 Good evening and welcome to our 440 participants who've joined us so far for this afternoon or this evening's presentation and the viewers who are watching on the podcast. 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 the hopes of Indigenous Australians. Hi, I'm Catherine Boland and I'll be facilitating tonight's informative and interesting session. My experience is a clinical psychologist who works in the area of men and anger and family violence. But I'm very pleased to announce I'm joined by very knowledgeable and entertaining participants who will be providing us with information tonight. First I'd like to introduce Michael Murray. Michael's a GP from Townsville. Welcome, Michael. Thank you very much. Michael, you work in rural and remote areas of Queensland. How do you find topics like we're going to discuss tonight differ from men in rural and remote communities? I think there are just less assets available in rural and remote communities than there are in metropolitan areas. And also it's something that I'll refer to tonight that we are having. We're going through an ice epidemic up in North Queensland at the moment and that confounds everything. Yeah. All right, thanks for that, Michael. And I'd also like to welcome Tony McHugh. Tony's a psychologist who's joining us from Melbourne this evening. Good to have you with us, Tony. Thank you, Catherine. Glad to be here. Good evening, everyone. Tony, I understand you've just submitted your PhD focused in this area. What has led you to have such a strong interest in this area? Well, I can honestly say 20 years ago I had no interest in the area whatsoever. And I was in charge of a treatment program at the Austin Hospital in Melbourne, which at that stage dealt specifically with members of the military and veteran members of that community. And the person who was running the younger management group after six months told me he couldn't do it. Didn't know what he was doing. Getting poor outcomes, setting him and it wasn't helpful to the choir. So I had to get my skates off. I learned the hard way by listening to folk and that's informed my practices overseas. Interesting routes to this work. All right, last but certainly not least, I'd like to welcome Simon Santosia. Simon's a mental health social worker and counsellor who joins us from Sunny Queensland. Hi, Simon. Hi, Catherine and everyone. He might recognise Simon's face as he recently appeared on ABC's Q&A back in February. How did you find that experience, Simon? That was one of the hardest things I had to do in front of a audience, a live audience of 200 people and a televised audience of about a million. So it was very, very nerve-wracking. Absolutely. Well, hopefully tonight you will be well rehearsed for our webinar. Thank you. I'd just like to go through a couple of ground rules for us all to make sure we all have the opportunity to gain the most from the webinar. So we ask all participants to consider the ground rules so that we're respectful of other participants and panellists and behaviour as if this was a face-to-face activity. So please post your comments and questions for the panellists in the general chat box. If you need help with technical issues, post them in the technical help chat box. Just be mindful that comments posted in the chat boxes can be seen by all the participants and the panellists. So please keep your comments on topic. If you'd like to hide the chat, if it comes to distracting, you can click on the small drop-down arrow at the top of the chat box. And your feedback is very important to us. So please complete the short exit survey, which will appear as a pop-up when you exit the webinar. So tonight what's going to happen is each panellist is going to give us a specific response to the case study, explaining their approach, followed by questions and answers between the panellists and between the panellists and you, the audience. There are a couple of learning outcomes that we hope you will achieve by the participating in this webinar. First of all, that at the completion of the webinar, that you'll understand the prevalence of dysfunctional anger, its consequences, and the strategies to help adult men overcome their dysfunctional anger. That you will have an understanding of the impact of childhood trauma, disrupted attachment, and masculine socialisation on emotional regulation in adult men. And practically to explore some tips and strategies for interdisciplinary collaboration between practitioners working with adult men who seek assistance for emotional regulation. And reading through the many questions and comments we've received so far from participants, I know that a lot of you are interested in hearing from our panellists about tips and strategies to engage men and ways to work with men who are presenting with these challenging issues. So our panellists tonight are going to centre their discussion on the case study which you've all had access to where we try to understand Trevor who's a 43-year-old male who's been divorced for five years. Trevor has got two adolescent sons who he rarely sees and he's in a new relationship with Jennifer who has three young children who live with them. Trevor's childhood was difficult living in a hostile environment with an alcoholic father who didn't give him much attention. He had difficult relationships at work and is often in arguments. Jennifer has told him to get help or she will leave. Trevor's tried anger management programs in the past but he felt that they didn't help. So we'll start with our rural GP Dr Michael Murray. Thank you very much Catherine. The initial presentation of Trevor often decides how one engages with Trevor initially. If one is lucky to have Trevor's partner referring in specifically for some counselling in relation to this situation one is often able to make extra time to see Trevor so possibly making a half an hour consultation rather than just a normal 15-minute consultation. But last being what it is often Trevor will come in with something else. He'll come in with headaches or insomnia or an e-pain or a backache and towards the end of the consultation we'll mention his anger problems. I generally then try and sit down and get some rapport with Trevor and try and get him to come back and see me. So my initial aim is to A get rapport and B to get him to come back. You also must remember that GPs are often treating the whole family and this makes it often very difficult to provide counselling to both partners if not impossible and I always tend to try and avoid doing that and if necessary I will ask one of the partners to see one of the other doctors in the practice. One also must take into account issues that may be coming from left field in relation to Trevor. If he's having problems at work he may be projecting his problems on to work and he may be an example I have had a situation like Trevor's where it ended up being a work cover issue. So one needs to keep extremely careful notes when one's seeing patients such as Trevor. As I've said the main task should be getting rapport and ensuring the return. Doing an adequate risk assessment is important and also doing a substance assessment. Now most patients and particularly male patients will not give you an honest substance assessment at the first visit so I always suggest that that's revisited at the second or third visit when they have more confidence in you. Remembering too that there are all there are sometimes medical legal issues involved after you've done your risk assessment. Then I would be using motivational therapy trying to build up Trevor's self-esteem congratulating him for coming in and often just sitting at the blank screen once one gets that initial rapport with him because often Trevor wants to tell you everything that's in this case study so that you can understand each other the considerable trauma that he's gone through leading to low self-esteem just listening to him and acknowledging him and then planning the referral understanding that he's got a high rejection sensitivity because of his childhood. One needs to be really careful as to whom one refers him to. We're fortunate in our area in having psychologists, mental health social workers, OTs and mental health nurses and also having ATAPs and also head space and Trevor fell into the under 25 age group one could think of referring him to head space as well. Does one refer him to a male or a female? I tend to avoid relationships with Australia even though relationships with Australia will see patients on their own because there is a high rejection rate among males in North Queensland through relationships with Australia who are for rather wrong seen as being on the partners on the woman side and I certainly wouldn't be sending them as a couple to relationships with Australia. They just haven't in that space yet. So my role would be to contain them to provide some motivational therapy arranging the referral and watching particularly for transference and counter transference issues that are very common in this type of patient addressing any comorbidities that he's got. He may have health issues if he's a heavy drinker. If he's been using ice that he's been self-injecting using dirty needles then that's often a good excuse to get them back. If one can find a physical reason to get them back it's often more acceptable to patients like Trevor. Assessing the need for medications for any comorbidities. Medications I would be using extremely rarely in a case like this unless he suffered from a morbid depression or a comorbid bipolar affected disorder and remembering that anger is not an illness with a pharmacological cure. And then I would be looking at the wider issues involved. We don't know what's happening with Trevor's natural children. Are they going to be the Trevor's in 10 or 15 years time? Are these kids belonging to his partner? Are they going to as they grow into their teenage years? Are they going to become angry against Trevor and against other people in general? Is the relationship doomed anyway? And I'm always very careful not to get dragged into medicalizing a social or a psychological problem. I would have concerns about the children and in a family practice of the children are presenting with things like bedwetting or soiling or behavioral problems. I'd be understanding of the situation and also understanding of the intergenerational patterns of this function which I've referred to above. And also remembering those people who are not in the room. If you're working in a small town you may know his parents or his and her former partners. We also have issues of responsibility to the water community to be speaking up in relation to partner violence. And remembering that one of the contributing factors to all of this are the high rates of divorce, the blended families and the absent fathers that we see particularly with fly-in and fly-out families in the area in which I practice. And also remembering to keep very careful notes in case your notes will end up in the family court. And lastly I'd just like to refer to indigenous patients. There are about 35 fold increased incidents of partner violence. So that's on top of the 25% incidents that we have in the Australian community in general. So Catherine I think I've taken up enough time. I'm sorry if I've gone over it slightly and thank you very much. That's all right. An extremely interesting perspective Michael. We might come back and pick your brains a little bit about some of the things you're saying with engagement. I see some of our panel discussion is talking about motivational interviewing and how to engage the family and where your responsibilities are. So we'll come back to pick your brains. But for now we'll turn to the psychologist perspective and for this Tony McHugh is going to give his perspective on Trevor's situation. Thank you Catherine and thank you Michael just before I move on to my slides which you will note are very busy slides. I'm notorious for it. So apologies. I just want to echo what Michael has said about motivation and being where the client is at. Sometimes one of the most important things we can do as Michael touched on opponent is to listen to people and often angry men and angry women for that matter have an expectation that they are going to be rejected. One of the most important things we can do in treatment and I call it treatment folks is demonstrate how to do it differently in the room then challenge people to take it outside. This fellow clearly has a poor self-concept as Michael has touched upon and he has that classic male inability to describe feelings and his anger is described by termitisation. He could be the kind of fellow I think that has lots of gut aches and headaches and the like. Michael's rightly pointed out safety and separation sometimes of treatment is incredibly important during risk assessments and how do we motivate people. I'm going to get onto my slides. A really important thing for people to remember is that the single biggest predictor of a child's mental health is their parents' mental health. That's a pretty big motivator. We can get fathers and mothers to look at how their anger affects their children. It's really important. So quickly onto my slides, the first thing that I've learned over the years is to tell people that there is a path going forward. It will be safe, phased, graded and tolerable. We're not going to cast them into the void and here although there aren't many around, manualised treatment approaches can sometimes be very, very helpful in doing that. Persuasively emphasising the need for it to become Trevor's problem and for Trevor to generate a list of beginning treatment owners and what might they be, sometimes there's things like getting people to listen to me, getting other people to change their behaviour, whether it be right or wrong, getting people to see common sense and the like. But whatever the reasons, it's very important that we get Trevor to identify what causes him to be angry. When it's a problem, what factors are involved as you can see there. First thing in session what I often do is look for low hanging fruit. What can people actually do? And I often look for three pieces of low hanging fruit. What can they do between that session and the next session? That they'll be able to come back and talk about as something that they have implemented with some partial or more than partial success. Identifying what is not in plan by being clear about what's acceptable and what's unacceptable and developing. One useful thing in low hanging fruit world is to describe circuit breakers, techniques for allowing people to not lose it in the moment and say things that they don't actually mean and set themselves up for behaviours they don't actually mean to carry out. And the final point on this slide as you can see is explaining to people that progress is not linear. It goes sideways, sometimes goes backwards. Whilst it will generally go in the right direction, progress can be difficult and subject to slip. And if it's worth doing, people need to persevere. Next slide is about keeping Trevor in treatment because as Michael has said already, there's a classic literature that says men drop out of treatment. Excuse me, just struggling with a tickle. So what we keep people in treatment by reference to is establishing credible wellness stories. But evidence based treatment works and I'd be happy to talk in a general discussion about the wealth of evidence that anger treatment works individually and in groups. Addressing unhelpful myths, there are some there. A classic that used to be talked about when I started at the repack 20 years ago is that clients will inevitably get worse before they get better. There is absolutely no evidence for that belief and it's a very unhelpful one to be spreading in people. And then plausible explanatory models and there are half a dozen or so. Find one that works for you, rehearse it, know it well, be prepared to talk about it or another and explain it to people. We're going to be talking a little bit about learning theory Albert Bandura tonight. I certainly know that some of Simon's stuff touches on what boys learn from men and what men learn from their fathers. So really important to have a model whereby you can explain why anger develops in the way this does so that we can get away from the idea that humans are programmed to be demonic. And there are books with those words in them, believe it or not. And both the UN and Steven Pinker, who is from Harvard, along with a very smart group of people, they were denied that that is in the actual fact the truth of the situation. Mentoring Trevor and his desire and desire should be an inverted Thomas, folks, because he's a partial desire. Let's face it, he's there because he doesn't want to lose his relationship, but it took him a week to actually commit to winning someone. So a desire is there and to be built upon and then causing Trevor to internalise this by illustrations. And this is the literature that exists on dysfunctional anger that people who are well liked get angry every week. But sometimes it's several times a week in folk who were described in very positive terms. Understanding that this anger can be evaluated, self-evaluated by people positively, and I'm going to say some more about that in that last stop point. There's a biology around anger that is only really now emerging, where people deny they're called pottergill from a fantastic book in 2010 that says one of the problems with anger is that before people get angry, they evaluate it in positive terms. I'm going to show the world kind of thing. Only afterwards they say that's 10 times I've made the same mistake now and it's really costly. So some people refer to it consequently as a hedonic emotion. We think of other negative emotions, anxiety and depression. We don't think of them as pleasure giving or positive value giving. But anger is really unusual in that people often see this as I'm going to show them. I call it a seductive emotion because it sells, and I know that's central for moralising, making emotions into humans, but seductive because it seems to promise a lot and never deliver, and it delivers to people detriment in actual fact. So continuing on with this theme of mentoring Trevor and his desire for change inverted commas, it's important to get him to articulate that there are psychological and sociological functions of anger. He's the leaf around anger and it's treatability. We need to sell positive messages and optimistic messages, balanced messages to people that treatment actually works and it does. And then talking in a wise and caring way with him it's critical to change. The literature on moral development is decades old, and I find it very helpful to ask people what they think of their own behaviour. Is this literally what they want to be doing? If they're in their wise mind able to look at it, what would they be doing that would be different? And not labelling, and so I'm just going to talk about language quite a bit, which is really good, not labelling people's anger in a pejorative sense, even though it can be quite harmful at times and very harmful occasionally. But labelling and criticising is not effective. Teaching him to know his anger, it's out of control by his own description and he needs to learn to regulate rather than have it unregulated. And this is the when the where, etc. But the crucial point here is what makes it go on? What maintains it? What are the incentives that he's not recognising? What causes it to have a life of its own? And this is about what I call pattern recognition. And it's a far less pejorative term than habits. We all have patterns as humans helping people to identify what their patterns are and then measure them by the use of metrics is very important. Motivating him again, cost-benefit analysis, it seems so easy. It's such a fundamental tool that got picked up by motivational interviewing years ago. Yeah, is he winning or is he losing? And if people are honest and committed, they can only help but understand in the long run that they lose out by being angry. And several books around the talk to this, some of them are quite old. Tavris is a book on anger, the misunderstood emotion. Just made out 30 years ago and it's true that people actually die earlier from anger. They get cardiovascular disease. The Americans and the Japanese have shown this for probably 50 years in a really robust literature. People even get tumors and cancers in greater proportion when they're chronically angry. And of course they have dreadful relationships not only domestically but work as we can see with this fellow. And here's a really important concept that I've talked with lots of people about that anger is one over happiness. It's the inverse of happiness. And we're not talking about Schadenfreude getting one's kicks from seeing people being miserable. I mean true happiness. Angry people are angry and miserable is my common finding. Getting towards the end, actively treating Trevor's anger. And there are methods, absolutely evidence based methods and we can talk about them later in the cognitive domain, the effective domain physiologically and behaviourally. And there are some really important key concepts that I'll refer you all to a book by a fellow called Daniel Kahneman, again from Harvard. Great teachers, just a dreadful way of getting there. You have to pay a fortune, not in favour of, I'll keep going. If you ask angry people, they will say that they are going at a thousand miles an hour, they cannot think straight, they make mistakes, they drive off the road, they break things at work and at home when they don't mean to. And there's a really robust literature that basically shows that people become cognitively diminished in their anger. So this is about skill development, skill change, and it shows all the proceeding steps that Michael's outlined have occurred around risk, et cetera. And I'll talk to this later if I need to. There are four domains we talk about in Quinn's site often, the cognitive, the effective domain, the physical domain and the behavioural domain. And I tend to try to choose one technique from each domain, self instruction training, happy to talk about that later to no brainer if it works. Teaching people to tolerate and not act upon their effect because men are comparatively not as good as women at describing a motion sleep. But stated if people have got chronic sleep, the literature is really clear, you can knock off one standard deviation of intelligence. So if it's a men's club, you move out of it, if you've got good average intelligence, you become average. If you've got average intelligence, you become less than averagely intelligent. And the final thing is exposure. Exposing people gradually to the things that they fear, the things that they are avoiding so that they can effectively move on these things in treatment. So that's my lot apart from some references where they are. Enjoy them and I'll now hand over to Simon. Thank you. Thanks Tony, that was wonderful. I think a lot of people would like to hear a little bit more about self... Thanks Tony, that was wonderful. I think a lot of people would like to hear a little bit more about self instruction training, but we will move to Simon to get his perspective on the case study. Thank you. I've always said and argued that working with men cannot be separated from the wider political social gender debates there is in our social work profession, but also in society about men and masculinity. And you just have to see the whole DV debate and the focus on domestic violence and how it's impacting guys in the community. So from that framework, from that perspective, we need to hold a multiple frameworks to be able to guide our practice and our interventions with Trevor. The first one I tend to use, and I use all these frameworks, they're all interconnected, is feminist understanding around risk and safety for women and children. So Trevor is not coming into our room in isolation. He's impacting as soon as he leaves our room into his family. So as we can see from the case study, his step children are in fear. His partner is walking on eggshells. He's disengaged from his teenage children who we know from the literature adolescent males really need that positive relationship with their dad. So there's lots of people at risk there. And using those feminist principles, we know the best way to protect women and children from harm is to engage men, quickly engage them effectively in ways they will engage and stay engaged in in the treatment process. And we can use that by using a strength based non deficit male engagement approach. And I'm talking about that in a minute in more detail. Once we've engaged him, once he feels comfortable, safe, once we've initiated his drive strength for change, so change happens from the inside out, then we can use our deeper understanding the masculine psychology, attachment, trauma, neuroscience, and evidence based interventions. A lot of what Tony was saying to create that motivation from change and create real change from the inside out. So I just want to spend a bit of time on helping people understand what the masculine engagement approach is and to do that we need to know what doesn't work. In all the research on engaging men, men report disengaging from services if they feel they are being judged, patronized, blamed or shamed for their behavior. Quite frankly, being the expert or telling the man what he needs or shaming or blaming him in any way, he'll just cut off and he'll disengage. And the strength based viewersmen reconceptionalizes our understanding. It came from the Howard government's funding of the men and family relationship program in 1998. And we've had 15 years of evaluation and research, unfortunately the program is no longer. But out of that came a whole lot of research on what effectively works when engaging blokes. The non-strength based engagement approach covers a friendly male style, so meeting the bloke where he's at and taking him on a journey. Being solution focused and solution orientated, using practical strategies and interventions that speak to him and the use of appropriate language. And that's the use of appropriate language that I want to talk a bit about because that first telephone call we have with Trevor is a sales call. And this is why I say we need to take our therapist hat off and put a sales hat on. Why should he come to see us? What do we have that he needs or wants? A lot of people blame men for not engaging and I argue it's our approach that needs to change. So that first telephone call we need to connect with him. How are you going mate? What's happening? You sound like you're in a you know you've got a lot of stuff going on for you. So simple language for boy jargon use positive non-judgmental action orientated language. And it's got to be about what's happening to him. What's the situation? What's happening to him right now? Stay away from the feeling words because blokes will always do something. And you will find and as you can see what Trevor does when you get angry what do you do? And he'll tell you what he does and then you go well is that working for you mate? Well it sounds like you're sitting on a lot of stuff why don't you come in and have a chat. Metaphors are really good for opening the lines of communication. Often use the metaphor for relationships are like cars. If we don't get them service they break down and a lot of us blokes ignore the warning signs and like an oil light in a car if we ignore it it breaks down. So coming into someone like me I don't call it counselling I call it having a chat. Coming in and having a chat is just like getting your car serviced. Language that's available to them that they can relate to. Once they come in and I built that rapport and I built that connection and I talked to them about what's happening using strength based language and metaphor. I very much talk about how is men with social life and I can either use the diagram that you see in your slide or I'll do it on the whiteboard and I'll brainstorm the messages he got to be a man. What are the messages he got to be a man growing up? A lot of guys get messages from their parents, from society, from the media that we have to be tough and strong in control. Be a provider. Feelings that are a sign of weakness shown no emotion. But there's another side of being a man that's equally as masculine that we can be not bound by gender role, caring and sharing, empathetic, able to show and express feelings. A lot of men experience shame by father and especially shame by father or shame in the school yard can develop what I call survival skills. So they will start to disconnect from their internal experience to keep themselves safe. So they will ask an 18 year old bloke what he feels and he'll say I don't know and he honestly doesn't know that he's developed that strategy to keep himself safe. So men will start to externalize their pain rather than have that insight. Once we broaden the conversation now and really talk about their socialization as men, where they got their messages from, how they were fathered, what were the messages they got of our fathering from their father, then we can start to really bring in the neuroscience and help them understand how our brain gets shaped. How often the emotional part of our brain, and if you look at Kreber's case, he's hyper-villageant to rejection. He's hyper-villageant to any hint of being disempowered because that was the experience he had as a child. So he's hyper-reactive and then he sets about stories of hostile intent. Once he understands his brain function and his reactivity, then we can start to really work with him on those practical strategies to help himself regulate. Awareness is the key to change and once he becomes aware of what's happening inside his brain, similar like a mechanic becoming aware of a car and teaching someone how to drop their own oil, we can then work with him in helping him regulate his emotions, developing the signs of dysregulation and practical strategies to regulate himself. A lot of the interventions that Tony was talking about we can use that also very much link the guide into pro-social men's groups and here in Southeast Queensland we had men's well being run eight-week facilitated men's groups and which take the blame through fathering, through relationships and really help them with pro-social support. And in this way we've engaged in, we've engaged in a practical strategy with helping to create change from the inside out and therefore we've protected the women and children in his life from harm. Thanks. That's me. Excellent. Thanks, fine. And so interesting and so relevant. I really like your practical tips for engaging men from a feminist perspective and then talking to them in a way that is non-shaming. And so many of our panel, in the panel discussion, have been wanting to hear a bit more about that. A few questions I'd like to throw to the panelists that have come up from some of the discussions and some of the questions and I'll throw this open. I noticed, Tony, you said a little earlier that obviously there are many other people, the ripple effect of Trevor's anger goes wider than just him. And I'd like to hear a little bit more about how you might bring up the conversation about anger as a parenting, having an impact on parenting. How do you keep Trevor engaged and bring up tricky issues like that? Anyone in the panel can help out answer this. Well, I'll have first Sab as you invited me to. This case material says that Trevor doesn't talk to his boys from his previous marriage and his current boys are quite frightened of him. As a parent, and it's not hard to imagine if you're not a parent, you don't stop caring about your children till the day you die. And even though we can be estranged from parents and parents from us, it's a really important motivational way that people care enormously about their children. I think if you ask people in a forced choice kind of way, what would be the most important thing, it would be their kids. And I think that this is a highly motivating piece of information. I don't assume that any client wants to be the way they are, whether it be for, and we've got three fundamental negative emotions. They talk about the big three. There is anxiety, depression and anger. We wouldn't think that people's anxiety disorders or depressive disorders would want to be that way. Why should we think that about disorders of anger? We can call them plural because there are more than one type of angry presentation, so kids are a fundamentally important lever. And then asking, Trevor, what is it that he wants to be? How does he want the parent? What is in his best imagining, notwithstanding everything that Simon has said is absolutely correct, we're often talking about a poverty of thought here. It can be a psychological mechanism for keeping things at bay, but I also think sometimes it's just that people have not had the models and the opportunities and they don't know how to express themselves. So getting him to articulate a vision, I'm not talking Sony mission statements here, I'm talking about a vision, a wise vision of how he would like to be, where he is now, and thinking a bit like an accountant. I don't know if anyone else does this, but I've been doing this for years. I've got a one, two and a five year plan. What do you want to look like in a year? Do you want to look like in two years? What do you want to look like in five years? Before I can even get halfway through this, raviology, they say, why would I want to be coming and seeing you in two years' time? So really getting people to conceptualize the future and working backwards in the steps that enable them to get there. The first step is to control your emotions, basically, for the betterment of you and the people you care about. I sort of take a minute, I've taken more than a minute, over to others. If I can just jump in, Tony, there's in the strength-based approach, there's also very much what's used as a child-focused approach, so bringing the children in the room. One of the questions I generally ask in the first session is, how did you want to father? When you said how were you fathered, that's number one, how were you fathered when we explore how he was fathered, then how did you set out to be a dad? When you first held that little baby in your arms, how did you first set out to be a dad? Then the next question is how are you actually fathering? And that's often that ah-ha moment where they realize that they're fathering how they were fathered, and that creates the drive strength, the change. It's a very powerful moment when it happens. Another technique that I do is get guys to visualize what would it be like to be fathered by them, so I get them to imagine what it's like for their children to have them as a father, and that also initiates that ah-ha moment. Fantastic, thanks Simon. May I just add something? Absolutely, Michael. Oh yes, I've done a fair bit of work with headspace, and particularly with young, angry men, and one of the tricks that I find that's quite useful with angry men is to just get a whiteboard and do a genogram, and just again, and just referring back to what Simon said and what Tony said, you get the genogram up and you say, well you know, just tell me a little bit about this guy, about this father, this grandfather, this stepfather, your half-brother, and just try and get them to ventilate how they see other men, and how they see other men's reactions, and the influences that their fathers and stepfathers had on them, and then as Simon and Tony said, then introducing how do you think this is going to have an effect on your relationship down the track, and children down the track, or children that you already have. So I'm a great believer in the genogram. If you put the genogram up, you see light coming on in the patient's head. Yeah, really good point, Green Tully. I'm just wondering also for the panel, a few people have been kind of asking about things not to do. So what would be some examples? I know Simon, you were mentioning not shaming, not patronising, but are there specific phrases that you would, or things or behaviours you would definitely avoid with a person like Trevor? I would not use language that would shame him at all, like, what are you doing? Don't you know, you need to take ownership or responsibility? Any language that quite often in my field, a lot of people can be quite overzealous in trying to protect harm for women and children, and in their overzealous age, I often forget that the person like Trevor is coming in quite disempowered, that there's a whole series of him being done to as a child. There's quite a lot of trauma in there, so it's important to, I guess, engage and not use language that he perceives as blaming him for his actions. Although he is responsible for his behaviour, as we could see in my diagram, that a lot of men are very vulnerable to shame, blame and criticism, and a lot of guys do drop out of therapy or counselling when they feel that they are being blamed, rather than the counsellor walking with them on a journey. And it's really, I guess, something to keep in the back of your mind is what I'm suggesting, is he interpreting that as shaming or blaming, but he won't tell you. So it's really important to check out with him his many interpretations of any interventions that we use. If I could add to that? Yes, please. I endorse all of that entirely. There's a really important stat that would be very important for people to take away. All of the big washing machine meta-analyses across the world have been done on anger. The modal number of sessions, that is the most common number of sessions that men show up for, as it's typically men, is eight. I'm deliberately going slowly here, it's eight. When, by estimation, 25 is probably the minimum. So Simon's point is incredibly important. This is what Daphne Barker, Jerry Daphne Barker says, and he's one of the leading theorists or practitioners, he says, just get people that keep coming back. It's incredibly important. Michael talks about their expectation that they are going to be rejected, because let's face it, if people are angry and hostile enough or long enough, people reject them. And a kind of Kevin Rudd question to you folks, who do they end up associating with when they're really angry and they're getting rejected by people? You got it, angry people, right? Whether it be down the local footy club, down the local bar, at the gym, at work, wherever, they're associating with angry people, and they're getting really bad advice from them. So what we need to do is simply to keep them coming back 20 times, 25 times. Now, the question was, how can we alienate them? The first thing is to give them imperatives. They'll shout, no? Because we've got imperatives in their mind all the time. They're telling everyone else what they should be doing. They certainly don't want to hear it from us, so do not tell them what to do, right? It's about listening, folks. It's about being there. Silences is another one. Silences can mean anything. They can mean, I completely agree with you. I completely disagree with you, and what's more, I'm judging you right now. So do not be silent. Do not be worn down by these folks who want our help, right? They will try to bamboozle us and beat us down at times, all right? Collusion, I should have said it first up. None of us are colluding, of course. I'm just patronising you. We do not collude with people, okay? Unexceptible behaviour is unacceptable behaviour. As it gets to a point, it's reportable behaviour. It's to be really clear about kids being at psychological harm risk thereof. And the last one, and I don't mean to open up a Pandora's box here, but I challenge you all in saying this to look at the literature. 2002, it's listed in my references as a paper by a colleague called Brad Bushman. He says the worst thing we can get people to do when they're angry is to vent. And catharsis is in the title when we all know it's a term that's been around for a very, very, very, very long time, and even the author of it actually changed the view on it towards the end of his career. The worst thing we can get people to do is go to the gym when they're angry, or go to the gym before they're going to a situation where they're going to be angry. Do not get people to engage in catharsis. It's disastrous. That's what the literature says. It's not what I'm saying. So don't do those things, and it'll be easier. These are things that I do feel quite strongly about, and I just want to remind you all about are substances, alcohol, and other illicit substances. Some studies show that 35% of all patients sitting in your average, normal, suburban general practice have had an illicit substance in the previous seven days. 35% of people sitting with you as you go into your checkup. Also, if you notice a change in a pattern in somebody in a family of getting suddenly angry and displaying anger at work or at home, always think of ice. It really is out there. It's becoming a huge problem in rural Australia. I'm sure it's the same in metropolitan areas, but alcohol as well is the number one problematic substance as well, so just bear that in mind. I also take the points of everybody else about just providing a safe environment for the patient so that they have somebody who can actually listen to them, and also just listening. The patient will come up with the answer themselves. It would be nice to have 28 sessions, I can tell you, Tony. That would be lovely. There are no such systems, Michael, and those that exist are under attack, as we know. All right. Can I ask the panel if anyone's got any comments, had a lot of feedback and questions about some of the specific cultural issues that may be relevant for Trevor, or clients like Trevor, from particular cultural backgrounds, and including, of course, Indigenous men. Any comments about how treatment might be particularly focused on individuals from different cultural backgrounds? Individuals from different cultural backgrounds? I can speak to the, I guess, working with Indigenous men. I worked for two years at Cowanow Aboriginal Health Service here on the Gold Coast under the ATAPS program one day a week, and with them it's again meeting men where men are at and changing the language. So rather than counselling, it's yarning, having a yarn, and I talk about the different types of yarning. There's a type of yarning where it's just how you're going is everything okay, but there's the deeper yarning. So that's the yarning they do with each other, but coming in and talking to someone like me, like a therapist, is having that deeper yarning about stuff that's bubbling away underneath, stuff that is really causing difficulty with you. Of course, any work with Indigenous people really needs to go through the elders, go through the people, through the community, especially as a non-Indigenous person. You need to be sanctioned by the community. You need the okay by the elders, and once they trust you, then the other people will come in and will be able to trust you. Much of the interventions are the same. They're just really tailored to the individual person, their level of, I guess, of cognitivity, where they are in their education level, and just where they're at in the state of mind at that particular time. I'd like to offer a couple of other perspectives on tools. Everything Simon said, what is culture is a really interesting question. So let me talk about a couple of cultures that we may not think of instantly. I don't want to work, obviously so, with military culture and veteran culture. They are a distinct cultural group, folks. Let's be really clear. There is distinct as Indigenous culture. Let's talk about other cultures from the working class culture. Now, if anyone knows no one, I'm a boy from the northern suburbs. You can take the boy out of the suburbs, but you can't take the suburbs out of the boys. And there is working class culture. There's absolutely no question. The local footy club, the local cricket club, and this goes to the point Simon's point about language all the time. Be respectful, yet challenging of people's language. Let's talk about some of the terms, not idiot. Noba. If anyone doesn't know, canine quadruped dog means something different in working class culture. So let me morph into criminogenic culture for a minute. I think we've got some people who work in prisons just looking idly at the chat. There's a culture that you learn in places where you are incarcerated and it is passed on. But something that's not often thought about is that you've committed a crime, and let's say it's a violent physical crime, the odds are enormous that you've had that same crime committed to you. And we talk about victims of crime as having PTSD, but often perpetrators have PTSD from their own experiences as well. So this gives us a really great angle to work with that culture. It says, you know, you've been traumatized, mate. Did you know that? Do you dream about things? Do you think about things you don't want to think about? And then think about unhelpful things that you'll do when you're time's up, et cetera. But culture, you know, culture is a really broad term. We need to think sophisticatedly. And we're drawn to obvious cultural groups because of the deprivations they've suffered and injustices and all those sorts of things. But culture is, you know, culture by culture. There are many different cultures. We're going to get in ahead with the culture, so to speak. And should I just add to that, Tony, that mass maleness is a culture. When I do my talks around this, I ask all the men that if when you were six or seven years old and you fell down on that playground and you hurt your knee and started crying, what happened to you? And every single bloke will say I got called names. And as soon as a child hears a male child, hurts himself, he will hear you stop crying or I'll give you something to cry about. And already that starts that internalization, that my emotions, which are innate part of me, men feel, men feel pain, we grieve. But socially, we're told that our emotions are not okay. And then we start to push them down and that's a part of our cultural norm. Then we get into a relationship and our partner says, but what are you feeling? You're not talking to me. And the very thing we've been taught to do with men to keep ourselves safe now goes against us in a relationship, which can cause a lot of problems in a lot of relationships. So that's why when working with men, we really need to understand the wider socio-cultural conditioning and tailor our approach accordingly. Thanks Simon. So interesting. I guess one of the other things that some of the panelists would like to know about is obviously as clinicians are walking the fine line between engaging with Trevor, keeping him coming back and engaging with these techniques, but also we have a responsibility to the other people. How do you manage those responsibilities? For example, when do you make a notification to the Child Protection Services? Or when might you get Trevor's partner in? And how might you collaborate with other professionals on those issues? May I speak to that? Yes. Yeah, look, I think certainly in Queensland we have, it is mandatory that we report child abuse or any suspicion of child abuse. So this is a fairly new topic at most GP meetings. I think discussing it with a senior colleague if you're unsure, I mean if it's an open and shut case it's pretty easy, but if you're unsure, discussing it with a senior colleague or discussing it with your insurance organization is certainly a way to go. And I think if there is a suspicion of risk nowadays we're in an extremely risk averse culture. So unless you're absolutely sure that something's going to happen and you're often better off discussing it with colleagues just sitting back because often a lot of mayhem can be caused by unskilled people making decisions about risk. So I would always be discussing it with other colleagues, with senior colleagues, with other disciplines and then I'd have no problems in making a notification of ourselves as a risk. That's just the way I approach it. If I could offer a couple of contributions and you've just touched on something incredibly important Michael and it was asked of me to not mention it in my slides, but if someone is coming to you and often it's not clear in session one or two but if they're coming to you and it becomes pretty quickly apparent that they've got an irritability problem so to speak, then we're obliged to give them the appropriate warning there and then and it might be in session one, but it might be session two or session three. If you do this Squire you say these things to me I am obliged to do this. Now we can't have that as a means of shutting people down for all the reasons we've talked about tonight. So the sensitivity with which you say that is really important. But if you think about the consequences of not saying it, there was the difficulty of saying it because suddenly we're potentially playing snap with people and we haven't informed them of what it is that we're meant to be doing. And Michael's right, the bar is set pretty low in Victoria, the legislation was changed last year. It's every adult in Victoria when they believe that a child is at risk, it's every adult, it's not every practitioner, it's every adult has an obligation to report well and you can be charged for not reporting. So I think to set up the expectation right from the start that we're being frank but in an incredibly sensitive way, we're not going to finger wag and bring out the shoulds and the musts and the imperatives. It was also the question of when do we involve partners? If we do involve them, it's preferable that we do quite clearly, but I reckon there are two ground rules. It's when the fellow can commit to behaving in the way that we've been modelling and talking about and coaching and teasing along and secondly, as a consequence when it's safe. We have to be really clear that we don't bring partners in and cross that boundary unless safety is assured because we can't have people be querying things in front of other people in either direction with unintended consequences. So we safe report but let people know that there are certain things, as we do, it's a theoretical guidelines for psychology, you cannot not say these things. I absolutely agree with both Tony and Michael, here on the Gold Coast we're very lucky to have a whole lot of networks that get together and do risk assessment and I get a lot of my referrals from our child safety in that environment. And the assessing of leads when I open the slides with feminist approaches, always understanding that there are vulnerable people in men's lives and our first priority is to hold the men account for his actions but in a way that he can do it from the inside out and the first thing is to engage him as I said and then start to really, the thing with men is once you build that rapport, once you build that connection with them, you can really challenge them. You can say, mate, with all due respect that's crap and you can really hold them to account. I really value phone calls from the partners. I actually do get a lot of phone calls and they say, hey, I just want you to hear the other side and if it's safe and only if it's safe and I always pose the question to the female partner, I say, if he was to say something, if you were to say something in the session that he wouldn't like, would you have any fear of repercussion afterwards and if there's any hesitation, then according to the literature and just common good sense, couple therapies, contrary indicators, you just wouldn't go there because you're placing her at risk. But ultimately, if you work systemically and if you're dealing with two people with disorganised attachment or attachment conflicts using an emotionally focused approach, you see a lot of them, the attachment trauma is reacting off each other and helping the couples understand that and understand the dynamics of what's happening in their relationship can really be helpful. But safety is the first priority. Thanks Simon. Very relevant and interesting. I feel like we could talk and talk and talk. There's so many complex issues here and so much interesting discussion happening on the panel board as well. But I guess we've come to the time of the webinar now where I'm going to ask each of you to just give a little bit of a reflection about some of the take home messages or the key things in working with men with dysfunctional anger like Trevor and with particular reference perhaps to how we can collaborate professionally. We'll start with you Michael. Thanks very much Catherine. I think I've certainly learned a lot just from listening to Tony and to Simon this evening. I think we should all remember that men need to be listened to and they shouldn't be spoken at or lectured. They do respect boundaries from the boundaries are given appropriately and clearly. They need to be understood particularly their childhood experiences because many men repeat the mistakes that their father's made and their children repeat the mistakes that they make. And I often find that putting it in the intergenerational perspective as I mentioned with the Dynagram is often a useful way of managing it without shaming or without blaming or without using any of those pejorative terms or attitudes towards the patient. So listening, engaging and not being afraid to get them back again for a further session and being open and honest with men. Thanks Trevor. Great, thanks Michael. And over to you Tony, can you give us your summary reflections? Building on everything that's been said tonight, I would simply offer these few thoughts. Teams are best. There's nothing worse folks. Let's face it, there are some very limited systems we work under, both in the private and the public sector. Limits are bound because there's only so much we can do and there's nothing worse to complete the thought of sitting with someone who's really angry in your room, session 1 of 10 for example, thinking by going, this is an interesting referral. I didn't anticipate this. So if we're really quarant-centered, we've got to think about how we share this client with other people. And our overworked GPs are an incredibly important source of ongoing support for people, but controversial for it because in the treatment program I always involved in, there were lots of, what, and I do say lots, really skilled psychiatrists who understood that the treatment for trauma is psychological, not medical. And again, under Medicare, they are not limited in the number of sessions. They can have 52 sessions a year and more before they even get questioned. Define some really thoughtful people, we're not asking them to do psychotherapy necessarily. We're asking them to do basic psychiatric management and helping to keep people safe. So having a team around us is really, really important. And the member, champion team always beat a team of champions. So if we're a team in name only, pretty pointless, to get on well with our fellow practitioners and talk to them and to be a great team around someone is better than having a collection of individuals. So they'd be my thought. No round limits, no when to get assistance outside, when to refer on to, and no round limits really clearly around what we're obliged to report. It's really important. Excellent. Thanks for that insight, Tiny. I'll be to you, Simon. I once presented a paper at a national men's conference titled, Creating a Secure Base Using Trauma Attachment Neuroscience with Strength-Based Interventions with Men. Basically what I've argued here, what we're doing is creating a secure base. A lot of men like Heather didn't have a secure base. And from the attachment literature, there's a disorganized or a severe form of anxious attachment, which causes a lot of this reactivity. Change won't happen unless it feels safe. Men won't share unless they feel safe. A lot of people say all men don't talk about feelings or men don't talk. They do if they feel safe. I've facilitated men's groups where guys can go to incredible debts, but there has to be safety. And unfortunately, a lot of the approaches are not safe. For instance, if a guy who can't see his kids because he's just separated, and why do men work? Why do we go out to work? Because we've been socialized to show our love for our kids. So when separation divorce happens, the very thing we have gone to work for is no longer there, and that's our family. So guys will drop into grief, but won't be able to identify the grief. So they will present to services angry. They'll talk about their ex-partners in a very angry way. If people hear that, often they go, you need to do an anger management course. We can't help. What they actually need is someone to sit with them and help them process their deep sense of grief, their deep sense of the loss, and use a lot of the strategies we've talked about. It's about humanizing men. It's about seeing them more than just their behavior, that they're people too. And the political environment we're in at the moment, my accountant said, I feel ashamed for being a man because every time I read the newspaper, it's about men are violent. And it seemed the only issue we have is our anger or violence. But there's a hell of a lot of stuff underneath bubbling away that's driving that. So I would say the first response is treat the person, not the behavior. Connect with the person, and then together you can walk on a journey to help treat the behavior. Thanks. Thanks, Simon. That was a wonderful insight. And summarized thoughtfully, I think, the perspective many contemporary men feel. In summary, I think that we've covered such a broad spectrum of topics. And I think the common themes that you've all touched on are the real need for non-judgmental listening and engagement with men like Trevor, keeping them coming back and engaging with them sensitively in a very particular way. I also think that there's so much information that we didn't have a chance to get into detail about the sort of empirical literature that's available to all of us and to inspire positivity in clients like Trevor, that there are very good treatments, that there are very efficacious treatments, and that they work. And the onus is on us to become aware of those. And I think excellent resources from you in particular, Tony, that we'll be tapping, well, I'll certainly be tapping into some of the resources on your list. I think that that's a wonderful reminder for us all to remember that we have very good evidence-based treatments in this area, provided we can keep these men engaged. Of course, we didn't get a lot of time to talk about how to treat comorbidities. Of course, we didn't get a lot of time to talk about how to treat comorbidity with substance abuse and alcohol abuse, but touched on the issues of child protection and involving family members and the effect of family violence on others. I think that probably what this leads me to think that some of the discussion is that if you are participants wanting to set up your own special interests or network in this group, then you should join one or perhaps join an existing one that touches on this issue because there is a wealth of information as you can see from our webinar tonight and a wealth of expertise and experience. This also brings me to encourage you to help us by filling out the exit survey which will pop up on your screen at the end of tonight and also extend an invitation to you to join future MHPN webinars and you can keep an eye out for notifications. The next webinar will be in November, which is titled Working Together to Manage Methamphetamine Use and that's on the 25th of November. Before I close, I would like to acknowledge that the consumers and carers who've lived with mental illness in the past and those who continue to live with mental illness in the present. I would like on behalf of everyone to thank our excellent panelists this evening. It's been enjoyable, entertaining and incredibly informative and thank you of course for all the panel discussions which we look forward to looking at in detail. That's been inspired and informative.