Good evening and welcome to this evening's webinar. This is a webinar in a series in relation to Borderline Personality Disorder towards the National Borderline Personality Disorder Training and Professional Development Strategy. And it's brought to you by Borderline Personality Disorder Foundation Spectrum and MHPN. So hopefully you've been part of our earlier webinar that happened earlier on but if not, welcome to this one and this is webinar two, Title Treatment Principles Borderline Personality Disorder. I'd like to begin with an acknowledgement of the traditional custodians of the land across Australia upon which our webinar presenters and participants are located. And I know there's lots of people, we've got over a thousand people who are joining us so far and you'll be all around the country. We wish to pay respect to the elder's past, present and future, to the memories, the traditions, the culture and hope of Indigenous Australia. I'm Belina Grady and I'll be facilitating this evening's session and I'm joined by a panel who I'll introduce shortly. I work, do some of these webinars for MHPN on a regular basis and will enjoy the opportunity to learn along with you. And in my normal day job, I work at the Australian Psychological Society and manager of strategic projects there and will try to do some supervision and some psychology interns as well. So I'm really interested like you are in this particular topic. As I said, this is the second series of webinars funded by the Australian government and if you didn't attend the first webinar which was called What is Borderline Personality Disorder, which is a good title for a first webinar, you can go onto the MHPN website and you'll be able to find it there. And that webinar was a really good introduction but tonight we'll pick up on that but also extend and we also have some other webinars that will be coming up as well as part of this series and there they are. So you can see there that there's a lot to cover and tonight we'll be touching on some aspects of treatment but more around principles and the next one will pick up much more detail around evidence-based treatments and access and then webinar four will have a particular focus on young people in the early intervention. Webinar five, self-injury and suicidality. Webinar six, management and mental health services, primary and private sections. So we may touch on some of those tonight but we're really going to hold off on the main focus and really focus on those incoming webinars and really talk about treatment principles tonight. So it's a bit of a reminder also that whenever we do these webinars just to remind people to think about your own self-care. We're very aware that late in the day people might be watching this later as a podcast as well but in the evening thinking about this topic and thinking about your own experiences or concerns you may have with clients so just be prepared for the conversations that we're going to have and the information you will be receiving and just monitoring your own self-care and in terms of what it is that you need to do to look after yourself. This is obviously a professional development event. We're not going to touch into clients or specific details around people but we're really wanting you to be mindful of yourself and looking after yourself as well. Alright you've worked even the bios of the panellists so we're not going to go through them in details but you can see here that we've got as always with MHPN panels we have a mixed group of people so that we can actually bring together some different perspectives and different ways that people are working but really towards how do we work together, how do we gain from hearing from different professionals and of course having a consumer as part of the panel is always something that I know people really appreciate and again keeps us all very focused and really thinking about what that might mean so we really appreciate that as well. So let's introduce the panel and get them talking with you as that's who you're really, you're here to listen to. So let's begin with you Safia and Safia is Associate Professor Safia Rayo and she's a psychiatrist and Safia you've had a strong interest in borderline personality disorder for quite a long time. What is it, where did that begin and how come? The basic fact is that I actually enjoy working with people borderline personality disorder. Once you get to know them, they are some of the nicest, kindest and thoughtful people you can meet. They're also extremely forgiving of me and they're very compassionate. They forgive all my shortcomings, running late or annoyingly sending them and they get very long the time and the work is highly rewarding and I have immense job satisfaction. Fantastic, that's great. It's always nice when people are very forgiving of our own faults isn't it, that's really helpful for us. Absolutely, absolutely. Thanks Safia. Teresa let's introduce you. So you're a psychologist and you have particular interest in this area and you're one of the authors of the NHMRC and I'm not going to go through the acronym, we're going to be talking about that tonight, but it's the best practice guideline and how do you think that these can be helpful for practitioners? How do they help people? Well they're very helpful and given a direction and a guide for all practitioners involved in trying to raise awareness and get intervention for this population. Particularly what's useful is the management, combined management lines, especially ED where the consumer, a client and a clinician all have input and it can be presented and useful to all across the board to know how to work best and how to manage. The guidelines are just fantastic and they're the first Australian guidelines that have been written so I think they're really good, a best place to start. Fantastic, I downloaded them and had a look at them and Fabulous is the resource. Okay, welcome back to our webinar. We've had a little bit of technological issues back here where my phone dropped out basically and then needed to get back in. So we apologise for that and hopefully we'll be okay from now on. So I think where we left you was we just finished talking with Theresa, is that right? And it's about to introduce Aaron so we've been talking about those guidelines and how fabulous they are and that we want everyone to have a look at them later on that we'll be using them to talk through tonight. So Aaron, let's introduce you and keep moving while we can. So Aaron, welcome and you're still here which is good to have you. So you're a consumer advocate and how long have you been doing this kind of advocacy work in relation to Borderline Personality Disorder? I've been doing advocacy work since about October last year when I attended a coronial inquest into the two deaths of some girls that were diagnosed with BPD. So I met with the BPD Foundation who attended that inquest as well and they invited me along to give a panel discussion at a movie night for a film called Borderline and I answered a bunch of audience questions and I sort of just hit it off from there in doing various works in advocacy. Yeah, I was diagnosed in 1995 with BPD, bit of a rocky road but I now work full time for the government. I'm also studying a Bachelor of Laws at Flinders University here in South Australia. Yeah, fantastic. Working and studying is huge. So thank you.  Thank you. So thanks very much for joining us and as I said earlier it's really important that we have your perspective here and that we appreciate you being here and joining us and it makes it much more holistic when we're hearing from a whole range of people and certainly this experience is critical to informing our work. So thank you very much. Alright, I've got a slide in a moment about technology, funnily enough. This is sort of our ground rule which I touched on earlier. So this is of course making sure we all get as much as we can out of the webinar. So being respectful for participants and panellists, we have question and answer this time. We don't have the chat. So people who are familiar with MHV and webinars would be very looking for the chat. We have question and answer because we've got so many people joining us we just find it's a bit tricky to manage the chat in such a big audience. So it's a question and answer. You will have chance to ask more questions but we also had heaps of questions that came through the generation process. So we've got lots of questions people are really interested in. If you do have any technical issues with ironic saying this now, there's a health desk who are very helpful. If you can see they can get us back online again if we put ourselves as our sound goes. So if there's any concerns that you do have, there's the 1800 number there that you can call in on and they'll do their very best to keep us all functioning very well. Alright, let me see what else we need to be talking about. The format tonight is also a little bit different. We're sort of throwing all the rules out tonight. We normally with MHPN and last time with the Borderline Personality Disorders webinar number one, we had to use to have a case study and it's usually that case study that we sort of focus on but tonight we're not going to go with the case study. We're going to have the presenters talking through going and having their presentations and then the question and answer at the end as we normally do. But there's no particular case that we're going to be looking at. So as always we have some learning outcomes that we're working towards. So the first one of those is identifying core treatment strategies for BPD, describing the application of treatment principles included in the, that's what that acronym stands for, National Health and Medical Research Council, clinical practice guidelines. So that's what Theresa was talking about before. And we're going to identify how to be therapeutic even when not undertaking formal psychotherapy. So this is a really important message I think that we're going to be descending tonight. So this is relevant to every practitioner. So that's the message that's really what we're going to be focused on tonight. So let's move into our panelist presentations and we're going to begin with you, Safia. So over to you. Thank you, Lynn. Thanks for that introduction. Let me start saying that body and person disorder is a very common mental illness impacting at least 1% of the Australian population. It impacts both men and women equally, however in clinical populations women are over-prevented. Men, unfortunately, we see them in drug and alcohol clinics or in justice and correction assistance. Today, we don't have any medications that work for body and person disorder that is patented or indicated specifically for BPD. However, medications are used commonly and they can take the edge off some of the symptoms. So BPD can clearly be treated and the treatment of choice is psychological treatment. The treatments that are popular and that are quite well known to clinicians are the specialist treatments such as dialectical behavior therapy or mentalization based therapy, et cetera. So these treatments are unfortunately very expensive and it requires extensive training in order to provide treatment. As you can imagine, vast majority of clinicians are not trained to provide either DBT or MBT or those sort of highly specialized treatments. As a result, most patients with BPD go untreated. It is seen as all or none either highly specialized expensive treatment such as DBT is given or nothing is offered at all. It is very wrongly believed that only a few highly trained psychotherapists can provide treatment for body and person disorder. Latest research shows that treatment principles can be learned by clinicians without putting themselves through very extensive and expensive training programs. That makes quite a difference to the patient's outcome. Now we have the National Guidelines as Lynn was pointing out earlier on. These guidelines outline treatment principles that most clinicians can apply in their clinical settings to help people with body and person disorder get better. The specialist treatment such as DBT or MBT are certainly useful and effective and may be required for small number of patients but not every single person with BPD requires specialized treatments such as DBT or MBT. So BPD I believe is a disorder every clinician can contribute to the recovery journey of people who are experiencing BPD and they can become aware of the treatment principles and learn the treatment principles and use it in every single clinical interaction. So BPD is every clinician's business and everyone can clearly contribute to the recovery. Thank you. Thanks very much Duffy. I think it is really important setting the scene to tonight's webinar. So perhaps people are thinking that I don't have the skills or I don't have the specialist training and I guess the really important point is that it's something that everybody can play a role in and that not all clients might need that level of expertise. So when we're doing that though I guess the point of tonight is that we're really looking at well what are the principles? What do you do and what's the most important part of that work? So this is where we're going to hand across now to Theresa and start to have a look at breaking down some of these principles. What is it that we would want to be doing? Now it looks like Theresa's screen is not working so we've got some gremlins in our system tonight but we can hear you Theresa. Okay so as I said just this picture for me epitomizes compassionate therapeutic understanding because when working with clients with a borderline personality disorder this picture is helpful because our shared commonality as human beings is that we all come into this world as innocent dependent infants. However influences with our heredity or environment or lack of humanistic nature and perhaps trauma shape the adolescent or the adult that presents treatment before you. So the other one is like building what's important when working with clients is building a solid therapeutic foundation and trust the regering way. So this is imperative. A strong therapeutic alliance can make a difference to the clients and also to good therapeutic outcomes. So being warm empathic authentic non-judgmental and having positive regard for clients are the hall maps for laying the foundation of the house for future work. Also being truthful I tell my clients how that I'm going to work from the start. I inform them of my personal boundaries what's safe for me therefore that makes it safe for them and I'll sometimes refer to them in the third person. I'll say you have to take good care of my client or I'm entrusting my client into your care. So the other thing that I find useful pictorially is Katman's Triangle in Persecuted Rescuer and Victim. So this one is very useful because we have to build a strong therapeutic alliance and if you tell them how you work from the outset this triangle can be very helpful because if you find yourself from this triangle as a therapist then your challenge is to get off it. So to maintain your therapeutic neutrality so I always give a note to myself that a rescuer therapist needs a compliant victim to rescue. So we're in the business of empowering our clients and teaching them skills to be their own rescuer so let the client rescue themself if you want to be useful get off the triangle because eventually you'll either be the persecutor you'll be the victim or you'll be the rescuer. So for your therapeutic boundaries make sure you stay off. Transference and counter-transference are the central challenges that are involved in psychotherapy for dealing with clients with BPD. We're always under that pressure to transgress our therapeutic boundaries and again the triangle can be very useful for this the things that can engender with transference and counter-transference it can evoke strong emotions. So anger and rage, anxiety, feeling of hopelessness, sadness feeling overwhelmed, love and compassion, irritation and being stuck. That's what can happen as some of the transference and counter-transference. So whilst we have to acknowledge where we're at under good supervision et cetera, transference and counter-transference we have to set the boundaries and just let them know let our clients know from the outset how we work, what way we work what's acceptable and what's unacceptable. So we have to make sure that our own immediate physical needs are met. We have to also remind ourselves that we are the caring professional in relation to our clients. We have to be very cautious with our self-disclosure. Self-disclosure is only useful when it's about the clients and I explain this from the beginning when we jointly develop our shared framework. If I make it about me I tell my client then it's not about you and my client deserves a full 50 minutes of my undivided attention as they've been ignored long enough. So this session has to be about you and less about me. When it comes to validation, validation is very important even from one session in the emergency department or one or two sessions. Validation is imperative. So the essence of validation is the therapist communicates to a client that his or her responses make sense and are very understandable within his or her current life context or situation. So the secret to effective validation is knowing when to use it and knowing when not to. And once it's begun, when you should cut it off. So be a cheerleader, be a coach, encourage, focus on strengths and acknowledge positively and reinforce the client for when they use their wise mind over their emotional mind. So validation, up the validation when sensitive topics are being addressed. Increase it then even within a particular session, the need for the therapist validation can be expected to vary. Stick with their emotion and therapy with a bottling client can almost be likened to pushing an individual ever closer to the edge of a sheer cliff. Just remember that the client is doing the best that they can. Validate and acknowledge you're doing the very best that you can. So it's over to Satya. Back to me. So thank you very much Theresa. There was a lot of information contained in those slides and you went through it. I'm sure people are taking pieces of that. There were certainly lots of talk around the importance of boundaries, being up very clear and up front as a staff. And I'm glad that you had that triangle there because I could see a question had come in about that. So the rescuer, victim, persecutor, somebody asked how do you get out of it? Well you said don't get on it. So that was very timely. So thank you very much for that. We'll continue to unpack these principles as we go through.  I think you'll have to unmute yourself Satya. You can't hear you. Sorry. In the next few minutes I'll try and highlight some of the most important treatment principles that are highlighted in the NHMRC treatment guidelines. Now the most important principle is that to believe that BPD is a legitimate mental illness deserving treatment. It is not just a behavior it is clearly a disorder of the brain and the mind. As my colleague Tereza was saying it's very important to take a validating and non-judgmental treatment approach. The research shows that when clinicians are active, engaging, enthusiastic, willing and wanting to actually work with people with borderline personal disorder then the clinical outcomes are better with those clinicians. So it's also important to keep the therapeutic relationship light and I tend to keep myself just as I am. That's probably the best bet. We also want to educate patients, their families, carers, partners etc. about the symptoms, causes, treatment and prognosis. See I'm sure all of us would know that we want to educate our patients about any illness. Any patient needs to be educated about any illness. However it's particularly important when it comes to borderline personal disorder because there is so much of misinformation out there. Often they have received misinformation, wrong information and they are often confused patients can blame themselves for symptoms families can blame themselves for some other symptoms. So it's very important to explain what is borderline personal disorder and have a good discussion. Also it is important to highlight the fact that the science of borderline personal disorder is only about 15-20 years old. So therefore it can be quite challenging to access evidence based and proper treatment. One of the important principles is to develop a treatment and crisis plan that is developed jointly and collaboratively with patients. This again is very important because it can be difficult for people of borderline to place the trust in the clinicians and let the clinicians guide the treatment and take over the treatment because they may have had experiences in the past which have not particularly been very helpful. So they might find it hard to place the trust. So in our practice we tend to get our patients to co-author the treatment plan. In fact we give them the template and get them to fill it up and we have several negotiations and finally we reach a treatment plan and a crisis plan that all of us own. It is also important to have clearly agreed upon goals for treatment and the treatment should be focused on achieving real change. Of course validation and acceptance of the situation, of the trauma, of the past is very important but so is trying to work on change. As my colleague Teresa was pointing out it's extremely important to attain to emotions. People with borderline personal disorder experience significant and severe emotions and clinicians who are working with them can also experience emotional reactions. So therefore to be aware of the emotions that are occurring in the therapeutic context becomes vital. It is also encouraged to begin self reflection. I believe self reflection should happen both for patients as well as clinicians. Clinicians should encourage patients and stimulate self reflection in patients and also clinicians when working with people with borderline personal disorder needs to constantly keep reflecting on their own thought process, their own emotions and their own behaviors. If patients are self farming, self injuring and it is important not to assume that their self injuring is to gain attention I think it is important to just ask the patients why they are self injuring. The most common reason why patients tend to self injure is because they are trying to regulate their most painful emotions. Often patients with borderline personal disorder may not be able to connect their emotions with their behaviors and their thought processes. So it's the clinicians role to help them make the connections between emotions, thoughts and behaviors and the necessary skills to regulate emotions and navigate relationships. People with borderline personal disorder may have experienced societal feelings and thoughts for years and years and years. Therefore it is not going to be possible to change the societal thoughts immediately. What seems to bring about the change in the societal thoughts is if their quality of life improves and their emotions and lives become less painful. So therefore it is very important to work on improving the quality of life. If the societal are just severe and if the clinicians feel that there is a danger then of course it is very important to provide intense supports which might include hospitalization for brief periods of time. As I was telling you in the introduction we still don't have any medications that are patented or indicated for treatment of borderline personal disorder. However almost every person with the borderline personal disorder does get prescribed with medications. So medications can take the edge of some of the symptoms and the consensus is that about 20% of the intensity of the symptoms can be reduced by using medications. So medications can play a role but what is important to remember is that medications should not be used as a sole treatment for borderline personal disorder. Also we know from the report that about 25% of the patients with borderline personal disorder attempt suicide with prescribed medications. Therefore clinicians have to be extremely careful when prescribing medications. I will say that there is a clear role for medications for co-existing psychiatric disorders such as depression, psychosis etc. Another trick and principle is to be mindful and take a very here and now approach to the problems. Looking at backwards, looking at the trauma, looking at the childhood and developmental issues is important, very important and that needs to be validated and understood. However in the initial phase of the treatment we would not recommend a trauma focused treatment. Trauma focused treatments can come in later on in later stages if patients wanting to discuss the trauma and when they are little more settled and the trauma focused treatments are best undertaken by clinicians and psychotherapists who have expertise in dealing with those sort of issues. It is also essential for clinicians to take a long term view of the treatment. In the short term they can be ups and downs, symptoms can exacerbate and manage. However in the long term we know that most patients get better. Another principle I would want to highlight is that weak clinicians need to advocate strongly for the welfare of people with borderline personal disorder because they often refuse access to services and emergency services. The common experience for several borderline patients is that when they go to emergency departments they don't get appropriate care. When they go to, when they try and access CAT teams, they don't get appropriate care. Given situations such as when they are trying to access emergency services, sometimes when they prevent themselves in family code settings, so it is very important for clinicians to have the well-being of people with borderline personal disorder. I'll probably stop here and do it to my colleagues. Thank you. Okay. Thanks, Sophia. And again, there's so much to cover in this webinar. You've touched a little bit there on some treatments. I'm just a reminder that we'll be picking up on that in the next webinar. So we'll be really really focusing on that because I'm sure people will be really interested in that. You also touched on another question that came through was around how do we support schools and families. You touched on that and the importance of psychoeducation, I guess, and that there's a lot that we don't, that people don't know. So helping people to understand the disorder is a really important part of that. So again, we'll continue that discussion. I am really keen to move on to you now, Aaron. You've been waiting very patiently and this is the perspective that has been important for us. So over to you. Thank you. Thank you, Lynn. I will be discussing what works with BPD consumers and what to avoid in interactions both long term and once off interactions. So things to remember with consumers. When dealing with threats of suicide, hospital is often the first port of call. By detaining and sending a person with BPD to hospital, some clinicians reinforce poor coping mechanisms inadvertently. If a presentation results in the revocation of a detention order, care needs to be taken in explaining the reasons for revoking the detention order. Simply stating to a consumer you don't have a mental illness is unhelpful and serious issues may arise escalating those sorts of behaviours. Medications should always be used as a last resort. Sometimes BPD behaviour can become aggressive and medication should be used as a once off to diffuse tense situation when all other avenues such as talking, distraction or reasoning do not work. Validation is not enough. While validation works in assisting a consumer with BPD that a clinician can empathise or sympathise with their feelings, there is an opportunity for a clinician to discuss alternative strategies for coping with feelings and or replacing behaviours with strategies that work. Sometimes it helps to re-emphasise feelings past and do not hang around forever. DBT, MBT and schema therapy may be beneficial, however not one treatment works for and it is helpful to be honest with a consumer about variations of response to treatment. A clinician should try to avoid projecting their own feelings onto a consumer with BPD. This is because projecting a clinician's own issues onto a consumer can frustrate a relationship unintentionally. Try not to overanalyse your own responses and identify when you are stressed, overworked or frustrated. Honesty can go a long way with a person with BPD and do not be afraid to discuss yourselves. Some of the best interactions I had with mental health staff was when they were frank and honest but not dismissive of my feelings. That is really important. Rescuing consumers with BPD should be avoided as this may reinforce a consumer's own BPD behaviour. Such rescue attempts may delay a person with BPD from engaging in helpful ways to overcome difficulties. Rescuing behaviours from a clinical perspective may also cause burnout and focusing all your time and energy on a consumer beyond normal boundaries of human interaction. Validation can help an opportunity to reinforce different methods of coping with intense feelings and emotions when replaced with healthy coping mechanisms. One of the best analogies that was put forward to myself was by my mother. A certain person I was having issues with at the time was that this person didn't hate me, they disliked my behaviour. Separate the difference between a person being able to dislike behaviour rather than disliking the BPD consumer as an entire person. That analogy can be very helpful and I can attest to this sentence by my mother changing my life. Being supportive is mainly advised from a psychological perspective. Re-emphasise that receiving a diagnosis of BPD does not make he or she a bad person. Advise that having BPD is difficult that can be overcome with persistence. Consumers may have intensely bad days but ultimately they are responsible for their own behaviour. I personally took 5-6 times at various stages to realise harmful behaviours were not helping with anything and sometimes it took longer to change them. Avoid bad language and loud conversations about BPD behaviours in front of a consumer especially if it's about them. Consumers may escalate poor behaviours as a result of overhearing a conversation between clinical staff. This is not manipulative. The reaction more likely result of their intense feelings being hurt. Imagine if I spoke of a poor behaviour over a loudspeaker in a shopping mall. Would you react well? Behaviour from a clinician should replicate what is expected from a consumer. Whilst many BPD consumers can be sarcastic, taking the approach of replying with sarcasm is inappropriate. Often consumers have little insight into how their language and behaviour affects others and need to be taught the ways in which their behaviour affects others. Condescending language and using the term crazy can antagonise a consumer. Try to avoid these terms manipulative in attention setting. These terms do nothing but reinforce at how poor BPD is misunderstood. And just lastly BPD consumers are human. They have thoughts and feelings like everyone. Most often in one-off scenarios consumers are brought in by police or ambulance in a hospital environment and are highly agitated because of the virtual adverse commentary received by these services. Stating what's your problem will only work to frustrate a person with BPD as they've probably just received an interrogation from police or ambulance prior. Be tactful with how you ask what is wrong. BPD is tiring, exhausting and frustrating not just for clinicians but for the consumers themselves. Most one-off interactions with BPD consumers can present with the worst scenarios and problems. Good analogy is to liken a person with problematic escalated BPD behaviours as a burn victim. You wouldn't withhold pain medication from a burn victim so why would you with emotional pain? And that concludes my presentation for treatment strategies for consumers with BPD. Thank you. Thank you very much Aaron. Again lots of information and food for thought I think in terms of your perspective and real awareness of BPD in terms of what it's like but a real awareness as well of what it's like for practitioners. So the frustrations that person with BPD might be experiencing but also some of the challenges. So thank you very much for that and I think it's really important for us all to be thinking about that and to hear that in such an open way. We're off to our Q&A now so I can see there's lots and lots of questions coming through. A lot of them are treatment focused so that will be next webinar so this keeps you coming back so you have to come next time for treatment specific ones. And I think that some of the questions that we're planning to ask you will pick up on some of the questions that are coming through as well. So certainly some of the questions are around public mental health system and how that works. We're going to look at that. And another question and I think we'll kick this off with you Sathya. One of the questions was really around how do we know about this when specialist treatment might be required. So we know that specialist evidence based psychological treatment such as DBT, not everybody is trained in that. So it tells me that not all patients are able to access those treatments but with our argument tonight is that there are lots that every clinician who's working with a person's borderline personality disorder can contribute to as part of the treatment planning even if they're not able to access specialist evidence based long term treatment planning. So are you able to talk a little bit more about that and perhaps around I did see one question that was around how do we know that. You said 20 years I think we've been researching and understanding this. So how can we feel confident that what people are doing is going to be helpful if they're not a specialist I guess. So I brought a couple of questions there. Okay. I'll answer the last question first. What we know is that we have done what are called dismantling studies. We have compared specialist treatments such as DBT, MBT and other treatments and what we find is that they're all equally effective. None comes out as superior to the other. We also looked at genderless treatments. Genderless treatments meaning treatments using common factors or treatments using the treatment principles that we outlined today. So if we do treatment using psychological treatments using treatment principles or if we use treatments using DBT or MBT they are equally effective. So research shows that if you work with people with borderline personality disorder using treatment principles what we call inferences common factors they are as effective as DBT. So therefore you can be confident that you can treat people with borderline personality disorder using common factors treatment with the treatment principles and that it will work. And that's what research shows and we at Spectrum do use treatment principles and we find that outcomes are quite good. So I'll try and explain what, summarize what the treatment looks like. Probably with an analogy. We know that when people have borderline personality disorder they experience intense emotions. Let's compare that car, no disrespectment. Let's compare that to a car with very very sensitive accelerators. And normally what would happen when we have intense emotions is that the thinking brain, the prefrontal cortex would bring in the relations, regulatory mechanisms and control the emotions. So those regulatory mechanisms let's compare that to the brakes of the car. It is as though people with borderline personality disorder are driving cars in their lives that has very sensitive accelerators and very poor brakes. Outwardly everything looks alright. So if we see someone driving very erratically we tend to judge them as poor drivers. If only we knew that they have very very sensitive accelerators and very poor brakes then we are not going to be judgmental. The task here for clinicians is to sit in that car, share some of the risks alongside patients and teach the patients how to drive such a car. What we know in science is that once you teach them, once they learn the skills, they are actually able to drive the car quite alright and they don't have any crashes and they are driving erratic. So the principle here is that the problem is in the car not with the driver. The problem is in the the regulatory mechanisms and the emotional brain or people with borderline personality disorder and it is not the person with it's fault. It is not the patient with it's fault. And if any one of us were to drive such a car, we would also drive very erratically. So the idea is to keep teaching the person how to negotiate the relationships, work emotions and all the other skills that they require. I wonder whether that sort of sums up what the treatment principles are. Thanks Sethi. I think that does and I died at the website and I'll give people the link later at the end. There's a website that does have those common factors and so that's kind of the research that you're talking about there. The research that tells us that it's a relationship that the therapeutic relationship that we develop with clients that makes a big difference. I really like that car analogy. It reminded me when I was teaching my daughter to drive and one day the car did have a fault and stopped in the middle of traffic. I really had to step into the shoes as the person with her when she was driving and really think about what does she need to do what's going on with this vehicle. So I think that's a really nice image for us to carry and to be able to think about what does that mean and what is it that we need to help and teach and guide people to think about in order to manage the situation that they're in. Thank you. I think that's really helpful. Let's ask another question. We're going to go on over a little bit tonight because we had our little technical hitch so we'll have an extra five minutes or so because it is important that we get a chance to hear from panellists a little bit more in some of the details that people are interested in. So Therese, I've got a question for you now which is picking up on that public and private practice setting. So one of the questions was, is anyone working in the public system and know about this 10 session business that people get? So the question that I'm going to place to you is how can psychologists or other mental health professionals work with people with borderline personality disorder if you can only see the patients for 10 times a year? Well, John F. Kennedy once said, do something. It's been my experience that working with students on practicum or working with the novice therapists they make the best therapist because assessment requires that the therapist along with the client constantly look for what is missing from the individual or personal explanation of current behaviours and events. So the question always been asked is what are we leaving out here, what are we not getting? So as mentioned throughout this presentation, and Safia mentioned a here and now approach, validation to the client regarding their lived experience, be upfront and collaborative in what their expectations are for engaging with therapy with you. Don't promise what you can't deliver. Focus on the assessment, what's happening here and now including any current risk to self. Psychoeducation of neurobiological factors contributing to emotional dysregulation, to impulsivity and how currently their lack of distress tolerance is impinging on what's going on for them just now. So sometimes showing clients a visual map of the brain and highlighting that currently the nine functions of your prefrontal cortex appear to be shut down and shut down mode. Over the next few sessions you and I need to work together to help you take control of this little part of your brain.  So teach them mindfulness, techniques here and now and how to engage and ground in the senses. So just anything that you can do that as evidence based and therapeutic can be done in three sessions, can be done in five sessions, can be done in ten. John F. Kennedy as I reiterate says do something, don't be afraid, you can do something, you can join, you can be empathic, you can educate, you can develop a relationship in those ten hours. It might be the best ten hours of that client ever had. Fantastic. I really like that end point that ten hours might be the best they had following these treatment principles and people develop that trusting relationship and that psycho-education, understanding what's happening, sounds like it's a really important part of the work. So there's a lot that you can cover in ten sessions. So thanks for that perspective, Fraser. I think that's really important because it really does give people a sense that what you can do in that period of time can be really helpful and it's part of that the whole picture I guess and each little step makes a difference. So thank you for that. Aaron, I've got one for you and we have had some people asking about families, carers, friends, partners. So all the people in the networks around individuals, how can all of those people play a role in helping the person with family disorder to get better or to get through some difficult times perhaps? There are a few strategies you can try. As with BPD, things are sometimes more receptive than other methods and it's just a matter of persistence that I was talking about earlier. One of the first things you can do is validate what your loved one or it may be feeling, that thing is recognizing that what they're feeling is an issue and helping them get through that emotion. This is achieved usually by taking a non-judgmental stance. So you wouldn't criticise or dismiss a person's feelings with BPD as you wouldn't say, oh that's silly, get over it or you shouldn't be feeling that, why can't you just snap out of it. That snap out of it only makes things worse. So if you can try to use strategies that are not blaming, sometimes distracting can really help. So if you can see a person with BPD is getting agitated, you can always try and distract them by going for a walk or playing some music or learning an instrument. There's all sorts of different ways and techniques you can try to do but you have to be prepared yourself to try with them because you can do that and they can reflect on that you're trying to give them a go and trying to get them through their emotions and that can help. So it's just generally a supportive role. It does take a long time to recover from BPD not always but with some it can take quite a while. So it's just persistence and to keep trying. You can try and use examples of others with BPD who might be doing well in the sense that you can show them that you can recover from that might help as well. Yes thanks Sarin that's really helpful. And I guess it's walking beside I guess and individualising it because each person is obviously an individual and at different times different things might work. So it sounds like there's a whole lot of again quite simple things that might be things that people can do together and form a partnership with the person. I imagine it's quite important that families in particular might get some help to themselves as well. Is that something that you'd be in terms of thinking about how do you support the person? Is that something that comes after you? Yeah you need to be able to take time for yourself as well because sometimes BPD behaviours can be very draining and very intensive if you don't take time with yourself just as a clinician would. If they spent and invested all their time with a person with BPD they'd probably burn out eventually and not be able to do any further work. So it's really important that you take time for yourselves and don't criticise yourselves if sometimes you get angry or say things that you shouldn't. That's really important because like a person with BPD we're all human we all make mistakes. Sometimes people with BPD make a lot more mistakes than others. I know I certainly did. And I think it's important to look at yourself and say I'm doing the best I can. I'm trying. I'm still here. I'm still trying to support this person with BPD. Great thank you. That's really important I think to people working because of course some people who are listening tonight might be working with family members as well and think about how do I support them and again the psycho-education sounds like it's really important for everybody to really understand what's going on. So thank you. Moving back to you again Safia we've got a question around DPs and whenever I facilitate these MHP in webinars this question always comes up about DPs and I know we've had lots of DPs who have registered for tonight as well and hopefully are here with us. I think there's about 1500 people who are live with us tonight now. So DPs they're very time precious. They have short time with clients, with patients. How can DPs work with a person with borderline personality disorder given all of those time pressures that they have? What can they do? The treatment principles that we have discussed today are particularly relevant for general practitioners. Let me try and see if I can put myself in a GP's show. GP's are time poor so first we would want to be able to recognize borderline personality disorder. One of the easier way of recognizing would be to give a questionnaire. There are some screening tools such as ZAN BPD rating scale or a McLean rating scale. So these rating scales can be given to patients and it's about 8 questions the patients answer and 8 to 10 questions if they come into the clinic from the waiting room after having filled the questionnaire. The GP's will be able to recognize whether these people have a diagnosis of borderline personality disorder or not. At least have a form of reasonable doubt. If they don't believe that they have a borderline personality disorder they can refer these patients to a psychiatrist for a one-off consultation to confirm the diagnosis very disposable. Once BPD is published it is important to also look at any other co-occurring disorders. Depression can commonly co-occur with BPD. Eating disorders can co-occur with BPD. Does and all problems can co-occur with BPD. So it's important to recognize the co-existing disorder. Once and treat them accordingly if it is depression treat them at antidepressants. Recognize that there is no medication for a borderline personality disorder. We need to teach them skills. It's important to validate and reassure patients and educate them as Teresa and Aaron were telling us earlier on. Also educate their families. In fact all the treatment principles that we have been outlining today are the ones we are expecting the GP's to be willing to give it a go. Of course they only have 10 minutes 5 to 10 minutes or 15 minutes maximum in their consultations. So even in each consultation if they can make a small difference, teach them one treatment principle each time. And if patients self-injure and come to the clinic, again take a non-judgmental approach just add into the medical needs of the person and just ask why did you cut yourself or why did you burn yourself? And the patient says because I was feeling painful emotions, validate them and try and see if time permits, try and unpack a little bit as to what could have been the chain of events that led to them cutting. Commonly, not only, commonly the interpersonal triggers are the ones which tend to lead to self-form behaviors. That's one way of managing. Also to be able to recognize when patients could be at a higher risk or a danger to themselves. Usually this happens if there is a pattern of self-form behavior patients doesn't let's say that cutting is a normal self-form behavior. And suddenly if a person is talking about something more serious, if they talk about I want to hang myself or I want to take care of a massive overdose. So this is something out of the pattern. If it is out of the pattern and if it is a very high lethal self-form they are talking about, that's a time to recognize that probably these patients are at a more immediate danger. Then you might have to give them more intense support. They might want to ask them to come tomorrow or if they are dangerous or imminent, of course you need to call an ambulance and entourage patients to seek hospitalization for short periods of time. Also to recognize that the access to specialist treatments is very limited. Also we have an entire generation of clinicians who are not trained in the treatment of a modern personal disorder. So therefore the GPs might struggle to find people to refer to. Also some of the mental health clinicians might have a bit of stigma around modern personal disorder and might not be willing to treat them and might in fact refuse to treat them. So it may be possible to find some clinicians who are willing to treat. At Spectrum we do try and keep a list of people who are willing to treat people of modern personal disorder and we are happy to hand out that information to GPs if they do give us a link. Of course that is very important for you from Victoria. Great, thanks Satya. Now I said we had some extra time but our time is really going very very quickly and I know that people have got lots of questions that we haven't got to. We will have a look at the questions that we haven't got to tonight and we'll look at how we can build them into the next four series in the series webinar. So I'm very pleased we've got four more because I know it's a big topic and there's lots and lots of questions coming through. It is important though that we do have some take home messages. You've heard a lot of information and I think it is really important that we do start to wrap up and start to think about what are some of the take home messages that are important for you to go away with and I'll kick off with you I think to raise our, what sort of messages would you want to go away with tonight? Well always bring hope to your therapeutic table so not sure a relationship that heals because most clients with BPD have wounds and scars to the soul and scars to the soul can take a very long time to heal so there will be times in your therapy when you're dealing with a regress, vulnerable and needy child there will be times when you'll have a willful adolescent there will be times when you're dealing with a very critical adult. Our job in the business of human suffering is to foster a healthy adult that operates from an integrated rational and emotive mind. Finally your hopeful message is that it is never too late to develop a happy childhood. Teach them to be their own parents to adopt a vulnerable child and give that child the support to develop a life that is worth living for them so I would say bring hope to the client that they can become better. They can rediscover their full potential by recovering and work with them to acknowledge that self is a continuous work in progress and they can with their appropriate help and relationship building develop a life that's worth living for them and I hope you as clinicians and healthcare professionals who have tuned in tonight I thank you for your dedication in this arena and I hope and wish you all the best for working with this very worthwhile client group. Thank you. Thank you Theresa and it's a pity we couldn't see you as you were sharing those thoughts but we certainly appreciate the images that you provided because I think they're lovely for you to take away with. So thank you and passionate about this work and it's great that you can feel like there are a lot of other people that are out there wanting to join with you in doing this so thank you. Aaron let's move on to you. What would be your take home message for people tonight? Thanks Lynn. I think being patient yet persistent with a person with BPD is really important. Understand that everyone's human and everyone makes mistakes as to the extent of those mistakes it can be difficult and tricky to manage but if you show that you're consistently supportive towards a person with BPD even though they may not appreciate it at the time they will in the long run. I know I certainly did when I look back at my interactions with my mom and my dad we used to argue a lot. I've also got a brother and sister so if you can try and get along and try the best you can to sort through problems and take each day at a time rather than focusing on past behaviours as it does nothing as you're in the here and now so I think providing support and validation particularly is really important but also showing them that it is possible to take responsibility for yourself and to manage your behaviours and there is a way you can do that. Fantastic. Thank you. Very helpful messages as well and I guess hearing from you and obviously the support that you see from people and your own commitment to improving and going about what you can do is really evident so really hearing that and seeing that which is fabulous. Thank you very much for those messages and so thank you for sharing with us because I think it has certainly brought a dimension that is so important and that we need to see. So thank you Aaron. And Satya, just the last word to you what would be your take home message for tonight? Out of all the messages we've heard and shared tonight what would be the main one for you? The main one is that the treatment of bodily and per-cell disorder is not rocket science and every clinician can contribute in some way to the recovery journey of the bodily and per-cell disorder. Remember the technology of car I gave you. The clinicians are like diving instructors so you need to share the risk along with the patient sit alongside, ride the same car and be compassionate, be kind and keep teaching the person how to drive such a car with hypersensitive accelerators and no brakes. For that matter anyone who is going to be a co-traveler in that car can contribute to bringing about changes and teaching skills for the person who is driving. As one of the scientists in our field put it, any reasonable treatment provided by reasonable clinicians in a reasonable manner may be beneficial to persons with bodily and per-cell disorder. So if you understand and validate them without judgments or without preconceived notions and teach them skills to manage their feelings and relationships and intense thoughts, fears, etc. they get better. So as Aaron put it, we all make mistakes and we're all human. We can only give it a go. I would welcome all clinicians to give it a go and trust me the job satisfaction is great and once you start working with people with bodily and per-cell disorder you realize that they are some of the nicest people and they get better and they remain better. So it is hugely rewarding work. Give it a go. Thank you Satya. So give it a go who's the take home message and I guess to help people to maybe feel a bit more confident with that we do have some resources and further reading and really comprehensive list of resources and things we look at. There's a whole range of different reading materials for you to look at and to build that confidence and I guess we're always encouraging people to work within scope and to be cautious but we also need to cautiously approaching this work and give it a go as Satya has some eloquently put it. I guess the other sort of message that I hear and I heard this last time when we had our first webinar and again tonight is this message of hope and really challenging ideas that it's hopeless and that there's no chance of recovery. So I think the message of hope is coming through really really strongly tonight and I think that's a really important message for us to have as well if we're working with people who are going to be stressed in time for us as practitioners to be hopeful and to hear stories of recovery and to know that it can happen and that we can play a part in that, that's a really important message I think and for families to hear that as well and people supporting people too is really important. MHPN has a range of practitioner networks as well which is another source of support so we're not saying go out and do all this without any support but there are resources there. There are other people who will be wanting to have a go so there are networking opportunities that are really important part of MHPN's work and they support the ongoing, the engagement and ongoing maintenance of practitioner networks so this is what we've seen tonight in terms of different perspectives, different disciplines coming together and in these networks people meet together regularly and they share tips and resources that build local referral pathways so I've heard a little bit about that and other people that are out there that you can refer to and engage in CPD activity so obviously that's an important part of giving it a go is to do this sort of support alongside that so you can find out about your local practitioner network by contacting MHPN and BPD networks are also being developed so if you have an interest in that this is an area that you're thinking I really would like to get more involved and I'm now starting to see that I can play a role that I want people beside me to do that well you can contact MHPN or go to the news section of the website. We also have an exit survey that should be popping up you can also put your interest in there so we would like you to fill out the survey it's a really important part of the work and part of the development of these webinars and particularly because we've got four more we want to make them as useful to you as possible and also the government who fund us are always interested in what you've got to say so please fill out the survey and add any comments in there is really important thank you for your participation tonight thank you for Redback for getting us back online after we had our little technical dropout and thank you everyone for persevering with that as well you can see there that certificates of attendance will be issued within the next four weeks you will get a link to the online resources that come with the webinar within the next couple of weeks as well so there's lots of support for you to really do this work and do it in a way that fits with who you are and what your practice enables you to do so before I close I'd like to acknowledge consumers and carers who've lived with mental illness in the past and those who continue to live with mental illness in the present so thank you very much again to our panellists for your input and the planning that goes into these webinars beforehand and sharing so much information that there's a lot of ideas I'm sure that people have got to go away with we know there's a lot of questions you have so please come back next time and that will be sometime in April we'll let you know through the usual channels and we hope that you can join us again so thank you very much and good evening