 Good evening everybody and welcome to tonight's webinar on supporting people with PTSD to participate in good work. We'll be using the term clients and patients interchangeably tonight and we'll also be sorting out exactly what we mean by good work. But before we start, MHBN would like to acknowledge the traditional custodians of the land, seas and waterways across Australia, upon which our webinar presenters and participants are located. We pay our respects to elders past and present for the memories, traditions, culture and hopes of Aboriginal and Torres Strait Islander Australia. So my name is Steve Trumbull and I'll be facilitating tonight's session. I'm a GP by background and professor of medical education at Melbourne Medical School. Tonight, Mental Health Professionals Network has partnered with ComCare to produce this webinar and just for background, ComCare is a government regulator, workers compensation insurer, claims manager and scheme administrator. It works with employees and employers, service providers and other stakeholders to minimise the impact of harm in the workplace, improve recovery and return to work and to promote the health benefits of good work. So we have disseminated the biographies of tonight's panelists with webinar information, an invitation. So the interests of ensuring we can cover as much content as possible will skip reading through the bios, but let's meet them one by one. Starting with Dr Tony McHugh, who's a psychologist based in Victoria. Hello, Tony, welcome. Thank you very much. Very glad to be here. Very important. We're very happy to be involved. Great. So what do then you find important particular area of work in your professional practice? I think this is one of the big issues that we don't work well enough at times. I think there's an emerging literature about how to work better with people to achieve functional outcomes and work as one of those things that we can see works incredibly important to humans. Fabulous. We'll definitely be talking about that tonight. So thanks for being with us. We're also joined by Dr Craig Barnett, who's from New South Wales and a general practitioner like myself. So Craig, what do you find important about this area of work? I very much enjoy this kind of area, Steve, because you get the opportunity to not only work with your diagnostic skills and your management skills and communication with the patient, but you also get to often work with a larger team of people. So I take sources of information from, say, my fellow psychologists and psychiatrists along with rehabilitation providers and hopefully with management within the workplace to try to foster optimal outcomes for these people who really struggle. I think one of the biggest challenges is there's a lack of common language and communication on some of this. So some people have very elegant communication about emotions and what's happening for them. Other people are really struggling to get that across and that may just proceed as behavioural change, whether that's anger or whatever. So that's one of the reasons I get involved in this. Great. Well, we're certainly going to touch on a lot of those issues tonight. So it's great to have you. Thanks very much. And last but definitely not least also in New South Wales, Christy Stonham, who's the manager of the shield strategy for Australian Federal Police. So welcome, Christy. And could you just tell us in a few words what the shield strategy actually is? Yeah, thanks, Steve. It's a pleasure to be with you all tonight representing the employer voice on this panel on behalf of the AFP. The shield service delivery model is transforming the way health and wellbeing is delivered within the AFP. And a key part of my role is to focus on the continuum of work health safety and rehabilitation services within the AFP. And it's a pleasure to be here with you tonight to provide some insight to what the AFP are doing in this space. Fabulous and always great to have the employer's perspective on these sorts of topics. So great to have you. Well, before we get started, just a few points to discuss about how the web player works. I'm sure many of you have been with us before, but I'll just run over these fairly quickly. To interact with the webinar platform to access the resources, you'll see you've got various options. There are the three dots in the lower right corner of your screen where you can access information. And under the information tab, you'll find the slides, the resources, including the case study that we're talking about tonight. There's a survey, a feedback survey to fill out for us. Come up more grand rules. Please be respectful of other participants and panellists, particularly in the chat box. It's a fabulous place there to chat with others. We can't see it, but the team in the back can keep an eye on it and let us know if topics are coming up and they'll let us know. But please do keep your comments on tonight's topic in the chat box rather than catching up with old friends as the main part of that. So what's going to happen now is each panelist will give a short discipline-specific presentation and then we'll go into a Q&A discussion between the panel. Our aim tonight is to discuss how practitioners and employers can work together to support patients with PTSD. And Craig said that working together is so important, but patients with PTSD are dissipating good work that supports their health and well-being. As Tony said, good work is so important for a healthy life. I'm not going to read those learning outcomes out loud because you can see them there and you can all create perfectly well, I'm sure. And you've also received the case, so hopefully you've been able to read that and aware of the sorts of issues that we'll be talking about. If you want to revisit the case, click on the three dots at the bottom right of the platform. So we're all set to go and we will start with Dr Tony McHugh, our psychologist colleague who's going to give us the psychologist perspective in just a few minutes. So over to you, Tony. Thanks very much, Steve. We should not make assumptions, I think, so it's important to define PTSD as the first thing we do. As you can see, it derives from the experience of threat of death, serious injury or sexual assault, or directly witnessing the same. That's according to DSM-5. It's important to note also that traumatisation is perceptual and no two people react to any given trauma in identical fashions. And we understand that PTSD cannot exist where an event has not been perceived as traumatic. That's referred to as the paradox of PTSD, and hence we talk about potentially traumatising events. DSM-5 relocated PTSD from anxiety to stress disorders. This was extremely contentious as the people who had in fact placed it there in the first place back in DSM-3 argued very strongly that this was not a sensible move. I think actually it is a stress disorder. I'm arguing against luminaries, but we're going to talk about PTSD tonight as per DSM-5 and ICD-11. We're overwhelmingly similar in definition. We won't be talking about complex PTSD and that might be the subject of another webinar in the future. Those classificatory changes however are very contentious as I've alluded to around the debates regarding criterion 8, the causal criterion, concept creep and expanding ideas of what harm might be to humans. Next slide please. This is the nature development and maintenance of PTSD. The onset of PTSD may occur after a potentially traumatising event from one month on. That is one month of symptoms, three months of chronicity. It means that you've got a chronic condition. Commonly comorbid with PTSD, anxiety, the most common comorbidity, mood and substance disorders. There are clear pre-peri and post-event risk factors for PTSD. Not all have the same predictive power. Gender and age for example are considered to be weak predictors. Peri traumatic reactions and post responses are perhaps the strongest indicator predictors and post trauma support is a particularly strong predictor. There are many, many theories of models of PTSD and many expert bodies offer information, describe research and offer clinical guidance such as the US PTSD Centre in Phoenix, Australia. I believe strongly that we are ethically obliged to know and implement such knowledge and treatment. Those graphs show that symptoms decline naturally for people over the first year post trauma. They also show that there are different trajectories and we need to be very, very mindful that I'll talk more about that later perhaps. Next slide please. All humans have latent vulnerabilities which are typically only expressed in the context of negative life events and potentially traumatising events. This is explainable in terms of a 1962 theory by a very important psychologist Paul Meale, the stress diathesis or diathesis stress construct. It's an explanatory model of stress responses that clients actually like and PTSD sufferers readily acknowledge. PTSD as that graph suggests is a disorder of recovery and most affected by it recover although different courses exist. Next slide please. How is PTSD best treated? One of the most important parts of tonight's presentation perhaps. The stage model of treatment is essential and many people have spoken about this Terry Keane is one who suggests six stages of treatment. John Brier suggests four and implicit in all of them are education and building a client personalised model of recovery and well-being. That is a term you may hear me refer to a number of times tonight. Also included are affect management, cognitive work, behavioural experiments and exposure like interventions. Early symptom reduction is important. That's what causes people to show up often but treatment is about more than symptoms. The meaning of what has occurred, current functioning and the meaning of that functioning to the self and to others are critical. Early treatment addressing the big three is critical. The big three emotions are anxiety and anxious avoidance is particularly important to address. Depression in the form of hopelessness, helplessness, awfulism and pointlessness is also important to address. But particularly important in my research and experience clinically is to address anger because it's a moral emotion and is connected to so many other emotions that appear post-traumatically. And it's an unrecognised until recently PTSD potentiator. Angry PTSD as I refer to is more than the very useful construct of post-traumatic embitterment disorder by Linden and I would encourage you all to go looking for that construct. It's readily available through Google searches for example. Both especially relevant when there is perceived or actual injustice nonetheless. Recovery hinges on the following new learning and adaptation to trauma focused CBT interventions. They include cognitive therapy, cognitive processing therapy, EMDR and above all prolonged exposure. They are the four evidence supported treatment interventions. This is best done in an envelope of slowness as suggested by Daniel Kahneman. And it's such an important book 2011 I would encourage you all again to go looking for it. And we need to emphasise mental toughness, hardiness, coping, self-agency and purpose. And Charles Bonanno and Lazarus are very important here and I encourage you all to remember your nature. The first quotes a bit tongue in cheek, but it is what he did say and everyone thinks it's the military but it was nature. Importantly he said if you have the why, the how will follow. It's very important for people to have a recovery ambition and to learn the treatment tactics and strategies that will help them. Next slide please. This is a fairly busy slide and other speakers particularly Christy are going to speak to elements of this. As you can see there are four stakeholder parties. There's the employer, the scheme, the worker and the trader. And I've underscored some things there that I think are important because time is precious. Mental health policies have to exist but they have to be enacted and leaders through to managers and all staff need to live and promote the truth of them. Also promoting diverse recovery stories is important by employers. Schemes need to act with dignity, empathy, wisdom and enabling client dignity rather. I need to really understand what mental health is and debunk myths. For the worker or the client to understand there are important health benefits of work. I won't talk much to that as Christy will talk to that. But again to develop a personal model of recovery and well-being by adopting tools, tactics and a sense of how they're going to recover. And for the trader it's our obligation to engage in efficient and effective treatment, debunk myths, implement and translate evidence-based practice, develop in conjunction with the client their personal model of recovery and well-being and to know our code in the sense that sometimes it's important to know when to conclude treatment sooner rather than later. That's what I've got to say for the present time. I will hand back to Steve. Thank you very much. Thanks so much Tony and I'm going to jump on an immediate question that's come up from Richard who hadn't come across the word awfulism before. I must say I've not either. Can you just tell us in a few words what awfulism is? It sounds appropriately awful. Awfulism is what angst-ridden people suffering from depression will talk about quite a bit. That things are awful. They are terrible. They are intolerable. It's a deep form of depression or depressive cognition where people are describing with great power how terrible things are for them. And sometimes it's important, not sometimes, it's frequently important to reality check, reframe, help people develop different takes on those ideas. Great. All right. Thanks so much and thank you also for giving us such a firm foundation to think further about the case on. You've already answered a number of the questions that have come up before the webinar. So let's now move on to Craig. So clearly Craig Tracey in the case here is spending time with her GP, but let's hear your take on what happens from the GP perspective when you're helping somebody like her. Thanks and thank you Tony because there's a lot of things in there that sort of reflect in what I do in day to day practice. I want the audience to first think about a psychologically injury as a wicked problem. We'll come back to what wicked means in a moment, but I want to really focus. It is a wicked problem. It's a very tricky one to solve. You need tailored management as we just heard from Tony the need to sort of personalize and understand what's going on for the individual. So unlike something like a shoulder injury where you can say, well, look, we're going to go through this sort of rehab process and we're going to lift a certain amount of weight. And then at 16 weeks, you should be right to get back to work. It's not quite so straightforward because it will depend on the exact circumstances, the resources the person has, the background, and of course what sort of work they're required to do and how the exposure has then affected that. Mental health situations as I'm sure all the psychologists in the room are well aware has a lack of visible features. So someone could present to work or present to the gym or wherever, and they may look fine, but it doesn't necessarily tell you what's going on under the skin there. And so they may actually be very scared, very vulnerable, rather confused and not sure what's actually going on for more why they're having these emotional responses. As I alluded to a little earlier, the communication in this space of mental health is incredibly difficult. And I think if you were to stand a small group of sort of claims managers and patients and perhaps GPs, perhaps psychologists, perhaps some psychiatrists and some social workers all in the one room, I'm sure that we would find very different approaches in the way language is used to communicate what's happening for the person. And with that becomes the other problem which is often misunderstanding both in communication but also in perceived ideas and beliefs. As a very clinical example, I have a lovely person who unfortunately has some fairly significant PTSD symptoms. And one of the relatives, one of the relatives constantly says to them, oh, you just need to pick yourself back up and get back and get back to what you were doing, you'll be fine. But of course that's not the position that the person is in. And simply that can happen in workplaces where people put their own speed or judgment on things. And finally, the risk if the person's mismanaged, and I can't emphasize this enough, if the psychologist, psychiatrist, the GP is on the phone to an insurer and says, look, there's a serious problem here. This person is actually deteriorating and becoming suicidal. There needs to be action on that and people need to be communicating. I recently unfortunately received a letter from a rehab provider in that exact circumstance. And the letter basically says, we tried to find the patient a couple of times and they did not answer. Period. No question as to whether they had suicided, whether they were dead on the floor or what, what further was to take place. And in fact, no contact with me except by snail mile. But look, so it's so important this is managed well because it is a risk, is a risk of a very negative outcomes. And I think sometimes workplaces don't necessarily understand the nuances of that. But nor are they exposed to just the same as I'd be a fairly hopeless accountant or a not so crash one engineer. But we do have success if we work on this. If we work as a team, our wicked problem can be reduced. I don't lay any great claims to academia with this diagram. But this is a diagram I use on a daily basis to think about where my patient is at and and how we might return them to work down the very bottom. So it's not the unusual and it was starting at the bottom of the diagram. It's where is the person themselves that can they actually get up out of bed in the morning? Can they actually get themselves dressed? Or do they to generate into tears and feel a need to return back into into hiding in their bed? Can they actually organize basic things like like remember to get their clothes on know where the car keys are remind the children perhaps to take their lunchboxes and so on. So down at that very basic level, you know, are they functioning as a person and can they care for themselves? If they're not, there's a lot of serious consequences that flow from that, both for the family and for the workplace that need to be considered. And then further up the scale is it's not like capable in a safe environment of having interactions. Can they, for example, go to a cafe with perhaps a trusted friend or significant others and have that cup of coffee? Or does things like their hyper vigilance, their anxiety prevent that? And on occasions, this is where rehab providers, if they're very attuned and also our psychologists, if they're attuned to the situation and given the latitude can actually make a big difference here. So sometimes meeting with an independent trusted person that actually knows what's going on for the person and monitoring what's happening to them can then perhaps take them to a quiet coffee shop and at the right time and see how they're responding, help talk them through how to manage that. And then at the higher end of the hierarchy, we have contributed to work. Work has some expectations. There's some rules. There's a cognitive load there and there's certain expectations and certain certain complex social leader actions. And under our workers' compensation schemes across the country, which we're very fortunate to have those in existence. We look to set aside the routine workload in such a way as to optimize an ability to come back into our workplace. Next slide. You remember I said a wicked problem. I'll let you read that rather than be reading the whole thing out. But wicked problems are these complex things that have multiple elements involved. So sure as a general practitioner, I'm looking at my patient. But I'm also thinking about how we might integrate them back into their social fabric at home and then of course further into a workplace environment. And this requires really key things. There needs to be that communication. We need employer, significant others in the workplace to sort of understand a little about what the patient's going through and what's good or bad and a way of communicating that information. And one of the tips, for example, is in the case of people becoming anxious or feeling overwhelmed on a particularly bad day. One of the, I can't remember which one, whether it was Black Dog or it's the other one, had suggested that one of the things to do was just to have a little red card. And if there was a red card on the desk, don't talk to Bob or don't talk to Jenny today because they're only just managing to cope with what they've got in front of them. Understanding what's going on and we've mentioned there the communication difficulties around language. For example, perhaps a rigor back to a works on scaffolding and so forth is not going to have very erudite, often not going to have very erudite language about their emotions and what they're feeling. They're just going to experience some of the things that perhaps Tony's touched on such as that anger and a need to sort of blame somebody for what's taken place. And there needs to be this agreement. If we are to address this as a workplace and human concern, we need to reach a position where there's safety, think about those things like suicide, drug abuse or alcohol abuse. And the person needs to be capable of managing themselves, but also taking that a little further to actually be meaningful and manage their responses in the workplace. So what do you expect from this? And I was really heartened to hear Tony in Tony's talk there that he was mentioning that time slow being steady about this. People's emotional state does not change an alter very rapidly in the situation of significant mental health illness such as PTSD. So whereas something like a shoulder, you may be expecting to see an increase every every two or three weeks and you wonder why if you got to five weeks and there was no change. It may be quite normal to see four or five, six weeks before you see significant changes. But obviously there needs to be that kind of feedback loop of watching what's happening and understanding what's going on for the person at their individual and tailing in those treatments. And so in particularly at the time, if there's any insurance fund managers listening out there, you know, when a clinician, an experienced clinician says to you, look, I don't think this person is going to actually achieve any further upgrade for a period of time. That may be three months, it may be six months in the more extreme. It's important to recognise what that means. And just as Tony was saying, be prepared to actually say where we are and where we're going. And so acceptance of an outcome is important. If we were to move some of our mental health stuff in the more extreme PTSD into a physical arena, would we expect someone with quadriplegia to be out there running? And the answer is, don't be ridiculous, Dr. Bernanter. That's that's kind of being a little silly. But sometimes I find exactly the same situation in mental health where the expectation of an outcome is beyond what the person's managing to achieve and showing through their trajectory over time and showing in the information coming from multiple parties, not just myself. So understand what the outcome is to be for a person is really important. Thank you. Thanks so much, Craig, and both you and Tony now brought up the issue about time for treatment. How long and I might ask, I don't know, we'll get to the Q&A shortly, but I just might ask both of you how long you budget for sessions with somebody suffering from PTSD, both from the GP's perspective and the psychologist's perspective. I mean, how long is please a string, I guess, but what's your general experience? Would you like to go first? Again, it's always the based on degrees of what's actually happening and how people are responding. I certainly have ex police persons who we've worked with over two or three years and have achieved outcomes for them. Now, the outcome may not be going back to a very industrious taxing work environment, but I'm really pleased to say that in some of those cases we actually have people working two or three days a week and coming home enjoying that work, even though the work in some respects is very light on and I mean cognitive and physically compared to their past workload and abilities. But it's a very positive human outcome. Great. And Tony, what about in your experience? How long do you generally plan for? Well, it depends on many things. The intensity of the distress with which the person presents initially, the history of their traumatization, their personal characteristics and those human vulnerabilities. As I said, we all have them. But as a rule of thumb, that two year period that Craig referred to when I was at the Austin over a couple of decades, we ran a treatment program where we provided two years of treatment, both group and individual and psychiatry. In my own practice, I would average about 45 sessions across 18 months or so with seriously traumatized police. But there's a project in Victoria that I've been involved in called Blue Hub and the average number of sessions provided is 28. And that's to remission or termination of treatment and with most people returning to work where they have been working. So it varies, but we need to work actively and optimistically because there's a really negative thing that happens in more and more treatment, treatment, effectiveness, tails off. It becomes iatrogenic and people start thinking I must be really, really unwell and people aren't telling me. So I think the more effective and efficient we can be, the better. Right. Thank you so much for that. And both of you have mentioned the police force or different police forces. So now we go to Christy to hear your presentation. Thanks Christy from the AFP. Thank you, Steve. I'll start with some high level context from an AFP perspective. And as some of you would guess quite rightly assumed the high risk nature of work undertaken by the AFP provides an interesting picture in terms of injury and claims profile. So by way of example, mental stress is one of the highest mechanisms of injury in relation to accepted claims over the last four years. And psychological injury claims have recently overtaken the rate of physical injuries in the AFP and account for a significant part of our premium costs. Alongside the psychological injury obviously comes time off work, which directly links to a productivity cost as well given it often takes longer to recover from a psychological injury rather than a physical injury. A funding for shield was received in late 2020 and represents the single biggest wellbeing investment in AFP's history. From my perspective it recognises the unique stresses and inherent risks associated with policing along with community expectation that we do more to protect those who serve us. The slide on your screen visualises the six key components of our service delivery model and examples of what they include noting that we are still working towards formaturity. Through shield the AFP is transforming the way health and wellbeing services are delivered to all AFP employees by shifting the AFP's health model to be one focused on prevention and enhancing operational capability and member experience. However, we are realists and appreciate it will take a time for that cultural shift to be realised. Next slide please. To better support our diverse footprint we moved away from a centralised model with limited health and wellbeing services to establish multidisciplinary teams in each major geographical location with a strategic centre that develops the governance standards and quality assurance processes to promote a consistent service delivery around the country. Shield is considered a deployable capability which offers access to dedicated teams of clinicians and health professionals who understand the unique nature of work within the AFP. The multidisciplinary team model you can see on your screen is designed to provide holistic and connected care. However important to note that these locally based teams are complemented and supported by a nationally based team including an occupational hygienist, occupational therapist and dieticians. In context of the case study we have before us tonight, Shield may have been utilised to deploy early intervention from a psychological perspective immediately after the incident which may have minimised the ongoing impact to Tracy that we now see described. Another pathway would be the Early Access Programme. So in recognising that getting access to support as early as possible is critical to recovery and that support will look different for every person. The AFP have also invested in an Early Access Programme that works complementary to Shield and provides flexibility in terms of treating preferences and offers a pathway to be reimbursed for medical treatment, physio, imaging and limited periods of leave. Next slide please. In AFP we are investing in our safety culture at a strategic level and encouraging command or business to lean into their role of managing risk indicators as opposed to having the organisation, often in partnership with ComCare as our insurer, manage the realised risk. Knowing that it will take time to realise the full benefit of that ongoing cultural shift, we are concurrently working to enhance return to work outcomes and reduce the amount of time people are out of the workplace if an illness or injury should occur and this slide focuses on that. We are taking a multifaceted approach to uplifting the capability and awareness of key stakeholders in the return to work process and helping the AFP move beyond just their legislative requirements or obligations and really seeking to promote the concept of good work and how that can be achieved. The inner circle on this slide represents the model of shared responsibility required to enhance return to work outcomes but important to note that this slide represents the stakeholders we have the most direct relationship or influence over in the AFP. However a key group as being referenced by Craig and Tony before me also includes the treating team but I'll come back to that in my next slide. The outer circle reflects the integrated and holistic approach being taken across multiple pillars of effort to enable that capability uplift. Through the establishment of a working group across the organisation focused on return to work, we were able to get feedback from those within the business to understand what were considered barriers in regard to return to work. Some practical examples of what we're doing to enhance return to work outcomes in response to that information gathered includes leveraging off the semi embedded model of shield and developing strong relationships with commands so we can be considered a trusted partner with open lines of communication. The model also enhances the case manager's knowledge of the work environment so they can go and return to work conversations appropriately. We're empowering leaders and developing leaders to drive return to work outcomes by investing time and effort in tailoring training and education packages for different levels of our workforce to help them understand their legislative obligations, their role in influencing a positive safety culture and relevant to this topic. The practical steps to follow once someone becomes ill or injured, which has a primary focus on achieving good return to work outcomes and includes tools, templates, reference materials to make the process easy for them to follow. We're also being innovative with our governance. For example, with return to work processes or engagement in good work in general, it requires coordination and integration between the client, the supervisor and health services. We've recently introduced a piece of governance called the employee support board, which brings all relevant stakeholders together with a common goal of developing an employee support plan that has structured goals, activities and objectives. The people involved in that process is largely driven by the individual and may include the supervisor, the rehab case manager, clinicians, a workplace rehab provider, and any additional support that person would like to include, including family members if they so choose. We're also in the process of developing suitable duties register to ensure that there is always a pool of tasks and projects that can be undertaken by someone demonstrating capacity to return to work. However, may not be able to return to the pre-injury position just yet due to medical restrictions. Next slide, thank you. As mentioned earlier, the model of shared responsibility includes with treating teams as they play a key role in the promoting of both return to work with the employee and health benefits of good work. As we know, there is a limited window of time to influence positive incomes, positive outcomes. For example, the longer someone is off work, the less likely they are to return to work. It's evidence that if someone is off work for 20 days, the chance of ever getting them back to work is about 70%. And that percentage drops significantly as days out of the workplace increase. So from an employer's perspective, it is helpful if practitioners can be overt and provide advice on alternative duties, whether that be internal or external to the immediate workplace, including any modifications that may be required. There is also data that shows that if a healthcare provider contacted the patient's workplace, it was twice as likely that the injured worker would return to work. Sometimes it is important for a practitioner to understand if there are any non-medical factors delaying a return to work, and the best way to do that is to ask the relevant people. For example, the employee, the supervisor or the rehabilitation provider asks the question, what in your opinion are the barriers for returning to work? It is also great if practitioners can be available for and participate in case conferences when appropriate, including responding to requests for information or reports as it will help the employer meet their obligations and also assist your patient on their recovery journey. Next slide, please. Employers should strive to create a culture that promotes and celebrates good health and ensure everyone understands what they can do to contribute to that. However, when injury or illness does occur, employees obviously play a crucial role in realising return to work outcomes. Every workplace will experience challenges with return to work, and the answers to challenges you may experience likely sit within your business, so set up the right forums or avenues to enable that information to filter to the top so you can do something about it. It's never a case of one size fits all, as the needs of each agency differ, and in the AFP we have a very unique risk profile in operating environment. While we take as much guidance and advice that we can from ComCare and seek to deploy best practice case management, we have to be agile and ensure the frameworks, governance and training implemented suits our operating environment. And while it is recognised that recovery will take longer from a psychological injury, it doesn't mean you should take a passive approach. Ensure that you are empowering all the right people to play an active role in trying to achieve return to work outcomes and always remain in contact with the employee. I'm happy to leave that there for the moment, Steve. Thank you and hand back to you. Great. Thanks so much indeed. Chris, I'm very taken by the diagram you've got for SHIELD there. It surely requires somebody clever to get it that put on the SHIELD held by Chris Evans as Captain AFP. It's a compelling image of everything there. It's great. Definitely not my creative license. All right. I'll put my camera on so you can see me blushing at that pop culture reference. Thanks for that. It's so good to hear about the communication that's needed. People have been asking questions about what we can do to try to get more information from health care providers when you are putting together a program. Do you have any quick tips for the audience on how you can get information from health care providers like Craig and Tony that actually help you do work at your end at the employer's end? Yeah, absolutely. A good tip from our perspective is making sure we're very direct and targeted with the questions that we ask. Don't leave it to be ambiguous or misinterpreted by the person receiving the request. Be very clear with what you're asking and relate it as much as you can to the role requirements. What is the scope of the role? What is required of the individual and what is the specific question you are asking? The clearer your question is, the clearer the response can be. Great. Thanks so much. And we've now got a good half hour or so for group discussions. So thanks everybody for keeping your presentations concise and really what we need to focus on. Look, there are so many questions that have come in and that people have been asking during the webcast so far. But one that's cropped up a few times is when people are seeing that the workplace itself contributes to the cause of PTSD. There was one particular question about whether bullying in the workplace can meet the diagnostic requirements for the diagnosis of PTSD when there's not the major trauma and things that have been discussed by Tony. And then following on from that, what we can do to return a worker to a workplace that they're finding difficult, as in fact Tracy was. So who wants to pick up on that one to begin with? I guess the diagnostic issue might sit with you. Tony, if that's okay, about what happens if bullying is seen as the trigger for the person's distress. Very good question. Diagnosis is an art. If diagnoses become expanded to include things that weren't in the original diagnostic classifications, I think we run the risk of disorders becoming less meaningful. Bullying is something that is unacceptable, always has been, always will be. I don't think someone has to have PTSD when a clear-cut case of bullying is in place and the bullying needs to be treated for its effect on a person's psychology, particularly anxiety, depression, anger, those sorts of things. We're dealing with humans. We're not dealing with diagnostic concepts and I think distress is enough and I think assisting people to deal with improper workplace behaviour does not require a diagnosis of PTSD. I'd add one final thing if I may. I talked about predictors of recovery in PTSD and it's how a person is received after an event, how they are treated. I have had a complete conversion across my working life. I now agree with the luminaries who say that is the most important thing in predicting trajectory of recovery and Christie's touched on it, Craig's touched on it. I can't emphasise enough how an empathic response, sometimes a firm empathic response because there is a problem with increasing concepts of harm. I think the response of the workplace, the scheme, the people surrounding the client is so incredibly important. I'll leave it there. Thanks, Tony. Even in the instant before Tracy's car was struck by another car, the case tells us that she was finding her work difficult. She was going through a marriage or relationship breakup separation. I mean, these sorts of predisposings about concept that I gather, different people will receive that sort of impact differently depending on where they are in their life at that point in time. And I think you'd perceive that in general practice a lot, wouldn't you, Craig, that there are different people exposed to the same levels of trauma who come out of it completely differently. And some of those resilience issues that Tony mentioned, what are your thoughts on that? Yeah, look, absolutely. I couldn't agree more and hence part of the wicked problem is the very individually, individual nature of this sort of an injury. So in the case of our particular patient, who's name just escapes me, Tracy, you really want to just know a little bit about what was going on leading up to this. And we've got a little bit in the case there, but you know, how is that holdable situation going and what sorts of triggers that's caused for her? Has it dwelled up all sorts of issues around perhaps things like, you know, child support and living arrangements and the like. So that's going to come into the mix. Although I think I think for most we would see the fairly traumatic event of this accident. And certainly if we accept that the case is written almost as a storytelling from her viewpoint, the scene of a colleague with blood over their face and not moving. I think for many people, even with a fairly strong background, we'll find that really challenging. And this sort of sitting at exposure is one of the great problems that our emergency services such as the police that Christie has been talking about a face on a daily basis. So they not only have daily risks, they also have cumulative risks of this taking place. So Christie, the way the case is set up there was about four weeks between the incident and really Tracy coming to attention. Do you feel that there should have been more proactive strategies going on from the employer's side during the four weeks between the incident and the claim or the call cry for help? Yeah, absolutely. I also think there was a room for an opportunity for the employer to intervene even before the incident. I guess that the case study outlines some of the context there and it really describes some of the compounding psychosocial hazards that were developing for Tracy in terms of increased work demand. There are also personal stresses that she was experiencing that I guess contributed to her moving up that mental health continuum before the incident actually occurred. There's an obligation and an opportunity for the employer to identify those signs and symptoms in an employee and intervene early to provide support, show empathy and reduce some of the psychosocial hazards in place. From that perspective. But like you also mentioned, as soon as the incident occurred, there wasn't an opportunity for early intervention straight away. And from my perspective in AFP, we would have definitely recommended engagement with a psychologist sooner rather than later to undertake in a debriefing process. That's for example that may have given insight to some of the indicators that a more serious injury may develop and some psychoeducational targeted treatment could have been provided sooner rather than later. Thanks for that. I should have mentioned before that I'm a presiding member with medical panels for the work cover worksite side of the system. And I must say the number of times we sit on a panel with hundreds of thousands of dollars of legal fees and stomach linings being expended and you think why do people feel obliged to throw petrol on a small fire after an incident. But it does seem to be that we're not as good at managing these emerging problems, these wicked problems before they become too wicked. Anyway, does any, do anybody, does any other panelists have any comments about it before we move on to the next question? Craig look like you were about to fire up there. Yes look I'm just to be curious Christy and forgive me because it's a bit of a devil's advocate question. Certainly for many of my people but working things like coal mines and all sorts of things. If they were to turn up to work and say oh boss I'm going through a bit of a breakup and yeah it's really getting on top of me and you want these extra reports done. I'm not sure what response they're likely to get from an employer. So how does the AFP are sure that that can happen because after all the workplace needs output. Yeah absolutely and that speaks to part of the wicked problem associated with the cultural shift required in organisations to reduce the stigma associated with having those open conversations and making sure people know that it is safer that they will be heard if they engage in those conversations because if people have a negative experience in trying to have that conversation chances are they're not going to have another one anytime soon. So it's going to take a lot of time to I guess across industries to reach that kind of maturity level but I think we will have to start somewhere and making it as I guess a cognizant effort in regards to our strategy our leadership frameworks and our general cultural aspirate aspirations will eventually have a force multiplier effect in that space but it will take time. Thanks Christy, thank you. Thanks and then to Tony. Tony someone's asked the question what is the status of early professional debriefing in PTSD events. I must say having worked as a GP in Mirrorsville after the fires in 2009. People didn't seem to be that ready for professional debriefing immediately after the fires but what are your thoughts about early intervention professional debriefing when there's been an obvious incident. A very good question and a very good observation to Steve. Often I think we're trying to apply things to people to clients that they're not actually seeking. I can remember when the Kosovars came to Australia in the mid 1990s. A lot of people went to bandana and places like that offering psychological interventions including debriefing. They pretty soon got the message we don't want that we want things that remind us of where we come from came from materials to make all kinds of clothes. They wanted practical assistance. To go to the question we really don't talk these days much about debriefing. I think debriefing done skillfully was probably a very useful thing but often it wasn't done as skillfully as it could be. We now tend to talk about developing skills. Psychological first aid and watchful waiting. And something that Christy referred to before is an obvious watching for when people are really having intense reactions because in most people their symptoms die down. But if someone's having nightmares or dreams as indeed I think Tracy was having these are signifiers for maybe we should be doing something more. But mandatory group based professional debriefing we don't really advocate for that anymore. Thanks for that. And while we've got to you did quote the famous philosopher. I thought it was Kelly Clarkson what doesn't kill you make you stronger but apparently it was me. That issue about I noted down mental toughness hardiness and coping. I've been seriously beaten up by medical students who are interpreting that sort of call out for resilience as being a way of putting responsibility on them for a damage traumatic health system that they're being dropped into. Any thoughts about that issue of who has sort of responsibility for hardiness. Look, I think it's like all things human. It's a shared responsibility. I can't insist on any client having what I call a personalized model of recovery. We've talked for decades about keeping clients at the center of our care. I don't know anyone who would say that we're trying to do that. But true effective fitness collaborative encouraging the individual system the employer the scheme and everyone to engage around how do we help this person understand that they are the most important. All the other parts are important. But they are the most important aspect of recovery that they are the agent of change. And it's not a critical thing. It's not a damning thing. It's when people finally have a plan for how they're going to get better because their treatment team has encouraged them to think optimistically about that. Then I think really good things can happen. I'll leave the dilemmas of the health system to others, but I don't think it's the responsibility of students. I worked in a public hospital for 20 years. Everyone's got a part to play in that. Absolutely. So what about you, Craig? I mean, we often find ourselves as GPs being almost recruited onto the patient side of the struggle with their employer that's going on. Do you find yourself in that situation? How do you balance your commitment to the patient while also doing what's in their best interest? Yeah, look, thanks. If I might just digress just a fraction on and pick up on Tony's comment and your comment about resilience. And I would love to say this is my thought, but it's not. It was a wonderful GP at a rural medicine conference in Port Macquarie this year. And she, like Tony, is a very dedicated academic and she stood in front of the audience that she was really sick and tired of hearing the word resilience. And her reason for saying so was she said the reason is it's looking at one part of it. It's saying what the qualities are that the patient needs to have. She said, now think about like a soccer ball. If you bounce that on concrete or bounce that on a good playing field, it bounces really nicely. Now bounce it in a swamp and see what happens. It doesn't matter how good your resilience is, it won't bounce. And I thought that little description was actually very good because certainly as a GP I do encounter occasionally situations where workplaces are perhaps just not accepting of a mental health condition. And no matter what the determination and the residencies of the patient and the treating team, that can be very, very tricky. But thankfully they've not fallen, but it does happen. In terms of working with the workplace, look, most of the time if I'm dealing with something like PTSD, a significant mental health diagnosis, I'll have, I want the patient to be involved with the team. I'll want a psychologist and I usually want a rehabilitation provider. And I might, I might be a little cheeky if I may serve and say not just any rehabilitation provider. Many rehabilitation providers are physios or OTs and sure have some psychological knowledge. But I would really prefer someone that's got a psychology type background or has lots of experience in this area so that they know it's not just about the physical vulnerabilities and know how to communicate with the workplace about finding what that safe work is. You know, such as our patient Tracy. I think, I think unless Tony were to overrule me, I think for the moment we're not going to be very keen with her sort of driving too far or having anything that's particularly taxing. What we want to do is try to get her stable and have some sort of graded return to something that looks like a workplace progressively depending on how her self state is going. Yeah, and I mean, you know, having a really well trained experienced OTs is familiar with mental health issues can be a fabulous member of the team. That's for sure. So, Christy, is the AFP providing a swap or a plexipave court there for the boundary bounced on? Is that what your shield programs all about really is it making a firm foundation? Absolutely. There is a really key focus on prevention and that in embedded in that is the education component and focused on building resilience within AFP members across their career life cycle. Because we know the inherent risks that they're going to face in in the role that they are performing. So your 100% right shield is is focused on that, but not just focusing on building the resilience. It's how we adapt the leadership and the culture to be more accommodating and managing those risk indicators as opposed to allowing risk to be realized in the form of injury or illness. Yeah, and Craig mentioned some success he'd had with quite badly injured police officer who managed to get back to some sort of work within the environment. I still remember a surgeon saying after he slipped and cut his extensor off in his fingers, could no longer operate. And he said, I'm a surgeon. I search. It's what I do. How do you deal with this issue of AFP officers who are no longer able to do what attracted them to the job in the first place? I mean, they might they might have wanted to be sort of active policing officers rather than whatever work they might have. How do you show that to be good work for them? And that's a real challenging situation, Steve. And most people who join the AFP join it for a career that they're in it for the long haul and they strongly identify as a police officer. So that's often a barrier to achieving return to work outcomes because it's hard for them to adjust, I guess, the mental model of what I guess bringing value to the community means to them if they can't perform that role of a police officer anymore. So it often takes a little bit longer in those extreme circumstances. But we have, I guess, varying levels of success in regards to return to work outcomes in that situation. But we will always be guided by medical advice and very open to engaging or exploring opportunities outside the AFP as well. If it means getting people engaged in meaningful work. Okay, so you can have somebody deployed elsewhere within the Commonwealth Public Service system or finding other suitable work with an employer who has the need of those skills? Yeah, absolutely. We follow the return to work hierarchy as outlined by our insurer. But we definitely look external to the AFP within the broader Commonwealth when the medical advice supports us with that. Absolutely. Okay, thanks for that. So we'll be moving to the final phase of the webcast shortly. Maybe one final question and this is, I think, probably directed obviously best at Craig. It's about the use of mental health care plans and psychologists who are providing sessions, which are obviously strictly time limited, although there's a calendar year issue there. So you find that the mental health care plan system gives you enough referring capacity or is it really not enough when totally saying 45 sessions is about a starting point or a budget? Wow, that's a load and question, Steve. Thanks for that one. Okay, so we'll move on to the final question. Look, I think the mental health care plan is a very helpful fallback. I've had occasions where claims with workplaces are challenged and at least allows me to provide some additional care to keep the person in contact with their psychologist. And obviously, if it's a situation well outside of the workplace and the workplace doesn't have any funding arrangement in place, then certainly the mental health plan provides some benefit. Unfortunately, as I'm sure psychologists, GPs, I'm sure a number of health professionals watching this thing. There's a great gap has opened up over the last 30 years between what the Medicare system pays for all refunds to the patient as opposed to what the cost of delivering those services are. And that creates a great divinity. I now have very much, I see on a daily basis, a two tiered health system. People who have got money in their pocket and can get a mental health plan and afford the treatment and a very long line of people who fall by the wayside because they do not have access to financial resources. And so they're on very long waiting list with I'm going to say charity. That's not quite fair, but charity like situations where we're building is still occurring, often being propped up by the goodwill or some other some other financial process. Sure. So mental health practitioners in very short supply. We've got a full range of practitioners are kind of suited to social workers and all points in between, but they are a limited resource. Maybe we can just have a final comment from Tony before we move to the wrap up about the sort of words you might use when coming to the end of a therapeutic relationship with a client or when you've achieved the goals that you've sought. What sort of words do you use when helping a worker understand that their sessions have come to an end? To use the analogy, it's a bit like parenting. If you want to raise a good child, it starts from day one. And if I get my TARDIS and I go back long enough, I can remember that I was taught that from the point of assessment we're heading towards conclusion. So I'm saying those kinds of things to people early days. It's just like getting to having an adolescent child and starting to parent that it's too late. You parent from day one, you prepare people for release from day one. We really shouldn't be having unexpected conversations about conclusion. It should be planned all the way along, checking in and really making clear that more and more treatment is not necessarily better treatment. I have reviewed cases in some of my other roles where I won't tell people how much treatment, but if I said 45 was a ballpark, you can multiply it by a factor of five or six. And what message is that giving people when they have had that much treatment? Someone's not telling me the truth about how unwell I am. So I want people to think about assertive, active treatment and proper treatment planning. There are always going to be hiccups where the original estimate might have to go out by a few sessions to recover a situation. But right from day one, we should be talking about when we both know that the time has come. And I say to people, it will be a sad day, but it will be a great day when we have to part. Alright, thanks. So while you've got the speaking stick, maybe we can get you to sum up in just a couple of minutes your thoughts about this topic and we'll go around the room. Thank you. I said at the start that this is such an important topic. It's got so much meat to it. We can't do it justice. But my take home messages are around diagnosis and formulation. An accurate diagnosis and appropriate formulation is empowering of the individual through us explaining why it is so, what the symptoms mean, what recovery looks like, etc. Treating assertively, I've made that point a number of times. These schemes quite rightly don't want to see supportive psychotherapy. They're funded by the Australian public and they want to see effective and efficient treatment being delivered. And if we're not doing that, we're in violation of our various codes and we're not acting in the best interests of the client. The point is to attempt to, with their personal model of recovery at the heart of what we do, reestablish their functioning. So focusing on functioning is really, really important. Scores on metrics, unless we've done them multiple times, 9 million, 10, 15 times over the course of treatment, they are not objective. They vary at any point in time cross-sectionally. It's hard to interpret them. Working with optimism is the next one, showing people of the possible, demonstrating optimism and encouraging them to be optimists. And finally, a bit of a negative kind of thing to comment on that we must help people address their irritability where it is a problem. Irritability with the employer, irritability with the person who caused the accident or the event. Irritability with themselves. Sometimes there can be considerable shame about being on these schemes and where the shame and anger is only a hair spread for ways. So anger is such an impediment to recovery. We talk a bit about moral injury these days. I think it's an okay enough concept. It's a bit pat at times, I think there are some things to be morally troubled about. Let's be realistic. I'm a much more helpful idea. I think it's traumatic embitterment disorder. That's Lyndon. It's a bit different to my idea of angry PTSD. But I think people are more often angry when having PTSD than classically anxious. And I think the move in DSM-5 was in my opinion, but I'm arguing against some giants, believe me. But in my opinion, I think it was the appropriate thing to do. Thank you. Thank you for that. And Craig, your final thoughts. Oh, look, I fully support the comments of Tony. This is a really massive topic. I want to return to the wicked problem. That communication is so important and it's communication at multiple levels across multiple people. So what's happening? What's happening to Tracy's partner? Obviously, there's stuff going on with the separation there. Had that not been the case, how is that functioning? And how is the mental health situation and the work of a claim affecting or con-care claim affecting the household? These are really very important things and it may have income implications as well. So as you're dealing with the psychological issues and the sort of medicine of the psychological situation as a GP, I'm also running parallel a whole lot of other things. What's going to happen if the income stays as it is? Have they got options to mitigate that? Are they far enough ahead on the mortgage? All that sort of thing comes into it and how are they socially functioning? I think the hierarchy that I use is a really nice little practical tool and harks back to some of its lovely to hear. Tony's very well founded, detailed knowledge pointing out that function is what we really want to look at and that the rating scales and stuff have some benefit but always look at what's in front of you. And for employers like Christie and others, making available the relevant people, the people that have the power to make decisions to share the information. And also those contact points, I had spoken for various reasons, had to contact con-care the other day to find the number that I've been provided with was just a general call centre and the person I was talking to had access to the case but had no knowledge of what was going on and particularly for psychological cases this can be a bit of a problem. Thank you. Well thanks Craig and the employer does have the final word. So Christie, what's your summer? Thank you. In summary, there's a couple of points I'll touch on and the first one is that employers obviously play a crucial role in realising return to work outcomes but ultimately they should have a strategic focus on preventing injury and illness and an abling early intervention that's reflected through their strategic documents, their cultural aspirations and leadership frameworks as that will all help to shape the culture and reduce the stigma associated with discussing and reporting mental health issues. Tony touched on it earlier as well but human-centred design is important in developing processes and focusing on the employee experience. It's incredibly important as an employer that you balance the experience of the person against the need to deliver on operational outcomes which I know can be a challenge. Lean into the problem. Don't do it alone. There's significant power in top-down leadership and using executive sponsors or champions can be incredibly powerful through being an influential communicator within the business, debunking myths associated with return to work processes and red manning of providing critical and user input to new initiatives and governance to ensure it is fit for purpose. And I guess my last point will be staying in contact with the employee. Don't let them be out of sight, out of mind. Keep their needs at the front and centre of your thoughts and make sure they feel valued and connected to the workplace still. Thanks. Thank you so much. Thank you to all our panellists. I'm just going to ask people not to leave us straight away. We've got a couple more things to do in this last minute. And the most important is to get you to give us some feedback on tonight's webcast. It's really important to us to know how it's gone and what we could do to improve these webinars and make sure that we're meeting your needs. So please do get on to the feedback links that you can do by that QR code there or to the survey monkey address, which will be there as well. So please give us feedback. For more information about Comqer, you can visit their website. The next webinars coming up for MHPN will be on emerging minds, practice skills to promote infant and parent mental health in the first 12 months, which is on Tuesday the 15th of August and another one in August on the 24th, which is looking at and relevant to tonight. Latest innovations to embed and sustain trauma-informed care on Thursday the 24th of August. Now, you might be aware that MHPN's networking programs supports practices to meet and network with others from their local community. And there are more than 350 of these networks across the country. So you can visit the MHPN website to find your nearest one and start one up. You can also send a message in offering to do that, start up a network around your area geographically and of expertise. Before I close, apart from thanking our panelists again and also for the very active discussions that were occurring amongst participants tonight, I would like to acknowledge the lived experience of people, carers, and colleagues who have lived with mental illness in the past and those who continue to live with mental illness in the present. So thank you to everyone for your participation this evening and I wish you good evening.