 OK, shall I start? Welcome. This is the webinar for Working Together to Support the Mental Health of Injured Workers. We've now got, I think, 289 people who've joined us for tonight's webinar. And I've been looking at the places that people are styling in from, and it's just wonderful. I think there was someone from Qatar online as well. I'm Prasuna Reddy, and I'll be facilitating tonight's session. I work as an organizational and health psychologist. I'm at the University of Newcastle. I'm a professor here, and I'm also the director of the Center for Rural and Remote Mental Health in the School of Medicine and Public Health. I'd like to introduce our panel, and I'll be asking each person to tell us a little bit about themselves and specific areas that they work in. So I'll start with Stephen Leo. Stephen is a general practitioner and joins us from South Australia. One of Stephen's areas of expertise is pain management. And so by way of introduction, Stephen, I wonder if you could tell us, what are some of the important things to know about pain that we're usually not taught at university? I think pain is an experience. It's very important to know that if it's not the regulatory pain, that's not equal to injury. Injury does not equal pain. It's an experience that's happening in the brain. And it's brain impulses like a lot of other things than they're influenced by other brain impulses. So the psychology is probably one of the most important aspects of dealing with a patient with pain. OK. Well, thank you. And I think we'll talk more about that when we do the case study. Joining Stephen is Franklin Basie, a physiotherapist. And Frank, you have over 17 years of consulting experience in occupational rehabilitation and injury management. Could you tell us how things have changed over time in occupational rehabilitation? They've certainly come a long way. And a lot of that has been based on the fact that there's much better research and better understood concepts around return to work and the support that people need. And certainly, most recently, the understanding about how safe work is actually good for health on the back of some of the important works that we've even had out of the UK. I think a certain highlight of the importance of return to work and how important it is in the earlier stages to get good action. And I think that has been always industry come along in leaps and bounds in most recent times. OK, I think that's going to be another question that comes up in the case study about returning to work and what factors can assist. D.L. Selman joined us too. D.L. is a psychiatrist and her career is in occupational psychiatry. D.L., you've worked with a range of stakeholders, insurers, employers, individuals. How do you manage or balance the sometimes differing expectations of these stakeholders? That's a challenging question. I think in the first instance, often there's not different expectations. And the thing I love about working in this industry is that getting an injured worker back to work in a safe and durable manner is the same expectation from the employer to the injured worker, to the treating doctor and to the insurer. They all want the same thing. It's later down the track where problems develop and there seems to be a bit of push and pull. And the way I tend to manage that really is with communication. Open lines of communication. I pick up the phone and speak to all the individual parties. It's about education. It's about making people understand the reasons for the decisions we make and working collaboratively together. Okay. Well, thank you. I know that's going to come up in the case study as well. And Peter Cotton. Really good to see you. Peter is an organisational and clinical psychologist now in Victoria. It's great to have you with us. I know, Peter, you've done a lot of research on organisational environments and how they influence staff well-being and performance. So can you tell us about some major findings about organisational environments related to performance? Well, I think in the organisational psychology world, there's a lot of work on psychosocial quality work and organisational climate, which do correlate with some of these sorts of outcomes. So there are efforts going on to move upstream to work in the prevention space. Better quality people managing environments do have less problems. I'm a clinical and org psych, so that's a bit sort of schizoid because the two often don't necessarily come together well. But there are good things happening in the prevention space because as we'll see when we talk further tonight, once the claim has gone in, things get a lot harder. So the potential is to move into the more pre-claim as it's termed early intervention space and the prevention space. So better people environments is the key. Yeah, I think we're going to hear about early intervention a lot more with the case study. Thank you all. I'd like now to look at the learning outcomes. Sorry, there are some ground rules that we have. But I hope that you've had a chance to read and I won't go through them now, but they are on your slides. The learning outcomes especially were focused on understanding the relationship between mental health and work-related injuries. And we're also going to look at how different practitioners assess, treat, manage and support people dealing with the work-related injury. And third, to recognize the challenges and opportunities in providing collaborative care. I think that's key to so much of the work that we do in work-related injuries. So each of our panelists is going to speak briefly to the case study. And I'm sure you have the case study in front of you. The discussion will focus on Matt. And he's suffered an assault in the workplace. The incident has left him in a state of ongoing distress and feeling incapable of returning to work. So I'll start with Stephen, who will give a short discipline specific response to the case study, followed by questions and answers between the panel and the audience. And Stephen, I'll ask you first to speak to the case study. You will be doing that. I'm just trying to get back. OK. From the general practitioner's perspective. Absolutely. No, looking at Matt, he's a young person. He's suffered a traumatic, a mentally traumatic incident. And he also has a physical injury, which is a fracture. Now, two important points come up straight away. I mean, the first one is that it's workers' compensation. So that has an influence on pain. And the second one is the victim of crime. And that also has an influence on the pain that he suffers. If you look at Matt in the two-week mark, the psychological issues, are they being taken care of by the employer? What are they doing? At the two-week mark, the pain could actually be better at this time. If anybody is at a fracture, you know that the pain is most right at the beginning. And after one or two days, it starts getting better. Certainly at two weeks, it should be a lot more comfortable. Then what medication is for is mental state. And what is this mental state? And certainly, taking other people's medication is a huge, huge red flag. That is a giant no-no for many reasons. The medication, what is he taking? Is he taking an opioid? You know, what quantity is he taking? Is he potentially addicted to these opioids? Now, he and his mother are actually breaking the law in sharing these medications and then taking any interactions between the prescribed medications. Because not knowing what you're dealing with is very, very difficult. And particularly, if you're trying to treat Matt yourself. If you look at Matt at a six-week mark, the pain should be substantially better. You know, the fracture would have been well on its way to healing and sort of have a reasonable strength. Is there something physically wrong? Is there something that has gone wrong with the fracture? Is it not joining or is there conditions like chronic sort of regional pain syndrome? There are certainly clear mental issues now. You know, the anxiety is identified, depression is identified, and post-traumatic stress disorder. And we talk about stress-stakey fields. Are they real stress or are they imagined stress? Is he suffering from sort of paranoia? Or, you know, is that the real threat of the check out there? At 12 weeks, the physical injury should be healed. By 12 weeks, most things are healed. The pain should be gone. Some questions that he thinks of the doctors. Is he doctor shopping? There's an admission that seeing other doctors would be surprising because that's not something you tell your treating doctor about. By the way, I've seen Dr. X, Y, Z, A, B, Z, and so forth. The use of illicit drugs, again, is just worrying with the marijuana. And what are these pills that are helping you cope psychologically, I wonder? The mental issues are the same. They clearly have not been resolved. And what are his actual requirements as stated in the case study? If we look at pain, mood, and sleep, it's a very clear interaction. Pain will affect mood, and pain will affect sleep. Sleep will affect pain, and sleep will affect mood. Mood will also affect pain, and mood will also affect sleep. So there's a clear interaction. And all you need is one of these things to go wrong or more. And they all affect each other. So always bearing in mind that certainly with med, there's sleep and there's mood. So he's got the trifecta. Certainly, some questions arise. First one is whether psychological factors can actually cause pain. If you have purely psychological factors, can you actually make pain? And the answer is no. And the next question is, can psychological factors modify pain? And the answer here is yes. Can psychological factors make pain persist? And the answer there again is yes. So if we look at that, certainly we've got some things that certainly influence his pain. He has a few of the psychological yellow flags. Testifying, works compensation, passive approach to his rehabilitation, an extended respiration, and disproportionate downtime for what he's suffering from, the wardens of normal activity, depression, anxiety, and stress, with lost control with the stress. You have to ask what the role of medication is within the treatment of depressed mood, SSRI, SNRI, to treat that. The anxiety, would you use a benzodiazepine? And certainly in the pain, what are the role of opioids in with him? Do you use them at all or do you tackle this? So if we look at a balance between serotonin and no adrenaline, they both modulate pain. Serotonin actually increases pain, no adrenaline, reduces pain. And there are medications that actually do both. And when you use any medication, particularly anti-depressants, do you want to know that it probably has more positive effects on things rather than a negative effect? Thank you, sir. I've taken a few notes from the questions coming, and we'll do that after the other speakers. Thank you so much. One of the questions that's come up that I'd like you to keep in mind for afterwards is whether you would do a mental health plan as well when you see someone like this and what would go into the referral if you pass that on. So I'll come back to that when we do that. Next, Frank. Frank, would you provide a perspective from a physiotherapist in MAPS case, please? I'm looking at this with a background of physio, but as an occupational rehab provider, and looking at this from the perspective of facilitating return to work, I think I'll go through the main points that I think are the concerns in terms of facilitating a safe return to work and talk to those points as we go through. Clearly, the issue of the ongoing pain for what appeared to have been a simple fracture is a concern, and I'm not speaking any further about it other than to indicate that we may be dealing with a chronic pain condition and with the psychological issues that are largely unmanaged. That can become a real ongoing issue, and the two, if they're not managed well, you can amplify one another. In return to work space, an over-projective or significant support person, while they can be beneficial, can also be very detrimental in the return to work process, and it would appear that Matt's mother is certainly someone who fits into that category, and I think that would really need to be managed. In the return to work sense, it takes the control and the sense of responsibility away from the injured person, and we need to bring that control back to them in managing and coordinating and setting some realistic return to work goals that are achievable. The social isolation is also a problem. We know that when people are away from work, they lose that important social interaction with people that are important to them on a day-to-day basis. In the situation, we've lost that, and beyond that now, Matt's lost touch with his social circle and his friends and his potential girlfriend for one of a better term, so that is an ongoing issue as well. The fear of ordinary behaviours are a real concern. They're certainly feeling well-entrenched at this late stage, and that is a concern, particularly when we're looking at return to work, where return to work will be avoided because of the potential for aggravation and that potential is a driving factor as opposed to reality. The reported inability to drive will be a practical consideration in return to work. In a situation like this, you'll often look at facilitating initial return to work and an alternative workplace so that you can facilitate a greater exposure to the workplace, et cetera. In this situation, if he's unable to drive, that may limit his practical ability to get to another workplace. I think there's a real concern about the level and type of communication between Matt and his employer. In situations like this, it's not uncommon for an employer to think, well, we'll step back and stop communicating to give Matt some time and some space. The perception from the other end can be that Matt thinks that his employer doesn't actually care for him and he's calling in and staying in touch. And in this situation, the working or injured worker's perception is absolutely paramount, so that needs to be really, really addressed. And again, the fact that his role has been filled, we need to address that as well because there may be perceptions from Matt that his employer has given his job to somebody else and is not looking after him and not supporting him, so he's got to manage that perception of a lack of support from the employer. The doctor shopping, again, is an issue because in a situation like this, you need a very well-planned, collaborative strategy which incorporates and aligns treatment goals with the gender work goals. That becomes very, very difficult when Matt is changing treaters on a regular basis. Again, the pain medication or the unmanaged pain medication in the use of marijuana is a clear issue. Matt's dyslexia may be a practical issue down the track. Often, we'll get people back into workplace performing alternative duties and often the lightest and simplest task may be simple administration duties. In a situation like Matt's, that may be actually a really difficult proposition because it's underlying dyslexia and that could add to his anxiety and depression as opposed to relieve it. But the last three are probably the real clinches. He believes that he can't return to work. We know that in return to work research, that is a single biggest predictor of whether someone will actually return to work or not. That means that needs to be really challenging. He's been off work for quite a long time and we know that chances of people ever returning to work dimension very, very quickly after the initial onset of injury and particularly say what people have more than one injury, which is the case in the situation. We've got to combine physical and psychological injuries. And the continued certified incapacity is a real issue as well. It's worth someone like a confirmation buy. If a person believes they can't work, they go and ask someone that they have respect for, their medical practitioner, who then confirms their belief by providing them a certificate that indicates that they continue to be unfit for work and the whole solicitude continues to be confirmed. So that is a real issue. And at this late stage and down the track, we're less than 50% possible chance of ever returning to work just on time alone. Okay. Thank you, Frank. Just one of the questions that's come up that you might think about in the discussion is how much would you tell Matt about recovery early on? What are the expectations that you think that's an interesting one about whether, for motivational reasons? We'll come back to that if you would keep that in mind. Thank you. And D.L., you're next, and we'd like you to speak please from psychiatrist's perspective on the case study. I'm getting really distracted by all of these comments. There's so many fabulous points. And I've been given five minutes to talk about something that I'd love to just chat about all night. What I'd like to do in my five minutes is leave you with some key messages regarding mental health and wellbeing and work and then talk for a couple of minutes specifically about Matt's case. So the first thing I'd like to share with you is my first take home message, which is good work is good for you. And that might seem completely obvious to you, but I think unless you turn your mind to it, you don't turn your mind to it. And that's certainly something I wasn't taught in medical school or psychiatric training. So I'm just going to cover it briefly and it will seem very obvious, I think. So people at work, what does it give you? It gives you meaning. It gives you purpose. It gives you self-worth. It gives you money to go out and have a good time. So people with mental health difficulties, if work is safe and good, it can be a distraction from the problems that they have. It's the social interaction. It also gives you stimulation, as opposed to not being at work. So often I see people who have been off work for a period of time and they have no meaning, no purpose, their self-esteem is plummeted. I say they can't go out because they've got no money. But more importantly, they've got all this time to sit at home and ruminate about their difficulties and their negative thoughts. They've become increasingly isolated, not just from their work colleagues, but they've stopped going out to see friends. They've said, I mean, what do you think happens when I go to a party and I meet someone? What's the first thing someone cares for me? What do you do for work? And I don't want to tell them that I'm off on compensations, please. People at home are bored. It's all their friends and family are off at work. What do they do? They sit around at home and they sleep during the day so then they don't sleep at night. They might engage in unhealthy activities like drinking alcohol and they're kind of just spiral out of control. Well, that's what I see anyway. This next slide is really just reiterating my first slide and what I see, I often see people, you know, six weeks after leaving work, three months, six months, nine months, and I often, not always, but often just see this spiral of increasing symptoms, increasing sick roll, entrenchment and worsening functional capacity and it just gets worse and worse for them. Now, the evidence is out there that being at work is not just a benefit to your psychological health and well-being. There's a lot of evidence to say that it's actually good for your physical health and well-being and the College of Physicians has recently put out a positioning statement. I'm not that sorry, recently, actually, maybe a couple of years ago to say that not worklessness is a equivalent health risk of smoking 10 packs of cigarettes per day. The outcome from cardiovascular disease and spiritual disease were suicide rates are higher and it doesn't just affect the individuals. The slow on effect on children is also apparent now with increased rates of physical and mental health and children for a work outcome in educational outcomes. A few more take-home messages and thanks, thanks touched on this one that it's important to know that the longer someone's off work, the less likely they are to return to work. So at three months' season, the chance of getting back to work at all in the next three months is 50%. And once someone's been off work for about two years, the chance of them ever returning to work is around 5% for people who are on compensation claims. So I think what we need to look at doing is try and minimise the time away from work. It's important to know that workplaces have obligations to provide reasonable modifications for their employers. There's anti-discrimination legislation. There's occupational health and safety legislation. So I think I'd encourage those of you out there who are certifying, when you actually go to write that certification, have a think about it before you put someone off work because you might think you're giving them a gift in the first moment, but say, you know, week one, week two, month one, it might not be such a gift. So I'd encourage you to think about modifications and you can really ask for anything, whether the employer gives it or not, some other story. But I often ask for reduced hours, modified duties, longer time frames in which to complete tasks, reporting to a different manager if there's problems with management. The next point I wanted to leave you with tonight is that so often I see people write reports where they say, yes, once my patient recovers, I'll go back to work. But if they're aware that actually being off work is adversarial to someone's health and well-being, then surely returning to work has to be part of the recovery process and not something that occurs after recovery. Thank you, Danielle. Odeo, one of the questions, the intriguing questions that's come up, which we might tackle, is, how do you put return to work versus recovery and improvement in mental health? I mean, so, you know, how important is the return to work or focus on mental health improvement? So we'll come back to that, I think, because of the emphasis on return to work when we come to the general discussion. Is that okay? I think we've got hands in hands, but I've still got a couple more slides. Oh, go ahead. Okay, then. Yes. Okay, so I just want to spend a couple of minutes talking about maps case in particular. And for me, there are a lot of alarm bells in maps case which can be generalized to other cases as well. So, first of all, there's limited education, training and experience needs dyslexia. That's going to limit other job opportunities available to him if he can't go back to his current work place. He's obviously had the traumatic experience at work and he's got a fear for his safety, which is going to make it harder for him to get back. Comorbid mental and physical health symptoms notoriously have a worse outcome than if there's just a psychological condition on its own. It's functionally impaired, which is associated with a worse outcome. We've been off work for that kind of magic three months mark where it's starting to become chronic. There's substance misuse and I know his dead is using just a bit of marijuana and a bit of alcohol, but in my experience, he's got a double or triple what his dead is using and that's probably closer to what he is using. There's a family history of somatization and possibly chronic pain and there seems to be a stigma about mental illness and his mother's shielding him from returning to work. We don't know why, she might have her own issues, but that's something that's going to get in the way. He's also not really engaged in treatment and where's the employer support? I saw someone's comment saying, where's the flowers and the cake exactly? There's been not much there at all and the fact that he's got the compensation claim also leads to a worse prognosis. So just a couple more slides. I put this one up. I know this is in a psychiatric lecture, so I'm not going to go into all his specific symptoms, but just to make a couple points, when someone's got phobic anxiety and phobic avoidance, it's often very difficult to get them back to work and I think these are the ones that we have to try and get back to work sooner rather than later because without getting back to work, that their anxiety and avoidance is just going to escalate. Which I've put functioning up here, so often I see people talk about symptoms and diagnosis without much emphasis on functioning and I think if we can turn our mind to functioning being a measure of someone's well-being, then that's a really positive thing. I mean, in my experience, someone who's going to work with some antipyretry anxiety and apprehension is doing much better than someone who doesn't have that anxiety but is sitting housebound increasingly isolated. So just in terms of what I do, I do reach Matt moving forward. I've said make time and I think that's really important because often when there is a compensation claim, the time when the clinician becomes without filling in claims forms rather than doing some active treatment. So I think we need longer appointments for these people and more time. There needs to be support, psychoeducation, alignment with him, being on the same page, assessing risk, not just the risk for himself but the risk that he describes with this other person. I'm not sure if it's real or imagined, it's probably imagined. There needs to be early collaboration between all the stakeholders and there's nothing wrong with picking up the phone and speaking to the employer or the rehabilitation provider. Early referral to a psychiatrist or a psychologist and addressing the barriers like fear and stigma in terms of treatment. I mean, the main stage of treatment are going to be the trauma-based cognitive behavioural therapy and medications, this man's probably going to need medications at this point. I know he's a reference to take medications so you might use one with a side effect profile that's of benefit. So, hey, how about we put you on some geloxythenin to help with your sleep? Sorry, with your pain? Well, okay, it depends on the health of your sleep. And this man's going to invariably have significant side effects from his medication and not want to persist with it so it's going to be about educating him about the side effects, going low, starting at a low dose and giving him an expectation for when he should achieve an effect. And then early rehabilitation and a graduated return to work program, if this is my man's day, why not be getting him back to work in the back office doing something with someone taking him to work at reduced hours and the horse is bolted on that so it's more about now work hard and the activity scheduling and all those things. But my last point is that returning to work is a time to increase treatment and not reduce treatment. A question that's come up while you were speaking is when is a psychiatric referral required? So that might be, again, a point that we take up in the case discussion. Is that okay? Thank you so much, D.L. And, Peter, you're going to present a psychologist perspective. Okay, well, because I knew that my colleagues here would so ably talk about Matt, I made a few brief points in the last slide so I'll come to that about Matt. But what I thought would be helpful would be to try and present some comments from the other side. Steve and Frank and D.L. have touched on these points. But just to sort of summarize, people who have a conversation claim move into a very vulnerable population and, as D.L. indicated, outcomes are often worth. That, for example, a mental and physical health of unemployed Australians is up to four times worth when people engage in employment. But health professionals aren't taught much at all about the role of work in contributing to mental health and wellbeing. Insurers overall, you know, there's lots of sort of local issues about, you know, subcontracted insurers and turnover of staff and case managers and inexperienced people saying silly things. But at the picture level, what the insurers want to achieve is positive health and return-to-work outcome. As has been emphasised, early return-to-work is by and large much more appropriate than keeping people off for a long time. D.L. has indicated the data around the longer people stay off work, the worse their outcome. And one example I'd like to indicate, because I often talk to sort of, you know, seasoned clinicians who tell me, you know, how serious the treatment is that's needed for people in this space. And some people do have much more common sense for people in this space than some people do have much more complex needs. But the evidence shows that return-to-work considerations and the role of work as a therapeutic factor should be an integral part of the treatment, not something that happens subsequently. And one recent example I can point to, most people will be aware of Origin, one of our premier youth mental health services in Australia. Origin released a report in the last couple of months. It's available online. It's called Tell them They Are Dreaming. And it's about young people with serious acute mental illness and employment. And they make a couple of key points. One, individuals with acute psychosis and other serious conditions. Basically, the top priority, whenever you survey in different ways, is that they want to engage in work. For all the reasons D.L. indicated about social inclusion, about meaning, about structure and so on. The second thing is, they provide evidence-based treatment to these people. It is structured. It is targeted. They have case formulation. And engagement with work is an integral part of the treatment. It's not something that happens after the treatment. So when you stand back and think about this population and compare with the workers' comp population, something seems to be happening quite differently. I think a lot of practitioners, particularly the psychologists, appeared up to working under Medicare, where you have a 10-session limit each year and it doesn't matter what happens otherwise, but you've got your 10 sessions. With this population, we do need to be much more structured. We do need to be more targeted. And often we do need to be much more directive. With Matt, I think the one sort of psychological bit of input that I thought of would be, he needs to access what in the jargon is called Trauma-focused cognitive behavioural therapy, which is the treatment's choice for PTSD. PTSD is a significant risk factor for moving on to chronic and persistent pain. So we need to work concurrently. So we need the physiotherapy, medical involvement, direction of physical injury. But what's clear is that he has not had early access to the most appropriate treatment for his mental health symptoms. If he's too distressed to respond to that, then D'El and her colleagues come in and can provide appropriate psychotropic medications that might settle him a little bit and help him to be more responsive. But that's what he needs to move on to. With individuals in Victoria, for example, WorkSafe Victoria has 10 or 12 approved pain management programs, multi-disciplinary programs. They've been evaluated and we know that they help people reduce pain, cope better, get back to work. Well, people who are at risk of going off work stay at work and get off their horrendous sort of narcotic chronic, sort of long-term narcotic analgesic medication. But what happens is a PMP pain management program is often regarded as a last resort. It typically doesn't happen to more than 12 months of post-injury, and we now have a KPI of trying to bring this back to three months because we can identify at that point when an individual will benefit from this type of program and should be referred. So one of the things, for example, that's happening in Victoria is that WorkSafe has now opened referrals beyond GPs to physiotherapists and psychologists to refer directly to pain management programs. I can see the slide there. There's some evidence that you can look up. But this term, work-focused treatment as opposed to more standard clinical care, work-focused treatments that achieve much better outcome. The longer someone stays in a compensation system, the worse their overall outcome will be. So we do need to do things a little bit differently at the standard care. We now have a thing called the National Clinical Framework, which all jurisdictions have adopted, and major professional associations have endorsed. Occupational physicians are on board. Other medicodes not quite yet, but we're looking on that. But that framework details best practice principles of treatment. These people, as I said, typically need more structure. A comment about mental health more broadly is I've just been working more in a sort of managerial context the last few weeks, looking at how managers deal with mental health in the workplace. Beyond Blue tells us that stigmas are reduced. We know that there's still a lot of avoiding. People avoid talking to individuals, engaging with them, trying to encourage them to access help. There's a fear of aggravating things, so there's more of a hands-off approach. There's avoiding. There's less structure. So people are often less, much more to their own devices relative to how we manage physical injuries. This is the opposite of what these people need. So I encourage people to sort of perhaps look at what Orange does with a more serious population and the role of work in more serious mental illness, because I think we can do a lot better in the work cover nationally compensation jurisdictions. The final point I'd make, which is not on the slide, is that some work I've done in different jurisdictions and with colleagues in the UK indicates that about a third of all psychological injuries are more based on low morale, rather than a substantive increase in mental health symptoms. So what that suggests is that these people, what they actually need is vocational guidance, vocational assessment, HR management, conflict resolution. When they get into the medical system, well-intentioned psychologists and GPs give them this dreadful label called adjustment disorder. Anyone have a bit of adjustment disorder? When they get that label, they often get worse over time. So there are some positive initiatives trying to address that issue. Triaging claims, which is mentioned in the slide. In Victoria, there's a program called the Workplace Support Service which tries to address interpersonal issues early. Queensland has a state-based program called Resolve at Work, where again, it's about moving upstream, trying to address work relationships before they go off the rails and people get to the point where there's more or a larger complaint. So moving upstream into that pre-claim early intervention space is really the key. But I think we can do a lot better tightening up and looking after these people much better. My last point would be, I suppose recently I talked to an audience of, dare I say, because there's someone online, very precious clinical psychologists about how they work with some of these complex cases. And my response was the point to the work that Origin does and to indicate that we need to come the other way. We need to have a focus on return to work as part of the treatment and triage out if the person's too chronic and severe to move forward in that direction. It's hard to tell and predict at the beginning, but we must have that return to work focus as integral to the treatment from the word go and look after people otherwise they're not going to move forward. That's probably enough. So it is the case that in Australia generally, and I'm sure people read this sort of data, we have had very liberal certification practices. There has been a significant drift towards longer time off work, disengagement from work and drifting onto TSP. The biggest growth in disability support pensions has been in milder mental health problems and chronic non-specific back pain, musculoskeletal injuries, and the evidence is that a lot of those people, if we'd reached them much earlier and engaged them in some sort of return to work, we could have prevented what's been termed perhaps provocatively and apologised as medically unnecessary disability. So that's what we need to address in this space. But again, overall, we're all trying to achieve the same objective. So there is the emergence of work focus treatment training and there are various programs around now that work with GP psychologists trying to help them align what they do when they do with anyone who has a compensation claim. I'll have to do it prefer. Okay. Thank you, Peter. One of the questions that's come up that I'd like you to address when we have our discussion is what exactly does triaging out mean? Okay. So if you would keep that in mind. Sure. Now we have an opportunity for a panel to answer the questions and the answers and I'll start first with whether any of the panel members would like to pose questions to each other and then we'll take questions from the audience. Who do we have? Stephen, Frank, DL, Peter. Do you have a question you'd like to pose before we go to the audience questions? No, hopefully. I'm happy to take questions from the audience. All right, let's go then. The questions that I outlined that were coming up as we were talking, one addressed to Stephen specifically was about a mental health plan. And would you do a mental health plan automatically when you see someone and what are the likelihood things that you put into that plan when referring to the psychologist or a psychiatrist? Certainly the mental health plan is actually for non-insured patients. In Matt's case, he is clearly under works conversation. So all of the funding would come from the work compensation side rather from a mental health plan. So although the plan is a good idea and all of the elements of the plan coming together and seeing that he gets holistic treatment, you don't really need a plan for Matt in particular. Okay, all right, thank you. Question for Frank, which had to do with motivation versus perhaps reality, is how much would you say about expectation for full recovery and return to work early on? Because you did talk about early intervention and how important it is to have people returned. Absolutely. Look, I think the focus with these people is more on function as opposed to their pain and their dysfunction. Certainly we're dealing with two issues here. We're dealing with physical injury and the unmanaged pain goes along with it. And because of the fact that it's been longer than three months and certainly chronic, there's also the unmanaged psychological conditions as well. You need to set return to work as part of the treatment and functional goal. And obviously there's a lot of evidence out there that indicates that it is good for you to provide that it's safe and we need to take all those things into consideration, et cetera. But that needs to be set really, really early on in the piece so that there can be some very, very dual-graded progression along the way. And so there's alignment of treatment goals and return to work goals because honestly with good management you should end up at the same place. So yes, you should educate that in the early stages on the importance of return to work, on the importance of return to work being an indicator of return to function and an indicator that it's also showing that it is on the path to recovery as well. Okay. One of the questions from the audience too was about barriers. What are the biggest barriers to return to work for people who have a psychological injury at work? It depends on the circumstances of each case. The way you would manage someone who has depression would be somewhat different who has mainly anxiety, et cetera, et cetera. But there needs to be real support from an employer and someone in a situation like Matt to return to work. That's absolutely critical. That support needs to be real. There needs to be a management of the perceptions of the other people in the workplace so that the person who comes back to work, such as Matt, doesn't feel that he doesn't feel support from his employer from those around him. That's really critical to make an initial return to work stick and then obviously needs to be managed. Are any of those factors that may jeopardise the return to work being sustainable as well? So, hopefully the function has been impacted and certainly don't give very, very intensive cognitive tasks. If concentration has been affected then you have to pick the duties that he does accordingly. Anxiety is an issue then perhaps you're getting away from a lot of customers' contact, et cetera. To manage those symptoms. And you'd have to do a lot of work very closely and collaboratively with these treaters to make sure that the tasks and environment were well suited to facilitate ongoing recovery. Okay, okay. If I could move a little beyond the individual, thank you. And I think that's a question I'd like to ask T.L. Because we've talked a lot about collaboration and some of the comments coming through are, well, you know, collaboration is ideal but also extremely difficult. And there's often a distrust in workers' compensation settings between health professionals, doctors, employers that can lead to conflict. So, let me turn the question to how can we build trust so that the injured worker is protected from the conflict? What are the kinds of things you can do from that collaborative practice framework? And I think there's every reason to work on a premise of trust rather than distrust. And I think the distrust comes in way down the track when injured workers are quite entrenched in the sick role and don't feel they can return to work and the treating doctors feel that getting back to work would be adversarial. So I think the way to build trust is really to start early day one of injury. And I think it's about talking together and providing information. So, I mean, often the workplace will get a certificate that says, you know, Joe Blow's done his work for the next month because of a medical condition. So you can understand from their perspective that it doesn't help them very much. They don't know what's going on. They don't know what they're supposed to do with that. So I think the more information you can provide the employer, obviously, with the consent of the individual, the more equipped that they are to help out to feel compassionate to plan their workloads. And I think that it goes both ways. I mean, the GP or the treating practitioner is only hearing one side of the story about the workplace difficulties. If there's open communication with the employer as well, there might be another side as well. And with that open discussion and communication, there's generally the chance for collaboration. So I think education is really the most important thing. And then goal-setting, it's set for the time with the same work in place. So if you're returning an injured worker to work and the employer says, I'm worried, they're not, I'm worried they're not well enough, well then we'll review it in three weeks or we'll review it in four weeks. Or for the employer who goes, I don't know that I'm ready to go back to work because they will, we're not sliding you up for a life-threatening period. It's too hard. Then we'll step back or stop the return to work plan or we'll modify. So I think it's all about engaging, collaborating and aligning and aligning ourselves most specifically with the injured worker because unless they're on-site with any return to work plan we're going ahead with, it's not going to work. So I spend a lot of my time in sessions with the individuals, you know, getting them to say how many hours they think they could work week one and all week two and when the employer says, this is what we're doing. And I think that really helps build trust as well. Okay. Okay. Peter, I'm going to move to you just to follow on from some of the collaboration work. It's a question of, can you please explain the triage out? And there's also been a question about compensable psychological injury and an incubation period of six months. So could you explain this? Okay. I'm just taking the second question first. I think that comes from some work I've done with ComCare and other people who have similarly done, indicates that your average psychological injury never occurs overnight. There is typically at least a six month gestation period where there are certain characteristics that become evident. For example, taking more time off work, disengagement, becoming more negative about things, draw and avoid, et cetera, et cetera. What the practical point of all that is to indicate that if we're getting managers as people manages to be more proactive and have their finger on the team pulse and knowing that we can potentially identify these people earlier. We do not want managers to become diagnosticians or quasi-counselors, but managers do have a role in providing or fostering an environment where people believe that the employer values their wellbeing and that if they have hassles, they can put their hand up early and get supported in terms of moving on to appropriate assistance, whether it's employee assistance program, seeing their family GP and a referral to a community-based psychologist, or also on this day and age, e-mental health. Australia is a world leader in e-mental health and the resources there are massively expanding and the evidence is that for many mild to moderate anxiety and depressive conditions, they're achieving comfortable outcomes. Let's not forget that from a mainstream public mental health point of view, roughly a bit under half of all people with genuine mental health disorders do not access treatment for a whole range of reasons. So the online option is expanding the armamentarium as it were. Now, the other question was just to remind you for a second. It was about triaging out. I think a lot of the work covering Shora's now starting to triage claims. Victoria does it, CAC Victoria does it. A lot of the providers, a lot of the big Commonwealth agencies, they have algorithms to identify complexity because the evidence says we can predict the complexity, the high risk of staying off work a long time, very early on. Therefore, we can plan better in terms of treatment we provide. I mentioned earlier that Paymention programs are often not until 12 months later. We know that we can potentially identify before three months and refer people at that point and we'll get much better outcomes. Similarly, often the psychology services, one of the reasonable complaints psychologists tell me about when I'm talking is that, well, I didn't get referred this person until 6, 12, 18 months after the injury. So how do you expect I'm going to get them back to work with a few sessions? Very reasonable complaints. So getting more aware of that mental health dimension, triaging and identifying, streaming into appropriate interventions. I mentioned the Workplace Support Service that works at Victoria Rump. They've also started a new program called the GP Influence Strategy where clients at Triage and our medical advisors do GP's and try and get at least partial clearance very early on. At the top of that, some people will be aware, we now have a trial of what's called the FIT certificate in Victoria, Canberra and Western Australia. And that is aimed at certifying people more on the basis of what they can do rather than what they can't do and on the basis of capacity. When you're dealing with a distressed worker, often, and it's no one's fault, treaters often get a jaundice view of the workplace. People are trying to make sense of things and they often make attributions which sometimes aren't accurate. Not all employers are toxic or evil. Most of the employers I work with, there are some dark places out there, no doubt about it. That's why we do need strong workplace health and safety laws. In Victoria, we've had 40 prosecutions in the last couple of years and if you read those transcripts, they do tell you about some evil things that employers do. The majority of employers with the majority of working Australians are trying to do the right thing, but often they're not knowing what to do and the polarization that happens, getting more distant from treaters, treaters getting into more advocacy, employers then thinking they don't want to... All of that stuff, we can manage that much better, working more collaboratively. So triaging out means I mentioned the third of the population in the psychological injury world that are more low morale based. UK's found exactly the same thing, that it's not a medical barrier to return to work, it's a psychosocial barrier. Family problems, hating a job, don't get on with your manager, et cetera, et cetera. So those people need more psychosocial interventions more than medical treatment and I include psychology in that sort of approach there. So there's been a review of the Workplace Support Service that says it is achieving better return to work outcome because what we do is appoint an experienced rehab provider and their role then is to liaise between the parties, try and get them talking, run facilitated discussions and try and address the interpersonal barriers. The research I pointed to, the Largerfield paper about work-focused CBT, what they do is part of the treatment from the word go is talking about work and identifying the problems and barriers. Some people are very stressed obviously and they don't want to talk about it, but seeding and starting that discussion, identifying the barriers, progressively problem-solving them and engaging in exposure to the work environment achieves much, much better outcomes rather than thinking that anything to do with return to work is subsequent to the treatment. So there are very triaging tools based on actuarial data, some of them based on more psychosocial and demographic characteristics. TAC, for example, their triage tool is more than 85% accurate in identifying very early claims that are likely to become highly complex in the long run. Yeah. Is Frank back? Because otherwise I'll put the question to Peter. I'm here on the audio, but did you hear in black? Frank, we talked earlier about, and some of the points that Peter has raised as well, about people, injured workers, being traumatized by the process, the legal process, and then the systems in work cover and so on. What are the kinds of things that can be done to manage these problems? I think you mentioned there were workplace inspectors and others that could assist in... Absolutely. In situations where we find employers are not fulfilling their obligations with regard to return to work and supporting their injured employees, then there are workplace inspectors who can go out and impress upon the employer their position and their need to support their employees. But beyond that, the role of an occupation rehab provider can often bring all the parties together and establish some common ground and some common goals and then move everybody forward because at Peter's point earlier on, that the system and the treaters and the employers and the injured workers' goals really should be all the same, which is recovery from injury, return to normal function, return to normal activity, and return to work is part of that process as well. The process can get a bit convoluted when the parties miscommunicate and think that people aren't fulfilling their obligations, and often that can be communication breakdown and a misunderstanding of what each person's role and responsibilities are. But with clarification and effective communication, those barriers can normally be broken down quite effectively. In the event that they aren't, then you've got to look beyond that to see if there are some real significant issues that are brewing there in the background. And honestly, it's good to have a rehab provider involved in those situations because if you don't delve into them and if you don't determine what those issues are and develop strategies to resolve them, you're not going to progress along the path of recovery and return to work. Okay. I'd like now to go back to each of our panel members to reflect and sum up. I've also been seeing some of the comments that are coming in from participants and if you'd like to pick up some of those as well. So I'll go back to Stephen, who presented from a GP perspective. Stephen, would you like to reflect or take a couple of minutes and also any comments that you've seen coming in that you'd like to comment on yourself? Now, certainly looking at the pain perspective, MAT is a clear case where multidisciplinary treatment is essential. I don't think it's handleable by just one single part of the team. You have to have the whole team approach. You have to have them coordinated and you have to have them talking to each other. I saw on the chat that certainly case conferencing is a brilliant idea, gets everybody talking. Another thing I think is honesty. Now, what does employer really want out of this? You want to give it a max? Is he aiming to get him back? Or is he going to get him replaced or get him put somewhere else? I think all of these things are really important and if people have an honest discussion, then you can progress along the correct pathway. At the last thing, if I go back to my first comment about pain, pain is very, very largely influenced by a lot of psychological factors. In fact, there's a major influence between going from an extreme pain to a chronic pain and always to remember that and to get early referrals rather than let things settle in too much and certainly getting back to work as soon as possible should be the ideal goal. Okay, thank you. Frank? Yeah? Would you like to reflect on what we've discussed and also any of the comments coming from participants that I haven't picked up? I think there's been some fantastic comments made by all the participants and it's been interesting reading them all and some very, very valid points. I think that situations like this we can often be overwhelmed by the complexity of the presentation in front of us and I think that we need to at times get back to the grassroots which is getting all together, communicating, setting some realistic goals, letting everybody know that we're talking about return to work as part of function and recovery and that if we can set some realistic, tangible goals and if we have the honest involvement and goodwill of all the participants then we can achieve some fantastic outcomes and there have been some fantastic outcomes I've seen in many years of doing occupational rehab for people with some really severe combined physical and psychological injuries that you would have but have come through with some real genuine understanding, goal-setting and willingness to work together and collaboration on a treatment plan that has worked for everybody and has ended up as a really, really, really good outcome. Okay, okay. D.L., I'll call on you now to reflect and maybe pick up the question about when is the psychiatric referral required? Maybe I'll start with that question first. I think a psychiatry referral is required early in these cases and not because I want extra work or other psychiatrists do, but I think when someone's impaired enough to have occupancy or not be able to work then that's the sign of a pretty significant illness of some sort and often there's a lot of other factors going on that need addressing and I think just like if you've got some with a heart problem you'd refer them to a cardiologist if you've got someone with enough mental health symptoms to preclude them from working then they warrant assessment by a psychiatrist even if it's just for diagnostic clarification looking out for what other comorbidities there are and treatment recommendations and return to work planning. In terms of my points for coming up today I think I want to return to my initial points that good work is good for you and I've seen lots of comments here about what about the hospital workplace and obviously the hospital workplace is not equivalent to good work. So we have to address those issues as well but I think what we're all trying to say here is we don't say returning to work is the end goal. We see recovery as the goal and return to work is part of that recovery but just like the comments I saw about what if you can't do your bra rough? Obviously if you can't function in the activities of daily living no one's going to be saying going back to work. What we're saying is that return to work needs to be planned for in a step-by-step progression and returning to work is an important part of that recovery process and obviously different conditions, different employers different people will require a different rate of returning but that should be the goal from the first day of being off work. Okay. Peter? Well without repeating things just note for example ComCare has started funding pre-liability treatment because there's recognition of what happens in the first three months after a claim is submitted can be really crucial in terms of shaping the overall direction and trajectory so that's one poverty factor. The other thing I saw a couple of comments around is the issue of litigation. This is always a challenge in most of the state's things people have access to common law. We don't in the Commonwealth but the challenge is and there's actually some research on this some people start mental health treatment the day after they've seen their lawyer and there seems to be some sort of tacit understanding developed that it will add 10% to your common law payout. Now the overall challenge is that no one can retire on a common law payout you can't buy your dream house and your boat so people often develop misinformed views about where they're heading. What I do in my private practice if I don't feel I can help someone or I don't feel they're motivated because they're sort of getting entrenched in that sort of perspective I will tell them that I can't help them perhaps they should see someone else because there's a waiting list. Perhaps also just to indicate as I said there's a lot of positive things happening the ComCare Act's been reviewed so there are changes coming in terms of trying to get the incentives right because one of the problems with ComCare for example the Commonwealth system is that there are perverse incentives once people get into the system to stay there, to settle in there and avoid engaging with return to work so there are changes coming it is always a challenge to get the settings right to genuinely support and reasonably compensate injured workers but also to encourage people to re-engage with employment because that is better for their long term health outcome. So that's probably enough, thank you. Okay, when I consider much of the conversation that we have it seems to me that the importance of collaborative practice in this industry and in the interventions we do is absolutely crucial and particularly in treatment options as well as return to work and a shared vision and I'm wondering for all of us to take home message in that because we do come from different perspectives and different expertise and when it comes to the injured worker we're dealing with a lot of systems that we don't really have expertise in and in my experience you often come across different ethical codes about sharing information or what's required so I wonder if each of us could address that a message about collaboration because that's really what's needed in managing this area. Sure, well, briefly I can speak to Commonwealth Care in Victoria and the other jurisdictions in Finland. When a person puts in a claim they do sign a consent that allows the WorkCover Authority to talk to their treaters about their injury and recovery not about other personal stuff so that is there and the focus should be on the injury and recovery and return to work so that's probably the key point there. Thank you. Frank, would you like to talk about that as well as a goal that actually involves collaboration? I think we've lost... we don't have the sound for Frank. Is it there now? Yep, now we do. I think the point to make here is that the earlier you get onto this the better because the clock starts ticking from day one and the earlier that you can get everybody together to collaborate on a treatment strategy and a functional goal-based strategy better your overall outcomes will be and if that means getting the treating psychologist, the doctor, the injured worker, the employer all in the same room potentially facilitated by a rehab provider to make sure that whatever agreements are made are then implemented at a workplace within the guidelines and boundaries that have been set then that will result in a good outcome as you're going to get. But we know with poor communication and with poor collaboration in these highly complex cases and when there's delayed action on the path of all the key players the outcomes are substantially worse. Okay. Diel, do you want to comment on collaboration? I know that you spoke of it very early on and the importance of having a discussion among the various players as soon as you can. I agree with everything that Frank said. I think early collaboration with all the stakeholders is of key importance to a successful return to work program. Absolutely essential. I often engage in where we get everyone in the same room and sash it out and come out with a shared goal at the end in my private insurance role I regularly ring the treating doctors to have a discussion about a plan forward or as an independent doctor I'm often ring the treating doctor a rehab provider, the employer and working together what the plan will be and sharing that with the employee and making sure we're all in the same pace together in my experience unless everyone's on the same pace it doesn't work. Okay. It has much better outcome if they're all aligned. Right. And Stephen I know the GP is often seen as the gatekeeper to a lot of the resources and do we have Stephen still online? I wanted to ask you how best we can use the GP? Actually I think these several methods I've treated very badly in general practice I think there is a big need for better education for better education in pain better use of resources in fact to access the resources often the GP in that case would be displundering trying to solve the pain issue without looking at all the others and I think there should be something there that triggers him he needs a more disciplined regime to treat him if he ever got to a pain clinic from general practice that's the first thing that they would do. Right. But often these things GP don't often know how to actually access these type of resources. Okay. Is it possible to have all the panelists back on the screen at the same time? That's terrific. Because I wanted to ask you if there are any key resources that you would advise people who may not be familiar with the system are there places that you would suggest they would look? Oh look I can briefly talk to that in one of the last, the second last slide I think that is a link to the National Clinical Framework they originally were two separate frameworks for physical and mental health they've been combined because the principles are the same DL referred to the health benefits of work agenda there is a consensus statement available on the Australian Faculty of Occupational Environmental Medicine website which summarises evidence about the health benefits of engaging in employment. So there are a couple of resources there. Okay. Any others? I know that there is an APS group in rehabilitation and I'm sure that they have a list of resources as well. Just briefly one that I've used a bit now Comcast put out a guide a few years ago it's called Managing Mental Health Workspace and I think that's a great guide and gives lots of ideas and recommendations for what kind of qualifications you can recommend to an employee that are reasonable. All right. Okay well it's nearly time to finish and I want to thank all the participants for the wonderful comments coming through I wish there was more time to address them Steven, Frank, Theo, Peter thank you very much. I have a note here from MHPN to encourage participants to consider setting up their own special interest network or join an existing one exploring mental health and workplace injury and finally to encourage you to complete the exit survey before you log out it'll appear after the test and then you'll all participants with different attendance within two weeks. So and I need to do a plug for the next seminar which is working together to support the mental health of families with pre-term babies. So I think we're heading out and thank you, thank you all Thanks for sooner. and participation. Lovely. Good to see all my colleagues Bye bye now.