 Good evening everybody and welcome to the nearly 800 participants we have joined in for the webinar tonight. We have three and a half thousand people registered which is a record for any of the MHPN webinars so it's testament to how important this topic is and it's great to have people collaborating together. So this is put on by the Mental Health Professionals Network in collaboration with ASCA and I'll talk about that in a moment. So firstly MHPN wishes to acknowledge the traditional custodians of the land across Australia upon which our webinar presenters and participants are located. We wish to pay respect to the elders past, present and future for the memories, the traditions, the culture and hopes of Indigenous Australia. I'm Mary Emma Layons and I'll be facilitating tonight's session. I'm a general practitioner and a psychotherapist working in Cairns in North Queensland and I've facilitated a number of the MHPN webinars in the past. So the first thing I'd just quickly like to do is to invite you to participate in a brief poll which Redback Conferencing is just going to pop up now. So if you're able to just answer the poll on your screen and we'll see how quickly it takes to get 800 people to respond. So I'm just going to keep talking while you do that. I did notice in the chat box at the beginning that there's people in some very cold places today so I understand it was minus three in Launceston this morning and even in Queensland it was zero in Charleville. I can assure you it is nowhere near that in Cairns at the moment and I think people in Melbourne say that it's about five degrees now. So it's one of the great things about these webinars is just having people from all over Australia. So I'm not sure if you saw on the poll there but we have a great distribution of people from metropolitan and regional centres and a couple of internationals. So welcome everybody. So before I introduce the panel to you I do just want to acknowledge the support of adult surviving child abuse in the production of this webinar. So you will have received the bios for the panellists before the webinar when you signed up and I'd like to just introduce each of them one by one. So first of all I'd like to introduce Jack Taylor. She's the coordinator of counselling services and Royal Commission support services and is from South Australia. Welcome Jack, good to have you with us. You've worked a lot with people who have been impacted by the Royal Commission into child sexual abuse and in fact I understand some of the funding for this webinar has come from the Royal Commission to help mental health practitioners support those people as well. So it's fantastic to have your expertise on this panel. I just wondered what first inspired your interest in this kind of complex area? I have had an interest in complex trauma for many years and I think that probably started when I was doing my social work training and I read Judith Herman's trauma and recovery and it had a massive impact on how I thought about things and how I practised. I initially started practising supporting women experiencing domestic violence and so I have a really significant interest in interpersonal abuse and trauma, you know the trauma that generates. So for me coming into a service that was supporting the Royal Commission was tailor made for me and I'm really enjoying it and I'm really enjoying the fact that we're now having a national conversation about complex trauma. Yeah thank you so much Jack and also joining us from Victoria, well I know you're in South Australia in the cold places. Naomi it's from Victoria, welcome Naomi. Thank you. So you're a social worker and I know that you're very involved in training practitioners in the area of complex trauma and I wonder if you could just tell us a little bit about that that kind of training work and particularly with regard to vicarious trauma just briefly. Yes well I've been in practice since 1987 and when I first realised that I was working with people with severe dissociative disorders and set about looking for training and supervision and people to refer to I very quickly found that there really wasn't a lot happening in Australia at that time which prompted me first of all to be going to the states to seek out training and then realise that that really wasn't sustainable financially and so my business partner and I decided that what a great thing we would to do would be to bring people out to Australia so that mental health professionals across Australia could benefit from training from experts in the field and after I'd been working in the area because I was working with clients for 25 years and at some point in that process I realised that I was experiencing the impacts of vicarious trauma and so that was really what spurred my interest and the need to be looking after ourselves as much as we are looking after our clients and that if we really aren't paying attention to our own well-being then then we can very easily find that we're doing a disservice to our clients because our own issues get in the way yeah that's so important thanks Naomi it's great to have you on the panel thank you for inviting me and I'd like to welcome John so John Ellis is a survivor and a solicitor who provides legal support to survivors from New South Wales it's great to have you with us John and I wonder if you could tell us a little bit about the kind of work that you do with survivors yeah Mary will for the last seven or eight years that's been effectively the only work that we've done which is working for survivors of sexual abuse started off in a Catholic context and that's because a group of people contacted me because they knew about my own history of clergy abuse and my own attempts to see compensation and redress from the Catholic church and they asked me to help them to do the same thing so but that's expanded and particularly since the Royal Commission was announced we've been approached by people in a whole range of institutions that we haven't had dealings with in the past and in quite extraordinary numbers and while that's a it's an extraordinary time in our community to be having these issues addressed on a national scale it also highlights the I think the great importance of the groundwork that we put in to doing this work so working in a trauma-informed way and ensuring that people have appropriate support through the course of the process thanks so much John and it's a privilege to have you here and being willing to share those aspects of your experience and such interesting perspective to the audience to have someone who's a both from the legal profession and a survivor so it's great to have you with us thank you and last but of course not least is Professor Warwick Middleton who's a psychiatrist from Queensland and wears lots of other hats as well but Warwick I just wondered from your experience having been involved in this field for such a long time what are some of the best changes or improvements that have been made to better support people experiencing trauma well you go back a generation and the effects of trauma and in the causation of mental health outcomes was barely noticed and if you if you look at the sort of conditions that go with complex trauma dissociative conditions severe chronic PTSD etc they were just emerging a generation ago and if you if you look at all the research that's been done on you know mental health populations we find that two-thirds of the of the average mental health population in patient outpatient has been sexually and or physically abused and if you add emotional abuse you're probably up to about 80 percent you know and and that's you can't always say that that's that that's the only causation of their presentation but there's an enormous confluence of of data which shows that having a really lousy childhood with a lot of different forms of trauma and abuse means that you're going to have a lot of problems down the track so I think that the fact we're having a well-commissioned in Australia's of the magnitude that is with the sort of scope that it is this sort of pretty well unprecedented in human history and does lead to the next question which is one I can just sort of leave an open question while we're focusing I guess on institutional abuse and in the context of our case today the you know the biggest the biggest source of severe childhood abuse still actually lies within the family so thanks mary thanks warwick now just on a technical issue just like to let everyone know that because we have so many people on we've got 910 participants and the panel we're needing to go to one camera at a time just to optimise the bandwidth in the webinar platform so the just to let you know many of you have participated before but for those who haven't the mental health professionals network is funded by the Commonwealth Department of Social Services to deliver this PD webinar and a lot of other things to practitioners who support individuals and communities affected by or engaging in the Royal Commission into institutional responses to child sexual abuse so this is specific funding that we would like to acknowledge there's just a few ground rules and then we'll get into the juicy bits so just make sure that remembering that this is a public forum so when you type something into the general chat box which is down there flashing orange 950 people can see it so make sure you're happy for that there's an arrow pointing to it right now now if you find the chat distracting because it's extremely busy with this many people there's a small arrow in the middle of the screen you can minimise it if you don't want to see the chat and at the end of the webinar there'll be a survey and exit poll and we would love to hear from you about how you found the experience and suggested topics for the future and other such things and MHPN does take notice of your feedback and it has informed subsequent webinars in the past thank you to those of you who submitted questions beforehand which there were several hundred so it is not going to be possible to answer everyone's questions but many of you will have your questions answered as we go through so what's going to happen oh just to go over the learning outcomes we're aiming for a better understanding of the impacts the multiple impacts of complex trauma a better understanding of how services and practitioners can respond effectively and that's in assessment and treatment and supporting people and then some really practical take home tips about how we work together which is the primary aim of the mental health professionals network before we go on just to let you know what will happen is each of the participants the panelists will present a discipline specific response to the story that we read beforehand and then there'll be a discussion between the panelists and we will include the questions that you submitted beforehand and whatever's going on in the chat box within what's possible so without any further ado I would like to welcome Jack and just to remind you very briefly that we're talking about Brad he's a father of two and he's experiencing a range of symptoms which have seemed to have been triggered by remembering an incident from his childhood so Jack how would you respond to Brad were you to meet him thanks Mary I want to start tonight by just flagging some of the common effects of child sexual abuse as I think it's important for us all to have an understanding of these I think in my work with survivors the feeling of shame and responsibility is very profound and I think one of the most common things I hear particularly from male survivors is I let it happen that's so real for them can also be commonly feelings of anger and outrage and these can both be internally and externally directed experiencing as Brad is doing at the moment vivid memories intense feelings but also at the other end of the spectrum numbness and dissociation feeling isolated difficulty trusting people and experiencing intimacy and often for men what in particular but not exclusively worrying if they will abuse children and questioning their sexuality particularly if they may if the abuser was a male and difficulty in trusting their own judgment so I think these are just some of the effects but as would seem fairly obvious these really do have a very significant impact on people's well-being as adults in doing this work in supporting survivors and as a social worker what I found to be really important is to adopt a trauma lens so whilst experiencing traumatic events can result in mental health symptomatology as we're seeing in Brad's case study when you adopt a trauma lens what we do is we ask what has happened to Brad rather than what is wrong with Brad so briefly trauma-informed practice involves recognizing the trauma histories of consumers it can minimize retraumatization which can be all too common in system responses and really importantly abuse symptoms as adaptations which are coping strategies these were this this is how the child survived the abuse made sense of the abuse so these it's really important to acknowledge that these are adaptive also knowing though that for some of these at least they can become quite problematic as adults and lead to health issues and really importantly recovery is possible we know now from the neuroscience that the brain the the plasticity of the brain so people can recover from these experiences there is hope so Asuka and others are now asking for a new paradigm to be adopted particularly amongst mental health professionals and it's being referred to usually as trauma-informed care and practice for an organization to adopt this there's five principles that are really important and the first of those is safety and when by safety we mean that the physical and emotional safety of the consumer it's also about safety to be able to be in a counseling space from walking in the door to reception through to the counseling room and particularly the relationship where the counselor needs to be safe trustworthiness which is the worker the counselor demonstrating their trustworthiness through transparency consistency and what I think is really important a willingness to be tested survivors have good reasons to be hesitant around trust we need to earn that trust thirdly empowerment which means the work is client led clients centered and strengths based collaboration we share power with the client obviously there is a power imbalance between a relationship between counselor and client but we do what we can to be aware of that and mitigate against it a very importantly choice it's really important for the consumer to have control and choices in what happens in the work all of these fit very nicely with the social work principle of the client is the expert of their life what we know now because of the plethora of trauma research is that it would seem that good best practice is very much around adopting a phased approach to trauma treatment and those phases phase one safety and stabilization I'm going to talk a bit more about that in the next slide as that's where Brad is at at the moment phase two is what we call trauma processing so that's actually looking at and addressing the memories of the trauma but it's really important that that is done with what we within what we refer to as the window of tolerance and I'm not going to mention anymore on that because I know Naomi's picking that up and phase three but the point of phase two I just want to add is around the person being able to get mastery over those memories so they become integrated into a coherent narrative that is part of their life story rather than having the impact it's currently having leading to that that you know the the manifestations of the trauma responses finally phase three is integration which is looking at working beyond the actual experiences of trauma to focus on how the experiences have affected functioning and I find that that is often in regards to relationships these phases are not necessarily not always linear they can be quite dynamic but we certainly there's sufficient research now I believe to indicate that it's important to use a phased approach so just because this is where Brad is at I just wanted to spend a moment looking a little bit about the work that gets done in in phase one and I think it's fair to say that phase one is a particularly important phase and its importance can't be overestimated firstly in that phase is establishing a secure base in therapy the abuse has taken place in the context of relationship that is the issue with child sexual abuse it is a relational abuse so that is that secure base in therapy can take work and needs the work to be really aware of the issues that that can present and work really hard towards establishing a safe or at least a safe enough space increasing safety what we find with survivors is that they may you know there might be certain behaviors and that that indicate risk and so you know some conversation around that some assessment of that mutual assessment of that and some safety planning can be important I find psycho education to be critical and that is in relation to both the child sexual abuse what it is I don't think we can ever assume people know that particularly some of the less well known aspects of child sexual abuse such as grooming it's dynamics and also the effects and the prevalence but also around trauma because if you can normalise the responses and people can survivors can understand that what is happening to them is actually a very normal response that can make a significant difference it also is one of the ways that we can start the work of undermining the perpetrators tactics to silence the child by giving them some information that challenges that skill development is critical so that we can support clients to be able to self-regulate their emotions there's lots of different ways of doing that lots of different techniques but that you know if this phase is often referred to by the need to work on and support clients to develop skills what I find to be really important about this phase is that it needs to be done at Brad's pace and it can take time and that can be a challenge for those of us working in an agency context thanks Mary I'll hand over to Naomi about the therapeutic relationship the dichotomy that Brad and other clients in a similar situation have is that to get better requires an entering a relationship dynamic that is reminiscent in its structure of past relationships where betrayal and abuse occurred so as Jack said the relationship is unequal what we're essentially telling clients is you tell me everything but I'm not going to be disclosing anything about myself also that we have the control of you know how and when and where that we will meet with our clients and of course we also have the control in terms of saying well I will leave you when I need to when I go on holiday when I take sick leave and you know that that's sort of the deal that is being struck there also that the contact that we have is going to be behind closed doors and is confidential now this idea this notion of a private space is meant to make our clients feel safe but it's actually very scary and triggering for clients like Brad and so I think one of the important things that you know when we think about that in terms of working with a client with a history of abuse is to allow our clients to choose where in the room they may wish to sit also our job is to step our clients towards those memories feelings and knowledge that they understandably wish to avoid and so immediately this can set us us up to be experienced by the client as the perpetrator and then the final whammy of all of this of this deal that we're offering our clients is the notion that if you don't open up and make yourself vulnerable to me then you won't get better okay so this is a really important dynamic that we're needing to understand of the the risks that clients are taking when they come into the room and it's important to acknowledge that right from the outset that the relationship is unequal that any trust will be earned that the process is collaborative and also to give our clients information around informed consent what they might expect from the process and issues to do with rights and responsibilities and just basic housekeeping things too and to provide that information to our clients in writing so it's something that they can refer to as necessary Jack mentioned psychoeducation and I would agree with her it's absolutely critical for working with our clients to help them to understand what they're experiencing and to normalize some of the symptoms and the behaviors and the things that they experience which can cause them to feel as though but you know they are crazy that there's something really wrong with them and one of the useful things to help clients to understand is how their brain will respond when they're triggered so at the moment Brad is being triggered by things that he's hearing about the Royal Commission if he can understand what's happening is in in his brain that might help for him to say okay this is a normal response so teaching our clients around the functioning of the brain that the cerebral cortex when they're triggered that goes offline so our capacity to think clearly to be analytical to understand concepts and to reflect just goes offline and what gets kicked in is the limbic system and this is where the nonverbal renational emotional and gut feeling of our memories is stored implicit memories that are both feel-good memories as well as traumatic memories and so when a client is triggered what happened is that the amygdala fires off and it responds as if the threat is current and the person is flooded with sensations with emotions or images and thoughts which they may not understand what's happening or why and then of course that fight flight freeze or submit response can be activated and this is all feeling and responding you know very out of control for our clients Jack mentioned the window of tolerance when I think one of the things that we need to understand is that our clients will present in in two main ways we have the hyper aroused client who may be experiencing panic attacks they may be self-harming they may be filled with rage flashbacks sleep disturbance phobias those kinds of things or we might have the hyper aroused client the client that may be has you know a loss of pleasure and drive they're highly avoidant they may be stuck in paralyzing shame decreased affect and connection both with themselves and other others experiencing depression fatigue and withdrawal and so the a lot of the work that we're doing in phase one of our clients working within that window of tolerance is supporting our clients to manage those hyper and hyper aroused states we want to stretch them a little bit beyond their comfort zone but also to keep them within the window of tolerance is a large piece of the phase one work that we do in therapy and then they can apply those skills in phase two when they're actually working on processing memory as Jack also spoke about when we're looking when we look through a trauma informed lens we're going to be asking what has happened to this person rather than what is wrong with this person and from this perspective we can understand that all the symptoms and behaviors are adaptive and functional and this assists to normalize symptoms and behaviors that a client may feel a lot of shame about or that causes them to feel that they are crazy or abnormal and we can explore with them where the symptom and how the symptom or behavior is assisting them whilst over time developing new strategies to safely express the underlying conflicts another important aspect that is important in terms of psycho education to help our clients understand things is that transferring the blame for abuse from the perpetrator to the self is a self-protective strategy for a child so for example children in children's home or foster cares may be telling themselves that I'm so worthless my parents got rid of me and so I must be deserve to be treated in this in this way but also that what might back that up is if I'm good then maybe I'll get to go home too in cases of abuse where it's been abused by priests or rabbis or other religious people they may be telling themselves that this is punishment for being bad punishment by God that they are sinful and often children in those situations are told that it's a special secret between them and the perpetrator because I love you so much and others wouldn't understand and even when they're now adult can intellectually understand that it wasn't their fault and clearly verbalize that to us to us at a cognitive level and an emotional level that belief that feeling is going to be deeply entrenched so the cognitive understanding is not enough to shift it the complex feelings of betrayal and powerlessness and shame and also often pleasurable sexual responses that a child may have experienced during the abuse need to be very gently and safely processed and if we strip back the the layers of healing from abuse the complex array of symptoms and behaviors the memory processing and relational issues perhaps the greatest piece of the work that we're doing with our clients is grief and lost work which entails processing very painful realities and emotions if you're looking for the case study and other documents down in the right hand corner in the documents tab you'll find those and now I'd really like to welcome John to speak about Brad's situation from the perspective of being both a survivor and a solicitor thanks John. Yes well my my perspective is obviously slightly different from Jack and from Naomi but I've been on the the other side of the council from people like Jack and and like Naomi and that's I guess part of what's brought me to to be able to be where I am and to help other people so I'm a survivor of clergy abuse I've acted for now about 400 other survivors in my work as a solicitor I've been involved in the Royal Commission process both for myself and also in accompanying other people to private sessions and 15 years ago it feels like longer than that I was much like Brad I was in the same position as him where things have been going along reasonably well in my life and then all of a sudden the wheels started to fall off and things started to unravel and that was a very confusing time in my life I didn't know what was happening a little bit like Brad there's been something there that I knew about but I hadn't seen how it had been affecting my life and when it came to be triggered you know I was in a very confused state and the sorts of things that Jack and Naomi have talked about creating safety creating giving guidance and information some answers to to what was going on was was what I really needed because it was an confusing and and frightening time and I was lucky enough to to be put in touch with the sexual assault counsellor who understood about trauma and could support me to manage the really the fear of the unknown and to give me information and you know even though it was a long time before we put the pieces together the fact that she identified very early on in the process that what you're going through are symptoms of a traumatic experience and that it was normal was a great help to me and one of the first things she did was was provide support and she allowed those memories you know what that trauma was to come to me in my own time she gave me information about the sorts of ways I was going to react to situations and that was very confronting at the time some of the things that she was telling me was going to happen I didn't want to hear and I didn't want to know about but when they did happen I was prepared for and there was an enormous strength and comfort in being able to come back to that and a little bit like what Naomi was talking about about that that disconnect between the cognitive and the emotional responses the emotional responses came first but at some stage during that through that process I could you know the the information that was given was in my brain and I could you know connect the dots between the two and so that being able to to have that information to understand my behavior and my reactions was really supportive and also knowing that it you know I wasn't the first person to go through this and that being given that information up front about what was going to happen really helped to normalize that experience and those reactions so the sorts of things that I was provided with mentioned support including referrals to other professionals who could help the information and guidance that I've mentioned about what was what was ahead making the time building up that relationship of safety and trust before we started to to deal with the more difficult stuff and providing providing choices providing information about what each option may entail and all of those things are things that since I've been working with survivors I've been able to incorporate in our own practice so you know obviously you know we're not mental health professionals so one of the first things we're doing in in terms of that first stage of of the the processes Jack described it is to provide referrals to professionals making sure that people have that professional therapeutic support provide information and guidance about the process as Naomi referred to you know there's an imbalance in the power relationship in when people come to us for assistance and it's very important that we don't take that the great trust that we ask from our clients for granted and that we take the time to build up the trust in terms of the background of how we we worked out how we would approach working with survivors a lot of that initially was instinctive it was based on my own experience of what what I needed when I was at that stage and the stage that Brad is at but since then of course the ASCA's trauma-informed practice guidelines have been published and and we try and follow those so it's it's important one of the really important things was was that information about what lies ahead information about what the process is going to be like and how it's likely to be experienced emotionally by people and what's going to happen to them and and obviously that's you know in our own way within the the window of tolerance so one example of that is that early on I was very hesitant about telling people the you know how difficult it might be at the same time as giving them you know the commitment to provide the support and to make it as as as least traumatic as possible but one of the some of the feedback we got back very early in the process was when you know people did hit the wall with it when they hit those rough patches knowing that that was likely to happen made it much easier for them to cope with and so so that that leads on to the where I think I was before we we stopped which was providing choices and information about what option what each option may entail so obviously when people come to us there are various options about the way we can progress with their claim but there are also other things to be talked about such as do they want to go to the police do they want to engage in the criminal process what will that involve how will that affect what we're doing for them do they want to engage with the Royal Commission what's the experience of that likely to be and I think one of the other things that that I picked up from Naomi's talk is about providing that control over the process to the client so they have information and choices and they can choose you know how they navigate that that path and that's been really important to us I just wanted to pick up on one other thing as well that that that I hadn't thought about before but but I came out in in Naomi's session that sorry I lost myself there talking about you know giving the client choice about where they sit in in the room where we try and take that a look one step further we give a choice about you know where they would like to meet do we go to the client does the client come to us do we meet at a neutral venue and and you know those sorts of things have been very important in the way that we work with people so the key points out of our journey so far one of the things we've learned is that that each journey is individual and respecting that is important in building up the trust between the client and ourselves and being able to work collaboratively to to produce the outcomes that the clients are looking for um the critical importance of making sure that appropriate support networks are in place so you know whether that's family members professionals other services that people need um plus our our team so we we work as part of a team with with our clients generating that sense of of control in the process and giving real and effective control to the clients um and that the process and how they experience that personal interaction with us is going to be much more important than the outcomes that we achieve for people and the final point um people come to us and if we ask them what they want generally the answer is justice uh and that usually leads to quite a long conversation about what justice means for the individual uh and there are an astounding array of things that people want to get out of our process some of which we can deliver and some of which we can't but you know having that conversation take place and collaborating towards coming up with the best uh closest approximation to the client sense of justice um has led to two outcomes that um we feel has been very successful and the the final thing I just wanted to acknowledge was was Naomi's point about the this gap and the mismatch that that often happens between the cognitive and the emotional responses a lot of the work that we do deals in that it's a cognitive area so we're giving a lot of information to people and we we put that down in writing and and people understand what we're telling them um but through the course uh of working with our clients uh quite often uh the emotional reaction how things are felt um is out of step with the the information that they've been given and again just to come back to the point I made earlier that that having that information put in place is something that can come back to us is something that gives that state safety and stability in the process uh I'll hand over to Warwick on that note look I I thought um Jack Naomi and John gave an excellent exposition in respect to trauma-informed care so I I thought I'm in my limited time I might not try and and duplicate too much of what they said I'm reminded when I when I went to university to study medicine at the beginning of 1974 I looked literally on my about my first day I met a man who's become a long-term friend and it's sort of interesting in the context of Brad's issue that that it was only nearly 40 years later that that I finally learned the extent of his sexual abuse within institutions and he too he too as as as did John went on to give evidence at the Royal Commission I'm reminded that when Jeffrey Dobbs who was is one of Queensland's most notorious pedophile of thin offenders was finally brought to justice and evidence was uncovered that indicated that there were at least 300 children that he abused and probably many more but the reason why he was actually brought to justice was not because one of the people that he'd abused came forward and reported him but was because he'd become so confident and complacent that he'd left a videotape in his video recorder and sent it in for repair and it says it says everything about silence that that just how powerful shame is in in maintaining that sort of silence that you can have hundreds of people abused by an individual and society manages to shield them in silence I'm reminded also just and it's been current in the Royal Commission and Ballarat hearings of of cohorts of boys where extortion and extraordinary numbers where something like 30 percent of an entire class you know have ultimately suicide and all have been sexually abused and it's one of those poignant facts is if you actually juxtapose the death and destruction that occurs at the hands of some of these sort of abuses and compare it with the death and destruction psychological destruction that occurs at the hands of some serial killers you actually realize that some serial abuses of children actually are responsible for more death and more psychological suffering and and yet you know we lived in a society that until a generation ago was was shielded from all of this add in add in you know the average threat of and a common abuse of threat is that no one will believe you that that I will kill you I will do something to your parents or I will do something to one of your siblings and and you get a strong sense of why why this sort of abuse that Brad had becomes so hidden you think about the case of Jerry Sandusky at Penn State and he he was a high-profile abuser where the abuse went on for decades where in fact a man actually came in and saw him sexually abusing a child and still still the authorities and the institution maintained the primacy of the institution and throw in the other threat that that abuses not infrequently make which is that if if the victim says anything that they will do something to one of their siblings etc and you get a sense that why at the individual level silence has been so prevalent you could think that we are on the cusp of descending into an abyss because every day now we're reading accounts detailed accounts of the sort of abuse that Brad's an example of and yet it's probably it's probably not that we're going into an abuse it's probably that that's for the first time that we're actually recognizing what has always been there and somewhat amazingly in Australia the Royal Commission does represent you know a landmark shift in how society actually views itself and in fact it was reported in the press the time that the Royal Commission was instituted that that in fact the popular vote in favor of having a Royal Commission was was was you know in order in the average survey of something like about 97 percent it was unassailable this some level everyone everyone knew someone or had been affected in a way that that made it very apparent that that institutions whether they be churches orphanages sporting bodies professional colleges whatever if if people within them can abuse and exploit they will and everyone pretty well in society knows or feels a personal experience of such abuse just talk moving on just to just to look at what a society is like where where it's impossible to have a Royal Commission where it's impossible for people like Brad to be treated and you know we're slowly emerging you know patchily from from societies where where they were patriarchal male dominated where women and children had few or no rights where there are high indices of corruption little respect for human rights and a lack of a free press and if it's hard for a single individual abused by a particular sexual abuser to actually find a voice then you know think of a society where you know to say anything risks death or imprisonment I might just just brief very briefly just talk about you know what it is that you know Brad's struggling with and what what individual healthy self would be into an individual who's healthfully adjusted and reasonably happy with his life her life is able to experience a full range of emotion is able to actually feel and and know where they have been so it's very hard to know who you are unless you can remember where you've come from there are that means there are no compartments or gaps in one's history that one is able to be vulnerable one is able to have boundaries to be able and to order to have boundaries one's got a usually have lived in an environment where boundaries were modeled it's healthy to actually in the healthy spectrum we have people you know whose ego defenses don't rely on you know angry outbursts projection splitting denial button where where they can be altruistic empathic where they can share humor and where we're being with them actually feels rewarding the person without healthy self would you know has some of the characteristics that Brad shows where there's affective instability where they're rapidly triggered into into very emotive states and where those emotive states impact on loved ones and family members and that's so common in the people that I see you know who present sometimes in the fifth or sixth decade with histories like Brad's the the actual trauma and abiding shame and the fragmented nature of memory and the patchy fragmentary re-experiencing of affect as such that that that indeed in process processing has been delayed usually until some sort of interpersonal crisis or job related crisis actually intervenes to the point where finally they actually take the step to to engage in doing something about it a little has been spoken about about therapy and I'm just gonna say something very briefly obviously for therapy to work in all its stages and that there needs to be patient motivation that there has to be a reason that this person actually has got enough wrong with their life and the way it's going for them to feel motivated that they need and want to change it's sort of interesting when we talk about endlessly about models and the many hundreds of psychotherapy models but the you know the biggest the biggest variable aside from patient motivation is the actual the nature of the therapeutic reliance relationship and Naomi's you know focused on that that that trust is something that's earned you've got one's got to be very aware that these despite the fact that they may be high functioning professionals that in fact their vulnerabilities in your hands and needs to be treated with with great care but just a brief note about the royal commission I look I applaud you know Jack's role and John's role in the royal commission I've also had the experience of going along with a number of individuals who have given evidence in private sessions I'm enormously impressed by the extraordinary lengths that that the commissioners go to to validate and accept the individuals that take the enormously brave step of actually standing up and actually going to someone who represents a major authority in our society to finally be heard when for many the process is is validating a process that's been endlessly invalidating final message obviously the one that will be reinforced by the royal commission that that all all societies and all institutions will experience abuse and exploitation if it can occur it will occur so and and the way forward of course is that we have webinars that we actually have commissions that we hear from professionals and from survivors of this sort of abuse and that we get to a point where there's a critical mass that where this will never be put back in the box so Mary thank you thank you so much warwick warwick um now actually Naomi I know that you had a question for warwick and it's actually come up through the the chat from the participants as well so Naomi I wonder if to start off our discussion together you would address your question to warwick please yes certainly um warwick brad's been taking antidepressants now for over 20 years um they were prescribed by his gp in response to his stress and heavy drinking what are your thoughts about such long-term use of antidepressants and would you review would you review brad's medication in light of the long-term usage his recent disclosures of past abuse and current symptoms and sort of like following on from that question when might medication be of assistance to a person like brad and which medications and when it when might it buy when might medication be contraindicated okay that's that's a complex series of questions I think anyone has been on anything for 20 years whatever the drug it's it's wise to review it I can understand why people like brad get put on antidepressants and and it may well be it may well be that that that they do get some symptomatic relief it may also be that it makes virtually no difference and all you really inherit some side effects and some sort of sense of psychological dependency about the the issue of taking something that that wards off dealing with the underlying issues I think it's also a little a little hard to make a judgment on on you know antidepressants when someone's had some sort of acute crisis and suddenly there's a lot of emotion and and distress and and antidepressants aren't necessarily incredibly good as sort of active agents for immediate stress situations like for example brad you know having an argument with his wife which is triggered by the realisation or the bemerging realisation of his son embarking on a sporting fixture that brings back memories of brad's own abuse I think in I think that the pragmatic thing to do is is in the longer term is to is to actually see whether you know brad's any better off with without the medication if and you do get and you literally do get patients as soon as you decrease and you do decrease these things carefully usually that the patient feels worse you get others where it makes no difference and you know if it's working or they had some assistance by all means you know continue with it if it's if it's the most efficacious and one that has the least side effects which ones to avoid obviously you would avoid antidepressants that that are potentially you know likely to you know be more dangerous in in an overdose situation and I'm particularly wary you know about tricyclic antidepressants which are used far less frequently now but also be be mindful that you know some some antidepressants commonly have impact on sexual functioning on weight and you know ones be very mindful of you know whether whether brad does have any particular side effects in the spectrum as as you're probably intimated by the question it may well be that the major focus of you know of of brad's long-term journey to wellness will not be provided by antidepressants it will be on a sound psychotherapy that's trauma informed that's empathic and where there's a good therapeutic alliance thanks thanks warwick so yeah the the evidence is consistently that the therapeutic alliance and the psychotherapy is the thing that can lead to lasting change and medications can just help with symptoms sometimes so that was a really important thing to clarify now I think that it might be a good time to bring john back in and warwick i know that you had a question for john and you've already talked a little bit a bit about the royal commission specifically but i know that you had a question for john if i do i'm fascinated because john has literally had such a pivotal role in in the in the um public perception about the work of the royal commission and he's been enormously courageous in taking on one of the institutions that has been i guess a primary focus of the royal commission and given his experience um with the royal commission my question to john is when the royal commission has run its course what will be the main things identified concerning sexually abused individuals if any that could have been handled differently by the commission the work you're asking about the how the commission could have gone about its work from your from your experience of it and your knowledge of it that's far and i guess it was that when when the journey started there was no no um final template on on exactly how it should work but as we learned from it on as and as you've experienced it are there things that might make it better where were we to do it again let's i find that a very difficult question to answer because when the when the royal commission was announced as you saw there was no template for it um you know i and probably a lot of others certainly had some inkling about what a massive undertaking it was and and what unchartered waters they were going into um and i've just been enormously impressed by the way that they've gone about it that the you know the planning that has gone into the way they've gone about their their work particularly that part of their work where where they are interacting with survivors has um been very impressive one of the things that that we do that the rock commission doesn't do um it apparently is is um giving people choice about a commissioner so they've got um six commissioners they've got male and female commissioners um and they've got a variety of commission staff who would attend on private sessions but i haven't heard about people giving being given a choice about um you know whether there would be more comfortable speaking to a male or a female commissioner and you know i don't know how much that has affected the way it's it's gone about its work because i don't think that when people are offered a private session they know who they're going to meet um so you know there wouldn't be cases where you know people have refused a session without saying that it was you know because the person that they were going to meet with but i'm sure they've there would have been private sessions that that may have gone better if there'd been a bit more choice offered to the survivor about who they were going to meet with um and also you know it's difficult for the commission but um perhaps a conversation about where that private session is going to be how easy it is for the person to get there giving them a bit more more choice about that again you know they can't they don't have the the flexibility that we might have to say you know if you don't like what the places we're suggesting to meet you know we'll find somewhere else i do know that they do they do that i know that that um maybe not the commissioners but commission staff have had sessions with people in their own homes where they have haven't been comfortable to go anywhere else um but really apart from that i struggle to find something that i could could suggest that the commission may do better well that's great to hear yeah of course there's the broader questions about is is the commission broad enough you mentioned the issue of sexual abuse in families um a lot of people that we deal with don't fall within the terms of reference of the commission because they were over 18 when the abuse occurred um but you know it occurred in a and situation of imbalance of power or where our client was a vulnerable person in that situation um but you know that again the the scope of the commission is then just a massive undertaking and and you know the line has to be drawn somewhere and i understand that thanks John thank you both for that i'm looked i would like to bring in a question that came from the um the participants and i'd like to address it to jack and this was actually about resilience so do we know anything about um the numbers of people who actually have these kind of extreme experiences happen to them in childhood and in fact um do recover without ever seeing health professionals and and what jack do you think is some of this you know what what do you have well it's a very long question but can you give us some hints about what what you think helps make people resilient yes thanks Mary look i don't have numbers at my fingertips in regards to to respond to that question but i certainly would think that it is quite possible one of the things that has struck me in doing this work we're actually seeing as the commission is itself people you know in in older age groups and i've certainly met many people who have come to us where i've been absolutely amazed and delighted with their resilience where they've come not for therapy they've actually come to participate in the royal commission so they want support in having their private session and in some respects looking at it from a societal view there would be you know there would be those that might say well you know there are issues in their lives perhaps in relation to some of the things that you know middle class australian would kind of take for granted but when i see how they have a process how they function it strikes me that they've got an amazing ability to to manage their lives and the thing that i i think that i value the most is it is about what they value it is about them living true to their values and i've certainly met survivors who have gone through the most horrendous childhoods and and these are often those that have been in children's homes so they had no childhood as such that they struggle with identity but they've worked out who they are through what they believe in and what they value and they live their life now not so much dominated by what society tells them they should be worried about but what is true to their values so i'm not sure that answers the question but that's certainly a personal learning i have from doing this work and i cannot overrate how much you know resilience comes in all different manners and no matter what the presentation of a survivor might be that comes through our doors there's always some resilience they are here they have survived they've survived the unthinkable and we need to to respect that absolutely thanks so much jack now another thing a theme that always comes up in the mhpn webinars and this is particularly relevant in complex trauma a lot of the processes we've been talking about psychotherapeutically take a long time and for many people the only access that they have they can afford is through Medicare and the 10 sessions and many of our alert health practitioners often ask about how to manage that so i think that i might like to address that to Naomi if you have any comments on what if anything can be done in 10 sessions and how how would one make the decision about whether to work with someone who you know has experienced complex trauma under that restriction you look about it's a very good question and it's something that i'm asked a lot when i give trainings or during case consultations too i mean i've been in the very fortunate position of working in private practice and so clients that come and see me have been able to come as long as they have needed to provided obviously that they can pay for counseling i think that it really depends what you can do depends on the level of functioning and stability of the individual i think that if you've only got 10 sessions to work with i think you can do things but really what you're going to be focusing on is helping them to find ways to reduce their symptoms and this is going to be really very beginning work i mean i i don't think that you can do a great deal in 10 sessions but i don't think that that means that we shouldn't you know work with people when that's all they've got available but we need to be very very mindful that we are not opening up material and then you know pushing people out of the door where they've got nowhere else to be able to seek some support so focusing on on safety and stability grounding techniques those kinds of things i think are what you'd be looking at under some under such circumstances and and then encouraging them to come back the following year when they can get another 10 sessions thanks very much Naomi yeah look it's something that comes up every time and and i think it's particularly in our collaborative work sometimes we can find creative ways to work together with other professionals to make sure the person is supported in an ongoing way um i'd like to bring john back in this i know john you have a question for jack and i might get you to ask that first and then i'm going to come back to you with some more questions just about supporting survivors through processes but um john if you could just ask that question to jack which was particularly about something that happened for brad in the case study yeah sure um one of the things that sort of jumped out of the page for me when i read the case study was that the the councillor quite early in the in the sessions with brad asked asked him the question now were you abused and my question jack is was there a better way for the the councillor to explore that possibility than than just confronting brad with that give when brad hadn't said anything about abuse yeah thanks john and i i agree when i read the case study i noticed that too certainly in terms of of my practice i certainly believe that it's really important to explore childhood trauma but i also think how we do this is just as important so in my practice i like to ask clients firstly if it's okay for me to ask questions about their life including their childhood and explaining the purpose for doing this and explaining that it is actually okay for them not to want to answer certain questions so i might talk about um you know that sometimes things happen to us as children that can affect us as adults specifically i would avoid using the term abuse because i don't think i think for many people that's not necessarily a term that resonates for them or or that they would use to describe what's happened to them or they may be unsure about that so i find asking a more specific question more specific questions about their childhood can be useful and an example of that might be when you were a child did anyone ever do anything sexual to you that made you uncomfortable but when i'm exploring this i think it's really important always you know looking at safety and so you know in this engagement process and then following into the assessment it is about creating safe or at least safe enough space for the client to be able to disclose if they want to also though just as importantly is how counsellors respond so if we're going to ask questions we need to think about how we will respond to this and it's very common in my experience for a survivor to feel that they are a bad person as we've talked about tonight in how they've made meaning and sense of why the abuse took place so they might be concerned that once we know this about them we know this secret about them we will judge them accordingly so for me this this is an area that we need to take great care we need to really tune in to to the client in front of us where the client is at i also think it can be useful to share information about child sexual abuse including what it is the dynamics emphasizing the parent balance and how this is never the child's fault so you can put it out there really clearly and and prevalence because that that brings in that you know if they do share this they're not aligned this has happened to other people and common effects the one thing i noticed in this case study when i was looking at it was it made me wonder for brad what how much of a burden carrying the secret you know the secret that he kept pressing down and pressing down how much of a burden that must have been over those years and thinking about how i as a counsellor could support him just to begin to share that in a way that was safe for him having said that i do think it's important also to note that we you know if we ask and screen for for childhood trauma we don't need to probe for the details of what exactly has happened that that is not necessarily going to be appropriate at this point in time if a client discloses and of course they may not which is also okay then i would thank them for doing so and ask them how they're feeling about having done that and i would spend some time on them before winding up the session checking that they feel safe to leave that they feel grounded and even go through and explore you know what how they're going to get through the next few days or perhaps to the next session just to check in that that you know they are doing okay and that they're going to be okay with this thanks jack um and so i guess that what you know there may be times when you can't provide that safety and i suppose i think about um gps who maybe only have a very short time and yeah so there were a few questions from the participants just about when is it unwise to ask those questions and i think it's good to acknowledge that we need to think about it i'd like to take it back to um john and so um i guess for brad if he does decide to disclose to this counselor what happened to him if it's never been reported to the police um are there any specific processes that the counselor needs to follow in case brad decides to do that in future that's for john yeah i'm not i'm not really clear on on what the the question is i would certainly what jack had said in in terms of you know the counselor not delving into the the details there um but obviously if if brad wanted to spontaneously disclose and sometimes you know giving people that opportunity is the you know the opportunity they're waiting for to unburden themselves about it you know for example one of the first things we say to people when they contact us is you know we don't need to talk about the details um but some people want to and obviously that's that's fine um from from our point of view one of the early things we do talk to people about is um going to the police and if they are minded to go to the police then then we wouldn't in our role you know start taking down the the details or taking a statement from somebody about what had happened um we would have them speak to the police first but i i think that would be a different situation if um the person was seeing jack on a only and and had spontaneously disguised yeah that's really helpful john thank you for that mary mary can i just jump in and say a couple of things i was i was just thinking you know the related issue about um you know having disclosed and also the issue of making a report to the police and i think one of the things that it's really important to be mindful of is that um talking to a client if they haven't been to the police and made a statement talking to a client about whether that is something that they might wish to do it's really important i think to step the client through what the pros and cons or cons of taking that action might be for them and for them to be you know to have a think about and take their time thinking about um what would happen what would be the the outcome for them if they didn't get the kind of response that they hope to you know whether that's a conviction or whether it's um you know a confrontation with a perpetrator and hoping for an apology because if a client um takes that action goes down that path too early in their process um it may actually be counterproductive in terms of their healing um and so i always talk to clients about um doing that if that's something that they wish to do um at a point where they feel that they are resilient enough that they have enough internal resources to manage whatever the outcome um might be of taking that action thanks Naomi i think that was really helpful look i'm just so aware that there's a massive amount of stuff that we could talk about and that lots and lots of the questions that people have raised we just haven't been able to cover but we i do want to acknowledge that there was particular interest in different kinds of therapeutic approaches things like somatic treatments and the trauma release exercises and perhaps that um approaches to therapy might be a subject of another webinar um i just i think that i can give you about 20 seconds each to just sum up a key point and i think i will just put warwick on the spot first is there just one thing that you'd like to leave people with warwick yes that that society is changing that the royal commission represents the confluence of a lot of work by a lot of consumer groups and also supported by professional organizations and researchers that are actually pushing us beyond the tipping point i don't think i don't think our society is easily going to go back to to one of silence so while while there is friction around the edges and and at times um debates um i think that that what is happening is ultimately very healthy and i'm also mindful that that there is a great influx in the number of educational opportunities conferences professional bodies guidelines etc so all of that's positive thanks thanks so much warwick and Naomi i'll bring you back in and i just wanted to revisit what you your picture with the spider and saying come into the parlor is going to stick with me because that is we're asking people to come into this extremely private and vulnerable space absolutely yeah was was there something that you would like to say just to finish up look yes and i would actually like to focus on what we touched on right at the beginning in in the introduction and that's that's about self-care i really would like to um thank the other people on the panel and all the people who are listening in for their bravery and commitment to do this work it really is incredibly challenging it does take a personal toll um as well as a professional toll and it's so important that we take care of ourselves so that we can go on and lead sort of like enjoyable and productive lives um and be you know have longevity in the field so that we can keep doing the work thanks so much Naomi john any final words from you yeah well firstly to echo what Naomi had said that's a that's a great challenge in in the work um i i guess one the final point i'd like to make is that you know the importance to for people to have accurate information and whether that's from the the councillor the social worker the lawyer or um you know whatever other service provider that they're they're approaching that that um you know they need to have accurate information about what the options are thank you warwick and jack i wondered if you wanted to um just have the final word from our panel thanks thank you mary i wanted to make two very quick points one i just want to quote Shapiro that it's our ability to connect that's our best therapeutic tool just touching on what warwick said about the importance on the therapeutic alliance i don't think that can be overemphasized with this client group the other point i just want to make and following on from what warwick said about society changing we need to continue this very very important conversation as mental health workers we are we see people who have had these experiences we need to continue the conversation the royal commission is fine it will finish but we need to make sure that this remains part of our public discourse for much longer to come that's what i'd ask everyone to think about thank you thank you and that's a really good challenging note to end on once again i'd just like to thank everybody for participating um we do apologize once again for the technical issues you will be able to download the webinar and you won't have the same issues the slides will also be available um and you will get a certificate of attendance even if you had to drop out early so we apologize for that please do complete the exit survey and everyone will be sent an email linking you to all those resources within a week um our next webinar will be announced very soon so keep an eye out for your invitation and i'd encourage you also to look at your own um local area networks and if you wish to start a special interest group in your local area including around the subject of trauma please do contact mhpn for assistance in how to get that going and i'm just on a final note and i think this is really important i would like to acknowledge that um there are many consumers and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present and mhpn is here to support practitioners helping those people and in fact it's not a them and us it's most of us so i just want to thank everybody so much for your participation this evening and we look forward to seeing you at another webinar