 Good evening everybody and welcome to the Mental Health Professionals webinar this evening on our topic of Collaborative Care for a Young Person with Grief, Lost and Trauma. It's an interdisciplinary panel discussion as the MHPN webinars always are. Currently we have 370 participant logs in online which is fantastic and we have 1,600 people registered for this webinar which is a record for the MHPN. My name is Mary Emma Hayes, I'm a GP in Ken's in Far North Queensland. I'm also a psychotherapist and I work at Headspace. I was in Council for four years and now at Headspace in Ken's for two years. So the young person that we're talking about tonight is somebody that would be familiar to me as to all of the members of our panel. Now I'd like to just introduce the Australian Child and Adolescent Trauma, Lost and Grief Network. I'm just going to get a slide for you with that on us. So this webinar is supported by the network so I just wanted to tell you a little bit about who they are. So we do particularly want to thank them for their contribution and involvement tonight. The network targets psychological trauma and or loss and grief suffered as a result of serious accidents, injuries, illnesses or life threatening events, witnessing threats or violence to family members or other loved ones, child abuse and neglect, severe bullying, violent, sudden or unexpected deaths of family members, loss and changes in family, friends and other important relationships in schools and communities, life threatening experiences such as disasters, terrorism or other major incidents. So you can see that's a very wide variety of events that can affect the people that we work with. And in fact a number of tonight's panel, which is Penny, Shane and Devali, are involved in the Australian Child and Adolescent Trauma, Lost and Grief Network. So I would like to introduce our panel members. I'd like to introduce Shane first of all. Shane is a psychologist from New South Wales. Just a reminder that the biographies for the presenters were sent out in the information about the webinar. So if you want to find out more information, please return to that. But Shane, could you just tell us a little bit more about the words he's done looking at Indigenous experiences of coping and resilience? So I'm an Aboriginal man. I'm a Canadian man from Northern New South Wales. I've been involved and I'm a psychologist. I've lectured in mental health and counselling Indigenous mental health specifically along the way and great to last for quite a few years. I've been involved within a lot of steering committees and on a lot of panels and committees over the years. I've been involved with the mental health professionals network before, but I've also been involved with a Catlin, who you just talked about, as a consultant but also as a steering community member. And I've had a lot to do with the Indigenous hub of that sort. And I understand that you did some particular work around coping and resilience. I've done some articles. You've seen my presentation that I've done an article on grief and loss, on complicated grief and loss in specific Aboriginal populations that's drawn out of my PhD. So a lot of my PhD was around cultural safety, around the need to decolonize psychology. And I looked at resilience within that Aboriginal resilience and the need to redefine terms when you're working with Aboriginal people or Aboriginal communities. Well, I'm really looking forward to your contribution to the panel. I think it will be really interesting and add an extra dimension to what we're talking about tonight. I'd like to welcome Penny Burns as well. Penny is a GP. Penny, how did a GP get involved in adolescent trauma, loss and grief to this depth? How did you become interested in that? I've actually connected with Beverly Raphael, who was one of my previous professors. And I was very interested in disasters and studied that at James Cook University. And then started looking at the effects of disasters on populations. And particularly the role of the general practitioner in supporting those communities are to disasters. And I'm now actually doing a PhD on the role of GPs in disasters. So it sort of went one thing to another. And I'm also currently on the New South Wales Mental Health Disaster Advisory Committee as well, which advises on responses after. So it sort of went from one thing to the other. Thank you, Penny. And I'd like to welcome Professor Beverly Raphael. Now, Beverly, you're on the panel as a psychiatrist. And I understand that you wear very many hats and have been active in a lot of different areas of mental health. What particular things do you, parts of your roles, do you bring to the particular case of Jeremy this evening? What interests you about Jeremy? Many things about Jeremy. He's a loner. The fact that he's probably an Aboriginal boy, we don't know, is with an aunt who's really supporting him that not dare much time. And I'm interested because he's got both physical symptoms and potentially mental health. We suspect he feels a lot of trauma and loss just because of the lack of a family around him at this young age. So I think it's a chance for us to make sure we look after all the sides of his well-being. And that's why I'm really keen that the panel addresses all of those things. I was a general practitioner once and certainly both work in Indigenous populations and as colleagues working closely. We've done a lot of work about children's trauma and we know that Indigenous children are far more likely to experience it. So we're very keen to know what's happened in his life and the physical and mental health issues that he's experienced in there. Thank you, Beverly. I wonder if you could move your microphone just a little closer to your mouth. Some of the participants are having trouble hearing. I think you can just move it a little closer. Is that fair enough? Yes. Thank you. And last but certainly not least, I'd like to welcome Scott Truman. Now, Scott is a mental health nurse by background and is currently working in the university role as well. Scott, some of us are not so used to working with mental health nurses and I know that you were commenting just before we came on air about perhaps some of the differences in your role. So I wonder if just briefly what particular things a mental health nurse might bring or keep in mind when seeing somebody like Jeremy? Well, in relation to Jeremy, for example, as Beverly said, he's clearly isolated from his family in the life. And so whilst the GP may obviously be involved in a psychiatrist and a psychologist, a more regular point of contact needs to be established with Jeremy. And if a referral was made to a mental health service, then obviously a mental health nurse would be able to have more frequent contact and on a more regular basis with Jeremy to build up a relationship between the mental world services and the patient. So it's that frequency and intimacy of contact on a regular basis that the nursing perspective would cover from. Thank you very much. Scott, look forward to your contribution as well. Now, I just wanted to remind us all about the learning objectives for tonight. So this is particularly about how we work collaboratively to look after people in mental health care, in the primary care setting particularly. So what we're hoping to get out of tonight is that we might better understand the mental health indicators in the context of grief loss and or trauma in young people, that we can identify the key principles from the feature discipline regarding their approach in screening, diagnosing and treating young people exposed to grief loss and or trauma and to explore some tips and strategies for interdisciplinary collaboration between practitioners, dealing with young people exposed to grief loss or trauma. And I'm certain that all of our registrants, of whom there are now 484, as well as our panel, know that one of the keys to working with traumatised young people is actually that you can't do it on your own and you need a team. So we are tonight talking about Jeremy, who we've mentioned already. So he's presented to you in the case that you received before the webinar. In summary, he's a 13-year-old boy who's recently moved from Central Australia to live with his single maternal auntie in a major city. He goes to the GP and he confides a physical health problem and the GP notices that he looks tired and drawn and fidgety and he might be in some kind of psychological distress. So I would like to invite Shane, first of all, to show us how he might first respond to Jeremy. I'm sorry, I've forgotten the ground rules. I've done lots of these webinars before, but I haven't actually done one for 12 months, so I'm apologised and I'm a bit rusty. Just be mindful that what you write in the chat box is visible to everybody, for our participants to be respectful and behaviour this is worth face-to-face. Try to show your comments and questions to the panellists in the general chat box and if you have a technical problem, go across to the technical chat box and remembering again that everything can be seen by everybody. And your feedback is really important and a lot of the things like the choices of topics that we use and presenters' suggestions of future panellists have come from feedback. So please feel very, very welcome to feedback. We appreciate it. In the bottom right hand corner of your screen is a document tab and the case study is in that. So if you wish to open it so that you can see it and refer back to it during the activity, you're very welcome to do so. We've been through the learning objectives and I would now like to invite Shane to respond from the psychologist's perspective. Thanks very much, Shane. All right. We've talked a little bit before about the case study. There are a lot of indications there that Jeremy might be Aboriginal. It might not necessarily be obvious to the GP or whether there's some saying Jeremy that he is Aboriginal and he may not be comfortable disclosing his Aboriginality either. So I think there's a lot of things that you can't assume one way or the other without talking to Jeremy. And I think the important thing is, as Beverly said, you've got to get a look at what's happening in Jeremy's life from Jeremy's point of view. Me as a psychologist and as a counselor, I would say that it's really necessary to build a rapport with Jeremy because it's not likely to happen otherwise. There are some really possibly alarming points in the case study that I think as a psychologist or a counselor, that certainly as a health professional in general, you would be flagging. You would have, I always go into a case with a working part officer and I'd flag almost everything that could possibly be an issue ready to explore or ready to see the opportunity to explore if Jeremy gives me a way in. I think if Jeremy came to me, I would probably have a referral from a GP or possibly from a psychiatrist talking about the mother's disability return. But also I might possibly have a discharge summary if Jeremy had been hospitalized or any physical or certainly mental health issues. There are some protective factors that are really good indicators and our reassuring in the case study like his relationship with his aunt. I mean it's concerning that he's moved but we don't know that he's moved necessarily for bad reasons. It might have been cultural reasons that he moved. He might have moved to go to a different school to get a better education. It might be horrible reasons as well. We don't know at this stage. As the other panel members have said, there's a lot of concerns there physically and I would leave that up to the GP to look at the stuff that the urine passing and also the scratches might be indicative of something. I was talking to another colleague who specializes in child and adolescent care and she made a good point about something. I had a lot to do with writing with Jeremy Kate but it didn't occur to me that the scratches might actually be from his aunt. His aunt might actually be abusing him physically or sexually. So you have to be really open for following that hypothesis through and not having a close mind about anything. I'll probably put too many things on my PowerPoint but I'll talk them through now but I'll give you an overview. You've got two minutes. I've already used three already. Yes. Confidentiality I think is a big issue given Jeremy's age. We don't know if he's capable of giving consent to treatment but usually probably it would be his aunt who grins into milk to close the gap. So Jeremy has a right to treatment even at 13. If he were like 14 for example he could actually give consent to treatment without his guardian or his care is concerned. So at 13 it's pretty tricky. I put up the table which is very dense but I put about more as a resource if it has. I put it in specifically. There are a lot of things on the left hand side that might be relevant but the idea that he might, Jeremy might be at this stage where he's trying to differentiate himself from his parents. That might be necessary for him to be away and it might be a positive thing for him. Again, as a psychologist, as a counsellor, I don't think Jeremy would open up unless maybe even there's the Aboriginal thing. Maybe it's the progress that's on the mail and that might be helpful in him opening up a bit more than otherwise he would. The idea is there's this person-centered approach and the importance of unconditional positive regard. Cultural stuff, narrative therapy can be really helpful. The dairy, the deep listening might be really culturally appropriate but effective. I would really put a lot of emphasis on building the therapeutic alliance in the relationship with Jeremy, especially at a 13-year-old at that age because you would need to put in the groundwork to get Jeremy to feel comfortable with you. Obviously I would look at Jeremy feeling empowered and including his aunt if possible. His extended family, even though they're distant, if they could be involved that would be wonderful because it's about assistance approach, ideally. The other thing is I'm trying to look at it in a strength-based way. There are a lot of indicators here that he has a good support network he could have, but also the importance of acknowledging the strength that Jeremy brings to the table and not being the expert and talking down to Jeremy, actually getting Jeremy to explore the issues that are daily on the screen and identifying the protective factors. I mean, there are quite a few risks that might be evident in the case study. The reason I put that up there is not to publicize my own article, which I am now doing. It's also because it talks about a lot of the trauma-related issues, the grief and loss issues that might be relevant for an Aboriginal 13-year-old kid. So I thought that would be a good resource for people. Thank you very much, St. I'm sure that it will be. There were some questions that came in from the participants beforehand. We now have 526 participants about engaging, how to engage somebody like Jeremy, and I think that you've answered a lot of that really beautifully for us. I would like to now invite Penny to give us a response that she might have as the GP who's seeing Jeremy. So Aunty has brought Jeremy to see her. What kind of things Penny might be going through your mind when you meet Jeremy? Thank you. Thank you. Look, I just had a quick couple of slides initially on just on adolescence and I'm sort of presuming that Jeremy may be Indigenous but I don't know that. So I guess I'm approaching it from a fairly generalist point of view. One of the important things about adolescence health is that there are about a 50th Australian population and they've got quite significant diversity, whether Indigenous or whether culturally from somewhere else. The major issues in adolescence are accidents and injuries, mental health burdens and behavioral problems, but the three common reasons that the GP would see a young person is for respiratory, skin or musculoskeletal conditions. So, you know, I have acne doc, but every time we see an adolescent we're always wondering about what else is going on with that person, partly because it's an opportunity to interfere with the fact that the adult disease burden is associated with conditions and behaviours that begin during adolescence. So it's a really big opportunity for us to be able to see adolescents and engage them in a really broad way. And Jeremy's story is incredibly multifaceted and when I saw it I thought, wow, I could spend two days with Jeremy. Usually we have 15-minute consultations in the surgery, but for first consultations we would normally have a half hour, so we have a 30-minute consultation. And if we know it's going to be long, people will sometimes make a longer one, but it's still a very short time to go through this huge amount of issues with Jeremy. So I have, you know, I'm very similar with Shane. The absolute priority is to engage Jeremy and also to connect with his aunt, but you have the advantage of already knowing the answer to the patient. So you have a huge amount of background data there about Sharon and about her family and what she's like. But engaging with Jeremy is absolutely crucial and it needs to be done at Jeremy's level and it needs to be taken very, very slowly and done in a way that's acceptable to him. He needs to feel safe and he needs to have his concerns addressed. And there's obviously confidentiality issues that Shane's touched on and then there's medical legal issues about consent and it's different in every state. And Jeremy had a difficult age for that with 13, but a socially mature adolescent can consent to treatment themselves in certain situations. So the commonest tool that general practitioners would use is probably a Heads Adolescent Health Check and you may be familiar with that. There is one in the, there's a nutshell document that has one that's a very good printout for Aboriginal teenagers and that's very useful. This in itself could take several consultations before you actually get through it and sometimes it's very difficult to approach early on, but it's a really good basis for starting. In the history taking, the conversation and initiation is really important. It's important to ask Jeremy permission for what you're asking him and also to speak to him in a way that he understands and without talking down to him, but in a very sensitive way. So, you know, you might start with, is it okay by asking questions about or some adolescents your age like to and do it that way. Jeremy's has also got some concerns that he needs addressed and it's very, very important that those are addressed as well because that's the reason he's come along. So if he goes away without having those addressed, he feels that he may thought the consultation wasn't what he was after. It's also important in the history to get as much as you can from Jeremy's appropriate at the time, but sometimes you also need to go outside Jeremy's knowledge and ask permission from him to talk that he's aunt or to talk to his school to gather more information. The physical exam here is again a really difficult issue. He's got certain signs that make you want to examine him, yet if he has got issues of trauma or grief, it's going to be a very difficult thing to do and sometimes it may not be possible to do it until the third or fourth consultation. It doesn't need to be rushed, it needs to be done slowly and sensitively and you need to have a good rapport and a good trust with Jeremy because he needs to allow you to do that. Now there are also opportunities in physical examination. Simple things like asking him if we can do his blood pressure, allow you to roll up his sleeve and see a little bit more of his arm and see what's going on there. And then there's a whole lot of other issues here with his weight and height and his scratches on his skin that you would need to address, but again in 30 minutes we would not be able to cover all of those and we'd need to come back another day to some of those. The key would be to get him to come back. There is an item 715, sorry a bit of typo there, to do a health assessment as well and again that could be another thing if you get him back later to do, to get a more comprehensive coverage of his health. So the important things at the end of the consultation are that we've actually managed to develop a connection with Jeremy and that he feels safe and engaged with us. And if nothing else happens other than that, then that's probably the most important thing. And the second important thing would be that he understood the plan of management that we developed with him and he understood how to access ongoing care if he needed it, so how to come back and see us. Adolescents often have trouble understanding Medicare and they don't have their own Medicare card and if they don't have support from an adult they may find it very difficult to walk back into the surgery. So it needs to be very adolescent friendly. Thank you. Thank you very much Penny. I guess that it was raised by a lot of the participants that Jeremy's main problem is his burning pee and you identified really well that even if that's all we achieve is engaging him and having his concern met around that, then that gives us the opportunity to follow up later on with other things. So I actually think GPs are really, we have actually a lot of power and influence which we don't always recognize and can really, because we're allowed to address the physical problems as well, I think it's often a key to engaging adolescents which is really helpful and then we can invite our primary care colleagues to come in and give us a hand. So I think that was very helpful. Now one of the professions that we might well refer to as a DP is a mental health nurse at least in some private practices and so I'd like to invite Scott now to have a response from the mental health nursing perspective. Thanks Scott. Thank you Mary. Yes my lens of talking about Jeremy here is quite different from the previous and the following speaking in as much as a lot of the interventions or plans which would involve a mental health nurse are really continuing upon what the referral is on either the psychiatrist or the individual and what the decision to get a mental health nurse is working in. For example if the nurse is working in the same GP practice as a mental health nurse practitioner or if they're working in a say adolescent child mental health service working in a government department or service health service then of course the response or the interventions with Jeremy will be quite different but that said it's quite clear that this young lad is at risk and the greatest risk that I see is that him slipping through the cracks or never engaging and I agree with respect with the other panelists that engaging Jeremy is the greatest need at this time and it may be that the GP is able to see the see Jeremy more often but if that is not the case then a referral service or to a mental health nurse for a viral service will apply regular and more consistent engagement that could be undertaken. Now the second point on that first slide could have been the very first one so much of this is contingent on the level of consent and engagement that Jeremy actually wants to make and that is if Jeremy engages then it makes it a lot easier to provide holistic care and support to him and his significant others but if he doesn't then that's going to cause some problems which we'll discuss in a minute. The central question from my point of view is and I would want to get either from Jeremy or from the referring GP slash psychiatrist is why is it that Jeremy has moved from Central Australia to be isolated with his arm? The central question for me would be why is that? Is there issues of death or loss of the parents? Is there issues of neglect? Is there issues of abuse? I just simply don't know but they are essential also to the point of Jeremy's thought. Jeremy's sitting here debate as the others have discussed he is not under 12 but he's certainly not 18 so he doesn't have autonomy to make his own necessarily at law make his own decisions in regard to his care. It's interesting that he was prepared to come along and see the GP but then he wanted to do it in private so there's sort of on the one hand a level of engagement or a power of say and then on another there is perhaps a lack of namely when of course he says why. It would be very much the case that the GP would have to make a Gillick decision based on that little case Gillick and determine whether even though Jeremy's sitting he has competency the ability to weigh up the decisions and give consent. Again I stress this will greatly influence the manner of future and management. If there's little or no engagement and certainly he was either not competent and didn't or if he was confident didn't give consent then there's huge issues of confidentiality who in fact is the person that would be able to provide the consent for anyone going care. The R may be but certainly maybe not. The parents will then if we need to follow the parents up the issue there is that we are cultful perhaps problems or issues and we also have the issue of are we going to do more damage than harm if we are trying at the embryonic stage of this therapeutic relationship to establish it and foster it and mature it. It's quite clear that there could be an indigenous aspect to this. If Jeremy does identify as an Aboriginal or Torres Strait Islander then there needs to be this central to the care that is provided and the ongoing planning in regard to Jeremy and that would require taking advices from those people who have the requisite knowledge and skill in regard to the protocols that would then be undertaken in that regard. Certainly if he were referred that is Jeremy were referred to a mental health nurse working in a service that's one of the first things that they would be wanting to do is to engage in appropriate culturally safe resources and assistance. The GFI referral it could be made to as I said a child and adolescent mental health team and certainly if that was made then there would need to be frequent case management particularly at the early stages in regard involving both the GP and a psychiatrist and if there was no referral made to a psychologist and those team meetings would have to take place on a regular basis. If the referral were made to such a team the mental health nurses would have to engage as I said culturally appropriate Indigenous local resources and they'd have to undertake appropriate culturally manners of interacting with Jeremy such as art therapy, narrative therapy, yarning with Jeremy as we go along. One of the big issues here though is that Jeremy's engagement as I said really depends on whether he faces a service or not. The interesting thing here is how are you going to get a history from Jeremy if he doesn't give consent and he is just competent because if the parents still live interstate in another state or territory then you've got cross-border cross-state issues of accessing his prior medical history and I think that would add another level of complexity to this case. That's all I've got. Thank you very much. I'll just pop through those slides. For some reason the video has frozen but I'm sure the technical people are onto it and in fact I can't ah there we go. Okay the slides have advanced and um Beverly I know I just wondered if I'd gone past your first one. So um Beverly we would like to invite you to respond as a psychiatrist now I guess that we probably Jeremy may have seen other practitioners before he comes to see you and um it would be really useful for us to hear how how you would approach someone like Jeremy when he has been referred to you. First of course I'd take notice of the referral words and what people have felt about Jeremy but I would really like to be tuned in because we know that many children experience adversity our research has shown and certainly Aboriginal children these Aboriginal have experienced much higher levels and we know that childhood adversity is one of the things that could have so many impacts in different ways and I think that we have to be tuned into the trauma component and I'd certainly be gently exploring what what his experience has been and also what information we've received from whoever's referred him to to as a psychiatrist that is myself and how we can take into account the complexity of things that have been probable in his life uh being in a big city from a remote place and no knowledge yet about his family his origins and his experience in the earlier stages of his life um we would be of course concerned about family conflict uh schooling there's no mention of schooling and is he in school now because the capacity to support him in school is a critical one uh possible health problems he's clearly presented with what appears to be a physical health problem and we don't have any answers to exactly what's going wrong either self uh for him himself or whether he's been subjected to some abuse there's a strong sexual issue in the theme of his thing uh in his dental organ which is which is described as seeing experience in the pain of it so it would suggest an effective process we don't know anything about that in detail and of course the dental practitioner will have address that because that's the primary thing that's brought him to care so it's the challenge for collaborative care is us all working together and playing a part possible health problems the possibility to abuse separation from family uh separation from culture we don't know whether his answers have to affect uncertainty about what is happening in his life now and what sort of social support does he have there are the sorts of things which will be able to interest again in his life when we understand better both the physical and the psychological symptoms the issue of grief and loss has come up very powerfully and it's very likely that he's experiencing loss of his familiar place if he's at worst associated with unhappiness and trauma because we all are influenced particularly early in our development by the stretch of about lives we're influenced by that but influenced by the nature of family and the strengths and identity of being part of a family and part of a community which is very powerful when you're a relatively small and isolated place so he must be experiencing some grief and loss about that they'll learn the losses that might have occurred and commit to death very common in Indigenous communities from accidents and a range of other factors so our concerns Jeremy is both in the experiences he might have had in the past how they're interesting now his story story of what he's asked about and it's absolutely right what everybody else thinks that engaging him making clear that we're not just interested in his feelings but we are very interested and concerned in with walking with him to get the physical symptoms better and to deal with him in ways which will be he'll be able to understand and feel better about and also to support him in a sense way because we want to go to speak to his culture and his needs and the the strange experience of being an adolescent boy and growing up and what this world got to offer me and what was my past world like so his stress and anxiety may be common experiences for him we need to understand that better he's still a child in a lone place because he doesn't have other families at his own aunties are very important in Indigenous culture and often they're very powerful and supportive people and she seems to be very supportive from what we hear but he is old enough to want the privacy as he asked for in the interview so he may have a lot to tell a lot of stories he needs to share a lot that that will influence what we understand about his mental health needs and we have to look at the fact that he may have experienced physical or sexual abuse and may have been neglected there might be transgenerational problems the self needs and families and circumstances indigenous families particularly his aunt is there and seems to be a solid care for him but it mentions in the briefing that she's away a lot long hours so what were his lonely times like who does he turn to and what happens in his life in a day-to-day way I think they're critical parts of this understanding so it's mixing our experience the sorts of things Scott said the sorts of things we discussed in terms of Penny's view and his general practice engagement and I think to the issues that Shane expressed so clearly it's highly likely there's sadness and grief in his life and we need to really be with him and walk with him to help understand that and be with and walk with the team the group of us in ways which are all sensitive and collaborative now asking the right questions is part of this and what sorts of things make you feel unhappy or making you sad that's the question I'd like to ask because most in your canoe also shape this in the idea of you know many young people have come from their sad and unhappy especially at this age when you're growing up everything's changing in your life and that's an opportunity to hear that bit of the story how do you feel in yourself these are the sorts of broad general questions and they're very similar to some of the things that Scott was saying it's opening up what sort of things have been worrying you and has this worry been around for a long time how do you feel about your situation now and what do you like what do you do well tell us about yourself and these are only a start and they're just my words I think it's very important to have an actual and open words and to take that discussion along a path that he responds to and seems to be okay about it's an important time not to have to structure the question not to bring out the checklist but to bring out the heartfelt feelings and wish to understand and be with him in the journey of history I think they're critical and I think that's what good clinicians good doctors and the people with skills described in the panel do so I think we have to be tuned in and be open and ready and encouraging him for his story both in the worry he has with wings and the worry he has with life and discretion him or someone else doing it the hurt the wounds that have probably been part of where is it now thanks very sorry Beverly no that's right I was just over to you thank you very much for that and I think what you said has been really resonating with a lot of the conversation in the from the participants there are 589 people online now and I think people are really saying that that the key thing is to is engaging him recognizing that he might be really frightened and not not rushing in to make any conclusions or foreclose on what might be wrong and I think it's important for the participants to know that the what we're really doing here is speculating on what the case makes us think of and the MHPN cases are deliberately very open and with very much information that we don't know because that is the reality of the work that we do and we see someone before us presenting with one thing there's always a great big story and that's why we often need a number of different people working collaboratively so in this case everyone in the chat room is pretty much agreeing that what he's presenting with is to the GP with a P problem and that's probably the thing that's going to help him engage. We're going to open up into the panel having a discussion about how we might work together for Jeremy and I know that you had a question for Shane which was really around we don't really know why Jeremy's with his auntie so I wondered if you just wanted to have a talk with Shane about what you were thinking about how Shane can help us with what might have led to Jeremy being here. Yes I would like to and I think it's really important that Shane himself is an indigenous man he may be more able to discuss with Jeremy some of the things that are coming up in Jeremy's life that are okay to talk about because it's the male person and also because it is part of the cultural background that they're both shared even though it might not have been exactly the same cultural setting. I think Shane has brings the wisdom and the capacity from his own experience in Aboriginal land but also his work with other indigenous communities in tuning in and knowing the sage questions to ask and the ways to take a sensitive issue forward because that's what we're talking about in the primary way that this or his presenters with a sensitive issue. In fact he told us this off is also indicates that it's a very big thing for him and we need to address that as well as his anxiety. Shane can we get your your help here about how we might understand what might have been troubling Jeremy in the remote community that came from what kind of things might you be thinking about? I think at his age I think you can't rule out experimenting with drugs and alcohol you can't rule out self-harm you can't rule out suicidality at the moment depression we've certainly got the evidence in the case study about the can you can you hear me? We can hear you we can't see you so I'm just waiting on the technical support to bring back the videos of everybody because we are now in the discussion section but we can hear you so keep talking. Okay talking so we've got evidence that he's not sleeping well that he's probably interrupted sleep we've we've got the scratches like I said might be self-harm I think there are a lot of things there that might be really concerning and I think I think it's a really tricky one because sometimes you get somebody coming from a rural or remote area and it can be protective living in a tight community but then sometimes it might not be it might be a risk factor if a lot of Jeremy's kids or some older kids as well are experimenting or making Jeremy do things he doesn't want to do he might have fledged that or he might be trying to deal with it in his own ways so I think there are a lot of things there that might still be issues and we would really need to know from Jeremy and take the time to not feel the pressure to diagnose too soon and find out from Jeremy hey what's actually happening with you and as Penny said it might it might need obviously extra sessions where you can get that that time to explore all of these really really important issues. Thanks Shane I've got a bit of a delay between the video and the sound so I can't always tell when you stop talking. The other thing is we can't put all the videos up at the same time because the audio will suffer so that's why we're just going to have one person at a time. Now Shane can I say one more thing? Did I mention Shane? Shane for Aboriginal people especially I mean you've got a lot of pressures when you're a 13 year old kid especially a 13 year old boy anyway but this overlaying factor of this Aboriginal sense of shame let alone the normal shame that a 13 year old boy would feel about and be hurting so I think that's something that you really need to negotiate as well it might there will be that the shame was what he did when he died in his room not necessarily because it was a gender difference but because of the shame factor of what's happening with him and what that may mean like whether it's next to the or whatever so I think you've got to really negotiate this idea of shame and it could be very hard for someone like Jeremy to admit weaknesses in front of people. And Shane someone in the participants has brought it up and I was also thinking that we actually don't know if Jeremy is Indigenous we think that he might be but that issue of in my experience the Indigenous feel of shame has helped me to think about shame more broadly and any 13 year old boy with this kind of problem is likely to be feeling embarrassed and awkward and and a sense of shame. So with that Penny because I was about to invite you to comment on how you would deal with that as a decade. I was just going to say I have actually seen adolescent boys who come in with this strange discharge that they weren't sure what it was and they've chatted to that with their friends so in a rural area and they've all decided that it's okay because they've all got it but this one child's end up coming in and it has ended up being an STI in this particular situation but it is very difficult. I find that for me one of the important things with adolescents is to have very frequent contact initially to develop that rapport. I find it very hard to get very much of the history initially and I find that it's really important to go slowly and so I will often end up seeing them fairly frequently initially to establish that rapport and then I'm very careful about referring on. I run it, I discuss it with them and obviously they're involved in their care but to send them to too many referrals or too many other people can sometimes be a bit scary for them. So this is something that I would take very very slowly but there is also a concern with the UTI in that you do want to or it may not be UTI be the urine the dysphoria you do want to actually find out what that is because there is a higher risk of kidney disease in children in Aboriginal children and so it is actually medically very important that that's addressed and so even though a lot of these issues are around psychosocial you know in the future we don't want him to have chronic renal failure so there are some very important physical things there that need to be addressed albeit very slowly and very carefully. Yeah and again I think that's one of the really good opportunities in general practice that we actually often miss especially when we're you know we don't have enough time but engaging somebody like this and assertively following up his medical problem that he has presented with that is worrying him those consultations where you order tests and you see him again and you follow up he begins to learn that you can be trusted and then when you open it up to talk about the wider area in the head's assessment and then maybe suggest the involvement of other people who's more likely to trust you and I've been noticing in the discussions from participants there's a question about if there does end up needing to be a number of people involved in Jeremy's care how do we hold it all together you know do we need one person that's kind of the coordinator of everything and is the GP placed to do that how do we decide who that should be do you have any comments on that or perhaps if anyone on from the panel wants to speak up my feeling on that is that Jeremy probably ends up deciding often it's the GP that might be the coordinator but if the person who relates best to him can sometimes end up doing that coordinate coordination and Jeremy is the one that is directing that with guidance but it's very important that he's happy with who he's seeing and so I feel that it doesn't necessarily have to be the GP it often is the GP but in some circumstances it might be the psychiatrist or the psychologist or the mental health nurse who's really guiding where Jeremy's being referred yes welcome whoever that was please go ahead it's Scott here I from my experience I'm not saying that the the team leader if you wanted to use that that phrase is necessarily the GP or anybody but I've often found that the carriage of the day-to-day matters is often if the referral is made to a mental health service done by that mental health team and then collaboratively have regular team meetings with the specialist that's good do you have any trouble getting specialists and GPs to participate in those kind of meetings no no but they're often time poor let's put it that way and just that near the sheer lack of GPs that are available makes it problematic and certainly in a place like Cairns for example it's extremely difficult to find private psychiatrists or GPs that have the time to enter into those it's not because I don't want it it's just the reality so do you have any any tips on how you how you could involve the GP and the psychiatrist I'll go to Beverly after this as well but how could you involve those people in a collaborative way when you might not be able to all get together in the same place well often from my experience there can be correspondence by way of a discharge or a referral letter and then I've often found that if the parties can't get together that often phone calls after hours or can facilitate the transferring of information certainly it's easier if everybody is part of the same medical record system and they're able to share though access to those records so that is not more than a second half of the rule and Beverly I wonder if you could comment on how you've been able to be involved with these complex kind of cases as a psychiatrist and I guess sometimes you might not even be in the same town and also there's a question from the audience if you could follow on after that just a little bit more about the actual elements of grief and loss that might be present for Jeremy but if you could stop you know how do we address sensitive issues like grief and loss in a collaborative way including Jeremy when we have you know professionals with different needs and times and funding well I think in this day and age there's three words or less I'm joking unless they work in the same facility it's very hard to have a conversation except by teleconference or something like that and I think you can do quite well with it but you do need to have someone who's the identified person it'll make it happen and sometimes it's a person in the practice but it's the person as Penny said in a way that should be the lead agent is the person that's got identified within CLT can talk with and the rest of us should fall into place alongside that in a collaborative way but tuned in with the expertise each one of us might bring through answering the question of the queries and the problems that he's facing so there might be a need for example to liaise for the school as the may well be through the developments following the findings testing the couples he's having with his wing but alongside this it's how we keep the support going in a generic sense as well as the expert support from perhaps counselling and other ways of support that he can tell his story and deal with any trauma that's happened in his person grief particularly we often use to set grief aside or just think it was the trauma often the two things happen together but grief is the great sadness and most little children even recognize sadness and know when someone's got a sad face and I think the sadness that can be there and young people can last a long time it and it's often associated with a sense of worthlessness and gentleness and especially if you've lost your mates even if they weren't good mates it's just lost them you can feel sad and grieving and quite often because of the primitive deaths in many remote communities particularly indigenous communities you are likely to have family losses we know and research has been done in those settings it's a higher ratio in my own experience um with indigenous communities primitive deaths are very common to accidents so loss and grief are common and the sadness is to start the angry the self-blame and the emptiness may continue unless there's counselling counselling and support particularly the support of others who are capable of showing you affection and kindness the ordinary healing things the goodness in people which often comes out when they're offering support and we shouldn't push things this is the only way to do it I think sometimes there's an expectation there's a magic way but listening hearing being there having eye contact and showing you care about what's happening in his life will be very important things for Jeremy to get to see a lot as well as the words and Beverly I've noticed that um in your approaching this in a very holistic way which is in fact not um well from maybe this is unfair to say but it's not in a sort of typical medical model way and um I was wondering actually perhaps Scott if you could comment on um from a psychologist's point of view we're having a lot of questions from the participants around um you know the interactions between um actually I meant Shane because he's a psychologist but I said but just around when you're not a medical person you're not a doctor or a nurse how how does you know what are some of the difficulties around that interaction and how have you found ways to work with doctors and nurses um when clearly the thing that Jeremy needs is someone that that he relates to as a person he doesn't actually care what profession we come from he's interested in who is hearing him so Shane could you talk about that a little bit um I just I just think it's um as Beverly did it so so beautifully she she peppered the holistic view with with the practicalities and the physical symptomology and and what she would be looking for and vice versa so I think it's um it's finding finding that way to tie in the the broader ways of looking at things and that's and the for example in Jeremy's case whether he's Aboriginal or not obviously the context is important um so having those dialogues um with your team um in that collaborative way where where like for example if there was a focus too much on the physical and on the diagnosing then I would I would throw in a conversation starter about the more holistic contextual stuff and and perhaps about the cultural stuff as well as if Jeremy was Aboriginal so I think it's um working as that um introducing the holistic stuff and you might be surprised um like like um Beverly um the the the conversation itself might change in nature because of that now I'm just aware that we're um approaching the end of our time and um you know there's a very lively discussion in these participants and in one of the one of the things which you know obviously we take feedback on board but that a lot of our discussion is speculation but I guess in reality when we the very first time we meet someone particularly somebody like Jeremy for 15 minutes all we can do is speculate and I think that was your one of your early points Shane was that that we must begin with an open mind and and in fact keep it and so I just wondered if you would like to give us a couple of sort of key points that you'd like to to finish up with and then I'll go through um the other panelists to see final comments from them. I think um and this is because of my research and and and what I do I think you have to look at a strength-based approach and and foster resilience in children and adolescents in this case but you also have to look at the the context at the structural issues that um at disadvantaged at cycles of um disadvantaged I think as well given rule and remote is that extra layer of disadvantage I think you need to commit to empower and be young um whether that's in the therapy room itself or just in general um we have to look at the broader stuff about reducing discrimination, reducing oppression, reducing racism and poverty in some in some parts. I think another another salient point that's coming up for me is you might have these battles with Jeremy feeling comfortable enough to talk in regards confidentiality but what might be the real issue is as he asks for his aunt to wait outside so his aunt knows something's happening but the salient issues for Jeremy might might be more about privacy than about confidentiality as a blanket concept so I think you know in a way if you understand that and check that with Jeremy it might spray up how you work as a collaborative screen. Thanks very much Shane. Now I'm mindful that I cut Scott off before when he was on the screen currently our video is frozen but I'm quite confident the sound's working so um Scott I wonder if there was a couple of um points that you would like to sort of make sure we go away with? Yeah from from my perspective um I agree with everything that's being said um in relation to the the level of or the importance of engagement with Jeremy it's so important that he just doesn't slip through the gates or just does not engage the big question for me is his age he's separated from his parents we really need to drill down and find out why that is and we also need to be careful and take into account that at some stage we're going to have to try and get a history and if it's from another state that's that very will be very problematic. The other issue is that I don't want to appear as though I'm 90 when we were talking about holistic care and bringing parties together for team conferences I spoke about you know the lack of GPs that are available I've been time poor because of the time of talking here I didn't get around to talking about well you know psychologists perhaps only have 10 sessions to work with people social workers may not get an invite or may not have fun to do that sort of thing OTs may get me out I think it's very problematic because all of the systems are so stretched and that is the reality but we're all I'm sure mindful of this and trying to work towards it that's all I could say. Scott I just think that's probably the critical point I mean we are talking about Jeremy and the issues around grief loss and trauma but it is extremely hard with our bits and pieces system with people working in private practice and public practice and some practitioners are located together and other people are trying to make a living out of Medicare and the medial health nurse incentive program and OTs and social workers often get forgotten and it's really difficult. The different funding models it just does not it just does not assist the willingness of all of the practitioners wanting to get together it impedes it in fact. Yeah but I guess the good thing about the discussion tonight is realising that if we keep Jeremy at the centre we can somehow find a way to make it worse. I think I'd like Penny to just give us your final thoughts following our discussion. Thanks Mary I agree obviously with everything that everyone else has said but I guess I think one of the things from the G point P point of view that happens all the time with patients not just adolescents but with all sorts of patients is not to miss the opportunity when someone presents with a medical condition they're concerned about to look at all the other aspects of their health and to go slowly engage them and then slowly work with them to achieve what they want. My second point is having seen a number of adolescents with sort of medically unexplained physical symptoms I think we need to be very careful not to over medicalise and refer them off here and there without carefully thinking about the impact that that has on their control over their own health and I agree with I just want to say something about Scott's point about the difficult with finding time. The thing I've found is that I like to put a fair amount of time in early on when I first meet someone so I'll see them quite regularly and quite often and try and have phone calls with other specialists that are or allied health that I'm going to refer to and I find that putting that time in earlier on that means I can fall back a little bit later on in terms of that valuable time. Thank you and the relationship with the the young person or the client is is strong and I know that they can come back to you. Yes. Thanks for that Penny. Now I've been rushing this through so I'm going to let Beverly have a little bit longer. Beverly you can have three minutes. Oh my goodness look I think this has been really important as a session because we haven't solved the mysteries there's a lot that we don't know that we need to know holding on with and being there for this young boy Jeremy is a really important thing. I think all of you have mentioned that he might be lost and lost. He's got a strong person in his aunt who's brought him along and had been able to let him speak privately. I think the comments about shame are true for many young boys particularly indigenous young boys as Shane mentioned and I think there's also the importance of not missing out on the physical health issue which has been his first card into this care system. I think too that we all have good intentions about keeping in touch and working collaboratively but what's said about the time demands is true so we have to make sure that there is someone who's going to be there across the time and this might well be the general practitioner who's likely to be there and hopefully will be able to see so many people change within the health care system so continually knowing someone you trust. I mean to go to a different doctor every time a different nursery time a different psychologist after a few sessions it might be very helpful to have a few sessions because if you built trust you want to be able to turn back to someone you know understand something about your problem so trying to have someone who's got a chance to offer some continuity at least the coming months until some of these things are sorted out a bit better will be really important and that person having been part of their responsibilities to have a continuity of links be it by email or whatever to keep all of us up to date about what can be most helpful and if we need to come into the picture. I think there's a great deal of goodwill and I think it's really really important as we can mobilise that I think when people see that they care about and when someone can show their kindness and concern makes a very big difference to feeling that you're worthwhile and to feeling that you might be able to trust this person and come back and see them again. I think every one of the panelists shown that that capacity they have and most professionals in this field do we don't often tune into it because we either stuck for time don't have a chance to spend more as Penny suggested or else we're driven by a risk averse culture which says we've got to fill in a form before we do anything else the most important thing to this young man will be someone who can meet his eyes he shows them and can hear his story and can act and make him feel at least that he wouldn't be afraid of coming back he wouldn't be ashamed of coming back need to carry a little bit of hope that he must have been there. Thanks so much Beverly I think that's a fantastic point to end on that that there it's about mobilising goodwill and building a relationship with this young person and that hopefully can lead us in hope. Yes and that someone's going to do something about the problem he expressed and the other problems that we believe and likely be crowding in these guys. And again there's lots of really lively discussion in the months to 587 participants but also about the the creating of this open space with Jeremy's questions and Jeremy's strengths can be drawn out and also there's a really interesting comment that often if he was attending school the person that he might actually be comfortable talking to might be somebody from school the councillor or guidance officer and I guess from what I'm imagining all of us would be happy to include that kind of person in we would consider that really important. So thank you so much to all of our panelists and thank you to all the participants for your contributions it's been very lively and I must admit I've been very hard to keep an eye everything so I apologise with your points haven't been raised with the panel. So I'd like to thank Shane for bringing us the psychologist perspective and also we've been really privileged to have your participation as an Indigenous man and to give us that perspective of how things might be for Jeremy and encouraging us to keep an open mind. I also found your distinction between privacy and confidentiality really helpful and then Scott I thank you very much for reminding us that we need to keep development in mind so that what he might be going through at his age and also things like the realities of you know legal issues and consent and cross-state borders and Penny I think you've reminded us of the really strategic position that GPs might have as being a continuous care provider in somebody's life over a long period but I think you've cautioned us about not over medicalising things and I'm appreciative that there are some general practitioners in the audience tonight and I guess it would be my wish that we could get this message out to all of the GPs in Australia to be keeping an open mind and not over medicalising things too early and that the relationship is really important and Beverly there's been very many comments in the chat box just appreciating your holistic view and your respect for all the professions with whom you work so thank you all very very much for your participation thanks to all our participants make sure that you complete the exit survey before you log out so after the session closes the exit survey is going to come up on your screen if when you complete that you will receive a certificate of attendance in about four or five weeks time and as I said we do listen to your feedback all of the resources mentioned tonight the slides and other resources that have come up will be sent to you via a link in the next couple of days. MHPN is hosting another webinar on the 25th of March and you can go and look at their website for that if you want to and that is on principles of collaboration so the actual nitty gritty issues around how we collaborate between sectors with all habits and pieces funding and so on