 Thank you very much. I would just like to welcome all the participants and the attendees to MHPN's Interdisciplinary Panel discussion. Tonight the discussion is on collaborative care and mental health of people from migrant backgrounds. We are very fortunate tonight to have four excellent speakers on the panel. We have firstly Dr. Joanne Gardner. Joanne is a GP with a special interest in refugee mental health. She works as an adult refugee health fellow at the Royal Melbourne Hospital and also at Co-Health. Joanne, may I just ask you, how did your interest in refugee mental health first come about? Thanks Michael. I was lucky enough to see an asylum seeker in about 1995 and I foolishly rang up his solicitor and asked if I could help and whereupon I started seeing many asylum seekers and my interest sprang from there. Great. So the word spread. Well done. And joining Joanne is Harry Minas. Harry is a well-known psychiatrist from Melbourne. It's great to have you with us, Harry. Hi Michael. You're involved in a range of projects and organisations. Some of that involves international work and also work here at home. Can you tell us a bit about this international work? We are involved in projects that are focused on developing mental health services in a number of countries in Asia. Our biggest projects are in Vietnam, Indonesia and Sri Lanka but we also work with some regional organisations like ASEAN and WHO and so on. So most of our work there is working with colleagues in university departments or in service agencies and with ministries of health and social affairs. So you have a special interest in systems and mental health? Yeah, very much so. Our interest is precisely that. How can we actually build systems that actually work better for people who have a variety of needs? Great, Harry. Thank you very much for joining us. We also have Lata Satyan. Lata, thank you for joining us. Can you tell us a little bit about your work in the area of family violence and strategies to prevent this, particularly in relation to migrants and the Indian community in your work as a psychologist and a teacher? Sure. I'll be happy to, Michael. Hello, everyone. A pleasure to be here this evening. Well, I have been a psychologist for quite a number of years and through that I started seeing several women who approached me on their own really to just talk to me. They did not come and see me as a professional as such but they wanted to speak to somebody who was an Indian and who perhaps understood the cultural background and who could help them in any way. So my work started that way but since then so I do work as a voluntary psychologist within the Indian community but also I conduct research in the area of family violence across migrants as well as non-migrants. So I'm involved in a range of incidents if you like on a regular basis and at any given time I'm assisting at least four women concurrently. Thank you. So your expertise extends all the way from Deakin University in Victoria to Facebook on the World Wide Web? Well, a bit of that I would just say. I think a few people have contacted me through different means which I'll go through my presentation as to how women actually contact me. Thank you very much, Latha. I'm going to carry on from where I started. Briefly I've introduced Joanne Gardner, a GP from Melbourne with a special interest in migrant health. Harry Minas, a psychiatrist from Melbourne with a special interest in systems and mental health and also with assisting third world countries in delivering better mental health through better systems. We also introduced Latha Satyan, a psychologist who teaches at Deakin University in Victoria and who has a number of clients she follows from the migrant Indian community with problems. The last person I'm going to introduce in our panel tonight is Vivian Radak. Vivian is a social worker by training and she is presently working with the Queensland Transcontinental Mental Health Centre. She leads a statewide consultation team to help improve the mental health care of migrant clients. Vivian, what do you find are some of the biggest challenges you find in improving the mental health care of clients with other languages apart from English? I think some of the biggest issues that we certainly see are around stigma, that there can be a lot of shame and stigma in having a mental illness, but also to I think really importantly about how mental health services are responding to clients from migrant and refugee backgrounds. I think there are a lot that we have to learn and that we can certainly improve. Thanks very much Vivian, that was very good. You may need to just speak up a little bit or turn your volume up a little bit. Thanks Vivian. Okay. Now I'll just go through a few grand rules for tonight. Of course we all need to be respectful to each other, participants and panellists, and behave as if it were a face-to-face activity. The attendees can post comments and questions for panellists in the general chat box. And the feedback from the attendees is important and finishing the short exit survey. Now the learning objectives and outcomes for today are threefold. Firstly to raise awareness of the migrant experience and associated mental health risks, particularly for women with young families. And really that pertains to the case study. And the case study gives us lots of information that will help us in achieving this learning outcome. Secondly, we need to identify the key principles of the featured disciplines approach in screening, diagnosing and supporting the mental health of people from migrant backgrounds. And this is achieved through the presentations from our excellent panel. And then thirdly, in our interdisciplinary collaborative discussions afterwards, question and answer with the panel, we will then explore tips and strategies for interdisciplinary collaboration among practitioners working with migrants experiencing mental health issues. Now without further ado, we will move on to the GP perspective. And Joanna would just like you to start, please. Thanks very much, Michael. Thanks everybody. I suppose at this point, here I am with Rishika, Cuddling Anisha and Ishaan sitting in front of me. And by this stage, hopefully, I have had some alarm bells starting to ring. And I'm thinking that this one isn't going to be straightforward. And I'd better think pretty carefully and tune in to the zen of the moment to try to work out what to do next. And clearly Rishika's posture, she looks very worried, very intent. And Ishaan, his attitude doesn't quite gel. He seems to be a little bit more worried about his passing, his exams than his baby. And the crying is obviously annoying him a little bit. So I'm thinking how shall I engage this pair and do my best? So the first thing I would think is praise them for attending, bringing the baby so promptly. I would try to perhaps normalise the idea that being a young couple with a little baby on their own without family support is very difficult. And I would probably talk about say that I have met many couples in a similar situation and I admire them very much. I think they're very brave. And that our practice, our surgery is always keen to help them in however, whatever way we can. I would perhaps ask Rishika a little bit about how she's going, her physical health, something fairly neutral. And I would ask Ishaan a little bit about how he's going as well to try to engage them both. Then I would try to do a very thorough examination of the baby for reassurance. Starting at the top of the head, working all the way down, doing every bit, making sure that they knew, and particularly Rishika, that I was doing everything I could to make sure that the baby was okay and to particularly engage her and make her see that I was a trustworthy person by the means of the way I was managing her baby at least. And then if possible, once I'd sorted out why the little one has a fever, I would try to see Rishika on her own. Now this isn't always easy, particularly as Ishaan isn't happy that I would do that. But quite often if I talk about first of all bringing the baby back in a few days for a checkup of the fever, you know, whatever it is that I might find a check of the chest or feeding or what have you, the sick baby is a really good in to this family, this couple gives you a really good way to engage them. The second thing is I would say to Ishaan and Rishika that, you know, women after childbirth do need regular checkups to make sure they're okay. And often this is women's business and it's important that Rishika has the opportunity to have a full women's checkup. It's quite possible that she may, I can't remember, she may or may not have had a six week check. She may or may not have had a pap scare, so at least I can offer that she does that. And most men in that situation are quite happy to go out of the room at that point, at least in my experience. If of course I was a male doctor it would be a little bit more difficult and I would try then to refer to a female doctor or a women's health nurse if I was lucky enough to have one in my practice. A quick point about language. Now this couple speaks very good English but it is very, very important when you are seeing people from non-English speaking backgrounds that you offer a trained interpreter. The telephone interpreting service is a free service that any GP can use to register. The interpreter can be on-site or over the phone and the interpreter can also be interstate and in certain circumstances I had actually arranged with the patient before using the interpreter that I would give the patient an alias and use an interpreter interstate so there was no way that anyone could work out who they were and this has been very successful. Now when we look at this family there are a few things obviously that come to mind and we are going to talk about. One is the possibility of intimate partner violence and how we deal with that in this complicated setting. Another is little anaesthetist sleeping problems and possible failure to thrive and that again is a way of involving other services perhaps in a fairly safe and non-judgment way. The third point is Rashika's social isolation and her need for support and how we go about facilitating that. And then I think it mustn't be forgotten that Ishaan is clearly under quite a bit of stress and as a way perhaps of supporting this couple his issues also need to be at least considered. So what can a GP do when they are faced with this sort of situation when we are querying intimate partner violence? I suppose if I have been lucky enough to get to the point where now I have Rashika on her own she might have seen me a few times. Maybe Ishaan is now comfortable enough to allow her to come because he realises that we are a trustworthy practice, we are helping his daughter. If things have improved he will be studying and working more effectively. What I would do with Rashika is I would first of all try to facilitate the discussion. The RACGP has some very good guidelines on managing violence and general practice. They talk about, for example, having posters in the waiting room so that the practice is revealed to be a fairly safe practice, a practice that considers these things. And I would try to allow discussion. I would ask the question. And often I ask these sorts of difficult questions in the third person, for example, something along the lines of, I know that some husbands and wives have difficulties at home. Is there anything worrying you at the moment that you would like to speak to me about today? So I would try to put it in a fairly non-judgmental, fairly open-ended way to really allow Rashika to respond at the level that she wanted to. And I would also be aware that she may not tell me anything or may only hint. And then a couple of visits down the track she may be prepared to say a little bit more. I think that the best approach would be a fairly non-judgmental and empathic sort of approach. And that I would validate her experience, whatever is going on, that her experience if she is being abused, that that is not acceptable. But at the same time, try not to push her too hard to make any particular step that she may not be willing to make because she is very on her own. She has a little baby to care for. And she's struggling hard enough as it is without getting pressure from me. What she needs from me is a supportive, kind person to whom she can come and who can at least tell her what her options are and what is acceptable in Australia. Give her a norm and that I can offer her information and resources in the appropriate language. At some point down the track, if things were really not very good, it would be possible to talk about a safety plan. But this would be way down the track possibly for someone in her situation. And I think it's important. I'm just going to have to ask you to move along with the slide. Yes, sure. Thank you very much. Thanks. I think it's also important that I be fairly very non-judgmental over any issues to do with culture or arranged marriage. And perhaps at some point check in about her family of origin attitude to separation and divorce. And be aware that as she's on a visa this may also present certain difficulties. Other supports that I might be able to bring in at a fairly early level would be an enhanced visiting maternal child health support service to help her with Roshika and Anisha or to offer intimate partner violence support worker. Thank you very much. Thank you. That was excellent, Siobhan. Just for the benefit of those who lack sand earlier on and who may not have read the case, we're dealing with a family, migrants from India. Roshika, the mum has presented with her husband and with her little baby. The baby is possibly not thriving. And there is a question as to whether Roshika, the mum, has got some bruising. They're under multiple stressors of difficulty in finding work falling behind in study and having a young baby in a strange country. So, Harry, just with that setting, I will just move on to your presentation, please. Okay, thanks very much, Michael. I think Joanne has identified all of the key issues. We should just go back a little bit. This is a Hindu family. A arranged marriage is not that uncommon. Ishan is one of very many students who are from overseas in Australia and who are studying and at the same time are working. He is working as a taxi driver, mostly at night, so he doesn't see his family so much. Roshika, who worked in a business role in India, has made many applications, but is unable to find work, so there may also be issues. She's not even getting interviews, so there may be issues and concerns about whether there's racism at play, whether there is discrimination against somebody from India. They've only been in Australia for 12 months, so they're still really just settling in. And it's clear that they have some significant financial problems. They're living in shared accommodation. Is it really necessary to find out what that shared accommodation actually is? Who are they living with? Do they have any private space? Are they able to have private discussions? Are they able to look after their child in a way that a young family would want to do? So, as Joanne said, it's a situation where both Roshika and her husband are under considerable pressure. There are concerns, I think, about every member of the family. If we go to the person who has been presented with the problem is the baby. She's small for her age. It's a matter of working out. And as Joanne says, this requires a very careful examination and assessment about whether she's actually developing normally or not and is sleeping poorly. And it may be that the poor sleep is related also to some of the problems that there are in the family between the mother and the father. Roshika, her situation is pretty tenuous. She's not financially independent. She's here with her husband. She's on a spouse visa, so if things fall apart in the family, it's very unclear what her situation would be. There are clear indications that violence is happening. She's got bruises. She tries to cover them up during the initial consultation with the GP. She is very concerned but is not talking about this, nor is her husband. There are some indications that she may be depressed. So at some point, I think it's going to be necessary for an assessment of her mental state. Work out, is she depressed? What is the severity of her depression? Is this related to her baby's difficulties? We know that the very young children of depressed mothers run into all kinds of problems. So this may be happening with her child. And there's quite a worrying comment towards the end where there's some discussion about the baby and whether the baby should be sent back to be looked after by her parents in India. Ruchika's comment is, she's all I have. This suggests that she's not in a very good state. There is clearly a need to carry out a very good assessment about her mental state, whether she's got a significant depression or other problems. The problem, of course, is that her husband, Nishan, is very reluctant for her to do anything on her own. He's not very keen for her to see the doctor by herself. He's not keen for her to go to the temple on her own. He says he's worried that the place where the temple is located is a bit dangerous, so he doesn't want her going on her own. He really doesn't want his wife, Ruchika, to do anything very much on her own. He's clearly in control in this family, and he's also under pressure, as Joanne has said. He seems to be running into some difficulties with his study, keeping up. That's related both to the problems with the child and the child sleeping and also the fact that he has to work. So I think what we have here is essentially a family which is in trouble. The baby's got some difficulties that need to be carefully assessed. Certainly the mother has some difficulties, but as Joanne has correctly said, we need also to be a bit concerned about what's happening with the husband and what his situation is. Some of the problems is the control that the husband is exercising over his wife's ability to see anybody on her own I think it's a little early for Ruchika to be the focus of this, although there are some very clear indications that family violence is likely to be happening. And I think the other issue is whether Ruchika's situation can actually be improved without engaging her husband Ishan. And so it seems to me that what we have is a number of risks to keep in mind. Certainly the risk of violence, worsening mental health problems in Ruchika, possibility that if things fall apart in the family that you may be able to remain in Australia. For the husband, he is the likely perpetrator of the violence. This by itself suggests that there is enormous stress within the family. There's a possibility that he might lose his wife and child if things are not resolved. And there's a possibility that he's not doing it all well in his studies. And I think we need to keep in mind some of the cultural issues here. An international student, it's costing somebody a lot of money to keep him here and study. There are issues of his own pride and the family's pride if he's not doing well in his studies. So those things may also be contributing significantly to his behavior in relation to his wife and also to his child. Although there's no suggestion of it, I think the possibility that the child, the baby might be at risk, needs always to be kept in mind. And so that's something that needs to be considered. There's the risk that the family might break up if things are not resolved. But as I mentioned before, I think it's unlikely that it's going to be possible to do anything effective about these multiple risks without actually engaging Ishan. And as Joanne has said, I think the entry point is the baby. I think both the father and mother are clearly concerned about the baby, about its growth, about its poor sleep and so on. I think concern about the baby is likely to be the most acceptable entry point to a broader assessment of how this family is functioning. There are obviously big problems in terms of family functioning. And I think assessing that is the most urgent issue. In terms of whether Racheke is referred by general practitioner to some specialist support, it's very unlikely that her husband would accept or maybe herself may not accept referral to a psychiatrist at this stage. Joanne has already said that it's a bit down the track in terms of actually being able to bring to the fore this issue of domestic violence. And it may be at some point a little bit further down the track that somebody else can be brought in to look at the issue of violence. And one of the things that needs to be thought about, I think, is the possibility of referring to a pediatrician who is known to have very good skills in both assessment of families and also assessment of possible mental health problems in the different members of the family. And this may be the way to actually get into this family and to start looking at what's happening, start getting the family to acknowledge the problems that do exist and open up a space to look for some kind of resolution of those problems, which may or may not involve specific psychiatric treatment. So that's it from me. Thank you. Thank you very much, Harry. That was an excellent presentation, as was Joanne's. And now we move on to Lata's presentation, our psychologist. Can I go ahead, Michael? Yes. Yes, go ahead. Thank you, Lata. Sure. Hello, everyone. I would just like to provide this presentation in terms of what my usual experience is with regard to women approaching me. Yes, sometimes we would expect that the first port of call would be perhaps a GP or a psychiatrist. However, the way women usually approach me is that they do so voluntarily. They somehow seem to just become aware of the service that I provide. I know that I do work as a voluntary psychologist because of course I do work as a lecturer in the university, but that work is separate to the work that I do within the Indian community, especially within the Indian community, but I also assist migrants from other backgrounds who are going through abuse. So the women usually just call me or tell their friend to perhaps check me out in terms of whether I would be able to assist them or not, and also to really become aware of whether I would be trustworthy enough. They would usually want to speak about their problems to somebody whom they can trust and somebody who does not know their family. So I might especially fit into that second category. They become aware of the trust issues a little later and then they become aware that perhaps I have helped other women and that I may know the system. So they become aware of this either again through friends or through other people. Some people have also just done a search through Google. They want their friends to do a Google search and then their friend informed the friend over here who was in hospital to call me and say that perhaps that I could help them or not. Again through Facebook, it's just because I have formed a group called the Indian Women Support Group and so if they try to Google anything again about providing support to Indian women, they may come across that or through an organization. And I've written there unlikely because they usually again would not approach an organization to talk about any difficulties they may be having. So overall, the woman who might be going through intimate partner violence such as Rishika herself would initially contact me on a very informal basis. But however, of course the advice that I provide would all be professional and I do inform them of the confidentiality issues and all of the other regulations that I would follow when they are narrating their stories if you like to me and their difficulties to me. So it is difficult for them to make that first port of call. It's really difficult. And a lot of the time the women have actually gone through several years of abuse ranging from anywhere between one year to 14 years of abuse before they've actually picked up the phone and called somebody or even told anybody of the difficulties that they have been facing for most of their lives. So it is a very difficult issue for women to even just pick up the phone and call. So, you know, Joanne has gone through about the GP and how they would diagnose them. I think it's a really important point wherein a GP could actually try and pick up on certain signs as to what might be happening within the family because apart from approaching a psychologist, you know, they would more so approach a GP for any other instance such as the child being unwell. So this is where GPs I think need to be trained further to pick up and look out for signs really in relation to intimate partner violence and then actually act on it. I do know of a few GPs who are quite aware of these issues and they do pick up on the signs and then do something about it. Unfortunately, some of the other people I speak to, they're aware that it may actually involve more paperwork and so they're not prepared to actually do something about it unless the family actually tells them something. So that is something that we need to be aware of as well. So if someone does contact us, it's about how do we help them and I think the first important thing is to understand the person and I see understand her. What I mean is that understand her holistically in terms of how difficult it must have been for her to actually just pick up the phone or to even approach you to tell you anything at all in terms of the difficulties that she may be having, whether the person approaches you as a GP or as a social worker or you come across her through another kind of training organization, but I think it's really important to understand when the woman starts speaking about her background to really be informed about her culture as well, her cultural orientation and the cultural practices and what I mean by this is that how difficult it would be for someone such as Rishika to open up anything at all about the husband and her experiences within the family because it is a matter of shame to actually talk badly about the family and in fact to talk about the difficulties one is experiencing within the household outside the household. So it's really important to be aware of that. We also need to understand the ostracization that may occur for the family when Rishika went outside the family to actually seek assistance and talk about some of the negative experiences she's having within her family. So we need to be really aware of that and that she may not want to seek formal assistance. A lot of the time sometimes they just need someone to listen to them to try and validate their responses that perhaps what is happening to them is a wrong thing. They're not really aware a lot of the time that in fact there is a law against family violence. A lot of countries around the world they do not have laws in relation to family violence or the laws are minimal. The men are protected to a great extent so we need to be aware of these things as well and as to how therefore the women may not be aware of their rights and of the law in Australia and so they may not want to seek formal assistance and so this is where we need to ask ourselves how then can we encourage somebody like Rishika to seek assistance so if they went to a person like Joanne who picked up on certain signs who was offering certain kinds of assistance and recommending her to come back for another checkup but then if she didn't want to come back alone or if the husband said that he was not going to bring her alone how then could we actually encourage her to seek assistance I think what we would need to do is to provide her with pieces of information perhaps brochures, information about helpful organizations resources, contact numbers and also some definitions a description of family violence itself I think that would be really useful for them to go back and read In terms of as a psychologist how I respond to something like this is I make an initial assessment of their mental health concerns I ask them a whole range of questions and try to gauge how they are performing in all aspects of their lives if they have children how they are looking after their children how in fact perhaps their children might be suffering as well and they may not be so well their physical and psychological health may be of concern so I do try and perform an initial assessment what I usually realize is that there are a whole range of factors that impact on their mental health and it's not so easy to just target you know only to try and for example provide counseling and say well this is what I'm going to do and you know to try and help build up their resilience it's not so much that there are many many factors and we need to try and understand those factors and in fact what I have realized is that in fact we cannot enhance their mental well-being unless those other matters are taken care of when I say other matters I mean something like basic necessities such as provision of food accommodation being able to stay in the country I'm currently assisting a woman whose visa runs out on Thursday and she needs to leave the government has told her this is an intervention that has been provided at the ministerial level and the minister of immigration has told her that she needs to leave the country by Thursday I've been coordinating for the past week a whole range of efforts to try and get her to stay in the country we have found a way and we are submitting the application tomorrow morning and I am hopeful that's all I can do at this stage all of us can do at this stage I am hopeful that she will be able to stay beyond Thursday so there are many other factors that need to be taken care of usually prior to us only focusing on the mental well-being aspect and so this is what I try and do to see how I can assist with those other matters as well and I usually have contacts with a range of people who are able to assist but something like provision of food I just send out an email to all the people I know and ask them for donations if they can provide groceries for example or money for petrol and so on and usually people have been very responsive these are just individuals within the community they usually provide me like you know just a few weeks ago I sent out an email on Sunday afternoon by Monday night I had groceries that would have been enough for a month for the family so these are the kinds of matters I'm talking about so when there are urgent basic needs to be met we need to be careful and we need to assist that and we need to see how we can respond to that and I think what needs to really happen here which will lead into my next slide is that we need to work collaboratively everyone together not just the medical professionals but I'm seeing people within the community people who are able to offer a whole range of other services everyone needs to really work collaboratively so that we can understand the challenges we can meet those challenges and we can assist the people because there are real practical needs it's not enough for us to only speak about the theory yes we need evidence-based practice for intervention to understand what family violence is but we also need to understand in terms of how the community actually needs our help right now and I think as professionals even for me as an academic for me what I see is that the translation of knowledge is very important yes we understand what family violence is and what interventions can do which interventions are effective but then we need to really translate that into our practice and I think it's important for everyone to do that you know to try and do the best we can and I think there are so many resources out there some of them are being underutilized in fact a lot of them people just don't know where to go for help for me just by trying to assist each woman and each person's situation is so very different just become aware of the system so much more but there's always so much more that I'm learning so I think everyone needs to really work collaboratively and I think in fact this is perhaps a great opportunity for us all to come together and understand what responses are available and how perhaps you know in fact if everyone could talk about the resources that they have available I think that would be great as well so I hope that we can all work together and really assist the people in need such as Rishika and Dushan and the family there Thank you very much Latha My pleasure and thank you very much for making us think outside the square outside the square of our particular disciplines but also mentioning the collaboration between disciplines which is so important in managing cases and now we're just going to move on to Vivienne Raddick's presentation Vivienne Yes, hello, thank you Michael I'll just move your slide on Thank you There we go Yeah, I think certainly the speakers that have gone before me have talked about a lot of things that I was going to cover and a lot of really important things so some of the things I might cover fairly briefly because we've already... Vivienne, sorry the sound is just dropping out a bit if you can just move it closer to the skin on your cheek it'll sound better, thank you Okay, is that any better, Michael? Yeah, that's much better, thanks Fantastic, my apologies for that So look, this client, all this type of client we would see Rishika, she would have been referred to our service probably through a number of different sources possibly a GP, possibly a friend of hers may have entrenched her to seek some help and I guess our starting point would be looking at doing a really good assessment considering what are the mental health concerns and presentations and certainly thinking about not just Rishika but the whole broader family that there are a number of issues for each of the members in this family Rishika, while she is the person who we see initially and hear about initially and certainly raises questions for me about is there depression or something else going on really needs to be looked at but so do the others in the family Certainly the baby we need to think about there are issues around sleep whether or not the failure to thrive has some medical causes and concerns and certainly if you're the baby who's not sleeping then it's going to be incredibly difficult to get sleep yourself and you're going to feel really lousy so those are some of the things that we need to think about both from a medical point of view and a mental health point of view I think it's very important when we're thinking about this family and this couple is looking at some of the personal history as well we know they've just come to Australia we know that there's an arranged marriage but we don't know what their goals and their hopes and their dreams are we get a bit of a sense for Rishika that she had a career before she had a baby and while she loves this baby obviously that whole process of having a baby giving up a career can be really difficult and we certainly have heard about Ishan and the fact that he's obviously experiencing lots of pressures around trying to raise a young family thinking about his study and trying to do well there and also a lot of the financial pressures I think there's some real indication that there may be some significant financial pressures not only are they here in Australia they're trying to support themselves by one person's studies they're raising a new baby what we don't know at the moment is what sort of depth does this family have both to come to Australia and to be able to study in Australia as international students that whole process is exceptionally expensive sorry I'll just get myself together here and move across to the next slide I want to talk a little bit about some of the cultural considerations for this family and when I'm looking at it and assessing with this family some of the things that I really want to look at what are their expectations of themselves so we know that probably Ishan is very committed and dedicated to studying and doing really well there and probably has that expectation of himself I suspect we've also got two parents that are incredibly dedicated to their little baby and want to be good parents I suspect also something else that we need to think about in relation to their expectations of themselves are they being good children that they probably have extended family that they have responsibilities for and what are those responsibilities and how are they impacting on this family at the moment as well and looking at some of those things we need to think about the broader extended family we know the family are in India we know they're unable to come out here and help this family but they are looking for solutions as well and one of their solutions is the idea of maybe the baby comes home to India we look after the baby you focus on your studies and your work which can sound on the surface of it a really kind of distressing idea but not necessarily this may be something that is going to fit for them and work for them and we need to keep that in mind so we need to think about some of those expectations from an only extended family we also need to think about particularly what is the explanation about what's happening if we say that we think Rishika has a depression what is her understanding and her explanation about what is happening for her she may have a very different explanation about what are the causes of how she's feeling and we need to keep those in mind we also need to think about and talk with her about if we think she has a depression what is the stigma associated with that for her she may not want to come and see a mental health service it may be too shameful, it may be too embarrassing she may not want to seek out assistance around the violence because it may be too shameful and difficult and in talking with them about her explanation of what's happening for her we need to build an understanding about what are her expectations and what is her understanding about how you raise children is it the role of just her as a mum or is it that she would expect traditionally that she would have her extended family supporting her and one of her struggles at the moment is that they're not here to do it and she's doing it alone so what is her explanation of how she can cope at the moment as well is really important I think we've talked a lot about the domestic violence tonight and it's very important and we need to understand her explanation of that and finally we need to think about language barriers is language a barrier for this family and particularly when we're doing things like counselling mental health assessments even if people have a good level of English it may not be enough English to be able to really participate in counselling or to have a really good assessment so while they may have enough conversational English I might use an interpreter to be able to assist with that process moving right along OK, just thinking about some of the social considerations this family's immigration status is something that we need to think about we know that they're here as students I don't know a lot about the provisions of the student visas but I suspect and I would need to look into what are their rights to access service this family may be Medicare and eligible which makes them ineligible to a whole bunch of services and suddenly makes the cost of seeing a GP getting medication, seeing support services prohibitively expensive so for this family if we said Rishika needs an antidepressant that may be too expensive if we're looking at putting her on a course of antidepressant for six months we need to think about those things really carefully also in relation to this family we need to think about what are the child protection obligations an issue is small we know she's not sleeping particularly well we need to get to the bottom of that and what is going on and see whether or not there are concerns for this baby we also need to think about the domestic violence as well what sort of supports does this woman need in relation to her immigration status again we'd probably have to think about whether or not there are domestic violence provisions for her in her visa so for some people who have visas temporary visas here in Australia they may be able to access domestic violence provisions in that but allow them to leave a partner but actually be able to stay in Australia whether that exists for somebody on a student visa I'm not sure and we'd have to check into it then we need to look at those forms I'm sorry for one reason or another we're running way over time at the moment so may I ask you just to have a look through your last two slides and just speak for about a minute to the most important something else that you used to make and then we can go straight into the questions that we need to ask of each other in relation to collaboration Absolutely so looking at those formal supports I think later she's done a really lovely job about talking about how she does that informally particularly for people who are unable to access services because of their visa status that's going to be really critically important so the things that I'd be thinking about for ongoing care we need to think about healthcare for the baby, for the mum we need to think about a mother and baby clinic we need to think about a pediatric review mental health care again issues around access to Medicare are going to be really important if there is an access to Medicare our standard options are really going to have to be scrutinised a lot more closely and looking at pro bono options or cheaper options that people can access informal supports are going to be really important and also to I think looking at some legal options and legal advice so here in Queensland we have a community organisation called Rails that would probably be able to assist really nicely for this woman and her child but I'll leave it there Michael Oh look at that that has just been a great overall social work aspect to this case and it actually mirrors much of what Lata was saying and I'm so grateful for it Lata, you had a question for Harry in relation to therapy for a sheik could I ask you to quickly ask that question You wanted me to ask the question You had a question that you were going to ask Harry or if you like we discussed this earlier I can ask Harry for you if you like Oh no that's fine, I'm happy to ask Harry Harry, yes I would like to ask you please in terms of which therapy would you prescribe to the client what I have noticed in most situations when the women are referred by a GP to a psychiatrist they are usually prescribed anti-depression medication and this may not really address a whole range of issues yes they may be experiencing depression and it might be one aspect however, I was just wondering if there are other alternative forms of therapy that you might suggest to the women there are lots of there are lots of alternatives like with everything else if the main contributor to the depression is the problems in the family or family violence or other such factors then they need to be dealt with I think the question of whether medication, anti-depressant or other sorts of medication is a clinical judgment that's made but it's certainly not the first thing that should come to mind and for this particular person that we're discussing it's way too early to be thinking about any kind of specific treatment there's a lot of work to do before getting to the point of making a decision about whether specific psychiatric treatment is necessary and then what kind of treatment is most appropriate thanks very much Harry Vivienne I noticed that you had a question as well that you might throw open to the whole panel in relation to working with this mum in that anti-depressant or psychotherapy may not be what you want could you pose that question please so my question is working with this family and working with mum we find that we think she has a depression and we talk with her about that and talk about options for therapies for depression and in explaining to that what would we do if she said look I don't think my problem is a mental illness I actually think my problem that I'm experiencing is because I'm being punished for something I've done in the past some sort of sin it's my own Joanne could I put that question to you please that is such a great question I've had that question and I think it's really interesting I think the first thing is to really explore her explanatory model and really get some detail about how she sees it and how she thinks it's affecting her and then go from there into how is this managed in your community if there was someone else in a similar situation how serious would the problem be how would you deal with it what needs to be done and occasionally people have found great relief when these sorts of problems actually have been dealt with in a cultural context in the Australian community people have had profound mental health relief so we must take it very very seriously so could I ask the panel then would there be a role for collaboration between the different disciplines to have this more open approach rather than looking at each discipline as being the source of specific expertise if I might comment Michael there's absolutely a role for collaboration the problems in this particular family there may be medical problems there may be medical problems there may be significant psychological psychiatric problems and I think it's likely like with everything else if we can identify what are the factors that are contributing to distress dysfunctional illness then those things need to be dealt with and in this case they're mostly social they're mostly social issues so if they've got financial problems that's going to need to be dealt with somehow if they've got relationship problems then family functioning the psychology of the family needs to be dealt with if it turns out that the mother has a significant depression for which psychological and social approaches are not going to be sufficient then it may be that some kind of a medical approach needs to be taken but as I mentioned before I think that's a long way down the track and in the presentation in the case there isn't really a lot to suggest that she has a very severe depression so it's the psychological and social issues that need to be dealt with first as far as she's concerned as well as the issues of ensuring her safety and the child's safety Thanks very much Harry and then just returning to you later two minutes to discuss therapy because you're actually dealing with it on a daily basis So in terms of therapy yes we do need to understand the person's background and they may have a whole range of spiritual beliefs and we do need to respect those as well however we do need to inform them that apart from the spiritual beliefs that we would like to validate their experiences I think we need to inform them and educate them about what family violence is and that in fact it is not permissible by the law so we need to firstly try and I think they have some understanding that they are going through abuse but they do not have a term for it we need to inform them that there is a term for it but also that there are laws in the country that would enable them to be protected and so we need to inform them some of the basic first before actually I think going into the therapy and we need to understand again their family's perspective they may again not want to come in for long term therapy they may just want to speak on an occasional basis perhaps until the next physical abuse occurs so we need to also give them the option of coming back to us when they are comfortable to but then informing them that there are these resources available should they need to access them Thank you very much Latha unfortunately time is moving on so I will be moving shortly on for a summation from each of our panelists you are allowed only two minutes to summate I will be quite stringent on that I make no apologies for letting the panelists speak longer than normal I think this webinar is all about collaboration and each and every presentation touched on collaboration so without further ado I'm just going to go back in the order of presentation again to Joanne would you like to just summate just for two minutes from your point of view Thanks Michael my summary would be first of all to try to engage the family as much as possible both partners using all the resources of the practice at one's disposal perhaps a mail GP for Ishan using physical health check to get him engaged for Rishika just becoming a friend becoming somebody that a place that she can come to and then the other thing is very much the importance of kindness that when you approach people who are struggling like this with kindness and competence a little seed can be planted and things may develop from there that was lovely I think that's extremely important thank you very much Harry would you like to sum up for two minutes please Thanks Michael the situation that's described in this case is unfortunately very common and I think anybody who deals with either in a primary care setting or in social support settings will know that this is an issue in the community which has been largely hidden in some immigrant communities it's more invisible than in others and we've spoken a little bit about the fact that the woman may be reluctant she may not be able to talk about the possibility of violence I think we need to keep in mind a set of priorities we need to be very clear about assessing risk and particularly risk to safety if there is any concern and I see a number of the comments from the participants in the webinar about why not go to the police there are mandatory reporting rules for domestic violence the situation I think is a little more complex in that intervention which happens too early may in fact make the situation very much worse and it may be that the person is at even greater risk so we need to keep in mind first the issue of safety and then move in a methodical way through to all of the other assessments that have been discussed Thanks very much Harry Laugher I'd like you to sum up but I'd like you probably to spend a little bit more time probably four or five minutes to sum up thank you Sure thank you Michael Yes I think what I would like to say is that when any of us listening to this or working in this area is intent on trying to assist anybody who is going through family violence I think we need to try and understand that it is such a complex issue that there are a whole range of issues within all communities whether it be a migrant or a non-migrant community and even within the migrant communities each culture has its own intrinsic issues and yes it is difficult for us to become aware of the culturally intrinsic issues across all groups however I think as professionals with obligation we have a duty of care to try and understand their perspective and so we need to try first of all as much as possible to understand each one's own culture when they do approach us to also be more open to other cultures and cultural groups interact with people just on a general basis so that we can develop an understanding of other cultures I think that's really important when you are trying to assist someone because of the complexity of the issues I think we need to try and be committed in the long haul for this it is not an easy task to try and reduce family violence it can be an ongoing issue sometimes it can stop there are a whole range of reasons why it can stop for example just last week a woman's husband left the country so she feels safe now and until then she had nightmares almost every day and she would wake up in the morning calling me with really terrible nightmares and her 14 year old daughter for example again would have severe headaches again because they had this realistic fear that the husband was going to kill them all and so this is where when somebody tells us that they are having this fear that they do fear that their husband or their partner is going to kill them I think we need to acknowledge that we may not have all of the proof that whether the husband or the other partner is going to kill them or not however we do need to acknowledge that and I think sometimes just acknowledging that would also help to develop a sense of trust I mentioned very early on that they need to develop a sense of trust in us to actually be able to narrate their experiences for me as time goes I become aware of so many more complex issues that have occurred in their lives again I think just because they do believe that I'm not going to go and do something wrong with that information so I think the development of trust is a really crucial issue because that's when you will learn about their experiences and then as practitioners like I said because of the complexity of the issues I think we need to be working collaboratively with the whole range of resources and organizations that we are aware of and if you're not aware of it to really become aware of them I'm trying to do that on a daily basis I don't know myself all of the organizations like for example I mentioned to you about this lady who needs to leave on Thursday it was only yesterday that I became aware of a whole new visa category that would be applicable in her situation so we need to be aware of the system and if one is not able to be fully aware of the system which is a really difficult thing to do to try a network to talk to others there are a whole range of people here from a whole range of organizations across Australia and I think we all need to be connected better somehow we need to ask people if we don't know to just pick up the phone and for me what I always find even if people are not able to help they usually provide me with another contact phone number so I think we do need to become aware of resources and to be aware that many migrant people they may be here as temporary residents and may not be eligible for a whole range of services people may wonder as to why they cannot just go to a GP going to a GP means a cost to them and they just cannot afford it and you may then wonder that well if they are on a student visa in fact they do need to have medical insurance yes they do need to have medical insurance but if they are on a bridging visa they are not required to have it or in fact a lot of people just cannot afford it and they do stay on without medical insurance so the reality is that people may just not have enough money to put food on the table for themselves or for their children or to even visit a GP they are going to pay a counsellor a psychologist you know and this is where I think more people need to try and put their hands up to try and do voluntary work as well for me I find that this is a challenge because again when I am attending to critical situations sometimes I am running around doing a lot of the work on my own because it is a big commitment as I mentioned for example sometimes I might just get a call saying well the person's visa was refused and the person has attempted suicide but then this is what I face no no please don't apologize no I can understand and we value your experience and expertise thank you Michael so I am sorry if it is too much for anyone over here if I can just provide you again with a glimpse of that so again I can just get a call saying the woman over here has no one over here in this country that she knows of and for a whole range of complex reasons she was refused to stay in this country and then she attempted suicide in fact one of the women I had spoken to in the morning and I had tried to reassure her that we would find a way for her to remain in this country because it would have been shameful for her to return to the country the family had disowned her back in India and she just thought that well nobody could really do anything and I got a call on Friday evening from work that the ambulance was about to pick her up and take her to the Alfred so I stayed at all night at the Alfred hospital as Michelle writing one of our participants has so well said it's the reality Lata and thank you for sharing so openly with us now we'll just move on to Vivienne and just for her summing up thank you Lata my pleasure I think the work that Lata does is absolutely amazing and inspirational thank you for sharing that I think my summing up points are the things that I've learnt tonight is it's so important to think broadly and holistically to think about the social and the cultural implications but also to think about not just the one person but the whole family that we're working with and we have to balance that up absolutely I've been reading a lot about everybody can see the complexity in this case but how do we balance up that complexity keep that in mind think about safety and also thinking about keeping engaged and working with this family that some of the risks are really significant and how do we ensure safety and I think the solution is about some of that creativity that Lata mentions and talks about we do have to get very creative with a lot of our clients particularly people here on student visas but also two people on bridging visas is really important thank you very much Vivienne and thank you very much panel you're very talented panel very knowledgeable I do hope you didn't think that I was being too oppressive in your timings we very much appreciate everything that you've done for us tonight I'm just going to sum up now from my point of view just my impression of this evening it seems to me that physical health was an entree to getting help for this family it would have been culturally appropriate for them to seek physical health both for the baby and for the mother and for the father the importance of engagement of all members that the presenting person is often not the person who needs the most help although in this case she probably is the effect of good rapport the huge amount of fear that must be present within the family the culture shock that they're experiencing the importance of a holistic attitude and the the translation of knowledge the translation of our knowledge across all disciplines to help this family the importance of commitment and understanding the complexity of the problem is extremely important and also an acknowledgement of the family as a family unit and each individual member of the family and also acknowledging that we don't have all the answers and that we sometimes need to look further into their expectations of care and into the availability of assets within their own community I do wish that we could spend another half an hour to an hour speaking on this topic but unfortunately we don't have time so the Webinar will be available to view again online and please don't hesitate to view it if you've missed some parts of it for the participants I thank you for your patience with the few technical problems that we had earlier and thank you for your questions and your participation it was very much appreciated by the panel please ensure that you complete the exit survey before you log out the session closes and certificates will be issued in four to five weeks the next Webinar is mental health, parenting, recovery and interdisciplinary panel discussion and that will be held on Thursday the 26th of June at MHPN I'm very grateful for the support of MIMA and producing this Webinar MIMA for those who may not know is a Department of Health Federal Government Initiative MIMA by going to their Web site and the link is there I would just like to thank again the panel for the great contribution that they've given us I feel that the participants gained a great deal from that hands-on experience but I also feel that each participant and each member contribute greatly and humbly from their own knowledge base I'd like to thank you all once again I'd like to thank you Joanne Harry, Lata and Vivienne and particularly for those for the amount of knowledge that you bring to this area in which many of us land on behalf of MHPN I'd like to thank everybody for attending tonight thank you