 Good evening everyone and welcome to the 898 people that have joined us for tonight and to the viewers who are watching the podcast. The Mental Health Professional Network wishes to acknowledge the traditional custodians of the lands across Australia upon which our webinar presenters and participants are located. We wish to pay respect to the elder's past, present and future, for the memories, traditions, the culture and hopes of Indigenous Australia. Hi, I'm Rachel Rosseter and I'll be facilitating tonight's session. I'm an endorsed nurse practitioner with a number of years experience working as a therapist and a DDT team. My experience working in a range of different clinical settings continues to inform my clinical work and Aboriginal medical health and my own academic work. Tonight I'm going to first of all introduce each of the panel members to you by their discipline and where they're going to be on the panel. But I also ask them a question at the start before we proceed into the presentations. If you want to know more about each of the panel members, the bios are up on the website and I'm making an assumption that you've already seen them. So I'd like to first introduce Dr Chris Warm. He's now the Senior Consultant for Seston Park Primary and Abbulatory Care. He's a GP psychotherapist and addiction physician in private practice at Flory Health Care, Paraca, and has been involved with the development of South Australia's Borderline Personality Disorder Action Plan. Chris, I wonder if you could just tell us in 30 seconds what are your preferred forms of therapy for VPG? Well, my favourite psychological approach for anything and you couldn't say one size fits all, but I just really like the way Victor Frankel put it. Some people are unhappy in the present, not because of the past, but because of the way they deal with the present. I find that helpful in a lot of settings. Yes, so the logo therapy approach is very helpful, that perspective. Okay, let me now turn to welcoming Ellen Sinclair. Ellen has over 30 years experience as a registered nurse and for the majority of this time has specialised in mental health. She currently works as a registered nurse in a private psychiatric unit in the Newcastle area and as a mental health practice nurse in a general practice in the same region. Ellen, I understand you're the author of several chapters in a new mental health nursing text. When do you expect the book to come out and what's the focus of the chapters that you've co-authored or contributed to? Thanks, Rachel. The book is actually due out in late 2017, so later this year. It's going to be a really, really interesting read for new practitioners, for nursing students and the main areas I've contributed to are family violence and the mental health of young people, both of which I have a lot of interaction with in the GP practice and also in the private clinic. Okay, thank you, Ellen, and we'll hear from you later again. I'd like now to introduce Janina Tamasani, sorry, Janina, who's the senior clinical psychologist at Spectrum and discipline senior for Victorian statewide services. Janina's clinical activities at Spectrum include coordinating Spectrum's assessment unit and undertaking comprehensive assessments and delivering DVT treatments. Over the last 17 years, she has also run her own private practice and provides psychological treatment and supervision. Janina, I'm very aware that working with people who experience severe difficulties with regulating their emotions and behaviors can be extremely challenging. Can you share with us one of the strategies that you use to care for and sustain yourself? Supervision, supervision and more supervision. I think it's critical. You can't do this work without supervision and it stops you from becoming isolated and allows you an opportunity to process a lot of the emotional responses that you experience in the work. So that's the first strategy for me that I've used over the years that I've been working in this field. Thank you, and it's one that I certainly have used and continue to use as well. Last but not least, I'd like to introduce Professor Andrew Chan. Andrew is Deputy Research Director and Head of Personality Disorder Research at Origin, the National Centre of Excellence in Youth Mental Health and a Profesorial Fellow at the Centre for Youth Mental Health, the University of Melbourne. Andrew, I'd like to ask you the same question that I asked of Janina. How do you look after yourself? Just one strategy that you use to care for and sustain yourself. Hi, Rachel. Thanks. Well, Janina's taken the supervision, which I would endorse wholeheartedly. I think the other strategy is when facing difficulties is to metaphorically take my own pulse first and to stop and think. And that's the most important thing in the clinical encounter is to be able to remain level-headed or to step back from difficult interpersonal situations and to be able to reflect. And I think it's a critical skill in treating people with BPD in any setting. That mindfulness of your own and awareness of what's happening for you and being able to, as you say, step back. Okay, well, thank you for that. And let me now turn briefly to the ground rules for this session. And they're up here on the panel. And if you find the general chat box too distracting down the bottom while you're trying to listen and you're watching all the chat, you can minimise that by clinking the small down arrow at the top of the chat box. But please use the general chat box to interact with one another and have some fun with us. Okay, so our learning outcomes, you'll be familiar with those having read the flyer for this seminar or webinar. And I'd just like to emphasise that our focus is on how we can work collaboratively together. So each of the panelists will centre their discussion this evening on Emma. You will have all had access to Emma's story. And in the interest of time, let's move directly to hearing from our panelists. So we're going to hear first from Dr Christopher Wall. Thank you, Christopher. Thank you. So I think I hesitate to quote the US as a leader in some fields, but this was from 2008 and I think it was a very good point. Despite its prevalence, enormous public health costs and the devastating toll it takes on individuals, families and communities, BPD only recently has begun to climb the attention it requires. And I think Australia is also really making a lot of headway where I think seeing big changes in attitudes among clinicians and hopefully among the general public. But I certainly remember a lot of instances where a lot of clinicians are fairly wary if not critical. And so hopefully this evening just helps people be a little bit more familiar and hopefully feel like there are things we can do and things that help. And I guess as a GP we also have the advantage that we may be expected to deal with virtually every imaginable condition. We don't officially have to deal with them all single handed. So sometimes the challenge for the GP is to work out when have I reached the limits of my capabilities? When should I get somebody else to help? And of course that will depend a lot on where you're practicing. So there are some things that are easy to say from an urban setting and probably a lot more of a challenge from rural and remote settings. But given that I've also got a particular focus on alcohol and other drug issues and perhaps other things that fall under the addiction area, sometimes whilst it's good to deal with the formal psychiatric part of things, there's also the whole notion of harm minimization. So sometimes there might be somebody who in the context of BPD also has alcohol dependence or opiate dependence. If they've got alcohol dependence I'd be keen to see if they are having some fireman. If that's an opiate dependence then I'd look at whether they're willing to go on something like buprenorphine or methadone and obviously in different states there are different rules and different routines. And yeah, I think the debriefing perhaps is as close as a lot of GPs will get to the supervision and sometimes will need to try to make sure our colleagues and other clinicians don't get too worn out and demoralized and sometimes they'll boost our spirits. Quoting a bit here from sane.org. They used to have a really neat little one-page handout that I would sometimes show patients and a lot of patients who hadn't yet been confirmed as having borderline PD would look at it and say yeah that's me and they've had it in fact very helpful. I think people have historically been afraid that if we say someone's got borderline PD that they'll be offended but if we express it respectfully and give clear explanations and if it carries with it a sense of hope I think that makes a huge difference. So the whole notion that people with BPD can get better. And I think DSM-5, the good old American Psychiatric Association fifth edition of the diagnostic and statistical manual one thing that they've really really changed in terms of personality disorders is to say that these are not that different from any other kind of psychiatric disorder. So it's not as though there are the desirable respectable access one conditions and the not very nice undesirable access to conditions. That distinction officially has gone and let's hope we can all start to see that this is like a lot of other conditions. Some of the things that were there all along in DSM-4, this is a condition that typically involves impulsiveness, risk taking. My interest in Victor Frankel, when somebody talks about chronic feelings of emptiness having trained in an approach that looks for ways people might find meaning and purpose in their lives that struck a chord for me. But there's also this paradox that a condition where people don't want to be left alone where people want support and companionship and sadly sometimes the behaviour of people with Borderline PD may mean that they are harder to be with than other people. So they don't want to be rejected, they don't want to be abandoned but then they do things that make anyone cringe and it can be a real struggle and of course that emotional intensive, the intensive distress which often again leads people to try and numb their feelings with the alcohol or the other drugs or sometimes taking away the distress through self harm which of course is also something daunting. Now I'm not necessarily saying this is something everyone can do but it's just nice to know that in addition to some of the more specific techniques there's also a less specialised approach but one that I think also has a lot of appeal called good psychiatric management and certainly in general practice it's going to be pretty hard for most GPs to set aside an appointment once a week but by the same token there are some people who if we plan to see them and give good treatment and support there may be a lot less instances of them coming into the emergency department or turning out in crisis so planned regular supported visits might be quite useful. In the GP role if anyone needs to get to the bottom of what started this it's probably not the GP and I think even the psychological treatment experts would often say they may not always need to get to the bottom of it or find out what was the original trauma. There might well be an original trauma but it may not be necessary and sometimes it may actually be positively kind of productive to dig and look too much into the past. So I think I'll finish with a slightly cheeky quote simply extrapolating evidence from studies conducted in patients with severe chronic or complex disorders encountered in specialist treatment centres may not only be scientifically questionable but may particularly annoy GPs and providing a detailed list of reasons for referring to a specialist. That's okay if you've got a whole lot of specialists saying please, please I'm bored, I've got lots of vacancies and time on my hands but I think most of us know that's not how it usually works and one of the people that I was really most satisfied to work with was sent to me as a GP with an interest in mental health a long time ago by the court diversion program and it was only after I'd seen him for a couple of years that finally the local public sector mental health team said oh, perhaps we should see this man as well and by that time he'd had several hospital admissions with traumatic, traumatic suicide attempts and all kinds of problems and with a whole lot of people helping and a colleague of mine initiating Suboxone and some other medication to help with his alcohol dependence, this man's whole life has turned around and he's living independently and I think his quality of life is a whole lot better. I better let the next speaker take over but thanks for listening. Okay, so thank you Chris and I think you've highlighted well for some of the challenges in GP land working with people who perhaps don't fit the criteria for the complex services or the specialist services as well and now I will invite Ellen to tell us and talk to us about how she'd actually interact with EMR and be from the mental health nurse perspective. Thanks Ellen. Thanks Rachel. I've approached this from a perspective of EMR actually being one of my patients that I've had referred to me from one of my GPs, very typical presentation probably not the most distressed person. So the first slide there is basically the approach that I take so we approach it as a team so EMR would be working it would be made very clear to EMR that she's working actually with the GP and myself in finding a way to relieve her distress and to find some answers. So the approach I would generally take is looking at therapeutic engagement looking at her current safety, what level that is looking at any medication she might have on board or not and of course looking at the biosocial, psychosocial assessment and setting goals with her in the monitoring and I just wanted to make a point at the bottom there that I devote 52 minutes to an hour to a new patient so if I saw EMR for the first time that's how long I would actually meet with her so I've got the information given to me by the GP and that versus quite often what the GP can spend with her which might be 6 minutes to 15. Sorry, wrong way. Alright, so of course the therapeutic engagement in mental health nursing is the crux of the relationship so we put a lot of work into that. It's not a linear process so this is something that's ongoing through my interactions with EMR and in part of that engagement process I would be actually looking at being very clear to EMR not only hearing about what she needs but what I can provide so very early work on boundaries, knowing her history knowing also that there is no diagnosis at this point so I only know a little bit about her history and what some of her major things have happened in her life so I'm only getting a clue about how to progress with this and work out what EMR actually needs so I would explain to her that I can assist with facilitating access to psychologist support groups she has young children, she may need family assistance there may be various things in the community she doesn't know anything about that could help her there could well be some follow-up needed so if she is actually referred off to a psychologist if she identifies areas that she would really like to do work with that requires say a psychologist intervention or someone that we discuss together that would be most appropriate then that's the direction we take but as we know with people with ongoing distress it's most related to how they interact their personal relationships the way they manage their emotions this could be a long-term ongoing need that she has therefore there's a very good chance that I'll see her back the GP certainly will and of course right throughout that she's had a lot of awful experiences to give her that recognition that how she's feeling and reaction to what has gone on in her life to validate, validate, validate and again validate is really, really important so the GP is going to be very, very interested in her safety so she's come with thoughts of suicide so that's of course the first thing that I need to check out with her so thoughts of self-harm she has had some history in the background there so I would be very direct with that a lot of us know how to do a suicide assessment but we need to know the plan, the means and how strong the urge is as we know a lot of people with borderline personality disorder or borderline traits have that suicidality at the back of their mind it's quite chronic I'm not sure at this stage whether Emma is like that but it's certainly a question I need to ask and I also need to look at her protective factors what she recognises as the strength in her community so whether that's her family, whether that's her friend just checking out exactly if that's her feeling about herself as a mother we know she has some anxieties around that but it could be an area that you could explore to find out if there is some positives in that for her and she could be very, very well aware that she's the main person in her children's life and of course if I uncover the fact that she's in acute danger with her suicidality then of course I need to contact the acute mental health services if she is in crisis so assuming she's not in crisis I would have a bit more of a conversation with her and anyone who presented with her circumstance as medications as we know there is no medication particularly for borderline personality but of course she may have been prescribed things by someone else for anxiety, for depression very likely they didn't help particularly if there were no other psychosocial therapies or anything used along with that if she had no support asking her from her perspective why she stopped and whether it made any difference whether she stopped whether she told anybody it might be a good time to ask about does she have medication left at home is that something that she's put aside just in case she needs it does she use over-the-counter medications does she use drug and... has she used any drug and alcohol to cope so a very important area to cover the biopsychosocial assessment of course she needs a chance to tell her story and through her story we would identify her strengths identify her priorities for treatment set goals for herself and work out, give her a very very clear understanding and a structure that she's supported that we have a place to go and that she is welcome to come back that we give her really steep hope for the future and that she feels welcome back again that she can come and ask questions that she can come and seek help again and I think my five minutes is up. Thank you. Thank you Ellen and we're going to move now from having looked at listening to Christopher and now Ellen on to hearing Janina's perspective as a psychologist. Thank you Janina. Good evening everybody and thank you for the previous speakers. I feel like some things that I've got in my slides have already been covered so when I was looking at this case study I was imagining actually this is probably not the type of client I would see in my public work but certainly is not uncommon for this sort of client it's referred to me in my private work so I was thinking about the group of psychologists in the community that often receives referrals from GP particularly through the Better Access program and where it's very clear that the person generally has a referral saying that they're depressed so I think it's really important in this instance with Emma not to immediately assume sorry I should leave my slide to assume that she has CPG I think a thorough assessment is important for me when I'm working privately this might take a couple of sessions so in that assessment if you don't feel yourself confident to make the diagnosis you can refer to that but there are a number of self-report measures that you can use I certainly like using the Diagnostic Interview The Borderline to Revive by Gunderson I find that very helpful but there are some shorter 10 item self-report measures that you can use as a screen which can allow you then to move on maybe to a more formal diagnosis for some psychologists clinical psychologists people will feel more confident possibly to make the diagnosis not necessarily those I think the other thing to do with Emma is she's come in saying she's doing your referral so she has some ideation around suicide I think it would be really important to do a quite a thorough assessment of those self-harm both in the past and any current ideation around self-harm behaviour or urges and also in relation to suicidal thinking it's been said already that there is chronic suicidal thinking that occurs in people's B2B as a function so we don't want to pan in if you start talking about suicide and I think that's one of the big problems that has happened is to panic and feel like they have to put a whole lot of urgent interventions in now clearly she's at imminent risk we need to do something I think the other important key here and some experience I know is to consider any risks to the children particularly if her mood is low she's destroying is she able to attend to her children there are any risks there strengths weaknesses we've talked about so her strengths is really important but also looking at what some of their skills deficits might be one of my I guess bug bears really that happens is a lot of clients might get this diagnosis they might be informed about what it actually means and for me when I provide physical education I like to think about how I'm going to provide the DM criteria in a more helpful way so I tend to talk about it as a disorder of dysregulation and then I cover the sort of areas of dysregulation and the core fundamental feature is really emotion dysregulation and the other behaviors like behavioral dysregulation cognitive dysregulation dysregulation of interpersonal relationships and dysregulation of self all stem from that fundamental core of dysregulation I found that that's been a much more helpful way to engage the client they find it much more accepting less pejority and it gives a way forward okay I don't have these skills I'm doing the best I can with what I have but maybe I can start to make some changes in this area so then I would talk to Emma about what really would be the treatment that's indicated to her and what we know from evidence-based is the most effective and I haven't listed all of those but there are a number of evidence-based treatments most people know about DBT but we have DBT we have CAT treatment cognitive analytic treatment misalization based therapy acceptance and commitment therapy this is data now for that it's not as many studies in that area but it certainly has some utility there is FEMA therapy there is previously said by Chris there is Gunderson's notion as subject management which has got a supportive element to it so there's a number of different CBT but it actually has some limitations particularly in this situation so then thinking about what you can actually offer is going to be really important but supporting therapy can also be important I also think that it's important to even out her husband he can be incorporated into this I think that's a really important element then if there's an agreement that you're going to treat her or provide her with some public treatment I think really focusing on engagement is going to be important to really enhance outcomes and so when we're talking about engagement authority for alliance we're talking about a number of different forms of alliance formation and they take time to build we have a contractual, a relational and a working and the first part around contractual alliance engagement is where we're setting up the structure of the treatment that we're going to offer and I think this is very, very important it sets out to Anna things like what degree treatment goals will be developing a crisis plan with her the frequency of the session your limit is the therapist some expectations and in relation to the limit might be things like can you accept calls don't you accept calls these sorts of things so that's really about setting that contract and sometimes that can take one session sometimes it may take two sessions and hopefully this one will start moving to relational for the alliance formation and that's where the experience which is a caring impact if anyone interests a curious and non-judgmental therapist who can validate or follow it your much more active and relational engagement or alliance formation and you're also very consistent and reliable this is going to be important for your open joint caring interactions that might turn you on to make sure you see cashier's understanding but then we go to working alliance this normally develops pretty much way down the track about six months maybe 12 months and this is where someone like Anna can start to be in a really strong collaborative relationship with you where she can manage any observations that you might see back to her as a therapist and she can experience them as well intended not as rejecting, not as malevolent not as abandoning those sorts of things then the other part to the work it's the communication style I think as a therapist it's really important to be clear and being clear means communicating what you understand about a situation legitimizing the facts of her experiences explaining your own feelings and expressing your understanding about her difficulties acknowledging her situation and maybe the situation that others in her life are experiencing around her and respecting her emotions etc and then I think the other important thing is developing a collaboration with those that are working with her also the GT the mental health nurse I think is really important and she needs to know that there's going to be an open dialogue and discussion there so we have some clarity around our roles and our responsibilities that might include how they're going to respond to crisis and you might want to support her to think what other sorts of support she needs also to boost her capacity while she's being used I put this in because I thought this was really important that sometimes as psychologists we forget some of the difficult pieces that emerge and then we have an action urge which is to refer the client on and that's very common in people who have the borderline personality disorder so we haven't set up a contractual alliance in the beginning with her but she's unclear about what I'm going to say can I touch you off? Okay so people can see the slides and so I think it's just being really clear but most importantly you managing as a psychologist to have supervision recognising your own biases and getting as much training in education I think that's fundamentally critical in helping someone speak with you Okay thank you Janina it's such a huge topic as in this I'm so much that we'd like to say but we've got very limited time so let's move on now to hear from Andrew and hear the psychiatrist's perspective thank you Andrew Thanks Rachel and thanks to the other presenters who've really done my job for me because they've outlined a lot of the important issues What I want to highlight is that should Emma get to see me as a specialist then she's likely to have jumped through a number of hoops and present some form of complexity and while on paper as Janina said Emma might not necessarily present to a specialist she will present to a specialist when there are complicating features and there are a number of elements to her story that suggest that as well as having some level of personality disorder she also gets intermittent mental state disorders such as depression and so it's important to be able to tease those apart in a good enough assessment and essentially as a specialist what I would be doing is identifying that there is personality disorder present describing the flavour of that personality disorder then identifying any other co-occurring mental state pathology and then overall estimating the level of impairment which would then help me to direct the treatment options and any assessment needs to engage the person in treatment so you need to balance inquiry with relationship building and when looking for a personality disorder what I'm looking for is a personality structure that prevents a person from achieving one of the basic life tasks that is a stable and integrated representation of themselves or others the capacity for intimacy attachment and affiliation and a capacity to function adaptively in the social group that is develop pro-social behaviour and or co-operative relationships and you can see from that by that definition then Emma does have significant personality pathology the significance of borderline pathology that I would be looking for is that it's a marker for severe personality disorder it's really the general severity factor in personality disorder and Emma certainly displays a number of the features although at relatively low levels what she emphasises is that the threshold in the DSM of having any 5 out of 9 personality disorder criteria is really a bit of a nonsense and in fact people with low levels of personality pathology can have very significant problems and often get short changed in the mental health system so teasing apart that complexity is an important part of the specialist approach and in distinguishing state from tray because the mental state disorders might need quite specific treatment I'd be looking for the longitudinal pattern of her presentation usually at least a couple of years by the time she's 35 you'd want to be having many years of presenting with a particular feature and it needs to be the usual way that she behaves that is not restricted to those times in her story when she was very low persistently for periods that might have been weeks or months but actually this needs to occur also outside of those times and it can be very helpful to draw a timeline going back over some of the events of the last couple of years or anything up to 5 years and trying to identify times outside of major depression or severe anxiety disorder or out of control eating when she was also displaying those personality disorder features. In offering treatment the previous speakers have really covered a lot of the important aspects but I think the key thing that I want to emphasize is the treatment needs to be structured. There is no evidence to say that any of the brand name psychotherapies is superior to any other. What they all have in common is that they are structured that patients are encouraged to gradually assume responsibility as treatment progresses. There's no kind of tough love for the beginning that people are assisted to connect their feelings to the actual events and actions in their life and that the focus of all the contemporary treatments is on the here and now going right back to Chris's presentation at the beginning not delving into the past for the sake of it but actually focusing on problems in the here and now. And all the empirical treatments all the evidence-based treatments are collaborative, they're active, they're responsive, they validate the experience of the individual and they're empathic in response to distress and these are really key features of any treatment. And then supervision we've covered but I just want to emphasize that we all are people and personality disorders at their core are relational disorders and so this patient group can be taxing to sit in a room with week after week and we all will have responses. It's important to be able to stop and think about those responses. So take your own pulse rather than just enact your impulses to get into an argument or reciprocate whatever the problem is that the person is presenting. And the kind of generic therapeutic processes that I would use and most specialists would use involve things like containment, keeping people safe, taking responsibility for them when they're not able to do so. That's a dynamic process. Sometimes you need to step in, sometimes you don't. It's always important to let the person know what's going on and talk them through when you are stepping in. Support, structure, again, very important. And involvement in the treatment that collaboration with the patient is a vital part of all the successful treatments that the patient gets to practice new relational skills with the therapist that they can then build on and develop in their life. And then the real aim of all of this is improved quality of life and improved functioning. The features of personality disorder actually get better over time whether you do anything or not. The reason to intervene is to accelerate the improvement of that psychopathology, particularly importantly to ensure that they are able to manage, better manage relationships and to have a vocational pathway through life that they can have successful and prosperous interpersonal relationships and that they can have meaningful activities in their life. I want to give a plug here for an app that was developed by a colleague of mine in Melbourne, Glenn Melvin, which I think is a really useful tool that anyone can use in their day-to-day work with people with borderline personality disorder. It's a safety planning app. It's based on Barbara Stanley's work and he's developed it into an app. It's available free in any of the app stores. It was supported by Beyond Blue and it is a very simple and effective and evidence-based way of supporting people to plan for crises and difficulties and so I would highly commend that to you. And then finally, specialists also work in multidisciplinary teams and this is the program that I've developed at Origin in Melbourne and just to show you that the treatment, the multidisciplinary treatment of borderline personality disorder is complex and it's clearly unrealistic as Chris's first set of slides said to just extrapolate these treatments into primary care but it is important to know what these treatments involve that they are complex and time-consuming and that they require a team that is working together with a shared model and that they need to integrate clinical case management, individual therapy and general psychiatric and medical care. And importantly, some of the key tasks that I would be doing trying to reduce polypharmacy involve the family. I'd include Emma's husband in that ensuring the safety of her children and then psychoeducation about borderline personality disorder or personality disorder in general being a disorder along the lines that I outlined earlier of a failure to develop adaptive responses to the basic tasks in life. And then I think a very important role of specialists in this area is advocacy for people with BPD. The greatest source of stigma and discrimination in borderline personality disorder is sadly from my colleagues and from the mental health system in general and it is important to advocate to have optimism because there is good reason for optimism, evidence-based optimism and to counter the soft bigotry of low expectations that people have for people with borderline personality disorder that we should be expecting really good recovery and good vocational outcomes for people with borderline personality disorder not that they are simply not turning up to our emergency department and annoying us. And importantly, we need to counteract discrimination when our colleagues say bigoted and disrespectful things about people with borderline personality disorder, I make a point of standing up to advocate for the legitimacy of the diagnosis and the legitimacy of the experience of people with this disorder. So that's my presentation. Thanks for listening. Thank you, Andrew. And we've covered a lot of territory in a short period of time. And as I've looked now at the questions and thought about what we've covered, I think that one of the things that often troubles clinicians is how to support the family and how they actually work with family and the person that's suffering and distressed by their difficulties. And I wonder if I'd open that up to the panel and if one of you would like to respond to or elaborate on that question. Well, it's Andrew here. I'm happy to elaborate. I think families are the greatest asset that we have in working with people with borderline personality disorder. And in borderline personality disorder, it's really the last disorder to shake off the kind of family-blaming stigma that has afflicted many psychiatric disorders. And it's absolutely true that many families struggle to manage and in some families that the relationship has broken down irreparably. But if you diagnose early and treat early, mostly families are intact or in contact with one another and that engaging the family is a key part of recovery and often they are the only people sticking by the person that you're treating. So involving them, seeing them as allies, not the enemy, is really a vital part of this. Being honest about the diagnosis, being honest about the family difficulties and very occasionally, and it's the exception, not the rule, if there is a relationship that is damaging or dangerous in the family then would I be advocating to step in and protect the person with BPD from a family member? But that's actually not the norm in borderline personality disorder across the population. Thank you, Andrew. And I think you've given us a really helpful perspective on that. You've also addressed the importance of diagnosing early and I guess as with most psychiatric or mental health issues that early intervention is going to make things a lot easier or a lot more hopeful. I wonder, you've made mention of people who, as they get older, their behaviour often, I guess, moderates. What's your experience and perhaps other panel members have a response to for the person who's, as they've got older, their behaviour may have moderated, but what's happening with their emotional suffering? That's a really good question because actually what happens is there is a natural rise in borderline pathology following puberty and it actually peaks in about the teens or 20s and declines thereafter. And most people with BPD, unlike what we thought in the past, will not actually continue to meet the criteria even a couple of years later. And so the diagnostic criteria drop off pretty quickly, but they live lives of quiet desperation and often their suffering is much more internalised. They often discover that the best way to protect themselves is to withdraw from people and so they often become more reclusive. And so they're often living quite distressed and demoralised lives, often quite disenfranchised and they really have difficulty being able to manage the day-to-day interactions with individuals in the community. I have to agree with that too. I meet many people living lives of quiet desperation and I think the key is to be really attuned to someone and ask specific questions to very gently ask about their past, to delve into things that they may not have been open about because they have learnt to withdraw and they're a little bit frightened about it. But just to really tune in that these people still, even if they don't reach the diagnostic criteria, still need some intervention. And Chris, would you have a comment from your perspective for the general practitioner? Certainly. I think one of the things that I'm hearing from Andrew, which I absolutely agree with, is that there is now a greater sense of hope, there's a greater sense of anticipation that even with no treatment a lot of people will improve. Obviously some people don't get to live that long. If somebody completes suicide then that's an opportunity lost. But I think not only is there an awareness that there are a range of ways of helping, but I think it's now seen that this is not a condition that remains constant or gets worse and worse. It is a condition that's very treatable and that has some complications that are also treatable. Thank you, Chris. And I guess now let's... I just wondered if we could swing from what helps to... It seems that sometimes we actually, as health professionals, make things worse. And I wonder if each of you might very briefly make a mention of ways in which we might, I guess, cause eutrogenic harm. Look, I think I should probably put my hand up and acknowledge that there was a question in the general chat about can we stop GPs from over-prescribing? And first I'd have to say that that can be a real problem. So I'm not going to say no one ever gets it wrong. I think one of the really tricky things is that there are some GPs that are in a system where they aren't expected to spend a lot of time and a way of cutting shorter consultation is to give a person a prescription. And in this particular condition, that's very risky and very unhelpful. I think bit by bit some GPs have picked up so they can do some additional training and actually a bit better Medicare rebate for spending longer and using some specific psychological skills. But yeah, that is a difficult thing. The other side of the coin is that, of course, this is partly because the person has such a lot of distress and they've tried to find ways of numbing the pain in response to one of the other questions in the general chat. I just quickly looked up some stuff. And one study looking at people with heroin dependence found that 38% of people seeking treatment for heroin dependence had borderline PD and antisocial PD. So in the drug dependence world, this is something we should be familiar with, used to, and we should be getting better at dealing with. I'd better let somebody else take over. Thanks, Chris. And I guess you've highlighted, again, the complexity and the ways in which people seek to, I guess, ameliorate their emotional distress. Could I just jump in there? It's Andrew. And I think Chris has raised a really important point that often it's very difficult to sit with someone who's very distressed and feel like you don't have the right skills to help them and that it is tempting to reach for the prescription pad in those circumstances. But I think there's another side to this which actually makes the task even more complicated. And in my slides, I was talking about trying to distinguish state from tray. The other area where people with BPD get short changed is that they get under-treated for very treatable mental state disorders. And so often when they have major depression or an anxiety disorder, some people become quite stingy with treatment. And so I think it makes the GP's task very difficult in a short consultation. You know, psychiatrists have the luxury of more time to talk and try and tease these things apart. But you don't want to over-prescribe, but you also don't want to under-prescribe or under-treat in general because there are, as you have raised, many hazards. And one of those is suicide, which you referred to. And we need to remember that about 8% to 10% of people with BPD will suicide and that there is a two-decade reduction in life expectancy for people with severe personality disorder. So this is a very serious problem that we don't want to just assume we should never prescribe for. Thank you, Andrew. And I guess you've highlighted again that tension and the complexity, the dilemma that we have and the importance of not being one-eyed in our diagnosis. I guess one of the things that I wondered, too, is that perhaps you could speak to, is what happens when we as health professionals become confused or start to respond to a message that perhaps we're special in contrast to another clinician? What impact that has? So you're asking me? I think that's a really... It's a real hazard with borderline personality disorder that we need to remember, as I said, to take our own pulse and that sometimes, as Janina said, the boundaries of the relationship can be blurred and that we need to, I guess, take our own pulse ring and alarm bell when we're feeling like we're the only person who can solve their problems or when somehow we're told we're so special. And I think there's a tendency when that happens for people to run a mile or alternatively to get caught up in the relationship and actually a respectful discussion about how you're human and that the potential for you to let that person down is just as much as any other. And then anticipating that you might and will let that person down and how are you going to handle that when that happens without undermining your own competence at the same time. Those conversations are all important to have upfront when that starts to emerge. Thank you, Andrew. This is Chris. I think that's one of the things that's especially disturbing for a lot of non-specialist clinicians that I think that whole experience that people with BPD may trigger powerful feelings in anyone they're talking to and doctors and psychologists and everyone else on this panel, we're not immune. At the same time, sometimes we've also got to be careful of hearing the person say something critical of a colleague instead of saying, yes, I think they've done something bad. Sometimes it's important for us to actually get on the phone to the other person and say, what exactly did happen that day or did you really do this or just so that we present a bit of a united front and help the patient develop their boundaries as well. Thank you, Chris. And I guess that at this point it would be useful, Ellen, to hear briefly your reflection on these particular challenges and that's the way in which we or you might work as a mental health nurse work together as part of a collaborative team. Yeah, I'll be thinking. Because I work in two clinical areas, both inpatient mental health and primary care. Both basically a team and interdisciplinary. So the one in primary care, of course, you start off with the three of you, if you like, and refer on to either psychiatrist, psychologist, possibly social worker, if that's what's needed for their particular needs at any particular time. So talking about being that special person, I think we've all been there. We've all worked with teams that have had what they call the splitting behaviour when some people feel that special relationship and other people only have the negative emotions instead. And I think what's really, really important is to keep that the person involved is the main focus, but not ourselves, to actually look at their needs. And to be, I suppose, mindful of our colleagues when we're working with them, even if it's intermittently like it might be in the primary care area, that we all recognise those struggles and not be blaming or think that they're... or feel even, you know, why aren't we the special one. So it does need to... You do need to be open about it. You do need to recognise that it's going on. You actually... I suppose professional enough to broach it becomes a problem. And to not run a mile. I actually think in one way it's a reflection. Yes, I've built a good relationship. They feel safe with me. That's great. But to be very open about it and open up the conversation immediately, I think it was Andrew or Christopher that mentioned it, that you broach it straight away, that yes, it's great that we can talk together like this, that we can work on things, that you see who I know are also very helpful, that, you know, I can't be here all the time. And I would like to think that there are other people that can work with you and are able to help with you. So, yeah, I think it is all the time. It is really a responsible clinician who broaches these things with each other and with the person as well. Thank you, Eileen. And Janina will give you a couple of minutes. There's so much to talk about here too, I guess from your perspective, not only with spectrum, but also in your private practice that the challenge of working across teams and collaboratively. Thanks. Look, I think we make it more complicated than we need to, actually. And I think that's because clinicians that cross services and across roles aren't clear and tend to react emotionally to what's going on with the client. And I think this idea of idolisation and devaluation, which is being spoken about, you know, clients don't do this to us because they wake up one morning and feel like they want to, you know, place us in a position that's in a much, you know, much more perfect sort of state and the person yesterday was worse. It's all in relation to what they experience relationally. And I think that we need as clinicians to be really mindful not to take this up as a personalisation about our capacities or I'm not suggesting it's not easy. We've all been idolised and devalued and I agree with Andrew's earlier point. We need to articulate that. And this is setting the, again, setting that contractual and relational engagement. You aren't going to disappoint the client. And there's times they're going to think you're the individual that truly understands them and there's going to be days where they think you completely don't understand them. And I think one of the problems that then ends up happening nitrogenically is we start to invalidate in the face of that. So I think it's really important to try to maintain a position of respect for the individual and understand that this is one of their core deficits. If they could do relationships better or if they could manage a motion more effectively, we wouldn't be seeing them. So, you know, the way I manage it is I recognise that this is one of their core deficits and my job is to help them to find a more effective way of getting their needs met. Because fundamentally that need for emotional connection is critical for all of us actually. It's not just the people of CCD. They just unfortunately have less skill because they weren't given opportunity to learn their skills to be able to get their needs met effectively. So I guess that's sort of the way I approach it. Yeah. And I guess that if I listen to each of you and the various perspectives, that commonality amongst what you're saying and perhaps it goes right back to those very initial questions where Andrew and Janina, you both mentioned the importance of supervision. That ability to have a space where you can reflect and also have that space where you can, I guess, sit with your own experiences is vital to be able to do this work effectively. I'd absolutely agree. And I think it's not just, sorry, it's Janina again. I don't, you know, sometimes we can't access supervision for whatever reason. And I think it's really important to say, well, who else can I consult with? Particularly around when you're starting to get anxious around risk, you know, you consult with a colleague. Whoever that might be, it might be a peer. It might be a peer sitting in a different agency if you can't get access to a supervisor. I think the process of supervision is not just about reflecting on your emotional experience, but actually acknowledging and recognizing and trying to do something different about how is my emotion possibly becoming therapy into hearing VA on my part? What am I doing? How am I reacting? I'm actually maybe limiting how I can do the best therapy that I can do for this personal best treatment. So I think it is the place, the process, but also a place to really look at how you soundtrack to provide good clinical care and treatment. Thank you. And I think that we might finish now by asking each of you to briefly suggest what other training might be available for those who want to learn more about how they can work effectively with this clientele. Chris, could we start with you? What would you suggest? I suppose I'm more familiar with the training that's available to GPs, and typically it will be stuff that will fit in with their quality improvement and professional development. And it depends. There will be sort of little doses and big doses for a GP that really wants to get much more involved. It's still a fairly small investment to do a 20-hour course. There will be different things that are available just for a couple of hours. There will be some things online. I guess GPs would need to just look at what's on the College of GPs website or the College of Rural and Remote Medicine. But there will be a range of different things and people will need to also figure out what suits their personal style. And yeah, right. Well, thank you. And Ellen, have you got any suggestions for... I would have to say that the extra training I had in dialectical behavior therapy is very, very helpful. Even if you don't use it as a planned therapeutic approach, I suppose it informs you how to approach the various difficulties that people with borderline personality disorder might present with and other disorders as well. So the emotion dysregularity, the interpersonal relationships, all those sorts of things. So yeah, so that would be my... And there's many providers, and it's something that I think is well worthwhile doing for nursing and probably most of the other professions as well. Thank you. And Janina, you've got to... Oh, look, yeah, thank you. I think for psychologists, it's really... Again, I think Chris said it, trying to find the treatment modality that works for you. You have to have adherence, so you have to be able to be genuine in your approach. So there is various trainings in DBT and ACT and MBT, there's a whole host. Spectrum offers some trainings in those areas if you're a mental health clinician, you can access that. I think my experience has been I have just gone after every training over the years that I have thought maybe was something that I could use and then discriminated when I didn't find it helpful. And for me, schema therapy and DBT are my preferred models of treatment. So I tend to gravitate towards those sorts of trainings. I think the other thing is reading. There is copious amounts of textbooks out there on BPD and various treatments. I think joining some organisations too, I don't know what Andrew thinks of this, but I'm a member of the European Borderline Society and the International Scientific Study for Personality Disorder. Those sorts of avenues are fantastic as well for getting information and then sort of channeling your energies into the training that you would like to do. Thank you, Janina. There's just so much out there, isn't there? Andrew, your final word from you before we wrap up for this evening. Sure. I think that there are different levels of training that I think everything from training in basic knowledge about BPD, a lot of which is online, through to training in individual psychotherapies. I don't think you have to train in an individual psychotherapy in order to deal with people with BPD more effectively. I think it's important to tailor the training that you do for the task that you need to do. As a GP, you're not necessarily going to train in cardiothoracic surgery, but it does mean that you can still look after people with cardiovascular disease. And I think that some of the training that is available online from the NEA BPD website is very good. At Origin, we're the National Centre of Excellence in Youth Mental Health, and we offer free training at the Origin campus and then also paid training in early intervention for borderline personality disorder. And we also run a training course in cognitive analytic therapy. And then there's also, I would endorse what Janina said, read books. Go online, get papers. And the International Society for the Study of Personality Disorders is also, I would say for enthusiasts, a very good place to keep up today about the field. Thank you. And I'd like to thank each of the members of our panel this evening who've contributed so richly from their experience. And if I was to... If I...as I reflect, I think one of the things that has really stood out for me this evening is that message of hope, that there is hope, and this can be a much, I guess, more positive story than that which we've been led to believe. And Andrew's suggestion that we advocate for people with borderline personality disorder is so important as a client. Having spent quite a number of years with that as one of my prime focus, so I'm really aware of how much we need to be doing that and to spread that message of hope and to be able to respond in an effective manner. So I'd like to thank each of you for participating tonight and for linking in. And I'd also encourage you if those who have been online to fill out the exit survey before you log off and you'll receive a certificate of attendance for this webinar within two weeks. This also will be a link to the online resources available for you. And I'd like to remind you that our next webinar on the 3rd of May will be supporting families of people living with dementia. I've also been asked to draw your attention to the possibility of setting up your own special interest network or joining an existing one for people interested in working with people with borderline personality disorder. So the Mental Health Professional Network currently has interdisciplinary networks in Victoria and Adelaide and they're looking to expand into other states of Australia. So contact the network if you're interested in being involved. And before I close, I'd like to acknowledge the consumers 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 to everyone for your participation this evening.