 Welcome to the MHPN Working Better Together online conference. I'm John Cooper, consultant psychiatrist at the Centenary of Anzac Centre and the chair of today's discussion. The Centenary of Anzac Centre provides free advice, consultation and support to practitioners nationally who work with veterans with mental health problems. And the case that we're about to discuss exemplifies the fact that this service is also available to folk who work to support veterans even if they're not clinicians. Specifically, our practitioner support service provides case consultation and access to a team of multidisciplinary experts for advice specific to your inquiry. We have access to psychiatrists, psychologists, general practitioners and social work family therapists, all very experienced in the complexities and challenges of veteran mental health. Today you will hear these experts as they discuss a current case consultation live and work through the best treatment options, evidence-based research and practice and how to integrate this for a better clinical outcome. The case that you will hear about is fictitious and a composite of typical cases that have come to the practitioner support service. When cases come to us they are de-identified and every effort is made to protect privacy and ensure confidentiality. So let's get started. Participating in today's session is Jane Poole, a social worker and family therapist from Adelaide. Richard Bonwick, a psychiatrist and Jeff Thompson, a psychiatrist both from Melbourne. Phil Parker, a consultant GP from Brisbane. And Christy Heffernan, a clinical psychologist from Sydney. For those on our call, you have had a chance to read over the case notes. But let's start with this particular case. And we have a worker, Jim, who calls in from an ex-service organization and second friends, which provides social support, welfare assistance and wellbeing programs to veterans. He has some training in community welfare and a lot of experience in working with veterans. So at this very early stage of the details of this referral, I'm wondering what the team thinks about the difference in taking calls from non-clinical folk who are working with veterans compared to the clinical referrals that we get. Jeff, what do you think? Oh, look, I'll jump in. Jeff here from Melbourne. I think one of the things that's really important for us as a group to be mindful of is that we're dealing with people who are not clinicians. Some of them may not have any sort of clinical background, and it's very important because often these workers are doing a really important and critical work and certainly can help facilitate engagement and access to appropriate support and treatment for our veterans. But it's really important that we support them if they are being exposed to challenging material, and also sometimes the veterans might have unrealistic expectations of what they can actually do as opposed to seeking treatment from the appropriate people. So supporting the workers and supporting them in setting clear boundaries while still providing important help I think is one of the important aspects of it. Yes, I agree completely, Jeff. So let's move on. So Jim is working with a 39-year-old female. She was an aircraft technician in the RAAF, one of the few females in her trade. She was in service for 10 years and was a corporal at discharge. She was referred to Jim's social support groups, which included some regular physical activities, such as park walks, yoga, and bike rides, and social barbecues every few months. She got referred because she spoke to an advocate about her back condition and the difficulties getting it recognized by DDA and told him that she didn't have any close family that she lived with and didn't really want to be involved with any ex-service stuff. The client has a history of depression and suicidal ideation following a motor vehicle accident. She was hospitalized briefly to manage this and subsequently referred to a psychiatrist for ongoing management. Although Jim's not sure how engaged she is with the psychiatrist. So let's pause there and I'm wondering what the team thinks are the likely themes or concerns that are likely to arise for Jim in this particular case. Christy from Sydney here, a clinical psychologist. I think a couple of the issues thus far are it's being referred to an ESO to provide social support and assistance. Sounds like a really good referer when somebody isn't actually engaged in regular social support. So I can understand why this particular lady has been referred to Jim's organization to actually get that social support. One of my issues around that is she doesn't seem to be a very willing participant at this stage. Regardless, she did attend so she's made some sort of, got some motivation to go but that's just something to flag at this stage in terms of her actual motivation to attend. And I guess one of the other issues for me with my clinical psychiatrist is just noting that motor vehicle accidents can be potentially traumatic events. And so that might be something that we're dealing with here that there might be some sort of trauma-informed care that we might need to think about at this stage. They're just my initial thoughts. Any red flags for you, Phil in terms of somebody with chronic back condition? Yeah, of course. She's got underlying medical conditions. They're sort of going to have a contributing effect upon her general emotional wellbeing and potentially her mental health. I think it's good that she's engaged with Jim and what she's provided is a fair bit of information which sort of surprises me for someone who is reluctant to engage and reveal elements of her past. So that's really good. He's obviously had a big effect upon her and he's quite supportive. It's important that we therefore use that to leverage a little bit more clinical support slowly and carefully so we don't lose her because we don't want to burn Jim with clinical expectations that are far too demanding for him. So we need to use his position to try and engage a general practitioner potentially at the start and someone that he might know who can give her an excellent level of support and encourage her to engage with. Jane here, social worker. Yeah, I think some information around the motives of her collapse and what would be really important. I'd also be interested in knowing it says that she doesn't have any close family that she lived with. So I guess that I'm wondering whether that's relationship close or proximity close. So some more information just in terms of being mindful to build a support network for her around maybe potential family and or friends. And I guess that the other thing that I would be mindful of with Jim is that sometimes people that do this really good as organisations have their own trauma history as well. Excellent point, Jane. Thanks. So let me give you a bit more information that we've got from Jim. He reports that his client can be difficult to manage. She often gets very angry with him about DVA not recognising her claim and that even though he tells her that he has nothing to do with DVA, this makes no difference. Despite this she is frequently calling him speaking to Jim. Last week she came into the office in a distressed state asking to speak to Jim. She told him that she had been speaking with another female vet who she met at a recent barbeque who told her about being raped whilst she was in the army. Jim's client broke down in tears and says she cannot stop thinking about her friend's story and has been having nightmares since she heard it. She then discloses to Jim that she has been raped whilst in the RAAF but has never told anybody about it. She tells Jim that she does not want anyone else to know about it and that he is not to pass it on to her GP or psychiatrist. Jim's not sure what to do. So, what's your advice expert panel? Jeff here. Look, this is a very difficult and I've no doubt a comfortable position for Jim to find himself in but it probably also comes about because of the success Jim has actually had in building a connection with the veteran that the fact that she's been attending, she's been revealing information she came to him at a time of distress. In spite of her protests about being angry with him which is really her anger with DVA, she's very much voting with her feet by her attendance and reaching out to him at times. So, clearly Jim's playing a really important role at that point but probably partly as a result of that he now has received from her some information which puts him in a difficult position and it's always difficult when you're told something and then very promptly said but you're not allowed to tell anyone and I'd be sort of I think it's important that we help support Jim with the impact it might be having on him but also give him some sort of clear guidelines as to what the boundaries should be and that is that he doesn't actually have to take on responsibility for this and to, as we were saying earlier, the importance of the queer boundaries that his role is to provide support and to perhaps reassure her that be distressed at this time is understandable but be encouraging her to take that information to the people who can help her with it such as her treating team. I agree. I think he needs to continually remind her that he is there to support her and that the best outcomes that can be achieved for her care is if she engages with people who are going to help her and to do that it might be worthwhile obviously figuring out whether she has a GP that she sees, we're not sure about that firstly and secondly whether she has received DVA support in terms of mental health care in the past. We don't really know whether that is this we don't know if she has a white card so it might be worthwhile him trying to discuss those options for care for her. Jane here, yeah, I was going to say what Phil was saying as well and I guess maybe working with Jim to facilitate if she doesn't have a regular GP but also maybe a referral to open arms for some counselling as well and I guess just trying to work with Jim to help spread the load for him. It's Christy here from Sydney. I would probably I agree with the comments that have made thus far it is really probably very uncomfortable for Jim to have this conversation with her and the sense of responsibility would be apparent but agree that reinforced to him one of the things that I would be saying to Jim and I think we need to feedback is that he doesn't need to be responsible for her safety or her care that a clinical team kind of is necessary but also sort of giving him just some information about that sexual assault rates can be really traumatic and it really does destabilise people that distress that she's experiencing is quite normal if she's been triggered and that safety and trust is really important in relationships and that her ability to disclose to Jim means that he's kind of developed that nice, safe and trusting relationship with her and that's really important but encourage her to actually then seek help by professionals who can help her with that and the difficulty probably of actually telling somebody for the very first time that she never told anybody about the sexual assault in the past but Jim is the first person that kind of explained to Jim that that can be a first hurdle and that it probably would be easier for her to seek help from here because she's already kind of disclosed that but it's also important to get her into help because she's the highly distressed nature that she's in. It's still here. Sorry, Christy, I agree that her asking for help or willing to disclose to Jim about the right suggests that she's now a bit more open to seeking help or seeking support for her background, yeah. Yeah, I agree and it might be, I mean particularly the trigger seems to be had even contact with the other female veteran in the group but you know in the background of a recent motor vehicle accident as well her sense of safety and trust in the world's already been shaken and destabilised by that as well. So, yeah, there's a combination of those factors. I think it's important it's building up now for her to really seek support. Jane here, yeah, agree with all of what's already been said. We just need to be also mindful that she did have a period of being quite suicidal after the car accident and we can potentially put two and two together around stress levels and monitoring her risk at this point in time as well and that's a really big ask for Jim. Yeah. Richard here, psychiatrist. It seems like the key role for Jim is to facilitate the right sort of support and assistance for her, the right sort of professional support and assistance for her and one of our major roles I guess is to provide information to Jim about what sort of services are actually available so that he can assist with that facilitation. He may or may not be aware of mental health services. He may or may not be aware even of the DVCS or open arms so I think giving him some clear direction about that is very much a key to this. I agree Richard, it's Christy again from Sydney but also giving him the list of emergency contact details that if it does escalate and he needs to call triple zero and that down to that level of detail I think we can provide that level of support to Jim. Yeah and maybe we could find out from Jim what kind of support he's able to get through and second friend and whether there's kind of a process already in place for supporting Jim with the work that he's doing as well and capitalising on that. It's John here. So would it be fair to say that in relation to these thoughts about how Jim is supported in his organisation is this the sort of situation where what's called trauma informed care would be relevant either for Jim as an individual or for his organisation as a whole in terms of further training or assistance in that direction? Christy from Sydney here. Yeah, absolutely John I think more education around trauma informed care principles are really important. I've mentioned them thus far just that increasing people's sense of safety trust, their level of control and empowerment to make decisions that they're really key ingredients with regard to trauma informed care because once somebody has been through a trauma they're the things that tend to destabilise people and to regain a sense of emotional control it's really important to try and facilitate and Jim is a perfect example of the types of people that we would usually educate people on trauma informed care principles they're really the first responders with regard to mental health we as clinicians we get referred from the first responders so it's really important that we educate people on the ground so to speak in that first responder role around what they can do to kind of stabilise the situation as well as give them the emergency contact details and things when risk is present and also the referring treating kind of teams and things that people can then access so I think that's really important and as part of the PSS we also do provide educational seminars to organisations like Jim's with regard to just increasing mental health awareness and also how they can maintain their own self-care educational seminars on what good family support systems look like for veterans and things like that so there's a number of educational seminars that we do provide to these organisations for this purpose to try and increase their knowledge and think about some skills they might want to develop in this area Thanks Christie let me be the devil's advocate here and Jim comes back to us and says that he's said and done all of those things to his client but she's still adamant that she's not going to seek professional clinical support what do we advise Jim under that circumstance Phil Yeah this is certainly a difficult one it's put him in a position where he will feel quite isolated in terms of his responsibilities of caring for her we probably need to we can't expect him to assess her risk although he might have some ideas about whether you think she's in a danger I think we need to find out what her agenda is she's obviously starting to open up and she's willing to engage with him and connect with him and reveal some of the really sensitive deep issues from her background but we need to probably we probably need to get him to continue to ask for her willingness to engage with people who can help her but it's so dependent on what she wants to get out of that I just wonder what the thoughts of everyone else is on this I agree I guess I would go with what's already in place we know that she has a psychiatrist for ongoing management but we're not really quite sure how engaged with the psychiatrist she is so finding out her level of engagement might be of use and again finding out whether there's any other support non-clinical support in her life in terms of family and or friends or she's working anything that might broaden the level of support that we can that we can get to this client and then if there is somebody that's particularly close to her then they may be able to help facilitate a referral for clinical involvement Christy here from Sydney I agree Jane trying to establish what other social support she's got is really important so that that's really important in terms of her care but also so that Jim isn't necessarily dealing with this on his own he also has the support of his own group so even though he hasn't necessarily been motivated to attend she has attended and while she's discussed with another female veteran her own experience she's triggered her own emotional reaction that there might be other people within the group that this can form a supportive environment for her and also for Jim as well so he's not necessarily managing this on his own and with time hopefully and still encouraging her to seek help and going back to her GP that support can facilitate her help seeking from a clinical support Jane again and I guess that the other thought that I have is that would be really important for the ducks to be in a row because there might be just a window of opportunity where this person goes yes I will seek some clinical support so having that information and trying to facilitate that as quickly and as seamlessly as possible would potentially help that initial engagement process and Jeff here, psychiatrist I think we've seen with his client that sometimes what she says and what she does they don't align so she has been voting with her feet she has been attending even though she probably is verbalising often that she prefers to be isolated and not connected so reassuring Jim that continuing to invite her out of their activities and to attend and to move amongst other ex-servicemen I think is playing an important role and to not underestimate the value of that for his client in an ongoing process I think also we can reassure Jim by informing him that people who've been sexually assaulted it's really important to be sort of forced or coerced or pressured to explore things until they're actually ready and to reassure him that that sometimes takes quite some time months could be years on some occasions so that providing he the limit of what he can actually do is continue to encourage her to be engaged with the people that can help her encourage her to look after herself and connect with people and connect with their group and reminding Jim of the fact that the things that he's doing are actually really valuable but there is a limit to how much he can do in terms of the decisions that she might make for herself in terms of her care Richard here, psychiatrist again it sounds like patience and polite persistence is the key often we want to fix things but sometimes you just have to be patient and just persist with what is the right plan and I think that's really what you've articulated Jeff Phil here I agree I think our ultimate goal is to build her clinical support team the right team for her one that she trusts and will engage with to get the best outcomes but we need to maintain support for Jim throughout this process and yes it may take time and we may need to give him options if he believes that her level of risk has increased as well Thanks Phil that's John here and if I can summarise what we've discussed today Jim working in an ex service organisation supporting other veterans a very difficult scenario of a distressed veteran with trauma background and other complexities around her medical and social circumstances we want to provide Jim with information and education we want to reassure and support him in the excellent work that he's doing part of that education is going to be around his self care and how to maintain good healthy boundaries and this is going to lead us into work that we would call trauma informed practice and that might be relevant to him as an individual so it would be relevant for his organisation and in his organisation if it's to support the work that they do so thank you all for your excellent contribution today thank you to those listening in today when you contact the Centenary of Anzac Centre Practitioner Support Service for advice we take your Veteran mental health question or problem we consult with our experts just like we've done today and we provide specific advice back to you this is a free service you can access this service through our website at www.anzaccenter.org.au or you can call us on 1800 VET77 thank you very much