 My name is Mary Melaes. I'm a GP and Psychotherapist working at a headspace site in Cairns. I've realised that my internet connection is getting me the information about four seconds slower than everybody else on the video. But that should not make any difference. This webinar is brought to you by the Mental Health Professionals Network. And we're very pleased tonight also to be partnering with the Private Mental Health Alliance for this webinar. So we would like to gratefully acknowledge their support. The Private Mental Health Alliance has a vision for a mental health system that addresses the need for consumers and carers to have a robust response between providers of mental health services in the private sector. And that's mostly where our nearly 300 participants tonight are working. Welcome everybody. And so there's all sorts of vagaries in the system which make working together difficult. So the Mental Health Professionals Network was set up to try to help address that and promote collaboration. And we have a lot of principles in common with the Private Mental Health Alliance. There's some very clever minds in that organisation who spent a lot of time and energy developing a document talking about the principles of collaboration which I'd really encourage you to read. It covers all sorts of things. So things like shared decision making and continuity of care, talking about who is the coordinator in their case, and how we speak about other professionals with our clients. How does the GP mental health treatment plan fit in? How do we send feedback? How do we best use a psychiatrist in the team? And all kinds of things like that. So I think it's very practical and will be a good follow-on from this webinar tonight. And hopefully the case discussion with the panellists who I'll introduce to you in a moment will give you a good example of how this collaboration can work together. So I'd like to introduce our panellist tonight. Carolyn Johnson is a general practitioner who has many interests and did help to develop the principles document in the Private Mental Health Alliance. Carolyn, I can see that you've had a lot of experience in primary mental health care research. And I wanted to show us what would be in a few seconds the most interesting piece of research that you've just been involved in. I guess most interesting for me was interviewing consumers and carers and GPs about how they monitored depression in the primary care setting, and just learning about the potential clash between the technical processes involved and the relational processes involved in that task. It does sound really interesting. Thank you and welcome to the panel. Jan, you're the consumer rep on our panel tonight. And I can see that you've actually been involved in consumer advocacy in a number of different organisations in Australia, including things like the Mental Health Council of Australia. And chairing some committees for the RANZCP, the College of Psychiatrists. So I just wonder if you wanted to give us a comment on your involvement with the College of Psychiatrists. I think that would be a really fascinating thing to do. Yes, I've been involved over the last several years with various aspects of the RANZCP providing a consumer or an Australian community perspective on a number of issues that have been raised there and also been part of the internal review process and currently sit on the members' advisory committee. Thank you. So that's representing actually our community in a really important role. So we're really playing psychiatrists on the panel. I can see that you also have had a lot of different involvements as well as your clinical practice. And I wondered if you wanted to give us a very... I noticed that you've had a lot of experience in consultant liaison psychiatry and I'm not sure that everyone will really have an understanding of what that is if you could give us a few seconds on that. Yes, very briefly. It's probably maybe understood more easily as general hospital psychiatry or it's moved into the community a lot more in recent years. But basically I suppose the issue in terms of collaboration is having to link in with different teams at different times in a hospital setting when people are suffering physical illness but also suffering mental health issues and difficulties and having to go from one team to another team, different teams having different cultures and having to adapt and work in with the team to get the best results for the patient. That's probably my best background in terms of collaboration. Thanks very much Bill and welcome to the panel. And last but not least, I'd like to introduce Louisa who's a psychologist in Melbourne now. Louisa, you have a specific interest and experience and doctorate in health psychology. Could you just briefly explain in a few words about health psychology? Health psychology is a particular area of psychology that's interested in the connection between mental health and physical health. So we do a lot of work around supporting people that maybe have been diagnosed with something like cancer or MS, maybe they've got chronic pain and then we can also spend time helping people to make, using I guess psychological strategies to help them make healthy lifestyle changes, lose weight, exercise more, reduce stress. Thank you very much Louisa and I'm sorry I got them in the wrong order from the slides. Now I've got a message to say that my internet connection is lost so I don't know whether you can see any or not. So if the slides don't advance someone else might need to do that until this is sold. So tonight we're going to just be using the webinar platform which has some, you know, it's a complex platform and things can happen. So it's important that we just remember that we are in a bit, we need to remember that there are 350 of us also now looking together. So if this were a face-to-face activity, so if you'd like to talk comments to other participants in the general chat box at the bottom, please go ahead just keeping in mind that everyone can see that. And if you would like to post questions for the panel please do post them in that box and if you need help with technical issues post them in the technical chat box. And so I would like to just quickly revisit our learning objectives as well. So by the end of this evening's webinar we hope that we will be able to think more clearly about how we collaborate together. So to recognise the need for appropriate collaboration, effective communication and where required to fair care, to be able to identify the challenges to and opportunities for collaboration that may emerge as the practitioners from the discipline featured on the panel work together to support CACI. And to explore key principles for effective collaboration, communication and cooperation between mental health practices. Now I'd just like to remind all the participants this evening that what we're trying to do is have a real discussion between people who've thought a lot about these issues. We're not trying to actually solve everything in CACI's case. And as we can see from the situation of a 21-year-old woman with a number of complexities and other people involved in her life and interested in her well-being, we're not going to solve it all in an hour and a half. So if you feel that a point of yours is not being heard or something's being missed, please remember that in real life we would be working these things out over time together. So just everyone will have seen the case beforehand. And so CACI is a 21-year-old young lady and initially she comes in brought in by her mum. Now there was one key point that I just really wanted to raise at the beginning which often comes up in the webinar about young people. We get a lot of questions from the participants about how to engage a reluctant adolescent. So if our panellists can keep in mind, if you want to offer any practical tips about that on the way, that is something that everyone wonders about or some people figure it out and other people just find it really difficult. And in this case, CACI doesn't want to be there. She's sullen, she's uncommunicative. She's 21, her mum brought her in. So I think the person who first gets to respond to CACI is our general practitioner. So on that note, I'd like to hand over to Carolyn to discuss your response to CACI. Thanks, Carolyn. Thank you. Well, I guess my first response is to remind everyone that most appointments in general practice if you're lucky are 15 minutes long and if someone's given you advance notice that they might need more time and it's a particularly difficult situation when someone's not necessarily engaged in care to get them engaged in a situation like this, are they safe? Not just the risk of suicide but the risk of self-harm. But we know patients like us who present a general practitioner have the risk of other things particularly with their physical health. So in this person, it might be risk of simply transmitted infections or pregnancy or all kinds of other things. So sometimes it's difficult to do that. And that's difficult to do. The other thing that's very frustrating is some skills to make a mental health assessment because like most GPs, as part of the general practice curriculum, not as specialist training, I've learned how to do a mental health assessment but I might not be able to do it properly in 15 minutes but I'm also recognising that this person needs to access care and she's sort of engaged in accepting a referral so I don't want to lose that one opportunity. I mean, it's very difficult to do it properly because if a doctor makes it, then it's difficult to do it. So a psychologist for this is potentially flawed. I mean, maybe she needs to see a practitioner that's on the mental condition in her practice trial who is actually more likely to have a mental health problem next and maybe there are other allied health professionals that would also help her. So in particular that she might need not only psychotherapy but medication that obviously is very close to what I just talked about before. And then I've also got to do a new care to her family who I know because I'm her family doctor. And I want to make sure that I, I guess honestly, I want to make sure that I don't lose space with them or let them down and that's a real tension in general practice. It's one of the great rewards of general practice of course and it's a great opportunity to help people because we do know the family setting but by the same token sometimes it can make it hard for people to engage with us because they're not sure of, you know, how we will deal with confidentiality. And then the last thought I'm having immediately is what about my duty of care to the patients who are backing up in the waiting room because we know in general practice we take all comers with all kinds of problems. And we see a lot of people with mental health problems and they have the equal right to care as people with physical health problems but clearly I'm going to have to manage the time for the rest of the day and hope that my other patients will understand. I guess the next thing I just want to quickly say is what I would hope it would be is a friendly whinge from GP's. A mental health treatment plan is not just a referral and in fact to meet even a portion of the requirements of the mental health treatment plan, the GP is required to spend at least half an hour with a patient so if they come in with a 15 minute appointment you're already behind the eight ball just assuming you're going to be able to complete the template right away. And that kind of is a challenge for us in general practice because we value the fact that we're the gatekeeper. We know that healthcare is very expensive and our role is to make sure we can filter people to the right place at the right time. That's not just important from an affordability point of view for the healthcare system but it's also important from a safety point of view so that someone who might need a particular type of care gets it from the right person. And unfortunately there are a couple of circumstances that we're going to care about. There's another patient that comes from the same time you get it. And the other thing I'm thinking of whingeing is this takes some toll. The fact that there's lots of people who can help it, lots of people in our health and in medicine's biggest problem but it's very unlikely that I'll be able to get them to work together in a cooperative way. It's much more likely that I'll have a pink ball start before I can do this. So just to finish up my last few comments, I guess this isn't really my wish list or my vision for where I'd hope that the care system is going to progress of primary care from prevention to early intervention. Not only do we need a lot of help, but we need a lot of treatment. But as a student I've gone long to integrate that prevention. And that really does happen after an episode of care that we had to coordinate general practices with people providing that they're outside the medical home so in this case it was effectively. I have a vision for other providers being really welcome into the medical home and that we can trust and trust each other enough to be able to focus on the patient's needs and not just on the business model of each provider or their reputation. And I guess this slide about being the elephant in the room, I suspect we all sometimes feel like the elephant in the room that we're doing. It's hard. We're trying to help people, but we don't really know what other people think of how we're working together. And I think this is particularly an issue for carers. And then certainly my work in talking to carers made me really clear about how they often have a lot of great ideas how to help people but they don't get a voice. And finally my vision is that whatever we do that it's focused on recovery and that we somehow have a shared understanding of what we really mean by recovery because my experience in general practice, everybody has a slightly different perception of that and a bit more transparency about conversations about recovery. Thanks very much, Carolyn. Thanks very much, Carolyn. The sound through your headset has been breaking up and the participants, it's coming in and out. So we were wondering whether you might be able to just use a handset. I'm not sure whether that's possible, but perhaps you could have a look at that while I would go on through the other panelists. Got clearer if I do that? Thanks, Carolyn. Thank you. And we will have some... In discussions I'm sure that there's going to be lots of practical issues. So I think Carolyn's dream about the medical home would be an ideal situation and we know that a number of... There are a lot of things in our system that can make that quite difficult and I think that our fragmented funding system in mental health care in the private sector makes it really hard to do sharing care when things are fragmented in our system. But anyway, maybe that means we have to change the system. Now, Louisa, I'd like to invite you to respond now. We start if Kathy was referred to you. What kinds of things did you be thinking about when the first met her? Thanks. So I just wanted to start by just giving you a quick bit of background about my thoughts around collaboration and what I think it is and when I think it's important and then I'm going to talk about what I would do with Kathy and still ask. So I guess, first of all, in terms of what collaboration is, to me, collaboration, it's about more than providing feedback. It's not just about the psychologist just writing the reports that Medicare asked us to do. It's about joint problem solving. So getting together with the other people on the team and thinking, okay, I'm a bit stuck with Kathy. I'm not sure what to do here and there. What do you think? This is what I was thinking and I'm missing something. So it's about us doing that together, me not holding it all on my shoulders. Louisa, can I just ask you to move your microphone a little closer to your mouth? Absolutely. Thank you. Beautiful. Is that better? I might hold it at the same time. And so it's about taking time so that we're all on the same page. I think this is so important that we know where, I know what the GP is thinking and that they know where I'm coming from with certain issues and a psychiatrist and family members so that we're just all, we're all on the same page. I think that that is going to be the best way for us to be able to give the best possible care to our clients. So when to collaborate? To me, the sorts of things I'm thinking when I'm working with patients is if I've got an idea about how I can assist another member of the treatment team. So the client might have told me something about one of the other members and I think actually I've got an idea that might help them with this so that's when I would be picking up a phone. I'd also be thinking about collaborating when I need help from the team. When I'm getting stuck with someone, when I'm not sure what to do, that's when I pick up a phone and say, look, what do you think about this? And something that I often say to my psychologist in my team is if you're trying to write one of those Medicare reports and it's taking ages and you're kind of going around in circles worrying about offending or worrying about how you're writing something, that to me is a really good sign that it's time to just pick up the telephone and it's too complex for those reports. I think to me those reports are quite simple about giving feedback. I think there are lots of barriers to collaboration and I think it's really great if we as therapists can think about what those barriers might be. I think one of them that I hear a lot is about time and we're all so busy and especially GPs. I know that as a psychologist we worry that maybe we're being a bit of a pain by calling and trying to talk to the GP or the psychiatrist and especially when we have a bit of telephone tag you think, oh, maybe it's just not worth it. Is what I'm going to say actually that important? Also that we might be anxious. So you know, what if the GP thinks that I'm incompetent or I don't know what I'm doing? What if I've got nothing really that relevant to say? And also sometimes the mindset of I should be able to fix this on my own. The GP has referred this person to me and I should be able to do this. I really try to be aware of that thought if it pops into my mind to remind myself that this is meant to be collaboration. We're all meant to be doing it together. I don't have to do this on my own. And so before I get into my particular thoughts around Cassie I've got four tips for collaborative communication that I think might be helpful. And there's four fikes to be communicating our formulation with our jargon. Just go simple, go casual. I think that the other people in the team really appreciate that because when they just get that simple understanding, a simple insight about their patient I think they're really thankful for that. Second tip, asking for an opinion. So look, you know, this is my formulation. What do you think? Am I on track? Is there anything that I've missed? Giving and taking. So giving advice. Yep. You know, this would be really helpful if you would be able to do this when you next see the patient, when they come into the consultation. Can you reinforce this issue or whatever it might be? And taking as well, asking them what can I do? What's going to help you do your job with the patient? What do you need me to do when I'm seeing the client? And I would also say about keeping to time. So just being careful to be succinct. And that way hopefully the other people in the team will have a positive experience and they'll be more likely to take your call next time. So in terms of Cassie in particular, first of all, I guess I'm thinking that I'm confronted with this ethical dilemma about the father and what he's, you know, had to deal with him. It's complex in my head. I'm thinking like I need to be transparent with Cassie and I don't want to keep secrets from her. But on the other hand, and I'm thinking I want to engage the family as well and they're just, they're going to be far more worried about her than I am. So I am thinking to myself, how am I going to deal with this? And I'm probably going to get stuck. So I'm probably going to pick up the phone and want to knock this out with other people on the team and probably, you know, the GT. My mind is probably going to be telling me things like I should get this on my own. They're going to think that I'm incompetent. This is an ethical dilemma and I should know what to do. I thought this out myself but I'd be pushing, you know, against that and picking up the phone anyway. In terms of picking up those signs of the mental state, maybe with questions of bipolar, I'd be considering a psychiatric assessment and I'd probably be in particular thinking about the item 291 where a psychiatrist can do a consultation and report. And then I'd be wanting to find out from the psychiatrist, do you want my feedback beforehand, afterwards? And then I'd be thinking about, okay, after that report, what advice can I get from the psychiatrist? How can what they've assessed help us with what to do with Cassie? And then that, I'd be picking up the phone and saying to the GP, look, this is what I'm thinking. What do you think? Because ultimately they're the ones that are going to do the referral. But again, it'd be, I've got this. This is what I'm thinking. What do you think? In terms of, you know, I guess another issue is how am I actually going to pick up the phone? Psychologists might be thinking, I don't want to pick up the phone. They're just too busy. I'm too busy. I've got a few little strategies about how to make that collaboration a bit easier. One is that with the GPs that I've got good relationships with, I'll get their email address. I'll have a bit of an email back and forth about the best time. So we're setting that up and we're not wasting our time passing messages backwards and forwards. That reduces that phone tag which can get annoying. And I also use my receptionist and say to my receptionist, well, can you call the GP? I think find out when they're free. Find out a good time and talk it out for us. And that way the actual health professionals aren't using as much as their valuable time. I'm also thinking about Cassie and the fact that she's asked for no written information to be sent. And really I'd be thinking about exploring that more with her. I wouldn't just be letting that go. And I'd be talking with her about what her worries were about that and trying to get it on board with the collaborative process. I'd be talking about the fact that under better access we really do need to give at least some feedback back to the GP. But I'd be encouraging or I'd be reassuring her that she's involved in that process and probably with someone like her. I'd be giving that GP report, giving a copy of that to her as well, so that she knew exactly what was being said. I think that transparency is very important. We younger people, particularly when family members are involved like Cassie's family are very involved in this. So I think it would be very important that she feels that she's a client and we're being very transparent with her. And if she said no, definitely don't want you to talk to the GP. I'd at least be trying to get permission to explain that to the GP. So the GP knew where I was coming from, so they weren't thinking, oh, you know, what's this psychologist doing? She's not giving me any feedback. Or is she deteriorating? Is this psychologist actually looking after her properly? So I'd be letting the GP know, look, it's a bit hard. I'm not really able to give you much feedback because she's worried, but I am working on it. I'm also thinking that I'd be wanting to communicate that formulation to the psychiatrist at any point that might help in particular. So I'd probably be asking, how might I explore the issue of the trauma around the rate with her? Should I do it now? Should I do it later? What's your opinion? So I'd be really getting their advice. And again, I'd be doing it over the sign. I'm a believer in doing that design. I think it's quick and it's efficient. And if a client stops coming after three sessions without reaching her goals, again, I'd be contacting the GP to let them know. Again, I'd probably call the GP because I'm thinking it's more than just feedback. It's more than just saying, look, she's dropped out. But it's about saying, look, this is my insight. I think this is why Cassie has dropped out. And I think she got uncomfortable when I raised this issue about the rape and about going there or whatever it might be. And so perhaps when you see her again, you know, reassure her that it's okay that we don't have to do that or maybe I'd be thinking maybe she's not comfortable with me. So, you know, when she comes back to see you, talk to her about other options and that's okay. That's the kind of thing. Thank you very much, Lolita. Really practical tips which I know our people appreciate. Now, I'd just like to invite Bill. So Bill has now received the referral from the DT. So Bill, tell us about how you would think about Cassie. Thank you. Okay, well, I guess just a couple of things in what I've put up for people to see was that I felt that collaboration isn't something you can legislate for. It's something that's probably built over time through mutual respect working together in some way. I think it's worth trying to listen out. I think I believe everyone has something to contribute. They're seeing a particular angle of what's happening to the person. And it's worth trying to listen out for that special bit of information or angle on how to deal with things that every participant in the team has to offer. I think it's probably worth mentioning that it's possible for us to harm people by going off in different directions telling the patient different things. Well, that person's no good to work with or whatever it is without actually dealing with that person face-to-face and saying, I don't think you should be dealing with this patient even if it's the doctor, whatever it is. You know, I think we should be sorting those things out amongst ourselves rather than making the patient leave in a sandwich and you can harm some people by doing that. Bill, can you just move the telephone mouse piece a bit closer? Thank you. And I guess this sort of person, Cassie, that we're looking at in this case, I know it's a theoretical case in a way that's probably based on someone real, there's so much uncertainty that she generates in a way that these are the very people that it's hard for the team to remain collaborating and working well together around. And so I thought she was a very good case from that point of view. And it's a matter of having enough strength or blue in the relationships in the team to be able to keep contacting each other in the face of the uncertainty that the patients brought up before us. Then I also wanted to mention about the tools that we might have, obviously communication lines and Louisa has mentioned that. I think sometimes doctors are hard to get through too, the psychiatrist and the GP, they feel as though they're very busy. And so we get used to talking to each other for a period of perhaps three to five minutes and getting a lot of information across. I think people should feel free to ring up no matter what if they're really worried about something and they should insist on trying to get through and most good professionals will respond to that. Otherwise, I think you can get brief pieces of information across in small periods of time. But if you really want to have a longer chat with someone, I think you just out of courtesy need to perhaps take them and look, I'd like to talk with you for 10 or 15 minutes. Can we find a time to do it? That might have to be after hours or something like that, but most people will try to fit in. Meetings between ourselves are very important but hard to do in the private sector, I think, and it would be nice if that. I know the MHPN has tried to facilitate that, but they work to some extent. Respecting medical legal governments as a doctor is something that I'd like for people to recognise that we're the ones likely to take responsibility most severely if something goes wrong. So it's important that we'd like to be kept in the loop of any communications. Now, moving to our case, Cassie herself, there's lots of things I thought about in relation to this young woman. I worried about whether she might have been suicidal in that very first presentation and she didn't turn up for the next session. Unfortunately, she didn't try and suicide, but I wondered whether, and that's why I was saying, don't only follow what the patient wants. Sometimes, rather than just giving her a thought, it might have been good to actually ask her. I find asking people directly, have you thought of harming yourself or killing yourself? So directly, most people actually answer honestly or hesitate so much. You know that it's a major issue and maybe an early risk assessment could have been useful because we as psychiatrists sometimes get a bit frustrated because we're asked to step in at the very last minute when a group, a team of people in the community have been working with someone that's been getting worse and worse and worse from our perspective and then finally we're asked to sort it all out and often the team members sort of wander off at that point and we're left with quite a difficulty. So early, even talking to us, the GP talking perhaps, if they know us about a case at the early stage can be very useful. I just point out that this girl was probably drinking a lot of drugs or maybe taking other drugs. They can mask or mimic various types of mental illness that makes it very difficult and so to really find out what's going on with a person like this, the team often has to work with the person over a few months just as this case illustrated in a way, probably four months altogether or something and finally towards the end the patient seemed to be a bit more engaged at last even though she'd gone downhill a little bit more and so that idea of sticking together really requires quite a lot of glue in the community team but it's very exciting really for us to be able to work as teams in the community because we are so flexible in a way, that's the risk involved with us but it's also the great advantage that we have the flexibility to actually follow people over a period of time and if we communicate well enough make quite good assessments and then finally I just wanted to mention the item 291 assessment which occurred in this case maybe I think where the psychiatrist comes in at the end and gives an assessment and people don't understand this perhaps quite so much if they're not familiar with the Medicare system but under this system the idea is to get the psychiatrist to give an assessment and a management plan for the GP and other community members of the collaboration team to help them with their treatment but for the psychiatrist not to continue following that person so the GP is the one usually that has to make a decision at some critical point. Do we actually get the psychiatrist only to do an assessment which can involve a further one review or do we want the psychiatrist to be involved in the clinical team for some considerable time perhaps and so that's the disadvantage of the assessment type item. The advantage is that you should get quite a good assessment from a psychiatric point of view and a management plan which shouldn't be just about medication but should be about other ideas in terms of psychological management and so forth but it is quite a useful item though because you can get quite quick assessments under this item that you won't get the ongoing management and so people have to decide what sort of role for the psychiatrist they want in the team. Thanks. Thanks very much Bill. And just with a gain clarification around the Medicare issue in order to see the psychiatrist the referral does have to be actually made by GP so if the psychologist is the main person working with the patient and realises that they need back then they need to collaborate with the GP for that. Now Jan, the participants have been making lots and lots of comments in the chat box around the involvement of families and carers because the reality is it's actually you guys who are looking after Cassie and Cassie herself is looking after Cassie most of the time and she just sees the health professionals occasionally so it's really really important that we can hear from you about what you might be thinking out about for Cassie. Thanks very much. Thanks Mary. The families are very often a great source of information but this issue of confidentiality and privacy seems to crop up so many times and it's also sometimes used I think as an excuse not to engage with carers but it is a really ethical issue isn't it? I mean we heard Louise talk about the ethical issue of the father, Cassie's father and what and how much and should she disclose this in the first place. So from my perspective I'm a consumer I feel very strongly about this particular issue of communication and collaboration. Collaboration is more than anything when I was at my worst, my thickest, I was seeing a GP, I was seeing a psychiatrist and I was seeing a mental health nurse at the hospital all in the one week and that went on for probably 12 to 18 months. Was I over-service? I don't think so. The three people, the three health professionals kept me alive. So I have some key messages here up on the screen that I'd really like you to think very seriously about as a health professional. Collaboration between health professionals is absolutely crucial. I talked to you, I mentioned that I was seeing three health professionals in the one week. It was interesting that I would find myself telling the GP some issue on perhaps Wednesday and I'd be seeing the psychiatrist on the Friday and telling her something different again. I don't think it's not in my mind that I was playing one off against the other. It was more what had happened in the last day or two that was particularly up and most in my mind and my concern. So in my mind, collaboration between health professionals and health professionals is crucial. You really do need to know what's going on with your partnership. If you see them weekly or fortnightly or monthly, it is really absolutely crucial that you collaborate. It's interesting Caroline mentioned as a GP the real need for her involvement. GP is really the first port of Coralante and certainly a very central port of call. I certainly emphasise Caroline with the patient backup that you have to and that GP's have to manage. Nonetheless, we often as a consumer and as a family member, we are often looking at our GP as someone who calls all of this together. I think the other point I'd like to say is communication must be timely. I talked about my own experience. Did I expect communication to happen on a weekly basis? Absolutely not. I guess it would be more that if there was some issue that I was perhaps seen by one of the health professionals as being at risk and I was from time to time that it was absolutely crucial that that be communicated to others. So communication in my mind is very much up there as well. I think the third point is that all health professionals involved in treatment and care must be fully informed. We talk about Cassie, don't we? This is perhaps a good question to lead into the panel members but what do you do as in my case that I would tell the GP something, I would tell the psychiatrist something else? All impacting on my treatment focus. So I guess that's an issue that I feel very strong about that all health professionals, particularly around risks I think, more than anything, risks if one sees a patient or a consumer and are particularly concerned. Bill mentioned that too, particularly concerned would be really important to pass that message across. And I think the other issue is around cooperation regarding information sharing. So it's not a matter of in the second and third, it's more around who is best managed, who is best placed to manage information sharing. And I think that's something that really needs to be determined from the outset. I think it's hugely important. I think from a family perspective too, families can be quite right. Families are the ones that end up holding a patient or holding a consumer close to them. And they do that mostly without training and without any sort of specific information or education about their task. They don't all wish to have that task and it's something that's often faced upon them, something that they prefer not to use. So I think engaging as best you can with the family is an absolute essential. I have to say that in my experience, my hope was not included in any of the discussions and if I could change something, it would be that a team of family members is to stay key with the consumer and with their permission that they be included and involved and that's something that we have sorted out from the outset. So look, I did, Mary, if I may, there is a question. I touched on it around confidentiality, and privacy and information sharing. So it might be a time to sort of open up the panel discussions, I think. Absolutely. And I know you had a specific question about that, so please go ahead. Okay. Look, this is something which involves carers so often. What information is shared with them? But in this particular issue, it's what are the issues around confidentiality and information sharing between health professionals? So the question would be, Happy has disclosed to her GT the information regarding her rate but refuses to allow others to be notified as she does not wish to revisit the trauma. So for the panel members, and I'm not sure who's best placed or whether you'd all like to have a perspective on this because it really is crucial and very pertinent to families as well. So there are the issues around confidentiality and information sharing between health professionals when patients ask for specific information not to be disclosed to others involved in this case as Cassie's care but would affect the treatment focus in this case that was regarding the rate. So I hand it over Mary to... Yeah, I'd really like to bring Carolyn back in with that one. In this case, the client disclosed the information to the GT, but I think this is actually a situation that we all have to manage from time to time. So Carolyn, how would you respond to Dan's question? Well, I think in this particular situation I would be working hard to make Cassie recognise the link between secrecy and lack of treatment opportunities. So I would respect her right to not want to revisit the trauma. I would try and work with her around that issue but also explain to her that there are some people with specific expertise dealing with this kind of trauma and that, wow, I will keep it secret until she's ready to disclose it. I do think that there are certain circumstances where you might find she gets more relief from her distress by disclosing. So we would just talk about it. We would talk about those issues, about why it's hard, why it might be hard but certainly it's very common in general practice to have different levels of disclosure with different people. The hard thing in general practice is how to remember who said what because obviously at some point you have to make a record in the clinical notes about what was discussed and if you talk to GPs they'll tell you that they often have cryptic ways of recording things in the notes that remind them that there are sensitive issues but that aren't available for everyone to read. So it is a challenge in a large group practice. But I also think that GPs could do more right at the outset when someone comes in and says they want a referral under better access because many people do want that because of course it makes psychological care or our care with social workers and OTs much more affordable. I spent a bit of time explaining to them that I think it's a great idea but the whole purpose of the Better Access Initiative is to permit this kind of collaboration. So while it's absolutely fine to have bits of information that she might not be ready to disclose, the actual concept of collaboration is absolutely key to the Better Access Program and that if people aren't prepared to do that collaboration then maybe they need to consider whether the Better Access Program is right for them. I think this happens a lot. It's almost the providers have this conspiracy of silence because it's too hard to have these conversations and explain to patients the importance of collaboration rather than the patients have really been able to think it through. I think patients are often speaking from their emotional distress and one of our roles as health professionals is to explain to them that while you hear the distress and you acknowledge it that that will have consequences in terms of this kind of system of care. Thank you. Jan, I just took the liberty of moving us forward into the Q&A session because I think you did that beautifully and we'll probably come back to the questions that you had. So I wonder if, Bill, you would like to comment more about... You raised the issue about risk and it's come up in the panel as well. So sometimes a piece of information might have an impact on the risk. So, yes, if you could just talk about some helpful ways to think about that. Yes, look, I probably didn't explain myself well enough earlier that I think the GP seeing Cassie at the beginning was in a very difficult situation. She was trying to maintain rapport with her and get her on board in terms of being able to work with her. But I was, I guess, pointing out there could have been a risk of suicide in a way and by just going along with the referral in some ways, if the young woman was suicidal it would be like she wasn't being listened to or that wasn't being touched on and she might go out suicidal. And so when someone, it seems fairly distressed, comes along and particularly where they feel that they... When you feel that you're not getting very good communication with the person it might be pretty important to actually try and work out exactly where they are as best you can even though it's very difficult to communicate because I guess, you know, that the person could have self if that's where they were at that particular time you're not getting much information. But that also applies all the way through, I suppose, with someone like this and I think that it's a matter of keeping that in mind and I'm sure the GP in this case was trying to get rapport going so that they could actually get to finding out what the patient was really thinking and feeling in the next session but unfortunately they didn't have that. I think the psychiatrist when they gave their assessment later in the course of the whole process, I don't think it was specifically mentioned but they should probably also talk a little bit of comment on the chat in the chat room about the... also how to talk with relatives and carers and what the ethics of that are. I think my understanding is that under privacy law there is an understanding that when you see a health professional they may communicate with other professionals for the patient's good but the patient should at all times have some understanding that's likely to occur. I think it's always good practice and improved trust if you tell your client or your patient exactly who you're intending to communicate with and what level of information you like to communicate because it does greatly improve trust but I don't think you'd need necessarily to get written consent and so forth if you keep that degree of openness about it and there's also been some comments in the chat room about the fact that we haven't talked much about the rape itself and how to deal with that very sensitive issue and just an initial thought I had about that was that people often tell you these things tell a person at some point when they're ready to talk and it could be any one of them, members of the team and I think it's very important that that sort of expected the person's allowed to talk as much for as long as possible in the time that's available at that time because that's a sort of a special communication and it's important to try to work out where to go with that information but not necessarily make big decisions about whether to go to the police straight away and so forth but to make another appointment if necessary and see if the person's male therapist whether they would feel more comfortable to be able to talk further as well with a female therapist or something like that but to show that you're not afraid of hearing and listening to what the person's saying and being very important in this sort of situation and probably not to encourage them straight away to talk with the family about it but to give them enough sessions to talk about it to see whether they feel like they could talk about it with the family because you might not know for instance whether the father if he knew what had happened he'd go out and try and bash up the ex-boyfriend or something and that wouldn't help the situation in any way, shape or form of it so you have to know more about the whole situation before you make suggestions about going straight to the police Look, what kind of thing... I suppose I was particularly... when you probably as a psychologist perhaps being the person that may be providing the therapy or seeing the person more often I guess there's situations where you do hear pieces of information which people don't want you to share with others So in a practical sense, how do you work with that? Yeah, a practical tip. Thank you. Yeah, look I guess it is really tricky because we are often trying to balance between building that rapport and building that trust but also knowing that there might be things that might help them if we are able to collaborate I guess with other members of the team I guess when I was hearing Bill I was thinking to myself I really like that approach of not panicking being able to take it slowly and I guess I'm also thinking it's tricky if we're talking about communicating and collaborating but that sort of thing that I can just find so fantastic about being able to collaborate that you can kind of have another conversation have a conversation with another one of the team like Bill, you can say, OK, Louise, so look, this is what they've disclosed, this is what's happening that's OK, I think just give them the space to talk about it yep, you're right, your theory about doing it finds it does make sense but perhaps they just need that time and I think that that can be really helpful as a psychologist to sort of have that bit of support I guess so that's what I was thinking Thank you, and I guess I'm just going to frame the question for Jan but it's possible I could have asked you so Jan, I think one of the realities is our mental health professional network panels always have holistic, reflective, highly confident practitioners on them the reality is that there are many practitioners for whom mental health is just a small part of what they do and a lot of GPs who maybe don't have a lot of expertise or don't have time or don't know much about trauma or all sorts of things and the reality is as consumers and carers you just have to see whoever you can see and they might not even understand the way that the mental health treatment plan system works or that it involves collaboration so what kind of advice do you have for us from the consumer care perspective about working with clinicians who maybe are not interested in collaborating? Well, that's an interesting point Mary I would hope that's not the case to be honest as I said, I think collaboration is the key to good holistic mental health treatment and care really Look what is interesting isn't a bill touched on the fact that perhaps in this case Cassie might prefer to speak to a female to actress or other health professionals about the issue of trauma You're quite right also I'm in South Australia and I understand Victoria that many private precarious books are closed, they're not taking mutations I think the better access has been fabulous and the ATAPS program has been fabulous but more particularly the better access to enable us to access our colleges mental health nurses and other health professionals and I think that has opened up for many the opportunity of being able to perhaps that choose what sort of health professional fits best for our respective issues and as I said that may be a female it may not be to be able to have that flexibility would be wonderful but I'm not sure that the Australian health test system really allows very much for that and I think also we can choose we can choose our GP we can choose to see whom we wish so I think that's a major issue in terms of health professionals choosing not to collaborate I think that would be almost a lack of duty of care I think it's absolutely essential that if you're treating someone particularly for a mental health problem that it really is it comes to the territory I think that collaboration has to be right up there probably more than anything probably more important than cooperation so I think it would be my advice would be from our perspective is to is to involve as many as you can in treating the individual in a more holistic type care as you possibly can and also not leaving out the family so I think the family members wherever possible and again if Cassie chose not to have her family involved which she has I think it would be something that I would want to see from a parent's perspective that that be explored a bit with Cassie to perhaps come to a point where she might be willing to allow you as a health professional to engage in some ways with the family member with the mum or with the dad so collaboration in my mind between health professionals is crucial So you might encourage Cassie or Cassie's parents to vote with their feet really and look for someone that they feel committed in that way and really Cassie is the basis isn't it for a really good therapeutic relationship and I think that's the key you know we're not all attracted to each other and as a consumer you're not necessarily attracted to a particular health professional and it's nothing personal it's just one of those chemical things that happens isn't it so I think it's absolutely crucial and it's you know just because someone chooses to move away from you as a health professional isn't saying that you lack expertise it's a matter of saying look what fits best for me and what fits best for your patient or the consumer that you're treating Thank you now I wonder you had raised the question and I think I might address it to Carolyn so let's say somebody in a treating team or perhaps the family with the question you raised has become aware that Cassie started to harm herself so I think I might ask Carolyn this how would we know or how would the family know who was the best practitioner of contact or who they should raise their concerns with Well I think the reality is in most occasions people would start with the GP whether they were the best person or not and as we've seen from this case study it's highly unlikely that the family have been involved enough to know where else to start I think the advantage of involving the GP is that it's local and close by and obviously if there is physical issues related to self-harm they can be addressed there as well but I don't think there's a right or wrong answer I think in an ideal world we would have developed a shared plan where we would have agreed who does which bit of those dealing with those issues and if anyone's ever read a mental health treatment plan template there is a little box that says emergency and crisis care now in my practice if I get enough time to do a mental health plan properly I always say to people there's a box here we have to fill in which talks about emergency and crisis care so let's talk about some of things that hopefully won't happen but might happen and then I explained even if you don't need this information it might be useful for you in the future here are the steps of care you get if something goes wrong like if you feel like you might harm yourself or if you become so distressed that you can't function or if you're becoming more unwell or you're worried about another family member so we go through and it's almost like a little brief hypothetical discussion and then I run through a hierarchy of crisis care and say to the patient do you understand these steps and how do you feel about them and sometimes they'll say we'll never call Lifeline or I would never call the CAT team but I would call you and okay okay well I'm only in the practice 3 days a week so if I'm not there what would you do then and we actually do a little rehearsal of these kind of issues now that only takes about 5 minutes and it's in the mental health plan as one of the requirements of a mental health plan but I guess you know it can only happen if you make space for that and you actually say here are some of the steps that are important and that's certainly what I would do with my and there's also of course a box on the mental health plan which says who's your care or key support and at that point I don't just fill in whoever's listed next of kin in the history I say to the patient okay this box is where we actually agree who would I call if I was really worried about you and you weren't able to look after yourself so you know if you came in here and you were so distressed that we just didn't even think you could walk home and I find if I crave it like that 9 times out of 10 patients do nominate someone they say look I am happy in that circumstance for you to call this person and I say okay so are you going to kill this person that you've nominated them because it's an important task you're giving them they may never be needed but it would be great to talk to them about it at some stage so again I'm just you know facilitating this idea that you need a plan it's not a referral it's a plan and in this plan we have steps for dealing with crisis like self harm and we also have a plan that we've discussed in advance about who in the family or the team of carers will support people would you involve or it's a wonderful question to ask because it often opens up wonderful discussion for example like well I put my husband down as my main carer because he's my next of kin but I get more support from my sister so I say okay well let's put both those names down and let's talk about how you're going to engage each of them and helping you so that if something does go wrong you know they're there to help you not to make it harder for you and I think those little extra conversations can make a huge difference to some of these kind of issues but ultimately I would hope if I've done a plan like that the patient would know to come back to the general practice and in my practice I'm very lucky if I'm not there not only I nominate another GP who's there on the days I'm not there that I often introduce the patient to so if I'm not here on this day you could see this doctor because I think you've met them before or they're nice or whatever actually introduce them or I involve the mental health nurse in our practice so I'd like you to see the mental health nurse in our practice that if a crisis arises given that we know that the TAP team is really only for people who are you know an extreme crisis and there's a whole lot of less severe crises here's our mental health nurse and I'd like you to meet them because they could also help in those situations that's really helpful Karen I can see that they are participants are really finding that useful so you're using the mental health treatment plan process as an actual planning around collaboration so for the person their family and carers and also you mentioned earlier about agreements that you will be collaborating with the psychologists and so on so I think that's really helpful I'm mindful of the time so we're beginning to come to a close I forgot to say at the beginning that participants once we close it will be great if you could downline and completely exit survey because you do listen to your feedback one of my favourite comments is that we all should have the NBN so thank you for whoever said that the redback platform is fantastic but at some time it's limited by the technology now I would like to invite Louisa back in Louisa there's been some really specific questions around as GP or even as families and carers and patients how do we know what a counsellor's whether it's a psychologist or other kinds of counsellors what their special interests are, what their skills are how do we know who to pick to refer to in this case the GP does have to look the person up on the phone but could you just give us a couple of little tips around that and then just some final comments thank you yeah I think that's a really really great question and I guess the thing that I do professionally is that I work really hard at building relationships with local GPs in my area so they know me and they know what it is that I do and what my special interests are I have good websites so I try to make it as easy as possible for people to find that out about me I think really the only way to have those good relationships the APS have a find a referral service which is great but as a lot of people will know the downside is that psychologists are able to self nominate I think it's like up to 15 different areas or something like that so there's often can be a bit overwhelming and you're not really sure what's actually a real specialization or just an interest area and that's often something that family members and clients themselves they're wanting to find the expert in a particular area so that can be a downside of that service yeah but I would say the main thing is just about having those relationships I don't think that there's any way around that I think the other thing that you asked me Mary was to make some closing comments is that right? That would be great thank you so yeah look I guess just off the top of my head I'm so passionate about collaboration and I just don't see how we can give a really good psychological service with that with that all the different professionals being on the same page and I think that you know it's hard because not all professionals not all other I guess the doctors and the psychiatrists aren't necessarily always wanting to talk to us and we do sometimes as psychologists I know I certainly do get the feeling with some of them that you know they don't have time and they just do want us to fix it and I just don't let that stop me and I will maybe not keep pushing with that particular person but I don't need to get it in the way of me taking that risk and picking up the phone to another GP and trying to collaborate with them and you know there's just been too far too many occasions where I've found a doctor to be so thankful that I've shared a particular insight with them and that makes it worth it it's just so important to have that in the future. Bill I'd like to just invite you back in as you've been listening have there been any sort of final comments that you'd like to leave us with? Yeah look I think we're sometimes hard to get hold of I think though if you have very good as psychiatrists if you have very good feelings about the collaboration you've done with particular people in the community you tend to want to come back to them and work with them with other patients and clients so that we can that's the thing that often will get us more involved with people in the community when we've had that good experience and it does take time as I say the other thing I just mentioned is that there was quite a lot of commentary in the chat room about how to deal with the families and another thought is that the family in this case was distressed too and it is quite appropriate for another therapist either within the general practice or outside to see if the family would like to engage with them to try and work out what they can do in this difficult situation I think it's helpful if there can be potentially communication between that therapist and the other team under very careful and specific circumstances but sometimes I've certainly been in that position of working with the family with the carer and helping the carer find a different strategy that works better and being able to tell from what's happening that that's helping with the therapeutic process that's occurring with some other people and that can actually be a very valuable way of helping deal with the family distress Thanks Bill so again the kind of complexity with the people that many of us are seeing it's so important to not be trying to handle it alone but family and carers and the treating team so thanks very much for that Caroline have you got any sort of parting messages for us I guess just to remember that we're hopefully all on the same side we all are aiming to get the best outcome for people that come to us seeking care so I guess it's important particularly for private practitioners to remember that teamwork also requires sometimes path on care not to hold on to care if someone's been attending the same person for care for a long time and not really changing nothing's improving it's a great idea to get a second opinion even if you want to keep caring for that person just to say I would have hoped things would be better than they are now and why don't we get some extra help people need to know that you care about them but also that you're not going to hold on to them I find this is a problem for me as a GP that people sometimes come and say they're not really helping but I don't really know how to get out of this therapeutic relationship and I always feel sad that they haven't been able to have that conversation and I guess in a way better access because it requires us to try and solve problems within a limited number of sessions, annoying as that is it does really force us to ask that question of well is this the best therapy, is the person really getting what they really need at this point in time and being prepared to path care on or at least share care thank you now Jan I deliberately left you to have the final say I think that you'll probably have some really valuable comments for us and so please thanks Mary look I think there are two points that I'd like to make firstly I think asking questions as a health professional really the key from many people I'm sure that you work with particularly with very personal, very private issues around abuse or rape find it very hard to actually open up certainly not until that trusting therapeutic relationship has been formed but I would encourage that you gently question or put gentle questions to your patient or your consumer that you're treating and Caroline also mentioned touched on it when dealing with a family very often we find just the word care if someone said to you or you said to someone who is your carer what you're talking about I have a husband I have a wife, my mum my daughter, my son so it's probably better to say well who helps you the most with your banking or your day to day issues. So that's the first point, the second point that I'd really like to touch on briefly is working as a team I think collaboration means exactly that, that you are working as a team but I'd be very concerned that if you felt that Cassie was seeing a couple of people that other person has about another health professional has picked up a particular point or a particular issue so I think working as a team is an absolutely fantastic approach and that the consumer or your patient receives the best possible care when people are working as a team my main concern is that you may think well this is being picked up by somebody else it's not that important I won't worry about it. So working as a team is absolutely crucial but please don't let something get through that you would think is important at a later date. Thanks so much Jan, I just wanted to say thank you to the participants as well for your contribution. We've had over 400 people on board tonight and I've noticed that the participants have been really pleased with the way that the panel has kept in touch and answered their questions. An interesting thing to note I think the panel is really stuck to the topic of collaboration and the participants have actually dealt with some of the nitty-gritty of the case and I think that's been a lovely process. So just in summary I think one of the key messages that certainly stood out for me was about planning to collaborate from the beginning and actually talking about that with the client so wherever they come through whether they come to the psychologist first or they talk to their family or they go to their GP that is communication and working together and having... I like to think about having some people on your side or in your corner so the more people we can have on the team to help you, this is just a whole lot more power and also the importance of actually developing relationships with those treating teams working out how to communicate and it seems to be about planning and practical things, trying to predict what might be necessary. So thank you everybody for really interested in panel discussion. Please make sure you complete the exit survey before you log out of the house and it will appear on the screen after the session closes. You will be issued with a certificate of attendance in a few weeks and you'll also be sent a link to the resources that are being discussed probably including ones that the participants have brought into the chat box. And the next webinar that MHPN are hosting is working together to support a child with Autism Spectrum Disorder Apologies, Autism Spectrum Disorder experiencing sleep disturbance and that's going to be on Monday the 5th of May the address is there if you'd like to register and I would also like to again thank the Private Mental Health Alliance for partnering with MHPN to bring this webinar to us and thanks very much and good night everybody.