 Well, welcome to the participants who've joined us for tonight's webinar and the viewers who are watching the recording. Before we start the webinar, MHPN would like to acknowledge the traditional custodians of the lands, seas and waterways across Australia, upon which our webinar presenters and participants are located. We wish to pay our respects to the elders past, present and future, for the memories, the traditions, the culture and hopes of the Aboriginal and Torres Strait Islander Australians. Hello, I'm Andrew Amos. I'll be facilitating tonight's session. I'm a psychiatrist and I'm a director of training, so I'm helping junior doctors become psychiatrists. I've got a very packed program, so I'm not going to do too much in the way of bios, but there are bios in the webinar invitation. But I'll introduce the panel. So tonight we've got a New South Wales based psychiatrist, Dr. Karen Williams, Dr. Bronwyn Hudson, who is a New South Wales based GP and addiction physician, and David Tully, who is a practice manager for family violence at Relationships Australia in SA. So Karen, you founded an organisation called Doctors Against Violence. What is that and how did it get started? Doctors Against Violence was where women was sort of created, I think for me and a few of my colleagues is we were recognising that we were seeing quite a lot of, well, a lot of domestic violence and family violence, childhood abuse and not really knowing what to do with it and feeling that real sense of hopelessness and helplessness that you get when you hear these terrible stories and you can't really do anything to fix it or change it. So it was born out of us trying to be able to initially just talk with each other and talk about strategies we used to manage patients like this, except that what we found was being able to use our knowledge and our experiences to change the way, well, to change things legally as well, like to put our opinions forward to government, for example, with coercive control, that kind of thing. We could sort of regain a sense of control for ourselves and feel that we were actually able to do something good with these horrific stories that we were hearing. So it was about turning patient's stories into something really powerful and maybe eventually being able to make a change to improve the situation. Well, thanks, Kenneth. Look, it sounds like a grassroots organisation that's really grown and is now very, very powerful. Thank you for that. So Dr Bronwyn Hudson, Bronwyn, how can you tell us how you ended up as a an addiction physician after you started as a general practitioner? Yeah, so I am a very proud general practitioner. I trained as a general practitioner in northern New South Wales in rural Australia. And general practice is a very broad field. And we see everything that comes through the door. And one of the things that I absolutely loved was caring for and being with the people that used and continued to use substances. And part of my role as a general practitioner was obviously being with people in all stages of their life. And that does include and involve people in domestic violence situations and people that use and continue to use substances. And I developed a passion for that. So after training as a general practitioner, I retrained in addiction medicine. And now I wear both of those pages very proudly and combine the two general practice and addiction medicine in a way that I hope brings some health and paths forward for the people that I care for. Okay, certainly a great combination, very, very needed. And David, can you tell us a little bit about the work you do with men who are violent? Yeah, thanks, Andrew. And thanks for the other panel members. Look, I think, particularly when we're thinking of this topic of coercive control, it's obviously really vital that we have some really good thinking and support services and legal and justice response to respond to women and children who have been subjected to coercive control. But if we want to really see systemic change in societal level, it's about working with men who engage in these sort of behaviors to recognise the impacts and damages that they call to make change as well. So I think that's another vital area that we all sort of understand, particularly in our own practice, you know, if we identify and screen and notice these issues in terms of memory, what we do is we engage them to at least be a wind-died risk and hopefully be a door to change as well if we can be as part of that overall process around supporting, you know, everybody who's impacted by the issues. It's certainly a vital function. The format of the webinar today is that each panelist will give a short, disciplined, specific talk about their area of interest and practice, and that'll be followed by a Q&A session where we'll address the questions that you have asked and we'll divide those amongst the panel members. So some will answer more, one question and some will answer more. Another, so keep the questions coming in and we'll collate those as we go and ask them at the end. We've got a number of learning outcomes and these are somewhat oriented around the case study that will have been in the webinar invitation that you're all being sent. And so essentially what we want to get through is the nature of coercive control. What are the types of strategies that are used by abusers in these relationships to diminish their partner's sense of agency, to eliminate alternative sources of the social, emotional and financial support so that that person's entirely reliant upon the abuser. We'll discuss the role of mental health professionals and other health professionals and in fact, other social supports in raising awareness and supporting people affected by coercive control. And we're going to spend a little bit of time elaborating on the importance of collaboration, and particularly appropriate referrals when you're providing care to people affected by coercive control. So even if you yourself may not be able to provide help to someone, they may not prefer to see a male clinician, for example. You can often refer them on to somebody else who might help or identify resources within their own networks that can provide help. So being aware of those will help with the process. The webinar is based around the case of Vanessa, which we've got in the webinar invitation. Vanessa, a very brief summary of that, then Vanessa is a 47-year-old woman. She did work earlier in her life, but she stopped working in order to take care of her three children. They're now entering their early to late teens and are less dependent. She's gone out and got a job. The partner, Vince, seems okay with this initially, but once she starts getting more money and more seniority, she's offered a promotion, he then starts clamping down. And in particular, he uses a number of techniques. So he's forcing her to put her money into their shared joint account. He's frequently checking up on her by sending text messages and finding out what she's spending her money on. And this emerges in her relationships with other people. She basically explains this as a pattern that all men have, something that's completely normal and unremarkable. So this is a nice little vignette that should ground the discussion that we'll have. Next slide. Okay, so our first presentation then will be David Tolly. David, I think, is going to give us a bit of an overview of what coercive control is and looks like. And then some specifics from the family violence practice manager point of view. So over to you, David. Thanks, Andrew. In terms of the practice management role in that's really looking at what family violence looks like and all aspects of an agency at the entry point in terms of care that you're providing into agency relationship. So obviously understanding coercive control is really important. The way we do all those things of bringing people into an organization, the way we work with them, the way we work with other organizations as well. But in terms of an overview of what what we understand coercive control to be, it's a, it's a term that's been sort of been around for a while, but it's been mostly being used within, you know, women, people who work with women, particularly that they are, you know, coming from a sort of a feminist analysis of power relationships in power relationships as they care predominantly in our sort of relationships as well. So really, it's a cluster of behavior. It's not just about single instance. It's a cluster. We really see that in a scenario with Vanessa and Vince in terms of, you know, what one thing leads upon another, which builds upon another and these upon another next minute, she's no good with numbers. So maybe he should just control the money and you can't be trusted to go out by yourself. So, you know, you know, you'll get yourself into trouble, this constant undermining. So really, we're focusing about patents, not just individual incidents and these behaviors are linked to ensure an advantage over one member of the relationship over the other. So it's really about not just controlling the person. It's about trying to control the social context that's around the person. And that's really vital for us as practitioners in the field as well about the way we can be both explicitly and implicitly recruited into being part of that context that can become controlling as well. And already it's a violation of liberty, you know, it's a basic deprivation of basic human rights and also the resources and the sense of agency in the world that we're required to have personhood and citizens which are vital for our mental health and wellbeing, you know, so it's a real violation of human rights, importantly as well. Yeah, just the next slide. And I think this is just a quote from a woman who was involved in one of our services we hear in terms of responding to women who are experiencing blood-borne viruses, but they also looked at domestic violence as well. And I think I really like this sort of quote because it sort of speaks to what some of those lived experience, of course, control as well. So just in terms of these words, it wasn't just the actual violence. I felt I couldn't do anything because it could happen again. I spent the whole time trying to figure out what he was thinking to stop it happening again and from him getting angry. But it never stopped. But with help, I eventually realized it was about him, not me. So really, I think, you know, that's a really good, I think, illustration of what those ongoing psychological, emotional, social impacts, of course, for control. But also, I think that last statement is also the signs of where resistance response could be and how service is going to help. So with help, she realized it was about him, not about me. So she stopped internalizing his tactics and saw that it started to see the control for what it was, rather than thinking it was something about her. So yeah, it's just the next slide. So really, there's a whole range of different tactics. And it's really important, often when people think family and domestic violence, we just think physical violence. And also, there's a mirror offering the work we do with men who use violence in their relationships. Well, domestic violence is just physical violence. I haven't hit her for a year. So therefore, I'm not being violent. Obviously, this is really incorrect in terms of the tactics that actually inform family domestic violence, of course, control. So obviously, there's clearly coercion. There's threats. There's intimidation, both subtle and subtle and explicit. There's a whole range of different emotional abuse. Like, for instance, with, in the scenario, that sort of idea, you're no good with numbers and you can't be trusted. You're stupid for going out anyway. That's all about that emotional abuse. Obviously, the isolation is about controlling information and support that may be contrary to the tactics of abuse. Very importantly, it's also children who use these sort of tactics as well and can maybe recruited into undermining that sort of parent child sort of relationship. Also be involved in repeating statements that the man has sort of coached the children to being that are undermining children. And also, it's about using male and other sorts of privilege. So privilege could be because of status in the community. It could be someone who's has involved in hierarchy of a church or a mosque or something. So there's all other forms of privilege that can come into coercive control as well. So there's been a sort of a quite a flurry of activity in different states looking at coercive control, both in terms of what it means legally and some of the advocacy of, you know, a work of, you know, like Karen has been involved in has been a really important part in terms of pushing for this to be happening. So we're starting to see some of that conversation that's been going a lot, lot in terms of, you know, the practice field of people who work with women subjected to coercive control is now starting to bubble up at least into sort of discussions about what it means legally as well. So in terms of this information, we're just talking about the new South Island Parliament joint select committee in coercive control. And what this really interestingly heard, and this sort of leads into some of the impacts and effects that victims survived, I've described it is more half a long lasting than the physical abuse in itself. And we don't want to hierarchy the impacts of family domestic violence anyway. But it's really important that coercive control is often the thing that actually leaves the long lasting psychological entanglements which often take a long time for a woman subjected to violence to untangle. So it involves isolation, subordination, humiliation, many different tactics. It leads to a whole range of psychiatric outcomes, including suicidality, depression, post traumatic stress disorder as well. You know, just similarly, just underlying those points. So we just know about chronic health conditions, mental health, anxiety, post-traumatic, massive links towards substance and alcohol abuse as well. You know, we even see in this scenario with Vanessa, you know, economic outpours, she's restricted from working, money's taken away from her as well. But also just that whole that your life rolls around managing the fears and consequences. And as I quote earlier, trying to predict those sort of consequences as well. There's also the impact of what we call maternal alienation in terms of damaging the parent-child sort of relationship as well, both as a tactic of sort of undermining the feeling of confidence the woman has in herself, but also as using children to sort of become allies in his tactics against her as well. So importantly, I think in this discussion, again, this is just a whistle stop across some of those important issues that we need to be thinking about children and how this impacts them as well, how they may be tricked or forced into monitoring their mother and how that experience of disruption, their parenting experience is really important, particularly if their mother's abilities and resources to print are actually impacted by the tactics of control as well. So just in terms of trying to bring this back to practice as well. So I believe that it's really essential to practice that we can recognize these patterns of course of control and understand that wider gender context of the power relationships they occur in, because a lot of the tactics we see in this scenario from Oh, well, he's better at managing money. He's just looking after me. Don't all men text you 20 times can really be seniors, just normative genders of relationships as opposed to sort of seeing them from what they are as well. So again, patterns, not incidents and understanding the cumulative weight of all these patterns of behavior in terms of what women are dealing with as well. So I think just understanding that wider social context is really and when we come to thinking about assessments for patterns of course of control, you know, best practice in domestic especially, we need to be aware that many of the normative constraints that women side conflict gender inequalities almost make some of these tactics somewhat invisible. I don't think they are invisible, but depending on the gender lens you bring, they can potentially seen as just being normal ways of relationship works. And again, so it's no accidents. A lot of the tactics using course were actually pick up on these gender stories and pick up on, you know, the way dominant culture unfavorably views women. So the attacks are on their quality of their parenting, housekeeping, their sexual performance, their intelligence, which really resonate with the wider stories that are actually available in our community. So that's that's why I think that wider sort of push around gender equality and justice is vital, not only because it's the right thing to do, but because it also sets a context for us to more effectively begin to see coercive control for what it is. Thank you, David. Look for a for a potted overview that was very, very detailed and I think demonstrates the the enormous breadth of the issue from legislation to to cultural assumptions, if you like, and certainly reflected in recent news stories, a bit of a push on to try and address the stereotypes about women at all levels of our society. So thank you for that. And I'd like to really emphasise that last slide, the importance of the social context. I think that that really is linked to the idea that it's not just health professionals, but all social supports can have an impact in this circumstance. We, of course, are looking for training to have a particular effect. So thank you, David. Next slide, please, Dan. So next I'm going to ask Karen Williams to give us a psychiatrist's perspective. And I think Karen's going to look a little bit more in detail at the actual mechanisms, the things that abusers use to control their partners and how that the dynamics of that then in the relationship. So over to you, Karen. Thanks, Andrew. And thanks, David. So as Andrew just said, I'm going to be talking about how we recognise coercive control in our patients, because presumably that's why you've registered today. And although we are often really going to be seeing the survivors, it's much more important, I think, that we understand the perpetrator, because really there's nothing that much remarkable about the survivor's behaviour. Their behaviour is a natural consequence of what is happening to them in their home. But the abusers' behaviour is very well defined. And if you understand them, I think it becomes a lot easier to really empathise with your patients. I think it's a lot more important to empathise than to just simply recognise what's happening. So what drives an abuser? And these guys, and I'm going to say guys, because this is empirically and statistically what we do know to be true, perpetrators of domestic abuse are more likely to be male. And so what drives these men ultimately in relationship is a fear of rejection, a fear of losing control. So if what they hate is that someone might reject them or leave them, they're going to do everything in their power to stop that from happening. And so how do they prevent the victim from leaving? It used to be a lot easier when women didn't really work and were expected to stay at home with the kids. But now that it's sort of socially acceptable for women to leave the house, they need to control not just her physically leaving, but also to control her mind and her thoughts about leaving. So what they do is set about the process of thought or reform and abuses will go through a phase of recruitment. So this is the phase where the perpetrator will choose a victim and find a hook that appeals to that person, which they're going to later exploit. The recruitment phase is dedicated to setting a scene where he becomes everything she wants, everything she needs. It's about establishing trust and that trust will later turn to complete dependence. It's important that we note that the phase of recruitment is an ongoing process. People often will talk about the love bombing process is something that occurs just at the beginning, but it's something that will continue all the way through the relationship. It starts at the beginning, obviously, continues on during and often will go on for well after the relationship has ended. The indoctrination component is a process of controlling the thoughts of the victim and that's using a whole range of modalities. So that's controlling behaviour. So they might control their victims' behaviour really overtly. You are not allowed to see your mum, you are not allowed to go out with your friends or it could be really subtle like your friends don't like you. I don't think you've got very good conversational skills or planning events at the time that she's about to go out or about to go somewhere or creating lists of chores or work to do so that she hasn't got time to even go out or something simple like not getting the children ready for bed and feeding them so that when she comes back she's going to come back to kids that are unwashed, unfit and she's going to have to do all of those things. And it becomes in her mind it's too hard to go out or just stay at home. There's controlling information. So obviously if he wants her to think a particular way, it's good there has to be a control of the information that she has access to. So that's why there's such a focus on controlling friends and family and work. There's often controlling of social media and even controlling health professionals. So I mean, I've had patients not be told that they're not allowed to speak to me and not allowed to see me because clearly I might identify the pattern of behaviour that perpetrator doesn't want identified. Then there is controlling the person's emotion. So not allowing her to be angry, not allowing her to fight back but encouraging that subordination that Andrew was talking about. Mocking her for any emotion that she has or blaming her any feeling or response on her periods or hormones or probably the worst of all blaming on her mental health gaslighting. And there's controlling her very thought. So obviously I'm describing these things as very separate entities but they are all intertwined. And the difficulty we face as clinicians is sometimes it's about prizing apart what feelings are generated by the individual and what feelings have been generated as a consequence of coercive control. So for example, you might have a patient say that, you know, do you go out? You want me to ask them, do you go out very much? No, no, I don't like to go out. I don't want to go out. And they will tell you that they don't want to go out. They don't like to go out. But actually, if you explore what is the reason they don't like it, it could be that they're getting asked lots of questions about why they're going out or they're getting harassed when they come back. Their partner is sulking when they come back. And so that over a period of time, they learn not to want to go anywhere. For attempts at coercive control to be successful, there has to be a power differential and an exploitation of that power differential. So whilst there may be physical difference in a physical power and they use physical violence, there are many other ways that that you can gain power over somebody such as threatening somebody with financial you know, lack of access to money or threatening them with homelessness or threatening them to take away their children. There's you can threaten to hurt family members. And I've seen that in very young survivors where partners if they have threatened young kids, if you don't do this, I'll hurt your mum, I'll hurt your dad or threatening her work or her job. And so this is where our society's traditions and cultures can really facilitate abuse because women staying at home whilst the men control the money or women not earning as much money as men do women being expected to provide the bulk of childcare. These are social norms that allow perpetrators a violence and automatic power differential that is routinely exploited in this country and around the world. And to perpetrators will work really hard to build a sense of omnipotence and to really amplify that power differential and they'll do that by monitoring where she is all the time and turning up in places where she least expects and keeping her on her toes and infiltrating all aspects of her life. So what kind of patients and this is a really important important part for us to recognise because there aren't a type of patient. We can have a really fixed idea about what can you still hear me? Can I can you still hear me again? We can have an idea about the types of people who are in these relationships and we can believe that it's the poor or socially disadvantaged only and that nobody else is is vulnerable to that. But this is just not true. The perpetrators of abuse operating all social spheres. And if you think about it, the best way to succeed as an abuser is to have more power, right? So the more power you have, the more you can exert that power over another. And so it's often the most powerful amongst us that are the most abusive. And I've got patients whose partners are very high up in government and police and the judiciary. And this has also been proven as well in studies that have shown that the worst of control controlling behaviours are much more likely to be used by people who have completed year 12 or above and who earn more than 100,000 grand a year. So what does someone under coercive control look like? So we can often again have ideas of what they might look like. We might imagine that they'd be anxious, so depressed and cowering, you know, the ideal victim and that's often what the legal system expects from survivors of violence. And that might be why you see them too because of anxiety or depression, but that's not how they always will appear. Sometimes they are high achievers. They are sometimes very resilient in appearance. They're very perfectionistic in control and very successful. So you shouldn't really have any strong ideas of what that looks like. Obviously, it depends in the context. So I wouldn't actually see many women in this situation because that's what I do for my job. But I am equally likely to see a woman like this in situations like with my reception staff or a friendship circle. My colleagues, it's literally everywhere. And so to ask about coercive control, I mean, I find that sometimes I can figure it out very quickly, but sometimes it's part of the ongoing relationship that I would have with a patient that over time the more trust and rapport that I have developed with a client over time, we find out more about the dynamics of the relationship. So my role is to explore patient's day-to-day life. What do you do? I ask very clear, direct questions all about who's controlling the finances, who makes decisions about things. You can always find lists of what constitutes coercive control and there's the 13 sort of main ones that people talk about, stalking, insulting, littering. And I don't know how helpful it is to list every single kind of coercive control. It's more important to start to see where a person sees themselves within a relationship. And often they see themselves quite below their partner. When you ask things, don't leave it as a, do you go out, do you have a social life? Because I don't go out much. It should always be followed with why. And I don't like going out. It should be followed with why not what stops you. Because the more you sort of delve into what drives people's likes and dislikes, you actually get a really good idea of what's happening for those patients. So in summary, you're going to look for coercive control in every patient, all of them. And it may be actually the reason for why they're there. It might be that the apparent diagnosis is anxiety and depression. If you're anxious because you're getting abused at home, that's normal. That is actually important that you are anxious. And it's more important survival technique. But we do often pathologize survivors of abuse without a doubt. Don't limit who you ask, because you can have male patients who are survivors. But we need to start seeing that this kind of questioning, this line of questioning needs to be part of all of your clinical assessments. Every time you see a person, think of it. Consider it. And then, of course, we talk about first, do no harm. Never ask questions about this sort of stuff in front of a perpetrator. There's no point in doing that. And you can actually put her into trouble because you could say, why would she even ask that question? Why is he even asking me those questions? You must have said something. Well, your expression indicated that you were fearful of me. So what, you know, getting into trouble just for that. Recognize that perpetrator of coercive control is not just going to be controlling her. That they will be controlling everyone in their environment, including you. So you are equally likely to be brought into a story and be controlled by perpetrator too. So recognizing your own vulnerability as a clinician, it's really, really important as well. And being really careful about letting patients know about the fact that we are mandatory reporters because, obviously, you don't want a patient to be freaked out when Docs is knocking on their door. So you've got to let them know if you're going to make reports. You have to let them know about this because you really traumatize those patients. And yeah, I mean, I think that's probably the main things. I did want to just do one thing on the fact that coercive control is gendered. I think it's really important that as clinicians and people that are possibly writing reports for legal purposes, that we recognize that coercive control and abuse in general is mostly perpetrated by men. There has been many studies. There's been a review of 21 studies that showed up to 94% of perpetrators of coercive control are men. That's huge. So the significance of that is sometimes you'll have him and her stories. And you'll say, well, they're both equally likely to be lying or both equally likely to be telling the truth. That's actually not true. They're not equally likely to be lying in the most. They're both not equally likely to be victims. The victims are most likely to be female. Aaron, you've anticipated some of the questions for the Q&A session. I think it's excellent to address that. And I'm sure we'll have an interesting discussion at the end. But I think a topic that really requires a bit of in-depth discussion. So thank you for that, Karen. And next slide. And next we have Bronwyn, who's going to be telling us a little bit about the GP and addiction physician's perspective on coercion and control and the intersection of those two things with a focus on substance use disorders. So thank you, Bronwyn. Thanks, Andrew. And thanks also to David and to Karen. And a massive shout out to Karen for starting the organization Doctors Against Violence Towards Women, because that organization has made a lot of headway and done a lot of work in this space. And it's due to no small effort on Karen and her colleagues' hearts. So I just really wanted to acknowledge the work that Karen's done in that space. And thank her, because if you do a little bit of a background search, you'll see the incredible work that has been done. And we owe her a debt. And I just wanted to acknowledge that. I also wanted to acknowledge the traditional owners of the land on which we are all on. And also acknowledge the incredible work that our Indigenous family and First Australians have done in this space. And the work that they continue to do, because it's a really complex and layered issue. And research consistently shows that any form of trauma increases somebody's risk of developing a substance use related problem. We know that people who use substances are significantly more likely to experience abuse by an intimate partner and are also more likely to be a perpetrator of domestic violence and whether that's overt physical domestic violence or the very subtle form of coercive control that we're talking about tonight. Substances add another layer. I was at AM was a GP. And in general practice, it's a complex space. Like you're dealing with anything that comes through the door, anything that comes at you. And domestic violence is a complex layered space. And when you add substance use, you've got another layer. You've got another target for controlling behaviors. And this is a really complex space. And I really want to thank everybody that's here on this webinar tonight. Next slide, please. So my colleagues have already spoken tonight about what coercion is. And we're talking about the manipulation of other people. And we're talking about the manipulation of their behaviors. And that comes through violence. It comes through intimidation. That comes through threats. It comes through degrading the other person. It comes through isolation. It comes through all of these very subtle forms that are not always obvious to the observer, regardless of how astute we are. Sometimes these forms of violence just slip through the radar. And it's not until we have 2020 hindsight that we can see, wow, that was coercive control. So the term substance use coercion, it's a term that's been coined. It's been picked up in the States, not so much in Australia, but it's really important. And the term substance use coercion refers to specific tactics that are targeted towards a person's particular use of a substance or abuse as part of a wider pattern of control. I think David was talking earlier about how these behaviors don't exist in isolation. It becomes a pattern. And at the outset, they look normal. They look loving. They look caring. Let me buy this for you. Let me get you your next hit. Let me buy you this bottle of vodka. Let me look after you. Let me care for you. So at the outset, they look like loving, caring behaviors. But as Karen said, we know that there's an agenda. This is specific. This is very targeted. And this is very calculated. Next slide, please. So from my perspective, I just wanted to talk about some very common tactics that are used not just in substance use coercion, but in coercion generally. Certainly in substance use coercion, forcing or coercing a partner to use, it's like use this, have a little bit more than what you were planning on having, controlling a person's access to substances, especially substances that somebody can become dependent on or from which there is a withdrawal syndrome from. So opioids, if somebody goes without opioids, there's a very clear withdrawal syndrome. They experience very harmful and uncomfortable symptoms. So somebody, if you've seen somebody in opioid withdrawal, you know what I'm talking about. But to see somebody in that space and then to say, I can fix your suffering, I'll just give you this little bit of heroin. I'll just give you this little bit of alcohol. So controlling somebody's access to substances, they've been also controlling their access to treatment. You know, I'm not gonna let you go to rehab. I'm not gonna let you go to the withdrawal unit. I'm not gonna let you go and see your psychologist. So not only preventing their access to treatment, but then also actively sabotaging their recovery. So somebody that's in early stages of recovery, they're 10, 12 days sober from alcohol and you walk into a dinner party, seven of the eight people are there with a full glass of wine. You know, that's hard. You know, recovery is hard regardless. Recovery when the people that you love and that are supposed to be your support network are all drinking in front of you or using it in front of you. That's sabotaging your recovery. That's not in your best interests. And then you add another layer of threats to reporting and Karen again and David have touched on this tonight, threatening to report to the authorities. I'm gonna call the Department of Communities and Justice. I'm gonna call Families, Family Services. I'm gonna call your boss and let them know how I saw you doing lines of coke in the toilet at blah, blah, blah party or has your dad know what you drink? Has your dad know that you've done this? So threatening to report them to those particular authorities or safe people then also threats to discredit them. So people who you trust and then you're standing in your family, you're standing in your workplace, you're standing in your communities then lost and then preventing access to support. So I'm not gonna let you go to AA, needle it out to the kids or you gotta do this. So you gotta do that. So it comes beyond just the obvious but then actively sabotaging or preventing people's access to support. Look, I've just, I've tried this slide in because research on the ground is pretty slim. This is an American study but the reason I've included it is because it's a literature review. It's a very comprehensive look back at the documented peer reviewed research in terms of intimate partner violence and substance use coercion. So 26% of people in this study use substances to reduce the pain of their abuse. 27% were pressured or used forced use substances more than what they wanted. 15.2% had tried to get help for their substance use and 60% in that group of the 15% were discouraged or actively prevented by their abusive partner. 37, over 37% had experienced threats to report them to those higher authorities and almost a quarter reported that they've been afraid to call police for support due to their use of substances. So people who have very legitimate concerns and very legitimate cries to help or wants to help are actively prevented too because they've been seen as doing something wrong. They've been seen as drinking too much or using a substance and those substances or those behaviors that are seen as being illegal or those things that are seen as being wrong or frowned upon are then prevented from getting the legitimate help that they need and that they deserve and that is their right. So next slide. How can we help? This is some awareness, awareness, awareness, awareness, awareness and everybody that here is on this webinar is concerned and you've clicked on that join now because you have some in cling that this is an issue. Just always have domestic violence on your radar and not just coercive control, not just the domestic violence that you can see. I've had so many patients say to me, I wish it just hit me. I wish I had a bruise. I wish I could show what was happening to me but just have this on your radar and the importance of the therapeutic relationship and again, Karen's touched on this. If a surgeon's tool of trade is their scalpel or their knife, our tool of trade is our therapeutic relationship and our ability to connect, our ability to ask the hard questions, their ability to have people open up to us and again, it's been said before but that question on the handle of your door as someone's walking out after they've asked you for their PAPS mirror after they've asked you to check their blood pressure or after they've asked you to do something completely unrelated to what they wanted to talk to you about. I was just wondering if this is normal. So just creating that space for that to be safe and stigma, it's number three on my list there but I kind of wish it was number one. If there's one thing that I wish I could fight against and I know that we are all fighting against this stigma. You know, I have patients that will not and do not come to the emergency department or come to a doctor's surgery and say, I use heroin, I drink too much alcohol because the stigma that's involved with that. Once you say that, once you say I use this or I do that or I'm on methadone or I'm on Suoxone, nothing else matters. No one gives a crap about your chest pain. No one gives a crap about your shortness of breath. No one wants to, you know, no one wants to delve into the issues that you have with your coercive partner. It like, it doesn't matter. Like the fact that someone uses substances is, it doesn't matter, we got to break down the stigma. I've got patients that will not present to the emergency department with, you know, crushing centralised chest pain. That's righting down their left arm and up their left jaw and then nauseous because they don't want to be labelled as the junkie or labelled as the whatever. And, you know, I know I hold my emergency colleagues' hands in mine when I say this. They're on the same page. No one wants to be stigmatising our patients. You know, we're all overworked. We're all dealing with a pandemic. We're all stuck in this system that is so resource poor, but like stigma kills. And if we can all just stop and check our own bias at the door and really stop and say, how can I care for this person? And, you know, as much as I had to say it, using Scott Morrison's litmus test of, what if this is my daughter or what if this is my wife or what if this is my whatever, it does enable us to see past the substance use and say, man, you know, this person's in trouble and just, you know, offering a safe place, educating others. You know, I'm not telling you anything you don't already know. You're all here because you care. And, you know, this next point, it's so difficult. And, you know, I still struggle with it. I still seek the support of my peers. Be brave. You've got to ask the questions. But you've got to know when to ask the questions. Safety is subtle. Safety is so subtle. You can't ask the questions in front of the perpetrator. You can't ask the questions in front of so many people. But learning that, like, 0.05% of the space that it's okay to say, are you safe today? Are you feeling safe? But just learning that space in which it's okay to ask. We've got to be brave, but we've got to be safe. And, you know, it's really rough. It's a really difficult place to walk. And there's many times when I've got it wrong. There's been times when I've completely stuffed it up and it's hard to then ask again. But we've got to keep asking. We've got to keep it on the radar. And we've got it, you know, that last point of, we've actually, actually, my last slide has been cut off and that's fair enough because I put my email address up there because I wanted to encourage everybody on this webinar to say, ask for help. Vicarious trauma is real. Like, I can't tell you how many times I've laid awake at night and gone, oh my God, is that person okay? But we need to care for each other. We need to care for ourselves, which is why that last point of my slide's been cut off because I think I put my email address on there and I thank you to the organisers for protecting me. But we actually need to look after each other because vicarious trauma is real and we can't look after others until we look after ourselves. But, yeah. I might interrupt you there. I think that's a great point to end that presentation on. I must admit to being a little bit short, I hadn't expected a Scott Morrison reference in this. Sorry. No, I think it's a point well made. And the whole intersection between substance abuse and coercive control, I was reflecting while you were speaking, patients who are affected by substance abuse and by coercive control, they will just get smaller and smaller and smaller until they're walking this tight little line that's completely defined by a substance or by a controlling partner. I think there are a lot of dynamics in common there. All right, thank you to the panel members. We're now going to move into the Q&A session. I've tried to group some of the questions that we've got from participants into themes and I think the main three themes are detection. We need to be aware of these things in order to pick them up and do something about them. That leads into the second theme, which is management but focused on safety. So you really need to be aware that there are dangers to patients and treat those sensitively. And then the final point to emphasise that there are networks. We're not necessarily going to solve a problem by ourselves but we can draw upon a lot of other resources if we're aware that they're in point people towards them. So we'll probably have a bit of a free-for-all in this Q&A session. I'll read out some questions and ask people to jump in. I might sometimes identify people if I think there's a link to what they presented. The most common question, which surprised me, was asking about the gender question but wondering whether there's similarly coercive control from female partners towards men. And I think, Karen, you really did address that. Do you think there's anything more to say about that particular topic? Are you just on mute? Yeah, I do find it interesting and it is so frequently asked, you know, is this, isn't it both ways? I don't admit just as likely, just as able to do that. And I mean, like I said, it's statistically not, no, it's not equal. And you've got to think about, as we talked about before the cultural setting that we have where men have that inherent power as much as we like to think that we have equality and we want equality. It may be something that we do actually aspire to but the reality of our lives at this day and age is that we don't actually have equality. We still don't have women paid the same amount. We still don't have equal representation in government or in the judiciary or law enforcement. And we don't have equal representation in any of the really powerful fields, I suppose, that make decisions. And what we also see is that in every other crime, you have males being the perpetrators of violence. They are more likely to commit homicide. They're more likely to rape. They're more likely to commit armed robbery. Every crime is more likely to be committed by a male. And no one questions that, but when it comes to domestic violence, that's when everyone says, oh, hang on a second, it's equal. This is the one place in the world where it's equal. And it's just, it just isn't. And I mean, I think it's partly our ideals now, our wish that that's what it is, that it is equal. But unfortunately, this stage, it's not. To be fair to the questions, they weren't necessarily talking about equivalence, I think in terms of numbers. A couple of people raised the idea of male-on-male rape in homosexual relationships, for example. And I think... That's why I said male perpetrators, but victims be male or female, yes. Indeed. Look, a related question from Mike, who said that, do you see this coercive control as a gender-driven mechanism, or are there other drivers of coercive behaviour? And I was thinking whether, for example, things like culture may have an impact. You, Karen, I think, mentioned financial imbalances. If you have more than 100,000 a year, if you're an alpha, for example, you know, if you have that dominant personality, that might be a factor. Any other factors that the panel can think of? Yeah, look, I think just to build upon what Karen said, then I'll talk about the cultural stuff as well. I mean, we're talking about coercive control, not that somebody, you know, what you have for dinner tonight or something like that. Well, often people get those things really, really confused. It's about those bigger cultural stories that actually support men to be able to feel justified in having that power of control. And the other important thing, and I think this is really important, we often, you get arguments about what's called equivalently, you know, women are just as violent as men. The biggest actual issue for men's and men's health and well-being, in my opinion, is, you know, violence by men against other men, particularly as children. You know, I've worked a lot in that sort of space, and that includes when we talk about violence against women and children, we're including boys and girls in that stuff as well. And we often, that somehow gets missed in those sort of arguments around equivalency as well. I think it's really important. Can I ask, the men that you see in the family violence clinics, do they tend to be violent outside the relationship? Or is it mainly in the relationship? Well, there's sort of a couple of different categories. You have what was called men who are sort of generalists who may be violent in many different contexts and other sort of criminal behavior, and that's like, you know, depending on your research, about 30%, 40%, but then you have another 50% to 60% who are just very violent, very specifically in the context of their relationship. It doesn't mean they're not bullies at work or in other sort of contexts, but, you know, so there's a real some split, and it's important, you know, that's part of trying to, I think, tease out what some of those dynamics are, which I think that question sort of wanted us to get into, but, you know, underlying that all men are used violence in their relationship use those sort of cultural stories to mitigate their sense of shame and responsibility about their sort of behavior, because this is just the way just men are, you know, and even we saw in our scenario with Vanessa talking to her friend saying, well, that's just the way men are. That's what sets the context for this not being detected or understood or problematized. We just say, that's just normal. That's just the way it is as well. And on the point of sort of cultural dynamics, obviously this may look different because you've got a whole other layers in terms of people's cultural background, their experience of torture or trauma if they've come here on asylum seeker or refugee sort of pathways, the whole experience of a culture ration and racism come in terms of all play out. But also it's important to think that, you know, often it can be really easy if you're from a dominant culture, you'll notice attitudes that support coercive control because you're so acculturated just to notice it not within your old culture, I think it's important, but it does obviously look different and presentively because of some of those dynamics around culture. I thank you, David. We've got a couple of interesting clinical questions. So one of them is from Jordan, who says, I'm a school counselor. How can I support students in this space as they become partners and potentially survivor or perp? I don't know if you've got enough time to actually address this in any detail, but I think it's an interesting question in terms of the education and preventing rather than dealing with the problem as it after it's already occurred. Just quickly, there's a whole field called primary prevention of violence, which particularly in Victoria, for instance, they're really, I think, taking quite seriously and looking at a whole range of different programs within schools and educating teachers. We won't hear a pleasure called Rise Above, for instance, where we work with local schools and have some online learning to really support that because I think you're really sort of giving the language and those concepts to start to notice this stuff early rather than just learning to sort of internalize this as just normal in the way sort of relationship dynamics work. Sorry, I was fumbling with the question list. I was just going to jump in there and say that, I think that's really interesting, David, because I think a lot of the time when people that are experiencing this abuse, I thought this was normal. I thought this is how everybody was, and I think that sometimes it takes an external person very gently and very kindly and very safely to say, how was that for you or is this just kind of challenging what we think is normal or challenging what the person who is experiencing that particular form of abuse is experiencing because for some people who experience is that it is normal. And for many of us that sit on the outside as the carers or as the significant others, we know that that's not normal, but their experience of normal is not the same. So just very gently bringing that up of, this is not normal behavior. I think also I think recognizing that coercive control is about exploitation of the normal. It's about pushing the boundaries of what is allowed and acceptable and then amplifying it and using it to your advantage. So the things like the beliefs around looking after children and saying, you should stay at home, like even in the case example, that's normal, isn't it? What we currently say is normal, but it will mention being a child. So a perpetrator will really exploit that normal social norm and similarly with sort of isolating a victim from her friends and family. They won't say you aren't allowed to see that person because I don't want you to talk to them anymore and as I want to control you. They're not gonna spell it out like that. What they'll do is just, as I said before, very subtly build wedges between her and her family, such that she's, it seems like care sometimes or it seems like a normal human response if it's an unhealthy relationship. We might say, don't spend time with that person. So he'll say, she's poisonous, she doesn't like you. She doesn't want to be a good friend to you. So it's disguising what's normal and that's what's so hard for people to see. And I think if we had a lot more conversation around that, yeah, like in schools, I mean, you do seek a lot of control happening in the school, you see little kids saying, don't play with her, play with me and that, you know, I'm not gonna be your friend if you don't do this. This is a basic human behavior that we're just not really open to seeing or educating our kids about. We're still really keen on times tables, but human interaction is not the thing that we teach children, unfortunately. Yeah. And it's patterns of behavior. It's not just individual isolated incidents, it's a pattern. It's a very calculated pattern of behavior. So not just seeing one incident but seeing these things that happen over time. And I think, you know, as Karen and David and Andrew have said, it's being careful as clinicians that we're not then brought into that conspiracy. We're not then recruited as being part of that coercive control as pattern of behavior and recognizing that we are being recruited and stopping that from happening at the outset. And that comes from the awareness of this being a possibility. And I think that's really... There's a lot more to say about this, but there's a couple of other questions I was hoping to get to about some specific groups. So there's one, sorry to interrupt you, David. Do you have any comments? This is from Penny. Do you have any comments about relationships of coercive control when the victim has a disability and the perpetrator's carer have a high degree of control, access to services, providing care and so on? Yeah, well, what we know is disability becomes a whole range of other factors when you sense of agency of things you can and can't do in the world where you need support to do that as well. I mean, I think the Disability Rural Commission found something like 10 times more likely to experience abusive sort of behavior, you know, depending on what the disability is and look like as well. And it's a whole other area where that as a sector, again, needs education and support to be able to help manage some of those sort of dynamics. And again, where control can be disguised as care, if that makes sense. Oh, well, no, they're just really unwell. So that's therefore, you know, when they get like this, we need to make sure that they don't leave the house or something like that, just as an example as well. So... Yeah. And also, I guess, what happens in those situations is that coercive controllers look for a hook. They look for a way in. And these relationships are complex as they are, just with the absolute bare minimum, so that whenever there's anything else, whether it's substance use or whether it's a disability, as soon as you've got another hook, there's another, if you can imagine somebody standing on the edge of a wharf and they're choking a fishing line in, and, you know, there you go, there's another hook. And disability is one of those situations where another hook is then provided for another layer of coercive control. This is not my area of expertise, but I have clinically been involved in some situations. And I think disability is a really complex area. And I have seen situations where a great deal of control has been put in place by actually very caring people, literally because they did not know what else to do and the level of despair was such that their own behaviour gradually got more and more extreme. Once they understood what they were doing and that there were other ways of managing the behaviour, very quickly that behaviour changed. So I think it's a very complicated area. You really need to get some expert advice in that area because one thing can look like in another if you see what I mean. And I guess that's where the referral pathways come into play, if there's something before you that you feel like, oh, there's a red flag here. I'm not sure what I'm doing here, whether it's you ask a colleague, ask somebody that's next to you in the consulting room next to you or your phone a friend or you seek some kind of support. If there's something that feels not right to you, trust that clinical instinct, it's there for a reason. And there are referral pathways. There are, the MHPN have referral pathways for you. There are places that you can seek support in those diagnostic and those referral decisions. We probably have time for one more question and I've got about 12 that I would like to ask, but Karen, I think you and I did a podcast a little while ago and I think we talked a little bit about this particular question. So Yolanda has asked about legal ramifications. When the perpetrator controls finances and the situation becomes litigious and the woman does not have the finances to defend herself, are there legal resources that she can access? I mean, the concept of coercive control is still barely recognized in the legal profession and as much as they've got a lot of, there is resources out there for them to be using, the people that are representing them and a lot of the time have very little time to spend on an individual's case and the nuances of coercive control, I don't think have been fully understood. Well, no, they haven't been in any way. And so, yes, it's terrible what is happening in the legal system because very often the victim has been painted as the perpetrator and are facing legal ramifications for themselves. We also know that there's a lot of vexatious claims being made as part of the abuse and again, it falls under coercive control, controlling her ability to leave and her financial situation because a lot of abusers will continue to use the legal system to continue to inflict abuse on the woman. I'm not sure if that answers- I really think, yeah, absolutely. I think as a society, we're really just starting to grapple with this and even the idea of superannuation and the way that inequitable workforce practices lead on to not having superannuation and therefore being dependent when you're retired, we're really only starting to grapple with that. And I mean, we're not where we need to be, but we're probably a little bit further along than we were 10 or 20 years ago. So hopefully things are going in the right direction. Look, I apologize, I haven't been able to get to all of the questions. I've tried to pick the ones that had the most support, if you like, but I would like to move away now from the Q&A and ask the panel members if there are final points they would like to make or to sum up their position. And I might start by asking David, we'll go in the original order. So David, can you sum up your thoughts, your reflections about the webinar today and any final thoughts or clinical pearls of wisdom? Yeah, or pearls, fantastic. Maybe some coal I could do. Even go coal's not a popular issue at the moment. But look, one of the things I've been thinking about as we've sort of been having this sort of presentation is the importance that at all levels, that advocacy that is mostly being pushed through women and the women's movement really starts to disperse into the broad way we sort of educate and train a variety of different professionals. Now, I'm sitting here with a panel, obviously you all had your medical training. I don't even have my first date up to date, but I think about social workers and psychologists. Like, it's sort of like we, by the lack of training around coercive control and domestic violence, it's sort of like we're sending social workers and psychologists out to do medical work and they haven't even learned about cancer or obesity or the really things that you see or in your general practice all the time. We're not really supporting that field. So I think that that I think it's important that education and the way a variety of different institutions take up some of those sort of ideas I think is important. Thank you, David. Karen, any final thoughts, reflections? Yeah, the one thing that I would like everyone to take home is for those of you that may be in a position where you are asked to be the mediator between a couple that have, where there's a history of violence, I think being really careful not to engage in that. There is no place for couples counseling in a setting of family violence. The risks are really high and you can't counsel people out of this. The survivor is spending her entire relationship blaming herself already. She will already be trying to reflect on her own behavior and blames herself for almost everything that goes on. It's quite pathological in that way. And the abuser, what we know about the common characteristics of abusers is that they will always blame her for her behavior for any conflict. So someone trying to mediate between that, it's an impossible situation. As soon as the mediator starts to say, it criticizes his behavior, he will damn that mediator and say, don't listen to that person. That person's not telling the truth. And she'll get into trouble on the car ride home. We see that happen so frequently. The importance is safety first. Get her out of that situation. That's the most important thing. If they wanna work on their relationship outside of that, fine, but immediately has to be at a safety focus and recognize that as clinicians, you're all vulnerable to being manipulated and controlled by this person. And all you're gonna succeed at doing is drag out that relationship, she'll stay in there longer and be more exposed to violence as a consequence. So it's actually contraindicated to try and use couples counseling in that setting. I thank you, Karen. And Bronwyn, any final thoughts, reflections? Yeah, thank you. I guess my final thought in terms of echoing everything that everybody else has said in terms of becoming a collaborator or becoming part of that story is to just really stop and check our own bias and our own stigma and being really aware of how we deal with people who use substances or haven't used substances or find themselves in a situation that does have an element of domestic violence, whether it's overt or one of the covert forms. But yeah, stigma is big and it exists whether we like it or not. So if we can just stop and check our own biases and provide that space for people. Yeah, thanks. Thank you, Bronwyn. Look from my own point of view, one of the things I realized being in the process of putting this webinar together was the point that Karen made, that the gendered nature of this issue. I hadn't even reflected on whether being a male presenter on this topic might be an issue. And when I thought about it, one of my first thoughts was, well, should I not do this and allow a woman to do it? And I thought there's an interesting approach and there is a clinical parallel. I think often male clinicians fear this particular topic and might excuse running away from the problem because they might think that someone being abused by a male may not want to confide in a male clinician. Now, that may be the case in many situations. But I think what male clinicians can do is learn to handle each of the situations they're in with a better outcome. That may not be being the clinician for this particular person, but it may be referring that person on to somebody who can help them. It may be as simple as just listening to them and allowing them to move a little bit closer to being able to divulge what has happened to them. You're not gonna save every person in every encounter, but you can improve over time. And I think Bronwyn pointed out the importance of education in this area. So that would be my final reflection. It's great that everybody's here. It means that you're interested in this area. You want to do it better. Being male is not an excuse to not doing it, but you do have to be sensitive that it may have an impact on what you're able to do. Okay, well, thank you. Any final comments from the panel members? Okay, next slide. So I'd like to thank everybody for their participation, the panel members, the audience. We wouldn't be here without the audience. And I'd also like to ask people to complete the exit survey. So either before you log out, you can click on the pie chart icon, a little pie chart with a section coming out in the lower right corner of the screen beside the speech bubble. Or you can wait for a message to pop up after the webinar ends. It's really helpful to get feedback on this process. It can improve future webinars so that we do a better job. People will get a statement of attendance. This was the second most common question. So a statement of attendance for this webinar will be issued within four weeks. And each of the participants will be sent a link to the online resource that's associated with this webinar. Next slide. So there are other MHPN products available. I'd like to mention the podcasts, in particular the In Conversation with Dr. Ruth Fine, which is available on the MHPN website, Spotify and Apple podcasts. And there's a number of that MHPN podcast shows including eating disorders beyond the unknown. The next upcoming webinars are Supporting the Well-Being of Infants and Children through a Trauma-Informed Lens on the 2nd of March and Suicide Prevention for LGBTIQA Plus Communities on the 22nd of March. So you can sign up through the portal on the MHPN website to be notified about those webinars, podcasts and upcoming network activity. Our next slide. So MHPN has a number of networks, over 350 across Australia where mental health practitioners can meet either in person or online. Mostly online at the moment, I would think, to discuss issues of local importance. And you've got a link there, mhpn.org.au for your local network. And you can also email networks at mhpn.org.au if you're interested in setting up your own network. And then MHPN can help guide you through that process. Okay, look, before we close, I'd also like to acknowledge the lived experience of people and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present. And thank you to everyone for your participation this evening.