 Good evening and welcome to tonight's webinar brought to you by MHPN, titled Coordinating Mental Health Care for People Experiencing Suicide Bereavement. Now, this is a very big topic and we have had lots of interest from a whole lot of people and we can see on the chat box that people are already talking to each other and letting us know where you're from all around Australia. My name is Lina Grady and I'm a community psychologist based at the Australian Psychological Society, usually, I have the pleasure every now and again of facilitating one of these mental health professionals network webinars. I'm very pleased to be here with you this evening and this topic is one that I'm particularly interested in having worked in schools and in communities and also about to finish my Master of Suicideology at Griffith University this semester. So really interested in the topic and really looking forward to our discussions this evening. I'd like to begin with an acknowledgement of the traditional custodians of the land and recognise that we are coming from all sorts of places around Australia based here in Melbourne, the Wurundjeri people of the Kulin Nations are our traditional custodians. I'd like to acknowledge their elders, past, present and future and acknowledge their contribution to our communities but also acknowledge for topics like suicide is one of the issues that they're facing significantly. So wanting to acknowledge that and bear that in mind as we think about this topic although our case study doesn't have a particular focus on that. It's a topic also that we need to be really mindful in terms of looking after ourselves and when we do webinars we know that they're fabulous ways of communicating and to be able to participate from the comfort of your home or your office but when we're tackling a topic like this we're also mindful that you're sitting at home perhaps and you might be on your own and don't have your normal supports around you. So right up front I want to acknowledge that this is a difficult topic and I can see from the chat already that people are starting to share some of their own very recent experiences around suicide and we know that people who have an interest in this topic are often impacted as all of us can be at any particular point in time. So we have resources that are available to you that you hopefully have been up to see which do have some information. So some websites and some phone numbers of course. So please think about what it is that you're needing where you're at right now and what's going to be most helpful to you and we will touch on this again towards the end and bear in mind that if you're feeling like you're getting too much you can shut down the chat box. You can even leave us tonight and get the video recording later and watch it another time when it might be better time for you. So just take a moment to really plan what you might need to do to look after yourself this evening is really important. I mentioned that we have a panel that we're going to be joining us and it's going through some information and you can see there and you would have hopefully already seen from their bios that you've got a very experienced group of people who are very interested and experienced in this field. So I'm going to go through one by one and just ask them a very quick question just to introduce themselves. I'll begin with Graeme. Graeme Fleming, Dr Graeme Fleming works in rural Australia and has a long history in suicide prevention and responses in the community. So Graeme, from a GP's point of view, how important is the GP's role in this work? Well, I think it's very important no matter where you are, often GP's are the first protocol but for rural GP's it's often the only protocol and GP's need to develop the skills to be able to deal with suicide and support the people who are grieving as a result of that suicide. And for more importantly, I think also to educate their communities about mental health and the things that we can use to prevent suicide. Okay, thank you and we're going to be hearing from you and some of your further thoughts about that. So thank you very much for joining us this evening and already can see the interest in the long years of this work that you've been doing. So looking forward to hearing more about that. Jane is our next panelist and Jane is a social worker and has been working with people bereaved by suicide for a long time as well. Jane, what is it about this work that is important to you or why you've been doing it for a while? May I think it's really important to provide the right sort of compassionate care for people bereaved by suicide, not just at the beginning but through many points throughout the process in the months and years afterwards. And most of what I know I've learned, I've been privileged to learn from people who are bereaved and who have taught me how to best support people. So I look forward to sharing some of those learnings tonight. Fantastic, thank you. Jacinta Hawgood is our next panelist and again Jacinta, you've been a psychologist and you've been working in research and practice with clients for a long time. You set up the master of suicidology course that I've been doing for the last three years. So again, what is it that you find rewarding about suicidology as an area of work and research? Again look, the most rewarding part I would have to say is really the privilege, the learning journey that comes from, I'm quite fortunate I guess, being able to integrate my lecturing role with both research and my practice. So that for me is the most rewarding element, being able to see how important evidence is and research and understanding what we do but also more and more I guess I'm really appreciating and learning how to put lived experience from the very people I work with in fact at the core and essential to everything that we do in all of those domains. Fantastic, thank you and really looking forward to what you're bringing as well. So already you can see that we've got a range of people with different professional backgrounds but also different places of work and different ways of working and I think that's what I love about these webinars that we bring that together and the idea that we've all got something to share and by working together we can really support clients and grow the knowledge and understanding that we need. So lastly, there's certainly not least, I'd like to introduce Dr Siva Barla who's a psychiatrist. So Siva has published papers in the area of suicide and you have that particular interest in collaboration between health professionals when supporting clients or patients. So why is this collaboration between health professionals so important to you Siva? Well suicide is something that really intersects a number of health systems, child, adult, general practitioners, counsellors, work and so on. So really a good wraparound service and making sure that we don't miss anyone who are left in the aftermath of suicide is important. Fantastic, thank you. I guess also in terms of self-care that we're not feeling like we're the only ones that can be doing that wraparound at a client or a patient that we're actually sharing the load and also helping ourselves in that way as well, looking after ourselves as best we can. So a great message and we'll explore that some more as well. So thank you to the panel and we'll return to them in a minute. We'll just do a little bit of ground rules and technical information. I see already people are getting some technical support and asking some questions and looking like a lot of that's been resolved which is great. Hopefully you are aware of how webinars work. We're kind of getting lots of webinars so they're available to us these days and if you've joined the MHPN webinars before you'll be very familiar with this. So the chat boxes people have been already exploring is able to be seen by everybody. So just bear in mind that treat it like a face-to-face activity even though we can't see all the faces, we know we're there. So yes, just think about that as if you are in any other kind of group setting and things that you're sharing and supporting each other and I can see that's happening already. If you find that the chat boxes is a bit much and it can, especially with lots and lots of people that we have tonight, it can get a bit busy and it can be a bit distracting. You're trying to listen to what the panel is saying, you're processing your own thoughts and feelings I guess as well. So you can ignore that or you can come in and out of it. You don't have to worry about that. Technical support is there. So technical issues you can put in the chat box and that will be responded to as you would have seen. Or there's also a fax tab that you can click onto or the Redback Help Desk is there with that phone number so you can write that down in case you're needing it and if there's a significant issue affecting everything you'll be alerted as we have announcements that we can alert you to that. So hopefully that doesn't happen. It's something that does typically happen just in case. At the end, feedback is important and NHPN do take that very seriously and continue to grow and develop these webinars to make them as successful as they are. So at the end, a pop-up will come with a feedback survey which would really like you to take the moment to complete and give us that feedback. It's really very helpful to us. So if you can do that, that would be great. So hopefully that's kind of covered off on all of the technical and how the webinar will work. We work our way through the panellists, have five minutes each to share their best kind of information that they can share in that short time even though they have lots more to say and then we'll open it up to some questions and answers and we've been given many, many questions because there were so many people registered we had lots of questions so we've been through that and we're really wanting to stick very much to our case study and our topic so that we can make it as deep and meaningful as possible and not jump between a whole lot of topics so there will be some questions that we won't be answering because of that and we'll also keep an eye on the chat and if there's anything else that's coming through there we'll pick up on those as well. So that's how the webinar works but really trying to get through as much as we possibly can. These are the learning outcomes. So really looking at how do we create this safe and supportive environment for people seeking care for suicide bereavement so thinking about what is it that we can do as practitioners and thinking about how we set that up implementing key principles providing an integrated approach and identification, assessment, treatment, support of people experiencing suicide bereavement and of course we've got one case example which is one example and we know that as I've already mentioned if we're talking about Aboriginal and Torres Strait Islander people if we're talking about LGBTI people talking about others with many complex needs and different kinds of experiences there'll be layers of other things that are happening so just being mindful of that but the principle hopefully that we share tonight and thinking about what suicide might bring in terms of bereavement that might be different to other kinds of bereavement hopefully gives you a really good solid starting place and then from there thinking about the other aspects that might be relevant to particular clients that you're saying. We're also wanting to identify challenges, tips and strategies in providing a collaborative response to assist people who are experiencing suicide bereavement and we've already touched on that and important for doing that. Just a reminder of the case study hopefully you've had a read through of that but just a bit of a reminder of the case study that we're going to keep coming back to you tonight. So in the case study Darryl, 38-year-old married father of two children who were aged 16 or four years old took his own life one month later and we're kind of positioning it at this point in terms of where our starting point is. His wife Melissa is struggling. She's lying awake at night with lots of negative thoughts. She's returned to work but she's finding it difficult to face people and she's feeling ashamed with the experience that she's had in terms of the suicide. Melissa feels alone and confused in this space and we've got some examples of what that means in terms of relationships and how people around her that she had been close to or behaving. Then one of the children who's the six-year-old boy is laughing out and Madeline, the four-year-old girl is crying a lot and missing her dad. So Melissa goes through the DP and she's looking at needing some kind of psychological care so that's where we're positioning ourselves and I can see that we've got 920 people online so far so it's a fabulous number of people joining us. We're really pleased that you are but it does highlight to us the importance of this topic and so we're really very conscious of trying to stick to the case study, give you some information and share as much as we can in the time slot. So let's move on to you now, Graham, and get your perspective from a general practitioner the sorts of things that you've been thinking about with this case study. I work in a town of about 3,000 souls and of over 10-year period we had 13 suicides and that was an awful lot of counselling and a terrible time and I understand how Melissa felt with a sense of despair and helplessness and confusion as a result of a loss of her husband and grief from suicide is a devastating event and it is probably not much different according to Barrick and others about the grieving process but it's certainly tainted with guilt and shame and stigma but the point is that recovery does sort of a curve and it's a bit like a deep wound, painful wound that gradually heals over a period of time and when Melissa presents, she might be looking just to see if there is someone that might help her and the first thing I really want to do is to establish rapport. I really want to know where she is in her grieving process and I really want to provide some hope for her that there is a future for her and she will eventually recover somewhat even with a scar at the end of the time. The second thing that I really want to try and do is to deal with the thinking that occurs in people who are about to suicide and to do something about the guilt and shame and suicide occurs when there are three things operating. The first one is when there's a sense of hopelessness and despair and the second thing that's required is a delusion that suicide is the only or the best option and the third one is a determination to die and here's my first take-home message that determination to die often isn't present in severely disturbed people because their brains are so shut down that they can't motivate themselves to get themselves out of the hole they're in and it's only when they start to recover that they get motivated before the depression lifts. So it doesn't really matter whether you're using psychotherapy or CBT or one of its variations or antidepressants or just a holiday. This is a warning time for three weeks people need to be watched like a hawk. You might wonder why people jump off lines when they're on holidays. The second thing that I really want to do is to allay guilt and I would point out to her that sometimes there are warning signs in the case of Darryl. There were warning signs. He was going downhill and he had taken to alcohol. He became more despondent and I'd point out that it's really very, very difficult to persuade men to go and seek help because it's a sign of weakness and it's not supposed to be the defenders of the family. It's becoming easier with education and with cardiac disease for men to go to get their cardiac symptoms sorted out and when you need education to convince men that that's the same sort. The other thing about Darryl is he's been drinking and you probably find that 50% to 80% depending on the side of people who commit suicide have alcohol on board. It's salient to remember. Sometimes there aren't warning signs on the surface but when you look back in the past you can actually see there were pointers to that particular suicide and sometimes there seems to be no explicable reason no matter how hard you look at the victim you can't find a cause and it's just that the severe mental pain they have or the delusion that the world will be better off and they believe it's an act of bravery to take their own side, their own life. And so the second take home message I would like to give to everybody is that intrusive suicide thoughts are a medical or a health emergency. It's no different from a 60 year old man who in actual fact has got central chest pain and is getting that on an intermittent basis. That needs assessment and management immediately not sometime in the future. The third thing I'd point out to her there is no right or wrong way to grieve and I would examine where she's in the grieving process and point out that what's happening to her is absolutely normal and she's not going mad. I would really be keen for her to find a support person in the network or a network which is essential for her recovery. I would suggest very strongly get some support from an empathetic GP which is extremely helpful and I would offer her my services on a weekly or even more often basis for the first three or four weeks and bulk bill her so she's not going to have any more financial problems. The third thing I would do is to suggest to normalise her routines and she discusses she feels a bit robotic and that's not necessarily a bad thing because at least it gets the routines going, takes the minds off things and she starts to make some headway to the future. I'd try and persuade her to get greater access for friends and families, grandparents, her siblings for help for the children and maybe to provide a father figure which is now missing in the family. And finally I would say look we need to think about some future approaches and some future projects and all the GPs who are listening will be saying how do you do this in 20 minutes or 15 minutes and you can't. It's no different from when someone collapses in your surgery with a heart attack you have to stop what you're doing until it's sorted out and if that takes an hour so be it. Usually the staff can sort that out and the future sort of assistance I would suggest she requires the advice of the financial counsellor or a bank manager. She needs to talk to the principal at the school about the welfare of the children and for them to be watched carefully and for the school counsellor perhaps to be involved. She should perhaps find an independent counsellor or a psychologist for herself but in real areas that is exceedingly difficult. It may take 6 to 14 weeks for an emergency to be seen and I would expect her to unload her feelings and frustrations with a psychologist as also with the GP to assist with the social considerations about how she's managing with her friends and what's going on in life. Some assistance with Centrelink and for that reason a social worker would be useful but again they're often not present in rural communities and the final thing that I would suggest is a conference with family and friends because this way we can get everything out in the open people tend to have rumors or think about what might have happened and what hasn't happened and who caused it and all that sort of emotional stuff and sometimes if everybody has understanding why people suicide not necessarily why Darrell suicided but why people in general suicide and what we can do about it that is extremely useful and my town we use public meetings for a postvention and they are very very helpful and successful so much so that we had one 19 year old boy committed suicide he played a wonderful game of football was best on ground for the day went out to a 21st party that night had some alcohol and was found hanging in the shed in the next morning all the young people in the town didn't go to work, didn't go to school they just stood sort of around grieving and the citizens came to me and said what do we do and I said let's have a public meeting we'll hold it in the football club rooms one young man was heard one of the rebellious feral young man from the football club was heard to say as he walked out we must mate, we must start looking after each other they were music to my ears so I think that public meetings after suicide are very very useful scenarios and the final thing I would like to say is care for the carer often there's a policeman or ambulance officer who's come across the scene it may be a neighbour and we need to actually look after those as well see them in a week, see them in a month see them in three months and I was tapped on the shoulder by one of my junior colleagues who said the reception staff think you're not your normal self and you need some help you might need some help and I can arrange that for you and once I got over impudence I started to think about it and she was right I did so look after yourself as well and that's my final take home message thank you Graeme, it had so much that you were sharing there and I think some of it is around the complexity of what somebody faces when life has changed in such a significant way so thinking about the sort of things for Melissa now that there's the grief and the emotions but there's all of these practical things as well and then the community and we know that people protective factors are people coming together when at the time like this people might come apart when you actually want them to be there but a public meeting can be a way of bringing that support together which you explained very well Hunter Institute has some resources that do talk about those meetings so it would be great for people to have a look at that as well because I'm sure if you haven't done that before or you're wanting to do it it would be really good to be thinking about how do we do it and how do we plan for that and who can help us with that so those resources are really helpful so thank you very much Graeme starting already to be thinking about what does this mean to me what does it mean to my community do we have school counsellors at the school do we have financial counsellors that people can access and do I know that do I have this at my fingertips if somebody comes to see me so every community will be different but what is it that you can access is an important message there so thank you very much Graeme now we're going to move on to Jane and Jane is going to give us a social worker perspective so over to you now Jane thanks hello everybody thank you the first thing I wanted to highlight is that suicide bereavement takes in the months after the death takes place in the context of the medical legal investigation of the death so family members have contact with and grapple with systems like police, colonial systems hospitals, morgue, forensic systems funeral director and at the same time there's also the bureaucracy of the death things like having to produce proof of death to the bank to Centrelink to other agencies and the investigative aspect of the death can really delay some of those bureaucratic processes it can take many months sometimes to get a final death certificate sometimes even longer sometimes a year or two family members often express that the investigation and the bureaucratic processes add another layer of trauma and stress on top of the death itself so I think we need to be mindful of the impact of that and provide that sort of the psychosocial support and help through that and it may also be that Melissa needs to understand the mechanism of death itself and the question about whether Darrell suffered in those last moments may be really burning and important for her at different points in the process and being able to talk to her GP or a medical social worker or other healthcare professional about what happened and trying to understand that may be really important we know that being able to spend time with a person's body after a loved one's death can be really important and especially when they provided choice information and support around that but it can also be really confronting and many family members experience finding the person's body and it's important for us to help reassure Melissa that her vivid memories of that her nightmares and intrusive thoughts around that are very normal in the context of her mind processing what she saw and how she feels about that and to provide that support and help through that and perhaps down the track to also if those memories and thoughts don't dissipate which they most often do to provide some really focused support around processing that with the aim of sort of integrating that story of the death event as Robert Neymar talks about integrating the story of the death event we also want to help Melissa make sense of what's happened and that might be accessing reports but it might also be just talking over and over what happened and trying to make sense of that for her the duality of the investigatory process often means it's very intrusive and lots of questions are asked but at the end family members can often be left feeling very let down that the questions they had weren't answered so processing that story and having some help to do that is really important I guess one of the main areas as well is that people grieve in the context of their family and that we need to be family sensitive in our practice in terms of providing support not just to the individual but to their family and the community in which they live and for Melissa that means providing support to help her explain and support explain to her children what's happened and provide support to her in terms of that explanation we know that children tend to grieve in bits and pieces that they perhaps need frequent checking in about their questions they may not focus on those questions for very long it might just be a brief period of time but to have that opportunity to the children and to provide them age appropriate information which may and that they may have questions and reactions and feelings that vary down the track and that children often don't have particular strong emotions and sometimes they do and that both of those things are normal in that and really I think providing support is about a model of perhaps being an expert companion through the process Jack Jordan talks about expert companioning from the moment at the desk right through the months and perhaps the years that follow not everybody has that ability but the GP or other services may be able to offer that service where people can dip in and out of the support that they need so that they can receive the sort of different help at different points in the process Jane and I think again giving us some examples of what might be a bit different from a death that is a suicide that involves perhaps lengthy investigations and inquiries and things that might not happen with other kinds of death so I think giving us some really good insight with one of those questions that was coming through was how is suicide death different what would bereavement be like so there might be some legal aspects and things like that that might make it different. I liked the expert companion I thought that was an interesting way and over time which of course for some people might be something that can build into their role but for others it might be a challenge so then again who do we know that might be able to play that role or how can we build that system of support around a client so great ideas there as well so thank you and we'll pick up on some more of those in the question then to time as well so thank you very much so Richard you now just in time so moving from DP to social worker to psychologist so interested to hear you're going to pick up on some of the research and some of the evidence around it as well so we'll hear from you as well so thanks thank you Lynn so look I was just going to touch very briefly firstly on a couple of background issues firstly about the terminology then about who is affected in a conceptual way and then what does postvention look like so firstly the coin that the term postvention was best coined by Schneidman in 1969 and it was to refer to both the therapeutic the educational and organizational activities that occur in the wake of a suicide and when we talk about bereavement in regards to bereavement by lost by suicide it's important to understand that the bereavement consists of both grief or grieving and mourning so grief is the reactions in the case of suicide with a whole range of reactions which we can talk about subsequent to this and mourning is the vehicle or the mechanism through which we grieve and so I've got a few terms there suicide survivor and bereave by suicide or suicide bereave and suicide survivor is something that is used a term used mostly in the US to refer to those who've lost someone by suicide whereas bereave by suicide is a term which or suicide bereave that mostly in the literature the Commonwealth countries refer to and we go to someone who's lost someone by suicide and this isn't necessarily too important but it can be important in terms of research so that we can more accurately classify and communicate and of course there's people who don't like to or have referred to themselves as not wanting to be referred to in these ways at all as well and then I guess one way in reflection of the complexity of the phenomena of bereavement and the very individual trajectories that people experience when they're bereaved by suicide we have more recently proposed by Julie Surrell from America and her colleagues a suicide survivorship continuum and if you want to look up this article it provides a bit of a multi-layered understanding just again to help inform policy and practice a little bit better and on this continuum the very most if you imagine circles with the small circle in the middle and the largest on the outside four circles the largest would refer to in this continuum those exposed to suicide which is roughly about 40% of those in a survey that might talk about being impacted in some way are those who have been exposed to suicide and that refers to people who have either known someone who's died by suicide or who have witnessed a suicide themselves and it doesn't necessarily mean that those who have witnessed a suicide such as for example train drivers etc just because they haven't known the person well won't experience also the next circle in on this continuum would be those who are affected by suicide and those who are affected according to this continuum are those who have significantly known the person who had a significant relationship or an intimate relationship but also may don't necessarily have to include a partner or family member can refer to friends or peers as well and then slightly in from this layer are those suicide bereaved in the short term and these of course whilst the groups get smaller these of course may refer to those family members as well intimate others also work colleagues etc in regards to the short term effects obviously those where acute responses or services might be of help and then at the very centre of the continuum is suicide bereaved long term and there's about 30% of people who over a long period of time start to experience more complicated experiences that cause quite debilitating impacts on them and usually I guess mostly in literature referred to as though suffering from complicated grief and they experience much more and go on to develop much more severe symptoms and problems so I'm so sorry here we go I'll just move on to the next slide in response to those experiences postvention is something as I referred to before that has a vision this is a visual pictorial diagram of looking at not so much a ripple effect if you like but a tsunami effect and I just put this together to reflect try to incorporate some of Julie Threlin colleagues continuum of understanding but also to demonstrate how there's a huge huge impact from one's suicide as I'm sure everyone's very well aware and what we know is what might be helpful in terms of response and see I've put their clinical individual type responses which might benefit those more seriously or intimately affected but those who are exposed with a much wider level at the community level or subgroup such as school settings work settings etc may benefit from both individual and public community responses that's just a quick visual of how we respond so applied to the loss of Darryl and I must say that this case study is really I thought quite a really good one because it depicts what in my practice at least what might come to me in terms of someone's presenting problems so Melissa's this experience it would be quite common and if we use the survivorship continuum to target our responses I would imagine that in this case study Melissa the children say the parents of Darryl and the friend Karen in the first instance would be seen as those affected whilst workplace colleagues in school peers etc still may be affected but would also be considered and those within the rugby teams or other extracurricular activities or other social clubs of Darryl that may not necessarily have known him well but have heard of the suicide would be an exposed group and the continuum goes into a lot more depth in that article and so I'd encourage you to have a look at that and then to look at the impacts that have experienced all these different levels and clearly these impacts can be quite fluctuating there's no linear journey in terms of brief responses but the reactions particularly from Melissa at least that I've read in this case study are very much rejection shame guilt feeling a burden particularly over time experiencing some anger and really struggling with the management of those feelings and also trying to the numbness etc experience in the acute phases also means that the processing of those is limited and immediate moment as well because she's trying to deal with the children's responses and very conscious of those and that leads to the questions that you also saw there that Melissa has asked about what sort of why didn't he seek help etc and so the biggest question that we've seen in the literature is why even if people are able to put the pieces together that answer to why is very difficult to find information for and it's very difficult and I think that needs to be acknowledged very much so that it's a very common question and of course there'll be physiological reactions and impacts withdrawal and a whole range of things I'm sure we'll discuss later developmental differences regards to the children need to be considered they require additional differences they require the truth factual basis especially ages of six and four they're important that needs to be considered and as I said regards to the previous slide the context there's multi layers of response that's required and how we do this if we're looking at postvention responses is we need to be proactive and not reactive so in other words they should be in each community a postvention plan that is known by many many stakeholders including these key groups of schools, different levels of the community where when such an event occurs there's able to be easy access and knowledge because the biggest finding in a lot of ASRAP's research is that people who briefed tell us that they didn't know where to turn and they didn't know what might be the right help was their response normal etc etc and so you know I've put a list of resources there that I know we'll talk a little bit more about but in the essence of time I think I just wanted to quickly select two slides which I don't have time I know to go through but I really wanted to put them here and it was to really show that of all the empirical evidence that we do have in the literature we know that general bereavement doesn't necessarily have any effective results from therapeutic interventions however those such as people who have experienced loss by suicide the high risk mourners so to speak are those who do demonstrate the greatest differences and positive results from having interventions such as these on the screen which you could I've put a few references there for you to have a look at support groups and group sharing others who've been through the same thing general group sharing and in some studies writing and narratives and storytelling is a really important brief and of course there's a lot more I'll have to close now but thank you for listening Thanks Jacinta so much to say such little time so it's always really hard to share a lot of information and I think what people often like in webinars is what do I do in my practice what do I take away and what can I implement tomorrow so I think this kind of information can be really helpful because you can look at that and practice there and say what are the sorts of things that I can do and then if there are some things there that might be really useful for the client who else can help and who might be able to provide that additional support or quite different support and I think the research is really important and we do want to be looking at what the evidence is we've got a lot of activity happening around the country in terms of suicide prevention and some research and funding that's going into a whole lot of new initiatives and really looking at how the research and practice can come together so I think it's an exciting time from that point of view but still a lot that we don't know and still a lot that we're learning and a lot of different situations and people responding in lots of different ways. There was one quick question around terminology that came through and Margaret has asked about those people who have attempted suicide and survived what language would be used for them and Jane has commented that lived experience would include people who are bereaved by the death of somebody as well as people who may have attempted suicide so that lived experience can cover both of those but any other language to center in terms of people who have attempted suicide and survived? Yeah Look I've spoken to many people obviously not just at post discharge from medically treated suicide attempts but those who perhaps have had aborted attempts meaning they themselves have pulled out of it or it has been an interrupted attempt where someone who's loved them or been close to them has fortunately been able to step in and the term more recently suicide attempt survivor is what generally is referred to at least in the literature so yeah but I mean again I'm very individual and I haven't come across anyone that I've worked with at least in hearing their stories that they have felt uncomfortable but I'm sure we have to be very sensitive the fact that there's some people who don't like to have a label not that necessarily use a label but I think it represents someone who's gone through such a significance and probably still in a fluctuating sense of time experiences those impacts Yeah so I'm definitely checking out exploring the language that people are comfortable with but being aware about language because we do and again Hunter Institute do a lot of work around media and the sorts of language that media use and often on Twitter you'll see them picking up on the pick up on the ABC today I saw this morning actually just on the language that's used and information that's shared so there's a lot of awareness around language and the meanings that people find around what makes sense to them I guess is part of that meaning making that Jane was talking about. I can see some questions which I'm going to have a look at in a moment but I'm going to move on to Steven now so thank you very much for your time we'll come back again to talk some more about some of those things so Stevie you're going to pick up on this and I'm hoping that some of the questions that people are asking you might answer anyway so let's hear from your perspective as a psychiatrist Well when I'm asked to see people as a psychiatrist it's really because of bereavement the morning has become pathological so the question is is this normal bereavement should there be some treatment provided particularly medication if I take a step back from this to explain that the research in this area is limited brief bereavement morning are such vague and profound constructs they vary across cultures they vary across families and individuals a metro rural area so there is no one size fits all approach and it's not a matter of medication or some form of therapy but it's really a journey that one has to enter into the patient ultimately suicide invites questions about the meaning of life or the meaninglessness of life what is it that pushes us forward and that in itself is the subject of another whole webinar I'm sure only a hundred years ago that Freud wrote the famous essay morning in melancholia said that morning was about a conscious most of the loved one whereas melancholia which we question is much more pathological and profound so this would simply when grief and normal grief is really about the other losing a loved one how that impacts on the individual their sense of self and their life and depression is much more about the self individual their self and their interpersonal function in some way so put them larger and I won't read through them because I think we're running behind on time and panel members read it but taking Melissa Prince in one month after the death of her husband I wouldn't be rushing any diagnosis diagnostic criteria for in the DSM five the latest iteration of the manual that the guide was used which is really expert consensus it's not to be all an end all but the latest iteration has taken bereavement out so it really leaves the judgment up to the individual mission to decide whether if this person after a sufficient period of time and that could be a month or 12 months there's no time specified if they meet all the criteria for major depression then that could be diagnosed and treated so in Melissa I'll be looking for a history of depression or emotional vulnerability that would heighten my threshold for diagnosing that and potentially treating it is a previous depression diagnosis that has applied treatment with antidepressant medication particularly is there substance use is there suicidal ideation those sorts of things but one month I would be cautious I wouldn't be rushing into any diagnosis if the year from yes we're still at a stage where Melissa's profoundly sad she's not sleeping she's not functioning well she feels guilty then I possibly can't say that and that goes to what just mentioned there are a percentage of people about 15 to 30 percent who have a much more sorry are you still there yes sorry so I thought I'd now just stop there and leave to the audience and you if you have any questions okay you're helping me make up time Siva very helpful is there anything in particular that you think is really important because you do have the slides there and people are asking if the slides are available they should be able to access in the resource with the resources so anything particular my slides are really taken straight out of the DSM-5 there's an ongoing debate really in the field of psychiatry about what is pathological grief what is normal grief what is depression and really the default position is to not medicalize anything for a significant period of time so 6 to 12 months should be allowed for the grief to resolve in various ways and normal support mechanisms to begin sometimes extra might be needed whether that family or community but really it should be up to the individual and I'll be working with Melissa here about what her needs what her wishes respecting and her decision making getting advocates allies and so on and it really depends on Melissa's background and family context yeah fantastic really important message I guess to really work and where is Melissa at and in the case study we're saying it was a month in we're saying that's very early you wouldn't want to be jumping down a path of looking at anything that was a real concern in terms of complicated grief or anything serious at that point but you'd be wanting to make sure she's supported and working towards understanding what's happening rather than even thinking about any of this at that point in time the temptation in all our paths to do something we're all trained definitions to act to do something but sometimes standing back and just joining the person on that journey is very helpful and also being very practical as the others have mentioned sometimes it could be something very practical just supporting her with accessing finances if the husband died without a will in the bank account during his name she could easily locked out and might have to go through the Supreme Court to get access to finance something as simple as that that can make a profound difference will help that need to be provided and supporting her through that journey rather than leaping in too quickly with treatment whatever sort that is and just allowing the process to unfold in a natural way I think I guess we're getting better over time at understanding the resilience of people and I think every panellist talked about that in one way or another with support and by helping people with some of those practical things people can be incredibly resilient even though there is something called post-traumatic growth in the psychology field it's not spoken about in the psychiatry field but that profound change in a positive way in the internal transformation as a result of traumatic experiences so it's something that we wouldn't say about the Melissa right now but helping her stay in that journey and later down the track reflect that some change a greater sense of meaning and purpose has connectedness to family a realisation of what our true priorities and life source might come about yeah great okay thank you thank you very much and yep the slides are all available so that people can look at those as well now we'll move on to the question Nancy and I've had a look at the questions some of them might have been covered already by SIVA which is great and some of them we're going to cover in the questions and answers that we've already planned for so we'll move on with that and then we'll see how we go with time so one of the first questions and one of the questions that's come up already in the whole list that we had from people when they registered but also I can see that the questions that people are asking in the chat tonight is around what to tell children so I've got a question for Jane and I think someone was asking Jacinta about what you mentioned about children as well so perhaps Jane and Jacinta could share this one so the question is how are children and young people best supported when they lose a parent to suicide so you already touched on this a little bit Jane but Jacinta I think you said something about telling children the truth and somebody's picked up on that so perhaps between the two of you a little bit more detail about what you might do if you were Melissa we're helping her work through options, what would you be saying? So if I might say a couple of things and then Jacinta might want to op in so I think the first thing is for helping Melissa understand the importance of making her space for her children to ask questions and to talk about how they feel or express how they feel and that might need to happen quite frequently it's not a great big one, great big conversation but a number of different conversations over the time and that it's important not to burden children with the expectation of certain emotions and family in extended family can often do that sort of try and say you must be really sad or you must but children often have very conflicting emotions around suicide and so it's important just to be able to not burden them with expectation around that and I think the framework of emotion coaching can be really helpful for really in bereavement where you provide an opportunity for the child to express what they're feeling and then tune in to what they're feeling and recognize the emotion as a part of an opportunity or learning or intimacy and listen empathetically and then importantly help the child have a label for what they're feeling and so you're feeling angry or you're feeling sad and it's okay to feel those things and then help set limits around behavior while also providing some problem solving about how to manage I think routines and boundaries are really important for children as they're navigating this and they create a sense of safety and security for children and helping Melissa understand how to re-initiate routines and boundaries and so it's important for her to involve others and ask for help as she you know we know that it takes a village to really help raise children and Melissa is now suddenly a single parent so being able to help her get the support that she needs I think provide often we want to come up with the right phrase tell a child of five or a child of eight I tend not to try and do that because even though it sounds really good when you can say a phrase like daddy's body stopped working or daddy made his body stop working that might work for some children but not for others so I think it's really important to try and be really focused on first saying what do you think happens instead and get their understanding and then go from there to start building a picture and their fears that they might have about what happened and finding words that reflect their understanding and meaning in the centre thank you thanks Jane I don't have too much more to add I think definitely the factual information is important and I definitely would start and this is keeping lived experiences central even for children where they can talk of course but is asking them what they do know about it and what are their thoughts around it first and particularly for mothers and fathers especially when my more experiences come from when their siblings have died so there's a lot of holding in emotions and we know from more recent research that all those communication pathways where we hold information or understandably because you're trying to manage your own feelings as well but that can actually cause more problems and for little kids I would first ask them do they understand what death is like when your body stops working but I get their opinion and perceptions first and then going to explaining the little ones who may not understand and we've had feedback from kids that have actually said that they didn't know what the word suicide was so explain them that that's when daddy took his own life so he killed himself or he didn't want to live anymore but with that explanation so giving factual information it's very important that you provide information around daddy couldn't cope anymore or your brother couldn't cope he felt like there was no way out sometimes when your heart hurts so much and in your heart your whole body starts to hurt and there's no way of stopping that pain at all that he saw that as the way out and the only way to stop that pain and then equally and necessarily spending a lot of time then on saying that for you this is going into what would you do to seek help particularly if they're a little bit older and making sure that people are well that the child or adolescent is very well aware of it's okay to seek help and talk about your problems this is what's so important and everything about you is so special and it's really really really sad we can never bring him back and going on to how to cope solving etc in ways that will assist that person to manage their feelings if they ever get to that point so and another big thing with children and we know they tell kids who weren't told when they were younger have told me in my practice that it has really haunted them they'll be very difficult for them not having been told and when they finally found out the answer that they felt ripped off in a sense and so I think it is important that we give factual information kids will fill in the gaps in their own ways they will hear over here stories from family members or cousins or friends or whatever and they will make sense of it in their way which can often be filled with myths or inaccurate information and so we want to make sure that they have the right information that we do everything we can to assist them to cope if they are in that same situation okay thank you it's obviously a question and I guess you're always working with Melissa on what she's comfortable and her making meaning of it as well in terms of how she approaches it but certainly thinking about it from the point of view about what we can expect children to understand and the impact down the track of sharing particular information and I can see in the chat that somebody has talked about the idea about a dad going to heaven and then waiting for dad to come back from heaven so children being quite literal as well so yeah very big topics I think for people so hopefully that's helped in the resources we do have some websites about talking to children about suicide so hopefully that will be useful as well looking at our big long list of questions and trying to keep track of what people are asking in the chat as well one of the questions that's come up quite a bit is around the lack of services and perhaps particularly in rural areas and I know we've all kind of touched on it a little bit but perhaps Graham a question for you is around how do you kind of manage within the rural and you did touch on it but in the rural community or it might have been a metropolitan community as well where we have systems where you can see people for a period of time or you can see a client but not necessarily the whole family when in fact you might think there's a benefit to the family any thoughts about that in terms of how we can kind of be thinking about working in a way that's meeting the needs particularly when we're talking about Melissa needing support over a long period of time but our practice might not enable that or a rural community might not have access to referral sources any thoughts about that Well there's a couple of things I would say firstly the general practice is the usual first call and often the only call you may be able to get access to a rural nurse or you might be able to get access to a rural counsellor but often there's a waiting period associated with that and often these people need help straight away so it's back to the GP again it is possible where people are not doing so well to actually arrange a teleconference and teleconferences or Skype can be arranged with a number of psychologists and adelaide or practitioners and adelaide my answer to the question was I wasn't going to get any government help and that's been pretty accurate over the last 30 years or any other help and so we train people in our local town to go and do a counselling course to become counsellors my wife for example was a teacher I said we don't need teachers we need counsellors so she went off and did a course in middle-earth counselling we train the nurses to understand mental health issues much better and so when someone came in and said I'm not coping or I'm feeling down or I don't know what I'm feeling we gave them a list of questions to ask the patient so the patient knew that the nurse was on board understood that the nurse was asking the right questions and they felt pretty advanced so that was a very very successful program so increasing community capacity is probably one of the most useful things apart from increasing community education and we certainly worked very hard at doing that in our town and we used any access group we could get into whether it was parents and friends associations or whatever or so people understood mental illness and mental health and where the sources of help were and we taught the people that the ultimate place was the local hospital where they would be redirected I could just add as well I've worked in the north-west of Australia for many years and now the north-east I don't know Queensland but we shouldn't underestimate as clinicians the importance of a supportive empathic connection with the person so even it's easy to feel overwhelmed by another person's distress and there's a lot happening for that for Melissa in a month but being available being accommodating in order to impact tremendously healthful so even if we are one we don't need to be overly concerned that we don't have all the grief therapy under our belts having a supportive approach problem solving and validating and again grief just want to reiterate that it is a journey it takes time, there's different ways of breathing and it's not something that gets fixed like a broken leg increasingly grief stays with you for a long time and just gets incorporated into life experience grief is the price of life as some people say so even decades after a person dies the tanges of grief come up and so on so again without feeling terrorised or overwhelmed by the patient worried that the patient needs a traumatic intervention even in remote areas if there's music that can be done via sensible orders put it all around skills and if need be as Graham mentioned there's some other reasons Fantastic, thank you I think people are really enjoying your non-medicalisation that people are really appreciating that this is fabulous It's worth remembering that suicide is a very rare event so the Australian suicide rates they tend to 15 in the population in some of the high risk groups Aboriginal and Torres Strait Islander people it can be 5 to 10 times that insulated population but even putting it at the highest rate it's about 150 100,000 people there and so giving good clinical care to the bereaved those who might be at risk of suicide that's really the key rather than trying to pick which person out of the 100,000 it's going to kill them so that's really put it to a full errand rather it's the low risk people such as Melissa's husband who yes he was drinking there are lots of people like that all over the country so it's not about we do have to bear that risk in mind and inquire about it in all clinical assessments but rather be dominated by it to provide good clinical care and help on problems Fantastic, thank you Cynthia did you just want to comment on bringing families and support people around the person because I guess that's the other thing as practitioners be providing that level of support but you were really clear around friends and families and the community helping people access that but sometimes that can be really difficult if people are finding it hard to do that and we did have in the case study that Melissa was finding conflict with Cheryl's family and some of her friends were avoiding her so perhaps struggling to know how to respond and these sorts of thoughts about how you might help Melissa to open that door as another opportunity of support for her Yeah like sure I mean one of the common experiences also displayed in that case study is that you know the blame from parents or parents in law and or people who are in some part of the extended family I think it can be quite isolating for the intimate partner at least in this sort of situation and a lot of psych education can be really helpful in that respect if Melissa is able to get counselling I think we're not well educated in any of the professions because there is a limited in fact there's zero curriculum in all undergraduate courses that dedicate a whole course not just to guest speak lecture or something on this so I would advise people to get a little bit of knowledge on this if they don't have a lot but just about how this can be an expected outcome so that feeling excluded it may begin there and it can be very real or it can be a self fulfilling course as well for people where they experience the public stigma and internalize that and it becomes very personal stigma and this is something that we're also not very well versed in at the moment but knowing that those sorts of experiences Melissa has I would very much encourage as Siva said I mean I don't think I think all of this has to be understood that all these sorts of grief responses are clearly not pathological clearly and are very very difficult and stigmatized still today events although less so than historically means that the person is going to have a whole heap of very different responses compared to even obviously natural death causes but also similar death causes and I would what I would do with people that I've seen when they've come to that point so as an interventionist you're reliant on getting a referral or etc but I would very much get Melissa in those early days some people just come from one or two sessions to get that educational kind of information but others will come and they really don't know how to seek help because as in Melissa's case they feel people are going to not want to go near her they turn their heads away some of that might be very real some might be imagined but in any case that reaching out thing can be encouraged by saying well Melissa your really good friend Karen here has obviously shown that she's very interested in wanting to support you and keen to do that etc one of the things that we find is really helpful but clearly you can decide for yourself but is asking your friend to perhaps bring you at this point in time each week for example over the next few weeks if you don't feel comfortable and reaching out for that help and so you set up a little kind of plan with the close connections that that person has it could be a boss or someone at work and it's quite surprising I think people's responses to that because they actually say look I wouldn't have rung well not only lifeline or more formal things but I wouldn't have rung those sources I just wanted to speak to someone to listen to my story and where I'm at but if they don't do that at least a friend's there to do that thank you so seeing a community around the person but recognising it can be really quite a hard time to do that but it's a really important thing to do now our time is nearly up and I can see there's lots of questions that we're just never ever going to get to and I guess some of them are really around suicide risk assessment and a whole range of other topics as well that are obviously really important to people and are very mindful of leaving some of those unanswered we have given you in the resources a whole lot of websites and links and children's book suggestions a whole lot of things that hopefully will give you a place to go away and have a look at and get a bit of information to answer some of those questions but it does highlight I guess for me the great interest that people have and I guess the lack of resources that are there or easily accessible for people to be able to answer so I'm very mindful of that and it's quite difficult to obviously answer all of those I do want to finish off though with returning to the theme that we did begin with and people have identified as well in terms of self-care and looking after ourselves and particularly given that we are perhaps leaving people with some questions as much as answers hopefully we have given you some answers and some ideas but you may still have a lot of questions and thinking about that leaving you perhaps a little bit unsettled to share an idea around self-care what do we want people to be doing to look after themselves in this particular space so Jane let's begin with you what would you be suggesting that people could do I find briefly a really helpful way is looking at self-compassion so Kristin Neff talks about self-compassion and there's a great very short self-compassion meditation that you can do just acknowledge the feelings that you're having and then recognize that those feelings are normal and that anybody in your situation who's helping people would have those feelings and then invite yourself to bring kindness to yourself in that moment and if you look up www.self-compassion.org there's guided meditations and evidence based information about self-compassion and mindfulness Fantastic thank you that's a great tip I think we might all need to go home and do that tonight there's lots that we've been talking about so thank you and I guess it's practicing what we preach sometimes isn't it we often talk to clients about having self-compassion it's great to teach to clients as well yeah do it too fantastic thank you Graham what about you what are your take home messages around what we think people can do to look after themselves I think debrief is pretty good with colleagues and we live in a pressure pack surgery and at the end of the day all the doctors sit together with the senior staff and we talk about the events of the day and we all go home quite taking nothing home hopefully that needs to be discussed tomorrow so we definitely and we're doing this for 20 years now just definitely try and debrief after every day Monday and Friday and if we're not debriefing now we'll debrief at the hospital with a nursing staff if it's been a medical event and I find that very very effective yep fantastic so don't take it home basically find someone to talk to so you can go home and have your own time great thank you really important and that takes planning and time sometimes to think about that it doesn't certainly have colleagues just with you all the time so planning that is great thank you what about you Siva what would you be your self-care message for people interested well I think main point I'd say is that it is a journey what can't be cured must be endured so we can learn to endure the suffering in life and perhaps it is essential that these unexpected things we have to endure it to our patients our clients and learning to endure it with nobility, wisdom and consumer fantastic thank you so a bit more of a philosophical approach which is helpful as well in terms of meaning I guess it comes back to that making meaning of things that happen so thank you and lastly but not least just in time what would be your take away take home self-care message for people I agree with everyone else I think we have to recognise as well embarking on such a very difficult and very complex field that we have to I like the Zulu proverb that says you can't really wipe away another person's tears without getting your own hands wet and it means that going into such a field there is going to be a high likelihood that you're going to experience some quite negative experiences yourself so always reach out love those who are close to you always put them at the forefront because it is a journey and the quality of life that you're taking that journey can only be a good one if you look after yourself okay so give yourself permission in that okay thank you and I can see people saying thank you that they're asked a lot of questions but people are thanking us for a thought-provoking session so that's always good to hear but we are very mindful hopefully you'll go away and look at some of those links and really find some ways to get the information that you might need talk to other people and really try and work out what works for you in your particular environment remember at the end we will have this exit survey that will pop up in a moment and certificates of attendance for the webinar will be issued within the next four weeks you'll be sent a link to the online resources within the next two weeks and look out for these and share them with your colleagues perhaps you could use that as a chance to set up a bit of a network or some collegiate support that could be a useful way to begin MHPN of course continue their series of webinars and the next webinar titled supporting the mental health of people living with obesity will be held on Wednesday the 6th of September same time same place 7.15pm and you can sign up at that link the upcoming webinars and another reminder there in terms of lifeline and phone number in the website as well as the other resources if you just wanted to have a read of something but we do really want you to take good care of yourself if you're interested in joining an MHPN network in your local area there's a link there as well for some networks that are another way as you're getting some extra support and to link in with other people in your actual local geographical area so that might be another avenue and other information as online activities and networks is available at the MHPN website so I'd like to thank very much our panellists for their work and their planning leading into this webinar we put a lot of effort into thinking about the topic and realizing that we had a lot of interest in that it is a challenging topic I'm hoping that the positive messages that have come through have given people some sense of hope that can then be shared with clients and patients and would like to thank our probably 1,000 people or more that have joined this live event and of course people seeing it later on so thank you very much for your contribution and your participation and good evening we'll see you at the next webinar thanks everyone