 Good evening everybody. Welcome back for the next of our mental health professionals network webinar sessions. Tonight's one is entitled supporting the mental health of people returning to work after a long-term injury. Welcome to the over 400 participants already who have joined us for tonight's webinar and the viewers who may be reviewing this on the podcast at a later time. Mental health professionals network particularly wishes to acknowledge the traditional custodians of the many lands across Australia on which our webinar presenters and participants are located. We certainly wish to pay respect to the elders past, present and future for the memories, the traditions, the culture and hopes of Indigenous Australia. Just to introduce myself, my name is Dr. Cymru Cunger, I'm a private general practitioner working and living in Crossapine with Sundays in North Queensland. Been in rural practice for about 12 years now and also been doing a bit of medical educating work over that time as well. It's certainly mental health and managing mental illness is something which all of us in rural practice see very very commonly and I know that for all of us as clinicians working across Australia this is something which we're always trying to do the very best for our patients that we can with. So thank you very much to everybody who's logged in. I'm hoping that everybody's had a chance to review the case regarding Mark, Mark's story that tonight's webinar is based upon. I'm also now going to move on and introduce you to the panellists that we've got joining us this evening and we're going to start off with Dr Roya Dabbastani. Roya is a GP in Melbourne, she works as a medical advisor for the Work Faith clinical panel but also remains in private practice in Melbourne. Roya, just to introduce you to the participants, just wonder what are some of the other common queries you get from GPs when you're doing some education for them? Roya, some of the main sort of queries would be surrounding what duties the worker can do, whether duties would make the worker less and just sort of general concerns about certification and sort of facilitating a return to work whilst kind of collaborating with their colleagues. Thanks Roya. Thanks Roya, that's great. We'll be hearing more from Roya shortly. We'll see you moving on now to Dr D.L. Feldman. D.L. is a psychiatrist who's in Melbourne. She's a specialised in occupational psychiatry, certainly one of the facets of the specialty which many of us haven't been too familiar with. D.L. has had many years of experience helping ill or injured workers return to the workplace. D.L. just wonder what's been the challenging cases you've seen in assisting people return to work? I think by the time they come to see me they're all a little bit challenged and some of the more challenging ones I see is in particularly the high functioning quite perfectionistic, high flying person who may not have had difficulties before and is very sensitive to their deficits and these things are a bit all or nothing unless they can get back to their previous level then they're not functioning. And the other type of difficulty I say a lot of others is when the challenge is when there's performance management difficulties and the challenging teething out what's the capability factor and what's the illness factor that can be challenging. Absolutely D.L. and those are certainly some insights that the audience will be keen to hear you explore a little bit further as we're going through the presentations. Maybe I'm now to introduce Dr. Carol Egan. Carol is a clinical psychologist too. She's also an educator to training psychiatrists also. Carol's been the director of training at the Institute of Contemporary Psychotherapy and she's co-authored a book on workplace bullying that provides a combined psycho and legal perspective. Carol one of your interests is people's relationship to their work satisfaction. How have you found an injury affects people's job satisfaction once they return to work? I find that it actually does depend on what sort of level they can get back to if they can get back to the same level as before then they're satisfied. But the biggest factor really is the employer's support and peer support but particularly the employer's support. That means a lot to people. Thanks Carol. It's great to have you on board. And last but certainly not least I'd like to welcome Dr. Mary Wyatt. Mary is a occupational physician with special interests in back pain and return to work management. Mary is also the founder of an education company providing resources to people involved in return to work management. So we're very grateful for her insight tonight. Mary how would you usually be involved in a case like this? Sometimes there's a treating practitioner and sometimes perhaps as an independent medical assessor but I'm also been involved in back pain research and one of the real issues faced is beliefs and understanding about back pain and how to self-manage us and that's particularly applicable in Mark's case. We don't do a terribly good job with this is the medical profession and sometimes that helps create disability as Mark's experiencing. Wonderful. Thanks Mary. We'll be revisiting a lot of that as we come along. So we start this evening just acknowledging that the work and the involvement of Safe Work Australia that they are the organization who have provided the funding to host the other webinar this evening and the link there is to their website. So there'll be plenty of resources available that will be referring to this evening. You'll be able to find there. We also acknowledge that although Mark's case certainly may seem atypical this represents a representation of the type of cases at Safe Work certainly do see come through their case load. We just need to start off this evening just with a few of the ground rules particularly for those who are joining an MHPN webinar for the first time. We ask that everybody who's participating please remain respectful of other participants and panelists. Although we're in a virtual space please act so that you are actually in a face-to-face activity. If you do have some comments which you'd like to share with the panel or questions which you'd like raised use the general chat box which you'll find at the left of the tabs available while in the screen. But however if you are having technical issues and we noticed that a few of you have been commenting on the audio so far but put those into the technical help box and we'll try to assist you with those as quickly as we can. Also do remember that the things that you comment on in those panels are visible to everybody so just think before you press send. If you'd like to hide the chat if it's becoming too distracting for you there is a small down arrow you'll be able to see at the top of the box to remove that. And we definitely would love to hear from all of you as participants on your experiences tonight so please make sure that when you do exit the survey that you do the little feedback survey which will pop up as you go. One thing which we are always mindful of is that you can all experience a range of experiences in our workplaces and I'm mindful that some of the content in tonight's webinar may relate to past or current experiences of some of those who are joining in. Please be prepared with your own self-care plan to take care of yourself tonight bearing in mind that this is a professional development opportunity and it's not really appropriately set up as a platform for discussion of personal issues. The resource document and the website which we refer to have a range of support services and phone numbers if anyone does feel the need to discuss any concerns but this is a professional environment we really do hope that everybody can share their thoughts, their questions and certainly hopefully enjoy the experience as we as we go along. So we're just going to go briefly through the learning objectives for this evening that we're looking at through a interdisciplinary panel discussion about returning to work at the completion of this webinar we are hoping that participants are going to feel better able to describe appropriate practices to sufficiently accommodate abilities, diversity and vulnerabilities of people returning to work. Implement some key principles of providing an integrated approach to the social and emotional well-being of people returning to work after compensated injury and identify some of the challenges, tips and strategies in providing a collaborative response to supporting social and emotional well-being of people returning to work. So who we're talking about this evening, the panelists this evening are going to be focusing on, the panelists are going to be focusing on Mark, a 30 year old who works in manufacturing where frequent lifting, bending and long periods of sitting are required. He's had previously controlled back pain but yet it's an advice from his GP on this occasion to limit lifting to no more than 20 kilograms but he didn't actually inform the employer. Good relationships at work and happily married with two children involved in their soccer, diagnosed with a herniated disc and his claim was accepted. Initially had one month off work that was prescribed opiates but the pain continued and he ended up with an additional three months off work. Been reluctant to move and there's been a lack of involvement in his normal activities despite GP encouragement. So we certainly recognize that there's a lot of challenges in Mark's presentation. We're going to move on now to to Roya to share the GP perspective. Thanks Roya. Hi everyone. So I'm just going to speak just from a perspective of GP and talk about how I would look at this case. I think initially it's very important to build trust and make Mark aware that I'm acting as an advocate for him but also that I'm still going to remain objective and if he has other agendas that that's not necessarily going to be facilitated. It's important to take into account Mark's health and all this belief in general including this surrounding the injury and work's role in that. Sometimes you know we find in the compensation setting that there's blame attached to things and a lot of bad feeling from the get-go and that doesn't really help. So it's important to sort of talk about these things and try and admit them in the bad as possible. The other important thing which I try to address early is to try and facilitate any work remaining at work rather than sort of signing them off as understood and then trying to get them back to work. That's much more difficult. I know certain it works so if we found the statistics are a lot poorer trying to get someone back to work rather than just trying to keep them at work. It's important to ensure that sort of any management is measured and doesn't add more sort of drama to the situation which may already have sort of other problems associated with it. And this is a really great example with the case of how you know early use of scams or the use of a certain language like herniated disc and things hasn't really helped Mark. So we're just leading on to the scams. That was one of my initial bugbears with this case was the speed at which the GP sent Mark to have a scan and we see this a lot actually. I see this a lot both in general practice and especially at work sites in Victoria. Again avoiding the use of strong pain killers. It gives the patient the wrong message and it also actually leads to addiction. Also just generally talking about pain education very early on and sort of reassuring a patient that pain doesn't necessarily mean worsening pathology. In general I would say that conservative management needs to be exhausted completely. We see a lot of cases where the patient's been sent to a surgeon very early and the surgeon will say all the patients had exhausted conservative measures and they've had maybe three weeks of physiotherapy. No psychology, not in occupational position, doesn't anything about pain basically. So I think that's really important to just set things going in the right direction early on. It's important to discuss social support, psychological effects, include colleagues early on if you think that there's risk, especially there's pre-existing mental health issues, there's going to be a significant risk of things deteriorating in terms of the work as mental health. So it's important to involve psychologists, psychiatrists early on. When considering return to work, it's important to try and remember that. That incorporates a large spectrum of capacities and one of the questions that I often get asked when I sort of call GP to discuss these things is, you know, well I don't, you know, what jobs can they do? And the answer is it doesn't really matter what jobs they can do, it's what their capacity is. So if they can use their right arm and if they can answer the phone, you just have to write, you know, that's what they can do if they, you know, if there's a particular limit they can't use, you just have to write that and it's up to, you know, then the occupational positions and whichever work safe body is involved and return to work coordinators and the worst sorts of people to get involved and to get opportunities to hold something like a case conference as well, at which you can invite, you know, all of those specialists and create and return to work coordinators and occupational rehab physicians and people like that to totally help, you know, it's much better to take a team approach to these things. And then in general, I find forward momentum is really important. A number of patients that we see who, you know, have been in the system for two or three years and nothing's really moving forward in terms of treatment or return to work. And along with that sort of status quo drags on, the less likely the patient is to ever get back to their old life, basically. So I think anyone involved in a patient's care, whether it be a social worker, a psychologist, a GP, a psychiatrist, she just kind of sometimes just, you know, every month or two, take a step back and say, is this patient actually moving forward or has anything changed in the last two or three months? And if the answer's no, then, you know, we need to sort of start again, see what the problem is. And in general, all the way through the process, I think a lot of workers just feel like they're not being listened to, like they have no control over the situation. And I think it's really important to try and give them back some of that control. So I always, you know, would ask the patient what they would like to see happen, what they think about, that has already happened, and if they've got any suggestions or expectations for the future. And that applies to, you know, partners and things as well, because often you feel you see break down in relationships. And, you know, just a simple break down in a relationship will change the whole course of a worker's recovery. So that's a really important thing to consider. Absolutely. So it really is key Roya to, you know, still be able to provide that objective approach, but to provide that overall patient advocacy experience, but to recognize when there's something more complicated going on and when we need extra help. And certainly the psychiatrist perspective or getting a specialist involvement is going to be necessary sometimes. And tonight we're going to be hearing from DL. DL, I'm wondering if you can help take us through your perspectives on the most. Yeah, sure. Thanks. So when I first saw this case nine months off on, my first thought where Mark is in a really big hole and the life is in Newark's social, recreational, family occupational is becoming smaller and smaller it would seem and harder to reach. And I think he's going to need a lot of help getting out of this very big hole. I guess looking back on a case that goes badly, it's easy to criticize the treatment that's being given so far. And I think it's easy to criticize this one particularly, but I think the GP has done some positive things like engage physio at least and also trying and get Mark engaged in some activities such as helping out with the newspaper for the support. I get the sense that it's too little too late really. And I guess in this case the kinds of things that I'd be wanting to have been happened would be much earlier identification of bifarcus social factors and interventions for them. So we know that he's a young man with a back injury and he's got a job that's physically demanding. So we already know that it might be a bit harder for him to get back to his full capacity. His compensation factors which can make cases more challenging. He's needing opioids very early. He's got this obvious pain fear avoidance and maybe if that was picked up at the very start then interventions could have been in place to address that. He's already a re-injury possibly. He's had a prior history of back pain so he's going to increase anxiety about a further injury. He hasn't told his employer about his difficulty. So at every issue it cannot seek any help. And the list goes on with possible concerns. So I would have liked to have seen much earlier collaborative specialist involvement and early psychological support. The other thing that really concerns me about this case is the prolonged certification from very early on. Giving him three months off is kind of sending a message well we don't expect you to recover in this timeframe. And it also for some people means that they don't actively see their GP on a regular basis and I've been hoping this man will see general practitioner on a weekly basis with a situation like this. I'm not sure if you'll agree, Roya. So unfortunately Mark's journey is not one that is uncommon in what I see. And in my experience people often have a physical injury that's associated with pain. When they develop a pain avoidance behaviour and become progressively withdrawn it leaves them with a lot of time doing nothing. And I find that they spend this time ruminating and it might be ruminating about their stresses and fears but it's also more time to focus on pain. Invariably they often develop mood and anxiety symptoms. They're medicated, they might self-medicate and I wonder if a lot of Mark's opioid use is self-medication as well. And what I see happen is increasing psychosocial stresses for him. He's having difficulties with his children, his wife, his disengagement social situations and I see this progressive pattern of increasing symptoms and increasing function in terms of the time. In terms of what I would do to help Mark move forward well the first thing I do is I think there needs to be time this isn't the kind of situation that you're going to address quickly or in a short consultation. I think engagement's going to be key in providing support. I think that what he hasn't had is a thorough assessment diagnostically I guess the medical side I'd leave to Roya or to Mary for my psychiatric perspective there's possibly many diagnosis that this man could have such as opioid dependence now. He might get diagnosis and adjustment disorder or depression. I find whether there were any traumatization symptoms given it was a recrelated injury was there any threat there. But I think I'd be reluctant to give him a diagnosis now while he's on such high doses of opioids as they could explain a lot of his psychological symptoms. I'd be looking for comorbidity such as other substances and GPPs like alcohol. I noticed that even though we've got a page and a half of what's been happening with Mark we've got very little about what he can do. So focusing on what he's able to do which will give us a platform to build on would be useful. Understanding his motivations what some of the barriers are for example if there are a lawyer breathing down his neck telling him to go for total and permanent disablement and I'd want to get a sense of his physical prognosis so we can look at return to work planning. The next steps I think are about education to him and his partner aligning getting him motivated and on site and working together with you. I'd be involving his partner really early to understand her concerns and address some of the issues she might not be aware of and also involving the workplace as soon as possible. It doesn't seem like there's been too involved. I think recovery in the return to work goal setting needs to be set pretty immediately. That doesn't mean that he needs to return to work tomorrow but there needs to be some sense that his treatment providers feel that he can recover and that a recovery is being aimed at and ideally he'd have a goal that he's going to go back to whether it's his full duties or modified duties or an alternate job if unclear on the information I have. I think in someone like him it's really important to set very small steps instead of big one steps that he can achieve and it might be something like we've got a two year old son how are you going to re-engage with him? Maybe this week he's going to read bedtime stories to him. A very small step to give him a sense of achievement. I think he needs regular review and I think most importantly avoid harm but enhance him further with more opioids and I think you really need to get multi-disciplinary supports involved and collaborate and take conference with everyone. Finally in terms of treatment my recommendation for where he's at now would be to get a thorough physical assessment of where he's at reduce the opioids and better manage his pain address some of the psychiatric and psychosocial factors so the ongoing legal issues related to his claim helping to slowly reintegrate in his community address the relationship issues. In terms of specific therapies I'd be recommending some psychological therapy with the targeted therapy cognitive behavioural therapy activity scheduling addressing fear avoidance just want to make the point that I don't think all therapies are the same and in this man I'd be recommending against the supportive count from on a monthly basis it's just not going to cut it. With regards to psychiatric medications I wouldn't be making any decisions about that now I'd be getting him off the opioids. If you do find he needs the benefit from an antidepressant medication for mood or anxiety symptoms then you could consider something like duoxetine for it to pain reducing properties and that may also be another avenue for getting him to take it if he's reluctant to and obviously rehabilitation provider involvement and functional restoration and the last point I'll make on this case now is that I think when he returns to work it's a time to continue treatment I see a lot of cases where treatment stops as soon as someone gets back and I think that's not the time to do it he needs increased support at that time. Dill that's fantastic obviously the audience also are finding just some great insights there Dill and thanks so much for bringing all those to us and hopefully we're going to get a chance later on to revisit some of those some of those concepts because there's a lot of Williams participation going on with that but you're quite right that certainly involving the multidisciplinary approach early is appropriate and having a structured fashion to that is so important as well and we really are fortunate for the input of such an experienced clinical psychologist as Carol Egan Carol I'm going to move on to you what would your perspectives be on Mark's case? Oops, let's go back a minute well first of all I think Mark's because he's been off to so long and he's avoiding everything he could avoid me as well so I'd be personally trying to establish a very strong working alliance with him and I would take the approach of motivational interviewing simply because he's having so much avoidance and so much trouble that I'd try to find something that matters to him that makes him want to continue or won't make him want to see me in the first place and I think that's largely what I could use as a legal would be that he's approaching a crisis his wife is losing patience with him and he might lose his job so that raises the tension and you would think that would make him want to want to do something about his state but at the same time he feels pain and injury and adopts his place of work so adopts a sense of belonging and relevance and he's withdrawn from his friends and there's often a big sense of shame with injury so in motivational interviewing I'd be trying to work with his ambivalence helping to identify his avoidance as actually a pain strategy a survival strategy and his social withdrawal is also a survival strategy it's trying to avoid the shame and the pain so then we look at these pros and cons of that strategy is it working for him he has to it's not a certain thing to be doing him much good if he's got so much loss of heart low mood and so much conflict and at the same time he's addressing all of that he's trying to affirm his self-efficacy his capacity for change and what he's been able to do in the past and in a way it's trying to awaken his need for change and commitment to that so then we start to mobilize and change talk with him as well as actively listening for his desires and goals and what he wants what the readers are keep his job and his wife and his kids and encourage his goals and dreams, his intentions and decisions but emphasise his ability and his self-efficacy I had to look at what a press operator does and they've got considerable skills in this problem solving attention to detail mathematical and computer skill mechanical and technical skills as well as needing some stamina stamina he might be having trouble with but the rest of it should be intact so we start to actually plan for him to combat the social withdrawal and reduce family attention by doing a bit more and they all mentioned sort of small steps all you could do is a little bit around the house doesn't really hurt to wash up occasionally and we start to move that towards an action plan for return to work the roadblock of course is the stamina that's where a lot of his anxiety is and that's where I would be collaborating with his team his doctors, his physiotherapists to establish what our safe activities and develop a realistic step-wise plan with him I've tried and helped manage his depression and anxiety his fear and and avoidance with CBT but you also have to remember sometimes when people lose function like this it's actually a grief process so I'd be concerned about being able to listen for long enough to his grief and to help him to move on perhaps that and to find some of the positive things like taking steps that try to facilitate his awareness in the moment of the avoidance strategies and a battle helping to stand back and reflect more I think most therapeutic modalities try to do that but also acknowledge his courage and role of the resistance that he doesn't want to do anymore or he wishes to to give up he will fail at talent so it's necessary to aid with him through failures and losses and I mean DL mentioned that that needs to be done even after his return to work well I agree very much for that now let's assume that somehow we've been able to help him develop motivation and work through loss and anxiety and depression so then we can move into some regular collaboration with his case military manager about the return to work plan but it might be necessary to remain in the career management if it turns out that physically he might not be able to do his job and he might need to adjust and try to move into another area and I'd be looking to somebody like Mary Wyatt and occupational position thank you thank you go ahead thank you Carol that's uh that's wonderful it's a great great insight there and I certainly noticed a lot of the a lot of the therapists in the audience sharing a lot of your your thoughts and agreeing and wanting to get into a little bit of debate later on on the the treatment modality so I hope we'll have an opportunity to to move on to those but uh yeah thanks Carol for for acknowledging that sometimes we do need to be able to take on the broader broader view and the broader approach as well and we are extremely fortunate to have Mary Wyatt joining us this evening Mary we'll move on to you now for sharing your thoughts on Mark's case thanks so much Conrad that pain management is going through a transition if you had come along with back pain to the doctor 30 years ago you would have been told to lie down and have some aspirin well seen and stay lying down for six weeks we have moved on from that but we're only part way there good evidence says that a vast mix of the nation and people understanding about how to manage their own back problem makes a material difference we are no longer putting people to bed but we are still over protecting them and this has likely happened in Mark's case so the only way we used to manage back problems was to remove pain and tell people to rest and the new way is to focus on restoring function this is a slide which talks a little bit about the fear of audit model and this says that our fear of pain has a greater impact on our outcome than the actual pain level itself so we're all on the spectrum somewhere and at one end of the spectrum is the copter and that's for example the farmer so he gets some soreness in his bag or it just mucks him around with his hauling his barrels of hay but you know it's just pain and at the other end is somebody maybe who worries a lot who is anxious not confident in their own abilities low self-efficacy and so when they get a problem whether it's the child having drugs or mortgage repayment problem or a bad problem they can be less confident and more worried and more fearful well there's a great group of people in the middle and Mark is likely one of that group it might be his next door neighbour had a bad outcome from a bad problem it may be something else that's going on in Mark's life or maybe he just really doesn't understand about how to manage his bad problem and then that combined with very opiates but he's been given has shaken down a path I'm afraid as doctors we tend to send people towards the avoidance end we worry even more we do all sorts of things such as a scan which says they've got a disc problem or a degenerate disc and so we tend to move people towards the avoidance end it actually takes quite a lot of time to explain to people about that problems and then every day medicine where consultations are typically short this will often not happen it really happens in general practice it can sometimes happen with good physio practices where people are being seen over a number of occasions and it happens in some specialist practice so in Mark's case this is a classic situation where prevention has been in cures as others have referred to is there some issue that the case that he says that Mark gets on with everyone and that there are some uncapped things that we don't know about it's always worth discussing with the supervisor what was Mark like before this happened are there any other issues so the way I'd approach this as a specialist in Mark at nine months is to really focus on his understanding of the nature of his bad problem and the resources I've sent there's an interview with Dr Olga Inbal who is a rehabilitation physician from Norway and that's an oldie but goodie and he is a fisherman from the family was a fisherman from the north of Norway and they're storytellers so he has a very rich way of talking to people about their back pain and I commend that to you to try and gain an understanding of the way we can talk to people about that problems he has good evidence to say that if you give people good understanding of their back problem you can have half the rate of lung term disability and Mark would be one of those typical cases it's terribly important to stress to avoid outlets there are two main I'll just take another couple of minutes there are two main types of that problem sciatica disc protrusion with sciatica there's no indication that Mark has that and then there's back problems so for everyday back pain even if the pain is bad we should avoid opiates there's a significant risk of dependency we've been at months the dose needs to be increased and it makes people often lower motivation and depressed so it's terribly important that the main treatment for Mark is activity keeping active whether it's walking 30 minutes a day walking in the pool doing his own stretch exercises but understanding and learning how he can manage his back problem is terribly important and that's what I finish wonderful and now Paul already has been a few participants wondering where they can get to those resources you've mentioned so for those who might want to click and it will open up in a new tab for you otherwise if you can click and save those those tabs for a later stage to go back and review and of course they're in the resources folder which we're just highlighting down in the bottom right hand corner of the screen there for you as well well we've certainly had a few perspectives there on Mark and we all recognize that there is a lot which could have been done much better for his case at an early stage and that although he may be feeling as though things are really a bit of right at the moment there's lots of hope still for us in going forward for him we're going to try now just to get through what probably is the more important part of the webinar which is the question and answer discussion for you guys with the panel and looking at the questions you've been posting but also those that you took the opportunity to submit with registration for us as well so certainly one of our common themes that's coming up particularly in the earlier stages Roya was about patient advocacy and coordination of care for our patients how do you think we can best coordinate the care of our patients through effective referral communication with other health professionals and even the employer hi yeah I saw the question and I think advocacy is important as well what I meant by advocacy just very quickly is and usually I guess with me I've been at the same practice for a number of years I've built up relationships with patients so they trust me already and they recognize that I'm their advocate and I will be completely honest with them about things so that's that you can still remain objective whilst the patient still believes that you're there for them and you can still be honest with them so I'll very honestly sometimes say to patients you know do you actually want to get back to work is this something you want do you enjoy your job or do you actually want to do something different so that's just getting through the advocacy but in terms of a collaborative approach I think it's really important to and I guess it's easier for me because of the work I do at work so it's given me an insight into the other side of that wall if you like to see how things can go wrong when things aren't done correctly so you know utilizing all sorts of specialists that we've talked about some of the already psychologists, psychiatrists occupational physicians social workers and it's important for all of those specialists to be on the same page in terms of pain and disability and injury and all those sorts of things and it's interesting to see all the comments because they're quite varied which is good but I think it's important to have a collaborative approach and for everyone to be on roughly the same page so you know sometimes you know if you're thinking of a psychologist or a therapy for example or a social worker or a counselor they have to have a similar attitude towards pain and disability and things like that so for me in this case you know I see Mark as the victim of his of his the choices of his GP as well to be honest you know the fact that he's been diagnosed with dysporelects and herniated disc you know other specialists or other people other professionals might look at that and think okay well he there's no way you can do his usual job and go back to work again and I actually don't think that at all necessarily I have plenty of patients who've got far worse pathology who do go back to physical jobs but I think it's all very you know anything believable but you just have to involve professionals early utilize things like case conferencing and I know the work space in Australia and Victoria at least is very keen to fund case conferences and I'm sure it's the same in other states and that's a really useful way for everyone to get into the same room and just honestly discuss things and you know and include the patient as well has that answered the question Sarah's way wonderfully wonderfully Royer I'm hoping Ingrid noticed you've been been writing a couple of questions there earlier about that tough thing and I'm hoping that's brought a little bit of insight there as well any of the other panelists if you would add any more on that point there well another of the important things is coming up there I'm just noticed a few more is just looking at some of the barriers in the success will return to work deal you know we've remarked on what happens when there's the loss of the the earner role and but also what happens with the loss of financial support after a return to work and that's certainly an area which might provoke some anxiety for the for the patient as at that point is coming closer and maybe even impairing their recovery you've found that when patients in the process of pursuing legal action maybe for for payouts and involving the legal profession does that really complicate the process all right and most definitely does and I'll answer this question from my perspective which are a treatment provider helping injured workers return to work but also doing some consultation for employers and some insurers and I see this sometimes play out really really badly but we also have to remember that sometimes it can play out really really well for people who are quite disabled and are really relying on those benefits and potentially a total impairment disablement benefit the ones that I have the most difficulty with will cause me the most distress though are the ones where from the outset incapacity is probably discretionary where maybe they could have stayed at work except they were certified as unseen or they could have done alternate duties and in those cases they often see a lot of difficulties with them going down this pathway and needing to prove their incapacity for insurance services some of the horror stories I see are when for example lawyers are involved and I've heard on many occasions patients being told you must stay at home for the next six months you can't be seen going out for coffee seeing friends doing any exercise and that's that's a really really frequent occurrence and also in patients that I see some of them say they're just scared to go out because they're scared of being called on surveillance or for the insurance surveillance and one of the most the biggest challenges and I think this is important for everyone listening tonight is the cases where there are ongoing legal issues or fights for total impairment disablement benefits where the treatment provider certifies and totally unfit until the issues are resolved and I think that these people become increasingly entrenched in the sick role the level of injustice just fuels they're constantly being re-triggered by the stress of faith and the outcome is is often very very poor brilliant brilliant yeah brilliant insight DL thanks thanks so much that any other panels so anything more to add on that point at all yes Carol here yes I've found that people don't even start to get better until the legal process is finished until that time this is ended just not knowing what's going to happen next but that they're going to get a payout whether they can go back to work they're just they're stuck and I see that later on in the in the claims but early on I think if we can try and get some of these patients to replace negative experiences and negative memories make more positive ones the outcome can be much better yeah but it's it is a that's a challenge indeed it is Mary could I just could I just go to that Conrad just we need to be a little bit cautious also because sometimes I mean we all we all I think have a sense that when this legal involvement things go down down the hill but sometimes legal involvement comes because there's been a problem that people will often only go to the lawyer and they really can't get their issues dealt with and so sometimes there's a cause and sometimes there's an effect I think probably well I know there's a effect but you know we have to keep it in mind yeah good point absolutely Mary some of the other participants and some of the audience have been commenting on that maybe sometimes the barriers are just too too great and that we might need to look at considering broader alternatives just wondering you know particularly when there has been a prolonged absence from the from the workplace or you seemingly insurmountable barriers for successful return how do you feel we can best support workers if we're needing to start considering alternative roles well there's a traditional hierarchy of options and starting with the pre-injury role I go with where we shouldn't discount the pre-injury duties and good quality studies say that about a third of the population has back eight most of the time a third has episodes of back pain and a third of the population never gets back pain so it's a pretty common experience and in one year 10% of the population will have an episode of back pain which is disabling that stops them doing their usual tasks so just because Mark's had an episode which has really been very painful and just because he's on opiates and he's had a he's got a bad situation at nine months from all sorts of angles doesn't mean that we can't get him back to his usual last hour it could be a long wait and the chances might be relatively low but I think that should be that would be my first goal my primary goal over the first couple of months and see how things went the next option to consider is what else can he do is there a modified version of his usual role is there another job at the same workplace it seems to have been good relationships can we restore those as the next option what else can we support Mark to do and this is where engagement is so terribly important Mark lost his identity his identity as a good worker and a family man and so we now have to as others have beautifully said he now needs to tap into what he wants so we've got to start in thinking about the future and that might take six months to enter even get to the point where he can start to be involved in retraining what is it he wants to do the key the key is engaging him what is he interested in if he has to go and job seek for some beating job a bitch is my second bottom goer he won't get another job so we really have to involve him as a person not a vocational assessment that identifies jobs that are not appropriate for him simply to stop his payments we need to pull Mark in and of course there are many things he may well be able to do in the future there are many transferable skills you'll have in that role brilliant brilliant Mary thank you very much for that any other comments from the other the other panelists on the other alternatives or the other sort of planning for the future that we could offer somebody like Mark I think it's Carol I think it's quite a jump for some people to actually think about doing something else about changing their career or moving into another area and support from the employer and from peers be very helpful there thanks Carol Carol while we've got you there some particular thoughts which were coming up during your presentation was obviously from from some therapists and psychologists who have obviously got some very passionate views about the different modalities of treatments which are available when just thinking about the useful therapeutic interventions have you found there are particular modalities of psychological therapy which are a particular benefit in assisting these patients especially if there's intercurrent disorders such as an adjustment disorder or depression also going on yes so I think if you stick to one model I think it's it doesn't actually work I find in most cases that maybe that's because I see the more complex one but I find that you you can say say in the case of Mark I think motivational interviewing was good for him so might acceptance and commitment therapy be good for him but sometimes it's even more complicated it you know if somebody's actually had injuries before or traumas before particularly complex trauma then you have to spend a lot of time working through the emotions about that before you can even get to any motivation so as I said before there's grief work that sometimes you must do so it's particularly if they've lost a lot of function or any function and then there's their core belief that they develop such as undamaged groups and this sort of hopelessness goes with that it could be using a lot of CBT or something like that it depends on how motivated the person is and how capable they are of actually doing that sort of problem solving in that what I sometimes do is ask someone if they're capable I ask them to do some trauma-informed yoga and mindfulness as well as seeing me and I think a multi-pronged attach and some flexibility in the model is important I think models have their limitations and there's certainly some comments that you know it's all about building the relationship and actually having that therapeutic relationship is probably actually the more important part of it and it's great to see so many of the therapists participating tonight looking at all of those different options so I'm not going to pretend to be the expert on all of those but I'm so glad to hear that everybody's finding their own ways which have been particularly useful there are two things there I think that building that therapeutic alliance is essential but another thing is that most models are actually trying to improve the reflective capacity of the patient the ability to stand back and reflect rather than being immersed in the symptoms or the emotion great great D'El, there's been quite a few comments from the participants about how might we manage suicidality you know once hopelessness is entrenched and we've really got somebody who is starting to feel as though they're losing their purpose in life I guess that the thoughts of self harm and suicidality probably do start to creep in and chronic pain you've already mentioned about the role that the opioids are going to have in clouding his judgment and his insight you've got any insights to share for the audience about how we might assess or address suicidality in something like that sure I think it's a really good question and a really important one and suicidal ideation is a very unfortunately quite a common experience in people such as Mark I think the first thing to do is be aware of it and be mindful of the fact that suicidal ideation and hopelessness might be there and make it okay to talk about it that doesn't mean going to a checklist and questions obviously of the session and asking about it but just making it okay to talk about the general topic and I also think that it's really important to involve others with a lot of my patients who might be experiencing suicidal ideation it's especially well I shouldn't stare at that but often with some of the minutes more the partners that come in and tell me they're really worried and I think bringing the partners into the sessions is really invaluable and then I think if it's present it's about not necessarily catastrophizing that in my search an immediate plan or intent obviously if that's the case then there's an emergency pathway to follow but managing it and helping them to find some hope and some meaning and some purpose and try to help them open up some doors to delay our approaches Can you bear other panels Scottie any thoughts there to share on that important question I agree and I've actually Jeremy I've shared a couple of patients and one or actually both of them have been suicidal at one point or another and I think just talking talking about it with the patient openly and talking about it with each other really reduces anxiety for all parties and enables calm management planning timely management planning Yeah I think with these cases as well we've made we've seen them quite regularly between the two of us and we've made them feel very unstrongly that there's a real support team around them that will help them move forward Absolutely yeah Another thing we're certainly noticing is that we obviously have got a national audience joining us this evening and it's obvious from a lot of the comments which are coming through that there are different rules and different systems which apply in each of the states and we are mindful that the comments which we're making tonight may not be applicable to every jurisdiction around Australia in terms of the providers and the processes which are going on but certainly in the resources folder you'll be able to find the relevant links to the state's bodies that might be in any area where you particularly are working and living So thank you very much to the panelists for all of those wonderful insights and presentations it really is a complicated area to delve into but we've seen that working together having the patient as an active participant encouraging an early return to work and being able to explore the things that they can do rather than dwelling on the things that they can't are all some really important points to take away from this So look I'm wondering might just give you the opportunity for each of the panelists just to share their little wrap up of the session and the take home messages that they'd like to send our participants off with So Roy, we might just start back with you there on that Thanks Conor I think everyone's really said this but try and be as collaborative as possible from the beginning really develop a good relationship with the patient and trust and I really think that things can be directed in the right direction and that's what I think it's really important to set things off on the right footing to begin with and unfortunately with markets it's a very common example of how things have slightly gone off off skew and how it's a domino effect when one thing is kind of not done quite correctly other things kind of lead from that but I mean even if that happens involving other professionals in a timely fashion can still bring things back to a good outcome for everyone Thank you Roy Yeah or do you got some some symbol messages there from some take home messages for the audience too Yeah and I think my take home messages are probably similar to everyone else's I think the first thing is to try and start working any capacity even if it's just a couple of hours twice per week and if you can't stay at work then plan an early return to work I think identifying and addressing vary as thoughtfully early on is really important a line with your patients and collaborating one thing I didn't get a chance to speak on today was the collaboration with the employer and I think open transparent lines of communication the more information you can tell them about their functioning their capacity to prognosis it is the easier it is for them a lot of cases I see is when the employer sends them off for an assessment because they just don't know what's going on not that they don't want to help but they don't know how to focus on function rather than disability is the other big thing that I'd recommend Thank you Thanks Tiola and absolutely having that communication open really to the benefit of everybody and you know we'd already mentioned previously involving the patient as an active part of that you know it's often when things are going as letters it's not all that difficult to see see the patient in I always try to make sure that they understand the certificates understand that the letters and the referrals that they're getting and that they're actively participating will all the way through there with it Mary have you got some hours and take home messages that you'd like to share with the audience this evening? Rather than repeat what's been shared already I might just add in something else and identify resources early so again prevention is better than cure who could have helped in the early stages we haven't talked much about physios this is a mental health webinar good physio therapists and in Victoria physios are becoming more active in certifying and advice and explanation but identify who your group or colleagues is best able to help this chapter early on and help him actively manage his state problem it is time consuming to re-educate people and give them some information but find who that is it's generally not a surgeon but it will often be a physio perhaps a must-have at a leisure position Wonderful Thanks, thanks Mary and Carol I'm going to give you the opportunity to share your final thoughts on that the case and which would be the many esteemed colleagues you've got in the audience as well on what your messages are for tonight So this might seem a little off track but because I think everybody who's said so much already about the important things like the relationship with the patient but I'd like to concentrate on self-care for the therapists and the people involved sometimes these patients are quite distressing they take a long time to get better and you have to be able to stay the course so your own supervision and your own capacity to manage the very heavy emotions that these people bring in and also sometimes the very distressing circumstances I think it's important to look after yourself Thanks so much Carol for that really important insight and that's an important message for all of us that's all we have collaborative networks and collaborative webinars and events like this that you do know that we all do end up working in silos to some extent but there are a lot of other professionals out there sharing the same stories experiencing the same types of cases and trying to help out the same types of patients so being aware of your resources for your own protection and support as well as for those of you patients really is so important So thank you everybody thank you panelist for more importantly thank you participants and audience members for your participation We would really love you all to make sure that as you're logging out that you do feel at the brief exit survey which is going to be popping up in there and this evening is of course eligible for your CPD and your certificates of attendance will be emailed out within a couple of weeks There you will also find the link to the online resources which we've included that will be coming up in the next week MHA and of course conduct a series of webinars throughout the year as we're moving on we're certainly not slowing down yet The next of the series that we'll be having will be on forced adoption that's coming up next week the ripple effects of forced adoption and I certainly encourage those of you in APS to be signing up for that one and of course veterans affairs has asked the NHPN to assist with another one on the very important area of responding to and treating post-traumatic stress disorder and particularly what works that's going to be held then a fortnight from this evening on Tuesday the 25th of October There will also be another one coming up on caring for young people with gender dysphoria on 9th of November as well so certainly do make sure that you're logging on for everything as you go We'd also just make sure that for those who are interested in joining a mental health professionals network that there are going to be some in your local area so there is a link there you can see what might be active that you can join into or join as a facilitator indeed and mhpn.org.au will have plenty of those areas on there So particularly when you do know that look you know that this many of the other many areas in mental health care might be a little bit of a special interest for you please do share your experience share your energy and your enthusiasm and get involved it really is a wonderful experience to be part of So as Carol just so rightly pointed out that we do have to look after our own self-care in these matters So certainly before I close we would love to acknowledge the consumers and carers who have lived with mental illness in the past know to continue to live with mental illness in the present Thank you everybody for participation this evening It's been a pleasure to bring it to you on behalf of Mental Health Professionals Network Thank you all for your contribution and participation We'll see you next time Good evening