 Well, welcome everyone to a interdisciplinary panel discussion coordinated by the Mental Health Professionals Network. Welcome, I understand there's 174 people or 175 people now online and 837 registrations for this webinar. I'm Professor Shanta Raj Ratnam, I'm from Monash University in Melbourne and I'll be facilitating tonight's session. I'm an academic psychologist, I lead a research group particularly focused on the impact of sleep disorders on health. I have a stellar panel that's joining me to participate in the webinar tonight and I'd like to briefly go through and introduce each of the panel members. Now, a bio was distributed along with the materials for the webinar so I won't go into too much detail. I'd like to introduce first Dr Christine Boyce. Christine will be providing the GP perspective on the panel tonight. Christine, welcome. Great to have you with us. Thanks very much. Great to be here. Christine, I understand you're well-recognized for all of your interests in refugee health. Can you tell us a little bit about how this interest came about? Yeah, sure. That can be fairly succinct. I saw one refugee, a former Kosova back in 1999 and I was able to work with an interpreter and I didn't feel so lonely in my consultation room anymore because there were three of us and I just thought I'll do more of this because this is more fun. Great. Great to have you here, Christine. So also joining us is Professor Nicholas Proctor from Adelaide. He's going to be providing a mental health nursing perspective. Nicholas, I see from your bio that you have particular expertise in knowledge transfer and community engagement in mental health. Could you tell us a little bit about the challenges in translating mental health research into practice? Rook, the biggest challenge is with mainstream mental health services. There can be a reluctance to be open to thinking about new ways of engaging, particularly around culturally competent, culturally appropriate services. That's a headline challenge, I think, we face at the moment. Of course, and that's going to be a theme that we continue to explore in this webinar today. So welcome, Nicholas. So next we have Dr. Georgia Paxton who will be providing a response to case study from a pediatrician's perspective. Georgia, I note that in addition to your clinical work, you serve in a number of leadership roles in government and other panels relating to refugee health. Could you tell us a little bit about how this interest came about for you? I landed in the migrant health clinic as the African migration paked and it was different than any form of clinical care I've ever provided and I was really interested in the fact that we needed different systems and that's probably been a platform for stepping into a greater role in policy. Great, well welcome, Georgia. Finally, we have Professor Louise Newman, a psychiatrist, well known to many and certainly to me, she's a colleague of mine from Monash University as well. Louise, I note your work in advocacy for the rights of asylum seekers and refugees. Could you tell us a little bit more about the work that you're doing in this area? Yes, I've been involved probably from the late 90s as well, started out looking at the issues of people from the former Yugoslavia and then became involved in issues, particularly facing children and young people in immigration detention. And I've been involved as chairing advisory committees for the Department of Immigration, trying to improve the situation of those people who are within restricted immigration detention and I've also done work in offshore detention settings and internationally, so it's been quite a long term interest. Great, welcome, Louise. So there are some ground rules that are noted there and I just bring that slide up for everyone's noting and I go move on to the learning objectives for tonight's webinar. So from tonight's webinar, we're aiming to better understand the mental health indicators in the context of Yvonne's refugee experience and the case of Yvonne has been circulated with the materials for tonight's webinar. We want to identify the key principles of the featured disciplines approach in screening, diagnosing and supporting the health and mental health of Yvonne and we want to explore tips and strategies for interdisciplinary collaboration for young people like Yvonne who have come from a refugee background and who may have mental health issues. So this evening we're going to talk about Yvonne, a Sierra Leone young woman whose parents were killed in a conflict and who came to Australia with members of her extended family when she was eight years of age. Her current age is a little bit uncertain. We're told that it could be 16 or 17. She's experienced a number of issues including intergenerational conflict at home and some degree of physical discipline and violence as well as racism and conflict at school. This has resulted in fairly erratic school attendance, reduced performance at school. She's living out of home now with friends and she's presented to her GP with a range of physical and mental health symptoms. We're going to examine those in more detail tonight. She's been indulging in risk-taking sexual behavior and her ongoing clinical management is presenting a number of challenges and we are going to explore those challenges as well. The case is a complex one and will help us to really gain a deeper understanding of collaborative mental health care models for individuals who are asylum seekers and refugees. So what I'm going to do is now I'm going to ask each of the panelists to give a short discipline specific response to the case study. So I'm going to start with Christine to provide a GP response to the case study. Thank you Christine. Thanks Chancellor and this was a case that I'm writing a lot of bells for me. I see a lot of adolescents from a refugee background with a very similar spread of issues. In fact, most recently yesterday, which was very interesting for me to consider yesterday's consultation in the light of knowing I was doing this this evening. And my first comment would be on the surface. It looks like an incredibly complex task for any GP, let alone a GP who's not maybe well versed in some of the specifics of refugee health to tackle. So in summary, I guess we've got a female adolescent of uncertain true age from a background of probable severe sustained trauma. And we're not even counting the ongoing trauma that my colleague Jill Benson talks about is not PTSD but CTSD continuing traumatic stress disorder. When you think of the challenges that await and face many people from refugee background after they've arrived and there's almost certainly the issue of intergenerational trauma, which as I understand it from a GP perspective is an incredibly complex one that I wouldn't even begin to understand. But I need to recognize that it's there. The acculturation issues I'm very familiar with it's an incredibly difficult task for a family, let alone an incomplete family without the actual parents to set about figuring out how to adapt themselves and guide an adolescent through an acculturation process without somehow losing their way. There are all sorts of issues that in fact that I'm sure Will will discuss as the evening goes on and it immediately strikes me that this case and like many of my cases will challenge all our systems, not just our health system but that the school system and social systems and ultimately a lot of this can end up, I've seen it end up with child of family services sort of goes on and on. Which starts to make you feel maybe a little bit depressed. But one thing that I come back to again and again is that although yes there are many complexities involved in people from this background, the essential skills that we're going to use and the essential networks that we're going to exploit are the same as we use for every single patient that we see and I don't have to list them all here and now but certainly with any adolescent for anyone who works in and enjoys engaging with adolescents I don't find the skills are really any different because it's rapport, engagement, communication, trust, they're very generic skills and this is what I love talking to medical students and GP registrars about just sort of without pretending for a moment that this is going to be easy medicine and recognizing that they're the basic skills. Now a lot of GPs do lack experience in refugee health. I don't think that should be a turn off but it certainly pays to have a few tips which I'm hoping we'll all be able to offer tonight for both GPs and other mental health professionals working in this area. From the GP perspective some of the challenges that would present with this type of case and that I've experienced with the young people I've looked after it's very difficult to a to ever get a systematic assessment happening because of the presentation so often presenting in crisis and I think there's hints of that here you have to deal with what comes in the door and you can't say look not interested in talking about that today I need to do an assessment urgent issues come in with a young woman there in many domains including sexual health risk taking and so it becomes fragmented. It's difficult to coordinate care as well as you might like to even within a practice often adolescents of from any background will see different practitioners within the practice they won't have kept a booked appointment so then they'll turn up for the unbooked appointment because the problem hasn't gone away so you have to try and coordinate amongst your colleagues in the practice involves really good notes and verbal communication and corridor communication and amongst others and in a case like this I think it's paramount that as far as possible the systems are speaking to each other which I think is a huge challenge and that would be what I'd point to as one of the biggest challenges about this because as a GP there isn't actually a really good framework to do a lot of this communication you're doing it you know off the side of your desk you're doing it often after you've seen the person or after hours when you can't actually contact anyone it's the kind of case that a case conference might end up certainly being something you'd want to at least broach with the young person but there's going to be complexities inherent in that as well I wanted to really talk about the issue of trust because trust is going to be an underpinning thing and in my situation I see these whole families so I would be seeing Yvonne's family and I would have to somehow negotiate that and I look after several young adolescent people from refugee background who have high conflict with their families and so you do have the mother the father the grandparent in on top of you saying do something about this young person you're the GP you tell him this is not acceptable behavior so there's lots of complexities and I was struck by the issue of control and I think control for me is often an issue this young woman if I go to the young woman I saw yesterday under two weeks ago she had a lot of control over her life she was in Africa and her comment on arriving here was that she felt partly dead because people stay in their houses all the time and she couldn't go out when she wanted and she had to go to school and so there's a lot of loss of control and they come into this environment so I would need to be showing this young woman that she can actually achieve some control over her situation at this stage and look there are many other issues that are probably more bread and butter like the issue of access to the services you know how you actually get there how we help her how we reinforce appointment times SMS reminders can be really useful so I'm sure we go into some of these things as the evening goes on their issues for the practice it hasn't been easy in my very diverse metropolitan practice and ensuring that you know everybody's on the same page and making the practice both as friendly for us and for the clientele as possible and then lastly I was struck by the importance of age determination and this is a very sensitive age around you know 16 17 18 where even a year can make a lot of difference so that's going to be crucial as well really just try to I guess summarize my response to to the case and some of the things that I think would underpin my approach thanks Christine that's really helpful and of course the registrants are very interested in a number of the issues that you have talked about and we're going to be drawing upon some of those themes particularly in terms of access cultural sensitivities in practice and so on in just a moment so thank you I'd like to now hand over to Nicholas who's going to give us a perspective about the case study from a mental health nurses response thanks Nicholas um thanks very much I guess my slides again reflect through to me when I read and I've just taken a couple of quotes from the case to to begin that sort of discussion with and I guess the first one is this note this point made about no memory of her parents who were killed when she was four years of age and that took me by surprise and I began to wonder about how that determination might have been made and being mindful of the possibility that Yvonne may self-censor if she's interviewed with other family members but also the possibility of that memory being in the form of images rather than a verbal memory or something that she could readily express her the demands that were placed on her prior to her arrival to Australia described as something that she enjoyed high levels of autonomy taking the responsibility of caring for younger children but of course that would come at a cost and that parenting role or that pseudo parenting role would have left very little time to devote to her own emotional care and well-being and I guess then there were questions about what happened when she was engaged in health services at the age of 15 and what was or what should have been the clinically informed response put forward by what would have been then a range of health care providers when she fell pregnant and there are two conflicting statements one really around the point being made where she performed well in primary school making friends very easily and yet a conflicting statement about having conflict and a direct manner of communication and I just began to wonder about racism and the experience of that and whether or not in primary school racism is less palpable or less the self-awareness of racism is less apparent but when later when people become aware of nuances and their language proficiency and social skills develop they can pick up on those nuances so it just begin to open up I guess these these slides are really about beginning to open up about her experience and what might be the backstory to contributing back story to some of the things that we read about in the case and the point that the point being made and this is something my my colleague in South Australia and I don't know if she's online tonight Monica McAvoy does really well in a nursing leadership position and across the state and that's really about meeting Yvonne where she currently is and just identifying how comfortable she might be about working with a female or male health professional and and I think it's very important in situations like this to accommodate those preferences very early in the relationship trust has already been mentioned and trust is a fundamental requirement for mental stability but trust is also fundamental in delivering on trust and whether or not there's scope for a person like Yvonne to have engagement with a community group because I think in this story community is missing and it's something I might come back to working out or jointly exploring what her explanatory model might be so we have a I guess an expression of an explanatory model in the case the way in which her symptoms are presented when how and why help is sought what the writer of the case describes as an optimal outcome or what are the issues in an outcome but what about her voice what about her perspective and whether or not there's scope to try and understand her perspective using her language and her experience and then working backwards from that certainly identifying and mobilizing relevant protective factors meaningful protective factors and being alert to risk protect risk factors I'm sure we'll come back to all of those sorts of things and asking questions about her alternative education path so what is her alternative education path outside of school where are her peers and role models and where is the local community you know how is she involved in work or other activities within her local community or is she involved in work and other activities school activities sport activities with people outside her immediate cultural group so I guess there's some there's some first person awareness and trying to understand her perspective but there's also trying to understand the backstory what might be some of the historical factors that are led to some of the descriptors that are expressed in the case thanks Nicholas I mean certainly a very comprehensive picture is now emerging of Yvonne's case and and from the approach that you've taken I'd like to now hand over to Georgia Paxton who is going to give us a pediatrician response to Yvonne's case so Georgia over to you I work in a service where we provide health assessments and long-term health care with a fairly flexible model of service delivery and I was reflecting on how we manage young people like this and basically we actually approach it from a health angle first sorting out what Yvonne's priorities are dealing with health screening and immunization people of African background who arrived in the 2005 six years generally won't have actually had initial health screening and probably won't have had initial immunization even and dealing with that and explaining what the screening means and providing information on why we're looking for things is actually quite a useful process because almost certainly I will find things on this granting test which I think probably actually helps to build credibility um she will almost certainly have low vitamin D which is one of my favorite topic areas um if she's got dark skin and she lives in the southern states that's a surgeon and if I can sort that out and treat it it will actually often deal with a lot of the physical aches and pains and I would always treat vitamin D first before attributing symptoms to somatization and the vast majority of young people I see get significant pain relief and feel a lot better similarly any adolescent girl is iron deficient and has menorrhagia until proven otherwise and sorting that out dealing with periods is a terrific introduction to trust and healthcare and people feel a lot better when their iron deficiency is treated and all of this will occur over two visits and if she did present with family I'd go through the general stuff first families often appreciate that and then make sure we had some timeline and deal with sexual health on the second and there's a variety of things that need to be covered um once I've at the same time essentially I'd also be trying to sort out what the social situation is and really for this young person she's in chaos she's not at school she's effectively homeless and how's it got to this point what's been the timeline what have been the circumstances she's 16 so she's compulsory schooling age she should be at school so why hasn't the education system stepped up to the plate and looking at who's been around and how it's got to this determination of pregnancy should be included I guess in this section and then after dealing with those things looking at um the developmental perspective in terms of adolescence as a time of development one of the areas I've had really helpful to engage young people who are talking about young people of refugee background school experience how long it actually takes to learn English the fact that adolescents or kids when they arrive in the primary school years will take at least five years to be thinking in English adolescents take longer knowing that you lose school content whilst you're trying to figure out what the teacher said and move between she's actually an English speaker I presume although Guinea is a French-speaking country so I'd explore that what's school been like for her explore the racism talk to her about what supports around and then adolescent risk screening I actually was very pleased to see Shanta work on sleep but I spent a lot of time sorting out sleep and have found that sorting out sleep is incredibly helpful to deal with anxiety to deal with rumination to deal with interesting thoughts which are often at night time and to help normalize routine so I manage that very actively look at scram time content Facebook social media time I my other job is in nutrition so I'll be in there with a dietary history and through this figure out what does she want what does she want to school what does she want of housing at the moment with age assessment I would argue that you can't determine age you can only assess age it's actually a really good opportunity to then go back and get the deeper deeper exploration of the narrative history and that's often where I find the detail is revealed it's to actually assess a young person's age you have to know who was around when they were young where were the points of transition and allows you to actually ask about family members about who was where when and what might be around in terms of age to look at the care relationships to look at the attachment it's actually a brilliant introduction to the narrative history in someone who may have had their story taken many times and find that quite intrusive if this is something they want to pursue it's really helpful and it allows me to examine schooling settlement and identity and I think it's not straightforward and I explain the process I explain what I'm going to show you but there are definite pros and cons of assessing age and changing birth date and I am very upfront with them basically if her age is changed from 16 to anywhere near 18 she it has huge implications for service actors for case support and I've had a number of young people where everything stops because the birth date gets changed yet they're still in year 10 and they've still got the same issues and then following up with that and actually writing a letter involving the young person in the process correcting it with them and putting in that form 424c I think again it helps them to realise that you are actually advocating and meeting their needs and once all of that is covered it's only then that in my experience I start to get some of the mental health aspects it's almost never revealed initially I think provider credibility is really important most of the young people I would see with this kind of story would actually be with the help of an interpreter but I think having already done the health stuff I've sorted out the medical contributors and I can say look we've sorted out your vitamin D we've sorted out your iron we've sorted out your other problems in terms of this is what we found this is what we've done do you think feelings might be a factor in how you're going now in these symptoms or whatever situation other kind of key tips I've found helpful I find the concept of dual permission is really helpful you can tell me anything and I won't be shocked I've heard stories like this before but you don't have to tell me anything it's your story and that's often actually I think quite a relief to young people and that can choose when and how they disclose also some teaching I had recently which has huge resonance for me was thinking about that adolescents who've experienced very significant trauma as young children make a different sense than manning of the trauma as they have increased cognitive capacity and a better self-identity and it's that issue of how they had a looking back most of my work is with primary care and JPs and I would involve the family where I can but in a negotiated process it's unclear whether this young person is presenting with family or not I think that's my last slide but thank you Georgia there's a question just from one of the registrants just a clarification could you just briefly explain form 24c? Form 24c is a very important form it's the freedom of information form to change your birthdate which can then change your migration paperwork thank you very much thanks Georgia that's that's very clear and hope to come back to you to pick up on some of those issues that that you've raised there particularly in terms of coordination at services that you just you just mentioned in your last slide with general practice involvement of the family and so on a number of the registrants are particularly interested in those issues so now I want to hand over to a psychiatrist Louise Newman to comment on the case study from a psychiatrist perspective thanks Louise. Thanks Chancellor I guess the initial point is that what what status psychiatrists might need to be involved this is a young person clearly who is having major issues as we've all stressed in their adaptation and in adolescent development so we'd be concerned obviously about school failure disabilities with peer and family relationships potential of maltreatment within the family unstable accommodation or virtual homelessness risk taking so a whole range of really quite significant issues and health implications that do need to be sorted out one of the major questions that I would have is how we can better understand how we've got to this to this stage where this young person is really having multiple difficulties in adaptation and particularly the role of trauma and all the trauma and loss that that she has experienced and how that's impacting on her current difficulties and some of the issues that might need to be a focus of attention so we have real concerns about a young person who for the first eight years of their life has experienced a whole range of traumas I think some knowledge about culture and the historical context where she's come from the situation Sierra Leone as people may be aware as clearly one of attempted genocide many children were exposed in that situation as witnesses of horrendous human rights violations massacre many families had members who were killed and who experienced torture and this child the young person has lost their parents that could have been under really tremendously traumatic circumstances so we have to ask whether that trauma and loss is still active in her mind in the way that we might think about a post-traumatic presentation the other issues that I think from a psychiatric and mental health perspective that we need to have a look at current issues about depressive symptoms anxiety symptoms the issues that they might be there in terms of risk of self-harm and even suicidal ideation for the young person who's clearly very stressed and an important clinical point is working on those issues that others have mentioned about trust about the difficulty we expect this young person has in engaging and essentially in complex care systems working out who might be the the best person or persons or service that she can actually engage with and often high-risk young people vote with their feet they will go to some services and not others they might be able to form trusting relationships around some issues and I think we have to be strategic and use whatever points of energy that we have to actually try and help them and we can work then in a stepwise fashion on some of the issues so for example my focus might be on trauma and post-traumatic stress disorder and the complex developmental effects of trauma and stress on a child those issues are unlikely to come up in initial meetings and it might take some time to build up a relationship where a young person might actually need to or want to disclose some of those issues so we do have to have a summer evaluation of their current capacity to engage and how we might actually work with that so I would like to look at depressive symptoms the need to see how depression and anxiety might be connected to some of the issues young people and again this is a culturally influenced presentation from some young people which from some cultural groups are more likely to present with somatic symptoms so physical complaints might have different ways of verbalising emotional issues and be able to do that to a greater or lesser extent so we need some cultural understanding of where this young person is coming from and the same applies to our very models of trauma she might be experiencing stress symptoms from our point of view in terms of a western approach to thinking about PTSD but she might have her own very different understandings of that and the other thing in engaging with a young person with this sort of background is that I think it might be helpful to think about how she has survived what she's been through that she probably has a whole range of strategies and approaches to attempting to live with what might be very unpleasant symptoms and experiences of stress memories of trauma so her way as common in adolescence in general but particularly adolescence from traumatic backgrounds might be to not engage or to engage in a very ambivalent way so sometimes to be able to talk about things and then maybe not be able to follow through with treatment recommendations and we have to factor that in and I think expect that as it's really quite common one of these things I think very important is intervention and the difficulties that we have as a victim in mental health services at the moment in firstly understanding complex cultural presentations and the refugee experience but also there are real limitations in terms of our evidence about appropriate intervention with young people from these sorts of backgrounds we're very interested obviously in helping better identify those who are having complex responses to trauma but we have a particular model which is the western psychological model of trauma recovery and I think it's probably not appropriate that we just assume that we can take particular western models of treatment and assume that they'll work and apply those without modifying them without exploring in much more depth that particular cultural groups understanding of trauma and recovery which may be very different from the model of our mainstream treatments the other thing I would think about particularly for this young person issues related to the expression of depression and again it's we can't assume that people from different cultural groups will be able to express in our terms a psychological model of depression but we do need to evaluate that and sometimes there might be a role for specific treatments for depression and anxiety depending on the symptom profile and how significant that might be and as everyone's mentioned I think the complexity of this case is the need to think about how we can engage if it's possible the extended family there's often in refugee families some uncertainty about relationships and of course there's intergenerational conflict and sometimes cultural clash particularly around adolescent development the rights and responsibilities of adolescents and this young person is clearly in a way trying to deal with a very different cultural context which might be in conflict with that of the extended family and very importantly I think as others have mentioned that the idea that we need to be able to work with these young people in terms of establishing a sense of purpose and meaning in life and one that helps them actually come to terms with accept their own history but be able to move through that so to have some fundamental engagement with educational or vocational engagement whatever she might need so I think part of the challenge for us all in thinking about a case like this is which services and professional groups can engage with which parts of such a complex picture and at what point do we call each other in yes no thank you very much louise look I think you've opened a number of issues that I can see registrants are also asking and I might now open it up for a conversation I think among our panel members drawing upon some of the issues that you've you've raised in your presentations so while we get set up for that there's a question that's come from one of the registrants which I think is is quite representative of some of the early questions that came as well so look I might put this to to Christine the question that's come is how do you deal with asylum seekers who do not want to go to a mental health professional for example a psychologist or a psychiatrist for cultural reasons and it's called very dark in Hobart you can never even see me we can see you yeah and so for a start off and in my experience and I'm more experienced with refugees who arrive with visas than asylum seekers who we've really only had in Hobart for about 18 months so that's not a big area of experience but I can speak to it because of the asylum seekers I have seen this is most of them most of them do not wish initially anyway the psychologist or a psychiatrist drawing on what Georgie said earlier on I think it's really important to establish immediately that they're not going to be you know forced to see anybody that that's absolutely their call that that defuses the situation considerably and I feel that if you've generated some rapport as a GP you have little choice really but to to step into that role at least initially until you've had a chance over repeated assessments and I absolutely advocate seeing asylum seekers and other really traumatized people very often so usually weekly it took me years to to figure out that when somebody's really difficult and you feel like seeing them less often then you actually see them more often so the asylum seekers that I'm currently seeing in this situation who generally do not want to see psychologist psychiatrist and will see me weekly and I'm acutely aware of my lack of any specific skills in the area but aware that the rapport and trust and connection that we're generating is really important and sometimes I share them I have a colleague and we may see them week about thanks Christine and I understand that you have a question that you'd like to ask the other panelists about assessment in this context of Yvonne would you like to put the question to the other panel members yeah sure I just looked at the question and again and look it's it's probably far too big a question but I wish something obviously I wanted to ask because I asked it and it is you know how can a GP approach an assessment of possible profound intergenerational trauma in in a young person look I might suggest that Louise do you do you have a response to that how a GP can approach an assessment of possible profound intergenerational trauma in a young person I've got a one word response and that might be cautiously and I say that because the young person might not be able to tolerate at least initially when we're first seeing them much in the way of thinking about that in this case we've got a young person engaging and running around a risk taking behavior which we might see as a way of avoiding a focus or thinking about trauma and the very difficult situation she finds herself in she's in a state of conflict if you like because obviously she would desperately needs and wants to be connected and accepted by family and the community on the other hand she's a trauma survivor who has is operating if you like on a survival mode which means sometimes not getting too close to people avoiding discussion of painful things that might bring up painful feelings and so on and we see this in a whole range of trauma survivors however it is I think the GP particularly someone who has a good relationship with a young person like this is actually probably much more comfortable in going to the GP about a range of issues and she might be going anywhere else is ideally situated to leave the door open to that sort of discussion but I would be cautious about it I'd certainly try and respond to what she brings up and maybe ask some very general if you like or opening questions that let her know that you have absolutely some sort of understanding about the dilemmas that she's facing and you can even I think use that sort of language any of us can we're talking to young people like this to be safe and this is a really hard situation to be in you're not sure where to go and sometimes you feel hurt or rejected and so Louise while I have you there in the spotlight I understand you've got some questions one in particular about psychosocial adaptation to a new home would you would you like to put that question to the panel oh yes that was a question about how we can try and understand the difficulties that she's having with young person in adaptation in terms of the refugee experience so how has her experience of displacement, dispossession, loss of parents obviously, loss of culture shaped the difficulties that she's having now and importantly how do we think about recovery from that sort of experience what should our expectations be and how can we help her maybe Nicholas Proctor might have some views on that yes I was just going to ask for Nicholas's thoughts on that okay well that's great question and it's one of those things that people themselves are not readily able to disentangle from other aspects of their experience but one thing that I think shows up as being an important strategy if you like is to use issues and experiences that happen on the day, happen on the day of the conversation or have happened that week as part of the explanatory opportunity to understand her perspective and look for associations between things that might be happening November 2013 and things that may have happened in past experiences and sometimes that might be also just allowing not just so much the verbal behavior but the non-verbal behavior to flourish so the therapeutic use of silence to be able to open up that space for feelings to be received and her life to be revealed so I guess a combination of things that are meaningful for her that are in her everyday experience that are not necessarily part of a verbal communication but they in fact may be features of a non-verbal communication or that space between herself and another person and allowing her as much time as possible to really explain how did it get to this you know just if I was to role play that I mean just say look you know go back as far as you like but how did it get to this take as much time as you like to be able to do that so I guess they're the kind of things that come to mind in thinking about that question the Nicholas I think that relates very nicely to a couple of questions that are coming in from registrants to tonight's session as well and one of these is the complexity when an interpreter is brought into the mix and of course in Yvonne's case that's not the case but how do you you've talked about the importance of communication nuances in communication what do you do now and how do you manage effective communication when you have an interpreter involved in mental in mental health I have a very strong preference for level three accredited interpreters to be used and that's because that that extra level of training and insight is tends to be very useful around metaphor and as I talked about early explanatory models and expressions for smaller groups we don't have a lot of level three not yet accredited interpreters and so confidentiality is a is a major issue particularly in the smaller jurisdictions and for example South Australia Tasmania and some parts of regional WA in New South Wales but allowing I guess as much as possible for the interpreter to have for there to be continuity with the same interpreter so making sure those bookings are made well in advance and and there might be some gender preferences around that as well so there's four things that kind of immediately stand out in working with interpreters telephone interpreters are very difficult you know the line can drop out and sometimes sadly and this is not a broad criticism but sometimes it's been my experience to find that they're making a cup of tea or cooking dinner while they're doing the interpreting so that can be a problem as well um I can I comment on this one as well it's Georgie from pediatric perspective um look we my services we see between 800 and 1100 attendance of the year and about 80 percent of our um work is with our permanent interpreter I think we work a lot with the newly arrived communities and the emerging languages and the reality is that we don't have level three not the interpreter qualifications I think there are lots of practical tips and tricks to understanding this work I think it's um a real problem that training on working with interpreters is not included in the undergraduate graduate health discipline curricula the practical things we have found is firstly we would always define confidentiality with an adolescent but I separately define interpreter confidentiality and that's a really good thing to do so I will go through what I have to hold confidential or not and then I say and the interpreter is completely down by confidentiality they can't tell anything that we talk about in here and that's a good entry for young people um we I think using very simple language and I can see some of the comments from um registrants down below about having interpreters trained exactly to say exactly what the clinician says I actually disagree with that and I think having worked with interpreters for a long time it's about recognizing there is a degree of flexibility and if I use simple language it is easier to interpret and you get a sense that the conversation is flowing you have the three-way dialogue the other thing that we have found to be a revolution is we ask our interpreters to wait inside our clinic with the other staff not the waiting room and we brief them and we debrief them and we ask their opinion on how the young person presented and did their language make sense and what was their take on it um there have been instances where we know confidentiality has been breached we'll simply avoid those interpreters at the same time we're running a clinic which where everyone needs an interpreter and there are lots of logistic issues with that but I think there are lots of practical tips and tricks to working with interpreters and it can be fine we have found it to be an incredibly culturally informative experience and I think recognizing their professionality and what they bring to the dialogue just is an enriching thing for clinical care probably mental health care but certainly for health care terrific georgia look uh while while I have you there um a number of the registrants even before uh the webinar tonight have asked us a lot of questions about uh access to service and system issues you had a question that you wanted to pose to the panel uh about uh you know where the mental health services would take the person could you do you want to put that on the panel members um look I'm quite embarrassed because I missed my flight on services which is probably because it's one of my um kind of key areas which I think is a real challenge my question for the registrants as well for the panel was would your service take this young person if they have resilience if they have performed well at school if they're saying they don't have symptoms if they don't turn up to their visit would you actually take them and what happened if they didn't turn up to the first or second or even the third visit as well I might start with louise if I could and see what what what your thoughts are would you would your service take this person what would happen if they didn't turn up for several appointments it would depend um I guess on um the referral process the referral pathway and what she's actually referred for um in terms of our area I guess um this is the point that it's so highly variable around the country at the moment in terms of what actual um services we have um for young people particularly from these backgrounds in my area yes um this young person could go to a refugee health uh service which has uh mental health practitioners situated there co-located and that's um part of an approach that we've developed um to really try and improve access um for these sorts of um uh problems which are often as we're talking about quite complex in terms of working out how much it might be um mental health issues how much are physical issues um and both need attention if on the other hand I were to try and um have this young person go to mainstream uh public sector child and adolescent mental health services that will be difficult at the moment um those services are largely um focused on very acute presentations and are very stretched now some of that's resourcing but I think part of the problem that we face is that many mental health services are not necessarily um culturally informed to the extent that they might be able to mount a better response to someone from a refugee background particularly someone who was a trauma survivor so there's a lot of interest in the moment a lot of discussion around trauma focused care and how to improve within the mental health system the capacity to actually understand that trauma can present in various ways from physical uh can mimic or look like other mental health uh disorders um but I think it's quite reasonable to say that we're going to get very variable response um if it's mainstream um services they will have a limited capacity to respond um if we have the luxury of having refugee health services then she can get a very good response I would actually be looking at what's also available in the broader community and not necessarily um since that we always have to send people to mental health services um I think in many ways it'd be better if we're building up um refugee services and other community health approaches which are more youth focused and easier to access well thanks thanks louisa christine do you have any comments about uh uh the question that georgia had posed about whether your service would take this young person and what your your services response would be if they failed to turn up to several appointments what would you do yeah it's a really good and a really practical question and um so in general practice um people from refugee background in hobart have great difficulty accessing GP services we're reliant on a small group of gps who then do most of this work and and there is very disappointing uptake of use of interpreters amongst the wider GP community that's an issue we have again and again so back to interpreters so our service certainly would be one of the services targeted um in a small community everybody being aware we do refugee health yes so we would would probably receive a secondary referral if this young person was attending a different general practice and it wasn't working out and and we would prioritize her as an adolescent and I think that's an important point to make because we get secondary referrals for lots of adult refugees and we don't take them all because we can't we would prioritize a child or an adolescent because that's just how it is we recognize you've got that absolutely precious window of opportunity where you have a chance to make a real difference as opposed to working with a lot of the adults where you're just not going to have that same amount of traction so yeah she's um she gets in pretty rapidly with us terrific thanks thanks christine one of the uh or themes that were coming from the registrants questions was also the potential role that schools could play uh in uh you know a situation like evans uh could i ask you to start with christine um you know one of the registrants for example is a it's a guidance officer serving many schools and what are some of the important things to consider uh for you know integrating students into a classroom playground situations uh and helping them to uh relate well to other students and to their teachers it's a really difficult one and i can speak just from experience which is that if you're working in the sector and it's a small place like hobart you rapidly get a feel for what schools are better equipped to to cope with the spectrum of issues and and you know you need to as much as possible work with individuals i always need a name for who i'm working with i need to generate rapport with that person so emails will go back and forth within the boundaries of confidentiality phone calls also and i think it's not until you have a clear idea of the school the the school counselors or or social workers or whoever and often it's not very much and only then can you really start doing systematic work with with the school otherwise i think it's just general stuff like understanding that most of my young people and adolescents from refugee background absolutely do not want to be identified in any way as being different or special or special needs are just so important you've got to work with this young woman and i can guarantee you that she will not want to be singled out in any special way whatsoever she would just want to have a mobile phone and she will want to be facebooking and looking to the world like everything is fine and can i add to that i'm not sure this young woman will want to delve into her refugee trauma from eight years ago and she will be much more focused on what's happening for her now and that will my sense of working with clients like this is it is all about the housing it's about the um financial cash flow it's about getting her back into school i think schools carry a huge amount of the care like for young people like this and even just getting her to school and getting the routine of school if there's any teacher or young person she connects with at school if there's a counselor they actually do a huge amount of work to getting stability into her life i would also add just looking at the registrants comments i'm not sure what sort of trauma services would take at eight to ten years after arrival and it's actually very hard to get people in when they've been here a long time even though that might be when they're finally ready to um consider this as older change so basically sorry could you it is a consistent sort of a series of comments that are coming about there is you know torture and trauma and how that would be dealt with could you just comment a little bit on on the point that you just made i mean this case you've on you said it's probably eight years after the events but could you just talk a little bit about services that might be able to be accessed in general for torture and trauma um in terms of the options for this young person on the whole group i work with need the help of an interpreter so private psychology is out i can try community health centers and that's often my best bet um school counselors often feel very overwhelmed by this and beyond their remit i wouldn't be able to get her into camp due to age and geographic restrictions and chances are she might not turn up um i i'm actually not got anyone to get the headspace um and they come back to us in our medical clinic um or go to the gp so hence my initials about working with the gps i really struggle to get young people into services and the other thing i would comment on two comments firstly the intake process is very lengthy as a clinician the meter spends an hour with a service and then an hour with another service and an hour with another service is actually a very big commitment and when i have occasionally got young people into mental health services they find the process of seeing an intake person and then seeing a second person then seeing a third person who might be the person that can prescribe they find that baffling they just can't understand all these same people asking that question and so they come back to me um i'm interested to hear if that's christine's perspective but i think we have so much of a focus on intake and assessment but not on therapy it's actually quite problematic from a clinician's perspective trying to access those services on behalf of young people christine do you have a response oh very very quick and easy response which is exactly the experience in in hobart and as gps we don't even try to get these people clinician burnout is really important we it becomes too hard we just deal with them ourselves we use the torture and trauma service they do their absolute best and they do a great job getting the young person to you know engage obviously as we already said is an issue and we have a few great services and it's not good to spend a lot of time talking state-based stuff in this forum but you know reconnect is a service run out of colony 47 and ngo in hobart that that another service there too that will look specifically at young people who are either homeless or at a risk of becoming homeless because of conflict within the family and they can be really good if you can you know get to the top of the waiting list thanks thanks christine i might ask nicholas had a good question that i might ask him to draw upon now nicholas you had a question about the use of deep narrative assessment interview in this in this case do you want to just i thought louise might be a good person to consider that that question you have um yeah look thanks very much it's really just that opportunity to um ask the question just how did it get to this and allow the time allow that space for feelings to be received in experiences expressed and i i really do wonder whether or not that's happened in yvonne's case and if it has what has been who's done that what's been the outcome as a result of that what i'm more inclined to think when i read the case is that there's been a series of brief assessments or brief interviews or brief interactions um and i i would be very keen to know what louise thinks about that and what what what are the potential pros and cons that um surround that possibility louise we're rapidly running out of time but we've probably got about a minute or so but if you'd like to share your thoughts to nicolas's question yes um sorry in briefly i absolutely agree i think that that's a very important process and that's what i would say is pretty central to this idea of recovery from all the various experiences that this young person has had um the important questions are when is she ready to do that who might be able to engage her in that sort of process i would probably agree that torture and trauma services if they're available for her so service providers with real experience in dealing with this level of trauma and loss would probably be very um well suited to being able to do that if she could engage to see them regularly but the whole idea of being able to come to terms with trauma it doesn't mean forgetting trauma it doesn't mean minimizing trauma but it means developing a containing narrative so a way that trauma and loss can be lived with um for adolescents that's a very difficult process they might spend considerable periods of time avoiding that and not finding that easy at all so it might not be the right time there might be other more pressing issues that need to be resolved first until she finds herself in a place that should start that process but i would certainly be working towards that thanks louise look uh we have so much that we can talk about and the registrants raising some really important questions as well unfortunately we're we're running out of time and what i'd like to do is to ask each of the panel members to just provide a one minute you know summary of their reflections uh i'd like particularly one of the themes that's emerging for the registrants comments at the moment is uh you know different cultural groups responses to mental health issues issues of stigma and so on so if you kind of can think about that when you provide some your reflections but perhaps christine i can just ask you to provide your final thoughts on this particular case thank you yeah certainly and so so six other cases were going through my mind as as i worked on this case tonight and kept coming back again and again to what's been a theme i think it can't be stressed enough and nicolas mentioned that george i think everybody mentioned it is that every professional working with a young woman like this is going to absolutely have to be prepared to focus on one of the issues from her perspective and it's so interesting looking at what they probably are and alongside what we would love to focus on like intergenerational trauma and acculturation and and mental health access one disorders etc etc and i think for the other half of my minute that i talk about resilience about that has been mentioned also to really put resilience up there how resilient this young woman is bound to be she's going to come through and she just needs like any adolescent even though her situation is incredibly specific and above anything she needs people preferably plural as in you know about a boy and you know you grant and all that sort of stuff and she needs a lot of people to just support her till she gets there and she'll probably get there thank you christine some wonderful thoughts there nicolas could i ask you to just give me a quick summary of your reflections yes um my first reflection is the is just to spend a little more time thinking about the role of schools i do think there's a role for schools particularly around understanding that the level of self-regulation that might be expressed by children in Australia in the Australian mainstream will be different to people who have refugee experience particularly new arrivals so supporting schools to be able to understand that and if you like have a vulnerability consciousness to have a consciousness of that vulnerability in the school environment i think is really important and the other thing is to is just to let people know about the MIMA website www.mhima.org.au mental health and multicultural Australia has a has a raft of resources a blog and other links that address a lot of the issues that we've talked about today which is a freely available all downloadable freely available thanks nicolas that's that's certainly very helpful and it's in one of the concluding slides the website that link is there so thanks very much nicolas georgia could i ask you to just provide your final reflections on on evan's case um i guess three main points the first is that to my mind mental health is part of health and i'm intrigued that we go so far to try and actively separate them we have quite different service systems whereas combining them i think can actually be an effective way to engage with the whole range of communities and groups the second about managing this young person situation in cases i think understanding our goals and starting with achievable goals and moving towards larger scale goals so it can be something really basic to start with and moving from there and then the third is about being more flexible as services our service started as an assessment service we've changed because of the people and population demographics and need change we do a lot of developmental work a lot of cross god's developmental assessment and i think we probably do a fair bit of mental health although we wouldn't call it that um we give people our contact and we say can come back and we've had the families do come back and they bring the cousins and they bring the extra kid they're sponsored and our attendance rate is actually 88 and has been for five years and we only see this level of complexity so i think if you use phone reminders and you are flexible and you do offer opportunity you can actually learn and engage and have a great time working in this area it's been quite an amazing privilege to work with these communities thanks georgia please just conclude with your reflection yeah sure um i think that one of the issues that comes through for me is the need to really understand different cultural perspectives on particularly on what psychological well-being or mental health actually means we do need to understand what other people's models are before we start thinking about engaging them it'll help guide us in our interaction with them we need to understand where she comes from we need to understand what experiences are likely to have been even if she can't disclose that or doesn't want to disclose that um with us i think the basic perspective that we can take is one of trying to maybe do something which is much more about understanding her perspective her story of trauma and loss and how we can then understand that much better and that means that there are multiple perspectives possible on that but the aim of working with her whichever service or model we're working with him will actually be to help her over time piece it together for herself in a way that gives her choice flexibility might be able to reduce some of the risky behavior help her regain a sense of purpose and meaning and of attachment and reworking relationships i think what that means in practice is in a practical sense is being very much guided by the young persons themselves being sensitive to what they can tolerate and what they can't being available having an open door and being flexible in terms of our frameworks so when the question was raised before about what if she misses appointments many people from trauma backgrounds will find those sorts of demands in terms of being there at a certain time behaving in a certain way very far into their experience if they're feeling overwhelmed they won't come they might want to come the next day i have a man a former detainee survivor of physical and psychological torture who just rings me out of the blue and he says i'm coming to your office now now whether i'm there or not well i might be in the state or i could even be out of these and he says no i'm coming to your office so what he's saying to me is he needs to be um have control a sense of control which was stripped from him by experiences of torture and trauma and i think similar things apply for this jungle we need a human rights framework we need to respect her right to have some control and help her build up a sense of self-efficacy and in terms of her engagement with us Louise thank you for sharing that perspective i clearly the registrants also are endorsing a number of the statements that you all are making as well and i think it's certainly resonating with a number of the clinicians who have have registered for the session tonight we could go on and explore this issue it is complex and we really justifies quite a lot of deep discussion but unfortunately we're soon running out of time so i wanted to thank the panel members for sharing their perspectives on this important case i wanted to thank all of the registrants for continuing to participate with interest we have 257 registrants online i see and i wanted to thank the mental health professionals network for hosting this important webinar the case really highlights the opportunities for and the advantages of collaborative mental health care to support a young person like Yvonne from a refugee background but clearly as our panelists have have highlighted there's also significant challenges from the point of view of coordination across systems and sectors and as well as ensuring cultural sensitivity in practices and also in interventions so i want to encourage the participants all of the registrants today to think about setting up special interest networks exploring mental health in young people from culturally and linguistically diverse backgrounds i want to also encourage you all to complete the exit survey which helps the mental health professionals network shape future webinars there is an announcement for then for the next webinar there a collaborative approach to supporting patients with coronary heart disease and depression anxiety on the 3rd of December finally as as nicolas mentioned there is support from this webinar and the materials provided for it from that particular website there and the website is shown again there for your for your reference so thank you to everyone for participating in the webinar tonight and that brings us to the end of the session and thank you very much thank you thank you thanks everyone thank you thanks for