 Good evening, everybody, and welcome to this webinar. We have four over 1,000 people from all over Australia and all parts of Australia as well, rural and metropolitan. So it's wonderful to see you there. Mental Health Professionals Network was just to acknowledge the traditional custodians at the land across Australia on whom which our webinar presented and participants are located. We wish to pay respect to the elders past, present, and future for the memories, the traditions, the culture and hopes of Indigenous Australia. I'll start off just by introducing myself and I'll introduce our presenters. I'm a facilitator for this evening. I'm a social worker and psychologist in private practice in mental health with children and young people. And I've done the number of the webinars which are always extremely interesting. You saw the bio of the panelists. So I just want to introduce them face to face. First of all, I'd like to introduce Dr Conrad Kingrew, a Queensland-based dental practitioner. Conrad, you've worked in a rural area and what services do you find existing rural areas for people who are experiencing loss and grief? We certainly do struggle up here with access to psychiatrists. We have a lot of dependents on our visiting psychologists. We're also fortunate enough to have access to more and more online support programs as well these days. So there's a lot there which hopefully is giving us better hope for the future. But no doubt, at the end of the day, there's a general practitioner in rural areas. Thank you. The next person I'd like to introduce is Professor Kate Wilhelm. We don't have Kate on camera. There's a technical hit here. I'll introduce you, Kate. This is Kate, a psychiatrist in the South Wales. She's the Clinical Director of Consultation and Liaison Psychiatry and Research Director of Faces in the Street, St Vincent's Urban Mental Health and Well-Being Research Institute at St Vincent's in Sydney. She is a Conjoint Professor in Psychiatry at the University of New South Wales and a Processorial Fellow at the Backdog Institute. I want to have you with us today, although we can't see you at the moment anyway. Thank you, and I'm really sorry to hold you up with trying to get online with this... No, no worries at all. We're rocking along now. I just had something I thought of asking you about, actually, given your experience in this area. Any comment you must have briefing on the association between complicated grief and physical health? Oh, that's not a brief one, but it will come up in my talk. All right, we'll leave it to end. We'll leave it to end. Next, but not least, Kate. I'd now like to introduce Greg Roberts, who's a Practicing Social Worker with 19 years' experience in working in the health and community services sector. And in 2001, he began to specialise in the field of grief, loss and trauma. Greg, I understand that you have just completed your PhD. What was your research topic about? Hi, thanks, Vicky. My research topic was on the spontaneous creative activities that Barry Parrance engaged with, particularly interested in the things that people did in response to their grief and loss. Very interesting. Which that was useful to them. Very interesting and unusual topic, yeah. No, it was interesting research to engage with the participants. Definitely, I imagine. Oh, thank you very much. And last, and not least, I'd like to welcome Associate Professor Moira O'Connor, Moira is a senior research fellow in the School of Psychology and Speech Pathology at Curtin in Perth. And Moira's program of research is applied and community-based, with a focus on health and well-being, and it's a psychological aspect of cancer and palliative care. And Moira, I just wondered if you said any comment about... I mean, from reading certain of the results material, I understand our thinking has changed about responding to grief reactions or how they impact on people. What would be a noticeable change that you've observed in your research experience about grief reactions and how they're perceived now? You mean in terms of the theoretical or in terms of how people react in terms of their grief, which sign... What? You're asking, sorry. Yeah, how people respond, yes. Well, people respond in unique ways, and one of the things about grief is that they are the multibariate responses and people tend to move forward, so restoration, but they also look backwards and oscillate between the two. Most people navigate the middle path, but we're going to be talking tonight about people who perhaps concentrate on either end of the hospital. Thank you very much, Moira. Well, thank you to our presenters for introducing themselves. Here we are. So, just a brief round-all for this evening. So, everybody can see what we're saying on the chat room. And, yes, wait until then to complete the exit survey, which will appear. And if you don't like the chat box, you can minimize it by clicking the down arrow. Just take note of that if you don't want to look at the chat with a bit distracting. There are learning outcomes describing the difference between complicated grief and depression, implementing key principles of providing an integrated approach in the early identification, and what a challenge of tips and strategies to provide a collaborative response to assist people who are experiencing complicated grief. Now, before we move on to Conrad's PowerPoint presentation about his response, just a few words to remind us about the case. Dorothy is 55-year-old woman. Her husband was 30 years back, seven years ago. She has no history of depression, but she's having disability coping after death. She hasn't wanted to participate in activities as she used to do with Arthur, such as fishing and camping. She goes over that day that Arthur died and feels responsible for not calling an ambulance. She's sometimes inconsolable, especially around universities such as birthdays and Christmas, and life isn't enjoyable. And often calls her daughter crying and saying she doesn't want to be here anymore because it's just not the same with our Arthur. So Conrad, thank you. Would you like to do your presentation? Indeed, Vicki. So as a general practitioner, and I know that these are sentiments that all of my colleagues online who are general practitioners are going to share as well, but this certainly hits us pretty hard. We would assume that Dorothy is one of our regular patients. We've probably been seeing her, you know, a couple of times a year at least, statistics would suggest that it's at least 1.5 times per year over several years. And so there's every likelihood that we've actually watched her through the progression of this. In fact, there's a very high chance that we were asked as general practitioner as well that we sadly passed away. So just to recap on the events that happened with Arthur, if anyone's not familiar with that, the case study was that they had been together, happily married, they'd raised their children. But when Arthur was very young, he was diagnosed with a valve disorder which required surgery. And now subsequently, seven years ago, he had a sudden cardiac event and passed away. And so my immediate concern there as a general practitioner dealing with Dorothy's scenario now is that this really isn't a normal progression for her to go through. We are certainly familiar with what grief is and we'd all acknowledge this isn't really what we think grief would be after seven years. So you do start putting up a little bit of a retrospective analysis on what actually has been going on over all this time. And so when we're actually talking to Dorothy or in fact even talking to her daughter who is obviously very concerned about mum, we start being a little bit mindful that there's some issues about guilt that's going on here as well. We've already seen in the case study that Dorothy is very concerned about why didn't she ring the ambulance? We already know that she wasn't going to drive fast to the hospital because she was worried about speed. And so you're worrying that there's already going to be some degree of guilt which is happening there and is becoming quite pathological for Dorothy. My concern then also is that we've been watching her for seven years. Do we then feel that we share some of that guilt? Do we then take some of that on board? We have to be very careful to not lay any guilt or any blame for this as well. Poor Dorothy is already kicking herself that she didn't ring the ambulance at the time. And certainly we might have that response of well maybe you should have rang the ambulance at the time. That's when you start coming into the really dangerous areas of the therapeutic relationship and I hope that many of my colleagues are familiar with concepts like transference and counter-transference. If we are actually imposing on Dorothy, well yeah, actually that's what you should have done. This never would have been the case. Then we might start seeing that actually that's a transference and that's really not helpful to it at all. And by the same token is Dorothy actually now starting to see in us that we should have picked something up as the general practitioner. That maybe we should have picked something up earlier and that we need to take on some of that lack as well. So whilst we're trying to make sure that we're there and we're providing help for Dorothy and that we're giving her a great supporting therapeutic relationship which we all wish that we can nurture for our patients, we always just watch out for those pamper issues that might be creeping in there as well. Now of course another part of the issue that happens with Dorothy is that we've been watching her evolve through another chronic disease over this period of time. And so we know that something like rheumatoid arthritis, that on its own is associated with disability, with chronic pain, with reduction in independence. And we might actually have been quite tempted to ascribe some of those symptoms that we now look back at and say well actually maybe that's more significant of depression. But we were actually thinking maybe that had more to do with rheumatoid arthritis. There's some concerns there as well that James needed to build on with time. But we have that wonderful unique situation that the general practitioner has, is that we know Dorothy, we know what her usual functioning level is like. She knows us, she trusts us. And we hope that her daughter also has that trust and faith in her as well and that's a sacred privilege which we as general practitioners hold dear. But I also think that that's something that you can't see the wood for the trees that sometimes it can be very difficult to see that actually there have been an accumulation of subtle changes which may have been happening in Dorothy's mood over a long period of time that we were allergic to. So it's been highly possible that we just weren't really suspecting a major depressive disorder or adjustment disorder at the time. And it's not really until now that we hear Dorothy's daughter that she just doesn't want to be here anymore that we actually really have to sit up and pay attention and look at what's actually going on. So although there might have been a significant increase in the number of patients and others in her regardless of at this point in time, we definitely preserve that sacred role of the general practitioner in remaining central to the ongoing care and coordination which Dorothy's going to need over a long period of time. So we're just going to move on a little bit to what are some of those practicalities of care that we look for with her. And one of them is that a very important tool which is available to us as general practitioners now is the general practice mental health care plan. Now it certainly has gone through some changes over the years and the access issues have gone up and down. But there is no doubt that the current item descriptors, Dorothy would be eligible for one of these items. So if you do have your mental health skills training level one, you would be eligible to build those as a 2715 or 2717. And if you don't have your mental health skills training which I'm sure there's not many of our participants who don't, then that's the MBIs items 2700 and 2711. Now as we mentioned earlier, grief on its own is actually a natural part of life and we shouldn't really be pathologizing that and saying that that's a disorder. But this is now moving on to a lot more than just a simple grief reaction. So whether it gets called an adjustment disorder or a recurrent depressive disorder, both of those are significant mental illness diagnoses. And although we might not as general practitioners be familiar with all of the garage of assessment tools that are at the hands of the psychologist, those that we really are very familiar with, the Kessler 10 distress sales or the stats score would both be completely appropriate for us to use in our initial assessment for her. But if there are other tools which you're comfortable with and proficient with in your daily practice, by all means go for it and use them. But whatever we do in our assessment of Dorothy, this flag that she just doesn't want to be here anymore, we can't brush that off. You can't hear something like that. So we do have to formally assess what actually is the suicidality risk which we're facing. We have to ask about intent. Are there access to means? And so that might be as simple as the prescription medications. Have there actually been prior attempts or attempts that have been there? And what sort of support does Dorothy have in place in terms of this actually coming to a potentiality? And it might be that if you're actually scared to some extent that Dorothy presents a serious suicide risk or harm to herself or others, you really do need to be familiar with the legislation in your own state because I know that here in Queensland she certainly might be eligible or might be required to be put under an involuntary mental health assessment and transferred for psychiatric care at that stage. So as the GP, what do we do now? We're dealing with her in front of us at this point in time, obviously at a crisis moment. So we have to think about pharmacotherapy going to be appropriate for her. And I would have to say that I'm very cautious about getting her off with plebular acetylidics in such a state. And whilst it might be appropriate that antidepressant medications such as our selected serotonin reuptake inhibitors might be appropriate for her we acknowledge they take time to have a therapeutic effect and it really seems reluctant to depend on that to be our sole intervention at this stage in time. I would definitely be looking at psychologist referral for Dorothy. I think there's a lot there which she's going to benefit from but it might actually be that at this point in time whilst she's acutely distressed that might not be the best way to go particularly if we are looking at a bit of a waiting time to get in to see somebody up here. Of course we also have some wonderful online resources which might be great for her to use. And Black Dog Institute, Beyond Blue, Lifeline, eHealth, a whole lot of barrages are great to use. But I think Vicki at this point in time I'm going to have to acknowledge that psychiatrists input might be completely appropriate for Dorothy and I'll be looking to involve one of my specialist colleagues for her at this point in time. The decision that I would need to make in conjunction with Dorothy and her daughter is that something which we need to look at as an inpatient admission? Or could she actually go for an outpatient appointment? And whilst I'm hopeful that she's going to comply with my request for a voluntary assessment, that means that Dorothy is available if she needs to go as an involuntary patient. So I'm happy to hand it back to you on that one Vicki. Thank you. Thank you very much Conrad. Now I'd like to introduce Kay, Professor Kay Wilhelm for her presentation and I will be clicking the slides for Kay on your instruction Kay when you want to go to the next one. Okay, thank you. Well I do think a psychiatrist has something to add at this point I have to say. And just looking at Dorothy's histories there are some gaps that I'd like to fill in and I'm assuming that I know the GP reasonably well but I haven't met Dorothy before because she's got no past mental health history. So I'd want to know a bit about her personality style in general. I mean is she somebody who has depended on her husband for her identity even though she's had a wonderful marriage it could well be that without him around it's been very difficult. What was the marriage like over time? I know she said it was great but particularly before he died one of the reasons for complication grief is if say they're in the middle of an argument and she kind of wished he was dead at that point and then this happened. So I'd like to know a little bit more about what was going on just before he died as well as after. And then there's the issue of her health. Whether she's had any previous health problems she's said to have rheumatoid arthritis and I would check with the GP whether that's a definite diagnosis but there is definitely a link between autoimmune disease and depression. It can be the straight effects of having an autoimmune disease and having an inflammatory process going on but also in people of Dorothy's age you can get something called cerebral vasculitis which can cause ongoing depression in its own right and if she's been on steroids because they also can cause precipitated depressive episodes. I'd want to know about the family history of depression and bipolar disorder and I'd want to know a bit more about what she's actually been doing but I'd be taking great note of the fact that the GP and the daughter who know Dorothy are both concerned. Next slide. So I would be interested in which trajectory is she on. One would be that she initially did well after her death and by doing well she was appropriately grieving her husband but seemed to be getting on top of it and then later developed depressive symptoms or whether she's been depressed all along since he died and that might have more to do with sort of adjustment rather than a discrete episode or whether she says she's been depressed all of her life and now things have just got worse which would indicate to me the possibility of more of a personality style. Next one. Next. And one of the things that I use is what I call a timeline where I just go through and look at the important events on her life. I'd marry up her medical history and some other issues which I thought were important. I find you can just do that by dropping a line down the middle of a page and doing it with two columns but I find that a nice way of trying to work out which what led to what. I've had lived with this one and said that she remembered she had postnatal depression and that now a friend of hers has died. I've just put those in as possible thing but that's just to give an idea of a timeline. Can I go on to the next one? Also on the Black Dog Institute website there is this form which can be used to try and put all the factors together on to one which people can find very helpful about what might have led to what and that's got also room for positive factors and what's the personal meaning of this to the person. So that can be a very useful tool and you can download that from the Black Dog website next. But from a psychiatry point of view the important things which would tell me whether this is a clinical depression would be as opposed to grief would be whether there's a change in her self-esteem and she's become much more self-critical and grieving along with having a depressed mood. Features like insomnia, fatigue, anxiety are more non-specific and don't tell me very much but I'll of course note them but the other really important items looking for a more what I'm calling a melancholic depression would be items like a lot of rumination, hopelessness, diurnal variation, mood variation feeling worse in the morning better as the day goes on and change in her cognitive pattern whether she's actually appears to be not functioning cognitively as well. I'd also be very interested in her history not only a panic and previous depression but a vascular disease, hypertension, diabetes and cancer. And I'd be extremely noteful if both the GP and the daughter said she was much more agitated because that can actually make one think of psychosis as well. Next one. Now this is something that older people get it's called a structural melancholia. It's often associated with vascular disease and with Dorothy this would be something I'd be trying to rule out because if you've got this there's no point in sending her off for grief counseling because she's in another place and she becomes a suicide risk. But this is an older people where they've got some vascular disease, they've got changes on their white matter hyper-intensities and these lead to depression particularly in the if they also have an enormous like rheumatoid arthritis or steroids any of those things. So I'd be very interested to know whether she's I'd be thinking about whether she's got this structural melancholic because that really needs to be ruled out before you could do anything else and people need to have antidepressants if they have got that. That is not the I wouldn't necessarily expect she would have that but it needs to be ruled out. Next one. Next slide. Hello. Conrad's mentioned a little bit about suicide risk. I'd be wanting to know if she's been using alcohol whether she smokes. People who smoke over 25 cigarettes a day have four times the rate of suicidal ideation whether she's using analgesics or sedatives because obviously these can make you depressed in their own right and can also have access. The previous history of depression we've mentioned of suicidality what's the relationship between the grief, possible depression and the ideas which led to which. What to live for, the plans have been mentioned. Who can she talk to and how concerned is Dorothy herself? Next one. I don't know if you can read this very easily. What I'm saying is I think there are three possible trajectories for Dorothy which is not clear from the from the story. One is that she was originally okay managing her grief has had a discrete episode which may be related to some of those factors that I mentioned and that needs to be then treated and that maybe with cognitive behaviour therapy, maybe with antidepressant depends on the character of the depression before she goes off to have the grief counselling because if she's got that going on she won't be able to attend the grief counselling and she will overvalue her place and how guilty she is etc. The next one is that there's been this slow steady burn of grief throughout and she's lost her roles, she's lost her identity and that's where I think grief counselling would come in first and it becomes the paramount thing and you'd just be keeping a watching brief to make sure she didn't become depressed. The third one where she says I've been depressed for as long as I can remember would point more to me that she's got a personality style, personality disorder and the grief is just one more thing on top of other issues in her life and grief counselling is still appropriate but you would need to factor in the use would arise that weren't obvious at the start that may be part of what's been leading to that. I'm going to leave it there and thank you and sorry I can't see you. Thank you very much Kay. We'll move on now to Greg Roberts and his responses. Thanks Vicki. So from my perspective if we were thinking about whether Dorothy might be able to be referred from a GP under a mental health care plan I'd be asking the question based on what we know is does Dorothy have a chronic adjustment disorder as far as a category that could be used for a mental health care plan. So I'm not necessarily saying that she does that that question would come up. So basically what we're seeing is that Dorothy's having difficulty in adjusting to the loss of Arthur who's been her partner and husband for 30 years. So I think it's quite significant that someone has been together for 30 years and even though it's 7 years it's somewhat understandable that Dorothy might be having some difficulty adjusting to that given they seem so entwined in their lives. There is also the factor that I'd be wanting to investigate the fact that she has survived for 7 years seemingly without much intervention and so there's something in that that may suggest that there's a certain level of resilience there in Dorothy. She somehow survived for those 7 years. And if we were looking at trying to assist Dorothy we'd look at trying to help her perhaps move through counseling from having this concrete living attachment to Arthur and looking at ways that she might develop some symbolic attachment to Arthur as well as adding in options for things that might help elevate her mood strategies for self soothing and things like that. And basically if we're working on the idea of continuing bonds this idea of helping Dorothy manage a changed relationship to Arthur and I see that as a key thing. If we're looking at whether this is depression or complicated grief that and a really simple way for me of thinking about that is that depression tends to be a more generalized lowered mood that impairs the person's daily functioning. Complicated grief or what we seem to refer to these days it'll probably change again but currently prolonged grief disorder is this idea of a person who has intrusive unabated thoughts of the person who's died that impairs the person's daily functioning and affects their mood. But we currently don't have a category in the DSM and so possibly the closest we get is an adjustment disorder. So adjustment disorder is where there's a heightened stress reaction to a change or perhaps a loss that's brought a change in mood which could be depression, anxiety a combination of the two and it affects the person's daily life and that potentially could be something that fits for Dorothy. So as far as working with her obviously as Conrad's talked about and Kay's talked about a really thorough assessment and what I'd emphasize there is that it's useful in my experience to do some formal assessments with some of these tools that I've got here on the slides. So K10, PHQ9 I personally find the WEMWIB is quite useful, the Warwick Edinburgh Mental Wellbeing Scale is quite useful. We do have the inventory of complicated tools as well that can be used but I think for me also not forgetting the informal which is hearing Dorothy's story, actually hearing a little bit about what has been her experience of the last seven years allowing her to talk about what Arthur meant to her what needs he met for her, was he the main person who understood her as a person and I think this focus on combining not just treating Dorothy but also providing some understanding to Dorothy around her sense of meaning and adjustment to that and reframing things and for me there's certainly some evidence that there's trauma perhaps in here as well because of the way in which Arthur died and Dorothy getting a bit focused on I should have called an ambulance and that can be quite distressing and quite traumatic to have that going over and over in your mind. If we were to work together as a team in a multi-disciplinary way really important to have good consistent communication pathways amongst the team and needing to bring Dorothy on board with that making sure that Dorothy has a sense of agency in being clear about what each person is actually doing and allowing her to perhaps talk a little bit about what she feels that she needs and what's needed for her. As I mentioned a combination of a willingness to offer understanding some space for Dorothy to talk about what this means as well as we're needed some treatment options for symptoms that are actually impairing her function. I'd be looking to help Dorothy perhaps establish meaningful connections or activities in her life as it is from now and I wouldn't be expecting her daughter seems to suggest they want her to return to activities like caravading and fishing and I think that would be rather confronting for Dorothy so life can't return to how it was in the past. Life will forever be changed for Dorothy and there needs to be some acceptance of that and working with her around that so she may do similar activities but doing exactly the same could actually re-trigger life for Dorothy so we need to be really cautious about that. And then just to conclude I think some models or theories as well that can be really useful in Dorothy's situation is things like the dual process model the two track model and both of those ask us to pay attention to how is Dorothy going with her loss experience and her adjustment to this changed relationship to Arthur, where is she at with that aspect while also looking at her biopsychosocial functioning so her day to day life how is she going with that and in the case study we don't actually know what her day to day life is like we hear about her distress but we don't hear about her day to day living. Continuing bonds which I've mentioned and some more emergent theoretical bases around expert companioning or exquisite witnessing relationship with Dorothy while she adjusts herself and maybe re-attaches to things that are important to her. So I'll hand back to you because that's sort of my perspective. Thank you very much indeed Greg that was very interesting. Moving along to Asante Prasina, Moira O'Connor Moira Hi we know then that primary general practitioners in particular have a very clear role to play in mental health and bereavement support and this is particularly the case of the population ages and the role of the GP is twofold so it's supporting that the GP support their patients and also offer appropriate referral when that's necessary however the research indicates clearly that this relies on a knowledge of mental health issues and bereavement, active listening and responding in a very short period of time and a willingness to refer importantly and again research suggests that this may be very problematic. A UK study of GP found that there was very little awareness of current models of groups. The GP's were stuck in the stage based theory in Kubler-Ross and old theories that are not relevant to contemporary understandings and education on dying, death and bereavement is often very limited in medical schools and this is not just GP's this is across health professionals generally certainly in primary care. In our study of GP we found moving on to the slide in our study of GP can somebody move slide on Bonnie please I'll do it In our study of GP we found a lack of clarity of consistency. There was patchy knowledge and really a little bit of everything thrown in and fact even within individual GP's they moved from one state of certainty to another state of certainty in a matter of minutes. There was also a very heavily reliant on personal experience which is fine for the patient and the relationship in many ways. It could lead to problems for patients that don't fit into a mould but it would also lead to burnout for GP's and we found that in patient care research. Some of the GP's referred but many really were very flushed into non-filling. There were some barriers, some obvious barriers and that included the mental health practitioner not getting back to the health professional GP to continue care and support the patient so there was a little bit of irritation around that some numbers and paid work especially paid work and lack of knowledge of referral pathways and who's out there and what's out there the next slide please. So health professionals emphasised their own worst type of loss so for some it would be the death of a child for others a partner of long standing and one GP mentioned stillbirth as being the most outstanding and when worst case scenario we know from systematic research evidence that complicated or prolonged grief reactions are less likely to be related to those factors such as the situation or type of loss and are more likely to be to do with a relationship with a person or attachment style which has been mentioned. The public health model of grief emphasises that most people don't need any extra support they're going to get by and accommodate their loss adjust to their loss and live with their loss with friends, family or the social world that they live in the community they're involved in some people need community support and that could be necessary to refer people on to those supports and a significant minority that we've been talking about need access to a mental health professional and this minority has been placed internationally around about 10% to 12% to 15% precisely. The long-greed disorder that we've talked about is one form of complicated grief it causes significant social and work problems and challenges everyday functioning and we've all heard of cases of people having great difficulty just getting out of bed great disability going to the shops getting out the house and that everyday functioning is impacted on greatly also associated with suicidality poorer health quality of life and also substance abuse and alcohol abuse importantly for all of us there's less likelihood of this group actually seeking assistance they're very reluctant to seek assistance from mental health services again we emphasize the GP for all of the brokerage instance it also involves separation distress and unrelenting yearning for the deceased and a sense of meaninglessness and difficulties accepting the loss and all of these remain elevated for longer than 6 months we can see from the case study that Dorothy is talking about some of these issues and so she does need if depressed all have complications of grief and we've been through how to do that so what is needed, what's the way forward and certainly we need research but we also need grief education to alert health professionals generally these in particular but also the community out there to the range of responses and there's not one set way of grieving but we might have some things that raise flags and we need to be aware of we also need to target our care appropriately to those most in need excuse me there is research that shows that if you're offering services, mental health services to people who don't need them it can be more harmful than beneficial and we need to base that on the intensity the complexity and the persistence of these symptoms of grief or mental health we also need interventions including one-on-one reports inevitably but also other forms of intervention and we've been trialing a metacognitive therapy for prolonged grief disorder and that shows promise looking at how people think about grief and what enables and keeps them going into this morass of being locked into this grief disorder and also we've with a therapeutic intervention a full middle group from that public health model and that's writing therapy for elevated distress and that focuses on some of the things that Grave mentioned such as making meaning telling your story and also a lot of research has shown that writing is in fact useful for people who've been through traumatic experiences so we really have a way to go but there are some really strong possibilities out there thank you thank you very much indeed Myra we move on to the next these references of Myra to what we call a Q&A session there are hundreds and hundreds of questions came through on various topics related to this but first of all our panellists also had questions for one another that I'll pose to start things off so Grave is asking for Kay and or Conrad to the question is how might we differentiate between a depressed mood associated with grief and a depressed mood associated with clinical depression would you like to start that off Kay and would you like me to repeat the question No that's alright I think a depressed mood just associated with grief would be more along the lines of what Greg's already talked about where they're ruminating about the person and about the incidents but it doesn't broaden beyond that if people have more clinical depression I would expect them to have more changes in their self-esteem and do much more ruminating on a broader level about guilt and bringing up other things from the past but it's that rumination that I think is very important but then some of those other factors that I mentioned would be more to do with the clinical depression, the anhedonia lack of reactivity all those sort of things that's about it was there anything you'd like to add to that to that question there's not necessarily a lot more to add to it I think it certainly goes back to the timelines that Kay had mentioned about the trajectory what was going on before the incident that brought the grief response on so we see in Dorothy's case that she seemed quite happy with things beforehand although she might have been quite diminutive and kept to herself and her small family unit that was satisfying to her and gave her meaning into her life we all know patients and individuals we would be worried about how they would cope with a real stressful event we know that they've already got poor functioning skills poor supports around them may have had prior depressive episodes in the past so it is very difficult to be able to define which way somebody is going to go and whether it was actually the grief that put them over the right but the other part too is that it's very seldom that particularly in general practice that these will just present to you one day saying this is what I'm presenting with you know this is the whole story because that trajectory knowing how somebody has evolved over a period of time when do you actually take a snapshot is never an easy question to answer thanks for your time just if I can go back and say that depression is also difficult because it can come on quite slowly and people can say well of course she's depressed because she's grieving and it can become quite bad before people actually realise that it's qualitatively different I'm not hearing anything back to you Vicky okay, thank you Grave was also wondering or commenting that he made this point in his presentation and that Dorothy has survived and lived independently for 7 years since Arthur's death what does this tell us about her would you like to start that off Conrad? Yes certainly I think it definitely demonstrates that there's some degree of resilience inherent in Dorothy we've been looking at her story and hearing her story so far and although we're seeing this acute deterioration in her condition now which really has been her daughter that is as bought to the light of day Dorothy must have some degree of resilience that she hasn't shut herself off from her activities of daily living we'd assume that she's still cooking cleaning, looking after herself going along to the shops doing all those activities that her family and her have always expected of her so for some reason or another it's obvious at an earlier stage that she was in in such a poor way and so that's really my perspective on this is that what is that because we at some stage we need to demonstrate or find in Dorothy where was that strength that kept you going through all of this she's already been through that terribly problematic time of having to sort out the wheel and clean out the rooms and do all of those horrible things which are often associated in that acute bereavement phase she found the strength back then to get through it we need to help Dorothy find where is that strength where is that resilience that might bring us back to that stage again so I'd love to hear what our social work perspective on that might be, Greg Thanks Conrad, that's very good what you had to say I raise this question because very often you see that we can think that someone is struggling and there's a problem there but I think we also have to look to what's been working and so just the pure fact that Dorothy's managed to get to seven years post loss surely tells us that over those seven years she has developed perhaps some coping strategies and the part that emphasizes for me is that in spite of the seven years that Dorothy is still missing Arthur terribly and facing a future without Arthur and maybe after seven years is coming to terms with the fact that this feels like it's just going on and on and that's sort of depleting her and I think as Kay also mentioned we do have to be cautious that if someone is experiencing the depths of grief for an extended period of time it may be something that can lead to clinical depression over time but I think we should definitely be looking at not just the immediate presentation but looking at the fact that she has survived for seven years and probably has some strategies in there as you say Conrad that we might be able to re-establish perhaps just come in and say that I think we do need to separate out those three trajectories that I mentioned because I mean one is that she survived but she's actually been drinking or taking analgesics to survive and deal with the pain and it hasn't been a very good adjustment and now it's just gone on and got worse the other is that she has been doing really well but we don't actually know and I think we're assuming we're liking to think she's done well it's possible that she hasn't and I think very gently we've got to find out more about what has been happening and I think that also goes back to what identity she's got away from Arthur so while I'd love to believe that she's been doing really well I don't think it's absolutely a given that because she's still there seven years later that she's been doing well yeah no and it's not necessarily that she's been doing well but more that she has survived for that huge time and I think your three trajectories are really quite useful for people to have a look at and it's really as I mentioned as well because we just have this case study that we need to hear more of Dorothy's story of what those past seven years have actually been like and what she has done to try and survive and how functional some of that's been or potentially not helpful okay thank you a third of questions from a panel member is that's quite a kind of big one what can we do to make it easier for GPs and health professionals to respond sensitively and appropriately to grief and refer appropriately if necessary would you like to start that one I think Kay's study was fantastic looking at what were the deficiencies of GPs felt that they had and Kay I'd really like to hear more about what solutions might have come out of that study Kay or Moira Moira Yes that's why I asked the question what do we do about this my idea is that we have education but it's very difficult to get very busy GPs running their own businesses to come along to professional development and they tend as you will know to go along to things that are of particular interest to them so when we can't make it compulsory Little log in 2006 wrote a paper just outlining some hints and tips for GPs to help them to refer and to help them pick up on complications of grief so something like that would be very helpful as well I feel but I think the more we can get GPs to go along and as I say with the aging population we're going to a lot of GPs are going to be faced with this daily basis if not a weekly basis if not a daily basis so I welcome any suggestions and we certainly will do more work in this area and if I could just pop in there Moira to follow up from that from my experience I've been involved in doing a bit of training with GPs in a few areas and I think as you said whenever I've done that even when well organized it's really hard time-wise for GPs to get to education sessions and most of them say to me that they rather by just going over a basic session about grief education they say it's amazing all through my training I possibly only did a few hours on grief and loss and I noticed that came up in your research Moira as well so I think one of the other things we can do is actually in real time so for social workers psychologists who have experience in grief and bereavement to develop good relationships with GPs and to be able to while working with clients to provide information directly to the GP about the individual situation of the person and so for GPs to have that willingness to have conversations with grief and bereavement counsellors as part of an education process alongside trying to incorporate more grief and loss education into areas like medicine, nursing, those areas that at present still don't get a lot of training specifically on grief and bereavement Yes I agree and we've done some work also with GPs in the area of patient care and with GPs and community doctors and practice nurses and primary care health professionals in general have been part of the Paidative Care team and that's not just during the patient's illness but after the patient's death looking after and supporting the former caregivers so yeah I agree there needs to be more relationship building so I agree totally with that and I think Conrad in your initial presentation talking about that team work and how essential it is Yeah absolutely more but that also is a two way relationship in that it is very important that us as GPs recognise where our boundaries are and where our strengths and their weaknesses lie and for many of us we would be completely folly to think that we're going to have all of these skills and techniques things like EMDR there's no way I'm going to try taking on something like that but ACT sure that's probably got a great role but it would be really useful for those of you who are actually having referring GPs for things like grief many of you will set your clients some homework to do between sessions and it's great if you can feed that back to the GP as well yeah this is the stuff which we've been working on over this past month could you please maybe reinforce this at your consultations between our sessions that's a great way for the GPs to learn and to pick up skills as well and it also is going to help a lot in making sure that you and the GP are on the same wavelengths when you're discussing the care of the patient there too so I wouldn't for the start say that I'm an expert on grief counselling I hope that I can recognise when something is going wrong but more importantly who I've got to reach out for to help there with it thanks Vicki thank you Conrad look as I said there are lots and lots of questions and we're kind of running out of time a bit but several questions asked about cultural issues, cultural and spiritual issues and given recent events for some time in Australia and elsewhere would any other panel like to comment on how we kind of address those with our Aboriginal and Torres Strait Islander community with people from the Middle East people from Asian countries for any particular thoughts about this you know would you like to start okay you don't have to give us a sense about it but what to think about when we address people from those backgrounds who might come in what's important to keep in mind I think to be aware that they may have different points of view there is a cultural centre in Sydney which it can refer to and multicultural centre get some ideas from them I'd be trying to talk to someone from that culture if it's possible to find out what's different I don't know that I have any particular ideas about that I just might mention that slightly different angle but in medicine today this month I've got something about using attachment for GPs and we do mention in there that while there are cultural aspects to it attachment theory in general does seem to transcend culture and I think it's a good way to go but I think you've got to ask people from the different cultures as to what's similar and what's different I was recently on a working party with a lot of working groups very difficult to hear is it crickets in the background no it seems to be some feedback from somewhere is it okay now I was with a group that were looking at education for palliative care professionals and those using a palliative approach in terms of cultural issues and one thing that I took from that was that people were saying ask the person what's appropriate for them rather than making assumptions that it will be different or it has to be different or that all people from a particular cultural group will have a similar but rather just what can I do for you, what will help you what will support you how should this go for you so I found that very helpful and you're very simple I think that's what I was trying to say so Greg or Conrad any further comments about that one or some spiritual kind of spiritual how to think about people add to what Moira had to say that really that perspective of working with the person because I think it's really important that we don't start generalising culture so you can have two people from seemingly the same culture but the nuances of how they enact aspects of their culture can be different so as Moira said I think it is a really simple straight forward and useful strategy to ask the person to be willing to not assume anything and allow them to teach you about their culture while you offer perhaps whatever expertise you have in your area so it becomes a shared relationship where you work together I agree completely and the other point which I noticed that many of our attendees have also raised is we need to also put this not only into the cultural mix but also the lifespan section of this as well since the death of Arthur of course her children have probably grown up and left home they've now started their own homes she's probably now worn through menopause she's now on quite strong medications perhaps for her rheumatoid arthritis so even though she's obviously probably from an Anglo-Saxon or Caucasian background living probably what is quite a suburban lifestyle the external stresses, the external factors that are playing on Dorothy might be completely separate to those issues affecting another 55 year old lady living two streets down from her it's very difficult forever for us to assume that you know one person from one group you know all the people from one group thank you another I won't try and get another question in but thank you all so much for your questions it's a very broad ranging and coming all age groups all sorts of circumstances and situations we've just got a few minutes left so I'll just start to ask this panel member if they could just sum up and reflect on what the issue of collaboration around this particular issue so I'll start with you Greg OK thanks Vicki I just think one of the key things as far as collaboration is just that, collaboration of communicating well with each other when working with Dorothy and not leaving Dorothy out of that picture it's actually collaborating with Dorothy as well and I guess the other areas that we would want to be connected about is the area of suicidality that might be there for Dorothy so from my perspective we just need to be cautious and think that Dorothy straight away is suicidal simply because she says something like I don't want to be here because sometimes when people are grieving they have this feeling of being completely overwhelmed and it's purely an expression of I just want this to stop but there isn't any active suicidality but then equally on the flip side we have to take that statement seriously and actually inquire and in my experience in my work around people who are suicidal really important that everybody involved with the person is aware that potentially that might be an issue and has everybody sort of checked with Dorothy about that so that we get consistency some people in the interdisciplinary team Dorothy might speak to more openly than others and so we need to keep checking that we're not inadvertently pushing Dorothy in a particular direction when she's just simply trying to express something but equally that we make sure that she's not actively suicidal so everyone on the team needs to be clear about that OK, great, thank you um moving on to so kind of do you have any reflections just a minute or so reflections on the collaborative aspects challenging area of work I think absolutely and this is a few real strong links that I and many of my other GP colleagues will take out of this familiarity I shouldn't say Breed's content but it is very very easy to cruise along for years and years and not really see the changes that's happening with the patients who we know so well so it really takes quite a bit of self-discipline to make yourself actually look for some fresh eyes maybe even do have your patients see one of your colleagues every once in a while just to see is there something that I'm missing you know could this actually be a thorough issue might this have been menopausal things that are going on so number one is to always make sure that you're not just sitting in a rut that can go on for years and years but number two certainly is that we don't want to medicalise normal grief response we don't want to you know sedate or medicalise that response but we have to recognise when something's not moving along it might be time to get somebody with a broader skill set involved at that stage thanks for your participation Thank you very much Conrad Kay you have any final reflections? Well I'd be called in when Conrad is worried and before Greg is called in it was where I see my place I see my place in this to create a holistic narrative of what's going on which looks at both social physical and mental factors and to screen out important reversible issues which could be perpetuating or getting in the way of her grieving and creating some sort of an overview and I agree with Conrad that at times you've seen someone for a long time and they may not want to tell you something very well and it may be sometimes that I could ask questions like about her drinking which she hasn't wanted to fess up to which may be an issue but I also completely agree with not over medicalising the case and if you've noticed I haven't been pushing antidepressants or whatever I think they have their place particularly if she's got a melancholic depression or very significant clinical episode but in general I think she needs to examine her roles in life do her grief counselling and I completely agree with my colleagues okay thank you very much with that couple of minutes left thank you to our panellists and thank you all very much for logging on and participating in such enthusiasm two messages I guess are that there's a lot to learn about complicated grief as it's sometimes called I guess one of the issues I think of is the importance of serving the vision and working together to support in this area so business is to all of you as you explore this further now I've been asked to encourage you to fill out an exit survey and keep an eye out for future webinars there's a couple coming up in April and May one on addressing social emotional being a bolder LGBTI people and in May one on supporting student experience and anxiety at the end of high school studies so that's they're both very important webinars there we are yes and also think about setting up your own MHTN network in your geographical area where you live I don't know if they can be conductive though and so on but you're exploring and finally before I close I'd like to acknowledge the consumers who have lived with mental illness in the past and those who continue to live with mental illness in the present and thank you again to everyone for your participation this evening and for being patiently about technical issues thanks again, good night