 I will try and talk a little bit today about complexity, the early goal that often occurs in a rehabilitation program for a patient to return to driving. It may be the first goal mentioned and sometimes one of the later ones or the last one to be addressed. The importance of team-based negotiation, single skills versus the dynamic activity of driving, the impact of age and developmental stages, the vulnerability of the patient and the therapist in the process, and the issues of seeking partnership and moving from an all or nothing position where I will drive all life loses its meaning and what we can do in the meantime. So just to quieten it down a little bit, I will focus only on 18 to 65 year olds who wish to return to driving, who are working with allied health staff and who have complex impairments following a quiet brain injury. Those complex co-morbidities often include mental health issues, substance use disorders and chronic pain. So just to remind us about the ABI area, there's a terrific study done at 2, 5, 10 and 20 years currently underway at the Epworth Hospital looking at the ongoing difficulties people experience after a severe acquired brain injury. These are self-reported difficulties, so very likely underestimated rather than overestimated. I'll just remind you that according to TAC data, 20% of fatalities in Victoria are related to fatigue and that's in the everyday population. So each of those areas, if we think back to what Simon said earlier about rally driving, they're all issues that are required to be pretty sharp for a person to drive safely. Further in that paper by Professor John Ulver and his colleagues, there was mention of the fact that driving is one of the everyday activities that does change between two and five years after injury, after an acquired brain injury. So those that didn't pass perhaps the OT driving assessment or didn't reach the medical standards at two years, some of those people had the chance to drive at five years. And that really underlines the need for driver assessment being available and for driving being revisited over time when a person has an injury. A knockback first time doesn't mean things aren't going to get better later, though it may. So we might travel the journey, but we may not get to where the person wants to go. Just to mention complexity, I will give you the data from the acquired brain injury service for those with severe or moderate brain injury who were referred in the last financial year. And I would like to just notice that only 31% of those patients had a brain injury by itself. Another 7% had brain injury plus substance use disorder. 29% brain injury plus a mental health problem diagnosed and treated. And 33% that group of most concerned who had both a severe brain injury, a mental health problem and substance use disorder. When we're talking complexity, that's the group I'm talking about today. Now, driving is usually, as we've heard this morning, an emotionally loaded goal. So people tend to say to us, when can I drive? Why not now? How are you going to stop me? You know, what's stopping me anyway? And I think we need to recognize, as we've heard this morning, that driving is an important aspect of everyday life for people. I'll just ask you to think for a moment, though, about what Paul Keating said. He said, when passion and reason vie for attention, the outcome is always deeper. And perhaps that very highly emotional goal can give us a creative space in which we can negotiate with our patients and allow for an ongoing relationship with a continued negotiation rather than a broken relationship. But it's not saying that's easy. So one of the things that may help us as clinicians is that when driving is raised, to reflect within the treating team about the return to driving. We know that it's the client choice, but does it reach those other criteria listed up there? Can we tick all or most of those boxes? And very often, if we talk together as a treating team, the information on those other aspects will come into the discussion and that will make it easier to form a cohesive and consistent plan. Also coming into that discussion is the need to consider the age and developmental stage of the patient. So we know that those who come to us perhaps on a learner's permit with an acquired brain injury that has severe impact, we're going to be pretty worried. There's going to need to be an enormous amount of practice if that young person is going to be able to gain skills at an automatic level when their actual learning is impaired and often physical aspects are impaired as well. There's often also different attitudinal aspects to the younger person who might see driving as a right of passage or might see it as an entitlement. To those who may be between 35 and 45, who may at that time have terrific financial pressures, mortgages, children being educated, that may add again to the importance of driving to that individual. And such pressures make for vulnerability often in the patient. We have found in assisting people to return to driving that if driving is so important for a sense of identity for the person, in other words, I am a driver, then return to driving is going to be terrifically important. If during a very disempowered stage of a person's life when they're in rehabilitation, the thought of driving and being in control of something, just for now, being important to them, again, driving takes a priority for that person that it may not otherwise. Other vulnerability, of course, includes the understanding of the patient of both their impairments and their prognosis. And the problem of depression is so common after brain injury. So just to bring us back, fatigue is a very common problem as we saw after brain injury, sustained attention and divided attention. I thought Simon gave us a terrific lot of information about the need for cognitive skills at a broad level. Don't forget, we had about 40%, I think it was, of our patients who had some difficulty with substance use, which of course complicates the cognitive impairments. And just for your interest, the mental health issues are very common. That 30-year follow-up study showing 48% of people with traumatic brain injury experiencing an Axis I disorder after injury sometime in that 30-year journey. And let's just dwell for a minute on, I think Janet was able to tell us and help us understand perhaps the experience of depression when driving and all the other things that can happen. It may be present to us. And I suppose in helping the people that we work with back to driving, we don't want to be revisiting the savage, harsh and dense forest that is being described here, but helping the person out. So just moving on from the vulnerability of the patient, I want to look for a moment at the vulnerability of the therapist. Nurses, social workers, allied health therapists, psychologists all often have very frequent contact with people, form strong relationships, become very aware of the patient's goals and their vulnerability, and may be very well aware that driving is that ray of hope that isn't perhaps shining into other areas of the person's life. The allied health worker often also hears about the person's attempt to drive, despite being advised not to, or their intention to drive. And of course observes deficits relevant to driving. So the person you can read for yourself may see the physical impairment, but then the light bulb goes on when they're thinking also about the other cognitive and psychological aspects that the person is displaying. And it's at that point the information really needs to come to the team so that that can be more fulsome in its reporting and the plan can be better organised. So we're trying to seek partnership, putting the situation right on the table with the person. And once the team has come to some agreement about what is being observed, we may need to raise that difficult issue of driving and we've talked about that today. And we may need to expect or accept a hostile or offended response. We know it's important that might be just going to happen. We need to be ready with the concerns that we have about driving and safety and perhaps the family concerns that have been reported to us. And to bring, for example, in some neuroscience to back up what we're saying about our concerns. And I'll draw from McGillchrist who wrote about this. So if we're looking at a little bird and we can see some special skills that that bird might have, it may balance well, it may have good dynamic movement, its vision might be good, it may or may not be physically fit, but it can do all the aspects required in the activities that we can see there. And pretty impressive dive down there to get a tiny little fish. But if all of those cognitive and broad attentional aspects that Simon described aren't present to the person on a consistent basis, then the broad planning around the activity may not be good enough for safety. Now it's possible to use an example like that from neuroscience on lots of different levels. So if someone is interested in football, for example, one could talk about Dane Swann of an excellent footballer from an excellent team. And think about the person who understands football, what are the particular skills that Dane Swann has? Or Roger Federer if they like tennis, doesn't matter. And when you go through the individualised skills with the person who understands a sport, you can say to them, so lots of players have got those skills, what is it that's different? Oh, Dane Swann can see the whole field, he knows how to make space. If he sees Buddy Franklin coming, he knows whether it's to handball or to kick. It's those broad attentional skills where everything is brought into the picture and the person can respond quickly. And it's those sorts of examples that sometimes help a person gain insight into what they're facing. So again, we've looked at seeking partnership, I'll just relieve you of that little bird. So we've talked about reflecting and seeking feedback from the person. Talking to them perhaps about insurance issues. If you drive now, it's documented in your file that you're not ready to drive. You won't be covered by insurance. Or how would you feel if you were driving and someone was injured? What can we do to support you? You want to return to drive. So we're trying to find common ground and we may need to do that over and over again. Those understandings may not stick. The person often has memory troubles. They often are quite perseverative in their goal, major goal. So in finding common ground, then it's possible over a long period of time with some of the patients we work with to look at the process that's been described today and I'm not going into that. So we're trying to bring the person to the point where we can be responding to the guidelines, planning the OT driving assessment, maybe saying I'm so sorry but there's a long wait for that. And indeed there might be, but the person might need more time for recovery. And discuss the timing and therapy to help the person to return to driving. But in the meantime we need to be building in the preferred options for the patient. So that not driving doesn't mean necessarily not working, not enjoying recreation, not getting out and about. So how can those other preferred activities be undertaken while the person can't drive? Sorry, I've lost track of where I am here. So we're trying to move from an all or nothing position, linking therapies and everyday activities to the preparation of return to driving without making promises that it's going to happen. Tricky, need to be very explicit, very concrete and very repetitive. From the beginning emphasizing the need for time and for recovery and practice and finding ways to facilitate practice. It may be finding brokerage to ensure there can be enough driving lessons, enough repeat driving assessments, finding volunteers who will drive with that person so as they have some practice. So with that complex group of clients that I'm looking at today, we're trying to move with therapy, with time, with recovery from isolated skills to embedded routines so that much of the driving task is automatic that leaves enough cognitive reserve for the big picture demands. So the person's whole mental energy is not taken up in the mechanics of driving. Remember that fantastic driver that Simon mentioned whose name escapes me just glanced at the dashboard for a moment before he rolled six times. We want enough cognitive reserve to be watching and avoiding those dangers. So the other in the meantime options that I've mentioned, how else can a person get out and about? So that anything that makes the license less of a barrier to engaging in preferred activities. So just to return to driving is a very complex end stage rehabilitation activity. Our experience would be that it draws on identity and lifestyle like few other preferred tasks and can leave therapists, families and patients very vulnerable during the long period that it may take to get back to driving or to get to the point where we understand that right now driving's not possible. If we've built in those preferred other lifestyle activities then perhaps the disappointment of that is somewhat mediated. Driving usually or return to driving requires very complex negotiation, better handled within a team than by an individual and maybe costly in terms of the process. So just as I leave you, don't forget about the little bird and the broader picture that's required to do a complex activity. That driving as a goal may allow us to work in a more therapeutically aligned way with a patient than some other activities and that we're trying to move from those splinter skills or single skills that a person might have to very strongly embedded routines where there's enough cognitive reserve for those big picture demands of driving. Thank you.