 So good evening. Welcome to tonight to the 583 participants that we've got here tonight. For tonight's webinar on a patient-centred approach to achieving better outcomes for people who've been schizophrenia and the viewers who are watching on the podcast. So the Mental Health Practitioner Network would like to acknowledge the traditional custodians of the land, seas and waterways across Australia upon which our webinar presents the centres and participants located. We wish to pay our respects to the elders past, present and future, for the memory, traditions, the cultures and hopes of Aboriginal and Torres Strait Islander Australians. So hi, I'm Julianne White and I'm facilitating tonight's session. So just a little bit about myself. I just want to, I won't take very long. So I'll just scroll down my screen. I'm an accredited mental health social worker having graduated in 2003 with a master's in social work and this is after 30 years as a registered nurse in a variety of health settings. And I founded the Emerance Foundation in 2009 and with my amazing team of counsellors, support workers, nurses, mental health nurses and mental health social workers who provide a range of support and therapeutic services across southern New South Wales and North East Victoria. And I'm thrilled to be your facilitator this evening into the discussion that is very much needed and very dear to my heart. So understanding the lived experience of people with schizophrenia and hearing from a range of speakers here tonight while having an opportunity to participate in this interactive question and answer session will hopefully reinforce your already existing skills or provide you with information and resources to be able to venture tentatively and gently into this space and that is working alongside people with schizophrenia. So tonight I want to introduce you to our panelist. So here we've got Russell. So Russell is the lived experience and an advocate for schizophrenia now. What I'm going to do is ask each one of these people an introductory quick before I go on to the next one. So Russell, in your bio you mentioned that you are always on a constant pathway to recovery. Can you please tell us that everyone here tonight what is one of your recovery highlights? Early days volunteer work was important in terms of the value of not only a voluntary hospitalisation and the admission, but also the value intrinsic in giving to others rather than being a taker. So for me about I believe in a philosophy of being good to others and that's helpful in terms of the values and the skills that I've learnt through the voluntary work that I've done. And I carry that through onwards and upwards in trying always to do those little things that people remember or helping a lady across the road or helping a mother with their shopping when she's got a hand full of kids and shopping and all that sort of thing. So just the little things that you can do to me is about making a difference and I guess motivation is about making a difference as well. So little things that I can do that I can contribute to. That is really beautiful Russell. Thank you for that. That's really lovely and I think that's really important to have to remember as clinicians that it's often the little things that really do matter. Now over to Dr Kathy. Dr Kathy Andronis from Victoria Sheep with the General Practitioner. Welcome Kathy. Now your introduction. Hi. Your introduction Christian is for your patients living with schizophrenia. What are some of the benefits of having a stable relationship with their general practitioner? Well having a stable relationship with a GP is usually the best way to get the best outcome really. So good engagement with the usual GP on a regular basis is really important for getting best outcomes, getting to understand that person, knowing their supports, understanding their families and most importantly to be holistic and to treat the patient not the disease. So a good relationship with a GP can hopefully achieve that. I've got a follow-up question for you in the Q&A about that but thank you so much Kathy. That's lovely. And now we go to Melissa. Dr Melissa Connell is a psychologist from Queensland. Welcome Melissa. Now Melissa I've got an introductory question for you and I note in your bio which is really lovely to read. Excuse me. That you work with the Australian Psychological Societies, Psychophysicology Interest Group and the Australian branch of the International Society for Psychological approaches to psychosis or the ISP is. Could you please explain? I've never heard of these amazing groups. Could you please say what do you do in these groups? Melissa sounds really interesting. Yeah thanks. Well we know that people who have a diagnosis of schizophrenia often struggle with the way this is seen through a biomedical framework and medication is often the mainstay and sometimes the only form of treatment and unfortunately medications also have a lot of significant side effects and adverse health outcomes so psychological approaches can really play an important role in treatment and they're not often recommended to people who may struggle with psychosis related difficulties so the organisations that I'm involved in are really trying to promote psychological approaches to understanding and supporting people with psychosis related problems. Oh wonderful look thank you Melissa I think that's great and I'm sure you're going to explain more about all of that in your presentation too aren't you? Yeah fantastic thank you. And now we go to Dr Richard Lakeman with the Mental Health Minister from Queensland welcome Richard. And Richard your question is what is it that you find rewarding about working with people with schizophrenia? I'm privileged to have trained as a nurse and a psychotherapist and one of I guess the unique experiences that we have has been prolonged periods of time over long periods with people in extreme states so that affords the opportunity to really understand or attempt to understand their experience and I find that enormously rewarding the different perspectives, the understanding that can arise and that kind of relationship over a period of time and I guess also in relation to what Melissa was talking about in terms of psychological strategies being able to adapt and apply those strategies in the context of that kind of different kind of relationship not quite psychotherapy not a 50 minute hour but walking alongside people and then seeing the rewards from that, the personal and functional recovery that generally ensues. Oh Richard that's a really person centred approach isn't it I really love that when you really appreciate that experience with people and the positive outcomes so thank you for that. So thank you to all our panellists tonight that was really excellent I really know we're going to have a fabulous evening so I hope my notes don't get in the way for tonight being my first webinar but to all the participants out there we're now about 740 participating with us but just to introduce the webinar platform. So there's a chat box which is your purple button so if you want to assume that's about with yourself and if you have a question please use the blue hand button and enter your question into the blue hand button and please put your question so I'll be monitoring the question throughout the presentation today. The slides and results are available from the light blue download button and there's a help button if you need assistance so that you can message red back directly or you can ring them on 1-800-733-416 Hang on a minute I went just a slide so the third slide so what we're going to do tonight is we've got everybody giving all the panellists giving a discipline specific presentation which we'll then be following by question and answers. We've already got up on the screen before the learning outcomes for tonight so I'm not going to go through them tonight because I think what we've got to talk about we want as much time as possible to talk about our case study. So if everybody's ready I'll move through on to discussing with our first presenter tonight and that's going to be Russell who's got a lived experience of schizophrenia and an advocate but I want you to just go back to think about the case study of Cynthia who will be talking about tonight and relating our information back to Cynthia and her personal particular situation so Russell over to you. Thanks Julianne everyone. Just some tokenistic things that have helped me along my journey that maybe in the context of Cynthia be useful for someone like her but bear in mind that it's just I'm just one off one off thousands of millions so this is really the key things that have worked for me that I'm trying to I guess relate so believing in myself or believing in something better medication which is was an imperative part of my medical team doctors and family alike it's important that I found a doctor that did believe in the medication rather than just prescribe it without any real knowledge or understanding of the implications of it and how to fine tune it and tweak it if a need arises sometimes however medication's not the be all and end all because in my case sometimes it overcompensates or undercompensates with the brain chemistry on the day so having a backup philosophy or some sort of belief system in that you can attune yourself positively too I found helped and the medication was a good recognised system and a staple I guess in terms of my recovery I really benefit from that belief in the medication both from my doctors and my family I'm not one to condone or condemn the church but more so I'll put it up there because it's a belief in something and you've got nothing else but hope then I think a belief in something is more tangible to subscribe to moving on to the next slide I talk about accepting the illness and accepting that you have a condition and although it's hard to get your head around life long you think as a consumer or as a participant myself with the experience it's easy to think you have a good day and you don't need the medication or that things are okay they're going to be okay but life cycles often if you're observable for everybody observable so it's important to be able to see the forest through the trees and also know that things will get better if you do have a bad day or a bad couple of days but also know on the flip side that not every day is a good day knowing vice versa that things can turn those ups and downs knowing the pieces of trust is where the insight is gained I believe when you outside of your comfort zone the biggest learning opportunity for any individual and for me that is where the mentoring and coaching and the support that I got through those periods of time when I needed help wasn't when I was doing really well it wasn't when I was at rock bottom and bedridden it was when I was on the way down really garnered me some strength and optimism in getting through the difficult times I guess accepting that you have an illness accepting that it's not a week well I've written it as a weakness but it's not actually a weakness because of all the support around you how lucky are we to have all the life coaches and the best people in the business in the health field and others industries to want to help people like us to be better people if you can get on top of your illness early by doing the right thing taking the medication following the treatment plan we can have a reasonable quality life I believe those things are important and as we get older we want to help the younger people so the support seems important I think just moving on to the next slide about the ups and downs I note that any ship will nearly always self right if tipped over the cycles of life the avan flow of the tide we all know these matter wars and things it's just helpful to know that things will come good again it's a bit like rolling the dice eventually numbers eventually the numbers come up they come good it's hard but like right now trying to present information that I'm not so confident in but I know that at the end of the day this seminar webinar will really work out for people and believing in what we're doing is helpful so talking about favourite foods there's sometimes moments in the schizophrenics or the person who's schizophrenic in his life where things aren't great the chips are down so having a favourite food or something to focus on as a reward or an incentive even if you can't have it at the time certainly a bit like the donkey and the carrot I guess it does incentivise you to reward and it does certainly help to have something of a grounding even if it's in your own mind but those obviously a lot of problems come up they can't always be discussed can't always be easily spoken about so having a little self reward is helpful and just one last notation about Christmas in family gatherings which for the schizophrenic or person schizophrenic it's very very hard often family gatherings for the pressure of stress the fitting in with the rest of the world and the family who know you, who knew you it can be very confronting and very difficult for other reasons as well so just finding it, keeping in mind a place where you want it where the person wants to sit has always been helpful for me just so you can care fit in but you can also have it get out if you need to it doesn't matter who you necessarily are sitting with the experience of gatherings or any other social activity where it's a little bit uncomfortable a bit like the rewards achieve it's a bit of a grounding technique that I've used and has really helped me along the way, rewards are positive they're not always constant but life's problems and answers aren't always constant so just having something to take the edge off I find through that grounding experience is really helpful and I think it's, that's me and I think it's back to you Julie Julie Anne. Well Russell look thank you so much for everything you've said Ben as a clinician your words have been really powerful and I really thank you for your honesty and I think there's an awful lot that we can use that will bring up in question and answers so thank you so much Russell that was really excellent. You're welcome. And you can go over to Cassie now and Cassie is going to talk about the diagnosis and etiology of schizophrenia so over to you Cassie. Hi everyone look the first slide that I've got is just the DSM-5 diagnosis of schizophrenia it really is there really as a revision. To make a diagnosis of schizophrenia you need to have at least one month of symptoms from a group including delusion hallucination disorganised speech organised behaviour or catatonic behaviour and what we call negative symptoms which are reduced emotional expression or lack of volition, reduced self care perhaps and impairment in one of the major areas of functioning for a significant period of time since the onset of the disturbance and so often we'll see people who have had disturbance in their work, interpersonal relationships or in their own self care. Overall we have to have reduced functioning for at least six months and it's important to differentiate that this person doesn't have schizoaffective disorder or bipolar or discretive disorder with psychotic features. When the diagnosis is very difficult and often these diagnosis change over time and it can be a lot more tricky than just applying a DSM-5 diagnosis and just briefly the etiology that we're looking at there's so many causes of schizophrenia it's not really understood that well as a disease. It's thought that genetics and environment both interplay and the precipitating and predisposing factors will be very different for every individual so it's very important to treat the individual as I mentioned earlier not the disease. People with the genetic risk we usually find family history as one of the greatest predictors of risk and if you have a first degree relative with schizophrenia you will have a badastix fold relative risk of developing the condition yourself and this increases to times 14 relative risk if you have two or more first degree relatives and 50% if your identical twin has schizophrenia but as we know that means that in most cases probably having an identical twin you're equally likely not to develop schizophrenia and so environmental factors are hugely important past traumatic experiences are thought to be important perhaps some exposure in utero to infections or in early childhood may be also important in the development but also things such as drug and alcohol very important. Brain chemistry changes have been noted but we really don't really understand those nowhere near 100% if we know there's a relationship between schizophrenia risk and autism and OCD for instance but substance abuse is a very important differential diagnosis drug induced psychosis in younger people can be very difficult to separate from schizophrenia and it may be a prodrome of schizophrenia or it may be just something related to drug use but we certainly know that drug use can promote and precipitate schizophrenic episodes so moving on to my next slide common symptoms and challenges well as I mentioned diagnosis is often uncertain and it's quite common for patient to receive multiple diagnosis so often they're provisional diagnosis and the diagnosis can change over time I've had plenty of patients who have been given diagnosis of schizophrenia and schizoaffective disorder and personality disorder and drug induced psychosis and in the end where it becomes very important to treat the person with what they need to be treated with at any particular time there's no biological marker for schizophrenia if you compare with heart disease where we can do tests and say yes this person has schizophrenia it's usually a historical assessment and so it really helps to know the patient or the client person and over time you may find that you need to modify your diagnosis or your impressions so diagnostic uncertainty is very distressing for patients and is very stigmatising and I think that that's what Russell was saying earlier and the importance he noted of accepting your diagnosis but I think that takes time and I think a GP often is faced with a challenge of having to give a diagnosis that people don't want to hear which is totally incompletely understandable so supporting a person through that just takes time and we know that people with schizophrenia especially in their early stages have a lot of denial of their disease because I don't particularly see that there is anything wrong with them. GPs are often put into a double bind which is often what has got to be one of the etiological factors of schizophrenia in the past because we must label patients in order to be able to prescribe medications and to start treatments to do plans so PBS and Medicare require that we have a diagnosis but we have to sort of be able to remain sensitive to patients' needs and concerns about that stigma and about the medication so in fact the diagnosis is really for us as providers and for administrators and so this is an important thing I find to explain to patients that I'm not labelling them as a person I'm labelling their illness at this moment and because we need to label it in order to be able to manage it and treat it with the best things that we've got available in our society and our community. Since he's a very typical patient but there's no absolute ideal or stereotype patient really everybody expresses their illness very differently and GPs are experts at individualised patient care and so understanding the person is the best way you'll get a good trusting relationship between the doctor and the patient and having a regular GP gives you best outcomes so there are studies that clearly show that the patients who have regular, reliable GPs that they see on a regular basis have the best outcomes in schizophrenia and in most diseases and illnesses generally actually so for GPs schizophrenia provides multiple challenges but also opportunities to help people access evidence based approaches that will help them to be most effective. Melissa mentioned earlier that she thinks it's important for us to promote psychological approaches and therapies in schizophrenia and I totally agree older GPs were very much perhaps taught in biological model of disease but we know that for at least the last 15 to 20 years GPs have been trained as they come through medical school and beyond in a biopsychosocial approach and as a GP we have to manage the biological parts which is the effects on the body because they're a high rate of comorbidities we have to manage the treatment and medications socially we need to manage isolation and social drift and poverty so there are lots of challenges related to being financially disadvantaged and obviously psychologically there are lots of effects of schizophrenia in mood, thinking, relating skills, anxiety so good engagement with the GP is on a regular basis is really important for avoiding the negative symptoms such as poor motivation, the withdrawal isolation, also managing anxiety, ambivalence helping people accept themselves, managing the stigma providing active follow up and engaging the whole patient is a whole of practice approach really so it's not just the GP it's also the nurse, the practice nurse, other GPs in the practice and also a multidisciplinary team to make sure that that person gets the best available care that is available for them locally and GPs are often the case managers usually the case managers and sometimes the only person that the patient will trust and if that's the case well we try to do all if we have to but we do it best if we have support and we have lots of people involved in the patient's care. We as GPs recognize patient's triggers a lot of the time so we get to know them and we can start to see early warning signs we often know their context and their family so this can be really helpful and our aim is to go along as Russell was saying early to support them on their journey so familiar GP would be really helpful so in the case of Cynthia the loss of her regular GP would have been something that would have placed her at more risk than the last few years and so as Melissa was talking earlier I certainly concur with her and people with schizophrenia absolutely definitely benefit from regular contact and counseling with FPS providers and they're able to engage with all types of FPS modalities with trusted therapy but it's really important about picking the right therapist and the right treatment and in the right dose for any particular patient at the right time and it's important that we avoid making judgments about people and make allowances though at the same time for their negative symptoms so there will be times that they don't really feel like doing particularly much of engaging so we have to be flexible and engage slowly and patiently so thank you Julianne. Wonderful Kathy that was a really great summary so thank you I think we'll have a few questions based on those in the Q&A. Now we've got Dr. Melissa Connell, so Melissa over to you. Great thank you so as I was saying before there can be a lot of value to bringing psychological approaches to supporting a person with psychosis so people do want to make sense of their experience and helping them to develop self understanding and build more effective coping strategies can have the benefits of reducing I guess the reliance on medications. Well medications can be very important, being able to get by on lower doses can lead to improvements in quality of life and well being. And as people develop better self understanding and are able to manage difficulties that arise hopefully that can also lead to a minimization of the need for hospital admissions and of course psychological approaches are always working within a recovery framework. So referral pathways to see a psychologist many people come through better access but unfortunately there's just 10 sessions a year so that often means you know meeting less frequently some people that have been lucky enough to get an NDIS package might be able to see a psychologist more often but there's also private health options and both government and NGO mental health services. So for Cynthia I think it's really important to get a good developmental history but I might do a timeline with Cynthia and look at some of the things that have happened in her life and how it's affected her because we know she's had some significant adverse experiences that may be predisposing factors in her developing psychosis later in life. I'd be using a stress vulnerability model and that could be very helpful as well with understanding the psychotic experiences that have emerged more recently for her. There are a variety of assessment tools that could be helpful, the SyRAPs the Maastricht interview which looks at voices and the BPRS. So I'd be wanting to work together with Cynthia to develop a collaborative formulation where we can look at making sense of what's going on together. I'd be wanting to build a really strong relationship with her so that she can build trust with me. Sometimes people with psychosis have had negative experiences with prior mental health treatment especially hospitalizations can be quite traumatic so building trust and having a strong experience is really important and I want to respect how Cynthia makes sense of her experience and I want to be careful that I'm not imposing my interpretations onto her understandings. So I'd like us to both, well to come up with the working hypothesis together. So I think to begin with we'd really want to look at reducing her anxiety and distress and we know that these are big precipitants of psychotic experiences. I'd be looking at building more adaptive coping skills for her to manage. Also there's a potential that there's unprocessed grief associated with the loss of her father that may also be precipitating her difficulties improving mood, increasing her activities and again that recovery orientation. I just want to point out that these are all very similar areas of difficulty that you'll find with other clients presenting for therapy to psychologists and often psychologists think that treating somebody with psychosis might be beyond their scope of experience or the expertise, very to do that but you'll find that people with psychosis have the same problems as everyone else. They struggle with loneliness with depression, feeling isolated and different from other people so there's a lot that psychologists can do to support them. For those people that might want to do more focused work with voices and delusions there are psychological approaches that have been found to be quite effective. Act for psychosis relating therapy for voices, compassion focused therapy for psychosis and CBT for psychosis. When working with voices the aim is to really look at the appraisal and interpretation of the voices and understanding the beliefs that Cynthia has about her voices because often that's where the distress lies and the distress is what fuels the struggle with voices. So you really want to be focusing on how she might change the relationship with voices because sometimes it's difficult to get rid of voices so how can you learn to live with them. And then relation to delusions, I'd be very careful because these are experiences that Cynthia accepts as they're real to her so I don't want to be invalidating or pathologizing of those experiences but I want to focus more on just reducing the distress associated with them, helping her to feel safer and building up her engagement with other areas of her life and it would only be over time if she was showing curiosity that we'd explore alternative explanations and that might be more within a CBT framework but that's something to do very tentatively. So over the longer time we'd be looking at things that are going to help Cynthia improve her sense of self how she might feel connected to others, finding meaning in her life, a sense of hope, opportunities for self-determination and always consolidating those more adaptive resources for coping and definitely linking her in with community supports. We'd want to understand her personal stress vulnerability factors because that's very important in relapse prevention. Ongoing support for managing anxiety services would be important. She may like to participate in hearing voices groups and it's worth exploring if there isn't any unresolved trauma associated with things like the bullying she experienced and there are trauma focus treatments such as the MDR that also have been found to be effective so I'm hopeful that I would have a long term relationship with Cynthia and we could continue to work together in years to come. Fantastic, thank you so much. That was really great and I think we're going to have a lot of good fantastic questions coming through about all these presentations so focus forward to that. That was excellent. So now we're moving over to Richard. So Richard over to you with your presentation now. My experience has largely been in terms of having a long term relationship with people either in long term psychotherapy in a set of community treatment teams where the time period is kind of open ended where we might work with somebody. So I would enter this relationship with a sense that we're in this for the long haul that we don't need to panic and the really the first thing is to get to know each other and build some kind of shared understanding and in particular attempting to understand the world of Cynthia experiences it with some curiosity with humility with respect with openness. Basic and pathetic listening particularly for the untold story. As Melissa alluded to often people come with a history of trauma. Often we come with their own assumptions about how things have arisen and we should always be open to be corrected. Some people might see this as an assessment phase. I see assessment as a sort of a process rather than an outcome. It may involve doing some explicit kind of conversation around voices. It might involve something like open dialogue which in itself is an intervention in that people within the network get together with an openness to develop some shared understanding through dialogue. Whenever you get to know somebody and this probably applies to people with a range of problems I always find it useful to ensure that people go away from the get go with something which is helpful to them. And it's always useful to normalise some of the extraordinary experiences that people that experience psychosis might have. Hearing voices are not that uncommon. Jumping to conclusions, having certainty about things that we later find out that weren't founded are really common experiences. So normalising that, sharing that can be really helpful. And exploring positive mental health, using a framework such as trauma, trying to find things that give positive emotion, that engage Cynthia, promoting meaningful relationships, doing things that give a sense of accomplishment, purpose, physical activity, nutrition, sleep and so on. I think the most significant and salient thing in Cynthia's story was that she's grieving. She's also a really significant person in her life. And that grief needs to be worked through and experienced as well. And it's okay. It's not a sign of pathology. So don't panic. And it's really useful to try and mobilise and extend any kind of supportive network. So Melissa alluded to the Hearing Voices Network which is a really helpful and overcoming sense that people sometimes have that they're alone in these kind of experiences that no other people experience just like them. And then we move on to a kind of working phase where Cynthia begins to actually identify with the nurse or other as a helping person. And here we might begin to explore a detailed developmental and trauma history. Not as a moment in time but building up this kind of historical understanding of where Cynthia's come from. And here we really strengthen and mobilise what resources that we have. The coaching role is probably quite key. It's a good way, a useful way to think about this. And we might coach with dealing with paranoia and truest of thoughts. And this is where we can get some insights from cognitive behavioural therapy and other ways of working with psychosis. So things like the insight that having a thought does not make it a fact. And so changing the thought being a fact too, I thought that but I really know this can be helpful. And it's useful to coaching around that to play with that idea. And similarly having a strong feeling doesn't mean something bad will happen. So I feel but I really know that. And still in the working phase assisting with coping with voices, this is a handout that I developed around some research around coping with voices about 20 years ago and it's still relevant. So this will be available as a link. And so this assists people in dealing with some of those beliefs about voices that can be problematic. That is that voices are all knowing and all powerful. So exerting some control over the voice hearing experience. Dealing with the intrusiveness of the experience which can often cause distress. Here we might look at rationalising medication and really clarifying the expected effects of medication. So medication will not necessarily alleviate all symptoms. In fact it's very rare that that is the case. So what is the role of medication and how can it be helpful? And here we begin to arrive at some kind of working formulation and we might begin to do some real goal-fitting about moving forward. In the exploitation working ending phase Cynthia really begins to exploit the helping relationship that she has with the health professional. To clarify what needs need to be fulfilled and have these needs met in the context of that relationship. And therapy at this time might become more formalised and negotiated as suggested by the formulation. So if there are residual traumatic experiences and we may do some trauma informed work EMDR is suggested as one possibility. I like to consider the idea of advanced empathy as being a form of therapy in its own right. And that's really about not only just appraising and communicating with accuracy how another person it feels but actually making a connection between how they feel and what's going on for them psychologically or what's going on for them in their world. That's been written about by Jerry Egan recently and again there will be a link to some work that I've written around this notion of advanced empathy. Here we might also begin to really look at recovery planning we may well be well into that but the idea of relapse prevention so a wellness recovery action plan who's going to do what and when and any referrals if needed. Richard thank you so much. You brought up some fantastic points there especially at the end about how to actually link all this up together because the big part of tonight's webinar is that whole collaboration and how can we get the best outcomes for people. We've got some fantastic questions here that have been sent through so I'm going to, I've got a couple though that I've thought of as well but Russell I wanted to just catch base with you a little bit if I may you were talking a lot in metaphors and we had a bit of a chat before tonight about the role of metaphors and clinicians' work of using things like that and using your phrases like you talked about the waves and you can be very you were mentioning too that some people with schizophrenia or other capabilities can be very do you want to expand on that a little bit for me? Yeah just for mine speaking on the participants' terms is really helpful so metaphors if someone uses a strong case of metaphors in their repertoire for talking I think it's useful to engage with that however people with Asperger's very literal you said go let's go down the frog and let's hit the frog and toad they'd probably go get a hammer and look for a frog at hand or a toad but there are in my case I was brought up my dad's old school and bit of a knock about sort of in some ways and some family inventors are so we have a bit of fun with metaphors so it works for me and I understand it I think for whatever makes sense sometimes there's no easy way to sugarcoat things other than metaphors Yeah that's a really good point. Thank you so much Russell I think it's really important so and I like your differentiating between people with other conditions that might also sit alongside schizophrenia like autism or Asperger's that might be very literal but it's very much that relates back to being very person-centered to understand the person. Now Kathy I've got a couple of questions here there's quite a few actually from Ryan particularly up about factors to promote or hinder engagement with GP and how can we influence that relationship to be better. Do you want to comment about that a bit? Yeah thanks Julianne. I think the main issue is to not rush the relationship to build trust slowly understandably patients with schizophrenia have quite weary of professionals. They've often had awful experiences in inpatient settings so I think we first of all have to understand that they're going to be perhaps anxious. In fact likely to be anxious when they come to see a new GP and so we should be understanding is that trying to make that person as comfortable as possible and to get to know them as a person. I think the most important thing we can do is to forget about the schizophrenia for a while and think who is this person here and what do they like doing? What's their everyday life like? Who do they live with? How do they manage their everyday life? I think once we get to know them as a person we then find that they open up and give us a lot more information about the things that are distressing them and therefore we've got more opportunities to be able to support them. Yeah that's a really good point. Give it to Ruffin each other, sorry about that. There's another question here also about working with adolescent. So perhaps Melissa perhaps you would like to address working with younger people. Do you take a different approach or is there a slightly different presentation for adolescent? What's your feeling about that? Working with younger people can be a really powerful time. There are specialist services for early intervention for psychosis. You've probably heard of George and Malben and Pat McGarry, they've been real trailblazers in this area. If we can intervene early and provide a lot of support and a lot of resources, there's the view and there is some research that's showing it can help to avert that trajectory of the more persistent psychotic disorder. So working with adolescents it's definitely a big focus of treatment and it is a bit different. You need to work a bit differently with adolescents and really I guess try to understand what's going on for them but it's quite traumatic when somebody has their first experience of psychosis as well. It helps them understand trying to avoid some of the stigma that comes with the diagnosis of schizophrenia. We often hold off giving diagnoses such as schizophrenia because they can be quite self-fulfilling. People can feel their life is over when they hear that. There's some really good points and there's so much media on some of the television episodes portray schizophrenia in their fairly negative lives. They can have a real detrimental effect. I think just what I've got to there too though Melissa if you could and then I might go to Richard. But there's a couple of questions one from Keith and Kathy about the management of atypical transient psychosis without usual features of schizophrenia. Melissa just how do you actually work with it? I think he just mentioned to you that you've held back from a formal diagnosis of schizophrenia. Would this be in one of those instances? That's not a diagnosis I'm familiar with but I'm assuming that's more of a brief psychotic episode. When we know that psychotic experiences are more common than we think and there are people in the general population that when they're faced with significant stresses their risk for experiencing psychosis can elevate and it may not mean that they are going to develop a schizophrenia type illness but it's an understanding that they have a susceptibility and stresses such as not sleeping, taking substances into personal difficulties, whatever is going on for that person and put them over that threshold and so these experiences can resolve quite well and people can go on to manage that vulnerability but have another psychotic episode in the future. That's just my understanding of what that question was asking. I don't know if you think Richard or Kathy. So Richard would you like to comment on that? I prefer not to around the diagnostic issues. I think we can get lost in the diagnosis but in terms of what we can all agree on is that there's some psychotic symptoms can be very transient. Psychotic type experiences can be very transient and under stress or when intoxicated and so on. But the experience of that cluster of experiences that involve perceptual disturbance, thought disorder, delusions and so on can have a much more pressing kind of quality and people in the chat rooms have been talking about people with a great deal of complexity, they're pushing people away, their behaviour is driven by paranoid thoughts and ideas and we can meet the person wherever they are I think and it's our obligation to do so and to extend to them some helpful strategies to deal with the experience. Thanks Richard, I think that's a really good answer and I think that being present with the person is absolutely critical of the rapport building isn't it and that sense of knowing the person is so critical. So Kathy could I ask you just staying on that atypical transit psychosis so perhaps the first person's first experience is psychosis, is that something that you would see in a GP clinic that you might be looking to collaborate more with some of the people around you. Could you comment a bit more on that too? Yeah, early psychosis is really really challenging. It's very much about getting a history from the family quite often rather than the person himself is often very reluctant to seek treatment and so that's where it can be helpful to have a relationship with that person or with their family and again we need to aim to treat the person as they treat their symptoms, treat their functional incapacity to support them really because I think that and avoid making diagnosis especially for younger people because a lot of these things perhaps a lot of transient things are drug induced psychosis perhaps it's just an extreme form of anxiety it could be a situational thing so I think that we should try as much as possible not to get too caught up on the actual diagnosis as well it's not particularly helpful for everybody all the time so mostly we just want to think about what can we do to make this person feel and function better in their everyday life Actually that leads me onto is a fantastic question here from Tom that was put up previously and indeed I'll just read it out as it goes is it time to put the terms skip the free into historical context how far have we come with the terminology is this something we need to get rid of so what's your feeling on that Kathy? Yeah that's an interesting question I think it's very much going to be something that's important to continue with from the very theoretical academic perspective because we know that medication does help people a lot it helps a lot of people a lot of the time but many people with schizophrenia just use minimal amount so we are sort of stuck with diagnosis unfortunately but I think we need to take those with a grain of salt the DSM is now much much bigger manual than the first DSM so we should bear that in mind when we look at any diagnosis and if anything as people have already alluded to have mentioned this evening psychotic experiences are part of a continuum anybody under stress can experience a psychotic illness people with a fever develop hallucinations just temporarily so we have to be mindful of not throwing out the bag with the bath water you know we accept that diagnosis are useful but we also accept that we just have to manage people for who they are. Can I also add something just the community community education similar to what Kathy's informed with or seemingly seems as she understands pretty well from my perspective from a consumer's perspective is that we're just normal people just to have an illness it's no different to diabetes or asthma it's just a manageable illness. Yeah it can be pretty ugly to start with but you know I don't want to say anything too negative but lots of things are ugly scabs are ugly but you know big deal get on with it and then life gets better recovery is possible and is evident in a lot of people these days more so than back in the 70s or 60s or even early 80s so recovery is possible life is an opportunity and with the right support and the right group mindset from our community at large we can as consumers live a pretty good life or a reasonably good life without the stigma without the traumatic sort of experience that you get at work or from workmates or people they just don't understand so education is really education for the self and for others it's really important to break down those barriers I think. Well Russell gosh you put some great insights I think it's so so true isn't it that it's just learning how to live the best possible life you can isn't it but while I've got you there Russell can I ask you I mentioned this earlier to you but there's a few questions I'm noticing on the questions here about diet so there's one here particularly is poor diet have an effect on yourself and your experience so what's your experience of the relationship between mood, behaviour and food so would you like to comment a bit on that? I can only try but I think it's probably better verse than I am but I'm happy to give it a crack I love a meat pie or five much as any other place in this country but in saying that I know what it does and the effect on the brain chemistry in the body is biological organic matter or whatever it is the bloodstream, the carbohydrates all those things can have an effect just like medication can have an effect just like eating too much on the side there are obvious non schizophrenic type decisions or problems associated with the wrong food or correct food so some foods are really good and we all we don't nobody doesn't take an eye sign to know what you know fruit, veg, water, grains, meat, staries and all that is mine's cheese my dear but it's just a matter of looking after yourself as if you were the last you know like as if Kathy I think you're probably, I reckon you're better versed in diet, dietary sort of things That's a really good segue Russell thank you If I just had a brief comment in about diet there's no doubt that psychotropic medication affects metabolism and people do put on weight and they do find it difficult to lose weight however I think that is only one of the determinants and the other more important determinants that I see is actually social issues related often because of poverty, financial distress, people can't afford to eat fresh fruits and vegetables or they may be isolated or they may because of their negative symptoms not feel like getting out of bed and cooking themselves a healthy meal or buying fruits and vegetables so that's where I think psychological support and social support in a multi-dition plenary sort of team allows people to learn how to cook, I have patients who have found cooking lessons extremely helpful and useful, dietitians can be really helpful when they understand a person's context and how they can best support themselves and therefore develop the healthiest diet that they can Actually great, thank you for that Kathy it's really good and I agree with you sometimes it is finances that actually hinder adherence to a good diet it's just pretty expensive, a lot of people are on very low income so that's definitely, but I think it's still from a multi-distance perspective really important to include a range of clinicians and whoever else we can actually utilise to have that person realise the difference that they can make. Quite a few questions here about medication adherence, so one from Mari that says could you cover strategies for medication adherence and coping strategies so Kathy just having you back again can you talk a little bit about medication adherence for it? Medication adherence has always been one of the biggest challenges in people who are diagnosed with schizophrenia because understandably the one people don't necessarily believe that they have the condition or want to believe the condition and may not have developed acceptance that Russell was talking about earlier yet for their condition I think that's really critical once people can be gently supported to accept that they have that condition and that may involve lots of counselling and lots of support then they often can see the pattern that they do feel better and function better when they are on a particular dose of medication or are having particular supports in their life so I think that's a very important part of it to get adherence but we also know that different medications have different effects on different people so I think it's a conversation that patients should be having with their doctor or psychiatrist or the treatment team could I change to a different medication? Can my dose be lowered? What else can I do? I think there are options I think often patients with schizophrenia aren't particularly assertive so any sort of counselling that increases their assertiveness will help them to be able to talk about those things and to increase their adherence and therefore decrease their side effects by minimising the doses so we're not treating more than we need to treat just as enough or just good enough really for that person. Fantastic, happy, that's great and really important to have that collaboration between providers just as important. May I comment on that actually? Yeah just briefly because I've got one more really important question that I want to ask Richard for. I think it's really the importance that we treat people with honesty, that we hold them in high regard and we need to be really honest about the effects of medication with people. Australia has the dubious honour of having the most involuntary treatment of any country in the world recent study in Lancet psychiatry of 22 countries and we double the median number and the highest in the world. Compelling people, coercing them does not make them want to take medication so we need to build good relationships with people, we need to be honest about the effects and we need to enquire about the effects so we need to say what is this medication targeting, what can you expect, what is the minimum amount. If this is going to cause metabolic problems people need to know, they need to know about the potential risks associated with medication and really collaborate with prescribers and those that care about them. Can I also add who's that? Russell this time, the other Russell. Sorry about that mistake people. The good looking one. You've got one minute Russell. I only need 35 seconds. The medication adherence is difficult but if you have some success and hit some runs early on you're going to have more like a prolonged success with the medication regime so you can make a big difference early on which involves good psychological treatment and support and the medication is sort of secondary but also just as important I think you get better strike rate. Thank you for that. I want to wind back to Richard if I can. Richard we've got quite a few questions around hearing voices and you mentioned that in your work there so I've got some from Anita and quite a few other people here just about coping strategies for hearing voices and then I've got something around how do you normalise hearing voices. Do you actually engage with people voices? You have got one minute to talk about the impacts of clinician engagement with voices. Can you do that? I think there are a few kind of issues or kind of techniques or approaches. One I mentioned was open dialogue which is a treatment approach that was developed in Finland and in Western Lettland in response to what was called their needs adapted approach to schizophrenia and psychosis. So that's where professionals and sometimes peers engage with the network in a humble way to try and build some sort of understanding about the problem. So we don't go in there with our diagnostic lens equipped with our bag of pills. We go in there when people are acutely unwell and we try and collectively make sense of this experience. I don't have time to go into that and the other is the voice dialogue which is where one actually construes the voices having something useful to say that the voice content is meaningful and says something meaningful about the person's experience and then somebody dialogues with that voice so the individual themselves can actually go into dialogue with the voice which are considered disassociated parts of the self and so one can actually learn by engaging in a dialogue with the voice. Like say what do you want? What will it take for you to leave me alone if they're intrusive and so on? So again that's another kind of technique and people are wanting to explore that there are training opportunities and things around that. I would say join ISPS that the organisation Melissa alludes to or referred to. They have a book list so they produce publications. There are many of them on these different approaches as psychological and social approaches to psychosis. So I'm gathering a lot of those will be up on the resources page once they're rich. What we have to do now because we're going to run out of time very quickly but I want to go back to everybody and just recap quickly if you've got a pressing point or something you just would like to say you've got about a minute each. So Kathy can we go back to you? Is there something you would like to just finish up with tonight as a parting message for everybody to remember? I think the parting message I'd like to leave is that we should see people for who they are and develop relationships with them and really patient-centred. I support everything that everybody else on this panel said and I'd like to leave everybody with the thought of our job is to really offer people hope and to hold their hands as we support them. That's beautiful. Thank you Kathy and I just think they're beautiful words. Absolutely. Russell what would you like to let everybody take away with them tonight? Just that family and connectedness family connectedness, social and medical support is really imperative to make a big difference. It might not seem so in certain days to the professionals but you take that home with you and you think about what was said in an appointment or a week later you think what somebody said and it can have a lasting impact so the recovery is possible. It takes often some time for the penny to drop with certain advices and certain aspects but the information is all together gathering and really important. That's a really important point you know that recovery is possible. Thank you so much Russell I think that's brilliant. Melissa have you got a lovely parting comment for people to take as I'll remember from tonight? Yeah I think we really want to respect people's right to determine their own experience and we come in telling people they're delusional or what they're aware and posing our interpretations onto their experience and in ISPS we have a lot of people who are considered experts by experience and they play an important role in educating mental health professionals about what really is valuable and I think we really need to do more listening and less telling. Really good point Melissa thank you so much for making that so important. Now Richard just one minute have you got something that you would like people to take away? I agree with everything everybody said and I think people listen to people but also talk to them. I did some research about 25 years ago around how people coped with voices and the most surprising thing was people said nobody's actually talked to me about this stuff before and people were really enthusiastic about sharing their experiences so talk, listen, try and be humble and try and develop a shared understanding with people. I think recovery and every kind of recovery whether it's personal recovery, functional recovery is entirely possible and really where we should be aiming. Do you have and I want to go back to Kathy too. We've got a couple of minutes for a little bit ahead by one minute. Just about collaboration do we have any of you got something passionate to say about improving collaboration between all the players, the people living with schizophrenia their families, the clinicians, the doctors. Is there anything any of you would like to add or comment about collaboration specifically? Thanks Julie and I'd like to make the comments that the best way to pull for us all to coordinate care and cooperate is to pick up the phone and talk to each other. That's the best way that we can discuss and help people and not to just fit as invisible people in invisible offices. Pick up and talk and involve the person as well that lives with schizophrenia. Can I add? That's a fantastic point. Kathy thank you for making that. It's so good. I've got a point Julie. The good looking one. The good looking one again. His best days tomorrow. Thank you. And my twin brothers. Just one point for me is that mental illness doesn't happen 9 to 5 Monday to Friday. As unfortunate it is for those that work office hours for us it's often a Friday night or a Monday morning or a Saturday night or Christmas parties or whatever. That's really difficult but having preparation or mindfulness as to what those certain things look like and having the mindset of not the worst case scenario but for the clinician to understand what the person might what they're about to go through on a Friday night or a Saturday because we go through more on a Friday night than most of us go through in a month when we're really unwell and it's really taxing so just that it's not an office job. It is a full-time job but it's not an office job. Really good point Russell. Look thank you so much for making that point. And I think that's something we can all take away from tonight. It's not a 9 to 5 experience but we as clinicians and carers in the community must be very mindful of this from that person's experience. Look our time's up and I just want to thank absolutely everybody for contributing. Thank you so much to Light. I think there's been a lot of information. Just click the side over. And I just thank all of the participants and all the presenters tonight for giving us their time and their information. It's just been great and I hope all the participants have learned a lot as well. I do want you to complete the exit survey. You can see that up on your screen by clicking the yellow icon please. Do that before you leave tonight. And the next webinar will be suicide prevention and safety planning for the veterans community. This is going to be in partnership with Veterans Affairs on the 14th of November. And I think this is going to be a wonderful presentation so we can all consider joining in that it would be great. And just a really important point to make here is that the mental health practitioner network supports engagement and an ongoing maintenance of practitioner networks. So clinicians from different disciplines meet regularly with other mental health practitioners, share topics and resources, build local pathways and engage in CPD activities. So if you'd like to join your local practitioner network please contact the mental health practitioner network here or go to the new section of the website and indicate to your interest in the exit survey. And please consider joining a network. I personally find it extremely valuable. And before I close though I'd really like to acknowledge the lived experience of people and carers who have lived with a mental illness in the past and those who continue to live with mental illness in the present. And on behalf of everybody here I'd really like to thank you and thank everybody for participating this evening. So thank you very much.