helpful uh, sure, um Yeah, I think the problem here is most people uh, if we talk about people with borderline trays have uh, uh an attachment style where there is both an immense fear of abandonment and uh, a desperate seeking for somebody who would Understand me and take care of me And I don't think you can avoid the activation of this and it sometimes does come as Hester was saying with an idealizing tendency that um, You know one moment you might be the best, uh clinician in the world But if that happens, it's likely that you're going to have clay feet Pretty quickly and we'll have to deal with that as well the thing is I think you need a way to think about the dependency to um You need a theoretical model an attachment theory as um treble was talking about provides us with the framework to understand this And with that in mind it it helps you to Think clinically about what's going on in the relationship And then to manage that in a way that um doesn't uh Allow the the slippery slope of of boundary Violations happening where the person's phoning you all the time and stuff like that So it's the combination of keeping a firm boundary Being available, but also finding a way with if we're talking about david to reflect upon what's going on to understand what his needs are How they weren't met in childhood how he seeks to meet them in maladaptive ways in his relationships with his girlfriends and perhaps his friends But also perhaps the therapist and over time hopefully uh begin to uh kind of process that and uh Help him to move away from this desperate seeking of care and uh to to a place where he's more uh self-sufficient Thanks Steph. Now, um, we will be we'll be continuing our panel discussion and and I can see lots of things already I'm really interested in this idea about we need to have boundaries that are both flexible and clear at the same time And I think this is a really complex work and test his recommendation for having supervision even if you're a gp Um, I think was really wise. What I'd like to do is invite the audience so you have a um You're going to have a poll come up on your screen And what I'd like you to do Is pick the one that you would most like the panel to discuss So there are uh those themes up there So things like about the prevalence and prognosis of personality disorder The relationship between personality disorder and substance use how to engage people with personality disorder Um things like choosing treatment and what order so if you could just choose your favorite and uh we'll That will just help the uh panelists to get a sense of what most interests you So hopefully you're seeing that survey at the moment And uh, the results are coming in there. I think it's getting close to adding up to 100 so we might uh We'll have 10 more seconds. How about that? Not that i'm exactly counting 10 Queensland seconds Okay I think we might close it there So actually the things that um people are most interested in Is the treatment options and the sequencing issues So what order do we do things and how do we choose what to do? Um, the next most, um Requested topic is around engagement. So how do we actually engage people like this to probably by definition are quite chaotic and and sometimes a bit challenging in their behavior So treatment options and the sequencing issues engagement and then pretty much equal around The relationship between pd and substance use and trauma So our panel what I'd like to do is to come back and we'll look at this from the the aspect of treatment options and sequencing issues And read back if I can just get my note. That's great. So now I can just slide back to our um panel discussion there So I think I might bring trevor back in So trevor with we'll go back to the case and to david so he's he's been to the gp and the dp's referred him to you What would help you think about where to begin? with david Yep, I think the immediate response needs to be safety We're not going to get anywhere if he's unsafe if he's still injuring himself If he's drinking to the point where he's putting himself at risk and then the issues from my perspective at least is to make sure we're establishing a safe place for for david and Again, the the key kind of interventions here The evidence is really clear that the integrated treatments are best So you're not you're kind of looking at treating both both diagnoses Both disorders simultaneously rather than than than one or the other historically It has been a bit of a ping pong match between Mental health services flicking patients who've got substance abuse over drug and alcohol And vice versa and people invariably falling through the gaps and hopefully we've learned from that over the last, you know 40 years Where it's been talked about so that integrated treatments are are giving prevalence Having said that it's actually not that easy to do because how who is the person that's that's um that's kind of negotiating Different treatment aspects and if somebody gets really unwell and if they need to be hospitalized To be safe than that that you know, that's a referral or that's a negotiation to try to get somebody in into a safer environment We also, you know conscious that this population is already over over represented in those more contained environments and therefore Step down options in terms of are there are there other things that people can do to manage those more More immediate crisis to avoid going to hospital if they can So so first of all safety establishing safety that can be suicide or self-harm contracts Um, it can be um looking at do they have a plan to suicide and come into them with that those things, you know as a as a priority and also Looking at their substance use and then if they're not prepared to kind of stop or or at least Engage in a conversation about it looking at can will they be more interested? Will they be open to reducing or at least, you know cutting down so that so that isn't Which is one of their main re which is a person's might one of their main respect is I guess in terms of any any self-harm or Suicideality substance use is often involved in that so if we can reduce the substance abuse and and Get them to a safe enough place that they're usually the first these are the first steps You know before we can engage in any of these repetitive problematic Interpersonal things that we've been mentioning It needs to in new safety needs to be priority And I'm Trevor. I'd just like to bring hester back in there So I think one of the things that gps can do is also some advocacy around very practical things So I might I often think about mazlo's hierarchy of needs and I know david's probably okay I think he's got somewhere to live and you know, he's going to uni He's probably got some kind of income support But hester it do you find that safety actually might involve things as basic as food and shelter? Oh, absolutely Absolutely. So homelessness is a real issue And you know the thing the thing for us in general practice is this is really hard stuff to do as a Single practitioner in your rooms where you've got 15 or 20 minute appointments You know, so actually having the capacity to bring in other services and be aware of what other services are out there So that the basic needs of having a safe roof over your head and food Are addressed because unless that's addressed you can't look at any of the other stuff And you know, it's not uncommon for me to see people that are homeless and they're using lots of drugs because life is just awful because they have nothing And if you found I mean, I think we probably all agree that having an integrated approach is Best practice but the realities of the system that's very fragmented You know, what are any you have some practical tips for how how for example a gp can know about all of those things that are available in their community And they're constantly changing the NGO funding changes the government. Yep exactly exactly and and as a gp You know, we're hearing that long-term treatment that there needs to be long-term engagement And yet what funding do we have the majority of people at 10 sessions a year, which is a drop in the bucket You're just trying is just starting at the end of those 10 sessions to get some kind of engagement and some trust there And then it's it's the end of it I'm always jokingly say don't get sick until october because you'll get 10 sessions in this year And then you can get another 10 sessions at the beginning of next year The other issue that is that we have is that mental health and drug and alcohol services are fragmented and mental health And drug and alcohol services are very small organizations And the ability for those services to work in the general practice and to work in with private psychology and counseling services It is it's very difficult You know, so but in terms of what's out there. I mean, certainly our local primary health networks Have been involved in some programs to actually access additional funding for people The dbt programs if you can get your patient onto them in the public system is a very long wait But if you can get your patient onto them, that's brilliant Private hospitals quite often will have dbt programs. So one of the things that that um, you know Is a real godsend if any of your patients or their families actually have private health cover So that that can support them as well. I I just I don't have any great solutions I think it's a really tricky area and we're letting this with the people down through the funding and system Issues that we have Yeah, and I mean, I guess one of the things you have mentioned there is is actually becoming aware of what is available in your local area And even if it's constantly changing being willing to be kind of flexible and innovative in cobbling together some kind of program But um, but and that requires so much collaboration and communication. This is why we have these webinars so I think um Jeff you probably are Perhaps in more of a position to provide that long term therapy and I wondered if you'd like to comment about that sort of domain Yeah, it's important to remember that that all of the evidence-based treatments for borderline personality are both intensive and long term most of them involve attendance twice a week and uh And often recommend at least six months, but usually a year or so of treatment those links are really established by Research considerations about how long you can do a research research project for most people know that people with Significant borderline issues will be in treatment if they stay in treatment for more than a year Sometimes for several years and that's that doesn't that's not determined by the type of treatment Now I'm sure a lot of people out there when they hear this we're for Psychologists when you've got people have 10 sessions a year It's going to make their hair stand on end. So how can we make this work? Um as Hester said that there is some support for some people from private health insurance But in my experience People who do engage in treatment And feel that there is some hope in it will often work to pay for treatment and I've seen people Who've had um success in therapy over the longer term who who I who will work really hard to to make sure they have the money to pay for treatment um, but for those people Who are so dysfunctional that they can't work even part time or they don't have the resources to do that Then yeah, unfortunately the public system is is what's available and uh, and as Hester said there's long waiting list for that But we need to kind of think about you know What what is it that is shown to work and then deal with the realities of that and uh, and often patching together sessions with the gp and uh, um Other psychologists can uh help to to provide more extended support, but um The the long-term treatment is possible If if the person engages and they do have the capacity to work and pay for their own treatment And thanks Jeff and I think one of the things that came out in both yours and trevor's presentations at the beginning was the um Importance of the therapeutic relationship and even if someone is very chaotic and just Hopping into the gp three or four times a year if that relationship and those consultations are Helpful and therapeutic. I've noticed that sometimes people can kind of calm down and become Come to a more functional place where they can then engage in the longer term therapy so I I think I'd like to bring um Trevor back in now and remembering that the audience is really interested in um treatment choices and and sequencing and the In the registration questions. There was a lot of questions about is there a difference? some some one way of viewing it is that the substance you is another unhealthy coping strategy for Emotional difficulties so someone who can't regulate their emotions in healthy ways is doing whatever they can to make themselves Feel better and the substance use is just part of that so the primary problems the personality disorder Other people view them as two separate problems so wonder if if there's a how do we Think usefully about that and how do we make a decision about which way to go? Yeah, I think you're right and I think um Yeah, people who have substance abuse problems when they're in active addiction will will often demonstrate a whole bunch of the characteristics of Would meet the criteria for personality disorder. It's kind of a chicken or the egg argument and I think I think the um the um key point is Where does the person where's the person engaging? So if they're if they're um They're contacting a substance abuse facility for example then and and it looks pretty clear that um, there's also personality disorder There is the is that facility um Open or skilled enough or or at least able to to bring additional kind of Services into address address so the motion regulation stuff and the stress tolerance and And start to kind of unpack some of those relational dynamics that are problematic for them So it's kind of not many doors It doesn't matter which door somebody comes through if we if we really are working towards I'm trying to provide as an integrated approach as possible and you're notwithstanding all the all the challenges that that people have mentioned that this is hard to do because people people In services services in particularly are not necessarily that that well integrated and and you know in first instance We need to be working very hard to kind of do more of that um But regardless of which door somebody walks through they all should they all should be able to go to get the range of Of treatments necessary I mean my my rule of thumb is if the drinking in this case in david's case if the drinking is causing problems The drinking is a problem and and it's not wise to just see it as a A coping mechanism because of an underlying personality I think I think they both need to be treated equally in that regard Okay, thank you and I think hester you I'll just ask you the same question So is is the I mean, I think you're there's a distinction between dependency or just problematic you but um Yes, so could you just answer that same question about is this just a way of coping with difficult emotions? Just unmute your microphone. I'm talking away. Nobody could hear me. Um, look, yeah, I think this can be A number of different things, but the really important thing from my point of view is that we're talking about substance abuse I have a great deal of difficulty with the idea of this. I know it's in the bsm But abuse. I think it's quite problematic in itself. It's it's quite judgmental but also we've got the issue of physiological Dependency and you have to treat that you can't just think absolutely It might have started out as a coping mechanism But they have actually developed a chronic relaxing medical condition and you do need to Diagnose, you know, where where are they on that dependency spectrum? And when they try and stop, what are their physical withdrawals like? We can't just allow people to think that they're just going to have to manage that that needs to be medically managed And it can be dangerous as well. You know complicated Withdrawal from alcohol, which may not be the case for this young man But he's he's you know, he's drinking daily Um, and he's very likely to have really quite uncomfortable Symptoms when he tries to stop drinking for supporting him understanding that he will need that support for his physical dependency that he's developed at the same time is helping him to understand how It originated as perhaps as a coping mechanism that he is now using that is causing him harm And understanding that it is a chronic condition that doesn't just you don't just detox when it goes away And so that's that's again where that collaboration between the different kinds of services might be really helpful if you don't have a Shop, I mean, it's absolutely very difficult to find medical detox Where I am. I'm not sure if that's the case in Sydney or Hobart or Canberra, but Many of these patients can be managed in the outpatient setting For us at GPs a lot of us are not confident around that but it is possible And what I would be saying to GPs is how to talk to your local drug and alcohol services get advice get support There's DASIS, which is a 24 seven Number in New South Wales which has drug and alcohol experts and there are other numbers in other states as well Dacus and DASIS in other states So get some advice around does this person actually need to be admitted Or can I actually manage them in the outpatient setting with picking up the medication to help the withdrawal And the detox can they do that from a pharmacy? The other thing I just wanted to quickly say is that you know to all the counselors and psychologists I love that when you when you call me. I love it when you speak to me I love it when we can work collaboratively I am fortunate as a GP that I can charge under Medicare for case conferencing So, you know, I really do value those conversations and it's really important that we do make time to actually try and work To have a common kind of goal With the with the patients involved and of course working together so call me Thanks, Hester and I know like the time's going really quickly as it always does and we can see so many different directions We could go so I have to apologize to the audience that we cannot possibly answer all of your questions tonight but um So Jeff, uh, I might just come bring you back in. Have you got any tips for us around things that have worked for you With regard to collaboration So when you have had someone where you've perhaps been providing the therapy and they've had a co-occurring substance use disorder or problem You know what what's work? How how can collect? Have you got any tips for how we can do this in a practical way to work together? Yeah, I would um pick up on what Hester said and I think it's important to keep in contact with other people involved in the person's care and if someone has A serious alcohol problem for example and they need detox Then yeah, you have to coordinate with the the local services and ensure that that happens That's not something that That should be supervised by a medical person and Yeah, I think it's just important the most important thing is that we talk to each other and as Hester was saying and make sure You know, we're on the same page and if if what if if there is some misunderstanding can make sure that's clarified uh, often the the what I find is that The the treatment of people with personality disorder is long term and this needs to be explained because Other people involved in the care can begin to question. Why is the treatment taking so long? Uh, but if you knew the person's large story, there's their trauma background Then uh, it would be obvious that you're not going to solve this in 10 sessions So I think I would just uh reiterate. I think the key is communication Great, thank you And I think one group that we haven't really mentioned tonight That's really important is that the families and carers of the patients that we see as well And I know trevor that's been an area of your interest and I just wondered if you wanted to comment around How you might collaborate with I mean, I don't know about david's particular situation that how do you begin? Yeah, look, I absolutely agree in some in some respects We can kind of look at the family and carers and loved ones as as um as being The diagnostically and kind of in terms of case formulation You want to include that to kind of see it because often they are like a trigger. They're they're often involved in in um in relapses So but they can be a great a great relapse prevention and in fact recovery support In themselves. So even though primarily we've been talking about collaborating between services Fair our carers families. I love ones that are often Even friends and even employers are often people that aren't Accessed enough in order to support that person Of course with the client's permission That they become part of the actual treatment itself and some tremendous work can be done with with couples and with with family interventions and and empowering Families to to be able to be recovery supports And notwithstanding that that we know that the carers and families have their own challenges. They're often one of the most distressed populations in our in our population And and often go unrecognized and their levels of distress unless they've got some skills to manage those will will often will often contribute to Distressed within the relationships that the the clients like jeff are faced with so if we can intervene at that level then we have an opportunity to to Kind of redress the whole system around the person and not just that that isn't an isolated individual because it never is so yeah Ways to do that again would be starting with In invitation by a by a permission with the client getting consent to do so um But also, you know looking at what what do they see that the issues to do that can be really useful information in of itself But also what part they may be playing in it and get into that that recognition And then looking at some skills to kind of manage that and then then overcome some of the dynamics that are being perpetuated by these relationships Thank you, so we're just very near the end of our webinar. I'm going to invite each of you to To just give us a Couple of a final point that you'd like to make and I just want to acknowledge that we still have 1,520 people online And more than that because there's groups of people as well. So it's just fantastic to See people's interest and and obviously the commitment to helping people with these really complex problems In a system that isn't always set up to do it in an ideal way Um, Hester, I'd like you to just comment if there's any final take home message that you want to leave the audience with tonight But yeah, thanks, Mary Look, I I think but apart from all the other stuff that we've said the other thing is really taking a good drug and alcohol history So that you understand where they're sitting on that spectrum of dependency But also that stuff around helping to enhance their sense of self-efficacy Because you know, we want to jump in and help and I get it But it's actually learning to walk that line between giving them the support they need But also helping them to take control of their lives and hearing their stories Being witness to their stories. I think is the most important thing I finished with Thank you. And I would like to invite Jeff now if you had something final that you'd like to say Well, that was a good segue from Hester because I'll start with uh empathy I think most people when confronted with These kind of serious problems with people with personality disorder their empathy goes out the window because Often strong emotion is a vote just in in the therapeutic relationship. So I want to say a couple of things one is uh, these are people if you knew their story If you were in their life, you would be like that too. So strive to understand What the person is struggling with and where they've come from the other thing I would stress the psychologist is use what you know if you've got training in in Psychodynamic therapy like I have or dema therapy or something like that. That's fine But many people in country situations may not have that training However, use what you know. Um, if you have training in other interventions, then you can integrate treatment by uh Looking at what problem markers are coming up in the session and use effective interventions to address that in a modular fashion Most of us do this anyway We we've we've all trained in all sorts of different therapies and we tend to find what works for us with our clients and Yeah, so my other message would be use what you know Thanks, I think that's really practical useful advice And and I didn't acknowledge that we do have a lot of uh, rural and regional and even some remote Participants in the audience Remember that what you've got is often good enough or at least it can make a big difference And then finally, uh, treva. I just wondered if you wanted to offer anything in the wrapping up Yep, I'll just extend on some of that too in as much as um, when when we faced with with multiple comorbid conditions that um That we're not necessarily starting with The worst-case scenario, I mean people will have strengths people will have things they can tap into To assist their recovery. There nobody's kind of You know, there's no no one actually lives in the vacuum even though some people's lives are very You know reflect that often if there are still strengths there recovery is built on strength It's not it's not built on on problems. We can skill people up to manage the problems But really recovery moves forward with people finding what's actually not broken what is working what they can lie on We can add to that in terms of our Liability of therapists to be able to be there for them consistently Thanks treva and thank you to all three of you first of all for your um, Really fantastically useful slides and resources and then for the conversations that you've that we've had It's it's been really helpful to know that even someone with the kind of complex presentation that david brought to us That there are ways in which people can be helped and indeed can recover And particularly that when we're able to work together with with each other with the patients and with their families and carers And even as treva pointed out all kinds of people may be useful And I guess that the key thing I got have got out of it all was that you know We need to know our stuff well know our theory well be thorough in our assessments But actually the relationship is really important with each other and with the person and their family so thank you all so much for um participating and I would just like to before we finish just to remind the audience to please complete the feedback survey before you log out So it'll come up on your screen if it doesn't there's a feedback survey tab at the top of the screen You will receive an attendance certificate in two weeks if you registered to the webinar And you'll also receive an email with a link to the resources associated with the webinar including our recording of the webinar in the next few weeks And the other thing is that um project air runs other activities You may be interested in and mhp and also runs their webinars So please keep an eye on both those websites for professional development and once again Thank you all very much for your participation this evening and hopefully everybody stays warm and enjoy the rest of your evening Good night