 on which our webinar presenters and participants are located and I'd like to pay my respects to the elders past and present. My name's Nicole Sather and I'm a clinical psychologist. I currently work at Phoenix Australia, the Centre for Post Traumatic Mental Health. I also have a military background. I spent 23 years in the Australian Army as a army psychologist and during that time I was the commanding officer of the First Psychology Unit so I was responsible for providing services to people who were deployed overseas and I spent several years as a senior army psychologist. I also serve now as a reservist as a colonel and I also have very much a family connection to the military. My father was a Vietnam veteran and I have a son who's serving in the military at the moment. I'd also now like to introduce our other panel members that we have with us and this truly is a national and international group that we have online. First of all I'd like to introduce Christy Heffernan who's a clinical psychologist and she's joining us today from Sydney. Hi Christy. Hello. Christy just recently joined us at Phoenix Australia and she set up our satellite as our first person working in Sydney so she's getting used to working by herself in an office. But you're getting used to that now aren't you? All the joys yes absolutely. You can do a webinar and not disturb anybody else in the office it's fantastic. Yeah that's great and this is Christy's first webinar so welcome. Thank you. Now I'd like to introduce Phil Parker who's a general practitioner who's joining us from Brisbane. Hi Phil. Hello. And hopefully it's a bit warmer than in Brisbane than it is here in Adelaide this evening. Still a bit chilly but I'm sure it's not as bad as I think. No that's probably your senses are all you're deciding how chilly it is. And finally I'd like to introduce John Lane who is joining us this evening from the US. Hi John what are you doing over in the US? I came over for the American Psychiatric Association Conference and then catching up at the moment I'm staying in LA with a buddy of mine who I deployed with a few years ago but just catching up with some of the other groups here in San Diego the Naval Medical Center there in Dalbar and can panels and marines and the sort of stuff to say catching up with colleagues of mine to see what's going on over here. Fantastic and it is one o'clock in the morning in the US so thank you a special thank you for agreeing to join us today. No it's actually really appropriate because it was Memorial Day so what a better day to be doing something like this on a day which the US celebrate there for one soldier. Absolutely a perfect day. Great thanks for joining us thanks everyone for joining us this evening. Okay so in terms of the context for this particular panel of course like any other interaction that we do we just want to make sure that we're respectful of each other and any interactions that you make that we do it in the same way that we would for a face-to-face activity and we certainly encourage everyone to participate there's an opportunity that you can join us through the chat box and just ask that you remember to keep your questions that you have on the top this evening's webinar and please also notice you have any technical issues that you click on through the technical support tab and you can also call Redback Healthjust if you're having any particular problems if there is a big problem which is impacting everyone we will certainly be telling you and announcing that via a general announcement. This is part of a whole stream of webinars that we are presenting this is part of the inaugural MHBN online conference and this particular stream is around mental health in the military and there's two others which are running grief and loss and also trauma and the impact of adverse childhood experiences. The format for this evening is that we're going to keep it fairly relaxed there's going to be a bit of a presentation to start off with and then we're just going to have a general discussion around our own experiences of being in the military and also what it's like to be a practitioner mental health practitioner. We certainly know that many of the people who are joining us have never worked with veterans before and it's great that people are interested in joining us and starting to learn a little bit more about what it's like to be in the military and what you might see when you are working with veterans and certainly what we're hoping is that by the end of this webinar what you will have gained from it is the improved understanding of why the military culture may influence veterans mental health in the way that they may present when they come to see mental health practitioners improve your understanding of the presentations that they might have the thematic and also the mental health presentations of veterans and finally to increase your confidence in engaging with veterans and how do you have conversations with them and how do you start to get to the meaning behind this story as well. Okay so to start off what we're going to do is to learn a little bit more about our panel members and in particular what it is that we would like to know about them is what their experiences have been within the military so what I'm going to do is ask each of the panelists in turn to tell us a little bit more about themselves to talk about their experiences in the military the types of jobs that they had the roles and what being in the military meant to them and then also to talk about what it's like to be a clinician who provides services to veterans and to start off I'm going to ask Phil if you'd like to keep us off thanks Phil. Thanks Nicole hi everyone my name is Phil Parker I'm a general practitioner in Brisbane I'm a next serving soldier and officer in the army and I served from 1988 up until 2017. During that time I was a soldier in signals corps, an officer in infantry and the last seven years my service has been as doctor of medical corps. In 2012 I deployed to Afghanistan as a senior medical officer in Buruzgan so probably in fact it's probably more than half of my life I've spent in the military so I can understand how difficult it can be to transition from military to civilian life. We all know that the career and the defense force has got a lot of challenges with it. It's an environment which nourishes teamwork and leadership and it's still the sense of belonging and that all of those who have worn the uniform have had to endure difficult work conditions and there's some that had to put themselves in harm's way to do what they expected of them and the outcomes in this in these cases has not always been ideal with some servicemen and women sustaining serious injuries or illnesses in the performance of their jobs. This can be difficult for the new except especially when they can no longer do that job they often become disjointed and lose their sense of belonging. You know some of these individuals become medically discharged from the service they feel discarded and they develop a great sense of loss. As a fellow veteran I understand the experience that many of these veterans have gone through and as a general practitioner I feel that I'm now well positioned to be able to provide them with some good care and my goal in their care is to improve their social and vocational functioning and I see the best way to do that is through the development of a social support network with everyone involved invested in the care of the individual. I want these veterans to be surrounded by people who know how to bring out the best in them and the ultimate outcome will be individuals who uphold a high sense of self-worth and motivation and I want them to live a fulfilling life. Thanks. Great thanks Phil and thanks for sharing your experiences both in the military and also importantly how you can work successfully with veterans. We might move on to Sydney now and to Kristi. Thanks Kristi. Thanks Nicole and hello everyone I'm Kristi Heffernan and I have served as a military psychologist since 2005 so across those past 15 years I've served full time in the Australian Regular Army and I continue to serve in the Armour Reserve now as a Lieutenant Colonel Psychologist which means it's now my part-time job. From 2013 to 16 I also worked as a civilian clinical psychologist on a military base. I joined the military as a psychologist to deploy overseas like many military personnel. I wanted to do clinical psychology work in unpredictable and interesting environments and to provide first response and early interventions. I continue to serve so I can contribute that knowledge and experience and I also continue to serve out of the respect and dedication that and the personal sacrifices that ADF personnel make and that motivates me to continue want to be connected with them. I whilst working in the Regular Army I was posted to Townsville and Sydney and I provided mental health awareness and promotions training, resilience-based training and clinical interventions and support for ADF personnel. We worked in multidisciplinary teams I always had access to people like Phil and John and now in the community I don't find I have the same ready access to other health providers or at least not in the same way. In that way it's my opinion that currently serving military personnel seem to have greater access to the benefits of multidisciplinary care in that primary care setting at least. Again that's just my opinion. I deployed on several occasions to Afghanistan, Iraq, East Timor and the Solomon Islands. My last deployment to Afghanistan was in February 2012 so I just missed Phil. I provided mental health screening for troops before they returned to Australia and I also led the psychology team in the Middle East area of operations that was tasked to provide the range of psychological support to troops during their deployment from screening, counseling and assessments to critical incident mental health support. I've seen how large numbers of ADF personnel cope well with the stresses of deployment and the general demands of service life including moving regularly around Australia on posting, spending long periods of time away from loved ones and family-based support whilst on military courses and deployments. I've also seen though that sometimes it takes a while for mental health effects of service life to catch up and mostly it's the other people in the veteran's life who tend to see the changes first and encourage them into treatment. I now see that the community clients will often have booked their appointment with the psychologist because they identified the need or at least their GP has suggested it but for veterans families are often the ones who have to provide that gentle nudge and in the community the veteran who hasn't established a good relationship with their GP often find it difficult to navigate the system whether it be the Medicare or the DVA Department of Veterans Affairs system. Being able to deploy with ADF personnel overseas to places like Afghanistan and Iraq allowed me to see how units, teams and individuals in the military work. ADF personnel are highly motivated to deploy and it's often referred to as the highlight of one's career. Military personnel are motivated to explore new environments and to test themselves in challenging situations and they go through rigorous military training so on deployment as the psychologist I was often seeing resilient people but even the resilient people have their limits. What's interesting to remember about overseas deployed environments is that it's not just the risk of being injured or killed that we as treating clinicians needed to be mindful of. The environments themselves can be really harsh. The climate has extreme hot and extreme cold weather. The physical challenge of carrying body armor, heavy gear and being able to remain fit and healthy whilst literally working 24 seven. When you're deployed you're there to work every day and you need to be flexible and responsive to the changing dynamics on deployment. In my experience I've watched ADF personnel respond to these dynamics extremely well and by referring to ADF I mean Australian Defence Force personnel sorry for the acronym but I haven't seen them respond very well to those changing dynamics and maintain their physical and mental health. It's not what's important though is it's not just the deployment itself or the multiple times that someone has deployed that matters. It seems to be what the individual experiences that matters the most. As a clinician in the community I think it's really important to understand that veterans may minimise the impact of what they have been exposed to during service both on deployment and in Australia. If the veteran for example never left a forward operating base on deployment they may deny ever having been in danger despite the risks of hostile forces launching often inaccurate but nevertheless deadly rockets at that base. When considering the mental health impacts of military service lateral thinking is required rather than the tendency to focus on just exposure to traumatic stresses. Trauma exposure does remain really important but it isn't the only stressor. Not fitting in with the unit missing family and the feeling of coming home and being isolated from military mates or experiencing the loss of a meaningful job helping overseas communities rebuild can often have detrimental impacts on mood and lead to maladaptive coping. Military experiences need to be understood within the context of the whole range of the roles and environmental challenges and be considered in the context of the strong sense of military identity and motivation to serve that Phil already talked about. During my time in the military I also served as the unit or in-house psychologist at a Sydney based special forces unit in the regular army and then took up a position as a civilian clinical psychologist in that same unit leading a team of in-house psychologists providing clinical interventions on the base. Providing interventions within the unit with a rewarding experience at times personnel were concerned about the impact that health seeking would have on their career. However I also noticed the challenge associated with a resilient capable experience veteran acknowledging to themselves they need help. Sometimes it's that self-stigma and not the organizational stigma that is difficult for military personnel to seek help but most of the time it's actually both the self-stigma and the organizational stigma. I draw on the strengths and resilience of veterans when providing clinical treatments acknowledging their changing views themselves is no longer capable but rebuilding that addressing the presenting issue and concurrently drawing on the once very capable adaptable part of themselves that got them through the rigors of training and operational experiences in the first place. As Nicole mentioned I currently now work for Phoenix Australia the Centre for Post Traumatic Mental Health as a senior clinical specialist here in Sydney where I provided advice and training to organizations, communities and individuals impacted by traumatic stress and to practitioners and ex-service organizations to support veterans in the community via the Centenary of Anzac Practitioner Support Service. I also continue to work as a clinical psychologist in private practice and provide trauma focused treatment to veterans and work with other emergency services and individuals impacted by trauma, anxiety and depression. I continue to work enjoy working with veterans acknowledging that providing support in the community to this group has its challenges including not having the access to the multidisciplinary team the same way as I mentioned previously. I understand some of the challenge but I also continue to learn about what challenges veterans face after service and understand also that sometimes we can treat military populations as a homogenous group but we all always need to consider an individually tailored approach for veterans. Understanding the context in which veterans have come from does help me my ongoing support of them in the community but also in my ongoing support to serving current serving personnel and their families in my armour reserve role and that is probably enough for me I think. Thanks Nicole. You've covered a lot of ground and we will catch up on some of those topics a bit later in our discussion. Finally over to you John. Yeah thanks Nicole. So I'm a bit like Phil I had joined the army at the rightful age of 17 that was the UN reserve in 1989 and then had nearly 10 years as a soldier and while I was doing that I ended up doing an art degree English student psychology part-time and then decided to work I'm sorry not decided I decided to do medicine because I was the administration sergeant for the director of medical services in Victoria and this was in the late 90s and I ended up not getting in the first year around because I didn't have year 12 biology so I moved to HODI did my year 12 biology at the local college and did my honours year in psychology and then with a sponsored medical undergraduate student and then worked for the army for a number of years as a general duties medical officer before starting my psychiatry training in 2010. So back to the reserves then in 2013 I deployed to Kandahar and in Afghanistan that's the role three multinational medical unit and so I was working as a psychiatrist with the mental health team there looking after most of the US forces but other NATO countries as well too and that was probably one of the biggest experiences of my life I think you know spending six months working in that environment in and seeing the range of different people from different countries and the way you know they're the same forces work you know and the attitudes mentalities and other things too so I finished my fellowship in 2014 and went straight into work when I started doing the small amount of private practice whilst working as a forensic psychiatrist and then switched over to full-time private practice basically so I could see military veterans police and first responders and they make up the majority of my the vast majority of my private practice now this has actually decreased a bit though because I'm currently doing a PhD through Adelaide University the Centre for Traumatic Stress Studies and I'm actually evaluating a skills-based intervention for emotional and interpersonal regulation there and trying to develop a cohort of peer counselors to deliver these sorts of interventions too I think a lot of clinicians can become you know pretty intimidated by veterans and you know it's fantastic hearing field and Kristi and you Nicole talking about your experiences and stuff and you know here's the four of us with probably an average 25 years of military service behind us but two people in the audience that don't have that sort of background or whatever else that can be really hard treating veterans because they can be grumpy they can be irritable they can not necessarily know a lot about themselves and they can be really hard to connect with and I think what I'd like to be to write to clinicians when you're dealing with veterans you have to remember that you know being in the military whether that's Army Navy Air Force is fairly institutionalizing and it's a fairly life-defining trajectory to a large degree too because you know when you join the military you get conditioned in a number of different ways and as a result you tend to lose a lot of personal identity and then that actually gets invested in your role and so who you are becomes much more about what you do rather than who you are as a person because who you are as a person is in some ways an elephant because what we're interested in in the defense force is can you do the job or not and you know this can lead to problems down the track because when people can't do their jobs they get lost because who are they now that they don't actually have this role or this purpose in their life and this comes about in my opinion because military people are conditioned and trained to be very task oriented and that means that we do all sorts of you know stupid things or what seem like stupid things and put up with a hell of a lot because the job demands an office and because the job demands an office what we have to do is be able to get distress and all the other sorts of things and put it in a box and put it away so that we can keep on going and keep on doing our jobs unfortunately this leads to problems down the track and particularly with sort of understanding of emotions or understanding and acknowledging what's actually going on with us and so you know particularly when you lose that sense of task and mission and purpose life doesn't have a lot of meaning and so what I have seen basically is that veterans can feel that they're broken and rock up to the doorstep of a commission and go I'm screwed what am I going to do and you know the poor commission is they're going oh where did we start yeah and this can be a really challenging job and you know like Phil talked about in terms of having some sort of social connection I think this was really fundamental and I was the coach for the archery team for the Indicus Games last year and you know I wasn't there as a psychiatrist I was there as the archery coach and you know this is really important to sort of recognize because the sense force people as Christy said are really resilient you know and they will try their best and they'll do the best they can and using sport as a means of adapting to what's going on and overcoming mental stress and distress is another way to leverage that whole task mission-purposing to re-establish a different identity and it's really important to remember that you know in the defense force we work in groups we work in teams no one's by themselves but when you leave the defense force you're there all by yourself you know and your poor family and often times you stuck with the result of that as well too so leveraging those social supports leveraging some sort of task and new purpose to find meaning in my and therefore a new identity is what I think is one of the more important things for clinicians to consider when they're seeing people in someone the final point I'd just like to say is if you do feel intimidated and you feel that you can't understand don't be afraid to say that because it could be a really easy icebreaker to say to someone look you know I can't imagine what it what it would have been like to do those sorts of things but I can imagine it would have been really hard so if you think I don't understand something feel free to tell me about it so just be open and honest and respectful and I think you'll find you'll get a pretty good result thanks great thanks everyone for sharing those insights lots of great points and ones we will discuss in a bit more detail and I think that the presentation shows the wealth of experience that people can have both from their own military service but also I think it really nicely illustrates that sometimes you don't know who a veteran is I think if you saw any of us on the streets you wouldn't immediately go they must be a veteran and all of us have significant military experience so I think that's a really good thing for people to keep in mind when you're working with people in the community remember to ask whether or not people have had military service don't presume that you'll be able to just tell by looking at them the next thing that we're going to do is I'm just going to give a little bit of an oversight as to what do we mean by a veteran what is a veteran in Australian context and what do we know about them in terms of a definition of a veteran it really means anyone who's spent at least one full day in the full-time military but I just remember that many people even if they've served for a very long period of time or have been on deployments won't actually call themselves the veteran we have over 600,000 living Australian veterans at the moment about a half of them have been deployed on different types of operations that could mean conflicts such as Afghanistan, Iraq, Vietnam the Second World War it could mean that they've been on border protection tasks it could mean that they've been on peacekeeping operations such as Rwanda or Somalia or East Timor or the Solomon Islands or it could mean that they've been deployed on humanitarian or disaster assistance both internationally or either within Australia we know that many people don't have any connection at all in transit services with Department of Veterans Affairs which means that they'll be out there in the community getting their health and mental health care there's over 58,000 people who are serving in the Australian Defence Force at the moment and about 5,000 every year will transition out of full-time military service into the reserves either active or inactive reserves or they'll discharge completely what we know about more contemporary veterans a lot of that comes from a recent piece of research which was done on behalf of Departments of Defence and Veterans Affairs the Transition and Wellbeing Research Program and that was actually led by the Centre for Chromatic Stress Studies at the University of Adelaide and from this group that participated in the research most discharged at their own request about 20% were medically discharged and only 3% were non-voluntary administrative discharges and what we find is most of them are engaged in meaningful or purposeful activity once they leave the military so in terms of employment or studying and about 62% are in civilian employment the most common reasons for transition are things like impact of service life on their family or looking for better job prospects and a small percentage will talk about health or mental health impacts what we also know from this research is that we start to see a deterioration in terms of general mental health and physical health as people transition out of full-time military service and in fact we see some particular risks for mental health in this cohort almost three out of four met the criteria for a lifetime mental disorder almost half met the criteria for a mental disorder in the past year and those who've been medically discharged were particularly at risk can remember that they include some people who'd only served for a very small period of time so for example people who might be very young of junior rank and who's never been deployed a substantial number also had sub-clinical problems so it didn't meet diagnostic criteria but we're presenting with other problems such as anger or drinking too much having problems socially connecting with other people or problems sleeping and we know that that can be a precursor for later disorder we also know that many of those who met the criteria for 12 month mental disorders were not medically discharged nor were they current members of the Department of Veterans Affairs so again that means that they may not be actively in care or they're getting their care from community services and we also saw an increase in terms of the risk up to you know the following the first year of post-transition so that first 12 months things went okay but from one year onwards we found that people really were starting to see deterioration in terms of their mental health status we see that help seeking in this group is actually pretty good compared to the general community standard it's higher than what we see in the community and it's in line from what we see in other militaries internationally and other veterans populations but what we do see is that they do need to improve how many people are getting into evidence-based care and how many are staying long enough in that care to be really starting to see some benefit so that's definitely one area that we want to be able to see some improvements in terms of getting people in evidence-based care and keeping them in an evidence-based care such in terms of the type of disorders that we see in this group over 50% have no disorders that's about 52% and then the disorders that we see in the biggest percentages around the 17% are post-traumatic stress disorder and also panic attacks and then the next group which is about 11% are depressive episodes and then there's a whole range of different conditions that we see so it's really important that you keep in mind if you're seeing a veteran that you're doing a thorough comprehensive assessment to be looking at all different types of psychiatric disorders more close like a social consideration for individuals. Finally, we also know that we will see there is a risk for an increased risk of suicide in veteran populations from some research again commissioned by the Defence and Veterans Affairs which was undertaken by the Australian Institute of Health and Welfare. We've seen contemporary veterans so those people who served between 2001 and 2016 who had served at least one full day in the ADF that there'd been 373 certified suicide deaths and what we see is that there is a higher rate of suicides amongst those who are ex-serving men compared to the general community but we do see that those people who are still serving either in the full-time or in the reserved that there is a lower suicide rate compared to the general Australian community and where we see a particular risk factors in ex-serving are those men who are under the age of 30 and they have a suicide risk of over two times higher than that of Australian men of the same age. So that's just to give you a little bit of a context of what we see in terms of the mental health presentations of those people who are veterans and they may be people who are serving or ex-serving and certainly we know that people who may sometimes access community services may still be serving members but particularly we're thinking about those people who have now transitioned out of full-time military service. So what we'd like to do now on the next part of the presentation is to start to have a bit of a discussion about what are some of the things that we should be taking into consideration when we're seeing people starting to present for mental health services who might be concerned about their health or about their mental health and to open up for a bit of a discussion with the rest of the panelists. So first of all, what I'd like to do is to think about what is the impact upon military service upon the sense of identity and the type of presentations that we see. From the research there seems to be some protective factors for mental health associated with being in the military. And I'm starting just what we have a bit of discussion amongst the panel members as to why we think that is. Maybe Phil, if you have any insights, why do you think there are protective factors for military service and what do you think some of those are? I think the environment within the military is significantly different because they are in close contact with peers, with colleagues, with their team and with the health providers within the military and in fact within the military it's a requirement of their employment to maintain their health. So they're more likely to be picked up if they're going a little bit downhill if they're suffering or if they're experiencing any symptoms of any condition whether that's physical or mental. I think also there is an opportunity to provide rehab and support and that's enacted pretty quickly within the military to try and get our service personnel back on their feet and to ensure we get them fit and well as quickly as we can. Whereas in the civilian environment that responsibility is left to the individual and quite often for these ex-serving personnel they don't understand the civilian health system as well as the average civilian person out there. They're not sure who to seek help from which avenues they need to pursue in terms of engaging the appropriate type of support that they need. Right so it's not just about the type of experiences they might have in the military but it's also the wraparound system of support which is readily available to them whilst they're in military service which is not so apparent as they move out of the military. Any other comments from Christie or John about what it is that seems to have some sort of protection for people whilst they're in service? I'd actually just like to echo Phil's comments and you know for people to be cognizant of the fact that it's such a highly regulated and structured environment so your daily routine from the day you know from the time you get up to the time you're at work at seven o'clock in the morning to the time you go home and afterwards as well to everything is done within that specific environment and the nature of the job entails frequent postings so you might be in one location for 12 months and then all of a sudden you're off to some other part of Australia and so you get used to associating with people who live in the same environment and so that fishbowl the companies you wherever you go in the country and you associate with those people within that highly structured and routine environment and so when you lose all those social supports that as Phil said when you're now an individual and you're expected to do everything else that's when it gets difficult and you know a simple example is that defence members full-time defence members don't have Medicare cards because their health is supposed to be provided for by defence now some people will go outside that system and get a Medicare card and seek private health treatment for their conditions because they don't want to affect their careers but for a lot of other people it's like oh my god what do I do how do I get a Medicare card what do you mean I have to go and find a GP how do I do that how do I actually get reimbursed for this you know that's that can be really quite tricky and then you know you know there's the issues with DBA as well and it can be quite difficult navigating that system on top of everything else and so people get frustrated and they give up so it can be quite difficult just coming from such a routine and structured environment to going to somewhere where people feel like they have to sense it themselves yeah fantastic and um quick thing what do you think how important do you think the role of mateship or camaraderie is for military members whilst they're serving I think it's hugely important Nicole as I said in my introduction but I also um I also think it's really important in terms of it provides that sort of that it's not just a support mechanism but a you know camaraderie means you've actually gone through some experiences with other people so there's that idea of shared experience as well we know that social support buffers mental health impacts and stress so it is really important so when they're still in service still serving then they're actually benefiting from that camaraderie what they're also benefiting and it's along the same lines is the supportive nature of leadership and the command that has that um has on serving personnel so the command structure within the military actually puts front and centre that the leader or the commander is actually responsible for the mental health of troops so that in itself is actually really protective in terms of if you have to go and do something difficult even if you have to move regularly and that's the challenge and if you have to leave your family for long periods of time and that's the challenge the person that you're going to do that with is looking after you they've got your back as well as all of your team members as well so that sense of camaraderie and shared experience is really protective for for current serving mental current serving veterans right thanks Cristian and obviously there is an idea that it's not just the importance of the team but also a sense of leadership and being looked after not just by your mates but also then by your chain of command and we certainly see that things that people talk about what can be frustrating for them is when they don't have that nice strong sense of being part of a team or not feeling supported by leadership we also often talk about people not only do they transition into the military they have to transition out of the military you spoke about some of the factors that can make that challenging for the individuals but what do you think are some of the factors that can help someone to have a positive transition experience still have you got any ideas about that what are things that make it positive for people I think just the willingness to invest in their care that's what they're looking for and quite often a lot of their serving personnel will go and see multiple practitioners to try and find one that they can connect with someone who's willing to listen and understand their background including their military background and for all providers all health providers out there who are listening who are not from a defence background it doesn't matter you just need to be able to provide a willingness to show your care and you're willing to understand their background and their conditions and you're willing to enact some of the support to ensure that they can get well yes fantastic but we do know that there are barriers to people seeking health care and medical and mental health care what what do you think some of those stigmas and barriers are for people even after they've transitioned out of military service John maybe you can comment on that yeah look there's I mean in terms of identity and particularly if you've been medically discharged you know moving from something because you feel that you've been pushed out can be you know a big barrier because it makes people want to isolate and you know when we think about transitioning you know taking us like a therapeutic approach Erickson had a lot of lovely stuff to say particularly about separation in individuation now he was talking about teenagers and young adults there but it's a similar process that people go through when they leave for military because they're going they have to actually separate from that family of origin from that community and create a new identity and unfortunately when they've got injuries or whatever else that identity can be quite broken because they take on those injuries and they take on those reasons for being discharged as being a part of who they are and what they are because they no longer fit for the original purpose and so as clinicians a big part of our job is actually helping people to move towards things rather than waiting for things and so it can often come down to saying you know rather than what you can't do now what can you do and what would you like to do because this is you know often a huge opportunity for people that we don't really see it that way because you know when you leave defence there's a whole bunch of different things you can do that are really well supported through DVA and through other organizations as well and I think that's one of the biggest things to consider just asking people well you know would you like to study what would you like to do and then just helping them try and come up with different things for themselves because they can start to move on with their lines yeah that's and that's a great point that you're making that they're actually a great deal of services which are available for people out there sometimes they don't know what they are and in fact sometimes clinicians aren't really sure what some of those services are and I should have mentioned before there's a whole heap of resources which are available for you and ideas about where you can go for more information and the type of services which are available for US clinicians and also for veterans but often that we find that there's other people in their lives which really can assist veterans in terms of going out to seek support and connect with others Chris if you are the type of people or organizations that can support veterans yeah there's quite a few organizations that are dedicated to supporting veterans obviously the Department of Veterans Affairs provides a whole lot of support and Open Arms is the counselling service aligned within Department of Veterans Affairs and they provide individual counselling but also really good group programs for veterans and their families which is really important so families get access to all of those support services as well There are also ex-service organizations which really focus on veterans and focus on getting them connected within communities which is really great as both Phil and John have mentioned that social participation and being in the community is really important it's already made for them while they're in service and when they're transferred out that's where we need to link them in clinical teams need to link them in with support services but then also those support services in the community can actually create supportive environments for them so ex-service organizations like Soldgeron Mates for Mates and RSL Defence Care really provide a lot of support to veterans yeah that's great and that's really highlighting that role it's important that we have a multi-disciplinary team to support people and that can also include not just clinicians but also some of these other ex-serving organizations and also families have a really important role don't say in terms of encouraging people to get into care and to stay in care and often they're the ones that really encourage people in the first place to get there yeah Nicole I'd actually like to really strongly support the psychosocial rehabilitation that ex-service organizations can provide too and so like groups like the Road Home in Adelaide for example that run a whole bunch of physical based activities as well as sporting programs and then no I'm running my groups through there as well too and then mates and mates in Hobart, Brisbane and Townsville so they provide some clinical services but a whole bunch of other activities as well and I think one of the biggest things that veterans struggle with is that feeling of being alone and though you know utilising not just clinical resources but the psychosocial rehabilitation support that you can get from these ex-service organizations is huge it's yeah it's enormous yeah that's fantastic but at great point I was just going to say I really like John's comment earlier about about avoiding social isolation and that's why we're trying to get these veterans engaged in social organizations we need to enhance their network of support so that there are more people involved with their care and that can only lead to greater self-value self-worth you know and they feel that they sort of start to return to that self that belonging to an organization which is really important just that sense of fit yeah this is somewhere I belong this is a group of people I can relate to and understand and you know that just helps yeah and it helps to rebuild that sense of identity as we've talked about that's you know the military sense of self is so strong when you're currently serving that sometimes that's really then hard to leave when you leave the service and rebuilding that takes time as we all know having served and transitioned ourselves it takes time to actually build a sense of who you are outside of that and those support mechanisms can really help yeah so that you know that's a really nice and important discussion around if you're a clinician not working by yourself with the individual but you look at building a multidisciplinary team but also looking at what other organizations may be able to support and really looking at the holistic needs of this individual not just their mental health and their health but their psychosocial needs as well it's a really critical part of that assessment and that that theme of helping people not to be socially isolated is really important Chris do you want to things I was interested in about if you do have someone who's come to see you in clinical practice how can you tentatively ask about their experiences that exposure to life threatening events yeah it's a really important question and I think it is a bit individual you need to get you know your client a little bit and what works for them in terms of probing questions when you know it takes a while to sort of get to know your your client a bit but it is important I think to as you said to know whether the the client has actually served in the military and asked whether they are a veteran but to just sort of ask them a bit about you know when you're on deployment what did you actually do what was a typical day for you you know did you did you operate in a team did you was your role did you role involve you sort of working by yourself a bit did you have to move around the theater which gives you a bit of an idea of whether they traveled around in a vehicle or whether they might have had to fly around in a helicopter or whether they spent most of the time on the ship if they're in the Navy or you know most of the time on a base if they're in some other service so it just really just really try to get an understanding of what that person did on a day-to-day basis then that that can then probe help you probe other questions in terms of what they might have actually been exposed to in terms of in terms of that sense of danger and also it gives you an indication of the sense of purpose that they got out of that sort of deployment experience and how then they might need to rebuild that sense of identity and that sense of purpose now that they're in the community so it's there's no hard and fast rule but it is really just you know gentle probing questions to really uncover some of those stressors and exposures that people were under as I said in my introduction a lot of people did not a lot of people who've been in service didn't I have ever been in a dangerous situation where actually when you when you peel away the layers from that it is a potentially you know dangerous situation and potentially traumatic it's just that it's not how it's actually perceived by a military veteran so and then that requires or can require some education then around what impact that might actually have in terms of their current mental health and wellbeing how they relate to their family why it is they feel like they want to be isolate themselves rather than actually connecting their community and those sorts of things and why it is they're hyper-vigilant a lot because they might be you know continuing to be quite fearful of their environment based on their deployment experiences that haven't necessarily joined the dots so it's just it's a gradual process yep and also and remembering that sometimes it's about the trauma that it's a it all difficult things that have happened as part of their everyday life that might have occurred exactly before or during a military service which isn't related to deployments and isn't even related to their military service oh true yep yeah Nicole that's actually really important to emphasise sorry um because like during you know normal military service was very very good at normalising the abnormal and you know this happens on a daily basis on a regular basis and you know we talk about deployments and things a lot of people don't deploy but a lot of people are injured physically and mentally through the conditions of their service you know through being in a very rigid hierarchical organisation that has a lot of authority and power of the individual and you know being able to explore those sorts of issues is really important and not just having someone go oh well I saw a bit of shit and you know so what everyone did you know yeah and actually being able to probe further and knowing that you know we are very good at putting things in a box and putting it away and just going without the normal everyone thought why am I special you know just asking those questions yeah great point and still yeah I was just going to say I think asking those questions is really valuable it shows you're interested in them and you're you're more inclined to get them to open up about their background sometimes that can be a bit hard they're a little bit reluctant to talk about some of those situations or their work roles or whatever it was they did and I often I often in those cases I'll often start and say what did you think of that you know in your time in the service you know did you did you did you enjoy it you know did you get a lot from and that can sort of open up that a box of that information about them and of course we know that that the view about their service history is a it's a big factor for any any mental health issues yeah and I and I think that you know in summary the really important thing is you need to ask about what was their their service experience and what was their meaning of their service for them but then also what was the meaning of their transition what was their transition experience and what were the conditions of that and then also what are their goals in terms of the forward thinking idea that many of you spoke about for the future just as a quick final point what do you think some of the when we're coming up with treatment goals for veterans what are some of the considerations that we should be keeping in mind and feel we might start with you on that I think it's important that the veteran themselves understand that they are they're sort of essentially in command of their treatment okay they're the ones that need to make decisions about the way forward we need to ask them what they you know what they see is is the is the outcome they want to achieve and and ensure that any any management any clinical management we provide supports that you know in the military the emphasis is on forcing them to to accept their healthcare but out in civilian world they need to accept that responsibility and we need to encourage that we need to ask them we need to we need to gain their support and we're pursuing management or treatment option right we've actually ran out of time for general discussion and so what we might do is I'm just going to go around the corner and give you a a chance to say your take home message and John we'll start with you yeah thanks look I think I would just say ask you know ask ask your patients what are their biggest problems and if you could do one thing what would that be and then how could you help us and so for me as a psychiatrist obviously mental health issues are a big thing but there's also a lot of substance abuse and there's a lot of chronic pain and so ask so that you can work with other clinicians to help that person in the chair in front of you actually get back and become more functional and get on with their lives yeah fantastic thanks John and Phil what would your take home messages be for everyone I think we often talk about the veterans who are suffering whether it's physically or mentally you know but we need to understand that all veterans no matter how healthy or highly functioning they are we all need to you know they all need support and they all need to know that they're okay for those who have lost their identity you know in the transition process they feel empty and it's important that we can sort of you know fill them with a sense of hope and motivation about their future and we can do that with the recruiting as many people you know within their clinical care to sorry to clear team to give them as much yeah fantastic don't be afraid to ask them don't ask don't be afraid to talk to them about what their needs are Christie have we still got you there I can't see you but can we hear you yes sorry I haven't I haven't left my picture has but I haven't left yeah thanks Nicole just as a last final comment I think you know some of the echo to some of the sentiments that have already been said that be curious and be respectful of veterans serving in the military does provide people with a unique sense of purpose associated with assisting people in need and it's often involves going overseas or traveling around Australia to help the civilian community it creates an environment for shared experiences and that shared sense of purpose is difficult to recreate outside the military but as we've discussed we need to find unique ways to be able to do that and for them to remain socially connected and working with their goals not just necessarily what we want to what we want to focus on in treatment for them but working on the goals that the veteran wants to actually have come to seek treatment for and I think that's really important and enjoy working with them it's they're an interesting bunch of people yeah great thank you and thanks so much everyone for sharing those thoughts and your insights and then also your personal experiences I think there's been a great discussion around how you might talk to a veteran and I just as a final my final point to people out there we know that many of you who've joined us don't have experience with working with veterans or might do it very infrequently there is support for you there and one of the things that is being provided through the Centenary Advanced Act Centre which is initiated with TITS under Phoenix Australia is the Practitioner Support Service now this is a free service which can be accessed nationally and if you're seeing veterans and you have any questions or you want some support or you want to talk about a particular case you can call in you can make contact through the website and get advice from a multi-disciplinary panel and that includes Phil and Kristy are also on that panel we have a couple of psychiatrists the social worker psychologist and a GP and we can give you some very quick advice about how do you look after that veteran and what's the type of treatment options that you have and what are the other services that you can mix in with so that's really a service I would be encouraging you to have a look at and to please be using don't need to be doing this by yourself we know that working with veterans can be extremely rewarding but there can also be challenges for people so that's the end of the webinar and I'd like to thank everyone for joining us couple of final admin points the whole point of MHPN is making sure that people are connected and there's special interest groups that are being set up so you know if you have any particular areas of interest so you'd like to join in with the network or find who in your area is also working in areas that interest you then please get on to their website and find out more there's more webinars which are occurring as part of this online conference and the next one is the activity which is next week the co-morbid mental health conditions in veterans strategy for assessment case for formulation and treatment which is on Tuesday the 4th of June there are the resources which are available which have been put together by panel members but also resources which are suggested for people through Department of Veterans Affairs so make sure you have a look at those we'd also really encourage you to fill out the exit survey and to give us some feedback thanks so much again to our panelists for joining us and giving us their insights a really good discussion that we had this evening thanks everyone for joining us on the webinar thanks to those people who are watching later on as part of this podcast and that's it for this evening and thanks everyone for joining us