 Hello, and welcome to this webinar on radicalization to violent extremism, fixation and grievance fuelled violence, navigating privacy, confidentiality and ethical challenges. A particularly warm welcome to all of you who've joined us tonight from the live activity and judging by the number of registrations that we've had for tonight, this is clearly a topic of great interest, we have over 2,000 registrations, which is quite extraordinary. A warm welcome also to those of you who are watching us later on the recording, and a very warm welcome of course to our panel, who I will introduce in just a moment. First though, I'd like to acknowledge the traditional custodians of the lands across Australia, upon which our panellists and our participants are located, and I'd like to pay our respects to their elders, past, present and future. I'd like to acknowledge the fact that the webinar has been funded by the Countering Vars Extremism Subcommittee under the auspice of the Australian New Zealand Cancer Terrorism Committee, supported by Department of Home Affairs and produced by MHPN, Mental Health Professionals Network. And this is actually the last of a series of three webinars on these topics. And the broad purpose of this series of webinars, it's twofold really, first of all, it was to, I guess, increase your awareness and understanding of the issues surrounding Countering Violent Extremism. And secondly, it was to support you to better identify and manage the threat posed by those who are at risk of this kind of behavior. So that's the kind of gist of what we were hoping to achieve by the series of three. My name is Mark, Mark Creamer. I'm a clinical psychologist in private practice and also a professor in Department of Psychiatry at the University of Melbourne. And in my clinical work, and certainly in the days when I was working in public sector psychiatry, I would from time to time come across people about whom I had serious concerns regarding their potential for violence. And I always found those very difficult and very challenging situations to manage. So I'm really pleased to be able to facilitate the panel tonight and to pick the brains of our esteemed panelists. So without further ado, let me introduce them. You've all had their bios, so I'll keep it very brief. First, I'd like to introduce Dr. Ines Rio. Ines is a very experienced general practitioner, and she is also a GP obstetrician at the Royal Women's Hospital, as well as seeing a very broad range of patients in her clinical work in a community health center. She also serves on a number of committees and advisory groups. So thank you very much indeed for joining us, Ines, and welcome. Thank you, Mark. At this point in these webinars, I usually ask people something light-hearted, you know, to break the ice and make people feel relaxed. But to be brutally honest, there's not a lot light-hearted going on, at least for us here in Melbourne at the moment. So I thought instead I'd ask the panelists what they were missing or what they have missed as a result of the pandemic. So to you first, Ines, what have you missed or are missing? I miss walking further afield than the hour I can around my home. So I've certainly become very much more familiar with the local streets, which I suppose is an upside. The other thing I think that I'm missing is that physical connection that you have with patients when you're not layered with PPE. Absolutely, absolutely. It's prompted all of us to think about different ways of doing our clinical work, hasn't it, and some of it I agree is not that comfortable. Anyway, thanks, Ines. Our next panelist is Professor Alfred Allen. Alfred is a clinical and forensic psychologist coming to us tonight from Perth. And Alfred has a particular interest in professional ethics, as well as in the intersection between psychology, mental health and the law. And he is also someone who serves on a whole lot of high profile panels and committees. So welcome, Alfred. Thank you very much indeed for joining us tonight. Thanks for the opportunity. Yes, and of course, we're a little bit jealous of you over there in Perth because you're not quite locked down in the same way as we are. But no doubt the pandemic has caused you to change some things or to miss some things. Is there anything you're missing or have missed as a result? I was reading a question because I really feel quite guilty to be standing here. I know you guys are all anchored down. So I think what I'm going to say is really going to... I don't know how it's going to go down, but what I really missed was going overseas this year and hiking in Europe. So I had to stay here. I went down to the south of Western Australia and had a really nice hike there, but wetter and colder and muddier. I think that's more than enough, actually. I've got to be on the mind. But I can certainly see what you're saying there about the overseas trip. And I have to be honest that I also missed out on an overseas trip this June, July. Thank you very much, Alfred. Our final panelist tonight is Dr. Danny Sullivan. Danny is a consultant forensic psychiatrist and executive director of clinical services at the Victorian Institute of Forensic Mental Health. As well as his medical degree, Danny has not won but three master's degrees. I better make sure I get them right. He's got one in health and medical law, one in bioethics and one in management. And he also holds academic positions at the University of Melbourne and at Swinburne University. Welcome, Danny. Thanks very much indeed for joining us. Can we hear you? Yes, thank you very much, Mark. I can tell you what I've been missing, which is the chance to have another holiday at the end of this. So as everyone else, I've missed a holiday along the way. But actually, it's the hope of a holiday in the future that we really miss. Wow, we haven't given up all hope of a holiday in the future, Danny, I'm sure. But it's the one thing that's keeping me going that one day we will be able to go on holiday again. Anyway, thank you. Thank you to all the panel. So tonight's webinar is just a little bit different to our usual ones. But we are going to try and grapple with some of these difficult issues around privacy and confidentiality and ethics with this population. And we're going to use some hypothetical scenarios as jumping off points for our discussion. You've all received these hypotheticals. I should say that they are purely fictitious cases. But I think you'll agree there's a whole lot of stuff in there that if you work with this population will sound a bit familiar. And lots of red flags for us as clinicians that would certainly be worrying me and I'm sure would worry you. So in just a minute, I'm going to ask the panelists to say a few words. Then we're going to discuss the hypotheticals. And then at the end, we're going to come back to some of your questions before we finish. And we hope that as a result of all that, by the end of the webinar, well, I guess there's a few things. The first is, I think, an increase in awareness of the issues. So we hope that you'll be more aware of the principles around confidentiality, privacy and ethics when you're treating or supporting someone who may pose a serious threat to themselves or others by way of radicalization to violent extremism, fixation or grievance, fueled violence. So an increase in awareness of the issues. I think the second learning objective that we have today is something about the when. So something about being able to describe the key indicators and circumstances for disclosure. When you can disclose, when you shouldn't disclose to whom, when you're working with this population. And the third learning objective for tonight's webinar really is about the how. So it's about having an awareness of the referral pathways and how to take appropriate steps, who to ring, who to get advice from and so on, if you're concerned about a person under these circumstances. So I've got some tech stuff. I've just got to go through very quickly. Sorry about that. So I'm sure you're all familiar with the tech stuff. You've got a purple button there, which will open a chat box for you. That allows you to post comments and to chat to each other. The blue button is the resources button. And although I'm going to tempt you by saying there's some really good stuff in there, I would rather you didn't look at it now because that would distract you. But you can if you want to. But NHPN will send you a link to those resources in a week or so after the webinar and you can look at them at your leisure. You've got a refresh button and exit button. And you've also got the feedback survey, the yellow button. And we really do want you to fill that in. But of course you can't fill it in until the end of the webinar. So I will remind you again at the end. So I'd now like to ask each of our panelists in turn just to say a few very brief words. We're keeping it very brief this time. And it's really to help us get the context a little. And I've asked each of them to talk a little bit about where they go for information or support if they find themselves in these kinds of situations. So I'd like to introduce our first panelist again in Israel and ask in is from a GP perspective. Who would you talk to? Where would you go? How would you get support if you were confronted by these kinds of issues? So over to you. Thanks very much, Mark. I will frame this in the context of the case that we have at hand. And essentially you've got an unsolicited telephone call from somebody from an organisation with an initialisation that you've never heard of before that's telling you some fairly frightening things about one of your patients and asking you for personal and sensitive information from them to be handed over without their consent to be used for a secondary purpose. So every here on my body is actually bristling at the moment thinking, wow, who are you? How can you ask for this information? And what do I do in this situation? How can I know that this is actually a legitimate organisation, a legitimate person, a legitimate request, and that I'm actually required to hand over such information? Over to you, Mark. Over to you, Danny. Well, sorry, I was just going to ask you can you just talk quickly through your slides there? Can you see the slide on the screen? I can, I can. Can you just talk very quickly through those? Then I'll come back to that question that you raised, because it's a very important one. Okay. So I suppose then I'll go through my thinking at that point. Certainly when they're actually speaking to me at that time I'd probably be doing a little bit of an internet search to see who FTAC actually are. And then at that time, consistent with some of the Australian privacy, so I've got to the wrong one, consistent with the Commonwealth Privacy Act which we have, we've got 13 policy principles and they actually talk about how and when you would transmit information. And certainly in this situation I'd be asking them to actually provide a written request that includes when, what, how information I would need to provide at that point. So I'd be relying on a lot of the codes of conduct and the legislation in framing that response. Okay, lovely. Look, thank you very much indeed, Enid. So I'm just checking. So in fact we did skip very quickly through a slide there but it's got lots of resources on it. And just to reassure people that those resources will be part of the list that you'll get at the end. But thank you very much, Enid. And I'll just go back very quickly to what I saw on the, I think it's the very first word of your first slide which was colleagues. And perhaps just how important it is to feel that you can talk to a colleague about this. Would you say that's really important? Yeah, I mean this is a highly complex situation and it's not something that you come across every day. So again you actually have to structure what information you actually get in and also your support structures. So certainly in that case I'd be requesting something that was written from the organisation that requested such information asking me for things like what, why, how, under what legislation and why I shouldn't be requesting consent. Then I would actually be talking to my colleagues and providing that information to the medical defence organisation in a de-identified form to say is this a legitimate request and what is, what are my obligations in this circumstance? Absolutely, absolutely. And look as I say we'll come back to that first part of your comment there in just a minute when we get onto the hypotheticals actually because it is a very, very important question. Thank you very much, Enid. Let's move on now and hear from Alfred for a clinical psychology perspective and of course someone who actually specialises in these areas of confidentiality and ethics. So Alfred can I hand over to you and just talk a little bit about the context of how you would get support, where you would get support and so on if you find yourself in this situation. Alfred. I've been mindful of the fact that if I'm judged on whether I acted professionally or not by disclosing or not disclosing confidential information, the test is whether I did what the reasonable practitioner would have done under the circumstances. And this is an objective test and is therefore important like Enid said to consult other knowledgeable colleagues attending webinars. This is another important one. And then to follow the right process. Now on my slide I've set out what I think one would need to do under those circumstances. First of all if you're an employee, you'd look for the relevant policy, procedures and protocols. If you're in private practice, ideally you should have such a protocol and a list of resources. And once again, going with this webinar there's a really fantastic set of resources. And then think about people that you, and in your resource list there should be people you could probably consult. And if you're in a state where there's a joint police and mental health team, that would be one option. The fixated threat assessment centre would be another one. And then just basically there's also obviously for the psychologist, Australian Psychological Society's guidelines and resources like the ethical guidelines for working with clients and also managing risk of harm. And I think that's basically some other work websites that people could also look at. And that's where I'll leave it Mark. Thank you very much Alfred. Can I just pick up, I mentioned too in is there about how we might talk to a colleague. If in the context of professional supervision, clinical supervision. So if I'm talking to my supervisor, my clinical supervisor about these issues, do I have to worry about confidentiality issues? Or is that considered kind of within professional boundaries or whatever? So when one will be talking to your supervisor, you should actually advise your clients in advance that you will be doing that. And the code, the psychology coach specifically also says that if you do speak to a supervisor, that is actually one of the exceptions. Standard A52 actually says that's one of the discretion that you have to disclose confidential information. So what you're actually touching on is a really important thing, setting up the supervisory and consultation agreements very clearly and probably documenting them and to make sure that every client understands that you will be talking to a supervisor or a consultant. Okay, good. Please do Ines, yeah? Yeah, just to add to that, Mark, I think it's preferable when you actually engage patients in the first instance and you start collecting their information, their personal and sensitive information, that it's actually clear in a general practice setting that that's actually information that's actually held by the practice and is available by all the GPs. And certainly most general practices work within that multi-disciplinary framework. And the other thing that's actually I think very advantageous is to think about the fact that you often use that information outside that immediate general practice to work with other people within a multi-disciplinary team as well. Okay, so it's a very good point and I probably will come back to that a bit later because as you say Alfred, it is a complex area but it's one of clinicians we have to deal with all the time. Anyway, okay, thank you very much Alfred. Let's move on to Danny. And perhaps now Danny if we could ask you for a psychiatry perspective on where you go to get information and support. I have also asked Danny though to just foreshadow a couple of the issues that we're going to go on and talk about. So I'll hand over to you, Danny. Thanks very much Mark. Psychiatrists and psychologists and general practitioners don't actually have particularly different perspectives on confidentiality and privacy. The fact about these matters is that you can look at the codes of ethics and you can look at your codes of conduct and you can look at the law and they give you guidance but they don't give you the answers because every single scenario is different and these scenarios are all complex. One of the things that's really important to recognise is that these scenarios, they challenge your duty to your client versus your duty to act in the public interest. F-TACS or Fixated Threat Assessment Centre exists in some form in all of the states and territories of Victoria or at least has access to those services and there are type of service which shares information between police and mental health under very clear guidelines and the reason for that is that the people who are of interest frequently have a mental health history which is relevant and frequently have been or need to be in contact with mental health services. So when we look at F-TACS what they offer is the opportunity for police and mental health services to share information in order to both averted public threat but also to link a person to treatment or to effective intervention. When we're dealing with these confidentiality issues we're dealing with that conflict between what we see as a public interest and what we see as our client's best interest and of course when you listen to us all speaking and when you're thinking about your own practice what we're thinking about first of all is our client and their welfare and one of the things to point out is that there are no straightforward solutions to this but in many cases we want to ensure that our clients don't hurt themselves or hurt other people because that's a bad outcome for them as well. From the point of view of a psychiatrist first of all we have a duty to our client and that's a duty based in our relationship. It's the overarching duty, it's a prima facie duty that is it's something that we have to think of as the primary duty but that's not to say that it can't be overridden by other competing demands. And sometimes there are statutory duties in some jurisdictions but generally those duties are not to breach confidentiality rather than to clearly set out situations in which you must breach confidentiality. So in the United Kingdom some of the F tax were associated with a duty to teachers and health professionals and others to notify police of concerns about violent extremism or terrorism and that was a very controversial duty. We don't have such a duty but what we might have is a moral obligation rather than a legal one. So the codes of ethics are really important to look at but they're the beginning of the discussion not the end and we've all spoken about discussing with colleagues. You don't want to be having that thought which colleagues should I ring when you're confronted with a dilemma. You should already have that situation set up. You should have a network of people that you rely on and trust and can speak about at short notice about these problems and what you might want to do is actually look at the code of ethics and in the discussion in fact they're not going to give you the answer but in framing the questions to them and discussing the scenario and getting their further questions and feedback you'll get a bit of advice on what you should do and that's a really important way of thinking about it. The reason it's important in these situations and we'll come through this with the scenarios is this concept in threat assessment called leakage and leakage is well recognised as a way in which people who pose a threat communicate that threat to other people in various ways whether friends or family or the health practitioners not necessarily explicitly but in enough ways to give concern just as suicidal people sometimes signal their intentions. So that communication should give rise to you to a concern about what to do and I suppose the take home message to foreshadow what we'll be saying at the end is really to not to seek some explicit guidance on what to do but rather to think about who you can share the discussion with and to communicate about the ideas that arise from your concerns because at the end of the day if your client commits an offence they go to prison for a long time or they're dead or they've done something very awful and it's not a win for anyone. You've got one more slide everyone? I've got one more slide. In terms of the people to speak to well I say that I often take these sort of telephone calls from people I've never met before general practitioners and other clinicians. So public mental health services in all states will probably have some ability at least to answer your question or tell you that they can't answer the question. You've got indemnity organisations although sometimes these are very rarefied and special questions but they can at least give you the satisfaction of knowing that you're doing the right thing and that you won't be persecuted for it but really the most important thing is your colleagues. It's your supervisors, your peers and the people that you normally go to to seek ideas about the difficult situations we all face from time to time. Thank you very much indeed Danny and that's an important point isn't it to end on there that if people take nothing else away from tonight, take away this, that you don't have to do this on your own in fact you shouldn't be doing this on your own get support, get help and so on. Thank you very much to all our panelists there. Now I'd like to kick off the broader discussion and start exploring some of these hypotheticals and I'm going to ask the panel members to just jump in at any point if they want to disagree with what's being said or add a different perspective to it. I should say at the outset that I've been very impressed with the number and the quality of questions that we've received from our participants and I would love to go through and answer each one in turn but I'm afraid I can't we haven't got time to do that. I'm confident that we'll cover almost all of them in the hypothetical discussion and we're also going to finish up with addressing a few more of them at the very end. But if we don't get round to your particular question, please bear with us. So now I want to talk about these scenarios. If you've got them in front of you, those of you who are participants at home who have the resources that were sent to you, I'm going to talk about scenario one to begin with. So here we've got a situation where the FTAC has contacted you, the GP. We're going to say the GP in this case but you could be another allied health professional but in this case contacted the GP about one of your patients, Mr. S, who is a 17-year-old male with high functioning autism and OCD. He's very socially isolated, spends a lot of time online. Parents don't supervise his internet use. And a clinician from the FTAC, so that's going to be probably a psychiatrist or a psychologist from the FTAC has contacted you saying that they've got some information, some reliable information that Mr. S has been speaking with ISIS online and that he's got some pretty nasty plans to blow up a local police station into Behead's civilian and worse than that they've found some weapons and some paramilitary paraphernalia in his home. And so the clinician, the FTAC clinician is ringing you as the GP or the health provider to get some further information so that they can do their risk assessment. You've had no previous dealings with FTAC, you're confused about what to expect and what to share, what's appropriate for you to share and so on. And I think this scenario highlights several issues that perhaps speak to the difficulties that we as health providers may have when we're working with patients who've got this kind of terrorist label on them and issues, of course, about what information should and shouldn't be revealed. It also raises issues about autism which I'd like to come back to, I will come back to at the end but for the moment let's put that on hold. It is, I'm going to put you in the hot seat because you are the GP after all. So I guess the question is, the FTAC clinician has run you. Can you share information with them and do you have any idea what information you can or can't share? So I might rewind to what I talked about about five or ten minutes ago Mark and just say, look as a GP this is actually quite a frightening telephone call. It's an unsolicited call from somebody that you don't know about from an organisation that you've never heard about before asking you to actually, with quite a lot of knowledge it seems about, disturbing knowledge about a patient of yours, asking you to provide information to them. Secondary purpose of that information with no consent and you're sitting here wondering is this a legitimate telephone call? Is this a legitimate request? And how do I deal with that? Now hopefully your practice has a mechanism and all practices should have a mechanism whereby they actually deal with such requests whether they're with consent or without consent and certainly you'd be asking for a written format of that. You'd be asking exactly what the request was for on the behalf of whom and why consent wasn't actually sought and how you're best to actually transmit that information as well. So that's where I'd be starting. I'd be asking for a formalised request. Okay, now let's just wind it back a little bit though because you're a bit concerned that you don't even really know what an F-TAC is and so on. So let's check it across to Danny. Let's say that Innis rings you with that exact question Danny. What is an F-TAC and perhaps what are my responsibilities here? What would you be advising her? Well it's quite understandable why someone might do that. It sounds a bit big brotherish. It's quite appropriate. I have to say that I've put the F-TAC number into my phone and it's saved there so that if I need to dial them they're there so I know they exist. But I'd be telling her that F-TACs have been around in Australia for some years and overseas for many years. They exist because there are necessary circumstances in which police and mental health agencies need to work together to prevent serious harm from happening to the community. And obviously that's a balancing act but I'd be saying you need to think about the cooperation that you need to give. You need to think about your client and I'd be saying give the information that you can, give the minimum amount necessary but think carefully about what might happen if you do or if you don't and I'd be advising her to do the same thing that Innis has already said which is to speak to colleagues and speak to your indemnity organisation if you have more concerns. One of the things that's important is of course this is sometimes very time critical and that's obviously worrying for clinicians and that's why you need to perhaps have some knowledge in advance and be able to think about what you can provide early on and what you might provide a little later once you've had a chance to reflect and think. And just sort of picking up on one of Innis' concerns is it legitimate to ask FTAC to put that in writing? You're saying a lot of these are time critical. Is it legitimate for the GP to say I'm not going to do anything until you contact me in writing? Absolutely. Okay, good, good, good. All right, so do you feel any more comfortable knowing is about what you might or might not share about Mr. S? Yes, I do and I think that Danny is right. I mean you're in a position where you don't want to actually you want the information that you hold about that person to actually be a part of the bigger picture to make an informed decision with regards to the risk that that person might pose to themselves or to other people. So you're not in a position where you want to be a barrier but you are in a position where you want to ensure that it's actually a legitimate request from a legitimate organisation and you also want to have a concept about whether consent is appropriate in that circumstance because I think you should always start off with the concept that your patients you work with collaboratively with that you have an honest and open relationship with and that consent is the basis that you work from but obviously in cases such as this consent might be not a good idea. It's a thorny issue, isn't it? I want to bring you in on something else, Alfred, now but can you just quickly say something about that? I mean it's ludicrous to me insisting that we get consent from the client in this particular case, isn't it, or not? So the Privacy Act premises is that we should always get consent unless it's impractical or unreasonable. So that is one of the conversations that Ines should probably be having with her colleagues is would it be reasonable for me to ask my client's consent and obviously Ines is also going to be a very good judge of that because she knows her patient and she knows the type of relationship she's got with her patient. Okay, okay. Let me take it at one level, Alfred. We've been talking to the clinician from the F-TAC, so we're talking to another health professional and so on and we perhaps feel a bit more relaxed, I think I would, doing that but can that person, can the clinician in F-TAC talk to the police in F-TAC? Is it just assumed that anything I tell the psychiatrist or the psychologist in F-TAC they will hand over to the police? I'm not an insider, so I can't tell you for sure, Mark, but my assumption would be that the GP, sorry, that the clinician will talk to the police because there are several provisions in the Privacy Act that could apply here and may even allow that clinician to speak to the police, so I think always assume that the clinician you're speaking to may share information and going back to something that Danny said a bit earlier, so always be conservative, only release the information that you need to and just assume that this is not going to end with the clinician. Okay, I think it's a very reasonable assumption to be carrying. If I come back to you, Danny, because why don't we then just miss out the middleman as it were, and I would feel much more uncomfortable in this situation, what if the police were to ring me or to ring Innis and ask for information about the patient? Would I be in the same situation? Because at the moment I'm only going to tell the clinician who's going to tell the police, should I tell the police straight away, is it legitimate to do that? Oh, look, I think that's a great question, Mark. Let me reassure you that in F-TAC there are very strict information sharing protocols and it's not a free-for-all exchange of information. So clinicians who work in F-TAC are still bound by, in our state, the Mental Health Act so they can provide information when there's an imminent risk of harm to self or others, but they have to sort of meet that test. They can't simply pass the file across. An information that is discussed in clinical review meetings between police and mental health really has to be used for the client's benefit. In that situation, I mean, I think you can be satisfied that there are robust protections, but that's not to say that the information won't somehow come into the hands of police and might in the future be used in, say, a prosecution. You can't be sure of that. So I think what you need to do is be circumspect about what's offered. If it's a police person ringing, well, that's a normal situation. We deal with that all the time in compulsory treatment in mental health, in family violence, in other situations in which the police have a legitimate interest in seeking information. And we have to think about whether the risk posed outweighs our duty of confidentiality to the client and that each of those situations is individual. Sure. Okay. While I've got... Sorry, Ennis, were you going to say something then? Yes. Yes, I was just going to add the fact that you are essentially talking between clinicians as well. And this is a really highly unusual circumstance for that individual general practitioner, but not such a highly unusual circumstance for that clinician in VTAC, in FTAC. So there's information and there's a capacity build that that clinician in FTAC will actually provide to you. I suspect that they will say, look, it's a really good idea for you to document in your notes this letter to actually document in your notes that consent was not sought for these particular reasons, that you've weighed the risks and the benefits in this scenario and specifically asked for what information is required. So I think that there is also that conversation that happens between clinicians and they can guide you. And I think as a GP, I would be requesting that guidance both from the FTAC clinician and, as you said before, from medical defence and peers, supported hopefully by some of my policies and protocols in my practice. That's a very good point, Ennis. And you've alluded a couple of times there to something I want to pick up later, which is about notes and what you put in your notes, but hold that thought because I'm going to come back to it in a minute. Danny, Ennis is getting a bit frustrated. Let's face it, Mr S is her patient after all and yet the flow seems to be just one way. It's FTAC asking the clinician all the time. Can Ennis reasonably expect some details from the police about the investigation, things that would help her as a clinician to better work with her patient? Can it be two-way? Yes, it can, but it's not necessarily an expectation. So, for instance, the police may well relay information which might change your clinical appraisal of the situation. So, for instance, the police may have capacity to interrogate social media databases or to look at what the person has been doing. They might provide some information which you, as a general practitioner, are not privy to and which drastically changes your estimation of the situation. So, in situations like that, certainly if you're ambivalent about providing information, you might ask really what the risk is posed or why it is that they have the degree of concern. And it's quite likely that the clinician or the police in that situation will provide information to justify why it is that you might wish to convey further information. But, of course, as the general practitioner, as the clinician, you're still thinking at the heart of it all about your client's best interests. Yeah, absolutely, absolutely. Okay, thanks for that, Danny. Ines, I'd like to come back to you and I'd like to slip out of the hypothetical just for a moment, wind it back a bit. Let's assume that FTAC had not become involved. Let's assume that Mr. S had just told you in the course of a consultation that he's been talking to terrorists. He's been talking to ISIS online. And I don't know if you've got the answer, but I'll ask the others if you haven't. Do you have any further obligation to report that, to say something, or how would you handle that if Mr. S told you he'd been talking to ISIS? I think that... Can I just go back one little piece, Mark, which is the sort of second arm that I wanted to talk about with Danny, which is the question about your clinical care of the patient, which is what you're extending to now. The issue is also from a GP's point of view, you've told me some really disturbing things about my patient, and I'm concerned about that person's clinical care. Have I under-treated that person? Have I appropriately picked up information about that person? Have I under-managed that person? And so that extends to that question now of FTAC not being involved, that the person's talking about that issue of perhaps... in a scenario where he's speaking about terrorists. I'd be very worried with the previous FTAC scenario because I have a very disturbing picture of him already. But if I don't have that FTAC scenario, there's a spectrum of worry, essentially, that's informed by the history of what's happened to him before. Is this a recurring psychosis where he hasn't acted on it before, it's been easy to manage, he's been adherent, has he been violent before? Has he acted on things? Is he planning things? Is this an escalation or a stable environment? Is there associated substance abuse? What other medical practitioners are involved? So there's not a yes and no answer to this. It's actually a spectrum where I'd be thinking about where is he at the moment? What's the safety netting? What's the enabling? What's happened in the past? And how can I look after him moving forward? Great, great, great answer. So we're taking into account a whole lot of different information in trying to decide in this particular case, in this particular time, is it appropriate? Can I just confirm something you said earlier, Danny? I'm right in saying am I not. I think you said that actually we're not mandated to report suspected terrorism, unlike the UK. Is that what you were saying? You're on mute. It is an interesting observation, but it was a very poignant issue in the UK where parents described their dilemma. Do I notify the police that my child wishes to go overseas and fight for ISIS and possibly die? And in doing so, do I then ensure that my child is imprisoned for a terrorism offense? So there's a dilemma that you really can't answer as a parent. So as a GP, I really appreciate Inez's primary concern but also recognising that the consequences of the sorts of behaviours that people are talking about here don't necessarily end well for them as well. But coming back to your initial question, no, I don't believe there is any primary duty. Yeah, okay, interesting. Okay, Mark, sorry, Mark, I'll just come in there. I agree with Danny there's not a primary duty. There are legislation in some states about terrorism, I think in New South Wales specifically, that may come into play here. But I agree there's not a general legal obligation. Yeah, okay. I don't know whether Danny... Yeah, no, that's fine. I want to stick with you actually, Alfred, because strange to me, Stephen, I don't know how they did it. Mr S's parents have got hold of your phone number, Alfred, and they've given you a ring because they want to know what they can do to block inappropriate content from Mr S's computer. What are you going to advise them that they could do? I think this falls a bit out of my level of competence. If I know that they know that IFTAC is involved, that's probably one resource. But otherwise, I would probably refer them to the Living Safe Together and the Mental Health Practitioners Network website where there are some information that may be useful, but I think that's my primary field of competence if I could do that way. Fair enough to... Okay, before we leave this case and move on to the next one, I would like to come back to you, Danny. We hear that Mr S has autism for high-functioning autism. We hear a fair bit about possible links between autism spectrum disorders and violence. I guess I'm wondering whether there's any truth in that, and I should say that several participants picked up on this and sent in questions, and one of the questions was actually whether a person who is on the spectrum would be dealt with differently. But can you just give us a very brief riff on this link with autism? Okay, well, I think the first thing to point out for people with autism are not more prone to violence. There may be some reactive violence in situations at home or domestically, but I think that's very different. But what is of interest is that if we look at violent extremism, we certainly see, I think, an overrepresentation of people with autism spectrum disorders, and it's probably a combination of the fixation and the way in which people become quite rigidly drawn into a particular topic. In some cases they're naivety and gullibility, so there have been certainly a number of situations in which people with autism spectrum disorders have been exploited horribly by people who are wishing to use them as a pawn in some sort of terrorist game. The third thing, I think, to point out is that often people with autism spectrum disorders lack the capacity to really weigh up in the balance and think about the pros and cons of what they're doing in a logical and rational way, so they're prone to perhaps coming into a particularly one-sided view of things. In terms of whether they're dealt with differently, there is no doubt that there is a degree of sympathy in the way that the criminal justice system will deal with a person if they commit an offence and they have an autism spectrum disorder, and certainly in particular Ian Freckelton has written quite a lot on this in psychiatry, psychology and law. But the main thing to point out, really, is that if a person with an autism spectrum disorder is drawn into this sort of situation, although they might be a victim, what we're also dealing with is clinicians is our cognitive dissonance, because we're thinking about them as our patient and as the person with the problem, and it's really difficult to reconcile that with a person who then might go and engage in some act, which is antithetical to our view of them as a patient needing healthcare. Okay. And would they be managed there any differently if they were on the spectrum? Managed by the mental health system or managed by the criminal justice system if it goes... No, I'm thinking more that the... Well, the criminal justice, I guess, the F-TAC police, you know, would they be managing this case differently if they knew that he was on the spectrum? Yeah, well, F-TAC is certainly keen in situations like this to ensure that people with mental health needs or other mental disorders are appropriately linked to services, particularly if that can be a way of circumventing something bad from happening. So the primary focus is upon linking people to treatment that can prevent outrageous to community safety. So they'd be dealt with, I think, initially, certainly, through a mental health spectrum, and there would be efforts to ensure that the person was in receipt of the appropriate treatment in the hope that that would prevent anything disastrous from happening. But obviously part of the situation you're dealing with is to stop that from happening and the police will intervene if that's a real risk. Yeah, good, good, good. Okay, that actually leads us very nicely into our next scenario. And this is a slightly different one, although it is the same kind of issue in the sense that F-TAC is contacting or F-TAC clinician is contacting the GP. In this case, the... In this case, let's assume you're a female GP contacted by an F-TAC clinician about Mrs. J, who is a 55-year-old woman, one of your patients, and you've known her for a long time and you're not aware that she has any mental health issues at all. But they've learned that Mrs. J has a history of a rotomania and she's had in the past quite powerful delusions involving a city counsellor and she has recently shifted those attentions to an MP. She was initially assessed by F-TAC as moderate risk because Mrs. J had alluded to getting rid of the MP's family and partner and children, but it's now been elevated to a high risk because they found out that she's got a gun license and a gun club membership. Mrs. J has refused to speak to F-TAC or to the F-TAC clinician, so they're liaising with you, their GP, and they think that she needs urgent treatment for her delusions. She's got no insight and so on. So I guess what this does demonstrate, and it's kind of something you were alluding to there, Danny, it does demonstrate that F-TAC is not just about protecting VIPs, although I'm sure they would love to protect the MP in this case. But it's also about identifying someone who's got a long-standing, previously unidentified mental health problem. But it also highlights similar issues to our last case, I guess, about what can be said and what can't. And I'll just whiz through those very quickly. Now, I should say, for our tech colleagues, I've lost two of the pictures there, but I'm hoping that Iniz and Alfred are still with us. I can still see Danny. I'm still here. You are good, that's all I need to know. Okay, so I guess three questions about what information can and can't be shared in Ms. J's case, and I know they're going to be quite similar to last time. Thank you, Alfred. How much information can we share with either the police or the F-TAC clinician by the GP? Are there some guidelines about how much information we can share in this case about Ms. J? It seems to me like F-TAC is better informed than the GP in this case. Yes, yes. So I think it depends. Okay, so let us go back to the general rule in this case. So the privacy act says that we can only use information for the primary purpose, we collected it, and if there's a secondary, we either need to get consent, or then we need to decide about the threat and so forth, and whether there's a reasonable belief. Now, this doesn't seem to apply here, but I think Iniz would say, well, look, actually, F-TAC is asking me to help this patient. I've got a duty of beneficence to help here, and if I can get into a conversation with F-TAC and the clinician at F-TAC, we can maybe help the client. And therefore, I would say that the information shared with the F-TAC clinician would depend on what would be the best interest of me helping my patient under these circumstances. Just keep in mind also, and Iniz has said this as well, earlier on, that the privacy act also says that when possible, we need to get consent. It's practical and reasonable. And once again, depending on my relationship with this client, I may have an open conversation with this client and say, look, this is a situation and these are the risks for you and where do we take this? What's our plan of action? Can I just ask you, and it may be the same answer, really, but one of the participants asked, I thought it was a legitimate question, I'll throw it about, what about the next of kin? As a clinician, as a GP or a psychologist or whatever, can I share information with the next of kin? I know that's one of the real difficulties and it would depend in the... But as a general rule, not with an adult, mature person, unless you believe that you've got a duty of care towards that next of kin. But that's a really difficult one and I think one would have to look at the circumstances, but as a general rule, I think you should rather be very cautious about sharing information with the next of kin. Yeah, sure. And it is a situation that we come across a lot, isn't it, and not so much in this... I'm not thinking much in this violent way, but treating adolescents or perhaps young adults and the parents are so concerned and they want to know what's happening and you have to say, I can't, I can't talk about it, unfortunately. It's very tough for the parents. Yeah, Mark, I think it's probably the people, family members of people with mental illnesses would say that that's one of their biggest frustration. So there's a balance to be found here and also keeping our patients involved and maintaining their trust in us. Yeah, quite. Did you want to come in there in this just quickly? Yes, I think that was a really important point, especially for the first case, because he was 17 and it certainly crossed my mind as a general practitioner that in the clinical care of that 17-year-old, whether you'd actually involve his parents, really a 17-year-old would be regarded as a mature minor and as Alfred said, I think that it would be somewhat tricky, but it doesn't mean you haven't got a bit of wriggle room, I think, about inviting the parents in and perhaps getting a more force and picture of what's happening to that young man at home, even though you might not be transmitting information to them, you might be garnering some information that gives you more of a context about that person. Okay, Danny, do we need to be concerned about, in this case, warning the GP about it or is it something we can wash our hands of and just make sure, just let F-tack or police make that decision? And I can't see you, Danny. I think the scenario is an important one because it does involve also a local area mental health service and once more, this is not necessarily frequent for GPs, but they are used to dealing with people who require compulsory treatment under the Mental Health Act or who decline treatment. And it's always a tenuous balancing act between preserving your relationship with the patient while insuring that you act in their best interest, sometimes when they're not able to do so themselves. And in a situation like this, I would be working with the area mental health service. Just coming back as well to the question about how much information can be shared with F-tack when the person of interest is declining to speak to them, you can still disclose information which is not necessarily harmful to the patient. So you can, for instance, indicate whether or not you have had concerns about their mental health, whether or not they've had treatment recently, whether they have spoken about this person and whether they've had treatment. So you can certainly, these aren't things that are necessarily of prurient interest to other people, but they're certainly very helpful for F-tack in terms of thinking about whether or not they need to intervene and with what level of intervention. They're also helpful for an area mental health service because it's likely you might get them to make a welfare check or you might notify the CAT team based on those concerns. Okay. Anna? Go on, Ines. Yeah. Yeah, I was going to say something very similar. I mean, in some ways, actually, F-tack have provided you with a lot of information whereby you need to actually certainly assertively manage this woman and you do that in conjunction with other specialist services outside your practice. So it's certainly been involving the area mental health service. And as you garnered more information from that woman, again, you would actually do that balancing act. Does there come a point where the disclosure of that information is required for the safety of her, the public, or in the best interests of the public with or without her consent? I do like this. I like the point that I think all of you have made, actually, which is very often if we're serious about the best interests of our patients, actually, we will be helping to prevent them from doing something stupid, yeah? Ines, you may not know this, but you're about to go off on maternity leave. I'll let you decide how likely that is. But let's assume that you are. And your replacement is a male doctor. How much are you going to share with the new doctor who may, of course, become a target for Ms Jay's delusions? How much would you share with him? How much would you want? I think I'd be quite frank with regards to what the history has been with regards to her delusions and her fixations and also talking about her management plan moving forward. And I think that he needs to have that information to keep himself both safe but to also understand what's actually happening with regards to her mental health and well-being. I think you can often say more than you can write in notes because in a conversation with a colleague there's some nuances that can come out that perhaps you don't document. I think that I'd be both dispassionate and frank with him. Well, I'm very glad you mentioned that issue of notes because I want to pick it up and I'd perhaps turn to Alfred first but I'd be interested in all of your views but that would be very quick because time's going very fast. This issue of notes, that we know that what we write in our notes is potentially subject to FOI and certainly subject to subpoenas and my personal experience is that my clinical notes are getting subpoenas much more often now than they ever were in the past. So it is something we need to be careful of. Do you have any thoughts about that Alfred about what in this kind of material we might put into the notes? I've got no doubt. You've got to put in your notes that you've been contacted by FTAG and that your notes should be so that even if you didn't know you were going to go on leave if somebody else had to take over you didn't have an opportunity to talk to that person that person should still from your notes be able to get a picture and be able to take the necessary steps. So it's very difficult because we can talk hours without note keeping but one of the things is you keep notes for the ongoing continuous treatment of your patient and therefore it means that if you're not available and somebody else has got to take over they need to be able to look at your notes and form a picture that can allow them to proceed and also protect themselves. The legislation has recently changed. I think it was last year, Alfred, wasn't it to actually incorporate that clinical handover as an important component of medical notes? Yes. Okay. As I say, time is running out. I want to have a very quick look at scenario three before we finish off with a couple of questions from participants. So scenario three is a little bit different because in this case, F-TAC haven't contacted you. It's you as the GP that's concerned about Mr. D who is a 34-year-old single male with a diagnosis of chronic schizophrenia. Mr. D's mother contacts you because she thinks that he's been attending right-wing rallies. He's been making racist anti-semitic comments. He's been hanging around without little motorcycle gangs and so on, and that he claims he's hearing voices that are telling him to burn down a mosque. He's smoking a lot of cannabis and so on. It is, you're the treating GP. What would you do in this scenario? The information's just come from his mother. Would you raise it with Mr. D? Would you contact F-TAC or what would you do? You're on mute. Sorry, I was just saying similar principles to before, Mark. I'd actually somehow get him into my room and have a conversation with him and determine what I felt was the risk in this scenario and maximise his clinical health and wellbeing. In determining the risk that this young man has to himself and others, I'd be putting the puzzle pieces together of the information provided by his parents and also any past history that I have. And certainly if I had concerns, I'd be rocking on the door of my colleagues and having some conversations with other people outside my room. Sure. Okay, good answer. Now, if you do want to do something, I've got it to you, Danny, for this. This is just the take-home message I support, or one of the take-home messages. If we are concerned about someone, if Innis is concerned about Mr. D, who do you think it's best to report it to? Do we go straight to FTAC? Do we ring our local police station? What do we do? Several participants have asked this question, so it's an important one. Danny, what do you think? Look, in this scenario, and it's made much more straightforward by the fact that this man has a chronic severe mental illness, I think you would go to your area mental health service. So thinking about this, FTACs have set up really to focus on people who have fallen out of treatment or have become estranged from treaters, or in some cases where treating services don't perceive that they meet the threshold. This is a man who's likely to be taken up by a mental health service, and it's much more straightforward, whereas the other two scenarios raise cases where the local mental health service might not see that they have a necessary duty to intervene in that situation. Yes, okay, so you're the psychiatrist in the area of mental health service then, if you want to pass the buck. You're the psychiatrist there. What are you going to do? He's got these delusions. He's got these voices telling him to burn down a mosque. You're still not going to contact FTAC. You're just going to rely on our capacity to treat his delusions? Look, I mean... Allusionations. If I were treating Mr. D, I'd be engaging him with our crisis team. I'd be looking at his amenability to treatment and his capacity to consent. It's likely on the basis of the scenario that he'd be in for a compulsory admission, and I'd really be seeking to explore his beliefs. I'd want to know how delusional and how fixed, whether he'd made any approaches or preparations. And I'd be thinking carefully with our service and with our leaders, with managers in the service about whether we made a notification to police about that. I probably wouldn't be thinking necessarily about FTAC. I'd be thinking about contacting the police if I thought there was a very significant risk of that occurring. Because the fact of the matter is, FTAC really is not going to be particularly interested if he's firmly engaged in treatment with us and we see that we have a duty to him. Yeah, that's very interesting. But when you say contact the police, and I'm thinking of the clinicians sitting out there in a rural area or whatever, are you talking about just ringing up the local Bobby, the local police station? No, of course most services will have a liaison person. They'll be able to speak in an informal basis about what to do about situations. In a situation like this, obviously this might well respond simply to assertive treatment to engaging him with medication and getting him off the drugs and removing him from his peers. But if in fact he's got a house full of explosives, he's got fireworks, he's got incendiaries in his house, he's got maps of the local mosque and you can see that sort of information, then I, as a clinician, as a psychiatrist would be very reluctant to be carrying the risk that I could simply discharge him home without the fear that he would do something dire and cause harm to the community. Yeah, yeah, great. Okay, I think that in reviewing those hypotheticals we have answered most of the questions that came in from you, from our participants. There's a few that we haven't and they raise a couple of interesting issues. So let's see in the last five minutes or so whether we can address a couple of these and I'll go to you first, Alfred, if I could. One or two, in fact it's a few participants asked about whether we risk being accused of professional misconduct if our concern is dismissed. So, you know, we're accused of breaching confidentiality when actually there was no risk there. Are we at risk of professional misconduct? So as I started off actually professional misconduct depends on what the reasonable practitioner would have done under those circumstances and basically generally doing consulting following the guidelines, following protocols, following legislation. One would probably be not be found to be unprofessional. Okay, can I answer that, Mark? Please do, Danny, yeah. Certainly, if you look at cases in Australia which have focused upon negligent discharge from hospital where a harm happens to someone or the duty of people like police to prevent suicide, people acting in good intention tend not to be found guilty of professional misconduct. I think it's fair to say that if you lay out your reasoning, the pros and the cons, you talk about the measures you've taken to seek other opinions and you come out with your decision, you might have made the wrong decision in retrospect but the fact that you've thought through the options is really going to defend you against claims of misconduct. Yeah, yeah, okay, good. That's reassurance of people, I think. Okay, another question that participants have sent in and I'll give this one to you, Ines. The question is really what's happened to our professional relationship once we've made a report? Can we maintain a trusting relationship with our client having, you know, spoken to F-TAC or whoever? What do you think? And is it reputable? I think that the answer is yes, you certainly can and I think that one of the premises that you need to work through is the fact that your therapeutic relationship is based often on trust and based on your desire, your fiduciary duty to that patient. And so I think that where you can, you are honest but in some circumstances you can't be completely forthright with regards to the transfer that information depending on the risks associated with that. But if you start off with the premise of I will try to get consent, if I can't get consent then I will try in a circumstance to inform the person that I actually notified F-TAC or whoever the organisation is and if I can't do that then I'll clearly understand why and try to repair or to continue with that relationship ongoing. Lean, hopefully as that person becomes more well we'll develop insight into that and why that was actually done and as was said before both for the interests of the public but also for their own interests. Absolutely. OK, Danny, Ines is saying there that she'd make a clinical decision but if she could, if she thought it was appropriate she would tell her patient that she had been talking to F-TAC about him or her what would F-TAC think about that? Would F-TAC be concerned that we are telling the patient that they're being investigated? Well, they certainly might but you can ask them, you can ask them what information you can reveal to them what it's appropriate for you to say that you're aware of they may well have police reasons not to disclose information for instance it could reveal that the person's surveillance or that their social media is being monitored I would check carefully with F-TAC what you're allowed to say and what you weren't but I think that the general sentiment is a really correct one where possible you work with your patients and that tends to be the better thing in the longer term if you can't work effectively with them then you obviously have to escalate to different levels and presumably whether or not it's going to put you under increased risk is also a consideration if I tell my patient that I've had contact with F-TAC whether that puts me at risk that would be a consideration also of course Yeah, absolutely I think you need to distinguish between the discomfort that you might face from reaching your patient's relationship but the point we made earlier about notes the other reason you take notes is to protect your colleagues when you're on leave so that they know what's been going on Yeah, yeah quite while I've got you there, this is a straightforward question I'm not suggesting that the answer is straightforward but I think it's a legitimate thing for people to ask and that is, what are the key indicators of progressing from ideology to action? In a few minutes? Yeah, well less than a few minutes, one you've got Max, yeah Well look, there's no particular indicators but you're talking about fixation you're talking about the level of interest you're talking about whether the person appears to have a balanced life with other aspects to it or whether they've become preoccupied with a particular grievance or idea and the other aspect we mentioned earlier is leakage so when they start to communicate plans or to make indications that they're preparing for something those are concerns that they're moving from thought into action Good, good, good, OK That's very helpful, thank you, thank you I'll come to you Ines but I'd like actually everybody's opinion on this this is going to be my last question and that is about what do we do to protect ourselves how do you protect yourself and other staff while also I guess maintaining confidentiality so you don't want to tell the whole clinic that Mr D has made whatever it is Mr S has these problems how are you going to protect yourself and others while still maintaining a level of confidentiality I'll throw it to you first Ines but I'd be interested in other's thoughts I think that there's the protection against your professional protection against burnout and then your physical protection as well in this circumstance and I think that the protection against burnout is actually about having colleagues about sharing these burdens with other people about being really clear what your roles and responsibilities are and what you can do and what you can't do and I think that the incredibly important things to have in complex situations such as this in complex working environments I think with regards to the physical wellbeing of you and your staff I think that you do need to work in conjunction with the organisations in that if you're concerned at that level this person is obviously somebody who would be involved with law enforcement and I think that you need to take their advice about issues pertaining to safety of you and your staff in those instances Sounds very good advice Do either of the others have anything they would like to add to that point? No, I'll just echo what Ines says a problem shared is a problem that's really much easier to deal with Very much so and that's a theme that's come through over and over again tonight and as I say it's a really important message Unfortunately we've run out of time and there's such fascinating topics and I had a whole lot of questions there that I was hoping to get to but we haven't quite had time but I think we have explored a whole lot of the issues and complexities around these kinds of cases so I hope you felt so too To finish up I would like to ask each of our panellists if they've got any very brief take home messages for our participants if you like So Ines let me start with you Any brief take home messages? Moot Many of these complex situations are balancing acts and I think that you need to actually think I think it was Danny or Alfred that said before that you need to write the pros and the cons and I think if you have a structured approach and I think that you need to actually these are not common scenarios in general practice but they're very concerning and you need to share that burden with your colleagues and other people to ensure a supported best response Yeah, absolutely Don't do it on your own Alfred, any take home messages for our participants? Mark, I think the big picture is that people consult us and confide in us because they trust us to help them and keep their private information confidential and sometimes we need to violate that confidentiality but we should always try to do it strictly necessary only provide the information strictly necessary to provide and only to people who need to know it so I'll leave it at that Great, okay, thank you very much indeed Alfred and Danny finally use and take home Look, I don't have much different to offer, the discomfort that's engendered by these ethical dilemmas really is an indication firstly that there are no perfect answers these are wicked problems, these are things that you need to do the best that you can and the way that you do that most effectively is by increasing the likelihood that you can communicate with other people about what you should do properly Good, alright thank you very much indeed and thank you to all three of you somehow we've gone back in the slide and I need to be further ahead so just bear with me Just a final couple of closing comments first thing I'd remind you is that MHPN supports multi-disciplinary practitioner networks all across Australia where people can get together and share tips and advice they can share professional development activities somebody to talk to and as we've been saying consistently tonight having someone to talk to is absolutely crucial so can I please suggest that if you're interested in joining one of those networks that you get in contact with MHPN in fact in the resources that we're going to talk about in a second you will find out how to get involved in one of those networks the second thing is as we said early on that there are some great resources associated with tonight's webinar not only what our speakers have provided in their slides tonight but I'd have to say that the material provided by Home Affairs is brilliant there's really simple how to tell stuff about who to contact how to contact them phone numbers and so on plus there's a whole lot of really good fact sheets for health professionals they're really good stuff so I strongly recommend that you have a look at that as well finally then I would like to ask each of you to complete the exit survey it really is very very important so before you log out just make sure you complete that so we know how we did today this was the final webinar I said in a series of three that were commissioned by the Department of Home Affairs and I would like to thank them for commissioning this series because I think they've been great I've really enjoyed facilitating them and I think we've had some really interesting and valuable discussions for clinicians in the field so thanks to them and thanks to MHPN of course and read back for the tech stuff thank you very much indeed to our panelists for tonight who I thought were brilliant thanks to Innis, Alfred and Danny I thought their contributions were magnificent and thank you very much finally to you our participants for your involvement and engagement and so on it really is your involvement that makes it work so well so I hope you found it valuable thank you very much again to everybody and good night to all