 Hello, and welcome everybody to this webinar on tips and strategies in using technology for mental health consultation. A very warm welcome to all of you who've joined us for the live activity tonight. And I have to say that the number of registrations for this webinar is extraordinary. We're up to nearly four and a half thousand registrations, so that's incredible. And I think what it says is the level of interest among clinicians, particularly at the moment, in this topic. So welcome to all of you. Welcome to those of you who are watching us later on a recording. And of course, a very warm welcome to our panel who I will introduce in just a moment. Before we start, I'd like to acknowledge the traditional custodians of the lands across Australia, upon which our participants and our panelists are located. And I'd like to pay our respects to their elders past, present and future. OK, let me just say a word about the background to this particular webinar. The webinar is being organized by MHPN, the Mental Health Professionals Network, but on behalf of the Victorian and Tasmanian Primary Health Network Alliance. And I think it came about really in recognition of the fact that there's a whole lot of clinicians out there who are being asked to use tele-counselling in some form or another for the first time. And there was a feeling that there aren't many good guides around about it. And although there is some professional development activities, they tend to be very expensive and often not accessible. So hopefully tonight we'll be able to discuss most of the key issues raised in this area. And I'm sure that by the end, you'll find that it's been useful. My name is Mark, Mark Reimer. I'm a clinical psychologist in private practice and also a professor in the Department of Psychiatry at the University of Melbourne. And as a clinician, even though my private practice at the moment is fairly small, like everybody else, I've been forced to rethink the way that I do my therapy in these strange and peculiar times that we find ourselves in. And so I've been using telephone and some video conferencing to do my therapy. And I must say that I've found a number of challenges with it. So it's a great honor tonight to be able to facilitate this panel and to pick the brains of our esteemed panelists. So without further ado, let me introduce them. You've got their biography, so I'll keep it very, very brief. Our first panelist tonight is Monica Moore. Monica is a GP with over 20 years experience in family practice. She now specializes in psychological medicine. She's the coordinator of the Sutherland MHPN group. And she's also an educator training medical students and GPs in mental health issues. So, Monica, welcome and thank you very much for joining us. That's right, take it off, please. Just unmute myself, yes, I'll get off mute, yes. Good evening, everyone, and thank you for inviting me, Mark. It's a pleasure to be here. Well, thank you. It's a great pleasure to have you. Now, I thought that we might ask everybody just a little bit about their personal experience of social isolation. So I wonder if you can kick us off, Monica. What do you think has been the best and the worst aspect for you from a personal perspective about social isolation? I'll start with the worst first. I think for me, it's the fact that I haven't been able to hug my granddaughter who was born in February, and that's been quite difficult for me. And my children, essentially, and it's missing out on friends. The lovely thing, though, is the ability to work from home. I never realised I'd enjoy it so much. And the kindness of strangers. Mmm, very nice. The kindness of strangers, I like that. If we'd had time, I would get you to expand on that, but I'm afraid we don't. But thank you very much anyway, Monica. Our next panelist is David Zuerab. David is a psychologist in Melbourne's Western suburbs. He's got a fascinating career background that spans education, housing, occupational rehab and disability services. But for the last four years or more, he's been specialising in providing cognitive behaviour therapy to clients in rural and remote areas. Welcome, David. Thanks very much for joining us. I'm glad to be here. And I'm very honoured to be with the panel tonight. Thank you. Thank you. And let me ask you the same question then, David, just very briefly. From a personal perspective, what have you found good and what have you found not so good about social isolation? Well, you only value the collegiate support working amongst colleagues when it's not there. So I see that as a bit of a drawback. And perhaps the positive would be being able to... It's just being able to do your whole day from the one spot rather than having to travel to and from, say, the home office to the work site. So there's a lot of time on commuting, doesn't it? Yeah. But I quite agree that the nature of the beast, I suppose, is social isolation and that we really have to make an effort not to become professionally isolated, don't we? Anyway, thank you very much, David. Our final panelist tonight is Tessa Moriarty. Tessa is a mental health nurse consultant with many years of experience in both public and private sector mental health services. She's an experienced group and individual psychotherapist and has recently started to specialize in providing supervision and therapy via telephone and teleconferencing. Welcome, Tessa. Thanks for joining us tonight. Thank you very much, Mark. It's great to be here. So finally, your views. What do you think have been the best and the worst of social isolation for you? The best things have actually been having to learn and do new things. That's been awesome. I've been used to working from home, so that's not been new, but it has been lovely. And I guess the worst thing, like yourself, Monica, has been missing not having that contact with my grandson and, of course, my sons and my extended family and friends. And it's something, I guess, that as clinicians, we need to be very aware of in our clients as well, that they too are missing out on that close personal contact. Anyway, thank you, Tessa, and thank you very much to all our panel. It's obvious, isn't it, that they have a huge amount to offer us tonight. So I'm looking forward to getting into it. Before we do, can I just tell you quickly about the platform that you're looking at? It's very straightforward. I'm sure many of you have used it before. There is a purple button, which allows you to open the chat box and post comments or opinions during the course of the webinar. There's a blue button, which allows you to access resources, including slides and panel buyers and so on. I would ask you to withhold your enthusiasm at this point. MHPM will send you a link to access all the resources in a week or so, and then you can go through with all the time in the world. And then the yellow button is to do the feedback survey, which we really, really want you to do, but of course, you can't do that until the end. So just reserve that until we get to the end of the webinar. Okay, so tonight we're looking at tips and challenges for providing tele-canceling. And I should note that we're gonna try not to use the word tele-health. The reason for that is tele-health is the word used to describe the specific Medicare item. So we'll try not to use it, but if we do slip into it, and I know I will, please remember that we're talking about tele-health broadly and not the specific Medicare item. So tonight I'm gonna ask each of the panelists in turn to give us a brief presentation about their unique perspectives on the challenges and the tips of tele-canceling. And I've told them that they can only have five minutes. So if they're looking a bit rushed, it's entirely my fault. But then we'll go off into a broader discussion where we can delve down deeper into the issues raised. And that discussion will be driven in large parts by the questions that you are participants have sent in. And we hope that following the webinar tonight, you will have, first of all, an improved awareness about the opportunities, challenges, and risks in conducting mental health consultations by telephone and or video conferencing. That you'll also have some practical tips and strategies to use that are gonna improve outcomes not only for your clients, but we hope also for you. And as a result of that greater awareness and those tips and strategies that you're gonna feel more confident doing tele-canceling with your clients from now on. Okay, so I think at this point, I will, without further ado, hand over to our first panelist, Monica Moore, to provide her particular perspective on tele-canceling. Over to you, Monica. Okay, thank you. I'm just gonna put up my first slide, okay. So that slide just represents how I had to jump in on the 16th of March, feet first, what I thought was the deep end. But in fact, I think has proven to be much less challenging than I would imagine. And so in terms of what I was looking at and the opportunities and the benefits that I've concentrated on since I started, okay, working from home and I'm using Zoom, okay, that's what I've decided to use, is that some patients actually prefer it. They've said that it's really lovely not having to commute. I've got some who travel for over an hour. It also means that, and this is I've heard from colleagues, okay, who have patients in the residential aged care facilities that it has improved access for these people to even see specialist psychiatrists and to get their, anyone with poor mobility, it's a boon to have the telecounseling. It's a really efficient way for GPs to work because it means that only the people who really need to come in and be seen in the surgery need to be seen. And so it actually saves not only the time for the patient but also for the GP. And of course, as a GP, can I just say, it's lovely to be remunerated for phone calls and for scripts for antidepressants or whatever it is that the patient is taking. And one of those things my friend who's a country GP said is that isn't it lovely not to have to give them the appointment which is in three weeks time because it's non-urgent and they can actually get their results, their blood test results, so they're scripted that day because it just takes a phone call. I think it's also good for the environment because there's less pollution with all this, you know, less traffic and less accidents. I was, I know about you, but I was watching that sort of thing about, you know, Venice with no tourists and the water's so clear, the air's so clear. And as I said, I've really been enjoying working from home. So unfortunately, you know, the things that really frightened me at the start were what if someone has a reaction? What if they have an ab reaction, they're really distressed, they can't do anything? What if the platform fails? And so, you know, there are some patients where it's actually been a little bit difficult, where they've said that the lack of physical of human contact has been a challenge and also that sort of thing about Zoom fatigue. You know, what Jean-Pierre or Péter Igleria was talking about when he said it's that, you know, that the constant presence of each other's absence because there's missing information in terms of the body language. And of course, we have to use a platform that is encrypted so that it's safe. I think in terms of my practical tips, and I think, you know, it'd be lovely to talk about this later, okay, is that I do send an email to patients before the session with a constant form with lots of information and also with some practical tips for the session that I've developed over time with some other information. And that's up on my website if you wanna have a look. I also keep my phone handy because if you do have poor connection with Zoom, you can always keep the video going and even though it's patchy, it's okay. You've got a really good phone connection the sound is coming through. It makes it so much easier. And I get to contact people details in case of the crisis. And I think, you know, in terms of, we can talk a little bit more later about the technical things about where you put the camera and the light and all that kind of thing. But I think I just looked up YouTube clips and got some advice about how to do it so that patients would feel more comfortable. I would feel more comfortable. Really like my heats with blanket and these cold mornings. And I use a lot of apps and websites to patient, giving to patients so that they can practise for themselves. One of the things about Zoom is that you can share your screen. So I can show them videos. I can show them slides from information. And so I think it's a really useful platform for me to use. I bought the private version so that you, it's more encrypted. And so that's what I use. So those were the sorts of things that I had to say. So, yeah. No other to test them. You finished a bit more suddenly than I expected you to, Monica, but thank you very much indeed. Sorry, I was trying to keep the time. No, you've done brilliant. You've come in comfortably under time. I hope everybody else is watching. I hope they're all gonna learn from you. But thank you very much. It was really interesting. I loved your first slide there and you talk about jumping in with both feet. I guess my question would be what have you done or how have you tried to make it easy for yourself to manage selling and selling it and working from home? One of the things that I did that made it easier was that I was doing it together with my two work colleagues. And so we were going through the same stresses together and we would talk on the phone and FaceTime during lunchtime. And there were issues with billing and so we had to find a platform that would help with the billing and I'm a GP and so I had to work out how to do it with Medicare online. It was a very stressful time. But we were supporting each other. So that was one thing. The second thing is that I tried to make my room comfortable so I've got a corner of the study. If I were to move my camera, you would see there's a whole mess on the other side. It's the other side of the study, it's very messy. But this side of the study is sort of, I try and make it a calm presence. So I was trying to sort of make it comfortable for other people and so I would be less stressed. And I always was asking patients, what could we do to make this easier because it's stressful for everyone. And I have half an hour gap between patients so that I don't get too exhausted. So that's all the things I can think of. Yeah, great. All good tips there. Thank you very much indeed, Monica. Yeah, and I like your first point there about actually having the capacity to get support from your colleagues. I think it's so important and highlights the comment David made earlier about, we've just got to be so careful not to get too isolated. But anyway, that's wonderful. Thank you, Monica. Let's move on now to get a rural health and CBT perspective. David, if I could hand over to you for your presentation. Yeah, thank you, Mark. So as Mark suggested, the emphasis on my experience going back to about 2016 was to the provision of totally counseling CBT in rural areas of New South Wales. And in the time that there were some things that seemed to be cropping up that seemed to apply to particularly individuals that were quite socially isolated. So the things that struck me were included. Supplies do have quite a struggle with access to services. If they're lucky, they may, for example, be able to see their psychiatrist through video conferencing personally. Most of my work done, I say with the psychiatrist video conferencing, that would have been, my understanding was, carried out at the GP's clinic. But so you could see there were shortages of particular types of health services in some of these areas. And for myself, I basically maintained the use of telephone for counseling. I suppose at the time, pre-pandemic era, video wasn't something that I was asked to provide by clients. And I had not a single client objected to having their round sessions run by telephone. In fact, it worked quite effectively, I thought. So the point being is that being isolated would mean that sometimes you have to go the extra mile to connect them up to services. Perhaps the one go-to place of shortages, usually widely already out there, would be the website infobexchange.org.au, which provides a very nice, neat database of services across Australia out there in the community. It's much, much easier to link up with clients with services within the community. And then, of course, the site would go to be linking them with services provided by, say, local council. Also, some clients experience loneliness or social isolation. This is pre-pandemic era social isolation. They just go days and days without really talking to anyone. And I'm pretty sure this would be the explanation why they have so much pent-up things to say. And you're over the session, after two weeks, perhaps not speaking to a soul. It all comes out in a flood, in a bit of a monologue. And knowing this is pretty handy because being prepared and being able to try and steer them back to the therapeutic agenda or purpose can be a little tricky at times. And then there are clients who lack informal support through friends or family. And it seemed to me that over that period, there was a pattern of people really struggling to navigate problems through relationships. And it may be one of that, have they been less socially isolated that this wouldn't have been as much of a difficulty? Now, for some tips, I suppose, again, particularly applied to telephone work. Sorry, David, to interrupt. I'm just going to have you ask you to move along a bit quickly. Perhaps just another minute or so. Sure thing. So basically, being able to say, yes, an acknowledgement for a heart during the session helps the client on the other end feel secure that they are being listened to because they can't see what's going on on the internet, obviously. Now, because it's not through telephone, there's a lot of visual cues in this. So perhaps more regular reassessments of the client's progress using K10s and revisiting on therapeutic goals on a more regular basis. I found it quite helpful to dispel any doubts about how things were going. Also, the expectation of what could be achieved in tele-counseling, I think one of them was saying that it's going into the deep end. And one of those things is that perhaps going in with different expectations of what can be achieved using the format, specifically because logistical things like bandwidth and time delays and everything else comes with this new way of working. And asking, especially again over the telephone, through a session, so how does that... Is this making sense to you and how do you feel about proceeding with this, just to get that complete confirmation that you may miss by telephones that you would ordinarily get by video? And one important thing I do want to just drop in is that there seems anecdotally, at least given five experiences other counsellors had experienced by themselves that over the telephone, people tend to be a little less inhibited in being able to disclose sensitive personal information. So that is one, at least one plus one advantage of running sessions by telephone. OK, so how have I done with time? We've run out, so I think it's OK, we might... Yeah, we might leave it there, but thank you very much for that. And of course, we will delve into a lot of that stuff in more detail as we go into a discussion. But because time is tight tonight, I'm going to move straight on and introduce our final panellist to get Tessa to tell us her perspective on telecancelling. Over to you, Tessa. So, just about forgot to take myself off mute. There you go. Thank you very much, Mark. So I'm going to win through my slides, to my end slide, which I talk more to, the issues, and I bring up some strategies and tips. So I think that, you know, a couple of the biggest opportunities for me have been that it is, as Monica said, it's time efficient and cost effective, but it doesn't rely on myself all the people I work with meeting at a joint location, and that I can actually work with people, actually, from all over the country. So I think it's a very accessible, but not location-based services. The challenges, of course, have been mostly platform availability and connection issues. I live in the tip of morning confidentiality and for some reason, sometimes my connection is quite poor, even on the telephone. The other challenge has actually been that, particularly, it's probably as simple as telephone, telephone counselling, as David just said, is the fear, even with professionals, that somehow it's actually not better. It's not as good as face-to-face, and I'm going to talk more about that in a minute. Some of the risks have the same as the challenges, is that the connection issues, you know, not only might I have problems with my connection, but as often does happen, it invariably happens. The people I work with will invariably have connection issues. And the other risk is it hasn't been a huge issue, and I think, again, it depends. The group of people that you're working with is managing a crisis. So I'll talk more about that shortly. And the other thing is the boundary issues. You know, with the COVID, it's brought so many people home, kept people at home to work, and so I think there's a number of issues around home becomes work, your workplace, and it's tempting to think you're actually at home, which you are, but you've actually got to work. So, and the other boundary issue is that sometimes there's challenges around both some of the people I work with, but I've also noticed that within myself, wanting to know more about me. Right, so I've kind of brought my issues and the strategies into a table, and going back to what I started with, the platform availability and connection issues, you know, for me, the biggest lesson to have been around, being planned, you know, being organised, being prepared in advance, making sure that the people I work with know in advance what to do if things go wrong and having a backup plan. It's as simple as, you know, having the phone ready and charged. In case the video platform actually doesn't work. And, you know, sometimes actually even starting with the mobile. The perception and care that somehow face-to-face is not as good. You know, I have actually been working with the telephone a lot longer than I have on the video platform, but I offer the fact that it might be a trial. So when people, whether they've been clients or professionals, are a little hesitant to use the telephone or the video, I say, well, let's give it a trial. My experience has been, many people are a little reluctant at first. They're anxious about it. And, you know, I haven't worked with anyone that hasn't got used to it in the end. But let's give it a go. And if it doesn't work for you, it doesn't work for you. So giving people an out as well. Managing crisis, you know, be it a connection crisis or a mental health crisis. For me and so many of you, it's very similar. It's the same as I would do if I was there, even though I'm actually not there. And working with whatever I've got. But, you know, simple little things, like making sure I've got enough information about a person, their address, other contact details, you know, and having advanced safety plans. But also, when the crisis has finished, making sure that both myself and or whoever I'm working with are debriefed. And I can't over-emphasise the importance of supervision. And I might say more about that in a minute. Sound issues. So, you know, the majority of my work actually is with professionals. I do some telephone counselling and EAP. But most of my work is actually working with people who work at the front line. You know, so boundary issues, working from home and taking care of self are really, really important to me. And I've noticed since COVID-9 how much more important to this, partly because so many more people are working at home. A couple of things I want to say is that it's really important to be human, my own theoretical approach to working with people in whatever context and whoever they are is that we're all human beings. And I'm a human, but it's also really important to be professional. So, you know, some amount of self-disposure, for instance, it can be useful. It can help engage someone I'm working with and it can actually help them explore their issues. But of course, it's the same as if I was in the office working with them. It's not for my purposes, it's for the other's purpose. Just one more minute, Tessa. I can do it. So the last one is working well from home. Again, it's about being organised, being ready, being prepared, being tidy. And the last thing I'd say about working well from home is separating my work space from my home space. You know, if possible, make sure you've got an offer to work from if you haven't, have a dedicated desk. But it's about a dedicated space, dedicated and protected time to actually do your work well and do it properly. That's actually it. Lovely. Thank you very much indeed, Tessa. And indeed, thank you very much to all of our participants. I think given that the time is moving on, we should go straight into the general discussion. But a whole lot of points that will raise there, I think you'll agree in those three presentations, that are worth delving into in a little bit more detail. So let's kick off the broader discussion. I'm going to invite all the panel members to jump in and add things whenever they want. We'll try and make it as interactive as possible. So they can disagree with each other even. They can add alternative perspectives, whatever. And I would like to say at the outset that I've been extremely impressed by the number and quality of questions that we've received from you, the participants. And I would love to go through each of them in turn and answer them one by one, but we don't have time to do that. Hopefully we've managed to incorporate them all into the themes that we're going to address now. But if we don't get around to your particular question, please bear with us. Okay, so let's go on then to open the general discussion. And I'd like to start, if I could, with something about practical tips. Let's get them out of the way because a lot of people did ask about practical tips. And several of you have mentioned a few, but I might come right back to you, Monica, if I could, and ask if there are any other practical tips that you'd like to offer. And then I'll ask the others to jump in. One of the interesting ones that someone said was how close or far do you sit from the screen? Do you do it close up like you're on? Or is it like in therapy where you're sitting well back and the car can see the whole of you? Do you have any advice on that one? Yeah, I was thinking about this, Mark. And it seems to me that because we're missing so much of the body language by not being in each other's presence, then the least I can do is to be as close to the screen but I try and sort of do it so that they can see like a bit of me, like it's not just my face because I think that that would be too hard. And that's, again, I was just looking up on YouTube and I try and have a light so that it shows my face. People can see my eyes and my facial expressions. And I do try and encourage them to do the same, especially when I'm doing EMDR. I want to be able to see their eyes. In terms of practical tips, the other thing is about wearing work clothes. I know it doesn't seem to make sense. It doesn't matter what you've got underneath where they can't see you. Get out of boots if you like. But when you put your work clothes on, you know, do you feel professional but you get that professional air as well? And I think that's important. Absolutely, and in fact, perhaps important also for boundaries, we're going to come back right at the end and talk about boundaries, but I think that's a good example when you work clothes on. Yeah, go on. No, no, you go on, it's all right. Yeah, the only other thing I was going to say is making sure that you've always got things that you would normally have in your office. Okay, so in other words, water and pen and paper and tissues and even, and you are suggesting that to them as well. I sent an email to people so that they can be prepared on their end as well. And I live on, you know, there's only two of us, we don't have children. So I'm not dealing with all the issues that other people have trying to create a workspace like Tessa did. So yeah, there's so many others, but I'll stop now. Absolutely, but I do like that idea of making sure that you've got a good email or information sheet to send to people. And I know that you very kindly shared yours. So as Monica said in her talk, they're on her website and the link to the website will be in the resources when you get round to having a look at it when MHPN send you a link to that. So there's some really good stuff there and including that kind of email, I think it's important. Can I just check in, because I want to move on to something else, but check in with David and Tessa whether there's anything you'd add there about the very practical things of setting up the session. Anything either of you would like to add there? Yeah, I'll look over there. There's a whole issue about, do you look at the person's face or do you look at the camera? And when you're working with a group, it can be quite hard not to look at someone's face if you've got four or more people on your actual monitor screen. I think it is important to fit square, so that people can see you and you have a little image of yourself on the monitor on the screen. So I think I try to use that as a gauge as well. I think it is important to sit not too close. So that if I want to kind of come in a little bit, I can. So that's that little thing I would add and I'd also agree with your moniker. So I'm going to have water, you know, pen, extra things. Have everything really on my desk so I don't have to get up and go. Yeah, good advice, good advice indeed. And I think the thing about looking at the camera is an important one, because it's easy to look off to the side, isn't it? Because I try desperately to look at the camera which I'm doing now, but I can't help look at the screen to my left, which is where I'm seeing the pictures of what's going up on the other panelist. David, I'm going to ask a specific question to you, but did you want to add anything on those particular points at this time? In terms of setting up the session, I found that people appreciate emailed head-ups and materials coming in through maybe ours or perhaps the day before or maybe all sent out at the session. People just sometimes have difficulty being able to access a printer and it made me, I mean, I had someone who had to go into work to support people maybe they needed office work, so they may not be as well resourced as we would assume them to be. So just checking in with some that they are able to make use of and have access to a particular printer when setting the strip. I think that's very good advice, isn't it? And I think it depends on the way you work and I'm not sure whether Monica or Tessa would even agree with me, but for me, even if it's a face-to-face session at the end of the session, I'm thinking, what am I going to do with this person next time? And that does give me the opportunity to send them any handouts, for example, that we're going to use in the next tele-canceling session to send them and set an agenda and say, this is what I thought we'd talk about next time. David, can I come back to you please? I just want to very quickly and not go into details, but do we need to worry about security issues? And I'm thinking both in terms of the platform that we're using, but also in terms of materials that we might be sending either online or via email. Is security an issue that you think we should be aware of? So, Monica mentioned the fee-for-service Zoom. I don't use it personally, so it's a step-up premium product and she mentioned encryption. My understanding is that Zoom doesn't have encryption unless they've rectified that in recent weeks. The Zoom, which is free, doesn't have encryption. But if you pay for the subscription, it is encrypted and you can make it more secure. So, yeah, so that's something to be aware of. What's happened, and I would point people to listen into the Radio National ABC Background Briefing dated 19th of April. And about 22 minutes into this, you can get it as a podcast, say it was a very incisive bit of journalism where they looked into the problems with 1,000 downloaded Zoom meetings, some of which were actually sensitive counseling sessions for up in the internet for everyone to see. Now, this is sort of, of course, without the consent of the people involved in those sessions. So, clearly, we do need to be very aware, obviously, that the platform that we're using is secure. I take that point entirely. Can I just perhaps move on, Tessa, and bring you in here? One of the issues that we're concerned about, I guess, is privacy, not only in terms of that kind of stuff I was talking about with David, but also just in terms of the, you know, if you're seeing the client in their own house, there's loads of potential for other people to be overhearing and so on. Is that something that we should be addressing with people? Absolutely, most definitely. And because we can only see what's in front of our eyes I think it's important to talk about that beforehand. So, it's part of the planning, so explaining the importance of privacy, you know, for them, but also explaining where I'm working from to ensure that privacy and that confidentiality. Having protected, like I said before, a room, a space where you're not interrupted, where there isn't, you can't hear the dogs barking out the back, where the kids don't come running into the room, you know, so that you're spoken with someone else in the house and that old who will look after the kids. I think those things are much more important, again, for, say, a counselling session than they might be for a work meeting. It's still important, but, you know, again, context does make a difference. Sure, and we might, if we get time, just talk briefly about children later, but it does strike me that that's potentially a particular problem with children, giving, you know, if we're doing a session with them about being able to ensure that they have privacy from parents or whatever. Okay, so privacy is very important. Can I move on slightly and talk a little bit about engaging people, how we might engage people in this thing, in tele-canceling? And I suppose that one of the things is the perception, perhaps, and I think Tessa alluded to this, that tele-canceling is not as good as face-to-face. I wonder if I could ask you, David, whether you would agree with that, or whether you think maybe that, well, that it is as good and perhaps, in some cases, it might even be better. What would you say to those concerns? Now, in terms of that, I did, in the presentation, mention that point about people over the telephone, perhaps being inhibited in disclosing personal information. That was one thing that came up with telephone calls, but are we also talking about tips, Mark, for how to build, say, therapeutic alliance? Well, yeah, that was gonna be my next question. So, since you've got the floor, why don't you go on with that? Yeah, no, that's good, you keep going. So, yeah, tips to build the therapeutic alliance. How do we engage someone? Part of it, I guess, is being able to convince them that this mode of delivering treatment is effective and it's gonna be okay for you and so on, and reassuring them. But tell me more about what you think, David, about how we might engage people. Well, probably it comes down to a matter of emphasis in things that we probably do normally, but particularly over the telephone, but even with video tele-counseling, perhaps a bit more emphasis than usual on psychoeducation, socialization to treatment, and maybe some informal conversation in the early phases of counselling as a nice breaker. So, whereas, in the face-to-face setting, everyone's present there just understanding that the counsellor is esteemed and tenderly, it's there for the client. To be aware of, but once you get into the realm of tele-counseling, particularly telephone, the client starts to perhaps feel that they may feel that something may be missing in this process. But you're taking them back to a place where you're reassuring that there is a process behind counselling, everything from the evidence-based strategies through to the areas that I mentioned before. Yeah, absolutely. And I guess we're talking in many ways, and I would actually feel this about the whole area, that it much of it is similar to face-to-face, and if you're gonna do it face-to-face, and we were talking, Tessa was talking about looking at the camera and so on, looking at the person, making them feel, as though you're listening to them, as you say, David, it's so important. Monica, can I bring you in here as well, and really just to see whether you've got anything further to add to this? Obviously, some people are uncomfortable with technology, they're a bit of anxious about doing it, and they don't have the benefits perhaps of coming to you. Do you have any strategies to help people feel more comfortable to engage them? I guess I've had most of the people that I've been working with, and I've been using the Zoom platform exclusively. I did try some phone counselling initially. Most of the more people that I already knew, but I've had several new referrals, and done them all on Zoom, and found that if we both acknowledge that this is disaster counselling, we're doing this for a reason, to flatten the curve, to keep it, you know, it's, can we just accept that perhaps we're just gonna try it out and see how it goes? And I think because I've been able to ask them, you know, what are your concerns? I've been able to address the Zoom concerns, you know, which is also on my consent form. And I do send them a consent form with lots of information, as well as the email before the session, just by talking about the difficulties and talking about the fact that it's new for me and new for them, and that the idea is to voice things early and to sort things out. And I think that's really how you build engagement anyway, with people in your room. There's always misunderstandings in the first session. Exactly, exactly right, yeah, yeah, exactly. Can I just add something to that? Please do, Tessa, yeah. Engagement, so one of the things that I noticed working, particularly telephone, is that I listened differently. You know, I listened and I hear things that I wouldn't see, I'll tell them I can't see. So I'm, you know, I'm not appearing the content or the emotion or the feeling, but I'm hearing things that aren't there, even. So, you know, I'm noticing what they're not saying, and as much as I'm noticing what they are saying. But I also hear more about tone, volume, inflection, you know, and I will ask more questions. I think you alluded to this before, David. If I think someone is distressed and I can't tell by listening, I'll actually ask them, and are you crying? Are you actually really distressed? You know, I can't see you, but it sounds like you might be. But I think those little things are really, really important, and I think that's one of the beautiful things about telephone counseling is I've learned to listen. You know, I think much better. It's an interesting point, isn't it? I can't help thinking about people who lose a sense, who go blind or deaf or whatever, and they talk about how much more acute their other sense has become. Yeah, very interesting point, Tessa. I just want to go back a little bit. This is a question I was going to ask David, but we were running out of time. So, but you've mentioned it, Monica, so let me bring it up. And that is about, you know, do we see this as something that's only while we're in this pandemic crisis? Or, David, I'll go to you. Do you think this is something that has much more of a future that we should be becoming more comfortable with even when we can go back to straightforward face-to-face stuff? Well, the first thought that comes to mind is that there may be everyday type of tasks that can be replaced by, say, videos, telework, but not necessarily counselling. So, for example, if you had down, say, three or four clients that you thought needed a bit of a follow-up from the previous session or just checking in with them, well, I mean, you know, in the past, I would have done that by phone, but I've re-evaluated that. And I think, given that video work is now seemingly just part of the landscape, I would, you know, wouldn't blink and just set up a Zoom call to have that type of face-to-face... Well, you know, video catch-up because even though it might be just an informal or just a very short catch-up, it can just add to the information that you're seeking. Sure, absolutely, absolutely. So, it has got potential going forward, hasn't it? Sorry, but can I just drop in, too, that this whole idea of that working through video and whether or not it can be funded, you know, through, say, the likes of Medicare, and I would have thought that after the era of the pandemic that we could have more multidisciplinary-type meetings out in the community, you know, breaking down these silos. This is the thing that seems to be coming up in mental health reviews often. And it may be that we feel throughout the health and medical communities that video conferencing was something that was always there, but never used in terms of those sort of multidisciplinary meetings. Sure, absolutely, absolutely. But as you said or implied there, you know, really whether or not Medicare choose to continue to rebate it will be a big factor in whether or not it continues, I guess, or at least at what level. Let's move on now. I'd like to move on and look at some of the more clinical issues. And one of the issues that a lot of participants were concerned about, and I'm not surprised, although I would say, I think it's equally true of face-to-face, but what happens when you're worried about the person? What happens when there's some risk? If I could turn to you, Tessa, first, and ask, do you think it's possible to do a good risk assessment through tele-counseling, through these platforms? Absolutely, I do. You know, I've been using and supervising telephone intake and risk assessment from services for a long time. And so it's highly possible. I think you've got to have a really good evidence-based tool, really good framework to do risk assessment from. And in many ways, they are a shortened version of your face-to-face risk assessment. But again, it's similar principles. You know, you've got to ask all the same sorts of questions that you would ask if the person is actually with you. I know that half the audience out there are thinking, what risk assessment tool does she use? Is it something that you could share or...? Well, particularly, there are lots around, so a particularly good telephonic assessment tool, actually, is the one that the New South Wales Health Department use, and they have a whole policy, procedure and tool for telephone, telephone-counseling and telephone risk assessment. But here in Victoria, we also have a very good risk rating scale upon which one can actually build a good evidence-based risk assessment. A number of the public sector services use very good clinical assessment and risk management tools. So I think it's also about adapting to whatever context or whatever group of people you're working with as well. So yes, I think it's really important to use an evidence-based risk assessment tool. Yeah. Okay. Useful. Thanks. So, Monica, if I could bring you in and just take this one step further. So what do you do...? What can you do to, I guess, help patients feel grounded and feel more secure when they're very distressed and you're not there in person to provide the kind of... the benefits of that physical presence? What would you do, Monica, or how do we manage that situation? Well, I'd love to get the other panellists sort of ideas as well because it's the one thing that terrified me when I started doing this, especially because I decided to jump right in and do some EMDR online with clients who'd already been doing the process. And so what I use is the sound of my voice. And I think that there is something about staying really calm and talking it through and saying, I'm here with you, I'm just talking this through, and then getting them to actually stamp their feet on the ground and to look around them and to name things, objects and colours, five things they can hear, five things they can see, just that very sort of simple grounding exercise. And I have found it very successful, surprisingly, and also to have a drink of water. So those are the things that I use. Good. And again, I hate to sound like a broken record, but they are the kind of things that we would use in face-to-face sessions as well, aren't they? Those kind of grounding tools. So we need to remember them and not think that we need something completely different and off the wall just because it's tele-counseling. But I've got to say, this is one of the participants presenting the worst possible case scenario. What if a person expresses suicidal or self-harm, suicidal intent, hangs up, refuses to answer your calls, and their emergency contact number is uncontractable? You know, this kind of worst case scenario. So that's why I get two emergency contact numbers in the go, but I don't have a second one to say, your neighbour, your workmate, someone, okay? I need to have two. We don't proceed until we have two because we're doing counselling online. The consent form I send for them to read beforehand, and then I say, have you read the consent form? We'll go through it together. Also says it gives them the lifeline number and the local mental health emergency number as well, so they can always refer to that. And we have a crisis plan, like what are we going to do? If the wheels fall off, what am I going to do? Shall I call the ambulance? Shall I call you? You know, what's going to happen? And so we talk about what we're going to do in the case of, if they hang up and they're really distressed, I send them a text message to say, you know, the phone connection was lost, the video connection was lost. This is lifeline. This is the mental health number. If you need to call me, I'm here. And then I assume that if they're adults that got to this stage, if they have actually expressed suicidal ideation and I have a contract with them, that if they say they're suicidal and they're not safe, I call the ambulance. I just say I'm going to hang up and call triple O, but I will do that in my rooms anyway. Yeah, sure, sure. Okay, thank you for that, Monica. I want to move on to something else, but just quickly, do either of you, David or Tessa, have anything on to add to this idea of managing distress in these settings? Just to reinforce what you said, Monica, you know, it's the normal request of any service that you offer, you provide an emergency contact. It's the same with a mental health service. It's an expectation that's common. It's across the board. So I totally agree with you. That's asked for at the beginning. And I think that experiences by a lot of practitioners would be that when there's a crisis that the client has encountered, that a lot of work is probably done by phone anyway. So really, with that in mind, certain things just haven't changed. It's just that if they have a crisis during a session, that might be different. But yeah, I would have thought it would have been always the case that a lot of crisis management is done between sessions over the phone. And I just said to, I think, I don't know if you would agree with this, but also having the police to provide a welfare check is another option, you said? Yeah, thank you for saying that. I forgot to add that, but, you know, we're in all our sails at the emergency services all the police have to do. Thanks for that. Let's move on. And I guess perhaps I'll stick with you, David, for the moment, but just very briefly, we've had a lot of specific questions about whether a particular type of therapy can be done in telecancelling, you know, whether it's mindfulness or relaxation or hypnosis or trauma focus work or whatever, big long list. And I know you specialize in CBT, but do you think that there are, well, does CBT work OK? And are there any that you would say no? You shouldn't be trying this form of therapy? Well, the link that I supplied through this webinar is the link that had been shared by my colleagues at Healthy Minds. So it's a very, very good information, rich website by the Western Australian government, which if you are doing telehealth, sorry, tele-counseling CBT work can come in handy in terms of having the handouts that I've mentioned previously available. Because, you know, some aspects of CBT, you know, are relying on a fair bit of information anyway, like if you're, you know, talking about activity scheduling, behavioral activation. These sort of interventions, I find, have a fair bit of background information attached to that. And that's part of having, you know, building up the therapeutic alliance as well. So they feel like they're part of it and they own the process. But in terms of what can't be, well, you know, the no go areas, Monica's mentioned in India a few times, you know, so that was the one thing I tried to mention here, but I thought it would be the one thing that it would be very, it would be a miracle to pull up. I'm glad you raised it, David, because I also picked up the fact that Monica mentioned that a couple of times. So tell us, Monica, you go all right with EMDR on Zoom. Okay, again, it was a thing of state first. Although I did watch a webinar by Majon Peters, who is a clinician from Europe who's been doing, it was put on by the APS. She's been doing EMDR for years now all over the world, and she only does it online. I also looked up some research and there is research to show that remote, you know, sort of using a video conference EMDR was actually quite effective. And so because these patients I'd already worked with some, I knew them. They were fairly stable. They didn't have personality disorders. They had specific issues they wanted to continue to work with. Then I said, okay, look, let's give it a go. And I don't use an app. I don't use any fancy gizmos. I just use a very bright marker that I hold in function. I'll go to the side and I'll just do my thing. And it's been extremely effective. I've been really surprised. It's almost as if there is something about being in the privacy of their own home and sort of doing it in a sense where there isn't anything else to distract them. There is something about that's very focused and very effective. And so I've been really pleasantly surprised with it. And again, you know, we do it slowly and gradually in little bits and use the grounding techniques. It's been excellent. So yes, I have something to fix with. That is very interesting. I must say that I wouldn't have thought it was possible. But I'm glad it is. That's good news. Chesa, you are quite interested in group therapy. Can you run groups? Absolutely, absolutely. I think the individuals, it's easier if individuals log in separately if they're using a video platform. It's actually much more difficult if, you know, the group as a whole is there and you're somewhere else. So, but it actually can work. You need to pay much more attention. You've got to keep the process flowing. You've got to have kind of some ground rules about how everyone manages each other or the, you know, the normal kind of communication rules about not speaking over the top of each other. It's really important to be natural too. And but also give people the permission to nod, to agree, to, you know, to work off each other's cues. So I think that's really important. The thing about group work, though, is that it can be really tiring. It's much more tiring than working with an individual for an hour or an hour and a half. Yeah, and you use Zoom, don't you? I do. And I prefer Zoom to, say, teams for group work because you can see everyone in Zoom on the monitor, whereas for teams, it only goes to four people. So, yeah. Okay, very interesting. I've got to keep moving along. I'm going to just show this to you, Monica, but I know it's a bit unfair because I know none of you would consider yourself to be child experts, but we did have a whole lot of questions about children. And we did allude earlier to the idea of the privacy difficulties when you're treating children at home like this. But have you got any other, just very briefly, any key issues that you would want to comment on in terms of working with children? And so I think the thing about working with children is that the younger they are, they're easily distractable. But my John Peters was saying, she does EMDR with children as young as five, that being able to see their bedrooms, they can show you their toys, their games, actually helps them to engage in therapy. And she asked to have the parents there to actually keep them from wandering away. The older children, the teenagers, one of my GPE colleagues actually had a teenager with social anxiety as a presenting feature. And rather than being dragged into the rooms by her parents, she was able to have the consultation in her bedroom where she felt very safe. And because her laptop was just beside her, she was able to enroll in the this way out course on social anxiety and start right there, right then, which would not have happened if she'd come to the surgery. So there are some advantages in telehealth for children and teenagers. Interesting point. David, can I just bring you in? You did allude to this, I just want to check whether there's anything more you want to say about it. But I'm interested in the idea of assessing progress during telecancelling. You did talk about perhaps using the K-10 or something a bit more regularly. Yeah, are we using different tools, do you think, or different processes to assess progress during telecancelling? In the time I've used it through phone and now video, I have really haven't found the need to shift my focus to other tools. The tools, you know, a few of them, a few of them I haven't really needed to change the mix. But I think you implied that you might do it more often. Would that be right? It's about the frequency. Yeah, yeah, yeah, okay. Yeah, I would agree. Can I just say, you know, I think it's important to ask how we're going with the process all the time. You know, I always finish a session that I'm running, whoever I'm working with, where I've been working with, how did we go, you know, how did I go? How did you find the process and what will you take from the process? So I think there's an ongoing evaluation as well as I think it's important to formally evaluate and review using a tool like K-10. I think it's a very good point, Tessa, and again, I'd say it's true for face-to-face. There's indeed a whole body of research, isn't there, about exactly that, about asking at the end of the session about the process, about exactly that, about asking at the end of every session how valuable was this session, any feedback from me or whatever. I confess that I don't do it, but I should, and I will, I will, I promise I will. Okay, let's just move on finally. We've got about two minutes to go, or a few minutes to go, and just think a little bit about self-care and whether or not there are particular issues we should be considering in terms of looking after ourselves in this. And I might come to you, Tessa, I think, and just, you've mentioned, well, there's been a bit of mention of boundaries, but can you say something about boundary issues here and whether or not these are particularly important? Absolutely. You know, I think it's actually more important when you're using a video platform to practice good self-care. Particularly, unlike you, Monica, I will sometimes find myself not having enough of a break between sessions, whatever it is. It's really important to pace your workload. You know, extremely important. Otherwise, because it is very tiring, believe it or not, because you're listening so hard, you're looking so hard, I think it can be extremely hard work. So self-care is always, always important. Also, supervision can't say how important supervision is. Extremely important. But the advantage is we can do supervision online as well. So that's good. Monica or David, did you want to add anything to this about looking after yourself and boundaries? Just on the boundaries, I was going to just reiterate what you said earlier, Monica, about as simple as putting on your work clothes or I think it's important, and also the background that people have talked about, that maybe gives some thought to what's in the background. It's not maybe too personal. I don't know whether you'd agree with that. You've got to keep that boundary as well because it's in your home. That's right. And it is true that people will ask, oh, what have you been doing and how is it? But in the same way that I get people asking questions about my life and my family and all that kind of thing in my room, and I just gently say, look, we could talk about me. I'd love to talk about me. But isn't this session about you? Let's focus on you. Let's reflect. We say, gee, we keep coming back to me. What's going on? Help me out here. So that also helps as well, I think. And look to say that initially I want to give hope to all you people out there. It's not that exhausting in the sense that when I first started, I was exhausting. I had zoom fatigue to the max. But the more I've done it, the easier it's become. And I've actually had some sessions where I've had to have no breaks and it's actually what's done okay. I actually feel a lot better now and could continue to do it. So there's hope, okay, Guy? Just letting you know. Very much so. And I'm glad that actually throughout the presentation I hope people have picked them up. All three of you have commented on a number of positives about it and being able to work from home it's not all bad. There may be some disadvantages but a lot of advantages too. I'll pick up on that point that you made actually, Monica, that I've just got this feeling that people actually are more likely to ask me about myself on tele-counseling than they are face-to-face. I don't know whether other people find that but more interested to know who is this person I'm talking to. Especially if it's just telephone. Is that something others would find? Absolutely. Well, yeah, but it's interesting again that the use of a telephone for a few years now the only questions that come across are what's your experience and how long you've been doing. It's a standard sort of question but nothing if you're saying questions about personal my personal life I haven't come across it but just so you're saying you have. Okay. Can I just add something to that? Yeah, please do. So using the video platform Safe for Group work was quite new to me in COVID time and I noticed myself noticing other people's wounds wherever they were working from and being extremely curious as I am kind of wanting to ask and I did have to watch that actually so that it wasn't about my curiosity but, you know, the purpose that I was actually facilitating that group for so but it just reminds me kind of the importance of what's the purpose of this and it was really about the newness of it and, you know, so it is important to pay attention to self. Well, okay, and so literally one minute any very quick comments more about looking after yourself, about working from home any tips that people need to bear in mind to look after themselves or should we wind it there? No, no, we're always jumping in. Yeah, go on. I think it is important to admit I have disclosed, okay, especially at the beginning when there was so much distress and there is still so much distress about what's going on overseas and, you know, the public catastrophe private calamities, you know, the personal losses, like it's all out there. It is important to say that, you know, sometimes I do cry that, you know, yes, I have a professional faith but, you know, it runs deep, like we're all going through the same things and that it's okay and that we don't, and people who say it's home schooling, it is not home schooling it is design for schooling so can we just adjust their expectations? That's the last thing I wanted to say. It's a very good point and I think this is the last slide that I unfortunately didn't get time to talk through in detail was exactly that about adjusting your expectations. So good. Okay, I'm sorry but the time has beaten us so we need to wind up. Can I just ask each of the panel members briefly if they've got a couple of three dot points as take home messages that they'd like to leave the participants with? I might come to you first, Monica. Any final messages for our participants? So if someone appears very upset at the end of the session one thing I have found very helpful is to ask them what they had for breakfast and to walk them through their morning. It helps to ground them in their adult self. The other thing is that people come with expectations of counselling itself and that still needs to be addressed so all the usual things and if you're using platforms, the third thing if you're using the Zoom platform do share your screen and show documents that you want to show them go through a structured problem solving sheet downloaded from the Centre for Clinical Interventions which is a wonderful website resources available later. Those are my three tips. Yeah, and that's good advice isn't it about the capacity to share the screen there I think it's nice. David any final take home messages from you? I really think perhaps that one message was about the sitting refitting expectations especially when starting out so let's assume that most practitioners have embarked on tele-counselling for quite a few weeks now but for anyone embarking on it currently to perhaps do a bit of expectation reset that you will encounter some frustrations and difficulties and technological meltdowns the enjoyment is in like everything else in life mastering the new platform and then beyond that it may become a permanent feature of your work maybe in a slightly different way post-pandemic but something you adopt in the long term. Might change the whole way you work it's an interesting way of leaving it there David and Tessa any take home messages from you? Absolutely first one is be organized be planned, be prepared plan your hour plan, your day plan, your week the other one is be kind to yourself things go wrong they will go wrong and when they do manage the best you can and be kind to yourself about it and the third one is be real as well being who you are this has taught me particularly COVID is I am who I am I am the same person that I was in an office as I am here and perhaps a little more and when we can that's been fun Have some fun that's got to be a good night to finish aren't it? Thank you very much let me just make a few closing comments here as we said earlier there are a whole lot supporting resources and you've heard our panelists allude to some of them as we've been through the webinar tonight as I said MHPN will email you the link to those resources within a week or so and I do urge you to take the time to have a look through them because there's some great stuff there I would also mention and I believe the slide is coming up a bit later after I said goodbye but I would also mention that MHPN supports a whole lot of practitioner networks where clinicians from different disciplines can come together and get support and share tips and resources and referrals and so on and so forth so do check them out particularly if you're in a relatively socially isolated area check them out because those networks are really really good okay I'm going to ask you please to make sure that you complete the feedback survey before you log out that means clicking the yellow button I believe and at this point then I'd just like to thank everybody I'd like to thank MHPN for organizing it, read back for doing the tech stuff, the Victorian and Tasmanian PHN Alliance for initiating it in the first place I'd really like to thank our three panelists and I'm sure you would join me if you could in thanking Monica, David and Tessa for what I thought was a great webinar and they've got such enormous skills to share with us tonight and I'm really grateful for that and I'd like to thank you all of you our participants for joining us tonight and for engaging and sending in the questions and so on you know it really is your active involvement that makes these things go so well so thanks very much to everybody and good night to all