 Good evening everybody and welcome to this webinar on suicide prevention and postvention and interdisciplinary approach and this is a collaboration between the general practice mental health standards collaboration and the mental health professionals network. Welcome to the over 1,000 participants that we have already this evening and the viewers who are watching later by a podcast and there are over 4,000 people have registered for this series which is really exciting. I'd like to begin by acknowledging the traditional owners of the land on which our webinar presenters and participants are based and to pay my respects to elders past and present. I'm Dr Mary Emma Lannis and I'm your facilitator this evening. There is a slightly new platform I've been doing these webinars for about 10 years so I'm probably a little bit more glitchy tonight than usual while I get used to the new one. It's great to have you all with us. My background is general practice and psychotherapy and then now I'm halfway through psychiatry training so I've got a foot in a few camps and I really enjoy the interdisciplinary work with MHPN. Just to let you know about the general practice mental health standards collaboration, GPMHSC, many of you won't have heard of this organisation but it's the body responsible for setting the standards and accrediting training in mental health for GPs and it's made up of a committee which includes representatives from general practice, psychiatry, psychology and the community. Our GPMHSC commissioned the MHN to plan, produce and develop this webinar exploring interdisciplinary mental health care in the field of suicide, pre and postvention. There are some fantastic resources from GPMHSC which are available in the resource tab. I'll show you about that in a moment. So yeah just if you're interested in GPMHSC finding out more there's the website for them and I'd like to introduce tonight's panel to you. So you did receive everybody's bio in the materials before the workshop so we won't go into great detail but it's a really experienced and very, very well informed panel tonight. It's going to be a great discussion. So I think I'll just first of all welcome Chris Ryan who's the psychiatrist on our panel tonight and Chris I've certainly really found some of your articles valuable. There's a couple in the resource box and I wonder if you just give us a couple of words about where you're based and what your role is most days. Sure so I'm a psychiatrist at Westmead Hospital in Sydney here that's a very large tertiary referral hospital. I'm the sort of psych, I'm a constatational arrogant psychiatrist which means I'm a psychiatrist. I only see people that have a medical problem of some sort so I spend all my time in the general wards or in the emergency department and obviously in that sort of environment particularly emergency department there's a lot of people that write rates concerns about suicide. Thank you and welcome and I'd like to invite Dr Louise Stone. Now Louise you've made a very heroic effort to be with us this evening having got stuck between Cairns and Canberra here in a hotel in Brisbane rather than with the webinar and you're particularly connected with rural general practice. Would you like to just let us know a couple of words about what you do on most days? Sure so hi everyone my name is Louise I'm a GP in Canberra. I have experience in rural remote and also urban practice. I work in general practice so I see lots of people with all sorts of issues and I guess I've got a particular interest in patients with sanitisation and mixed emotional and physical symptoms and also I guess the general things that we do and I also help to run the Masters in Psychiatric Medicine for the NSW Health. Welcome great to have you and Rebecca you're a clinical psychologist and based in Melbourne I understand and you've got a really interesting role with the APS could you just tell us a little bit about that? Yeah thanks hi everyone so yes I work at the APS and have for many years overseen as part of my role the professional advisory service so a service that provides advice to psychologists around ethical and professional issues that they come across and it's in that context I'm going to talk about the questions that come to us around you know working with clients who present with high distress and potentially with you know risk of suicide. It's great to have your expertise Rebecca and I'm sure that those issues are applicable to all of the professions represented in the participants tonight. I think we're up to 1,123 all over Australia and possibly international I don't know welcome wherever you are and just to give you a little bit of a rundown of what you're looking at on your screen and how to navigate. To access the chat box for the participants you can talk to each other on the purple chat icon. When you're looking for a copy of the slides and the resources that we refer to they are available from the light blue arrow. If something happens to your screen and you need to refresh there's a green plus icon and there's an exit button which is the red cross. There is a help button if you need assistance and you can message red back directly that's the company who are providing the platform for us and you can ring that number 1-800-733-416 if you have any problems. I'm just going to move across here and show you a little bit about the chat box. So this the purpose of the webinar is to give us as professionals the skills we need so that we can help people more effectively in the future. Many of the topics that we cover including this one may affect us personally and they're very important stories. We do often include consumers and carers on our panel but we need to make sure that we don't put those into the chat box because the story itself that we've been provided to discuss is already potentially triggering enough for some people and so we really want to make sure that we don't burden each other with other stories but we do strongly encourage you to seek the support of colleagues if you need it. When you registered you did automatically agree to the ground rules and if you're unsure of them they are in the supporting resources tab in the bottom right hand corner and again Aidan's story we're going to be talking about Aidan tonight is in the resources tab. The way it's going to work is that each panelist will give a response to the story followed by questions and answers that will be between the panel and the panel and the audience. We have welcomed the questions that you submitted prior to the webinar and we'll be including those as much as we can. Please bear in mind the time goes really quickly and if you do post a question that doesn't get answers please accept apologies in advance because it's never possible to cover everything but we'll do our best. Now just to remind you of the learning outcomes at the completion of the webinar hopefully we'll be better able to recognise and respond to mental health issues which may indicate risk factors for suicide. To be able to support bereaved patients, communities and ourselves when responding to a death by suicide and to be able to implement tips and strategies to enhance communication and build capacity between practitioners when we're treating people who may be at risk of suicide or responding to a death by suicide. So we will have our three presenters in a particular order so Chris is going to speak to us first about prevention, Louise about postvention and Rebecca about communication between practitioners. There will be a lot of overlap and interweave and once we get to the Q&A we'll all be contributing to that. So I'd first of all like to welcome Chris. Just to remind you a tiny bit about Aidan. The GP in a country town has seen Aidan and all of his family members knows them all and Aidan's a young man who's 20 and you've read the story so I think I'll just hand straight over to Chris. Thanks Chris. Thanks very much Mary. So yes I'm going to be talking as Mary said about the prevention side of the story. Just to recap quickly perhaps to pull out the most important elements. We know that Aidan is a mechanic's apprentice, he's popular, he's affable and he's relaxed and we also know that you have a good relationship with him. Back when he was 17 he had an episode of what was diagnosed quite reasonably it seems as an amphetamine induced psychosis. We know that he's a sensible fellow because after that he immediately gave up speed and cannabis and in fact he's uncommonly sensible for a 20 year old apprentice because not only did he tell you about a conflict that he was having with his father but when you suggested he see a psychologist he did and apparently he benefited. Now he's back saying you because he wants a work certificate. He's pretty upset because he's just broken up with his girlfriend and he is worrying that he's had thoughts of his own death but it seems that you followed up on that and he's reassured you that he has no plans to suicide and actually he would never consider killing himself. It's not really clear what other history you took at the time but he agrees to see a psych, go back to see the psychologist and to see you again in four weeks. Four weeks later he's done neither you contact him but he says he's fine. So here's my first impression of this case. It sounds like you did everything pretty much right and that's important because it's natural to ask yourself in these situations if you could do or should have done more but I'm not seeing it. We really weren't told that much about how much detail you went in to when he mentioned thoughts of his own death and ideally I would have liked to get a little bit more information than we were presented with but you probably didn't have that much time. He came in for a work certificate after all and it probably took a while for him to get to the whole I've had thoughts of death thing. So I'm guessing you were pretty pressed by that point. We're also told that he was looking dreadful, tired and angry and that could be concerning depending on the context because it might indicate some sort of decline in functioning. So what else could you have asked him if you'd had time either in that appointment or possibly at the next appointment which depending on how concerned you were could have been perhaps a little sooner than four weeks, perhaps next week or in a fortnight. Well basically the answer to that question is more detail. The idea with taking these sorts of histories is to as much as possible find out what it's like to be Aidan. What happened in the break up for example? Aidan said that she slept with one of his friends. I mean what happened there? How does he feel about it now? He said that he had thoughts of his own death but he wouldn't kill himself. So what thoughts of his own death was he having at the time? If he still thinking about that and also when do those thoughts come up? You could also ask about features of major depression or perhaps a relapse of his amphetamine use or alcohol use because I guess any of those are possible. Notice by the way that I'm not asking any question that might be classically considered as looking for risk factors for suicide. And this is because and I suspect this is going to be the big take home from me tonight. It is not possible to usefully categorize patients who present in psychiatric crisis into those that are at higher or lower risk of suicide or serious self harm. You can't do risk assessment so you can forget about it. I'll leave it there for the time being. Thanks very much. That's a very attention getting point to leave it on and I know that we'll be coming back to that in the panel discussion because people are certainly required to do risk assessments in their work and it's related to the Mental Health Act and all kind of things so if we don't do that then what do we do? But I also appreciated your comment that really the GP actually did a pretty good job and I know when these things happen we always look back at what else we could have done so it's really helpful to think what could we do more. And now Louise you're going to talk about from the GP perspective because I know when I read this case I certainly my mind was taken back to the dreadful experience as a GP of having lost patient to suicide and particularly when you have the family as your patients as well and the whole community that's affected and people looking to you for help so really looking forward to hearing from you Louise. Thanks. Well I'm most relieved to hear that question coming from Chris because it makes me feel so much better and one of the biggest questions that we always have as GPs is what could we have done differently. I think it's hard as a GP to understand just the degree of pressure that you're under in an average day when you've seen so many people in so many settings and patients may or may not give you permission to actually explore where they're coming from. It's quite different when a patient turns up to accident emergency or they turn up to a psychiatrist or they turn up to a psychologist they definitely help seeking. They might be coming to us in this case for a piece of paper for their work or for a script and there's only so far that you feel you can press the questioning and particularly when it's squeezed in on a Friday afternoon. So as a GP as Mary said those moments that you remember always are the patients that you lose and it is always there's always this sense you have of what could have been prevented and what you should have done and it's difficult and we carry those around with us for very long time. I think as family doctors though we also have other responsibilities and when we're looking at a small country town we always have responsibilities not only to the family but also to the community and remember that when you're a country doctor your kids may be in Aden's year, they may be in the same year as the brothers of Aden, the brothers might have been in your lounge room it makes it incredibly difficult to manage your own grief and also to deal with the responsibilities that you share for community. Weirdly enough when crises like these happen people often turn to country doctors and we end up doing community-based things. We go into high schools, we talk to the teachers, we debrief various people including first responders, we can tend to get together with them as well. So a lot of responsibility and on top of that as family doctors we also have that nasty jangle in the back of the mind that this is going to be a coroner's case. So I just wanted to talk a little bit about some of the questions that might arise including do you go and visit the family, do you attend the funeral, those sort of questions are actually quite tricky to negotiate and there are no straight answers, it's something we all have to work out in our own way. I just want to say as country doctors we do seem to have a few responsibilities and one thing I think is that people necessarily aware of healthy grieving. It's something that used to be well known in the community but it's not so well known now so it's not uncommon for us to spend up to a year of the relatives of someone who has died by suicide coming into us and talking about what's normal and needing advice about when they should go back to work, how much they should be working, whether it's normal to not be sleeping and those sorts of questions. Obviously we need to spend some time with the parents and deciding also between the parents what's going on because often the parents will have very different opinions about for instance how to run a funeral and it's not it isn't uncommon for people to come in and help need help to actually work through that. It's important to think about whether there are ways in the family and also in the community to reduce the risk of suicide imitation particularly amongst adolescents. This would be a small community and so Aidan's death would resonate throughout the whole community and you feel like for some time that you have this ear up looking out for any risk factors in other people. It means that you're always practicing with that slight edge of what residents has there been amongst the community with Aidan's death. And finally there's that question of us and without turning it all towards the practitioner the rate of suicide amongst doctors is quite high. In fact it's 4% which is very high the rate of suicide attempts amongst doctors. We are perfectionistic types and that means that we question ourselves and it can be very easy to take on that responsibility. We worry that people will blame us for missing something. We worry that the community will no longer trust us and in fact it's often a time that GPs will choose to drop out of the professional together. So it's a time when GPs need particular support and in a small town that can be difficult because most of the community are their patients. So it's something that I always encourage GPs to do to find support networks. There are plenty of them and there's plenty in the resources that we've provided to reach out beyond the small community as well as within the small community to get the support that you need. Thanks so much Louise and we'll look forward to talking further together shortly. And so I guess what Louise was finishing off there really leads well into Rebecca your role around supporting practitioners with the ethical and professional challenges that they come across in their work particularly psychologists however it's relevant for all of us. So I'd like to welcome you now Rebecca. Thanks Mary and yes book I totally agree I'm just going to just flick one slide too much. So I totally agree that all of the areas that I'm going to cover at the moment are areas that psychologists ask about but I think all professionals working in the mental health space and particularly facing the issues of working with someone who might be communicating suicidal thoughts or be highly distressed where there's concern about risk would be raising some of these potentially some of these questions. So the first one that we get is around competence because working with someone who presents highly distressed potentially at risk can be really stressful for the professional and especially we find in private practice where you might be working in a context where you don't really see this presentation all the time and so you're questioning whether I guess whether you're up to it. Now mostly what we find when we start to speak to people and if you think about quizzes outline around what needs to be done mostly mental health professionals do have the skills to be able to at least do that initial assessment and take some action based on that like whether that be to refer on or whether that be to work with the person yourself around these issues whether you have to actually take action to protect that person but in the end if you're going to work in the mental health space there is an obligation to take some action to make a former clinical judgment about what you're going to do to protect this person. So that really leads then to confidentiality because if you decide to make a disclosure then that's another challenge that we find psychologists bring to us. There are limits to confidentiality and one of those is where you need to protect your client. So making that decision isn't always easy and what we usually recommend is that you have a chat to your client if you feel that there's a need to disclose to protect them. Bring that client along with you in some cases you could talk to them about who you might make that disclosure to often you might be a family member or someone else who can come in and work with that person to keep them safe until you can link them into a service. Now in the case of Aidan that didn't need to happen because the GP had done the assessment he had come to the clinical judgment that a referral to a psychologist was appropriate in the end all he has to go by is what the client is bringing to him at that time. So that's all you've got to go by. So you need to be able to form a judgment to take some sort of action at the end of that assessment. So what about confidentiality after a suicide which is a question that's really quite interesting because actually confidentiality does actually remain even after someone's death. And certainly in Victoria, New South Wales and Tasmania there is legislation that actually legislates that confidentiality around health information remains for 30 years after someone's death. That's not in the other states but we generally use that as a bit of guide. So that is challenging then when you potentially after the death might have family members approaching you for information. So that takes us to communication and how communication should work between health professionals but also between others when someone's at risk of suicide and also after suicide. And one of the recommendations we make is that practices have clear protocols around how they undertake their work including in communication. So having a documented protocol that actually outlines under certain conditions how that communication will work and it would cover things like what information is to be shared when and with who, what sort of follow up. Now it's not clear what information I went from the GP to the psychologist whether the thoughts of suicide was communicated with the communication has been different, possibly would it have made a difference, maybe not. But I think engaging with other professionals more is something that we should do and especially if there are risk issues then there might be different ways of approaching that depending on your assessment. Again in this situation Aidan was clear that there wasn't any risk and he also accepted the referral to the psychologist there was absolutely no indication that that's not going to happen. So what about speaking to family members? So that's really important. Obviously family members contact you, you need to treat them with compassion. It's really important to talk to them and potentially even to meet with them. But also you've got to balance that with your obligations around confidentiality. And I always say it's a little bit like providing psychological first aid. You can provide them with information and support make sure they are linked in to services if they need to. But also in this particular case because the family was really well known to the GP the GP would probably want to be monitoring those family members as well. And of course keeping really good records is important. There may be a coroner's investigation. So even though you don't want to think about the worst case scenario your documentation is your best defense. So lawyers always have this golden rule around the more that a presentation departs from your typical presentation the more you need to document. And I actually think that's a really good rule to have for mental health professionals as well and in a case like this. Because that documentation is really what you have that support the basis for your decision making. And finally reflective learning. Like it's really important to have that process of debriefing and with a senior colleague or someone who can speak to. And over time it's important to also reflect on the incident I guess on how you dealt with the feelings afterwards. I think it's really important for yourself care to go through that learning that sort of reflecting learning process. I think hindsight sometimes can be a bit like a slap in the face. Don't slap yourself in the face. That's not what it's about. But with any service that we provide it's important to then go back. If you didn't get the outcome that you were expecting could something have been done differently. And would that have made a difference? Perhaps not. But I think we can always it's always important to evaluate what you've done. Look at what could be changed. And that's part of learning from this as well. And that's it for me. Thanks Rebecca. I really valued what you were talking there about for the family compassion versus confidentiality. And it's a really it can be very complicated. And I know that that's being reflected in the chat box as well. So what I'm going to do is because so Chris dropped us a bombshell in his last slide which people are really concerned now about well what are we supposed to do? So I think we felt that there were a few things that would come out of this. And we have a little poll to help you guide the direction of the webinar. But I'm going to go straight back to risk assessment. And Chris I'd like to bring you in with that comment that you made. So if we can't do risk assessment we've always been taught that we have a duty of care to do risk assessment and then do something called safety planning. And I wonder if you could comment on that given the research. Sure. So again just to be clear exactly what I mean when I'm talking about risk assessment I'm talking about and people did think that this was possible for a while. The idea that people that presents to a GP's office or to the emergency department or anywhere in the other clinical situation that perhaps it would be possible to extract clinical features or demographics and using those you could work out is this person at higher risk of suicide than other people. And if you could do that I guess that would be great because then we would know to focus our resources on those people. It just turns out that you can't. People have looked for this over and over again but as soon as somebody presents in some sort of psychiatric crisis so basically as soon as you think to yourself oh this could be you know this person might raise concerns about suicide then they fall into a class of people who are at definitely an increased risk of suicide but they're all at an increased risk of suicide and there are no clinical or demographic features that you usefully make any one any that you can usefully divide people into those at higher or lower risk in that already high risk group. So that's what I mean by risk assessment is the idea that perhaps you could pick the losers as it were the people that were more likely to suicide of the people you're concerned with you can't. So since you can't you don't have to you really can't be expected to do something that you can't do. All you need to do and there's no nothing small about this is do the sorts of things that I was suggesting so you just need to as much as possible understand this person's predicament where are they coming from. Do are there features of some psychiatric illness that might that they might benefit from treatment of that and then with that person and with their family try and work out the best way forward. It's just standard medicine really so you know actually most doctors are pretty good at that they don't have to be worried about risk scales or writing down high or low risk or anything like that they just have to try and understand the patient and then work out with them the best way of going. Thanks Chris and I'm sure we're going to keep coming back to this but I'm sure that the experience of being understood and heard around those things that are really painful is in itself really valuable and is therapeutic. So having the doctor ask more details or whichever practitioner it would be and actually being able to talk about those painful things is very helpful. What I'm going to do now is we will move to our poll so what will happen is that there are four themes that have come up on your screen now which we felt you participants the audience might be interested in discussing further we've touched on risk assessment already so we're going to have about 30 seconds Redback will bring up the poll for us and a pop-up will appear on your screen and you just choose one that you would most like us to discuss there'll be you know 20 to 30 seconds for you to to answer the questions and then you'll be able to see the results at the end so we'll just give it a few a few more seconds I understand that the poll is up and you can see it I can't so I'm just trusting the universe that it's all working well and look I think any of the topics that that are on the screen have really come up already in the chat box tonight too and on the basis of previous webinars I'm sure you're helping each other with with these issues as well I guess this case is particularly set in a rural community where the GP is even more likely to have multiple relationships not only the GP the psychologist probably has you know kids that go to school or coaches the netball team as well as seeing some of the clients so I think we're just about to the end of the poll so I think you've had a long enough and Redback if you could close the poll and show us the results now if it transpires that I can't see the results then I'll just need match pin to write those in the chat box for me so I can't see them but I'm just waiting to hear what the outcome was and then we'll keep going so we're just waiting for the the big calculator the big room full of computers that like the ones that sent the space shuttle into space no I think we might just keep going so I think I'm going to first of all I think we'll go to Rebecca people in the audience have been asking about safety plans now Chris spoke to us just before about working with Aidan and his family about what would be most helpful and you commented Rebecca about the idea of a safety plan and it wasn't clear whether there was one so I'm wondering what you think about safety plans and the idea of of practitioners actually sort of documenting a formal safety plan and notes Rebecca thanks yeah I mean I think it is what's promoted now as best practice is to develop a safety plan and to work with your client or your patient to do that so it's really got to work for them so it's tailored specifically for their presentation so it's really going to cover really practical step by step information for that person to keep them safe I mean that's essentially the aim of it so it would include things that would for them identify when things are really getting tough would be to give them prompts around what's important, reasons for living people that they can speak to in you know their family or their close community that will support them at that time particular coping strategies that they can use and when they might get to a point where they really need to then make contact with the health professionals so it's really about kind of like a sort of step by step process to keep them safe and I think that that is generally an expectation that if there's someone who's at risk that you put in some sort of safety plan like that thanks Rebecca I guess one thing I've done is think of it more as a coping plan so when you're feeling really distressed whatever things that you do that help you cope with that and that might include the phone numbers that you're going to call or the people you're going to contact I just don't use the word safety plan but I think it's probably got the same content but I was really thinking Louise as a GP it's an interesting situation because you might be seeing Aidan for this consult when you've got you know an extra squeeze in appointment in that hour and he only had a 15 minute appointment and it's always complex so I was just wondering as a GP where does safety planning fit in if it does? I think it does I think in our mental health treatment plans it's the bit that we do try to write in for the patient to keep I have a great belief in the bits that are ripped off the bottom of the prescription pads and are stuck on the fridge I believe in things that are stuck on the fridge I believe in things that I scribble notes and I'm always astonished that patients keep them I do think there's something about giving a patient something to take home that they can hang on to even that reminder of the relationship with the clinician I think is important that it's something that you've worked on together that you've come to some conclusions about I just wanted to comment on the rural and remote question because that's something different rural and remote I think is a different question because you have a combination of impulsivity and means so Aidan has access to means in a farm there's poisons there's various implements that he can use there's always gums there's always equipment and there's isolation if you add to that the fact that in a rural community there's usually also a heck of a lot of alcohol and a fair free range of drugs you've actually got access to means and in terms of safety planning certainly in rural that's something that I used to think about a lot because to me going back to what Chris said with the question of risk assessment for me a lot of what I had conversations about was impulsivity and how to manage that because working in rural accident and emergency in my little town one of the things that we would certainly notice was this acting out and not having any breaks on that acting out and so a young man like Aidan going from distress to suicidality very fast and then having the access to means so I think that's something that I think of a lot more now than I guess I used to before I was exposed to rural practice Thanks Louise now I have got the answer to our poll which was that risk assessment is is still rated really highly so I think we do need to keep particularly focusing on this and I suspect Chris I'd like to bring you back in the idea of the safety plan and I noticed you spoke about how working out with Aidan and his family what is likely to be most helpful so also just that question of confidentiality so if you are concerned about him and you think his family will be a support but he doesn't want you to talk to them I guess it's a two-pronged question but if you could comment on how to approach talking to the family and how we go about it if the young man doesn't want us to and then also how that feeds into the idea of a safety plan Thanks Chris Sure, so look I mean he is as a general rule if somebody doesn't want you to talk about their medical problems you shouldn't but or at least you shouldn't if they're competent to make that decision and that's sort of relevant because sometimes for example people might get so depressed that they don't want you to talk to the family for incompetent reasons like you can't talk to my family because I deserve to be punished and they'll try and stop me from being punished so if the person incompetent they don't really understand why you know their request for confidentiality isn't really born of any competent desire then I think whole new rules apply but for most people generally speaking if people are competent in refusing that you should respect that however almost everybody will with negotiation agree that it's okay you can speak to somebody and that's particularly if you're really concerned as you point out to the person why you're really concerned and why you really really do want to speak to somebody that doesn't have to be your dad doesn't have to be a mum if that's going to be but there must be someone that we can talk to almost always you can negotiate that sort of thing it's pretty unusual for me to be really worried about someone who would really like to talk to somebody but that person is competently refusing I mean it does happen but that would be that would be quite unusual and in terms of working out the management plan which I'm also not mad on the safety plan name myself but in work but I'm very mad on working with patients and their families to try and work out the best way of doing things going forward and that would include a lot of things that are typically included in a safety plan and would also include writing stuff down because I completely agree writing to people don't remember everything you say anyway and writing things down is a great idea and part of that will in most cases be getting support from the people that are around and that includes the family so it's going to be hard to do that if we don't speak to them Thanks Chris this is probably like a little bit tangential but it was an interesting question that came up right at the beginning about attendance at the funeral and you know the GP's part of the community the young man might be friends with his kids there's so many reasons why you might want or feel it's appropriate to go to that funeral it would be enormously difficult to do that but it might be the most right thing to do and I wonder is that crossing some kind of professional boundary or how do we think about that yeah I mean look I mean I think in this case you're right because it's such a small community and the GP clearly and the family are all well known to each other that it might have you know just been an expectation but I think it can it can be difficult and can be seen as a boundary issue because of course you know there's there's essentially an aspect of disclosure and attending a funeral as well and you know if you're not a close friend but you know in in this case as well I mean you don't really know how the family's going to respond you know sometimes families can be really can feel really angry at health professionals you know they can kind of they can be a bit of blame initially before you know they really understand what's happening so it did surprise me a little bit in this case that the first communication with the family was actually at the funeral so you know I do think you know if you've been working with a family you know the family well that there might have been some communication before that you know to call up you know offer your condolences see how the family is actually coping yeah so I think I think then you can check whether it's appropriate to attend the funeral as well whether the family feels comfortable with you attending thanks Rebecca Louise I'd like to invite you back in because I'm just thinking if you were at the GP and you did attend or even in subsequent conversations you know I think that the GP's already asking why why did this happen was there anything I missed could could anything have changed the situation but I'm pretty sure that that family and friends that may also ask the practitioner why why did this happen and looking to you for that really unanswerable question I just wondered if you had any thoughts about you know how you handle that and I think we'll probably come back to Chris and Rebecca on this question as well you know how do we answer when people say why well I think the first thing you do is that you ask rather than answer people often have concerned did I miss something should I have been there last week did I say the wrong phrase at dinner on Friday and was that the final straw I think the thing that that people are often asking about is whether or not they could have done something differently they're often going over in their minds particularly close family things that have happened and it's all incredibly confusing they've also had thoughts of comments come from the community it astonishes me the sorts of comments that come from family and friends and in all sorts of circumstances of people that will say things to people they hardly know that are very thoughtless and very hurtful so giving people a chance to express those is terribly important so that you get a chance to to correct misapplications that if I had been there for that five minutes I could have prevented it it would never have happened that sort of question I think the why question there are two things that are terribly important to say the first is that suicide is always the culmination of something very complex it's never just one thing it's never just one decision that doesn't come on the back of a whole lot of background and I think it's terribly important for people to understand that there's not one intervention that they could have made that would have changed the course of history the other thing that I think is terribly important is the role of mental illness and I don't mean that everyone who suicides has mental illness but I think it's important for people to understand that there is a lack of judgment that has occurred that in that moment of suicide a person felt that there was no help available and that in that moment they didn't feel that they could reach out to the supports that were there and the reason I say that is that it's very important to get across the message that there are supports that there are always supports that there are always capacities for people to reach out but in that moment someone like Aidan was unable to do so because of the mental state that he was in I think getting that balance right is terribly important and hard and takes a lot of empathic energy in the room to be with that person and to try and hear what they have to say but I think they're the two things that are important that moment is saying it's complex and the second thing saying that there was no point at which there was no help it's just that in the moment that person could not see the help that was there is that help Yeah I found that really helpful I mean it's so kind of delicate and complex isn't it I'd like to invite Chris back in just to comment on that I noticed Louise you pointed out there that not everyone who who has suicidal thoughts or behaviors or who does die by suicide not everybody does have mental illness and so Chris I I wondered also if you wanted to comment on how we might help people with the why question why did this happen Yes so well I mean not everybody has mental illness that's certainly the case and the studies are a little difficult to interpret but probably the majority of people would have had some sort of diagnosable illness or syndrome of some sort it's not like people just you know decide without any other reason generally speaking they're going to kill themselves I don't know that that's a particularly I mean that can sometimes be a useful thing to say to families but it is incredibly complex and it's really going to depend on the individual circumstances I think it's good to try and get out ahead of various things that people are probably already thinking so it's probably good to get out ahead of the idea they're almost certainly blaming themselves for what's happened so to sort of suggest that in this sort of circumstance many people find themselves blaming themselves or feel that they should have seen something people can often develop these sort of omen ideas that you know they should have known that when he walked out of the house and slammed the door a week ago that they should have intervened and I think it's probably pretty important to to the extent that it's possible and where people are up to varies and it also depends on your relationship with the family but if you can get out ahead of that stuff and identify that and perhaps neutralize that I think that probably does help at least some people I mean people are going to feel terrible all so don't be realistic about this this is that awful awful thing to happen to families and there's only so much anyone is going to be able to do but I think there are some things you can do another thing that is sometimes worth going out ahead of but again you've got to be very cautious about this is that families can find themselves being very angry with the person that has suicided so just being aware of that possibility and in some circumstances acknowledging that even that can happen and that that's a pretty normal reaction can sometimes be useful so this sort of normalizing of these normal reactions because after all these people haven't been through this before hopefully they don't know how they're supposed to feel and it is probably worthwhile trying to assist them in understanding that as difficult as it is I don't think there's anything easy about this No, thanks because I think we all agree with that I just keep feeling for this poor GP who has so many roles and so much so many different functions in this community Rebecca I just wondered if you wanted to comment on that same question about how do we respond to those questions from family and friends about why? Yeah, I mean I think Kristen Louise has covered it really well but I think in a case like Aidan's bringing it back to the fact that there were many things happening he was struggling with a lot of things that these were things that he was trying to deal with that he did have mental health problems giving him that information if that's something that's going to help them is really difficult if there's a confidentiality issue so what you can talk about is general information about mental illness so general information about I mean they obviously knew that he was seeing the GP for these problems if that's the case and then you can just talk generally about mental illness rather than specifically around things that Aidan was communicating I guess I'm coming from that really difficult perspective of balancing confidentiality with what you can say and usually it's really about providing the information of why people do take their own life in the end you know that sort of feeling that nothing's going to help them and they're feeling totally you know this level of hopelessness I think Louise's point around clarifying misperceptions that might come from the community is really important because one of the things about a family coming to talk to you is that often they don't have anyone to talk to because people in the community their friends and other family members often don't really know how to have that discussion with them about how they're feeling how they kind of can make sense of it themselves so it's really about providing them support and information that's going to help them work through it Thanks Rebecca now Louise I'm going to come back to you as the GP because the participants that you know have been noticing that there are you know the other family members that we haven't really specifically addressed yet on that note there are 1,600 participants still with us which is fantastic so obviously a conversation that we really need to have so Louise I suppose the two people that people have particularly noticed is the other some Tim the resilient one and then I think the father is on everybody's minds as well so I just wondered if you'd like to comment on the family members since it might be you that they come to see Thanks Yeah look this is one where you would have a conversation in the practice and work out who's working with who it may be that you see mum and your partner see dad or however but you would mobilize the whole practice because it's going to be tricky for any one person to actually see the entire family I will say coming back to Rebecca's question about confidentiality one of the things you learn as a rural doctor really quickly is how to put sort of barriers in your head so you work out what mum's told you what dad's told you what auntie flows told you who knows what and it is the skill that I've been grateful for my entire career but it is very difficult and that does make it harder and also the context do you go to the farm do you sit down with mum in the kitchen and do a home visit and have a conversation there or is it better in the practice do you see them one on one or do you see them together and this is where you sit down together in terms of the sons if they are typical country adolescent boys it's going to be actually quite difficult to get them to talk at all and so sometimes you find yourself having conversations with these kids bringing up you know when I've talked to other families have had these circumstances some people have said that you know they have nightmares as that happened to you and trying to get these kids to talk but it has to be when they're ready and that's the hard bit is trying to find ways to interact with these young men as much as you can reasonably without hovering so that when they're ready to talk they see you as someone who is who someone they can talk with I just wanted to comment briefly on the value these days of suicide helplines that have chat rather than phone calls I find that adolescents and particularly boys the idea of ringing a helpline is just way beyond anything that they would be prepared to do but the idea of hanging around on something like the suicide helpline for an anonymous person to type on the screen and they type back and they can call themselves Prince Smith and no one knows who they are is incredibly helpful and I make sure that I drop that into the equation fairly early I also find school teachers are particularly helpful in this circumstance and there is no way you would not in this circumstance be having a conversation with those two boys year-level co-ordinators at this point Thanks Louise it's really practical help they're no doubt born out of experience On the topic of helplines I wonder Chris I might bring you in on the evidence as to whether they actually work do they make a difference Essentially nobody knows the evidence base for helplines is poor it is probably the case that people feel better I mean we know that people tend to feel better if they talk to somebody it would be very surprising if that wasn't the case for people with the ring helplines and stay on the phone and certainly I've got plenty of patients that part of their management plan is as because they find it useful to ring suicide helplines do they actually make it less likely or does the existence of a suicide helpline decrease communities overall suicide rate nobody knows and perhaps that's a little unlikely but perhaps that's not the only thing that we should be worried about That's an interesting comment there it's not the only thing we should be worried about one of the things that was placed in as a pre-registration question was around sort of primary prevention so is there any evidence about things that we can be doing in communities or in primary care before people start to have suicidal thoughts or to be considering suicide as an option Chris I might ask you first and then I think I might come to Rebecca on that one so is there sort of primary prevention early intervention that has some evidence or is worth doing what kinds of things make a difference well the the clearest evidence on suicide prevention just focusing on that as I say I do I do think that there's broader issues at play here I don't I'm not sure that we necessarily want to be always I mean I don't know it's about suicide but I don't know that we always want to be just focusing on we've got to get those suicide numbers down but if we do want to get those suicide numbers down then removing access to means of suicide has very strong evidence that it decreases suicide so guns having guns not available that's very good the when we move from Panadol which you just screw out of a the tin and you had to punch it out so it took a bit longer that that makes a difference the fact that there's catalytic converters on cars now so it's harder to kill yourself by carbon monoxide that makes a difference and putting barriers around places where people typically jump off makes a difference interestingly it doesn't seem to be the case that if you put a barrier around where people typically jump off then people will go to some other place that they could just as easily jump off it's not it's not like when a barrier goes up on a bridge people go well I can't jump off that bridge anymore so I'll just go to that top of that tall tower and jump off that that's just not what people do so that's sort of stuff very good evidence for and if you've got a suicide place in your community these are around then in terms of primary prevention a really important thing to think about is can we put some sort of barrier there so that people can't do that as easily again it's really pragmatic it almost feels a bit confronting talking about it in such pragmatic terms but I think that is clearly what the evidence says so it's really helpful Rebecca I wanted to bring you back in just around what things we can be doing at a community level or a very early intervention level whether you have any comments on that as well yeah I mean I totally agree with Chris the strongest evidence is to remove the means and you know like he covered that beautifully but I always think about this really interesting study that I read where they stopped using a I think it was in Sri Lanka and they stopped using a particular quite toxic pesticide and the suicide rate just went down enormously so you know it really is about you know removing the means that is the strongest evidence but obviously look there's a lot of education now about you know people be you know increasing awareness of suicide you know you know looking after each other and just you know kind of noticing and asking questions I don't know like really that that has made a big difference certainly the research I don't think you know is clear on that so really sadly that just removing the the means is what really is supported by the literature thank you Chris yeah it is also it is worth saying and as I say this is it's not great evidence on this but a lot of people suicide because they've got a mental illness it's a good idea to treat mental illness effectively I think that there's a regional amount of evidence that actually does decrease the suicide rate in those people but more importantly it helps their mental illness so identifying associated mental illnesses or substance problems and then addressing them I mean I know that sounds absolutely obvious but you know obvious things worth doing and throwing in there I've got to say Mary throwing in there you know if they have a roof over their heads food to eat and you know some social determinants of health that doesn't hurt a living wage would make a big difference as well but again I think those sort of the primary prevention points of view I guess from my perspective as well yeah thanks Louise I was actually about to invite you back in so I'll get you to stay there just for the audience I'm not sure I think Louise's camera is a bit glitchy so you may just be seeing a still photo of Louise that she's still with us Louise we haven't actually talked very much about practitioner welfare and compassion for the practitioner as well but I think you've got us to think about that when you talked about the practice you know dividing up deciding who's going to do what within the care of this family but I wonder if you wanted to say anything about you know how we look after each other as professionals and how we look after ourselves when this kind of just you know it's just dreadful it's dreadful as a practitioner it's dreadful as a human being it's dreadful because you're a parent yourself and you think about if this was your kid it's just so difficult how do we cope when people people in the community like Chris I think who are prepared to stay a stand up and say that we can't prevent suicide I whenever I teach I teach with a very senior psychiatrist and one of the big things that he does in those workshops is to move away that myth we don't have the same sense of guilt if a marathon runner who's thin and fit and has a great diet has a heart attack we don't feel that we should have known and we should have prevented and we should have done things and we should have you know come in ahead of that of that terrible outcome but somehow we have this I think Chris put it as like an omen feeling that we should have somehow divined that we knew and we could have been there in that moment and prevented suicide and that guilt and shame is truly awful and I think we need a peer group around us to be able to support that mental health is only one of a huge number of things that we do we worry about missing meningitis we worry about missing you know bad outcomes in pregnancy we worry about missing cancer there are a gazillion things that GPs worry about every day and so it's understandable that they think that maybe if they've had just that little bit of knowledge or that little bit of skill or that little bit of capacity that they could have come in ahead I think it's important for us as clinicians to have support networks around and to be giving that message particularly the young doctors that there are some things that aren't preventable one in five of us will lose a patient to suicide during our career and I think the more that we say that and the more that we come across that some of those may not be preventable by us the less inappropriate guilt and shame will be spread around and the less damage will be done Thanks Louise we are believe it or not just approaching the final few minutes of our webinar tonight and so I'm going to ask each of our panelists to give us a final message Chris I'm going to invite you first and I just wanted to comment I found that really valuable what you said for about actually helping people with their problems treating their mental illness and Louise's comments about you know helping them have the things that they need to have a meaningful life and to have well-being so I think that was that was really helpful about actually this isn't just about preventing suicide this is actually about assisting people with their problems and treating illness I just wondered whether there was a kind of final message that you wanted to add or to clarify or how you like what do you like to leave us with this evening Look I think I just really finished by saying with respect to suicide and with respect to the problems that lead to suicide the approach to that is the approach to good medicine so it's taking a good history being interested in the person it's finding out about them I realized by the way that GPs only have so much time I mean it's amazing what GPs do in the time they have available I'm a psychiatrist it takes me 15 minutes to say hello so I'm not being unrealistic about this but the more the more you can understand the patient where they're coming from what their resources are and how you can harness those resources to help them and how you can treat any identifiable psychiatric or other problems that they've got the more you'll be able to help that person like doctors do and it turns out you'll probably prevent some suicides as well that'll be great Thank you and I think you know it's very clear that far from saying look don't bother having the conversation at all because you can't predict anything it's actually the opposite it's really about it frees you up to have this meaningful conversation with a person and to really help get to the bottom of things and help you know engage their supports and do what you can so it's really the opposite almost it's actually a very real rich level of engagement with people Yeah, it's completely the opposite Yeah Rebecca what would you like to to leave us with tonight? Yeah, I mean I was going to say Mary what you actually just said which is that we all do the very best we can we use our skills and our training you know whether you want to use a risk assessment tool that's just one tool that you have then you've got your interview you want to use your observation you want to be talking to other people you want to get all the information you have and then make the best clinical judgment that you have and act on it and in the end that's what you've been able to do and that's that's you know what your hope will work for your client it doesn't always work but you're doing the best you can and if things don't turn out then you know you've got to be kind in yourself as well because you've done you're the best you can and that's really as a professional that's the obligation that you have the responsibility that you have to your client Thanks Rebecca and Louise just I'll give you a few seconds if there's something else that you would like to leave us with tonight Thanks Louise I just I just wanted to say thank goodness for multi-disciplinary teams we couldn't do this work without a group of us around the table in the hope that one of us will be in that moment and will catch someone like Aidan or Nathan or any of that family and the more that we're able to share the load with this sort of complexity the better off the community will be Thanks so much to all of you it's been really very engaging the time has just passed and we've still got 1600 people online thank you all so much for staying with us tonight and I hope that you got as much out of it as I did make sure you complete the feedback survey before you log out the tab is there at the top of your screen that will open you will be issued with a certificate of attendance within four weeks and you'll also be sent a link to the online resources don't forget that the webinars do go up on the MHPN webinar library if you want to refer colleagues or watch it again yourself if any content in tonight's webinar was distressing please sit care for yourself by calling Beyond Blue is one suggestion or your GP or local mental health service and of course you may have trusted colleagues who you feel that that you can make contact with and I really echo Louise's comment about the multidisciplinary team and this is work we all do together if you would like to join an MHPN network in your local area there's the link to find out about the local network so you can join one today and again the MHPN website has information about all of their activities and once again thanks to the GPMHSC for partnership in this webinar and inviting MHPN to work together in this way on this incredibly important topic and can I commend to you the resources from GPMHSC they're very comprehensive they're really practical they're really useful and they're available to everybody not just to GPs they're in the resources there so please take a look at those and once again thank you to everyone particularly our panelists tonight but also to all of our participants wherever you are including the person in Bulgaria and thanks for staying with us and for your contributions to the chat box and I hope that everyone has a great evening good night