 Hello and welcome to this webinar on mental illness, terrorism and grievance fueled violence, understanding the nexus. Very warm welcome to all of you who've joined us tonight for the live activity and judging by the number of people who've logged on. This is an area of great interest to you, as indeed it is to me. Very warm welcome to those of you who are watching us later on a recording and of course a very warm welcome to our panel, who I will introduce in just a moment. First, I'd like to acknowledge the traditional custodians of the lands across Australia upon which our panel and our participants are located and I'd like to pay our respects to the elders past, present and future. Just to give you a little bit of context before we get into things, the... Let me just get this name right because it's quite tricky. The Citizenship and Social Cohesion Division of the Countering Violent Extremism Branch of the Department of Home Affairs, that's quite a mouthful, isn't it? But the bottom line is that they have commissioned MHPN to develop and to deliver a couple of webinars for mental health professionals and the broad aim of these webinars really is to increase your awareness, the awareness of health and mental health professionals around issues relating to violent extremism and secondly to support practitioners and services to better identify and manage those threats when they come up. So this is actually the second of three and there'll be another one coming up before too long. My name is Mark, Mark Creamer. I'm a clinical psychologist in private practice and also a professor in the Department of Psychiatry at the University of Melbourne. And in my clinical work and certainly in the years when I was working in public sector mental health, from time to time I would come across people about whom I guess I was pretty worried about their potential for violence. And I certainly found that very challenging indeed. And so it's a pleasure for me tonight to be able to facilitate this panel and to pick the brains of our experts in this area. So without further ado, let me introduce them. Everybody has their bios already, so I'll keep it very quick. And first, I'd like to introduce Dr. Ines Rio. Ines is a very experienced general practitioner. She's also a GP obstetrician at the Royal Women's Hospital. As well as seeing a very wide variety of patients in her clinical work in a community health centre here in Melbourne, she's also on several advisory boards and groups. So thank you very much for joining us, Ines, and welcome. Thank you, Mark. When I introduce people in these webinars, one of the questions I like to ask them is what they do to relax and to get away from work. So let me put it to you, and I heard through the grapevine that you've got a fairly exciting trip coming up. Is that right? Oh, yes, I suppose I'm very excited about a walk I'm intending to do in Spain, the Camino de Santiago, which I'm sure many others have done as well, or are intending to do. Isn't it amazing, though? I was thinking that only, I don't know, ten years ago, perhaps I, and I don't think many people have heard of the Caminos, and now they are so popular, aren't they? It's a big thing. One of these days, I shall do one. Thank you very much, Ines. Our next panelist is Professor Michelle Pate. Michelle is a forensic psychiatrist and a professor at Swinburne University. She has a lot of experience in areas such as stalking, fixation and grievance-fuelled violence, and she is currently the clinical lead on the Victorian Fixated Threat Assessment Centre. So welcome, Michelle, and thank you very much, indeed, for joining us tonight. Thank you. So let me ask you what I asked, Ines, or let me lead you to an answer, really, again, about what people do to relax. And I hear through the grapevine that you're a bit of a sailor. Is that right? Yes, from time to time. I like to get up to Queensland and sail up with Sundays, but unfortunately, I don't get a lot of time to do that these days. I must say, if you're going to do sailing, it sounds to me as though the week Sunday has got to be a good place to do it. One of these days. All right, thank you, Michelle, welcome. And our final panelist tonight is Professor Alfred Allen. Alfred is a clinical and forensic psychologist coming to us tonight from Perth. He has a particular interest in professional ethics and also in the intersection between psychology, mental illness and the law. So welcome, Alfred, and thanks very much for joining us tonight. Thanks, Mark. Let me continue the theme one last time, then, and ask you about things that you do to relax. You're also a bit of a walker, I think. Is that right? That's right. That seems to be a theme. It does, doesn't it? A good way of getting away from it all. Have you got any exciting walks planned? Yes, so I'm planning to walk in Europe, specifically in Czech in July. Looking forward to that. Wow, that does sound impressive, I quite agree. Good. Well, anyway, I'm very pleased that everybody has strategies to get away from work when they need to, because I think it's pretty important, and especially if we're working in an area like this. So tonight, we're going to explore the issues around grievance-fuelled violence. And we're going to use the case vignette of Andy as a jumping off point. Now, all of you should have read Andy's case. It was certainly distributed to you all. And I would emphasize that this vignette is entirely fictional, but hopefully it contains enough reg flags and warning signs that are familiar to you that this is the kind of case that you can imagine, perhaps seeing in your clinical practice. And we're going to use Andy's story as a jumping off point for our discussion tonight. I'm going to ask each of our panelists to do a short presentation about their particular perspective on Andy and its story and the issues that are raised by that. And then we'll go into a broader discussion, driven by questions that you, our participants, have submitted. And at the end, we're going to have a quick look at some of the common myths in this area. And as a result of all that, we hope that by the end of the webinar, you will have a better understanding of the link between mental health and extremist ideology, albeit not a causal link, but a link nevertheless. We hope that you'll be better able to identify the potential for grievance-fuelled violence and the indicators of radicalization, especially where people are exposed to abhorrent material online. And that's increasing that I think an issue for us in this area. And finally, we hope that you'll have a better awareness of the referral pathways and be able to take appropriate steps if you're concerned that your patient might be, perhaps on a pathway to some kind of grievance-fuelled violence. Okay, I've got to do a quick technical chat with you. So this is a new, you may have noticed, it's a new webinar platform. And so it certainly scares me, I don't know about you. But anyway, at the moment it's working all right, we're going to keep our fingers crossed and I sure it will be absolutely fine. So all the usual stuff is there. Actually, so you've got a purple button to press to open a chat box. If you want to chat to each other or make general comments, use that. The blue button will take you to the resources. By all means, have a look at them now, but I'd rather that you hang on because MHPN will send you the link to the resources in a week or so and you can look through them all at your leisure. The green button is a refresh button if your screen freezes or something goes wrong and there's also a help button to allow you to talk directly to Redback who are our technical experts behind the webinar. There's an exit button when you want to get out. And the yellow one at the bottom is the feedback survey and we would really like you to complete the feedback survey but please wait until the end of the webinar before you do so. Okay, so now without further ado, I would like to hand over to our panelists to give their presentations, to give their unique perspectives on Andy's case. And first of all, I'd like to hand over to Inez to talk about Andy's story from a GP perspective. So over to you, Inez. Thanks very much, Mark. This is complex. Another day in general practice when you're not really sure what's going to walk in the door next. It's the first time you've met him. It's a work injury. So you're already thinking about all the work, safe paperwork you have to fill in. Your practice manager's concerned and you have an angry and agitated patient. So you're certainly hoping that you've got a double appointment and perhaps that you have a cancellation or two on top of that. You've obviously got multiple issues to deal with in Andy's case. First and foremost, you've got your own safety issues. Your own safety and the safety of your staff and the other patients. You've got a gentleman walking in. You've got this picture already before he walks in the door. And you may decide to do certain things to maintain and support your own safety. You might decide to reorientate the room so that you're closer to the door. You might do a semi-standing up consultation. You might ask one of your practice managers to actually check in a few minutes after you've started the consultation. You might even ask a practice nurse to come in and sit with you on the pretext that there might be a wound injury from the pallet injury on his foot. And in some cases, you might even leave the door slightly jarred. It's fairly incumbent to think about those things before he walks in the door. You've then got the presenting issue itself that you need to deal with. And in this case, it's actually a relatively defined, easy medical thing to deal with, but you clearly need to address other issues. It's fundamentally the role of the GP, and it's largely expected by patients that you do provide that sort of comprehensive care. And the general practitioner in this case really does. He opens up the door and says, look, as a GP, first time visit, I'd like to explore your past history, what medication you're on, what your living arrangements are, et cetera. And that's pretty much what you expect of yourself as a GP and by and large what patients expect. Your next immediate issue, and all of this actually adds to your understanding of Andy, because you've got this, you know, you've obviously got some concerns, and developing that picture is enabled by asking all of those questions. The immediate issue really is to establish his safety to himself and the others and other people, and you do that through that conversation. And on top of that, you work out, you know, what's happened before, what the risk factors are, and it informs your assessment of his aberrant thinking and behavior, and more aberrant thinking and behavior might come out during that discussion as well. You work out the deterioration in his functioning, and from that get a grasp of, is this a psychotic illness? Is it mental health illness? Is it a substance use issue? Or is it an extremist ideology? Or perhaps you can't work it out. You then need to actually think about how you can enhance that picture. You want to inform your understanding of Andy and what's actually happened over time in different, and in different situations, and certainly Melanie, the psychiatrist, does this for you. She gives a history of serious mental health issues. She tells you about his protective factors of employment, family, and housing, expands on the risk factors of isolation, his lack of a close other and online gambling. You get a sense of his underlying personality features of resentment, anger, and poor social skills. And you find out about the recent non-adherence to medication, but also to follow up and the changing behavior that's happened over that time period, which seems to precede the cessation of medication, but certainly seems to have escalated after that. On top of this, you actually get the picture of Wayne. And Wayne reinforces very much what you've seen in your room and the picture that Melanie provides, probably after the consultation, obviously, but these triangulate a picture of Andy. And Wayne's worried. That's why he's talking to Jane in the waiting room and that's why he's divulged information. And so you get a picture of increasing dysfunction and problematic behavior of others. It reinforces what you've witnessed. And then on top of that, you've not, well, you're alerted to physical changes that he's pulled away from his family. He has a changing group. And possibly that there's alcohol and marijuana involved. So really, where does that lead me as a general practitioner? There's a constellation of red flag. He has progressive and cumulative concerns over many months in many areas and in many settings. You yourself have witnessed this agitation, a targeted hatred and extreme views. And that picture has been reinforced and developed by both Melanie and Wayne. On top of that, you have his protective and safety netting factors being compromised and being pulled back. His family, his psychiatrist and potentially soon his work. Now that has two effects. Firstly, it has the effect of potentially increasing his dysfunction and problematic behavior. But it's also bad news for the ability for that to be addressed and identified by other people. So from a general practitioner's point of view, is this the interplay of mental health and extremism, fanaticism and violence yet to be determined that I'd certainly be greatly concerned? Over to you, Mark. Thank you very much, Ines. Thank you. There's a whole lot of stuff in there that hopefully we'll pick up on as we go along. But I'm interested that you ended up saying there that you're greatly concerned. And I guess just briefly, because really this is going to be the topic of discussion for the rest of tonight. But just briefly, where do you think you should go from there? What would you normally do as a GP from there? You're in a privileged position as a GP because you do have a continuity of care. So you're going to see Andy back in two days' time. Essentially when he relays the room in the first instance, you have a picture of what you've seen. You've had a picture of the information that he's provided you and you have a picture that's actually been provided to you from Wayne via Jane. I certainly would be speaking to Melanie in the next instance. In this case, he's actually got the picture of Melanie, but I'd be really formulating a way forward along with Melanie. Okay, that makes good sense. Thank you very much, Indeed, Ines. Let's move on now and hear perhaps more of a specialist's acotary perspective and perhaps a bit about the research and maybe expert consensus. So I'd like to hand over to Michelle to give us that. Michelle, over to you. You might be on mute, Michelle. I see the storm clouds gathering here is what I was trying to say. Yes, I think it is very reasonable at this stage to be, well, thinking of many things, but one of those needs to be, is this man radicalizing. So let's refer to something I put up in the previous webinar, which explains a little about the concept of lone-actor grievance-fueled violence, which is defined in the box below. Now, fixated people sit up in that category of attacks of public figures, but what really concerns us tonight, I think, is our lone-actor terrorists. And lone-actor terrorists, as opposed to group terrorists, much more likely to be grievance-fueled, and even if they attack, very often that attack is masked by some sort of ideology, religious or political or otherwise. Very often, of course, these people don't have much sophistication in the ideology. They have only a fairly superficial knowledge of that. Now, right-wing extremism is fairly under-researched in the Australian context. So I'm going to give you a few points, particularly as they relate to this case. Okay? Now, right-wing extremists, as most of you would be aware, have a xenophobic ideology. They believe in the superiority of the white race, and they assume that racial mixing threatens the survival of the white race. So based on skin colour, based on national origin, based on religion, all of these groups are seen as outsiders, people that they hate. And I should include the Jewish community as well. So we see right-wingers increasingly becoming more heterogeneous and broader in their spectrum, and that's something that partly stems from the downfall of the caliphate and Islamist activity globally. So right-wing extremists in order to sustain their movement have had to expand their focus, increasingly, to other causes and co-opt the grievances of other communities. So we're seeing now increasingly anti-refugee, anti-LGBT communities, anti-establishment, anti-gun control, anti-democracy, generally. They operate alone, but they are inspired by... and supported, indeed, by online extremist communities. What they do is they put out a lot of conspiracy theories and misinformation. They may misrepresent demographic data or use debunked science and draw people in that way. They are continuing to evolve as groups. We...of course, they've always attacked us. There's nothing new about that, but those attacks and the frequency of those attacks appears to be increasing. OK. So if we get back to Andy, I think there are very reasonable grounds in this case on the information we currently have to suspect, at least, that he is being influenced by right-wing extremism. And this radicalisation, once again, I've defined in the top of the page there, radicalisation essentially is a process. OK. Is he radicalising? Well, here's a number of the indicators that would suggest to me that, as I've said, he may be influenced by this sort of ideology. There's many more things I'd want to know that we don't yet know from this, things like his past history of violence, his weapon access, his weapons ownership, is he preparing for an attack, for instance? Is he training in combat or otherwise? And particularly, who's he talking to? What's he talking about on the internet? Does he have co-ideologues on the internet? But if we look at this list, I guess one of the things I wanted to focus on here is symbols. He has the number 88 tattooed to his arm. That is a right-wing symbol. It stands for H-H or Heil Hitler, being the eighth letter of the alphabet. So that's concerning. And also, I guess I'm curious about his funding, the fact that he's perhaps not as financially well-off as he used to be. Now, that could be that he's spending money on drugs or other things, but I would be very concerned also that he is donating money to extremist groups. So as I said, there's many other questions I have here as a single health practitioner. I probably won't be able to access a lot of that information. And that's why these sorts of cases really require a multi-agency lens. Mental health problems, clearly, from what Ines is saying as well, we have a mentally unwell man. It appears that his mental state may be deteriorating. Which came first? Did he stop his medications because he was radicalising and didn't want to see a psychiatrist who was a woman, for instance? Or has his mental illness actually made him more vulnerable to radicalisation? Well, we know in relation to mental health and extremism of any sort that around 40% of lone actors will have a mental illness. And that's pretty consistent across ideologies, including right-wing extremism. Why is that? Well, it may be that people who are more psychologically vulnerable, people who are disenfranchised, who might be alienated, are drawn to these sorts of ideologies because it appears to be a bit of a solution to them, perhaps simply because there's a sense of community in these groups. Also, people who already have an interest in this in right-wingers who may have been involved in protests, for instance, are people who, when they're unwell mentally, may actually become more of a risk there. Their beliefs may become more intense, their prejudices may become more intense, and they may have more resolve to act on those beliefs. And then there are individuals, of course, who are mentally ill. They may have a delusional illness, but they incorporate right-wing or other terrorist ideology into their delusional system. And the right-wing ideology, particularly, is right for that because of all the conspiracy theories, of course, that people pick up on. So I might leave it at that, Mark, that quick overview of how I see things at the moment. Indeed, very, very useful, Michelle. Thank you very much indeed. Can I just pick up? You did make a few references there to the internet. And obviously, this is something that has massively changed the landscape, not just in this area, but right across society. But can you just comment a little bit about, perhaps, why you think the internet is so effective in the spread of right-wing ideology? I think in general, there's little doubt that social media has really helped mobilize extremist views. For right-wingers, there's a range of the alternative social media platforms that they can use, and a number of things, like news channels and extremist messaging apps and image boards like 4chan and 8chan. And particularly with those sorts of forums, they're very loosely moderated, so it's the case of almost anything goes and you get essentially a breeding ground called hate speech and ideas. So as I said before, the internet is also attractive from the point of view of sharing ideas, being with kindred spirits, and promulgating this information, which is very often has very little basis to it, but obviously people are very willing to believe these things and incorporate these sorts of beliefs. Yeah, quite, quite, quite. All right, thank you very much indeed, Michelle. I much appreciate it. Let's move on now, if we could, and hear a psychology perspective, but particularly a particular emphasis on how we might go about making decisions with regard to Andy. So if I could hand over to you, Alfred. Thanks, Mark. So Andy consulted us today. How do we defend ourselves and our decisions if they are challenged on 18 February 2021 because Andy did something bad or because Andy made a complaint against us with a privacy commissioner? What questions might a critical and skeptical cross-examiner ask us? First, what was the context and did you identify the problem? Did you see the red flags? What process did we follow when we saw the red flags? What information did we collect or fail to collect? What conceptual framework guided your decision-making? Did you identify the issues you had to make decisions about, such as whether it's necessary to consult, refer, or make a report to the authorities? How did you reason in coming to your decisions about these issues? Did your decisions flow logically from the framework we used and the relevant information we had at the time? Did we review our decisions, for example, by consulting a peer? What did we do next? There are points where you will want to talk to others about Andy. So what are the rules about disclosure of confidential information? First, if you form a reasonable belief that there is a real risk of immediate irreversible harm to others, you face an emergency and you can immediately do what's reasonably practical. Otherwise, you follow the policy, procedures, and protocols of the organization you work for. Or in private practice, you follow your professional rules and they should be compatible with a Commonwealth Policy Act. The crux of this legislation is that you must only use information for the primary purpose you collected it for, unless you have consent to do otherwise. You may disclose information if you reasonably believe it's necessary to do so to prevent a serious threat to the life, health, or safety of any individual or the public health or safety and obtaining consent is impractical or unreasonable. Note the following, the word reasonably is of paramount importance because the case law says that there must objectively be tangible support for the belief. The Privacy Act gives you a discretion, not a mandate, and you must still justify your decision. This is disclosing information and respect your client's autonomy and privacy as far as possible. In law, the word reasonably indicates that judges will use an objective test. Was the tangible evidence such that the reasonable practitioner in your position would have done what you did? The best way of finding that out is by consulting peers, ideally with identifying your patient or with a patient's consent. The person you consult must be an appropriate person. Somebody peers would have consulted and you must make a written record as soon as possible about who you consulted, where and when, for example, date and time. What was the tangible evidence you had that led you to believe you should breach confidentiality? What was the advice that you received? In conclusion, Andy's case highlights several issues. We often make decisions in a vacuum because we don't know what we don't know, the dreaded unknown. Second, the tension between protecting our clients and patients' privacy and protecting other people from harm. And third, the importance of resources, such as a network of appropriate people and organisations we can consult or refer to. Thanks. Thank you very much indeed, Alfred. All sorts of interesting questions there. You, I guess, have provided us there with a number of sort of guidelines, but presumably they're not sort of absolute laws that are carved in tablets of stone. And I'm wondering if you can comment on how important you think considering the specific context is when you're making these kinds of decisions. Is context important? Yeah, so the issue that I often see when practitioners face a coroner's court or a tribunal is that they cannot fully remember the context. Two things then happen. First, practitioners do what humans do when they cannot fully remember events. They fill the gaps with what they think happens. The problem is that our memories are poor and they are therefore often wrong. And when they're caught out, it looks like they were lying. Two, other people using secondary material reconstruct the context. And that guides their decisions about the rightness of practitioners' decisions. So it's really important to capture the context and the best place to do that is obviously in our clinical records. Your patient records is really your first line of defense. I'll leave it at that. Yeah, yeah, no, absolutely. Okay, thank you very much indeed Alfred. And thank you very much to all our presenters for those formal presentations. I'd now like to open it up into a broader discussion. I'm gonna invite all our panelists to just jump in whenever they like and disagree or add something if they've got a different perspective or whatever. I should say at the outset that I've been very impressed with the number and quality of questions that you, the participants have sent into us. Excuse me. They'd be really good and really thoughtful and so on. And we would really like to go through and answer everyone in turn, but unfortunately, we haven't got time to do that. I think that we will get through the majority of them, but if we don't get to your particular question, please bear with us. The questions you sent in, I think generally fall under four broad headings. So the first one, it was about the nature of grievance-fueled violence. The second was about the professional responsibility and ethics. The third was about assessment and warning signs and the fourth was about management. And so we will try and get through all of those four areas, picking up some of the questions that you sent in to drive the discussion. So let's do that without further ado. Let's talk about the nature of grievance-fueled violence. And I'd like to bring you and Michelle right at the beginning if we could to go back to almost the essence of what this webinar is about. And that is the relationship between mental health and grievance-fueled violence. You did make some references to it, but I wonder if you could unpack it a bit, say a bit more about it, and I'll kick you off with a question. Is it, can mentally ill people really be terrorists? Is that a fair description to say to call someone who's got a mental illness? Yes, sir. That's possible, fortunately, not at all common. But there was a belief, I think, for many years, it's only in recent times that this has been debunked, that you're either mentally ill or you're a terrorist and you can't be both. And as I've said, some mentally ill people are vulnerable to radicalization, vulnerable to getting drawn into this sort of ideology, more often acting alone if they acted all. Many of these people were radicalized without necessarily ever committing any violence. So people can have radical thoughts without necessarily having a committing a terrorist attack. And many won't have the capability to do that if they have a mental illness. But some do, and there are people out there who are quite intact, personality-wise, who are high-functioning and who are quite capable of conceiving of a plan and carrying out an attack. It's that group that we are most concerned about because they're the ones in any mental health setting who are somewhat ignored, turned away, because they don't have a florid, bizarre presentation. They have quite delusions, scheming delusions, and they're the ones of concern, as I said. Well, I was going to ask, actually, are there particular conditions, particular disorders that you think are more of a concern? Well, yes. Certainly delusional disorders, which is a psychotic condition without the bazaarness and other symptoms of schizophrenia, and also schizophrenia itself. And also, we're seeing some problems with people on the autism spectrum as well. They're the diagnoses that sort of stand out, I guess, in the lone-acted terrorist research at the moment. But more... Sorry, go on. No, just to say, would it be fair to ask about personality disorders? Are they going to be fairly commonly represented? It's always fair. It's always fair, obviously, when I say vulnerability, some people have mental illnesses but also associated vulnerabilities, which include personality disorders and personality traits. But the thing to realise is that with the people that we deal with, very often it is about major mental illness and personality disorder, per se, as a standalone diagnosis is less common. I might say, though, that a personality disorder is often... or major mental illnesses may be misdiagnosed as personality disorder. Yeah, OK, that's a salient point to make, isn't it, really, for us as clinicians. All right, thank you for that. A number of people, you know, since we're talking about grievance-fuelled violence, ask questions about what can come under that rubric. And I wonder if I could bring you in, as with a difficult question, really. I feel a bit embarrassed about asking it and I'm glad that you're answering it and not me. Do you think that domestic violence can be called grievance-fuelled violence? And can you talk a bit about whether you think mental health, mental illness has a link there in domestic violence? Domestic violence is fundamentally fueled by disrespect and inequity. And unfortunately, we know that it's common, very common, probably one in five women and probably one in eight or one in nine men who have experienced it and have massive ramifications on individuals and families. It doesn't go hand in hand with mental health issues. It's really underpinned by that disrespect, hatred, inequity issue. And certainly, if you've got a grievance-fuelled violence that's towards women that's a misogynistic one or towards, you know, particular groups, that can fuel violence, especially when you have a position where you can, there is inequity and you can impose that hatred on someone and that translates to violence in a domestic setting. Sure, sure, sure, very complex, doesn't it? All right, thank you very much for that, Inez. And just quickly, again, I feel a bit unfair asking you, Alfred, this question, but what about racially-inspired grievance-fuelled violence, if you like? And I guess if we know that someone has strong racial views, for example, anti-Semitic views, is that something that we should factor into our decision-making process? Actually, I think the previous answer answered that question because I think anything that disrespectful of people should be factored in, and whether it's racial, domestic violence, sexual abuse, all of those things demonstrate an attitude towards people. And if we think of the history, I mean, some of the biggest mass murders in history were created because of racial reasons. So I don't think there's any reason, well, one should think about that. Also, I think there's some evidence out there that animal cruelty is also something that should be factored in. Yes, a history of animal cruelty. Yeah, yeah, it's okay, good, good point to make. Yeah, all part of our risk factor kind of profile, isn't it? Yeah. Michelle, I wonder if I could come to you with just a quick response. We hear a bit about sort of copycat kind of stuff. I'm wondering if there's any sense that that might be relevant here, some kind of copycat effect. And I suppose one of the things I'm thinking about is the increased apparent tendency to use motor vehicles to run down pedestrians. Do you think that's a kind of copycat thing operating? Well, copycat contagion effect, some people call it the Columbine effect after the school students in Columbine, but yes, I think if you're feeling suicidal and vengeful and all vengeful and something like this happens, it does provide some inspiration. It also provides methodology. And I think that's why we're seeing the increase in vehicular assault trucks, cars, mowing people down. As you say, there's been certainly an increase in that since particularly 2016, when there was a particularly tragic truck vehicular assault on people in Nice. So, yeah, people see these things. They see the attention and the infamy that these people receive, which is what a lot of lone actors particularly are looking for and espers them on. Yeah, yeah. Raises all sorts of very different questions for society, doesn't it? Let's move on to the next area that you as participants asked us about. And that was the broad area of professional responsibility and ethics. And I have to say, I think it's a fascinating area and I think we could easily spend a whole session on this. And I know that we can argue with each other about aspects of this. So, I'm just gonna pick out a couple of things that people sent in. And perhaps I'll start with you, Inez, because you did raise this really in your talk. Andy was coming just really because he had an injury to his foot. Do you think that the GP is justified in probing a little bit and pushing a bit further? Or do you think that that in some way perhaps violates his autonomy or his rights? Mike, I probably wouldn't call it prodding and pushing. I think I'd just call it exploring. And I think it's standard practice for GPs to actually go outside the presenting agenda. In this issue, the presenting agenda was actually a pallet that fell on a forge to actually think about that person as a whole person. And the only way you can do that is actually explore their broader issues with regards to past history, present history, sorts of things that were actually raised, medication, family history of issues. So I would say it's actually standard practice and it's clinical care. And it's how I see myself as a GP. I'm not sure if others feel the same. Well, I was going to say, let's bring Alfred in here. Would you agree with Inez there, Alfred? Is it a perfectly legitimate thing to do when I go and see my GP for them to ask me those questions? First of all, I think the GP's conduct here was very appropriate. And my own experience is that clients, patients, if they trust us, they will give you all the information you need and you can just explore. And that's quite appropriate. However, we need to also remind ourselves that the Privacy Act is actually quite strict about the information we can collect and that we should also adhere to that. But my own experience is once again that the Privacy Act and our professional ethics are both actually flexible enough. And that in a case like this, I would think it would just be natural to do what the GP did. All right. Well, while I've got you, Alfred, let me take it a little bit further. In our vignette, we saw Jane, who I think was the practice manager, she witnessed Andy having an altercation with his boss, Wayne. Would it be appropriate for her to then go and share that information with the GP? Do you think? Is that legitimate? Yes, I think so. Because first of all, she observed it is her own observation that she's reporting. She's got a responsibility to the GP to inform the GP that this person is apparently out of control and potentially a violent person. So under these circumstances, it was quite appropriate for the practice manager to do so. I would have been more worried if the practice manager would have gone and actually started collecting information from Wayne, for example, and started asking pertinent questions. I think there's a balance there. But once again, what happened in vignette where Wayne, out of his own accord, spoke to her about it. That's also appropriate. That's just human to listen to Wayne under those circumstances. And the GP ringing Wayne, is the GP allowed to ring Wayne? I mean, obviously, ideally, she or he would talk to Andy and say, is it okay if I talk to your boss? But without doing that, is it acceptable to ring Wayne? So if we go back to the Privacy Act, the Privacy Act says very clearly that you've got to obtain consent if it's unless it's impractical or unreasonable. And so that's the parameters that we've got to work in. So unless there's a real, very good justification for doing it without consent, one's got to have to be very careful about calling Wayne without the consent of a patient. Sure, sure. Michelle, can I bring you in here? I have another question for you, actually. But do you want to make any comment on those last two issues? I do, actually. I think that when people are making alarming comments of a potentially terrorist nature there, as we'll see later, there are places where you can seek advice and make contact. And one of those is, of course, the National Security Hotline. Say what you like about that. But I think that if Wayne's workmates were fearful and they really felt that something was going to happen, they have the option of doing that, then that information can be conveyed that way. But the other thing is, I guess, is with these potential lone actors, many of them do talk about how they're feeling, what they intend to do, and sometimes violent intentions before they act. 80, 90% of them will do that. If more people picked up on that, what we call leakage, we probably wouldn't have the attacks that we had. So again, it sounds harsh, but I think we have to realise that leakage is a significant factor in these lone actor attacks. Mark, could I speak to that as well when you're ready? Yeah, please do. Jump in, innit? Yeah. Look, I must say I agree with both of those cases. I think that with regards to what Alfred was saying, it's quite natural for a practice manager to come to you when she has observed something to ensure your own safety in that circumstance. And often, GPs work in the context of a general practice. So that information is often shared. I think the idea about ringing Wayne is somewhat different to that. He's actually quite different to that. With regards to work safe, there's actually a triad between you, the employer, and the patient, but that's really related to his foot injury. When we're talking about the other issues, which is his dysfunction and his hatred and the sorts of issues that he's espousing in that room, it doesn't actually take much to get this out of, and I think it's actually just sitting back, opening the conversation and listening to him. I think you'll find out lots in that room. And I think that ringing Wayne without his consent is a very different issue to potentially ringing Michelle without his consent, because she's a professional. Yeah. Okay, thank you very much for that. I'm reluctant to cut it off because it's such an interesting discussion, but I'm the timekeeper here, and we have to get through these things. I do want to quickly ask Michelle if I could. Are there any mandatory reporting requirements in this kind of situation, perhaps different to what we would normally consider? No, not yet. The...certainly overseas people are being prosecuted for not reporting information they knew before these attacks occur. I suspect that it's really a matter of time before we start to see similar prosecutions. If people aren't passing that information on a serious information that could result in, you know, public safety concerns, we really need to be considering whether it should be mandatory or at least we have to be aware that these sorts of things may become prosecuted over here as well. Wow, interesting, very interesting. Alfred, I've really got to move on, but I just want to ask you one quick question. So just a very brief answer, and I promise that if we can do this another time, we'll expand on it. But I guess just the broad question about do you think sometimes we need to relax our legal and ethical obligations, if you like, a little bit in situations like this? Is that legitimate? And as I say, I'm afraid that has to be a very brief answer. Well, it's not for us to relax law and ethics because they're broader issues, and I think Michelle has just pointed to it. If necessary, there will be legal changes. Until then, we must operate within the parameters that's been set for us. And they're there for good reasons as well because they make sure that people trust us and we are effective as long as people trust us. Yeah, good point, good point, good point. All right, thank you very much, Alfred. Let's move on and go on to our third area, which is about the assessment and the warning signs and so on. If I could start with you, Inez, and I guess I'm just interested in the broad question about whether it is something that's always possible or whether it's possible to differentiate between a mental health issue and an extremist ideology. I guess sometimes the boundaries might be quite blurred. Can you just comment on that? I think there's really spectrum. At the easier end, there's somebody without a history of mental health problems. There's no evidence of depression or anxiety in your consultation. They're not thought to sorted. They've got a firm grasp on reality. They're pretty logical in their thinking, but they've just got this intense bias and hatred towards defined groups. And I think at that end, you're saying, well, actually, this is not a mental health issue predominantly, this is actually an extremist issue in the way that people think and act and behave. Then there's the much harder end, which is somebody who knows got a severe mental health disorder. Perhaps it's been unstable, they're being poorly adherent to medication, difficult to treat. They've got a sort of tenuous grasp on reality. And they have this sort of fixation or hatred towards groups, but you're not really sure if it's actually part of a psychosis or not. And I think, Andy, for me, is somewhere in between that. So sometimes I think it's easy, sometimes it's hard, but I think often you're sort of in the middle somewhere. And with further information and time, you get a sense about which end of the spectrum you're dealing with. Yeah, yeah. Okay, Michelle, could I bring you in? Several people have asked about this, and I don't know whether there's a simple answer or not. But people have asked about whether there are risk assessment tools that can be useful in this kind of situation. Are there any tools that we should be aware of for this kind of work? There are tools. There's really no international standard for reliability and validity of tools in this area. You'll hear names like Trap 18 and Vera R and what have you. They're professional judgment tools. They're very comprehensive. But as I said, as far as the sort of cases we see, which are people who have mental illness as well, not always that helpful. In our joint fixated-thread assessments sort of settings, we use, I guess, evidence-based-thread assessment frameworks to enable us to identify the risks and then use those risks and target them for treatment. So sort of identify risks and manage those risks. And that's really the key thing at this stage, really, for us. Yeah, yeah. Okay, fair enough. Alfred, can I bring you in? I guess one of the problems often for clinicians is that people may well talk about things without making that transition from talk to action. And it applies, I think, with self-harm, as well as it does with harm to others. But in terms of this area, particularly grievance-fueled violence, do you think there are any warning signs that someone is likely to act on these ideas rather than just talk about it? Mark, you've actually mentioned suicide and it's basically very similar here. Does Andy have a plan? Does he have a specific target or targets? Is his plan logical? Does he have the means to do it? And this is actually where it's a bit of a concern with motor cars nowadays, because in the past, we were worried about weapons. Nowadays, people use motor cars. So I think the most important thing is whether Andy's got a plan and how concrete that plan is and how well-developed it is. Yep, as you say, strong similarity with the way we would assess suicide risk, I guess, yeah. Mark, can I just... Sorry, Michelle. Michelle, Michelle, you jump in, yeah. I just sort of jump in and add to that. I think this really highlights, again, how important it is to have information. And very often, these are cases that one single health professional will never have all the information on. We have, as I said, we need to access things like what they're doing on the Internet, what they're saying, who they're talking to. And so this is why, I guess, these multi-agency approaches have been established so that we can actually properly assess all the information, assess the risk from there. And very often, that's difficult to do as a single professional. But what you may be able to do is highlight the fact that this person really is a concern. You need to be seeking advice about this. While I've got you, and perhaps just leading on from that a bit, Michelle, do you think that violence is the... We're talking a lot about violence, of course, that's what the webinar's about. But is violence the only risk that we should be aware of with our extreme right-wingers, or should we be alert to other issues, do you think? Yeah, well, I mean, violence is obviously the big concern with these people, but they cause an awful amount of disruption and damage. They do protests. They hate rants on public transport. They've done arson attacks and graffiti attacks on mosques and synagogues. So a big concern in that regard. And the other thing that we have to think about, particularly given that these people are often also our patients, is that they place themselves at harm. If they're carrying on like this in the public space, they run the risk of members of the public attacking them. And they also run the risk, if they step into police environments, that they'll get themselves hurt as well, or killed. Yeah, sure, sure, sure, sure. Ines, if I could come back to you, and I did land that domestic violence question on you, so I'm gonna do something a bit similar here, really. It's obvious, well, I think it's obvious that gender is a factor here, that men are much more likely to be violent, and I would think of these kinds of acts as well. But one participant asked an interesting question about if you have a patient who holds very extremist men's rights views, is it appropriate to let them know what you think and that their views are not acceptable? Is it best to be upfront about this with the patient? What would you think, Ines? I think you have to be clear for your own physical and emotional well-being, what your boundaries are. So if you're feeling physically or emotionally intimidated, I think you have to be very clear with the person about what you will accept and what you won't accept. Language like, please don't speak to me like that, or the consultation will end. If you do that again, I will end this consultation. So again, clarifying that really clearly. But I wouldn't suck myself into their world. You're not gonna change their mind by playing tic-tac about arguments about this or that. And in fact, it will actually potentially put that person's back up against the war more. You might feel you might want to do it, but I feel that that actually won't be beneficial at all. And as I said, would be potentially disadvantageous and certainly to your rapport and getting further information out. So I'd say don't get sucked into their world. Don't start the argument and just develop a rapport with that person. And if they ask you what are your views, you might choose to say something like, this is actually not about me. We're exploring your views. Or you might choose, depending on the situation, to actually express your views, but I wouldn't start getting into an argument with them at all. Sure, sure, sure. And thank you for your help. I'm not sure how Michelle feels about that actually, because she'd probably have more expertise in that too. I'll ask her in just a minute. Can I just note your comments about safety that you made in your talk and again there? I think it's very important and I want to make sure that people are aware of those. If we get time, actually, I'll come back to them. But let's ask Michelle now. Well, first of all, very quickly, Michelle, did you have any comments you wanted to make about that? But then I'd like to ask a broader question. I want to move on to management. Well, I agree with Innis on that. I think when we work with these people and try to manage them, there's really no point in confronting this sort of thing. You're not going to change their mind. As Innis said, you don't collude with them, obviously, but the important thing for us is to have some rapport so that we can actually work with them and they can trust us. Yeah. OK, we really must move on to management. And I wonder if I could stick with you, Michelle. And I guess just ask a very general question and I realise it's a bit difficult to answer, but it is one of the learning outcomes. So I'd like us to have some kind of answer. Can we just clarify again what you see as being the primary referral pathways in a case like Andy? What are the options from here? Could you just fill us in a little bit more on that? I think it's certainly a complex case. It's not as straightforward as mental illness or extremist ideology, as Innis pointed out. It's a sort of case where I would absolutely be seeking some advice. You can seek advice through line managers. You can seek advice through a trusted colleague or somebody with some expertise in this area. You can obviously go to your medical defence unions, but also there's going to be, I don't know whether it's been sent out yet, but certainly a resource there from Home Affairs, which provides contact details of the relevant organisations within each jurisdiction. And I'd strongly recommend that you actually discuss the case. You don't have to discuss the case by name. It can be done anonymously, but in terms of knowing whether you should be concerned and whether it warrants further referral. So this is someone that the clinician can just get on the phone and talk about the case and get some advice? Yes. These organisations in the resource sheet that's coming out are all people who take calls from health professionals about these sorts of concerns. There's also hotlines within particular health disciplines as well, like the APS, for instance, who will provide that sort of advice. But just, you know, the main thing is that you don't assume you've got all the knowledge or all the information that you need to make an assessment about this person. Sure. Yeah, absolutely. And I think, as Alfred said in his talk on a different issue around decision-making, really, but talk to your peers, get some second opinions on it. I think it's crucial. Don't have to carry it all yourself. Ines, one of the really heart-synced things for us as clinicians, I think, is the non-compliant patient. What happens if Andy says no? He's not going to talk to the psychiatrist. What happens, I guess, one of the options for people who refuse to engage with the services that you want to link them into? Ines, can you give me some thoughts? Well, you know, it's always preferable to actually get... To bring somebody along with you, to actually get their consent, to get them engaged. And if not their consent, at least get their assent so that they know what you're doing and they're moving along with that. That's not always possible. In this case with Andy, you are actually seeing him in two days' time. So hopefully within that consultation, which will be a fairly lengthy one, I think, you'll develop some level of rapport. He seems to be opening up. If he says no at that stage, if you feel that you can wait for two days, which goes back to my original issue about the immediacy of safety to himself and safety to others, then you can revisit that in two days' time. But sometimes you have to go elsewhere without consent. And I think Alfred actually talked about that beautifully before in the instances and the sorts of thinking that you need to do prior to doing that and the sort of documentation you need to do prior to doing that. Hmm. Yeah, absolutely. All right, thank you, Ines. Let's bring Alfred back in. As I recall, Alfred, in your talk, you did say something about, of course, if it's an emergency, then you need to do whatever is required. Can you comment on whether or not you think a situation like this, as far as we've read in the vignette, would that qualify as an emergency? Do you think, do we have license to do whatever we need to do in a case like this? So the question is whether there's any tangible evidence that there's a real risk of irreversible harm. And I think Andy is a concern, but he doesn't have concrete plans and the means at the moment. Those are questions that we really don't know. I think actually both Ines and Michelle has actually answered this question. This is a manageable patient. We've got a duty to actually manage this patient. We should use the resources we've got available. There's several resources that one could consider here, maybe under the mental health legislation, maybe just contacting people who've got expertise by using the health lines. And this is actually, I think, the main thing of this presentation is the resources that people will get from this presentation. I think in the past, that's always been a problem. We got to this point and we couldn't really tell people what to do, especially private practitioners. Now we can tell private practitioners, they are resources, use the resources. Absolutely. So we will remind people at the end there about the resources again, because there's some good stuff there. Was someone trying to jump in there or am I hearing things? I think I'm hearing things. Okay, so let's move on then and move the discussion on a little bit to this kind of fun bit we've got at the end, which is about myths. So we thought we'd end tonight's discussion with a bit of a chat about some of the common myths in this area. And it's something a bit different. We're going to do a live poll. So we've identified four common myths around the area and we're going to get you to vote on which one you would most like to see the panel discussing and perhaps which one you think maybe most widely held. So if I can ask Redback to start the poll, everybody has now got 30 seconds to log their vote and to tell us which of these four myths you would like to see discussed by the panel. And okay, so get your votes in quickly because as far as I can tell we haven't got any votes, which might just be a technological problem. I'm not really sure. Not to worry, I'll just keep looking and see if anything happens, but we should really wind up. No, okay, not to worry. I'll just guess which one you chose as being the most important. Let's actually go with number one. And I might bring Michelle in on this one to begin with. Why can't we just close down all these extremist sites? You talked about how the internet is being used to drive right-wing extremism. Why can't we just shut down all the sites? Well, that might be my bothersome short-term benefit but it's likely to lead to a bit of a cat and mouse game with these sorts of sites going underground and then it gets very difficult to actually monitor them. So we're actually in the worst position. And I guess it's a bit like, these four are a bit like Hydra. You chop off its head and then another head pops up somewhere else. So this is the problem we've got with these sites. So it's not as easy as closing down the sites. Yeah, okay. Does anyone else want to jump in on that? Or, and or number two, people have a right to these views. What kind of society are we living in where we're telling people what they are and are not allowed to think? Does anybody want to go with that one? I could look into it. Who would you... I think people may have a right to these views, okay? But they don't have a right to attack and kill people who think differently and that's the point, really, that these people are actually committing violent acts against people who think differently. Yeah. Yeah, I think I agree with that. I mean, it's a very entrenched principle in our society that you're free to think what you want but you should not harm other people in the process and it's really when it comes to a risk of harm to others and a society that we're getting worried. Can I just add that I think if we have pervasive views like this in our society, we actually end up with a society that's incredibly dysfunctional and goes against other aspects of our society that we value such as equality and equity and fairness. So there's certainly not views that I think as a society even without violent outcomes that we want to pervade. You know, I think as a society we actively want to develop a culture that goes against such views even if they don't end up in violence. Well, yeah, it does make sense. We're going to say we've decided already that we can't just go around shutting down websites left, right and centre. We can do a little bit with legislation perhaps and, you know, deep we do about expression of certain types of view. But most of it perhaps is, as you've said in this, if we're going to take a more positive approach it is about perhaps promoting more healthy ideologies and more healthy cultural norms, if you like. And I'm wondering whether this is something that we could and should be doing early on in schools, for example, that we should be perhaps devoting more time to building good citizens and good strong cultures than perhaps we do at the moment. That's right, but let's not just put it all on to the schoolteachers, which we do tend to do. I mean, I think a lot of this actually happens within our homes, amongst our friendship groups, you know, in the way you treat people down the street that look different to you, that don't have the same advantages to you. And the sorts of things that you see as a child growing up and what the normal positive view of the world that's actually provided to you by your parents and formative group. Yeah, yeah. Okay, let's look at number three and perhaps I'll bring you back in again, Michelle. Anti-feminism is not a violent ideology. Not a violent ideology to be anti-feminist. Is that a myth? Well, no, it's not. It's emerging as a big problem for public safety, not just females. And I think it links in again with this particular case vignette, if we take sort of the extreme of this, which is what we call involuntary celibates or incels as the people themselves call themselves. This is a group that's an online hate subculture. It's made up mainly of white heterosexual males who are unable to get any sort of romantic or sexual relationship. And they blame feminism for that. So feminism has upset the natural order and now only physically attractive women will make with physically attractive men leaving them out. A lot of them have mental health issues, as you probably imagine, social anxiety, autistic spectrum, people with depression, suicide, body dysmorphic disorder, that sort of thing. But ultimately it's gathering a lot of momentum online and of course when they get online their grievances are validated and it leads to this moral outrage. And what we're seeing is mass attacks as a result of this incel ideology. There's been eight mass attacks around the world just in recent years. So yeah, it can be a concern. It's very frightening isn't it? Well, lead on to the last one for me then. So is it true to say that these extreme right-wing groups are a cohesive and organised force in Australia? No, it's stretching it to say that they're still fairly fragmented but they're probably a little more organised than they were and that's a concern. There's a number of different factions out there and actually in practice the distinctions aren't that sharp between these groups. So you hear different groups, Reclaim Australia, you know, the Patriots Front, True Blue Crew, all these sorts of groups but there's a lot of overlap in their beliefs. Sometimes it's just a case of sort of grabbing a little bit from here and a little bit from there and it's a bit of a mishmash of ideas. Yeah, yeah, quite. Okay, but certainly there are a lot of myths around then and a lot of myths and misunderstandings and I guess one of the things that we need to do is to make sure that people get access to facts and reliable information. Not always easy today with today's media but still it's really important we get accurate, truthful messages out there. Unfortunately, time has virtually completely run away from us. So to finish, I'd just like to ask each of you if you have any very brief take home messages that you'd like to leave our participants with tonight and any final words, perhaps I'll start with you, Inez, any final words you'd like to leave people with? I think probably three. Firstly, in a situation like this, think about your safety before somebody like Andy walks in the door. Secondly, trust your gut. If it doesn't feel right, think about it. Go home and think about it. Talk about it with other people. But lastly and probably most importantly is don't do this alone. This is a very complex situation and reach out for help and advice. Isn't that important? I agree, 101% there. Thank you very much Inez. Michelle, any take home messages from? I guess I said at the start that I could see the storm clouds gathering and the thing with storm clouds is we don't know if they're going to materialize. We don't know whether they're going to end up in your own backyard. But what we can do is monitor the situation. If things get worse, there's risk factors gathering. We can address those. And in the case of group grievance fuel violence, mental illnesses is clearly one of those factors that we can address as mental health professionals, health professionals, but we can't do it in silos, not with this group. We really have to be working with people. Good. Thank you very much, Michelle. And finally Alfred, any take home messages for our participants tonight? Inez and Michelle didn't leave me much to say, did they? I think the important thing is to build up and maintain a relationship of trust with Andy and to manage the situation as Inez and Michelle said. And I think this is really where it's a difficult thing for us as practitioners because society expects us to help protect society and its members. And that's very appropriate and necessary. But at the same time, people will only trust us. Our patients will only trust us if we also respect their rights. And I think this is why it's so important to keep in mind professional responsibilities and to get that balance right. And I think the take home message for me is consult, consult, consult. Over to you, Mark. Thank you very much, Alfred. Tremendous. What a fantastic lot of useful advice and information we've had tonight. I just want to make a few quick closing comments. The first is to let you know that there is going to be a third Department of Home Affairs MHPN webinar, which will be broadcast shortly. We think before the end of June this year, so within the next few months, and details of that will be available very soon. The second is, as you see on your screen, that there are a whole lot of excellent resources available. Michelle made reference to these earlier in the night. You can click on the Supporting Resources tab, but really I would encourage you to wait for a week or so until MHPN sends you the link and then you can access them at your leisure. But I must say that the Department of Home Affairs has some really good resources, particularly in the form of fact sheets for health providers and mental health providers around many of the issues that we discussed tonight. So I would strongly encourage you to dig in there and have a look, some really very useful stuff there. Okay, I would strongly urge you, encourage you, plead with you to fill in the exit survey before you finish tonight, both about your opinions regarding tonight's webinar and also perhaps about platform, which largely worked in one or two very small technical glitches that we got through. I would very much like to thank all our panelists. I thought it was a great discussion tonight. It was a real pleasure for me to facilitate it. So I'd like to thank very warmly in is Michelle and Alfred. And I'd like to thank you all, our participants, very much indeed, for your engagement, for joining us tonight, for your interest in the area. And it really is your engagement, your participation that makes these webinars go so well. So I hope that you found it valuable. Thanks again and good night to all.