 Good evening everybody and welcome to this Mental Health Professionals Network webinar. It's very exciting tonight to have a general practitioner audience. Currently we have 65 DPs online and we have over 160 registered. So hopefully some more will join us through the evening. So this is an interdisciplinary panel discussion about recognising and responding to complex trauma. Mental Health Professionals Network would like to acknowledge the support of the Adult Surviving Child Abuse ASCA organisation, which is really useful to know about as a GT. They have a great website and we'll be hearing some more about the work of ASCA throughout the evening, including their excellent principles in caring for people who have experienced complex trauma. Mental Health Professionals Network is funded by the Commonwealth Department of Social Services to deliver this professional development series of three webinars. So tonight's just the first and we'll be meeting Tanya tonight, our patients, and we'll follow through managing her care in the subsequent two webinars, which will be open to other disciplines who work under Medicare. So this is for practitioners who support individuals and communities affected by or engaging in the Royal Commission into institutional responses to child sexual abuse. So that's a very current issue in Australia and some funding was granted to help raise awareness for practitioners who will and already do see people affected by these issues. So I'd like to...my name's Mary Amalaes. I'm a GT in Cairns in Far North Queensland. I work at a headspace site and I worked previously at a headspace in Townsville. Many of the young people that I see have experienced complex trauma. So this is a particular interest of mine and I'm also pleased to have been involved with the MHPN, including the national webinars for a couple of years. I'd like to welcome our panelists tonight. There was information provided about their backgrounds as part of the materials for tonight's webinar. So Kathy Kesselman is a GT and tonight she's here representing ASCA and also as our consumer advocate. Kathy, welcome and I wonder where you are and if you'd like to comment on anything about where you are tonight. I'm in Sydney in my study, thank you Mary. Thanks Kathy. Now David, you're in a genuine Royal practice in Long Creek in Western Queensland. How are things in Long Creek this evening? They're very good, thank you Mary. It's very warm but a very nice night and I'm in at the practice so it's nice and quiet. My two-year-old wasn't partied to the webinar tonight so I had to come in here. So there are things that may be more attractive about being online in front of 100 people? Yeah, he would have enjoyed being online as well, that's the problem. Now Iggy, Iggy is a mental health nurse with a lot of experience in this field and I understand Iggy that you just recently moved to Tasmania. How's that been for you? It's been great. Notating that it's beautiful down here. A little bit on the chilly side today but lovely. Great mountain views. Welcome Iggy and Professor Louise Newman is the psychiatrist on our panel tonight and Louise will may be well known to many of you for a lot of the things that she gets asked to comment on in the media. I wondered Louise if you wanted to just say a little bit about where you are this evening and about your interest in complex trauma. Sure, look I've worked in this sort of area for most of my career. I'm mainly with the children. I was very interested in seeing actually sorts of traumas on child development. Most of my research in my family is looking at the developmental implications of child abuse and maltreatment and there are currently better ways of looking at interventions for this group. So I'm very much interested in trauma including not only child abuse and maltreatment but trauma that at the moment is very topical and that's trauma to refugees particularly asylum seeking children. Thank you Louise and welcome to the panel. Most many of the participants tonight might not be used to the format here so just a few ground rules just to make sure that everyone is aware. You do have a chat box underneath the window where the slides and the pictures are. There's an orange box that will be the slushing that says general chat. Now you can chat to each other in that box, participants and the panellists can also see that and may join in the conversation. Please feel free to support each other as you already have been. Just be respectful of each other and remember that everybody can read what you write in the chat box. The other thing is it's really important is your feedback and Mental Health Professionals Network have tailored the webinar program often according to the feedback and requests from participants. So please stay online when we finish and help by completing a short exit survey and in a couple of weeks we will receive an attendance certificate if you need that for any purpose. Now the learning objectives for tonight have also come out to you beforehand and this is a really important and practical topic and I can speak for myself in that having an understanding of trauma has actually transformed my experience of general practice. So our learning objectives tonight are to understand the prevalence, epidemiology, characteristics and impact of complex trauma to be better equipped to recognise the physical, mental and psychosocial presentations which might indicate unresolved trauma and to acquire tips and strategies for interdisciplinary collaboration to support people who've been exposed to or experience complex trauma. Before I dip onto that slide, I would just... So what will happen this evening is that each of the panellists will give a response to Tanya if they were to meet her, how they would respond from their perspective. We've asked people to be as honest as possible and also to give us their expertise and I think you'll learn a lot from those brief presentations and then we'll come back to Kathy who's going to give us an overview of the principles of the ASCA Trauma-Informed Care Guidelines which is really useful for us and then we will proceed to a discussion between the panellists about what comes out of a response to Tanya. Now thank you for everyone who submitted questions before the webinar. I will do my best to try and ensure that we cover as much of those topics as we can and the other thing to keep in mind is that we are not trying to resolve everything in Tanya's care in an hour discussion and just as we would most likely be following her for years as CPs most likely how you'll feel at the end of this evening's presentation is that you'll have learnt a lot and there'll still be for Tanya a lot of unanswered questions so please don't feel too frustrated if things that you consider obvious are not yet being addressed and please come back for the subsequent two webinars. So I would like to first of all hand over to Kathy who's representing Tanya I guess so you've probably all read the case study beforehand. Brief summary, Tanya is 36, she's presented at the GP with some signs and symptoms that might be perhaps challenging in a general practice setting and they might indicate that she has experienced or been exposed to complex trauma. So Kathy welcome and thanks for letting us know how you would respond to Tanya's situation and think about trauma. Thanks so much Mary, really I'm going to be putting hopefully complex trauma in a bit of context and I suppose I'll just start by having been a GP I know the challenges of general practice and the GP's often need to identify, acknowledge and hold the pain of people's life histories but what I didn't know when I was in general practice was the number of people who've experienced complex trauma and we know by conservative estimates that's 5 million Australian adults. That means that every day GP's will see a number of people who are experiencing the impact of complex trauma and these patients have diverse presentations, often multiple comorbidities and additional challenges such as unspecified pain or medically unexplained symptoms and Tanya is definitely one such patient. So applying a trauma-informed lens helps GP's to recognize trauma underlying such presentations and to respond appropriately and move away from discrete diagnoses based on presenting symptoms to look at the context of people's lives. So just very briefly, what are we talking about when we talk about trauma? Well trauma is part of the human condition. I mean it's impossible to go through life without experiencing trauma. It's a real perceived threat to life for themselves, threatens to overwhelm the way we cope. We can talk about classified trauma according to single incident or complex single incident for example a sexual physical assault in adulthood, a natural disaster and obviously they have profound impacts. But complex trauma, when trauma is experienced as a child, it's often repeated, it's often prolonged, it's often extreme and it occurs during those crucial developmental periods and it's often perpetrated by the very person in charge for the child's care. So obviously that's going to have profound impacts and has profound impacts potentially on the developing brain and potentially every aspect of a person's functioning as they go through life. So we know that two-thirds of people presenting to public and private mental health services have experienced the trauma of child sexual assault and child physical assault. And this slide here looks at 10 categories of adverse childhood experiences and it's taken from a very profound study in the States that's been going on for 17 years now called the ACE study and it shows sadly that the number of ways in which child can experience trauma and what we know about complex trauma is it comes cumulative over time and the impacts become compounded. And when we look at Tonya's history and I'm sure if we drill down further we'd find a number of these different traumatic stresses. Thank you. Thanks very much Poppy and we'll be coming back to you later on to talk a little bit more about the ASCA Principles. Now I'm in Fun North Queensland and the internet seems to be several seconds slower. So I have advanced my slide and I'm just waiting. Now David you're going to respond to us next and I like your first slide. It feels like how I feel right now. Thanks David. Thank you very much Mary. Everything's slower in Queensland. I really when I read Tonya's case in preparation for this this is really the first thing that came to my mind and I guess in some ways to me it reflects what I think is going on at both the practical level in the GP surgery itself but also really in Tonya's life. By the time you get to see Tonya everyone's going to be just a little bit touchy. You would have already had a call from the reception staff. They're going to be upset. Tonya importantly is going to be upset. Even other patients may be upset and the place is going to be fairly chaotic by the time you actually reach the waiting room. And so it got me thinking about how I approach the practical aspects of this in my own practice and you know it would be really interesting later in the webinar to hear from some of you as to how you in your own practice to do this because some of the questions I had for you were what procedures does your practice have in place for this kind of presentation but also really any kind of emergency presentation. How equipped are your staff for dealing with the agitated or the aggressive patient and what have you got in place for your own safety and for safety of your other staff and also the other patients. So with respect to Tonya I guess I'm pretty lucky in my practice. I have a work amongst the medium sized practice which is purpose built. We've got quite a lot of consoling rooms. And so usually there'd be one free. The other thing that I'm very lucky to have is I have a practice nurse with the mental health experience. And so usually if the girls rang me and told me that someone like Tonya had presented you know as always it's almost always when you're fully booked you'll be running 20 minutes late and what I would normally do is get my practice nurse to grab Tonya out of the waiting room take her into somewhere quiet and just give her a chance to talk and just to get some stuff off her chest. To actually kind of get some of the issues out and to take a lot of kind of the heat out of the situation if at all possible. I'd normally duck back in and see a couple more patients and then I'd pop back after I finished and try and have a kind of a focused consultation with her. And to be honest I'm normally I am honest with them I normally explain the kind of logistical problem fact that I am late and the fact that they don't have a formal appointment but really try to explain that I just want to listen and I want to work out what we can do now and then as soon as possible schedule kind of a more appropriate appointment. So you've seen a couple more patients and your nurse calls you back in and at that point I guess you need to play it a bit by ear. Tonya still might be very upset, she still might be very hostile she still might not be in the mood to talk to you at all. It sounds from the vignette like I've known her in the past and so I might kind of use some of that past history to kind of get her leg in and ask how she's going but of course it could also go the other way you know perhaps we separated on acrimonious kind of circumstances in the past. So I kind of play it by ear but really the goal of that appointment for me is to find out what she really, what's really worrying her now and is it something really simple that you could sort out with a medical certificate or a letter of support something that might help her with regards to paying the rent or to get the bank offer back. The other issue is her risk. You know we hear this ad nauseam, it's drummed into us but it is important you know I think really we have to assess is she at risk to herself? Is there others at risk? Are there risks that we haven't thought of? Is there a risk that she might be homeless tonight? Is there a risk that she might go and reuse drugs or take up some other kind of detrimental activity? So really I think considering all of those things and then come up with a plan for what we might do now. So in my mind if I thought she was safe I'd be working out when I could get her back. I'd be working out, you know is it worthwhile giving her small supplies to medications? You know the use of benzodiazepines is controversial and I know that you know you talk to different GPs and everyone will have their own opinion on how they should be used and everyone's opinions are valid to be honest but in my practice you know I certainly don't shy away from giving people two or four or six days of PAM. We have you know I'm going to limit their supply and I'm going to see them soon. Especially if I know them and I'm aware of their past history and I'm aware of their social history. The other advantage I've got here is that it's a small town. You know we all share the on-call. We all know... And so it's pretty easy to keep track of who's doing what. It raises the question of when can you get back? I mean every practice again is different as to how they schedule this. But in my practice here we schedule emergency spots that don't open up until 8.30 on the day. They're quite handy. In this situation I might be able to feel one of tomorrow's emergency spots. I've been here long enough to the girls will let me do that now. But really every practice is different but you've got to have some kind of way that you can get time your back in at least half an hour time. You know 15 minutes is really tricky and I know some of you must be groaning in horror even thinking you're giving up half an hour of your schedule but she really needs some time. The thing I would also be thinking about but not necessarily engaging yet is what are the kind of external supports that we're going to need in her? Of course the kind of contrary to that is if you don't think she's safe what do you need to do right now to make her safe? Who are you going to get on side to help you? Certainly we have a community mental health team here in town which would be able to help me but I also have the ability to be able to meet people for short days if I thought that was going to help and I've done that in the past. That might not be a good option for Tanya she's going to have two kids at home we need to kind of work out the practicalities of her being able to come in but sometimes it gives people a chance to actually come in and just take the heat off and diffuse. She comes back the next day and for me again as I said you've really got to give her enough time. The idea here is that you're wanting to try to just start that therapeutic relationship. It's not going to be built in just one day. You really get to start getting her trust and getting a rapport and aiming to provide to someone safe that she can just start to unload some of the things that are troubling her. I don't have to teach you to suck eggs we're all GPs and we do this stuff day to day but the full medical history is important. Every medical health patient has medical comorbidities that we need not ignore. We know that she's overweight we know that she's hypertensive we can't ignore all the background stuff we're there to look after them in a whole. Try to get a full psych history that's always a challenge but certainly it's something I enjoy chipping away and working out but remember also you don't have to get all of this now I mean you've got time up your sleeve sometimes digging too deep and things is actually detrimental to your cause. I do think it's important to know about her medications again I think finding out what she's on now and if she's taking them what she's been on in the past and how they went and why they were stopped and also her alcohol and other drugs history you know how much is she drinking you've got this kind of wishy-washy collateral from one of your staff members but really what is she taking in her social time? Get an accurate idea of her current social circumstances as I kind of touched on before you don't want to find out suddenly that she'll be homeless the minute she walks out of your door do you need social work help is there other things you can do for her? Family history and background you'll see there that I've said to do this cautiously it's not the time and place to suddenly dig up her past traumatic history I think you really need to have the grounding and the trust before you go delving too deep into that kind of stuff sometimes it comes out and it just happens that way but certainly I wouldn't go digging too far I've put set some rules and I guess it ties in a little bit with the benzodiazepines and we see that she's had energy prescriptions and stuff in the past before and I certainly as a general rule kind of get a I hate the word contract but have a kind of a deal with the patient that look I've got to make the effort to see you and I'm going to see you as regularly as you need to be seen but you come and see me you know your scripts from me you see me for the time being it gets too confusing seeing other people and I find most people don't really mind that I do think it's worthwhile exploring some of the reasons why she might not be able to see you or why she might be finding it hard to see a GP does she have a car for example you know her finances completely troubling her you know we have a private billing practice here but we make arrangements if people really can't afford to pay then we make arrangements to try to use item numbers and use care plans and what not as I'm sure you all do to allow us to see Tanya without it costing her too much and then from there I also arranged my next appointment she has that appointment in her hand before she goes and depending on the situation that might be in two days time it might be in a week it might be two weeks again it's one of those things that's a bit rubbery depending on the person but really for me I think that it's all about the logistics of that initial consult I find it so challenging and as again as I'm sure you all do but I think time if I had to really summarise that time would be the one thing that we need to try to find as best we can and I believe it there Thanks very much David now I'd like to welcome Iggy who's the mental health nurse on our panel tonight and once again Iggy's got a really interesting first slide so Iggy thank you very much Thanks Mary I think what David has outlined are some very lots of innovative angles of approach on what is going to be truly a challenging situation and with a caveat in mind that the folks tonight are going to be working in a very busy primary care setting what I wanted to do was focus on just some I guess more principles of approach and understanding of the situation rather than I guess certain sort of set things that one might do because I think the important thing is that we shy away from a very task-focused approach and right from the get go understand that someone like Tanya is going to experience things like institutions agencies, healthcare settings in a rather sort of threatened way trauma background means that whole experience of the world is one that's quite dangerous and threatening so with that in mind I guess the way I would sum it up is that right from the beginning of any interaction that healthcare workers would have with someone like Tanya it's a very mind that the relationship, the interaction is the actual treatment how we approach and engage and interact with someone like Tanya is actually part of the clinical care treatment from the front desk right through to the consulting room and so I guess a way to approach that might be to just continue to ask oneself internally how to minimize harm you know I'm saying that I'm not suggesting in any way that anyone throughout to deliberately sort of provoke or harm a person such as Tanya but I think bearing in mind her sense of place in the world there are lots of potential for inadvertent harm that we need to be mindful of especially as David mentioned when a person brings in a baggage of a whole range of prior international histories and use of services that may not have gone the best that may have caused you know tensions in that relationship that really is part of the the whole treatment so I think important to bear in mind that it's part you know bearing mind that the relationship is the treatment you know our contribution as healthcare professionals to that relationship from the very beginning and all of the staff that are part of our services you know are exerting an impact right from the beginning and that's why I think it's particularly important to reevaluate and really reframe how we might understand what are very difficult and challenging behaviours and move away from I guess making clinical assessments or judgments on the basis of outward behaviours alone because once we start doing that I think sort of pejorative understanding can come into play and we can lock into a situation that could quite easily polarise I mean I'm just looking at the case study where the sort of front desk staff are sort of talking about this patient and being a small community I mean the sort of things that get known about particular people and how that might influence and that whole interaction that relationship from the front desk onwards is important to bear in mind so reevaluating for instance common things that are said about people like Tanya that their attention seeking their constant use of service is something that's about seeking attention I think it's important to understand that with the complex trauma history and going back into childhood we're essentially looking at somebody who's never been able to healthfully and safely attach and that's what that's what she continues to do in our life and some of the history of unsafe attachments where these things are often escalated and can cause a relationship breakdown so you know Tanya somebody who is likely to push and pull in relationships her sense of boundaries are going to be damaged from that trauma history and how much we push and pull in return will matter and I think we can at times mirror Tanya's sort of sharp lurches between feeling victimized and being a victimizer herself so again just to reiterate the care that we need to take in using things like limit setting and boundaries and that they're not done in a way that puts the car before the horse because in my mind the whole issue of boundaries only makes sense for someone like Tanya in a safe enough good enough relationship and that's not to say of course that we somehow approach every situation like this as if we're walking on eggshells and become sort of overthinking about how we might approach these relationships I think it's more about maintaining a genuine interested engagement to help that sort of therapeutic relationship along and if falling out happens if relationships do get disrupted or broken down what's more important is that follow through commitment trying to pick up pieces and repair that relationship rather than trying to avoid any problems altogether because inadvertently I think inevitably we're going to encounter rocks and bumps along the way in a treatment relationship like this and bearing that in mind again on the basis of the previous two slides I think it's important to recognize that all staff in an agency a service from non-clinical to clinical staff are actually also part of the treatment relationship again it's about safety from the front desk right through to the consulting room how do we actually support and bring together all staff so that we're in communication with each other we're all on the same page as much as possible and we're all conservatively trying to bring about a situation of providing us with safety and the interaction in the relationship as possible with someone like Tanya so that also means providing enough support for non-clinical staff to be able to debrief and talk out some of the difficulties they might have at the front line of contact with Tanya and accounting for the possibility that we may be working with staff with their own trauma history there really is no species barrier between consumers and staff when it comes to trauma as Kathy said it's prevalent it's a social problem above all and that needs to be borne in mind so adequate education debriefing clinical supervision of all staff I think including non-clinical staff may not be such a bad thing to try and co-hear that sort of shared approach of one that emphasises safety of the interaction of the relationship for all types of concerns for me it's really about how one is it's a way of being when it comes to working with complex trauma rather than technical interventions or technical tools about doing X or Y or trying X or Y and saying to the patient to try X or Y I think for me any of those technical interventions technical tools psychological tools and interventions are only good as the quality of the relatedness of the relationship that does take time to develop and I understand that that would be a very tricky thing in a busy primary care setting but perhaps over time not feeling like we need to do it in one go but over time to work towards the safety of that relationship that allows those sorts of strategies and tools that we use safely with someone like Tanya and to be grounded and guided as much by sort of adequate clinical understandings and a framework that can help make sense of building that relationship and that can guide the relationship and safely couch interventions like for instance CDT and here I'd have to say that ASCAP provides excellent training for all clinicians and ranges of health professionals on complex trauma and be very useful for people whether they work in mental health or not primary care or other settings to get the benefits of that sort of training to gain that sort of critical grounding and framework and theory that will guide how to conduct those relationships safely I'll leave it there Thanks very much Iggy Now Louise I've very much welcome your response to this as a psychiatrist and there's some particular questions around diagnosis and things which we might come up to in the panel discussion Thank you very much for presenting your response to Tanya Thanks Thank you, I think a lot of very good points have already been made and obviously one of the difficulties in Tanya is that people who might be having trauma and primary care feelings is that you've often got crisis-driven presentations whether the crisis in our minds is a small issue or a life issue for the person coming along and health-seeking it symbolises a very big issue which is one of the difficulties in feeling safe in relationships having difficulties in health-seeking on the one hand speaking a lot of health but then sometimes from our perspective in following advice so that immediately sets up these complex relationships that we can have with individuals who are highly traumatised we feel ourselves disempowered or we're trying to establish workable relationships and seemingly nothing we do can help that person be more contained and that's one of the major challenges how do we set up a relationship where there are feelings of safety over the time a person can be helped to deal with some of the ways in which trauma has affected their emotional states their behaviour and importantly their self-regulation so these are people who often go between extremes of presentation and find life very challenging so those are our problems as clinicians in many ways but we do have to manage that kind of interaction to get called in if there are issues and they're available but if there are questions about risk particularly if someone's repeatedly presenting self-harming behaviours or suicidal ideation or if some people are worried that someone's actually developed severe clinical depression along with daily life stress and crisis or which occasionally of course can be an issue where someone becomes extremely distressed in a post-traumatic way meaning that they're having experiences of remembering or going back to events which have been very damaging and very traumatising so a more picturesque experience so sometimes there are those sorts of questions to be worked out over time and I'm not saying it can be done immediately and it might be only possible over a longer period of time but it's important if we can to try and find out about someone's background usually when people present with these very complex pictures of trauma related symptoms and difficulties they have experienced significant early maltreatment so during critical developmental periods particularly those periods of rapid neurodevelopment so brain growth and organisation that's going to be very significant in terms of our understanding of someone's core disabilities they might then have those core disabilities related to emotional control their disabilities in mood regulation and ongoing trauma related symptoms as well as those most important disabilities in dealing with other attachment relationships so we frequently see people who've experienced early attachment trauma really working very hard to try and establish those relationships but sometimes failing that having poor choices in relationships being unable to judge relationships so we see patterns of relational disturbance but very painful experiences for people who like anyone else are trying to establish a sense of safety and security with others these also people who might have had terrible experiences of making disclosures of abuse or maltreatment and not being believed or validated in terms of those experiences that might make it again even harder for them to seek help or to form trusting relationships with clinicians or people who might actually be helpful because they're never sure that that relationship is going to be sustained or won't be portrayed in some way so that is a very powerful dynamic so early trauma itself can influence development in a broader sense so we're talking about not just people in terms of relationships but also how they experience themselves how they can or can't use other relationships and these are people who are much more likely at this case to have problems with trying to self-regulate through inappropriate use of drugs or alcohol having a whole range of bodily experiences which we can think about is related to early trauma pain of unknown origin multiple traumatic experiences which can be very disturbing and a whole range of anxiety related presentations as well so certainly there's no one single way in which someone like this might present no one single clinical picture and the challenge for us as clinicians I think is to have that trauma aware open state of mind when complex people present to us and to have a very high index of suspicion that that person may have had a whole range of traumatic experiences the most significant of course being trauma in the early years trauma as a hand of attachment figures so the people who were meant to be protective have actually betrayed that relationship and abused that child so again it's not the event is not particularly helpful it's not helpful in many ways but it's not helpful as regards trauma or the developmental impact of trauma because virtually the whole range of symptoms that the DSM describes can appear in people who've experienced early trauma so a way of summarizing that is to think about how can we better understand and talk to someone in a way that helps us get a handle on how they experience themselves so that we can then use that to guide how we structure a relationship with them but particularly to understand what things might trigger very severe or anxiety or dates or angry outbursts or whatever the issues are and there are usually triggers for these interpersonal triggers or feelings that are recalling past negative events and we see people in desperate ways trying to make themselves feel regrouped and more stable the DSM might call some of those symptoms of particular disturbances but in a functional way these are ways that can often be attempting to self-regulate. Sometimes we will see very complex responses to stress so people who might become very dysregulated so extremely angry repetitive self-harm ongoing risk of suicidal behaviour and sadly some places suicidal is not uncommon in this group of course but people who might very easily get themselves into situations where they're re-formatised so re-victimised and that's a very distressing phenomenon. The other thing, a point I've made about Tanya and many people in this situation is that they're actually parents and trying as best they can to parents in a safe way, their own children but of course there are issues brought up in the relationships with their children and they can actually remind the person of the issues that they've had the abuse they've suffered in the past so parenting can become a very challenging experience hard relationships for people with complex trauma histories some are very anxious about repeating negative interactions with their own children and things that they've experienced some will actually some people will present wanting to talk about being a parent with trauma and abuse and the impact that might have on their own capacity to protect these parents so these are very complex relationships so we need to think in terms of our clinical response as other speakers have stressed this issue of how we better engage with people how can we set up safe relationships where there are clear boundaries and a shared understanding of the focus of clinical work that we might do everyone has stressed the need for someone like this and it's absolutely essential actually having a proactive approach of booking appointments whether they might be necessary or not is that possible so the person has a sense of ongoing connection and support whether that's with the GP or other people in the practice or if you have access to psychology to be able to have that sort of backup as a way of helping contain someone's understandable anxiety I would avoid what I call making premature diagnosis and we'll be coming to reliance on the DSM I think the DSM has limited utility sometimes it's helpful but in trauma related frameworks not particularly so maintaining our capacity to think about trauma and how it has affected people and how many of the symptoms so-called that we see are actually ways that someone has tried to survive in a dangerous environment children who are abused live in states of fear and live in dangerous environments and what they do in that situation as best they can are used whatever mechanisms they have for self-protection that's an adaptive response in a very dangerous environment we do need these to be able to obviously use our skills about listening and containing someone but essentially to validate their lived experience and their attempt to put their own story together we need to be guided by people who come to see us about the pace at which we do that and those are hard decisions sometimes but essentially people will give us a lot of signals about what they can tolerate and when they're guided by that and the last point I'd make is to think about self-care if you're in the position of working a lot with highly traumatised people with very disturbing stories sometimes that we might get to hear about over a period of time that of course can have effects on all of us and we do need to be aware of any more complex reaction that we have so whilst we're trained in terms of basic clinicians' approaches to try and deal with someone's anxieties and help people deal with their own emotional states which is what we mean by containment so acting as someone who can help be a support for persons a person experiencing strong and just regulating emotions we need to be aware that that can have into us Thanks very much Louise I'm just observing the comments from the participants and there's lots of really good nuts and bolts discussions about how we make these quite complex treatment arrangements under Medicare which is not very nuanced and I also I'm going to allow I'm happy to talk about the ASCA principles of trauma-informed practice but I'm just observing at this stage that we've talked about Tanya for over half an hour and no one has mentioned the words or line personality disorder yet so I promise you we're going to revisit that and there's also a very interesting question about she has a request that we write a letter or phone her boss today so I'm going to come back to that as well David I might put you on notice to that one Kathy if I can just invite you to talk about how we can look after people like Tanya in a trauma-informed way look I think obviously the other panellists have covered this very well and I think the principle here is firstly to have trauma on the radar as Louie said and to remember the impacts of trauma, understand trauma dynamics and these core principles really reflect what people have said already principles of safety, some people have experienced complex trauma have never felt safe that's an absolutely foreign concept and it can take a long time for people to feel physically and emotionally safe to learn to trust when people have been betrayed by their primary caregiver it can take a long long time to trust as Louie said one needs to work at the pace that the person brings to you but to push them forward where they don't want to go to be able to make choices some people have experienced some survivors who don't even know that they can make a choice they wouldn't know what that means what they want, what they wish what their desires are they've never asked themselves that to collaborate when people have been abused in the imbalance of power and certainly when one comes to see the doctor that's an authority figure so it can feel hierarchical and it can replicate what's happened in prior abuse quite inadvertently not implying any ill intentions here so remembering that remembering how someone can present and how someone can feel and of course empowering people acknowledging that to have survived in whatever way people cope is a strength and to help people acknowledge those strengths and build on them and of course absolutely core what happened to the person thinking about the person in the context of their life because when we think about people in the context of their trauma then the way they've coped the way they're presenting their challenges make very good sense we need to remember that there is hope there is optimism research and there's a lot of research out there you know ASCII's guideline has put together 20 years of research around complex trauma we know that even early trauma can be resolved and then when parents have dealt with their trauma they obviously do a lot better and we shouldn't underestimate that every interaction as Iggy said is absolutely critical from the person at the front desk to we've done training for cleaners in hospital situations because they have a lot of patient interaction with social beings the brain is plastic so those interactions and the power of positive interactions to repair the damage for ruptures to repair for those new brain pathways to be laid down absolutely critical and I think it's been so well covered I think back to you Mary there's a discussion Thanks Kathy the burning question that keeps popping up is are we going to ring Tanya's boss and I don't expect you to know a perfect day today but you might start the discussion Thank you actually I thought maybe in case people don't have the case study I might just quickly read out what the question is so you asked Jane to help her today she tells you that her boss has just told her that she's used all of her sick leave and in future any time off will be unpaid she accuses her boss of not understanding and explains that without an income she will struggle to pay the rent this is what she says I do my best with my kids I've worked at that shop on and off for 15 years and this is the thanks I get it's not my fault I got chronic fatigue and you guys haven't been able to help me so I figured you're going to have to help me now I need you to call my boss and explain David now I can't hear David David I think you might have your phone on mute I can see you talking Ah right sorry I'll fix that Mary sorry pardon me in the time I've been practicing I haven't called anyone's boss yet so I suspect in that time I have learned ways of getting around it I usually kind of explain what that means to them me getting involved in that kind of thing and explain that it's not really I've kind of explained what I can do and what I can't do and I don't think that going outside the therapeutic relationship especially early on talking to a boss is necessarily helpful and when I explain that to patients they often actually say well yeah you know what I actually don't really think you should talk to my boss about this stuff so I know that's a kind of a wishy-washy answer but once I actually sit down and talk to people normally and I explain the kind of what their rights are as an employee and about all that kind of stuff usually people don't push the issue that makes sense Kathy if you were Tanya how would you feel if the doctor that you just come to see today wouldn't do that for you or how might you respond? Look I mean I'm angry with the world anyway so you know I really feel out of control you know I'd probably feel betrayed I wouldn't understand it I mean it would depend on my pre-existing relationship I would think with the doctor whether there was a degree of trust whether there had been prior positive interactions that I'd perceived as positive but you know I'm desperate I don't really know I think I know what I want but I'm very confused and I'm bouncing all over the place so I may find that very difficult hmm I should say I should say I haven't called anyone and I kind of said this in my little tiny presentation that I have written letters for people before if they want to and the reason why I've done letters instead of calling people is because I allow them to read what I'm going to say beforehand and try to see if they're happy with the wording and to make sure that it's going to have something that's going to just blow up on me down the track but I really do explain a lot of those implications to people because I think a lot of people don't realize their rights and but I do appreciate what Kathy just said that going in the wrong way you could really come back as yet another person kicking them in the gut look you know I didn't say this was easy David I was on your side of the desk as well it's very challenging now I would like to come back I think I well Iggy you asked a really interesting question which I think relates a bit to I mean Tanya probably fits the diagnostic criteria for borderline personality disorder we've talked a lot about how we might respond to her without mentioning that at all and you asked a question that in complex trauma what you see is not always what you get so should we throw out the DSM and I noticed Louise saying that it wasn't always terribly valid but sometimes it was useful and I just I just wondered if you could comment on the whole idea of borderline and this kind of presentation look I just from speaking from my own experiences it's a bit of an issue for me how healthcare systems and mental health services have become so drummed into responding to complex trauma and the distresses and all the other sort of complex sequelae that come out of complex trauma in very behavioral fashion or bio-behavioral really where you know clients, consumers are responded to on the basis of outward behavior and if that outward behavior is aggression is seem to be challenging and difficult then it's a sort of a like for like fire with fire approach sometimes and that's where it gets into this whole discussion about risk and how we deal with risk. My concern is that sometimes outward behavior can actually be very different to what that outward behavior is often defending again for somebody with complex trauma. I mean often a deep sense of shame about oneself can be manifest in aggressive presentations and if it's met with simply on the basis of aggression alone it can actually fuel and escalate the whole problem. So that I guess that's what I'm getting at is that when it comes to complex trauma it's really important to shy away from surface judgment on the basis of what you're seeing and just see a little bit more trying to sense into something a bit more that's going on for that person and acknowledging for someone like Tanya the fact that despite all her ups and downs she's been able to sustain some level of employment all this time and validating and acknowledging that might actually be a way into getting behind that aggressive outward. It's purely superficial but that aggressive manifestation of all of those relational turbulence that are going on underneath and that's why I don't think the DSM really helps to guide our responses at this point. So really it's coming back to what you said about the relationship being the place in which the work is done rather than a diagnostic framework. Louise I'd be really interested in what you think about the actual table or diagnosis of borderline personality disorder which does get made and has some use sometimes but obviously as a psychiatrist you're probably expected to make diagnoses more often than we are. How do you weigh up these different kind of ways of thinking about somebody like Tanya? I think there are two separate issues. There's one of whether we have to for reasons of documentation or hospital systems, mental health systems used for DSM diagnoses which in many ways we do and stats may be reasonable if they're understood as pretty shorthand limited ways of describing the way people might present. However, the DSM system is not explanatory and prides itself actually. I'm not telling us about causal factors already going into that and our job as clinicians and as people who are understanding things in a psychological trauma-informed framework is as he said to try and understand the meaning behind behaviour and when that doesn't happen it's exactly when we see problems of people using diagnostic labels as if they explain everything in a premature way and sadly in a very pejorative way and on the borderline term has become absolutely laden with pejorative meaning. So we assume that those people who attract that label are going to be difficult individuals who are going to try and get things from us and be manipulative and this sort of language is used quite often about people and what that does it stops people thinking about the why question. What has happened to this person? Why has been to personal functioning so difficult for them? What trauma related symptoms are they and how can one best work with them and usually getting a label doesn't guide us in that way. I should say however there are some individuals who come to treatment who themselves have looked at the DSN system, have gone through the diagnostic criteria and might be interested in which apply to them which things actually do seem to explain some of their self experience in which case we do need to talk with people about that. There is a lot of argument about whether we should actually get rid of the whole borderline diagnostic category and talk much more about trauma responses which I think is probably much more useful. Sadly in DSN 5 there was a proposal that was being discussed for a condition that was a condition about developmental trauma that explained a lot of the features that we're discussing but that didn't get into the DSN or the new DSN which is unfortunate. The DSN is a pretty rough and ready guide to many issues and I think we should not use it in a way and pretend that it explains everything. Thanks very much Leigh and I guess my understanding is that the term borderline actually came out of psychoanalytic thinking that there was people who had neurosis and people who had psychosis and borderline presentations were people who sometimes presented as neurotic features and sometimes as psychotic features. It's actually quite a... The late 1930s where there was a discussion about where these people would fit within an existing system and essentially didn't fit so they were somewhere on the border of neurosis and psychosis and it's a lot to them. And I think for me the fact that their symptoms can be so severe actually indicates the level of their distress and often the level of damage that they've experienced in their lives. Now I would like to invite Iggy back in. Iggy, how would we know if we are GP's trying to refer someone for additional support because we've recognised that this is going to take more than the GP and it's going to take a team approach and some really good counselling. How would a GP know what kind of clinician to refer to, particularly if we're not going to go down diagnostic paths? How do we know what treatments are going to be effective? How do we know that an allied health professional has got the skills and experience to deal with this kind of complexity? The first thing that comes to mind is the database of clinicians who work with complex trauma that ASCA has collated. So this might be a question just a certain for Cappy. There are also I suppose psychotherapy associations. I'm a member of one myself that this specialised in treatment modalities of this variety that encompass a whole variety of mental health clinicians, psychiatrists, psychologists, nurses, social workers and others who are trained in particular modalities, like the conversational model for instance, and that's the database of the surgeon. Yeah, look you know, having said that though, it's not always straightforward making a referral, especially if they can't afford private therapies and long-term private therapies. Yeah, look I guess yeah, that's the way it's a tough tricky one that we come up against since I was talking to a colleague today and you know, often folks like Tanya get bounced around from services to services and everyone seems to put people like that in a too hard basket and we don't have specialised complex therapy services unfortunately that are publicly funded. I know there are a couple of good outpatient therapy services here and there, Sydney and New South Wales, but I suppose many of us have got, what we've got access to is allied health professionals and patients like this often can't afford long-term private therapy so they can get 10 sessions per year under Medicare and I don't have to cook and even answer it now whether sometimes engaging for 10 sessions and having to disengage sometimes might be more harm than good. But anyway, David, I particularly want to ask you about this because you're working in Longwich so I don't imagine that you have a selection of trauma-informed local therapists to choose from that Boltville and that Tanya is prepared to see and doesn't know from primary school or the supermarket. So what do you do in a rural area? Oh look, I knew this question was coming. It's very hard basically. On the plus side we actually do have quite a few clinicians in town who do mental health. There are some issues on the very plus side they're all free. So that's a big bonus in the sense that people can often engage for a long period of time. But the reason why they're free is because their funding comes from lots of different places. The rural flying doctors, some people might not know but in Longwich they have a non-clinical base, a non-retrieval base they have a purely mental health hub and so they have quite a strong mental health team in town here with a couple of mental health nurses, two or three psychologists and a social worker all in the one office. Plus there's community mental health which I mentioned and also a lot of periphery kind of non-government organisations. But at the end of the day the workforce throughout all those places is very transient. For example in the community mental health team I think that they're funded for about 11 positions but they've only got three or four filled departments and most people only stay for a short amount of time. And the skills people bring with them can be really varied. People, in the time I've been working here we've only had one clinician who's had a fair bit of experience in dealing with trauma and the problems actually occur unfortunately when she left town it actually kind of was difficult. She'd engage with quite a lot of people and then had to leave because of the social circumstances and that was traumatic in itself. But lately I have been experimenting with having patients fly down to see a psychiatrist for a couple of visits so they can get that kind of initial face to face in the room kind of experience. And then there's a couple of psychiatrists who are happy to see people over telehealth which has been interesting. I haven't done it with trauma. I've done it with other things like depression and anxiety and so I'm really not sure how it worked with complex trauma. But certainly and I'd love to hear Louise's opinion on that but it's an interesting option in this day and age. Thanks David and Kathy's just put up the link to, well Nicky put up the ASCA website and people can actually ring ASCA themselves as can practitioners for advice around these kind of questions. Louise I wonder, we're actually approaching the end of our time so I wonder if you could answer David's question about how you feel telepsychiatry might go with this kind of issue but also then have an opportunity to give us any final summing up points. I think telepsychiatry is sometimes a very usable option. It's not going to give the same I guess interpersonal connection in many ways but it can really be useful in getting another opinion on some of the questions that might come up. And giving the person a sense that the relationship and treatment that they're having is probably very useful for them. So I think that sort of way for these sorts of patients it can be yet another validated sort of experience. So it's all about how we use it. Well obviously you're not going to do long term therapy or intervention generally via teleconferencing but for clinicians on the ground it can also be a way of supporting them in what they're doing. I think for me just a couple of summary sentences after what we've been discussing it's been really I think important that everyone involved has stressed this issue about relationship and the importance of trying as best we can to understand someone's history and experience even if they can't tell us or maybe they don't want to tell us or disclose in a very fragmented way some of the details. We try and maintain that focus of having an open mind and being receptive and keeping us all in our work. We also all seem to stress the importance of trying to recreate a sense of safety putting some time into people planning ahead, building up structures around someone if you like that might help someone feel a bit more together in terms of their emotional experience. No one underestimates the difficulty of some of the clinical issues that come up with patients like this and of course tonight we haven't got into all these issues about different sorts of treatment modalities but I think important to stress that there are evidence based approaches. There's a lot of research have gone on into helping people with these sorts of states and conditions and the treatment outlook is much more positive now than it has been. Thanks very much Louie. Now Iggy this is maybe it's a loaded question and I'm asking you because you're not a GP my sense is that for example in David's town where people come and go the GP often seems to be a consistent personnel in the town and my observation is that I think just a consistent, reliable relationship with the GP over a long period of time can in itself be therapeutic and it can give someone an experience of that consistency and containment and the GP obviously needs to have supports around them to do that and to have a lot of clients like this. I just wondered what your observations and experience have been over time whether you've seen that actually sometimes enough. That's actually very true. I've had clients who have reported to me very good relationships with GP that provide that emotional holding environment that helps just attenuate the worst of their distresses and can help them through these sorts of difficulties and can avoid the sharp escalations and sharp falls that can ups and downs that can often happen in these sorts of relationships. Look I think there's no reason why primary care practitioners, GPs other healthcare professionals couldn't gain additional skills to work with complex trauma. Bearing in mind the importance of ways of managing these relationships. It really is all in the relationship management that is so crucial. It can be complicated but there's also a no-brainer side to it in some way, some genuine human concern with a clear sense of boundaries and the adequate support and supervision of that can be very helpful. I think in healthcare environments what we often call the trap-hold is we've got to be doing something to fill the space and the pressure of doing that can often exert with the surduances. Maintaining certain boundary, compassionate human responses and not feeling like we have to achieve everything in an all-or-nothing fashion can itself often be very helpful especially where there are limited resources available. Thanks very much for that, Iggy and I think that's been your key message all the way along that the relationship is the really important therapeutic thing. Now David, I just wondered if you had any couple of some final things that you wanted to say? Not really, Mary. I think what Iggy just said is exactly right and I think it's kind of mirrored a little bit in a few of the comments about just being human with people and just spending time and listening and stability. It certainly plays a big role in helping people along the line. You might feel completely out of your depth but you might not realise how much good you do. Thanks very much, David. And then Kathy, I'd like to bring you in just to finish up your points that you want us to make sure we remember. Well I think the role of the GP is so critical. The opportunity to engage with people on an ongoing basis and to build that relationship enables the possibility of a relationship of support and a relationship that maybe not therapeutic in the traditional sense but is therapeutic over time. So maintaining that trauma lens obviously absolutely critical and understanding people holistically as human beings treating people with human principles. It's really what trauma-informed principles are. Thank you very much. I'd just really like to thank the whole panel. I think it's been a really interesting discussion and once again there's just no way we can cover the enormity of someone like Tanya's even her initial presentation, let alone following her up over months and years. It's been great having all of your input and I would really encourage the participants to consider coming back for the second and third webinar. So the next one's on screening, assessing and recognising complex trauma and that's on Monday the 5th of May so that's actually moving on a little down the track of Tanya's story and then on that one she's referred to an allied health professional and then the third one on the 11th of June will be working therapeutically with complex trauma. So that will be a lot more about what kinds of treatment modalities have evidence around them and what kind of things work and I think the whole thing is going to be underpinned by the points that everybody is so beautifully illustrated today that the relationship itself I really liked what you said about there's no species separation between the staff and the patient we're actually all humans and sometimes we need to know how to look after ourselves and stay safe and within that we need to just allow ourselves to be human and I think this is very very powerful. I actually think there's also great symbolic power of the doctor which we can use strategically and can be really helpful and we don't often talk about that so perhaps we'll in future webinars. Can I encourage everybody to stay on and fill out the exit survey and to also just be aware that the mental health professional network runs a whole series of webinars there's a whole lot stored online on their website if you want to go and look at any of the historical ones and there are also often local networks in your area so if you're interested in meeting up with other clinicians who have an interest in mental health psychiatrists, other GPs I'd encourage you to participate in those. Thanks very much everyone for coming along tonight and if the panellists can just stay online briefly and good night and thank you very much to all the participants.