 Good evening and welcome to this evening's webinar. This is the fifth webinar in this series. Hopefully you've joined us previously, but if not, you can access them on podcasts later. This topic for this evening is management of self-injury and suicidality. And at the moment, we have over 900 people joining us at this live event. So thank you very much for your ongoing interest. And I'm looking forward to this evening's topic and the panel who are going to be joining me in a moment. My name is Lina Grading, and I'm a community psychologist. I've had the pleasure of facilitating these webinars for this series today and some other webinars along the way for MHPN. In my day job, I work as the strategic manager at the Australian Psychological Society. And I have a particularly interesting tonight's topic because I completed a Master of Suicidology last year that was a three-year program. So I'm very interested in looking at that tonight in terms of what that might mean and what it might look like for people with borderline personality disorder. You can see that we have a last webinar in the series that's there. And you can see the date and we'll remind you of this again again later on. And this is a series of national borderline personality disorder project that's been funded by the National Mental Health Commission. And you can see, again, we'll remind you later that the Australian Borderline Personality Disorder Foundation website will have the previous webinar. So you can have a look at that as well. I would like to acknowledge the traditional custodians of the land where we're meeting. And in Melbourne, there were a few people of the Cullin Nation and people joining us from all around Australia. So you'll be mindful of the local, Aboriginal, Torres Strait Islander communities in your area. And of course, it's important that we're thinking about what all this means for Aboriginal and Torres Strait Islander people as well. We do have a panel tonight who will be joining us. And we're going to introduce each of those in a moment. The way that we do this, these webinars, is that we have a case study that hopefully you've read already. And if you have read that, you'll be aware that obviously with a topic like this, we are talking about self-harm and we are talking about methods of self-harm in not detail, but certainly we will be naming the range of methods that people use in the case study. We've had examples of that. And with a topic like suicidality and self-harm, it's really important that we do remind you around your own self-care. And we say this every time, but I think particularly tonight, we do need to really highlight that, that we can be working in this space and still find this very difficult and very confronting. So it is important that we do just give you that little reminder. And we will put up some numbers in a moment, just as reminders for you of Lifeline Beyond Blue and the suicide call bus back service, so that you've got those. And just important to think about your own well-being, what it is that you do to look after yourself. We do go for an hour and a quarter, but you don't have to watch the whole time. You can always stop and look at the podcast later as well, so that can be part of your planning to take care of yourself. So please just take a moment to have a think about that and what that will look like for you. We have sent you the panelist's bio. So hopefully you've had a chance to have a look at those as well. And I don't want to read through them and take up valuable time. But we do have, I'll introduce each people individually. We do have Pip Bradley. And Pip is a mental health nurse in Victoria. Pip, welcome to you. And I've got a question for you. You've worked with people with borderline personality disorder for a long time, and you joined us previously on one of the webinars as well. What's your top tip about remaining positive in this work? What keeps you going after a long time? Well, it has been a while. For me, I think that keeping in mind the histories of invalidation and trauma and misattunement or misattunement that people with BPD generally have, if I keep that in mind, it really helps with compassion and understanding the reason for the problems that they have, that they have had genuine struggles all their life and have a genuine need for help and effective support and treatment. And also, I think keeping in mind that what I do does make a difference. It can make a difference to the quality of someone's life. Sometimes that's really quite overt, and sometimes it's more subtle, that in many ways we can focus positively on the differences that we can make. And I also think, I guess, about the values that inspire me and that when I focus on the values and how I want to be in my work, that really helps me a lot to stay positive. Okay, fantastic. A few top tips there. So hopefully people are starting to understand some of the things you're going to be talking about today. And I think with this webinar series, it has been one of the themes, has been this positivity and hope that perhaps people haven't always thought about when they've been thinking about working with people with borderline personality disorder. So we'll continue with that theme already, which is fantastic. So thank you. And we'll hear from you shortly. Let's introduce Melissa. And Melissa Kent is a psychologist from Queensland. So thank you for joining us, Melissa. And I understand that you coordinate a borderline personality disorder network in Ipswich, West Morton, which is in Queensland. We've got a map here to show you where that is. What is it that you enjoy most about coordinating a network? Oh, look, I think it has been such a really useful tool to have for myself as a clinician. And when I'm working with the majority of the population of people that I work with live with BPD and support and keeping up morale is really crucial. Probably the most invaluable thing that comes from being part of a BPD-MHN is the connections that we make across government and non-government, across private and public, across the region, putting faces to names and really having a contact person in all different services who you can contact to discuss the thorough pathways or cases or whatever it might be, because that contact is really important. So that would probably be the most invaluable thing that I think everybody really appreciates. Great. Thank you. And that not doing this work alone, I guess, is a really important message there that, having your support around you, keep doing the work. You can see on the slide that there are seven practitioner networks which provide a forum for practitioners with a shared interest of one personality disorder. So hopefully there's one fairly close to where people are at home so that you can tap into that. And there's a resource, fact sheet in the resources tab so that you can get a bit more information as well. So you heard it first here from Melissa. So thanks, Melissa. We'll hear from you soon. And last but certainly not least today is Mali. And Mali is here with a lived experience hash. And one of the features of these webinars as well has been having a person with lived experience on the panel. And it's a really important part of this work for us as practitioners is to hear this voice. And so Mali does some work, advocacy work. So, Mali, what do you find much rewarding about your advocacy work? I think that the most rewarding thing is that over the last six years that I've been kind of talking in this space, I've seen a lot of change happen. So I've seen people getting access to treatment at a much younger age. And I'm seeing their treatments not take as long as what they minded because they were more focused and I guess more efficient and honed in. So I think it's really good to know that, you know, there are people within their teens and 20s that are getting the help that I waited until my 30s to get. So it's good that they have kind of, I guess, the ability to have a completely different life at such a young age. Yeah, fantastic. Thank you. And that's also been a theme throughout these webinars. I've talked a lot about the age of diagnosis and looking at young people. And our last webinar was actually about young people. We had Origen who were here with that. So that's really confirming that message and that things are improving. And people like you are there to support younger people as well, which is great. So thank you. I'm really looking forward to hearing from you as well shortly. Thanks. So we always have some ground rules. So if you've joined us before, you'll know the drill by now. If you're new, that's good. So we want to make sure that people do get the most out of the live webinar and also people looking at this later. So we're not going to have a live chat tonight. I know people do often like that, but we find it's very difficult when we have over 1,000 people that we have now who are joining us live. It's pretty difficult for us to manage that. So there is provision for you to ask some questions. So you can put forth some questions, which I'll be keeping an eye on and hopefully get to answer some of them. We also have some questions that people put forward when they registered that's got a big long list here that hopefully a lot of them will be answered through the panel's discussion, but also in a Q&A. So the statements around behaving as you would in face-to-face activity is not quite as relevant, although when you're asking questions, of course, it's a professional development event. We won't be able to look at any questions that are looking at particular clients or particular individual circumstances. If you have any technical issues, hopefully you don't, but we do have great technical support available for you. So if you can't get the information that you need to help you from the frequently asked questions to have at the top of the screen, there's a phone number there with the Redback Help Desk. So there are Redback people who are waiting if you need them. And if there's anything major, we'll let you know, but hopefully that won't happen tonight. So we're looking at learning outcomes for this webinar. And so what we're looking at specifically, and we're not going to be talking about borderline personality disorder in general terms, we're going to be launching straight into talking about non-suicidal self-injuring suicidality in borderline personality disorder. So if you do have questions around borderline personality disorder more generally, you'll have to go back to the previous podcast and have a look at those, because we're going to be launching straight into suicidality and self-harm. We're going to look at analysing risk factors for suicide in borderline personality disorder and implementing management strategies for non-suicidal self-injury and suicide risk. So it's a big topic and lots of information that we're going to be sharing with you. The PowerPoint slideshow and the case study can be found in the Resources Library tab at the bottom right. So you can have a look at that as we go along. Hopefully you have had a chance to look at the case study, but I'll do a bit of a recap in a moment. The other thing at the end is that we do really appreciate your feedback. So at the end, just take a moment for us to complete the feedback form, because we do, this is obviously really important in terms of being funded to do this work, but also as we continue to improve this work, and that's MHPN been doing this for a long time, but continue to develop new ways and making sure that we continue to improve and take on board your feedback. So stay tuned at the end for that as well. Now, before we move to Pip, I might just do a brief recap of the case study and the case study is a bit of a different one to normal, actually. It has had quite a lot of information that I'm not going to recap the whole thing, but it's about Rebecca, and this is a made-up case drawn from people's experiences, people that they have worked with, but it's made up, it's not a real person. And we're talking about Rebecca, and she's a 28-year-old woman, and she has this long history of self-harm and suicidality, and you can see throughout the history that's been written that this changed over time, and you can see that there are different circumstances in her life that came in and perhaps impacted on that. And at different points in time, we ask the question around what would be the risk assessment. So if you were the practitioner working with Rebecca at that particular point in time, how would you be thinking about that? What would your reaction be? Is what we're hoping that you've had a chance to think about? And then you can check it against what our panellists are going to talk about. And if you haven't had a chance to read it or to look at it, well, our panellists have shared their thoughts about that as well. So let's keep moving forward and start our panel chat. So the way we do this is that each of the panellists will go through some of their thoughts and their reflections and information that they're going to share with us. And then at the end of that, we're going to have some time for question and answer and a bit of a conversation to flesh out some of those things. So if you've got some questions for the panellists, you can send those through and we'll keep an eye on those. Otherwise, we'll look at some general questions and we'll have a conversation about some of those towards the end of the session. So let's move on to you now, Pip. And you're going to begin with some information about what it is, the extent that we're talking about. Yes, thanks, Lynn. So actually, I'm going to talk more broadly about self-harm and suicide and how to assess these and some ways of managing the risk around self-harm and suicide, kind of in general terms. And then Melissa and Mali are going to follow up with specific detail and reference to Rebecca. So we have some data on the slides there. And these data are really concerning the high levels, the high rates of suicide and self-harm in our communities. And they indicate the degree to which self-harm and suicide is a really serious problem for health services in general and also for family and social systems. Self-harm, that's the overarching action in itself, includes acts with suicidal intent and ones without suicidal intent. And it's very difficult to predict who is at risk of suicide. So regardless of the intent of the person who is self-harming, death can result even accidentally, especially if lethal means are used. And people can complete suicide who have never self-harmed or communicated suicidal thoughts before. But at the same time, we can have people with some chronic suicidal ideations persisting over years with no adverse outcome. So there really is no evidence-based method of protecting or preventing suicide. And for chronic suicidality attempts, that prevention can be counterproductive. We do know that. We've learned a lot around how hospitalizations should only be used really cautiously, given the well-documented iatrogenic effects of hospitalization. So what do we do? What guides our clinical judgments? Clinicians are really supported by there are evidence-based recommendations for assessment of risk factors based on the combination of risk and protective factors for each person in each particular situation. So I'm going to move along to the next slide now. And in terms of assessing risk, given that it is difficult to differentiate between self-harm intent and suicidal intent, instead of focusing on the client's motivation, we focus on the dimensions of lethality, the lethality of the actions and the ideations. And also, are these actions acute, or is the pattern or the current intention of the client or the person acute or chronic? We have really well-accepted, well-known and long-standing definitions of acute and chronic risk. So I don't think I need to spend time on that, but it's just very briefly acute risk referring to a high-acuity mental state with lethal behaviours sufficient that a person may die generally with an intention. And chronic risk is the ongoing likelihood of risk based on a person's actions, person's pattern of self-harm, as a way of managing intense emotional distress and life stresses. I'll move along. So in terms of assessing the changes, to assess changes in risk, so we're assessing the changes from acuity, from connoisseurty to acuity, and the changes in lethality, we look at the static dynamic and protective factors. So once when we have a formulation, a baseline formulation of static dynamic and protective factors for a person, we really can work on understanding the changes and understand what needs to be kind of added into the treatment to establish some kind of balance to help the person to maintain safety. We can only have a formulation of these static and dynamic and protective factors when we know the person knows. So initially it takes time to develop this, but once we know the person, having a formulation around these factors helps us to understand the balance of risk factors and have a dynamic formulation of what's happening for the person at any point in time. And then when there are changes, we can work with the changes when we know what they are. So we're assessing along dimensions of acuity and lethality, and Spectrum has developed a matrix for mapping these dimensions, which helps with planning responses. So I'll move to this matrix as, it is a really helpful way of planning the treatment for people at different time points. We saw with Rebecca that she did have different levels of risk and was at different points in this matrix at different stages according to the kind of her current mental state and the life circumstances. But Melissa will talk more about that in detail in her following this. So according to changes in a client's life conditions, they may be at different points. So we're assessing along the dimension. We can see on the left-hand side of the screen, there is the chronic pattern with low chronic risk and high chronic risk. And then on the right-hand side, we have changes from the chronic pattern to a new pattern. Starting in the left-hand quadrant with low chronic risk, we usually continue with treatment as usual, helping the client to develop strategies to managing their emotional distress and for managing the triggers in their lives. If there is a change in pattern to the lower right-hand quadrant in the person, there is some change and because it's still a low lethality pattern, though, we work on what are the changes with the person and help them to manage those changes, to problem-solve those changes and to develop different coping strategies. The top right-hand quadrant here is the highest risk pattern that's in this high lethality with a significant change in pattern, probably from chronicity to acuity. So that's where we're much more cautious in our treatment. We may be able to implement protective factors in the community or we may consider an admission at that point. The admission would be to kind of help to stabilise the immediate acuity and, you know, generally, brief admissions are recommended for that and then the top left quadrant is where there's high chronic risk. So it's still, chronic patterns still a repetitive response to life difficulties but the lethality has increased. And again, you can continue with careful community treatment at that point but assessing the changes with the person. Why is there a change in lethality for them? And there's the matrix here. It's just a reformulated version of the matrix that the NHMRC guidelines have adopted and their guidelines around assessment and management of risk. So again, it follows the same kind of four quadrants assessing different time points for the client as they have different levels of risk and stress within their lives. So in terms of managing this risk, therapeutic risk management is really about trying to maintain clients as much as possible in their community context. That's where the real treatment games are made. We do know that if hospital or other interventions are used, they should be brief because of the AHG and the consecutive longer admissions and because of the risk of reinforcing chronic self-harm patterns. The acute pattern usually settles in a few days and the chronic pattern will resume after that. So that's the point, the thing about admission. Well, we may admit people and they will still have risk issues on discharge and they will still not be entirely well or entirely in some ways kind of settled but there is an improvement and it's important to kind of manage that admission around time for the acuity to settle without getting into the stage where chronic risk is being reinforced and people become anxious around the risk and then it's really difficult to decide at which point you might discharge someone. The things that are involved in chronic, and therapeutic risk management, when a client is non, it's important to have a good assessment and formulation and these lead to meaningful treatment approaches and it's really within the ongoing treatment and therapeutic relationships that the real work around managing risk is done. The real risk mitigation happens in that longer term work where clients are learning skills and strategies for managing their distress, managing distresses. Within those therapeutic relationships, they're repairing the kind of potentially adverse relationships they had when they were young where their ability to regulate emotions weren't taught at that age and so we're kind of doing that work in their treatment relationships as they enter our treatment settings. We have to understand the chronic risk pattern and have a formulation of the static, dynamic and protective factors and develop a treatment plan that documents this risk therapeutically in the community, balancing the short term risk and the long term gain. The plan needs to be developed as collaboratively as possible including the client and family and carers as appropriate and all services involved. It's really important to evolve all services otherwise the community team might establish a plan and then it's really difficult for the inpatient unit to follow that plan if they haven't been consulted. Having a primary clinician is important and plans being signed off by the people who can support the clinicians to keep following the plan so that's, you know, clinical managers, clinical leaders, consultants, psychiatrists, people who will support the clinicians to follow the plan. When a client is not so well known, we're much more conservative in assessment and management of risk because we need to take time to get to know the person's passion so we need to ensure community supports are in place which may mean increasing protective factors that's often increasing contact with the client or enlisting your supports in the community to help to manage risk in the community without at the same time, without burdening your supports. And equally, we may consider a brief admission when a client is at non-press assessment purposes. And just my final point that really here is about how we do risk management and this is really about remaining empathic, validating, non-judgmental. Sometimes it is really frustrating for clinicians to have clients with repeated patterns of self-harm but any evidence of frustration or judgment towards them really just doesn't help. And actually it's not appropriate because we hold the belief that clients are doing the best they can and they have these problems for good reason and we're working with them on correcting those issues and learning other ways of managing difficulties but at their starting point they haven't had those opportunities. We're maintaining their autonomy as much as possible, remaining a collaborative relationship with their client and their family and carers, maintaining a focus on the longer-term goals of recovery. So whatever we do in terms of managing risk, we want that to be consistent with the goals of recovery rather than kind of potentially reinterfering with the client's capacity to recover. And that's all from me at the moment. So I'll hand it back to you, Lynn. Thank you. Thanks, Pip. That's a lot of information and I'm sure people are taking on board and I think there's a couple of important things that people might be taking note of, those guidelines that you talked about and Melissa's going to get and talk about that again in a little bit more detail in relation to our case study, but they're available. So the NHMRC guidelines, Sport of Blind Personality Disorder, really useful guidelines that would be good for people to have a look at. They were developed in 2012 and they'll be available on the website that I'll show the link to later. So a really good resource more broadly as well as for that diagram. And I guess what we're hearing you talking about is the importance of the relationship and the therapeutic relationship and seeing the suicidality as part of the overall treatment and part of the response that people are having. So the importance of relationships turning out for me is one of the main messages there. So thank you very much, Pip, for all of that information. Let's move on to Melissa who's going to continue, really, and talk a little bit more about some of the principles and then revisit that diagram again and talk about Rebecca from our case study in a little bit more detail to try and answer some of those questions about how you might respond at different times. Thanks, Melissa. Sure, okay. So thank you so much, Pip. And one thing that really came through when you were talking was about how... The emphasis that you were talking about changes, things changing, looking for changes. And that's one of the main points that I would like to pick up and run with, which is that when we're talking about someone with BPD, the risk can change from time to time. So our risk assessment really needs to reflect that. Our risk assessment isn't a set and forget. It should be ongoing. And there's some really clear guidelines in the NH and MRC, this little thing here, guidelines for how to work with BPD. There's some really clear guidelines in there about when we should conduct a risk assessment. And that's those there up on the slide. So a number of really crucial points when a person first contacts a health service, when a person begins a course of structured therapy, during a crisis, if the person develops another mental illness, for example, a substance use disorder, a major depressive episode, psychosis, if the person's psychosocial status changes, at transitions between services or at discharge, when their management plan is being reviewed or altered. And also the fact that when we're doing our risk assessment, risk assessment should also assess whether the person's behavior may constitute a risk of harm to others as well. So for more information about that, you can see the guidelines. So along with the general indicators of risk of self-harm and suicide with general psychiatric population, there are some indicators are specific to people with BPD, indicating that there's an increased risk. And so this is also when a risk assessment would be undertaken. And these are the sorts of things to watch out for. For example, as Pip very, very clearly said, when there's a change in the chronic pattern of suicidal or self-harm behavior, when there's a coexisting psychotic features or depression or substance use, in fact, the strongest predictor of... In fact, the strongest predictor of increased risk or change in risk is a combination of depression and substance use in this population. Impulsivity, history of incest. When a clinician loses hope or a clinician becomes anxious, that's an increased indicator that there's an increased risk. When there are high legality attempts, when there are repeated attempts in a short period of time, when there's a romantic relationship break-up, loss of a stable job or support, abandonment, perceived abandonment, sexual assault, when there's substance intoxication and when there's access to medication. So they're above and beyond the general risk factors for people at a risk of self-harm and suicide. People with BPD, these are the specific indicators. So if we think about Rebecca, the case study, which I'm sure you've all had a read of, when we think about her, and we look back at the indicators of increased risk. So over time... So there's some of the static risk factors that Pip has talked about. So the history of incest and that sort of stuff. And over time, there's also been depression coming up or substance use or psychotic-like features coming up. So all of those indicate times for risk assessment or times that risk might have increased. And specifically, when we talk about Rebecca, in the case study, there are a number of time points. And if you're following along, which is what I am doing here, there's a couple of time points where it specifically says, what is the risk assessment at this stage? And the purpose of having those points in there is to really emphasise the idea that risk changes over time and we need to always be assessing and keeping an eye out. So if we look at Rebecca, we've got, say, the time point of the last three months. And what is the risk assessment at this stage? So at this stage, the risk assessment for Rebecca is she's in the bottom left quadrant of the risk assessment matrix that Pip talked about and that's in the NH and MRC guidelines. And that one there is low chronic risk. It's the bottom left. And the reason that she's at low chronic risk is because she's having suicidal thoughts but she's not acting on them. There's no self-harm and there hasn't been any change in her pattern or the lethality of her self-harm or suicidality. So at that point, we have low chronic risk which is treatment as usual. But then we pop to the next time point, which is two weeks ago. And at that point, some things have changed. At that point, it looks like Rebecca's pattern has changed. So she's moved from a chronic pattern to a bit of a different pattern. Her suicidal thoughts have increased. And so that has sort of popped her into the low acute risk because there's been a change. And what we need to do with Rebecca in this case is to be really curious about why this change has happened. So she's started cutting. She's overdosed and her suicidal thoughts have increased. We want to be curious about why that's happening and we want to continue treatment but put her under a bit closer observation and we'd probably adjust the management plan at that point. Then we go to the next time point, which is last week. And again, this is within a week. In this case study, things have changed. So Rebecca has moved into the top right quadrant, which is high acute risk. And it's in a red box for a reason because this is the most serious kind of place to be. What's happened there is there's been the end of a relationship and clearly a depressive episode, as well as some psychotic-like symptoms and she started using cannabis. So all of those indicators of increased risk in BPD are there. And also there's been a change in the lethality of her method and also in the pattern. So at this point, we would be considering possibly we would be increasing community supports and we would be considering an admission, as Pip talked about, brief and goal-oriented. So then as we go on one year later, again, things have changed. And at this point, she would be in the top left quadrant, which is high chronic risk. And the reason for that is because her methods of self-harm and suicide are quite lethal. They're quite high. But there's a fairly stable pattern at this point. So at this point, we're going to be watching for any signs of emerging mental illness again, any new behavior, any new symptoms and we will be really carefully watching everybody involved and really responding and assessing when and if we see anything change. So that's how we would apply the risk assessment and the matrix to Rebecca herself. I'm happy to answer any questions about that later on as we go on. I just wanted to say a really quick word because I've gone, I'm going over time, but a really quick word about families, partners and carers. It's really important to remember that families, partners and carers can play a really important role in supporting a person's recovery. And I know that sometimes there's been a historical bias towards perhaps consciously or unconsciously blaming families for some of these symptoms. And that can really be unhelpful. So I think when appropriate and when safe, it's really important and with the person's and sense to involve the family's partner of carers in risk management and risk assessment. And also keeping in mind that self-harm and solidarity can be quite distressing for families and partners. So it's important for them to engage in self-care too. What I often do is develop a separate crisis plan for carers, partners and families. So go through things for them that they can do in times of crisis. So that was where I'll leave it. I'll put it back to you now, Lynn, and we can move on to Marley. So thank you very much. And I look forward to hearing any questions and discussions later. Thanks, Melissa. A couple of questions are coming through already, but I'll hold off on those. And another really important, lots of important points, I think. And again, the idea of the therapeutic relationship being so important, you can see how critical this is over time to working with people and get to know them really well. But it's great to have included the families and partners, carers, people around, the individual as well, to be able to put, I guess, a circle of support as well and for the practitioner not to feel like they're alone and certainly for the client not to feel like they're alone as well. So thank you, and we will come back with some of those questions later on. So let's go to you, Marley. So this is the Moved Experience Advocate Perspective. So let's see what you've got today. And I can hear dogs joining us and dogs barking in the background. They're not my dogs, I'm going to put that out there. So, yeah, we've heard both Pip and Melissa talk about collaborative, you know, relationships and working in that way. But what we really need to focus on is that all treatment should be consumer-led treatment and that collaborative is always possible. And so everyone has the right to be part of their own treatment and to lead it. So the first thing that I would do if I was going to do some kind of assessment of Rebecca is I'd simply talk to her and I would ask her what she wants. Recovery goals have to be her goals, she has to set them. And I think a lot of the times one of the best things that clinicians can do is to actually be able to put their plan aside and focus on what the client needs. That's a big plus. And so it can be a bit hard and I'm aware of that but realistically their goals need to be set by them. So when we're talking about things like, you know, patterns, I can see really easily in Rebecca's patterns that they are highly influenced by other people. And so that tells me that she hasn't got the skills to be able to regulate her behaviour and her reactive behaviour around others. So I think that what we also need to look at is treating the environment. It's one thing to treat her in a room or an inpatient setting and then put her back into that environment that is triggering her. That's a really interesting point that I don't see happening a lot with treatment. The other thing that I want to talk about is the unrecognised self-harm mechanisms. And in terms of Rebecca, they're all over the place. Inappropriate relationships, we don't talk about this enough. We don't talk about relationships that are violent, that are abusive, that are emotionally manipulating. That's a form of self-harm. Being involved in them is definitely, you know, a mechanism of self-harm and worthlessness. The idea that they don't deserve to be treated better than that. Financial decisions also play in. A low socioeconomic background is only going to make her situation more challenging. You know, and things like obviously drugs. And when we talk about drug and alcohol use, we also have to really look at the mechanisms involved in obtaining those drugs. That in itself can be self-harming. There's a lot of things that people do to access drugs, especially illicit drugs, and those behaviours need to be looked at as self-harming as well. So indicators of acute cell infidelity, you know, I think that Pip and Melissa have pretty much covered this off. So, you know, I'm kind of not going to go into that. The only thing that I'll mention that they didn't mention is when people actually present as calm and relieved and have a bit of like a carefree attitude when this is not really what you've seen. That's actually probably one of the most scariest times because, you know, in my own experience, it means that I've made a decision not to be here anymore. And so, you know, there are no problems because I'm not going to be here tomorrow. And it's important that clinicians pick up on that because that is kind of, you know, very, very highly acute. When we look at the crisis reaction and treatment, this is really important as well. So the assessment of any risk should be done where possible by a clinician or a worker that knows the clients, that they understand the pattern already. Doctors and nurses have a big role to play in this, I guess, assessment and in the treatment. What we really need is for doctors and nurses to be really focused and do their job as well as they would do it with someone who didn't have a mental health issue. So for instance, things like wound care and the ER and just your physical health, that needs to be done with respect. It needs to be done appropriately and in a timely manner. And what we really need is for doctors and nurses to simply show up and do their job and, you know, leave a lot of that kind of conversation to people who are trained to have those conversations. We know that there's a lot of off-the-cuff conversations that go on in ERs that lead to really damaging, I guess, you know, behaviours in clients. Your language is really, really important and a lot of them don't have the language. Clinical language can be really triggering if you're talking about someone's cutting being superficial. It's important to realise that there is no such thing as superficial cutting. Someone is cutting their body and that is not superficial. I think that short inpatient admissions are a great thing, but I think they should have boundaries. So when the person's admitted, the best thing, I think, to do is be really upfront and say, you're only going to be admitted for two days and that's kind of it and give them a boundary around that. I would also scan for addictive behaviour in terms of self-harm. You know, for instance, I self-harm for 20 years and the last five years of that were probably more addictive behaviour than they were a coping strategy or a physical release. So that's important. Support systems, everyone's spoke about that as well. I just definitely want to talk very much about peer support. It's not something that's either been encouraged with people with BPD because there is, you know, research out there about the contagion. A lot of that research, in my opinion, doesn't stand up to real life and peers can be an amazing asset. They're definitely, you know, something that I use constantly and I've done for others. So when you talk about ongoing management as well, once again, I think Pip and Melissa have really spoken a lot about this as well. I think we really need to look at, you know, even in the acute setting where there's still self-harm and probably even some quite high suicidality, just getting someone into it, you know, some DBT treatment or something, you know, like that, you can start simply with that. You can start with one skill and build that up over time. You start with one goal and you work on that. So maybe, you know, you do a bit of a harm minimization plan. You're not, you know, going to kind of say to them, that's it, you have to stop self-harming because that can be overwhelming. But just encouraging someone to minimise their harm, to not self-harm as much as they have been or the frequency or the severity and really celebrating those things as well. It's a long road to recovery for someone. If you think about how long it took them to get to the point where they decided to start physically harming themselves, you can imagine it's a long road back. But it's important of, I think, both Melissa and Pip have said to stay positive about that and to really celebrate those small victories. And that includes having conversations about shame and guilt mechanisms, having conversations with them about, you know, accepting things like their scarring or the physical aspects that we're left with from these types of behaviours, you know, such as, you know, brain injuries and things like that. It's important to have these conversations and say, hey, like, you can go out into the world and still be, you know, an amazing person. It doesn't matter that you've got these scars, you know, like, you know, not everyone's going to judge you. It's important to have those conversations because those things, scars and the after-effects can actually trigger more self-harm. I think that trust is a really big, important thing and I think as well that you should never assume that someone isn't self-harming. You should, as a clinician, always kind of be checking in, even if it's just like, literally, you know, like, how are you doing with that? Do you have any more thoughts? Trust, in my opinion, is always more important than risk assessment. So if you're someone's primary clinician, your trusting relationship can be, you know, fractured and ended by reacting too dramatically or overreacting to a situation. So it's really important, I think, to get to know the person's pattern and to not be alarmed when they do something alarming. Remain calm with them, have conversations with them and hopefully you have prior planning for what you will do when those situations come up. Yeah, and I think that that's the best way to deal with that. Wow, lots and lots of information, Molly. Thank you. And I know you've gone through that quickly as you could. Yeah. People will have the slides that they can look at in more detail again later on, but I guess we're hearing the same thing about the importance of the relationship, aren't we? The therapeutic relationship and the trust that forms is really important. And I'm also hearing you say, we need to ask the hard questions. We need to sit with some of this as practitioners. And I know earlier on you were saying that this isn't often what happens, that sometimes people are hesitating or concerned about asking questions, worried they might do more harm. So I guess you're giving us permission to ask some of those questions. So thank you very much for all of that information. We do have some questions that people have been sending through. So let's have a look at some of those and we'll pick up on some of these important points again. And I guess we are hearing about the importance of the relationship and that this often takes time. And the case study was over a period of years and we're talking about this. So Kilpatrick has commented on that, saying that these are lovely well-thought-out ideas that he's talking about in the presentations and the ideas people are sharing. But also as psychologists in private practice in a regional area, how does it work within the framework of better access or A-taps? So this is a bit of the reality. We can kind of know as practitioners what we want to do and hear the importance of this. But in terms of the reality on the ground, anyone like to have a go at answering that question? Anyone, really? Well, I can tell you what we do in therapy. I see my therapist once a fortnight now, but I used to see a previous therapist twice a week. She was a magician. She could literally find programs everywhere. We had, obviously, your 10 sessions. Back then it was 16 when it was bumped up. She found a suicide stream through some other funder and got me three sessions there. I now use a place called Waddle House, and they have given me quite a few sessions. We used to use an enhanced primary care plan as well on top of it. A lot of it is, I think, the clinician getting tricky and finding money, but I've definitely had circumstances where my friends have paid for my treatment, which was not okay. But I've also had amazing clinicians who, you know, reduced their price for me and things like that, and sometimes did phone consults instead of doing face-to-face consults. Okay, so really creative. Creative, yeah, trying to find different ways at different times. Okay, thank you, Mali. That's really useful. People, Melissa, would you like to comment on that as well in terms of other ideas or even the fact that it is challenging? I might leave that to you, Melissa. I'm actually not familiar with private practice. I'm afraid I've only worked in the public sector. So, to me, it's actually relatively easy to see people for a medium or longer term. So, I'll hand it over to Melissa. Okay. Okay, thank you. Yeah, look, sorry, sorry. Jump right in. Yeah, look, I think it is really difficult. I think that we have to sort of think outside of Medicare Better Access where possible, and really similar to what Mali said, there are different sorts of streams of funding that we can start to look for. ATAPS sometimes is still in the region for you, depending on where you are. If there's private health, if that's an option. And I think, though, if we really are within the bounds of Better Access, as well as adding, perhaps, a GP management plan or what do they call it now, current disease management plan, I think we have to really be really careful with the 10, say, slash 15 sessions that we have and really prioritise what we're doing and be very clear with the client about what we're prioritising and together with them. So, we agree and have a really clear treatment plan and make it consistent across time, so whether it be fortnight, lean, monthly, whatever you decide, but really set it out over the long term as much as possible, but be very clear. And in a lot of the evidence-based treatments for BPD is really clear what we focus on first and most the time it's the life-threatening behaviours. So, it's about looking at exactly what we're talking about tonight, minimising, managing risk and that sort of stuff because we have to try and do what we can so that people stay alive and also people stay in treatment. So, they're the two both kind of the priorities that we should try and take. Yeah, okay, thank you. That's really helpful. Another question that's perhaps a bit related and I think, Marla, you picked up on this. Dee asked, what are the community resources that we can connect clients with to build their support network? So, I guess if we're looking at creative responses and putting the community around people, what are some of the ways of doing that or what are some of the networks that might be available? I think you can look at what the person is good at or what they like for me. That was art and so anytime I was able to be artistic I'm a professional artist now, but anytime that I was engaging in that, my risk was lowered incredibly because it's something really positive. So, I think finding what someone likes and really doing strength-based work with them, you know, and that could be anything. It could be a community art group. You know, I'm currently in a program with an organization called Frontup that supports artists with disabilities through the Art Gallery of New South Wales. That's amazing. There are lots of programs out there that I think people could be really utilizing and it builds a community and it will build a network. And, you know, definitely, like I said, peers. We don't have a lot of that in BPD, but Project AIR is working on something around peer support and a peer program. And I think once we get that up on the ground, I know that from what I hear, you know, people are so ready for that and it will be a great tool. Fantastic, thank you. And I guess it's about seeing the person as an individual, isn't it, beyond their diagnosis and saying what is it that their strengths are, what is it that they're connected with. Pip, do you want to comment on that as well? Is that something in terms of your work committed in that work, as part of that? Well, I think it's actually really deeply fundamentally important because, you know, what we're aiming to do is to help people to live their lives and kind of have their own goals for their own lives and live the lives the way they want to. And so that necessarily means connecting them with things that are meaningful and important to them in the community and social networks. Again, I'm actually really spoiled working in a specialist public health service because I'm not so involved in those aspects of people's care. And usually there are other service providers who do it. But I really love Lamie's answer and I think finding the things that you love. And I think clinicians, even if clinicians don't know exactly what's out there, just making the contact, well, really sort of cheerleading or upskilling the clients so that they can find out for themselves as well because, again, that's a skill that the client, you know, can usefully have in their lives. Yeah. Yeah, fantastic. Thank you. Melissa, anything to add to that one? I suppose another little plug for MHPN. That's where we find a lot of our connections is at our BPD, MHPN, we have a lot of representatives from non-government organisations, which have support workers and programs and that sort of stuff that can be really, really useful. So that's if you can get involved with maybe what... If there's a network, if there's a network directory in your area, that will often give you some idea to of some of the organisations and things that are available for support. Yeah, so don't see yourself working in isolation. See yourself as part of the community and tapping to those resources as well as the practitioner. All right, thank you. Now, we've got a few questions around families and I think it is probably really important. Melissa touched on this and one of the questions, which is just a few from me, Young asks, what strategies do you use to stop family freaking out about self-harm? So I think you didn't say freaking out. You said that it can be difficult. So, Melissa, do we want to start with you, seeing as you touched on that earlier? Yeah, sure, look, I mean, there's probably a few different things. There's the keeping in touch with families, encouraging to ask questions, validating how freaking out is normal, I guess, and understandable in the context. Education, about some of the stuff that we've been talking about, about BPD, about risk, about indicators when something is changing. Also, I think families, connecting families with family support, peer workforces, whatever it might be. And there's also a number of more formalised ways that families can get support around this sort of stuff, such as the Family Connections Program, which is a 12-week program for helping to manage some of this stuff. So, yeah, so I think, mainly, yeah, education, keeping those lines of communication open and just reminding the families and carers, et cetera, that probably freaking out or making demands to stop this kind of behaviour is probably not going to help because it needs time and treatment for this sort of stuff to change. Yeah, fantastic. Lots of information in there. Pip and Mali, I can see you both nodding in agreement there. Anything to add? Pip, anything else? Well, I think that was a great answer. Thanks, Melissa. I think the only thing I would add is that, yeah, it's actually really normal to freak out. I mean, who wouldn't freak out if in the face of self-harm and in somebody that you care about? So I think it is quite important to have your support, so the family members have their own support and to sometimes even seek professional support so that they can have their experience, they get validation for their experience and still, at the same time, somehow manage to remain calm with their family member. Yeah. Yeah. I can hear your neighbour's dogs are going to say, you might want to meet yourself, I mean, it should be the neighbour's dogs are not enjoying our chat. Mali, you were nodding as well. Anything to add to that? And I guess we can talk about family members or friends or partners or people close as well. Yeah, I mean, my experience is a bit different. I never had any real care. And I also have amazing friends and having myself work as a counsellor and not-for-profit, all my friends come from that space and most of them are actually trained clinicians in some way. So I never really had that experience of freaking out, I guess. But I always think that it's really important. I've met a lot of carers recently for carers to be in their own support groups and to hopefully be seeing a clinician as well. There was a period of time where my clinician also had sessions separately with one of my partners. And I think that was really helpful for her. So I think it's really important that carers take care of themselves as well because what they do is very impactful and they need to be making sure that they're safe as well. Fantastic. Thank you. It's a really important message. I'm conscious of our time and I do want to touch on the therapist. We're hearing a lot about the important role that the therapist plays and this ongoing relationship and being there and asking some hard questions and how difficult that might be for people. So there is a question here that I'm now trying to find. Managing the complexity, if the client refuses to have other involvement, how to manage preserving the therapeutic relationship and manage therapist anxiety and the client's suicidality, knowing all along we go against client's wishes if we destroy the therapeutic relationship. So an impossible question. So I guess it's managing all of the things we've been talking about, isn't it? It's about managing the safety and being conscious of that and the duty of care that we have, but it's important to maintain the relationship. And we've heard from Mali the importance of the client driving and really being there, their wishes being in leading the work. But I guess the anxiety that the therapist can then feel in all of this. So how does the therapist manage their own anxiety? Who'd like to start with that one? I think that's Melissa. Is that okay with you, Melissa? Yeah, yeah, sure. Sure. Sorry. No, no, no. I think the idea is similar to what everyone sort of been touching on tonight is you don't do it alone and don't try and do it alone. Even if you're like a sole practitioner in the middle of nowhere or whatever, there's definitely, you need to get some support. So definitely supervision, someone who's experienced in this kind of thing, even peer supervision, peer consultation, people who are experienced in this kind of thing can really help. I think also in terms of managing the relationship as well as the risk and that sort of thing, it's really clear to set up, it's really good to set up really clear guidelines right from the start with the person of what is going to constitute what. So what is going to constitute an increased risk, what's going to, who we're going to contact. So what I'm talking about is a crisis management plan or just a management plan in general. So that's one of the very, very first things to do and to get in place. So under what circumstances am I going to tell who or are you going to tell what or who can we call what can we do in this circumstance and really have an agreement and have that set right from there because then it's less likely to break the trust and that sort of thing is it's really clear. The agreements are really clear from the start. There's no surprises because you can refer back to the agreements that you've had. So that's probably the main thing, get supervision, don't do it alone, get a network and also set expectations from the start. Yeah, great. Thank you. Pip, anything to add? I think, yeah, no, I think that's a really good point and I was thinking just of adding that sometimes even if the client doesn't want information to be, you know, or other services to be involved around risk patterns, sometimes it can actually strengthen a relationship if the clinician is clear about what the clinician needs, you know, that they will work as much as possible to keep it as simple and uncomplicated as the client wants, but there are times when, you know, it is their duty to consult with other people and to involve other people and that they're trying to do that in consultation with the client, they're trying to get the client's agreement and yet it is something that's important for the clinician because there is a mutuality in the treatment relationship. So while it's fundamentally and deeply about trust for the client and trying to let them lead the treatment, the clinician also does have some rights around their needs and trying to explain that in a kind of a collaborative sort of way, I think, can help. Yeah, great. But to reiterate what Melissa said about being clear at the start about, you know, what you can and can't do. Yeah, great. OK, thank you. All right, I think we're getting very close to the end of our webinar, which is always very difficult. I can see questions and people have taken time to tell the questions, but I'm sorry, we're just not going to get through them. We do want to have a couple of minutes for each of the panellists to have a takeaway message, sort of thinking about what we've been talking about tonight or things that they think are most important for people to take home or take away with them. They're probably at home at the moment. So, Marley, would you like to start with what do you think would be the most important message for people to take from tonight? I think that one of the most important messages is to treat the human, not the diagnosis. Everybody's different. Everybody experiences BPD differently and they respond differently to treatment. So, it's important to not be set in your kind of plan of how you're going to attack, you know, this person's illness. I think being really aware of your language when you speak, when you listen, and looking for the things that aren't said is also really important with BPD. It's very, very difficult for people with BPD to be vulnerable. So, a bit like what Pip was saying is that we can outwardly be saying that we don't want the help, but that actually might not be the truth because to ask the help is very, very, you know, confronting and it leaves you open to rejection and people failing. And so, it's important to kind of, yeah, do it gently, gently, but don't kind of, you know, write us off. I think it's also important just to be human because we don't talk about the wonderful things about people with BPD which are that we are incredibly compassionate and loving and loyal people. We feel everything very strongly and that includes love, respect, and all of those wonderful things. So, I would do pretty much anything for my clinicians because they were 110% there to help me save my own life. So, I'm very loyal to them. So, I would stay alive for them even if I didn't feel that I could, which is a big thing. Thanks, Marley. Lots and lots for us to take away from that. And so, thank you for that. Melissa, what about you? Your takeaway message, what do you want people to remember from tonight? When it comes to self-harm and suicidality, don't set and forget. So, when we're, I think, keep risk factors in the back of your mind and look for any changes and respond to those when they happen because things can change and we need to be able to respond. Great, thank you. And Pip? Well, I think, for me, I'm going to reiterate the theme about the relationship and how we do any interaction with clients, including risk assessments. I really like Marley's point about trust being front and foremost important, just as much as perhaps a risk assessment is important. And when you think, we talk about dynamic risk factors, dynamic risk variables, and given that we know relationship issues are potentially representative of vulnerability for people with BPD, then the relationship with us, you know, we ourselves can be a dynamic variable in the client's risk profile. So, the way we communicate, the way we interact and the way we respond can increase or reduce the dynamic risk factors. So, you know, usually we think of our treatment relationships as being protective, so we want to kind of maintain that. And along with that, to follow up on the theme of having supervision and support and doing this work because it is challenging, it is hard. And we don't want our anxiety in the face of risk to interfere with really what are the clients' kind of longer-term goals for recovery. So, managing our anxiety in the presence of risk. Fantastic. Thank you, Pip. So, so many important messages. It was really hard to get them down to a minute or two each. I know. One point. So much. We could keep talking for another hour, I think, but we're not able to do that. So, hopefully, we've provided lots of information for people and lots of really clear messages around what's important and I guess an invitation to continue to find out more and to do some networking and use the networks that Melissa's talked about. If you are looking for some more information, here's where you will find it. So, this is Spectrums and Australian BPD Foundation, the list of resources that you'll find for this webinar. On that website, you'll also find the previous, the podcast of the previous webinar. So, I really encourage you to go back and have a look over at those. You will also get the link with the PowerPoint, so you'll get to look at these slides again and to go through them in more detail and you can look at this presentation again, of course, because I know there's a lot of information that people will be wanting to take away from tonight. And I guess it's been very affirming of the important work that people are doing, I think, and the importance of the work, the challenges of the work, but the value and hearing from Marley about the important role that people play. So, hopefully, that's the message people are really taking away. There's the link again for the Practitioner Networking Opportunities, MHPN. I feel like we've done lots of promoting of that tonight, so hopefully people get on board with that. And we do have our next, the final webinar in the series, which is Management in Mental Health Services. It will be held on Monday, the 26th of November, so keep an eye out. You will get the link to this webinar and you will get the invite to the next one. MHPN supports engagement, ongoing maintenance of Practitioner Networks, and it's really important that we kind of keep in contact and keep up with the MHPN information that comes through. We also would like you, as I said earlier, to fill out the feedback survey and you'll find that just as we log out, or just before you log out completely, you'll find that survey pop up. Please do take a moment to fill that in. And I've got a message from Marley. You want to say something about Borderline Personality Disorder Week, so go far away, Marley, before we finish. Thank you. I just wanted to say that BPD Awareness Week is October the 1st, the 7th. We now have eight events that are happening nationwide. Melissa will be at two of them. And so if you want to connect with people, clinicians, that are like-minded, that have the same struggles, please go to one of the events. You can access them via, probably our Facebook is probably the most live, so you just go to facebook.com slash BPD Awareness Week. You'll see all our events up there. Please get involved. We've had over 200 people with lived experience have actually worked on the project with us. So please come to an event and show your support. Fantastic, thank you. So people are not alone doing this work. I think it's a really clear message. There's lots of ways to connect with other people and to get some support to do the work. So I would really like to thank everybody for their participation tonight. We ended up having over 1,500 people join us live tonight. So thank you very much to people at home. Thank you to the panel for your work in preparing those really detailed, comprehensive slides. So I'm sure people have really appreciated it. And for your willingness to participate and share your thoughts. And Melissa Cat has made an appearance. So we've had Pip's name as dogs. And now we've had Melissa's cat. I think it's really time to end. I really appreciate also Mali's contribution tonight. It's really important that we hear the voice of your voice and your perspective, Mali, and your willingness to share your own experiences and to help us all learn and to do this work better. So I really appreciate your contribution. And I just want to acknowledge the consumers and carers who've lived with mental illness in the past and continue to live with mental illness in the present. So just want to thank everybody again, people behind the scenes as well, Redback people with their technical support and the MHPN team as well, who are there doing a lot of the work behind the scenes. So thank you very much to everybody. And I look forward to seeing people join us again for our last webinar in the series. So good night, everyone. Thanks.