 Good evening everybody and welcome to this special follow-up webinar which is an interdisciplinary case study panel discussion brought to you by the Mental Health Professionals Network. Some of you might not know who they are but they're not for profit organisations contracted by the Commonwealth Government Department of Health and Aging and their role is to essentially make available to roll out interdisciplinary mental health workshops right across Australia and the idea is that we're going to create sustainable self-supported clinical networks and the object of this webinar is first of all to identify discipline specific approaches to the diagnosis, the treatment and management of adolescent mental health presentations with particularly a feature of depression, suicidality and maybe even cyberballing. And secondly to recognise the ways in which mental health interdisciplinary collaboration will obviously contribute to a better patient outcome. Now the session outline is really quite simple. The webinar will be composed of two separate parts. The first will be a facilitated case study panel discussion. The second will be an opportunity for you as webinar viewers to ask questions and obviously to receive answers. We will only go for an hour and a half but in this time the panel will share with you discipline specific tips and strategies for working with our clients tonight. His name is Tim and obviously field questions from only welcome. All of you who have logged on you've obviously shown interest and commitment to adolescent health because you've allocated time out from your busy schedule to watch this webinar live and we're very, very appreciative particularly because we know it clashes with home and away and we appreciate the sacrifice that you're making. So as you know, this is a follow up webinar to the first one and today the focus will be on you getting some specific tips and strategies from the panel about working with adolescents with this type of presentation. I'm particularly pleased to be able to welcome some new panel members and even a new discipline in the form of a mental health nurse practitioner who you'll meet later. In order to appreciate this webinar in 3D and Technicolor with surround form please ensure that your sound is in fact activated on your computer and the volume has turned up. During the webinar I would encourage you all to post questions by typing them into the message box. Now sadly given the amount of participants we may not have time for your specific question to be addressed but you can always participate in a post webinar forum to continue the discussion. Please note that the PowerPoints from this particular slideshow will be available as a resource on the Mental Health Professional Network website which is www.mhpn.org.au. You need us to say any inappropriate questions will not be presented. I'm going to moderate the panel discussion tonight and my name is Michael Carr-Gregg and I'm also going to moderate the question and answer sessions. So to the case study and this is the most important part of this we will have online for you to see and hear several people and I'm going to introduce them as they come online. So the first thing I want to say is it's true today that the majority of young people in Australia are no longer grossly malnourished, they're not shoved down coal mines or less. Precious anxieties and tensions which really are with many of our clients, our patients are growing up in a psychological wasteland without nurturing or support growing up in circumstances of pervasive adversity and limited resources such that their developmental trajectories are certain to be irretrievably compromised. 75% as you can see of all mental illnesses begin before the age of 25, one in four of these kids obviously can have a mental health problem and only 30% they profess. The truth is that mental health disorders now account for 49% of the disease burden and that is significant. Measures both death and disability or 55% if you believe the Australian Institute of Health and Welfare. Young Australians appear to be suffering mental health problems at an earlier age than before, experiencing them at higher rates than older age groups and retaining their increased risk beyond youth into older age. So I guess this is timely and I would be delighted to introduce to you the subject of our case study tonight who is in fact a 17-year-old Year 11 student. He doesn't particularly want to seek health, he's not a particularly sophisticated consumer of health services, let alone mental health services. So he's not particularly keen to be there. He's been brought along with an assessment by his mum and she thinks he's irritable, argumentative and is worried about his poor academic performance. There's no previous history but he does seem to be a sensitive lad. The family history basically is a mother who's tense, the father who was a heavy drinker and of course a paternal uncle who has bipolar disorder. When you talk to him, Tim basically thinks his mother is sort of the wicked witch of the West. There's some tension with dads and tension with a particular school teacher. Significantly there was a recent falling out with his friends. He doesn't appear to have much of an interest in schools, doesn't really have much of a sense of the future and complaints have been tired a lot of the time. So he is in fact the next patient of yours, Mary. And I'm interested to know what you're going to do. Well thanks. Can I just check that you can hear me on speaker because I can pick the phone up if necessary. Before you do that I'm just going to introduce you, Mary. You are a GP and you're a psychotherapist and you work at Headspace Townsville. You have a mixed role as a senior clinician and that includes seeing clients from medical psychological medicine and psychotherapy appointments. You are also making a very strange noise. It was me, my phone was about to lose battery so I was going to lose you all. I'm sorry. That's alright. So you're very experienced GP in working at Headspace which is a national initiative with 30 centres around Australia and is one of the Townsville General Practice Network programs and you actually work there with five other doctors at Headspace. I believe you work four days a week so you're a very good person to tell us how you are going to deal with young Tim. Thank you for that Michael. I'll try and live up to it. The other thing I'd like to say is that a number of my points are in fact the same as some of the other presenters later on. I'm not going to lay those ones because I think there's more erudite presentations coming up but one of the key things is engagement with young people and I think GPs often struggle because of our time constraints and I'm aware that I have a luxurious position where I can take an hour for an initial appointment with a young person but even if you don't have an hour you need to give young people the sense that you are genuinely interested in them and they do, if I'm allowed to say they do have a pretty finely tuned bullshit meter and so if they, I'm from North Queensland so I apologise for that. If they sense that you're not genuine they are not going to tell you anything so I guess the key thing is to be really genuinely interested. It's a little bit delicate sometimes in this case mum's brought Tim in so mum's going to want to say some things to you as well. With a 17 year old I would generally see them both together first for a few minutes and then I'd see Tim on his own and I generally wouldn't see mum on her own unless Tim had already consented to that. Now there's, somebody else is going to talk about a head's assessment but I think it's a really good model for approaching adolescents so the things that you could talk about first are less challenging so who do you live with, what grade are you in at school, what subjects do you like, what don't you like and then you work towards the things like sexual relationships and drug use and then I wrote death but you know suicide is self-harm. I think the doctors in general are trained to cut the chase because we've got such a short time so we want to know what the presenting complaint is and sort it out and get it out the door generally in 10 or 15 minutes and if we go straight to those sort of questions with a young person they probably won't answer them so I find the head's assessment a really useful model and it doesn't have to take an hour. You can get used to it. I'm just changing the slide. So I won't continue with the head's assessment because someone else is going to talk about that some more. I just want to mention about self-harm and suicide risk. I think we've all got fairly good at asking the screening questions but I think sometimes with people turning in doctors tend to panic because we think that we're going to have to do something or we're going to have to fix it but my experience has been that it's often worth actually asking quite a lot more and the young person had a commission to talk about their suicidal ideation, maybe plans or previous attempts but to actually talk a little bit more or quite a lot more in fact about when it happened what have they been feeling like beforehand and how did they feel after? Because it's a topic that people find so difficult to talk about. It's probably the one thing that Mum is most worried about and will panic the most if she has any sense that Tim's at risk of harming himself or killing himself and so he's probably learnt not to talk about it so for us to give him the chance to talk about it can be very, very valuable. With engagement I think it's important even if he didn't want to come there's probably something that he can recognise that might be valuable for him to address so he might actually be really distressed about those relationships at school so he's working down all of his mates and he might actually be quite pleased to talk about that so I guess my approach is to try and find out what's important to him and that's what we focus on. GPs are probably most of the ones on this webinar anyway would be to setting to writing general practice mental health treatment plans and one of the things that we have to do there is look at goal setting and I found that a really useful question is it actually comes out of solution focused therapy but the question is how will you know it's been helpful so if I refer you to a psychologist or you take a course in this medication or we make a lifestyle intervention or all of the above how will you know it's been helpful what will be different and I find that they're often able to come up with quite specific themes then other than just I want to be happy. And then the final thing which we'll be covering again later is that medication is not always the first line in fact it's usually not the first line in depression. Young people are not in that sense to very many of the drugs and their effectiveness and there is a lot of evidence for other things so I think it's worth remembering that it's not first line that can be really difficult for DPs in a health service or a counsellor or anybody else that you can really refer the young person to. I guess my point there is also not to underestimate the value of your own interaction with that young person so sometimes if you're able to say look I understand that things have been really hard for you I'm pleased that you've been able to come and have the courage to talk about it and I think that it will be important for us to see each other regularly. If you're able to make an appointment to see them once a week even for 20 minutes have things going what's happened in the last week sometimes that can actually be enough because you're an objective kind of listener you don't have to know any magic counselling skills you just have to be safe and respectful and I think that that's often not valued enough that this DP can I guess for the young person because the doctor is feeling that they're important enough to make time for sometimes that in itself can be really helpful so often there's a lot more than that is needed but if you're in a small place and you're it don't be scared because I think sometimes you're actually enough so I think that's my point. Well done and plenty of time to spare. Other PAL members even though I haven't introduced you individually do you have any comments or questions about what has just been said? No they're all absolutely in all. That's fantastic. Alright well then I'll move on to our next presenter Simon Kinsella. Doc Kinsella is a Melbourne based clinical psychologist with over 17 years of experience he actually completed his PhD researching the links between family conflict family functioning and life satisfaction he was a senior clinical psychologist at the Austin Health Child and Adolescent Mental Health Service and in the Adolescent Day Patient Program at the Albert Road Centre for Health and currently Simon works full time in private practice where he consults children, adolescents, families and adults. He's also an honorary fellow in the Department of Child and Adolescence Department. He holds statutory positions as an independent medical examiner and as a panelist for the Disciplinary Review Board and is also the current chair of the Victorian State Committee of the Australian Psychological Society and the chairman of the Melbourne branch of the Australian Psychological Society. So he's eminently well qualified to talk about the psychologist's perspective on a young man like him Thank you, Michael. In reading the case study one thing that really stands out to me is the value of the information that the GP has already gathered. That information about the reluctance of Tim and the anxiety that the mother and her desire to be involved in the process is really critical from my point of view in terms of how I might approach them and some of the pitfalls that I might already need to be aware of before Tim walks in the door. So for the UGP out there it is very valuable information for us to know that the Tim is reluctant and the mother is overbearing that Tim sees him as being an A. To be able to confront that early on with Tim would be a very useful part of the engagement process. I'll just change slides. Okay, so the Heads Assessment Tool I also don't want to go into a great deal of detail about it but I think others are going to be talking about it as well. But I suppose it's another structured clinical interview technique there's several of them around. The nice thing about Heads Assessment Tool is that it sets out very clearly most of the important dimensions of what might be happening in a young person's life and it gives you a platform to have a conversation about what's going on at home, what's going on with their employment and their education, their activities and so on. And there's plenty of information about this tool on the internet all you need to do is actually Google Heads Assessment Tool and it will come up and actually give you a list of helpful questions and non-helpful questions to ask so it's a great resource. Another way of looking at the Heads Assessment process is also look at the four P's which is something that's prevalent in CAM services. So we might look at the pre-exposing factors, the precipitating factors, the perpetuating factors and the protective factors which is, again, another nice way of structuring your formulation of what's actually going on with a young person. But the problem with both of these approaches is it gives you a way of looking at the biological factors, the psychological factors at person and for their family. As Mary said, engagement really is critical without it you don't get anywhere, obviously, and young people are very good at picking up when you're not being genuine. So there's always this tension going on when you're meeting people around about 16 or 18 years of age where, in all likelihood, they're being dragged along by a parent or at the very least, their parent has been the one who's initiated the contact. So the tension between recognising the young person has some sort of an issue but it may not be the issue that the parent's bringing them in with or at least that might not be the thing that they want to talk about first. Mary made a very good point that to begin with, to talk about what they actually want to get out of meeting with you is going to get you a lot further than saying, OK, Martin is in the press. Tell me about that. So engaging and setting the scene, I suppose, this is the space for them to actually explore their issues that it's not just a forum for their mother or father or whoever to foist their gender argument. It's really important. The other thing that's critical in this sort of scenario is setting the boundaries and confidentiality. As a 17-year-old, they're entitled to confidentiality but parents often aren't ready to give that up so there's that delicate dance again between acknowledging to the parents that you can respect their position but also working with the young person and creating a space where they feel safe to explore what's going on and when they walk in the door, obviously you don't know what it is they actually want to talk about so it's really critical that they feel that there's a degree of safety and that confidentiality is respected. And I guess that sort of flows on into the other points that I've got there about giving feedback and the art of presenting your views as well. The young person might walk in and say, well, you know, I'm not really depressed. I'm just angry. I'm irritated. And I'm nagging all the time. And, you know, school falls a bunch of the heads part of the language but, you know, so the schools are falling out with them and well, the teachers are already all ears as well. So they try and present this nice rational explanation of why they're actually not doing well and the art of getting presenting back your view might be that, well, depression analysis actually often presents like that there is this angry attitude and things like failing at school and losing friends. Two of the most common features in young people who are becoming depressed or who are becoming psychologically unwell and otherwise as well. And that is your view that what they're experiencing while they don't see it as depression actually fits into something that can be described as depression and then how you work with that is important. So they might have the assumption that if they're depressed, they're going to be morose and under the burden of 24 hours a day. And I suppose it is a message that what your professional opinion is but to acknowledge what it is they actually want to work on. So they might say, for instance, in his case he might actually want to begin by working on issues to do with his mummy and neck, for instance. That might be the most salient thing at that point in the therapy and it also might be the safest thing for him to work on. As you read through the case, that is further on, obviously gets into issues that sound like hallucinations potentially get into psychologically as well. These are layers that take time to get down to and in initial sessions you're not necessarily going to get down to them without a great level of trust first. So this is where, I guess, the problem deep becomes important. Exploring a little bit about, you know, I came after an ag and we're dealing with those issues so what if in a way you could work with your mum to actually mitigate those sort of problems but then turn your attention to, so what is actually going on at school? Obviously, yes, your mum, let's agree, your mum is an ag but she may have a valid point here. Why do you think your friendships have dropped away and why do you think your mother has deteriorated as well and getting into a bit more of a dialogue about what actually might be going on there can be very valuable. And again, creates that perception that if it's a mission to talk about these difficult things, marital issues, and if it's a mission to talk about suicide, the more... I guess one of the things that I was trying to do very early on with our lessons, picking with adults where you might try and encourage them to explore the options and generate the options themselves, often with our lessons, it's very helpful to give them some tangible answers that they can say, well, yes, it is, I believe, that I just can't concentrate on class anymore or whatever it might be. So, instead of opening up to all the possibilities for a young person, you might actually narrow it down to a couple of things that they can work with and you can use your intuition about what might be going on based on the business and business information you've picked up along the way. Whenever I hear issues with the Revolved Nations and potential for the society and the question over medication, obviously, I'd be very keen to discuss whether the GP or with the psychiatrist what they do actually use. It's, again, helpful if you've already established with the young person that you believe that they're the problem is to then be able to talk about what that might look like how that might actually develop over time if it's not a problem. So, if you go back to the case study, it talks about potential experiences that are a bit like the Revolved Nations, to be able to give them some understanding that is very helpful, obviously, but it is also important to then get a second opinion actually about what else might be going on there. I'm certainly going to be just relying on my own opinion, particularly in the 17-year-old because as many of you probably know, one of the times in life when disorders like schizophrenia and bipolar sort of emerged sort of late adolescence where the adults would say, no, here's a young boy who's writing in the thick of that period that he's won and is potentially candidate for an emerging doctor. So, I think that's all I can say for now. That's great, Simon. Thank you very much. How many things do you want to say to this young child? Not at all. Okay, all right. Great pleasure to introduce Peter DeParis, Dr. DeParis. He's a child and an adolescence psychiatrist with some allied health care service, CAHMS actually, child and adolescent health service, and I think he met with his friend at his university. He graduated from an allied medical school in 1983 with a medical officer in the world of... Australian Navy, General Practitioner, and Work in Pathetic Care, but before training in the country for the glimpse by possible in South Australia. Since 1995, Peter has worked by inpatient and outpatient CAHMS as a visitor in South Australia and the UK. He has lived in mindfulness, faith psychotherapy, development of mental psychology, and model understanding of psychiatric diagnosis, and he's published on the Confidence Arounding and Diagnosis of Pediatric Biotolic Disorder in the USA. We are very interested in your perspective on this, over to you. Thanks very much, Michael, and thank you also to Mary and Simon, who, as a psychologist, would have, in Tim's case, according to the case narratives that we have here, would have made my job relatively easy in the way that I've been able to engage him and his mum on-site thus far. I suppose I think... I'm not going to go too much into certain key things here, which are like the safety issues, because I think Simon and Mary have done a good job around that, and I did get the feedback from the first edition of this webinar that people wanted me to talk a little bit more about what I said in the natural energy presence of... I'll come to that. I think a slightly different tack, perhaps because of the safety issues and the Confidence Arounding thing. Up front, as I was... get developing a rapport with him around his normal life and the drawing and changing ground, and interest, et cetera, that I would say that the Confidence Arounding would have a certain limit around safety that they would have to speak while others are very concerned about safety. So just...anyway, so... as the case history had it here, there were some questions from Simon and Louie at the end there about this last year he was hearing voices, and as we came in, I explored the vocal voice that were occurring in his... I'd often late at night when he was heading off to speak, so hip, bogic hallucinations. It was a critical male voice, and after I had spent a bit of time with him over a session or two, and did some more pessimism, other than what he's mentioned. One got the history of Mettie Farland earlier in his life, and a father who was quite negative and critical, and so one would talk to him around the dynamic, what's the meaning of these, and sometimes I'd talk to kids who were kind of voices, social hallucinations, and it often is traumatic memories but coming through, so you're having a bit of a dream, just sort of awake, and it's just coming through while you're awake and this kind of stuff. Of course, I may assist him as having other pieces, but in this case, it's him. No, this allowed him to try to rest and someone worked to rest his auditory hallucinations. I would put Min Min into that kind of box and he'd come up reassuring what's in him about those. Also exploring him the family history of the term monk with bipolar disorder, I asked him, as he goes on, about his so-called highs that have been talked about. This was just him really, when he had a few drinks, he himself he'd been described as attentive and somewhat shy, kind of lad, but he'd been treated by the alcohol and that seemed to be really what was happening. And I'm getting a little bit of a temporary antipressence buzz from the rising ethanol level for a little while there, and there was nothing to suggest with a true hypomania. So again, reassuring him that there was no alcohol at this stage in his life. And what I with him was that, you know, this was a lad who his mother had come and managed with him to go around the marital difficulties and the marital deprivation and Tim, in essence, was one beautiful convent where he had, I think he needed to be presented as marrying his mum so no one had had to kind of be able to learn to hospitality in a relationship with her. And he was feeling somewhat rejected and a loss of his father who had been come quite close more close to him between the age 10 and 13, according to his history. And then there was written in his current life around falling out with his friend Max and ordered to come to the male teacher and also there was a girl he liked and he was at his about the size of the bowling centre on this fact. And so there may come a time in this where I'd be able to feedback the link between precipitating factors and predisposing factors about his vulnerability towards issues with older or more powerful males and his issues with the girl and other ex-gibberish and feelings there. Finally, of course, the right language and finding that he could make some sense of that. And what I'm getting at here is actually what's important in individualized and meaningful biopsychosocial k-formulations involved is for these I'm talking about. This is far more useful to me in my understanding of what's going on to him than simple TSM diagnosis but it's just a non-logically based on what has him in here and how he's quite contextualized. So it has to be contextualized and then what you can do is you can see back to him. And what I tend to like to be able to understand is the evolutionary paradigm and and give him some some idea of attachment theory and rank theory which play into our species in such a way that where attachment between human beings is very important and where your place is also important. So grief has lost and also shame and oppression when one feels like he is he can be excluded by his peer group and then I believe that and we're saving it as a full word. But it's natural where programs were made to actually feel depressed in these context. That kind of normalized doesn't mean that it's healthy but it starts to give a meaning to the symptom and then they might be a way of moving out of this state. So that's what I've got here in terms of the slide and the narrative of the slide. It's just a quick bit to the next slide. This comes from Jim McKenna's anthology even though I'm not done yet because he was the keynote speaker in the parenting conference here in Adelaide some years ago and he in the context of the attachment was pointing out that we are we are really hungry for the kind of post industrialized living environment so we might get too lost just a lot lost here at the moment. Stay on him. So what I then often get the whiteboard and get out from the color of the whiteboard mark and give him a little lecture on neuroanatomy neuropsychology and evolutionary paradigm make it very clear that there's an opportunity to use the language for where they're at. And point out I talk to the brain, the nervous system and I talk to the immune system and this is where the emotions are simplified in SNS that kind of make it easier that this is where the moods and emotions that have been entered. And I talk about fight-fight-free response and a lot of other things here we would know after how the frontal lobe gets turned off and you go into one of those pre-automatic modes and then I point to the brain to them and talk about this as if you were on a nervous system and there's a few parts there's a sympathetic nervous system or SNS and also there's a parent sympathetic nervous system or P and SNS and I would point out to the medical she can go to say there's a special nervous system and then she says there will be a peaceful nervous system of P so that you can be one or the other and talk about different animals more like a mouse or cat or a cat with a dog or I don't know any mouse maybe two or five and a scribe or a mouse then point out that in the modern world we have around in many ways off on the bay and on the perpetuate and leave that around for a very long time and so the increasing evidence is that depression is a burnout date it has an inflammatory aspect to it of being sympathetic which stresses the motor by too much and he would understand that because we were able to talk about all the stresses and this would be the third as I was saying how he put the blame on the context and his life and when one agrees with him with that then point out that maybe he has got this kind of stress run down in the name of the state and nervous system and then point this aside from that agreeing and talk about sighing and awning, laughing and sobbing now none of us have taught these things just from your own section in the room think that's who you try to agree with yoga and that athletes like I have got four lines of gold and other figures like Julia Gillard using Diabetic Breathing so my fellow Australia I'm seeking to ignore Prime Minister using a very slow Diabetic Breathing technique that keeps my frontal lobes on, on, on and stuff like that dogs that you're wanting to avoid dogs by chimpanzees you're wanting to use your awning to signal them that they can all go to sleep or anyway so this is kind of like a whole session and then eventually it ends up with the fact that things come to go breathing and you know they all feel about some work from me but at the end of things that move with science they seem to actually go and I'm having a normal 100% anxiety state with that particularly with just because of stress but also improving their sleep problems and so moving right along I hope that makes some sense further natural antipresence and there is evidence behind these things particularly with re-deprivation you meet with three in the dark and you meet with X5, 5 and D 5 and D deficiency around half of the neary main or about this around half of the Australian population that have multiple disorders including type D, these hands with D3 and progression but kind of depending in the evolution of the paradigm of that 17 year old so-and-so lad you know he was out hunting with the men and the other young lads and bonding with the ripples or the men and group stuff that went into that tumor the sentences of their chemistry sometimes you know away from that we could get back from all that and all of this kind of stuff obviously of course all the time is working on 114 and checking that one time is getting rid of it but I'm not really finding that this seems to make sense to the kids these days and in fact there's an article just last time on numeric psychologists what the world is called lifestyle and mental health and it brings together a lot of the increasing evidence around this area need terms to heal the life changes next slide and then there's more traditional approaches so with him there would be again I think we're kind of an academic sense and meaning and narratives perhaps family therapy is the one we've got a couple of people who want to read it you know it all went successfully because we actually managed to get him and his dad in one day and dad re-engaged it with him which was quite healing he got on well with now Mary mentioned that antirestress medication starts to decline and those are kind of guidelines and forced to cure depression often when one sees psychomotor recidivation they may be the first line but often I there are other side effects increased recidivism with dialysis and with the agitation effect that might occur about 140-150 and then there's also the issue of withdrawal effects and the epistestri have been unknown to me as part of that some problems with the mad magic genesis and osteoporosis but they're not one thought they were going to go and prescribe this first one at the time I'm committing myself but at least there were nine CBO CBO effect is strong now so I try and play that up with the amygdala the balancing amygdala and amygdala so I try to play that up next very much because I've finished it just a bit that's great it's now my first place to engage in the garden who provides mental health assessment and intervention for children adolescents and family within a multi-divisible private practice in Frankston, Melbourne she has extended her experience with women years of serious mental illness in sort of family conflict and when we find that there have been since the fall and has worked out as a mental health nurse in a rural range including Pam in patient settings in the universe she's called clinical membership with the PACSA and is credentialed with the Australian College of Mental Health Nurses and we're looking forward to your stay posted thank you my slide when seeing the slides I've had an expertise in the model with the 4p model but I've actually had a presenting problem so you can call it in the 4p plus 1 at the last I am thinking who's presenting the problem who's in concern and who wants the referral and what I'm actually saying that's quite important I use the model with 4p and 5p model to think about the information that I might put forward to an adolescent or a family I've worked in hand for a long time and it's the breathe battle of what can work to do I use the model I've been trying to think about intervention because that's what people were asking for follow-up and these are the presentations that I'm going to do in this assessment I'm an expert in the therapist so I'm thinking epistemically about a lot of things that I do and so I've added the statements on these the P's I'm thinking from the Sam's who's in the who's in the who's in the who's who Who actually feels a lot of problems The for the creation of the Indian child model in his house. Why did he say, why not last week, why not tomorrow? What's actually the silica seeding that might be, what mum said the silica seeding, might be something that Tim did, that might be something else. What are the predispose factors, you know, why is this kid? And in family, he comes from the family of three children. So why is this this one? This suicide who's having some sort of hallucination has a conflict with his mum. We don't hear that this kid is having a conflict with his mum. You know, what's that about? He thinks it's because he's not a boy's family, he's because he's not a boy's family, because he's got a good relationship with the girls. Certainly, you know, the order of the birth, when dad is a family, if I remember rightly, the story was about the youngest daughter, thinking about her family after the birth is the youngest daughter, I think. So, I mean, I'm not sure how old he was at the time, but depending on the age, he's cocky with his capacity, the development stage, but his dad, I think, was really fighting for him. The pet who raised that sentence, what are stand-in dynamics? I mean, we know mum and dad were getting along very well, and it's only recently that some work has been done on the diet between father and son. But I'm thinking about what's the relationship between mum and him, and his sisters, and all of that sort of stuff. Is that what's actually perpetuating the problem? Because if some of that is perpetuating the problem, then that's where it's being mentioned, I think. The particular fact that, you know, what distance is he actually breathing? Because he trusted the therapist with the things that we've seen so far, he's wonderful, not only a little less trustee-like, but some of the kids are coming by off of here. They don't trust anybody, they just sit around and talk, and you really have got to work quite hard to engage them head-to-head. You know, it's one of those places where kids come in, and sometimes they're pretty hard to actually engage, because they see a lot of people and they're quite angry. What I see as a fact is there's a situation where not so many of the kids are gathering in two, two kids in a farm, and they're actually using them and developing them with family, so I'm having a family and kids eat them, and say, I can send them to your family. I don't know, you know, what goes on in your family. And I mean, even with small children, they're like, I have a whiteboard in my house, and they actually help draw the picture and hang it in the back of the girls' circle to the boys' square. And off they go, they're like, they're like, I'll have to do two, two in the family, who's not in the family? They don't want the family. I've actually had them grab the whiteboard dust, and they're like, I don't want them then. You know, they're not someone who I find helpful, or who I like. So in a grand, it's a very powerful therapy that's really not that hard to do. It's anything that can be used without a lesson, and what, you know, maybe the family's dynamic, something that needs to be worked on, in addition to the individual work that they need to do. I see, when I prove this genocrancy, I hope that as it moves on the whiteboard in terms of the family, or in terms of genocrancy, see some sort of connection, because there are three generations of alcohol-inducing families on it. And mum's been the biggest issue to that in the first child in their lives. So I wonder what it's been like for her as a mother to deal with a husband who knows what he's doing, when he's drunk, how it's been seen. What's it been seen? No, what's him being seen? What's his sister being seen? We don't really know what his role has been in the family thinking mum and dad separated. You know, does mum rely on him to touch? Does mum get him to be a replacement for the mother? No, no, no, no. No, it would be enough to depend on, you know, the sisters. I find all those questions quite interesting. And actually, right from a whiteboard, which usually is an externalised kind of technique, it actually shows what the problem might be that they've been seen as a problem, even though, you know, they're looking like the other five problems. The way I see it is with his sister, and he did boys he's seen them as those things which he can now see visually. And I actually think they would do some sort of work with the hack where he says, maybe down back they're saying, can you read Eddie? Will we show Eddie some problems? These people, they may seem to be not just a problem, he's the one that has presented the therapy. But the whole thing about that's going on in the family. So that's, I think, I've used most of these therapies to do rather than a history-taking. It works both ways. So I guess that is some of the things in terms of that you can do, family therapy, style of intervention, you don't have to be a family therapist, it's really just family thinking that works. It can be a therapy, it can be this, it can be this two stages. So to be able to do it with a genuine plan and talk about it, and have it in CDD to calm our cycle, especially if it's a two-team intervention, that's quite powerful. And it can change the dynamic in families and change the way people think about themselves and the way they jump up. I mean, getting anybody in group, group, group, group, minimization, it might help to address some of the systems and the family systems and the attachment issues. Obviously, attachment issues. Clarifying the family roles, the family, the family, the relationship. It's nice to see the work need to be done between him and his sister because maybe he needs to see that the dad is dealing with the family so he does have a long relationship as a sibling in some sense. You know, that sort of work that can be done with a negotiation about the relationship and so on and so forth. I think there's a lot of trauma in this family and it may be, actually, for some of the hard trauma that's been going on in the family, I don't think he did say, you know, what Angling has just done, going on yelling and screaming when the adults think he's asleep. I mean, he can't sleep through that stuff. Um, some other... Because I'm a very early family therapist, I think family therapy, but I thought it would be important for all of us thinking from a minimum health point of view and in terms of who outside might want to be and who's in between things, but... So I don't... I... I... I... Because I've always been a public health... I don't think they have a factory for the mother, he needs... You know, it's not just that, it's for children and adolescents. They're both having me. So they have to rely on their parents or somebody to bring them. They have to rely on what character they can and be done. That's why I think it's very, very intense because it has no cost. Um, there are characters who can both feel through the ideas. They can come without having to... They can not... You know, they can't... They can't... They can't... They can't do that. They can't do that. Um, 8-Had is I think important. Um, there's new funding for children and adolescents. And then what can be done for their family and come home. The Men's Health Nursing Centre program, I don't think a lot of people know about that, but for people who are at risk of hospitalization or have been to hospitals, a GG team referred to a men's health nurse and people can be seen. So one of my teams is called Suicide Allys in New Zealand. You know, they're from the nation. They're from the hospitalization. They're from the men's health nurse to do home delivery. You could actually do risk to their settlement if you're not coming home in a GG team. They've been quite a useful role. And a men's health nurse under these programs can be involved for, you know, 1 year, 2 years, 3 years. It's not time to miss it. So they're very useful. And I'm going to have to stop there. Thanks very much for that. In spite of our number, we've got a small problem with the memory while connecting. We're still living things on the phone, but we won't be able to see her. But she can still live things for that good. We have been on the road with questions and I'm going to start finding them straight away. First question is to Peter. What do you think the young person is hearing and turning up? Ideally, mum can't take you, but the kid doesn't want to come. So you've never seen the kid at all. It's not after the first session that he's been up and up. Correct. I think one would... I would phone him or if two and three have to have to buy a bus or a car, my Mary first up. Where to go with that? Let her, right? Probably the first person to just reach you if you come to him and they're quiet. From my point of view, you'd rather have a feedback that he wasn't turning up. I'd like to find out a bit more about that and see if I could find out what the issue was before getting there. Any other questions or comments on the first question? About how do we engage him? How do we engage him if he doesn't want to come along? It may be that he will really need to be in the house and then the mental health person can actually go out and do some sort of intervention or it may be the mental health person who has to go and spend some time after having a coffee with Mark if he's at 99. And can I just say, it's still so old-fashioned that he has to do this as well. It's good to know, no? No, no, it's not right. And the other thing is that at the head of the house, we have an intake process where there's a phone callable. So it's a mum ring that makes the initial contact whenever we take off the ring. They would ask to speak to the other person. So often they've had a bit of time to think about it, prepare people on the phone and then one talk from the phone before willing to come in and come in person. So that's just an advantage of having both voices. Beautiful. In this case, there is a question of giving voice and some suicidal ideation. And given that the GP has a good rapport with him, I'd be on the phone, expressing concern that he had an arm, and certainly that he could be doing this at all. Fine times for my age. It's just risk-saving to risk depression. And I have worse words than maybe a high risk. Beautiful. The next question, which I'm going to provide to the panel members, what do you do if a mum, this is on the part of that consultation, has been 12 years old? And I think we'll start with our GP. Well, if he's 12, I think mum really probably has his part of it. But I'm fairly assertive with parents that I often see them with the young kids and together first. And I'm saying since the beginning that my normal practice would be to see the two together and then maybe open on their own towards the end. I was there. There are a lot of 12-year-olds at Wampum today. I'm more difficult with 12-year-olds when my mum talks to her on her own first. I'd be interested with how other people respond to that question as well. Anyone else? I see a lot of disorder-based groups. And I often say to them, the young couple, do you know why this mum won't meet me? You and mum? I talk about just the kids. I say, you know, mum will come. Do you know why this kid did this? Do you know what it is that mum won't? I'm not going to say mum won't come. What is it that mum's so worried about? So it's just that we're talking to him about him. I talk about the problem rather than the people. Fantastic. There have been several questions here on this particular issue, and it's one that I think we all want to answer too. I wonder what sort of burden a Z would have had for someone like you to bribe medication? Well, they're just not getting better and they're getting worse. If there's a degree of... I think the really important thing is always checking on safety and where the lab life is and the rest of the lab life is with regards to a civil liability action. And with that, one has gen-gen score, that, that ideation, how much time a person is in her intent is, and how much disability, potential intervention. And then other plans, you may be made threat, other attempts at that effect may, bearing in mind those that might be initially have admitted. I, coming back to the medication science thing, I think it's after a few weeks that they haven't died. I don't know how I'm going to describe it. But I generally find that this is kind of a so-called natural and present or... Well, well, that's TLC approach. Plus also for the feedback, I mean, everybody's been on the same page around the important part of the meaningful via social face formulation. And it's amazing just when a person and self actually understand that for themselves, I think it helps the narrative self to discern different domains. Self and the narrative self and self-psychology helps to organize those kind of deep aspects of self and probably at the physiological level which is stress. So that's an antidepressant effect in itself. So I'm actually finding that I'm not needing to go down the antidepressant too often. But after a few weeks, I'd like to watch what I've seen about 10 milligrams or a week, about 20 milligrams, warning the young person and family to look out for a graduation reaction, particularly about that. I think it's a gastrointestinal headache and that. But something I might also try before that was to do to Maths and Maths and Maths and just mum or dad or whoever has the bottle bottle and do they three nights a week? The adolescent is allowed to go out to Maths and Maths and 10 milligrams, maybe 20. And just make sure they get sleep. And maybe seven, three nights in a row to find a really, really re-established that if some kind of antidepressant seems to be a part of the problem. So, yeah. I hope that kind of gives me some information. Michael, I call Mary. Can I just ask a couple of really good questions about the Medicaid case? Sure, sure. Headspace has on their website Headspace.org that I use. It's called the Knowledge Centre. And they have prepared things called Evidence and Maths. And that is used to assess the rising young people and it's looking at all the up-to-date evidence and then sort of clear guidelines on that. And the other one is to be on the on-blue guide to maintenance and depression in the adolescent children and young people. The guidelines are quite good there. And they're the kind of problem on the on-blue website. Yeah, and they're on the headspace website. And the on-blue is that the headspace website has also got a really, really good headspace if anyone can get that. Oh, that's fantastic. A couple of specific questions. And there's one for you. Are mental health nurses qualified to carry out their assessments? That's one of our webinars. Mental mental health nurses, are they mental health nurses? Yes, yes, both. Yes, yes. That's what they mostly do. Mental health nurses are signing the CCCS in quality mental health assessment and then in-day-to-day assessment. Brilliant, brilliant. Okay, okay. Another question that's come through and that is to all panel members, how important is his sexuality in such such assessments? And I'll tell that open to anyone. Barry? Barry? Yeah, yeah. Pretty critical, really. I think, I think, was there a specific detail about sexuality? I can't quite recall at the moment. It never had a girlfriend, but he was keen on this particular girl with hyperbolic photos. Yeah. It's probably more critical if he thinks he might be a homosexual or maybe he should be back coming out. And obviously, there's a whole other round of issues but he's obviously struggling with establishing relationships in the first instance and struggling with the reaction of your peers to that well. So, I don't necessarily feel that it needs to be sexuality much in relation, but he's not quite there yet. Yeah, I'm going to point to the person who asked the question that part of his assessment is in fact the question that goes, many young people, your age, your experimental thoughts, different relationships have you had a relationship with the girl, the guy, or both, using the gender, gender, language, but is the facilitator I shouldn't intervene with? I won't. My next question is from an OP. There's just one reason why not. We're on the panel that there will be a role role in OP and also in particular case. My feeling about it and as you can see from the slide that I put together, I think in OP can be part of a mental health thing. I mean, working in that, we had, my colleagues, social workers, those who speak to us, it depends on their training. I think the difference is not as important as the skill base, the tool base that will actually bring to working with any client. And I agree that I've always often worked with OCD as part of the primary care that I work in and I think they bring a great, pragmatic, functional kind of perspective to when you have case discussions and things like that and as well as actually working with young people. And they're also really good at pulling out the kind of practical things that are a problem for the open that people might not think to ask about. So I think that's an excellent variable as part of the team. Okay, great. The next question relates to what would happen to Peter if a GP would be with him in an environment where there was no type of available or no local team? What would the treatment or the action be in those cases? What else is in their area? I mean, there's generally some kind of camp service covering all parts of our country. And even visiting services and they wouldn't be able to link that to child and adolescent in the city. And we do have at least in this state. Could you take us to South Australia and camp him out there. And some times it's not the OK way with treating adolescents with depression. It's got a very difficult case so we camp out there on the day. They contact me by phone or e-mail. I discuss the case with them. I would like the child for the teenager maybe to be admitted of local Riverland, Hotland. And then we all can help a few days in time for the young person and family. The GP sometimes doesn't need any help. Beautiful. Next question is what if you continue to deny any present symptoms and then a patient's life stops coming only despite his mother who has a super evolved and almost all are the practitioner first? Some things beyond the under control were thoughts. The other one was I sometimes am very concerned with parents about that and that individuating or separating from the family and becoming their own person is a lot of what it was about and a way to respect that is to allow them to be on their own. Doesn't all work sometimes. I agree with Mary and I would follow a similar approach and if Tim did engage probably one of the first things I would be trying to talk to him by phone or maybe email to see if any sort of connection could be re-established but if all will fail I would probably be in the end of the therapy later to summarise what we've done summarise what the strength of being and talking about a way forward for him and how we might go about finding a way forward. One of the engines can be quite useful when you have these kind of mothers. She would reign since her have had therapy at her own for some time. Her neediness can be del-delted and she can lead the child's therapy line. Absolutely. I think it's just to report the therapy line to the young a hidden form of another way some colleagues are behind me they serve a more difficult to engage at less and they do a lot of work I haven't got the details but they published a paper on that quite a lot of tests so keep engaged. I sometimes think that when adolescents become engaged it can then be caused to the family saying you're now seeing this you're now seeing this you're now seeing this you're now seeing this you're now seeing this you're now seeing this I sometimes think I'll talk about things in a way that can actually re-engage you I know that it's other people in your family it's not just you Excellent. Sometimes when you're engaging they can't tell you they get a job they get a girlfriend they can't tell you they can't tell you how are we going to help best best DC dignitaries with regard to attending a GGE how would the panel go about doing that I think I'll have time for that first Very good question I'd be wanting to explore a bit with the individual what are their perspectives on this because there are obviously some each person is going to have a different view about what they mean I'll be talking about their concerns about presenting to a mental health and I'll be also discussing some of the statistics that we saw earlier on 75% of the mental health issues in the young people 49% of the people who are experienced on health are at some point in their life I think all those factors are very important in grounding young people in fact helping them feel a little less normal Well to reiterate what I said before and also to thank Anne's point for coming back to talking about presenting problems and that's what life normally looks for a team and by that I'd say I'm interested in them in the context of their life and then when you get the full story and you feed it back to them there's a meaningful narrative why they're up here and it's not like bad or communication that's very rare and so I think that and having good humor why are you discussing Mary I think it's important thinking of the attitude of the health professional and self I guess I told medical students a lot about with mental health as any other aspect of health but for the grace of God and in fact maybe I do go there and you know I think it says perhaps the medicine B and D in our situation that will never happen to me but I'm not talking about the process but I'm talking about the appreciation that I could be in your shoes including with mental health problems and I think that that has to convey the attitude to clean you you can call it transparent if you want but I think it would be conveyed that I'm not thinking that it would never happen to me all right beautiful well guys we've reached the 750 mark and this is your opportunity for a spring coming up and since we can't see you Mary now that we might start with you I don't think so I'm not really I don't think I have anything particularly to add to that I guess the relationship whatever your distance it can convey to the young person that you are in this situation and you want to see them again again it's important for you to see them again next week they respond to that and I'm not sure it actually matters that would you agree with me that these are really inspiring about a lot of mental health here in Australia it could be I'm not sure that that's what we are here for but I mean the people who have the adolescent often come first if they go anywhere and I guess my husband that would be an experience for them if you have the ability to remove just a couple of barriers that exist for young people to actually see what would they be I'm thinking in many cases the financial area really that would be the question at him that he's probably designed for in a way it's easy for them to get to having children not having money making people aware that they can get their own medical card once you've seen talking about confidentiality honestly up the front of the interaction not to comment on things that you can't join but also indicating that you can I think you can join okay that's fantastic thank you very much can you give me your summing up please yes just to remember the context and to show the young people and their family that you're really aware of the context find the meaning the why have they had a problem at this point in my life and I think and she did a great job of all the developmental muscle tree and tree and dynamic because one has to I've met a lifestyle that's the evolution paradigm also one has to and then you know you never get the safety issues suicide prevention it's always to keep that in mind and that's then coming back to the strengths and strengths to have a good college or basically when they know that you like them you want to help them so it's kind of a very non-difficult powerful and that's the point to that that the long-term outcome comes like a dynamic and that's a therapy powerful relationship can I ask you one question we know that titers are not fabulously distributed across the country in fact I believe in Australia is there anything you've done about that? I wouldn't no it's okay you've sprung that on me I don't know to that I mean the economics unfortunately are the five factors going through the gap through it on people like an Adelaide from the eastern and northern I can expect a funding public health services or a radical Medicare where you look at the postcode maybe trying to find some incentive and that goes to GPT too that goes well trying to get some area in South Australia we've got Elizabeth in the North and South and sort of Adelaide that's a big political thing sure I'll sign it on you just a final line for GPT before the college is paid and I can't run together and you can ring in 181 at number and also email quickly and they can in 24 hours it's available thanks very much appreciate it and you can read your closing comment comment please I was thinking about the lack of high-tech in this area that's one of the things there's one psychiatrist down here who's also the head of child psychiatry and he's the only child psychiatrist down here so a lot of the work provided in private factors is I work with GPT and pediatricians and myself we work as a bit of a trio to be able to manage the health of the children the child psychiatry and then when we all panic then we get into the result and the psychiatrist and ask for his opinion when we run out of ideas it's the only way we've been able to manage what goes on down here on the peninsula all right Michael I could just I mean the the college psychiatry and Medicare have come up one off we've done over four sessions and those psychiatrists take on the books about feeding back the GPT mental health the psychologist and having them tip on then one can do four reviews a year and so there is an acceptance of psychiatry there's resource and needs to be used more within the consistent moment that's Peter final words Simon Stella I think all of the presenters have made a great point about how to work with young people I suppose one of the things that I keep referring back to in my mind to perhaps be a person for young people young people I find a father to engage with people who put their profession before the person and to engage with them and talk about their strengths and weaknesses and their interests and all of those normal conversations that we might have with people who are our patients are very important people who are our patients so you get greater knowledge greater connection I think much greater capacity then to be the professional second follow up with how you can be an effective helper in this a lot there's plenty of very good products that you could read for all of the other presenters I guess that's what I'd like to finish up with well guys thank you very much well you are the expert survey and you're invited to post comments on tonight's webinar online form in the Indian Health Professional Network online we're still getting this we recognize that nothing is perfect we really like your comment every participant will be sent a link to the sources that have been in the webinar certainly within 24 hours and I just like to extend my thanks to the audience for participating and I really appreciate the effort and thank you all very much thank you thank you good night