 Good evening everybody and welcome to the mental health professionals network live webinar this evening This one is about working together to overcome the challenges of rural practice in mental health now. I'd like to welcome me 200 plus Participants tonight From all over Australia and in fact, there's a couple of people from overseas too. I think we have someone from India And I I've been watching the chat box and I can see there's people from literally all over Australia So a very big welcome to everybody I'm Mary Emily. I'm a GP in Ken in North Queensland. I work currently in rural inner youth mental health at a headspace site But I was a rural DP for about five years on the asset and table and And I've facilitated quite a few of these webinars and I think you'll find it's a really Interesting platform and a good way of having a discussion together and the people that we've got some on the panel tonight I'm sure going to provide you with a really interesting discussion and lots of useful tips and food for thought so You will have received the bio about our Panelists before tonight session and how to look at those so I'm just going to welcome them one by one So first of all, I'd like to welcome Graham. So Graham's a GP and he joins us from South Australia Graham plays a lead role in a project which has successfully reduced suicide rates in his rural area and Graham I actually am fairly sure that you initiated that project There was a very big project to take on and it's lasted a number of years So what's um, what do you think have been the keys to the success of that Graham? There's four platforms that we use one was community education, which is vitally important The second one was increasing community capacity. That means training people to do different things Like training counselors to be around locally training the nurses to be more up front. We're dealing with mental health problems GP's more aware of screening for mental health symptoms The third thing we did was run a schools program where we actually Emotionally or behaviorally challenged children in the school and the fourth thing we did was promoted early intervention at very early Stage thinking if we could get things early, we could actually manage some likely rather than be sent off to Adelaide So that was that was the four platforms, but at the most important one was just Education of community widespread any organization I could get into a spoke to Fantastic and it's such a great example of collaboration not not just between Mental health clinicians that the whole community that's fantastic to have you on the panel And I'd like to welcome Captain David West. David's a mental health nurse and a Navy captain and it's great to have you with us Understand that some some of your role in the Navy does include mental health work And I wonder if you'd like to share with us some of the most challenge or maybe one Challenging experience you've had in that role if you're allowed to certainly I Provide mental health support at sea for warships deployed Out at sea often several days sailing from from any port and of course, we've just wound up in Heart of the Middle East, but maybe we'll have a very strong presence continue to have a strong presence in the Middle East So in terms of a rural or remote and although that's my civilian practice there's not much more remote than being three-day sale from anywhere in the middle of the Red Sea and Your helo is broken. We can't get spares And and we only have batches of broadband internet because Strangers it may seem the the skipper has higher priorities than Providing for the needs of deployed mental health service And remote Welcome to the panel and I'd like to welcome Tim Kerry that Tim's a psychologist and a professor in mental health from the Northern Territory Improving access to services is a key interest of yours and it's obviously really important in the territory and some of your Research mentions things like patient-led scheduling and the close relationship between psychiatry and clinical psychology But can you just you know in three words or less tell us a little bit about how that works and the benefits in a rural and remote area? Yes, Mary. It's great to be here. I run a psychology clinic Within the public mental health service in in our spring. So I get referrals from case managers and psychiatrists and I Operate a patient-led model of service delivery. So once they've been referred the patient kind of Book their own appointments rather than me scheduling into appointments and and I found that Doing things that way improves service capacity and and also access to services a lot Fewer missed appointments So the clinics are fuller and people can can get into to see me without long waiting time Thank you. That's a I mean it's such a simple idea, but it's sometimes we get stuck in the way that we do things So thanks for that And I would also very much like to welcome Professor Alan roses So Alan is a psychiatrist on our panel tonight and part of his work involves working in far West New South Wales and With remote community So could you tell us a little bit about your work in the remote communities and some of the challenges that that you might have to face Alan? Yeah, thanks, Mary. I I've been Based in everyone on shore for 30 years that for 35 years or so I have now been working in far West New South Wales based around Broken Hill and the small townships around most of them Aboriginal majority towns like what Kenya the The most perplexing thing the that I Still find there is the fragmentation of services in those towns as many services that come into those little towns but See a coordination is limited and sometimes the funding is very limited the Commonwealth has a habit of putting projects into what they consider to be Complex or what they mean is difficult towns where they they provide funding for you know an average of 18 months and They change everything about and expect things to change But then they don't follow up with with any funding to make sure that things are sustained so We're used to being Cultural if not clinical band-aids out there and trying to pull things together And doing our best Want with visiting services to keep a continuous service going Thanks very much Alan and I think this is a really experienced panel for this topic. So that's Fantastic to have you all just a few ground rules Many of you have probably participated in these before and you have a general chat box down on the left And the orange technical help box is flashing a lot at the moment Participants your audio will get better once we have fewer cameras on screen. So just hang in there Please speak to each other in the chat box and often as great conversations are going on there I have received copies of the questions you submitted at registration I won't get to address all of them, but I will try to include as many things as we can Make sure that you post your comments and questions for the panelists in the general chat box And we do keep an eye on that and any technical problems in the technical chat box Remember the other people can read your comments and so just behave as if it was a face-to-face activity And if the chat is distracting to you There's a small down arrow that you can click and then you don't have to watch it at the end of the webinar there's a Feedback an exit survey and it's really helpful to mhpn for helping to determine What kinds of topics and and technical things about the platform and so on to help us Continue to improve the webinar series So we're going to speak about Jason. He's situation. You've already heard about He's a 42 year old man who lives in a remote area of South Australia Due to mounting debt He's been unable to operate his farm and he's taken a job in the mine on a fly-and-fly out basis to make ends meet He's stressed by both his financial hardship and the forced separation from his family Just quickly going back to the learning outcome The main thing about tonight is understanding the challenges Which I'm sure everybody who's participating and on the panel already has a lot of ideas about that identifying the key principles of the future disciplines approaches and Exploring tips and strategies for how we can collaborate to assist people in rural and remote settings And I would now like to welcome without further ado Graham to respond to us as You would Jason when he comes to see you in your local town as his GP thanks Well, this I was doing this 10 15 years ago quite regularly, but not so much anymore The first reaction is how do I handle this in 15 to 20 minutes when I've got 30 to 40 patients to see and the Overlying thing that you've got to remember is I might have someone coming into the hospital with central chest pain a six-year-old Diabetic has collapsed and what I have to do then is to actually stop what I'm on doing and sort that out I've been a loser patient and this is no more less serious This guy may needs to be sorted out And he needs to be sorted out now because he may finish up dead in a very short period of time as well The overriding thing that I see about this guy He has no insight as to what's going on around him And my first and only priority is to gain rapport and to keep it And the way I do that in actual fact is to take a quick history from him I'd be asking them about non-threatening things like how was work at the mine? Did he have friends at the mine? How were things going up there? How did he cope with being backwards and forwards? How was things going on at the farm? How did he cope with his relationship with his wife and his children? How did he think all that was going And he also had a friend that committed suicide How did he feel about that? Did that have any effect on him? And basically just trying to establish rapport and some sort of mutual understanding The next thing I really want to do is very quickly as I can Because I've got to really try and get rapport but I'm time limited But really is important to get a handle on what's going on here I ask him if he's aware of the stress and situasing and how he feels he's coping I want to know whether he's got friends at the mine When he's still got friends in the town or whether friends in the town have dropped off I'd like to know a little bit more about his alcohol ingestion and particularly any other social drugs He's having at home. He certainly won't be having him on the mine because he'll lose his job And the thing that is overriding my sort of thought is He probably has brutally inside into It's The stress that he's under has the effect on his mental state And one of the things that I've learned is that rural men have learned to be emotional Philistines to survive the weather the banks the agencies the governments and the cell their market They're their crop or that they're output on on the world market where there are terrible fluffy wastes And these guys have to be able to suppress their emotions just to survive to get by so this is where we start And one of the things I've found very useful is to use a model that I developed about 35 years ago when I was living in an isolated mining town And there was certainly was no access to any of what a sort of mental health system at that time and I actually learned this 10 Direct questions which belong to the model when the important thing about these 10 questions is they tell you how well the guy's Functioning what's his functionality with life in general and I can slip these questions through quite quickly How do you sleep? Do you have trouble getting off to sleep? Do you wake up in the middle of night? Does your mind go at 3,000 miles an hour? If what's your energy like you let the lethargic I Don't ever ask about whether people are depressed because I very fine people very rarely find people are depressed I find them flat irritable frustrated cranky Cheese off lots of other things, but very rarely will ever admit to depression I ask about their motivation whether it's difficult to get started with a lot since things they like I want to know about their concentration where they can read and watch TV or whether distractive all the time I want to know about their memory. I want to know about their self-esteem Whether they feel good about themselves or they're self-denigrating, which is usually the way when someone is feeling down and I want to know what their socializations with Like whether they were drawn when they still talk to their friends or do they want to not go out anymore? I want to know about where their appetite whether become a picky eater And I want to know about their libido whether it's diminishing and those 10 questions I've learned over the last 35 years Sum up how people are going at the end of the day when I finish training these people I want all those 10 questions to be answered the negative that everything's going well and no side effects. That is the end point I'm after. I actually don't talk about depression. I talk about brain shutdown And if people have got access to the model in front of them You'll see in the center is a thing called the mood center and I explain to people that in their brain They have a mood center. It's probably perhaps not like that. That's a good way to explain it Which normally controls those 10 things and it also stabilizes the autonomic or the automatic system And when the mood center shuts down then they get all those symptoms of insomnia and tiredness and depression and and poor motivation Distractable and then they get all those things are answered in the negative and they get psychosomatic symptoms such as headaches and palpitations turned up stomach Creepy crawly skin tight in the chest and These things will actually could produce chronic stress and I explained to patients that the chronic stress in itself Is enough to shut the mood center down now this guy Jason has got a numerous stresses in his life Which almost certainly will shut his mood center down which would have produced the symptoms And therefore we've got a cycle which he is actually depressing and going down and so explain to him that he's brain shut down It's why I can't sleep while he's tired while he's miserable and that when he's drinking he actually feels a bit better But in the long run, he'll actually feel worse the next morning and it actually makes the whole situation worse I mentioned quickly about the things that switches the mood center on But at this stage it's not something I would concentrate on too much the My initial management is still to maintain rapport and assess the risk and then consider what my options are If the interviews don't very very badly and he has become angry remember He was already already paranoid and he might think it on picking on him like everybody else has been And he just storms out of the system Then I think I've got an option to schedule in will detain him and for that I would actually Call the local policeman who probably in my area might be 150 kilometers away But would use him to actually bring him in and detain him But hopefully it hasn't got that bad because when I detain patients. They do very badly they go to Adelaide They get shut up locked on a probably an accident emergency for three or four days They come back after being seen for 24 hours very angry. Don't want to see me under any circumstance so for most reasons I would try and avoid scheduling them the if the the the Situations gone pretty well. I might try and persuade him to come it up to hospital where I can say I can treat his stress I can make him feel a lot better and I can actually push medication if I think that's where I want to go I can push that quite quickly otherwise I might Negotiate to discuss it with his wife and to be home and just to take some medication there overall My my most important thing is to provide hope and say we can fix the brain shut down We can fix these financial problems by talking to a counselor or getting some solutions to him And with his problem is looking is the missing machinery and the fencing material So we promise to look into that and try and find a solution to that problem as well Certainly, I'll be making another appointment in a very short period of time depending on the severity and what my risk assessment was Be seeing him in 48 hours 24 hours maybe a week get some medical some Do a full medical get some bloods for thyroid and There's some general screens and so Basically, I would say we'd have some time off For a few days until we go to this all settled down Ask if we can bring in discussion with his wife because his wife has also a problem And so is his family discuss with his wife some of the options and make sure everybody's on board moving in the same direction So in five minutes, that's perhaps how I'd go about solving this particular problem in my area Brian that was really helpful. There's so much feedback from the participants about that model and the 10 questions So that's just fantastic on that note everybody you will be you will have access to the slides after the webinar Finish so I think a lot of people will be using that Graham. Thanks so much Now I'd like to welcome our mental health nurse Davis So if you might see Jason under under a slightly different circumstance and we'd be really Interested to hear your thoughts about responding to Jason. Yeah, thanks, Mary and certainly a different a different circumstance but very much flowing on from Where the GP has assessed His status at the moment and I really love they The model I really love the the 10 questions the 10 questions are pretty much fantastic. Excuse me just for a sec We can see your slide David. Just just a bit of Interference there and and certainly very much excluding the organic cause and I know that you know that we've spoken about that as a As a baseline but but certainly making sure that the general practice has excluded the organic cause and The the mental health team so mental health nurse within the mental health team would look be looking at a bias like a social Assessment finding out where where he's up to in his community in his family what might be leading to These these odd experiences perhaps that he's having and and building on the rapport very much relying upon the rapport from General medical practice Pretty much they've referred to us. We're now we're now moving on from from that initial referral Any number of Specific assessment tools can be used modified Maudsley looking at the mental state examination and neurovege and I noticed that the 10 questions are a bit of a quick and dirty Mental state examination and neurovegetary assessment and they are really really very very good. I just Have to keep endorsing them His level of insight at the moment is very adjacent level of insight at the moment is very very limited and Working at how we can plan care with him. We've managed to get him past the The resistance in mental health worker and being able to collaborate with him and with his family to work out You know what's going to be useful for him. What's going to be useful for his family and trying to maintain that relationship? GP's said that that relationship is good In in that assessment and trying to build on the the usefulness of that relationship Also worth noting that some the abilities of clinicians within a region can be variable We will have teams Made up of five nurses. We may have teams made up of three social workers We'd like to have a multi-disciplinary team, but we can't necessarily have have All of those disciplines within one area and We'll often have new graduates because they're the they're the people who we can attract to country And being able to the teams to be able to support individual clinicians providing those that group I noticed my slides are moving on. So so so should I? And certainly very important to ask about suicide even though he may not have mentioned about suicide It's really important to put on the table showing the person that you really do care if they are thinking about suicide and Perhaps demonstrating to that person that you're the person that you would ask about Jason works for a major mining company and So they will often have a work site health provider And I think it's reasonable for us to collaborate with them and getting whatever Missions we need to maintain in the confidentiality for him and his family and a lot of people get really concerned about maintaining Confidentiality in that that means that families can't tell us stuff I think that's that's something that we need to to break down and say that whereas we will need to maintain Their families confidentiality and that individuals confidentiality within a family but the families can tell us whatever they think we we need to know and similarly the plan of care needs to be To involve clinical choices You know what's going to be Usefully him over the long term We very fortunately have access to telephoto. We can get a psychiatrist opinion If we think that's kind of useful to manage his care and we can often get a psychiatrist opinion within a few days through Through our telephoto process. It does need a local clinician at the at the client in and Having that local clinician can sometimes be a bit of a bit of a barrier But that's that you know, that's certainly necessary to support him at the at that end and I know that we sort of touch slightly on it and I also know that Alan's quite Has quite an opinion about involuntary treatment But I think that we should consider involuntary treatment As we heard if we if we need to invoke the mental health act well, we that's what we need to do and It does very much need to be specific to his risk and and The idea of making it as least restrictive and as least Confronting as possible within whatever Whatever our circumstances and people file, you know, they don't want to be too restrictive But often early involuntary treatment if it's if it is necessary can be really very useful in Changing a person's life around and living with psychosis or dying by misadventures certainly very very restrictive so perhaps thinking about involuntary treatment and Mental illness from particularly mental illness with country people is quite episodic and perhaps We may be able to prevent involuntary treatment or prevent the the complexities of the the road Down this man's mental illness if we can engage him in some strategies about what does he want to happen next time? What does he want to happen when he becomes unwell? in the future and Of course, he is living in a real property and he's living with children And I'm not suggesting that we need to take his children or his guns away But we do have to ask the question about and what are the risks we have questions of ourselves and perhaps of him What are the risks regarding the children and what are the risks regarding your firearm? And I know that that's not perhaps mandated in some states and but it's certainly in South Australia with a medical practitioner prosecuted because he didn't follow up with the Firearm And then Dave in my quick and dirty five minutes that'll probably do Thanks, David. And when you come back to us, I'll just get you to move the mic a little closer to your mouth Yes, it's getting a bit quiet towards him. Thank you Now I'd like to welcome him So I think Hi, it's pretty likely that Jason is going to get referred to a psychologist and really keen to Hear from you about how you might respond to him. Thank you. Okay. Thanks, Mary. I hope he does get referred I really felt for him reading the case study. So I'm assuming that that he is the person That's for me as a psychologist and I I Just clarify that because it could actually be that Wendy Wendy's the person who comes along So I'm assuming from this that Jason somehow does come to see me as a psychologist So in the first session, I'd want to I want to explain to him about The psychology service that I that I offer including the way that you can make appointments and and things like the limits to Confidentiality, I'd want him to have as much information as possible So he can be making an informed decision about the service or the treatment. We're about to embark on together I also want to get some idea of his level of risk while we were having a conversation Most importantly, I'd be interested in hearing about the problem from his perspective And I'd be keen to find out how he thinks it's a benefit from coming along to seeing me I'd also discuss with him including Wendy in the treatment, but that wouldn't be a given And certainly wouldn't occur without his permission In terms of the context some of some of the things that occurred to me as I was reading the case study I'd be interested in knowing about any previous problems that Jason had on the farm and how he felt them I'd also be interested in hearing from him how he and Wendy came to be on the farm How long they've been there, what they did before that and so on It would also be interesting for me to learn about the way in which the decision to take on the fly-in-fly-out work was made Did Wendy and Jason make that jointly or did it because it's something that occurred to Jason Did some friends of his tell him about it Initially it was going to be a temporary measure, but that seems to have changed So how did it change and what happened with that My formulation of the problem would be informed by Jason Hughes on what's happening He appears in my opinion to be experiencing significant conflict between wanting to earn extra money On the one hand to support his family, but also having to abandon them in order to do that He feels like an outsider at work yet he doesn't socialise with his friends when he's back And he can't play cricket in the thing he used to play in because of the work that he's doing He had a grand plan, but now he doesn't see an end in sight And I'd be interested in exploring that within his future of lost hope for the farm's future What does he see in the future now? Does it bother him to have lost hope for the farm's future Or does he have different priorities now The treatment I would provide would be to help Jason locate and resolve the main sources of his distress Around those kinds of things that I've just talked about An important focus may be his conflict about supporting and abandoning his family at the same time It could also be useful to support Jason's sense of powerlessness when he's away There were comments about Wendy having to get tradesmen that Jason thought he could have done Along with his feelings of being an outsider at work, how does he feel about that? I think the treatment for Jason would seem developing clear, unconflicted and important goals about For example, the sort of husband, father and friends he'd like to be As well as confident strategies for how he might move in the direction that he'd like to head in Treatment may also include Wendy, I mentioned that before And it may be appropriate to look at a couple's perspective Or it might transpire that Wendy could benefit from ongoing psychological support as well I mean she's having to carry a lot of the load when Jason's away And treatment progress in the work that I do would be monitored using standardized questionnaires Such as the depression anxiety and stress scale and the outcome rating scale And session rating scale as well as keeping behavioral observations and notes of changes In reported attitudes and activity level That's me Thank you And I was just thinking about how the outcomes that you're talking about would result in The 10 questions that Graham looked at also being resolved Yes, definitely He would be going back to his GP and if there's a mental health in that practice So those people would also be able to see the resolution of those things As a result of solving the problem So thank you very much, Kim And last but certainly not least, I'd like to invite Alan to respond from the rural psychiatry perspective And your psychiatry delivery in western New South Wales is face-to-face, I understand I'm sure you can really tell his psychiatry as well Yes Thanks so much for your response Okay, well maybe that's a good place to start because I think the issue for telepsychiatry is And especially now that we have item numbers for psychiatrists as well as other Commissioners to be able to do telepsychiatry Sometimes I think we overbalance and only do telepsychiatry Sometimes in association with a GP practice And sometimes more directly I think the problem is if you have a nationwide telepsychiatry practice It would be helpful if sometimes you can see that person in person And I think that's with any telepsychiatry practice And sometimes you can make arrangements so that you can You may be having a combination of a visiting practice and a telepsychiatry practice And I think that helps The other thing that would help is to make sure that you do make contact And keep contact with the team or the people who live on the ground In that township who could help you maintaining that practice I'll address the slides down, something I'm sure we could discuss further In terms of ground rules for telepsychiatry practice Which I think is a really important component But I think we need to keep developing those ground rules So just working with what has already been said before Because I think it's lovely to be working with such a dream team Of people who are pulling together all those factors And I won't go over them except to say the things that stood out for me With Jason's critical issues was that he said he was stressed out He's feeling depressed, the excessive alcohol intake That he had a mate who suicided recently Which obviously plays on his mind Although he won't talk about it And there's a relationship strain and it goes quiet If Wendy tries to discuss such things as his mate's suicide He has a mistrust of his neighbours, he's in battle He has conspiracy theories encompassing the locals Including it seems possibly the GP He's been... Wendy first got him to see So there is a question of formal assessment Of whether he is formally paranoid or whether the stress is just causing him to be in battle This is an issue for assessment And also what everybody has said about the eliciting any suicidal ideas And then doing something practical about allowing those Can we have the next slide? Oh, I moved to the next slide, obviously Here we go But behind the clinical issues there are some very other important things Which could be the risk or resilience factors And one that's very worrying is the loss of his grand plan dream I don't think everybody needs a dream to pursue That provides meaning and purpose in the middle line Secondly, the issues are being lonely, separated and unisolated Particularly when he's in his thesis Thirdly, his sense of family abandonment He feels that he's irrelevant to them So since they've abandoned him out of their day-to-day lives when he's away And he feels useless when he is there So in a sense, abandonment goes both ways There's a loss of interest and enjoyment which amounts to that technical term, anhedonia And he also has a sense of alienation He's an outsider particularly in the new culture That comes back to Durkheim's concept of enemy When you're feeling marginalised in some way from your community He has a loss of habitual role as a competent farmer A competent provider, a fixer of things A competent husband, a father And he has a sense of deep shame That's worrying too And he's got a mounting farm and household debt And we know that there is a statistical association with household debt And in this case, farm debt and suicide So we have to watch that as a worrying signal And then there's the issue about drought Which is a slow burn disaster It's not just a crisis of his life Because a lot of people in his community are affected by it When everybody's affected, then you're resource people Your local resource people aren't available to you So this is something we need to watch Not just with him and the family but the whole community Wendy's concerns She's trying to keep Jason engaged and involved in family life She's worried that her husband is unhinged and may suicide She tends to use terms like losing it And she's worried that GP will think that her husband is losing it And that brings some shame to her So there is some issues of stigma for her She's worried about the gossip network And sometimes in dying communities And in communities that are contracting The gossip network seems to outlast the support network And it worries people They want to try and keep their business private In those circumstances Rather than being able to draw on the communal resources We'll come to that And then there's the issue of who cares for the carer Especially in a small community Who cares for Wendy if she's not prepared to talk about it Outside the family So we need to consider those as well There is a concept around In the literature called solastalgia Which means This is the third point there The distress of loss of solace Caused by the degradation of the environment To the home and the sense of belonging It sounds like your life and the environment Are turning to sand If you translate that into indigenous terms We haven't talked about the possibility That he may have indigenous heritage as well So we need to ask about that But in times of drought We find indigenous Aboriginal communities talking about We belong to the land If the land is sick, so will we We feel sick as a community Sick as individuals And if the river dries up, where will we meet? If the river dries up, so will we So you hear terms like that used So there's a personification Of what's happening to the environment Then there's this issue about dealing with complexity And it's what I call a quintuple whammy I know what a quintuple whammy is Because I've had a quintuple bypass So I can count to five And quintuple whammy includes Being indigenous or marginal in some sense So in a sense, he's feeling marginal Even if he hasn't got indigenous heritage He's feeling marginalised in his life And in terms of loss of role Secondly, living in remote areas And living in remote areas Secondly, living in remote circumstances Where even lack of transport can be A form of disability And sometimes people can't afford the petrol When they're living in drought conditions And just trying to hang on So that becomes a form of disability Living with multiple deprivation Like homelessness or poverty And this family certainly in poverty Having a mental illness And then also having a coma Or the drug and alcohol or physical disorder Now that's... I think that adds up to working with complexity And the way to work with all those factors Some of them are clinical and some of them are functional And some of them are cultural So we need to take a holistic approach And I think everybody before me has taken this wider approach And I think it's my role as a psychiatrist in this situation To endorse this wider biopsychosocial cultural Environmental, the world, the universe And everything type approach to it Taking a holistic role So that brings us to the final approach Which is the communal adaptations that strategies Rather than just looking at what we can do Clinically and individually And with this couple or this family We need to recognise the whole community That he comes from, this little community Maybe undergoing communal hardship We need to look at communal awareness Raising farm gate meetings Mental health education We need to remind ourselves of and call on Communal strengths and resilience Because these communities have been through this before And even though they're going through hardships They can draw on strengths If they're reminded of what they did last time And what they could do And if their ideas are invoked and honoured We need to help them instill hope and optimism And realise their extended kinship networks These are traditional healing factors That we sometimes lose But these little communities Have often had in spades But are not invoking now Because they think their community is disappearing Like those shifting sand And we need to draw on holistic solutions Including those spiritual dimensions Of the biopsychosocial cultural approach And we need to ensure that Jason And others in that community Have meaningful work and communal roles So they feel that they are included in their community And they do mean something Not only to their families but communities They need reminding of that So there are clinical factors And I think there are wider factors in the community Thanks so much, Alan So I think what I'd really like to do now Is to invite Graeme back in So Graeme, you've referred Jason If there is a clinician for him to see In your community or perhaps via telepsychiatry And he's come back to you There's been a lot of questions from the participants Around the kind of complications of Boundaries and role conflicts in communities So there's a fair chance that Your children might go to the same school Or your partners are in the same social organisation So I wonder if you've got any reflections From your years of experience About how you handle those kind of situations If you had someone as concerning as Jason And you also had some other relationships With him and his family How do you care for him and yourself In that situation? Graeme, I think you might still have your phone on mute Sorry to say again? I think he was still muted So don't mind starting that sentence again Are we back on now? Yes, Graeme Okay, sorry The community has probably already Got opinions about this guy He's probably said some things People with notices were drawn Notices he's different I think small communities People notice what's going on around them And that's one of the disadvantages But one of the assets because what we do Is train the community to recognise people And send them in to get some help At the end of the day what we need to do Is to take all those labels off them And make them normal members of the community If we do that we actually succeed quite well So I don't think we need to worry too much About privacy We're all used to living in the same fishbowl There's only people that move in From outside that have some trouble adjusting So we're used to living in the same fishbowl And we need to learn to be supportive As a community and actually In fact get rid of all those labels And whatever else I make And do it all well again And functional again And that's the whole point about the 10 questions There's a lot of getting people back to normal function And enjoying life again And Graeme I know while I've got you I know that you also had a question for Alan A really practical question around ketamine So do you want to address that to Alan And we'll bring Alan back in Alan there's been some work about ketamine Being very good for reducing depression In some people Now the question I would have About transferring detained people to Adelaide Which I've got to do by air Which is always a risk and danger And the safety using ketamine Rather than sedating people out of their brain With all the other sedatives we use Yeah I have some reservations That come out of literature about ketamine To about some dissociative states That have been written up And I think until that's clarified I would reserve my judgement on ketamine And people get quite disturbed And fearful of those dissociative states If they occur Although they occur in a minority But it's still a worry So I would think we need to find out A bit more about those possible adversities Thanks Alan Thanks very much for that Now Graeme I wonder also If you've had much experience with your patients Of using the e-services Whether that's counselling via the internet Or phone or seeing a psychiatrist Any thoughts about that? The psychiatrists are really hard to come by One visits the whole area Which is probably 20,000-30,000 people every month So it's hard to get them in And if there is Sometimes you can get them in Basically what I can't provide We don't provide The problem with telehealth is often There's a word single though That's getting better But if they need follow-up Often you don't get the same psychiatrist again So I must say I've got to a stage Where I try to manage most of the stuff myself If they are privately insured It's still for the patients $300, $600 to get to Adelaide To see a private person It's very minimally refunded So it's a great expense Access to psychologists And psychiatrists is very difficult We can use mental health plans But again it's probably a three month wait To get in as a psychologist And then there's probably monthly meetings With the psychologists It's all just very very difficult What I do do I'm the people who are computer literate As I use some of the websites To do some of the CBT work That I don't have time to do So I use places like mood gym Or the black dog has another CBT stuff I tend to just use In my normal concentrations And actively scheduling Or some motivational interviewing Where I see that appropriate And just move things as I see fit And if there is someone Who is somehow accessing a psychologist Or working with a mental health nurse There's been a lot of comments That's an odd panel being a dream team So I'm going to ask David and Tim next as well But just with you What are some tips that you'd have On collaborating with a GP If you are a mental health nurse Or a psychologist What do you find helpful as a GP? Well I think we're just Open communication Normally I have trouble getting access To a mental health nurse But once that does happen We need to be on the same page And working in the same direction So we need to have the same sort of ideals And we're heading to what each other's doing So I think that's just Important as working as a team Thank you very much And Tim might go to you next What are some of your sort of thoughts Around collaboration So if Jason was actually seeing A mental health nurse in the general practice And seeing you as well What kind of things have worked for you And your clients in the past About communication collaboration? Yeah thanks Mary I've been really lucky I think In the places I've worked in I worked in rural Scotland for five years And actually worked in GP practices So collaborated very closely with GP With GP's there With type notes into the patient's file That the GP could read The next time they saw the patient In the job that I'm in now I'm in the public mental health service Where I collaborate very closely With psychiatrists and mental health nurses Who refer people to me And I have to say as a psychologist I feel really lucky Working like that David mentioned excluding things Like organic causes before And I can just assume all of that Already being done Because the people who come to see me Have already often been to their GP And certainly been to their psychiatrists Or mental health nurses Before I get to see them So having me being able to focus On the psychological aspects Of their recovery Means that the psychiatrists And case managers can focus on The other aspects that are important as well Thanks Tim I wonder if you had any comments about how you work Collaboratively over distance With looking after someone like Jason Yeah, working collaboratively With both the community psychologists The generic social workers And the GP's I think it's best to get them to owe you one Have a collaborative relationship In which you have supported them At a tough time When they've needed a bit of Clinical input Or urgent intervention That you've stepped outside your role a bit And in that manner That you can then sometimes get them To step outside their, you know Step outside whichever solo they happen to be Getting access to generic support I think is really, really useful Being able to know where To find the NGO that's going to fit in With your client now Because you've developed that relationship In the past And I know that Graham referred to A time when the program comes And then it goes away That it's no longer available And that's something that I might refer to As NGO fatigue, non-government organisation fatigue Where clinical providers in an area Who are accustomed to having Organisations that are funded Come in, do a great program and then disappear And it happens so often That you then end up not engaging With the next program Because you think, oh, they're just going to last For so long So being aware that That can become really fatiguing Really becoming aware that You pick the fruit when it's ripe That you use those supports When you can And if I can just go back A bit to the comments about Ketamine Rural people are very wary of Ketamine They've often known about Ketamine For its veterinary use So they'll often see it as A drug that's been used on animals And whereas I certainly know that A combative unwell person in an aircraft Is not a good thing Telling someone that you're giving them A drug that they recognise as something That's been given to their animals Just one more layer of concern For them at the time That's really interesting to suspect this, David And I know that sometimes at the other end The sedations that are used And things to transport people safely Can then have a really big impact on What's possible at the other end In terms of assessment And how long it takes Before you can actually assess someone That's really interesting stuff And I wondered on a practical question How do you find out who's on the ground In the community? Like if you're not in that community And you're looking after someone Who you visit once every couple of weeks Or you speak over Skype or the phone What kind of local resources Can tell you which NGOs are there And who's good at the moment? Practically Yeah, the Health Mafia knows these things The local community health service Will have a visiting service Will have a with them And I certainly all know that There are a couple of towns Where there are hospitals But no community mental health services Or no community services And certainly having a relationship With the key players Within that hospital Or within that local medical service That's the key, is knowing the local people And I often do that By providing Mental health specific education To the practice nurses Or to the general nurses To the allied health staff Within that area And by offering that That bit of community education To those individual clinicians They'll often then speak about Their own circumstances And their own clients And that will often lead me To who are the providers in that area Who are the useful people to know Who are the community champions And so I think that Brings us back to what Alan was saying About one of the sort of technical Well, strategic things about telepsychiatry Would be to sometimes actually See people in person as well And I'm sure one of the things about that Is actually getting to know the local players On the ground And Alan I wondered if you'd like to come back in And just give any further comments About some practical things About providing tele-services Because there's been a lot of questions From registration And from the participants Just around the practicalities Of providing like e-mental health care Of various different sorts Yep Am I still off here? Says I'm still off here You're on, we can hear you Okay, thanks I think we need to develop standards I know in my own profession The College of Psychiatry The Royal Australian and New Zealand College of Psychiatry Do have a position paper Which is fairly detailed on telepsychiatry Which they really conceive of Something around an item number And I'm aware that that item number Can be used like anywhere in the nation And you get paid for the item number But the problem is you, like in city Thiefers service practices You don't get paid for liaising You don't get paid for liaising With the people who work on the ground With the GP Unless you're doing a care plan And that doesn't amount to regular liaising And you don't get paid For liaising with the family And sometimes you're particularly In a very remote location You have the family Are the major supports And they need to be in the loop In a respectful way And with the provision of the person Who's there with the disorder if possible So I think it's really important That we actually find ways Of doing it respectfully And also where possible Not always possible Having some time where you can Review that person in the town It might only be every few months Or every three months Or something that you come into town But at least to see the people You're still supporting Or still seeing clinically If it's possible Otherwise it's very important To develop a relationship with the GP Who's managing them Or the mental health team And it comes back to How you find out that resource And the local health districts Should be able to tell you Who's working on the ground All the agencies that are working In their patch Part of the problem though Is some NGOs are federally funded And are not tied to providing Support services around catchments More around postal codes Or some other concept Which doesn't align with the LHD The LHD funding Which means one of the problems We haven't got to anywhere in Australia Is planning together Whether we're FISA service, NGO Or public services How we create a plan for a locality Or for a catchment And how we then work together To that plan And I think it's possible That we just don't seem to Have got around to doing it And I know that some of the Mental health commissions Are getting interested in doing that And I hope that comes about Thanks very much Alan And I think you raised A really interesting point there About how you include the family When they might be the primary support In a very remote place If you're providing tele services And so I wanted to bring Tim Back in just to talk about Some of the ways that That you might go about including Jason's family in this But also the question is What to do when Wendy might actually be his main support But perhaps due to his paranoia Or perhaps for other reasons That we don't know about He actually says he doesn't want You to talk to Wendy So I suppose there's two questions One is about ways of going about Including the family But then what do you do If the person says no Thanks Mary I think it's a really important issue And one I had First-hand experience with A couple of years ago I was seeing a chat for Some chronic depression He told me that he didn't want His partner involved in the treatment He worked full-time He was quite functional In all sorts of ways He was also linked In the psychiatry and so on His wife ended up making A complaint about some of the Things that we were doing Which she wasn't happy with I contacted my professional Indemnity insurers And they were very clear that The solicitor I spoke to Said that he was from Adelaide He said it's a finable offense In South Australia To talk to anyone else About a patient's treatment Without that patient's explicit Permission and consent So that was a real wake-up call For me and very good to Find out about On the other hand I'm seeing a couple at the moment But I'm seeing And I see both of them And I see them separately But I'm seeing them for Separate issues It's one of the challenges Of working in brutal and remote Access where the Access to clinicians is limited I also saw a woman About 18 months ago Who was going through a marital preparation Her husband wanted to come And see me as well Because he didn't have much money And couldn't access private practice Psychologists But in that instant I didn't end up being Because I thought Because of the context Of the marital difficulties That were going on I didn't think I could Legitimately see both of them At the same time And keep those Therapies separate If you like I didn't want couples Therapies as one of Individual therapy For the issues They were both going through So once I've got an easy answer Unfortunately It's a difficult issue I have to say It's one of the issues I really love about Rural and remote practice Having to grapple With the Kind of ethical And professional Dilemmas I feel like I'm just hedging A bit now But it is A really difficult issue I'm not sure You answered your question Just your thoughts Are really helpful I'm sure We don't come up With the answers In these webinars We share ideas I think that's What collaboration is And it just made me think About debriefing And supervision And I wondered David If you had any thoughts About When you are dealing With these complexities Where you might have To see People with Lots of crossover With you And your family And each other In the community How do you Look after yourself And how do you Kick Making the best Ethical decisions When things are complex And not simple And clinical supervision In the aisle At the IGA Yep I've been there I noticed there was A couple of Comments About telephagology Rather than telephagography And Just used this opportunity To Say that The Icelanders Uni Has a telephagology program Which links into One of the rural towns In South Australia A bit of a pilot program And A bit of A way That they provide The provisions For their students By Having them Engage In A therapeutic With A couple of clients Over a period So you can See the same Psychologists On a few occasions For their term Whilst they're also Being supervised By A Practical Teleclinical psychology Is happening It is a pilot It's not Is generally available But certainly I provide clinical supervision And I receive Clinical supervision By telehealth Through telehealth And certainly I Will have to Agree Very, very strongly With Alan You have to meet the person In person You have to meet the people In person On a few occasions A year Providing that support And receiving that support Only by Digital telehealth network I think It wouldn't work You need to be able to breathe The same air For At least some part of that Yes So having that Strong External Clinical support By a person Who's in a similar position But physically That's really That's very And Graeme I wanted to go back to you I guess particularly with Your Work in the The area of Suicide prevention How do you Again I suppose it's a similar Kind of question But sometimes These are really Very difficult situations And as you pointed out Stations Just as much of At risk of dying As some of the people Collapsing in your Emergency department And you have to prioritize that But how do you as a GP You know Hold yourself together I've not Done very well in that Department And I should be Shame to myself But The way I've done it Is just to work harder And As long as I keep Working harder I find I can just put it In the back of my brain But I can't now Watch Anything on television Where anxiety Or stress Builds up I just have to get up And walk away But that is To expose your therapy And that's The daylight's out of me So I'll just keep Getting up And walking around But I can do Without movies And that sort of stuff While I've Got you there Just a couple of interesting Things One of the The tricks I use Was to turn my wife From a teacher Into a Mental health counselor When she became A mental health counselor I said We can't work in my area Because that's Going to be a conflict For us But It's just One of the Mental health counselors But I've made it work In another area Because of The conflict involved There's just one other Final thing I really want to say That I think is Really important About suicide Prevention Most of our people Nearly all of them Get well Again But the risk For their suicide Actually increases As they're getting better Particularly for The first two Or three weeks And it doesn't Matter what Modality you're Using Some psychotherapy Medication As They get better Then Often they'll Be motivated To go And Suicide Because The depression Doesn't Improve as rapidly As their motivation Does And if people Tend to be A little bit Reactive And work On the Spare of the Moment These people Need to be What So if Someone's getting Better I'd be Watching him very closely For three to four weeks Until Those suicidal thoughts Have evaporated All together. And Graham What do you mean by Closely? How many times a week Might you see him? Well it depends If they've got Strong suicidal Thoughts I never ask People with Those suicidal Because they Always say No I say Have you got The stage Where life's Not worth living And they say Oh yes You can do I thought I Might drive My car Into a tree Or I might gas myself And I said Well if you don't Think about it Well yes There's a rope In the back Of the car That to me Means automatic Admission Or detention You know You just Gotta work out How How strong Those suicidal Thoughts And how Further Progress down The track You've Just been so I really appreciate your Honesty And I think that's one of the Things that's lovely About these webinars People are really Real people Who are trying to do Real work And that's I know The participants Appreciate it too And I wonder If you had any Final Messages You'd like To get across As you can The message Most mental illness If we get it Early Can be reversed Can be put back to normal And I can't Emphasize the importance Of early intervention Of studying To screen people Even your surgery It's very easy To ask those Three questions You've got a sore throat Have you A use Does it keep you awake At night Yes it does How long have you Been sleeping All about three Of all months All of a sudden You've got a trigger That maybe There's Something else Going on back there So you've got to Keep looking at your Community To ensure that Where they go They're going to Get the right support For example I wrote out A list of questions My nurses Ask when they come To accident emergency So when someone Comes with emotional Problems or whatever Instead of saying The doctor's too busy Or fobbing them off Something's done So I think If we Get community Ownership And community Driven Responses It doesn't take Money it takes Someone that cares And it's got The motivation That's a great Note to Finish on from you With your Years of really practical On the grand experience Now I'd like to Invite David If you'd Have a few Final comments For a couple of minutes Thanks Mary We're discussing A man in a rural In a rural town And his wife And their circumstances And in many respects He's an amalgam Of many of My own clients And I'm sure With the other Panel members I think it's Interesting that We Tend to Think about Men's Mental health In terms of Seeking You know We've Just said that You know Men are Emotional Philistines So rural men Have had to Be emotional Philistines In order to Weather their way Through the Bluster Of rural life And certainly Very Very Very Very Strong Brave Men Are Completely Paralysed By fear When they start Talking about Their own emotion And so I I Try to That Instead Take it away From the Help-seeking Context Because That's The language We tend to use People And I try and Put it into The Take action Context This is about them Taking action In order to Improve Their lives Their families' lives Their lives And their lives We would Make It's Really practical I'll use it Tomorrow Thanks very Nice David Tim Would you Like to Offer a couple of Final comments Not really I think We've kind of Covered Just about Everything I Can think of And I must say The Participants Are covering Lots more I'm having a hard time Keeping up With all Of their comments There's Some great discussion Going on I think for me Meeting Jason Where he's at Giving him As Graham Mentioned Giving him Some hope That Keeping in mind The context That Jason has He's A farmer And all that That means About his connections To the land He's now Dislocated from the land In a For three weeks at a time In a Community Where he feels Like an outsider And also the impact On Wendy That She's kind of Carrying the can And looking up For the kids And the farm And keeping things Together They're really Doing it tough At the moment And it is Something That I think That they'll Need a lot of support With But it's Also something That I think I'll be able to Get through Rural and remote People are Amazingly Resilient And creative And I've No doubt That they'll Be able to Figure out A really Satisfying Solution To this And so Thanks so much, Tim And Alan Yes, you can Back up here I First of all I think the issue Of stoicism Is really important And it's not Just an issue Of rural men Although obviously It becomes A fairly Marked In those Circumstances That have been described But The problem About men's Mental health In general Is something And the way That they Have A physical health That's not About mental health And We need to address That And there is In Next February There's The themes Mental health Service Conference Of Australia A summer forum On that issue On men's Mental health With Max Birchwood Coming from England Amongst Others And the issue There is That it happens In drought Conditions That happens In younger Farmers As well This is a Young dad In some ways Early middle age It also happens In young Disaffected men And We also Need to think About How their Women's Folk Deal with this And adapt to this And How they can Help them most So Men's mental health Isn't just about Men And how to Get past this Fairly similar Issue How to address Suicide We've heard the opinion That we shouldn't talk about Suicide directly Because men Don't want to talk about it That's true On the other hand We've also heard about You should ask About suicide At some stage Well, I think There are ways to get There By bit You start asking About Whether people Have felt Our thoughts In some way Whether they felt Get to asking About whether you think You might do anything To harm yourself You know It's a continuum And I think You can get into a conversation As far as stoicism You can join That conversation Either individually Or that's where Men's groups do come in Because then Men can start Talking about emotions Gradually And I think It's a matter Of making sure You persist Until you actually Start dealing With some of those crises When people Feel really comfortable With each other And I think There's a commitment With permissions We think We just engage At the beginning But in fact And it's been talked About earlier today Tonight That we need to talk About Sustaining That engagement Engagement occurs At every stage And as you get More and more comfortable With people You can talk About deeper things So I think We really ought to Be involved Without the last thing With involuntary Treatment And people ask me To address That There are Sometimes when you have To do involuntary treatment I don't think We do enough Either urban Or rural To make sure That we make the conditions Appropriate And congenial For doing Voluntary care We know That we have A repertoire Of evidence-based Ways Of Producing A therapeutic Alliance And of Finding ways Where people Can keep Their agency And keep Their living will Like-shared Decision-making And there's technology That has helped That along And we need to Use that repertoire Systematically So that we Maximise the amount Of Involuntary care Because I think We overuse Involuntary care In English-speaking Countries Not just Australia Both in the Community and in Hospital And there are better Ways of engaging People As Graham Says too In a way When they need help They won't shy away from it Because they're You're going to remove Their agency Thanks so much Alan And I'm sure that's Actually probably A topic we should Consider for another Webinar because I think It's a really Complex topic With lots of different Ideas And that's Actually a really Good idea So thank you so much For everybody's Contribution tonight Particularly Your humanity And the practical Tips that everybody Has provided And I know that The participants have Appreciated that There's been About 260 people Online tonight And I know lots Of people download These later The podcast are Available in a few days Time The next Webinar Will be Working together To support the mental Health of injured Workers Which is a really Interesting topic On the 19th Of August You can register Through the MHPN Website Please make sure That you completely Exit survey Before you log out And you will be Within two Or three business days And thank you all Again And we look forward To seeing you At another MHPN Webinar Thank you And good night