 Good evening and welcome to providing psychological services to people affected by bushfires, a webinar produced by the Australian National University in partnership with the Australian Psychological Society and the Black Dog Institute. My name is Bruce Christensen. I'm a clinical psychologist and the head of the professional programs in the research school of psychology at the Australian National University. And I am pleased to be your host and moderator for tonight's webinar. I wanna begin by acknowledging the traditional custodians of the lands we are meeting on, the many and diverse First Nations of Australia. I pay my respects to their elders, past, present and emerging and extend that respect to all Aboriginal and Torres Strait Islander peoples present tonight. The end of 2019 and 2020 marked the worst Australian bushfire season in history. These fires have been unprecedented in several ways. They began even before the official start of spring, have burned more than 72,000 square miles of land, killed over a billion animals and ravaged their natural habitat. The fires destroyed nearly 3,000 homes, at least 80% of the Blue Mountains World Heritage Area and countless acres of agricultural land, factories, public buildings and places of work. Tragically, 34 people have lost their lives and countless more have been injured in the process of seeking safety and fighting the fires. Economists estimate the impact to be approximately 3.5 billion Australian dollars. In the wake of their destruction, the bushfires have also caused untold psychological and emotional suffering. Communities in effective areas have borne witness to unspeakable trauma and loss. Their social networks and families have been disrupted. Their livelihoods and futures have been threatened. Their feelings of stability, safety, hope and self-confidence have been shaken. And across it all, people are profoundly saddened and demoralized by our poor stewardship of the environment and the resultant impact of climate and extreme weather. Importantly, research suggests that in the long run, it is the psychological toll that has the deepest impact on people and communities. And as a community of mental health professionals, we extend our heartfelt sympathies and commiserations to all those affected by this crisis. We acknowledge their profound loss and stand in awe of their courageous resilience and charity. And we pledge our commitment to stand along with those affected and offer our help and support where possible. It is in this spirit that we have organized tonight's webinar as an opportunity to hear from experts about how we can provide support to those affected and the clinical, interprofessional, cultural and technological considerations that can foster our reach and impact in doing this work. To deliver tonight's webinar, we have gathered together a distinguished group of health experts. I will in turn introduce our speakers and ask them to provide a 15 minute presentation on a topic related to providing psychological services to people affected by bushfires. After hearing from each of our five presenters, we will have time for questions taken from the listening audience. I now direct you on your screen to read the webinar disclaimer for your information. And just before we begin, I would like to highlight some technical aspects of today's proceedings. If you can't hear the sound clearly, you can dial into the webinar using the number listed in the chat box. For technical help in this webinar, please email the address on your screen or call Zoom on the number listed in the chat box. During the presentation, please send questions to the panelists using the Q&A button. The webinar recording, slides and resources will be available in two to three working days. Prior to the completion of this webinar, please complete the evaluation survey, again found in the link in the chat box. Our first speaker this evening is Rob Gordon. Rob's current roles include clinical psychologist and psychotherapist in private practice and consultant to the Victorian government. He is also consulted to the Australian Red Cross for disaster recovery, a role he has held for 30 years. Rob is distinguished for his work on understanding the impact of disasters of the social system and how to manage the trauma associated with disasters. Rob will be speaking on the characteristics of clinical work in post-disaster environments. Rob, if you please. Well, good evening, everybody. It's great to be able to share some of the things I've learned over 30 years of working with a whole range of disaster-affected communities, floods, fires, cyclones, earthquakes in Australia and New Zealand. I want to emphasize that I think there are several features of clinical work in a disaster-affected environment that are quite different from our normal work in a clinical setting. The first thing to consider is a disaster by definition is a collective event. It's an event that affects a whole community. And this really means that what are activated are a series of social phenomena that go well beyond the individual's experience. In the recent fires, we're now six weeks to two months down the track, depending on where it is. And we see phenomena like tremendous help being offered, but at the same time, lots of judgmental criticisms of who got what and the feeling that some people have double-dipped and got what they're not entitled to, anger and hostility against the fire brigade for not having done what was expected, and so on and so forth. And what we need to understand is that the disruption of the community is simultaneously a disruption of the social context that we normally take for granted to provide the frame of reference for our interpretation of events. There are really important things that are fundamental to our daily experience that we take for granted, such as having a reference group that allows us to compare our own experience with that of others. So for example, as a psychologist, we have a reference group of other psychologists. So when we have a question about our experience or our conduct as a psychologist, we can consult that reference group and work out whether we've got a problem or it's normal. There are issues of social comparison. How do we work out whether I have a more significant problem than somebody else? We normally have a frame of reference for that. And there is a phenomenon that's been observed since the 1960s, first observed by Thomas Merton, called relative deprivation, which says that the people in a disaster environment tend to benchmark their own loss and trauma by comparison with that of the most significantly affected people they're aware of. So that we find that people who maybe had a very traumatic event but didn't lose their house don't feel nearly as entitled to help compared to those who lost everything they own, but maybe evacuated early and didn't have a traumatic event. So this complexity is very disorienting to the people involved. And I'll mention a bit later the whole problem of help seeking, which I think is a very significant dimension to be worked with. But I want to just emphasize that we know that the most significant factor to determine whether a person will need professional support after a disaster is in the first instance, the severity of the impact. Now, I want to make a simple point that under normal circumstances, only a relatively small proportion of the community actually make use of mental health services and other government funded services. The rest, which probably includes many of us, pride ourselves on undertaking our lives with our own resources. And as far as possible, we actually see ourselves as not needing to contact professional services. In fact, many people go through their lives without having to reflect on their own mental state. Now, if we were to take an arbitrary figure for example and say, perhaps 20% of the people use a whole range of government funded services, health and welfare and such like and the other 80% don't. The ones that use the services have gone through a social process of enrolling themselves in the role of being a client of a helping agency. And that's a process that involves a discrete series of social interactions and may have taken weeks, months, years to really come to the conclusion they need to consult a psychologist. In the aftermath of the disaster, the community has just hit with this complex experience and people are suddenly thrown into this state of distress and need and trauma and they haven't had that enrollment process. So in the beginning for most people, there's a disconnect between their self representation of their problem and the services they see around them. I can illustrate this with a farmer from one of the rather remote bushfire areas who said to a person after my talk to that community about understanding their own reactions and recognizing their own stress. He said to my Red Cross colleague, gee, I'd never thought that I should consider my own state of mind. I never thought I should have to look after myself. So his simple idea was, it's a problem that's happened to my farm and that's what I need to focus on. And yet there's a very high level of distress in these farmers. So I think that this means clinically, we can't simply go into an interaction with one of these, I call them the 80%ers, the let's say those people who've never used services before. We can't go into the interaction with them with the same assumptions that we have in our normal clinical practice. And many people will tell us afterwards that they've been to see a psychologist, but they really didn't understand what they were on about and he started talking or she started talking about things that weren't really relevant. So what we need to understand is we need to enroll them in the role of being the client of a psychologist, which really means we've got to much more sensitively explore their experience and help them understand how this might be understood as a psychological problem and how our assistance might be of help. Last night I was visiting another community in Victoria that were a year into their disaster recovery after a fire last year. And a woman described a whole series of what I'm pretty sure is a somatic anxiety responses. But then told me she was very worried about her health and was seeking an appointment with a neurologist. So she has no basis on which I suspect to understand this anxiety state. And most people go through their lives without having to think about it. So I think there's an educative informational component there. And I think it's very important that we approach them with a lot more informality, not taking our role for granted and helping them understand what's going on for them and how we might be able to help them. And I think at each stage we need to engage them and seek their cooperation and agreement with our perhaps more intensive work. I would suggest for instance that we don't go into automatic processes of taking a life history, family history, et cetera. Quite often people are very confused about what that implies. Instead I think what's so important for them is to encourage them to tell their story and see what you're dealing with. And very often we will find that the most unexpected people have had really very traumatic experiences. Bearing in mind of course that the essence of the trauma is not necessarily what happens, but what I think is going to happen to me at the most important points. Now that really says that our services perhaps need to be more informal and flexible than we would normally undertake. And I can't emphasize enough the value of being in the communities, attending community meetings, introducing yourself, describing your services, giving some very simple descriptions of what you might be able to do and always providing just a little information that might help people go away and think about why they might be able to use psychological services. Now I just wanna emphasize another factor and that is the research much of it done in the US but also in Australia indicates that there are four main clinical problems. The first is post-traumatic stress disorder. The second is depression, then anxiety states and substance abuse. By and large, these are the most dominant diagnosable mental disorders that are present. But I wanna emphasize another factor which is not really a diagnosable mental disorder but is very disabling and that is distress. Now, most of the people that we will deal with after disaster have probably not had such experiences of disabling distress, of being momentarily completely overwhelmed with their situation and unable to see their way through and then pulling themselves together and going on and doing what they have to do and then later on having another episode of distress. Many people don't even understand what's happening to them. And so in this state of distress, I think often the simplest interactions of encouraging people to talk and describe and helping them compartmentalize and organize the problems they've got to make contact with the various services, not necessarily mental health but financial support, case support or whatever other technical problems they might have to deal with. And we find really that this distress, if it's not managed and dealt with, then leads to a series of repercussions in their lives. And we know that down the track, and in fact from my information, it's already happening in communities now, the deterioration of relationships, the emergence or the reappearance of family violence leading to deteriorated relationships, social conflict, increased use of substances. And I think these are very important issues to identify very early and encourage people to use the variety of services that are available. And I want to just come back to the idea of help seeking, that what the research has shown in the United States and elsewhere is that there is a discrete social process that underpins help seeking. And that involves absorbing information that allows people to reflect on their own state and conceptualize it in such a way that their understanding intersects with the services available. And this means anything we can do by way of education and information to services, offering for instance, to write short pieces in local newsletters or information sheets or Facebook or other sources. The feedback I've had over the years is that often people will say, when I read that I realized what was happening to me and then I knew what to do because many of these people have got a resilience and a capability that many of our ordinary patients don't have. They've actually reached the end of their tether. And so what we have to understand is that many of these people will benefit from what by comparison with our clinical work with more seriously disturbed people is minimal interventions. And I would say it's very valuable to have a light touch and to be reaching out, participating in informal activities. I know that people have told me when I've had a 10 minute conversation with them after a meeting and listened to their story, made a few suggestions, helped them understand something that's happening and met them maybe a year or two later and they've said, that was so helpful. That really helped me understand what I needed to do. So my message in essence would be, try to be more flexible, more informal and meet people where they're at in the first instance. And if they do really need a full-scale clinical intervention, that'll be very obvious. So I hope those issues are helpful and I've got a couple of papers on the website and I hope they're of assistance too, from my experience. Thank you very much. Thank you, Rob. Thank you for those observations and indeed they are very helpful. Next, I'd like to introduce Christine Phillips. Chris is a GP and is currently the medical director of companion house medical service and a professor of social foundations of medicine at the Australian National University. Chris was one of the founders of the Refugee Health Network of Australia and has looked after traumatized survivors of war and environmental disasters like the Canberra bushfires and the recent South Coast bushfires. Chris, if you will. Thanks very much, Bruce. I wanted to talk in this talk about the experience of general practice, both generally and in particular for those GPs who are down in the regions that have been fire affected. I want to talk about the ways of what GPs are seeing and also the most effective ways of collaborating with them and also for supporting them to collaborate with you. In this talk, I'll be talking about what we see from my desk in the fires and I'll also be talking about the ways in which, as Rob said, patients present to us and how we will be encouraging them to move to see mental health professionals and also at what point mental health professionals might also wish to collaborate more closely with GPs. If I think about the fires, after the fires in the general practice, what people are generally seeing is a number of different types of distress. First of all, there is a worsening of the chronic disease amongst those patients who already have chronic disease and that's a large proportion of the population. We know from multiple studies into bushfires that hypertension always becomes more uncontrolled after fires. We also expect that diabetes, lung disease, the chronic diseases that people are suffering from and which they may have had reasonable control from are actually often worse than after the fires and that reflects the amount of somatic stress that they have and also sometimes the difficulty of actually accessing medical care or accessing pharmacological care. People also suffer from an increase in somatic stress as Rob has pointed out and this can be difficult for them to put there, to define really. Recently I found people coming in with gut pain, which is highly painful, but it's not related to any underlying gut abnormality, but it is difficult for them to settle. It is very difficult to settle your gut pain. That's not under your conscious control. Then we have people presenting with psychological distress and that is really a concerning process for patients because they are presenting with distress that may not be something that they've experienced before. They have often suffered very sensory experiences in the fires and it's very difficult to process those and think of their way through it. Many of my patients have got videos of the fires and this is not something I've seen in disaster before where people have come in and played the videos repeatedly on their phones of their experiences in the fires or on the beach sheltering from the fires and substance abuse is the emerging issue that we can sometimes see underlying psychological stress and added to that is the social distress of people struggling with housing loss, work loss and the functioning family unit. If we look at what lies underneath all of that, it's a series of many people who are displaced or evacuated and who have a loss of their usual social networks. The social disruption will be experienced as crowded, temporary, unsatisfactory housing. Nobody likes living in a caravan park for any long period of time and nobody likes sleeping on the couch at their sister's place for a long period of time. And it's not surprising that this actually generates quite a lot of lived distress as well. The loss or the contraction of work, many of the regions have really struggled with this because they were relying on casual or tourist work and that's been lost and the loss of animals. Many of my patients are talking to me about the screaming of animals. There was such a loss of animals on this occasion that and loss of loved animals, loss of your stock and loss of your pets, that that has impacts upon people. As people move into and evacuate into other areas, they start to suffer from problems associated with the contraction of their social network because there's less of their immediate community around or they've gone into another community that doesn't have the social networks that they had and there is, we are starting to see the compounding experience of floods following fire, which in turn had followed drought in many countries, many areas. So Professor Sandy McFarlane speaking after the Ash Wednesday fires made this comment that what we learned after the fires is that people trust their GPs, that they're the people they go to and that they seek rather than outside counselling and that is certainly true that people trust their GPs but it is an exhausted resource as well. Currently, many of the GPs in bushfire affected regions have also of course had the same experiences and so while people trust their GPs and will come into their GPs, there is an enormous need for GPs also to have their mental health colleagues coming to support them in their endeavour and they will be welcomed in doing that. This is a slide from the Royal Australian College of General Practitioners advising us as GPs. This was disseminated not too long after the fires but what we should, when we should consider referring somebody and it relates to as you can see some sustained experience one month after the experience the person has suffered what's on your screen at the moment and you can see that they are not expressed in psychological terms. These are expressed in experiential terms or in terms of social loss but although you could look at those and you could translate them into psychological terms people are actually experiencing those in terms of the distress and the disturbance of their life and I think it's interesting that the College of GPs has not actually used any kind of diagnostic framework over the top, it's just said look at these experiences and consider what that means. This is a comment from, and it relates to a comment that Rob has just made. This is a comment that one of my patients made some years ago after going to see a very good counsellor in relation to a PTSD that they had suffered from the Canberra bushfire and this was not again not a person with a great deal of language for psychological experience and so this person had said how could I trust this counsellor? She looked me up in a book and she told me I was already in the book and it was this statement that her life was encapsulated and her experience was encapsulated in the book which was a DSM that actually engendered a lack of trust in this patient who really just wanted that interpersonal contact with somebody who was willing to sit and listen to their experiences. So we have to in general practice keep our antennae up for problems that are emerging in relation to people with emerging psychological distress and in particular I guess our antennae are up for these people, they're up for children. We know from the Christchurch quake there's quite a lot of long-term follow-up from the Christchurch quake and those children have had sustained emotional dysregulation. They have remained affected by that huge and uncontrollable experience that they had and I think that is useful for us to think when we're thinking about the experiences of these people who have suffered from the fire. We're also particularly going to keep our antennae up for people who have suffered previous trauma, war veterans or people who have experienced in the past partner or family violence. But we also know that after any major catastrophe that family violence appears to no-go. So that families that have not been visited by interpersonal violence or violence against children this starts to be something that occurs within that relationship. In fact, this has been referred to as a hidden public health problem. In Hurricane Katrina, the rates of interpersonal violence doubled from four to 8% of the population in that state. There was an increase in intimate partner violence after the Black Saturday, 2009 fires and it's also been reported in the Christchurch quake. So it behooves us to keep our antennae out for interpersonal violence into partner violence even in families where that may not have occurred before. And that brings within its own responsibilities if you are a mandated reporter and that violence is occurring towards a child, then that is a mandated responsibility that you will have in terms of reporting it to that state. The other issues that people that we would keep our antennae out for the defenders, the people who stayed at home and defended against the fires and the firefighters themselves. They have had, many of them have had very, very long tours of duty and were not necessarily prepared for the experiences that they did have. And finally, our helpers. We are helpers, you are helpers. In the helping profession, sometimes we can get exhausted and burnt out by what we see as well. And it's interesting to consider this particular slide that also has been disseminated to clinicians in the bushfire affected areas to say, think a little bit about whether you yourself can use this psychological lens to understand your own reactions. Are you experiencing heightened reactions to patients? And this would apply to clients or to students or to other people in which you have a helping relationship. Are you experiencing increasing arousal such as sleep disturbance or irritability? And are you starting to use avoidance strategies such as alcohol? If we are working with mental health services and with mental health professionals, I guess our first thing would be to identify need. And we will be doing that really through psychological distress and referring to the right person. And as GPs, we need to know about you and what your capabilities are. The local primary health network is the appropriate service to distribute information to GPs about your capabilities. But just being in the community so that people know you is going to be a critical thing. And if you're good with children, if you are experienced with war veterans, these are things, if you know any language at all, including sign, these would be really useful for us to know so that we can match patient with person. The Medicare Bushfire Recovery Initiative, which will be talked about in a little bit by Julia, is a step on from the usual better access processes. It applies to anyone directly affected by fire. It entitles the person to 10 sessions till December 2021. You do not need a mental health plan and you do not need a diagnosis. Now, this means that people can self refer to mental health professionals and may not in fact see a GP as well at all. And this stresses the need to be in the community so that you are known. The Australian government encourages people to build those sessions. This is a slide from a primary health network, just to give you the sorts of information that would be available to people and available to mental health professionals. It's describing the setup that we have and it's also describing the services and the links that you can click on tell the general public they can access these websites. All of the bushfire recovery counselors who are available in that region or will be available by teleconference to that region. If you're working with GPs, it's important to stay in touch with them. If you feel that the person's illness warrants medication broached with the person and the GP have a response plan for suicidality or other risks such as violence. And I'll conclude by making the comment and it's the comment also that Rob made is that communities build resilience in our experience with the Canberra bushfires which was not to the scale of that some of the fires in our region. It was one of the most important things was activities that strengthen community and it will be the same with these major fires that land care activities and garden activities the Phoenix groups will be valuable. The local church groupings or the men's sheds or the country women's associations whatever other local associations that support people in their social world are important. Programs for children that are fun and animal rescue programs. I don't think it's an accident that we are seeing so many people engaged in rescuing animals at the moment and animal and bird recovery. So they are programs to actually repopulate the land. I think all of these speak to the need to think broadly about community resilience and response and to encourage that when you're speaking to your own patients. I commend you in your wish to serve and the general practice population will be very keen to work with you for the benefit of patients in this region. Thank you very much for your time. Thank you, Christine. We appreciate your insights and observations. Next, I'd like to introduce Glenn Williams a descendant of the Reagiri people of New South Wales. Glenn is a psychologist and project manager for the Mind the Gap project at the University of Wollongong which is developing and delivering best practice mental health services in the region. Glenn's distinguished accomplishments include over a decade's work with the Australian Indigenous Psychologist Association to address cultural awareness amongst the mental health industry within Australia. Glenn will speak on some aspects of cultural safety when working with Aboriginal and Torres Strait Islander people. Glenn, over to you. Thank you, Bruce, and good evening to everyone. As you can see, the next section as identified by the slide, the host has asked you to start your video. Okay, sorry. Cultural safety when working with Aboriginal and Torres Strait Islander people. My underlying aim is for you to transport your clinical and professional skills and implement them in a cultural context. But before I start, those of you who will be working with Aboriginal and Torres Strait Islander people, I would like to suggest that often the best teacher of cultural understanding will be the person sitting right in front of you. If you experience any uncertainty around cultural influence, simply take the time to ask a question. A question such as, I'm not familiar with the aspect, this aspect of your culture. Is it appropriate or is it something that you can explain to me? Tonight, I'll be touching on the diversity of Indigenous Australia, the importance of knowing your own cultural bias, risk and protective factors, and a simple outline of social and emotional out well-being model. Okay, my slides won't move forward for some reason. Okay, just click on the slide once. I did, yeah, I'm sorry. Okay, thank you. Often from a non-Indigenous perspective, Aboriginal and Torres Strait Islander people are frequently viewed as an homogenous population. Such a view promotes the notion that all Aboriginal and Torres Strait Islander people display little if any difference between language groups. This further promotes the idea that all Aboriginal people are experts on all things Aboriginal. This is not the case. I want you to think of Aboriginal and Torres Strait Islander people sitting on a cultural continuum with traditional lifestyle at one end and at the opposite end will be contemporary lifestyle. Aboriginal and Torres Strait Islander people will vary where they sit on this continuum and often can and will fluctuate between the two. Strong suggestion from the slide is in order to promote successful, is in order to promote successful clinical engagement, we become familiar with the local cultural norms of the people we are working with and understand any historical events that have impacted upon that particular community. And I think this is a very important aspect. Homogenous thinking from a clinical perspective leads to the assumption that all Aboriginal and Torres Strait Islander people will benefit generally from a single approach. There is a strong support within the industry that narrative therapy is the best approach for Aboriginal and Torres Strait Islander people. We need to be diverse in our approach and at times thinking outside of the clinical box and seeking guidance from a local elder or engaging in a traditional healer are also good ideas as well. To further dispel the idea of homogenous tribe, I would like to share with you one of my favorite versions of the Australian map. My purpose is to simply highlight the diversity within Indigenous Australia. As we all know, we have two very distinct groups, Aboriginal and Torres Strait Islander people, each with its own cultural underpinnings and each with their own history. The map displays over 250 different language groups with estimates of up to 800 different dialects being spoken traditionally. And today, we currently, it is estimated that we speak approximately 13 traditional languages which are in common use across the country. However, traditionally, each of these language groups have their own cultural law and that is L-O-R-E law, customs, rights, rituals and practices. And so as you can see, a very diverse community. In my local community, we have three distinct clans. And if I cross the local river, which we have here, I step into another language group. So I cannot encourage you more strongly than to know and understand the local dynamics of your community. To introduce the idea of cultural bias, I'm going to quickly present the idea of individualism and collectivism. If we look at the top of this slide, we'll see Yellow Arrow representing a continuum. Those of a Western culture will lean more towards the right of the continuum and align with the individualistic approaches. And those with an Indigenous background will lean more to the left of the continuum and align with the collectivist approach. As we view the two lists, we can see that just on this one cultural approach, there are two different ways to engage culturally. Cultural bias can cause discord in a therapeutic alliance. And it is aware, even just on this simple approach between collectivism and individualism, that there are some very distinct differences. And due to time restraints tonight, I would just like to focus on the third line down there. Obligations to others versus individual rights. And I would like to pose this question. Would you cancel an appointment due to a non-urgent family request? Let's say you have an older sister and she rings you on the morning of your psychologist's appointment and asks you to look after her children while she attends her dental appointment. And sadly, the two appointment times clash. An individualist would probably reply, No, I have my own appointment that I can't miss and would then encourage their sister to find someone else to look after the children. There's a high probability that this is not the approach for a collectivist. There is a high likelihood that due to the obligations embedded in culture, to more broadly focus on the group and not the individual, that in a collectivist's group would lead the individual to look after the sister's children and not attend their own appointment. Indigenous Australians are often bound by obligation to the group and this predominantly will come first over the individual. Such an approach is common in Indigenous Australia and is one of the many reasons appointments at times are not attended. Do we then, because they're a community and also family obligations that need to be met, do we then address this in therapy to satisfy a more assertive approach to keep the appointment at the cost of ignoring cultural practice? Unless there are other mitigating circumstances, I suggest this would be a point of cultural bias aimed at satisfying the clinician's frustration. When you, as a clinician, are experiencing a level of frustration when working with an Aboriginal or Torres Strait Islander person or you're not progressing in therapy the way you had planned, I want you to stop and engage in just a moment of self-exploration and ask yourself, are you experienced the impact of cultural bias at this moment with this individual? Ask yourself, why is there avoidance to this topic? The answer may be simply linked to the notion of men's and women's business, which is very real in Aboriginal and Torres Strait Islander lives and you may not be the right gender to discuss some of this information with. Be aware of taboos in your area. This is why you need to have an intimate knowledge of the local community's cultural practices to define what is acceptable and what falls outside of cultural practice. For those of you who are or have a desire to work with Aboriginal and Torres Strait Islander people, seek out a good cultural mentor in your area. It is incumbent upon us as practitioners to mold our therapeutic approach around an individual's culture rather than ignore culture and have the individual fit our therapeutic approach simply for the ease of our mode of practice. So as the slide says, seek ways to integrate culturally responsive practice into evidence-based treatments. Due to the past political and historical determinants, there is not one Aboriginal and Torres Strait Islander community across Australia who have not been impacted by transgenerational trauma. This is an ongoing concern and as clinicians, we need to understand the historical and political content around transgenerational trauma within our community. Transgenerational trauma highlights that there is a level of community, family and personal dysfunction and the resilience across these three domains has seriously been eroded. Two primary contributing factors that have a contemporary context are the stolen generation and the sustained high levels of incarceration. Both have and continue to contribute to the dysfunction that is passed from one generation to the next, causing a range of risk and protective factors that we need to be aware of. As you can see, this slide looks at risk and protective factors relating to serious psychological distress for Aboriginal and Torres Strait Islander people. Upon immediate observation, we can see that the weight of the risk factors is greater than that of the protective factors. Risks include poverty, poor health, adverse life events, family removal and remoteness that equals poor access to services. The resulting impact of the risk factors can be seen at the bottom right-hand corner. Some of the adverse outcomes are that we need to address in our areas of expertise a collective sense of anger. This leads to increased aggression and conflict, poor social emotional well-being, sadly, abnormal high rates of suicide and elevated rates of anxiety within the community. We can see in the little green box the protective factors, remote living, often equals connection to the land, culture and spirituality. In light of the current events, we can consider another adverse event is the impact of the bushfires. Even though the bushfire emergency was widespread, I can only speak for the southeast coast of New South Wales and some of the people that I have spoken to in my local community express that there is a very strong feeling for the damage done to the land. There is a loss of access to some of the land and limited access to ceremonial land. There is a strong impact upon the flora and fauna that has caused further community distress and individual distress. And this is currently impacting the psychological distress of affected communities or what is called social and emotional well-being. Some of you may have been exposed to this model, but social and emotional well-being is not an alternative expression for mental health. And within Aboriginal Torres Strait Islander people, mental health needs to be viewed across all the above seven domains. There exists across these domains an intimate connection to body, mind and emotions, family and kinship, community, culture, country, spirit, spirituality and ancestors. Referring back to the not being an homogenous group, not every Aboriginal or Torres Strait Islander person just subscribes to the above domains in the same way or in the same intensity. However, when these connections are disrupted, we say so has the social and emotional well-being of that individual being disrupted. Disruption has come from historical and political social determinants, as you can see by the outside indicators on the model. And understanding this model will allow for a deeper appreciation of and act as a guide to work with Aboriginal and Torres Strait Islander persons you may have as a client. Working with Aboriginal and Torres Strait Islander people is not a test of how good your clinical skills are. It becomes a measure of how well you can apply your clinical skills with cultural understanding. And as we look at mental health versus cultural practice, if an individual presents and they disclose that they have been speaking to a deceased person, often our first inclination working in mental health is to assume the individual is experiencing perhaps a mild psychotic episode. We need to know what are the cultural norms for this person's community? Does it include interacting verbally or visually with a deceased? And just more generally speaking to the dead often is a common practice within indigenous communities. Another example of sorry business rituals is in other parts of Australia, people can be repeatedly hit their forehead with a stone clutched in their hand. This causes bleeding and can leave scarring. As a practitioner, there may be an immediate thought of self-harming when in fact, this is an accepted practice. For this reason, I cannot stress how important it is to know and understand local customs with the Aboriginal and Torres Strait Islander people who you will work with. One easy way to solve most cultural understanding is to have a respected elder in your community as your cultural mentor. And just in closing, this book, Working Together, some of you may be very familiar with it, is a valuable resource that will go into greater depth than I could hear in this brief time tonight. It is a free copy and it's available electronically. So can I encourage that if you don't have it, can you please download a copy because it will be a very good guide for you as you engage and work alongside and with Aboriginal people. And having said that, I thank you for your time and I'll now hand back to Bruce. Thank you very much, Glenn, for sharing your expertise and wisdom with us tonight. I'd like now to introduce Julia Reynolds. Julia is a highly experienced clinical psychologist, engaged in research, practice development and clinician training in the area of e-therapies. She was recently awarded the College of Clinical Psychologists Award for Outstanding Service. Julia works at the Australian National University's Research School of Psychology, where she is helping to develop an e-therapy clinic to serve rural and regional areas of New South Wales and provide placements for postgraduate students. She will be speaking on some of the process and clinical implications in delivering digital e-therapies to bush-affected areas. Thank you, Bruce. Good evening, everybody, and thank you so much for joining us. I'll just get my slides up. So my presentation is about telepsychology and video conferencing. And I noticed in the chat box, some people were asking about this. And whether this may be something that could help people provide services into communities that they wouldn't normally work with. And I think that's very much the case. So it's becoming increasingly feasible to deliver services over telepsychology. And in the last few years, there's been some rebates available through Medicare. So if you're not already using video conferencing in your practice, you may wish to consider looking at this. So currently, as I noted, there are already some existing items available to deliver telehealth under Medicare, most obviously through the Better Access program. So these are available to people who are registered providers under the MBS, as you'd be aware. And Christine also mentioned the Bush Fire Recovery Access Initiative. And that actually has some video conferencing items under it. Bolt-billing is, of course, encouraged. And what's interesting about these items is that people can be in whatever location they need to be, that there's no geographical restrictions on this and people can self-refer. These items can be provided in addition to sessions provided under already established items, like Better Access. But the telehealth criteria for the established items have not changed so that people will still need a mental health plan to be in certain locations if they're going to access those items. So I think if you're interested in exploring, developing a video conferencing aspect to your practice, it's important to think about how you're going to let clients and refer-ers know, especially if you're not in that community already. So this can be very simple, such as just listing telepsychology as a service in your usual marketing, for example, through the APS finder psychologist. And you can also approach communities through primary healthcare networks. As Christine said, these are trusted networks and they're already in connection with GPs and their communities. So they know what's needed in their environment. More broadly, you can also list your service in the Australian College of Rural and Remote Medicine telehealth directory. And you can see there that some of our colleagues have already done that. It's free to list in this directory and it's sourced by PHNs and also by local pathway tools. So the link is provided here to go to that website, but we also have a handout, which is available, which has this and many other links that you can follow and find out more. The other thing that you could potentially do is go to the Rural Doctors of New South Wales Network. They're currently seeking expressions of interest to support the New South Wales recovery response. Now, they're not specifically looking for video-conferenced services, but I contacted them and they said they would welcome expressions of interest from psychologists who are interested in delivering those kinds of services. And currently they're seeking people's availability and to hear about that for the recovery period. And at this point, they're just looking at February, December this year. So if this is something that interests you, there are a few issues to consider. And of course, the first one you'd want to know really is what are the outcomes like, the clinical outcomes like for telepsychology? Research to date suggests that these are pretty similar to face-to-face therapy. Although I must say we do need more research as there isn't a great deal, but what is available is certainly fairly positive. Telepsychology has been successfully used with people in remote and rural areas and successfully used to treat PTSD, sort of post-traumatic stress and other related syndromes. Research has tended to focus on anxiety and depression. So we do need more research, particularly across other conditions and particularly for civilians in non-urban areas. It's very easy to find reviews online for particular conditions and you can just go to one of the free online literature directories such as PubMed and plug in telehealth or telepsychology and the condition you're interested in, you'll be able to find it. The other aspect of outcome that's interesting is therapeutic alliance. And overall, this seems to be quite similar, although there is some variability. A recent meta-analysis actually found that therapeutic alliance in telepsychology was a little lower than that in face-to-face therapy, but it didn't seem to impact outcomes as much. And this was a very interesting finding, I think. Therapists often rate therapeutic alliance lower than do their clients, although that seems to improve as therapists become more experienced. From my experience in working in telepsychology therapies, I think there is a qualitative difference in this work compared to delivering services face-to-face. And the main difference for me is really around the client's increased autonomy and a more equal power structure within the therapy. And this may fit particularly well with people such as Rob was mentioning, where they're perhaps not as enrolled in the psychological client role. So the client in telepsychology has a more overt role in managing the space. The therapist is more involved, I guess, in terms of planning ahead, coaching the client in any skills or knowledge they need to participate in the therapy and to consult with the client. And it's very much a co-created space. One thing I find particularly interesting is that from the beginning, both openly discuss the quality of the connection and the satisfaction that the client is experiencing in the therapy. So initially, this is focused on the technology, but it seems to develop quite easily and naturally to talking about interpersonal and therapeutic process. So if this is something you'd like to explore some more, there are some logistical and sort of professional issues to consider. And these, I think, are some of the key areas. These are very well covered in the APS's free telehealth resources, which are available whether or not you're a member, anybody can access those. And again, there's links for those in the handout. But I'd like to just illustrate a few of these points in the time that we have available. So safety and support planning is very important, obviously, and is somewhat different to face therapy. You need to develop some very clear protocols with individualised support plans for each client, not just those who are identified as being at risk in some way. At each session, it's important to confirm the location, the client's contact details of where they are and how they can be contacted that day, and to just reconnect and refresh your plan in case you lose connection with the client. Plan to manage risk and distress within and outside sessions, and it's great to start that planning really from the very beginning of your contact with the client. It can be very helpful for clients to have a bit of support post-session, and you can plan ahead for that in non-urban areas. That is probably not going to be a formal helper or a professional relationship, but there may be community organisations or other personal contacts of the client who could pop in and even just have a cup of tea just to see how they're travelling after the session. Informed consent, your usual protocols and documentation will probably need some extension. Obviously, it's very important to talk about confidentiality and how you're managing data security and the limitations that are associated with that. The client's role in managing their confidentiality but also their personal support needs is very important. That needs to be very clearly understood as part of the consent. And I think part of the reason it's very important to talk about data security is that the client needs to understand the things that they can do to manage their privacy, for example, not sending you emails, open emails with very personal information in it. It's important also to think about the limitations of telepsychology and discuss those with the client. Obviously, videoconferencing is not suitable for all conditions and it's important to be very clear about what support the client can access from the therapist and from other people in between sessions and to have very clear expectations about the therapist's availability. The consulting space, Rowan's going to talk more about this a bit later but considering the virtual meeting place that you will use for your therapy, I would just like to note that there are platforms available that are developed specifically for healthcare and I prefer to use those both in terms of being assured about security but also they tend to have some functions that are very conducive to conducting therapy. Traditionally in videoconferencing therapy, clients went to local medical centres or community centres and logged into the session. Increasingly with browser-based platforms, people are able to log in from home or from wherever they would like to do. This does provide some convenience for clients but also does perhaps increase some of the issues potentially around privacy. So it's important to make sure that you talk with your client about potential privacy risks in their environment including the possibility of unintended disclosure. For example, they may have things on the shelf behind them that they may not wish you to see. So just getting them to check that before they log in can be really helpful. The other thing is I guess that if a person is actually logging in from home, then there could be a potential emotional impact if they're talking about very distressing things in their personal space. So that's important to discuss and consider when you're choosing where the person will log in from. There will need to be some adaptation of your communication skills. There's a range of these and these are fairly well covered in the APS ECBT modules and I have some other resources in the handout that you might like to follow up. But it's good to discuss these issues very openly with your client. You will probably need to be more explicit in turn taking for example so that you don't end up talking at the same time. It's important to discuss the issue of eye contact when you're attending to your client in the session, you'll be looking at the screen and that means that your eyes will be going below the camera and for some clients that can feel as though perhaps you're not really connected to them. You may be able to adjust your camera and your screen in order to minimise that but you can also discuss it with your clients and from time to time make sure that you do look directly into the camera. On the other hand when clients are talking they can have naturally we tend to look inwards and have an inward focus when we're discussing important issues and so that can mean that the client is talking and then realise that in fact you're no longer connected to them. So it's helpful to remind them to check the screen periodically. Most therapeutic techniques can be adapted for use in video conferencing and this can include in session activities such as basic grounding techniques. It's great to get that established and negotiated very early on in the course of therapy. Thinking about how you co-conceptualise and analyse issues and processes with your client if you like to use a whiteboard. There's many platforms that you can actually have a whiteboard that you can both use and of course syncing through and planning ahead how you're going to send and receive material around monitoring and consent forms and information. There's also a great opportunity to integrate digital technologies such as apps and other programs and websites particularly between sessions to increase your client's access to good psychoeducation perhaps peer support and also some skill practice. This is just a beginning. Where would you go next if you wanted to find out a bit more? As I said, the APS has a section of free telehealth information and resources on their website, the ECBT online modules. You can sign up for those. There's a number of papers and resources in the handout and I think it's also really important to talk with your peers as you develop new areas of work. There's also a flyer in the APS portal for the Black Dog community of practice and if you're an APS member of course you can get onto the forums and talk to your colleagues. Finally, I'd just like to bring your attention to a webinar that's coming up in the APS Institute on the 23rd of June and this is about telehealth and really focuses on the legal, ethical and compliance challenges. So that will be very valuable as well. Okay, thank you very much and I'll hand back to Bruce. Thank you Julia for bringing us this important information on an innovative and emerging practice medium. I appreciate it. I'd like to now introduce our final speaker for this evening, Rohan McKnight. Rohan is the digital training coordinator at Coordinaire, the southeaster of New South Wales primary healthcare network. Rohan works across the region to support primary healthcare providers in the use of health informatics and advises on clinical information systems, telehealth, secure messaging and other e-health strategies. Tonight, Rohan will be speaking on health-grade technology for telepsychology. Over to you Rohan. Good evening everyone and thank you very much for having me. Just a moment. I wanted to speak a little bit tonight about some of the technologies that we can use to effectively use telehealth and deliver it to patients in these areas. And so I represent the primary health network in the southern part of New South Wales and our area was pretty profoundly impacted by these bushfires. And some of the more rural areas of our catchment already had fairly limited access to providers and this is with this increasing need, telehealth can be a really effective way to increase the workforce in the area. And some of you have alluded to this in the comments that you're seeking a way to contribute. That's really something that our area is really in need of at the moment. So and then some of you have already reached out. So thank you very much. I also, it's also a way that your services can be believed in an area that you don't necessarily have to physically be. And some of you alluded to this in the comments that ideally having a physical interaction with a patient is preferred by some clients but telehealth can be an effective way to deliver it. So firstly, I wanted to touch on some of the broad concepts of digital health. And the first one is privacy and it's essentially the core of any service that we deliver that uses technology is making sure that patient's private information is kept safe. And the guiding principle of this will be the Australian privacy principle, principle 11. And essentially when you're working with health information you need to make sure that you're taking reasonable steps to make sure that information is kept safe from misuse, interference, loss or unauthorized access. And I'll run through some steps and some guides on the next slide as to how we can do that. So the Australian Digital Health Agency has pulled together a fairly good guide on the ways that we can manage information security and healthcare. Essentially it boils down to these four steps. Making sure that whatever technology you're using including telehealth, that you have strong passwords and pass phrases on absolutely any part of technology that you're using, that you use two-factor authentication to any systems that you are trying to use and encrypt absolutely any information that you store or transmit about a patient's health information. So Windows has a tool built into it called BitLocker that will meet the minimum requirements if you're sharing information. And it's a fantastic tool for a start. Making sure that you secure your networks so that you stay current with any updates that your systems be at your physical devices or networking infrastructure needs using basic antivirus or firewall software. And it's really important to make sure that you try and store or transmit and transmit rather all information through Australian networks to make sure that you're protected by Australian privacy regulations no matter where the data is moving through. And that's really important thinking of things like any of Google's services, for example. Sometimes they're infrastructural redirect traffic outside of Australia and then you're not bound by the Australian privacy principles which isn't ideal. And it's also important to try and both avoid public Wi-Fi networks yourself and also encourage clients to do so, although in areas where infrastructure's been damaged that may not be possible. Those networks are inherently insecure so it's important to try and if you can to avoid them. Backing up your information and as providers protecting our own information is really important as well. So- Sorry to be so quick. Just wondering, do you have presentation to share or- Oh, is it not coming through? No, you need to click on the share. There we go, sorry everyone. And click on the- Yeah, there we go, we'll share that through. There we go, my apologies. Yeah, and so as I was saying, making sure that you have backups as well of any information that you might store about your clients will touch on areas where that information may come from in a moment. But essentially, the premise of it is a three to one rule. You wanna have your data in three places. So one primary record that you're using and then a secondary, send two copies of that data stored elsewhere. You want that on two mediums. So for example, on a hard drive and a tape drive or a tape drive in a cloud solution and at least one system off site. So having your data stored somewhere physically around, like in your practice or at home and then one elsewhere. And this was one that impacted some practices in our area when they lost power. Some practices were directly impacted by fires. Having off site backups is hugely important to make sure that you maintain integrity of your information and always make sure that you're testing your backup. So if you ever do need to recover from that, from a disaster that you can. And awareness is sort of the final step, making sure that you keep your entire team trained even if it's just yourself staying up to date with policies and procedures. The Australian Digital Health Agency has a threat notification that you can enroll for that sends out healthcare providers, specific digital health risks and it's worth staying on top of. So being more specific with telehealth technology, the real basics of it is having a high quality camera. Ideally you're looking for something that can do 720p with 30 frames per second. For a to bill a service for Medicare, you have to deliver it using both video and audio. And it's looking for a camera that fits into your environment and that's clinically appropriate. So some cameras have a wider lens, others have a more specific focus that brings it in on your face. You can also have cameras that are designed more for a conference room setup. So if you've got a specific room that you choose to practice in where you wanna capture a wider area, there are cameras that can do that. But essentially it's just looking for something that's reasonably high quality. Microphone, there's a lot more variation. So with microphones, it's trying to find a microphone that focuses on specifically what you're looking for. So whether it's a boundary microphone that captures the room, a table microphone that doesn't interfere with. So for example, I'm wearing a headset that may interfere with the connection you're trying to form with a client. You might choose to use the tabletop that will be able to limit background noise. But if you've got a loud computer, that may cause issues. So it's very environmentally driven, as well as whether you choose a wired or wireless microphone will be dictated by your environment there as well. The computer is pretty much anything these days will a modern computer will be sufficient. Although if you are trying to use some specific technology for example, Julia mentioned earlier their background making as a way of unintentional disclosure. Most computers with a reasonably modern process that can do something where it will artificially create a green screen and you can change your background to something that would be more appropriate if you need to as well. But so essentially any modern computer but your fast internet connection is going to be really important as well. So a minimum of two megabits per second will give you a usable interaction. Anything below that the quality starts deteriorating. And Julia covered on the space as well but making sure that you've got things like appropriate lighting are gonna be really important to giving you a good interaction with your clients. So when we start looking at platforms within the telehealth space, Medicare doesn't give any specific guidance nor endorsements for technology outside of saying that whatever technology you choose to use needs to have a high video quality. You is private and secure and that you as a clinician are confident that it's able to deliver the service within privacy and security laws. The Australian Psychological Society has some fantastic essential guidelines on this. So you're looking for a solution that's client centred is fit for purpose and maintains your privacy obligations. So if you're doing those three things, any platform where you can reach out to your consumers is gonna be appropriate. There's some more in-depth things to consider though. I'd strongly recommend finding something that is accessible. So making sure that the process for registration, installation, what platforms it's compatible with is really important. I like to recommend products that use something called real-time communication or RTC web-based solutions where essentially you can go to a website, hit, join the meeting and that's the entire interaction from the consumer's perspective. So it's really simple. And being easy to use or supplies to you as a provider. So finding a platform that you're comfortable delivering services through. Something to really pay attention to though is those closed and open meeting spaces. So for example, with Skype, if you're allowing people to dial in, it may not be a closed space. If someone may be able to call your account during a consultation. Some services provide meeting rooms that a patient can wait in and then be joined by you where you can do things like consent and disclaimers and have them proactively engage with those. Recording, so if you choose to record the consultation, how you do that, some platforms have that built in. Pricing models as well. So making sure that the service that you're using matches the expectations. So if you're only delivering a service fairly seldomly, having a expensive telehealth platform might not be for you. And managing payments if you are taking them as well. So a few that I generally recommend, Coveview is probably my favorite platform. So it was developed as a startup inside the CSIRO and it's currently the backbone for HealthDirect's services. It provides platforms where you can access services with a booking area for patients where they can join. It's run purely through a link. But essentially, as long as your patients are able to engage with it and it's secure, you can use it. So Skype, go-to meeting, the platform we're using right now, Zoom, all of those could be used. So there are a few other technologies in the health space that I think link in nicely with this as well. So the My Health Records one. So Rob touched on this before that you may not need to take a full, and it might not be appropriate to take a full clinical history for your patients, but if they have a My Health Record, it may be able, maybe a place where you can get an understanding of the rest of a patient's health history if it's the first time that you're seeing them. And if you've got appropriate software, you can actually link back in and provide information back up to the My Health Record as well. Secure messaging as well is a tool that a lot of general practices are using. So there's various brands of this technology, Health Think Argus, Medical Objects, reach out to your primary health network to find out what is used in your area. But essentially, this is an encrypted mailing technology where you can share referrals or receive referrals. You can provide response letters back to referring providers if a referral's taken place. And it's essentially a modern faxing tool. And I'd strongly recommend that you pick those up regardless of whether you're providing telehealth services or not. And that's essentially all I wanted to cover as kind of a very high level. But I'll provide these with my slides, but the information security booklet that I mentioned before is available online. The APS has a fantastic telehealth consideration for healthcare providers section on their website. The Strain Digital Health Agency has a mental health specific toolkit if you're interested in connecting through with the My Health Record. And there's a link there that I'll provide that essentially will help you find the contact information for your local primary health network because every PHN has a similar person to me who can help you through what might work for your specific practice in terms of technology. Thanks very much, Rohan. And indeed, thank you very much to all our presenters for excellent presentations this evening. We have some remaining time in the webinar. And as planned, we'd like to go to some of the questions that have been coming in on our question and answer box and ask our panel members to respond to them. And the first one I would like to put to our panel and to Julia in particular is a question that comes from Roz Kaye. Roz says, acknowledging risk issues, for example, suicide, are there any particular disorders or populations that e-therapy is just not suitable for? Hello. Thanks, Roz. Yes, I definitely agree that people with very acute and severe risk issues or with very acute and severe distress, this may be less suitable for those people. And also for people where substance use is an issue and they're sort of acute intoxication or withdrawal states that may be really affecting them. That being said, I think that there is also the capacity to have different levels of support as well. So for example, if you're working with someone who does have a local mental health worker, sometimes that person may be coming to the local mental health clinic with a video therapy session with support from the local mental health worker. So it doesn't always have to be from the person's home. Without other kinds of support. Thank you. Thanks, Julia. The next question that I'd like our panel to respond to and in particular, I'd like to hear from Rob on this question comes from Mariana G. Mariana says, there are many families who prefer to look for psychological support for children or adolescents in a disaster situation prior to the adults or sometimes they look for service only for the children and the adults believe that they don't need it. Should we look at this behavior as resistance and how should we proceed in this situation? Yeah, thanks, Mary Ann. In a disaster context, I would be more cautious about some of those traditional constructs which I think presuppose. I mean, resistance presupposes that you already understand that you've got a clinical connection. The way I'd see this is that the parents are still in a heightened or state of arousal and focused on their highest priority, which is their children. That's where their first worry is and they haven't yet been able to come back and look at themselves. And so I think this would be part of a general strategy which is begin where the person is, begin with what's their concern and then as that is engaged with and resolved or helped, the arousal starts to decline. As the arousal declines, the person's in a position to start to think about themselves to reflect on their own state and then you can begin to work with that. So it may be that you might be able to pick up the role in which the role that the parents are playing in the child's difficulty and provide some clues there. If you work with children but don't feel comfortable working with adults, it may well be that you can organize perhaps to have somebody come and participate with you in a session or maybe refer them to somebody who can have a chat with them about their own conditions. But yeah, I'd keep those more technical constructs out of the early stages and it's only as you settle into a more overtly therapeutic situation that I would be considering those. I hope that's helpful. Thanks very much, Rob. The next question I would like for Glenn to address if possible. Glenn, I have a question here from Sam W. And Sam asks, are there any issues with the reception or trust of non-Aboriginal and Torres Strait Islander clinicians? And if so, do you have any suggestions on how to proceed and build this trust? That seems to be always a question that a lot of non-indigenous practitioners ask. And I think short answer is yes, sometimes there can be issues with trust. And one of the greatest things that you can do to engage and I guess get to be vouched within the indigenous community is to be seen at indigenous events. So if they're having a NADOC day event, go to that. If they're having a health event somewhere, go to that and start to have your face and yourself known in the community, start to build some alliances with some indigenous people in your community. And that generally starts to build the foundation. And once that community vouching starts to take place, you'll start to see a dribble or if not a flood of Aboriginal people using your services simply because you've taken the time to invest in building those relationships at a very foundational point, which then can lead to clinical engagement later on. So yeah, a lot of time and a lot of investment. Thanks very much for that response, Glenn. One more question perhaps that I will just open to the panel more generally if anyone has input, please let us know. This comes from Carol M. And she asks, do the fire Medicare sessions apply to people who have previously been impacted and would be triggered again? For example, three years ago, we lost a whole town here in WA. Would they be able to access the sessions? Look, my understanding of the intent of these sessions is to respond to what this current fire causes. But one of the fundamental things we know is that the current fire will have massive repercussions for people throughout the country who've got past experiences. And I think it's really important that we allow those people to participate in the service as well. And my understanding is that is the intention. I have that broad definition. Maybe others who have. I've sent a link through in the Q&A that covers the specifics of that item. But it does, it is broad enough to capture people who are affected by the fires. And it specifically states that they don't need to be directly impacted by the current fires. All right, thanks very much, Rohan and Rob. Sorry, I had suggested that it might be the last question, but one has just come in here, Rohan, specifically around technology. And I'm wondering if I could ask you to address it. It comes from Connor S. And Connor asked, is cloud software safe? For example, Google and OneDrive and does this meet the safety requirements? So cloud is a really big term. It essentially describes anything that's stored offline where you're accessing a service through a third party provider. So be it Google or Microsoft. So in a lot of instances, those solutions will be safer than what we individually and small business could set up from an infrastructure perspective. The challenge is finding ones that are designed for healthcare or that are accessible for us as providers. But broadly speaking, there's nothing wrong with using cloud. But what you're looking for is things that are stored in Australia. If they are really sensitive information that they're stored in sort of pockets of data that aren't shared with other users, those sorts of things. So it's a hard one to answer in a general way. If you've got specific technology, again, reach out to the digital health person at your PHM and we can give you specific guidance on individual products, but broadly clouds fine. Great, thanks for that, Rohan. Well, that brings us to nine PM and it's when we would say, said we'd bring the webinar to a close. And so I wanna end this evening's webinar by first of all thanking the five presenters for providing such a cogent, detailed and pragmatic advice as our mental health community is searching for ways to help bush affected communities and bush affected areas. I'd also like to acknowledge our partners, particularly the APS Institute who's provided technical support and the Black Dog Institute for their help in advertising this webinar. And I'd also like to acknowledge some local support in Connell Monahan and Carling Dickens for helping us put this together. Of course, we extend our concern and our thoughts to those who have been affected by these bushfires. As I mentioned, admire your courage and thank you for your efforts. And we hope that this information has gone some distance to equipping clinicians to add to our efforts to address this crisis. Thank you very much for tuning in and good night.