 Hello everybody and welcome to the over 600 people we currently have online for this MHPN webinar tonight Borderline Personality Disorder, translating evidence into practice. Great to have you all with us, we've got a fabulous panel tonight and I think we're going to have some really interesting conversations. I would like to begin by acknowledging the traditional custodians of the land, seas and waterways across Australia upon which our webinar presenters and participants are located. We wish to pay our respects to Elders past, present and future for the memories, the traditions, the culture and hopes of Aboriginal and Torres Strait Islander Australia. So my name is Steve Trumbull and I'll be facilitating tonight's session. I'm a GP by training in a metro rural and remote settings at various times and a professor of medical education at the Melbourne Medical School. Before we meet the panel, I would like to just remind people that the purpose of the webinar tonight is to give health professionals the skills they need so they can help people more effectively in future. There'll be personal stories of illness tonight which are very important and MHPN often includes consumers and carers on our panels as we have tonight. The chat box, however, is not a form of personal stories. It's designed to complement the panel discussion by allowing professionals to share resources, experience and thoughts during the webinar but it's not a place for people to post personal experiences. So thank you for respecting that. If there's any content in tonight's webinar that causes stress, please do seek care if you require it and contact us via beyond blue on 1300 224 636 or contact your GP or other local mental health service. So here's tonight's panel and the bios were disseminated with the webinar invitation. So in the interest of ensuring we get through as much content as possible, I'm going to skip over those bios and presume you've read it. The first person we'll be hearing from tonight is Sophie Lucas who's in New South Wales and a peer worker educator lived experience. Sophie, it's always fabulous to have somebody with lived experience on the panel as an expert tonight. So what is it that inspires you to do the work that you do? Thanks for joining us. I guess I do the work that I do because I feel like I've missed out on a lot of great care that could have happened like from hearing someone else who's gone through similar mental health journeys that I've been on. And I think that would have really helped me especially when I was younger. Yeah, I've been with mental illness since a very young age. And yeah, I lived experience stories was something I didn't know about till. Years after my first diagnosis. So that's why I do peer work to share my story and to inspire others and also to help anyone in a professional way like this is what it's like on the receiving end of treatment. Fabulous. Thank you so much. So what you contribute tonight will help others and that's all about paying it forward. So it's fabulous to have you. We also have on the panel Dr Diana Bart from South Australia. Now, Diana, you're a clinical psychologist by background, but your real role here tonight is to introduce some of the research concepts current within the management and supportive people with BPD. What was it that led you from clinical psychology into more the research side of it? Thanks, Steve. I guess one of the things I found in clinical practice is I wasn't really sure what to do. I'd go to the literature to seek answers to these questions. And often in this space we're working with people with BPD. There were many gaps in the literature and that kind of sent me down a path of being really interested in clinical research. Great. Well, I will. You bring that to us tonight. That's fabulous. Thank you very much indeed. We've also got Professor Bryn Grenja, South Australia. Bryn, are you in New South Wales? New South Wales. New South Wales. Okay. Well, fabulous to have you. I thought you were in New South Wales. What's on your desk at the moment in terms of research projects? What are you currently working on? Well, it's really exciting to be here and thanks and it's so wonderful that 600 people have joined and to see also quite a few good friends joining too. Project AIR is a personality disorder strategy that I'm working with and we're really passionate about spreading hopeful messages about effective treatment across Australia. We've been doing a lot of work in New South Wales, but we're also really happy to have shared our experiences with people in other states and territories, South Australia, Victoria, and doing a big piece of work over the next five years also with Queensland. So we're really excited to be here and to do this kind of webinar. Right. Well, it's a fabulous connection between research and clinical practice. So we're fabulous to have this opportunity to hear from you. So thank you so much. And last but not least says Professor Sathya Rao, who is a psychiatrist based here in Victoria, just around the corner. Actually, I'm in Carlton at the moment. Sathya's services in Richmond, but I must confess, I know very little about it. You're the clinical director at Spectrum. Sathya, can you tell us a little bit about what that service is and what you do in that role? Thank you, Sathya. Spectrum is a publicly funded statewide specialist service. And we specialize in working with people who have a birthside disorder on a complex trauma condition. So we provide psychological treatments such as medical behavior therapy, visualization based treatment, substance and commitment therapy, and an integrated common factors approach at Spectrum. We also provide secondary consultations to all the public mental services and some of the private sector and some primary sector across the state. And we also have, we do some work interstate with complex, where clients might have some complex needs. And that's briefly about us. We also do a lot of training and we have trained about 5,000 clinicians last year. And we also do some research and advocacy. Thank you. Great. Wonderful. Well, thank you. It's great to have actually you and everybody tonight with such expertise in this field for a really informative discussion. We're not having a case presentation tonight and a case discussion. We're talking more about each panelist will give us a presentation and then we'll have a conversation about that. And most importantly, we'll react to your questions that you can post in the Q&A, which means I must now take us through the mechanics of operating the system. See that there are three dots in the lower right corner of your screen and that's where you can access a whole lot of information. Under the information tab, you'll find links to the slides that are being presented tonight. Other resources that the panelists are recommending to us. There's a survey there and also you can access technical support. The ground rules for tonight is to be respectful of other participants and panelists and to keep your comments on topic in the chat box. Obviously, what's in the chat box is a publication so be very careful not to put anything there that you wouldn't wish people to be reading and hearing. So what's going to happen now is each panelist will have a short discipline-specific presentation followed by the Q&A between the panel. The learning outcomes are really important. We take this very seriously and it's what we base the evaluation around. So the aim is to discuss the latest borderline personality disorder, BPD research, evidence-based assessment, intervention and treatment strategies including psychotherapy with a focus on how mental health practitioners can best work with people who are living with BPD. The learning outcomes are there, you can see them. Outline the major themes and findings from recent research on BPD, improve understanding of the way people present with BPD, prevention of stigma, interventions and treatments and particularly identifying evidence-based strategies for how we as health practitioners can effectively support people living with borderline personality disorder. So there we go, that's all the introductory stuff done. We need to get on to the major reason why we're here tonight which is to hear from these four experts and then to get involved in a conversation about what they've said and what questions you have. So don't forget to be posting your questions under the Q&A tab there as mentioned before and we'll see what pops up there. Here we are, we've got somebody now, Michelle's off the mark so it is possible to post a question. Thank you Michelle, we'll get to that question coming up about high school students which is great. Before we get there, Sophie's not too long ago for you high school but we do want to hear from you about your presentation now so thanks very much indeed, over to you. Thank you. From a clinical perspective, borderline personality disorder is compromised of nine different criteria and a person needs to meet at least five of those for a diagnosis. This means there are 256 combinations of criteria for a diagnosis. From a personal perspective, I see this as we are also individual and can have such different experiences and with that comes a lot of strengths that we all possess and also differences in what treatments may work best for us. Despite people with a diagnosis of BPD being able to live amazing lives and reach our dreams and goals, cold strengths and positive values there's still so much stigma around. This makes it hard for us to speak out and to receive the treatment that we need and to access services. Next slide please. To be treated with respect and dignity. When things are rough, we need to be heard. We need empathy, validation and for someone to hold hope. Just like anyone else with any other diagnosis. We seek treatment and support. We seek connection, yet we are met with stigma, harsh reactions often made to feel like we don't matter, sometimes denied treatment. Next slide. October 1-7 is BPD Awareness Week in Australia. In 2019, the theme was flipping the script and was held created from the voices of those with lived experience. A lot of common stigmatising words that are strongly associated with BPD were reframed into something more hopeful. I shared these posters including these two slides that you've seen just before and right now. I shared them last year throughout a peer and clinician-led group for people living with BPD that project their strategy read. A lot of the participants found these posters helpful and such a beneficial way to reframe the hurtful words that we are often met with. Next slide. Redefining the language we use, not just as people, but also as mental health professionals, can be beneficial for everyone. Using words that convey hope and optimism, using strengths-based and person-centred language that is not stigmatising can have a huge impact on someone. Dialectical behaviour therapy is the gold standard for treating BPD. I still remember the first time I tried DBT. It was early on with my diagnosis. Group therapy was something I wasn't prepared for and I was only doing DBT then to make others happy so I felt it didn't really work. I went to about three sessions and then dropped out. I didn't feel comfortable sharing really vulnerable parts of myself in front of what felt like strangers in a therapeutic setting. Sorry, the lights turned off. At the same time, I was doing 101 schema therapy as part of the DBT group. The psychologist I had been put with was able to keep seeing me for the time allocated and with some gentle nudging, hope-holding, validation and person-centred care, things started turning around for me, albeit briefly. I'd spent a lot of time seeing psychologists and doing CBT, but nothing really changed for me mentally. Once I got into schema therapy, it's like the puzzle pieces started fitting together. I also got to try something new with that psychologist and ask them a few questions. They were just some based on my own interests such as if they like cats and seeing the psychologist in a more personable way really helped with creating a safe space. As a peer worker and having been a participant in peer group therapy, I feel like no more aspects of that person can help break down that barrier and make building rapport easier. Unfortunately, I could only see the psychologist for the year, but I was able to find another one locally who also does schema therapy and was able to take me on. After giving consent for a bit of a handover between the two psychs and with the new one having a bit of knowledge about what I want to work on and what's helpful for me in a therapeutic setting, I got everything sorted and started with them who I still see to this day. I know it's a safe space. I was able to ask a few questions of my own at the start and doing that made such a positive impact for me with helping to build the rapport and create a safe and trusting environment. Next slide, please. Next slide. Thank you. I've also done a few more rounds of DPT. Attending on my own decision really helped make it easier for me to learn the skills and keep practicing them on a daily basis. Being ready for DBT in a group therapy setting made such a huge difference for me. Knowing that I had to be vulnerable in front of strangers, knowing that the skills I learned needed to be practiced daily and knowing that I had to put in a lot of work for change to be felt and seen. I also really appreciate when the clinician practiced the skills with us. Knowing that they used the skills and the skills helped them makes them feel more favored. I find that it is such a powerful impact with peer work and a part that I really enjoy. Talking about the skills I use and when I use them throughout the day and being able to be honest about it being hard at first but with practice comes achievement. Next slide, please. When someone asked me how best to support someone living with BPD, I tell them a few of the things that have helped me throughout my life. Listen to them, really listen to them. Validate them and hold hope. Be there for them yet also keep your own boundaries in place. Be open with them when you need to take a step back or are busy and let them know you'll be back for them. Remind them of their strengths and remember that self-care is important for everyone. Thank you. Thank you so much, Sophie. That was exactly what we needed to hear. It was really important. There are a number of questions that have come up that relate to what you've been saying. So we'll save those until we get to the conversation part of the end. But there's certainly lots of things people want to hear about. So thanks again for telling us your perspective. We will now hear from Diana, particularly with a researcher's perspective. Who do you, Diana? Thanks. Thanks. So as mentioned, I'm the research coordinator at the BPD Collaborative in South Australia. And we're a statewide service that was established in 2019. So I'm going to speak to some of the research that relates to the steps for model of care that we've adopted and how we aim to engage people with a lived experience in service development and delivery. So the literature shows that specialist therapies for BPD, such as dialectical behaviour, mentalisation-based treatment, transference-focused psychotherapy and schema therapy are effective in reducing overall borderline personality disorder symptom severity when compared to non-specialised approaches. However, access to intensive evidence-based treatments is limited due to the duration, cost, and also the lengthening to density of training for therapists. As such, stepped care models have been suggested. And that's defined by beginning with the least intensive treatment that's likely to be effective, monitoring response to increase or reduce intensity of the intervention according to the person's need. Next slide. So compared to specialised therapies, there's much less research into brief interventions for people diagnosed with BPD. Some research that comes from Victoria found that in order of coroner's records, among people with a diagnosis of BPD who died by suicide, 25% had presented to an ED in the previous six weeks. And this is kind of paired with research that shows that there are inconsistent responses to people with BPD in emergency settings, which suggests that it's important for us to have structured ways of responding to people in an acute crisis. Other research has shown that people with BPD benefit from psychoeducation soon after diagnosis when compared to weightless controls. Also, brief interventions such as Gold Car, which is promoted by Project Dare, have been found to reduce BPD symptoms of various distress and improve quality of life. And this is a approach that we've been implementing across South Australia for the last three years. Next slide. When considering short-term interventions, meta-analysis suggests that psychological therapies less than six months in duration may be effective. However, the studies have many limitations, which means that strong conclusions can't be drawn, but it does suggest or contrast with historical recommendations from clinical guidelines that short interventions should not be offered. It's also been suggested that less resourceive, intensive therapies could be developed through integrating common factors from effective evidence-based therapies for BPD. In a real-world setting, patients in both the short-term and extended care clinics with BPD demonstrated outcomes. So while some patients need longer treatment, the results are encouraging for short treatment as a first step in care. In South Australia, we've currently have a non-randomised control clinical trial comparing naturalistic weight lists to 12-week group intervention developed based from common factors of evidence-based therapies that we're evaluating. Next slide, please. One of the other projects that we've been working on is our peer-group co-production. So it was clear in the development of our model of care that consumers wanted to act about peer-groups specifically for people with a diagnosis of BPD at the time. A co-production approach was undertaken with a committee of people who had lived experience of Borne personality disorder. A peer group was developed, which is 10 weeks long. It's co-facilitated by a lived experience officer, Jess, in a senior mental health commission here at BPD Co. We interviewed participants, 22 people, who'd completed the group, and then themes the responses from those interviews about how they found the group. The key themes that came out were that it provided them with growth and change. It helped them to feel connected and feel understood, and one of the clear things that came out was the importance of the shared experiences. So it was also noted that the group helped them create a situation where they felt safe, and they particularly valued the equal footing between them and the facilitators. Next slide. So we've also had a number of students to research projects with us over the past couple of years, and these have looked at attitudes towards people. The first one, Sierra, found that positive correlations between personality pathology and minority stress among estranged sexual and gender minority populations, which suggested that clinicians should ensure they consider sexual or gender minority status and the associated minority stress when diagnosing personality disorders. We also had Rhea, who found that psychiatry trainees at the end of training had a significantly more negative view of patients with BPD compared to early and mid-stage trainees, which was very concerning and highlights the need for us to look at interventions in that space. Finally, Molly evaluated a foundational training, a one-day program that's being offered to clinicians, and we delivered that with experts who lived experience. She found that dis-improve clinicians' attitudes towards people with a diagnosis of BPD, particularly for those early in their career or whether they had less experience with people with BPD. Final slide. The key messages are people with a diagnosis of BPD may gain benefit from structured psychological interventions spanning from one to three months while waiting for access to more intensive evidence-based therapies. It's important to engage people with a lived experience of BPD and their carers in training delivery and the co-production of interventions. Thanks. Lovely, Diana. Thank you very much indeed, and certainly there's been a very positive response in the chat box to Sophie's presentation and also some responses to Diana's presentation. I think it would be interesting when we do get to our conversation to compare the research versus the personal experience of Sophie and such things like being in a group and what that feels like will come to that. As I say, all these teasers coming up once we get on to our conversation. But first of all, we'll hear from Bryn, who's going to give us the clinical psychologist's perspective. Thanks very much. Thank you so much. And look, thank you particularly to Sophie and Diana for those really important introductions to what it feels like in terms of the lived experience and what actually helps. And I think there's a few myths that are being broken down here tonight around things around stigma, about hopefulness and about the real benefits of psychological therapy, which is the treatment of choice. And Sophie talked about her experience of both DBT but also doing schema therapy and the importance of the relationship and how it is that that really helped to build trust and to build a real sense of recovery journey for her. So I'm going to just say a few words about when we ask people with lived experience and when we study longitudinal outcomes and ask the question, what do people really want? Well, what they really want is to love and to work, to be able to get on well with others and to hold down a job or to finish their study and to do something meaningful. And when you look at people who do well in therapy, often it's alongside psychological therapy, they're also contributing in some way or maintaining some sense of stability. And in many ways, what it does is reinforce our basic understanding that in many ways, this BPD is often a disorder of relationships and being able to get on well with yourself, with a therapist, with partners, with families, with schools, with employers. And so when we go in and offer psychological therapy, we need to very much think about how can we help the person develop a more stable and more constructive relationships with all of those aspects of their lives. Next slide, please. So I've developed these seven steps to good enough therapy and it's really, I suppose, trying to show the wisdom that we've learnt from both research and our own clinical practice for what can really make a difference. The first, of course, really does reinforce what both Diana and Sophie talked about and that is stigma is a really big problem and we really need to focus on compassionate care and ensuring that people understand what's going on for them. I think, you know, Sophie talked about how she didn't know what was happening to her for a long time. A lot of the people we work with say that the problems that they had started when they were at school, but nobody actually recognised them then and it was only five or 10 or 15 years later that they actually found out and got the right diagnosis and worked out what kind of treatment they needed. Many people with lived experience say that the start of their recovery is when they got the diagnosis and that helped them to plan for what needs to happen next. And even though diagnosis is controversial, what we do know is that not telling people what's going on for them, not helping them to understand the nature of their difficulties keeps them stuck often and that often leads to a lot of negative outcomes. So we do need to be hopeful as well because we do have treatments that do work and as Diana said, short-term therapies do have a place. Although there can be a lot of helplessness and hopelessness about personality disorders and a real kind of a myth that you can only do effective care if it's very long term, the research from our group and also internationally shows that even brief episodes of care can really make a difference and so I think we should all start off with the idea that doesn't matter how short our contact is with somebody, we can do good work and really help. The third step is really to focus on relationships both inside the therapy and also outside in terms of families, peers, employers and really to focus on, I suppose, what it feels like inside people talk about in terms of not really understanding themselves and not really understanding others. We also know in that step four everybody has the capacity to make choices and being able to make choices and showing some agency really does help to set people on a recovery journey and that can be difficult because often people at the start of their care often say, I don't know what I want, I don't know, I want you to help me, I want you to tell me what to do and can be very kind of like, I suppose, external in their locus of control and our role as therapists is really to be curious and try and help them get onto the stage where they can recognize that they do have choices and that they can do something different today, tomorrow and over the next week that'll make the following week better than the week that they just had and just start in the here and now around how to live a life worth living and how to improve the moment. That means that we have to be active in the therapy room. In many ways, this is not the kind of work where you just sit back and hope that by the person talking about all their problems that they'll all just kind of get resolved. You actually kind of need to step in there and help them shape what the future might look like and what things that they can actually do to help them with their current challenges to really help them learn how to solve them themselves and how to provide our input and our guidance in that journey. And to do that, we know that often people with these difficulties have trauma. Not everyone has trauma who has BPD. Some people do. Some people are in situations where they also have multiple diagnoses. They might be in a neurodiverse. They might have other kinds of challenges, substance dependence or whatever. And in many ways, our first goal is to create a sense of safety, stability and predictability. And that can even be something like just saying to the person, you know what, this is your hour. I've set it aside at every week and I will be here whether you come or not. And let's just see how far we go. And that, I think, gives people a sense that, you know, you're predictable, that you know that you're going to be there for them and that you're offering yourself to hold a space in your mind for them. And that really makes a big difference. And I think the final thing, and this is probably, you know, a common experience is that this can be hard work and people can, you know, feel very suicidal. There can be all sorts of crises and difficulties and therapists need to look after themselves as well. The best way to do that is really just to have a trusted colleague that you talk about what's going on in the progress of the sessions with your client so that you can calibrate your own reactions, maintain your own hopefulness and in a sense help you to look at your own counter-transference responses, which can sometimes be blind spots. There can be rescue fantasies that we might have. They could be impulses that we might have to reject the person or withdraw or overlook. And so that we can try and maintain, I suppose, a good enough therapy approach where we can be honest and recognize our limitations as well. Next slide. Just a final comment on that and I suppose this is one of the key messages in Project A that I work with. We say a lot is to keep coming back to you. And that is it really helps in many ways to slow everything down because with people with personality disorder and BPD, often the experience is people become reactive. So they become very risk-averse. They become very panicky and worried. And often what people really want is for you to be reflective rather than reactive. And that means that we need to model to be contagious through calm to help the person slow things down. Just like when you make a cup of tea, you've got to boil the water, put in the tea, let the hot water seep with the tea leaves. And by the time you poured it out, you're in a different place than you were when you first put on the kettle. And that kind of sense of letting things brew and letting yourself really share and understand the situation is such a powerful, I suppose, way of us thinking about what we can do to be effective in the room and with families and carers and others who we might be consulting with at the same time. Thank you. Thanks, Bryn. Seeing in the chat you've given Fran a light bulb moment at least with your presentation, which is great and plenty of others also getting a lot out of that. Lots of conversation going on about the challenge of appropriate diagnosis. I'm sure we'll come to that in our discussion as well. So now the final presentation of these prepared ones is the psychiatrist's perspective from Satya. Over to you. Thanks, Tim. Before I start my presentation, I just want to thank Sophie, Diana and Bryn for the excellent presentation they've done, which makes my job much more easier now. I'm going to talk briefly about what's the current understanding of the causation of borderline personality disorder, diagnostic issues, and the biological approaches to treatment. Next slide, please. Let me start with the age of onset. BPD usually emerges during adolescence. And according to the NHMRC guidelines, one can diagnose borderline personality disorder from the age of 12. Post-puberty, of course. And, of course, we need to commence appropriate treatments. And there's a lot of good work from Australia to show that early intervention works quite well. However, we know that BPD can present across life stages at any point in the life stage. Late manifestation of borderline personality disorder is also known. It can manifest for the first time, even in 50s and 60s. We at Spectrum have recently diagnosed someone with borderline personality disorder for the first time at the age of 76. And we offer treatment, and this person has successfully improved. Next slide, please. So what causes borderline personality disorder? We know that biological and cyclosophistic factors together probably cause borderline personality disorder with each person having a unique pathway to developing BPD. However, there is dispute regarding the relative contribution of these factors. Next slide, please. We know that there are some problems in the brain. Specifically, the emotion brain, the amygdala, is overactive. And the part of the brain that is meant to control, modulate or regulate the emotion brain is less active. And half of the reason why people seem to develop BPD is probably because of genetics. The genetic irritability effects in borderline personality disorder is about 55 to 68%. This is a mathematical model. What it says is that if it was 100%, every offspring would have developed borderline personality disorder. It is also known that the first degree relatives have a higher chance of developing borderline personality disorder. It's about five times. Next slide, please. Trauma is very, very common in borderline personality disorder. My colleague, Brinn, alluded to this. And trauma-informed care is absolutely essential. However, trauma alone does not seem to cause borderline personality disorder. Trauma is a clear risk factor, but not essential for developing borderline personality disorder. Trauma in the presence of biological factors may result in borderline personality disorder. My colleague, Brinn, again mentioned that not everybody has trauma when they have a diagnosis of borderline personality disorder. So when it comes to trauma, correlation, yes, causation, probably no. Next slide, please. So what is the contribution of biology versus environment when it comes to causation of borderline personality disorder? In the past, this resulted in the debate of nature versus nurture, which is probably now quite outdated. Now we need to consider nature and nurture, nature via nurture or nature via nurture via nature. Next slide, please. So when it comes to borderline personality disorder, co-occurrence is very, very common. It is actually the norm rather than exception. Sophie earlier on mentioned how each person with BPD is unique when it comes to the symptom profiles. Only 5% of people with borderline personality disorder end to present only with BPD. BPD has been said to be the king of comorbid kingdom by one of the experts highlighting the significant overlapping and co-occurring mental health conditions. This is a very important issue that we need to consider both while we are considering diagnosis as well as when we are looking at treatments that we offer for people with borderline personality disorder. So you can see on the slide some of the important co-occurring conditions in the interest of time. I'm not going to go through this list, but I'm going to wrap it up in a discussion. It's like this. So it is important to note that the mental health conditions that coexist with borderline personality disorder do not respond to medications robustly unless borderline personality disorder is treated with psychological treatments. Where borderline personality disorder co-occur with other mental health conditions, best possible result comes when both conditions are treated simultaneously. So in summary, if there's borderline personality disorder, we must treat borderline personality disorder with psychological treatments unless we do that whatever the other co-occurring conditions that's going to be along with that is not going to respond to treatments very well. Next slide, please. Let's look at some of the biological approaches to borderline personality disorder. Unfortunately, there are no medicines that are patented or indicated for borderline personality disorder. There is no evidence to suggest that we can prescribe any medication very confidently in borderline personality disorder, especially because these medicines cause so much of side effects and there's a risk of overdose and also most importantly, it distracts from the psychological treatment that is so important. There is very limited evidence for some medicines such as Lomotrigin, Ruprimage, Omega-3 fatty acids, Deficioil, and Quartipin in small doses for crisis management. Electrocondylsypt therapy and trans-cranial magnetic stimulation, they again don't seem to work for borderline personality disorder even if BPD co-occur with depression. Psychedelics, which are now going to come into the market from July, it's an interesting option. Again, we need to build evidence and test it out right now. There is no evidence. Next slide, please. So in summary, the take-home message is having borderline personality disorder is not the person's own fault. It is the disorder of brain and the mind. There's a statement made in the NHMRC practice guidelines. I think this is the best one sentence, two sentence I've seen in the guideline. Next slide, please. This is my last slide. My take-home message is that as long as you don't judge, as long as you try to validate the valid and as long as you can tolerate the emotions, both your emotions and their emotions, and teach them skills to improve the quality of life, you can contribute to their recovery journey. You take all. This is a statement from a Canadian expert, Joe Patis. All the best. Thank you. Thanks so much, Sathya. We've got a solid half hour now for our conversation and you've all given us lots to think about and we'll get to that immediately. You will have now seen, those of you who are not having internet troubles will have seen a slide pop-up that's got a couple of QR codes on it. We didn't know what these were three years ago. We do now. These are an invitation for you to take out your mobile device if you're not already using it for the webinar. And if you want to register your device to lead or join an existing VPD network, then you can get a link to a URL to do that. Or if you wanted to start one in your area, if there's not one in your area, you can click on or shoot the other QR code. So just a moment while you do that, if you want to express interest in that, it will give the team at MHPN an opportunity to communicate with you about that. So thank you all so much for your presentations. As I say, the response in the chat room has been absolutely fabulous to all of them. And I am seeing more questions in the moderator's area than I've ever seen in one of these MHPN webinars. So there's plenty for us to deal with. But it seems more than appropriate to go back to Sophie and ask Sophie one of the questions which is coming. This has been from Ryan. He's asking about readiness for DBT. And saying basically, thanks Sophie, I'm curious about your thoughts or one might be some of the general indicators for when a consumer may be more likely to be ready in inverted commas to commence DBT and get real value from it. What are your thoughts on that? Because you said that you didn't like the group then second time around, you were sort of ready for it. What are your thoughts? I guess with me, when I first got diagnosed with BPT, I wasn't given any information about what it was. And I just got told that the only thing that will help with that was doing a therapy called dialectical behaviour therapy. And I also got no information about what that was or what it involved. So I was just going in blind. I remember to be accepted into this DBT group, I had like I went to an assessment day and it felt like I was there nearly all day and at the end it was like yes you do have DBT and we'll put you on the waiting list and we don't know when it's going to start but it should be early next year and there was still really not a lot of information given about BPD or DBT so again I was still just like no information whatsoever so yeah that wasn't that was not helpful for me yeah as I said DBT felt but just didn't feel comfortable for me that yeah doing the one-on-one therapy, the schema therapy being able to still do that without doing the DBT component Do any of the other experts have any thoughts about that question? How you can tell when a person is more likely to respond than not? Brina, it looks like you're on mute. I think there are two parts to this one is that understanding the diagnosis and being able to you know often if you show people the denying criteria and you go through them they kind of have a light bulb moment and say wow I didn't realise that there are other people that have these problems not just me and if you then follow that up with psychoeducation about what actually can help and what recovery might look like and introduce them to people like Sophie if you have peer workers in your service or in your team that really helps people to kind of like understand and have the sort of the aha moment not only like I'm not alone but also there's hope around overcoming this yeah second thing in terms of being ready for DBT I think that then leads into the idea that why DBT might work and one of the core principles there is that one that we talked about before about being active like the person needs to go in with an attitude like I want to do this for myself and I want to try and live a life worth living that's different than the one I've just been living and if the person goes in with that attitude I think DBT has got a lot to offer as do the other psychotherapies what can happen though is people can be so I suppose stigmatized or traumatized or helpless and hopeless that they think that somehow there's a magic cure and there is no magic cure as Satya said you know you can't just attend DBT and expect that things are going to change unless you bring yourself into that and a willingness to work on it Thanks for that and I should say that Andy from everyone's psychology in the chats picked up on Sophie's words about going in blind and just how awful that must feel and what you've said Brynn is that the power of the peer support person who can give you some orientation to what to expect it means that you're not blind you're actually seeing it through somebody else's eyes so that's a fabulous insight thanks so much for that so another question actually I'm going to go right back to first principles here I've seen something in the chat that's called my life because I didn't know borderline personality disorder border of what I've got no idea why we call it borderline it might seem a very basic question but can somebody give me just 30 seconds on why we have used that why borderline I can answer it it comes from 1938 and our understanding of psychiatry then was that there were people who had neurotic disorders like anxiety and depression and there were people who had schizophrenia where they lost contact with reality and a person called Adolf Stern said actually you know what there's a group of people in the middle so they're neither just anxious and depressed nor are they completely lost contact with reality with hallucinations and delusions but they have this kind of complex set of problems that kind of fit in the middle of what he called the borderline so that's how the shame comes about it's really unfortunate that it's sort of stuck over all of those years but that was the original thinking around why that term was there. Okay thanks for that you've solved it for me that's wonderful something good that came out of 1938 I guess with some thinking it's actually quite some time ago now so great to hear that there's new research and new thinking going on speaking again of research there was one thing that Dana mentioned which the first time I saw her presentation I was struck by it and others have been struck by it as well including Erin who's asked the question why are psychiatry trainees near the end of their training holding negative or more negative views of people with BPD is this sort of the hardening of the heart that we see within medical schools and what's behind it that's a really good question I mean the research didn't address that specific aspect in terms of why people held those attitudes but I guess there were some hypotheses about why it might be so in terms of whether the psychiatry registers having more experience within say emergency departments or acute settings and then perhaps being influenced by some of the systematic stigma that might be occurring in those settings but it's definitely an area which we're wanting to look at further to actually sort of unpack what some of those reasons might be so I must say as a GP emergency departments seem to be the worst place to see people at their worst and it sounds like that might be something that's going on there it does lead us to some questions that have been asked about the really awful end of this suicidal ideation or attempts and whether the panel has any quick tips quick tips for a very complex problem for what to do when somebody is expressing the suicidality Do you want me to make a comment? Question without notice please jump in Steve maybe can I make a comment about the psychiatry training first unfortunately I'm really sorry to say even to this day we don't train psychiatrists adequately in the treatment of bodily person disorder so that's the reason why they don't feel confident towards the end of the training and that's why they pick up the prescription pads very quickly so we are trying to work with the college and advocate for more specific training for bodily person disorder coming to the societal ideations and behaviors the life becomes so painful so unbearable for people with bodily person disorder and the psychological pain that they experience pushes them towards the societal behaviors so what we find in our setting at the spectrum once we start working with them with psychological treatments most of the times within about 6 months time the societal behaviors tend to reduce quite significantly and I'm sure Brin would agree with me and others would agree with me there is very good evidence to show that when people are in treatment when they are receiving psychological treatments people don't actually resort to dying by suicide so it's the lack of treatment which tends to result in that of course within the NHMRC guidelines we have proposed a way of trying to understand who could be at an immediate risk of trying suicide was this who could be at the risk of having the ongoing chronic societal thoughts and behaviors so there is some risk methodology about what that one can refer to in the national guidelines thank you thanks for that and a shout out to Lauren who is an early career psychiatrist in the chat who is acknowledging that more training is needed in this area is very difficult to cover everything but this does seem to be a really important one and making the diagnosis as well and that's actually a question that's been asked by somebody whose name I'm referred to which was about communicating the BPD diagnosis and we're still struggling with that term but the comment was I've had experiences where communicating the BPD diagnosis has led to relief in understanding experiences improvement in self-development but other people are effectively traumatized by the diagnosis just wondering what people's thoughts are about the response to being given a diagnosis of BPD and what that can mean to the person maybe Sophie we should start with you any thoughts before maybe we go to Brynn yeah as I said I didn't get a lot of information about it when I was first diagnosed I was in hospital I remember a nurse told me they always knew when someone with BPD would be admitted because they always had brightly colored hair which I have and they would have their fluffy comfort toys or fluffy slippers and that just felt really judgmental I've got a lot of other friends with brightly colored hairs does that mean they also have BPD? Absolutely not so I think giving the person information about BPD would make it so much easier I know if I'd been given factual information about what it is how people get diagnosed the nine different criteria ask if you want to know what criteria you met and learn how to maybe at a later stage learn how to see that you fit the criteria and you're just finding out that there are treatments available and that they help and then if you know of peer workers put them in contact and hearing that hearing from other people that they've been there and you know within their best life I'm so pleased to see a comment from Jane in the chat that her son found comfort in the diagnosis and strength to go forward so that's great what about you Bryn, what are your thoughts about the diagnosis and what it can do for people I agree that what's really important is the way it's done and you want to spend time helping the person understand it and do it in a really compassionate way but the most important thing I think is to make the link between diagnosis and treatment because there's no good just saying you've got BPD go away, there's nothing we can do for you, what you need to say is you've got BPD and guess what this is good news because actually we know how to treat it and I can help you get them or I can start them myself or this is what the journey might look like in terms of accessing the right kind of evidence-based treatment, psychological therapies and helping the person see what the next step is on their journey not just leaving them with the diagnosis with no further information right, all right thank you so much for that seeing a fair response also to Sophie's statement about the brown-colored hair being a diagnostic indicator of BPD and the nurses I was taught at medical school that tinted glasses was an indicator reliable indicator of mental illness but then the 80s came and everybody had tinted glasses which I thought was quite a good thing a number of people have also asked questions about BPD in younger patients and sort of threshold diagnosis in teenagers and younger people and one of the questions was from Anita about BPD in adolescence and that adolescents are rarely diagnosed with BPD confidently however more and more young clients in Anita's experience are saying they've been given this diagnosis I was wondering, Satya maybe you ever thought about that thank you it's an interesting question because for a long time we believed that personalities did not fully blossom and develop until the age of 18 and so therefore a lot of child psychiatrists and even adult psychiatrists believed that we should not make a definitive diagnosis of BPD because sometimes the symptoms can change and the diagnosis can change however that's an old belief now particularly in the Australian context Professor Andrew Chan has done brilliant work in this field and he's a leader globally and he has demonstrated again and again and again that we can confidently make a diagnosis below the age of 18 and we can confidently treat people below the age of 18 earlier we treat the better it is we don't want people to have symptoms and struggle with all the symptoms for years and years and years so if it looks like BPD we should make a diagnosis of BPD and start treating of course we want to consider a diagnosis only in people post puberty so in fact in the Australian context we would encourage people to make a diagnosis from the age of 12 that's in the NHMRC clinical practice guidelines but the scenario is still not changed completely I think people are getting more and more confident I would encourage families and consumers to actually ask and demand for a clear diagnosis and treatment it was interesting to hear you mention Andrew Chan and I went to school with Andrew in the 70s I still can't get used to people who have known since they're 12 having a huge impact on the country but that's great good to hear that he's kicked on look there's a question I'm conflating a few people's questions here which is about the interface between people with BPD and people also using other drugs or various drugs now and that given medication a bad rap the cup of tea from Brynd it seemed to get more traction with the audience than the psychotherapeutic approaches but people have been asking questions about people who are also using other drugs non-prescribed drugs and whether there are any thoughts about that Sathya I see you've come off mute you wanted to comment about that I'll say it's quite a bit I'm happy to comment and also write by my other colleagues to make additional comments because they are sure they have very interesting views on this first of all I think we need to be kind and compassionate for people who use substances then they also have bodily person disorder first is to recognize that bodily person disorder is a complex difficult painful disorder to experience so people are desperate to try and manage it in whatever ways they can and substance use is one of the common ways nearly two-thirds of the people tend to use substances now again we have done some research at Spectrum and shown that when people have evidence based treatments their substance use reduces dramatically so in our patient population treatment by the end of treatment we are not specifically treated for substance use but they all come off drugs majority have done so again what we are all trying to emphasize is that treatment is the key when we talk about treatment it is a psychological treatment that's the key thank you for that more questions also about the overlap interface now that we know we're talking about a borderline between two big groups of diagnoses people are also asking about young people with autism and other things people with eating disorders was also another one that's come up in the chat now we did see a long list of comorbidities in Zethia's presentation but do any panelists have any thoughts about how we approach people who might have more than one diagnosis and whether that impacts on the way we provide service spring you look like you can talk on that yeah it's a very common so comorbidity I think is probably more expected to be part of anyone's history so I think the NH and MRC makes it quite clear that in all of these cases whether it's substance dependence autism, ADHD eating disorders our goal is to treat the person and there to be one therapist that you know helps the person with the core issues that they're struggling with from the lens of BPD the key thing that we're really trying to help the person with is to develop a stronger sense of identity of who they are, what they want in life and where they want to go and to give them a capacity to have a voice and to develop and strengthen their voice because often people you know have difficulty understanding their emotions, they have big emotions they might be very hypersensitive they might be trying to manage their difficult internal feelings through impulsivity through eating of interpersonal conflicts or control or whatever but trying to understand that and being curious and sitting there with the person and trying to really kind of get yourself inside and see the world through their eyes and be curious and try and hear what's going on for them and to try and help them to start to through this process of talking and the interchange of that and them learning from you and you learning from them that is going to strengthen you know what's going on for them and to help building on and to try and help them to learn skills and strategies and ways of being able to understand themselves that are going to be much more hopeful and helpful through that relationship That's a great opportunity to ask the question of Sophie. Sophie does Brins curiosity resonate with you? Yes it does it really does like I've got I'm also diagnosed with anxiety so I feel like that really comes up a lot and I guess since we've been with BPD now for quite a number of years I've kind of learnt and I'm still learning what anxiety feels like and what BPD feels like and you know it's about treating the person and not just looking at one diagnosis and I feel that that has happened to me previously and that I know that BPD is very complex and that there are treatments that work but also there's also different treatments for different diagnoses that can also help when you do live with BPD as well and having curiosity about person and also finding out the person's curiosity as well as I often speak about one of my strengths is being curious and that has helped me through really dark times is trying to keep my own curiosity alive which helps get me forward to the next day when all I can do is live my life minute by minute You talked about that in your presentation and having a degree of curiosity about your therapist whether they're a cat person for example I'm a rampant dog person I must confess but how do the other three panellists feel about that I mean what sort of openness and self-disclosure can be helpful in building that trust and rapport with the person and what sort of barriers or appropriate boundaries do we need to set any thoughts about that I'll jump in and say it's a balance so you need to be both real in the room but you also need to be safe so my general kind of philosophy here is don't be weird don't you know go down the path of overly self-disclosing nor go down the path of being so kind of like professional that you become like some sort of frozen kind of robot sort of situation but you kind of want to be real but appropriate in terms of who you are and what you're trying to offer and what you can do and to be willing to show your own limitations and show your sense of humour and also show sometimes your own emotional reactions too so it's fine to cry and it's fine to laugh and it's fine to be there with the person as long as you're being honest to yourself and you're being clear about what's going on for you and differentiating about what's going on for you but keeping the focus on really helping them on their journey that's really you know how we can be in the room and be as helpful as possible but of course it's got to be in a safe environment so the structure of therapy the consistency and the basic ground rules need to be really clear Thanks Bryn we're going to have to get a merch store going with these webinars we've got people wanting to make mugs with keep calm and make a cup of tea don't be weird I think would probably be a really good t-shirt to be administered or given out to all psych registrars when they begin their training fabulous comments so thank you so much for that we're at the point of our evening now where we just need final comments from each of the panelists as we pull it all together so let's go around in the same order Sophie is there any final quick word you want to say to the audience before we wrap up I wish we could have more time to answer more questions because I feel that you know having this space is really important there are hundreds of questions we haven't got to tonight so I'm sorry about that but what did you want to say at this stage but I'm sorry I can't answer all the questions but yeah just keep being curious and you will get an answer to your question at one stage fabulous and curiosity is probably the antidote to burnout so that's great great advice thank you for that Diana what's your final thoughts for the evening I think curiosity is a really good one to reflect on as a researcher is keeping up to date with the literature being open to new ideas and ways of doing things particularly when it comes to around engaging people with a lived experience in treatment and listening to their voices and be willing to try different things which I think we've found to be a really powerful experience for the co-production of the peer group and I guess also keeping the role of patients sort of reported outcomes in terms of integrating into treatment and being able to learn more from a research perspective to be able to answer some of these questions there's just so many gaps in the literature and much more needs to be done absolutely couldn't agree more thanks very much bring your final comments okay I think just go back to that final comment about keeping calm and making tea we do need to recognize that burnout is a risk that we need to look out for ourselves we need to have somebody that we trust that we download to and we need to also slow things down ourselves and really recognize that when we're working with people who are really struggling that has an impact on us and we need to take time out and seek the kind of support that we need so that we can maintain our own hopefulness and compassion to go back and gain and do the work over and over again thank you that's really important words and final words after your thoughts I would like to emphasize again what Ben said about not being weird in therapy one of the ways to do it is to be aware of whatever we are sharing with the patients as to whether when we are sharing something is it to the benefit of the other person or is it just to get to our own frustrations if the answer is the second one of course we shouldn't do it and they should be clear limits and flexibility but as we put it in their dialectical behavior therapy the relationship between a client and a therapist is a real relationship it's a honest and real relationship although professional I would like to emphasize that there are no medicines for people with borderline pulse and disorder so let's not get preoccupied with medicines and people get better all the time with psychological problems I have had immense professional satisfaction working with people with borderline pulse and disorder so I would invite all the clinicians mental professionals in the group to give it a go absolutely that was your final comment on your slide give it a go and go with the best of intent so thank you all so much for participating in tonight's webinar there's been a lot of requests for part two we might get to four seasons like succession maybe but hopefully none of us will be getting on a plane to Sweden anyway that's a weird reference but thank you all so much why I'm going to ask you before people click off to complete the exit survey and provide feedback it's really important that we know how to provide these webinars better so please use that QR code or click on the link and fill out the feedback form the recording will be available that will be sent out and you'll get follow-up communication so you can access the recording there are more webinars coming up MHPN's three day online conference from the 28th to the 30th of March I suspect that's actually past altogether better I can't see my slide there it's gone anyway that's alright emerging minds the next webinars are being held in May and June so there's decolonising mental health and working with Aboriginal and Torres Strait Islander children and family wow what a timely topic that one is and also responding to childhood bullying again very important so please keep an eye out for notifications for when you can register for these webinars or visit the upcoming webinar page on the MHPN website and there's also the podcast program that releases episodes on a fortnightly basis so we're a minute over time but before I close I would like to really thank the four people tonight they've been comments saying it's the best panel we've ever had and I'm up for that and they've been some beauties but before I close I'd like to acknowledge friends, people and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present thank you everyone for your participation this evening and we all wish you the very best for your work going forward and for the evening ahead thank you