 Hello everyone and welcome to this webinar on mental illness terrorism and grievance fueled violence understanding the nexus and of course unfortunately tonight's topic has particular significance given the events in Christchurch on Friday and we would like to send our deepest sympathies to all of those involved to their loved ones and to the broader community the issues that we're going to be talking about tonight may have considerable relevance to what happened on Friday but I do want to make it absolutely clear that tonight we're not talking about that event all of the content of tonight was prepared long before but at this point I would like to warmly welcome all of you who've joined us tonight for the live activity and we have had at last count we had 2999 registrations I'm hopeful that we fit over the 3000 but that is an extraordinary number and really I think is a testament to just how important people see this topic as being a warm welcome also to those of you who are watching us on recording and of course a very warm welcome to our panel who I will I will introduce in just a moment before I do I would like to acknowledge the traditional custodians of the land across Australia upon which our panelists and our participants are located and I'd like to pay our respects to their elders past present and future now this webinar has been commissioned by the department of home affairs with the idea of providing health professionals with a better understanding of this very complex area and helping them understand better what to do and how to manage these difficult situations when they arrive my name is mark mark creamer I am a clinical psychologist in private practice and a professor in department psychiatry at the university of Melbourne and my particular interest is in the mental health effects of trauma and so generally I come at this issue from the other side of the coin helping survivors of terrorism and violence but as a clinician and particularly when I was working in public sector psychiatry from time to time I would come across people about whom I had severe concerns and I always found it very very challenging and so I'm very pleased tonight to be able to facilitate this panel and to be able to pick the brains of our esteemed panelists so without further ado let me introduce them now you all have their webinars and sorry their biographies so I'll keep it very brief first I'd like to introduce Ines Rio Ines is a very experienced general practitioner and also a GP obstetrician at the Royal Women's as well as seeing a wide diversity of patients in her clinical practice in a community community health center here in Melbourne she's also a member of several committees and expert advisory groups and so it's wonderful to have you with us tonight Ines thank you very much for joining us is your microphone still on mute do you think Ines I do thank you very much and thank you very much that's all right great pleasure you're not the only one to have done that I can do that before myself on many occasions um I heard a rumor that you've got a bit of reputation down at the health center there is that right oh probably got a few reputations probably some good and some bad mark I heard you were a bit of a comedian oh um I think that it's low it is though um I told Mark the story that um I actually came home from work once and said that um the the receptionist staff was saying that I was actually the sunniest doctor at North Richmond Community Health and I came home and told my children that and they said it must be a very sad place to work yeah well I think a good offensive I don't know there's going to be much room for last tonight but generally speaking a good sense of humor is clearly very important thank you very much Ines um our next uh panelist is Alfred Allen Alfred is a clinical and forensic psychologist coming to us tonight from Earth he has a particular interest in professional ethics and also in the intersection between mental illness psychology and the law uh welcome Alfred thanks very much for joining us tonight thank you very much Mark um I often like to ask people uh what they do to escape the stress of work what kind of first strategies do you have to relax um primarily I like to walk and do ice and so forth okay and I heard a rumor that you've got a habit of getting up the unrealistic hours of the morning sitting yeah if you're on the west side of the country and you're three hours behind you probably need to do things like that to keep up with what's happening on the other side of the world well I can see the logic but I'm very impressed that you'll get up at four o'clock in the morning to go thank you very much I'll go to pass luxury okay thank you very much Alfred our final uh panelist tonight is uh michelle pate michelle is a forensic psychiatrist and a professor in at uh swinburne university she has enormous expertise in the areas of stalking fixation and grievance fuel violence and she's currently the clinical lead in the victorian fixated threat assessment center thanks very much for joining us michelle welcome thank you very much um I wonder if I might ask you the same question I just asked Alfred actually you clearly work in an extremely stressful area um what what do you do to relax to get away from work um what's relaxation sorry uh no it's um uh part from the alcohol uh occasionally do a bit of sailing but uh but really no I relax by being around people who can have a bit of a uh a chat and offer a bit of support at the end of the day I think it's a very very important lesson in there we won't dwell too much on the alcohol but oh yeah being with people who care about you yeah I quite agree okay michelle thank you very much and thanks to all our panelists tonight can I just for the participant benefit draw your attention to a couple of technical issues um on the bottom there you'll see an open chat tab if you want to send in comments or questions during the course of the webinar if you click that you can open it and send stuff there's also a resource library tab which contains a whole lot of good stuff the slides and the vignette and um and a whole lot of resources but I'll talk about that again at the end and I suggest you don't worry too much about that now because we will send you a link to that after the webinar finish and look at it at your leisure there's also a technical support tab in case you get stuck and we'd be very interested in hearing your opinions your experience of this platform when you fill in the exit survey at the end of the night so tonight we are going to explore the topic of grievance fuel violence uh and the issues surrounding it and we'll use our case vignette of emir as a kind of jumping off point I would make it very clear that um this case is completely fictitious but I think that it does um raise a number of issues if you like that we would want to discuss tonight including uh perhaps some broadly held stereotypes and some red flags that we as clinicians might want to be aware of so in a minute I'm going to ask each of our panelists to talk briefly in turn about their unique perspective of emir's case and then we'll open it up for a broader discussion and I hope that at the end of that process um that participants will have a better understanding of the link albeit the non-causal link between mental illness extremist ideology and abnormal fixation that participants will be better able to identify fixated behavior radicalization violent extremism and the potential for grievance fuel violence and finally that um we'll all have a much better awareness of the referral pathways where we can refer to and what kind of steps we should be taking if we're concerned that a patient might be heading down this track okay so without further ado now I'd like to hand over to our first panelist to innis and ask innis to um talk a little bit about her reactions to emir's story particularly from a GP perspective over to you innis thanks very much mark um I think I'll just walk through the journey that I actually see emir being on at the moment but to start off with the great privilege of actually being a general practitioner is that you really do get to know as soon as the time and in the context of their own life and their own journey um and I see particularly with emir you've also seen the journey from other people's perspectives certainly you've got a long-term relationship with his mother layma and you've also seen from other health practitioners point of view how he's presented and what issues have been from their lens and so you get a sense of his life over time and also his potential his health but also his illness over to a long time period and the effect on himself and also the effect on others so just to get a sense from my perspective how I would regard sort of walking through the journey from an outside perspective you've got a young man with a schizoaffective disorder meaning he has both schizophrenic component of delusions or hallucinations but also an affective or mood disorder which I suspect is um bipolar disorder interesting to see what Michelle says later and it's not clear from the history from my point of view what these delusions and hallucinations are however given the threatening nature to his sister in particular and some of the issues involved with some of the violence I do suspect that there might be a paranoid component involved there. There's a number of elements in his mental health history that actually indicate that by the severity and risk from my point of view as a general practitioner he's been violent on a number of occasions the lease has been called he's had inpatient care he's now in a community treatment order and so all of those indicate to me that there's quite a severe illness mental health illness there and there's also very significant wide ranging effects on his life he's stopped his education he's not working and there's very significant sort of familial disruption and disharmony and additional to those he doesn't actually accept that he's unwell he doesn't own his own actions he blames others he feels that he has an insight that others don't have um he doesn't feel he's unwell so all of those actually indicate to me the seriousness of his disease and he's left with both positive and negative symptoms of his disease which are both causing illness um the positive features of his disease the delusions and hallucinations have decreased with time and thus the diagnosis of residual schizoaffective disorder however he's left with these predominant negative effects which have been described as the blunted emotion the social withdrawal in effect the lack of full engagement in a meaningful life but i think it's really important also for me to actually understand that he's got several protective factors and it's those protective factors over time that will help safety netting but also help you work with him his family his team to actually help him he's got a place to sleep at night he's got a safe place to sleep at night and that's really meaningful many people in the situation don't he has um the oversight care and very much the love of his mother leila and i suspect other family members as well and he has an ongoing care and relationship with a gp or gp um and he adheres to his medication so there's a number of positive factors that actually can be worked on so i spoke from my point of view as a gp i wonder you know what is my role and i think my role is actually to work with him his family his team to actually minimize both his positive symptoms and his negative symptoms of his disease it's actually to maximize his activation and enablement in his own um in his own care in his own life and it's also to provide that sort of multidisciplinary patient centered whole person medical um medical home and in particular i've been asked to speak up a little sorry i'll speak up a little and in particular um it's important to understand that it's not just about his mental health we understand people such as him you actually have poor physical health outcomes as well so it's a matter of actually obviously dealing with his mental health maximizing his mental health but also um addressing issues that will end up with um so that he doesn't end up with increased chronic disease i will learn the fact that he's more likely to have lower levels of exercise with the factors for chronic disease increases of substances etc um so really essentially with this gentleman we've got a young man who's at who is at risk as a result of significant and ongoing severe mental health problems although he's stable but his negative symptoms of withdrawal and disengagement with positive aspects of his life and his being his family's work that is hobby's exercise has actually put him at greater risk so those negative features actually can draw him into a greater risk paradigm of illness and unwellness in both negative and positive features through schizoaffective disorder and so you have a constellation of you know so he comes back to me and as a GP i notice a constellation of symptoms that are very much red flags he's becoming increasingly withdrawn his personal hygiene and um grooming of becoming worse he's mumbling to himself his less eye contact his communication has become a more perfunctory and a particular concern is having increasing violent outbursts focused on asia starting to fires coming to the attention of the place and this renewed energy and interest in people dying so there's a constellation of features that are making feeling wide at this stage so i'm saying to myself you know what's actually happening in this situation he's pretty bad before but stable now he's getting worse and there's fairly objective sync to science that he's getting worse so is this his schizoaffective disorder worsening and if so why is it medication compliance is it substance use is it another chronic health problem that's actually compounding this and also very importantly in this case it's inhomicidal no danger to others and i'd be particularly worried about asia and her husband given what's happening at this stage but i also need to think about the risk that he might be putting himself to um and explicitly think about the risk of suicide and harm to himself so um i have a situation here where you know i know him well i've seen the changes and unwind he's very susceptible from mental health issues point of view his history of violence his lack of engagement in the meaningful world and then he turns up in combat elicits and is involved in what seems like family situation fringe groups and so now i'm extremely white and you know given the issue and the potency and the tragedy of cross church um that is that is a real fear um so the question is you know what do i do and i think that that's probably something we'll tease out more as a group but i think as a gp i'd be explicitly asking questions i'd ask a range of closed questions and open questions i'd speak with my sister can't trust in case of work on mental health care team and others i'd speak to him about his care being confidential and unless i believe he's at risk himself or others i'd probably speak with layman again that's something we can explore later but i certainly would not be looking after this by myself i would need the support the perspective the expertise of a range of people to actually assist me in this thank you lovely thank you very much indeed and it's wonderful and as you say there's a whole lot of things there that i'd like to pick up on when we get to questions and we can discuss as a group but for now i've got to keep an eye on the time so i'm going to keep things moving along if i could and i'd like to hear from alfred perhaps if we could now a little bit more about a kind of psychology perspective but maybe with an emphasis emphasis on how we might go about making decisions with regard to it so over to you alfred good evening my first ask today is to tell you what a critical and a skeptic cross examiner might ask you next year this time if email goes on to do something bad first were you sensitive enough to identify the problem did you see the red flags did you know what questions to ask and information to collect did you have a framework to guide your decision-making did you identify the issues you had to make a decision about such as whether necessary to consult to refer or to make a report to the authorities did you use your decision-making framework to analyze the available information in a systematic way did you did your decision flow logically from the framework you use and the relevant information you had at the time finally how did you and others respond after you made your decisions so how did you respond i cannot examine all the possible responses but we usually want to consult or warn somebody in these circumstances and that might involve violating our patient's privacy so what are the rules here the ground rule is if you form the reasonable belief that there's a real risk of immediate irreversible arm you face an emergency and you immediately do what is practical otherwise you follow the policy procedures and protocols of the organization you work for or if you're in private practice you follow your professional ethics and they should be compatible with a commonwealth privacy act so the crux of this legislation is we need to we need consent to use information for a purpose that was not the primary purpose of collecting information unless we've got consent or it's impossible or impractical to obtain it in which case we have a discretion to use it without consent in some circumstances and there are two that are particularly relevant today first when a police officer calls you and asks you for information the rule is only provide information if you or she has a court order or warrant unless there's an emergency obviously second if you reasonably believe that it's necessary to disclose information to prevent a serious threat to the life health or safety of any individual or to the public health or safety you can disclose information the word reasonably is of paramount importance here because it says that there must be there must objectively be tangible support beyond a mere belief or an assertion so reasonably in law indicates the question is what a reasonable person in your position would have done under the circumstances and that you can only find out by consulting other people ideally without identifying your patient the person you consult must be an appropriate person and you must make a written record of the consultation as soon as possible about who you consulted where and when what was the tangible evidence you presented what was the advice you received so in conclusion today from your perspective I think would be to improve your sensitivity and to try and develop a decision-making framework that you can use and to understand how you could develop a network of appropriate people and organizations that you can consult or refer to thank you very much thank you very much indeed Alfred that was wonderful and a whole lot of issues there that we will undoubtedly come back to and I think I'll perhaps pin you down a bit when we get to questions about how those things might apply in this particular case or in this case but before we do that can I just ask you a broader question I suppose that when we do these for many of us I suppose I am talking about myself here when we do these find ourselves in the situation of having to do this kind of assessment we're sort of flying by the seat of our pants do you think that there's a place for us to be more conscientious about having policies and procedures in place to guide us through this kind of thing totally I think I think it's especially the case for private practitioners and organizations obviously as well so I think the better the protocols procedures policies the better for the organization or the individual yeah yeah absolutely okay and I think that your slides actually probably the good beginnings of something like that but we'll come back to that in a minute can I just say we are very frustrated with protocols and procedures and policies I myself but they're very good yeah exactly and and and you know I suppose you started off your talk really with this kind of in mind but that's um we don't feel we need them until something goes wrong and then we wish that we had some kind of policy so yeah all right thank you very much indeed Alfred thank you we'll come back to you very shortly but for the moment let's move on to our final panel member and get a specialist car tree perspective and perhaps a little bit about what the research and the kind of expert can expert consensus tells us in this area so Michelle if we could go over to you and get get your your views on this one over to you Michelle thanks Mark I guess my um overwhelming impression of this vignette was he's how vulnerable this individual is he's vulnerable in many many ways and I think there could have been any number of adverse outcomes in this particular case but I think it's reasonable to at least consider the the risk of radicalization in this particular case given there are a number of indicators there and I put up there the definition of radicalization it's a it's a process the process by which people come to accept the use of violence to promote their ideology their political religious or ideological views and the the problem with this particular case is that as I said there are a number of indications and people who who radicalize to violent extremism we tend to group under what we call it's not working hang on the moment I'll just go to the next slide there they tend to basically people who are radicalizing tend to have displayed changes in various areas of their life key areas of their life like their social relationships their criminal activities and their ideology we can certainly see changes in the social relationships here particularly with Amir becoming more withdrawn more isolated possibly having more of an online presence and certainly rather estranged from family members ideology is unclear from this he's a fairly secretive fellow by the sounds of things from the family's history but if I was going to explore that these are the sorts of questions I guess that we would pursue we'd be asking him I guess about his views but also does he identify with extremists and that's generally obtained from the sort of information he's collecting the the social media his and websites he's watching people he's talking about for instance rejecting the views of people who don't concern their own views so having radical views that don't fit with the rest of society perhaps the rest of his family leading to the arguments that we've heard about uh and joining activist groups or religious groups for instance and people who radicalized the violent extremism as I said before are people who can be categorized under this lone actor grievance fueled violence umbrella so as you can see from that lone actor terrorism sits there because very often personal grievances and injustices are more of a dominant factor than the ideology itself so that's what they share in common these aren't mutually exclusive types and if you look at the top these see attackers of public figures which are our fixated people basically the other thing that these groups are sharing common are higher rates of mental illness than the general population and again we just look at the next slide you can see there that the rates of mental illness among lone actor terrorists are quite high at 40 percent and talking about mental illness here as opposed to the rest of the population certainly with group actor terrorists we're talking around eight percent or so so it's quite significantly different but very similar to the other types of lone actor grievance fuel violence our fixated loners our apolitical lone actor mass killers so these are people who just looked at the workplace killers the school killers etc so we tend to fit this under lone actor grievance fuel violence and this is just to sort of try and demonstrate that I'm not suggesting for a moment that mental illness causes terrorism or causes these lone actor attacks terrorism's multi-determined it's a complex complex situation mental illness is only one contributing factor to that but it's it's a contributing factor that we can do something about and that's the really important key here emir appears to be vulnerable he has mental illness we need to be looking at the mental illness in addition to obviously addressing the other risks that that might be there so I'll I'll leave it there but that's just a quick overview of the area that's lovely thank you very much indeed Michelle there's a whole lot of stuff I'd like to pick up on there actually but if I can just initially you use the term I think lone actor or lone wolf would you call would you suggest that emir would you call emir a lone wolf or a lone actor well I wouldn't call him either at the moment he's a potential lone actor but we use the term lone actor in preference to lone wolf one of the things about lone actors is that they have a drive for notoriety they really like to be recognized and using terms like wolf suggest cunning and power and stealth and we really don't need to indulge that with these particular people so we use the term lone actor the media tends to use lone wolf it has more of a sensationalist kind of sound to it but yeah all right thank you very much Michelle so now let's see if we can kick off a broader discussion I'm going to invite the panel members to just jump in and disagree or add an alternative perspective or just make a comment or whatever whenever they want but we're going to be driven largely by the questions that you as our participants have sent into us and I must say that I have been very impressed by the number and the quality of the questions that you've sent in for us when you when you registered for the webinar tonight and we will do our very best to get through them all but please bear with us if we don't get to your particular question if we think about the ones that you sent in we can divide them into three broad categories so the first theme is about a better understanding of the relationship between mental health and grievance to violence the second theme is about assessment what should we be looking for what are the warning signs and the third is really about intervention what should we do how can we manage this better both as a clinician and perhaps as a from a broader systemic perspective so my plan is to work through each of those three broad areas in turn and then we've got something a little bit different to to finish up on so let's start off with the first one and I'm going to come to you first if I can Michelle and I guess you know we know that the majority of people with mental health problems are not violent but clearly or presumably the fact that someone has a mental illness doesn't preclude them from being violent no and obviously there's many examples of that but but certainly our mental illness can make people vulnerable to because you know people obviously is often the associated vulnerabilities of mental illness as well that make them vulnerable to terrorist messaging so some people will be vulnerable and I think that Ines went through the positive the negative features of mental illness and all of those things can can certainly make a person more at risk but the the issue is that mental illness certainly doesn't preclude violent attacks as we used to think in the old days if anything if a person is mentally ill and they develop these sorts of views it can actually provide more results so having delusions might actually increase their results for instance to act on these beliefs so that's the that's the issue that people miss sure sure sure and you kind of answered this already but I'll throw it back to you anyway why do you think it is that that there are higher rates of mental health problems among among these kind of lone actors well we we don't precisely know but we we do know that some people with mental illness and as I said with the sort of associated social deprivation and stresses in their lives will be drawn to this or the messaging as a as an apparent solution perhaps to their to their problems that might be more vulnerable to the to the propaganda for instance that terrorists put out so that's one reason I guess in a sense group terrorist particularly group terrorist recruiters are not necessarily going to go out there and recruit people who are obviously mentally ill and you know it's I guess what we're also seeing is that group of mentally ill people who have delusions and are now incorporating terrorist themes into those delusions and so that that is also a problem we're also seeing people who are feeling suicidal perhaps homicidal and they see the media coverage of attacks and sort of methods solution of sorts so we see that copycat element as well and people who are already vulnerable yeah you you you actually mentioned suicidal there as well as homicidal I was going to bring in a fear in here actually if I could because a few people have asked about the connection between radicalization and self-injury and I might come back to Michelle's comment in a minute but for the moment as a GP in this would you would you have any concerns about Amir harming himself did you pick up anything or what kind of indicators did you pick up that might worry you about Amir self-harming um you've got it I think if you've got a serious mental health problem I mean the issue of suicide is one that's a fairly common prevalent issue and then you have somebody that has an underlying significant mental health problem and you have this world that's actually happening that you're not really sure as the practitioner what's happening in this private world so I think you have to actually be attuned to the fact that he might actually have self-harm and be suicidal and in this case particularly that he actually might be homicidal or harm particularly his sister Aisha because there's a number of factors I think that are um a flag for those issues and the issue about being violent is um the objective markets seem to be violent towards the outside and outside people Aisha and her brother etc violent outbursts but one doesn't know what's happening internally in his world and I think you need to explicitly think about it um and screen for that yeah um I want to come to you Alfred in just a minute and talk about what the ethical issues are when we think as as Innis said that he might be violent but I'm going to throw another one at you and I'm not sure if this is quite your domain so don't hesitate to bat it back if it's not Alfred but um I'm interested in the role of drug and alcohol abuse and and or drug and alcohol use perhaps not abuse and and our role I suppose in uh how important it is that we ask those kinds of questions and whether that might play a role in in triggering this kind of grievance fuel violence I'm not aware of any uh research in that regard I wonder Michelle not going to be able to answer that one um I'm not aware of any uh specific uh link uh but Michelle you know well if if we're talking about loan act to grievance fuel violence not including that fixated groups those attackers of public figures who are a pretty pure bunch who don't tend to touch substances um we have we are seeing significant problems in that area and um so much so that in our fixated threat assessment center which deals with loan act to grievance fuel violence we we have alcohol and other drug services provided to those people and certainly a number of the attacks have the attacks that we've seen even in Australia have um have been associated with substance abuse as well so certainly it's a disinhibitor it's something that some people will be actually psychotic when they commit those attacks so it's it's something that we certainly factor in and it's one of the risk factors when we look at radicalization and uh violence um I was going to since you use the term psychotic I was going to ask Michelle whether or not there are uh higher risks associated with certain disorders and and that would be an obvious example do you think that people with psychosis are at higher risk for example and people with depression psychosis particularly general term I certainly can uh certainly say that people with uh paranoid type psychosis are at increased risk of violence generally and um when we look at more recently there's been um studies of loan act samples and the diagnosis that stand out in those samples are schizophrenia delusional disorder and autistic spectrum as well so they're the they're the and they have the stand out diagnosis um if you call will test expect them a diagnosis but certainly they're uh the problems that we're dealing with in uh loan act samples okay um let me come back to you Innis if I could because there's an interesting question here that I hadn't thought of but I think it's worth exploring and I'm wondering whether in primary care settings in particular but possibly in specialist mental health settings as well that um there's a danger that if we identify someone as having a serious mental illness that that might actually act as a barrier to recognizing sort of extremist ideologies and potential for violence the idea that um we're too ready to perhaps put it down to the illness that just because he's got schizophrenia or whatever do you think it might be a barrier or is that an unnecessary concern I think it's a concern and I think that it's a concern in a whole lot of aspects of uh clinical care I think that sometimes when you have a diagnosis you keep going down that path of diagnosis that's that's true across a whole lot of aspects of clinical care and you need to be able to sit outside sometimes we'll look at the clinical picture and say periodically does this actually fit the picture so I think that it is something you absolutely need to be aware of and I think that you need to be aware of those the things that Michelle's talking about because there is some blurring here and in general practice in primary care you often actually don't have a very clean diagnosis with things we're used to as GPs and primary care professionals we're often used to looking after um things that haven't quite resolved so ambiguous circumstances and still managing them so in the case of anemia you need to be in a situation where you are managing the situation managing it safely thinking about a range of things before you've actually got a clear diagnosis of what um these escalating symptoms are actually due to all right so I want to move on to to um look at the assessment issues but but it seems then what we're saying is that um mental health problems in grievance fueled violence are very common but they're not essential and uh that this stuff might occur in the absence of stuff as a kind of um I don't know bridging question because I don't know where else to put it uh Alfred I wonder if I could ask you to comment on this and again I forgive me because I might be being unfair throwing this one at you again so just bat it back if you're if you're not too sure about it but it just does strike me from various news reports and the amount of media coverage that we're getting nowadays that these kind of incidents of lone acts of violence are uh or have been on the increase in recent years do you think that that's true are they increasing or are we just more aware of them and if they are increasing have you got any idea why I think they are increasing and I think the copycat element is probably um a reason for that I think what we're seeing is I think mental illness play out in a social milieu and we've kind of grown used to this terrorism over the last 20 years or so and obviously it affects people with a mental illness and it will affect people especially if they're paranoid schizophrenia so I think there is probably an increase I think there's also an increase of using motor cars and things like that to commit crimes and uh it's once again what people see on television and there's a lot of coverage of these things on television it gets a lot of TV attention absolutely and as you say that kind of potentially fuels the sort of copycat uh copycat kind of stuff um and I think the yeah yeah copy copycats maybe not the right word but it's kind of like it's become very common so it's very much up in people's minds and also people with a mental illness yes yes exactly exactly and of course I don't think I particularly want to go down this path now but um but there has been a lot of suggestions that perhaps the quality of care that we have for our seriously mentally mentally ill uh is not well it's different to the way it was in some ways it's much better but it is uh we don't have the kind of institutional care that we used to have where people could be uh looks after and I don't know as I say that maybe that's a beautiful to go there unless you want to comment on that well I think the institutional institutionalization has been coming for many years and in some countries it's very advanced I think it's one factor I don't wouldn't like to say that's a crucial factor but obviously it's it's probably one of the issues yeah okay thanks Alfred I'd like to come back to you Michelle if I could and and let's talk about we're now really getting into the idea of assessment and and uh how we're what we need to be asking so on um do you think that there's any way that uh any way to identify whether emir is actually planning a violent attack you know what what kind of signs might we be looking for well there's unfortunately no way to predict future violence as you know but um but certainly there are a number of factors in this particular case that are known to be associated with violence in these sorts of contexts uh his history of violent outburst is certainly one of those um his poor social adjustment uh the difficulties he has there and the um I guess underachievement in life in general disenfranchisement um we don't know about many other factors that might contribute to that but uh on their own and I should say as well of course he's uh he does as I said seems to have collected a lot of wounds along the way so he has injustices perceived or otherwise uh which stem from you know the bullying in the early years and the failure to achieve as a result and so on so those things together certainly point to uh certainly a greater likelihood of violence um but really the best one of the best predictors available to us at the moment actually comes from these people themselves because over 80 percent of these people are actually telling other people about their violent intentions before they commit the attack uh and when I say other people I'm talking about people around them family members colleagues online contacts um and that's that's great from the point of view of prevention obviously that's an avenue for us to find out about these things before they happen but it does rely on these people obviously in passing the information on to the authorities yeah yeah which is uh well let's hold that for me because I think it's a really important point and I want to talk more about families and the involvement of families and so on but it's a very important point um Ines you you were worried about MIA and you you said the last time you were talking something about the fact that you were worried about its homicidal tendencies were there any particular things that you uh you you know that worried you in particular about the the risk of violence towards other people um I think it's well for me it seems fairly clear the fact that he's actually um tried to hurt Aisha again I think he um um tried to light the car of her husband increasingly violent outbursts along with this sort of paradigm of increasing withdrawal and being more evasive so there's that sort of I would say that there's in the way I read his story there's the three phases there's the post acute care phase where he has the residual schizophrenia then there's that middle phase and then there's a very lying phase at the end and certainly in that middle phase I'd be ringing up his psychiatrist saying look I think he's getting worse from my perspective he's showing um more positive features more negative features and in addition to that he's actually got some violent features here and I'd like a pretty prompt assessment of this person um and I'd so that would be I would actually be pulling in the levers of the other care team and the expertise by the case management um the psychiatrist and the mental health team to actually assist in that and as I said in the in the first instance they'll have their own lenses and have had their own experiences so it's about patching together um I look a more wholesome look at Aminia and I know with that is actually the perspective that his mother brings because because there is no doubt that his mother is getting another perspective at home and it will also be extremely worried about presumably her daughter okay I agree entirely look there's a whole lot of stuff there I really do want to come back to this idea of bringing other professionals in and also engaging the family but I'm going to put it on hold for the moment because we'll talk about that in what we actually do about it let's just stick on assessment if I can um and perhaps I'll just go to you Alfred if I could again and um I guess this is an over idealistic question but you talked about having policies and procedures in place before is it feasible to talk about a kind of checklist that people should be going through to identify the risk of violent behavior or is that too sort of structured I don't think there are any risk prediction instruments that we can use in this area but I think having a formal assessment structure is always good and it helps it's what I call you know when I refer to the decision making framework it just helps one organize your ideas and it's systematic way of looking at the material that you're collecting and making sure that you collect the writing information yeah yeah absolutely okay um Michelle if I can bring come back to you and um if we just leave radicalization sorry if we leave mental health to one side at the moment can you just comment more generally on the potential relationship between radicalization and the potential for violence Michelle yes I mean as I said radicalization is a process ultimately leads to violent extremism that's the direction it's headed so that is about the person then conducting some violent attack or supporting someone else to do that or some other form of violence or disruption bomb hoaxes that sort of thing so that's the path people are on and they get to the point of violence because they come to a point where it's justified in their mind their beliefs actually justify violence is the only solution so that's the part and parcel of the process yeah yeah okay let's move on then and talk about what we're going to do about it so we've identified that Amir is that risk we don't know whether he's going to act on it or not but we've identified that he's at risk Ines I'll bring you in again here if I could because you've mentioned the family a number of times and I now want to give you free head to have a go at it so if we start with Layla because you talked about possibly bringing his mom bringing Amir's mother in can you just talk a little bit about how you might make that decision and when you might make that decision that's a that's a big deal isn't it to be asking his mother in it is a big deal um it's a bigger deal if it happens without his consent clearly and so the the issue about um Layla's obviously a very big protective factor in his life is obviously somebody who very cares about him very deeply and provides a lot of care provision and is also somebody that can give you a perspective of what's happening in his life outside the room and the visitor that you have so I think it's important in principle to actually have her involved both from an information point of view but also from a care provision point of view by and large as a general practitioner when you do have a long-term relationship with somebody that's something that actually happens it happens as in a conversation with a patient where you say hey um next time can you bring your mom in or um you see another in a in another situation because she comes in for another thing and she opens up the conversation and tells you what is actually happening at home clearly in those in a second instance you have to be very clear about the confidentiality that you are actually providing because Amir is an adult he's not strictly under the care of uh Layla and so you can gather information quite easily in that sort of scenario but you clearly have to be very cautious about providing information to Layla about her son unless that's obviously with consent of her son all these other all these other circumstances where you feel it's warranted and they're sort of so sorry no okay i'm sorry to interrupt it's a very interesting question and i was going to bring alfred in because he's our kind of expert on professional ethics what what comments would you have about that alfred in terms of involving Layla as as in this says you know if Amir is quite happy to give you absolute consent then i guess that's a bit simpler but otherwise what are the ethics of involving Layla or perhaps other family members yeah it's very difficult because in a way this gp seems to have a fairly good relationship and a long relationship with the patient so you don't want to go and do something to ruin that relationship on the other side obviously you've also got the ethical issue of not breaching confidentiality so it's a very difficult one it would depend on the circumstances i think if you're sitting with what you really consider to be an emergency it may be you may be justified to actually violate these confidentiality and speak to his mother but one's got to be you know it's very difficult to answer an hypothetical question about this one yeah absolutely absolutely because also of course there there is potential to bring in other family members as well i mean i'm interested in Innis's comment that what what if she sees the mother in another setting and the mother is telling her things where where does that go if mum says you know i think that he's planning something i think i think one would sit down with mother and work out a management plan how are you going to deal with this because in a way mother is obviously looking for you to do something but and and it's a kind of like a cry for help really in a certain sense so so you've got to do something about it you cannot ignore it and if it comes out later that you did ignore it i don't think it will be very well received so i think the answer is sitting down with mother and trying to work out a way what to do just purely on on what i read here i think the most obvious thing would be to consider readmission into a psychiatric hospital and maybe to try and ask mum whether she would be happy to assist with that and that may be one way of dealing with the situation i think if you've got a very experienced gp working with a client over a patient over a long period of time sitting down with a family member they could probably try and get a meal back into it in a to a psychiatric hospital let me just take you back about 30 seconds uh you said that if we don't do anything then it's not going to look very good or whatever but can i push you a bit harder on that if we if we look at this particular case with the kind of it's not black and white it's not clear cut but there are enough warning signs if we don't do anything do you think we're at risk there of accusations of professional misconduct or even perhaps legal sanctions it's a very difficult one and i think this is where you i if i was a the gp i would want to consult somebody like michelle um and as i said in my overheads uh not without identifying my my patient and get a second opinion on this one i wouldn't i wouldn't take this on my own back and it does come back to inis's comments about the importance of um yeah not doing it on your own of engaging other professionals and i'll come back to you inis actually uh there is something else i want to ask you but inis but um is there do you want to add anything to that about the importance of involving some colleagues perhaps you know that the cardress and other key workers um how would you decide that that's an appropriate thing to do is that's pretty routine for you or would it be unusual well no i think it'd be fairly routine i mean if you've got any clinical scenario especially if you've got a care team around him already he has a mental health team you're doing shared care with him essentially um so that phone call would have been would have happened fairly early on as soon as he noted a a clinical deterioration fairly soon you would have rung up and said hey um things aren't looking so good at my end so could you please see him fairly soon perhaps it's a medication issue hopefully you've got some information to be able to provide them so that there's a um a better care algorithm you know a more false and picture of perhaps why this might have occurred whether it's adherence to medication whether it's actually substance use as michelle was talking about before or whether you say well actually don't know what's happened that things seem to be getting worse so that's a fairly common that's a very common situation i think that the issue is really when you get to that point in which is um how quickly do i need to respond and will he take part in this assessment so that's when you actually start having that think about um how soon do i need to respond to this before he's potentially at danger to himself or to others and that's when you start having that think about if he need an assessment order if he won't do that voluntarily and as um elford was saying that in that situation it's much much more preferable to have it in a voluntary setting in the community and so that's probably something we bring up your you know learned colleague who has much more experience in this society and say look this is the outcome we need how can we best get to this um okay i'm jumping around a bit but while you're there in this if i can come back to layla and your comment about um you know that i might see layla in another setting as a GP i might see her in her own right or whatever if she does come to you first asking for advice um do you have ideas about what you would advise her to do when she's worried about it i think that there are some principles that elford actually outlined really well which is that first thing is that you want to maintain a really strong relationship um in a trusting relationship with an ear because that's actually fairly crucial in you being able to assess him and help him therapeutically but also assess his risks moving forward so i think that that's really crucial and um but obviously the the discussion you have with layla as much as you can you don't actually want to affect a negative relationship with an ear so if you can actually bring a meal along with you in this discussion in some ways i'm not saying physically in the same room but if you can involve an ear and say hey me i'd like to have a chat to your mum about this for your family i think things are about at home i'm seeing her soon do you mind if i have a chat to her about you if you have that sort of relationship with him it's it's you know um it's much better from your point of view um and it's also much better from a relationship point of view and then you can actually discuss that with both an ear and with layla there are clearly circumstances where um that's not going to happen and then in the layla situation you need to decide is this uh are you going to be in some ways a receptacle for information so that you help get information to get a clearer picture of an ear um and how much of his um because you don't want to necessarily bake his confidentiality it doesn't mean you won't because there are some circumstances as elford said where this is actually a risk framework decision-making process um the other thing i would say though you've asked specifically about how i would help layla and i think that in helping layla i would actually first try to elucidate what her issues are and i suspect her issues are firstly about aisha so i think that that's actually really crucial here is her concern about um potential threats and problems with aisha and clearly actually what's happening with an ear and that discussion about how much i can tell her about an ear really involves my relationship with an ear i'm sorry it's so um muddy that discussion but it often is a muddy landscape that we're talking about yeah i understand exactly it is a very um it's a very complex area isn't it without any any simple answers um michelle can i put you on the spot then for some simple answers um what's um uh in broad terms what does the evidence tell us or if we haven't got the evidence then perhaps the expert consensus tell us about what the interventions are going to be with someone like m here what what kind of interventions do you think have the highest chance of success well we'll make the assumptions i suppose about what we've found here but you know i'm i'm putting my money on this fellow having uh it deteriorating in you know mentally and needing some mental health care at this point in time and i think that uh we need to be able to identify that there are other processes going on it may be that he is radicalizing and that's something a little outside the understanding of uh of mental health services what we need them to be able to do is to treat this man but we also need to be able to look at all the other pieces of the puzzle some of which mental health services don't have um in the sorts of services that are developing now as joint services with police and and other agencies we can start to look at the extent of the problems uh by for instance actually knowing what he's talking about on social media for instance um who he's talking to uh what their backgrounds are what their influence are so these are all things that are really important to understanding the risky poses at this point in time and whether or not information needs to be shared at some level and i think no one is asking mental health services to do that uh what we're asking mental health services to do i guess is to do what they do best which is to treat mental illness but for us all to work together to share that responsibility yeah okay um just while i've got you um someone's asked a lot where i think it's an important question but i'd just like to preface it with a reminder of what i said at the beginning and that is that the vignette that we're using tonight of amir is not only entirely fictitious but it was deliberately designed to challenge the myth to challenge the stereotypes and that kind of thing uh but having said that i wondered whether or not we might look at involving someone's playing with their microphone i said i wonder if we might look at involving um sort of culturally appropriate organizations within the community to what extent do we try and engage community organizations in helping us to manage someone like amir yes i mean when we have an issue like this um we have uh we have services to essentially help them disengage from this path so that they don't progress to violence and uh we draw on all the agencies that we need and and uh obviously they're their cultural uh cultural associations etc um employment agencies and there's any number of agencies that might be appropriate and it's not a one size fits all but it's about building skills we've got a very disenfranchised uh young man who's underachieved in life who's got lots of present and around that and uh you know we need to as in a said try and build a life again a meaningful life for this fellow and um that will include obviously uh multicultural agencies etc yeah okay before i let you go because i really want to actually move on to something else now but before i do a very legitimate question people have asked is is there any training that they can get are there any training courses or programs that clinicians can go to to help skill up in these kinds of areas they are being run in a number of different mental health disciplines at the moment and uh they they do come along but at the moment we also have some excellent fact sheets that have come out from um department of home affairs has put those out with lots of expert involvement i find them very well written very easy reading and um i think a minimum for health professionals in terms of what they need to be able to recognize so they are available on on the website there as well good and we'll talk about them in a minute when we talk about the resources i'm going to throw it back to you in this if i could and i'm going to ask for the quickest answer possible i'm afraid and that is that our first rule is to do no harm do you think that there's any risk that intervening with someone like amir uh might actually make things worse might even increase the risk that i think that very i think that there's always a risk that intervening will disrupt your relationship with him perhaps put a disruption between his relationship and his mother and further disenfranchising from a protective system would put him at greater risk however i think it's fairly clear from this case that this is escalating and something needs to be done and it needs to be done from a multi-point approach okay all right thanks very much to everybody i'd like to just move on and uh do this uh last bit and that is um what we've done is to um identify some of the really common myths that we think people have about um grievance fueled violence and we've got them up on the on the on the screen here so what we're going to ask you to do is to um vote on these i'm going to ask um rennan in a minute uh at redback to start the poll and ask you to vote on which one of these you would most like to see covered so if you could start the poll please rennan and uh if you uh participants could please um just vote for which one that you think you would like to see uh discussed perhaps which one you think might be one of the more widely believed ones and then we'll get um well we'll get our panel and particularly perhaps michelle to address those so is everybody pressing buttons i can't see anything happening but maybe that's just my end so uh you've just got a few seconds left if you'd like to vote for one of those myths to uh be explored click your button now and i think we'll close it off rennan did we get any responses that i didn't see on your my screen have you got any if you have pop pop them up okay uh all right just bear with me out there um because the numbers are flashing in front of my eyes here um okay so let's go with that one that um the the top one that we've got is that radicalization is always linked to religion michelle can i turn to you and just ask you uh what you would say about that is it true that radicalization is always no no it's um look there's a whole spectrum of uh of extremist ideologies out there we have you know left wing wingers right wingers various religious uh ideologies that we also have nationalists and separatists and anarchists and so it goes on so it's not always linked to religion at all it's really a political communication right um does it i any of our other panelists want to comment on that one i'm going to pick up on the others as well but um any other other panelists want to comment on that one let me then um pick up on number four because i think that came in two according to my numbers uh which is an interesting one asio has unrestrained power to arrest those they believe may be radicalizing and uh is that true michelle asio has surveillance powers they don't have arrest powers if they need to arrest that's something that the state territory or federal police will do but asio like uh like state counter terrorist services really don't want to be arresting people who are radicalizing unless they're committing offenses uh really the the push nowadays is on prevention it's early intervention prevention uh from that course and and obviously stopping the progression to an attack uh and we have you know we are increasingly uh services and and resources are being put into that uh very approach with um with uh services that help to disengage people from that path so um yeah yeah okay and i'm relying on innocent alfred to just jump in if there's any comments they'd like to make on any of these um what about that first one and certainly as a clinician it doesn't sound right to me um heaven helps us if it is right that's what i'm saying uh yeah no it's um there is a lot of radical thoughts out there i think we've all had radical thoughts you only need to step onto a university campus and there's radical thoughts out there but of course not everybody believes that uh violence is the solution to those were violence is the way that uh their beliefs should be promoted so um it's much you know obviously radical thinking is much more common than actual violent extremism and indeed i think i'm right in saying that well i don't want to get into sticky ground here but that um thoughts about violence or thinking about violence is very much more common than actually acting on it absolutely yeah you'd agree with that i would absolutely yes yes yeah uh and then the final one was then uh that you have to be in a group to be radicalized you can't be radicalized if you're not in a group is that true well not no no i mean obviously people can self radicalize it's easier i guess to be in a group groups offer a lot of advantages um and uh they help overcome some other hurdles to actually uh to physical violence but uh but people can self radicalize it's just that lone actors um even though they're described as lone actors very often do have links with a group or have had links with the group who've helped them to with the radicalization or planning attacks etc yeah okay all right so um there are a whole lot of myths around and i know that one of the um one of the fact sheets that you mentioned earlier that i think is in our resources thing that people can look at later has a longer list of myths and and yeah things that people believe okay the clock is ticking away and we've just about run out of time so to finish i would like to ask each of you whether you have any final take home messages for our participants any any final points that you'd like to leave our participants with and i might start with you in this and anything any final points that you'd like to make you're on mute i think you're on mute thank you for that i think from a mental health well-being point of view think about both the positive and negative symptomatology and also think about and work on protective factors i would say that would be one you know or two issues that are really important another issue is actually to work within people to actually activate them in their own care which is linked to that i'd also say raise your point mark about sometimes when things aren't going along the trajectory that's expected to actually just step outside and think have i got this diagnosis right what's actually happening here and importantly how can i engage other people and other services to help me um help this person best okay good thank you very much in this alfred any final take home messages for our participants uh you're on mute as well i think alfred are you on mute yes sorry yes i think it's important to to appreciate that demer is a risk even if there's no terrorism in here and that as a mental health practitioner should be very aware of our duty nowadays to actually also assist the society in prevention of harm and he is clearly very ill and as such that's why we are experts at and that's why our first focus is how do we actually stabilizing because once we stabilize the problem might even go away i mean it's never going to go totally but that's other things we should focus first focus yeah yep i'm afraid that we you're breaking up a little bit and i'm not sure that's your headset or whatever but we did get the gist of that we got most of it um so thank you very much indeed for that alfred and finally uh michelle just check that you're not on mute and then and over to you if i could for some final comment now again that's it's this is a complex multi-determined kind of problem but you know mental illness isn't the sole cause or driver of this uh but we have to realize in this new age of um you know terrorism if you like there are increased rates of lone actor attacks for various reasons they have higher rates of mental illness uh mental health professionals gps other health professionals can obviously do something about that as alfred just said some of the time that's all that will need to be done uh but we can you know it is something that is as i said a shared responsibility it's no longer just about more enforcement and intelligence agencies we have something to offer that the police haven't got so that's the message i guess i was like to give at this stage yeah absolutely and i think it's a very important uh it's a very important message to leave on isn't it really that we all share responsibility particularly as mental health professionals but but the whole community perhaps shares a responsibility thank you very much indeed thank you very much indeed to all of you um just a couple of closing comments here and a reminder that uh there are some great resources available we will or mhpn will send you the link to the resources um in a few days at the after the webinar and i do encourage you to look at it because um in particular the fact sheets that michelle referred to i thought were particularly good these are prepared by the department home affairs and and targeted at different health professions with some really useful information so i'd encourage you to have a look at that when you've got time over the coming day um i'd also encourage you if i could please to make sure that you complete the feedback survey before you log out um but for now uh i think it just remains for me to say thank you very much indeed thank you especially to all our panelists to in this to alfred and to michelle thank you very much for what i think was a great webinar i was very pleased with it and thank you also to all of you who participated in the webinar uh thank you for your engagement and your involvement it really makes a big difference to us so i hope that you found it valuable thanks again to everybody and good night thank you good night