 I'd like to welcome you all to this conversation session on grief, loss and mental health and to respectfully acknowledge the traditional owners and custodians of the land both here and wherever this session is being viewed and pay my respects to elders both past and present. My name is Monica Moore and I'm a GP working exclusively in mental health and with me is mental health social worker Julianne White. Welcome Julianne. Oh thank you Monica, thank you for being here today. It's really exciting. It is. It is exciting. Yeah. We've got a lot to discuss in grief and loss and mental health. Okay. Where would you start? Look, I always try to, you know, it's using those lovely curious reflecting skills instead of, you know, I often find people come and say, oh, so what's brought you here today? And I'll have to go, oh, look, you know, I've got this, you know, I'm depressed or this, people often don't come in and describe a situation. They say, look, I'm depressed, I've been really anxious, I haven't been sleeping well. Yeah. And when they sound good, they'll describe sometimes a very complex, tricky lots of information. You've really got to be a bit of a detective, don't you? And try to listen to some key pointers or, oh, sort of suggest some things that they might bring up. That they might bring up. But you can actually hook into, like they'll say when you got that sounds interesting to me. I'd like to explore that more. And it's interesting that you say that, you know, like one of the things, you know, if we're starting to talk about grief and mental health and loss, is that it's not, I mean, I don't know about you, but certainly in general practice, it's often really muddy and not clear why someone's coming in. Someone might come in and they might come in with a, they're really angry. OK, and they're really angry, for example, because of the way they relative was treated when they died. And so, you know, what they have to do is they, you know, we have to listen to that story first. Yeah. And that's when you find out that someone, you know, are really important person in their life has passed away and how awful it is. So, you know, even just listening. And I think that word, listen, I mean, in general practice, we've only got 15 minutes and sometimes that extends, obviously, but it's difficult to do. And so, but if we can actually listen to someone and really allow them that space, it helps them to calm down and then they can think more clearly. That's right. Absolutely. And then they can tell, you know, what's happening for them. And I think, you know, how do you sort of determine what are the things that that are going on? Because it's often not just the death, isn't it? I mean, there are all sorts of other sort of griefs and losses. So what are the things that, you know, I was reading your presentation and there's lots and lots of different types of grief and losses. I know it's really interesting, isn't it? When you actually and you can get caught up in the hole. Is it this or is it that? But that's fascinating. But it is one. Perspectives, yeah. So what's lovely is that we don't actually have to see grief as conceptualised around death. I think if we keep, if we just have that very narrow view of grief, of just being associated with the loss, with the death of a person, then we're really not, we're not seeing and acknowledging for people that for a lot of things that happen in life, we do feel sad. We have lowered mood or we're very anxious and they're very, very normal reactions to coping with adjustment or coping with change. So a lot of people can have, you know, this is where we do that whole looking at the different types of grief, like ambiguous loss, disenfranchised grief, complicated grief. So tell me about ambiguous loss. So ambiguous loss is a really interesting one and I think it's really lovely for us as clinicians to help someone to see that this is something that shifted for someone. So the person hasn't died, but something has changed. So we often think in mental health, so someone might have a psychosis or a changed personality or they've become extremely agitated or this being a major. Or dementia particularly. Some of the Lewy body dementias where there is actually some frontal loge changes, personality changes. They might have been a very calm, normal person before and whatever normal is. And then have had some huge personality change, a lot of anger or, you know, sort of some shifting between, you know, the normal person that they knew versus the person that they've changed to. And that often is really missed. So we can actually call that an ambiguous loss. Is it a loss? Is it adjustment? This is where perhaps as clinicians we get a bit stuck in, you know, it looks to me like anxiousness or we say they're stressed or we don't quite know what's wrong with the person or we just go to the medical diagnosis and ignore the psychological impact for people. Because as you would know, the anger and the frustration that people present is just a behavior. When we can't communicate what's really going on. So if someone said, oh, look, I'm grieving the person I was, that's an ambiguous loss. Is it grief or is it depression or what is it? So people really don't feel that they can say, look, it's just grief. I'm grieving. I'm grieving for the person I was. What we, in some of the literature I noticed too, that when someone's being diagnosed, particularly with bipolar, for example, then previously they just said, oh, I just having mood changes. Life's just a bit tricky. I'm a bit up and down. But this is me and this is who I am. And then you get a diagnosis like, oh, okay. So sometimes they have a reaction which could be perhaps a bit of anger or frustration or confusion. It's just interesting you say that about sort of the diagnosis. Because as a GP and GPs in the audience would know that when you diagnose someone with an illness, especially a chronic illness like diabetes or parents when their children are diagnosed with asthma and just how taken aback they are. And there's all that sort of idea of a loss of health and the fact that they are no longer the person that they were. But there's also fear for the future. This is sort of a, it destabilizes the future. They don't know what it's going to be like. And that in itself is a process that, as clinicians as GPs, one of the things about being part of that family sort of network, supporting someone through the process. And one of the lovely things about being a GP is that you have that, sure, the consultations might be short, the GPs in the audience will know, sometimes they're a bit longer, but at least you get that chance to sort of meet people on a regular basis and provide that support and the information that they need to have, to make the referral pathways that are actually going to be helpful in their journey. But it's more about sort of being that person that they come to that they can listen, that gets listened to and then they can actually negotiate what they want to do with the process. And it's sometimes not easy to do. But I think it's a beautiful position to be in, from both of us, from the GP, but also as a mental health social worker. Should we actually be listening and to be curious about that person and to offer some different insights into, like they might be just seeing the anger or the frustration and say, am I just an angry person? Nobody's an angry person. But we have angry reactions to events that stress us. So I think even shifting that so that we take the problem from the person and we can actually just see the person, just say, look, it sounds to me, this must be really hard for you. Would I be right, that paraphrasing and summarizing and then checking in with people is so critical, isn't it, regardless of whether we're doing grief and loss or we're doing some other health issues or more serious mental health presentations? It's interesting what you say about that sort of validation because there's a great book that I recommend to all GPs, everyone really, called The 15 Minute Hour by Stuart and Lieberman. And they talk about a technique of having a consultation where you bathe someone and essentially, the letters in bathe stand for asking them what's concerning them, what's bothering them. In other words, how can I help you today? What concerns are you bringing today? And then A is for affect and how do you feel about that? And then validating that emotion, it might be anger, it might be fear, it might be sadness, whatever it is that that might be. And sometimes you have to guess a bit what it is and ask them, you know, is that what you're feeling? And T is for trouble, as in what troubles are most about it? Because sometimes, you know, you might have an idea in your head about, oh, well, this is the issue. I mean, we're talking about that sort of ambiguous loss. I mean, I remember a patient who came in and she burst into tears during a pap smear and sitting down talking about it and it was because her husband had left her. And so my thought was as a GP, oh, you know, maybe the pap smear brought on tears because she's worried about STDs, you know, like maybe that's what's going on, you know, that's where my GP brain went. But when I asked her what troubled her most about it, it's actually that it was her best friend that he'd gone off with. And that's what distressed her most about it. And so that's the T in Bath and then H is for handling. How are you handling that? And so I happened to remember that and I said, so how are you handling it? And she stood up proudly and she said, I'm handling it really well. I've frozen the bank accounts. Everything is good. I'm gonna get through this. I've got really supportive friends and family. And so just, you know, the E is for the empathies is saying it's a really difficult situation, but I can understand, you know, you're handling it really well. There's all these emotions coming up and anything I can do to help. So it just also shortens the consultation when you target it like that. And I think it works really well for these situations where people have high emotions. But, you know, as you're talking, there are so many ways we can grieve losses and to be able to just keep the consultation short so you can target on what's important for that person. Absolutely. And I think, you know, when we were talking about the different types of grief too, when we're seeing a single event like that, there could be for a lot of people feeling at the time quite traumatic. So they actually have a trauma reaction, which might be outside of their sense of, you know, how they manage things. It might be a real emotional or a huge, you know, sort of stress reaction in their brains, you know, you were talking before about the Dan Siegel's model of the brain. I think this might be really good too, because if someone has a big event, that's a traumatic event, and then they go into that whole fright and flight response, do you want to... Yeah, because we were talking about that, you know, that Dan Siegel, who's a psychiatrist, you know, talks about the fact that, you know, if this is me, you know, then we've got that's my spinal cord and that's my brainstem, you know, sort of this is me sideways. And my thumb is my limbic system and so that sits there. And then my cortex wraps around my limbic system. So then I've got the brainstem that controls heart rate and blood pressure and respiration. And my limbic system is all about my emotions and my vital flight response or freeze response. And then my cortex is all about creativity and problem-solving and memories and connection and all that kind of stuff. And so if I am in a highly aroused state, if I'm either scared or if I'm really angry about something or extremely distressed, then Dan Siegel has that as the hand model. The cortex is not engaged. And that's why when someone gets a shock, they're often speechless. They can't communicate. And certainly when someone's really upset, you know, as a GP, we would have people, you know, coming in and they're brought in a child who's having a, you know, a febrile convulsion or something like that for the first time and how distressing that can be. And they're shouting at the receptionist, you know, I've got to see someone, I've got to see someone. And that whole reaction, you know, the cortex is not online. And I think there are a lot of, you know, you were talking about traumatic grief. And how that can sort of, it can be not just what's happened now, but what's happened in the past and it sort of calls all that up. Absolutely. And it, you know, the cortex is not going to be online. We're going to- But that's our job, isn't it? You know, when we're mirroring and we're doing that, thinking about, well, what do I, we can get the situation, instead of being caught up in it, oh my God, they're angry. We've got to, you know, fix this situation. You've got to escalate this, sit in a corner and instead of being punitive, at that reception is so important, isn't it? It is, it is. I think we do therapy for the minute they walk in the door. That's right. By having greeted by the staff. Well, you go out and meet them. And then you can see there's some agitation here. They're not going to respond. They're not going to be, you know, in their frontal lobe. They're not going to be thinking and analyzing. They're going to be reactive, as you said, you know, in this state. So we need to go, so what's, you know, those that they, I love the acronym, Bay, I think it's really lovely. And just to be able to go, so what can I do for you? What's happening here at the moment? Even though it's a really stressful situation, you've got to fix it, but then... And even naming the emotion, you know, the research shows that when you actually name the emotion, you know, you're really angry, you're frustrated, you're sad, you know, it sounds like you're a bit scared, you're concerned about something. But just naming the emotion can bring the cortex back on. Absolutely. It's really quite striking. And that's critical when we're doing psychoeducation and teaching in a session, isn't it? Because if we know if that person's still in that stressed state and you're trying to give them strategies or ask them what they've done before, what's worked previously, and they're in this, you know, responsiveness, or even just exhausted, often they come in very exhausted if they're not sleeping, if the worries are overwhelming. And we've got to try and do this education. You've actually got to spend quite a bit of time de-escalating, just stabilising, holding eye contact, engaging with the person. So, you know, you're talking about strategies. And so what strategies do you recommend as a social worker, you know, when you're working with someone with great? Look, I do something that I write on everything. I was explaining to you earlier, this dual-processing model. I just love it, because it's just so clear. We write on back of envelopes, on serviettes, no matter what I've got. And I've got this, you know, one I did earlier, and I just bring out this where I write it all. Just say, look, I want to draw this for you. And so it's two concentric circles. And it actually, it shilts and strobes. We've got the model, so from 1999, brought up a model that actually just fits with, but counters some of the older theories of grief and loss, the stages and phases and tasks model. We know that there are still some tasks of mourning, so warden's tasks of mourning are still relevant. But perhaps we're moved on from saying that you're going through a stage of grief. Stages, yeah. You know, the anger, denial, bargaining, and some concept of moving on, because we're really going away from that, that people have to get rid of the grief or get rid of the concept of life. Just get move on, get over it. And you know, you can't actually deal with what's happening today if you haven't got over it. You know, just put it aside. It's about bringing it along with you, integrating it with your current narrative. So the dual processing model has a loss orientation on one side and a restorative orientation on the other side. And what we say to people is that it sounds to me like you're oscillating between coping and being in the grief. And life is about dealing with loss and change, constantly dealing with things that just stress us, stress our coping mechanisms. And what we're doing is, I see my role as a clinician, is just helping a person identify what might be the trigger. I might be over here, being really caught up in my grief and feeling extremely frustrated or broken or hurt or not understanding, regardless of what the loss is, whether it's a job. You know, I had a guy that, you know, he was devastated, absolutely devastated with after 20 years of marriage, he found out that his wife wasn't a virgin when they married. He was. And he found out about it and he said, oh my God, I can't be married to this woman anymore. And then he was just angry and, you know, she wanted to leave him because he was now turning into this angry man. But what I did with him was to help him redirect that anger to a grief, so that you must be grieving the lost hope or value that you had. It doesn't mean you love your wife less, but you are grieving something that you had as a really strong value in your life. And when we reframed it as a grief, and we then looked at what might have been the triggers in his life now moving forward, he was able to actually say, well, actually, no, I'm not angry. I'm just really disappointed, overwhelmed, a bit frustrated. And he had all these other words to describe this reaction that he had instead of just going from, you know, zero to 10, being angry, I'm just angry. That's right. And he was able to say to his wife, look, I'm feeling, he could own the emotion, I'm feeling frustrated. So that's what I love about the dual processing model. We can reframe things for people around, well, actually it looks like you're coping quite well. At the moment, would you say, you know, always checking in with, is this coping? What might be other losses along the way that you could identify? Because there's never just one loss is there. Even if it is a death, there's never just the one loss. Because say, if a person's lost their spouse, they've just lost the partner, they've lost their role, they've lost their identity. You know, one woman, oh, this was so sad, Monica, this lady came into me and she handed me a photo and it was of her Medicare card. She said, look what arrived today. It was the Medicare card with just her name on it. She said, he's really died now, hasn't he? He's off my Medicare card. I know. And I just was so struck with, this was yet another loss. This was more traumatic for her than when her husband died. It was now, I'm alone, see my name. There's only one name on my Medicare card now. This is it. So that lost role, that lost, you know, that sense of who's on the journey with me. So it's more than just a single loss. People have multiple losses. Yeah. And one of the things you were talking about sort of was also about the loss of dreams. You know, when people get to a certain stage in their lives and they go, oh, well, I always thought I would do the XYZ, but now I can't or I'm never going to be able to. And that often presents, doesn't it, as a bit of depression or anxiety and people ruminate a lot over what, if I'd only done this, I could have done that, if this only happened or blaming other people, don't they? So they often come in and say, I'm not sleeping, I'm not eating, or I'm putting on weight. So all the other symptoms, and often not noticing the fact that perhaps there's this grief around this lost dream. You know, the promotion that I missed out on, or well, even like in a chronic illness, if someone gets something before the retirement age, and then it just changes the perspective, we were always going to travel, you know, and we can't do that now. That's right. You know, that's so hard for people, isn't it? And that adjustment. That's right. And I was thinking, you know, in terms of the adjustment, how would you help someone through that adjustment? Like what sort of things would you do from that sort of, you know, sort of emotional perspective, cognitive perspective, behavioral perspective? What are the things that you would suggest would be helpful for clinicians? Look, what I love, that's why I love going back to that dual processing model. I really use it as my grounding tool. Okay. So, look, and I'd be interested to know what you use too, so that'd be really good. Yeah. But because what I love about that is that because you can go, look, what might be the triggers that will bring up the grief or the loss again for you. So it could be, oh, you're gonna have to ask me that question again. Well, it's just, it's more the, because I love the way you had it set out, you know, these are the sort of the emotional, the cognitive, and the behavioral interventions that might be really useful. Thank you for that. Yeah. And I know you'd go back to the dual processing because that's a wonderful starting point. Yeah. And look, and I often feel too that, you know, when you're just so engrossed in the person's story and you're listening and you're thinking, you don't want to be thinking of the next thing. You want to sit with that person and be, and validate their responses and also be truly present, that mindfulness. Yeah. As, and in present in the situation with the person, I think it's absolutely critical. If you can actually sit with the person, hold eye contact, perhaps, you know, do the whole leaning in, you know, the micro skills, you know, leaning in and opening yourself up with curiosity and saying to them, so I'm really curious, I'm really interested. You've often then forgotten, you know, where you might be wanting to take that person. So I think if you have a default that you go to, so that's why I love the dual processing because it's really grounded. It's simple. So from there, would you then, because I'm thinking as a GP, okay. And I suppose I use a little bit of that sort of solution focused model in the sense where I go, what can this person have more of that brings life into their life and joy and what can this person have less of that, you know, is about ruminating on the grief or ruminating on the losses. And so not that you don't honor the losses and the grief, but that you certainly don't spend, you know, there's no need to spend all that time sort of morning. Now I say that with a caveat, okay, because there are lots of cultural differences. And sometimes within different cultures and people in the audience, although that more, much more than I do, you know, would have prescribed ways of mourning, prescribed ways of doing grief. And in certain cultures, you're not allowed to express some of these losses that we've been talking about. You're not allowed to express some of these griefs. And that actually makes life a lot harder when you're not allowed to do that. And you see, we call that a disenfranchised grief. So a grief that's a loss that someone's had that's not socially acceptable, that's not seen to be sanctioned so that how we'd normally react to grief, which might be in some cultures that could be never talking about, you know, say if we only to see grief about death, you know, there's cultures, there's reactions and cultural practices around certain griefs if it's about a death. But if we actually name something as a grief and it could be around a miscarriage, for example, or an abortion, or, you know, sort of successive partners in some of, you know, blended families where there's, you know, people are grieving the loss of somebody, but they don't feel that they can call it a grief. They're not allowed to grieve. Or even with an adult child, they come out and say, you know, mum and dad, I'm gay, you know, and they're just not allowed to, the family aren't allowed to say anything or do anything about it, you know, like to get the support from their friends. And they may want to do some physical reactions to the grief. They may want to cry or just feel very emotive. And actually, that brings me to another thing because often, you know, we've had the masculine feminine models of types of grieving, you know, I think it's really important to dispel all of that. There are no, you know, gendered roles, wouldn't you say, around women do this and men do that? I just think that's just got to dispel all of that completely and talk about as intuitive grieving. So that sense of being immersed and invested in the emotive reaction to the grief and the emotive expression of the grief, however it is for you as a person. And then you could be in the instrumental mode, which is the doing, the busyness, the task-focused solution-orientated. And it's about helping that person say, because, you know, I have people come and say, I never grieved my mother when she died or I never grieved, that's what's wrong with me today because now I'm feeling emotive. And I often just say to people, no, but at the time you grieved appropriately, it was an instrumental grieving. You did what was needed. I love that. So it's an instrumental grieving and an intuitive grieving. And at times, we can just beautifully have that lovely flow between one another. And there's a time, I love that, you know, there's a time for everything. Sometimes there's a time to be intuitive, to be deeply immersed in the emotion of it and go, my God, I'm so overwhelmed by this. And they go, right, well, what do we have to do now? I've got to actually get the dinner ready. I've got to go and do shopping. I've got to go to work. Yeah, I've got to sort out the wheel. I've got to, you know, empty mum's house. I've got to do, yeah. But people need to see that that is grief. You grieved appropriately. You just needed to be busy. And also it helps to educate partners, you know, because there will be one partner doing intuitive grief and the other partner will be doing the instrumental grief and there's conflict between them because they don't feel like they're travelling the same path. That's right, absolutely. And you can't, if there's one person doing all the problem-solving and they're taking over, you know, we had a significant grief in our family a couple of years ago and, you know, I had two sons that came in and they came to the rescue and, you know, stepped into the position and they were brilliant, which gave space for the rest of us to be intuitive, to be deeply immersed in the emotional, the hugging, the caring for, you know, the supportive work that was done. And then there's a time for that to be flipped over for them to then be able to sit back and go, oh, my God, I can't believe this terrible thing happened. And for those of us to be caring and supportive. And it's interesting, you know, because it's also bringing up as a GP, a young mum was telling me about her son and their pet had died and she was distraught. They'd had the pet for many years and everybody in the family was distraught. But her young son, you know, primary school age, just seemed to be getting on with life and, you know, life was good and she was really concerned. Should I, you know, can you give me the name of a psychologist who can go and see? He's bottling it all up. What would you think about that? I'd actually just sit with her and say, so what part of this is really you're struggling with? Yes. Because the other thing as part of understanding loss or grieving associated with any loss is for us as clinicians to help people to understand the meaning. Because the meaning is directly proportional to the degree of the depth of the loss. So if something has a great meaning and great attachment, there will be a greater loss or an experience of grief. But I also think that children can be, because I was thinking, you know, and I wasn't laughing at her, we were laughing together at the end of it, when we sort of said children have a really pragmatic view of the world. They do. And this animal was in his life all this, you know, all his life. But in the same way, like he has other really lovely components. He's got you, he's got your husband, he's got his siblings. Like, you know what I mean? Like his loss is not the same as your loss. And so he will grieve differently. And, you know, we went through the usual things, like he wasn't bedwetting, he wasn't like he wasn't regressing in his age. He wasn't, you know, no problems at school. He wasn't irritable or absent at home. He wasn't having more conflict with his siblings. Like we went through all of the sort of, the things that might be markers of bother, you know, for a child. And to say, no, and he's not a sociopath either. You know what I mean? He really does love, he does care. It's just that this is the way that he's, you know, it's a pragmatic view. Sometimes children can have a fairly pragmatic thing and their loss just catches up with them later. And I think it's a wonderful opportunity for us to introduce to people, to teach them how to talk to their, you know, for that like that mum to go to her son, and say, you know, what we call a teachable moment. So to go to them and say, look, you know, you must really miss the cat. Yeah, yeah, yeah. So tell me about the relationship. Tell me about what you miss most about. That's right. And so she was going to organise a cooking session with him so they could stand together and say what they really loved about it. You know what I mean? Because actually he might have, and some people feel like, sonny cat, should I, should I grieve it? Should I be crying over a cat? Like they come to a certain stage just for their development, don't say little goodies. And they just think, oh, maybe everyone will think I'm weird if I do this, so. That's it. Yeah, that's it. And this is that part about, you know, disenfranchised. If we don't let people grieve things appropriately, but give them perhaps that education to say, look, you know, as a mum, you can use these teachable moments with your children to just allow them to say, must be very sad. But we do sad, we don't have to be crying. Sad is interesting. And they even talk to the child about, tell me about, must tell you, I had a beautiful young nine-year-old in session last year. I said to him, so tell me what's the opposite to happy? And he looked at me and he goes, not happy. And I'm like, you're right. The opposite to happy is not happy, not sad. So if we're not sad, it doesn't mean we have to be happy. We just have to be not sad. And the opposite of happy is just not happy. And the opposite of angry, no, I just love it. And the opposite of angry is not. Calm and serene. It's just not angry. It is what it is. So here we're not angry and here we're angry. So I think we can actually say to people, look to it to be, not sad is just not sad. We don't have to then be happy. And I think sometimes that positive psychology creeps in in ways that perhaps not intended. It is just not, just be positive. It's misinterpreted. It is misinterpreted. It gets misinterpreted. Yeah. Totally. And I think, you know, when we're talking about, you know, I use that sort of positive psychology a lot. Yeah. Okay. And the positive psychology that I use is more in relation to, you know, focusing on, you know, what are the things, sometimes, you know, when people find it really hard to get through the day. And yes, you acknowledge it's really hard to get through the day. But can you get to the end of the day and go three things that I'm grateful for? Can you wake up in the morning and say, you know, before you get out of bed, close your eyes and focus on the five human beings that you've either are positive forces in your life today or have been in the past and just think about them and say, thank you and I wish you well. And then as you connect with those five people and then get up and go through your day, you know, to use the concept of mindfulness, which is really just paying attention in the moment. At the end of the day, keep a ta-da list, not a to-do list. You know, like a ta-da. Look what I did today. Look what I did today. Look what I achieved today. So that fits into my 15-minute therapy. You know about 15-minute therapy? Tell me. It's just 15 more minutes. It's just simple, 15 more minutes and just another 15 more minutes. And you can do another 15 more minutes. And how was that for you? And just, you could do a ta-da maybe. You can actually get through the next two or three hours. Just 15 more minutes. Yes, okay. And so at the end of the day, you can write down, I got through. Yeah, I got through 10 of those 15 more minutes. Absolutely, absolutely. And you see, often too, when those feelings just overwhelm and people then start self-harming or doing other behaviors of concern, often giving them just a simple quick, short strategy, just 15 more minutes, that mindfulness to go to the center, acknowledge where the feeling arises in the body, and they go, 15 more minutes, it's all I need. And then when they get to that, I can do 15 more, with that sense of positive achievement. Yeah. And you know, as a GP, I mean, we do see people who, you know, have had lots of trauma in their lives. And so, you know, societal ideation and behavior will occur, you know, self-harming. And one of the real benefits in my area, at least of the Mental Health Practitioners Network, is the fact that when we meet, you know, we've got now 145 people who've actually attended. And so the group is 145, even though our monthly meetings are a little bit less than that, usually between 20 and 30. But every clinician presents on their own work. Right. I mean, people who want to, some people don't want to. But we know who people are. The GP's in our area, you know, if they want to know of someone, and you know, if someone in the audience might do this already, you know, that you just send an email to the person who's organizing the network and facilitating and say, look, I've got this patient or this client who needs someone with these skills, and do you know of anyone? And I normally send an email out to the group and get lots of people responding. It's a really good resource. Yeah, that's wonderful. And look, I think, like, this is when I love this conference too, like, I think that the theme is working better together. Yeah. And in HPN, actually, we've got one in Wagga. So it gives us that opportunity to meet and greet and think, oh, I might collaborate, or we can actually get our peer collegial support. I think that's absolutely critical. And I think from a GP perspective, knowing, you know, because you just don't want to always go to the default. Oh, I'll just send them to that person. If you know that they do grief well, but this person does self-harm well, this person does eating disorder as well. You know, we can't be everything to everybody. We've actually got to be, you know, real, like, you wouldn't go to see an orthopedic surgeon if you had a gastric problem. You know, you go, you choose your clinicians very wisely, don't you? Because you know that they'll be able to understand and listen in. And if you're the first, you know, the gatekeeper, the first portal call for a lot of clients, you know, if you're listening and thinking, this could be, I'm wondering, is there grief instead of perhaps just something else? Depression. Yep. Yeah. We could say just depression, should we? Well, no, it's just that... It's so complex, isn't it? You know, because GPs prescribe, you know what I mean? Actually, that's a good segue, isn't it? Yeah. Well, I don't want to just talk about medication as a GP, you know, but this is not the forum for it. But, you know, sometimes, because people come in and they say, I just want to feel better. Yeah. And so you go, right, okay, you know, medical director or whatever, you know, best practice, whatever it is that you use. I shouldn't be saying these things. But, you know, and then you just, you know, yes, here's the script, sometimes it's so easy to do that. Do you find people want that? Is that, do you find people come in and go, oh, I just need something, give me something? My friends on an antidepressant, my mother's on antidepressant, my sister, yeah, could I just have an antidepressant? I'll feel better. It's not an uncommon presentation. And so, or even a sleeping tablet. Okay. And so just taking that time to say, look, we could do that, definitely. And I think that it is important to reinforce that sometimes in prolonged grief, like a prolonged grief reaction in complicated grief where people have aspects of feeling, you know, a lot of self-blame or they just feel that life isn't worth living or they have, you know, like really severe problems or they've experienced depression before, that an antidepressant, like an SSRI, might actually be a really good thing to add as a support. You know, I often talk about, it's like a plaster cast on your arm. You're just using it for the moment so that you can have that support, that extra thing that will let you get through life. Okay. And through this really difficult, you know, adjustment process. And so antidepressants can be really useful. I guess, you know, the research sort of says that benzodiazepines, you know, sleeping tablets, Valium, they don't help. They don't make any difference to the grieving process. And with a certain number of individuals can actually cause harm because they make, you know, groggy during the day, they can interfere with working machinery and become addictive, like all that kind of stuff. I mean, addiction, probably not so much within this sort of grief and loss sort of environment, but you know, they're potentially quite harmful. So I think anything that you can do, you know, we live in the world of apps. And so, you know, there are so many apps which are about meditation. There are so many apps which are about sleep and sleep hygiene. There are apps about logging your worry thoughts. Yes. It's just brilliant. I love that, too. The concept of worry time. Yes. It's actually giving people permission. It's often said to them, you've got to get your worry book. There's an app for that. There's Worry Time app. Yes. A Worry Time app. Get your biro when things worry you, write them down. Have worry time. Have a legitimate worry time. Because you can't trick the brain either, you know, with worry time. If you say, I'm going to worry about that in worry time, we've actually got to do it. Do it. So that you're actually teaching your brain and setting up new neural pathways that actually say, yes, that's right. You will do that on Thursday at four o'clock because that's my worry time. And I get my book and my biro, write my worries down, like my shopping list, close the book and put it away. That's right. I think it's a really good mindfulness strategy to deal with worries, especially the ruminating, the precipitating type of worries. That's right. That's it. That big word. Because, you know, we're born without the capacity to sort of produce adrenaline. Yes. And so we're born, you know, a bit of a warrior, all right? I mean, some people might say that then your life events exacerbate that sort of capacity to produce adrenaline when it's not needed, but certainly having these strategies to manage. So I think as a GP, it's kind of untangling. You had on one of your things, you had, you know, most people think of grief as it's going to be this sort of straight line, you know, just getting through the process. Yes, it's difficult. And then you had no grief. It's actually like this. You start off like this and you go, that's right. And then you come out the other end. And I think it's that we're here, you know, in this really messy sort of tangled stuff. Except Monica, it's really important not to let people think it's chaotic. Grief is not chaotic. OK. There's a pattern and a rhythm to grief because it's always... So it feels chaotic. It feels chaotic because we don't know the triggers. It's our job to go, grief is not chaotic. There are key markers and points along that journey. It actually is like that, OK? But it feels this. So you've got to say, so what might be the... What will be your triggers today? And when grief is acute, you actually have lots of triggers. There are a lot of things that go, oh, my God. You know, let's go to death, even though grief is not just about death. But, you know, if that person that you loved has died, then it's everything's a trigger. Like when I make a cup of tea, I used to get two cups out. When I get in the car, both of us went. When I came home from work, they would be there. When I've read the paper, there's someone to talk to. Like, oh, you know, the yearning that people feel, especially, you know, if you've lost a child. And yearning is just not with grief of a death of a loved one, either. That yearning, that sense of, I want this person, that deep physical longing and wanting to hold, to hug, to touch. It also comes in with other losses as well, like that acute traumatic loss, that yearning for the lost limb, or the lost life that you had, that yearning for it. It's almost like a sort of a panicky loss. It is, isn't it? And if it's that's ruminating over what that life would have been like, it could have been like this, I would have done this. So the triggers are there. Whenever there's something in our little, you know, the person's world or the systems that impact on that person, there will be a trigger. And I think our job is to be that quiet presence that listens to the story. You know, and I often do like a mind map for people, and I'll do a circle as they talk, and I'll just do a circle and put something in it, and then a circle and put something in it. And I say to the person, do you mind if I just put some things down on this page as we're talking? And then we line them up or link them up and say, in any given day, you'll go, here, here, here, here, here. Where are the triggers for you in this day? Not just the anniversaries. We often just think triggers might be the birthdays, the anniversaries, or when I lost my job, or this thing happened, or the house burned down, or tangible triggers. We've got to think about what are the other triggers that might happen. So, you know, if you're at work and it was because you missed out on a job promotion, it could be when, you know, the person that got the job walks past you, you go, oh, you know. Could be something else completely, you know, it might be that at work there's a bullying situation. It might be that, you know, there's another situation and there's conflict with the neighbour over the tree. Like, you just don't know in the context of people's lives, you know, how many other factors are sort of impacting. And I was just thinking about that word impact and something we haven't mentioned already, but something that's very high on my list of things, you know, when I talk to clinicians and it's clinicians' self-care, because you know how you talk about being present, about listening, it's really hard for us as clinicians to be really present to other people's griefs, you know, sort of, and that sort of emotional experience when our cortex isn't online. That's right. When we're aroused. And so it's really important for us to do our own self-care. Absolutely. So how do you do it? How do you do something? Actually, you know, I did a presentation yesterday to GP registrars on anxiety. And I had someone come up to me afterwards and said, how do you do it? How do you look after yourself? And I mean, you know, there are so many things. I use an app. I use, you know, a meditation app. I do meditation every day. I exercise, you know, five days a week. I have good relationships. I have good network of friends. I can talk to them. I can say to them, can I borrow your frontal lobes? They know me. Because mine's not working. Because, you know, if I'm like this, I'll go, can I borrow your frontal lobes? You know, I have things that I work part-time because I'm an introvert. And so I need time off. I mean, there are lots of things that I do. And I think I also have supervision and I also talk to my peers. And at times when I've needed to because of something that's really triggered something in me, I've had counselling of my own. You know, I think it's important that we recognize, you know, we're human beings. And so sometimes we need to do that. You know, it's not enough to just say, and I think often in GP land, you know, people go, no, counselling. That it's important to acknowledge that sometimes it's really helpful. Yeah. Yeah, absolutely. It doesn't mean we're weak. It just means we're human. Yeah. And that's where that supervision, seeking supervision. And not just one supervisor, but a supervisor or a range of people that can respond to different aspects of your life. Mentors. Basically, like, 99% of my practice is around grief and trauma. And we have a wonderful, positive approach in our offices. We know that every single clinician that we work with is going to have some tricky, complex clients all day. We might have four or five very, very tricky situations. At the end of the day or in the middle of the day, we catch each other in the corridor. And we just stop. We never just go, you know, whatever. We just make a point of stopping and being mindful and just acknowledging the other. And... You know, there's research that after... I think it was Hurricane Katrina. And, you know, one of those big, you say, USA hospitals where they had lots and lots of people with sort of injuries. It was just crowded. It was hot with aweful. Okay. And that they did this thing where they said, all you have to do is clinicians. And actually it wasn't just clinicians. It was sort of staff as well, like cleaners and, you know, trolley people. And you just have to make eye contact and smile at someone else who works here. Okay. That's all you have to do. And if you're within 10 feet of them, because it's an American research, if you're within 10 feet of them, you have to say hello. Right. That's it. That's it. And that's engaging. Okay. Eye contact engaging. And the... And then they didn't actually ask the clinicians and people who work there, the staff, how they felt. They asked the patients what their experience of being in the hospital was. Okay. And they compared it to another major hospital where they didn't do that intervention. How interesting. But that's a key... And the patients benefited. Absolutely. But isn't that so key? It's about the quality of human relationships. That's it. And just helping people to re-engage and find that space. That's it. And so... And, you know, when you were saying about the receptionist, you know, if you get a receptionist who comes in and just... She's busy. She's done something else, you know, but she just makes eye contact and smile, hi, be with you in a minute. You know what I mean? Like, that's all that you need. Absolutely. When someone is really distressed to bring their cortex down. Absolutely. Now, isn't it interesting, and I think that we've got to, as clinicians, also be very aware of the DSM5, our diagnostic criteria and classifications. Yes. Because there's the new diagnostic criteria of prolonged grief disorder. Yep. And complicated grief. Yep. And traumatic grief. So I think we've probably be really mindful of the, you know, what... The difference between, perhaps, clinical depression and what complicated grief disorder might be called prolonged grief disorder. Yeah. So I think it's really key, too, that we're very aware and we can actually do some education for people around what prolonged grief disorder might be. And you've got one of those wonderful slides. We have some slides, yes. Yep. So people can go to that reference spot. That's right. Yes. Because we've got some slides and we've got some references. Yes. But you can access as well. But, you know, you've got that lovely slide where you've got the ICD-11 classification, as well as the DSM5. Yes. And that sort of, you know, it gives some prompts as to what you're sort of looking for. But what I love to use it for, Monica, is when I'm writing back to the GP, because, as you know, under a mental health treatment plan, I've got to do, and I love it, I absolutely love it, although it's a very time, it's a labour of love, I'm sure. That's right. And I must have a bit of a dig at the GP. So I don't get anything back from GPs. I would love a letter back from the GP, or just a quick note. Anyway, we'll worry about that later. Actually, we're not taught to do that. Oh, I wish you would. Gosh, it'd be nice. We're not taught. Because I've got to write after the first session, the sixth session, and then towards the end of the tenth session, and I do these lovely big letters. Can I just take a little sort of side issue, a little side box, a little side box. When we're dealing with all the other specialists that we deal with, if I write to a specialist and refer someone, and then the specialist writes back to me, and every time that patient goes to see the specialist, the specialist then writes back to me, the specialist, the cardiologist, the renal physician, the neurologist, they'd feel really like, why is Monica writing to me? She's already referred, unless it's a referral, please continue to see this person, or a change of, like, something's changed. Yes, something's changed. Something really drastically has changed, okay? And I need that specialist to know about it. They would be kind of going, what's going on? Yeah, she's overdoing it. What's going on? Yeah, like, hello. But what I find in the mental health space is because we're doing therapy, and I'm doing stuff, and I know they're going back to their GP because you're reviewing them, especially if they're on medication, and you're reviewing the effectiveness or otherwise, and then I'm saying, look, I'm doing some CBT, a bit of acceptance and commitment, and maybe I'm using some group. I'd like to challenge, you know, I might write to the GP and say, look, I've actually reviewed the client's story, looked at this, and I'd like to put to you that maybe there's some grief happening here, because I've written to a few GPs and put in the diagnostic criteria for complicated grief disorder, or prolonged grief disorder, or whatever, traumatic grief. So I'd like to consider that perhaps that this could be a differential diagnosis or a possibility, and maybe medication is not best practice for this person. They may be presenting like chronic depression, however, perhaps it's not best practice for this particular presentation, and I'm just wondering or curious what could be, and you put it out to the ether, I ring, if I'm really concerned, I'll always ring a doctor, and I think that's the best thing. So if you want, I think, and even my colleagues who are psychologists, and they will say, like, I really want to communicate with the GP. Look, GP's out there, I might be speaking out of turn. And social workers. Yeah, just put it out there. But if you really want to communicate with the GP, don't wait for the GP to write to you or ring you, pick up the phone and say, I'm calling you because of blah, blah, blah, just letting you know. What do you think? And I think because there's a GP, I mean, I do remember really, it was so wonderful to, when someone rang me up and said, this is what I think because as a GP, I know a little bit about a lot of things. And the people I'm referring to know a lot about a narrow field because that's really what a specialist is. And so when a specialist then contacts me and they know a lot, that means that I don't have to use my brain to fit any more stuff in. My brain's only limited. It's got lots of little bits. Okay. And so that's why a phone call to say, I think this and I think that. What do you think? And what do you think? And I think this would be best practice. And then the GP can either, I mean, the GP might not agree, but at least you've put it out there as a healthy discussion. Absolutely. And they're aware of it. If you put it in a letter, sometimes it doesn't register. It slips in under the radar. True. True. So that's really important, that collaborative. And if we want to have patients, to give our clients patience to get better and or to feel that life has more meaning and that they can live with this thing that's happening to them. That's right. And they know that they've got some new skills and new strategies. Because often say to people, look, you know, if you, you can't just take the same strategy or the same tool for your toolkit, you know, the toolkit analogy. You wouldn't just do mindfulness every time you feel a bit anxious. You know, you might need some 15 minute therapy. No, it's not absolutely really good. It's very good. Yeah. But, you know, you need a range of tools so that when you've got a problem, we're just not teaching people to fix this problem today. We're actually helping them to fix that can recognize that feeling and think when something else happens, oh, that was similar to that feeling. So then they've got tools. They might come in and check in, am I doing the right things? Am I doing the right things? And our job is to say, what if you, so I love that, babe, because it's how are you handling this? And how are you handling this? What are you doing? Because that's a real positive thing, separating the person from the problem, isn't it? Yeah. And I think, you know, as you're saying about, you know, things happen again and again. As a GP, I know that, you know, I mean, talking to other GPs in our experience, and, you know, when a young person who we're looking after gets a really serious illness like, you know, young man with a melanoma and everything that you do and the specialists do, it doesn't work and he dies. When a child dies, when someone, you know, a patient or family I looked after for years and years, and they were gorgeous, you know, like three young girls and their parents. And there was a horrific car accident and the girls survived when the parents died. And you know what I mean? Like the impact that it has on us, okay? That's our own grief. That's our own loss. And it will happen. It will continue to happen throughout our working life. And so it's that thing about, you know, developing strategies that we can actually use each time, having people that we can check in with, that can support us through that process. Having body-based things like yoga. You know, there's, you know, we're getting someone in, hopefully, throughout the year to talk on trauma-informed yoga, like all of these sorts of things that are really helpful to help us to deal with the difficulties of life in general. You just mentioned something really interesting then about that car accident and just what went through my mind then is that severe trauma, going back to traumatic grief. When there is a trauma, if we understand what's going on in a person's mind where they might have dissociated and one thing I say to everybody I lecture or talk to about grief is there's no such thing as denial. I want to get denial out of the grief language. Nobody denies that something has changed. Nobody. We might dissociate. So we separate ourselves from it because the brain stops us physically so we dissociate and distance. It's a survival strategy. It's a survival strategy. But to say to someone which I think is very judgmental, progerative and subjective, say, you're in denial. Or for us to be whispering to each other, they're in denial. Hate it as a phrase. Hate it as a phrase and I think it's very judgmental of people. Whereas if we say that they're distancing from the grief or it was so traumatic that the brain actually segmented that traumatic experience off. Because it's just too traumatic to actually get into the image. It separates as we know in trauma that the thinking part of the brain separates the emotive reaction to it out so that we can intellectualise the loss without having the emotive experience which is where that very specialised trauma therapy comes in like exposure, EMDR, other therapies to help with that reconnection of the emotion with the actual intellectualising of it. So I think we must be mindful to if someone doesn't have a reaction that they're expecting, that we're not judging them for it and say, oh well, you're in denial or that there's a depression or something else happening, we could actually just say that this must be so traumatic. Because the definition of trauma especially in chronic traumatisation is where you feel helpless, hopeless and having no control of a situation triggers, if it has a lot of meaning then it triggers a real grief reaction for people and I think that's got to be really mindful to help people educate and say, look, I just don't know what's wrong with me. I'm not feeling anything and it doesn't mean you're in denial. It just means your brain must have been so traumatic for you and I think that's really, yeah. It's something else to keep in mind. It's just a complex field, isn't it? It's such a tricky field. I'm sort of aware of the time and that we could go on talking for ages. We could, so easily. But I'm just wondering, is there anything else that you would like to add to the conversation that might be useful in listening to this conversation? Look, I think it's just as... we're human beings. We feel as our clients do, we're not unique, we're not special. We've got a little bit of knowledge. They've got their knowledge. I think we've got to assume that everybody that comes in brings a story, brings their own competence, brings their own professional capacity, whatever. It doesn't matter where they are on the scale of life. They bring something to that encounter that we've got as human beings and we're human and I think the connection of two human beings over things that we feel intimately like others, we all experience loss, we all experience grief. It's the one thing that we all experience and we all go through adjustments to grief, whereas with other mental health presentations, we don't all experience schizophrenia. We don't all experience paranoia. That's right. But adjustment and grief and coping with loss are things that unite us as a human being and I think to connect with another, whether it's through our body, our use of self, simply sitting back and just typing at the computer and all that's interesting, but we actually can lean in, we can reflect, we can paraphrase, we can use our empathetic skills, that that actually then gives that person I've been heard, I've been listened. I think that's, you know... And you don't have to do a huge... You don't have to spend the whole consultation listening. You can just listen to someone for 90 seconds and really give them attention and then do an empathic interruption. Just one moment. Can I just make sure I'm hearing you correctly? Absolutely. This is what you've just said. Now, we don't have much time, so can we just, you know... And that's what the whole 15-minute hour sort of thing is about. And I think that, you know, as GPs, we do have to do a lot of stuff on the computer, I must admit. You do. But you can sort of... Like, you can do the focusing and then go, like, just a moment, I just need to enter that in the computer and then, you know, you do your stuff and then you come back to the person. And I think, you know, sort of from my perspective, is just that life is an ongoing process of working out what works for you as a clinician. You know, whether you're a GP, a social worker, a nurse, an occupational therapist. You know, there are so many, you know, psychologists, there are so many people who'll be listening in. We've got psychiatrists. I'm going to forget people. Okay, so just... Sorry about this. But it's more about recognizing that we can always sort of learn a little bit more and be gentle with ourselves, a bit of self-compassion. Absolutely. You know, the old Brene Brown be real, be honest and be vulnerable and... Except that vulnerability. Actually, that's really... Except that vulnerability. And maybe that's a really great thing to finish on, too. Yeah. That we don't have to be, you know, everything. Yes. The beautiful thing that I love about, you know, the whole approach as a profession is to be curious. Have all of our, you know, it's the art and the science, isn't it? Have all the science. Know our theories. Know our therapies. Have a good, you know, toolkit of things there. So we're not just doing the same, that everybody will, you know, like Groundhog Day. Same story. Same treatment. It's about each person's unique. Yeah. To be curious. To be open. Maybe you could be... To be vulnerable. To the audience as we say goodbye. Goodbye. Thank you. What a lovely word. And so be real. And Brene Brown's a beautiful thing about being vulnerable, being open to vulnerability and to actually acknowledge that we as humans are connecting with other humans. And in the whole grief and loss field, not be frightened to call something grievous, just say, I'm curious. Do you think this could be grief? It sounds like this is... And rather than going straight to the sense of, you know, what's a, you know, tricky diagnosis? Am I missing something? Just be very gentle. And I think it's the art and the science of working in this space. One final thing, though, is I don't want people to be frightened. We all should do grief and loss as part of our clinical repertoire. Instead of thinking, I need to find a grief specialist. I would like every clinician, regardless of where you are, whatever qualification you've got, to be able to sit comfortably and say, I can do grief therapy. Grief therapy is just understanding how grief intersects into a person's life and how, you know, perhaps we can help them reframe and acknowledge that grief exists and it's not just about death. And I think that's, you know, that we can all do it and not just think, I've got to keep referring off to specialists. We do need them. But perhaps we all need to be able to sit comfortably in this space with people. But Monica, this has been what an amazing opportunity to actually sit with a... Someone I haven't met before today. We've spoken on the phone, but this has been delightful. So thank you very much for your insights. Thank you. And thank you to everyone in the audience. And I hope that it's been helpful. And I'm taking away Baze and the 15-minute hour. And I'm taking away a lot from today. And that ta-da moment. I like that. That's so cool. So thank you so much for today. Thank you. Really exciting. Okay. I hope we do it again. Yeah. It'll be so much fun. Okay, thank you. Thank you. Bye.