 Good evening everybody and welcome to the Mental Health Professional Network webinar, an interdisciplinary panel discussion on recognising screening and assessing complex trauma. Now tonight I'm a disembodied voice. My name is Mary Emma Leyes. I'm a GP in Cairns in Far North Queensland and unfortunately I had some computer problems tonight and you can't see me. But you can see our esteemed panel and the discussion is going to be just as useful as ever. So my apologies. The technology platform is fine. It's actually a problem at my end. So I'd like to acknowledge the support of the adults surviving child abuse organisation in the production of this webinar, which is presented jointly by ASCA and MHPN and was funded by the Commonwealth Department of Social Services to deliver this professional development series of three webinars. This is the second of three and this is for practitioners who support individuals and communities affected by or engaging in the Royal Commission into institutional responses to child sexual abuse. Now I'd like to introduce to you tonight our panel. Dragan Rife is our consumer advocate this evening. Now Dragan, I understand that you're based in Sydney and as well as being the consumer advocate you are yourself a psychotherapist and a teacher. What balance do you have at the moment between your training and your counselling work? It's probably a bit of a 60-40 training heavy at the moment. There's been a lot of trauma informed practice training being rolled out sort of nationally so I've been doing a lot of that lately. Thank you and welcome very much and we look forward to hearing from you during our discussion. Now Michelle, you're a clinical psychologist and you're also involved in training and I understand are you also based in Sydney? What's it like there tonight? It's unseasonably warm in western Sydney so I'm in the room that I've worked in all day seeing people in Penrith, west of Sydney. Thank you Michelle and it's a pleasure to have you with us. Now Johanna, you're a GP as well with a special interest in mental health. What is it about the mental health work that made you kind of change direction a little bit in your general practice? I was seeing a lot of people coming through my normal general practice. We joke about how women do see tears and smears and I see quite a few lots of tears and realised that I didn't have the training I needed to care for those people as well and so that led me down the path on some training in grief and loss and trauma and ongoing research in the area too. Thanks very much Johanna. Now I can hear on the audio somebody's breathing. It could be mine but just if anyone's got the microphone very close to your mouth you might want to just move it back a bit. And Professor Warrick, Adjunct Professor Warrick Middleton who's a psychiatrist on our panel tonight and Warrick you're also very involved in training and I notice that you've had a particular interest in the field of trauma and dissociation for really, well I understand you've been at the trauma and dissociation unit. You helped establish that nearly 20 years ago but I expect your interest in trauma dates back further than that. How did you become interested in that specifically as a psychiatrist? Well I always actually think that trauma is actually a core part of psychiatry. My conceptual framework is that it's not a special interest or a specialised area but it's core psychiatry and my overall perspective is that probably pound for pound how humans treat each other probably has more to do with the causation of mental illness than any other single factor so it's always been a core central issue. Thanks very much Warrick and we look forward to your expertise in our panel discussion as well. Now just a few very basic ground rules before we get started. Just remember that everyone, we're sharing a shared space. There are hundreds of participants on that line and shortly I'll be able to tell you how many. We had over 2,000 registrants which is a record for an MHPN webinar and it just shows how interested people are in this topic. So just remember that other participants and panellists can see what you're writing in the chat box. That can be extremely helpful for the discussion between the participants. So just treat it as though it were a face to face activity. You're welcome to post comments and questions into the general chat box and I and the panellists will keep an eye on that. If you have a technical problem go into the technical help chat box and just remembering that the comments can be seen by everyone. And when we finish your feedback is really important. So please complete the short exit survey which will appear as a pop up when you exit the webinar and MHPN certainly takes notice of your feedback with regard to technical issues, panellists and topics for future discussion. We've all read the case study beforehand and this was the second episode in our story of Tanya who is 36 and presents with some things suggestive of a background of complex trauma and in tonight's edition she's presenting to the psychologist for the first time. So tonight we're really focusing on assessment and engaging, helping someone feel comfortable because the learning objectives for tonight is to understand the prevalence, epidemiology, characteristics and impacts of complex trauma. Actually just a technical thing I'm assuming that someone else is advancing the slides for me. Thank you MHPN. We also hope to be better equipped to recognise, screen and assess the physical, mental and psychosocial presentations which might indicate unresolved trauma and we're hoping to give you some take home tips and strategies for interdisciplinary collaboration to screen recognise and assess people who have been exposed to or experienced complex trauma. So without further ado I hope that I will appear on camera at some stage this evening but I am here on the phone and so I would like to welcome Dragan to present the consumer advocate perspective thinking about some of the things that Tanya might be experiencing as she presents to this first appointment. So over to you Dragan, thanks very much. Thanks Mary. Okay, so from a consumer perspective obviously Tanya could be experiencing quite high anxiety even coming into the meeting. She's come in, she says ostensibly just because her doctor suggested it so we don't know if she has a high investment in meeting with the practitioner but I'm imagining there'd be high anxiety, really a hypervigilance around what do you think of me? There can be a real feeling of I don't really, even walking into a clinic or into a reception area, into the actual room, a real feeling of what do you think of me? Do I even belong here? Is there anything here for me at all? Maybe I'm just going through the motions or going through the system or maybe I think that's what I'm doing but actually I am wanting support, I'm wanting something because she's turned up. On the slides you'll see I've put at the bottom the practitioner viewpoint if you like so very much essential to stay in that very open non-judgmental place because there will be that hypervigilance to being perceived. For myself I remember that the way I dressed wasn't right or the way I wouldn't feel professional enough coming into places I'd feel there was a real gap between me and the professional so all of that stuff is going to be going on even around what I looked like in my dress or on the earlier case study she smelled highly of tobacco and stuff so she may be aware of those things for herself with how she presents in the world and some of that might be protective, that's often something that happens. We might be heavily tattooed, we're our clothes in a certain way, these things might be protective things as well. So very much that non-judgmental place and recognising that as a practitioner you do hold the power in that moment. There is that power differential, someone coming in for support is coming into somebody else's system, somebody else's service and so that idea of the dominant paradigm, again, do I even belong here? Is there anything for me here? Especially when you get into culture and multiculturalism whether that's ethnic culture, whether it's gender sexuality culture it can be very, very sort of separating to come in and not feel that you're represented in any way. So as much as possible as a practitioner it's wanting to equalise that power differential as much as we can, all the obviously the joining things, the sort of, I don't know, someone never underestimate the therapeutic benefits of a cup of tea, like those sorts of things. Like John Brear talks very much about we're all bozos on the same bus, you know, that we're holding that kind of point of view as a practitioner. This is moving away from us and them. This is moving into okay, we're all in this boat and as a consumer if I feel the practitioner is trying to get on the same ground that's going to enable me to then join with them. So safety first, trauma-informed practice very much. It's all about safety, it's all about relationship building. Tanya does blurt out a number of things but she's not going to really connect and really talk about what's going on for her until she feels safe enough and that's going to be safety relationally, that's going to be safety in the environment, whether she even feels comfortable coming into this practice, what that's like for her coming into the practice, the environment itself, whether it feels like an institutional thing, whether it feels welcoming, whether it's comfortable for her. She's a very abrasive I suppose in a way, in the way that she's approaching the reception, in the way that she's complaining and things like that. That's probably again another coping strategy on keeping herself safe. So safety is recognizing that people's strategies or behavioural mannerisms could very well be protective and most likely someone's going to be experiencing high anxiety and fear. That's what a lot of these things are obviously covering up a high degree of fear. Coming into contact with people, we're talking interpersonal trauma when we're talking about complex trauma. So people can be the dangerous ground. People can be the relationship itself can be what's highly feared by somebody. So this slide is referring to the fact that often as a consumer, we know that we can be erratic. We know that we may not feel in control of our emotional state or that we may dysregulate and there can be even more shame sort of compounded with that, sort of knowing I don't feel in control of my own self. I'm aware that I can get snappy and I'm aware that I can give the receptionist a hard time or I'm aware that I can just disappear and not be able to engage at all. Often consumers are aware of that but don't feel any control around that and so creating safety like an intra-personal sense of safety is that we are doing some of that very basic sort of tool sharing around regulation, around the window of tolerance which I think Michelle is going to talk about after. But we are using those to help someone learn how to regulate, how to stay present, how to down-regulate if they're getting very sort of hyper aroused and that's part of our job and it's very simple even, just very simple things that we can do and it can again help someone feel more empowered, can help them feel more able to even be there but it has to be given in a way that isn't going to create more shame. And just the last slide that I've got here is just the idea that yeah, she's here for whatever reason she's here, maybe she's just here because the doctor said maybe she actually has some hope that this might be useful for her, maybe she does want to connect with somebody and maybe she does want some support but she may resist that, she may fight it, she may over-attach all the attachment stuff that can be played out relationally, it can be avoided, it could be manipulative, all sorts of things will happen in the room but the person is there, they've come and our job as a practitioner is just even sitting with that and building that relationship in the moment and understanding that all of those fears and anxieties could be playing out and a lot of those relational strategies could be playing out and the expectations, the wonderings of what are we as a practitioner going to provide, what does this even mean? People can come into these situations not even knowing how to be, not knowing what's expected of them. And again I'm referring to John Breer again, he talks very much about the organic movement towards health, towards wellbeing, that there is something inside us that does want that and does reach for that and I think that's what Tanya is also doing somewhere in there as well and as a practitioner there's a great opportunity to join with her in that moment and maybe create even a threat for her to be able to come back to that so we do often as a practitioner have to hold for hope, hold the optimism that recovery is absolutely possible for people. That's it. Thank you very much Dragun and I really like your pictures. Thank you. Now Michelle I would like to invite you to respond to Tanya and she might be the kind of person that would come and see you as a psychologist. Thanks very much. Sure can you hear me okay? Yes. Good eye. My initial thoughts were I really wanted to recognise that she made it in the room so picking up on what Dragun had deft off, acknowledging that there's some risk for her potentially in meeting with somebody with perceived power and her perceptions about having a head read and she is taking a risk so what's it taken for her to do that but also the real skills and abilities that she's relied onto in the chaos of her life to make it here. Ten minutes is nothing. Ten minutes later there's nothing in the context of Tanya's life. So I appreciate that she's made it and for this this highlights many importance of having a trauma-informed context. It's not enough that we do what we do behind the door in the therapy room. The practice has to be accessible and set up to reflect trauma-informed values so the kinds of strategies in a practice that would be experienced as pleasant by most people I think are really critical for trauma survivors extra sensitive to those interpersonal cues of being disapproved of or not belonging. So making sure that services are warm enough so boundary warmth and provide people with a welcome never a rebuke at the reception desk and a cup of tea is offered and is genuinely offered as offered each time. Somebody walks in the door that there is a place for them here. I would wanting to be to recognise that the barriers to Tanya's seeking this kind of helper are real and not overly not pathologising Tanya at all in that regard that she's found it difficult to connect and to find the right service and to find the right person. This may not be the one either but the barriers to help for her are real and services can own some of those barriers. It's not all about Tanya either. I thought not only accept her apparent ambivalence to seeking help but to embrace it really. It makes sense that she'd be finding it hard difficult to trust people. She probably her life experience has been she does need to be wary of others and to understand her ambivalence in that context but extend that acceptance to recognising and respecting any of her adaptations to trauma as having had some survival utility as making sense for her either at the time or in the context of her life experience. So when she says things like who'd blame her regarding her mother's drinking taking it as an opportunity also to recognise and validate these are her adaptations to trauma and like blokes do some minimising the sexual abuse she'd experienced respecting that minimising as a coping strategy. So an initial meeting assessment and thereafter taking extra care that nothing we do clinically resembles a doing to Tanya that I'd expect that she would find that triggering and I'd take extra care not to do to Tanya. In the initial session I'd be focusing much more on process and content so taking opportunities to validate her connections how would you be hey I guess making helping supporting her connections between past and present or between experience and emotional experience. We know enough of the story to know that she's being impacted by multiple trauma and loss and resist my own temptation to want to get the story and get the facts but actually respect her boundaries and limits about what she doesn't want to talk about and her fears about having a head read so keeping the focus on process in the session. From the case the write-up will given to association appears likely and I think it's important that we can roll with those changes in state that we don't become disoriented and disturbed or confused about what's happening for her that we stay steady and accept any need for repetition or reorienting statements and support her if it's to self-thus and self-regulate. So I'd have something like this in my mind I guess a graph alternating between the top and down to the bottom so recognizing hyper-vigilant or highly emotionally reactive states but also recognizing as stress responses and fear responses are hyper-aroused or withdrawn on numb states and supporting her efforts to regulate that knowing that eventually we'll be looking for that window of tolerance where a cognitive processing and connecting thoughts, emotions, sensations is going to be better in that central zone but that may be hard for her to stay in and hard to recognize at least initially so not trying to move her from either of those states but support her movement from either hyper-aroused or hyper-aroused states. So in terms of a formal assessment I'd be putting aside pen and paper at least for now and certainly no formal tick box assessments and anything I did write down I would be visible to Tanya as it generally is anyway. I'd make this a really transparent process. If anything systematically I'd be thinking about her strengths more as a lens for me to make sure that I'm keeping an eye on what is going well in her life. There's certainly a lot of terrible things that have happened and a lot of terrible things continuing to happen but I'd be wanting to systematically think about what's going well, who are the people in her life that are safe, the safe relationships or validating relationships thinking about how does she cope with the little things, the little things that go wrong are often revealing of the big things. So what are her strategies, what are her capacities to self-serve and how is she managing that. So not evaluating them as good better otherwise but just understanding how they're working for her. So any diagnostic assessment I'd be holding pretty lightly and that's current and past diagnosis that she may bring with her and be honest with myself and with Tanya about the limitations or benefits of a diagnosis that might apply. It's likely that many diagnoses might apply. Just some research that I thought spoke to some of Tanya's experience. This paper by Reece, three or more forms of gender-based violence increased the risk of a serious mental health problem by 11 times. I think it was 90% of the women in this study who'd experienced three or more forms of gender-based violence had a diagnosis of a serious mental health problem. From the adverse childhood experiences studies, an ACE score of four or more categories of adversity in childhood which Tanya certainly meets and exceeds if 46 times more likely to attempt suicide than people with an ACE score of zero. The odds ratio so quoted in the final piece here developing a range of disorders are very much higher for those who've experienced childhood sexual abuse including psychosis. It's likely that she's met the criteria for multiple diagnoses, cumulative trauma. Symptoms are going to be more complex and just less likely to fit any one diagnostic criteria neatly. By the end of the first session I've got some immediate decisions to make I think regarding her request not to tell the GP about the doctor shopping and medication. I'd actually also see the doctor shopping in some ways but it's resourceful that she's doing what she needs to do and she's making some choices about what she needs to manage her experiences. Her request not to tell the GP I'd be thinking about and I'd also be thinking about how to address the self-harm that we haven't addressed directly in the session but now I've seen and she knows we've connected over that. I found this psychologist in the case study. I'd make it clear at least from my point of view that it's her decision to come back but I'm offering a place where she won't be judged and be in trouble and she'll be treated as an old woman with courtesy and respect. I'd also be thinking pretty quickly, hi Mary about, I can see Mary on the video which is a good sign, that supporting the GP I'd want to recognise that Tanya's been a patient of that same practice for 16 years which there's something about the way that practice operates and also Tanya's capacity for development of that relationship over time so I'd also view those as strengths. And then I guess I'd be less thinking about what she needs from me in the immediate term, support for emotional regulation, those sorts of skills Dragam was talking about, her awareness of triggers, how I can support her growing awareness of those, managing intrusive experience or dissociation but also quite likely I think some immediate attention to her understanding of her relationship with children, so her distress that they're not needing her anymore and I think some immediate attention to actually reframing her role as a mother, as a meeting to adult children and as children emerging to adult are certainly very much needed but in a different way so thinking about ways to help preserve and support those relationships in her life before we move forward. Thank you very much Michelle and I am now on camera and online so my apologies for the difficulties at the beginning was an issue at my end. There are 650 participants online so welcome everybody, now we know how many of you there are and so I'd like now to hand over to Johanna who I'm quite sure was pleased to hear that Michelle as a psychologist would be keeping the GP in mind. Johanna? Yes I was, I thought that was very sensitive psychologist there Michelle noticing the long standing relationship with the practice and I guess I'm coming in speaking as a primary care practitioner who sees trauma in our community but also to acknowledge that the trauma amongst our healthcare community as well and I think that again reminds us of the humanity of what we're dealing with and of its prevalence. Of course this is a really overt case and it's partly that way to teach us but I'm hoping that we'll also be absorbing some subtleties as well about how to care for the less obvious trauma victims amongst our client base and in our midst. Aska would say there's up to 4 million adult Australians who are survivors of childhood trauma and neglect and so that's a large part of any day to day primary care work and I'm sure many of you who are listening have seen that face to face in the work that you've done. I just thought I would bring in the idea of preparing myself, my own self and heart for seeing Tanya and being really Johanna can I just get you to move your microphone a tiny bit closer? Yeah I'll try doing that, is that better? That's great thank you. Yeah just being really aware of the counter-transference or almost the neurology that's going on between her and myself when we meet I'm already aware that some of that's been sparked at the front desk and there's a sense of Tanya arriving almost with a vibe that I may absorb and react to without even being aware that I'm doing it. And one of the clear vibes that I sense in her story is hopelessness and this is something I sometimes think of as something that we've had since childhood and that comes with her as she travels through life and that we can absorb and start to treat her as though she's hopeless if we're not careful. At the moment I think we're at a key time in mental health history where we can actually be saying with confidence that she does have some hope and that there are treatment options available to her in our community that could give her hope. The other key thing that I notice in her relationship is ambivalence towards the practitioner and towards key figures in her life story and again that's something to be really aware of of the pull in both directions to reject her or over-involve with her and even join in with secret keeping or those kind of things that she's asked for. In general practice we sometimes talk about heart-think dread and we have a case that makes our heart think when we're thinking of seeing them when they're on the list for the day and again I think that's a really key thing for us to notice in our own bodies that will help us to prepare for seeing her when she comes into the room and it's something we need to actively manage to not just let it push us around but to actively hold her in mind as we're managing ourselves. So Hannah, I'm just aware of the time and you've got some fantastic things on the rest of your slides so I was wondering if you'd be able to just quickly go over them without too much explanation. There will be chance in the discussion for that. Thank you. Can you still hear me? Oh that's way better. I just want to dimension affect regulation as well as a key thing which Michelle's mentioned and then the concept of coherence that we're trying to hold this person coherently and that's an active almost antidote to some of the splitting and this connection she has within herself and with other relationships and I would see that as holding myself as well as holding her as a whole person her present history, her context and history, her body and her mind as well as the thing she's bringing with her and the thing she's not bringing with her that I need to keep in mind. And again the system, the system can become something that's not coherent. Some of these slides I've intentionally put here for you to read later this is one about making sure that we prioritise safety instead of the history taking which can sometimes happen in practice. Again this is a slide my conceptions of how I think about safety in someone's social setting, their relationships, their body, their mind, their emotions, their sense of self and even their spirit. And I would see in Tanya that she has had things that we can notice in the story in each of those areas. This is an adapted from Christine Courtois complex traumatic stress disorders from 2009 and she just notices the things that complex trauma alters in a person. And we'd see this in Tanya's story she's using things to herself sooth including medications. She has some moments of disconnection with herself and has gone still and vague in front of us so attention and consciousness has been altered. Her perception of herself she talks about feeling nothing without her children. Her perceptions of the perpetrators in her life that she idealises her mother and has mixed feelings towards the other people in the story. Her relationships with others really experience abandonment at multiple levels. Her connection with her body which again has been a little bit hinted in the multiple visits to the doctor. And then changes in her system of meaning. She says nothing good ever lasts for me. I've made a slide there about some key notes on what dissociation is and those are just for your information to read later. And then this is just my hopes for her. My hope is that Tanya will be listened to with safe connection that she'll grow in hope and power that she'll be taught to be less phobic of her emotions and be confident to soothe her own levels of arousal. That she'll understand the triggers she experiences. She'll begin to see the relational patterns that are happening around her and between her and others. That she'll start to notice all of herself and learn to be kind and caring including intra-psychic where she talks to herself. She'll engage other help and that includes practical things like where she's going to live and her workplace of course. And that she'll be helped by a team that collaborates that actively works against dissociation of the system. That would be my hopes for Tanya. Thank you very much Tanya. Now I'll just ask you to mute your microphone and I apologise for rushing you through. I've also had my internet my internet connection has dropped out again and my camera has disappeared. Still here. Now I would like to welcome Warwick to speak to us about how he might respond to this as a psychiatrist. And Warwick bearing in mind there's also a lot of great material in your slides. I wonder if you would mind just basically doing a quick overview. Then we can get on to the discussion. Thank you. I was going to just briefly offer a somewhat different perspective. Society and psychiatry for over a century has been periodically grappling sometimes with some intensity and sometimes not with the issues that cause sorts of complex syndromes represented by Tanya. Complex trauma reflects the type of trauma where a person in a relatively inescapable situation is repeatedly exposed to trauma and frequently at the hands of people that would normally be their caregivers. Whilst in our society it's mainly based around ongoing child abuse, physical, sexual, emotional abuse. In other contexts it includes scenarios such as child soldiers, sexual trafficking, slavery, etc. At the more severe end of the complex trauma syndrome are those individuals who have been dissociating from a very early age as a way of compartmentalising and other the affects and memories of ongoing trauma. It's one way of surviving when there's very little by way of escape or alternatives. Some years ago I published with a colleague a naturalistic study on 62 patients who fulfilled diagnostic criteria for DID, Dissociative Identity Disorder, and I just briefly highlight a few points that arose out of that because it epitomises the fact that these individuals would, if a DSM is applied to them, satisfy typically 10 or 12 different diagnostic entities and the whole concept of complex trauma revolves around the fact that you can either say that this person's got multiple diagnoses or that they actually have a complex symptomatology that is associated with something that affects most aspects of their life, belief systems, and sense of self. In our group of 62 it's very obvious that these are the serious end of the mental health spectrum but also epitomises the reality that a lot of them end up with diagnoses that have got nothing to do with trauma, like nearly a third of ours had a diagnosis at some stage of schizophrenia and 20% without fulfilling diagnostic criteria had been given at some stage of diagnosis of mania. Naturally most of them are depressed but most of them also are very prone to somatize. One of the reasons that the concept of complex PTSD or disorders of extreme stress not otherwise specified sort of took off was it was a way of avoiding what was seen as the stigmatization that went with the diagnosis of borderline personality disorder and as you can see people in the highly dissociative end frequently fulfill criteria for borderlines and if you took a population of borderline personality disorder patients you'll find that they are highly dissociative but they're not exactly the same but they're two overlapping groups. These people are more likely to have Schneiderian first rank symptoms than people with schizophrenia and befitting their dissociation they have a high dissociation score. I mentioned briefly the history of conceptualizing people such as Tanya involved building a model around complex trauma that incorporated a number of affects. There was a recognition of the fact that these people affect very unregulated that they're prone to depression to anger to suicidality to impulsive sexual engagement at times that they dissociate that they're prone to somatization and the majority of people in that group will fulfill criteria for somatization disorder. They are locked into a relationship frequently with perpetrators suffer long standing shame and this impacts so deeply that it affects their entire concept of what life is about and their sense of meaning and worth. The discourse that we've been having and I'm not going to dwell on this is one in which in the late 19th century there was serious examination of hysteria which then faded which then the people in this spectrum have largely got subsumed by a broadening of the concept of schizophrenia and any real focus on dissociative conditions complex trauma was very much under-emphasized until the late 70s when incest arose out of an environment where the symptomatology and course of Vietnam veterans gave impetus to the plight of those many other people in society who suffered complex trauma syndromes and slowly little by little the battered baby, the shaken baby syndrome became accepted as did the reality of the high level of sexual abuse in children and it's an interesting concept when we look at Tanya that to think that a lot of research would indicate that the commonest age at which a child begins to be sexually abused is about the age of three. So these people frequently have arrived in adulthood having been sexually abused for most of their childhood and in recent years it's become apparent that some of them are subgroup actually continue to be the victims of ongoing incest into the adult years and these are the victims of the Joseph Fritzels of the world. Also in this world in recent years we become much more focused on the issues of political or organized abuse such that the victims of intrafamilial abuse are also frequently very vulnerable to being abused in groupings of pedophiles in politically powerful groups, in church groups and it's very interesting that at this point in time that our society is embarked on something more wide ranging in this area than anyone has ever attempted and that's the Royal Commission which in our particular case has a frame of reference that hasn't been equal previously in human interaction with this issue. And I guess it's only in this year that we've actually had the United Nations demand that the Vatican immediately remove all clergy or known or suspected child abuse and turn them over to authorities. It's been unthinkable a few years ago and this is the world that Tanya is now being assessed in. So all of the things that Michelle and others have said totally agree with. She needs care, respect and to be made welcome the most fundamental thing that you can actually do in regard to an individual is to actually listen. So I'll leave it at that. Thanks very much. One last thought. Yeah sure. It's a quote from a humorous, I suspect, but it goes on the lines of never try to teach a pig to sing at waste your time and annoy the pig. Probably the best thing that we can do for individuals such as Tanya as a community of health professionals is to do the best research possible, to do the best clinical work possible, to publish in mainstream journals as possible. It's a complete waste of time to try and convince people of things that they don't want to know. But there are many people who work in this field who begin to actually get it, to hear the music, if you like, of what it's like to be chronically traumatised and realise that all of those people that in the past were diagnosed with hysteria or unusual forms of schizophrenia actually had another explanation and it lay with usually the intra-familial abuse of children. So I'm going to leave it with you. Thanks Eric. Actually I wanted to just ask you to follow up by asking I think I'll get you to pose the question to Dragan but with the complexity of some of the clients that we see, sometimes therapists and clinicians can develop an almost sort of nihilistic view and I know that you had a question about that so I just wanted to answer that to Dragan. Yeah and it goes along the lines of the observation that from time to time in respect to a challenging patient with a complex trauma syndrome, one may hear a colleague say something along the lines of well you can't save them all you know. What does this comment mean and how does one respond? I know it'd be very interesting Dragan's thoughts. Yeah I think as a consumer you're aware of that too. You're aware of practitioners thinking you're a hopeless case and one may feel that oneself that there's no real hope for me, no one's really going to be able to help me. I think because complex trauma recovery is not a nice linear path and people can appear to go backwards before they go forwards or people can do both. It's more of a spiral or a whole messy jumble of journey. I think it's really really important as a consumer to feel that the practitioner does have hope that we can recover even when it looks pretty rough, pretty hard. I think that's just essential because often consumers themselves feel hopeless, feel like yeah, can't save them all not going to be able to save me, no one's been able to so far, what makes you any different. It's often a very bleak place to be so I think it's our job to hold the optimism. Even while knowing it's challenging, not everyone makes it whatever that means. Recovery is a journey according to what that is for that person. Thanks Dragan. I guess you're speaking from experience too that it's been really important to have clinicians who hold on to that belief that you're not beyond help. You had a couple of interesting questions as well and I was particularly in the case study, the psychologists noticed that Tanya had some fresh, self-harm scars that she hadn't mentioned and she noticed the psychologists noticed them. Now I wondered if you wanted to address your question about that to Michelle. Yeah, Michelle my question's around having noticed the scars because we're wanting to work with what's present in the room although it's very early, early days obviously it's the first meeting but what do you think around just speaking to what's there, like how would you deal with that? You've seen them, she knows you've seen them is there anything one could say before she has to bolt? Yeah, thanks Dragan. I mean I'd really hope that at the end of the session she's not bolting and I'm already wanting to rewrite that and hope that I've slowed things down and made things safer so that she's not needing to bolt. But I think I probably would have, I've noticed some older scars on her legs and I think when we're talking about how you deal with this stress I might have framed a question about that earlier anyway. Now that I've seen it I probably wouldn't pin her down and get her to stay. I'd be, you know, verbally I'd be respecting the fact that she needed to leave but I certainly wouldn't ignore it the next time and hope we get another chance to talk about it. I think that's part of the working in this way as well. You really, you don't know if you're going to get another chance to be with a person and recognise something so taking opportunities when they're there while keeping in mind and keeping in balance how safe is it for the person. Do they feel safe enough to talk about this? So briefly if I asked about the self-harm I would have prefaced it with a statement of lots of people, we do anything we can to manage ourselves and manage distress and many people even talk about harming their bodies and using that as a way to manage distress. Does that make any sense to you? And Michelle you had a question for Dragun about shame and I think this is probably an appropriate point to bring it up because I suppose one of the reasons Tanya is not wanting to make a thing about her fresh scars and that you've understood is that she may in fact be feeling shame about that. So you had something that you wanted to ask well I thought you could ask Dragun. No sure I was hearing what Dragun had said which is a good and important perspective about how much shame and vulnerability people might feel in that first session. I just wanted to hear from you what do you think the most important things are that we can offer to not provoke further shame but to provide an environment where shame might be reduced and certainly not provoke further. Yeah I mean I'm quite an advocate of appropriate psychoeducation really because that in itself acknowledges power and understanding and so understanding what's happening within the one's own system can help minimize shame. Understanding that feeling of feeling out of control getting triggered etc. understanding that it's your sympathetic nervous system response but using appropriate language to help people really understand and thereby have some sense of empowerment around what's happening because once we know something we can start to do something about it. I think that's one way that shame can start to be diminished. I'm normal you know I'm not just some freaky out of control person and also I guess again using I don't like the word normal but there's that realising of somebody's experience maybe you know the understanding that they're not alone. People often feel very isolated, feel like they're the only person that's happened to so you know some ways of bringing that information out that they're absolutely not alone that you do have some understanding of where they're coming from while obviously not being able to know where they're coming from but ways to just try and join and bring it out to more of a human experience rather than their very own sort of very small isolated experience. Mary could I jump in there? Yeah look I was going to invite you in now anyway so that's great. Good. I was just thinking of something that I find myself doing in that psycho education space where I talk about how normal it is for children to feel shame and why you know I sort of use a couple of frameworks there to talk about why shame becomes normal. I talk about magical thinking in children that they think that things that happen in the world are because of them so when things go well they think they cause that and similarly when things don't go well they think they're the cause of that but also issues around powerlessness that the experience of powerlessness for a human is excruciating and the experience of a child who's experiencing right the way all different types of abuse including neglect that they're powerless to change what the adults around them are doing but the experience of blaming oneself is a way of giving yourself some power because you did have power but you obviously used it wrongly and therefore we're not able to prevent what happened and so I quite consciously bring up with my patients that part of getting better in trauma is being able to tolerate knowing that you were powerless and the other area is the area of connection that for children to be connected to their perpetrator is often a real double bind that they're drawn to connect and want to connect to their perpetrator and therefore if they can see that the perpetrator was the cause then that increases their double bind and so one way of relieving that is to say that they were the cause and that the perpetrator was not to blame and so part of getting better again is to learn to tolerate ambivalence towards our perpetrators because often those perpetrators were kind and good and loving sometimes and that was genuine and real and at the same time they were horrendous and frightening and bring up all sorts of feelings of revulsion and anger in the child and just learning that that is part of getting better in trauma is then makes it really not about shame that something was wrong with them. I don't know if that's of any help. Thank you and I wanted to actually also the two of you just to discuss the issue about Tanya had disclosed something to the psychologist that she didn't want her to tell the doctor. Drugan, I think you actually posed the question on that so I was just wondering if you had thoughts on it or if you wanted to just speak with Johanna about that. That's a tricky one. From a consumer perspective I would totally understand that her asking if you don't tell the doc but from a professional point of view there may be a professional responsibility in there so I'm actually interested in what the other panellists have to say on that. Maybe we'll go to Johanna and then perhaps Michelle. Yes, I kind of think I'm being invited into some secret keeping there and my alarm bells would be going off as to how to make sure she still feels safe while yet not sort of colluding with her in secret keeping because secret keeping is often so rife in the relationships that have patterned so the way I would normally solve that is that I would ask them if they minded if I wrote a letter which they then checked and then together I would get a consent to send that letter so that's how I would normally solve that problem but I've become quite clear about that having made a mistake or too earlier where I got agreed to that and it then put me in the position of being quite professionally isolated and of undermining the care she was receiving from another professional. That's a really practical tip. Johanna, sorry. Johanna said because she's setting the boundary but doing it again in a very respectful relational kind of way, you're getting collaboration with it. You're alongside again. You're not doing too. That's the difference in that approach, isn't it? Yeah and I guess there would be a little bit of checking too if there was something about this particular GP that made them feel unsafe so to actually use that language and actually start the process of teaching them about assessing relationships for their quality of safety. Thank you and Michelle, I wondered if you've had experience or thoughts on addressing that issue when you are asked to keep a secret. I agree with Johanna about not being, not including secret keeping so actually making it clear to Tanya that I think it's regarding the doctor shopping, isn't it, and her looking for other medications to help manage herself and so validates. And that she does what she can to feel better but also profess my unequivocity and I'm not sure how these drugs are going to be working together for you. And is there any way I can support you to be having this open conversation with your GP about what you need medication to do for you and how it might work better for you. So I agree with the, you know, if it's writing a letter that the letter is open that the person always has a copy of that letter. Does she need my support to have that open conversation with the GP and place her at the centre of that. They're the drugs that she's using. How can she use us better as resources in an open way to access what she needs. Thanks Michelle and I'd like to bring Warwick back in and Michelle you had a question about I mean so far we've been focusing on helping this person to feel comfortable and safety issues and then you had a question about formal assessment and diagnosis which I think it would be really good to ask Warwick if that's okay. I have one to ask a question because I suspected it would be coming up in a general chat and it is about assessment tools etc. So Warwick I guess I wanted to ask you a question if Tanya was admitted to your trauma and dissociation unit. How much weight do you put on diagnosis with the current system or the just retired system? Well obviously diagnosis is important and it's really important that people in this spectrum don't end up with a diagnosis that's pretty unhelpful or unfortunately occasionally end up with a diagnosis that she used in somewhat pejorative way which then becomes a rationalization for failure or therapeutic nihilism and I guess in the past when I was training we used to hear things like the best form of treatment for borderlines is to refer to them in a very pejorative way of putting it and if that was one of the impetus I guess for the whole concept of complex trauma as a way of getting and I don't know what it is about mental health but when we get to complex trauma like syndromes we so frequently end up with descriptors or terminology that doesn't sound terribly inviting like borderline, hysteria, histrionic etc. In terms of assessment what I would do is however long it takes take take a full history do the things that we're trying to do but I would also ask a lot of questions about things that may not have been part of the traditional assessment interview that I might have been taught as a registrar. I would be interested in dissociation whether there are loss of time, absences of place, whether she finds herself in unusual places and can't remember how she got there, whether she finds things in other handwriting, what actually does go on because we know that she seems to have some sort of affective change that happens pretty quickly and what is she experiencing during those. One can augment that sort of assessment by using some instruments one that's commonly and easily used as the dissociative experience scale which takes 5-10 minutes to complete and which gives you some idea about this is the general level of dissociation a person has, it's not a diagnostic instrument there are lots of other instruments that if one has to pursue that for some medical legal reason that one could, the dissociative disorders interview schedule prepared by Colin Ross, which addresses I guess a lot of the multiple diagnosing entities that coalesce in complex trauma, the somatization the depression, the suicidality, the self harm, the dissociation anxiety and the one thing it probably doesn't address much is the classic PDSD and the difference between complex trauma and PDSD is that complex trauma really incorporates PDSD but has so much more as we know about how one perceives oneself about not having a sense of self and we also get that sense with Tanya, she doesn't have a very centered self at all and it's picked up in the sort of things she does, she tends to seemingly live her life for children rather than being able to live her life for herself and you see that with traumatized people in clinical settings that they're the one that everyone else pours their problems out to but actually incapable of fulfilling their own agenda. So there's a sort of things that be in the background as I would carry out in a way that she felt comfortable with a diagnostic interview that was interspiced with establishing a rapport the sort of things that Michelle was talking about and that may so there are some aspects of history and some aspects of assessment that you may never get to there are some people who will never fill in a questionnaire. They've been traumatized in institutions where questionnaires usually meant bad news. Good point. Thanks Warwick and I know that you had a question also about boundaries which I suppose is parallel to what we're talking about but for Tanya herself she may have been brought up in a boundary-less kind of environment and that has particular implications for therapy. So I wonder if you wanted to discuss that or ask Michelle. I'll ask Michelle. Michelle's a good one to ask this. People in a complex trauma spectrum have been brought up frequently in boundary-less environments and because they've never experienced boundaries growing up they have a lot of difficulty in actually deducing what a boundary is and in therapy that can be quite challenging for professionals and the question I would pose to Michelle is you know at what point does someone's boundary-less behaviors mean that they become untreatable? Well I wouldn't I'd be not thinking about as they're untreatable but this treatment relationship being unworkable for us and I think it's unworkable as soon as one person feels unsafe that it's untenable. So safety mutual safety is really important for us and so if I'm feeling unsafe then it needs to be attended to. So I've been thinking more about boundaries as something we negotiate from the beginning and you model that negotiation of safe boundaries right from the beginning of the relationship rather than see them as barriers. I'm taking I think it's a lane to pause words about we know you breach boundaries it's about confessing it and being aware of where the boundaries do start to slip and being aware, mindful for yourself the boundary-lessness starts to kind of affect you in the relationship and re-attend to them so that they're mutually safe and negotiated. I hope that kind of answers your question. I guess I just came back to the concept of mutual safety. So can I follow up? Can I follow that up? Yes please. I mean what might be of interest particularly to our colleagues is can you think of scenarios where in your treatment of someone in this spectrum where boundary issues made the ongoing continuation of therapy undesirable or impossible? I can remember hearing in a supervision of somebody where they felt they were being watched and stalked outside of the clinical rooms and you know that was just an example I can think of that's a very blatant example Michelle you were, yeah now I see that. I was thinking I haven't experienced and I think that's partially luck where it's been untenable in this context it may become untenable for the other person and I haven't been aware of that and haven't seen them so I have to acknowledge that but from my own perspective I tend not to set up a lot of requirements of how frequently people need to be here for this to be therapy so for some people actually monthly is all they can tolerate at least initially and for some people it's been on and off over a couple of years before they've come back and said okay I'm in for something a bit more intense and a bit more ongoing so kind of leaving, letting the person kind of also sort of drive how close is too close until I feel close enough to do some of the other work. I wonder too, this is Joe, if there's something inside us that is sensing it as well when responsibility is not sitting clearly for things like affect regulation and you know even simple things like keeping bookings of appointments and the timing of the appointment and so on. I think there's some very subtle things with the boundaries that again are needed with a vigilance in this area and I guess inside myself I'm watching for that sense that somehow the responsibility has shifted to it being my problem rather than me collaborating with somebody about a problem that they have experienced. I don't know what you think of that framework. Is there something to Warwick there? I think it's interesting when we're now talking to Joanna and Michelle that collectively I don't get the impression that there have been a lot of people that they've met in the complex trauma field that have actually necessitated the termination of therapy and yet it's easy to listen to some people's perspective. You'd think that this was a major issue or that there were multitudinous, untreatable borderlines out there. They use their terminology that makes life impossible and that we would all live in this hellish environment of lashing and people stalking us and breaking into our houses and doing all sorts of things. Yes, I mean in quite a number of years in this field of very occasionally in a very careful way had to desist with therapy with a very small number of individuals but I think Michelle makes the point that from the first session, in fact, from the first moment of the first session you're frequently demonstrating sound boundaries. I'll just give you an example. I can remember 19 years ago a very, very traumatised person arriving with her with her multi-millionaire father and impressive mother and she had a history of severe mutilation, self-mutilation, suicide attempts etc etc and they arrived at my office, she in tow with the parents ahead of her and he is an articulate, impressive, powerful man and the first thing he said as he came in the door, he said Doctor, before you see her, we would like a word with you first and I threw them out and that was actually very helpful. She never got that but if I had let them come in and put you served her position and there would be no way that we would ever go anyway. Thanks Warwick. Look while I've got the two doctors online, there's been some questions in the general chat room from participants of whom there have been up to 760 about the use of practicing and it's something I only recently came across as well. So maybe Warwick, do you want to speak about that first? No. Okay, Johanna, do you have any experience with it? I didn't quite hear you. What did you say? It's Platus and P-R-A-Z-O-S-I-N. It's a cardiovascular medication. I haven't used it. Warwick, I know you don't want to talk about it. Do you know anything about it? Look, it's certainly mentioned but just about every drug known to man is mentioned at some time in the context of trauma. Whether it's an illusogens, whether it's opiates, and there'll be a paper somewhere. There always is that trial them in some group or other. I'll just make the point. I've never found any medication that solves complex trauma. At best, you're getting some symptomatic relief from some portion of the effects of the trauma but you're not in any way processing or resolving issue and frequently, early on, you're dealing with matters of basic safety. Like the man that I just described who came in ahead of the patient. I mean, he was an ongoing abuser. Giving her Praceton or any other medication is not going to solve that. Yes, people in this complex trauma spectrum almost invariably suffer with dysphoria and in some it becomes more profoundly depressive in nature and some have some response not massive to antidepressants. Some get some relief from inclusive voices or being triggered by taking small moderate doses of major tranquilizers. Some, because of their major sleep problems take sedatives to help them sleep but none of those in themselves are actually a primary treatment of their underlying complex disorder. Thank you. We'd like to just go back to Michelle. There's some questions coming in from the participants and in fact I think everyone would have a comment but we'll go to Michelle first. Just regarding the particular kinds of therapy that therapeutic approaches that you might use or theoretical models. So there's been discussions about acceptance and commitment therapy or exposure therapy or CBT. How would you, how do you approach what you use with a particular client yourself? I guess actually I'm thinking about the skills and the assistance they're needing and which of these therapeutic approaches would be a good fit for them. So if they've had prior experience what was helpful, what wasn't helpful is a really good starting point. People have been developed in a version to don't CBT me or I mean might do some CBT strategies. I actually think are quite helpful helping people manage the moment but I would be led by what the person's prior good and bad experience or expectations are. There are no ideas about how change is going to occur so their theory of change, I'd be relying on that for direction as well. And I think probably rather than hearing to a particular therapeutic approach but to be using principles, some of the principles of ACT I can see that coming up on the chat quite a bit. I think are really useful, the acceptance of internal experience. So sitting with a learning to tolerate internal experience. So some of those principles are also within a DBT approach. But I think for people with complex trauma I think being transparent about what I'm offering and a collaborative approach to is this helpful for you? How is that working? And not to insist that a person fits a model of treatment because the evidence says they should. And Droghan I wondered if you wanted to comment on that from the perspective of being both a consumer advocate and a therapist. How would you approach that question? Droghan? I can't hear him. I think he might still be on mute Droghan. He's trying redriving Mary. Okay sure. Johanna did you want to comment on that one? Because I think it is quite important. I missed the flow of what you were saying Mary. Yeah just really about particular therapeutic approaches because I think we've been talking about a general approach of being trauma informed which is really about the relationship and how we approach the interpersonal aspects of the relationship. But are there any particular therapeutic approaches that you think have particular value or in fact that you shouldn't use? Well I guess my overarching thing is again around relationship. I can't say it loudly enough and I think the literature is starting to really shout it as well. It's more important than any particular technique. But at the same time I think with dissociation it's really important to notice our bodies in space and for grounding to be part of what's offered and taught and become something that people have a competence in. And sensing their bodies and not being disconnected from their bodies and using their bodies to calm them and bring them into the present where often they are in not an unsafe place. And I guess interpersonal therapy would be my key note of therapy. But of course there are other forms of therapy that have been shown to make good effect in this area. And once again I think it's not so much the technique but the people involved and how respect and safety in boundaries etc are being communicated. And Johanna there was another question earlier on which I'd like to address to you. If you were a GP that didn't have the same experience with conflict trauma and training and possibly even the appointment structure that you have for longer consultations how would you make the decision about when to refer somebody like this? And how would you know who to refer to? That is tricky and there's been a number of comments in the chat box about the limitations of 10 sessions for this group of people. I agree with some of what Dragan said that those 10 sessions can be used to good effect and that their goal initially is stabilizing and for some people their local GP is actually the best person to do that because they've had long standing relationship with them and it is a place where they can be learning some stability and settling. But for others there's a need to ask for more help in that area and there are lists of trauma informed and trauma specific counsellors available through ASCA, the Adults Surviving and Child Abuse National Organization and I would encourage people to get to know the people in their neighbourhood and again mental health professionals network can help with that with connections to people who have had training in the area of trauma. And for those who have a particular interest I'd encourage them to pursue that interest with their own learning so that their practice can be more trauma informed. There's lots of opportunities now in our learning community to learn about the latest in the treatment in this area. Thank you. Now can I just check Dragan, are you back yet? Yes, I'm here. Great, I just wondered if you wanted to comment on the question about who ought to be involved and how you make the decisions about when to refer and how to choose appropriate clinicians. Or in fact other support people as well. Sorry, say it again. Yeah, look how would you like say your GP to choose who to refer you to and who to involve? It says I'm off. Oh yeah, here I am. Well I guess initially it's always collaboration isn't it? So it's asking me, the consumer, who I want to be connected into, what services are going to be most useful for me or what people, it's going to be most useful for me to get connected into. I mean again it's that instead of doing too it's getting alongside because even in that initial experience I can either have an experience where I have some sense of choice or I have some sense of even a very small amount of empowerment or I can just be in another situation where a professional is just telling me what to do and doing to me and that's just going to be same old, same old. So I would always be wanting someone to ask me. I find that consumers actually do have a good idea of what they want often even when they may initially say I don't know. I find that with a bit of patience and just asking that people do know what they need, they know what they're looking for. I'm not sure what else I can really say to that. I think it's really important. So I think it came back to what Michelle said a lot earlier about not doing things to people. About working together and making sure that the person themselves actually has the power about a lot of those decisions. At the same time it's feeling taken care of. Michelle are you happy to just come in and comment further on that one? Just about collaboration and how to make those decisions. Yeah I'm just happy to know things, comments coming up about teaching people things. And I've always been able to know everyone about teaching people things. So I think we might be able to offer some information about strategies that have been successful or helpful for others. But I think it's a different stance of offering it. It doesn't diminish your expertise. But I think teaching can very much feel like a doing too. So just take care around how we offer information about strategies, therapies and psychoeducation, otherwise known as just good sound information about stuff. Yeah because it's very much there. I mean as Warwick's saying there's not even a medication. There's no one medication that works. There's no one therapy that works. There's no one approach that works. So we can't come from the place of wow you've got to go and do MDI, you've got to go and do DBT this will help you, this is what you need. We've got to come from that place of okay here are some options, here are some things that might be useful. Here are some people I can connect you to. What do you feel is going to be most useful and giving people the knowledge if you like that they can try different things. You don't have to go to one therapist and then that's it. You can try different things. You can find the recovery path that's going to work for you. And the very act of being able to make a choice and being supported to make choices I think is probably more important than what you choose. Yeah absolutely I agree. And look on that note all of the resources that people have discussed tonight and even the things that have come up through the chat box will be available on the website afterwards. And for those who've had technical problems the webinar is available as a download later on. You can watch it online or if you want to suggest it to other people as a resource. I guess what's been coming up time and time again is about the actual relationships and helping people to be empowered. I wondered if either Michelle or Dragan since I have you both on camera if either of you have got any particular online resources. I'm aware that we've got a lot of rural practitioners and a lot of times the kinds of expertise that you guys have is just not available where our participants are living and where their clients live. So they're online or telephone resources that either of you would consider really useful. I guess it's already been mentioned I think Jonas said but I'd certainly be pointing people towards ASCA. They've got their website resources up and running now so there's tabs there on finding out various things about complex trauma. There's webinars on there there's a whole range of stuff for professionals. The 1300 line is a support for survivors as well as actually for health professionals. In an area you could ring up and say do you have a complex trauma therapist in this area and the person the councillor on the end of the line will be able to have a look on the database see who's around. We're also getting organizations up on the database that are trauma-reformed as an organization. I guess I would probably start there as a resource for people. Thank you and look also we're just really winding up now so Dragan while you're there I just wondered if there was a couple of things that you wanted to say quickly just to finish up and then I'll pass on to the others as well. I think the two main things that have been coming out loud and clear and that people have sort of been discussing a lot as well is that it's all about relationship building the relationship and it's about hope that it's holding hope that people can and do recover. Thank you so much Dragan for your participation. Michelle, a couple of things that you'd like to finish with. I think what keeps me buoyant in doing this work also is that being appreciative of how amazing people are. People do amazing things. They find amazing ways through to recovery and constantly surprise me as well as being saddened by the terrible things that people do to each other but ultimately whatever therapy you're doing people are relearning that other people can be trusted and other people can be safe and have safe resources so whatever else you're doing I think that's essential. I think that's so valuable when we have practitioners from so many different disciplines online as well that it's the relationship and providing someone who can be trusted. Thanks so much Michelle. Johanna? I just wanted to thank everybody for being online. Your presence listening and making trauma something that you want to be informed about gives me hope for our system and just for I guess a fulfillment a little bit of what Warwick's been noticing that trauma's allowed into our conversations more than it ever was and I guess just again that sense that we are our instruments in this process and we need to look after ourselves in how we experience the emotions that we meet each day in the room around this topic and a real encouragement to watch for the quieter ones than Tanya who don't want to cause any trouble and don't make a fuss at the front desk but who are hurting just as much as she is. Thanks Johanna and Warwick certainly not least I just wondered if you'd like to just sum up for us what you'd like people to take away. Yes I'd like people to take away the collegiate nature of so much of the very difficult work you and we do and I'd like to emphasise that getting together on webinars is an incredibly healthy thing to do in a multidisciplinary way and it's also very helpful to avail yourselves of the less professional societies that have longstanding close interest in the sorts of work that we've briefly touched on here tonight and there are a number of both local and international societies, some professional, some consumer orientated that have a great deal to offer. I'd finally just say if anyone wants to make contact with me and if they want any of the instruments I've briefly said to any of the papers that I've alluded to just send me an email and I'm most happy to do that. Thanks so much Warwick and those resources from tonight will be available on the website a few days after the webinar as well. So I'd just like to thank all of our panellists for your expertise and the way in which you've been able to just so usefully and helpfully discuss these things with each other for the audience to see. You know genuine collaboration and action and I just think it's been a really valuable evening. I need to really apologise if the technological problems at my end have had an adverse effect for the participants. I've just had quite a few issues with a number of things tonight so hopefully it still flows smoothly enough for you. So thanks again for coming and please make sure that you completely exit survey before you log out. You do need to do that to get a certificate of attendance. You need CPD points for your participation. You'll be sent a link to the online resources within a couple of days and this was the second in a series of three webinars. The first one was aimed at general practitioners but I believe is now available on the website but the live audience was GP. And the third and final webinar in the series will be held on the 11th of June and that's actually about the therapeutic process. So tonight was a bit more about assessment and next time was more about therapy for those people who had those questions. So look I'd like to just thank you once again for coming on. I urge you to complete the exit survey and there's more information just there about MHPN's other activities including local networks. So once again thank you all very much and we hope to see you again at another MHPN webinar. Hopefully the next one on the 11th of June.