 Good evening everybody. I'm just going to commence with the acknowledgement from our cells and mental health professionals network that we acknowledge as the traditional custodians of the lands across Australia upon which our webinar presenters and our participants are located. We wish to pay respect to the elders past, present and future for the memories, the traditions, the culture and hopes of Indigenous Australia. So I'm your facilitator for this evening, Dr Conrad Cungrew is my name. I'm a rural GP in Prosopine in North Queensland where a mixed general practice like many others will identify from in an area that doesn't have a terrible amount of tertiary mental health support but nonetheless plenty of members of the community who struggle with their mental illness and mental health issues. I'm going to introduce the rest of our panel also. Hopefully you've all had a chance to peruse the biographies of the panelists which were disseminated with the registration. But I'm going to introduce you firstly to Sally Young. Sally Young is a social worker based up here in Queensland. She's worked in child and youth mental health at the Marta Hospital and also as a psychotherapist in private practice. Sally, let's just open with some of the differences you experience in working between public and private systems in mental health. Well I guess one of the, I think there's big questions in our services about the sort of the continuity of care which whether one's working from a public point of view or a private point of view I think is a real challenge to our overall mental health system and I think it's something we have to be mindful of on each other's side of the ledger we're working from. Great stuff. Thanks Sally. We're now going to introduce Dr Tim Fitzpatrick. He's a Victorian rural general practitioner by himself. In the case we're going to discuss tonight is this sort of something that you tend to see a lot of in rural practice Tim? Not in my clientele. I'm more comfortable with older ladies with high blood pressure or middle aged blokes with prostate problems or that sort of thing. I must say I'd feel pretty uncomfortable with this teenager and I'd hope she wouldn't feel too uncomfortable with me but she probably would initially I reckon. Great. Thanks Tim. We'll see how we go with it. Now going to introduce Associate Professor Rachel Rossardo who's a New South Wales based nurse practitioner with a very long history in mental health nursing. Rachel you've worked overseas in a number of countries as well and I'm just wondering if you've noticed any differences in self-harm patterns overseas compared to Australia? Certainly when I worked many years ago in Madagascar and Solomon Islands it wasn't something that was even on the radar but more recently I worked in the Middle East and while I didn't have very much evidence of that there was that sense in my interactions with the young people that I worked with that it was something that was probably there quite likely hidden and a great deal of shame associated with it for the few that I didn't talk to. Yeah, absolutely. And last but certainly not least I'm going to introduce Professor Philip Hazel who's a New South Wales based psychiatrist. Philip you've recently been involved in a very large community study on self-harm. Can you just quickly give us a... tell us a little bit about that? Sure Conrad. This was a survey that was led by Graham Martin a colleague of mine who's recently retired with Queensland. We surveyed 12,000 people ranging in age from 10 through to the late 60s asking them about their recent self-harming behaviour that is the previous four weeks and just in that previous four weeks that 1% of the population that we surveyed had engaged in self-harm. There were differences depending on the age group that people belong to and gender but I'll come back to that probably later in the webinar. Fantastic, thanks Philip. So yeah, warm welcome to all of our panellists. Now we're just going to go quickly through the ground rules for tonight. We just want to make sure that everybody gets an opportunity as much as they can out of the webinar tonight. So just a few simple ground rules we need to follow. Please be respectful of other participants and panellists. You know although we're in a virtual space we're all sharing the same opportunity so please behave as though you're actually in the room with each other in a face-to-face setting. You'll hopefully found the general chat box down at the bottom of your screen there where we'd love you to post your comments and questions for us to consider. If you are however having technical problems pop those in the technical help issue and just remember that whatever goes into those boxes can be seen by everybody so keep everything onto the topics of discussion. Now if the chat box is actually getting a little bit too distracting for you you certainly can hide that. There's a small down arrow at the top of the chat box which you can use to minimise it. And then also we are very, very keen to share your feedback at the end of the webinar so please before you log out you'll see a short exit survey pop up which we'd really appreciate if you'd all go ahead and complete. Why are we here tonight? We're very keen to learn about this as much as we can and that's what our set of learning objectives are here for. So we're going to use the case study to hopefully give the opportunity to describe the motivations and help-seeking behaviours of people who self-harm in associations between self-entry and psychiatric morbidity, suicide and substance use. We also want to be able to implement some key principles of providing an integrated approach in the early identification of help-seeking behaviours for people who self-harm. And we'd love to be able to identify the challenges, tips and strategies in providing a collaborative response to assist people who self-harm and increase their help-seeking behaviours. So we're going to now move on to our case study for this evening which hopefully once again you've all had an opportunity to peruse but we're just going to basically revisit some of these topics. So tonight we're going to be focusing our discussion on Stephanie, a 20-year-old girl who has been self-harming for six years. She is the eldest child in a family of three girls and was sexually abused by her father between the ages of seven until she left home at the age of 17. Stephanie began to self-harm at 14. Stephanie was completing year 12 when she left home at 17 and has struggled to finish school because she is sharing a flat with three friends and is working part-time in a supermarket whilst trying to complete a TAFE course. She does not want to socialise with her flatmates at times. She generally cuts her arms and sometimes writes words like hate, love, pain and general lines on herself. During the ages of 15 and 18, Stephanie is harmed every day. Stephanie is also indulged in heavy drinking and drugs and finds it difficult to form emotional relationships with people. She went to her GP to seek help. The GP put her on antidepressants and referred her to a psychologist. Some of the CPT therapy offered by the psychologist helps temporarily, but Stephanie does not think the antidepressants are helping. So we're actually going to call on Sally Young first. Sally, we're wondering, you know, as the therapist who might have been trying to help Stephanie in the lead-up to this scenario where we've got it at the moment, if you might share some of your thoughts and insights into this presentation. Thanks, over to you. Oh, thanks, Conrad. Look, I should just mention that I now work for Children's Health Queensland in Kims, and so I'm speaking from that point of view, from a Kims point of view, although I think it's called Cams in the rest of Australia, outside Queensland. Firstly, I want to say that Stephanie's a young woman who lives with significant risk in her external relationship world, her abusive father, her apparent lack of close relationships and supports, the burdens of her anxieties about her younger siblings, and the lack of a protective mother, that there's a mystery in the narrative as to where her mother is. Stephanie also lives at risk of her internal state, which is so painful at times that self-harm is an attempt to feel better for it. So I guess that sort of last part is how I try to sort of think about self-harm. It's an attempt to feel better or feel something often. In the assessment, I like to have in mind that Stephanie is a significantly traumatised young woman, and it's very important that the assessment in itself doesn't re-traumatise her through our style of questioning. In this, I always think of the risk of the overuse of risk checklists or assessments. Although they certainly have their place, but it's important it's not primary in the connection and at the price of connecting with Stephanie. Although equally important, it's important that Stephanie gains a sense that the clinician is not frightened to talk about her self-harm or potential suicidal thoughts if they're there. Of course, as part of an assessment, if it's possible to get something of a developmental history and an assessment of current functioning, it's important to get a sense of what belongs to over a long time and what belongs to the current situation to think what would be useful. Of course, we'd be assessing for trauma, anxiety, depression, developmental issues, and it may be all of these factors, but what is the mixture of these factors in thinking about Stephanie? It's important that risk and safety be key themes in the dialogue with Stephanie as these relate to the area of her trauma. For instance, one might ask a question of Stephanie of how does she manage the part of herself that wants to hurt herself? So how can she be safe with herself as it were? Also important in assessment, it's particularly young women to identify are there any secure adults or friends in Stephanie's life who may support her and may also be allies to the treatment. Stephanie may need help working out who she can trust and how she can trust others, as that may not be part of her life experience of knowing how you can work that out. It might also be important to introduce the idea to Stephanie that she has a right to feel connected to others and to actively support the development of connections, and perhaps this might be her mother or other key people in her life, as there's a bit of a pattern in her history of withdrawal and isolation. So this is an area of vulnerability. She may need a clinician who has the capacity to reach out to her, particularly in the early stages of connecting. She'd be the sort of girl who, if she didn't turn up for an appointment, it might feel much more important to ring her than to send a letter or just wait for her to contact, given her level of vulnerability. A level of active reaching out might be very important. In the work, it'll be important to acknowledge her strength, her amazing survival capacity, given her history, and for instance, she's left an abusive home, she works and she attends TAFE, and that she's help-seeking, that all these things in themselves are strengths that need to be recognised alongside her vulnerabilities. It's very important that Stephanie's given an opportunity to feel listened to and to tell her story. Some of the challenges in the work would be determining the question of whether to notify Department of Child Safety and or the police regarding the potential abuse of the siblings and of Stephanie's past abuse. So working this out will be a difficult area. I notice that Stephanie tends to isolate herself and may avoid or fear the consequences of attempts at justice for herself and her siblings, so that may take some work as well. Perhaps in the end of this dilemma, the therapist may feel obliged to take responsibility for a notification so if the siblings don't sound terribly risky, and that Stephanie may experience this as a betrayal of her privacy. So important to keep these issues in the relationship to continue to talk about them as openly as possible. Given Stephanie's history, trust may well be difficult for her. It's important that the therapist stays sensitive to ruptures in the therapeutic alliance, that one might sort of injure her emotionally without quite realising it. So staying perhaps extra sensitive with a girl with this history. She may well be ambivalent about seeking help and this needs to be understood and borne in mind. Given Stephanie's painful situation, she may have a tendency to symptom substitution. For example, in the history, the movement from self-harm to drug use. So it's important that the intervention is focused on Stephanie and the whole of her functioning and experience, not just one behaviour. So we really are trying to help her. In the challenges of collaborative work, given Stephanie's level of risk and her suffering, the more opportunity she has for a stable therapeutic relationship, the better. However, also given her history, she may be the style of patient or client who, oh, I've just lost my screens, who may present from time to time and at emergency departments or may sort of be a bit haphazard about her appointments. And so it may need a whole of system awareness of her. The therapist may need the support of the multidisciplinary team to help and contain and manage the anxieties regarding working with Stephanie. I mean, it would be surprising if she was an easy patient to work with. Important that the team and the professional network does not mirror Stephanie's trauma. For example, fragmentation, lack of connection, lack of appropriate information sharing. It's important that, a bit like the idea, it takes a village to raise a child that may take a network to be containing for Stephanie. It may be important she has support in the transfer to either her GP or an adult service once she is over 18. And the termination of the work may be difficult and may need planning over time if possible. And I appreciate that that's the ideal and it doesn't always work as ideally as that. But that's what Stephanie needs. Thanks, Sally. Back to you, Conrad. Thank you. Thank you so much for that, Sally. That's marvelous. So we've brought up to what some of our concerns are and we can certainly see the damage that can be there. But of course now Stephanie's turned up with her GP. Tim, what are your thoughts about this? Where are you seeing the position for Stephanie at the moment? Yeah, sorry. Yeah, so Plan A hasn't worked. You've sent her off to the psychologist or the social worker and you've tried some medication and you've got this young girl who I would feel a lot of trouble getting a rapport and a trust with, I would think. And from what Sally said, it's a hell of a lot of time required, isn't it? And you may not be very time-rich. You might have a waiting room full. But I would like to try and get some trust and rapport with Stephanie. And I'd like to try and make her think that she has someone who she can come back to, if the initial referral hasn't worked and she might develop some sort of relationship, therapeutic relationship with you over time. All right, so my initial referral to the social worker and anti-depressants hasn't worked too well. And I'm thinking she's probably beyond my skill set and I'm wanting to get some extra expert help with her. But I'm mindful she's going to have to retell her story to a fresh person every time. And I'm wanting to try and get some trust and some ongoing relationship that she sees me as a safe person to come back to and confide in. And I might, you know, end up having her longitudinally for a long time and be there after hours for her and manage crisis and stuff like that. So I'm interested in trying to build rapport and trust in a therapeutic relationship. But I am wanting to refer on to more expert opinion on how to handle her. I really found Sally's presentation valuable and I'm mindful that a lot of the stuff she said is going to take a heck of a lot of time and I'm probably not very time-rich to do a lot of that stuff. So I'm looking for strategies to, yeah, improve trust and so on, but within the 15-minute consult or I suppose you could get her back for longer consults too. So anyway, I'm looking to refer her off but get her to come and see me within the month and see how things are going, make sure she feels contained and looked after. And possibly I would give her an after-hours contact number to find me if there's a real crisis and she needs someone to talk to. But I'm taking that the safety check has been done to some degree, suicidal ideation and so on. But it would be worth revisiting that too. Fantastic Tim, thanks for that. So we recognise that sometimes these presentations really do test our own skills and boundaries and we certainly recognise when we do need the care or the assistance of others around us. And it might be at this time that we're needing to call through to the hospital or to one of our local services to be able to assist us with the care of a patient like Stephanie at this time. We're now going to ask for the perspective of Rachel. If Tim's called you at the mental health team and is needing to pass on, Rachel, I'm wondering if you might be able to share your thoughts on this presentation and some of your experiences. Thank you Conrad. I'm delighted to hear Tim that you have the willingness and desire to make sure that Stephanie can come back to you that she knows that you're there as a consistent person because I think it's really important to recognise that acute care mental health services adjust that. Their focus is triage specialised mental health assessment, crisis stabilisation, a focus on short-term options tailored to individual needs, and anyone who's assessed is not requiring admission and are then referred often to appropriate services in the community. Now this will vary a little bit from area to area but it will certainly, especially in rural areas, be very much the case if you do have access to acute care mental health services. As a clinician on triage or seeing Stephanie, my first focus is, of course, is she at immediate risk to herself or others. And bear in mind all that Sally's already said is our capacity to actually reformatise Stephanie. So I'm going to be very gentle and yet hopefully thorough and engaging with her and seeking to understand what's happening for her. I would hope to do a comprehensive assessment where I'm trying to understand much more clearly the function of self-harm for Stephanie. And I'm keeping in mind that she's got a 10-year history of sexual abuse and she's been self-harming for more than six years now and she's 20. So this is not something that's just been around for a couple of years. This has been something that's been part of her life now for a significant period. I will have some degree of concern about increasing use of alcohol and drugs to manage her emotional distress and look at the challenges that she has with emotional isolation and her interpersonal skills and it seems that she's got very little on the way of family support and perhaps struggling to achieve some of her developmental tasks. At 20, she's still attempting to complete secondary school while she's working part-time. And I also see that she's already had first-line treatment, CBT, and a trial of antidepressants. Also, as I think about Stephanie from the story that we've got, I can see that she's also vulnerable to further abuse. On the other hand, I see that she has some readiness to engage with services. She's turned up first to her GP and now she's come for a further assessment. And I'll be looking to very carefully identify her strengths and look at the examples of resilience. And Sally's already reviewed some of those for us and suggesting that this is the young woman that despite all the difficulties has been able to keep going. She's moved out of home. She's living independently, living with some peers and working and studying. So, Stephanie, I think it would be important that if at all possible I organise a psychiatrist's review as an outpatient. What I want to do is make sure that we're not missing anything else that may be part and parcel of what's driving the self-harm. We know that she's got a significant trauma history, but we haven't got enough there to tell us more. I'd be wanting to exclude things like an anxiety disorder, depression, attachment disorders, complex trauma disorder, or emergent access to personality disorder. And I'd be asking for a formulation and treatment recommendations. But at the same time, I would also look to see if it was possible to connect Stephanie with some additional community support services. To reduce her social isolation, she's at TAFE and she's trying to study the possibility that there's TAFE support services that may be helpful. And for those of us who are in rural areas, using some of the online resources that are available can be very helpful. And I've listed a couple there that I found to be useful for young people. Now, I'd just like to, I guess, draw our attention to areas that I think sometimes become an easy option. I've, someone's referred to me in the acute team and, no, they don't meet the criteria for crisis intervention, but I need to refer them somewhere. This young woman's got a history of sexual abuse. Let me refer her to sexual assault services. Or let me refer her to drug and alcohol services. And then I've actually done something. And I'd just like you to consider that when you consider a referral to sexual assault services, be thoughtful about this. Stephanie currently manages her emotional pain with self-harm, drug and alcohol misuse and withdrawal. And if we think about what she's going to need in the way of internal resources to go to sexual assault and start to address the trauma that she's experienced, some recent research suggested that one of the things that was most predictive is whether young people complete treatment for where they've been sexually abused is if they are using avoidance symptoms. So perhaps now may not be the most useful time to refer Stephanie to sexual assault services. If I then think about drug and alcohol services, I would be asking myself, is substance misuse the primary concern here? Or is it an indicator of underlying issues that need to be addressed? If substance misuse is having a marked negative effect on Stephanie's capacity to study and work, then it may be appropriate. And I'm raising those points for us to think carefully about. And then I'm going to look as well at the risks here, not just the risks of Stephanie from herself. And I, with the little information that we have, I would think of her as having a possible chronic risk at the time of referral rather than acute risk. We've got no history given of suicidal ideation or past suicide attempts. But there is a significant risk of autogenic harm. And we run the risk of exposing Stephanie to stigmatising attitudes in some mental health settings. We run the risk, perhaps, of her being labelled as borderline or attention seeking. And we also run a risk if we're not careful of focusing on a pathology rather than on her resilience and strengths. And there's a risk associated with unhelpful referrals. At all times, although I may be working in acute setting, I'm going to keep in mind and keep forefront that my focus needs to be on establishing a safe therapeutic space and also making sure that I'm staying connected with Stephanie's GP so that there is that continuity of care. And I'd like to draw your attention to the increasing resources that are available for us when we think about trauma-informed care. And Cosalini said that it stands to reason that the most devastating types of trauma are those that occur at the hands of caretakers. And Stephanie's experienced that. We need to make sure that as other caretakers, we're not also imposing more trauma. So effective trauma-informed services not only address the impact of past trauma, they seek to be aware of and sensitive to doing no further harm. And I like to remind myself at all times that symptoms such as self-harm are adaptive. Stephanie's used this because it worked for her and it has worked for her. And she's hopefully in a space where she's now ready to start looking at some other things that may be more helpful. But if we are able to work from a strength-based approach, we can be empowering if Stephanie's existing resources and make sure that we connect her with people that are going to take that strength-based approach. Over to you, Conrad. Wonderful. Thank you very much for those insights, Rachel. That's a fantastic picture of the thinking that we were at with this type of presentation and really has built on a lot. And you've certainly acknowledged there that sometimes we need to make sure that she's safe. Get that safe therapeutic space going on and then see what sort of expert care we can access to to really make sure we put evidence-based strategies in place and help her out with it. So you'd already highlighted the need for us to perhaps involve an outpatient psychiatry review. And I'm going to, under now, Professor Phil Paisel, if you might share your thoughts on Stephanie's presentation for us. Sure. Thanks, Conrad. I should probably let people know that I'm a clinician researcher, so I tend to research the things that I see the most of and self-harm is one of the problems that I guess we see a fair amount of, there's not a lot of, in clinical services for young people. And it's one of the clinical problems that I'm most likely to be called about after hours when I'm on call on nights and on weekends. I'm going to be talking about some more general issues and then attempting to, I guess, get back to Stephanie's particular circumstances. So the first slide we've got up here is a data from a predominantly European study that you'll notice if you look across the bottom. There's Australia got honorary European status for this study. It was included in a European cohort. And it was a huge survey of 15- and 16-year-olds that was undertaken in schools. And the key questions were around the prevalence and motivations for self-harm. To make sense of what's there in the figure, you're probably best paying attention to the medium dark bars because that reports on the rate of self-harm in the previous year, which for most of us is the easiest thing to make sense of. And you'll see that for females aged 15 to 16, the rate of self-harm in the last year was sort of up there around the 10% overall. There was a fair bit of variability. It was noticeably lower in the Netherlands and somewhat higher in Australia, but around about one in 10 girls. And it turned out to be about one in four or one in five boys in this age range. The same rates have been found in many other studies, but this one just is so robust because there were so many young people involved. For this study, self-harm included people who were suicidal, but it also included people who were self-harming and didn't have suicidal ideation. When you look at people who self-harm, where there's clearly no suicidal intent, actually for the most part the gender difference is almost completely washed out. The rates are pretty much the same for males and female. Now, that's a lot of young people self-harming when you think about it on total numbers. Of course, very few of them are getting to clinical services. We estimate that it's only about one in 10, one in eight people in the community who self-harm, who come to clinical attention, and they may not come to clinical attention because of the self-harm. They may come seeking help for other problems. And there are likely to be some differences between those who get to clinical care and those who don't. But one of the main reasons that people get to hospital for self-harm is pretty obvious. It's that their self-harm requires of itself medical attention. So cups that are too deep or an overdose that's made them sick. That's one of the reasons that people actually get to hospital. So still paying attention to the same study. The young people who participated in it were asked about their motives for self-harming. And they were able to choose from the menu and they were able to choose more than one motive. But you can see the standout one in terms of the most common. We've got one to get relief from terrible state of mind. That seems to be probably the most common motive across the age span, really. The first motive for self-harming is really that dealing with internal and unpleasant emotions. And for some people, self-harming actually provides temporary relief. In fact, I suspect it's the people who get noticeable relief from self-harming who continue to engage in the behaviour. People who do it and it doesn't do much for them tend to do it once or twice and then stop. Wanting to die is up there. There's still a pretty common motive and then wanting to punish oneself. And only then do we start getting into motives that are about communication with other people. So just in case there was a myth out there that self-harms largely, you know, manipulative behaviour or a cry for help, no, it's not. It's predominantly about managing one's own feelings and often very unpleasant feelings. What we know about the natural history of self-harm, I guess, maps on to Stephanie quite well. So the typical age of on-site is somewhere between 12 and 14 years, I think from memory. Stephanie was around 14 when she started self-harming. The course is variable. Most people have ceased within five years of starting. So Stephanie's an outlier. She's already continued self-harming for over six years and it doesn't look as if the behaviour is moderating. So she's a little unusual. The typical reason people give cessation of self-harm is that the behaviour is no longer serving a useful purpose. And when I've talked to people who were previously self-harmers and no longer engaged in the behaviour, they really attribute treatment to being the main cause for stopping. They usually describe it in terms of, well, I found other ways to cope or I no longer have problems or that the self-harm is just no longer useful. I'm sure people are pretty interested in the association between self-harm and psychiatric disorder. And the source I chose to present this evening to answer that question comes from a systematic review. So again, we're talking about big numbers. It comes from a colleague of mine, Keith Horton, who's based in Oxford in England. So he did a systematic review of 50 different studies from 24 different countries. Bottom line, more than four out of five people present to hospital with self-harm meet criteria for at least one psychiatric diagnosis. It's quite common for people to meet criteria for more than one diagnosis. The most frequent disorders were depression, anxiety, and alcohol misuse. And then additionally for people aged 18 years and younger, attention deficit hyperactivity disorder and conduct disorder. That's not to say that those conditions were necessarily the reason the person was self-harming. You need to remember that these are very common disorders. So anxiety affects about one in 10 people. Depression about one in five, one in six. ADHD is pretty common, maybe about one in 20. Conduct disorder maybe a little less so. So anybody who's in strife and presenting to hospital is likely to meet criteria for one of the more common mental health problems. That's not to say that self-harm doesn't occur in association with more rare conditions such as schizophrenia or bipolar, but just because they're less common conditions, we are less likely to diagnose it when we see people in hospital. Now the other issue was personality disorder, and this study was done back in the days when personality was diagnosed separately from the other condition. And Keith Horton and his colleagues found that about a quarter of people, a quarter of adult patients met criteria for personality disorder. Before I leave the slide though, just to word of caution, these studies would have been derived from hospital record data, and the diagnosis would have been made on the run and they may not be that reliable. So diagnosis often changed once the crisis situation is over, both the patient and the doctor are able to see the situation a bit differently. So just take the data with a little grain of salt. What's the association between self-harm and death by suicide? Well, again, I'm going to reference Keith Horton. This is a study he did himself from presentations to hospital in the Oxford area in the UK. He was only concerned with patients aged 18 or less, younger than Stephanie. About three quarters of these people were female and they were followed up for at least three years following their self-harm presentation to hospital. So 1% of these people at three years were deceased. And of those who were deceased, half the deaths or 0.5% were either suicide or an undetermined death. The factors associated with suicide or an undetermined death were being male. Intriguingly cutting at first episode because we often think of cutting as being a less, perhaps a malignant form of self-harm and whether the person has undergone psychiatric treatment. Now that's not because psychiatric treatment causes suicide, it's because psychiatric treatment is a marker of more severe mental illness. But from these data remembering that maybe only one in 10 or one in eight people who self-harm ever get to hospital or ever get to clinical care, it suggests to us that for the most part, the outcome for people who self-harm is not fatal. In fact, in most situations, self-harm is a reasonably benign condition. But at times it becomes malignant and really that's where our clinical schools need to come into play to identify the problems or the patients where the problem is turning malignant. What are the characteristics that indicate that things are turning bad? Thanks Conrad. Fantastic, Phil. Thanks so much for sharing that information and that evidence base there for us. So we move on now a little bit to our session. We're just going to try to cover some of the broader concepts that we've covered here. And then we're also going to try to address some of the questions which have been coming up through the audience both tonight and also in your pre-registration opportunities for questions. So we might just start off. We've already heard that Stephanie's engaged a little bit from what's happening with her flatmates at home. And she's also indicated to us that she's very worried about her privacy and confidentiality. A setting for some of us might be that one day we get a visit or we receive a message from her flatmate saying that they're concerned about Stephanie and would like to come in and speak to you about their concerns. How would members of the panel manage this type of issue? Sally, I wonder what you might think on that. Well, I guess it's a sort of common dilemma for us all. I mean, I guess the sort of first level of boundary would be one, I'd take a position of... I'd be interested to hear their point of view, the flatmate's point of view, but I'd need to protect Stephanie's privacy. I guess there's even a step for that, which is how do they know that Stephanie attends the clinic? So somewhere in the conversation one would be trying to... if they rang or something like that, trying to sort of listen for how they know that, this is something that they've known through Stephanie or some other source. I guess I would be encouraging them to... do they have Stephanie's permission to speak to someone? This may or may not be the case, but that would be the ideal that there is some discussion with Stephanie. If not, I guess one would just be taking that position of listening without revealing anything of Stephanie's situation. I guess depending what they say, I'd also... I may be encouraging them to let Stephanie know they've been in contact with me or I may ask them for permission to let Stephanie know that they've been in contact with me. It continues to be an area of delicate negotiation to protect Stephanie's privacy, but with such an at-risk girl, one doesn't want to have too many high boundaries where a flatmate is very worried about or can't communicate with a professional who's helping her. They're my first thoughts anyway. Anybody else on the panel have any thoughts about how we help with other flatmates or friends, particularly in the area of social media where our patients are less concerned about their confidentiality on digital space than they are in the real world? How we might address this issue? As a GP, I get phoned a lot from concerned relatives and various people. I'm worried about mum, I'm worried about my sister. I usually say, oh, thanks for taking the trouble to phone in. You're obviously concerned. Is it all right if I let them know that you've phoned in and it could be a very powerful thing coming from someone who's close and caring about them to hear that someone else is worried. If they're acting in best interest and they're sharing information, sometimes it can be a really useful thing. I reckon if you can use it like that. Great. Sorry, Conrad. I guess the ideal would be if the flatmate would agree to come with Stephanie to an appointment and talk about her concerns with Stephanie there. That would be fantastic. One of the features a lot of people are asking about online is the appropriateness of DBT dialectical behaviour therapy in a consideration like this. Just wondering what might be the clinical features in Stephanie that might lead us to suggest that this would be an appropriate part of the treatment plan. Are you happy to expand on that a little bit? So I guess the signals with Stephanie that indicate she might do better with DBT are some of the conflictual relationships she's had or the isolation she's had from her peers and give it to their chronic emptiness. Another feature that triggers the need for... Well, I think triggers the need for DBT is that the person has problematic interactions with helping resources. That doesn't seem to be a feature of Stephanie at this point. Any other panelists have any experience with DBT that they think would be particularly useful or warranted in this position? Hi, it's Rachel. I have worked in a couple of rural areas where the team have not been able to deliver a full DBT program because it's very resource-intensive, but where a number of community team members have developed some skills in leading school groups and they've run short programs with young people like Stephanie who, especially if Stephanie started presenting on a very regular basis, very distressed or having cut more deeply in requiring medical intervention and using that connection to help her get some skills on board to look at ways that she may be able to develop some distress-tolerant skills and a broader range of effective emotion regulation skills and sometimes that can be helpful. So it's absolutely one of our more resource-intensive sessions that needs to be delivered by somebody who understands and knows how to use that and sometimes that's not easy to obtain in a face-to-face setting. I just wonder if the panel would consider the use of e-therapy or Skype or other online technologies for Stephanie to help with delivery of services. Rachel, is that something you've used much at all? I think this is a really interesting area and had an experience, a number of experiences, working in a rural area where, aside from my own therapeutic skills there, there was no private psychiatrist in town and there was very little in the way of resources and I started using Mood Gym and e-couch as an adjunct to my regular sessions with seen people and found that sometimes they were really useful where I had a young person who had limited emotional literacy so their capacity to describe their internal world or to talk about it was very limited and for some reason when they would do a module of Mood Gym and then come back and talk to me about it, they had the experience of, I guess, finding that in that rather innocuous online world there was someone, there were other people who were describing the sorts of things that they experienced and it seemed to be a useful adjunct and something that sometimes people found easier to negotiate rather than talking to someone. It's certainly something that's handy to have as one of the adjuncts for us. We've already mentioned how important it's going to be for us to be able to establish and maintain a therapeutic relationship with Stephanie or with adolescence in general and being able to establish, report and maintain their trust and to have that relationship going on longer term. Tim, I'm just wondering if when Stephanie was sent around to see us in that first instance and we'd suggested that she needed to be referred on to the hospital if she'd actually been reluctant to follow our advice would we be in a situation where we need to perhaps schedule her under the Mental Health Act? I don't think so. You didn't think there was any immediate risk of serious health harm. I suppose it's really hard for her to get somewhere if she's a teenager with no car and the nearest place is an hour and a half away and not very accessible for her. It might be one maybe you or someone could in theory phone her every day with her permission and see her very intensively for a short period of time just to see if you could get some sort of connection and trust and you felt comfortable enough to persevere on your own perhaps with phone consulting a nice consultant if you have one who you can talk to just to get a bit of support for yourself and backups. It'd depend on your time and resources and all that sort of stuff and how you were going yourself otherwise probably how slow it under you were. It wouldn't be out of the question though. I think it would be a reasonable thing to do. I was talking to Sally who saw her initially and sharing my thoughts with her and using a bit of your network and expertise and yeah maybe it would be one you got out for a while without sending her off somewhere but yeah probably getting a bit of backup somehow. Thanks Tim. A lot of the participants have been asking about how we might best build a relationship and be able to get Stephanie to open up about things. Sally I'm wondering if you were noticing that this young patient presenting to you did have a series of scars but wasn't actually going to be saying anything about it how would you approach a patient to get them to open up about the damage that might be there? Thanks Conrad. I think this is a sort of really common dilemma for those of us working with young people with these difficulties. I mean I think there's probably in any session there's a sort of timing question as to when one speaks to something that's unspeakable for the young person. If there are cuts that I can clearly see I might when the time feels right in the session say something like I wonder what those cuts are saying at the moment or what those cuts are saying to me. To try and sort of help the person speak through the wound as it were as to what they might be communicating to themselves or to other people. I think there's that common dilemma of a person who self harms underneath their clothing even more of a dilemma in winter and if I sort of had a sense of someone that there might be hidden cuts I might frame a question or something like look sometimes I ask people do they have cuts that I can't see. Would you feel alright with me asking you that question? So I would just take it back one step more distant. So they're a bit in control of where it goes from there. It just gives the young person a little bit more way of managing a question they could find intrusive. But I think we're always on that edge between not being too intrusive that it's traumatic but not ignoring signs that need to be understood and noticed. That's my thoughts. Thanks Corrad. That's fantastic. A lot of our participants this evening have been asking about the role or the merits of medication in a presentation like this. Philip I'm just wondering in your experience is antidepressant medications safe or effective for this type of patient population? Yeah thanks Corrad. I'm going to do a little bit of an advertisement here which is for the Colleges Psychiatrists Guidelines on the Assessment and Management of Self-Harm which in the process of being revised and they're nearly complete and when they are complete they'll be available on the college website and they'll be accessible to anybody. We just have to Google our ANZCP and then sort of follow the prompts. I was one of the authors of the guidelines so kind of know the content pretty well and the recommendation about antidepressants in the context of self-harm is only to prescribe them if there is clearly a condition present that's responsive to antidepressants and that doesn't include the self-harming behaviour. So we know that antidepressants don't stop self-harm. So what are the circumstances where you would prescribe an antidepressant in the context of self-harm? Well the most sensitive disorder to antidepressants is actually obsessive compulsive disorder so that's a good one. More severe forms of anxiety. And then third on the list is depression. Depression doesn't respond so well to antidepressants although that's what they're called. And that's especially true when we talk about people under the age of 18 where the response of depressive symptoms to antidepressants is not particularly good. The reason for that is that often they've been prescribed for the wrong kind of depression. They've been prescribed for depression that's really arising from circumstances in bad situations and the best management of that kind of depression is to help the person through the situation and to resolve the difficulties. The kind of depression that responds to antidepressants is the one where there's more obvious physical symptomatology associated with it, where the person slowed down, having significant sleep disturbance and by that I mean trouble waking, sorry, trouble staying asleep. I tend to wake up early in the morning with the appetite suppressed, with the greed of lethargic, those kinds of symptoms. And I just want a final comment which is actually there are some antidepressants which in the short term are known to increase the risk of self-harming behaviour, particularly in young people, the two that stand out of MIVA vaccine and peroxazine. That's frightening. Rachel, I'm going to pass the final question on to you for this evening. A lot of our participants have been worrying about all of the broader impact for the family. We're worried about the role of the father, but as we already mentioned, the role of the mother and the sisters involved here. In the broader context of managing self-harm in our young patients, is there a role where we can better involve or support the parents or family involved in care of patients like this? Thanks for that question. I think it's a really important one to give very careful thought to. We can sometimes fall into the trap of alienating the rest of the family with the focus on the young person and especially where there's perpetrator of violence as part of the family as well. And finding ways to be able to connect with the family, and it will be sometimes a very tricky balancing act, but it can be very rewarding and very helpful for both the young person and for the family. And again, if I was to refer to some of the my own experiences in that regard, is where I've worked in teams where we've had a young person who's very troubled and the split between the team and the family has been making things much worse and where we actually engaged with one of our clinicians to see the family separately to see the young person and where it's possible to put that time and effort and I think it can make a big difference in supporting the family because they will be struggling as well. And it's also important to use some of the resources that are available online and there's a number of those that you can refer family to. And resources like Kex, a book that I've got in front of me at present when your child is cutting, there are a number of those sorts of books and resources available and I'd actually encourage each of you to make sure that you've got access to some of those resources that you can share with family members. It makes a big difference for them to know that they're not totally outside of what's happening to their child. Fantastic, Rachel, thanks so much for addressing that so succinctly. It is something which we're always concerned about. So that pretty much brings us to an end of this evening's webinar just in recapping some of the main points that we've covered tonight is the importance of providing these patients with a safe place to open up and to speak honestly and confidentially, making sure that we're looking after her safety at all times, knowing the team around you who you're going to be working with and being able to refer effectively within that team, having some online resources available if your actual physical or healthcare resources don't stretch to that extent and also the very important point there that don't be quick to jump to prescribing antidepressants for these patients unless you think there's a clear condition there which is going to respond to it, but the use of appropriate psychotherapy techniques by appropriately trained members of our team really is the key to ensuring that we get some there with this. So thank you so much everybody for your participation this evening and to all the panelists, thank you again for your help as well. We're just going to remind you that when you log out there will be a brief exit survey which will appear. We would ask everybody to please make sure they complete those and we will be sending out, emailing out the attendance certificates for those who need to obtain points for this. We have referred to a lot of online resources this evening as well. Those will be collated and linked to those will be available on the webinar and of course you're all logged in for the Mental Health Professionals Network website. So do keep an eye on that for the next webinar. That one is actually going to be coming up on 27th of July on bullying in the workplace. So everybody think about that one. Now of course the key of the Mental Health Professionals Network is collaboration and it's fantastic to have an online resource environment like this but it's also great if you can look at developing a network in your local area. So there's a lot of those available. There may already be one which you'd be able to join. Of course we've been looking at a lot of youth issues this evening and it's important that we also know what our local resources are on there so there's a link to those. And of course back to the MHPN.org.au website for a vast range of resources as well as webinar links to all of the previous podcasts and sessions which we've had. So with that, thank you very much to everybody. I'd like to certainly close in acknowledging the consumers and carers who have lived with mental illness in the past. Those who continue to live with mental illness in the present. Thank you to everyone for your participation this evening. Good night.