 Good evening everybody and welcome to the mental health professionals network webinar tonight working collaboratively to support the social and emotional well-being of Aboriginal and Torres Strait Islander youth in crisis. Currently we have 550 participants logged in which is fantastic. We're very pleased to have you all and I've noticed that we have people from lots of rural and remote places tonight. Kananara, Alice Springs, Noolamboy, Mount Gambia welcome and I'm also very pleased that myself and two of the panelists are from far north Queensland so I feel that we're well represented tonight. MHPN wishes to acknowledge the traditional custodians of the land across Australia upon which our webinar presenters and participants are located. We wish to pay respect to the elders past, present and future for the memories, traditions, culture and hopes of Indigenous Australia. I'm Mary Emma Layers and I'll be facilitating tonight's session. My background is in general practice and I have a master's in psychotherapy so I've mainly been working in sort of special interest primary care mental health for about 15 years. Most all in far north Queensland I do a bit of medical education teaching GP registrar and I've actually just commenced psychiatry training so I've been really pleased to meet Marshall through this process. You were provided with the biographies of our panelists along with the webinar invitation and I hope that you've had a chance to read them so I'd like to introduce our panelists before we get going. Just before we talk to Lewis, so Lewis is in Atherton on the on the Atherton Table and in Far North Queensland there's a bit of a buzz on his phone which we think just might be due to his location and we can't do much about it. So if you notice a buzz when Lewis is on the phone please just acknowledge this is one of the limitations of rural Australia. So Lewis is a Gitome man from the Jurtebelligan language group which is the rainforest people of North Queensland. He's a senior medical officer at the Atherton District Hospital and for the non-medical people in the audience he's a rural generalist doctor so he does everything. He's kind of the old-fashioned bush doctor. I hope Lewis will clarify that if I've got that wrong. At the Atherton District Hospital and he is a rural generalist. Lewis was actually the founding president of the Australian Indigenous Doctors Association and he's been directly involved in health advocacy for Indigenous Australians for more than a quarter of a century and has served on numerous federal and state health committees and reference groups throughout his career. Lewis I noticed that on the photo that you sent us you have your children and I wondered whether there was a particular reason why you provided us with this lovely picture. Ultimately it's a quick way of letting everybody know that I've got skin in the game. Those are my daughters and ultimately I want to see that we try and make the world a slightly better place for them and for their journey through it. For Aboriginal people there's still an awful lot of difficulties that we experience and so anything that lists the boat for Aboriginal people is the boat for my children. Which is fantastic and thank you so much for joining us tonight. Then I'd like to introduce Marshall since his camera is there. So Marshall is an Aboriginal man and a descendant from the Noongar people which is in South West Western Australia. He is a child and adolescent forensic psychiatrist in South Australia and sits on the Youth Justice Board of Western Australia and the Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention Advisory Group. So it's fantastic to have someone with Marshall's knowledge and experience on this panel. Lots of the questions from the audience have been around these sort of things. Professionally Marshall's interests include complex childhood trauma and offending, aggression and violence and juvenile sex offenders and problematic offending behaviors. So Marshall could you tell us a bit more about the Mental Health and Suicide Prevention Advisory Group? What are they trying to do? Well the overarching aim of the actual group is to provide the federal minister's health and Aboriginal affairs about advice that's gleaned from community members across the country working in various areas and people on the ground about how to improve social, emotional being and mental health for our people and also to reduce suicide rates as well. It's at the federal level but looks at locally based solutions appreciating that you know it's not a one-size-fits-all approach and what works for one community may not work for another but also drawing upon not just sort of clinical knowledge and expertise but also interweaving to the cultural practices and local practices within that as well. Suicide prevention is a very complicated and challenging area because people present generally end-stage and crises across the board for Aboriginal people and sadly too late sometimes for for our people and I don't think that the Western approaches are actually flawed but because suicide prevention itself is actually quite complex but the solutions aren't really based on white evidence base or one sort of illness pattern it's not just depression that results in suicide from an Indigenous perspective it's the ongoing impact of colonisation but more contemporarily there's lost grief trauma and often more more importantly but mentioned but not really understood is this constructive shame and how powerful that actually can be. So the goals really are to look at the mental health and social well-being as they relate to Indigenous people but also ways to address them as well. Thanks Marshall it's great to have you and I'd like to finally introduce Jeff Nelson. Jeff's a clinical psychologist working in North Queensland in private practice and also he does a lot of work in boarding schools that cater specifically for Indigenous students and with men in the correctional services system. Jeff is also an Aboriginal man and he's from Cairns working predominantly with Aboriginal and Torres Strait Islander clients but I must say not exclusively because I'm a GP and I'm able to refer to Jeff and he also does great work with white fellows too. His focus is on working with the Aboriginal and Torres Strait Islander cohort which has allowed the development in his opinion of a range of effective strategies that target emotional regulation and positive decision making in environments that are sometimes stubbornly resistant to change. A majority of his work in schools uses assessment and he's talking about psychological assessment which he'll explain more to informed systems and family-based intervention with the intention to provide Aboriginal and Torres Strait Islander children and young people with equitable access to opportunities so that they can enjoy positive life outcomes. Jeff I'm wondering why you chose to work in private practice. I suppose the history was that I sort of worked beside big bureaucracies and I probably didn't do that very well and one thing I noticed was that you know our mob have got a lot of high complex needs and as far as access to services I thought it's quite low so what I did was move away from the big machine and into a much smaller machine and do what I could to you know work with one-on-one to start with and then into the schools and more generally to bring the idea that we bring we bring best practice to Aboriginal and Torres Strait Islander people and work with our people we don't and I have a lot to say and you'll hear this during this webinar that I don't think we do any great magic we just work with our mob and it works most of the time so that's why I went away from the big machine virtually. Well it's great to have you here as a as a private practitioner as well as being an Aboriginal person because we do have a lot of private practitioners in our audience and remembering that MHPN is around how we how we collaborate across the different sectors so it's fantastic. I just wanted to quickly run through the ground rules so just remembering that if you're operating in the general chat box so you can put comments or questions for the panelists just remember it is a public space so behaviours if it were a face-to-face activity if you need help with technical issues there's a technical help chat box and remembering that everything can be seen so it is a professional development activity so all the comments should be related to what we're talking about now some people may find the chat box quite distracting in which case you can hide it so there's a small down arrow at the top of the chat box when we finish we have a short exit survey which will appear as a pop-up when you exit the webinar and your feedback is really important to us and it helps us inform improvements and what and ideas for future webinars this webinar is a little bit different to our usual format so we are not having a case study which you may have noticed what we're going to be doing is having questions and answers between the panelists but also keeping a close eye on what you would like to talk about and we have noted the themes from the questions that you submitted prior to the webinar when you registered just remembering that there are now 635 people online and over 2,000 people registered so we had a lot of questions so please don't be offended if your question doesn't get answered and I'm just going to have a look remind you of the learning outcomes so we are keeping in mind the reality of youth suicide in this group and we'll be having also a kind of general conversation about how we work effectively with Aboriginal and Torres Strait Islander young people so we're looking at implementing the key principles of providing an integrated approach in the early identification of Aboriginal and Torres Strait Islander youth experiencing psychological distress how do we identify them, how do we help develop appropriate referral pathways to prevent crisis and provide early intervention and identify challenges, tips and strategies to implement a collaborative response to Aboriginal and Torres Strait Islander youth in crisis. Now I would like to mention that there is a resources box down in the bottom right hand corner it looks like a little folder and in there you'll find some resources that the panellists submitted beforehand and Marshall has a slide presentation in there which he won't be showing on this screen but is there is a reference point so if you happen to be able to download it onto your computer or a double screen there may be times when he might refer to one of those slides but otherwise just make a note and have a look at them afterwards. So I think without further ado we might get on with having a conversation so I'm going to actually ask Lewis the first question because it's the one that has come in the most from the audience as well so people want to know what what do we need to do differently with when we're working with Aboriginal and Torres Strait Islander people around engagement, getting on well, being effective councillors and clinicians. So we kind of have this idea that there must be some special techniques or ways of working and Lewis I know you've got some really helpful things to say about this. Well I think I think the the main trick is actually there is no magic trick to it at all. In conversations that we had before this I made the point that this is almost the same as Shylock speaks from from Merchant of Venice you know where he says I'm a Jew, have not a Jew eyes, have not a Jew hands, organs, dimension, senses, affections, passions, fed with the same food, hurt with the same weapons, subject to the same diseases, healed by the same means, warned and killed by the same winter and summer as a Christian is if you prick your stewing not bleed, if you tickle a stewing not laugh, if you poison a stewing not die. I think one of the one of the big mythologies that we have when it comes to to any form of health care, mental or physical health care among diverse diverse patient groups is the idea that we we have a system that works really really well for for white people and if we just do the little crossover course then we'll be able to get that to work well for for Aboriginal and Torres Strait Islander people or any other ethnic group and I think the reality is that a lot of a lot of what we do from day to day may not be quite as effective as as we think and the thing that is most effective is actually dealing with the person in front of you at their point of need whoever or whatever they are trying to to make sure that the tone of your conversation is something that they're going to best comprehend when you ask questions that you ask questions which are going to make some sense to them and they can see context of those questions and then you know the chance of them answering the question goes up by a factor of 10 and a whole bunch of those those incredibly simple things about just communicating with other people and I think that it's the big mistake that people make to think that Aboriginal people are markedly different in that regard and and really you know we're not yes there'll be some some some cultural considerations but I think that this is true of almost any group that you that you're going to communicate with and you know if you just move to a different town from where you are now if you move to a different state then even if even if the ethnicity of the of the your patient group is not much different than what it is now you're still going to find that there are significant cultural differences you know because culture is those things around us that that help help you know explain the world as we perceive it so that the the big trick is actually that there is no trick and and you know if you start by treating that other person like a human being and and you know good old golden rule stuff you know what's over you with that mentioned to the you then I think you'll get through an awful lot of that stuff and at the end of the day I think Aboriginal people by and large are used to the idea that that a lot that white fellas will get things wrong from time to time white fellas will make some social faux pas I think we tend to expect it and and as long as you know when we know that the intent is good then then the minus and can easily be forgiven thank you Lewis really I always really enjoy talking to you and I'm always impressed with your you know knowledge of literature and all sorts of things as well I think metaphors and and artistic language sometimes very often express things that we just can't put into power for presentations um Jeff on that on that note of um you know that that we need to just be treating it everybody with respect in it and everybody the same I know that that there's a lot of um in some circles reluctance to use things like psychological testing instruments or because they haven't been validated for youth with Indigenous populations and I know you've got some some thoughts about that so I wondered if you'd like to come in um yes Mary I will look I've um over the last few years I've been doing a lot of assessment within schools in the Cape uh the north end of the Northern Territory and through to Kimberley and Pilbara and I've been using psychometric instruments that some would argue that you shouldn't be using um and the thing is the reasons for saying that the tests are unsuitable or will provide invalid results are very very hollow they'll say that you know number one English second language but then in Australia we have a lot of people in your second language they'll say that you know cultural effects on the way people think there's a lot of there's a lot of ways to sort of discount the value of actually using validated established tests um I very much argue against this and the reason I do is that if you actually run through the tests and you get scores you sit with kids you sit with family you sit in community you see the way kids are behaving you know you'll know when a 12 year old is acting like someone very much younger that says to me that there's something positive going on here and what we actually do with some of these assessments is that we can actually gather further resources so that schools have a better opportunity to provide you know the best chance of a great education so um I've had this argument probably at least once a week for the last two years and I'll probably rule for them for the remainder of my time but the thing is we do everything in a certain way and it's interesting Mary this webinar in the fact that you've got three Aboriginal men who work with Aboriginal and non-Aboriginal people and we're talking about how we work and potentially talking about how non-indigenous people should work now we've never been non-indigenous so I don't know whether what we're going to say is truly accepted by everyone but look we will do what we do we're doing really good work with kids up here kids are getting a lot of benefit out of it I see that for myself and that's not because I do it so until we get to a stage where I think that what our current practices are not effective we'll continue all I'll continue doing what I'm doing and I space is there's also you know historically this assumption of a sort of homogeneity around originality as well that there must be one Aboriginal opinion about all sorts of things and and clearly that's not true and so I don't expect the three of you to all agree on everything I thought necessarily and I wanted to bring Marshall in so Marshall you're actually a psychiatrist so one of the things that you get trained in and examined on to become a psychiatrist is psychiatric diagnosis and we use predominantly the DSM in Australia and I wondered how relevant that is for working with the young people who you work with who have like complex trauma and and and so much complexity in their lives how how do you work in a system that requires the DSM or is it useful yeah I think the DSM is useful to a point but I think you better you know and I think it is relevant but it's the manual and of you know not of how to do things or what to actually look for and if you sort of think I mean the the risk is that you do see something and you categorize it and you put into it you know an illness pattern but you know if you take a step back disease is around impairment not being able to do stuff and really what's going on there and so forth and so on and where people get stuck is that you know certain diagnoses associated with issues of stigma being devalued personal experience and so forth and the issue is that stigma is compounded by institutional racism which is alive and well and with a lack of perspective cultural practice the thing with kids and kids who work in progress or a transition so not everything's going to fit into a diagnostic category and that's okay you don't have to have a diagnosis it's okay to see with the uncertainty as long as you can sit there and call it that there's nothing wrong with having a bit of this or a bit of that it doesn't mean to say don't when you're talking about it's just appreciating the fluidity of child development the fact that things change and also that kids lives occur in context um the thing about the DSM for the Aboriginal people is DSM hasn't caught up with us yet you know the there's lots of stuff going around early childhood trauma and development and you know PTSD in kids but it's very very narrow and what we see are lost grief and trauma it manifests differently in kids and versus teenagers versus adults but predominantly what also we have issues are ashamed guilt identity formation lack of feeling valued all of that stuff doesn't fit into a category so the categories are useful to a point especially useful medical legally when you have to communicate with people and professionals and so forth but to sit there and give someone a diagnosis that can be stigmatizing but it can also be quite validating for some people and giving give them something tangible just something that's very very nebulous and I think just it's okay to not to have a diagnosis there's also useful to have ones and it and it varies between people as well the thing is not to put all your eggs in one basket and just appreciate the fact that look kids change stuff changes and that's okay but as long as you are making you're making progress and getting traction and trying to help get people out of whatever they're in the space they're in and then that's what you're aiming to be doing hmm and I just to let the audience know of whom there are 665 now um we haven't been able to upload Marshall's slides yet but you will get them by the end or after the webinar so apologies about that Marshall I know that one of the things that you you notice in the clients who you work with despite very adverse circumstances and trauma and you know involvement with the forensic system and so on one of the things you emphasize is finding their strengths and their resilience yeah well you know what do you look for how do we how do we look for that looking at it is just sitting with someone in their space and looking and trying to really get an idea of who they are as a person the context of their life circumstances we know that you know when they come to a forensic you know if they come into in custody or whatever we know they're a high risk I don't need anything to tell me that I know that because of the you know how they've come to be there in this and their circumstances and it's really just about being humans about sitting with someone in the and meeting them in the space that they're actually in and just trying to see the world through their eyes and then from there you can look at people's strength and you know looking at you know tapping into things like you know what are kids interested in what are you good at what makes you happy what makes you proud what do you like to do you know it doesn't always have to be issues of academic performance and so forth and so on and I've seen so many kids labored as a bad news kid but when you sit there and appreciate the context of their life behavior is a form of communication um and if you don't actually appreciate the behavior for what it actually is the narrative behind it you're missing it and it's where the narrative when you actually understand the narrative and appreciate the narrative that's when you start to see strength because what they can do is you're on a good story about their life and that's the life the life narrative is what we're tapping into and you want to move you know they've obviously going on a narrative that is you know they're on a narrative story or a narrative cycle I guess in a way that that's gotten to where they are now so the the issue is about how do you tap into the resilience in them and the strength in them is to get them on to an alternative narrative yeah thank you but uh Lewis I I know that you also work um do some work in the prison and I just wondered what what that experience has taught you I know you've got a bit of a yarn for us about that that I think would be great at this point um yeah so there's a prison not far from here and and I do a regular clinic there and I think the the sad thing for me is um how many of these guys are there for for the for what's ultimately silly reasons so and for a lot of these men they will they will get intoxicated while they're in intoxicated they do something silly um you know these guys aren't robbing banks um not not many of them have actually been charged with inside trading um you know they're mostly mostly they're just getting drunk and doing something stupid um and then they're ending up in prison for it and the problem is that one of the awful things that you see with the young people coming through is is this acceptance that this is the wall that they live in um uh that just when I was a a young fellow myself just um in the first couple of years or actually before I started medical school I was working on my tribal property down near Tully um and my father was actually managing the um the the farm and the local headmaster came to us he'd managed to get some extra funding for the primary school um to get a groundsman and he was hoping to be able to employ an Aboriginal man in that position and so he came to us and you know asked the questions over to you know if somebody here will be good at um looking after the lawns yeah yeah yeah no problem um you know they need to be good with kids oh yeah yeah yeah no problem they need to be reliable and turn up to work all the time oh yeah yeah no problem they'll need to be good at fixing engines and stuff because if there's a you know they'll need to be able to do basic maintenance and repairs on the on the most yeah yeah yeah no problem yeah they have this long list of things and and yet no problem we could fill that and the last question he asked was oh oh and by the way um um no criminal record or or what recently or or at all um and um and the the intriguing thing is that I was the the only Aboriginal man um um on that property who didn't have a criminal record for someone one or other reason we managed to eat uncle Claude um the position because it had been some years since he'd been arrested for breeding while black um and um and the computer systems among the police were not all that good back those days and so they weren't able to track him and because he hadn't had a recent conviction then um then he slipped through the police check okay um but there was this incredible normalization um of of that that prison is is is a virtual right of passage and um and anything that we can do to start trying to get through to these young guys as they as they have some engagement with health systems or or police systems or you know the justice system that actually just they're not irrevocably set down this past um is um uh is you know that that's the thing that elect hopefully will will change lives and when we only get to change in one of the time um um but that's you know but that's good enough and and if you can get one of these kids to just stay out of prison um then the opportunities that they have in life um are magnificently greater than they otherwise would have been um and certainly we have the story over and over again with um uh Aboriginal medical services giving delivering services inside prisons um and invariably they'll have an issue with the um with the male Aboriginal health workers um many of whom will have had a criminal conviction again usually for something that's pretty ridiculous um but nevertheless they'll have a criminal conviction and they've got to get all sorts of exemptions made so that this this Aboriginal this male Aboriginal health worker can now actually attend to Aboriginal men within the prison system um and you know it's just it is it's just so distressing um that this experience has become so normalized um you know as Aboriginal as Aboriginal men we're we're 15 times more likely to do time than than you know the average public can out there um and um you know and that's a fair bit actually um and Lewis I I remember having a conversation with you actually the first time I met you about um about you know when we grow up we think that our experience is normal and I remember you telling me about um something that happened with when you're a medical student and and realizing that that not everybody grew up automatically going into a room and looking for threats weapons and yes when I would have been when I was in 30th a 30th year medicine um and um and so with uh we were doing a country term uh this was at Tamworth um went to the to the workman's club with the with the um group medical students that were that were my rural group lovely people lovely kids um we're having a good time um having a bit of a dance and a couple of intoxicated boys on the side of the room decided to start crashing into myself and the the young ones that I was dancing with and you know that was extremely humorous for the first half dozen times or so then it started to get a little tedious um you could see that the guy who was the leader of the pack was standing on the sidelines and I went over and I just said oh look you know brother was extremely humorous the first dozen or so times but would you mind calling the boys off because it's just getting a bit tiresome now um the young lady that I was with the member of my group um then put herself between between us because apparently putting a a pile of estrogen in between two lumps of testosterone cools everything down apparently not not in the world I come from but maybe it doesn't exist and um and but you know everything all pitted out on the way back to the to the hospital accommodation these guys were just into me about oh you didn't know what you're doing and and he was quite bewildered I didn't understand what they were so concerned about and um one of the guys in the group Gary who was he spent 10 years in the army before coming into medical school fairly worldly wise white boy from the western suburbs of Sydney and I was talking to Gary because I didn't understand what these guys were so upset about and um and then he explained to me that oh well they that this is you know this whole thing is a is an environment that's unfamiliar to them and I said well I don't know what the danger was I you know I knew who the threats were I knew who the leader of the pack was I knew which order that I needed to take him out in I knew where the weapons were there was there was a couple of bottles on the table to my right and there was a few chairs and I had two main exits um to the left hand side so I knew you know how to defend myself who to take out and how to get out of there I I don't understand it anyway and he had this long conversation with me where where for the first time it had it had then it adorned on me that these middle class white kids um have never had to do that that they've never had to walk into a room and scan for threats weapons and exits and uh so when I was 21 years of age at the time and it was just I could not comprehend the idea because I had never entered a room in and my conscious memory that I hadn't done a scan of threats weapons and exits it's it's the first thing you do even my daughters who who have grown up in a much kinder um environment than than I did um they noted the first thing you do is scan for threats weapons and exits and um and it was just don't get me wrong I I really hope that my grandkids are able to grow up in a world where they don't need to do that anymore that'd be fantastic but um but there is just a it's a it is a different world view um and um and one of those I think one of the really interesting things when you look at the that stressors for young indigenous people when I was in headspace this was a an issue that came up at times and one of the interesting things to to to get through to people is that the you know that the the top 10 stressors um for your average middle class non-indigenous Australian child um probably wouldn't make the top uh you know anywhere in the top 100 of the major stressors that that um that you know that that rural based Aboriginal child um would undertake in their life um and that the you know the whereas whereas that that middle class kid might be concerned about whether or not they they um you know who what subjects are going to be taught at school tomorrow and tomorrow um you know a lot of the Aboriginal kids might wonder if they will get fed before they go to school tomorrow um you know just and and there there is that that that different experience but I think once you can appreciate that just a little bit um um then I think the the that it doesn't take long for the communication barriers um to break down and when you're talking to somebody it's if you have the ability to peel back in your own head um uh you know things that I do because I'm a human as opposed to things that I do um because it's the culture in which I was raised um um you know shaking hands and saying g'day um that's not a human thing that's a cultural thing um um having a form of greeting that's a human thing I hope that makes sense yeah absolutely and I can see that the um the audience are really getting a lot from what you're saying too and I'd like to bring Jeff in now so Jeff um you know I think we have an understanding that that the young people that we're going to meet in this line of work often do have really complex stories and I wonder how you begin you know when you first are working with a young person in your very first session what are the kinds of things that you do keeping in mind that at this moment you don't really know anything about them um well there's probably two two parts of this and if I forget the second part Mary bring me back to it but if I look at a normal every day first session now a lot of our Aboriginal and Torres Strait Islander kids and adults are referred to me because I'm an Aboriginal man and so automatically there's a sense of comfort to one level but they a lot of the mob here don't know me so we start at the beginning um the clinic I work in is brightly coloured I don't believe in having white walls and white roofs that's not for me um they have a choice there's a yellow clinic room there's a green very nice green and a blue I say which one do you want you take your pick go into a room I I'm not a big believer in the whole session psychology talks about the first session first one and a half sessions being a you know information collection assessment piece um I've got clients who are very very tentative about being anywhere near a psychologist so for me my first session is 70 percent working with your client 30 percent hoping that you'll provide something so your clients keen to come back so we start with the story I move quickly to well you know in the ideal world what what would be a great outcome of this and I always work with whiteboards I've got whiteboards in every room I've got whiteboards everywhere um I'm very very keen to get my clients off off their feet up onto their feet and engaging so behaviorally so we'll start on a whiteboard you know within a short time I'll be throwing a whiteboard mark at my client saying come on let's let's do this and once you get them up moving around it's a really really good thing I get a lot of the story I see I get to the end of the first session and you know it's always about well you know what are we going to do together so if we're going to go in a particular direction what is it and I'm always big about what it's not it's not about what we're moving away from it's what we're moving towards so it becomes a joint mission so to speak um and there's a whiteboard that's full of horrible stuff because my drawing capacity is zero my writing is very very poor maybe I should have been a medical doctor but um and I'll do that with my male clients and my female clients um and it works I mean I'm very happy to say that my clients do come back and we go into some really really difficult spaces and they can sit with the difficult space and we can work through things you know we don't win every time but I think getting people in and moving and writing is a good thing the other thing that I'm very quick to point out to people in my first session is that you know the healing doesn't happen here it happens outside the window I just point out the window and and they get that so that's that's my first session but in in the context of that in the context of the first session and in the context of a reluctance of a lot of non-indigenous psychologists especially to to work in the indigenous space you know I always say to people you know I said you know you've got a first session with your client your client comes in sits down you're wearing a blindfold you don't know who your client is you can't see your client which to me is very debilitating because I probably take more out of the connection between what was being said and how the body moves without anything else but let's go back to the the original question though I always ask other practitioners you know you're sitting here with the blindfold your first session is going along very well there's engagement there's rapport it's all going the way you'd like it to go someone comes in halfway through the session and says oh you've got a blindfold on we'll take that off and you notice that your client is actually an Aboriginal woman my question to everyone is what would you do differently in the knowledge that your client is an Aboriginal woman and if anyone can say well I need to do this because I'd like you to think about why you think we need to do something different if it's all going well why do we change the recipe so that's two parts Mary that's great Jeff I mean I we've had conversations around CBT derived strategies because that's something that I teach GPs and you know there's been some discussion that maybe you can't do CBT based strategies with Indigenous people but I I know that it's exactly what you just said if it's working just keep doing it and I I'd like to bring Marshall back in Marshall I imagine that some of the young people that you meet it's actually under really difficult circumstances to them so they're either incarcerated in prison or they might be under the Mental Health Act and so these issues around helping people to feel safe and engaged must be even more difficult I just wondered if you had any reflections on working in those kind of environments or meeting particularly when you meet a client for the first time well I mean by the time it comes back to that principle is that you've got to you've got to assess the safety of the situation first first and you know depending on what you what you're sort of dealing with in front of you if someone's acutely you know heightened and distressed and threatening you've actually got to de-escalate them and you know there's no I don't know maybe it's just the way that I do it but it's about trying to really stop being a clinician and just start and just be a human engaging people have a conversation you know around issues of respect you know trying to appreciate the space they're in acknowledge the space they're in that it's a crappy situation and just try and really de-escalate it rather than try and going into things first and that's the way that I'd sort of generally tend to do it I mean there's no hard and fast rule to it but it comes really down to being human showing some respect acknowledging that what's going on is you know and acknowledging the space that people are actually in I'll stand if people are standing up I'll stand up until I've got a queue and I said I feel it's safe enough to sit down they might feel safe enough to sit down and once they sit down yeah they're still agitated but it's still treating them you know like a human being and having a general chat not actually dealing with the acute reason why they're in hospital probably talking more around issues of what's going on for them what's going on in their family and just try and really de-escalate and talk around things rather than going straight for the you know acute risk assessment or acute issue because they're not ready to actually go there then but again I mean I could count on my hand the number of times that I've felt unsafe and you know 10 or so years and it's been probably in an emergency department in the middle of the night people you know working with kids in custody it's actually a very safe space to be working in before going into talking to someone you always gather the info you need to about the safety and what's going on for that person if someone's too upset and distressed then you have to walk away and leave for a bit but in order that you don't leave the person there you work with the staff there and how you're actually going to de-escalate them because you don't want people sitting there in a heightened distressed state doesn't actually do them any favours and it's a you can't actually do anything like that and I wondered also so I mean one of the things that happens when when we identify a risk of suicide that we're really concerned about you know in in many states and in some professions when we have to consider the Mental Health Act I just wonder if there's any you know sometimes the we might you know keep someone in a particular environment for assessment or then for their safety but that environment might be itself traumatizing or not serrated. Absolutely absolutely um I mean I'll work with I come across young people who live with chronic suicide ideation they don't end up staying in hospital I mean if we look at the classic example of a young person with complex trauma who's been exposed, primed and normalized well sort of for hyper vigilance and like Lewis was saying that defensive stance that's all really overwhelming they don't have any self-regulation and people defer to self-harm and suicide suicide ideation as a way of trying to get out of the situation they're actually in and that's a really hard space to be sitting in. Now I think the thing I may be able to submit sort of decency ties to a risk but I deal with risk every day whether it be suicide or violence or this that or the other but it really comes down to okay someone's got suicide ideation not to get too reactive about it it's to really again sit in the space and explore what it's actually about what's the acuity what's the intent what's the mechanism but you know so that's the risk side but then it's about well what are the protective factors where are the resilience factors here people have been assessed to death by about being dangerous but it's I think we need to start looking at the strengths and you know in those situations it's looking at okay what are the supports what are the strengths okay yeah you've got self harm or suicide ideation what does that actually mean and the question I always ask people is you know one okay you get those thoughts does that happen when you feel in relaxed or stressed if they say it's when they're stressed then I know it's an issue around sort of emotional regulation of times with duress and poor coping strategies and so it's about working with that whether if it's all the time then it's a bit of a different thing because it's you know sometimes the situation and sometimes it's not and then it's being as in anything with this it's about being curious and exploring about what are you going to do to really at this point in time alleviate distress to a mere to your own risk and by and large we don't always have to admit people to hospital with suicide ideation however there are situations where it's a little bit more tricky that is if there's issues of intoxication the home environment's unsafe there's been a chronic problem with an acute exacerbation and then you're right we put people we put people into hospitals to give them a break and reduce the risk but hospitals can be a very traumatizing environment I mean I think with a lot of kids that I see there's this construct of safety and chaos there they've come from they live such a chaotic normalized existence that when you put them in a hospital it's sterile it's quiet there are there are people that are trying to you know sort of help them and so forth and that's a very foreign thing which can be incredibly alienating so you know the classic example the chronic and suicidal person some of the borderline personality construct and when they're in crisis it's not necessarily possible it's the best place for them because sometimes it's actually being at home with their own family and supports I think the thing about suicidal ideation is not to shy away if I want to get nervous about it yeah we've got to recognize you've got to deal with it but I think as clinicians we actually have to be uncomfortable to be about curious with risk and learning how to sit with it I'm not saying that we have to carry risk and have sleepless nights but it's about in order to really make a good idea of risk what people say and what they do is one thing but what if it can texture factors so a fairly long-winded answer but I think it's for the highlights of fact that it's so you know it's about being comfortable in you know talking about risk and then that also helps a millirator and hospitals aren't always the best people the best places for people if if they're suicidal sometimes it makes it worse yeah and I suppose I mean a big thing that that you talked about there is you fit because you deal with risk every day you've kind of got used to it so it probably doesn't make you quite as anxious oh I guess I'm going to and I'm sorry go ahead oh no well we we we have to find ways of like we don't want to do coercive things to people because we feel anxious and sometimes we don't think so clearly when we're anxious but after you get help and that's where you kind of I mean I guess for me I think the thing is if you're in that situation and you know you've got someone to stress in front of you and that's making you to stress the transference the counter transference and playing ours then you've got to sort of sit and go okay sometimes okay just to step out get have a think about it get some advice from a colleague about what to do and then put other structures in place because you also look after someone you look after yourself you've got to manage your own anxiety about things and it's completely understandable to get anxious about this sort of stuff absolutely I'd like to invite Lewis back in Lewis this question is just out of the way for you but it's come up in the the participant question I and I I suppose I'm just asked like a lot of Aboriginal and Torres Strait Islander clinicians navigate this kind of complex world where everybody expects things of them and like and I know all three of you have been involved you know in politics and leadership and advising government and all sorts of stuff and I'm sure that on a personal level you get you know our stuff by friends and family all the time so just Lewis how can how can we support Aboriginal and Torres Strait Islander staff and is there anything that you wanted to say about that just to recognize that complexity for those people I suppose very simply it's just being a little bit mindful of the that by by nature of who this person is there will be a lot of calls on them the the the there's a sorry there's a term here in Queensland Aboriginal people in Queensland refer to ourselves as as Murray's and so so you you might you might hear about somebody being the MBE and the family which isn't the you know middle of the British Empire that's Murray being educated or you know in the Southern states they you know they're not Knights of the British Empire they're Corry being educated and so if you're that if you're that person who has a little bit more experience of living between the two worlds then then you'll often be called on in a role in some sort of translator role to help the the two groups of people not being able to to to figure out what's going on and and it does get incredibly taxing at times and certainly with in the Australian Indigenous Doctors Association we we we're frequently hearing the stories of young people who are going through the through exactly this even while they're in medical school you know that young Aboriginal person who managed to get into medical school that's that's that kid in the family with with great promise and so they're you know the amount of these kids who are taking time out of their their their medical school years to go back home and fix things is is extraordinary and but I think you'll find that that's also true throughout the the community of Indigenous health professionals that whoever you are and and whatever level you're at you know if you're an Indigenous Hospital administrator you're going to have a skill set that gets called on frequently even though you know you might have done you might have done a degree in accountancy but you're still going to get caught on to be some sort of cultural translator on a frequent basis and I suppose for a lot of us we we do it because we know that we have to do it and that's just and that's what it is but but if people are able to just from time to time show some appreciation for the fact that that we don't get to just go home and let go of it at the end of the day then then I think it makes the experience a little a little easier well one of the things that I used to say frequently in in cultural awareness programs to doctors is one of the things that I do find a a little funny at times though is is how much similarity Aboriginal people have with with doctors we both come from cultures which are extremely hierarchical and and in an Aboriginal community I would make sure that I never openly disrespect an elder if I disagree with an elder I would do so in a way that's that's quite and gentle in the background and and for those they dignity in a medicine you'll see young trainees do this in front of a consultant that does the same thing that they won't openly defy the the consultant we both groups of people who if somebody from the outside comes in to attack us we'll circle the wagons and look after that person who's a member of our club you know it's true if we're Aboriginal it's true for the for doctors and the other extraordinary thing is that both groups that I belong to have extraordinary levels of substance abuse and that substance abuse relates to the chronic and unrelenting grief the slight difference is for Aboriginal people that grief is frequently very personal and connected within your family and for a lot of doctors that that grief tends a little bit more to be other people's grief but there's that that thing of that in my own profession I know one of the things that makes makes life so much easier for me is having a bunch of colleagues who do have an insight into my world even even those who would tell you that they don't know an awful lot about Aboriginal people it doesn't take long for us to talk for them to get an insight into my world and for me to derive an extraordinary amount of support for my colleagues yeah thanks for that Lewis and I must say that actually I've been very fortunate to have met you but and I know Jeff quite well we have a lot of shared clients and I think I've learned a lot through working with both of you and friendship too um Jeff I think one of the things that's really tricky in in rural and regional and remote areas we might want to collaborate with people but there's no one there to collaborate with and I know that's something that you've been thinking about you know yeah how do we actually get people to feel comfortable to work in this space or what are your thoughts around that um there's a few actually and um that's probably very relevant today with what's been going on for me over the last week um generally speaking you know with and I speak from within the psychology world I don't try to speak for anyone else but generally you know we have a indigenous psychologist association um and I think our numbers are getting close to the three figures or might just surpass that but um probably for me with my clear focus on being very good clinically and working with you know I think sometimes clients that no one else is going to actually see um many of our psychologists sit in big universities and in other more corporate spaces and good luck to them um they're getting well remunerated but I just sometimes get quite frustrated and I did a talk at UQ last year saying can you just leave us alone can you just let our own mob work with people clinically for a while before you take them into the the great halls of universities um so if we assume that there aren't that many um indigenous psychologists working on the ground we need non-indigenous psychologists to pick up the speed now I'd pick up the slack now there's no shortage of trauma specialists in Australia um but I don't see many of them working in that space um which you know it's really really difficult we or I we just advertise for psychologists to work with some very difficult schools um and advertised nationally and there's been zero response not even one person that's actually rung up or emailed or and so that's the frustration but when it comes to collaborating across disciplines you know I mean as Mary said we work very closely together so the great thing about Mary is um you know Mary is a GP and also psychotherapist so there's a different level of understanding so I can call on Mary but also I mean I get supervision from the Central Coast of New South Wales I get I get supervision from England through Skype um there's not much going on here so as far as us developing a workforce that can actually deal with some fairly complex kids that we have a chance of actually turning around early um sometimes it's very very difficult because you don't know who to call on and when you do there's this concern that they may not be good enough or that their peers might sort of you know frown on them for for being in the space and I've seen that so many times so we do it we we do handle risk we we when we work in small places we don't have the the big support systems that sit around us that help us when we've got um suicidal clients um and we have to take that on the chin so yeah it's very very difficult at times it's very very hard but you know we do our best and you know maybe one day we'll get all of our own indigenous psychologists working in the field and a huge bed of great non-indigenous mental health clinicians standing beside us it's a dream. Marshall I'd like to invite you back in um I know so I what I'm interested in is I I really like the social and emotional well-being model as a way of thinking and I find it really applicable for for everybody not just for indigenous people um and I wonder if you've got any somebody in the audience asked about um how can we get collaboration between the services that kind of operate under that model so that perhaps our Aboriginal community controlled health organizations have social and emotional well-being teams um how can we collaborate with the more kind of quote unquote mainstream services like the state-based health services or general practice the have you got any experience with that or any sort of thoughts about how that that can work those two different kind of paradigms almost? Well I think it comes down to respect and respect of different forms of knowledge and expertise you know the thing that comes to mind is um you know I think that we we need to appreciate that the social and emotional well-being services that we have in community controlled organizations are incredibly valuable that represent an incredibly high skill set and I'm talking I guess culturally here you know Aboriginal mental health consultants that we have actually have a vast amount of knowledge that probably doesn't always get translated across um in the way of value to sort of mainstream services where where people are kind of you know working in sort of very very structured teams um and at the end of the day what we I think it's you know that there certainly needs to be collaboration and part of that is about having the discussion about you know who's doing what how they're doing and what they're actually trying to achieve I know that sometimes there's reluctance by mainstream services to the you know to use the better term to really look at the sort of the grassroots clinicians and how they're doing stuff and it's actually incredibly quite valuable and I think it's quite I don't think that people don't want to address the issue or but they probably struggle with how to actually do it and what they actually need to do is actually think about well if we keep doing the same we're going to get the same so let's try something a little bit different I mean you know speaking about where I work at the moment our team is 50 indigenous we have a psychiatrist you know we have um non-indigenous and indigenous workers and the skill set ranges from social work to mental health consultant mental health nurse and there's just collegiate respect across the board so it's just about how people sort of communicate with each other and respect their own backgrounds and knowledge bases and it's not about feeling threatened or and if there's issues of you know what and this whole other issue around things like lateral violence you need to call that for what it is so I don't think it's just between service and certainly across the board and the thing that keeps going back to me is about respect and you know validating people and their experiences and what they actually have to bring none of us are smarter than the other at the end of the day it's just about how we see the world and how we do our job yeah it makes me think about what Lewis was talking about with with the hierarchies in medicine and the power differentials and and he must have seen so many parallels and I I also was thinking that you know what you're describing between the professionals in the team is the same kind of stance that we need to have towards our clients as well that's shared humanity and that respect so it's almost like that parallel process Marshall we're just coming to the end of the time and I'm just going to ask each of you if there's a just a couple of things that you that you wanted to say and reflecting on the conversation tonight that you'd like to leave the audience with so you can go first okay I think at the end of the day it's about when you're working with anyone at Aboriginal people they're human treat them like you would treat any other person you know who you have respect for because now people have come to you and you have the privilege of actually having to hear of hearing their story and trying to help out and be curious um you know don't don't sort of shy away from things we're not sure ask but I think the thing about trying to deal with tricky situations is be curious about you know the people that are sitting in front of you but also the context of their lives and then trying to work through it with them rather than telling them what to do or what to do and so forth and I think by and large we do that but I think curiosity is the thing that sort of keeps coming back to my mind and also about respect for the person and the space they're in and the fact they've come to see you yeah and the other thing is it makes your own job so much more interesting doesn't it because oh yeah it does absolutely endlessly fascinating and often I love listening to people that feel a great privilege thanks so much Martel um Jeff I wondered if you have anything that you'd like to kind of finish up with you've got a couple of minutes you don't have to hurry oh awesome um I suppose the big thing for me is you know the my motivation for getting up every morning and and coming to work and I'm always happy to come to work it's not because home's horrible but um I've said many times you know like the great thing about my job is everyone gives me something they leave something behind and if I ever find that I'm not feeling that or getting that I realize that I'm off my game and if I focus on going well what is this person actually teaching me or giving me in the process um once I'm in that space I truly believe that I'm working with my client and you know it's as Martel said it's a incredible privilege um to be doing that you know we if you're working in this space and you're not working for the larger organization the if you want to charge a gap between what Medicare is going to give you well you're not going to be getting anywhere near the people you need to work with so what I don't get in you know a 30 40 $50 gap I get in what I learned so I think everyone can take that away and realize that it's a very enriched environment well then maybe we'll get more people doing what I do really um a kind of gentle challenge there Jeff it's really helpful and I I mean like this theme about um the human relationship has come up so much in the chat box as well and how difficult that can sometimes be when you're working in organizations that are focused on keeping the computer happy or filling out risk assessment forms and in the middle you're trying to do something that's more human than otherwise so we acknowledge that that can be a really difficult space and Lewis I'd like to um to bring you in and um I just love you to tell us another story what's been coming to your mind um oh actually I'm sorry to disappoint you no stories are really coming to mind um that's okay whatever you'd like to say Lewis look I I just entirely agree with with those closing points that Marshall and Jeff have made um and uh you know don't be frightened of dealing with with with Aboriginal people um um it's it's not as you know not as different as a lot of us like to like to pretend it is um uh the the keep in mind that the cultural gulf that we're asking you to cross is exactly the same cultural gulf that that's the three of us cross all the time um you know when when Jeff or Marshall and I are dealing with with with white folk then really you know it's it's exactly no different than if there's a white practitioner dealing with our folk um that that gap is the same that cultural difference is the same but it doesn't really get in the way and anywhere near as much as a lot of people think that it does um and and you know once you just start getting through those those little bits of issues and and just start meeting that person and start dealing you know meeting them at their point of need um and seeing what it is that you can that you can do to help them um um you know it just keeps everything nice and focused um uh the the uh you know I I am incredibly grateful that I have had an an extraordinarily fortunate life um uh in the world that I was born in um uh you know not actually truly being a citizen having a very variable right to vote um being part of fauna and flora um the privileges that came to me and and I think the thing I suppose the the one thing that I want to leave everybody with is when I look back at my life I know that the the thing the extraordinary thing for me is I have been the beneficiary of the of the generosity of a whole bunch of white folk who owed me nothing um they were just good people who tried to do what they could you know one young Aboriginal kid uh get his way through medical school these guys stood beside me and helped me through and and that you know that obviously had this huge amount to thank this this cadre of I'm sorry to be sexist but the truth is there's a cadre of largely old white men um who through through nothing more than just wanting to do that which was right and being good and decent people gave me a world that I could never have imagined that I could never have thought um was possible um and and you know so I would just beseech everybody on this on this webinar you know please keep that in mind that the that you you can have an extraordinary positive input into the the life of that young Aboriginal person um and just you taking that bit of time to meet them as a person maybe may just happen to be that thing that one magic thing that day that that makes them realize that I have value I have purpose um and and that might just be enough to give them a level of success that they could never have imagined Lewis thank you so much for that I I can't really say anything else so important so I just want to thank this review immensely for this discussion I feel really privileged to have been a part of it and um I know that the audience have really the feedbacks outstanding so just to finish up the formality thank you everybody for your participation we had up to about 660 people and I know that a lot what happened is a lot of people downloaded and watch it again later or for the first time so in the end there might be thousands of people watch this which is great so please make sure that you um complete the exit survey before you log out and it will appear on your screen after the session closes you will be sent a certificate of attendance for this webinar uh if you were logged in for it um within two weeks each participant will be sent a link to the online resources associated with the webinar and that will include the slides that Marshall had prepared so we've got some webinars coming up um supporting people living with borderline personality disorder is on Tuesday the 21st of March and um supporting families of people living with dementia is on Wednesday the 3rd of May 2017 we have not invented a backwards time machine I think that's just a typo so if you're interested in either of those please sign up at the mhpn.org.au website and also remember that we have local networks so the personal relationships are absolutely key and that is one thing that you know that's really why mhpn was set up and has really gone a long way to achieving that so there are local networks all around Australia you can see where they are on the link there and some of them have special interests as well so if you've got any interest in um those networks and the other online activities just go to mhpn.org.au um and before I close I think it's really important that we also acknowledge the consumers and carers who have lived with and lived with mental illness in the past um and who continue to do so uh and a lot of their experiences are also similar and I think what we've learned tonight will help us in our work with all of our clients and I hope also in looking after ourselves and our relationships with colleagues so you just I can't really thank the panelists enough tonight I feel quite moved by it so thank you everyone for your contribution and participation and um we'll see you again good night