 Good evening everybody and welcome to the Mental Health Professionals Network National webinar which is an interdisciplinary panel discussion on collaborative care around anxiety and worry in adolescence. My name is Mary Melaes, I'm a general practitioner from Cairns in Far North Queensland. I work at a headspace site and previously worked at Headspace Council and I'd like to say a particular welcome to all the headspace staff I know are online tonight. I personally do work in adolescence but the main reason I'm here tonight is I'm the facilitator so I'll be introducing the panel and then facilitating the discussion together. So I'd like to introduce our panel members, not in any particular order. So Lena Sanche is an associate professor in general practice and she also does some general practice work as well. Now Lena, where are you based? I'm at the Department of General Practice at the University of Melbourne and my clinical work is with a teenage section of the branch of family planning Victoria. So it's an adolescent health blocking centre for sexual and reproductive health and prior to that I've been working in general practice for some time alongside my academic work at the University. Thanks very much Lena, welcome to the panel. Now Dr Mandy Deeks is psychologist. Mandy, you work with Gene Hale, is that correct? Yes I do, I work at Gene Hale for Women's Health. So we're based in Clayton but we do a lot of work nationally. I work in the Translation Education and Communications Unit and also a counselling psychologist. And Clayton does have a Brisbane, is that right? No Melbourne. Melbourne, yes Melbourne Victoria. There you go, my geography is not very good. Now Sally I know that you are in Brisbane and you're a social worker and a psychotherapist so is there anything particularly that you'd like to tell us about your work with young people? Just that I work for Marta Child and Youth Mental Health Service and have done for many years have an interest in both individual therapy and family therapy. Welcome Sally. And Professor Brett McDermott is a psychiatrist on the panel tonight. Now Brett you're also based in Brisbane but you have a number of both national and international interests. I wonder if there was any one particular thing that you wanted to, maybe the most exciting bit of work that you do with young people? Oh that's a good one. I'm probably through the Beyond Blue Board I suspect. I mean that's I've been on the board for about eight years and I think you know we have kids and adolescents very much in mind at Beyond Blue so maybe that. By the way I also recognise a lot of names and I want to apologise to all those people. We thought that I once had hair. I don't have any hair anymore by the way. It's all those adolescents. Thanks Brett very much and welcome to the panel. Now just there's a few ground rules which everyone's been handed out before when you signed in. So just remember that if you type things into the general chat box everybody else can read them. You are welcome to answer each other's questions and the panel may or may not interact with you. It depends how what else is happening at the time. So I will keep an eye on the chat box and try to raise your questions and thank you to everybody who submitted questions based on the case study. What we'll find is that the time goes extremely quickly so I apologise in advance if your questions don't get specifically answered and the other thing is that there will just certainly lots and lots of detailed missing from the case and that's always how life is. Things don't fold over time. So it's impossible to answer all the questions about the actual midi-grility of the case as well. And it's really, really helpful for us to have your feedback at the end. So please stay online and complete the exit survey which pops up when you exit the webinar and MHPN do really analyse the feedback in detail and that informs the future webinars, topics and technical things as well. So thank you very much in advance for completing the exit survey. So learning objectives for tonight as we talk about season, we hope that we'll be able to better understand anxiety and worry as it occurs in adolescence, identify the key principles of the featured disciplines approach in screening, diagnosing and supporting adolescents experiencing anxiety and worry and to look at some really tactical tips and strategies for how we can collaborate between disciplines when we're managing cases like season. So it is again a reminder intended to be open and ended to provoke thought and generate discussion. So I apologise if you're frustrated, missing bits of information. So this evening we're going to talk about Susan. So she's a teenager who's changed behaviour is worrying her mother. Her parents have recently separated and her deteriorating school attendance and academic performance, her loss of interest in sport and changed eating habits are causing concern. This assistant principal has noticed and talked to Susan's mum and mum saw the most likely place you could actually get Susan to go was the local GT. So on that note, I'd like to hand over to Lena for our first discipline specific response to meeting Susan. Thanks very much, Lena. Thanks, Mary. Right, well, this is an approach I would normally deliver in an hour, but in five minutes, I hope to convey to you what I think the job is of someone in primary care is the first line for many young people, the most young people in fact. And I think this quote from the annals of internal medicine summarises the approach very well, that good medical care of a young person really doesn't depend on what specialty or what area of clinical medicine you come from. But it's the sensitivity that you have to be enormous changes that are going on during this period of time, not only physically, but the medical changes as well, the development in cognition and these kinds of things and the changing relationship between the family and the peer group. And being aware of these things, the background and sensitivity to it colours the way we approach the young person. So I feel that my job as a GP when first meeting with Susan is to engage her in a positive experience with health care. To do that, that's the first and most important and equally to deal well with her medical issues. But if I do that at the expense of being able to engage her in a positive relationship, then I've probably lost her forever in some ways. And as we can gather from the case history, they're fairly reluctant to come at 15. 15 is a particular time I think where young people are starting to figure out where they where they fit in in their life. There's main challenges. Who am I in all of this? Am I normal? And where am I kind of going in my life? And they're often doing this more with relating to their peer group and these kinds of things. So this understanding of where she's at in terms of her development, and that's what we call the developmental perspective, really important to keep in mind. And also being aware of the epidemiology that at this age issues such as depression, anxiety and other risk-taking behaviour really escalate. So I think the key clinical skills, because in my experience, young people of 15 or so in this situation are probably being brought in by their parent. And I suspect that Vicky has brought Susan along and she might be quite anxious. So often I have to validate what Vicky would have to say and validate her concerns in the interview, while also conveying to Susan that I'm interested in her perspective. And at some stage, I'm going to be getting time with Susan on her own to talk about how she's feeling. I need an approach to confidentiality, because this is very important for young people, particularly from about this age, to understand that they can develop a confidential relationship with their doctor. And that's with certain exceptions, of course, where life is in danger. I need really good communication skills to be able to undertake a proper risk-and-protective factor assessment. And I really feel with this young woman, I need to not only assess her medical issues, but also her psychosocial issues and really work out what's going on. And I would hope that my clinic really is a youth-friendly clinic with materials around that young people will engage with and nice friendly receptions and those kinds of things that are sensitive to the developmental needs of young people. And also, before I even see a young person, I've got a connection with a network of other health care providers with young people. So, Mandy and Sally and Rita are all on my network, as well as people that might be able to deal with drug and alcohol issues to do with unprotected sex and those kinds of things. So I think that's the general framework I'd refer to. So my job in meeting her is really to engage with her, to build rapport between her and I. And I can do that by greeting her first, right from the waiting room, saying hello. Vicky, who have you brought with you today if I don't already know who? And so Susan, rather, and bring them into the room and take an interest in Susan in herself. I might not have seen her for some time. I might get the story from Vicky and then say to Susan, we're going to have a chat in a minute, so I'll get you to take some notes on what your mum's saying when we pick up on it. And when I get some time with Susan on her own, I kind of want to engage with where she's at. She probably doesn't want to come in there today. She's shy and she's embarrassed about what might be going on to her. And it will take her time to trust me. So I might engage with her and say, oh, it must have been a bit tricky for you to come in today with mum. It looks like you're not really that enthusiastic about being here. But while we're here, how about we have a chat with some of the things she said and maybe pick up on it? And I try and get her cooperation along the way. And all the time, and I'm assuming she might know me, but maybe she doesn't, I would explain who I am, what I'm going to do and why I'm doing it. Each phase of the consultation to make sure she understands the agenda and the process that we're going to follow. In terms of the way I'm going to be, obviously a non-judgmental approach is really important. And being myself, a lot of people feel they have to be like a teenager to engage with teenagers. And they just sort of see that as being a try hard. They don't really engage with that. So it's important to be myself to not use any jargon until unless she uses it first, then I might pick up on it and really be quite open and honest and straightforward with her. And even though I might only have a short time, I really have to appear unhurried. And I would hope that in this situation, I could have a good 15 minutes. And if not, I'd be organising for a double appointment in the very near future. So after I've been through this and some of the presents, all the stuff in the history I would assume that as a GP, I wouldn't know that. So I'd be endeavouring to find that out. And after I've sort of explored some of Susan's concerns, I'd kind of say to her, look, I tend to like to do a bit of a health check on young people that I see. And some questions that I ask all young people, which I'd like to go through with you, if that's okay with you, you don't have to answer if you don't want to. But I'd like to see how you're getting on in your life because sometimes this can affect the way you feel. And with that sort of entree, if she's okay with that, and after I've discussed confidentiality and I guess that's really keen being able to say that what we talk about is between us. But there are some exceptions that if you were to tell me you were going to seriously hurt yourself or hurt other people or if someone were abusing you in any way, that's the time at which I might have to work with other people to keep you safe. But I'd try to say that I would negotiate that with her together before we had to contact those safe people together. So with that as the background, I would then start to explore using this wonderful framework called the HEADS Approach, which I hope many people have heard about. And if not, there is a publication that outlines it, but it's basically a little mnemonic for the practitioner to explore the different areas of a young person's life, to explore their risk and protective factors, and be very open-ended in the style of questioning you use. So things like, you know, where do you live? Who lives with you? And I might draw this on a family tree. How are you getting on at home? Has anything changed recently? And this will kind of bring out some of the issues that might have been going on for Susan. Under the heading of E, and it's not done in any particular order, it's just as the conversation flows, I'd explore education, employment, any changes in that recently. We know from the history that Susan has been deteriorating in some of her grades. In activities and tears, I would explore online behaviour as well as is indicated in the history, there are things going on, their friendships, what sort of things she likes to get up to. And these are kinds of things that inform me about her strengths, as well as some of the challenges that she's got going on. And before I get to the more sensitive areas of the drug cigarettes, alcohol, sex and sexuality, I might ask permission again and warn her that look, I'm going to ask you some more personal questions now. And if you don't want to answer that fine, just let me know. But remember what we talk about is confidential with those exceptions. And I'd ask her to say that some of the parties you go to these days, many of the young people might be experimenting with drug cigarettes or alcohol. Do any of your friends use these things? And how about you? And so on. And I would move through the history and after with some rapport, I would be asking around all these things. In particular, my risk assessment really must look at depression and anxiety and any risk of suicide. And I would be quite methodical about going through that with this young woman in particular and to get a degree of, sense of the degree of distress and the amount it's impacting on her life. And that would also inform some of the safety issues. So I can detail any of that a bit later, but just as an overview, that's what I would go through. If I had to do a physical examination, I would be very cautious, well not cautious, but very respectful about that, reassure her about normality along the way, highlight anything that I might think needs further examination. And at the end of all this, I might say something like, thank you very much for talking to me today about all these things. It's not an easy thing to do. And here's what I think is going well at the moment and here's what I hear from you might not be going so well. And I think really it would be good for us to work on some of these things. And I would make a plan with her and talk about what the next steps might be. I'd make sure that she knew how to find me again and whether this would pose a barrier for her in terms of cost or anything like that or needing to get there with her mother. And in some cases, and maybe not so much in students, but possibly I might need to talk to the people at school or to talk to her mother in a bit more detail. And I would rehearse with Susan what I would say. I'd reassure her I didn't have to tell them the detail of what she was telling me but would she be happy for me to talk to them about some of the trouble she might be having at school or something like that. And we would work out the words that I could say with her so she would feel confident. I wouldn't reach her trust or confidentiality. So occasionally I would need to do that to get a whole picture of what's going on. If I really did think I needed to send her to see a psychologist or a psychiatrist or a social worker or another youth health professional I would I would do that in a sensitive way. And maybe I'd say look I really think there are some significant issues going on for you at the moment you've been through quite some trauma recently in your life with your family changes and there's some concerns that you have and I think it would be great if we got someone who had a special interest in their and special expertise to help you and I would try and stay in contact with you and make an appointment after you've seen them to make sure that you engage well with this person and see if she's open to it and I'd tell her a little bit more about how they work and what to expect and ideally if there's time get them to talk to that person before they even go. Above all provide some things to hope that you know I've seen lots of young people in this situation and in my experience it gets better with the right help and I'd also provide some resources for her to try and get into them and there are some very good online options for such as reach out.com or mood gym or these kinds of things that might help her in the meantime. So basically I think you can almost get away with anything with the right communication skills that with the focus on empowering the young person and making them feel connected and also helping care and cope with this transition and just as a summary slide it's about creating connectedness for this young person in the clinic setting so that they feel safe, valued and listened to and I've listed here some of these things that I've ingredients for that that I've been talking about but I think I might have gone on long enough so I think that's my five minutes I can hand over to you. Thanks very much Lena and I can see that the participants were appreciating your approach very much so I think that what would happen in the case of Susan is that she would have gone to fear psychologist and so I'd like to welcome Mandy to give us your response. Thanks Mandy. Thank you Mary. Yes so I've taken on Susan after the referral and I think Lenny's set it up beautifully in terms of the importance of the relationship that is the key to me it's all about just working out how am I going to develop or connect or get this relationship happening. I think one of the things that I follow is I tend to have the parents or the client's parents come in for the first 10 minutes. I've already had a conversation usually the parent is the one who booked the appointment saying I've got the referral I might have had a conversation with the GP about you know it's a bit of background to understand where perhaps the pitfalls are or what might you know what direction might be best to go in. So I tend to bring the both in together so Susan would come in with Vicki and that and that sort of sets up how it's going to be so it will be very much around okay so now we're here this is the this is the plan this is how the session tends to run we'll tend to have the first 10 to 15 minutes together then I would like Vicki Mum to leave and we'll have some time together where Susan and I can just talk about some of the issues and then depending on how we're going we may bring Vicki back in at the end of the session or we may not and that will be up to to Susan and I to work out and depending on whether we need to check in on something or work out what the next steps are so absolutely the relationship is is the vital thing so I would be focusing very much on Susan in that period but listening a little bit to Mum looking at the relationships that they have together and also I think it's important to understand the anxiety levels of Mum you know so what what Vicki actually displaying is she got any anxiety type things and what might they be doing with the relationship and how are they conversing I think once once Mum leaves it's very much about setting again the ground rules of confidentiality making sure that I do think that Susan has you know there's informed consent that she's old enough to actually be sitting here and understand what the rules are and then I can use some of that first initial conversation to start the ball rolling that we've had with Mum if I've got silence or perhaps body language that suggests we aren't going to you know delve straight into things which is obviously quite often we can use some of the more general questions I tend to you know just ask well we heard you know a little bit from Mum or Dad and actually now I'm actually interested in what brought you here I know they may have made the appointments but what actually has brought you here and that's just a very general question and I'm quite interested I get such a wide variety of responses to that very just a few words actually and then I leave a little bit of silence I don't try and feel silence is straight away just to see you know what happens but I wouldn't let it be uncomfortable so if I feel there's nothing happened we can start a little bit of education I might have heard that Mum has mentioned the word worry or anxiety I know that's in the referral from the GP so I just ask a general question you know do you think this is worry do you think this is anxiety is it more than that what's the difference and then we have a bit of a discussion about what worry is what anxiety is and then we can touch base again I don't tend to use a formal screening tool right up front I think that actually can impede the relationship I'd rather build those general questions that I know are in a lot of the scales that we use into the conversation so I might ask about you know what what what makes you excited do you still have the same level of excitement you know Mum talked a lot about social media so is that something that you know makes you happy gives you pleasure what what kinds of feelings do you get out of that and then I'll also do very much a head type analysis so it's looking at what else is going on here and what are the personal psychological vulnerabilities so you know has has Susan actually experienced low mood before has she been anxious at any other time what's her lifestyle like what's her activity levels like what are her interests like we've heard a little bit from Mum about family history you know what what are her thoughts what what kinds of things does she think about her body body image and obviously I'll just go very gently depending on the relationship and how I feel session going the next thing I really like to understand and I think it's an important thing for adolescents is understanding around emotions even feeling you know I think it takes a long time sometimes to actually know what what is that emotion what does it feel like what's the label for it and how does an adolescent express an emotion and I think that you know we have labels we know that there's joy we know there's fear we know there's surprise but sometimes adolescents have different words or we all sometimes have different words actually and I think it's nice to check in is it a primary emotion is it something that is an automatic response and I will be checking as I've been talking to Susan knows that is that something that just popped up was it a reaction on her face so an emotional expression or is this something that perhaps is a secondary result has she actually you know she's been thinking about this so I often find that I see a lot of anger when really it's the sadness that's sitting underneath it or there might be an expression of shame or guilt but that's also expressed as anger so I'm just checking what are the emotions that are being expressed do I think that Susan actually understands what they are does she have the emotional literacy to express those feelings and that's something that she and I would visit later on if I feel that there's some work to be done around emotions and and what kinds of things set her off what was she like with Vicky when they first started in the room and and how does she react what emotions were written on her face and perhaps looking at those to further down the track as well obviously language is really important and you know the thoughts that Susan has made how are they being expressed in the case study Susan's words were she will never amount to anything and and those words are it pretty much they could really relate to all of the things I've got listed in that PowerPoint she's over generalizing she's personalizing that she's actually never going to amount to anything she belittles herself she minimizes her success in the case study you know she's really good at netball she's been really good at school and yet their things she'd rather push away and then that she will never amount to anything is a great example of catastrophizing it's the black and the white it's you know this is all over for her and I would be listening to those those words the language that she's using I would ask her questions around the kinds of thoughts that she might be having the next um the next thing I I you know just as a an aside if you like a lot of the case study of Susan talked a little bit about some symptoms and I do a lot of work with young women and so adolescents in polycystic egotary syndrome and we know that women have high levels of anxiety if they have polycystic egotary syndrome around 45 percent will have a clinical anxiety disorder and so she's got some of the symptoms I'm not saying that she necessarily has it and I don't want to necessarily pathologize but I think it's an important thing to sit you know in the back of our minds what else is going on here is there a condition of some kind we know she's got the the hair growth and the weight changes so is this a pattern and then really even if it's not PCOS what kind of pattern is it and I I find another nice tool if you like for the toolkit is actually having some kind of diary I find a lot of adolescents love journaling and sometimes if I can't find an an anchor we might use the menstrual pattern as an anchor and then look at all the different events and and thoughts and emotions that go with it so we've got something that's quite concrete that she might not feel as exposed around that we can start to have a look at and I'm very we talk about the rules around that you know Susan can show me the whole thing she can send it to me she can just talk to it she doesn't have to share it but it's to start thinking about are there any patterns and that's just one tiny tool in the toolkit if you like and then I think very much along Lenna's lines is I would rather not leave the consultation without knowing or understanding or determining where is the anchor so where is the anchor for Susan but is that in a person is it in a something that she's doing is it something that we can anchor her in and also setting up you know what if things get worse what what are what's going to be helpful for her how will we work on that and when when does she say you know hey hang on I actually need a bit of health here that's it for me thank you very much Mandy I just wanted to let everybody know that there's 540 people online at the moment it's a really big audience tonight and people are having really good conversations listening and contributing to each other as well which is great I'm just advancing to the next slide and I'd like to welcome Sally Young our social worker on the panel just to talk about how you would respond to Susan thanks Sally look I some of what I'm going to say really goes with what people have already said but I just wanted to start with the first slide of I think it's impossible to think of anxiety in adolescence without thinking of the developmental backdrop the the anxiety about the body puberty development and that's in the sort of case study how experiences and I think alongside that there's that increased self-conscious sits alongside other aspects of the increased sensitivity to the opinions of the group where in the case study there's the reference to the use of the mobile phone and the sense of what the group means there's a bit of a question in the case study as as to what's happening for Susan in the peer group the the anxiety in adolescence of no longer being a child and not yet an adult an adult and I think Susan's mother refers to feelings she's walking on each shelf and I think that feeling often goes with the way the young person can move backwards and forwards developmentally at this stage and diagnostically being alert to the to the extent and the form of the anxiety that that some anxiety is completely normal and one could even argue healthy in adolescence as part of identity formation but in terms of diagnosis listening to the extent of it that in the consulting room again as people are saying the importance of making a link with the young person the acknowledgement of the emotional pain and be aware that often adolescents have a very mixed feeling about seeking help and there may be a wish to be understood and a wish not to be understood and and to be alert to that mixed feeling in the room the importance of encouraging Susan to tell her story and and when did you start to feel this way being one way of starting and one of course is listening to both the content of the story but also the way the story is told to get a sense of the young person central again in the room the importance of being empathetic but also observational one's one's connecting but also assessing at the same time and I'm very fond of a quote from a child psychotherapist and alvaro who talks about being close enough to feel that far enough to think that being curious and interested in Susan suffering but also being alert to Susan's feelings of being intruded upon that it's important not to attempt too much in in in an initial session and particularly an initial session to think a bit more as a consultation than than therapy as one's always trying to in an initial appointment leave some space in one's mind to work out what will be important to do from here again another sort of thought I find helpful in in working with adolescents is being alert to the emotional temperature in the session not making it too hot too overwhelming nor too cold too abstractive or too cognitive to sort of keep a keep a sort of warmth an engaging warmth in the in the session hapsis goes without saying describe defences if needed but don't don't try to sort of attack or dismantle defences particularly in a in a consultation as others have mentioned be aware of anxieties about privacy and yet avoid committing to absolute confidentiality in in the in the case description there was a mention of Susan's room bringing her mobile phone into the session and I think this is quite an interesting problem in working with adolescents in that the phone I think is the adolescent form of the teddy bear everyone's got one and everyone's relating to it so you know important to sort of keep a bit of a an open mind to what what does this phone mean who is she connecting to who does she feel she constantly needs to be connecting to but also at times needing to set a boundary which which might involve asking her to turn off her phone so she can be present in the session um some just some provisional thoughts I had about the case study um for Susan the significance of losses was mentioned that her parents had um marriage had broken up and how this has affected her alongside the loss of um was also mentioned that her um relationship with a boyfriend friend broke up and the potential humiliation of him going out with a friend and I I guess one's listening to both these losses how does this connect to um anxieties about her body and gender identity at the end of the case nut study that was mentioned that it was quite a painful area for her um and and even an ordinary adolescent sometimes girl to have been dad's girl um feel that they they lose their father um in in the process of puberty to some extent in the ordinary sort of distancing and and so being alert to what what's happening in the family um listening out for have the changes of adolescence felt more like losses than gain um is there a real missing of being being a younger girl as other others have mentioned that the loss of the steam does Susan feel bad about feeling bad and is there there are sort of a cycle of feelings about um um the situation she finds herself I often try to stay alert to what's happened to um the secure relationships um or or is there a secure relationship for Susan and I like to ask a question like who do you speak to if you've had a bad day at school if you're upset or if you're worried but who do you speak to um in your family just to get a sense of where the where the links are where the connecting points are or whether there's been a loss of being able to connect equally listening out for the um sibling relationships and has that changed over time as each of the siblings move into different developmental phases and what that has meant Susan's a middle child and I guess classically does she feel in the middle I guess one's also listening for um in the session of how worried is Susan about herself or is her experience of the world that other people worry about her but it's not something that that's um that she's so alert to herself because in listening to that one's also listening for who's going to be most useful to work with um how much what one works with um Susan and how much one helps the people who are supporting it support the parents support that says just some management dilemmas um I guess in in an initial sessions um or even series of sessions one assessing what does Susan need what does she want and can she make use of help as to what sort of therapeutic help is going to be um again to be most helpful um and and what combination of whether one refers on or continues to work with the young person or whether one's clinician works with a parent or the parents or individual therapy so on um in adolescence these dilemmas of how um how much to involve the parents they're both central and um as as the young the adolescent goes through adolescence sort of less central so negotiating where the best impact are the parents able to carry some sort of worry together and um and do the parents need some psychoeducation to understand if Susan is suffering from anxiety as to how to understand that well particularly what irritable anxiety looks like because that's often misunderstood in families and and at the end of um particularly in a first session um often discussing with the young person what will be said to the mother and and I like to use some form of words like this of your words of private but would you be happy for me to speak to your mother about the themes and burdens of your work worries so sort of negotiating what's private and what's not um I think that's all from me thanks very much Sally I've just um the feedback from the participants is um people are finding it all really valuable so I'm just actually letting everybody run through all their slides although they were a little bit longer than usual but um Brett I'd like to welcome you to um respond um as you would think about Susan from your perspective as as a psychiatrist thank you yeah thanks very much and thanks for the opportunity to talk um of course by the time uh they've come to me uh they're usually completely cured because people like Sally work in my service so I'm in a very kind of fortunate position really um let me just a brief comment about um my approach and it's not that dissimilar um to whatever else I said I always see the young person first um I might have to negotiate but that's what I like so I think that my approach is um to really make it incredibly clear that I'm that I'm very genuinely interested in the young person from a very broad perspective and very respectful of their views and in fact usually start with quite a long discussion about anything that's not the presenting presenting kind of issue so you know we often have these interesting conversations about what they're watching at the moment what they're listening to at the moment what they're thinking about at the moment what issues in the world that they find um interesting or um challenging or creating angst um and I think with that kind of approach I've actually never had an issue um talking to young people in fact the parents are always really annoyed that they've talked to me for an hour and they haven't talked to them for the last couple of months um so that kind of seems to work for me um when people come to me it's often about an opinion uh for a diagnosis or it's often about an opinion about treatment so um apart from the small private factors that usually are in a tertiary referral that's kind of nice so I hope it's kind of major issues I wouldn't know if this is actually in the context of normal development because a lot of Susan's story is in fact incredibly normal and something that one shouldn't apologize and if you think back carefully a lot of us have many of those issues so normal normal is always within my own differential I'm interested if there is some sort of discontinuity from development and I'll go over and talk about this or whether there's um or this is actually a continuous developmental problem that lasts a long long time before the young person's presented in which case it opens a whole different range of of kind of diagnosed issues um I'm interested in whether this comes to sort of some sort of identified patient issue and I'm interested in if the person's enacting or acting out a much more deep-seated kind of family issue than the vignette suggests and of course um I'm always interested in kind of safety so I'm kind of a pictures guy I think there's much too much talking in mental health which is by the way a joke um so I'm kind of interested in this idea of a developmental trajectory um what we've heard about Susan is where it's kind of highly suggested that this person's been on a normal trajectory it's highly suggested that this person this individual this young lady had no particular issues in primary school or you know pregnancy early life those kind of issues um now clearly my role would be to very you know in some length go through all of that and come to this decision because if it's a discontinuity as this figure suggests then there's usually a trigger and the trigger is either kind of inside their brain or outside their brain so it actually might be something organic but it could also be a stressful event that's happened it might be the separation of parents it might be a peer issue but it might be something else and obviously over the last 20 years I've seen a huge range of events that can trigger a presentation just like this or it might be a development of continuity so if we go back in the history we might have actually found that you know the whole gamut of possibilities including you know an unwanted child early temperamental difficulties you know serious dysregulation as a toddler problems getting into primary school you know major problems with friendship groups during primary school a whole range of issues over a long long long period of time and for me as the sort of a diagnostician that opens the whole issue of more profound and ongoing dysregulation and whether this is actually on a trajectory to an access to kind of personality dysfunction in years to come she's too young to diagnose that at the moment but again it opens a whole different gamut of possibilities this is really important in planning treatment I wouldn't go into a treatment that's a fairly short term that might be something like CBT something that's looking for a reasonably quick turn around or a brief solution like a family therapy that has a brief turn around if the gentle lady's been on a on a you know under the normal curve of development for many many years so diagnostically I kind of have these major decision points and I'm looking to see whether this more fits like a response to a event or it's been a lifelong issue and you know obviously it's an incredibly simplistic little diagram here but I'm very interested in how all this plays out and of course the most profound problems are when you have impairment at school at home and with your peer group as opposed to impairment in just one of those areas so I'm looking broadly to see where if there is pathology you know how pervasive it is and how it affects a young person across their various domains the I kind of anticipated that we might have treatment kind of questions in Q&A so I probably Mayor I'm probably pretty happy to leave it at that and someone will inevitably ask me about medication I suspect in Q&A thanks well if they don't Brett I will because I know that the audience probably wants some important of that but I'll give you a break for a moment now there was a really interesting scenario that Sally raised so Sally you sent that in I wonder if you'd like to this mention say what you were thinking about the scenario with her friend who comes with her to the second appointment and I think Kat you could you could speak with Lena about how she might respond so could you ask your question and then I'll get Leonard to respond my question which in my experience is a common sort of dilemma is that Susan turns up up to her second appointment and when one goes to the waiting room she is sitting with a friend of hers they're both dressed identically in black Susan says to the GP I'm not coming in unless my friend can come what would one do yeah but that is something that I frequently encounter also with young people who come and see me in a different context and quite often I find if it's their their friend and his perfect to friend who's a girl they say look she knows everything about me as much as I know about me I tell her everything so I kind of start off accepting that at face value and so we might be talking about some quite personal things is that okay with you and she they invariably say yeah that's fine the friend knows everything I'm actually quite comfortable to talk to them both together I think on a second appointment where I've already built rapport with the young person and I have the story I'm quite comfortable with that if I've got a good relationship and I do feel I want some time with the young person alone I wouldn't be worried after a little bit of time to again say well I'd really like to have a chat to you on your own is that okay with you but in general I find the friend is actually quite supportive and can be a way of keeping the young person engaged with the consultation in the area that I work in in sexual health for example they're often both there to hear the same thing and quite often you kind of doing a group consultation with one index patient and you've stuffed out up front that they're not worried about keeping anything private and this kind of thing so I'm quite flexible with that it'd be different if it was maybe a partner in intimate relationship I might be more inclined to get time alone in that situation because there can be issues of control and this kind of thing that you want to separate out but quite often the best friend is a supporter knows a lot about that young person in the first instance thank you I was good to say also in mental health it often happens that the one discovers the friend has some difficulties as well it's often a bit unclear who's bringing who but I agree with you thanks Sally and there's some people in the audience who's saying it can work both ways and I think in my experience sometimes it's been about having them in to begin with while everybody gets comfortable and then then it becomes easier to ask to see them on their own and as everyone has said engagement's the key so I think I don't know CPs and maybe everybody in mental health just become fairly pragmatic so whatever works Mandy I was just wondering if we could invite you back in to help us think about parents so quite a few people have been really interested in the impact that the parental separation might be having on season and things like do we need consent from both the mother and the father given that the mums make the appointment so just perhaps we'll answer that one Mandy if mums made the appointment and brought Susan in would you make an attempt to involve Dad or do you think we should or how would you make it to Susan around that? I think reading the case study one of the things that was quite clear was that she actually had a very good relationship with her father so I've been looking at a lot of the comments that have been coming in and you know I think it's actually really important that we remember that there are to do parents here I find a lot of the times and I really only see adolescent girls but it is Mum who brings the daughter in but I'm conscious of how to involve Dad so it's about exploring what the relationship is really like and understanding what's the right timing if you like to bring Dad in because if we've all said the relationship is the most important thing if Dad is the parents that she actually has the strongest relationship with I would like to involve him earlier on it comes down to in terms of who's the paying client or who's the paying party Mum has brought Susan in in this instance I would want to know what Dad's thoughts are from Mum about this and your tea on board if the only time I think we always have to be really careful is if there's a court order if there's some kind of family dispute going on if we can involve both parents ultimately that's the best thing but safety and the client so Susan is my focus and what's best for her is going to be the thing that informs which path I take Thanks Mandy and I know that you had a question about physical symptoms so I wondered if you wanted to pose that question possibly that to Lena Yeah I find but a lot of adolescents come in with a physical type pain so they might have pelvic pain or I've had a couple of younger girls with migraines but what has actually been called stomach migraines and I find that I know that it's attached to anxiety in some capacity and I want to keep the relationship you know bubbling along and I know that there's the somatic but there's also this element of anxiety interacting I don't want to you know bring out the issue of the physical pain but I don't want to ignore it and so it's acknowledging keeping the relationship going knowing that a lot of the time when the anxiety starts to resolve itself a little bit that the pain also diminishes and then having the conversation you know with Susan for example about what that's all about that can be really tricky sometimes so I'm interested in other people's thoughts somebody sounded like they were going to comment there I just need to say that my internet connection has frozen so I don't know whether I'm still moving but I'm not moving on my own screen but the audio is still working so we'll keep going now Sally I think that might have been you going to say something or was it Lena? I was just going to say about the area of physical pain I think it's just always important to have that sort of position of being available to listen to pain and just as talking about it it often does emerge that it's actually psychological pain but it certainly doesn't help to prematurely name it as psychological pain but I think if the therapist has the position of listening to the story of the pain that it often it often allows something to be sort of understood and moved on through that It's Lena here Oh sorry Lena and then that Yes sorry I was just going to say that it's a common presentation in general practice and that's why I think it is imperative that the GP holds the mind and the body together and while you're you're going down the track of excluding physical causes everything's quite connected and it's very important to engage with the young person in their life context the psychosocial context and their physical context and keeping both things alive that idea that one can influence the other and then the discussion is always open about the management of the pain whatever the cause turns out to be And Brett you were going to say something in there too Yeah just very briefly I mean I'm always very comfortable with the concept that pain always has an element of physical and always has an element of emotional and I am very upfront with that you know the relative quantum of each obviously changes all the time but really very early in the conversation I try to help people not to see this as a dichotomy and most people find it very helpful And so Brett just on that note and I think we will bring the medication question in I mean a lot of this is about spectrum so Sally spoke to us about the fact that adolescence is a time full of anxiety so a lot of that might be normal So deciding when is something normal and when does it become a disorder but then how do you begin to make decisions about when you need medication I think I mean you know it's probably not that scientific and it's probably kind of experience and a bit of art as well I think that I usually don't go on symptoms I usually go on impairment so if the presentation is overwhelming the person if they're now no longer functioning at an acceptable level with their peers or at school or at home So I'm very kind of interested in functional impairment I'm influenced by you know things like the Australian practice guidelines for depression in young people which clearly say a talking therapy first it clearly says medication not first because obviously a psychotherapy can teach you a skill that might be useful next time it might stop it might help with relapse prevention So generally if people have got high levels of impairment so much so that they can't access a talking therapy or if they're finding it hard going with psychotherapy then you know we have a frank conversation about you know the pros and cons of medicine I have it first with the young person I then have it with the parents and obviously this person's 15 everybody has to agree and then I'll make it clear it's a brief trial that's time limited and to have someone a medication for a long period of time is just irresponsible and I talk about things like it's a window of opportunity for them to go back and access and use therapy again so we have those kind of conversations and people often want to walk out of my room with a script and I say well I want you to go and think about it and you know come back next week or if you know if you're really kind of interested come back in a few days but that's the kind of process I have Thanks Brett I one of the other things that I've had a lot of questions about I guess thinking about people in rural practice but also particularly for our DPs in the audience sometimes you're in places where you can't access counselling psychologists or social workers or OT or mental health nurses and you're there on your own or it's a bit of a wait to see the psychiatrist what I'm going to ask Mandy from a psychologist's point of view are there any you know really practical hits or strategies or even resources that you could suggest the kind of time pressure DPs to actually help a young person straight away have something that they can take with them to deal with their anxiety? I don't really mean to do a bit of a self job but at Dean Hales actually we have a whole anxiety portal and it's just for women and broken into life stages but it's also broken into and I've been watching a lot of the chat that's been happening and I think the comments around anxiety actually is normal it's part of being a human being and I think we need to understand you know what is worry what is anxiety what is an anxiety disorder and so actually on the website it's broken into life stages and also worry and there are questions around it there's self-assessment because I think if you can do a little bit of the education but then also have the tool so there's a tool kit for young women for women of mid-life and older women but there are self-assessments questionnaire so you could actually do the assessment and get your results and go off to the GP trying to save a little bit of time in that initial phase and then the tool kit is very eclectic if you like so there's cognitive behavioural therapy but there's also all of the other different I mean I have loved listening to Sally and her thoughts and approach is just fabulous and really interesting and I think it's about understanding who you are as a young woman and what would work for you so helping the client understand a little bit more so that when they go to the counsellor in their rural areas there's a little bit of a head start we know that a lot of DPs are sending their clients there too as a head start so it's part of the tool kit the things like the Australians psychological society have great referral and tip sheets and information services available so there's lots of there's mood gym and the anxiety type cognitive behavioural programs which I think an app there's quite a few apps now starting so as long as they are government supported or university researched or they have that background as we all know as professionals that's the important thing I think there's actually more and more almost daily great resources out there Thanks Mandy and I just wonder Patsalina if there's any tips that you would dig to other DPs for that same question because it comes up Yeah I think I agree with Mandy there's a whole lot of resources out there I'd like to mention reachout.com which is not only for all young people and that has a number of peers that have written up their stories information sheets, back sheets other sorts of avenues to seek help online and we know that you know 99% of young people are online these days and usually on their phone not so much at desktop or anything like that and probably very rarely accessing this information in print so I think the online resources are quite good the other one is headspace of course which does have also resources and e-headspace which is an online kind of counselling possibility and as Mandy said nerd gems e-couch there's a number of other resources like that that might be useful to have on a little extra handy young people if they need some more information about what might be going on to them and how to help themselves Thanks very much Lena and just thank you to all the participants who are posting really good resources in there and they will be available a few days after the webinar on the MHPN website Now just approaching the last few minutes of the webinar and I'd like to invite Sally back in Sally we haven't really addressed all that much about Susan's family situation and I just wonder if there was any thoughts that you've been having about her place in her family or anything that's been coming up for you that you'd like to bring in I guess it's a very important question that even if one's just working directly with Susan to sort of have the picture of both her internal family in one's mind how she sees and represents her family and what they mean to her but also have a sense of how this family operates and I guess what the story I certainly would be interested in the story of the parent separation was what that story was was that a shock was that something long coming and that there was a relief all the sort of ranges of different responses that could be so and also one still listening for or working with other parents still able to be parents together although they're not a couple anymore and that might be quite a a central point in terms of of the structure of the support being able to be offered to Thanks Sally that's a really interesting point and Brett you wanted to say something about families as well We have a bit of a technology delay I actually wanted to say something about resources not about families That's fine Very quickly something that GPs busy GPs can do straight away is to actually remind a young person and remind the family that they've had useful coping skills in the past work out what they are and prescribe them People often under stress or distress forget all the fantastic things that they've actually found useful for the last 15 years You see this in adults as well and people have stopped doing them So I kind of work out what they're good at work out what has worked in the past and then actually prescribe it back and monitor it and that can give you some quick quick gain Thanks Thanks Brett and look I would I do that too and I also we've had lots of questions about the value of exercise and there's no doubt that exercise is valuable and I think sometimes the trick that GPs have and psychiatrists is we have a prescription pad and I keep an old-fashioned yellow prescription pad and a pen and I write exercise prescriptions and other kinds of lifestyle things on it sometimes is a symbolic act Because we're just going to invite everybody to just have their final few words So I think Mandy if you would like to just sum up what you think you'd like everybody to just remember from tonight Thank you Well that's There's been so much really interesting conversations happening and it's the first time I've been part of a webinar like this so to look at the chats and the sharing of information and I think for me to stand out is that we know the relationship is really important that it's about connecting with the young person in some way but also remembering the context of that person's life and all of the things that go with it so it's sort of like yes a no-brainer but that we all you know have shared similar types of information and that there are lots of resources and to have this ability to share the information like this I think has just been fantastic and makes it part of the conversation it's an ongoing journey as the adolescents as Susan is experiencing right now Thanks very much Mandy Lena I think we started with you and I think you're probably going to continue with you Yeah look I think it's been great discussion and I think we're all following a similar perspective actually I'd just like to re-emphasise the importance of creating that connection in the clinical environment especially at first encounter to help the young people feel safe valued and listen to and to create that space for them to have that relationship with you on their own while at the same time supporting their families and helping them connect with their families and you know dealing with the medical and the psychosocial all as one I think that would be my take home message Thanks Lena Brett Just some summing up words for us Sure in this particular case I think the key is actually communication and establishing a relationship of a young person so that respect I agree with everybody else and you know what you want to do is you want to have this young person feeling incredibly comfortable coming to you and you know they at some level know exactly what the problem is in fact they usually do but they need someone safe and containing to actually say that to and a lot of this isn't clever a lot of that is providing the space and the safety for them to do that and you know within that context I think you know you can do great work with with these kind of presentations Thank you and Sally I was just having a thought that what a great multidisciplinary team this panel would be and that it could be in Susan's case it may be individual work as the way to go but it may also be that a team of the GP, psychiatrist, therapist and the school may actually end up being a team that holds her particularly if her problems emerge to be quite severe but it was also occurring to me as a team we would be the same number of people as is in her family which is also another area we'd be looking for to maximise the containment for her Thanks Sally that's a really important point and obviously the MHPN is about collaboration so I mean I think that some of our systems make it quite difficult to do that and we have people who work in the public sector in the private sector and general practice in schools but I think that keeping in mind that working together is going to be the most effective especially I think with young people but possibly with everybody but Sally that was a really great point and look I'd just like to thank all of our speakers so then a thank you for reminding us to keep development in mind and to focus on strengths and all your useful points about just how to how to engage young people and help them feel comfortable Mandy you reminded us to kind of take charge in a way and explain the process all the way along so this is why I'm doing this mum I'd like to do this Susan I'd like to do this and then thinking about what is the anchor for Susan and then Sally told us that the anchor might be the teddy bear which is actually mobile phone so that was a really insightful observation and I think the idea is what you spoke about the adolescent wanting to be both understood and not understood at the same time is really I find that really powerful and the reminder that anxiety is a normal part of adolescence a lot of the time and you know things are always on the spectrum and to keep in mind that there's lots and lots of role time to assume and existential issues to people that might be part of their normal development and I think Brett's point about engagement at the beginning about to spend your normal self authentic self and Brett is genuinely interested in you know the quirks of the individual young person in front of him and what interests them and I think each of us has our own style and our 500 participants tonight all do as well and thank you to everybody for your contributions into the chat box the resources the PowerPoint slides will be posted on the MHPN webinar page within the next few days and the webinar itself is available as a download if people want to watch it or if you want to pass it on to friends if you think you found it useful I would like to remind you all please stay online after you hang up this just allow the exit survey for us you will be sent the link to the online resources and we have another webinar this is the Collaborative Care and Mental Health of People from Migrant Background that will be held on Tuesday the 3rd of June and the address is there if you would like to register for that I would like to remind the panelists to please just stay on the telephone afterwards and once again thank you very much to everybody for your participation and we look forward to seeing you again there's just a little final slide there about the MHPN they're a local network very often in your local area and if you're interested in meeting people face to face please go ahead and have a look and more information is there thanks once again everybody for your contribution good night