 Hello and welcome to this plenary hypothetical as part of the MHPN All Together Better Virtual Conference. It's fantastic to see so many of you logged on tonight and I'm thrilled that you've been able to join us. Before we start I'd like to acknowledge the traditional custodians of the lands across Australia upon which our panelists and our participants are located and I'd like to pay our respects to their elders past, present and emerging. The All Together Better Conference aims to explore the impact on our lives of the COVID pandemic and a succession of climate related natural disasters. And for this hypothetical tonight we've assembled a magnificent panel of experts who are going to help us explore these issues and explore the layered impacts on individuals, on families and on communities. I won't be introducing the panel individually so I really urge you to go to the conference website, have a look at their bios because they really are a stellar group. Over the next hour or so I'll be introducing various parts of the hypothetical and asking our panel to respond and as for you and as in real life our panelists are not aware of what's coming up and so they're going to have to think on their feet. I'm going to have to think on my feet as well. We're all keeping our fingers firmly crossed that the wheels don't fall off. If you're experiencing any technical difficulties you can post to the chat box and our tech people will get back to you straight away. Unfortunately we're not in a position to respond to any questions or comments regarding the content of tonight's hypothetical. What I'd like to do today as part of this hypothetical is to take you to a small town called Jamesville. Jamesville is a little rural community about three hours drive from the nearest city and like many rural communities it's a very close-knit community. A lot of life tends to revolve around key community hubs like the pub, the footy club, the rural fire station, the primary school and so on. Jamesville was deeply affected by the COVID pandemic. They had two particular ways, one in 2021, one in 2022 and several of the elderly members of the community perished as a result of those waves. But Jamesville has also experienced a number of really serious natural disasters. So two years ago they in 2021 they had a bad bush fire that didn't quite hit the town but it did destroy a lot of agricultural land nearby, a few houses on the very outskirts of town, a number of farm buildings, livestock were killed and so on, crops were damaged and a farm laborer, a man died as a result of those fires in 2021. A year later in 2022 Jamesville was hit by a very bad flood when the river burst its banks and water flowed down the main street and left in its path a trail of devastation, albeit not permanent damage but a terrible mess and took a long time to clear up. But more urgently for us tonight, only a few weeks ago at the end of February Jamesville was hit by a very bad bush fire. Basically the fire was was heading straight towards the town, it looked as though it was going to to actually destroy the whole town. People were told as they usually are in these situations to either leave now or stay, some decided to leave some decided to stay. When the fire hit the town it destroyed a number of houses, it destroyed or at least damaged the primary school and it looked as though the whole town was going to be destroyed but somewhat surprisingly and unbeknownst to anyone that it was going to happen, the wind suddenly changed direction and the fire moved away from town. But it was a very serious disaster as we said a number of houses were lost, livestock were lost, pets were lost, an elderly woman living in a house on her own on the edge of town perished when her property was destroyed and a young volunteer firefighter was very severely injured, severely burned, when she was caught when the fire changed direction and she couldn't get back to her truck or to her team. And so it's really this most recent disaster that the community is struggling to come to terms with now but on the back of all those other disasters. Rob Gordon, I'd like you to bring you in if I could. Rob, you're an expert in disaster recovery and you've been sent to Jamesville as part of the state disaster recovery plan. What are you finding in terms of the impact of this series of disasters on the community of Jamesville? Thanks Mark. Look what we're finding is the whole place is a buzz. There are people who were very threatened and traumatized. Some people who have had bad things happen to them, destroyed property and narrow escapes but there are a lot of other people who are carrying all the traumas from the previous events and so all that is being reactivated. So we're seeing a lot of emotion, a lot of anxiety but within that there is a core of people who are busily getting the whole environment organized and trying to create as clearly as they can an immediate response plan and a relief plan. So there are plans to open the hall and to have various groups providing services but there are people actually just taking initiatives in all directions just to do what they see as needed. Wonderful and I want to come back to you in just a minute and ask about what strategies you might be using but just for the moment I'd like to bring in Penny. Penny Burns, Penny you're a very experienced GP. You are the only GP in Jamesville which let's face it is an extremely tough job. Have you noticed any changes in your clinical practice over the last few years but particularly over the last few weeks in terms of the perhaps the numbers and the types of presentation that you're getting in your practice? So yes I have Mark over the last period of time I've been seeing families and people with lots of struggles ranging some people struggling other people sort of you know getting together and moving forward and trying to move on to a new life but during this last sort of a few weeks we've actually seen that all sit backwards very quickly. Our waiting room on the first morning was full of people waiting to get into the waiting room to see doctors. There was a lot of distress in the waiting room people saw that as a safe place there were people crying. Everyone was aware that people had died and everyone knew our little old lady Mrs Smith and so that was ripping through. We had staff members who were affected and one had to rush out as the fire was going through. There was distress and there was a lot of need for calming and so every patient we were seeing was taking longer and we were seeing a lot of physical effects as well so we were seeing both the psychosocial and the physical. And you raised a very interesting point there that you and indeed your staff that let's think about you for the moment you're not only the person trying to help the community recover but you are also part of the affected community. How important is it that you look after yourself at this time? It's really important but we're very very bad at doing that. I myself am really bad at doing that and we we will jump right in. So you know what happens to our community affects us personally and professionally but we will give our all and so I'm putting myself on 24 hour on call so that people can access me because there's no one else in town the nearest hospitals every several hours away I believe and I've got family at home that I'm really worried about so I'm frightened but I also want to be there I'm sort of driven and I feel responsible to be there for my patients. I said well I was going to say it's an extremely tough period isn't it? I'm sort of cautiously hopeful that by the end of our hypothetical you all have made links with some people who might be able to support you as well as the community. Thanks Penny. Andrew, Andrew Koo you're a very experienced psychiatrist long interest in the mental health effects of trauma and so on but also an interest in rural mental health and as part of the state disaster recovery plan you may be called on in the future to provide some assistance to the people of Jamesville. At this point given what you know are you expecting that there might be much in the way of diagnosable psychiatric conditions and we're going to see a kind of epidemic of diagnosable conditions? Well I think on the background mark of cumulative trauma traumatic circumstances over a period of time with local loss of life and it's usually very connected and that social connectedness is very important in rural communities as well as a general decreased access to general medical health care as well as mental health care that I think we could reasonably expect that there's going to be quite a notable increase in psychological distress that that Penny's seeing you know Ruinsen that that that we've already heard outlined previously. So I think in the context of this increase in general psychological distress and angst we could also expect that there'd be an increase in the clinically significant type presentations or diagnosable psychiatric conditions. But it's important perhaps to make that distinction I'm very glad that you did really that there might be a lot of distress that doesn't necessarily cross the line to to psychiatric disorder. We don't want to diagnose everybody. Absolutely and we often see in these situations this has kind of been referred to in a general sense but in a more sort of sort of scientific sense there's just as many people I guess are going to show this kind of post-traumatic growth and sort of start doing a lot of very strength based functional things moving forward as people that are going to kind of probably drop their bundles a bit. Fascinating I hope we get a chance to talk about post-traumatic growth but we'll see how the time goes. Camelia Wilkinson you are an education developmental psychologist you've been working with the education department in the broad region of which James Jamesville is a part on a project for the last couple of years looking at the impact of COVID and lockdowns on the well-being of children. Lockdowns finished a long while ago now they've been back at school are we still seeing the effects of that in Jamesville primary for example are we still feeling the effects of the lockdowns? Absolutely Mark. As the others have suggested there is a lot of distress with the latest events however there's compounded trauma indeed. There's been research from Melbourne University from Royal Children's Hospital from WA that shows that children have been affected highly by the COVID pandemic it has left a distinguishable mark on children. The disruption to education they increased anxiety and stress increased issues with mental health and depression the social isolation just to mention a few issues the children have been carrying all these worries and have left a mark and then if you put that in the context of what is recently happening in Jamesville there is also a doubling effect that is happening reverberating throughout the community. So in terms of what we're trying to look at with the department is how we can best support the children. Good I will come back to you and talk about that but yes that's interesting that you think they're still being affected in Jamesville primary we'll come back and talk more about that in a minute. Chris Hall you're an expert in loss and grief again you've been involved with the state disaster recovery plan allocated to assist Jamesville in its recovery. I want to talk to you a bit down the track on loss of loved ones and so on but at this point do you think that a loss and grief paradigm or loss and grief model has anything to offer the Jamesville community in a broader disaster recovery sense? It probably won't surprise you to say definitely and I want to put that in some kind of context so I think historically people have thought about grief in terms of a death related loss usually of kin or a family member and historically it's been a very individual kind of intracyclic focus much has changed in the last two decades we know that people that grief can occur really as a result of any significant loss whether that be a person a place a possession or even an idea even a sense of safety or order of predictability and so absolutely the differences in the way people negotiate and navigate their grief is also a point of both potentially sometimes conflict in communities as some people have a view that we get over these things very quickly when in fact we know that these losses continue to resonate over very long periods of time and I think the other thing is that often the way people define themselves as a grieving person and we saw this during the Black Saturday that even when a neighbor or somebody down the road had died they might not describe themselves as bereaved but in fact ah so again the way a community comes together to support itself and to co-create a new kind of meaning I think is a really important part of the grief experience. Sure sure and helping them to understand it from that perspective I'm sure we'll come back and talk about that more as well Kemi right you're an exercise physiologist with a particular interest in mental health you currently live in the city but you grew up in Jamesville we're born in the area grew up in Jamesville you know it very well you've still got holiday house there you know the footy club really well we call it the footy club it's actually the football cricket netball club but everyone calls it the footy club yeah um do you think that that a place like the footy club has anything to offer in terms of helping the community recovery? Absolutely I think it's a really vital considering it's a hub for where people you know meet and engage I think it can be really useful in terms of recovery both in the immediate sense and long term in creating you know a positive community environment it can also create really strong support systems and we can actually use physical activity or all those kinds of sporting clubs to really you know help manage some of the stress that the other presenters have talked about in the short term but also in the long term as well. Excellent I'm a little more skeptical but I shall come back to you later about that we'll talk about that down the track um thank you uh Kemi Neville Neville Goddard you are a you've been a volunteer firefighter for many years and much of that time you've been involved in peer support at the moment you are the peer support coordinator for the whole region of which Jamesville is just one one particular rural fire station um this this um team this rural fire service has been through a very tough time recently how do you think it might have affected them? Thanks Mark yeah I would expect a whole range of responses where we're talking about one group of people in the fire brigade but they're all all individuals they've all got different things going on in their lives some of them while they've been fighting the fire may have lost their own house there'll be a multitude of different responses within that brigade they and it may be very different now that it's visited their own home a lot of them identify very strongly with the role of firefighter and and that involves protecting life and property and if we look around town and there's property and life lost that can be devastating for someone who defines themselves as protecting their home their town their people from from fire and other disasters so yeah very very good point usually very impacts from this latest event um which people may have been holding themselves together through the others but this one can be different to all the others because it's visited our home exactly I take the point entirely I think it's a very important one it actually leads me nicely on to the next thing that I want to say because what I'd like to do now is to introduce you to Jimmy McCoy Jimmy is a very well respected character in Jamesville he's about 40 years he runs a small car mechanic business in town he's a very keen football player and he's the captain of the rural fire service um he's got 25 years experience as a volunteer firefighter under his belt um in fact I don't know if I should say this but the fact is that he is widely known as mad Jimmy and I emphasise that he's not known as mad Jimmy because of any question at all about his mental health on the contrary mad Jimmy is so called because he is tough he is extremely tough if ever there's a a a fight on the football field it's mad Jimmy that's straight in there to help his mates when he's doing his firework or going to a car accident or whatever it's always him leading from from the front he will always put himself in the most dangerous situation and the fact is that that um you know most people in the time but certainly the young people look up to mad Jimmy as being completely invincible and the fact is that he has you know he's been through all these events for many many years and never seems to have shown any kind of sign at all of of mental health problems he really is tough Jimmy is married he's been married for 15 years to Betty Betty is a childcare worker and they have two children they have a son Jason who is 12 years old so he's just started at the nearby high school but that's in another town he has to catch with us to go to this new high school so he started there only a matter of weeks ago really um and a daughter Alice Alice is 10 years old and uh she is still at Jamesville primary school Rob can I uh bring you back in I'd like to ask you in a minute whether you've got any reactions to to Jimmy there but before I do that let me ask you what kinds of things you might be doing to assist the community of of Jamesville in the in the overall community recovery um one of the really important things is to develop a community interface with the recovery systems and the formal systems um one of the difficulties is that people often just get straight about their physical recovery and don't actually participate in the broader activities of the whole community they can be quite isolated and we notice we noticed in Black Saturday they would often come in in the third and fourth year having uh really totally exhausted themselves and not availed themselves of any of the support services so we'd be wanting to I'd be wanting to access the various uh uh nodes of information like the GP and uh I certainly want to get alongside the footy club and help them understand the role they might play and uh I'd be wanting to have representatives of recovery uh registration and support psychological first aid anywhere where people gather even at the rubbish dump if people are taking the debris from their houses down there you'd want someone from the council who would be able to start networking because the international research shows uh uh quite clearly the most reliable predictor of the adequacy and speed of recovery is going to be what's called social capital or social networking and linkages so I'd be wanting to get straight into this as as actively as we could and that would mean also getting alongside people who are uh on adrenaline in hire rouser who are on about their business because uh arousal produces a kind of tunnel vision and people just get the bit between their teeth and they do their thing uh maybe not even understanding the the recovery system around so I'd be wanting to get meetings and bring these people together to give them roles and to help them uh see themselves all as part of a community based system because um presuming there's clearly a lot of um there's a lot of emotion going around within the community of all kinds isn't there and I I think the point you make is really important in terms of presumably preventing all that emotion having a destructive effect absolutely and uh you know what we know is that um organizational glitches bureaucratic insensitivity uh conflicts unavailability not being heard all create elevated arousal elevated emotion creates elevated arousal elevated arousal actually undermines the very cognitive skills you need which is stopping and being strategic and seeing the whole picture and prioritizing and and people get into this narrow focus of doing the most concrete thing that seems obvious and uh and then of course end up cutting across each other and creating conflict yeah yeah good all right thanks for that um can I just get you to comment very quickly since you've got the floor if I've got to ask you now we're going to be talking a lot about Jimmy as his hypothetical unfolds but do you have any initial reactions to to Jimmy's um you know I've met people like Jimmy and uh after Black Saturday there were Jimmy's who'd lost their family and uh everyone kept saying uh shouldn't we be doing something and they were running around helping and in one case that I know the man was not ready to ask for help until the third year and then he said uh I think I need some help and I think it's much better to for people to get alongside them and help them uh support them to do what they want to do in this short term rather than tell them what we think they need because Jimmy's going to need to experience some cracks before he's going to step out of mad Jimmy's role and being the the leader uh and it's very important that we that that there are networks and I think a good strategy is to identify people who can get alongside Jimmy and keep an eye on him and when he starts to drink too much or whatever they can start uh perhaps talking to him about what's available we'll see what happens with Jimmy in just a minute thanks thanks Rob um Camelia we've talked about the fact that um uh we've talked about the importance of hubs in the community and and we talked about the fact that the primary school has been damaged it was damaged in the floods and it was quite more severely damaged really in in the recent fires how important is that physical infrastructure to children so I'm thinking about Alice for example she's 10 years old with primary school do you think she's going to be affected by the fact that her school has been physically damaged I believe yes I believe so it is about social connectedness children connect when they go to school all the research I made referenced to earlier on that's what it shows COVID has left a mark on children because of the social isolation yes they connected online but it wasn't the same when you physically go to school and you interact with your peers and your teachers and other people that are within the school system it creates like a different world for children and that gives predictability and it gives them a sense of security when that is gone like in in the case of Jamesville with with the school being affected it will it has a distinct effect on children children struggle um to connect to their learning to connect their social peers yeah just taking that to the next step then you you have um your role has been expanded by the education department now and they want you to help Jamesville primary school through the recovery process just following on from that is there anything particular that you you are advising the primary school to be doing absolutely finding that place in a physical sense and maybe the talking to kemi about the footy club will be one thing I would suggest in organizing events or organizing opportunities for children to get together and meet not necessarily to learn I believe with so much trauma and so much going on in children's lives the learning will be very superficial but it's about giving them a sense of predictability and some sort of routine and doing things so that's what I would be suggesting that's what I suggested already um and we're just in the preliminary stages of developing an actual plan of how we'll put it together but that will be the first thing that I think it's essential excellent well let's ask kemi about it although I'm sure if we ask her whether physical activity would be helpful she'll say too much sport is barely enough but anyway let me ask you anyway kemi um camellia has has contacted you and said you know we'd like to organize some activities or particularly some physical physically based activities for the kids is that a good idea do you think that's going to help their psychological recovery absolutely I think it will I think um based on what camellia has said you know creating that sense of of um social connectedness and we know that in Australia you know sport is a huge part of building those types of relationships it's also something that they would have engaged in maybe prior to um the most recent natural disaster you know things might have started to come back to some sense of of their normalcy and then it's been taken away again so I think the sooner we can introduce those types of activities it's going to not only help the children but you know I think we're also acutely aware of people like jimmy you know they're thinking about their children or maybe what they're potentially missing out on so we're adding to their level of distress uh or that is potentially a heightened level of distress for people like jimmy because they are so concerned about about their children and the children of the community and wanting to stay and build the the community sense that they had when they were children and and potentially grew up in that area so that kind of social networking is very important what about the the um the physical aspect of exercise is that um helpful in recovery and burning up some energy yes yeah absolutely helpful in terms of managing levels of distress managing obviously any of their emotional or mental health um you know overall creating a good sense of well-being um is is really important and for school children particularly for children in in um Alice's age it's a really key time where they start to develop that love for exercise knowing how their body moves um you know really understanding uh movement itself and that has big implications for their future physical activity behaviour and also just management of symptoms and setting up really good healthy patterns um and physical health okay thanks um penny i'd like to bring you back in because um community and my guess is that everyone knows everybody else's business so you're seeing a patient one day and she says that she's really worried about betty about jimmy's wife betty um does this raise any issues for you in terms of sort of confidentiality confidentiality and boundaries and so on uh or would you feel comfortable just raising it with betty next time you see it um look it does raise issues and it depends what she said if um if she just mentions that she's um feeling uncomfortable um and doesn't go any further then that makes it a lot easier um if i see betty on a regular basis that makes it easier if betty comes in i can sort of gently um progress with her how she might be feeling um and and we do that all the time in general practice so i would see during this time i would also be out reaching patients that we thought were vulnerable as well so not just betty but other patients so our elderly people our people that we know that are more anxious originally and we'd also be out reaching to um patients with physical conditions so diabetes because they'd be deteriorating but absolutely there'd be no reason not to um but we do have to do it very carefully well you do raise it with betty and um she the floodgates open basically she gives you this litany of problems that she hasn't really told you about before that they're under a great deal of financial stress uh there's tension at home the kids are fighting she's worried about jimmy jimmy has become withdrawn she's really she really does seem to be at her wit's end um is there anything that you can offer her i mean you sell db you're up to your ears in in work you know is there anything you can do are you going to give us some medication or well not not initially by any chance um no look what i can give her is time and we found that in previous disasters that every consultation takes 10 15 minutes longer and so i would be able to give her time and listen listen to what her issues are what she's feeling some of them will be old issues that haven't been addressed that have been brought up by this distressed i could also normalize what's happening for her she's gone through this horrendous event this is making things more difficult to cope i could also help her understand how she might be able to move forward um in terms of general health and also in terms of um focusing also on what she has which is useful and i would probably want to get her some support if i was concerned about that i wouldn't go straight to medication by any means okay well something that you know but she hasn't really raised it is that her mother was um admitted to a nursing home at the beginning of the pandemic and a year ago beginning of 2022 uh the nursing home was hit with a blast of COVID and several residents died among them her mother uh in the months leading up to it people weren't she wasn't allowed to visit her mother and she knows her mother felt very lonely and abandoned do you think that there might be some grief issues to work through that um absolutely and having experience the same thing myself definitely um and i think a lot of people experience that and i think that was um one of the really difficult issues around COVID is that fracturing of the community and and increased isolation of those that were most vulnerable so absolutely i think that could be an issue you're very fortunate because you happen to have an expert in loss and grief as part of the state disaster recovery plan are you okay are you going to suggest that betty maybe gets in touch absolutely good well chris she does betty gives you a ring and says that her gp has asked her to ring you um loss of a loved one is you know it's always a difficult situation but are there factors in this case that make it more difficult for her to process that loss well there's no question and again we need to contextualize all these losses uh in the light of everything else that's taken place um certainly uh we know that deaths in aged care facilities in particular where there's not been an opportunity is to be present at the time of death to to um to be able to engage in perhaps funerals or other sorts of rituals have have been um deeply troubling but again we want to get a full picture um and i i tend to take a position of not knowing in relation to other people's experiences and you know for her to teach me what is is the most difficult aspect and i may be surprised by that but certainly uh there's an important part there of setting some context around um around those sorts of experiences of the loss i think often um and i haste to use the word normalizing but providing a kind of a framework for understanding the nature of those losses again her concerns might relate to the children how they've been managing that experience they might be relational difficulties people tend not just to come with a an experience of breathing um they come with a whole range of of other concerns as well quite quite and you mentioned the children there as it happens Jason and Alice were very close to their grandmother would you potentially have concerns about them not necessarily concerns um i think one of the the important messages is we need to overcome our desire to protect children the children in the absence of information will construct meaning and often uh that meaning can be unhelpful but i'd be wanting to know uh that somewhat of the nature of their relationship how they've managed that um we also know that children will often put their grief on hold until mom and dad are okay um and so we'd also be kind of wanting to know what they might have observed um in terms of their behavior their their adjustment again it depends on the nature of the death was it particularly sudden or unexpected had it been foreshadowed in some way what was the nature of that relationship hmm sure sure okay thanks um never all um the fly service as we've said in jamesville has been through a huge amount recently um what kind of programs have you put in place if any to to assist the team in recovery um yeah we would have been involved probably if we were invited we don't impose ourselves on people um uh we uh respond to requests to uh to work with brigades and that so there may have well have been some some assistance put in place if we go back a couple of years ago there were fires perhaps there might have been livestock lost and uh connections established with people uh i know that um uh it's only been the case over a number of years that uh the piece of put program does get involved in some of the broader local initiatives um but back to the firefighters themselves uh focusing on on on them as people as individuals as i said they won't all be responding the same to this sequence of events they will be affected differently some may be farmers who've lost livestock um some may be trades people um some may be professionals uh working perhaps at the the secondary school uh in the next town so that we've got a real mix of people here um and uh some of them may have sought assistance some of them may not um some of them may appear to be okay um but be diluting themselves and not okay but quite a lot of people who appear to be okay appear to be okay because they're actually okay they're they're very important we shouldn't judge them just because they've been through this because they're problems but let's talk about someone in particular uh Neville um you've known Jimmy for quite a while and he's not i'm not not suggesting he's falling apart but you've noticed some pretty significant changes he clearly has become more withdrawn he's he's started to drink more and so on um it's very hard to raise these issues sometimes especially with someone like Jimmy but often easier just to sit back and hope it gets better are you gonna you're gonna say anything to him uh what i would be it would depend how i as the the coordinator of peer support in the area have got to know Jimmy and and if i have over the years then then i could make use of that but it may well be that others are in a better position to interact with him people at Jimmy trusts and knows better um so well you do you do feel you're in in the position to talk to him so you do you do just ask him how he's traveling and um obviously he's pretty reluctant to say anything but gradually as he chacked him over a coffee a whole lot of stuff comes out and he does start to acknowledge the fact that he really isn't traveling very well that he's not sleeping well yet when he falls asleep he's getting nightmares um that that you know he he's he feels that he can't help and he can't help his family he can't even help himself so how can he help Betty and the children and so on he's really not in a very good place um what are you gonna do it's one of the things that that's hardest for firefighters to to deal with whether they're a firefighter on the truck or a captain uh there there's a heavy load that captains carry because they they send their people into danger and and you've explained that one of the firefighters has been injured um and the worst thing is is the sense of helplessness hopelessness and and adequacy that can be experienced when events like this happen um i think i'll be having a conversation along the lines of um about how firefighters love to help people but uh things can turn and that can be our time to receive help and and have some conversations along those lines to to work on opening Jimmy up to the possibility that yeah maybe it's maybe it's my turn to receive some help i'm the one who's been there on the football field in the in the fire brigade being there for everybody else but just to try to open up a bit of a chink to um get the possibility that well maybe it's my turn to be on the receiving end of some help and just see see where we can go with that sort of line of thinking okay so you've got a bit of a chink in there but not much more at the moment uh you know he's he's going to take a bit more working on i reckon and one of the issues for him is that he is absolutely terrified about confidentiality can you honestly put your hand on your heart and assure him that other people in the team won't know that you know that it will be kept confidential other people in the footy club won't hurt yep look it's an absolute cornerstone of what we do in peer support with confidentiality uh we we couldn't run this program without that it can be hard to gain someone's trust but it's such a fundamental plank of what we do that i'd be emphasizing that and and really that's where i would hope that over these years of involvement we've actually built up some credibility and and we're careful about that whole question and and we're very conscious that in a small community it's not just the simple black and white confidentiality of blabbing to somebody it's it's indicating that that you've been talking to somebody when you'd have no other reason to talk to them to them through the peer role so i would hope that over this last couple of years we've established that track record of confidentiality um because we have been around for a while fair enough okay good good um rob can i just bring you in quickly to comment on stuff that never was saying there and in fact we've been picking up um this idea that jimmy um that jimmy feels he's not really functioning in any kind of role he's he's not a good father he's not a good husband he's probably not doing very well at work he doesn't think he's a good good captain anymore of the fire service this loss of role is that important in helping to understand his um his mental health problems yes i think it's very important uh because probably that's the tip of the iceberg he probably had feelings of failure and helplessness during the fire particularly the the nightmares would indicate that to me and the withdrawal would suggest he's got such a lot on his mind and he doesn't want to be exposed to other people shame and that sort of thing and i can remember on one one community after black saturday who were very worried about their fire chief actually went to the trouble of organizing a whole evening meeting to talk about natural reactions basically just him because they knew that if they got the whole community to come and they all sort of shared their concerns and they set this up and he actually came along and he listened and i had a long talk with him afterwards and i think he went and got a bit of support i also wouldn't hurry it i'd wait really the time for him to come forward but one other thing i would do is i would uh see how we could offer him other forms of support i'm thinking of financial counselors for their financial problems and maybe support for the kids to sort of just give him a sense that he doesn't have to shoulder all of this sure okay good i'm not sure that he's ready to take that support yet but we can do our best to to offer it to him let's talk about another avenue of support kemi and i would like to apply the blowtorch now because um this is a rural footy club do you think that he's going to this is a place he's going to be comfortable talking about mental health problems is he going to get any support from his mates down the footy club realistically well i think it depends on what kind of level of support we're talking about are we are we talking about um you know the them being touch points for him you know that that regular check-in of people that can notice a series of change of behavior so that withdrawal and can really highlight maybe some concern are they people that he would have talked to about his problems or or um stresses in the past and then as um i think it was rob said um you know having people there for support in places where people would normally gather i think remove some of the barrier where he may be willing to go and talk to someone if you've got people around you that are all engaging as the perfect example before you know in um you know psychological first aid or at least talking about how to recover you know and in implementing some of those things then i think you know they are the right people to be to be monitoring how he's going and and really creating that sense of community i do admire your optimism but i can't help thinking that he's going to be pretty reluctant to tell his footy mates that he's uh he's got mental health problems but anyway i will learn that for a moment but let me just follow it on because i also have a hypothesis about um the the two children also play footy at the footy club um do you think that the attitudes of the older players for example about being tough and macho and and perhaps you know not canton and sing weakness for mental health issues do you think that filters down to these younger players as they're starting to play footy through the club absolutely i think if they have um you know particular perceptions i think given that he's a role model in the in the football club if he has that sort of perception of of you know he has to be tough then that that narrative will filter down into the younger players um and whilst he is a tough nut to crack um you know people often open up when they start to move their body and it isn't just about having a conversation you know as we start to get people to exercise and do physical activity often they'll start to talk about topics that they maybe wouldn't have talked about if they were just in a one-to-one seated um i guess scenario okay fair point fair point um penny let me bring you back in um betty has told you that she's worried about jimmy she said that he's um he's not sleeping he's irritable he's losing his cool he's shatting at the kids and so on it's very very unlike him he's drinking too much he's withdrawn it it's very very unlike him but he's a bloke and he doesn't go and see the gp very often it's extremely rare that you'll see jimmy and your surgery unless the something really bad uh is there anything that you might try to do to try and get would you even want to try and engage him um absolutely and and i would be very keen to be re-engaged with him and with the whole family um so i would still want to be seeing even i've sent betty off i'd want to be seeing her regularly and i'm then able to touch face with all the other members of the family but the thing with jim what we often do is we often use a physical um reason to come in so it might be um that betty can suggest that maybe he comes in has a different check up or he hasn't had his cholesterol done or needs his blood pressure done these are also really really important things because he may have he may actually have hypertension he may be at high risk of a stroke under these conditions these are things that we see following disasters so there's actual physical events that um we need to be cognizant of the work as well so i would use those as an excuse to bring it back in and then see if i can touch base with him as as a way in okay well there's a few of you sort of chipping away at jimmy there nevel's done a bit and uh and so on uh and and you do that as well and look there is a definition he is he is beginning to get to the point where he thinks he might discuss it um you're fortunate in having um an expert psychiatrist on tap uh as as a result of the state disaster recovery plan um are you going to contact contact andrew do you think yeah and look in the first instance i might actually just ring andrew and mention this mention jimmy and say what do you think you know he may not be ready to come and see you yet but i'm going to continue to follow him up with whatever excuse um for the results um if he is ready then that that's obviously an option but sometimes we hold patients for a while as gps and we see them several times and go through various stages before you actually get them referred off but absolutely i'd be on the phone you'd be on the phone to andrew what do you think andrew is that um would you be willing to provide that kind of what we call his secondary consultation to penny perhaps in the early stages of course i wouldn't and i'd be saying to penny that i love the way that you're approaching this and trying sort of spending time trying to build rapport uh which is so important to engage people in their own treatment he's not going to get better if he's if he's there under any kind of duress um whereas if he's engaged in his treatment no matter what's wrong with him whether it's hypertension or whether it's ptsd um his chances of getting better are significantly enhanced so i would say leave him with you build trust and and if penny builds trust penny might be the person that's going to be best for him he might like to see a psychiatrist that's a big step i think for someone that's someone like jimmy often i work with people like jimmy every day um and often they would prefer to be rolling up at the gp practice then rolling up to see the shrink well that's true so the idea of seeing a shrink scares the willies out of him at the same time there's a little part of him that would rather see a bloke to be quite honest and uh and he does a fantastic job with him um but he does get to the point of saying well you know i wouldn't mind having a chat to andrew um you're going to have to see him on zoom just you know a very very quick response to this uh we've all had to get used to doing telehealth and seeing patients on zoom a whole different board game are you okay with that comfortable with with doing assessments or treatment on zoom yeah uh yes i'm very comfortable with that it's something we've all had to get comfortable with as you say and in fact i've like a lot of my colleagues and and certainly a lot of allied health professionals that provide mental health uh support have i think been pleasantly surprised with um with how good it's been and how effective it's been and certainly it helps address a lot of access issues that help in terms of time as well as distance um so very happy i think it's much better than the phone because they can see you they can see how you respond importantly i can see their non-verbals as well as their verbals and it just allows just that one step better connection than than just talking on the phone so if he's happy with that i'm very happy with that and we'll see where it goes from me well i'm not sure that he's happy with it but he's willing so he comes along and you have a couple of sessions of of assessment and so on with the view to perhaps engaging him in treatment um i know it's difficult because you've only seen him a couple of times but have you got any ideas off the top of your head what your first priorities are going to be for him so the first thing i'm trying to do um is build a connection to to try and engage him in his treatment to try and build some kind of uh therapeutic rapport and trust in that that i might know what i'm talking about and one way really to do that is to to be able to talk with him about what he's going through and and demonstrate to him that i might be aware of some of the things that he's going through and be able to normalize a fair few of those things i think a really important thing is they say look it's it would be normal and having been through what you've been through over the last three few years but really having just had one of your own men critically injured in a town-based or community-based very traumatic event that will be normal that you're struggling at the moment and in fact if you weren't i'd be almost more concerned about you so let's hear you know why don't you let me know what's going on um here are some of the things that i might expect that you might be feeling in a time of psychological difficulty or distress things like sleep problems things like irritability and anger things like avoidance things like relationship difficulties things like um reactivity in the household increasing your use of alcohol you know getting a little bit of anxiety if the if the phone rings for the fire service again or if someone's trying to engage you from a professional point of view so just try to sort of build rapport that way he has all of those he has all of those um he's seeing a lot but there's a lot of people involved in this case now you know we've got Penny uh we've got Chris seeing the um seeing Betty perhaps we've got Chameleon looking after the kids we've got Neville involved um is there is that an issue that there's all these different people working on this case are you going to try and pull everybody together big job uh that can be an issue particularly if um if there's not a consistent message being delivered across the board uh and that can very much be got around by um appropriate communication between different treaters and often the hub for that isn't actually me often the hub for that is the very important gps that are just so good at that at just um brokeraging out and keeping on um on top of what's happening with different people uh within that family unit so I would be certainly communicating closely with Penny and if I felt there were specific things around certain issues involving others I'd be I'd be happy to call them or receive calls from them as well okay good all right well you see him for a few sessions you continue your assessment and eventually you come up with a formulation and you come up with a diagnostic picture where you think he's probably got PTSD with some associated depression and and substance abuse as well for some alcohol abuse but the good news is that he's engaged with you and it looks as though he's going to hang in there and and he's going to let you help him Chris if I could just bring you back in very quickly um Betty is still not traveling terribly well in the DSM 5 um albeit it's in the um conditions for further study we've got a new a new condition called um what is it prolonged complex bereavement disorder what we used to call complicated bereavement um you know is there a place for that is is that something that might help us better understand Betty's reaction well the latest TR version actually it has included prolonged grave disorder as a condition so that's moved from the conditions of interest um and it parallels also very closely the ICD diagnostic criteria for prolonged grief disorder so what we're looking at there is again a bereavement that's exactly lasted for at least 12 months uh six months in the case of children adolescents where there's really quite profound disability high levels of distress um and again we've now got some very effective treatments for prolonged grief disorder that have been uh uh trialed and are well established but so this yeah we're talking here about yeah probably less than 10 percent of the bereaved population and of those who have prolonged grief disorder only 20 percent just have prolonged grief disorder most also have either a major depressive disorder an anxiety disorder of PTSD so it's reasonably unusual to see somebody who just has uh prolonged grief disorder okay um so it is it sounds though it does have some validity some use in a clinical setting and we're not simply pathologizing normal grief which I suppose is what people are slightly concerned about that's right and there's been a lot of debate about that you know i'm actually quite comfortable that there is actually a very clear um proportion of people where something has derailed that very normal adaptive process of accommodation to a significant bereavement sure okay neville jimmy is very angry and uh he blames the rural fire service for his condition he's talking about um suing them for negligence for not providing a safe workplace are you going to encourage him or discourage him in that pathway uh i wouldn't be either encouraging or discouraging him i'd i'd be focusing on supporting him in his the circumstance that he finds himself in whether he sues the cfa or not there's is off to the side from me um uh and there may be other things that sit behind that desire for him to do that and uh he may be frustrated and angry and there may have been actual lack of support or there may have been perceptions of lack of support um but uh i'd i'd be focusing on being there for jimmy in the circumstances he finds himself in i certainly wouldn't be um encouraging him or discouraging him but supporting him through whatever course of action he follows okay so yeah we'll come back to that in just a second just very quickly um who rob just in a in a word or two would do you think it's good for jimmy to be pursuing league election look it may be very important for him to uh clear some some things in his own mind which he holds responsible but uh what i say to people who are considering this i say please remember that going to court is not necessarily a means of getting justice as you see it because it it's a machinery for administering the law and the people who have the cleverest lawyers often win the case so i'd say by all means take legal action if you feel that's justified but don't pin your recovery on that your emotional recovery is quite a separate thing you may or may not get satisfaction for court but don't make your emotional recovery depend on it yeah i'd say otherwise it's probably not going to be good for your health sure um andrew just very quickly you're actually seeing jimmy um very quickly do you have a view on on whether this is a good idea or a bad idea so i would be saying to him something pretty similar to what rock said um i would also be balancing that with uh with evidence from from all the studies that have been done around the world that compensation or looking for compensation or compensation issues tend to worsen the prognosis so in other words your outcome will be affected problem almost certainly in a negative way by this and there are a lot of reasons for this um but also will probably prolong disability for you these processes never happen quickly it should just like you know if you're looking to address a situation with a specific um treatment if you like you always got to look at pros and cons so you've got to look at um what's its therapeutic value versus what's its side effects or adverse outcomes adverse effects and and really in many of these work related or compensated compensation related cases um you know that ultimately the outcome is worse for the person than it than it would have been if they just try to let it go through other other surface yeah well that's all very well for you to say andrew he has been chatting with the plaintive lawyers and the lawyers are geeing him up they reckon he's really got a good case here but you might be interested never know that the lawyers think that um that that the central plank the central plank of the rural fire services mental health response is the peer support program so these plaintive lawyers are geeing jimmy up to say you should make the peer support program the central target of your claim do you have any reactions to that uh i i assume that that's that's implying in in in a negative that there wasn't enough peer support provider i'm not i'm not quite sure how that all all fits together what he's saying is he didn't do the job it didn't stop him from getting ptsd right okay yeah um uh not something i've encountered um and the i'm not sort of talking back to something andrew said before about that uh the importance of consistency of messaging and and normalizing and there would have been a consistency there because that's a certainly part a key part of what we would have been doing is is normalizing for for jimmy that the responses he's experiencing are um a normal response to the very abnormal sequence of events that's occurred there um so let me let me just put a bit more pressure on um yeah if he does proceed and we don't know yet whether he's going to but if he does proceed almost certainly you'll be called to give evidence you're that you're the coordinator of our region um just in broad terms do you think that you would be um giving evidence to suggest that the rural fire service has failed and it's duty of care to jimmy or would you be saying that jimmy should have taken more responsibility for his own mental health yeah i'd be probably ramping things up a few few few levels above my volunteer pay grade to seek advice on that good good good i think it's actually yeah yeah and and and i would anticipate that that in the fire service that i'm part of that there there would be support um for me in my role and and and jimmy is still entitled to peer support in in his role um and we would be doing the best there it may test the relationships but um there it is and when lawyers get muddled up in things um it can get very tangled and twisted well that's right we shall see what happens jimmy is still considering his options as i say he's getting conflicting advice from people like andrew and uh and so on and his lawyers on the other hand say come on you could make substantial amount of money out of this jimmy he's considering he's he's he's mulling it over so so we shall see camellia yes you um asked to provide a bit of support to the high school in the next town which is where jason goes and they've asked you to see jason have a chat to him he's um he's not traveling very well either he's he says that things are very tough at home dad's really difficult to get on with and so on um he's having trouble settling into the new school and so on so these are all things that you'd kind of expect but then a few sessions in once he trusts you out to the blue he admits to you that he's having sexual thoughts about other boys in the school how are you going to react to that or what are you going to suggest for this young man i will just probably allow jason to talk to me about what those thoughts are at the moment they're just thoughts and it is not uncommon for children at that age to actually really try to work out their sense of identity and where they fit um so i will just provide the space for jason to continue to feel safe in trying to bring out whatever is coming up for him it's interesting that you use the phrase there to feel safe because if i can bring kemi in again um jason tells camellia that he doesn't feel safe in the football club in the footy club terms like gay and faggot are used as insults there are constant jokes about homosexuality uh he's probably justified in feeling a bit unsafe in the footy club isn't he as far as i know we've got no openly gay afl players despite the size of the league we've got one or two nrl players is he justified in feeling a bit frightened about the fact that others might find out absolutely he's justified in in feeling you know that it's not a safe place and you know uh that is true for not just him but lots of a lots of people that grow up in in potentially rural towns or in this um in sporting clubs that have i guess maybe a very traditional sense or um you know in the club and i think he's completely justified um how we change that is another question altogether ah pity because that was my next question so the footy club kind of they they realize that they've got a bit of a problem with the culture here and so they ask them they're asking whether you would be willing to come in and do some work with the club around culture which might involve mental health it might also involve um attitudes to issues around gender identity or whatever um is that would you be willing to do that i don't know that i would be the best person to do all of that i could certainly facilitate it as part of my role within the football club but i think that there are other people that have skill sets particularly around that messaging that we could bring in to be involved in the creation of those programs i wouldn't see it as as as my role specifically as an exercise physiologist in terms of creating values and and um creating a safe space there's definitely ways that we could do that and help participants to come up with what they would envision a safe exercise environment would be and try and influence it that way as another way within my own scope do as a matter of interest do you think it would work it's hard i think in in the ideal world uh you know it's great to say that it's really inclusive but as you pointed out mark you know there aren't any openly gay um uh or anyone that identifies as maybe gender diverse in our current sporting in our national sport um so i think it is hard and i don't think it's going to happen overnight if if at all mm yep okay all right thanks for that um andrew back to you in your discussions with jimmy he admits that from time to time he thinks that life is not worth living it's not too surprising but he also says that he thinks that betty and the children would be devastated if he did any harm to himself and so he says sometimes i think about just taking them with me and as soon as he says that he says oh but of course i wouldn't do it um what are you gonna do you know act on that is that is that a concern is there what what are your options there okay so when well first of all i need to assess this is questions around risks so i need to assess his first of all his risk to himself and then his risk to those around him his loved ones so and the way we tend to do that is we assess how much they're thinking about it how much they're preoccupied by the frequency and intensity of those thoughts then we ask them about have they got do they get times where they feel a strong urge to to carry out or to plan some of those things so you know have they got a are they are they planning ways in which that would happen or have they thought about ways they would make that happen then have they engaged in any behaviors to access means by which to carry that out and all of this needs to be based on a knowledge of his past history in terms of his if he's ever had these thoughts before and if he's ever done anything with regards to risk to himself and risk to others so i'd be interested in terms of we know that in rural communities and and particularly in rural communities where there's been cumulative trauma or increased angst that there's increased rates of domestic violence so i'd certainly want to see if i could find out through collateral sources or through him if this has been an issue but i wouldn't be acting on it to answer your question directly i wouldn't be acting on it straight away i wouldn't be you know ringing the police and and warning all his family straight away i think that we need to engage in some kind of dialogue and i need to flesh it out more perhaps you might talk to penny penny you have had some concerns for a while about jimmy and domestic violence there there hasn't been as far as you know any physical violence but you get a clear picture from betty about an escalating level of verbal aggression um and it crosses your mind and when you talk to um andrew you know it sort of adds another piece of the jigsaw puzzle what about you do you think you would want to act on it um look i really agree with andrew in that i would um you know if i had the opportunity to talk to i'd want to know more about it flesh it out more i'm seeing betty regularly so i'd probably want to flesh it out a bit with her as well um i would um you know in the background while this is all going on i'm also concerned about the daughter who's not yet had much help so no one's seeing her but yeah look i think i would want to consider it very seriously and i'd want to um hopefully continue to touch base with him but i wouldn't be making any calls as long as i was happy with um the conversation that andrew had and that i'd had with him around the fact that he what you know was um probably unlikely to do it the thing i would also ask is you know what's stopping him from doing it you know or what's stopping him from considering that you know and often people say my children i'd never do it because of my children so i think that's also useful sure sure although in his case he's talking about taking the children with him but still so what we'll do perhaps in some some watchful waiting we'll keep a close on him as andrew says we'll do a very detailed um assessment about about the risk and so on so that we can come to some kind of um some kind of judgment all right well um i'm afraid that our time has run out and we need to um draw this hypothetical uh to a close i'm pleased to say that things are improving in jamesville um the the community is showing some good recovery with the help of robin and various others the um the mccoy family's doing relatively well they've got lots of support from various people in the community things are beginning to settle the children are settling and so on so things are looking pretty good jimmy is slowly improving but he's got some pretty serious problems um he's by no means completely recovered he's still we definitely meet criteria for diagnosis of ptsd uh as we heard he's still considering the possibility of launching a legal action against the royal fire service for negligence but while he's considering this he um he strolls into town one day and he goes into the news agents and completely on a whim because he's never done this before he buys a midweek powerball lottery ticket with a jackpot 10 10 million dollar prize and amazingly he wins the jackpot allowing us to answer that age old question will a large amount of money really cure ptsd okay well look as we as we leave jamesville and the mccoy's i would like you to metaphorically join me in thanking our magnificent panel um rob gordon uh pennie burns andrew coup camellia wilkinson uh chris hall kemi rite and neville goddard thank you so much to all of you i can hear the applause resounding around australia from here i'd like to say thank you very much to mhpn for organizing it and indeed organizing the whole conference and thank you very much to jt productions for the tech side and most importantly thank you very much to you all to our participants uh for joining us tonight um i hope that you found it valuable i hope you find it useful and i hope also that you enjoy the rest of the conference because there's some amazing stuff in the program and i'd particularly like to draw your attention to the plenary session tomorrow night at six o'clock on wednesday wednesday 29 which is going to be looking at the nexus between mental health and climate change taking a deeper dive to some of the stuff that we've looked at tonight please um stay online for a minute and complete the evaluation if you could and and when mhpn send you one for the whole conference do that too i know it's a pain to fill in evaluations but it's really important for us so if you could do that we'd be extremely grateful but at this point again i'd like to say thanks very much to everybody i've enjoyed it i hope you have too thanks very much and goodbye to all