 Good evening. Welcome to this MHPN webinar on the topic of grief, trauma and anxiety. This is brought to you by MHPN, which is an online professional networking platform designed to enhance and promote interdisciplinary mental health care across Australia. And tonight we have three outstanding speakers. We've arranged for you to hear from some of the brightest stars in the constellation of Australian trauma professionals. You are in for a real treat. So welcome everybody. Pour yourself an orange juice or a small glass of cardiovascular protection fluid and prepare to consume a veritable smorgasbord of blue ribbon expertise. The webinar is hosted, as I mentioned earlier, by MHPN. Some of you might not know. This is a Commonwealth funded project supporting the development of this interdisciplinary collaboration in the local primary mental health sector across Australia. So we will have all sorts of disciplines listening today. It's currently supported by 500 local mental health networks and if you want more information on MHPN after this, just go to their website, which is on your screen. On top of that, today's learning objectives are really quite straightforward. We're trying to give you some practical skills, some knowledge and some strategies which will enable you to identify mass, personal and or various trauma in patients, in treatment teams and of course communities as a whole. We hope at the end of today you will be able to recognise some of the principles of intervention and of course the roles of different disciplines in providing a staged response to trauma, including of course psychological first aid, psychological recovery and post traumatic mental health conditions. The webinar will be comprised of two parts. We will have an interdisciplinary panel discussion so it will be a bit different from other webinars which focused on a case study. And then we'll have questions and answers which are fielded from the audience itself. And I look forward to reading those and passing them on. Now there are a couple of ground rules that we have to stick to. I'm going to moderate the panel discussion and if you send some questions through to me I'll pick the best one. So please submit your questions for the panel just by typing them into the little message box to the right hand of your screen. And if your specific question is not addressed or if you want to continue the discussion you can do so in a post webinar online forum on MHPN online. Please make sure that your sound is on and your volume is turned up on your computer. And the webinar recording and the PowerPoint slides will all be posted on the website within 24 hours of the live activity. If you have problems during the webinar please ring technical support on 1800 733 416. So according to the Australian Centre for Post Traumatic Mental Health up to 65% of Australians will experience a real or perceived threat to their life or safety or to their loved ones. Now this might be in the form of a car accident, an assault, bushfire, a flood, a war or even a terrorist event. Almost anyone who goes through such a traumatic event will be affected. How organisations and health services respond to trauma can of course have a lasting impact on a person's ability to recover. Now thankfully most people recover on their own with the support of family and friends but others may develop mental health problems and will require more help. Their problems may include anxiety, depression, post-traumatic stress disorder, risky alcohol and drug use together with difficulties with relationships, work and daily life. But we believe that emotional recovery is as important as physical recovery if people are to go on to live fulfilling and productive lives. So to kick off tonight we're going to hear from Janice Hinson. She's the Director of Social Work Services at the Royal Brisbane and Women's Hospital. She's recently returned to this role after a secondment to the Human Social Incident Management Team as deployment manager for disaster recovery for Queensland Health during the summer floods and cyclones in Queensland. So she'll have plenty of expertise. So I'll hand over to you. Okay thank you very much Michael. I hope everybody can hear me because my computer seems to be looking very strange. Can everybody hear me? I can hear you loud and clear. Excellent. Thanks. Well I'll just continue and if it drops out just let me know. We'll go. Okay. Well thank you very much for that terrific introduction. I thought that I would start to the proceedings off tonight by doing a bit of a case study approach to what happened to us here. And just to run through a few things and then very happy to take questions after that as we go through the night. Well look I was tapped on the shoulder at New Year this year to come in off leave to secondment to what's called up here the Human Social Incident Management Team which is part of the Queensland Health Disaster Management Response. And I was brought in originally as planning manager but I realised from the first days that the need wasn't for this role which was very much more at a strategic level but for a system in getting help out to affected communities. Now Queensland Health had broader strategic systems in place and a well defined partnership with other agencies such as the Queensland Police Service, Emergency Services and so on. But I felt that there was a great need for deployment systems down on the ground which actually weren't in place. Now I'm the chair of the Queensland Social Work and Welfare Leadership Group. So fortunately I was able to put out a call through my network for volunteer deployees because it was really a systems approach that I felt we needed to take. I had a huge response from Queensland Health staff so I started the process of setting up a database for these people. But they also needed approval from their line managers to participate. And let me tell you it wasn't always easy to find out who the appropriate managers were. I had a lot of interesting conversations with a lot of different people over that time. But the hospitals were really extremely generous in releasing staff often from departments which were depleted of staff who were also affected by the floods. And then of course those left behind became even more stretched as they had to cover their colleagues. So it really was a system under difficulties. I don't have much time to tell you about the highs and lows of the process that we went through because I'd really like to focus on what we learned about mass disaster. But just to give you an example we were located on the top floor of a building which was evacuated at the height of the flood. But unfortunately because the computer systems hadn't been set up for us at that stage we didn't get the evacuation notice. Eventually we realised we needed to move when the water started lapping up around the building. So we did move and had to quickly find another home and were relocated to another hospital. But again the phones and computers there weren't set up. And unfortunately that was also the day I had a request for the first group of 21 deploys. Now they had to be located, approvals obtained from their hospitals, tetanus injections given, psychological first aid training provided. Find out the sorts of transport that we need to get them there because of course the roads were all out. And then we had to transport the group to the flood affected areas of Toowoomba and the Lockheed Valley. Now I can tell you my mobile was running hot because I tried to set this system up. And I had calls from all over Queensland. So every time I ended a call there'd be six more messages for me to return. And it was quite a frantic time with technical people working all around us, deployees arriving, needing to be sent to their tetanus injections and so on and so on. So it was a pretty frantic day that day but we did it and we did it on time. So I guess what are the lessons we learned? Well the first is don't expect your emergency offices to be set up. You're involved in a mass disaster. The chances are that there may actually be some accommodation for you somewhere but those rooms, even if they are specifically emergency rooms, won't have been used for quite some time. So computers won't be set up, phones won't be on, all that sort of thing. So you'll just have to cope until all of those systems are set up and that can actually take some time. I mean for instance we didn't even have hot water where we were for a while so we couldn't even make a coffee for ourselves, let alone for the deployees who were coming in and out. However once we got going we had access to so many resources and for me having worked in many organisations where resources were pretty stretched, that was just an absolutely wonderful experience. For instance we couldn't get the first group out to all of the country areas they needed to go to. So what happened? We managed to get a raw flying doctor service helicopter. I can tell you the deployees were pretty stoked about that because apparently the pilots were pretty cute. The next issue is that there's no one answer to fit all in a disaster and that you have to stage your responses. The next thing is that the first thing you have to provide is psychological first aid. And we can talk a little bit about that and what the processes of psychological first aid are later on in the evening. But I wanted to say a few things about it and the first is that psychological first aid is not domain specific. Some people in Queensland Health originally felt that deployees should be only mental health staff and I hope I don't offend anybody by saying this but from day one both the affected communities and the deployee team leaders that I dispatched up to those communities were asking for social workers from acute areas and particularly from emergency departments and from community settings. And this is because there was a recognition on the ground that those workers are skilled in trauma management and in outreach to affected people. In fact our data showed that we had a 60-40 split of social workers and nurses with approximately 70% of the social workers coming from the acute and community context. Our experience was, and again I hope I'm not going to be offending anybody, but our experience was that some of the mental health staff struggled with outreach instead seeing their responses being centered only in the recovery centres and I have to say that those people were also criticised by their own mental health colleagues for this sort of approach. The best response was from those staff who took a first response approach of door knocking, doing things like handing out water as a way of approaching people, going to cattle sales, talking to farmers, finding out where the hangout spots were for the local community. For example in one town it was the local laundromat, somewhere else it was a GP surgery or the pub. One group went to a James Blundell concert out in the bush and mingled with the audience or people just walked around the streets and talked to everybody that they could meet. Really they just went wherever they could find people and this is clearly a vital stage because it's one where people become engaged. In the medium and long term stages post the disaster, mental health services have a big part to play. But again I have to say that's not for everybody because not everybody requires that level of assistance. Those medium and long term stages have also got to be respectful of the existing services in the communities which will often have been working very hard to manage during the event and they usually don't take too kindly to external agencies coming in over the top of them post the disaster and we have seen a couple of incidents of that sort of thing. And the next point is that we must recognise people's existing strengths and supports and how they're functioning at the time as a disaster. We saw some people who'd lost everything and immediately set about restoring their lives and others who lost much less but were gazed and helpless. I think the thing is that people come to a mass disaster such as a flood with all of their pre-existing issues and pre-existing ways of coping. So key issues in disaster management and I don't seem to be able to get my next slide coming up because I am having great problems here with the computer. It's okay. Is that okay? Good. So the key issues really are the importance of psychological first aid as basic care and that really involves listening to people providing practical assistance and listening and listening and keeping on listening. The second point is that I think we've got to recognise that most disaster responses are really a disaster in themselves because no matter how well we think we've organised things things will always go wrong and I think don't expect that the one disaster that you've been called up for might not evolve into another disaster. For example, the summer floods here merged into the devastating cyclones in North Queensland and then into the Christchurch earthquake for us. Then when the earthquake happened in Japan and all of the unrest was happening all over the world we all felt the world was going mad and for us sitting in our little bunker every day we kept wondering what was going to hit us next. You've got to be aware of the well-being of people that you send out into affected areas and I was really constantly concerned about their safety. The roads were very poor. People were walking through toxic mud. They were working long hours. When it first started we weren't even sure where they were going to be accommodated and a lot of people turned up with sleeping bags because they thought they'd be sleeping out in the field somewhere but in fact we were very lucky and we were able to put people into motels and the people in South East Queensland were actually quite lucky because they had good accommodation, they had air-conditioners and that sort of thing. Poor old groups that we sent up to North Queensland however just post a cyclone of course the electricity wasn't on and some of their motels had generators but they went off at 11 o'clock at night so our people had been working since about 7 o'clock in the morning through until 7 or 8 o'clock at night through that terrible heat and humidity that you get around Cyclone Susan. They dropped into bed for a couple of hours sleep. Once the generators went off of course it was really hot again and they couldn't sleep so by the time they got back to their home base they were really pretty spaced out from their experiences there. Okay, in terms of the process that we used in deploying people I established a process of a briefing here with us before they left putting a Queensland health team leader into the community so that those people had somebody locally that they could have contact with and then close contact in the field. That wasn't always possible because we didn't always have mobile reception so sometimes it was pretty scary thinking what's happening to our people and we couldn't get hold of them and then when they came back through Brisbane or wherever they... whichever town they were coming through we did a debriefing on their return. We liked to do a group debriefing but that wasn't always possible. For instance, we, particularly after the Cyclones deployed people from a weeper all over the place so obviously they couldn't come to Brisbane for a debrief so it used to be a one-on-one over the phone. We were also given employee assistance contacts in case they wanted to debrief further or they were particularly stressed about things that they'd seen and we made sure that everybody had that backup just in case it was necessary. Now look, we also learned as we went. I mean, for instance, the first group we sent up we did send a pack but it was a pretty poor pack. The last group we deployed were sent up with a pack containing masses of really practical things that we'd learned over time they would need. Jan, you've got one more minute. Okay. I think don't minimise people's internal and external mechanisms because most people go back to reasonable functioning. Realise that people often have a need immediately post the event to minimise their own distress. Remember that we're visitors in effective communities and people's lives that are very sensitive and vulnerable time and be mindful of that. Try to quickly identify the established or emerging leaders in communities and in teams of helpers because they can be very useful to you in terms of identifying community power dynamics and helping you avoid becoming embroidered and pitfalls. Don't forget that after the event as well as during, people need practical help and it isn't helpful for people to fight for months for resources to get back on their feet. Check on the welfare of your teammates and other professionals. That's a really important thing and I can't stress how important it is to spend time engaging with others and establishing genuine respect for rapport. For instance, don't say to a traumatised flood victim how it looks like rain. Be sensitive to what they've been through because our ability to do that clearly impacts on our ability to conduct accurate assessments of need and to gain the trust of those who are trying to help. You don't want to be seen as a fly-by-kniter by communities, particularly by our rural and Indigenous communities. And finally, I think I'd just like to say that despite the tragic circumstances all the deployees and myself found it to be an immensely rewarding experience and I met some wonderful people at all levels of help that I'd never spoken to. I felt as if I was again doing what I'd entered social work to do which was helping people and I was immensely proud of the response from all our staff. I hope that's the minute. No, that's good. Thanks, Jan. You've already got some comments from people watching, particularly a bushfire survivor from King Lake who agrees wholeheartedly with what you've said in regard to the first response saying it was vital. But we'll come back to questions for you at the end. Thank you very much for that. It's now my pleasure to introduce, well, let's be honest, a higher life form, a clinical psychologist with many years' experience in the assessment and treatment of mental health problems following trauma. Associate Professor David Forbes, he's the Deputy Director of the Australian Centre for Post Traumatic Mental Health and Associate Professor of Psychology in the Department of Psychiatry at the University of Melbourne and a chair of the Working Party for the Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and Post Traumatic Stress Disorder. David, over to you. Thank you very much. Thank you for that overwhelming introduction, I might say. And look, just to kick off, I do want to endorse what Jan has just gone through. Thank you very much, Jan. That's very, very informative in terms of the role of your, personally and for your organisation through the disaster in Queensland and to endorse all that you've spoken about and perhaps we can discuss some of those details a little bit later on in our presentation. Look, I thought that to mix it up a bit, I would go through a few kind of statements of principle, if you like. So it's a relation to kind of trauma, anxiety and grief responses more broadly rather than necessarily being pegged to disaster. But of course all of this does apply. And so these are principles perhaps for where we can talk about how do they vary and how do they adapt in the context of specific events perhaps afterwards. The first point really is to reinforce something that Jan has said really, which is for us to be crystal clear that responses do vary. They vary in terms of valence, but in terms of we often talk about terms like post-traumatic growth. So people can be negatively affected by these events, but they can also feel strengthened by these events. But those things can also coexist. It's not as though they exist as one or the other, that people can feel negatively affected and strengthened at the same time. The other thing to be thinking about is severity. That in fact responses vary considerably in terms of severity. For some people the functioning and mental health effects are negligible. For others they kind of range through right up to the severe end of the spectrum. And they can range in duration as well in terms of brief emotional effects through to long-lasting or even unfortunately in a certain case it's kind of permanent effect. So I think the key part is that there isn't exactly as Jan was saying, there isn't really a one-size-fits-all response to trauma that it does vary on all of those dimensions. The key underpinning issue is that a minority of people will develop serious mental health problems. The vast majority will be affected but go on to recover in one form or another. So the issue then for us is kind of raises issues about screening and assessment and what do we know about what the key predictors are for those that are likely to develop more significant mental health problems. If these responses do vary, how do we know and what are some of those indicators for people that might develop more serious problems? And here we kind of think really in terms of pre-event predictors, kind of event-related predictors and post-event factors as well. So I might just go through some of those very briefly. Kind of remembering that this would be a very kind of brief, principled presentation. Pre-existing vulnerability factors. So they're kind of history of exposure to prior trauma, history of mental health problems. But importantly, and I guess part of the good news is that the pre-existing vulnerability factors are smaller predictors than those that relate to the event or those that relate to after the event. So they're there, they're things that we need to be aware of in our assessments and in our screening process that they're smaller predictors. The bigger predictors come in terms of exposure-specific factors, the nature of the exposure. Key things there are the degree to which how predictable it was, how out of the blue it was, the degree of control the person felt they had during the event, the degree to which they felt that they or a family member's life was threatened, how long it went on for. So the more of those kinds of indicators that were present as part of the event perhaps the higher the risk. And I know here we're talking to some degree about natural disasters but to go beyond that we also know in relation to traumatic exposure that interpersonal trauma has a higher risk of mental health effects. Assault, particularly sexual assault, the highest risk of mental health effects. The other thing that relates to the event itself is the person's response. I've talked about peritraumatic responses, the person's response during the event and post-traumatic response which is their response in the aftermath. So some of the things we're looking out for in doing our screening and assessment is the degree to which the person may have had the higher risk types of peritraumatic responses which is dissociating during the event, feeling during the event as though time was slowing down or speeding up or they felt distanced from themselves, those kinds of more dissociative or felt numb, those kinds of more dissociative responses raise our antennae a little bit about its impact on recovery and also those that are particularly hyperaroused, particularly keyed up on edge where that just doesn't settle over the course of the aftermath of the event or the days afterwards. So they're the two, perhaps two of the higher risk reactions that we need to look out for in our screening and our assessment processes and of course if we have post-traumatic responses that appear to persist with high levels of distress that persist for days or indeed weeks afterwards. And post-event predictors, ongoing life stresses and as we know with disaster, disaster throws up not only the disaster but a whole series of life stresses that the disaster throws up in the aftermath of having to negotiate all manner of issues. But the other big predictor is social support. In my view really that's really good news because social support is something we can do something about and in fact social support is our biggest predictor of recovery. And if we're talking about significant mass disaster that includes not only personal social support but also issues like community cohesiveness and support more broadly. If we're thinking about screening also, often we talk about screening for mental health problems like post-traumatic stress disorder and a very important is often we gravitate to post-traumatic stress disorder because it is the disorder with post-traumatic in its title. But we do need to one understand that as we said there's a whole variety of reactions that people can experience. We're looking out for subclinical readjustment problems but also other common post-traumatic mental health problems like depression, generalized anxiety, simple phobias, traumatic bereavement and whilst I haven't got it there also substance use escalation and substance use disorders also. Whilst post-traumatic stress disorder is a common mental health disorder one might experience in the aftermath of trauma, it's by no means the most common one. Indeed, depression would be the most common mental health disorder people might experience in the aftermath. So there were just some brief issues in terms of screening and assessment for us to be thinking about and happy to talk about those in more detail later on. In starting to think about intervention and levels of intervention kind of reiterating what Jan had said earlier that really we think about these things in three levels. These are the three levels we thought about in Victoria in the aftermath of the bushfires as well as we understand have been part of the Queensland health response. So the first level is exactly as Jan was saying around psychological first aid. I hope that can be one-on-one as well as in the context of community development activities which I'll talk about further. Look, it is international consensus, psychological first aid. We also need to face that we don't have a great deal of evidence to support its effectiveness at the moment. We know that routine psychological debriefing as it used to be described historically, where routinely people are asked to in the aftermath of this event recount the details of those events. We know that it's not optimal to be going through these events using psychological debriefing routinely. And the psychological first aid does take evidence-based principles of what we know helps and applies those in the immediate aftermath. But having said that, I think we need to acknowledge that we need to build a strong evidence base to the effectiveness of psychological first aid. And I'll talk in a little bit more detail shortly about that. Level two is really for those that don't respond to the early intervention around psychological first aid who continue to have mild to moderate readjustment problems, a process that we will be describing, a process around what we've called psychological recovery, to be delivered by primary care providers, general counsellors, and there's some moderate evidence around some of those interventions, and then specialist interventions for those that actually develop frank mental health disorders, disaster or post trauma, and there we're probably on the strongest ground in terms of the evidence-based for interventions that we know work. In terms of psychological first aid and again to reiterate what Jan had said, it's really delivered by a range of people in the aftermath. It certainly doesn't need to be a mental health professional, provided peer on peer through local community supports, general health supports, and mental health professionals also, but it's certainly not necessarily just the domain of mental health professionals. And really it's about kind of basic support and making initial contact and engaging with the person in the aftermath, attending to their practical needs, issues, stabilizing and dealing with any excess levels of arousal. Also attending to psychological needs, managing distress, providing coping strategies, around managing distress, and critically as we're saying before, providing education and assisting people with engaging in social supports. Again, the finding around the importance of social support goes from disaster survivors, motor vehicle accidents survivors, assault survivors, veterans and military personnel. Really the finding around the importance of social support really cuts across trauma-exposed groups. So it's really something we can't emphasize enough. Having a look at the next level, and this is kind of a newer type of intervention, something we've called Skills and Psychological Recovery, and it's a flexible intervention that was developed in the aftermath of Hurricane Katrina in the US, and it's really identifying those who after the provision of psychological first aid continue to experience multi-moderate readjustment problems. And that people in those contexts may attend for one session, a number of sessions. It may be in the counselling room, it may be out in the field. So a brief flexible package, there was a quick assessment process where the process could drill as quickly as possible to the acute most difficult presenting problem and provide a useful intervention for that. The process that could be provided across the health spectrum with GPs, primary care providers, general counsellors, welfare workers, really designed to be as flexible as possible in terms of who provides it and where it's provided. The kinds of interventions included in Skills for Psychological Recovery are things that we know have good evidence bases from other areas of intervention. So things like providing problem-solving skills, for example in the aftermath of disasters, disasters throw up a whole manner of problems for the individual to have to negotiate. So in certain circumstances it may well be that sharpening problem-solving skills can be the most effective thing we can do to allow them to not only deal with the immediate problem they've got to solve, but the raft of problems that are likely to unfold over the course of the weeks and months ahead. Activity scheduling, assisting the person potentially, re-establishing schedules where they can get a sense of control and routine back in the context of an event that's thrown off their routine. An intervention for re-establishing healthy connections and social support, interventions for managing reaction and also providing some assistance where people are stuck in their thinking, which is getting in the way of their readjustment. And certainly again, Skills for Psychological Recovery is something we use in Victoria in the aftermath of the bushfires. I also understand it's going to be rolled out shortly across Queensland in the aftermath of the disasters. And finally, and I'm sure Mal will be talking about this in more detail shortly, the issue about evidence-based interventions for frank mental health disorders that occur in the aftermath of these events. And I guess it's important to not think of these things as necessarily phasic, where we provide PFA first, then we provide SBR, then we provide interventions for mental health disorders, because it may well be that for a small number of people they're developing quite severe acute mental health responses quite quickly. And Mal will be talking shortly about, you know, tertiary care and high level of care provided. But when we're talking about evidence-based interventions, critical is that we're talking about being able to provide these both psychological and pharmacological interventions for post-traumatic mental health disorders. And in the aftermath of a disaster, possibly a mass disaster, the idea about ensuring that these are potentially considering a competency development program where practitioners may feel like they've got a good idea at how to address these difficulties, but may need some training in order to feel a bit more skilled and a bit more confident in providing these kinds of interventions to survivors. So they were the key principles I just wanted to talk about at this stage, and happy to pick any of those up a bit later on. Outstanding. Thank you very much, David. It's now my pleasure, last but not least, to introduce Associate Professor Malcolm Hopwood, who is a Consultant Psychiatrist and Director of the Psychological Trauma Recovery Services at Austin Hospital. Now he's been in the role of the Director of PTRS, formerly the Veteran Psychiatric Unit, since 2000. And I'm very interested to see what you have to say. Malcolm, over to you. Thanks, Michael, and hello to everyone. It's a great pleasure to be here and a lovely daunting challenge to follow a higher life form. I will do my best. What I'm going to focus on in my comments tonight is really looking at the group of people who do develop more severe problems following disaster, and indeed many of these comments would be germane to people who develop post-traumatic mental health problems from individual trauma as well. I think I want to commence by emphasising something David said, that we need to be very wary in our care of individuals post-disaster in making assumptions about what proportion will be affected in a severe way in terms of their mental health. Out of, I'm sure, most often a natural sympathy for the plight of those affected, it often leads to a sort of assumption that all individuals will develop a mental health problem and that's simply not true. We know that rates of the kind of symptoms David was talking about earlier are very common in the first week or two post-disaster, but that by one month the proportion of individuals affected will have decreased very significantly and there's a further drop over the following months. Those comments are germane to a couple of questions I noticed popped up about separating out the symptoms of acute stress disorder from later post-traumatic mental health problems. Yes, I think the distinction is of some significance. What I'd generally be saying is that the role of mental health treatment in the first week or two isn't anywhere near as important as the other measures that make up psychological first aid. So unless someone's got very severe distress early on, the role of someone like me is in all likelihood fairly limited. In that proportion who then go on to develop an enduring diagnosis, David's already mentioned that in fact post-traumatic stress disorder is not the commonest diagnosis. There is again a natural tendency to lean towards that diagnosis but it's important to practice our usual level of diagnostic precision. After all, our evidence base is generally derived on the presence of a specific diagnosis with all the limits therein. The commonest major mental health diagnosis following disaster is in fact depression and probably the second most common is varying forms of anxiety that don't necessarily neatly fulfil full criteria for PTSD. David's already mentioned problems of substance abuse which we know although sadly not uncommon in our communities as a baseline, certainly increased post-disaster and obviously the pattern of that substance abuse will depend upon the affected population and probably the age and gender mix of the population as well. I think an important thing to emphasise is that comorbidity is common. So if we talk about a rate of post-traumatic stress disorder following disaster and a rate of depression for example it's important to acknowledge that many of those with the same people with two diagnoses. So comorbidity in this setting is probably the rule rather than the exception. You may notice that I haven't included traumatic bereavement in that list. Currently that reflects to some degree our difficulties of knowing where that fits in our diagnostic hierarchy probably including both where it fits in relation to other mood and anxiety disorders but also where the beginning and end of bereavement as a normal response and traumatic bereavement begins and ends. A couple of comments about reflected in the fact that many individuals post-disaster will not have an enduring diagnosis. One of the things we need to be very careful of as an unintended artefact of our interventions is that we don't end up artificially defining people by their trauma. So many individuals in affected communities will say yes there was a terrible disaster in our community I now wish to get on with my life. I think we need to be careful to observe and honour that and be careful of not by unintentionally making a diagnosis that may not be terribly relevant in fact make them feel further stigmatised to the future. I've also noted a couple of questions that talk about the need for initial interventions to be culturally congruent for the affected community. Undoubtedly true and that's equally true for the more significant mental health interventions and I might come back to that in a moment. If we then look at what are the symptoms of concern that if I'm involved in the response to a disaster that should lead me to consider this individual might need a higher level of care and obviously what constitutes a higher level of care depends on where you operate but I suppose I'm generally talking about tertiary level care. Unfortunately some of the enduring mental health diagnoses we see after disaster are associated with suicidal ideation and very rarely but deeply concerningly occasional completed suicide. In fact we know of the anxiety disorders at least some studies suggest post-traumatic stress disorder is associated with the highest lifetime suicide risk. We also know in assessing suicide risk generally that whilst we have often stressed the static factors in an individual's risk profile such as a family history of suicide dynamic factors are probably more significant in influencing suicide risk. These would include for example loss of home loss of family members loss of occupational role many of the barriers that many individuals post-disaster will face. So we're talking about a high risk time. So if in doubt for goodness they can inquire about suicidal ideation then please assess carefully and then manage appropriately. I would add that these are issues of a great concern to affected communities and certainly our experience post Victorian bushfires is that suicides within a community constituted a major re-traumatization of many individuals in the community. Of course depression and substance abuse are common in individuals post trauma and the question may be when is it sufficient that I need to consider a referral for a more intensive level of care? Well obviously depression associated with suicidal ideation but where substance abuse merges into dependence and detoxification will be required before intervention or where either depression and or substance abuse because they can co-occur may be sufficient to impair that person's capacity to participate in psychological therapies such as exposure based CVT other structured psychotherapies or even their capacity to participate in plain community recovery activities where they impair that to a significant degree may be a referral to a more intensive service might be indicated. One of the issues often confronting us post disaster is well that's great, where do I refer them to? So many disasters involve massive disruption of our usual health service systems. That might be as simple as the hospital that serviced this area is no longer there, the private psychiatrist who worked in this area is no longer there, the GP's surgery is now out in the ocean or is now a heap of rubble and the situation may be further complicated by the presence on the scene of a large number of caregivers. So one of the phenomena that's occasionally reported post disaster is the overburden of carers individuals arriving at a scene desiring to be helpful but in some ways often confusing our systems response. There's no simple answer to this but to acknowledge that our usual loci of care may be disrupted in thinking about how to operate within that partially disrupted system a couple of learnings from our Victorian response to bushfires might be relevant. Most people in disaster prone areas clearly prefer to have their services delivered locally. So considering how can we re-establish systems of care within a local context ideally with clinicians who are potentially familiar with that environment or at least familiar with major consequences of disaster. There's often a great dilemma about the capacity to develop specific services to respond to the needs of people after disaster versus upskilling if you like more general mental health services. The reality after most disasters is that there will not be sufficient specific services to meet that need alone so we need to do a combination of things but particularly we need to think carefully about who needs intensive high level care. We need to use those resources most effectively. Thinking then about the sort of treatments that we might find relevant in major mental health problems post disaster. A couple of comments I'm on to make and clearly it's beyond the scope of tonight to do a review of the entire evidence base around interventions for post disaster mental health disorders. What I would say is that we do now have a significant evidence base around disorders like post-traumatic stress disorder and major depression. What is clear is that that evidence base is very much focused around the discrete diagnostic categories and doesn't always take into account the comorbidities. Further in the case of depression and to a lesser degree substance abuse the evidence base we have is generally not based on individuals affected by disaster. So for example the pharmacotherapy of depression evidence base we have most routinely exclude people affected by disaster. So within those limits what we do know is that pharmacotherapy may have a clear role in the treatment of depression and indeed of substance abuse but the evidence is modest in circumstances like post-traumatic stress disorder. Generally for each of those conditions the cornerstone of treatment particularly depression and PTSD are going to be the newer antidepressants the SSRIs and the SNRIs. And there is an evidence base surrounding their use particularly in depression and to a lesser degree PTSD. In the way I think about treatment for PTSD a range of stages may occur commencing with engagement involving psychoeducation involving arousal management maybe involving pharmacotherapy and treatment of the comorbidities like depression and PTSD oh depression and substance abuse if you could pardon with the ultimate aim of moving to exposure based cognitive behavioural therapy wherever possible. So I think we see the treatment of severe PTSD is for some people the journey that's going to take a little bit of time. I realize that constitutes a pretty inadequate summary of what's a vast evidence base but I think it's important that we're all aware of the highlights of that evidence base and consider where our practice deviates from that evidence base why it might be so. Thank you Michael. Outstanding. Thank you very much indeed. Appreciate that. In terms of your last slide on referral systems did you want to speak to that? Oh I see we're actually going to go through some of these. Yeah sorry Michael I got held up along the way. That's alright not a problem. Okay well what we're now going to do are some questions and I'd like to kick off for the whole panel with the first one. I'm biased because as a child and adolescent psychologist I'm very interested in how might these presentations vary in children and adolescents and I'll start if I may with Jan. Yes thank you. There obviously is a difference in presentation. I think we probably if I could just say that screening tools are available and for instance we had a huge storm here that ran through the gap in Brisbane a few years ago and screening tools were applied and they found as we would expect that there was a low level of ongoing or long term distress and anxiety amongst the children which wasn't being overtly expressed so for instance the teachers were feeling oh the kids are okay they're coping alright because they just wanted that being able to express that and that was one of the things that we noticed also with kids going back to school through Toowoomba, Locky Valley and so on there had been some terrible things of course because the children died there were suicides and I won't go into it but there were really some terrible things and the children knew about that there was also some deaths of helpers emergency services and so on so the children did know all that and found it very difficult to express that so there was a lot of effort put in through our child and youth once things settled down to trying to get the kids to cope but with adults too like I was saying they respond the way they live one of the things that we always felt for instance was that it was very difficult to reach out to men particularly like country farmers and so on and you could have any number of services set up in a recovery centre but like a truckie from Grantham is not going to go up and do forgive me here but a psychiatrist sitting in a recovery centre and say I feel a bit depressed Doc it's just not going to happen so I think what you've got we really felt that what you needed was to be very careful how you offered help it was possible it should be preferably local preferably without the mental health label because that really did put people off people constantly said I'm not mad why are you sending out these people I'm not mad I've lost my house so there was a bit of a in the beginning it was very much I'm okay go to the person down the road they've lost more than I have and then after a while the communities became a little bit angrier about why should that person get this when I haven't sort of things like I was saying before varying stages and people respond varyingly but I do think with children it was very much more difficult thanks very much David look I'll predicate my comments by saying I'm not a child and adolescent specialist so I just predicate my comments with that first but I guess the key thing to be thinking about is you know that obviously reactions were varied depending on what the developmental stage and age of the child is and that we wouldn't necessarily be expecting to similar types of reactions but in younger kids we'd expect to see things like if we were seeing reactions things like withdrawal irritability or tantrums possibly other ways of acting out or increase in separation anxiety you know and in older kids we might start as the kids kind of age obviously would start to see symptoms that look more like we see in adults really we'll start to see things like irritability anger people being kids be adolescents being kind of bothered by the memories of what's occurred kind of withdrawal behaviour and kind of the kinds of depressive responses we might see in adults beautiful David I wouldn't have a lot to add to David's comments about presentations but would add the relatively non-symptom like presentations that younger children may have brings up an interesting question about how they're going to be picked up in our service systems so one of the areas we focused on in training post-Victorian bushfires was teachers, headmasters and other key community leaders who are going to have contact with kids mum and dad may pick up that they're kids that are stressed but their behaviour at school may well be one of the greatest indicators of what's going on so he devoted quite a lot of effort to that and I think it's worthwhile that was particularly useful in noting that in a severely affected community any of the adults who are responsible for picking up a child's distress may of course be dealing with their own distress so if a child has confronted a traumatic experience it's got to be a reasonably high possibility that mum and dad did as well so if we've informed their teachers and other key community leaders the greater the chance that someone's going to pick up on their distress and seek appropriate assistance Alright, brilliant I'll go to some of the questions from our audience one of them related to whether media played a role in increasing post-traumatic stress disorder Jan I think it's a bit of a balance isn't it because you need to inform people and the whole of Australia is interested in what's happening in areas like this and what they can do to help but I think it can sometimes become news reports for their own sake rather than it is something that's very helpful and I know that people in our affected communities got very very angry with the number of media personnel that were rushing around the place putting microphones and cameras in their faces I forget who it was but somebody was talking before about the number of helpers that can descend on a community and it was immense we had an organized response through government resources but then all sorts of other groups started coming in so people would say to us we've been door-knocked and spoken to 50 times today would you please go away I just want to get on with cleaning up my house so I think continually personally the things that we were told I think that continually having the traumas in front of people can be very stressful for people and certainly that's what people were telling us that they would just prefer to get on with things and you sort of get to a critical point where you can get stuck in it and it's so difficult and so stressful that you really do need to once you've got over all of that immediate sort of hideous shock the people were telling us that we just want to get on we don't want to keep seeing it repeated again and again in the same stories again and again so I think it's traumatizing whether it does anything further so thanks David just briefly to say a couple of things that Jan raised one was the actual contact with the media and the continual contact with the media and I think we do need to be conscious of trying to protect people in the immediate aftermath of trauma where they find themselves in situations where they're exposed to responding to the media in a time and a place that they're just not able to do so so I think we do need to be cognizant from exposure to the media in the early phases look the other issue is the kind of exposure to media coverage and as we've seen now we can often have 24 hour coverage and I think that whilst the media therefore we would encourage people to get information from the media and the media could be a tremendously important source of information having said that we would be advising people to limit their exposure to the media get information from the media and then to give it a rest and to continually be exposing themselves to the 24 hour coverage can certainly not assist I won't go as far as to say we've got strong evidence to say it's definitely harmful but I'll be pretty confident it's not assisting in their recovery and I guess that would be particularly true for very young children absolutely right, the parents do need to assist to guard their children's exposure to the media which can often come on in the middle on TV I agree with David I think it's an unfortunate thing isn't it that you can't just get the smooth you get the rough and the smooth so one of the great needs of communities in the first weeks post disaster is information and our mass media is a potentially magnificent organ for disseminating information including might I add information about potential mental health consequences and pathways to care I noticed one of the questions that's popped up was related to how do we destigmatise mental health care after disasters and indeed generally and I'm sure one of the ways is through good media depiction and I would generally say that if I think about the reception that mental health response post disaster gets it is on average better than it used to be and I think part of that has been the use of the media for good at times but it does unfortunately come with those intrusive risks and we all you know they don't need to be elaborated on they're definitely there okay while I've got you there another question is when might inpatient care be considered yeah just occasionally it is an issue that we need to think about post disaster clearly someone who's intensely suicidal would be one of those indications we have a responsibility to keep people safe it's actually quite interesting that our responsibilities do that isn't any different post disaster to other times but our response to suicidal ideation is sometimes influenced by feeling like because they've been affected by a disaster I couldn't do an assertive intervention like inpatient care and I think we need to be just careful of that for those who develop substance dependence inpatient detoxification can be useful a third small group that I think it's really important not to forget about disaster aren't selective in who they affect and amongst the people they affect will be individuals with pre-existing serious mental health problems so if you have schizophrenia and your doset box is burnt in a fire along with your accommodation and the case worker who came to visit you is preoccupied with many other things post disaster or in a difficult spot and they're a very vulnerable group and one could extend that to other conditions of course that we need to not forget the most poignant symbol I saw of that was about four days post hurricane Katrina most people will probably remember the images of people gathered around the football stadium in New Orleans which is as close to a high point in New Orleans as they get and on about the fourth day there was a group of several hundred people gathered in the football stadium all of whom when you looked at them looked a bit lost, looked a bit unfamiliar didn't look well dressed they're in fact the residents of the local psychiatric hospital in New Orleans which was built surprise surprise in one of the lowest areas of New Orleans just a poignant demonstration of a group yeah, brilliant a very interesting question I think to consider do either of the other panelists have anything to add to that? not to that but am I able to give a comment on the previous issue that was discussed? of course and I apologize I seem to have lost my camera here so I'll just press on if people can hear me that's all that happened of God David look I just want to talk about the media just to let people know I think about an organization called the Dart Centre in Australia and really the Dart Centre are doing some fantastic work in working with the media in terms of a responsible role for media in the context of trauma and disaster often media are the first people on the scene in the aftermath of a disaster as well and conscious of the degree to which people within the media are themselves affected so I just did want to talk about the fact that the Dart Centre is doing some great work with the media one in terms of how to assist journalists in the aftermath of these events and also about assisting them to develop standards and processes for supporting those who are affected themselves can I just add too I think that's some excellent comments because when I was talking before about needing to care for the carers we've also got to remember there are other systems that intersect with what we're actually doing in the disaster management and part of that systematic approach to it is what's happening with the media and whereas we were sending Queensland health staff out who saw some pretty terrible things but they had a system of supports and debriefing and so on available to them they also had a professional skill base behind them journalists have their own professional skill base but maybe not the sorts of things that would support them through seeing some of the stuff that they had to see so I think that although that's what I was saying before it's a balance between what the media can very sensibly and usefully provide and looking after themselves as well Brilliant thank you for that another question has come in about the limitations of CBT and what other structured psychotherapies might prove useful Janne I think I'm probably better to sling that over to our other two presenters I was just being polite David and can I just say I've not only lost my camera I've lost my whole screen with the questions coming up as well so if anyone listening to this you can come in and rescue me that would be appreciated so look in terms of CBT look I will go out on a bit of a limb here and say that in relation to disorders like post-traumatic stress disorder, depression panic disorder simple phobia is the kinds of disorders we might more likely see in the aftermath of trauma and disaster that CBT probably is one of the is probably the paradigm with the strongest evidence base so I wouldn't be saying for a minute that CBT has a monopoly on the effectiveness of interventions but it's probably one with the strongest evidence base but there are important other interventions like IPT interpersonal therapy developing a strong evidence base and some evidence base growing also for acceptance and commitment therapy that's starting to generate some interest also but I probably would say that at the moment the strongest evidence base probably would be in the CBT area but importantly probably mainly because that's the area where there have been most investigations and coming back to the principle of absence of evidence is not evidence of absence that's not to say actually that other interventions aren't very effective but there probably haven't been as many kind of controlled trials as there have been in CBT I can now I'd support those comments entirely and just add a couple of things on top I think what's terribly important is to think about an informed discussion with the person in front of you so we share a knowledge of an evidence base that of course most of the people who come to see us have no knowledge of whatsoever and we clearly have a responsibility to discuss with them the relative merits and the relative weaknesses of all the treatments we can potentially provide I think it's also important in many people post-disaster that discussion happens at a time when their best place to think through the issues involved so for example the individual who's currently homeless, penniless and not quite sure whether the rest of their family is is probably not in a really great position to decide for themselves whether they wish to commit to CBT or act similarly if they're currently suffering a severe depression or they're currently alcohol dependent that's not a great time to either think about or commence such a therapy so it's about appropriate education and discussion and appropriate timing Can I just add something there too quickly having said that I wouldn't, sorry I think that one of the things that we've noticed through looking at complex trauma treatment is that the process of re-establishing and assessing meaning really does positively affect somatic trauma symptoms etc and that that may actually aid effective processing of further cognitive behavioural interventions down the track and I think we should remember too that memory in relation to traumatic events isn't processed in the same way as ordinary painful but not traumatic events, memory of a trauma is often broken you know bits of it are missing and I think that all the literature seems to suggest that healing from that sort of complex trauma happens independently from memory processing and probably doesn't have positive effect in treatment outcomes so that a lot of psycho-educating of clients regarding memory and trauma can be quite useful towards normalisation Yeah brilliant David a question for you what if any instruments in terms of psychometric instruments would you recommend in the screening of a Fort trauma so if we're talking about screening for trauma so if we're talking about very brief screens so there's a brief screen called kind of screen for primary care which is basically just four items just trying to pick up key groups of trauma symptoms so it's called a primary care screen if we're talking about screening for PTSD more broadly something like the post-traumatic stress disorder checklist is a useful screener public domain good psychometric properties and if anyone wants to email me I'm happy to kind of send them the links to getting a copy of that but important to say remember again that they're screeners for PTSD screening for mental health problems post trauma more broadly things like the K-10 are kind of useful screeners for general mental distress general mental and emotional distress what I've called just screenings for the level of distress and also starting to kind of identify what are some of those other risk areas that we spoke about earlier on now look I wouldn't add too much to that I think there's clearly a balance in these matters of feasibility of an instrument and they're appropriately well tailored I don't want to add to that to consider never forget the substance abuse dimension given that alcohol remains the substance of abuse in our community the audit is a very simple scale that often yields surprisingly useful results in knowing just how much someone's drinking support the use of the audit I think that's a great idea we've got about four minutes left so I'm going to ask for some very quick question, quick answers how does attachment theory inform current practice Jan was there an attempt to keep families together in Queensland oh yes absolutely there was it was it was very very important that we did do that and we really focus very much on trying to do it the other thing too is that families came to the disaster with their previous issues so we did also find that there were a number of trial protection problems that surfaced and so on so they had to be addressed too but it was important to keep the families together okay David did you want to say anything about that? absolutely other than to reinforce that maintaining the family integrity in the aftermath of trauma is critical given what we're talking about attachment and social support and familial support these things are absolutely critical and one of the most potent predictors we have in terms of ongoing development of difficulties or otherwise and to echo that beware of the family whose attachments were poor prior to disaster they're clearly an at-risk and vulnerable group aren't they? yes it's a sobering thought to think that certainly if you believe Pat McGarry 20% of the Australian population already have a psychological problem so that's certainly important to remember we've got a message from a victim of crime's worker who spends his or her life listening to traumatic events they're wondering Jan if you could give them any advice on how they can cope with that other than supervision okay supervision is a really important thing but so is informal debriefing and to find somebody that you can you feel you can trust that you can just go and debrief with in a much more informal sense self care is very very important and I think one of the things that in the sexual assault field that we talk about a lot is getting workers to avoid seeing the picture of the abuse narrative and while it's absolutely vital that the worker empathically and actively listens to the client's disclosure they really should try not to visualise the traumatic events in their minds because it actually does get stuck very often and particularly in sexual assault area where people are hearing the same things over and over again from their clients so try not to see the picture in a vertebrate commas I think that it's very important that the organisations that people work for are very aware of things like the carious traumatisation burn out and so on and that they have a lot of education about it. There's a whole pile of things we could talk about but certainly the self-care issue and avoiding seeing the picture is a very important way to go about it. The other thing I should say is that you don't need to feel healed in order to live a happy, healthy fulfilling sort of life and often as workers we want to fix the problem. Sometimes you can't fix the problem but you can help support people to lead a healthier sort of life and having that more realistic goal I think is a very important thing when you're working in this sort of area as well. Thanks David. Any advice to our sexual victims of crime worker? Look to reiterate what Jan has said but also self-care supervision is a very important part of the picture. The other part is that there probably is some value in not doing trauma-focused work all of your clinical work that they're trying to actually have some variety in not doing trauma-focused work as all of your clinical work. The other part of it also is important is to say that even times when your cases are all presenting with trauma related problems we're not necessarily engaging in the trauma-focused phase of therapy throughout therapy where there's a lot of work we're doing around it and when we're dealing with the trauma-focused phase it's done episodically as an episode of care. So as best as possible of some value in not doing the episode of trauma-focused therapy for all the clients at the same time. I think it is important that there is some balance and variety. Thank you. Mal, any comments on that one? Just to add that it's a really important question and I think part of the importance of that question is the capacity of this work to become overwhelming and to actually impact on the clinical care that you deliver. And that can be manifest in a whole lot of different ways from a sort of over-identification with the emotions of the person who's been traumatised through to a disengagement at the other end of the pole. So a self-awareness of how you're going in your own work and utilising all the measures recommended by others is really important. It's a great question. Thank you. Jan, I'll invite you to please give us your final three-minute reflection on any of the major points you wanted to make about group trauma and anxiety. Okay, a few things. First of all, systems don't always work. The best will in the world, they don't. And you have to be flexible and work within those. Always be aware of the people within the system and I think that it's very easy to when everything's falling about around you, it's very easy to forget that we've got a care for others that are trying to do the helping as well as care for the community. I think the thing we need to remember very much that particularly in a mass disaster, the first thing is an outreach role and we must all of us learn how to do that. A multidisciplinary role is incredibly important. I think that there's I think my biggest message probably really is that most people get over it and go on. They may go on as a different level of functioning, but most people don't completely collapse. Some people do and I think that's I get very, very concerned that we might miss some of those that end of line sort of situation with people and I get very concerned about children within a disaster system. There's a lot we can do psychological first aid is an incredibly important thing I would very much like to have every member of Queensland Health for instance trained in psychological first aid or anti-mortem interviewing that sort of process. I think probably they're the main things. Thank you very much. David. Look at Hartz and I what I'd say in some that's different to what I've said so far to do the truth, but I think that which is that in the aftermath of trauma and disaster there's no one-size-fits-all response. There's all kinds of different responses we see that vary along all of those paradigms. In terms of the timing of responses as well for some people they'll actually travel along okay and then there'll be a trigger down the track an anniversary or a loss or some other event that will occur and other stressful event that doesn't appear related and they'll experience difficulties. I guess the key part is that we have flexible interventions tailored to individuals that provide people the care that they need when they need it and that we also just keep monitoring and tracking people to be aware that in fact variations fluctuate over the course of time and that how people are presenting early on it needs to be monitored and monitored with some of the higher risk issues identified earlier. Thank you very much, Mal. Thanks Michael and thank you for your chairing and to MHPN. It's been a very interesting experience participating and I can't help but notice the level of interest the webinar has obviously attracted which is fantastic from my point of view and I sort of apologize on our mutual behalves. I can't help but notice all the great messages and questions we haven't dealt with that shows the level of interest there is in this area. In echoing what the previous two have said I think it's important to state that some of the principles we've been talking about are the result of enormous development in this area over the last 10 to 15 years. Disasters naturally bring out the desire in us to care and help people who have been affected by terrible things. But we now have a body of knowledge that tells us how to be helpful when to be helpful and also when to back off and the ultimate goal of anything we do should be to assist people to recover because most will and to identify well those who don't and direct them towards evidence based care and if we can participate as individuals in a system that helps do that then we've probably achieved a good thing with our working day. That's just fantastic. What a good note to end on. I'd like to thank all the presenters and of course I too am sorry that we couldn't get to all the questions. There were many, many more than we could handle but that's okay because you can continue this interdisciplinary discussion on the online forum on MHPN Online. I would ask all the participants to complete the exit survey before they log out and remember that you will be sent a link to all of the online resources that we've discussed and remember that the next webinar, mental health and intellectual disability will be held on Tuesday the 14th of June 2011 at 6.30 and of course you can always go to the website for more information. So I'd just like to thank all the people who have contributed to this most especially Nikki and Tanya who just do a most incredible job for MHPN and I thank you very much. I wish you all a very, very good night and we'll see you next time. Thank you. Thank you. Thank you very much. Thanks everybody. Are you still there panel? Yes. Yes. Well done. Just outstanding work. That was so interesting. Thank you. I'm so sorry about all my computer problems. I kept having major problems right the way through it. Oh my God. It was incredibly interesting. I really enjoyed that. Thank you very much. You're most welcome. Well guys, thank you. I'm sure Nikki will be in touch to thank you independently but I hope you all have a great night and thank you. Thank you very much.