 Hi, I'm Lucy Brogdon, Chair of the National Mental Health Commission Advisory Board. Welcome to this online conference. What an innovative approach to sharing knowledge and learnings right across the country. I understand there are thousands of you online ready to learn and work. The Mental Health Professional Network is truly taking a novel way to share wisdom with all of you and it's to be applauded. Working Better Together is the theme of this conference and it's a great opportunity to learn more about mental health in the military, about grief and loss and about trauma and adverse childhood experiences, all important topics that need our best attention and our best minds tackling these issues. We know the issues faced by our military and the risk to develop mental illness. We also know there are protective factors. This conference will bring together that conversation and work out how we best protect our serving people. Grief and loss affect all of us at different stages in our life. Understanding what drives that in people and how to best support them in their journey is really important. One of the frustrations for me at the National Mental Health Commission is seeing how stubbornly our incidence of mental health sits when we look at other non-communicable diseases. And what we know is that it is trauma and adverse childhood experiences that often lead people to a journey in the mental health system. If we can better address those experiences in childhood, prevent them, mitigate their impact and try and understand trauma, we set so many people on a more positive journey through life. Thank you all for coming online to join the conference and to be part of these important conversations. I wish you every success. Thank you. Hello and welcome everybody to this webinar on the military experience and mental health understanding the Nexus. And this webinar is being delivered as part of MHPN's inaugural online conference working better together. A very warm welcome to all of you who have joined us tonight for the live activity. And I should say that we've had an extraordinary number of registrations for this theme in the conference. We've had over 3,500 registrations for the military and mental health theme, which is an extraordinary number and I think a testament to just how important this area is for us as clinicians. A very warm welcome to those of you who are watching us later on a recording and of course a very warm welcome to our panellists who I will introduce in just a moment. First I'd like to pay our respect and acknowledge the traditional custodians of the lands across Australia upon which our panellists and our participants are located. And I'd like to pay our respects to their elders past, present and future. My name is Mark, Mark Karima, I'm a clinical psychologist in private practice and a professor in the Department of Psychiatry at the University of Melbourne and I've had a very long interest in the mental health effects of trauma and particularly in veteran and military mental health. And I've always been intrigued by the relationship between military experience and subsequent psychological health and well-being both good and bad. And so it's a great honour tonight to be able to facilitate this discussion and to pick the brains of our expert panel. So without further ado, let me introduce them. You've all had their biographies and so I'll keep it very brief. First I'd like to introduce Brad Murphy. Brad is a very experienced general practitioner coming to us tonight from Bundaberg in Queensland. He's had a fascinating career, joined the Royal Australian Navy at the age of 15. Six years later he retrained as an intensive care paramedic and then sometime later pursued a career in medicine at the age of 35. He has a very strong interest in indigenous health, in veteran and military health and in rural and remote health. So he's ideally placed to join us tonight and give us the benefit of his experience. Welcome Brad, thanks very much for joining us. Thanks so much. There are a million things that I could pick out of your biography that are fascinating but I'm going to ask you about something that's not in your biography but just intrigue me no end. When I was young we used to have a travelling fair coming around when I was growing up in England and I was always fascinated by the boxing tent. I was never allowed to go in of course but I thought it was amazing and I understand that you're actually involved in a boxing tent side show, is that right? Indeed I am Mark. In fact the last one that remains in the world so Fred Murphy would say, he's waiting at home with a cold beer for us at the end of the night. It's a pretty amazing activity to be involved in. I was going to say, I'm amazed that it is still going on anywhere but now you say that it's the last one in the world, I can well believe that, yeah. A great thing, I'd love to talk offline about that at some point. Thank you Brad. Our next panelist is Loretta Poerio. Loretta is a clinical psychologist and is the DVA mental health adviser. As well as a clinical practice, Loretta has worked in a whole range of organisations including the Department of Defense, SensorLink and Department of Human Services. She was Assistant National Director of BBCF, now known of course as Open Arms for many years and within her family she has close connections with both the defense and military community. So thank you very much for joining us Loretta. I'm afraid that we can't see you at the moment but welcome. Welcome anyway and thank you very much for joining us. Thank you Mark. I hear through the grapevine that you've got some interesting travel coming up. I do. I think about two and a half weeks now I'm going to Rwanda. I was there in 2017, I presented at a global mental health conference and one of the organisations I met has asked me to come back and do some training for their psychologist and counsellor. So that's what I'll be doing. I've been there for 10 days. It sounds an extraordinary experience. The state, the blindingly obvious, there's a country that has had more than its fair share of trauma, isn't it? But I did understand also that you're going to have a bit of an R&R at the end, is that right? Yes, so Safari is actually in the middle because of all sorts of reasons. We're going to Kenya and Tanzania. Some of the husbands will join me for that part of it. And that enables the counsellors and psychologists to have an opportunity to work on some of the things that we've talked about. And then the second part will be actually putting case consultations, case presentations and putting some of the strategies and techniques into practice. Sounds great. Sounds great. Well, good luck with that. Thank you very much, Loretta, and let me now introduce our final panel member, Duncan Wallace. Duncan is a very experienced psychiatrist, having worked across a whole range of civilian and military sectors. As a Navy reserve medical officer, he deployed to East Timor, to Iraq, to Afghanistan and to the Persian Gulf, as well as a number of humanitarian missions. Duncan is currently the psychiatrist with the ADF Centre for Mental Health at HMAS Penguin in Sydney. Welcome, Duncan. Thanks very much for joining us. Hello, Mark, and hello, viewers. I was chatting to Loretta there just at the end about having a bit of R&R, and I often ask people what they do to relax. You've got a fascinating hobby, I understand. Duncan, something to do with horses? That's right, yes. I took a polo a few years ago, and I'm loving it. And I got some chakras booked on Sunday, so really looking forward to that. I don't know that I should show my ignorance when I ask what a chakar is, but it's a game. It's an inning, in a game. And I just also mentioned that my experience with the boxing tent, I was up in Birdsville for the races and went to the boxing tent and ended up giving first aid to a young ringer who dislocated his shoulder when he lost about with one of the professionals. I know the boxing tent very well, and I'd be way too puny to participate. Absolutely. I think, yes, absolutely. But still, that's very interesting, and it's not surprising that there aren't too many of them left, I reckon. Thank you very much, Duncan, thanks to all our panel members. Let me just give you the participants a very quick orientation to the tech stuff. So to access the chat box, you've got an open chat tab on the bottom of the screen. You can put in comments and questions through that. There's a supporting resources tab. I would encourage you not to be looking at that at the moment. MHPN will send you a link to that after the webinar, and you can go through all the great resources in your own time. There's a tech support tab, as well, if you get stuck. And please do at the end, when you do your exit survey, please give us your feedback on how you found this platform, because it's very useful for us. So let me just introduce this webinar series, then. DVA have commissioned MHPN to deliver a series of 14 webinars in the broad area of Veteran and Military Mental Health. This is the 11th in the series, so there will be three more before the end of this year. And previous ones have included topics like PTSD and anger and sleep and substance use and so on. And if you haven't seen those and you'd like to, they're all available on the DVA at Eve's website and also on the MHPN website, so give them a look. Tonight's webinar is going to explore the nexus between the experience of military service and mental health issues and we'll be using a case vignette, a chap called Tom, who you've all had a chance to read, to act as a jumping off point for our discussion. I should say that in two weeks' time, at the same time in the evening, on June the 4th, we will be revisiting Tom two years down the track. So we'll have a different panel of experts and we will look at how he is two years down the track and all the various different issues that are raised by his presentation at that point, as opposed to now. So that will be a good thing to stick in your diaries for two weeks today. And just while I'm in advertising mode, let me say something about next week. Next week we're doing a session on the implications of veteran and military mental health research for clinicians. And as a kind of starting point for that, we've got an interview with Professor Richard Bryan to discuss the various kind of recent innovations. And I forgot to check before we went live tonight, but my understanding is that that video and indeed an audio version will be available within the next day or so from the conference website. So if you're interested in that, have a look over the next week and join us next Tuesday for the panel discussion of experts looking at the implications of that for clinicians. Anyway, let's get back to tonight. You've all had a chance to read Tom's story and I'm sure that it rings a few bells for many of you. Tonight we're going to use his story as a jumping off point, as a way of kind of exploring some of the issues associated with someone at Tom's stage in his military veteran career, as it were. Each of our panelists is going to give a brief five-minute presentation about the issues raised by Tom's case from their particular perspective and then we'll broaden it out into questions and discussions with everybody. And hopefully by the end of the webinar, you'll all have a better understanding of military experiences and particularly how they might affect the serving member or the veteran at home or on deployment or during transition or indeed in their life as a veteran. We hope that you'll have a better awareness of the kind of indicators and red flags that veterans serving members might present with. And as a result of both of those two, of course, we hope that you will have a greater level of confidence in terms of helping serving members of the veteran. Okay, so without further ado, let me hand over to our first panelist, Brad, to talk a little bit about his reactions to Tom's story from a GP perspective. Over to you, Brad. Thanks, Mark. Just by way of sort of introducing this, the thing that really jumps out at me in what I do on a daily basis, in general practice, I have a practice that's pretty well focused on veteran health. I've got at the moment well into 300 veterans that I look after, which is about the ship's company of a guided missile frigate. The difference is when I was in the Navy that they were all healthy. And now I have patients of all sorts of varying degrees of mental and physical health concerns. And I think the big thing, when I was doing rural health some years ago, a mentor of mine was talking about the impression about country towns. And a lot of people go, I've been to a country town. And he used to have this saying about if you've been to one country town and you've been to one country town. And I think that rings really true for me with the veterans. My own experience around the military was I joined at 15. I was very young. I joined straight out of year 10, so I still haven't finished high school. And I left after six years. And I served during the Great Peace at a time when there weren't any conflicts, thankfully. But that didn't mean we didn't train for them. And if anything was to happen at the drop of a hat, we would have deployed accordingly. And so the thing that really strikes for me is that there are people on very different timelines so far as the ages at which they serve, the length at which they serve, what they serve through, whether they serve through peace missions or humanitarian missions or inactive service more recently. And therefore, they come with similar but different concerns. And from my own perspective, it's really great because as an Australian trained doctor with military experience, it gives me instant rapport with the patient. But part of my introduction is to say that, you know, while we share some experiences, each of our journeys are very different. And I don't expect them to understand mine nor me theirs. And I think that's really important as we move forward. I think the other thing that sort of goes on here is that one of my mentors in Bunderberg some years ago was saying, why are you doing veterans health? They're a dying breed. And I mean, sadly, I suppose, they're certainly not a dying breed. I mean, I'm being inundated by a new generation of veterans that are coming back with all sorts of physical and mental health disturbances. And, you know, you don't just inherit the patient, you inherit or the veteran. You inherit the wider family and, you know, the partners, the children, the likes as well. And what comes out of Tom's story is that, you know, his wife Sonia has had her own coping mechanisms during his various service, and it extends back to her father as well. You know, she's had a lifelong exposure to military deployment, whether that be, you know, working within Australia, working away from home, working overseas. And so she's learned to run the family on her own. And I think that's, you know, that's really important to think about. So Tom comes home and all of a sudden he feels disenfranchised from a family. He doesn't fit in. He's got his own coping mechanisms on how to get through the day as well. And so I think that we need to think about those when we're looking forward. One of the really important things that comes out for me that I see on a daily basis is the opportunity through open arms to actually refer the partners and the children into the open arms process. You know, accessing care can be an expense. And if people are struggling, you know, having access to the likes of psychology services through open arms can be a real bonus. And through our practice, we have a psychologist working out of here. And as an opportunity, we're actually able to use the open arms process to engage her. And that means that she gets the opportunity to care for these people and work with them in a practice where they're actually quite comfortable. So it also assists me and my team in building that rapport and that comfort status with the veteran and their family sort of wider, you know, moving ahead. The other thing that I'm really aware of is that I have a patient at the moment who's going through a terrible strife. And he was a young fellow when he joined the Army. He came from a very well-to-do family, had a great education, certainly wasn't experienced on the street in the life, went off on deployment to Afghanistan, and got himself in a whole range of trouble while he was over there because he witnessed events that he was told he couldn't get involved in because they weren't allowed to get involved in local politics, understandably. As a result of that, we prepared this fellow, we trained him up to a heightened state of awareness and response, and then we bring him home and we don't necessarily turn that situation off. And even if we do, I don't know that we turn it off well enough to give people the skills to be able to re-engage with civilian life. So as a result, he got into a situation where his partner was assaulted and he started to hit the fellow who did that and didn't know when to stop and ended up in prison. And I just find that the greatest travesty that this great guy and he's just such a gentle meat sort of guy, but he saw a rage and responded in a way he didn't know how to stop. And we're working through that at the moment through PTSD training and retraining him generally so he can get his life back. And it's really wonderful to go on that journey with these guys, and I see some of that in Tom's story moving forward. Just moving forward, I think the thing is there's a whole lot of resources that I see as a veteran on Facebook as well. So there's the Overwatch program, the Veterans Promise program. There's a whole lot of stuff where the veterans are actually out there doing things to support themselves. So the Overwatch program, for argument's sake, is overall three services, but there is an Army and Air Force arm of those. And the idea is that they have people on the ground. Locally, there are people in Bunderburg. They can call me if there are clinical things that need to be sorted. And if someone gets into strife, it's actually about trying to get veterans involved in veterans' care and getting them to somewhere where they get access to veteran-friendly service. And I think that that's really important. So there's a lot of services out there, but you've got to get people to places that have some understanding, have some appreciation. And if they don't, at least that they're open to gaining that because there's a lot of resources available through DVA, but general practitioners and the community generally, finding those can be a real challenge. And I think that we can certainly work towards ways to make that better accessible. And we certainly are. And my experience of DVA on a daily basis is that the guys are really keen to find ways moving forward. A lot of the veterans come with tainted views of DVA over the years, and rightly so. I mean, it's been quite an arduous task in some ways. I was going to pick up on that, actually, Brad, in just a minute, but can I ask you just perhaps one more minute, maybe? Yeah, sure. And I think they're important things as we move forward to look at how we engage people through that process. And I think the other thing moving forward is that the thing that I notice is that there's a very significant similarity, I think, to the work that I do around work cover in that often the process of getting people through their claim for entitlements through DVA can be very much like work cover where people are actually having to deal with things that bring up issues around PTSD and the like. It often keeps them unwell until they get an endpoint. And I think so as a result, the pathway for me, certainly, in getting someone to an entitlement decision with DVA can be very different to actually engaging with them on a pathway towards getting clinical outcomes. And I think it's worthy of knowing that. And also, I advise the veterans as we go through that, that part of this is that they have an emotional connection with this and they've got to go through an administrative process and turning that off can be really helpful on the way through, although it's very difficult. So I think that working them through that, guiding them through that, I find that it often takes a while. But if you spend the time with them, it's very rewarding. And on a daily basis, I certainly see that. And my practice is certainly moving forward by taking on veterans as we move ahead. So it's great stuff. Brilliant. Thanks, Mark. Thank you very much, Brad. Thank you very much. And I'm sorry to sort of hurry you along there. There are a whole range of issues that I'd love to pick. Well, we will pick up on actually in the discussion that you've raised there. So I will come back to you and expand on a few of those if we can. We need to move on now, though, because of the time. And I'd like to perhaps hear something of a psychology perspective from Loretta, and perhaps even something about what some of the research might tell us. So I'm not sure whether we've got a picture of you at the moment, Loretta, but either way, can I hand over to you for your perspective? Yeah, absolutely. I think... I don't know what's happened to the picture, but... So in terms of engaging with a veteran, there's a lot going on for Tom at the moment. There are multiple levels of loss. And also to look at what is happening for Tom in terms of his transition out of the Defence family and that the... I think the understanding that we're dealing with a particular culture and a family. The belongingness, the strong mateship, the strong values of professionalism, loyalty, integrity, courage, and teamwork. And very much a collective culture where the team is certainly emphasised by the individual. So it is something that, as practitioners, we really need to be mindful of, that we need to learn how to speak the language. So it's... Sorry, I'm just trying to get the camera on. There you go. I hope you can see me. So it is about... I'm acknowledging that there is a different culture. There's a loss of identity. There's a loss of family. There's a lot of family and what we could try. You know, the in-group, out-group. And that this can often raise issues of feeling threatened and a real reluctance to accept that there is a change that's coming towards him. So part of this is recognising the bomb but also acknowledging and recognising the service to his country. In terms of the losses, as I indicated before, that there are multiple losses here. If you look at his family of origin, so we need to look at what is happening for Tom on quite a number of levels. The other, I think, here is understanding that for many people, what we have is very much a... In transitioning into the defence force is a high level of training. They're trained to react to threats and to be focused on threats. So as Brad said earlier, that their body is on a different thermostat. Their thermostat is actually up quite high. And in new situations that withdraw the... You know, being isolated, the coping strategy of using alcohol, the disruption to sleep, all these things tell us that there is dysregulation. And part of that is... The part of engaging with Tom is about understanding that this is a normal response and that he has been... And this is what a lot of people do tell us that are transitioning out, is that you've trained us to go to combat, to have these very high... You know, in these high-tempo situations, but you don't train us how to reintegrate back into civilian... into the civilian world. So it is important to prepare Tom for change. And it's interesting that in the UK, they actually talk about a cultural awareness training for the civilian world. And that's... And it's an interesting, I think, something that the Canadian armed forces are looking at, quite a lengthy transition training course for all people transitioning out of their defence force. So part of engaging with someone needs to be mindful of the culture, be mindful of talking defence language. And there are... So it's about motivating. How do we look at the pros and cons for Tom of continuing on the path that he's on or looking at usually, you know, I suppose acknowledging and accepting that change is happening and that how does he prepare for that shift? What are the skills that he needs to have? How does he engage in his family of origin? So it's his current family. So these are the conversations. And it's also about education. And this is where the transition and wellbeing research program is really important. We know that family and friends are really critical to bring people to treatment and to seek help. But we also know in terms of the defence culture, there is a strong sense of I can do it on my own, I'm invincible. And so there are a lot of layers of training and expectations and values that really... We as practitioners really need to be mindful of how that is actually impacting on person's ability or I suppose... I don't know what the word is. They're feeling of safety with us as practitioners. Do we understand? We know from, again, the research that military people do engage these are with practitioners and with services that they feel are veteran aware. And that is really critical. I think that we understand that that's something that we need to be educating ourselves on. And so the cultural awareness training is not just for people leaving defence, but also for people working in this area to understand the cultural nuances that are going to help us take... Be that bridge, I suppose, for members leaving defence to help them through and to create a sense of purpose and safety and also expectation around what being in the civilian world is about. We understand that cities for defence personnel are difficult in terms of how they see the civilian culture. So it is important to really be that bridge for them. And also, I think, involving family members, we know, and as I've said before, we've, from the Transition and Wellbeing Research Program, the Family Wellbeing Study certainly indicated that... And the Pathways to Care that support is really critical. And we'll try and pick up on some of that already. Can I just give you just one more minute, perhaps? Yes. So, again, it's knowing the research. Dr. Paula Davovich's research on transition and she looks at the key issues of identity and values and sees the transition out of defence as a third stage of development. And so, which is a great, I think, a really useful way of seeing that transition piece. Access to treatment, I think, hopefully that will come up in the discussion. And that's it. Lovely. Okay, thank you very much, Loretta. Thanks very much indeed. And again, there's a whole range of questions there that I would love to follow up on, and we will in the discussion. Thanks very much for that. But at this point, I'm going to hand over to Duncan to get a psychiatry perspective and perhaps a current military perspective. So, Duncan, over to you. Thanks very much, Mark. So, when I looked at Tom's case, what the factors that stood out for me were the withdrawal, his withdrawal from the family, the occurrence of repeated disturbing memories of a stressful past experience, feeling ashamed and nervous and irritable and the insomnia that he was managing with alcohol, concerningly. Plus the history of a disabling musculoskeletal injury. All of these factors, I thought, were suggestive of the presence of a middle disorder and should alert the clinician that he was experiencing significant problems. So, looking on the next slide, this led me to construct a differential diagnosis of possible conditions that he might be experiencing. One or more, and these include chronic post-traumatic stress disorder, major depressive disorder and alcohol use disorder and adjustment disorder with anxiety and depression secondary to his severe ankle injury and panic disorder or generalized anxiety disorder. And remember, panic disorder, panic attacks can sometimes be the first presentation of PTSD. So, it's important to always keep that in mind that it might be part of another condition as well. So, looking at my next slide, part of my response was to really hone in on his strong sense of identity in the Army. And this is especially drawn from his father-in-law, who was really his father figure because of the early loss of his father with a severe alcohol problem and the loss of his mother as well. So, I was also particularly concerned at the feelings of shame at his potential loss of his military identity. And those sort of feelings can sometimes be associated with suicidal ideas. So, that was starting to flash a bit of a red alert for me as well. I think it's important not to underestimate as Loretta was showing the strength and meaning of military culture that's imbued in members of all branches of the Defense Force. And if we look at my next slide, it shows a copy of the Australian Army's contract with Australia. And this is a mantra, as it were, for Australian soldiers. So, while you're reading it, I'll just mention what the mother of a young soldier that I saw as being discharged from the Army with a very severe mental disorder. He'd only been in for three years. But she said to me, when's he gonna get over this soldier stuff? And I had to break it to her that this soldier stuff runs pretty deep. It's pretty much on the hard drive. And when you see this contract with Australia, you can see the intensity of the feelings that are associated with that. So, then my next slide then also emphasizes the importance about military culture and how clinicians need to be competent in understanding military culture in assessing and treating serving members and veterans. It's not essential, but it's certainly desirable. And learning about it is not as difficult as you may think. It's obviously easier for Brad and I because we've had many years of military experience. But if you're a clinician without that sort of history, then there's certainly other ways to pick it up. And I think the best ways to do so to ask your patients about their work, their role in the military in a bit of detail, what exactly did they do? What sort of hours did they work? Was it shift work or did they have long hours of on-call with it being called back for ceremonial duties eating into their own personal time? How much time did they have to spend away from home out in the field by exercises? And that's irrespective of their history of deployment as well, which is part of the full service history that I recommend that you take the next step. Finding out what recruit training was like for them, what was their initial employment training when they learned to become an infantry soldier or a radar operator, whatever. The postings that they had in different garrison, Australian places, and then their deployments overseas, the nature of their deployments, whether they were combat or humanitarian assistance or peacekeeping, and also a bit about their history of promotion, whether they were promoted early, whether they're promoted late, or whether they're promoted not at all as a patient of mine who'd been a private for 33 years, which also says a little bit about the members as well. When your patients start talking about in-acronyms and using jargon, ask them about it. What do they mean? Don't let it slide. So I think if you take that approach, you'll be able to fully engage with the patient and you'll pick up a great deal about the military culture as well. Thank you, Mark. Thank you very much indeed, Duncan. Yeah, I think that's a really interesting point you've ended on there, that you don't necessarily have to be an ex-service or a veteran to treat veterans, but you do have to have that kind of understanding and cultural competence, I think is a very nice way of putting it. Can I come back to one of your slides though? Where you were talking about, you looked at sort of differential diagnoses, and I guess we're saying that at the moment, Tom may not even meet a diagnosis. Of course. Some of the things that we might look at. And given that the diagnosis is not black and white, it's not necessarily either you've got it or you haven't, people talk about sub-syndrome or conditions and particularly sub-syndrome or PTSD. Can you comment on that, I guess, and whether that's relevant for us when we're looking at military and veteran population? Yeah, thanks for asking that question. I think it's really important and the more we know with the high quality research going on, that sub-syndrome or PTSD is important. So what is it? There's no specific definition, but basically if somebody has been exposed to trauma, they've got a degree of symptoms and a degree of impairment, but they haven't got enough to make the cut as it worked to become a full case of PTSD. Now we know that this is still significant to have sub-syndrome or PTSD. We know that it's associated with also emerging features of altered neurobiology, and it's also associated with a range of physical health conditions like musculoskeletal conditions, respiratory and GIT disorders, in comparison to control groups as well. And significantly, it's also associated with delayed onset PTSD in military populations especially. It's also in civilian populations but in military populations especially. So we think it's really significant and we think that it's an opportunity to perhaps engage in some early interventions and early treatment as well. Yeah, good. Okay, thank you, Doug. And I quite agree. I think it is important. And I guess as clinicians, we need to be course about the way we use diagnoses and not assume just because someone doesn't get across the line that they don't benefit from health, as you're saying. And as we go to talk about, Tom, in fact, that I think will come up repeatedly in our discussion. So let's move now to the broader discussion if we could. And I'm gonna ask our panel members to jump in whenever they've got something to add or indeed to provide an alternative perspective or indeed to disagree with each other. That's perfectly fine as well. In order to do that, we've had a number of questions from our participants. And I'd like to thank you very much indeed for all the questions you've sent in. We've got some very intriguing ones there. We will try to get to as many as possible but please bear with us if we don't necessarily get to your question. As a start though, and really as a bit of fun, what we've done is to take four questions from the selections you sent in. Four questions that kind of represent, if you like, some slightly broader themes. And so we're going to run a kind of poll as a bit of fun. So you can see on your screen now what the questions are. So the first question is, what can the general community do better? Sorry, yeah, to support members and veterans. And I'm gonna use my prerogative as a facilitator there. To expand that one, to include not only the general community, but also what can DVA do better? What can ADF do better? What can perhaps the ex-service organizations do better? The second question is, what types of cancelling models do veterans favor? And I'm gonna expand that out to look at treatment more broadly. What helps, what works? Not only just what veterans favor. The third one is about, how do we better advocate for and support veterans who don't fit the traditional hero story? I think that's a very interesting question. And I guess what it's doing is raising a whole lot of issues around the expectations we have about what a real soldier is, or what a real man is, or what a veteran should or shouldn't be like. So that's the third one. And our fourth one is, again, an interesting one about, what are the differences in the impact of combat experiences versus humanitarian experiences? And I'm gonna expand that out to have a discussion more broadly about the different types of clinical presentation that we might see. So can I ask Renan now to start the poll, please? And we'll let the poll run for 30 seconds. You've got 30 seconds to vote. It looks to me as though you've already started voting, actually, which is fine. I'm not promising that we will necessarily do the one that comes out top first, because it might depend on doing things in a sensible order, but we'll certainly make sure that we spend some time looking at the one that you want most. So if I can ask Renan to bring up the final results, and it looks to me as though the most popular, by far, actually, is the one about what kinds of treatment do veterans favor. And as I say, we're gonna expand that one out a little bit to look more broadly, I guess, at treatment and intervention. Look, I think that maybe, and I know that we should start with the second one, but why don't we start in order there and look first of all at what the general community and what DVA can do better, and then that will slide us naturally into treatment and we'll spend a bit of time on that. I hope that's okay with you. So let's move on then and have that discussion, if I'm just gonna try and move the slides back one. If we could have that discussion now, and perhaps if I could ask you, Brad, first of all, we talked about the difficulties of engaging people with DVA, I think you mentioned this in your talk, and generally speaking, if we look at Tom, he's someone who seems to want to kind of isolate himself a bit. I'm wondering whether you've got any comments, Brad, on, from your perspective, what we can do to help Tom or someone like him engage, both with the DVA and the broader community? Yeah, thanks, Mark. What really strikes me, I think, is we can get caught up in various, how models fit, whether it's CBT or the life, but what these guys, the guys and girls respond to is trust and feeling safe. How you deliver it, I don't think really matters in one respect, if they actually trust you. And I've had some really great experiences with guys recently, we had our own dawn service here at the practice this year, and I had a fellow come along to that. He came and saw me two days later on a Saturday, and he said, you know, I really feel safe here, and I wanna talk to you about what actually triggers my PTSD. He's been a patient of mine for two years. So I think that if you can work towards, I mean, you know, I've got some relationship there because of military experience, but the relationship really is about taking the time, and it's often time in general practice you don't have, but you've gotta take the time to get to know these guys, take the time to listen to the stories of the families along the way, take the time to get involved with the children as well, because, you know, these guys are all very pertinent parts of this journey. And I think DVA, we need to continue the great work that's already happened. We need to get this message out there. I think that there's all sorts of ways we can do it. I'd love to see a practitioner or information line set up so that the guy in Targa Minda West could ring up and say, geez, I've got this veteran, I really don't know what to do with him. Can you give me a bit of a hint? There's so many things you can do. These guys can get anything they want in lots of ways. You can put an argument forward. Things like antidepressant therapy if you've got a range of things that have a word. There's a lot of stuff that's not on the PBS that if you can demonstrate that they've tried various things, you can get things often that aren't available. And I think if we can do that and do it well, it's great. Yeah, absolutely. Just to pick up on a point that you made there very quickly, support from poor clinicians. I would remind people that the ANZAC Center at Phoenix Australia has a support service for clinicians that you can just ring up and get expert advice from experienced psychiatrists and psychologists and whatever. So that is there. But I think the really important point you make there, Brad, is about the need to develop the therapeutic relationship, to develop trust with the person in order to engage them. Can I come to you, Loretta, and ask, because we're talking about how the community can kind of support. Ask more broadly about families. Brad in his talk actually gave us some nice examples about the challenges faced by families. But do you think it's important to try to engage the family and perhaps even peers in supporting the veterans through their process? Absolutely. Critical. And I think that this is one area where through the department is currently going through what we call transformation. And we are using co-design principles to engage both veterans and family members to design the programs. And also defend as well. And so we're looking at ways that we, that where the department can engage. But also as clinicians, we understand that how important that is because it is that support. And research has told us and has been very clear that it's the family members that reorientate or family and friends that reorientate the person to the civilian world. And so they are a really important breach to that reorientation. The other is, I mean, peer support is also becoming very important. And we as open arms are actually in the process of rolling out a national peer support program. And they've had great success in Townsville, Sydney and Canberra with utilizing peer support workers. They're almost like a transitional object. They help engage veterans wherever they are in the community. They go to hospitals. They work with a soldier on, mates and mates and other ESOs who are critical in this pathway as well to enable them to get to a point where they feel safe, where they feel, I suppose, the motivation to then take that next step. And so the peer workers, as the family and friends, help get veterans to the help that they need. So they're really critical in that pathway to care. Yeah, absolutely. Well, just taking that one step further, Duncan, if I could bring you in, I guess that a lot of guys like Tom seem to fall between the gaps, as it were. And I'm wondering, are there any more structured ways that we can try and stop that happening? Any ways to stop losing them from the system? Well, firstly, I'd just like to comment on what you were asking Loretta about. I think it's really important to have the spouse in the assessment. It's a routine part of my clinical approach. Always ask the spouse. And remember, it's not always a wife because we're getting young female veterans. It's very important to get their partners in, at least for the assessment. And I certainly always have the door open to them attending subsequent consultations. So coming back to you, the other question, how do we stop people falling through the gaps? It's really important that people get a GP before they finish, before they transition out. I think that's really important. There's a special DVA item number for an extended consultation so they can sit down and have a look at their whole record and have some mental health checks as well. I think that's a really good start. I think the ex-service organizations, there's quite a number of them now, which are also appealing to younger veterans, which are doing a number of outreach programs to try to link them in as well. So there's no foolproof answer to this. I think the other thing that Veterans Affairs is engaging in is trying to get people become a DVA client from their entry into defense and right from recruit school and to make everybody known to DVA rather than having to put their hand up at times when they may be not predisposed to seeking help. Yeah, absolutely. In fact, I was going to ask Loretta there. Is it likely that Tom would have had any contact with DVA while he was still serving? Yes, yes, we have... The DVA has on-base... We call them O-Baths, representatives, so they are actually on defense bases and they provide information about services that DVA can help them with. And of course, when some people are leading the defense, they have compensation claims they want to start. So what's... And one of the... I think the things that we have improved a lot is that trying to get the whole health record and the compensation claim in the... through our system before they discharge. And that is a thought, as you can imagine, of tension and worries for people. So through what we call My Service, which is a new portal on the DVA website that has that conducence straight through claiming as well. So the O-Baths are great open arms on some bases as well. And they, of course, run the Stepping Out program for transitioning members. And there's also a trial at the moment for transitioning members called SOAR, which is an attention reset trial that is happening on some of the bases as well. Okay, so there's a whole lot of stuff there available for them. And hopefully, I'm sure all of this stuff will be available in the resources section for participants when they come back afterwards and have a look. But I guess it is about, and perhaps come back to you, Brad, to talk about this, that it is about helping people to be aware, as you said in your talk of these various services, because would you agree that, I guess, as Loretta was saying, that the process of applying for a DVA claim can be very stressful for veterans? Yeah, you're absolutely right, Mark. I mean, one of the things is, if you look over the longevity of time, people find out about DVA at various times and often very late in it. So if you look at some of the Vietnam veterans, certainly, you know, there was no such thing as on base advice and the like, I actually did rent a department within Navy that sort of coordinated people out of the service on medical discharge. And I learned about DVA after I got out of the Navy. So, you know, I think there's various experiences. And so while DVA is really good at some of the resources, some people don't know about that. Makes and makes are awesome. There's a whole range of them, and I don't want to give preference to any one of them, because they're all really good. The problem, I suppose, for me in the rural area, and I used to be very remote, but now I'm regional, but, you know, they're available in different areas at different degrees. I've got people that still travel back to Brisbane to get their health care with our practice. And makes for mates is very strong, and the stuff that they're able to achieve there is awesome. There's a lot of, you know, group activity around Bunderburg that allows them to gather and have coffee and tea and bring the families along. And, you know, it's exactly what the guys were saying. You often get the truth from the partner. It's a different sort of truth. There's obviously his, hers, and the truth. But, you know, that role is really important, and without that, you're only getting one side of the story and you're just an opportunity. And I think the other thing that's really strong, I just wanted to make a point about, is that people have these very interesting experiences, and PTSD is probably one of the big ones for me, that people often start to address it after they get out of the service, because identifying and acknowledging you've got a problem with PTSD in the service means that your career is likely to be stilted and held up. And I've got lots of experience with that. A lot of people who use open arms, as it is now, because that is still a confidential way of accessing care. But sometimes their first discussions around PTSD happen after. The other thing is the diagnosis is really important for their DBA entitlement. It's not important, from my point of view, in that, some of these guys are in trouble, and that's all that's really important. Putting a label on it isn't as important as recognizing the need to access care. Yeah, I think that's a very important point. And as you rightly point out, our needs as a clinician are not necessarily the same as the needs for compensation or indeed if we're working in medical-legal settings and the diagnosis becomes very important. But that point you raised is exactly what I was going to ask you a little bit later. So you foreshadowed it, and I might still come back to it about the difficulty of acknowledging these problems while the purpose is still serving. Let me, though, come back to the question that people did specifically look for an answer for, which was around cancelling models, therapy models, treatment, whatever you want to call it. And Loretta, let me ask you specifically about the question that was on the slide there, which is do you think the veterans tend to favor or avoid certain types of cancelling or therapy? In your experiences, are there some that they're willing to engage in and some they're not? No, I think it's an interesting question because it really does depend on the relationship that once you do establish safety, and we have said that quite a few times tonight, that if your client or patient trusts you and they think that you know what you're doing, then that is a big factor. The other thing, as a clinician, sometimes I could be, you know, the cognitive processing therapy just doesn't, it's just, so I go to EMDR. One uses whatever is going to work. And so as a clinician, I think we do need to have a broad toolkit of evidence-based treatments that we bring out and, you know, as one client, he wouldn't write, but he would draw. So I bring in, you know, so we'd have a session and he would sit and draw this particular scene and would really engage with it. And he was probably, and so he would love coming to sessions. So it's really, as long as, and that emotion regulation is really critical, and I think it's really where what I'm seeing, even talking to psychiatrists and psychologists, but that is really a key thing for any one that we engage, which is those skills. And that's March Alina Hands or it's the Stair Program. Yeah, absolutely. I agree. I agree, Tally. And I guess what I would like to do tonight is not go too far down the track of treatment for established conditions, although I take your point about the types of intervention that you write. I'm really pleased, though, that so far we've been spending a lot of time talking about the various other supports and services that are available to Tom, even though he might not necessarily be getting involved in strict mental health care. Although I do agree with your point there about emotion regulation that it seems to me this is something that at this stage he could benefit from a lot. Brad, if I could bring you in, you know, because you're the GP, you're seeing Tom first, given his presentation, do you think it's premature to be linking him in with a specialist mental health service at this stage? Or what do you think the next steps might be for Tom, Brad? I think it's about talking to Tom. I mean, I do in that I have a range of psychologists that I refer to that are veteran friendly. I've got a range of psychologists that are veteran spouse friendly. I've got psychiatrists that I use via Skype and they are just awesome and one of those allows me to then gear them towards a PTSD course. And surprising how many of these guys are guilty, well, I don't have PTSD, I can't do that course. And yet they just give them the skills to re-engage with community. And, you know, you just wouldn't... I've been out of the Navy for 35 years and it could just as well be yesterday. And when you look at the way that people engage and the fact that these guys often feel guilty about what they've seen, what they've been involved in, you know, various things that have happened through their service. And, you know, I have the same experience with my service and with the ambulance and I don't want to share that with my wife. I mean, I don't want my frame of reference to become hers. I mean, it's, you know, it's a terrible thing. I carry that and I've dealt with it. I don't want to share that with my wife. So who do I talk to? And I think this is an opportunity to establish that safe ground and whether that's with the GP or with the psychologists and likes that you refer to, depending on what you've got. When I was out of bush, there were no psychology referrals available. Now, of course, with technology, there's access to a lot of this stuff and I think we need to make ourselves aware of what is available. And the other great opportunity that I've got is I get the chance to be involved. So if we do teleconferencing, I can sit in with the permission and obviously you don't go down that road without it, but I can be involved in that. And so we're all part of the same journey. People aren't telling the same story over and over and you become part of that journey and safety and trust that comes from that. And I think that is just invaluable. Yeah, absolutely. Just to put you on the spot, would you envisage giving Tom any kind of medication at this stage? Are you going to give him something to help him sleep? I'm going to hand over to Duncan in just a minute, but I'm interested in your perspective, Brad, for the GP. Something to help him sleep or are you going to start him on any antidepressants? I think it's about getting to the bottom of all this and particularly around the alcohol use. It's about what he's comfortable with as well because a lot of these guys will say, well, I don't want to take pills. So I think it's about getting to a point where you're comfortable. I think that if you had 10 patients in the room, the answer would be different. I think sleeping pills have a role. It's not one of my favourites, but it absolutely has a role. Sometimes you need to make sure that you engage the family in making sure that the administration of these is done safely if you think there's any chance of self-harm in the life. So I think it's a case-by-case scenario, but I think there's absolutely a role that the patient has to be on board because otherwise they won't take them. The other thing is that there's a great opportunity here, some bolter for argument sake, great opportunity to sell that to the patient on its basis of its side-effect profile of helping around pain. And I've had personal experience with it myself. I've had a spinal fusion and been on some baldy years back and it actually was tremendous at helping with my back pain. So I think that there's opportunities here to look at side-effect profiles. We sell it around insomnia and helping them sleep with the likes of metazepine. So I think if you know your pharmacopedia that's available to you, there's great opportunities to sell that. So it's not just about, I think you're mad because if you've got the trust, it's not about that, it's about helping their symptoms. Yeah, sure, absolutely. And I guess a repeated theme that you've said a number of times, Brad, but I think others have said as well is the importance of intervention being a collaborative process. You're sitting down, you're talking to your patient or to the veteran and perhaps their family and working out what's best for each individual case rather than one side-effects all. So I agree, I think it's a very important point. But can I bring you in, Duncan, as the psychiatrist and the expert here? Yes. I'm interested in your thoughts with someone like Tom about whether medication is appropriate and or whether referral to a specialist mental health person is. Sure. I wouldn't be there at medication just yet. I think he needs, as Brad was saying, he needs a comprehensive assessment with some screens, like a PCL. If you really think it's PTSD, then I would be looking to get a capstone, a clinician-administered PTSD scale to get that diagnostic accuracy involved. And then I think you explain the range of treatments. The evidence base shows that psychotherapies have a strong evidence base, so that'd be my first options if they don't have a comorbid depressive disorder and emphasizing the trauma-focused psychotherapies or EMDR are number one before coming to the medication options. Yeah, OK, sounds great. And just for the benefit of participants, I've got a sneaking suspicion that Tom's not going to do very well, and that in a couple of weeks' time, we're going to be talking quite a lot about those kinds of treatments. So if you're interested in those, come back in at 4.9. Loretta, how important do you think some kind of occupational rehab is for Tom? Is it important to try and help him to get into some kind of meaningful employment or, you know, voluntary or paid? Yes, it's one of the... And if you're looking at, I think, both Department of Defense and DVA, looking at more of well-being focus, which is, you know, the social determinants of health, we know employment, and also that new sense of purpose is really critical. So Defense has the Career Transition Centre, I think it's called. Our department has the Prime Minister's, you know, employment program, which has been incredibly successful and through the rehabilitation section within the department, we've had some really good success stories. But I think for Tom that in engaging, again, it's that motivation, where is the hook here that's going to get him to therapy and to help him look at planning, you know, where does he want to be in 12 months' time? And also to... And that's where that emotion regulation really needs... We need to get him into a state where he doesn't see threats at every turn. So, you know, get that thermostat to a point. Whether that's bringing the wife in, we know with open arms that a lot of... We have a lot of people coming along for relationship counselling. So it is that purpose, but employment is key. Yeah, yeah. OK, let's move on to the third question, which was about the perception of, you know, not being a hero or not living up to the expectations or whatever. And Brad, you made some very important points earlier about the difficulty of acknowledging this stuff while you're still serving. Perhaps I'll bring Duncan in here. Is that still a problem, Duncan? Do you think is it still an issue that people would be frightened about the impact on their career to acknowledge mental health issues? Yes, I think it always is. People worry that they're not going to make that next deployment, they're not going to be promoted. What will people think of me? People will think I'm weak. I think that's a constant concern and it's certainly been borne out in the recent pathways to care report from the Transitional Well-Being Research Program from the Centre for Traumatic Stress Studies University of Adelaide. So that's a constant problem. But having said that, we know that those barriers to care like that can generate stigma, but we know that people who do have mental disorders have the highest rates of stigma, which is very strange. But we know that often that doesn't hold them back from seeking care. So it's a bit of a mixed bag. It's one of those sort of go figure situations. It is, isn't it? I agree. It's much more complex than it looks at first sight, isn't it? Yes. But nevertheless, I think anything we can do to reduce stigma. Brad, if I could ask you, in some ways, Tom is kind of a fairly traditional kind of veteran. He's a male. He's sort of, you know, young middle age. He's heterosexual. He's got a wife and kids. Do you think, though, that the veteran population is changing over the years? Are we seeing different kinds of veterans now? We're seeing different kinds. I served in the Navy at a time that we bought a cruise ship and renamed it HMAS Jarvis Bay so that we could have female toilets and showers. So they were the first sailors, female sailors to go to. So and homosexuality was something you kicked out for because the Russians might find out and get all our secrets. And in my case, they would have known all of my antibody prescribing, I suppose. So it's absolutely changed. And so it's a different world. I mean, you know, when I went on deployment, I'd send a letter home to mum or whatever you and take three weeks turnaround. You know, people aren't just emailing anymore. They're typing from overseas and the like. So, you know, the opportunity to stay in touch with families different to some degree. So, I mean, we're in a very different world and I mean, the opportunity to use that both within and after the service I think is, you know, really a great opportunity. And these guys are coming out with skills that, you know, that I'm... Well, they challenged me to keep up today. Yeah. That's right. So we are looking at a much broader kind of population, perhaps, than we have in the past in terms of gender and age and a whole range of other things. Let's go on to our last question, which is an interesting one. And I'll deal with the specific question in a minute. Before we address that, can we have a more general chat about the presentation and Duncan, you had a nice slide about what you saw as being the warning signs in Tom's presentation. Is there anything that you would add to that that perhaps you didn't see in Tom's? What are your key go-to warning signs when someone walks in? Well, I think it's levels of symptoms. Certainly psychomotor agitation, rebels of risk, risk of harm to self, risk of harm to others. And also, when they have comorbid pain conditions, which is pretty common, as Tom, with a musculoskeletal injury, very often the guys particularly have a number of painful musculoskeletal conditions, which in themselves will disable them. Throw in an alcohol problem and if you get that complex comorbidity, that's when it's really starting to become very concerning. Yeah, absolutely. I think it's a really important point, isn't it, that interaction between physical injury or physical pain and then exacerbating the PTSD in a kind of vicious downward spiral is so important. So yeah, I agree, and Charlie. Okay, Loretta, do you have any pet sort of signs that you would look for as being warning signs when someone walks through the door? I think that the avoidance coping strategy and the, again, we're talking about continuum. But one of the things, I think that we've fallen into the trap of and it's been talked about around the research, the transition and wellbeing program into the substance syndrome or so, there really is something here that says, do not think that just because a person does not make criteria that we shouldn't be doing from early intervention and that's really critical because we know from the research that it does develop over time and it does escalate after transition. And of course, if you medically discharge, then you've got multiple factors there that indicate that there is needs of support. So I'm very, and we're getting a stronger evidence base around prevention, but of course, it's often difficult to research that area and what has been that early intervention, we have very strong evidence base that if we intervene there, we will get results. Absolutely, and of course, that is our challenge with Tom, isn't it? Our challenge with Tom is to see if we can intervene now and prevent that downward spiral into chronic long-term disabling kind of condition. So if we do what you've all said tonight, I'm sure he's gonna be okay. Can I just finish it, Brad, just very, very quickly? Do you have any particular red flag signs that you, over and above what people have said so far that you would be particularly concerned about when someone walks in? Two quick points for you, Mark. I think the telltale sign for me, because I have patients that I see for a lifetime, I hope, the telltale sign for me is when they say, oh, look, there are other people that are more important than me, that you know, you're really busy. So you know, you see them, when they stop coming, that's my telltale sign. That's hard, because if they pull off the radar, you forget. The other thing is that complex relationship between pain and mental health, and I get that all the time, and I spend a lot of time talking with my patients around that, because it's about understanding that I don't think they're mad, I don't think they're putting it on, even if I catch them and I certainly have walking in from the car park, and then of course, walk normally, and then they're much more painful when they get in. The link between pain and mental health is really important. The treatment is very different, it doesn't mean it's not real, it's just that maybe instead of increasing their narcotics, maybe it's about giving them fish and chips on the beach, and I think once you can sort of acknowledge that and help them along the way, because narcotics aren't the answer, and these guys have got 40 years worth of treatment, you know, you can only increase the narcotics so far before you actually get to the real issues, so we try and get to it early. Yeah, good, very good advice, very good advice. Who am I gonna pick on? I think I'm gonna pick on Duncan for this particular question, which was, come back to the one on the slide, which was, what are the differences in the impact of combat experiences versus humanitarian? Duncan, I think I'm right in saying that we don't have anything in the way of solid data, but what's your clinical, do you have any clinical experience in that way that leaves a difference? Yeah, look, I think you'd need a literature, thorough literature search to drill down into this, and I think you could expand it a bit more by having combat operations, peacekeeping operations, and humanitarian assistance operations, and I think it's all about the nature of their experience, what they're exposed to, so you get people in an infantry unit are gonna be exposed to a number of firefights on a particular deployment, you got people in special forces, they might be exposed to 30 or 40 firefights during the same deployment, and you get people in a cruisey peacekeeping operation, and then you get somebody who's been to Rwanda, which has got extremely high rates of PTSD because of the nature of what they're exposed to, and again, about humanitarian experience, humanitarian assistance operations, what we were exposed to, for example, on Operation Sumatra Assist, is very different from what the Indonesian TNI soldiers were exposed to who did the actual body recovery and burial of a quarter of a million people. So I think PTSD is gonna be a little bit different because of the nature of the exposure and the nature of the exposure varies significantly with the different types of operations I've described. Yeah, absolutely. So we can't draw any hard and fast rules, I think it's absolutely right, and I'd love to start getting into the area of things like moral injury and rules of engagement, but we can't, so we won't go there. Unfortunately, we're running right out of time. I should say that I have been allowed to run over by a couple of minutes because we had the video at the beginning, but I am conscious that we're running out of time now. So it was a fascinating discussion. I would just like to ask each of our panelists if they would like to give any final take home messages for participants, just one or two dot points. Brad, anything that you would like to leave our participants with? You're on mute, I think, Brad. Ah, there we go. Three quick points for you. I did say I was challenged by the technology. Everyone's different. Everyone's different. The same as any other aspect you get, but everyone's different, treat them as so. The veterans part of a team, don't forget the family and the peers. And the other thing is that if you're not sure whether you're making a difference, I guarantee you are. And I got a Christmas text from a mother who said, thanks for giving me my son back, who otherwise wouldn't have been here because suicide, a very serious suicide, attend. And I think, you know, you just got to take that time and spend the time, get to know them and, you know, do what you're taught. Yeah, it's great. Yeah. Thank you very much, Brad. Thank you. Loretta, any take home messages from you? I think that, well, for me, it is about reiterating that to think about trauma around the cumulative impact and also that I agree with Brad and reiterate, I think that it is about, it's an end of one, and that we need to take a long-term view and the support that is required in a system. So we look at families, friends, whatever family is defined as. And I think that also that team approach, so as practitioners, we're entering a very interesting and I think exciting stage because of any mental health as well. And I think that as practitioners, if we don't work together, then we'll continue to see people potentially fall through the cracks. OK, good advice. Thank you very much, Loretta. And finally, Duncan, any quick take home messages? Yes. Understanding military culture is important in treating service members and veterans, but it's not absolutely essential. You can learn how to do it. It's not as difficult as you might think. Learning how to do it is best done through asking the patients about their work and taking a full service history as I outlined before. OK, thank you very much, Duncan. Thanks to all just a few very quick closing comments. The first is to remind you that MHPN run multidisciplinary professional networks so people can get together and share ideas and support each other and referral networks and so on. And they particularly run veteran focused ones. So you can see on your screen there a list of places where the veteran focused networks are. Just click on the join a network document if you would like to be part of that. And if you would like to start one, just get in touch with MHPN. As we said, there are a whole range of resources associated with this webinar and MHPN will send you a link to those resources. I strongly recommend that you go through them and have a look because there's some really useful stuff there. And I always give a particular plug to the Atty's website from DVA, a whole lot of good stuff there for practitioners, for veterans and serving members and for their families. So don't forget to check that out. Please make sure that you complete the feedback survey before you log out. It's really important for us to know what you thought of tonight and to get your feedback about it. At this point, though, I'd like to thank both DVA and MHPN very much for their work in putting this webinar on. I'd like to thank Redback very much for their support for the whole conference. I'd very much like to thank our panelists. So I thought we're brilliant tonight. We could have easily gone on for another couple of hours. So thank you very much indeed to Brad, to Loretta, and to Duncan. And thank you very much indeed to all of you, our participants, for your engagement and for joining us tonight. And certainly, your active engagement makes it a whole lot better for us. So thank you very much and good night to all. Good night.