 Hello everybody and welcome to this webinar tonight from the Mental Health Professionals Network. We would like to acknowledge the traditional custodians of the land, seas and waterways across Australia upon which our members 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 the hopes of Aboriginal and Torres Strait Islander Australia. So Steve Trumbull is my name. I'm a GP by training. I'll be facilitating tonight's webinar. My current role is as Head of Medical Education at the University of Melbourne. So responsible for the medical course there. I'm also a presiding member of Medical Panels Victoria. So looking at work cover and peer assessment and things like that. But I'm delighted to be able to facilitate tonight's panel. We are partnered tonight with ComCare to produce this webinar. And you probably already know, but just to remind you that ComCare is a government regulator, workers' compensation insurer, claims manager and scheme administrator. ComCare works with employees, employers, service providers and other stakeholders to minimise the impact of harm in the workplace, improve recovery and return to work and promote the health benefits of good work. And we'll be talking a bit about good work tonight. So I might just get the next slide to show us the panellists' biographies. I won't go through those in detail because they were circulated. But on the panel tonight, we have Dr. Deal Philman, who was one of our medical students back in the 90s. Hello, Deal. Unchanged. Now a psychiatrist though. And a psychiatrist who specialises in rehabilitation or industrial psychiatry, I guess. I'm sure you've got a better term for it than that. But I'm really curious, what do you find most rewarding about helping people who are struggling with issues at work as a psychiatrist? Nice to see you, Stephen. Occupational psychiatry is what I'm calling it, even though there is no such specialty. There probably should be. I love working in this space because, as we know, people in this space are often very vulnerable. And we know that their trajectory can go quite badly. And I really like to help them get on the right trajectory. I like to collaborate with other people, their treaters, the employer, the insurer. I like to leverage off the resources of the insurer and employer to help in their recovery as well. Great. Love about it. Work is a very important part of the person. So obviously that's an important part of their treatment as well. So fabulous. Well, thanks for joining us tonight. Also to introduce Dr Stephen Kay, who's a GP here in Victoria as well. Now, Stephen, how can a general practitioner be successful in supporting someone experiencing workplace issues? What do you do that makes you most successful? Hi, Steve. Thanks for that intro. The main thing that really needs to be done is taking time and being curious with the patient with their workplace issue, whether it be physical or mental. Time to explore the workplace itself through the patient's eyes. Their other influences, their domestic life, their education, their finances in broad terms, of course. And then have the connection and the relaxiveness to engage with the workplace in order to sort out with the patient the ideal outcome to provide a good work environment. Fabulous, Stephen. And back in the day when I was working at Monash and Deal was one of my students, John Murto, the one of the door ends of general practice used to have a sign above his consuling room desk saying, be curious. And that really stuck with me. If we lose the curiosity about the people we're working with, we lose the joy in our jobs, I reckon. So it's fabulous to hear you introduce that concept already. So thank you very much indeed. And also we're joined by Suzanne Gibson from North of the Murray, New South Wales, clinical psychologist. So Suzanne is a clinical psychologist. What are the main elements of success in supporting somebody who's experiencing workplace issues? I think what's unique about working with someone who has the workplace issues that they're trying to overcome is the need really to collaborate with all of the stakeholders within the process, not just other treatment providers who are helping that person, but also the employer and the return to work professionals. Because I think what they bring to the table are those key pieces of information that will help you to really inform your decision making, inform your advice that you're giving to the patient and the client and help you to develop that comprehensive plan that's going to give them the best chance of recovery. Fabulous Suzanne. It's so good to hear you talk about teamwork because that's obviously underpinning everything that MHPN is about. That's that network of professionals. And looking at the chat room, I can see we've got people from social work, psychology, all sorts of different disciplines here. So that's absolutely fabulous disability mental health counselors and so on social work again. So fantastic. And I'm glad that you see that that team as being what it's all about. So now the next slide I think will take us to the learning outcomes which are there. And what we want to do is look at assessing functional capacity to work with people with psychological injuries. And we will hopefully give you tonight the skills and knowledge to outline the benefits of participating in good work for patients who are experiencing health conditions that may impair their ability. To work. We'll also look at assessing a patient's functional capacity for work, particularly based on the psychological health and wellbeing. We hope you'll be able to explain a person's current capacity to work and also to provide advice on suitable modifications to support a patient's continued participation in their workplace. And finally, how to establish early expectations for continued work participation and recovery, which is an issue that comes up all the time that I'm sure we will address tonight. So I think the next slide now will take us to our first presentation, which is going to be from Dr Stephen Kay, our GP, because very commonly patient like Lisa will end up with her GP as has happened. We won't go through the case here again, but just to remind you that it ends up that she feels completely overwhelmed when she goes along to see her GP seeking a medical certificate to a week off work to rest as she's finding it hard to cope, needs to get her thoughts in order. So Stephen, Lisa's booked a 15 minute consultation with you. Here she is. Over to you. Yeah, thanks, Steve. This case is somewhat typical and unfortunately the 15 minute consultation is the one that usually gets booked. The GP in their role around the country is ideally placed to really take the central space for management of these sort of cases. The accessibility of general practice around the country is substantial, albeit that there is a workforce issue at the moment, but we hope that GPs are still the number one port of call for most workers' compensation injuries, be they mental or physical. And the GP role is really to do that, that, you know, in-depth assessment to learn about the patient to be curious, as we've said before, which can often generate a very complex and challenging consultation. And clearly 15 minutes may not be enough time. So we need to be wary of that time factor and that rush to make that happen. Certainly the understanding from everybody's point of view, but in particular from the GP's point of view, is that work is a very positive thing for health and not working is a very negative thing. And that brings us to the concept of the benefits of good work, health benefits of good work, and really has been shown multiple times, multiple studies worldwide that working as appropriate with good work is a positive contributor for people's general health and for their overall well-being. Next slide please. So in this case study where we've got a distressed 43-year-old, so it's an adult, she's in mid-life, working, obviously has a number of people who she works with in her team, so it's quite a responsible place. And once the GP has assessed her and taken it in detailed history and examination, really to identify if there's any physical problems going on as well. So we really need to make sure, and I know this is a mental health case and we need to focus on that, but from a generalist point of view, we need to make sure that we're not missing any physical ailment going on. And specifically thyroid disease and calcium disease in this particular case. So drug usage, substance abuse, other psychological past history, maybe not related to work or maybe related to work, all needs to be explored before we can come to some sort of conclusion about where we're going in this case. Next slide please. So once we've come to the conclusion that physically Lisa is okay, that she's suffering from a mental illness rather than a physical illness, we need to then engage with her in that framework and continue to actively listen to what she says. And to provide empathy and support so that we can be seen as a trusted advocate for her through this journey that she's now commencing with her workplace on site rather than a combative environment with her workplace. So from a mental health point of view, we want to try and assess her ability to work and what level she has, what capacity she has at the moment. We'll talk about that in a few moments. So that we're assessing her all the time and assessing her current abilities. Next slide please. So then once we have a feel for how she can work and what her functional capacity is with the basis of the health benefits of good work, we as a base want to try and encourage her to stay at work and not to miss work, but nevertheless to make work safe for her. So the benefits of good work and there's many definitions for the health benefits of good work. So we want her workplace to be fair, respectful to create a level of autonomy for her to work in an autonomous fashion safely and to have an idea of the interests of herself as well as the workplace as well as society at large in order to create positive encouragement. So in this case we need to remove the negatives of work, maintain her at work with those positives to keep her buoyant and a fly. From a GP's point of view, we may well need to use people like Suzanne and DL to help with her psychological care to improve her outcomes. We may need to commence medication to again to align her thinking. We may need to use other therapists as well. And we certainly we're the best placed inevitably to do a certificate of capacity in order to communicate with the workplace via paper or digitally, but also as a compulsory thing, but also with her permission to communicate verbally with the workplace and therefore develop a plan of attack with either the managers in the workplace or the return to work coordinator to create a safe environment for her to work in. Next slide please. I want this is a very long slide and I won't go through it because you can have a read, but really we're trying to assess her capacity to work and so we're trying to create we're trying to understand that. And then create an environment where she's within her capacity, but nevertheless trying to keep her at work and that's that delicate balance that we need to come to in order to aid and facilitate her recovery in order to get to back to full unimpeded work. Next slide please. So we've got a there's a number of resources that are around this. This one is from concares website as a snapshot and an idea process to to follow those threads in order to to give Lisa in this case the best the best possible opportunity to to recover and to get back to normal unimpeded from any mental health and psychological illness. I think to use that. Yeah, thanks very much, Steven. And just while before you move on, I think a few people having some trouble getting into the chat room that might be resolved by now there's 1200 people online and seems to have just blocked things up a little bit. So apologies if you're not in the chat room as yet. That should be opened up soon. So thanks very much, Steven, I think I have heard that there's a com care guide at GBs. Sorry, the com care guide that helps the GB assess a patient's capacity to work and actually as it turns out I think that resource was developed by part of it with deal filming and the late Peter cotton. It was developed some years back. So is that something that you think the average GB might find useful, Steven, it is in our resource list of people wanted to to grab that. Yeah, I think it's as you said it's in the resource list being provided for tonight's tonight's webinar. And it certainly is it gives a lot of structure. So often these consultations with people in this fashion are often have a heightened level of distress from the patient. And there's a chaos involved is a chaotic world that's going on, you know, just needing to run away and just get away from work, because that's the source of the problem so we as the clinician need to understand that unpack that. And so we need structure to do that. So com care with the College of Physicians and deal have produced assessing patients capacity to work guide which gives that structure so that each of the components can be analysed and can be graded in order to share with the patient some line in order to keep her at work and get her to recover at the same time. Fabulous. All right, good to know. And again, under the little information icons where you'll find that resource. And it looks like the the elves in the background have fixed the chat room and people are now coming in. Looks like you've got speakers rights which will be interesting. There's about 870 people in there now. It's going to be like the world's most chaotic cocktail party, which is fantastic. So look, thanks for that, Stephen. That's very helpful. Inevitably, I guess, or hopefully you might work alongside a psychologist. So maybe we'll move on now to see what Suzanne Gibson has to say about the psychologists perspective. Yeah, thanks. And actually, just before you start Suzanne, the colleagues posted a link to that GB assessment guide in the chat box as well if people want to do that. But don't look at it while Suzanne's talking. Okay. Thanks, Dave. I just wanted to start off by touching on a topic that that's even also spoke about, which is the health benefits of good work. So what really stood out to me when I read through the case study is that Lisa has a really strong desire to retreat from the workplace to quit her job and to go away and hide under the do so to speak and considering the amount of stress that she's under the symptoms that she's experiencing and the amount of time that she's been under stress. I think that's completely understandable and completely normal. Well, an initial period of rest is likely to be helpful for her to settle down some of those symptoms and to allow her to implement some self care strategies. It is going to be really important for Lisa to be able to re engage with the workplace as soon as possible. And this idea is encapsulated within the consensus statement which talks about the health benefits of good work, which as you probably know was developed by faculty of the Royal Australasian College of Physicians in 2011. And what they did in this statement is collate the evidence that demonstrates that returning to work not only helps us to maintain good health, it also helps us to recover when when we're unwell. So I think from a psychologist perspective, you know, this isn't news, right? If we think about work as providing an opportunity for goal oriented behavior, then it really taps into those principles which underline some of the evidence based treatment strategies that we know tend to be helpful to people to overcome any mood disturbances. So behavioral activation, for example, is very much aligned with going back to work and being engaged in activity. And for some people, for some of us, you know, engaged in pleasant activity. So it is likely that having that return to work process start will help Lisa to lift her mood by using those behavioral activation principles. You know, another treatment strategy which very closely aligns with the return to work process, although it's not so relevant for Lisa's case is the treatment strategy of graduated exposure. So when I'm working with people who are experiencing high levels of anxiety, due to a workplace incident, it's really helpful to be able to use that return to work process in line with the graduated exposure process return to work provides lots of opportunities for exposure. And so those two processes can really align nicely. And the other thing that returning to work allows for is practicing those skills that someone is learning within the treatment room. So I can imagine for Lisa, you know, learning maybe some self care strategies, perhaps some assertive communication skills, maybe some problem solving skills are all likely to be helpful for her with these challenges that she's facing. And so going back to work will allow her to practice those in real life, so to speak, and you know that's likely to allow her to consolidate her learning and really put those skills in place. And then I think whenever we're working with someone who is attempting a return to work or facing workplace challenges, if we can focus on really trying to up skill them and equip them to be able to go back into the workplace that's going to be really helpful. Of course, need to ensure that that workplace they're returning to provides would work. But if we are able to give them those skills to face those challenges that they might face at work. It's not only going to be helpful for them now in their current situation, but also for any future challenges that might come their way. I'll add the next slide please. So in terms of when you're thinking about how you might provide advice around someone's functional capacity. And I was thinking about this from what I do with my clients and really there's a lot of information that we're gathering just as part of our normal assessment and treatment process that tells us what someone is capable of doing. So when you think about, you know, the type of information you're thinking about in the mental status exam in the symptoms that someone might be reporting in what they're telling you what they're doing from day to day, any assessment you might have done. And also what they've been capable of in the past, you know, with Lisa she was managing a team of 30 people. It takes quite a lot of skill and ability to be able to do that. The fact that she was able to do that in the past really informs what she might be able to be capable of going back to in the future. And I just wanted to mention this last one, which is a functional capacity evaluation. So this is a semi structured assessment, which is usually completed by a work place free provider. And it can provide you with really detailed information about what someone's functional capacity might be from a psychological perspective so it can be really helpful. I'm sorry. So once you have that information, then it's about really matching that with the demands of the job to translate it into workplace function. The next slide please. So here I've just really provided some examples of how you might translate symptoms that you're seeing in the treatment room into those work related functional limitations. It's really just about taking them from the treatment room into that work context. This is obviously not an exhaustive list but just provides you with some examples of how you might go about that. Next slide please. And so the other piece of information that can be really helpful in informing you about what the client that you're working with might be required to do at the workplace and how they're going to be capable of doing that is information about the types of demands that are required within the job. So this is just an example list of questions that again would be asked by workplace free have provided when they're doing a workplace assessment to determine exactly what is required of someone from a psychological perspective. So if you're able to get this information, the answers to these questions, then that allows you again to do that real map between what you're seeing what has been reported to you and what is needed within the workplace and you can provide a really detailed explanation of what someone is capable of doing or not. Now the next slide please. And then to finish off I really just wanted to mention the idea of graduation which I think is really key to success when you're working with someone who is attempting to go back to work. And you know this is a principle that we use generally within the treatment process, but it very much aligns with the return to work process most return to work processes are graduated in nature. And so starting with what the client is currently capable of doing, helping them to figure out their end goal that they want to get to and then developing the steps that take them along that process towards that end goal is going to very much match what is happening for them within the return to work. And so your treatment's been aligned with that return to work process and it gives that person the sense of consistency and you know a pathway towards their recovery. So that's it from me. You're sure. No fabulous. Thank you very much. Thank you. Now we'll go to the psychiatric perspective so deal over to you. So the Steven and Susan hard acts to follow and I'd love to collaborate and work together on some patients with them get that with you guys. I actually wanted a couple hours to do my bit and I was told I could have about six to eight minutes so five minutes. So I was trying to think how I can fit it into five minutes and I remembered that a picture tells a picture's worth a thousand words. I thought I'd start with a couple pictures. So this one's really to illustrate that I'm really quite worried about Lisa like I think that she I feel like she's about to explode. She has so much going on doesn't she? I mean she's had work pressures for a couple years and quite significant work pressures dealing with clients who have faced significant stressors like the floods, the fires, COVID and having to support a massive team of 30. She's lost her boundaries between work and home. She's not being the best manager that she wants to be and I think she's quite perfectionistic and that would be hard on her. She's got some relationship issues. There's some resentment building to her partner who is not really pulling his weight. She's not being the best mum that she wants to be to her kids getting quite snappy and she's starting to worry about her physical health to worried about her heartbeat. So I think it's coming at her from all angles and I'm not surprised with Suzanne said that she wants to just hide under the covers. Next slide please. I kind of feel that Lisa's at a bit of a crossroads and I'm a little bit worried for her. She's already taken a couple of days off work and she's asking for another five, which is a bit of time and I don't know if being off work for her is going to be used for good. And she's going to work out how she can change things at work and how she can better upscale herself and prepare herself for the challenges ahead or whether she is going to just jump under that doing a cover and spend all her time stressing, worrying, maybe starting to drink some alcohol, disengage, lose confidence. So I really think it's a hard place. She's in at the moment and as the person deciding to do a certificate, we've got a lot to think about and we'll come to that. Next slide please. So I guess I should share some psychiatry. So I think some of the things as a psychiatrist I'd be thinking about right now is the stresses. So we've talked about some of these, the build up over a long time, the challenges with her role itself, the responsibility. She's lost that boundary, that safety of home being away from work with, you know, work going into her personal life. She's got some protective factors too, doesn't she though? She's quite, she's help-seeking. She's going to see Stephen. She has no prior history of mental health difficulties. We don't know of any maladaptive coping mechanisms and she works for a large government organisation, which makes me think they'll be able to support her with some modifications more easily than maybe a smaller employer, although they should be able to support her as well. So I think about her symptoms. She's got a whole range of symptoms, rumination, preoccupation. She's distressed. She's tired. She's not sleeping. She's ruminating. She's got a lack of motivation. She's got physical symptoms of anxiety. Objectively, she doesn't, she looks tired. Her self-care is maybe a bit reduced. She's anxious. Things I'm thinking about, first of all, as Stephen pointed out, is making sure there's no organic contributors like thyroid function. Hopefully someone's done that before they see me already. And also reassuring her about her heart. She's worried about her palpitations and I want to remove that as something else to worry about. I also want to make sure she's not self-medicating with alcohol or drinking excessive caffeine to get through her day because that will increase anxiety too. Then I'd be thinking about diagnosis and I don't necessarily need to diagnose her at this early stage, but in the back of my mind, I'd be wondering is this a normal reaction? Is there no diagnosis? Does she have an adjustment disorder? Are we seeing an emergent depression or anxiety? I'd want to think about trauma symptoms because I think they can be missed a lot of the time if we don't ask and obviously she's had to deal with a lot of distressing customers and staff in distress. So baby, there's a bit of trauma there and thinking about her personality style and the impact on how she's presenting now. Next slide please. So I thought I'd put a slide in about certification and do we certify or not and what we need to think about and I think it is something that takes a lot of thought because I think prolonged certification can be a significant problem. So I think the first question we need to think about is what type of certificate, just a general medical certificate or a work of compensation certificate in this setting. I'm not sure what you would think. How long are we going to certify her offer? So personally, I think a week on top of the two days she's already had is getting up there for a bit long and ideally I'd be doing a couple days and asking her to come back. Although I know as a psychiatrist it's not always so feasible and maybe in GP land it's difficult too. But I think it's really important at the time of the first certification to set expectations of how long you think that person should have off because I think setting goals the research shows results in someone more likely to return to work within a time frame but certainly from the outset less is more I think. I think we need to think with Lisa about the purpose of the certification, the time off work. So is it so she can line a bed and under her covers and just avoid and hide from the world or is it so that she can use that time purposefully to look after herself, to re-engage with exercise, to re-engage with friends, to maybe see Suzanne and learn some strategies and also for her or her advocate or her GP or psychologist to speak to the workplace and work out how her role can be adjusted so that when she does return it's to safe work. I think it's really important to talk about the benefits and the disadvantages or the risks of certification. I think we all know that when you're anxious the worst thing to do is to avoid something in general. When you fall off your bike the first thing we say is get straight back on. So I think we need to think about the risks of suggesting someone stay away from work if they are anxious and let them know that it's not recommended long term and we should be getting back with supports. Next slide please. So just in terms of what I think about specifically in Lisa's case in terms of how do I evaluate her work capacity well just in a basic nutshell for me work capacity to be able to be fit for work means she needs to be able to attend regularly and reliably perform at the expected standard, abide by a code of conduct and work not be an occupational health and safety risk and I think at this stage work unchanged would be a little bit of a risk for her. I then think about the job demands. What's been done so far? Is there anything she's done to work out a way to manage better at work? Her view on how things can be changed. I'd love to get some feedback from her employer about the supports that are available. I'm then going to do a detailed functional assessment and have a look at her functioning and I know you've got a resource on that and then marry her functioning up with some potential temporary modifications and I won't go through all of these now but for example she's fatigued it gets better as the day goes on so maybe we need to think about shorter days in the later start time. She's not concentrating so well so maybe we need to think about lower expectations reduced KPIs reduced outputs not as much multitasking she's feeling snappy irritable she's got less to give and so maybe we think about giving her some more autonomy and limit some direct reports. She's unable to switch off so maybe for her if she is still working from home returning to the office and resetting some of those boundaries would be useful and lastly I think we need to have a look at her role as well and make sure it is good work and that it is one full-time equivalent and not more because I wonder if she's doing a lot more than that. Next slide please. So in terms of just my general overview of a way forward for Lisa it's about making time. We've talked about this listening and evaluating providing validation and psychoeducation as Suzanne suggested make sure there's no organic factors as Steven's gone through reduce any harmful coping mechanisms and put back into her life some helpful coping mechanisms. Consider treatment psychological therapy probably first up and then we might look to see whether there might be a role for medication be thoughtful about your certification and review regularly especially once she goes back to work. Thank you. Thanks so much, Dylan. Thank you to all of you for being so concise in what you've talked about. There's actually a huge amount of interest in the questions in the chat room that people are asking about. I've been desperately trying to pull things together. There's an unfeasible number of Jeremy's in the chat room. I'm not sure what a collective noun of Jeremy's is is that a box and that's a whole report. I don't know if you've heard of Jeremy's in the chat room or if you've heard of Renner. Anyway, the Jeremy's were asking quite a lot about the workplace but putting it all together I'm wondering what we can do if as a practitioner we're lacking information about the workplace itself. We often don't know a lot about the workplace including what the patient's work role is what's actually involved in it what suitable duties might be available to them if they can't do their usual work or in that particular case, how can I get more information? Steven, is that something that you can pick from general practice? How do you go about finding out those things about the workplace? I guess the first thing to say is that you don't believe the patient 100%. So the patient will often say there's nothing that I can do there's no job that I can possibly do in the workplace that will be safe for me as DL explained to have that safe workplace is very important and the patient initially will say I want the week off as Lisa has said that she wants the week off because she feels that there's nowhere that's safe for her to go back to the workplace. So again with her permission speaking to her manager going up the tree and finding out what the workplace is actually like from an independent person albeit involved or getting an occupational health and safety officer to be involved or return to work coordinator person to be involved and to tease out the needs of the job as well as the current tasks that are being done and trying to match them up so that she's not overwhelmed especially with a reduced capacity as she is at the moment. So it's often it's all related to communication and open and frank discussion about the workplace itself and coming to a consensus between interested parties to create an environment that's safe and productive for Lisa. Thanks Steven and DL you've seen it from both sides I guess what do you do in terms of finding out more about the workplace? I agree with what Steven says I think it's important to obviously get consent from your patient first and then decide is it going to be a verbal discussion with someone from the workplace you're going to ask for written information I think verbal is best and if it's verbal are you going to have your patient present with you and are you going to share information as well as receive information and I think it might be the manager it might be someone from HR it might be for someone from people support depending on the size of the organisation so finding out who that person will be and going to the right person is ideal I think as well as getting information about what the actual demands of the role are it's really important to understand what the workplace can and what they can't accommodate because we don't want to be writing on the medical certificate restrictions that are just not going to be followed through within our patient ends up sitting at home for longer how long the supports can be provided and also sometimes the workplace will have other supports even if there's not a claim like access to rehab providers and things like that so I think it's really important to find out all of that and if there are other concerns like there's performance management which we know there are as well at times they're getting that information as well what the particular concerns about performance are so we have everything in front of us to work with Thanks Dio now on those lines a few people have been asking about whether we're expecting too much of the person and not as much of the workplace and what really is the workplace's responsibility to make changes and to support the worker in their return to work somebody's made the comment that sometimes they're given work that would sort of kill anybody brain dead and that can actually be a negative thing if they go back to a role which might reduce their self-esteem does anybody have any thoughts on that and Steve and I suspect you probably think as a GP or that a lot of GPs would feel as a temptation just to put the person off work rather than That's certainly the course of least resistance it's just to she'll be happy because you've given her what she wants which is a week off work and then the next week she'll come in and nothing will have changed because nothing's changed so nobody else has been involved the workplace hasn't been involved and so the demand then will be to again take the course of least resistance and have another week off or another two weeks off and that cycle gets perpetuated and we end up with a single patient who started off as Suzanne said a very capable manager of 30 very busy job who's popped and suddenly hasn't been at work for multiple weeks or months he's out of the work stream he's just not able to do the work anymore because she's been out for so long and the outcomes of that is always negative it's never a positive and the data supports that the data that's been generated around the world that with long periods of being off work altogether have a very negative impact on the person's social health and workplace environment so that's certainly not the way to go but it takes time and effort to intrude in the other way to actually get inside this whole problem and to try and repair it effectively and I added something to that as well yeah please Suzanne so you know I think first of all whoever asked that question you're absolutely right the workplace does have a responsibility to ensure that they are firstly providing duties of some sort for someone to return to work and there are some requirements in some areas around providing meaningful duties as well I think though in terms of the work that you're doing with your client or your patient really thinking about that graduation process can be helpful in this instance you know it might be that the duties that someone is returning to initially aren't the most meaningful duties that they would ideally like to be doing but there are likely to be benefits as Stephen was saying around just getting back into the workplace getting back into a routine staying connected with their colleagues and so really trying to coach your client or patient around that of like yep I understand that right now this probably isn't the most exciting duties for you to be doing the idea is that we're going to gradually help you to get back to that job that was meaningful for you so trying to reinforce that idea with them I think can be helpful Great Susanna while you've got the conch and before we go to DL did you want to just speak a little bit more about some strategies for overcoming the reluctance of people to go back to the workplace what are some other things you might do apart from those words you used just then Yeah I mean I think when we're working with reluctant people in any context it can be really difficult I think the first step is really to start from us so when I have someone who's really reluctant to engage in any process including engaging in the return to work process I really try and remind myself of why it is that this is going to be helpful what is the evidence that I'm aware of that this is actually going to facilitate their recovery so I think firstly returning to what it is that we know about why this is good for the person it can be a really helpful place to start in terms of working with the person you know what I tend to see is that when people are reluctant it's often because they have some concern about how psychologically safe they're going to be when they return to work and both DL and Steven have spoken about ensuring that the workplace is a safe workplace to return to so I think the first step is really ensuring that it is going to be safe and that needs to be done in collaboration with the other parties the return to work professionals and the employer have much more information about the workplace than we do and so making sure that you're working with them to ensure that safety is going to be a really important first step I think the other thing that's really key when working with someone who's reluctant is making sure that there's a very clear and structured plan in place for how they're going to approach that return to work process so you know we all know working with people who are struggling with mental ill health they tend to have issues with concentration and focus and memory and those sorts of things and so making sure that there's a detailed and structured plan about when they return to work how long they're going to be working for each day what sort of duties they're doing what support mechanisms in place what strategies they can use if they notice their symptoms all of that is going to be really important for reassuring the person that there's going to be clarity around what they're doing when they go back also what I find and to be honest I don't know if there's evidence around this but what I find is that you know when I'm working with someone who has a compensation claim they can often feel like the power to make the decisions over their life have been taken away from them to a certain degree so making sure that you're involving them in the process is going to be really key to helping them to get some ownership over it having them set their own goals and even having them plan out the steps that they can take towards that goal can be really important and I also think then taking them back to their values and how work connects with their values is another way to really tap into their motivation so work aligns with our values for most of us in certain ways it might be that work allows us to have a sense of achievement or it allows us the opportunity to make a positive impact connects us with other people or it even just allows us to provide for our families and so reminding that person that you're working with of how work connects with their values and aligns with their values can help them to be reminded of why it might be important for them to go back to work Thanks Suzanne, fantastic comprehensive DEL, do you have anything to add to what we've been talking about? Not much because I think we're dealing with reluctance for me that most important thing is understanding that reluctance and trying to address it so in Lisa's case if it is that vocational goal of work coming back to this untenable job then it's going to be about addressing that vocational goal as well and making sure the job is safe. I agree wholeheartedly about working together but I think my patients who are reluctant to go back I think it works best when I get their buy-in for the return to work plan so I'll say to them how many hours do you reckon you can do in the first week and I'll usually run with it if it's three hours twice a week or four hours twice a week that's fine if they say one hour then maybe I'll try and build on that but I think that empowering them to feel they're in control is really useful and the other thing I do is often call it a trial their work capacity is untested we're going to call this a trial and we're going to feel safe that we can stop it at any time and also if they are on some insurance benefits or compensation it's not just going to stop immediately we're going to test it for a little while because I think there can be a bit of anxiety about losing that safety net too Absolutely Steven anything from you, any thoughts? Look I've really just to highlight that a return to work needs to absolutely be safe and absolutely be meaningful if possible you know and that's most definitely what needs to happen so we're engaging the patient and getting that buy in from the patient as well as the workplace so engaging the workplace and getting them to encourage and embrace the patient to come back to work in a safe way is absolutely crucial having that group feed of tasks and duties to try and get them back but always in a safe way and that does take time there's a time component for all three of our specialties that needs to be encouraged to be spent with the patient and with the workplace maybe in a case conference maybe by phone there's all sorts of different methods to create an environment where first of all the issue is identified by everybody and respected and then a plan is put in place to return the person to work can I just add as well just I think it's quite important to note and also going back to work is a time to up treatment not reduce it the number of people who I see who are back at work and so they've stopped seeing their psychologists it's like no see them more regularly to identify and address issues as they arise rather than you know not have an appointment for a couple months and come back and it's all fallen in a heap very important deal same with medication of course we had a webinar last week very stopping medication is when they needed most was hugely important so I guess work is the same thing although there has been quite a bit of discussion on the side about people who might be re-traumatised by going back into the workplace and whether it ever gets to the point where they do have to actually change their employer does anybody have any thoughts about how we approach that if say in Lisa's situation she's not there yet but if it gets to the point where she has to change how do we support people through that sometimes it happens sometimes it happens where the workplace is just no longer appropriate for that particular person and you know can we facilitate a change of career a change of job location or whatever is necessary then sure if that's what is needed to happen in order to get the person in a safe workplace then that's fine that's not easy but if that has to happen then that has to happen that's the rules I agree with you Steven there are some circumstances where it's just not going to be possible to get the person back to their old workplace I can't remember where the stats come from but there is some stat around it being much more difficult to find a new job than it is to return to your old job so I think considering the change of workplace it needs to be after a return to the same employer has been absolutely exhausted we really need to know that we've tried everything that we possibly can to accommodate what that person is capable of doing in returning to their old workplace before we then move on to a new workplace I have to agree with that I always say don't make long-term decisions on potentially temporary emotions and sometimes you need to call it early to early come back fire for your patient as well Thanks for that I'm just wondering actually I'm asking on behalf of Allison Steven, what item number do you charge when ringing an employer to discuss these things a little bit depends if the patients with us or not well I'm being obnoxious here because I guess my point is there really is no payment is there there are telehealth there are telephone call payments in some system so depending which jurisdiction you're working under and which region so some do have telephone compensation item numbers or item numbers appropriate for telephone calls with the patient it's really an extended consultation at the end of the day perhaps additional telephone call and then there's case conferencing has its own item numbers as well so there are ways work compensation generally is more generous than standard Medicare than the standard MBS certainly has within the identification of communication as a central core reason for its function and improving the outcomes Can I just add as well that some of the employers will fund a 15 minute appointment with you as well if you ask That sounds entirely reasonable another thing that's emerged is about the interface between our clinical system and the legal system and the sense from some of our participants that the two systems are not always pulling in the same direction and it's going to be pulling in the same direction and that sometimes it appears that what we're trying to do clinically is not aligned with what the workers trying to achieve legally are there any thoughts about that about what we do as clinicians when we feel that the worker is either consciously or unconsciously being led into an illness behaviour that doesn't involve return to work if I put that discreetly enough who's up first on this one Suzanne you've got the green ring I'll have it both so I mean I think we've all had that experience where we perhaps are seeing some behaviour that isn't aligned with what we would think would normally be going on for someone who's experiencing the symptoms that our patient might be reporting and I guess my approach in that situation is really just to continue focusing on helping that person to get better I think when you're working within a compensation scheme it can be quite easy to become hypervigilant I guess to those sorts of things going on and it's not necessarily helpful I guess to go in with a high level of suspicion with clients in trying to work with them and facilitate their recovery I think the other thing that we can keep in mind is that there are systems in place and processes in place which are designed to make it difficult for people to do anything illegal or to malinger those sorts of things and they are often managed by the governing body or by the insurance company and so I guess what I feel that allows me to do is to go in with the mindset of I'm just going to be here to do my job to try and help this person get better based on the assumption that they are telling me the truth about what's going on and let the insurance company or the compensation scheme do the job that they are built to do I'm not implying that the client would be doing these things deliberately but it just seems that sometimes the systems are set up in a way that it tilts people against what we are trying to achieve whereas it's hopefully everybody pulling in the same direction The runaway factor that Lisa is exhibiting is give me a week off which will turn into multiple weeks is no doubt is a negative it's the data around the world is very strong the longer people stay off work altogether the less likely they are to restart in their workplace and in fact potentially restart in any workplace so they can be long term unemployed or unemployable because of their time off work so we know that and we have to keep reminding ourselves of that and exactly as Suzanne says take that high road take that that clinical outcome optimism to continue advocating and batting for the patient to try and get them back into a frame that encourages them to get back into the workplace in some form or another All right great thanks I got time to add something I think it's getting a little bit better I think a few years ago when there used to be a lot of surveillance done the lawyers used to say go to your room shut all the blinds don't leave the house for six months and what do you get at the end very thick and capacitated agrophobic patients so now that there's not really much surveillance I think that's getting a bit better but I think it's important to have the open conversation if they do have a lawyer involved make sure your lawyer's not advising you things that are going to get in the way of your recovery and talk through that and the other thing I think is if you think they've got capacity for work then I think it's okay to say to them I can't fill in the certificate for you I know it can be hard but I think you've got a partial capacity or I think doing something is going to be better for you than where you are at the moment How do you set things up to yield that you can have that conversation what are the elements that you have to establish before you can be so patient centred but outcomes focused? Yeah that's a very good question I think it's all the things that we've talked about already it's making time being interested in your patient understanding them developing trust and rapport and it's certainly not something you'd pull out for the first, second or third session that would happen over a period of time where hopefully you do have that therapeutic relationship and you've got to say what you think help your patient not injure them and I think if you say it in a way that showing your best intentions for them and their outcome then it can be taken okay look I'm going to do something terrible here and ignore the questions and ask one of my own which I'm genuinely curious about I've noticed that the incentive for a worker to participate like even though they might not be able to leave the house to go to work they can go to their daughter's wedding and I've heard that sort of held up as evidence that the worker has more capacity because they were able to attend their daughter's wedding but I would have thought the drive to do that is going to unleash levels of ability that they might not be able to unleash to turn up to work every day is that fair do we need to obviously suspend judgement on people when they are able to do things because they really really want to do them yes is the answer is it okay good I'll move on I've got a really good question yeah Suzanne do you want to go? Yeah I mean I think that's a really tricky situation because being able to engage in those things is likely to help them to recover and so I have worked with some people who are very reluctant to engage in some of the strategies I'm recommending to help them improve their mental health because it might be seen by the insurance company as you know hinting at some capacity that they don't feel that they have I wonder though you know that example that you gave whether a reduced capacity is perhaps appropriate in terms of sure they might not be able to go back for 40 hours but if they are able to go out to a social event would it be possible for them perhaps to you know perform reduced hours per week or something like that and that's perhaps the way of working with that kind of situation sure that makes so much sense I'm interested I know we've touched on it a few times but I'm not sure that we've really nailed one of the common questions that's come through a lot tonight which is about resources that can help us to reduce functional capacity for work you've touched on them in your presentations but just more or less as a summary what would you see as the most useful resources for objectively assessing functional capacity for work who's up on that one is that you Suzanne or DL or Stephen I've got no idea so I'll try to get over to you what's your favourite definitely not my favourite but there is a little five-minute video on the website I think of me doing a functional capacity assessment and it's more for someone who's off work than at work at the time but it's a starting point yeah I think the lack of all of us jumping to answer the question identifies that it's a really tricky issue and you know getting that right is complex and multifaceted really it's the engagement it's certainly a key feature in that the trust and the clinical relationship that you develop with the patients and then having a framework and a structure to identify what they're capable of and perhaps incorporating the return to work coordinator who will further unpack that and identify lots of different features that the person is able to do rather than focusing on the negative and what they're not able to do focusing on the positive what they are able to do within the workplace itself okay great thank you for that I must say on the physical side of it it's often seems quite straightforward you know the number of kilograms no bending no lifting no squatting and things like that the psychological aspects seem a little bit harder to put boundaries around but I guess that's what really needs to be made very clear to people I'm often intrigued that sometimes the return to work coordinators seem to be suggesting that people become children's crossing supervisors seems to be the default job I don't think of a worse place for somebody with mental health issues than trying to supervise children crossing a road in traffic or playing soccer there you go absolutely it just seems like a really really lousy place to be but it seems to be on the list of that and carpark attendance but anyway um just thinking about other questions we've only got a few minutes left before we get into the sort of the summary part of it there are still questions I guess about potential bullying in the workplace this case did not well it did raise flags I guess about the potential for some bullying or at least negative interpersonal interactions this is something that we need to get involved with as clinicians and obviously that would contribute to an unsafe workplace does anybody have any thoughts about that particularly Suzanne looks like you all highlight it again um yeah I mean I think that can be quite common that you see people who have experienced some bullying in the workplace and in terms of facilitating their initial return to work it's often necessary to ensure that they don't have especially frequent contact with the person who's been involved in that um and you know that's going to be absolutely necessary in ensuring that the workplace is safe I guess though you know um none of us can control the people that we work with and none of us can control who we interact with in the long run and so ideally and I completely acknowledge this is not always possible but if that person is able to learn how to deal with someone like that and how to manage that interpersonal interaction and um you know be able to face them then that is going to be helpful for them in the long run but you know I really want to add a caveat that I do understand that that's not always possible no I certainly agree with that and actually just on an earlier point as well there's a few people Lee and Tien and particularly and several other OTs who have remarked me that OTs can be very good at doing functional capacities both physical and psychological and that they should be part of our network so that we do get that expert input to return to work absolutely I think bullying is a really big issue you know within the interpersonal relationship disasters that sometimes happen at work um you know can you get a group session can you get some sort of mediation to happen um you know needs to be identified called out workplace involvement um and then some sort of mediation which can often be very difficult to generate the bully often is not interested they haven't done anything wrong they don't see it as an issue um you know seen as a witch hunt sometimes and all of these other issues come in so it's certainly very very complex and very difficult to do that to resolve those things sure no I think there's no question about that let's now finish up because we're in the last 10 minutes or so so I just wanted to go around the three of you and get your final reflections I guess on Lisa's case and other things we've talked about um tonight um Suzanne maybe we'd go to you first of all and then um Stephen and then Dio what are your final thoughts about what we've discussed tonight well um there's three key points that I hope people walk away from tonight's webinar with and the first one which you know we've all reinforced by a lot you're probably sick of hearing about it but it's really about that um principle of staying active and staying engaged with the workplace um as soon as possible after someone experience as a psychological injury and and you know the evidence base that really supports that as as a recovery strategy um the other other key point is around that idea of collaboration of drawing upon the expertise of the other people involved in that return to work process in order to provide a really detailed and well-informed plan for helping that person to recover that you're working with um and then the third one is around graduation so taking that idea of this is where we're at this is where we're going to get to where you want to get to and what are those steps in between to help you to get there which as I mentioned really aligns that process right all right thank you very much indeed um Stephen I guess your final thoughts about the case and what we've discussed tonight yeah look I think this is a a really you know a true to life case I don't think it's it's hypothetical at all I think we're all seeing patients in this sort of space she seems like a legitimate person who's got a legitimate job of quality and you know she's she's met some rough seas to passage through and you know I think our role is um is really to encourage and support her through that to navigate her way you know through these these difficult times um using all of the skills that we have and whether that's you know using a team approach using medication using you know some structured structured format within the workplace to to help her through all of this and there's probably all of those to be honest um to make it to make it actually happen um you know having the team involved having that that coordination and communication is uh is what the GP in this particular case or probably in most cases to be honest is the central uh central player to coordinate everybody else around so having those um you know communication channels wide open to to have discussions and it takes time there's a time process that needs to be reserved aside to provide that service to to help this person um needs to be paid time no one's doing anything for free but needs to be appropriately remunerated um in order to make it happen which is which is challenging you know access to general practice is a challenge for a couple of days access to psychology and to psychiatry is is much more than that sometimes um so getting those getting those access points to to help um Lisa along can be can there can be delays in time which which perpetuates the whole illness model um and and the overarching with all of this is that the benefits of going to work and benefits of staying in safe meaningful work is needs to be remind everybody needs to be reminded of that all the time so that that's that's in fact the way back to work is to have safe meaningful work provided um in graduated um and a graduated care plan to get this person back to work and back to full function thanks Steven actually a few people have been saying that Lisa sounds exhausted and that maybe she does need a bit of rest is that something we need to juggle against not I guess encouraging inappropriate time off but um she's either about to blow or about to collapse I'm just wondering if she does need some time to rest and how we judge that um yeah that's and that can certainly be be suggested and discussed whether that's as the L initially said whether that's part of a standard sick leave certificate whether it's her taking annual leave or even long service leave as part of that break um or whether that's the liability falls to the works compensation organization that's perhaps a little bit up for grabs um and you know having a break is fine but you know having a break may not be the right thing and maybe the right thing that's all part of the discussion yeah all right great thanks for that so DL your final thoughts about what we've discussed tonight absolutely and I think we're all saying similar sentiments but I just wanted to say something about having the break I think it's all about moderation so it's good you know she can have a rest but don't rest for 10 days in bed and not leave your room so my take home messages are I think we've all said them focus on functioning not just on symptoms diagnosis and treatment avoid avoidance maintain meaning purpose activity distraction keep it keep someone engaged while they're off work if they're off work work to resolve the issues from day one keep it work if possible and when you're filling out that certificate of capacity understand the benefits but also the risks that's it fantastic thanks for that so we're heading into the home straight now please don't leave us everybody I'm going to ask you for to complete the exit survey and provide feedback if you don't we will play political jingles down the furniture until you do so please do fill out that that questionnaire when it pops up or hit the pie chart icon in the lower right corner of the screen to get that to fill out so thanks for participating everybody there's a few things I wanted to mention com care have on their website comcare.gov.au some information about a conference they have coming up on the 7th 8th of June that may well cover up some of the other things that have been bobbing up tonight in the discussions so please have a look at that website the next webinar is for MHPN again to be there's an emerging minds webinar the next one's on the 15th of June which is about building parents understanding of play to nurture infant and toddler mental health there's also one on age frailty loneliness and suicide in older Australians on the 29th of June and another one MHPN on collaborative care for people living with ticks and Tourette syndrome on the 6th of July so plenty going on and judging by what's been bobbing up in the chat I think there's a big demand for a webinar and dealing with difficult personalities in the workplace who might be bullies contributing to the situation so there's a lot of interest there I wanted just to remind people that MHPN's networking program supports practitioners to meet and network with each other from the local community and that there are more than 350 such networks across the country so the MHPN website.org.au will help you find your nearest one if you want to start one up because there's not one near you then there's an email address there that you can contact networks at MHPN.org.au or put it in the survey when we get to filling that out at the end so thank you DL, Suzanne Steven thank you all very much and also to the MHPN team behind the scenes that make these webinars possible before I close I would like to acknowledge that the lived experience of people and their carers some of whom have been on the call tonight I've noticed who have lived with mental illness in the past and who continue to live with mental illness in the present so thank you all for the thousand-odd people who have attended with us tonight thank you to our speakers and we wish you well look forward to seeing you at the next webinar good night everybody