 Welcome to the MHPN Working Better Together online conference. I'm Dr John Cooper, Consultant Psychiatrist to the Centenary of Anzac Centre and the Chair of today's discussion. The Centenary of Anzac Centre provides free advice, consultation and support to practitioners nationally who work with veterans with mental health problems. Specifically, our Practitioner Support Service provides case consultation and access to a team of multidisciplinary experts for advice specific to your inquiry. We have access to consultants, psychiatrists, psychologists, general practitioners and social work family therapists, all very experienced in the complexities and challenges of veteran mental health. Today you will hear these experts as they discuss a current case consultation live and work through the best treatment options, evidence-based research and practice and how to integrate this for a better clinical outcome. The case is a fictitious composite of the typical cases that have come to the Practitioner Support Service. When cases come to us they are de-identified in order to predict privacy and confidentiality of the veteran's concerns. So let's get started. Participating in our consultation today is Jane Poole, social worker and family therapist, Richard Bonwick, consultant psychiatrist, Jeff Thompson, another consultant psychiatrist, Phil Parker, a general practitioner and Kristi Heffernan, a clinical psychologist. For those on our call, you would have had a chance to read over the case notes so that everybody is on the same page. I'm going to introduce the case now and we will then get on to our discussion. This is a case that exemplifies the complexities that often are associated with veterans and their mental health issues and it's certainly quite typical of cases that we have assisted with. So the referer is Judith who is a clinical psychologist working in private practice with multiple years of experience with veterans. She's trained in trauma-focused therapies, specifically prolonged exposure and cognitive processing therapy. She's working with a 42-year-old male who joined the Army in his early 20s and was a rifleman for two years before being medically discharged. He has disclosed to Judith that as a child he was sexually abused and that his father was a cruel man. His mother abandoned the family when he was 11 years old and he felt responsible for his two younger sisters. He also shared that he was relieved to be medically discharged from the Army and that he was doing very well until the last few years. He has worked for a building company since his mid-20s and is married with two teenage children. Now we have a lot more details that we're going to discuss but I wonder with that initial introductory information. Jeff, do you have any initial thoughts when you hear that level of detail about what might what might be going on with this chat? Thank you John. Jeff here, psychiatrist. Well look I think that this case as you said is a complex and challenging case and also not an unfamiliar case at all. The combination of early life challenges and time in the Army it's interesting that he was he felt a sense of relief to be medically discharged. It does seem as though following that time he's had a period of good functioning. You know it sounds like he's had stable employment, he's married, he's got two children so up until this point in time it would seem to appear that things are actually going quite well. But John here, yeah so it I guess raises in my mind the question of why now but let's get some more information to see whether we can help clarify what might be going on. Several years ago Judith's client began the process of applying for DVA compensation entitlements. He found this process very difficult because of having to revisit the experiences he had while serving and felt like he was not being taken seriously by advocates. He thinks this is the point where he began to unravel. At this point or just after this point he attempted suicide and was admitted to hospital. Since then he has made another two suicide attempts. Part of his discharge plan was a referral to Judith for treatment. Besides the initial disclosure of abuse as a child and negative experiences during the army he refuses to recount any further detail of these experiences and threatens that he'll stop attending their sessions if he's forced to talk about it. I think that's another point for us to sort of reflect on what might be going on here and I guess in terms of an attempt to do trauma related psychological work. Christy what are your thoughts about why a veteran might be so adamant that he doesn't want to do this kind of psychological treatment? Thanks John. Christy from Sydney clinical psychologist. It is an interesting case but again not uncommon with regard to somebody who's had something happen in their life which seems to be the going down at the DVA compensation route and having to then start bringing back memories of things that have happened in the past that we're already suspecting a pretty traumatic memories potentially for this some particular client. It's not uncommon then for people who've got a trauma history or potential trauma history that they've not necessarily talked about or openly sort of even thought about potentially for many years because they're probably engaged in quite a bit of avoidance behaviour around that so avoidance of any thoughts avoidance of any situations or people or places that potentially have triggered those memories and so those memories have sort of laid dormant for a while so that avoidance behaviour and avoidance of those trauma memories pretty common in cases like this and potentially those the trigger of the DVA claims has really started to unravel this particular client and his ability to then actually potentially regulate his emotions around those memories. Thanks Christy it's John here again so I guess part of the take home message that you would be giving to Judith is not to be surprised about this avoidance and start thinking about strategies to manage it in order to proceed. Yes let's get back to the case then Christy. The main presenting difficulties include intrusive memories and nightmares which are obviously reflective of his PTSD and low mood irritability and daily suicidal ideation so in addition to his depression and PTSD past feelings of contrast have noted borderline personality issues. The client has tried multiple medications but they have had very little effect. He sees the same GP because of his wife's insistence but feels the GP doesn't understand his military background and has his own agenda. The veteran is aware that his wife speaks to the GP about him and attributes this to her own attempts to seek support. He has noticed that his wife and children are growing more distant and feels remorse that his actions are driving them away. He thinks they would be better off without him. Now as a psychiatrist I'm always enormously grateful when I have the benefit of a multidisciplinary set of colleagues to help in this situation and I think here we've got some really important issues that relate to a person attending a GP but also some family and social issues that I'd be interested in your thought Jane about the impact that that's likely to have on the work Judith wants to do with this veteran. Thanks John Jane here social worker look I think that there's a few issues in here and and certainly working from a family inclusive practice and encouraging Judith to talk with her clients about the family situation and where that's at I guess one of the concerning things that I have here is that in terms of suicidal ideation we would usually consider family and children as a protective factor and for this particular client it could actually be a risk factor in terms of his family being more distant from him so I think some exploration around that and encouraging Judith to do that would be really important. Thanks Jane and Phil I'm wondering what your thoughts are when you hear that a veteran is concerned that his GP doesn't understand the military culture that he's coming from. Yeah hi Phil here from a general practitioner perspective I think it's disappointing to see that he has not developed a strong connection to the GP and that may be part of his strategies to avoid confronting his issues but to obtain the best outcomes for these types of patients it's important that we consolidate a team approach to give these patients the best support and often that surrounds the the holistic work and support of the GP. I think in this case it's important that we look at that relationship and try to find out what his concerns are why he cannot connect to the GP if he thinks that the GP is not invested enough in his care then maybe we need to communicate that to the GP or look elsewhere because this is essential to building the foundation of his care. What do you think about the issues of he and his wife both seeing the same GP is that potentially an issue and might he be better off having his own GP? Potentially yes but I think I think there are pros and cons to it. I think it can be better in terms of developing his trust it might be more appropriate to look elsewhere but if you have a general practitioner who can who can manage that well and has a has a good insight into the issues then then it has the potential to work well but to him personally at this stage he his emotion stays quite fragile and it might be worthwhile considering whether he would be interested in changing GPs in order to to build that connection. I agree with you so I think there's some pros and cons in in staying with the same GP or changing GP. I guess the other thing is that the information that we have is that the veteran is aware that his wife speaks to the GP about him and attributes this to her own attempt to seek support. So I'm thinking that if his wife needs support then maybe you know Judith might be able to in some way have some contacts via the client to the wife to link her with her own support system. This is Phil here it would be interesting to to determine what the veteran himself thinks about his wife talking to the GP about him. It's really important in these cases that we that the the patient who is autonomous in their care and he may feel it's being managed externally which is which is sort of counterproductive towards getting him to be motivated. Yeah it's Christy from Sydney here I probably would also concur with that sort of the wife probably needing her own support and I probably suggest to Judith that maybe Open Arms is a is a good counseling service that the wife would have access to the partner of an ex-serving veteran so that might be a good avenue for her. Yep Christy I agree and she would be eligible through Open Arms so that would make some good some good sense. John here I think there may be some people who haven't been aware that Open Arms is now the new name for what used to be the Veterans and Veterans Family Counseling Service so we used to refer to that as the VVCS so the VVCS is now Open Arms and I agree that that would be potentially an excellent resource that would be freely available to this veteran's partner. Now I'd just like to give you the last piece of information that we have with this case and that's the very important aspects around Judith's response to her work with this veteran and how she's managing that. So Judith has sought supervision about this case from another senior psychologist but doesn't have any clear direction moving forward. She's been trying to engage her client in trauma-focused therapies for several months now but isn't getting any traction. She reports feeling lost and powerless and is considering referring on but is concerned for the client's safety. His triggers for self-harm include feelings of rejection and abandonment. He continues to attend their weekly sessions but there is no fine treatment goal only that they are working towards helping him feel better. So to reflect on this case we've got really important issues around risk. We've got a very complex situation both in terms of the day-to-day practical issues but also diagnostically. We've got family issues. We've got a service system that is struggling with this chat and we've got a therapist who is well motivated to do good evidence-based treatment for PTSD but we have a veteran who appears to be engaged and that he's attending a very reluctant avoidant to do any trauma-focused work. So there's a fair bit there for us to talk about in terms of the advice that we'll give Judith. Who would like to to dive into that set of complexities? Richard, psychiatrist here just to to try and pull that together. I think the key issues with this veteran is probably still in the middle of his compensation claims which is a very unsettling thing and seems to destabilise the whole situation. I think in these circumstances the key is really establishing trust and to move beyond that is probably pushing the boundaries a bit too far. He seems motivated and ready to engage and I think that needs to be the focus of developing a trusting therapeutic relationship for any trauma-focused work that's actually considered. Christy from Sydney here from the clinical psychologist perspective I'd be advising Judith of the same along the same lines Jeff that really agree with you that trust needs to be the foundation here and often when veterans go through the DVA system it can really rock their sense of trust and safety in the world and so we want to encourage Judith to establish a therapeutic relationship that rebuilds that set of trust that potentially his client has lost but also to rebuild his sense of safety and stability and once that sense of safety and certainly once the risk around suicidal ideation and the reduces then then I would be suggesting that trauma-focused therapy is appropriate but until that risk is is stabilised and until that trust and safety is developed in the therapeutic relationship I wouldn't advise the trauma-focused therapies it particularly going through imaginal exposure and and potentially even the in vivo exposure at this stage but really just focus on emotional regulation strategies to decrease his risk. This is Phil here from a general practice perspective I think I agree it's a small step to building good outcomes and in this case it's good to focus on the foundation of his care which is which is his support now we know we know that he's already engaging with a psychologist we don't know whether he is getting that funded through DVA because he certainly does have an entitlement to non-liability healthcare so he's entitled to a DVA white card for mental health support and and that way you know the financial burden of of his mental health care is no longer no longer a problem we we certainly need to enhance therapeutic relationship with with AGP and we need to widen him to give him more support so he's got greater protections there's there's a note there about medications and I'd be interested to know who has been prescribing that medication so that might be a question that we should we we could ask but we need to know a bit more about his family functioning about how strong that relationship is whether he has good social support you know be a true mate or or even organisation outside and whether he's quite stable at work you know he's been out of the sense for what 20 years now so and it seems to me he's quite successful so and that might be a protective factor so it'll be interesting to explore that a little bit more too thanks I agree I agree too I think that that's that that's all really really important and I think you know the fact that Judith has been able to establish a relationship with this chap and has he is attending sessions every week he's a really positive thing and that gives Judith the opportunity to be able to potentially work with him to improve his support network to check in with the family I'd be interested in knowing how his teenage children are going you know whether things are going okay for them in terms of school what sort of support this chap's wife has or needs and what kind of support the family and potentially the children have and need as as well and I think giving Judith the feedback that what she's doing is a really is a really good job and whilst at this point in time it's kind of not the right time to be looking at at at any trauma therapy foundation work is really important for any future treatment that this that this chap might need yeah Jeff here it's good to see that we're all on the same page and all in agreement you know I would endorse everybody else's comment but I'd actually like to highlight the fact that we've really got quite an acute and unstable and uncontained situation here you know he's had an inpatient admission he's had three suicide attempts in a period of time and I'm not sure exactly what period of time and he's got ongoing suicidal ideation so we are really dealing with what is still quite an unstable and acute clinical picture and I think one of the priorities there's a there's a couple of priorities in terms of making sure we've got a good risk management plan in place I think there's some uncertainty here about how we put all of this together what the various contributions are there may be some issues around diagnosis that are not clear so I think it's a priority that developing a better understanding both at a diagnostic and formulation level and management plan is should be sort of the top of our agenda and I think because of the complexity of the case I think we should be supporting Judith in that there's a lot more here than she can possibly expect to do on her own I think looking at the GP issue as we've talked about but this is not an advertisement for psychiatrists but I think that there's probably an important role for a psychiatrist here it's a complex case there's some uncertainty around medications now that might be compliance issue it might be that suitable medications weren't trialled it might be that maybe the trials that were given were not adequate or maybe the expectations of the the patient were beyond what we can expect medications to do so I'd be really keen to make sure that we are sure I'm sort of a multi-disciplinary treatment team and I notice in the in the case that Judith was part of his discharge plan and I'd be interested to know what else was part of that plan our psychiatrist was still involved and if not I think we should get one as a as a year priority Jeff it's Christy here from a clinical psych perspective it's certainly what I would be advising one of the first things I would be advising Judith is not necessarily managing a client that that it has this sort of risk profile and needs a risk management such a comprehensive risk management plan never to try and manage that on her own as a clinical psychologist that really needs to be part of a multi-disciplinary team and I agree she's got this referral as as she's come out of hospital so whether or not you know asking the questions does he still then have a treating psychiatrist is it the psychiatrist from the inpatient facility or you know does he have I noticed in the notes that there has been a past treating psychiatrist have noted personality issues and also question PTSD and depression I'd want to know where that information was coming from and how long ago that that was but certainly needs to have a current treating psychiatrist probably in the case and connected with that GP to feel I think that's really important and I note Jane too that you mentioned that you know the the family given that they're sort of distancing themselves that that's sort of becoming a risk factor for this client so we would probably be interested to hear if there's any kind of family interventions or something that that perhaps we could point Judith in the right direction to try and improve that as a risk factor as well but yes certainly multi-disciplinary teams totally required in this case it's John here can I be a little bit bold and maybe reading between the lines suggests that Judith has possibly landed on the wrong formulation and again I'm bracing myself for my colleagues on the panel to shoot me down but I wonder whether what he's dealing with here is in fact somebody who's got quite active borderline personality issues that have been exacerbated by the stress and significance of his compensation processes and that the focus of treatment I wonder whether should be primarily on those sort of borderline personality issues to try and make sense of the risk to try and make sense of the need for everybody to be on the same page so what do you think you think I'm barking up the wrong tree it's Jeff here I don't necessarily want to take you on Dawn but I think that this is a really important question I think that there are some indicators here that certainly raise it as a possibility the you know the childhood trauma and the cross-sectional picture as we see at the moment might be suggestive of that and the only reservation about it is that he had a long period of time of relatively good functioning and some that can happen you know it can be quiescent and it's only when stressed or challenged and you know that the memories of the past perhaps coming forward can activate some personality issues but that period of good functioning does raise a question in my mind as to whether or not that's the case and that's what I think getting a better understanding of what the formulation actually is if that is the case and if that is playing a significant role in the presentation then the sort of therapies and psychological interventions should be geared towards that and that would add to the sort of the containment that we're looking in the building of a relationship and trust if that was the case I think that there's a there's another possibility here too which is that there may be a significant depressive picture going on that may be lost in the midst of everything else and my reason for thinking that is that there's a a number of sort of nihilistic themes about his family being better off without him and that might explain why he functioned well for a period of time and and the picture we're seeing now is actually quite different so again with the information that we've got we can't really answer these questions but I think it does add again weight to the the need to have a very sort of clear diagnostic and picture and a accurate formulation. Richard here some of that may have occurred during his multiple inpatient admissions and I would hope that all those who've been treating him are in communication certainly accurate diagnosis and good formulation is the key to treatment and I guess John you're just raising some some possibilities there you would hope with three acute psychiatric admissions some of that's been explored including collateral history that might give some weight to an underlying personality disorder diagnosis so I think it would be important for any treating team members and particularly for the clinical psychologists in this case to try and liaise with the the inpatient treating team and see what what additional information had been obtained during these admissions. Phil here I think I think we also need to ask questions about other contributing issues or factors here such as you know what level of alcohol use is being is involved here whether he's relying on substances to allow him to function and like more probably more pertinent to his service history does he have any comorbid conditions you know because we don't have that much history about his military experience although it was only a short period of time you know does he have any ongoing pain issues or other contributing physical injuries how's his sleep going you know we need to ask these types of questions. Jeff here I agree Phil I think that's really important he may not be prepared to talk about his experiences in the army but we could at least ask him about what the diagnosis was for the basis of being medically discharged and that might give us some clues but he may not. And Christy here from Sydney Judas may have some of that information already so we'd probably at this point go and get back to Judith to kind of get a little bit more information because she has started some trauma focused therapy so she she must have she have an idea of what what she's focusing on I agree we'd need to go and get that more information from Judith but on back on the you know the the question around borderline I agree that there's probably a lot of information that Judith can get from the stays that he's had within the inpatient facility also you know that John's right in terms of the the abandonment that that occurred early on in his life as well as the childhood trauma childhood sexual abuse also that what can happen when veterans go through DVA and having to go through the compensation system and being questioned and you know can bring up feelings of abandonment then as well that potentially they're not telling the truth even though he was relieved that he got medically discharged from the military that can often happen that people are relieved about being medically discharged but can still feel somewhat abandoned by that discharge process so it can can be a bit destabilizing so DVA process might have brought up those that that abandonment stuff again. Jane here contributing to that is you know this chat was that the information that was got from Judith is that his mum left the family when he was quite young he was only 11 years old he had a really cool dad and he was also in a position for caring for his younger siblings so there's there's a lot in terms of his family of origin that Judith may already have the information but but maybe just trying to get some collateral around that might give us a clearer picture or give Judith a clearer picture diagnostically as well. It's John here can I just back up a little bit and ask you Christy we don't know from the information we have at this point whether this chap's PTSD is related to his military experiences or his childhood trauma. If it was one or the other should that change the nature of the psychological approach? It's a great question John it depends determining what like going down further in the chapter after we've you know this particular client's suicidal risk has been reduced and you might revisit trauma focused therapies again deciding on on sort of which trauma to work on is a really interesting kind of dilemma and what we would usually focus on is the the trauma that the client would would refer to as their kind of worst trauma and the reason that we do that is because it's it's important to address the trauma that kind of is that the that kind of is at the center of the emotional and and you know cognitive kind of difficulties for the client so it a lot of that happens within collaboration with the client of course but yeah Judith would have probably I would be talking to Judith about this she would probably have a good sense of of where where that sort of index trauma or the worst trauma if you like where we'd need to work on so yeah it does make a huge difference and it's very much part of your formulation of of how to try and reduce the impact of the traumas that somebody has had in their life and and try to do that in the in the best most effective way for the client it's John again Christy and I'm sorry but you've you've provoked this next question would your approach be different regardless of the trauma if you were confident that patient with PTSD also had borderline personality structures if I did think that the borderline factors were there I would be very keen to make sure that that we'd we'd addressed emotional regulation skills that I felt like they that he would have the ability to be able to manage his distress increase his distress tolerance quite a bit more because you know when we're doing trauma focused therapies what are the one thing that that I would sort of stop trauma focused therapy for is if the risk level had increased again so in order to try and try and manage that I'd make sure the emotional regulation skills are really only that's what would be how I would manage the active kind of idea of borderline personality in this in this particular case it wouldn't stop me from potentially visiting the childhood traumas that wouldn't stop me at all it wouldn't necessarily mean that I'd just focused on if he the trauma was related to his military service that I would just do that because he was in his early 20s when that occurred but certainly I would be very I'd have to have a fair bit of confidence that he'd have good emotional regulation skills before we did the trauma focused therapy thanks for a seat now I'm a little bit conscious of time I was wondering whether there were any other thoughts or comments that you would like to make before we wrap up this case and decide what it is that we're going to feed back to Judith Jeff here there are a couple of quick comments and I'll make them as quickly as I can um thinking about Judith and and her situation um you know very briefly I think it's important to emphasize to her the the importance of ongoing supervision that might be geared towards helping her to work on her management plan etc but also dealing with the impact on her of dealing with working with such a difficult and complex case I also noticed that you know she's reported feeling sort of lost and powerless and perhaps something for her to explore in her supervision is whether or not that's hers or whether or not she's picking up on the patient's experience which comes from the past traumas etc but one important thing to also highlight and this is something I think as clinicians we often wrestle with this this notion that perhaps what might we what we might think is in the patient's best interest in terms of their their treatment but being concerned about how our our patients are actually going to respond to that and that's that's always a tricky situation personally I think that it's important that we make the best clinical decisions that we can and if if it seems that that is going to have some risk associated then we develop a the best plan we can to to mitigate that risk so if Judith doesn't feel that she's got the skills to provide the sorts of therapy that she concludes that this particular man wants then she should be supported in her efforts to refer on but be encouraged to look at what ways that she can actually do that to minimise the risk of feelings of rejection and abandonment but we don't want that to prevent her from pursuing what she thinks is is the best treatment options Jeff this is Phil do you think it would be worthwhile Judith asking the patient himself what he sees as an effective outcome as a as an ideal outcome for him? Phil look I certainly in the way I work I always try and make it as collaborative and open and transparent as I possibly can and I think if you you can get him on board with being engaged and deciding you know strategies and approaches and and you know what his objectives are I think you you're going to start to build that trust and I think more often than not that's a very beneficial thing for both the clinician and the patient. This is Phil and I suppose once we get him a bit more involved in his own care he might be more motivated to accept some of our suggested management approaches. Jeff here yep and in particular he's he's much less likely to feel rejected or abandoned. Jane here I guess the other thing that I was just thinking is I wonder whether it would be worth having a conversation with Judith to ask the client whether it would be possible for maybe Phil to contact to contact the GP to have a discussion with the GP because that would also maybe allow Phil to find out a little bit more information about the other family members including including the wife and how they're tracking and and how they might be able to be supported. Thanks Jane it's John here so let me just summarise what we've discussed and I guess the decision that we would make under normal circumstances is to decide which of us are then going to carry this case forward and liaise with Judith around this case and I imagine that it would probably well correct me if I'm wrong but maybe Christy is a fellow psychologist would this be a case that you'd be happy to to pick up and do the leg work with Judith? Yeah absolutely yep no problem at all. Good okay so we have quite a complex case we have significant risk issues we have difficulties engaging in the type of therapy that is the most appropriate and I think I hear a saying that we would support Judith in continuing what appears to be a more supportive type of therapy particularly while risk is significant and the complexity around the formulation is being sorted with a view to including the the veteran in the decision about timing of changing tack to a more trauma focus but it's also apparent that there's a lot of information about what's happened with this veteran in his past and certainly in relation to his past treatment and we would be looking to converse with Judith about getting that information if she doesn't already have it so that we can further refine our formulation and provide some ongoing support for her with this difficult case so thank you to all our experts for your contribution today thank you to those listening in today when you contact the Centenary of Anzac Centre Practitioner Support Service for advice we take your veteran mental health question or problem we consult with our experts just like we've done today and we will provide specific advice back to you and ongoing support related to that this is a free service and you can access this service through our website at all the w's anzaccentre.org.au or call us on 1800 VET777 thank you very much