Good evening everybody and welcome tonight's MHPN webinar. It's been a tricky day or week or month for a lot of us today, but I hope what we're bringing you tonight will be of help. I'd like to welcome the over 660 participants. We have so far joining us tonight live and those that might be watching the webinar at another time. First of all, the MHPN would like to acknowledge the traditional custodians of the land, seas and waterways across Australia upon which our webinar presenters and participants are located. We wish to pay our respects to Elders past, present and future for the memories, traditions, the culture, hopes and cultures in hopes of Aboriginal and Torres Strait Islander Australians. So hello everybody, I'm Nicola Palfrey. I'm a clinical psychologist and director of the Child Trauma Network at the ANU. I'm glad to have you all alongside for this really important topic. There's been a huge amount of interest and it's amazing to see how many of you are online tonight given everything else that's going on in our world today. So we are experiencing an unprecedented situation at the moment with the COVID-19 panic and you might be distracted from tonight's webinar as lots of us have been making quick alterations to our lives. I'd like you to take a moment if you can to focus on what we're doing tonight. Step away from your distractions if you can. If it's not possible, we completely understand that. Don't worry, this will be recorded and you'll be able to watch it at any time that suits you in the future. So the purpose of this webinar is to give health professionals the skills that they need so they can more effectively help people in the future. Personal stories of illness are of course really important to the work we all do and MHPN often includes consumers and carers on our panel. The chat box is a tendency to connect with other people but we do ask you not to share your personal stories in this forum. It's designed to complement the panel and allow discussions of professionals connect with each other, share resources and experiences of practice. So I really thank you for respecting that tonight. If any of the content in tonight's webinar causes distress, please seek care for yourself. If you're a client from Beyond Blue at 1-300-22-46-36 or contact your local GP or mental health service. So tonight's webinar is covering suicide elderly and adults. I know there's a lot of interest from the hundreds and hundreds of questions that we've got before the webinar about other client groups including children and other vulnerable populations. There's actually a host of other webinars in the MHPN library that you can access on those topics and they're listed in the resources at the end of the webinar. Okay, so let's get going. You will have had a chance to see the bios of the panellists with material that's been sent out so we're not going to go through that in any detail because we want to get into it tonight. We are not sure if Dr Graham Fleming is going to be able to join as quickly as he can but I'm sure you can all understand given he is a GP in a rural location, he may well be caught up at the moment. So we will see if he's able to join us. If not, we will work with the two fantastic panellists. I'm only here. Oh, Graham, welcome. Sorry, everyone. No problem. Lovely to have you joining us. Graham, not giving you a moment to catch your breath. I'll come back to you in two seconds. I'll throw some questions to our other panellists to give you a chance to catch your breath. So I'm wondering, Tim, if I can start with you. You work in the ED of hospitals and have done for a long time and you've worked with lots of people who present with thoughts of suicide, either suicide attempts or self-harm. What do you think are the preferred approaches for responding clinically to those sorts of presentations? Yeah, I think with me it's all about a sense of connectedness and engagement. And I hope we can talk about that at length when we have our open discussion today. But we've done four studies now with calling people who have attended the emergency department and seen a mental health nurse in the ED. And the common theme that comes out of the four studies we've conducted is the therapeutic value that people derive from being listened to and understood. It's as simple as that. Fantastic. Yeah, and I hope we can dig into that today because I think that's a really important point. Dr. Lino Grady is also joining us from Victoria. Welcome, Lynn. Lynn, you've recently moved back to private practice. I was wondering how that might have impacted your understanding of working with clients who were suicidal, giving you work in this area in both clinical and research fields for a long time. Yeah, thanks, Nicola. I have just in the last few months returned to doing some private practice work or some direct work with clients. And I've done a lot of writing and study and training in the area of suicidality. So it's been really good to get back closer to the ground and I guess it's put me back into a space of having to deal with the issues that many of the people I've been working with are dealing with. So private practice is a pretty challenging space and really challenging at the moment. And what that looks like in terms of someone who presents with suicidality can be a very big responsibility and can feel a little bit overwhelming at times. But drawing on the things that we're going to be talking about tonight I think can help us to feel more confident and to be effective in that space. Fantastic. I think that's a really important part of the discussion we're going to have tonight. Thank you. Dr. Graham Fleming, welcome. So glad you could join us. As I mentioned, Graham, you work in a rural area. Are there any particular challenges or approaches that you use in this space? Yeah, I've got three essential principles I always go by. The first is rapport. And the second is rapport. And the third is rapport. So at the end of the interview I need to know that the patient left knowing that I know how bad they felt and that together we can find a solution. Fantastic. Okay, great. I look forward to hearing more about that as we go along. So just a last bit of housekeeping before I be quiet and we actually can get on with the rest of the content.  There's a chat box that we invite you, as I mentioned before, to enter your comments, sharing resources or ideas with your colleagues that are joining us tonight. If you have a question, there's a hand button for help. The slides and resources will be available and they're available for download from the download button. And if you need help, the lovely people at RedVac will help you out with any technical issues and so forth. So as we go through tonight, each of our panellists are going to give a short each five or seven minute presentation based on their work and their area of expertise. And then we will be opening it up for Q&A. We've had, as I said, hundreds of thousands of questions already come through. We'll take some as they come through tonight and we'll hopefully have a really productive conversation at the end of it. So tonight for the learning outcomes for today very quickly, we want to define the concept of risk and known factors associated with increased risk of suicide. We want to identify the needs of a person, very importantly experiencing suicidality, including assessment, risk formulation, safety planning and ongoing monitoring. And then lastly identify the importance of appropriate referrals and collaboration with other professionals when working with a person experiencing suicidality. Okay, so let's get going. We've already had the case of Nathan sent out to you, so hopefully all of you have had a chance to go through that. So we won't go over that again. So I'm now going to throw over to Graham in your own time to take us through your perspective. Okay, so one of the things that we need to know is that suicidal thoughts are very common. And we all have them. They're often transient and even recurrent. Sometimes we're in embarrassing situations. We wish we could turn into a heap of dust and blow out underneath the door. And sometimes we just feel life's just too hard and we really would like to escape. But most of us can put that off. But when these thoughts become constant rumination, intractable or intrusive suicidal thought, this calls for a mental health assessment of well-being and function. The suicidal leg flag on top of the iceberg of emotional and mental problems is a triad of symptoms of insomnia, lethargy and feeling cheesed off or as I like to say pissed off, which people identify. Doesn't matter who they are. As soon as you mention pissed off, they know exactly what we're talking about. So there are in actual fact three main components for people to get to suicidal thinking. The first one is a sense of object hopelessness and despair. The second one is there's a delusion that suicide is the only or the best or the easiest option.  And sometimes we've got to remember that people's brains are switched down and are feeling lethargic and they can't really get themselves organized. The big risk comes as they start to improve when motivation improves before the negative thoughts start to lift. Now, I'd like to address some of the things on that first slide, the sense of object hopelessness. And I come back to the fact that the most important thing is rapport. And if you don't establish rapport with an adolescent, you might as well refer them on to somebody else. Report is critically important that people know how they feel. The next thing we need to do is because the sense of object hopelessness and despair is there, we need to provide hope. We congratulate them on making the first step and opening up about their feelings and we can commiserate with them how bad they feel. And the next step is to promise them support. It's no good saying to them, oh, things aren't that bad because in their brain, things are that bad. And if you minimize the feelings, they'll think you don't understand. But what I'd explain to them is conditions of extreme stress or longstanding chronic distress. The brain shuts down and the mind is consumed by negative thinking. And although they cannot see solutions, there are always solutions. And together, we will discover them together. The second thing I want to do is provide support. In the case of a broken leg, you would at least organize pain relief, crutches and a fizz out until all is well. And it's no different from mental health when the brain is actually shut down or as it were broken, you will stay and buy them until the appropriate counselors or financial counselors or psychologists, psychiatrists. And in this case, Nathan's already found help with a clinical psychologist and we need to support him in continuing to do that and the GP can help to facilitate that as time goes by. The third thing we need to do is provide resources. Reforces the protective factors already present. He's got his sister that we can confine with. He's got parents, although the parents are a little bit standard-offish, but obviously they care. And when Nathan was concerned when his parents found him committing suicide, he actually responded to their concern. We'd also point out and give him the list of numbers of lifeline and other institutions around. For me, it's my number that I'm available. The hospital and rural areas are always trained to accept people. There's head space for adolescents. We can refer them to the black... beyond blue and the black dog on the internet so they can go and search through that. Sometimes we come across typical intransient patients and we have to explain you have a duty of care to keep them safe and you're going to stand by them until a solution or something is happening. Slide three, sorry, in your case it is slides, no, slide six. One of the things I want to point out to Nathan is that severe and acute stress or chronic stress causes a brain to shut down to such an extent that they can't actually think through things as well as they would when the brain was working properly. I explained to them the brain shuts down because the neurotransmitters cause a whole range of symptoms which I'll explain to you in the following model. The brain that needs to be retrained how to develop new strategies and the psychologist's will position to do that. For long-standing chronic stress or family history or mental problems, medication can often be used to help switch the brain back on a bit more quickly. I use this occasionally also to warn people about triggers which can make matters worse. In Nathan's case, this was a nasty email that he got from his girlfriend who told him to back off. It was really just a small straw that breaks the camel's back. We need to point out to him that over the background of things not going so well in a while, this was just another thing that happened. The other big problem is alcohol. Alcohol is in itself a depressant and a very powerful depressant at that. It also causes people to dissociate or do things that they wouldn't do under normal circumstances and probably 50-80% of suicides in this country have alcohol on board. The fourth thing I want to do is to explain my slide with the model on it. The model is about nearly 35 years old at least, and the only new things I've put on there are ACT and CBT and transmitters. This is a way I explain to people how the social arrangement and the psychological arrangement work together or the biological component work together. If we start with a model, in the middle of the model is a center called the Mood Center which sits in the brain. It's probably several centers, but it normally controls someone's ability to sleep. It controls their energy. It controls their mood, their motivation, their poor concentration, memory, appetite, libido, socialization, self-esteem, and stabilizes the autonomic system. That's our breathing and interjection and heart rate. So if people's brain shuts down, they can't sleep generally, or uncommonly they'll sleep all the time, but generally early morning, waking at 1 or 2 o'clock in the morning with a racing mind. They become lethargic. They feel cheesed off, down, frustrated, irritable. Their motivation becomes poor. Their concentration becomes destructible. Their memory is poor. The appetite, they can become picky eaters. Libido is lost. Socialization become withdrawn. The self-esteem is low. And the autonomic system starts going haywire. They get headaches, dry mouth, aching muscles, chest pain, palpitations, abdominal pain, any of those sort of things. And if you have a look at the model, it says that when those symptoms happen, you have chronic stress. Now chronic stress is also known to shut the brain down as will chronic illness, chronic pain, some medical illnesses, particularly thyroid disease, drugs such as alcohol, cannabis can all help switch the mood down. And now we can see a cycle which explains the downhill spiral of people getters.   Cut the million dollars and a week up the width some days makes people feel good. Acute stress in actual fact causes a surge of transmitters in the short term, but then they blow out and chronic stress comes in and that shuts the mood center down very quickly. Counseling, psychotherapy are helping and you'll also see on the CBT ADT as well. The final thing that I need to point out is the risks associated with suicidal thinking. It's often the suicidal thinking can come on exceedingly quickly without warning. And I've seen this happen many, many times. I don't know if anybody knows a story about Daddy Crawley. I was at a meeting with him in Clare and he presented a very good picture of suicidal thinking whatever he knew. He knew exactly what was going on. He knew exactly all about it and he explained to the people, a thousand people in that town all that day all about it and yet he still managed to go up his medication, didn't pick the signs and neither did the chairman of the Department of Psychiatry at Adelaide University or also committed suicide. So this can happen very, very rapidly and for that reason we need to be watching Nathan very closely as a GP and even though he's seeing the psychologist the GP probably needs to see him every couple of weeks or couple of times a week in the early stages to monitor the situation. I think that's about all. It's really important, I think, yep. So we might leave it there, Graeme, because we want to leave some conversation at the end, so thank you very much for that. I'm going to pass over to Tim to take us through his slides and his perspective. Thank you, Tim. Thanks, Nicola. Thank you all for chiming in tonight. It's great to see so many people on the list. I appreciate your time in these troublesome times. Before we talk about therapeutic approaches in the open discussion I was going to focus mainly on risk assessment practices, which at least in my experience in the public health system I've been working in emergency for 20 years now. There seems to be still a lot of faith placed in risk assessment practices such as tick box risk assessments, risk assessment scales and risk stratification. But I think this provides a full sense of security. Like Graeme said, I think it's important for us to view suicidal thoughts as a normal response to what are often very abnormal circumstances. And so suicidal thoughts are very common. The act of suicide is decisively rare, which makes the job for us of anticipating who will go on to end their lives extraordinarily difficult. Research that I already indicate that there is no evidence that are focused on risk factors such as whether someone has a plans or means for suicide, has any impact on circumventing suicide, and there's no evidence to support the clinical utility of categorizing people as high, medium, or low risk of suicide. 95% of people who are so-called high risk of suicide don't go on to end their lives, and the majority of people who do end their lives by suicide are in the low risk category. So even the Royal Australian New Zealand Colleges are conscious in their guidelines on self-harm that suggested that any form of risk stratification is not warranted for determining follow-up. So in the case of Nathan, we see that the GP referred Nathan to the psychologist with the idea that he was at medium risk of suicide, and I think, well, how do we determine whether someone's at medium risk of suicide? How do you make that call? Where do you draw the line? And for how long do you consider someone to be at medium risk? What's the use-by date on that determination? And as Graham alluded to as well, risk fluctuates dramatically. People can be acutely suicidal one minute and an hour or so later, that risk can be significantly diminished. The Australian Commission for Healthcare Safety and Quality recently published the Comprehensive Care Standard, and that process involved a massive scoping review of risk assessment management and practices across the whole of health, not just mental health, falls, pressure injuries, all aspects of health. But the commission determined that there's no really well-validated screening tools for suicide risk and no evidence of such tools are able to accurately predict suicide risk. The Comprehensive Care Standard also suggests that risk screening assessments have become a formality and that leads to really this over-gipplication of risk screening and assessment processes and poor patient experience. Oh, what's happened there? Some of you might have seen the UN Special Reporter press release in October 2019, which was around suicide prevention for the World Mental Health Day. And the points raised in that press release was that there's sufficient support for screening. Large percentage of suicides are actually not planned, but impulsive gestures. And we need to consider the context in which people often experience suicidal thoughts, such as drug and alcohol problems, trauma, loss, relationship issues, stress. They all compound the risk for suicide. And there's this growing body of evidence indicating that an over-aligned on pharmacological approaches, hospitalization for suicidality might be counterproductive and lead to an increase in suicide risk, where we should be focusing our attention on having conversations with people on how to transform their lives and how to recover from these kind of situations.  Sorry, it's Nicola here. Your screen's gone black, so if you could try and refresh... Ah, I'm doing it right now. Yes. Can I still be heard? We can, yes. The screen is on the Internet, I think. It's making things hard. Yeah. Fighting against Netflix, something. Yes. Here we go. We might keep going and we'll see if the tech guys can help us out. Yeah, I can see you guys. Look, I might do my last line anyway, and that's mainly about, I think, it's really important for people like Nathan to really acknowledge the stress of the situation and how this has caused him's great distress to normalise the situation without minimising it, so it's an understandable response to a really challenging situation. And with people like Nathan, I'm often saying, well, how willing are you to explore options other than suicide? Yeah, let's talk about options other than suicide, about self-care, not self-destruction, being connected with the world, not isolating yourself from the world, ways that people can maintain their health and well-being and ways of keeping safe. I've discussed with people all the time, how will you be maintaining your safety when you leave the emergency department? And I think people should always leave interaction with a health professional with some hope that things will improve. Great. I think we've got one more slide. No. No, I haven't. I'm sorry. Things are working against us today, but we've got your face back. Thank you so much, Jim. Hopefully for the second half things will go a bit more smoothly. So now let's hand over to Lyn from your perspective as a community psychologist. Thank you, Lyn. Thanks, Nicola. And hi, everyone. Good to be here. I guess when I was looking at this planning for tonight's presentation, I was putting myself in the shoes being the psychologist that Nathan's been referred to by the GP because that is something that I'm doing these days. And we know that it's really important to hear the story, to hear the person's story, not go through a checklist of things to add. So just to pick them off, we're actually wanting to hear the story. We're wanting to understand what some of the concerns might be, what some of the risks might be at the moment, how the client's thinking about the experience that they've been through, having a suicide attempt is major and we want to try and understand that as well. But of course we've only got a short time and a period of time to do that and we need to make pretty big decisions in that time. So what I'd be trying to do is I listen to Nathan's story and building the rapport, building that relationship and taking it seriously as we've heard about already, is trying to pluck out some of the most important factors. And I'd be thinking about the risk and protective factors that we know about. They're at a health model in terms of population level that we talk about in terms of the framework. But I'm still plucking them out to make sense of them. So we know some of the things that have happened to him recently. We also know how he's feeling at the moment.  He's feeling like he's hit rock bottom. He's 30. He's moved back after 10 years. He's lived with his parents. He has support from his sister but he's concerned about that in terms of the kind of role model he is for his niece, nephew. And he's worried about what people are saying about him and his masculinity and how he sees himself. So there's a lot going on in terms of shame and working out who he is and that loss of identity in all of this. We know that there's a historical aspect with personality around impulsivity that he's had longstanding issues with impulsivity and just taking although he hasn't had previous suicide attempts or if it's to actually harm himself. But we know impulsivity is one of the issues that we'd be concerned about and it really taps into what we're talking about in terms of being able to predict what people are going to do in their legal office and we really don't know. So impulsivity is a concern. Alcohol is also a concern. But the shame and the feeling, the feeling haunted in terms of nightmares is something I think is interesting and something we don't hear much about in terms of the trauma following the suicide attempt. It's not a lot of research or writing about that at the moment. So there's lots going on for Nathan. So we really wanted to build that relationship, give him a chance to talk about what he's experiencing and then gathering this information through that process. And as I said before, working in private practice, you only have this short period of time and you may have other clients lining up outside. So you have to manage this and be able to pull out this confidence and most important features of the story. One of the things that I thought was really important and through some of the training and some of the work that I've done with consultants and consultancy with working with and training with other mental health professionals is our confidence around this is not great, I guess. So I've plucked out some of the things that I'd be thinking about as a psychologist sitting in the room with Nathan. I'd be having lots of these thoughts that are probably a bit panicky, potentially, and a bit unhelpful in terms of feeling confident and giving that confidence to Nathan and the hope to Nathan that we're going to be able to work through this. We're going to be able to come up with some ideas and helping going away, feeling heard and hopefully with some hope. So there's a lot that you're trying to do in this short time. So some of the things that I've listed there in terms of some of these typical kinds of thoughts that I've heard people talk about and I've experienced myself. So the whole question around risk is, is he at risk? We can't talk about the level, but we do need to identify what we're going to do in terms of his needs at this time. So we need to be doing some kind of assessment. There would be an expectation that we have questions that we've asked and that we have documented. So it's really important that we are assessing what's going on for him at this point in time. We also need to recognise that he probably won't be telling us everything, that we know that clients can come and see a mental health practitioner or another health practitioner and not tell them everything. And I certainly have clients who come to me now and tell me in the third session around their suicidality or their thoughts that they have from time to time and they didn't tell me that in the first session and they weren't necessarily having high concerns around that, but it's something that's fair for some people. So they won't always tell us everything straight away. We have to build the trust before they can do that. So we have to expect that there's perhaps some other things going on that we don't know about. I might be questioning whether I'm the best person. I would be wondering about that, but I'm the person in the room at the time. They can do something at that time. And I need to be really feeling that I can actually do something to be helping him and to not let him give into that hopeless kind of feeling that I can sometimes be feeling when I know the stakes are pretty high here. We don't always deal with life and death when we're studying psychology. It's not something we talk about very much. So I really need to be aware that this is something I need to be able to stick with. I need to have a level of comfort with it and trust myself and trust the process of safety planning and gathering information and building relationships that's actually going to enable us to be able to work together. I'm going to be feeling like I might have missed something. That's one of the things I hear about all the time and I appreciate that. Could I have done something else? Did I do everything that I missed something? And we have to learn to be able to stick with this and that's quite challenging. One of the ways that we can kind of use or I guess a model that can help us is risk formulation. This comes from a paper that came out in 2015 by Persani and some others but the reference is there are new resources and this is a way I guess that we would formulate all that information that we're gathering. So bearing in mind we've got this short time we're getting the story, we're getting lots of information. Some of it is to do with risk. Some of it is to do with protective factors. Some of it is static sort of risks that we can't actually do much about and some of them are more recent risks that we might be able to work with. We're looking at the status in terms of what's actually going on to this person compared to other people. We know that being a male, being impulsive, a relationship break down these are some of the things that we hear about that create a real concern for us. But we're also hearing some of the protective things that are possibly there and some of the things that might be okay that we want to build on those and we want to be really working towards what else can we add into the mix? What are the available resources that we haven't perhaps tapped into yet that we might want to do that? And we might want to get a bit more information so that we do understand and check that we're not missing some of the most important things that might be important for us to know. Importantly, we need to understand what matters most to him and some of that's going to come through in the story that he's told us, some of it's going to come through in the things that he's lost. It's the loss of identity, the loss of this relationship and the way that that happened. He's devastating to him and devastating to his sense of who he is and that shame that he's feeling about this whole process. So we can unpack that in a way that helps us to understand what is important to him and how can he still see some of the things that are important. How can he reclaim some of those things? And it might be through the conversation with him and asking some of those prompting questions that don't dismiss how he's feeling but help him to perhaps re-look at things again because they're the things that we want to be building in. We want to recognize the importance of family and friends. We know that he's living back at home again and we know that the parents, you know, that's quite a challenge for him. They are there. Mum's pretty impacted by what she's seen and we need to make sure that they're getting proper support as well. So Beyond Blues you have a book that's available to download which is really important but we do need to do some more work in terms of supporting family and friends because even if you engage as well with a mental health professional and comes to appointments he's still going home and he's going to be with his family and hopefully with his friends. So they need to know what to do as well so they don't unintentionally do anything that can be damaging or harmful but also that they have some support around what is a really difficult time. So we need to do some more work around that but that resource is available. And finally the best tool that we have or the best thing that we can do is to really focus on safety planning and Beyond Blue also have an assets available online called Beyond Now and it's based on the safety planning work that's jammy and brown did in 2012 so it has a reasonably solid evidence base. Some of it's been looked at in emergency departments with different populations so it's the best we've got at the moment. So it's really focusing on pulling out all of the information that we're getting through the story and incorporating it into a safety plan that's done collaboratively with the client and this is what can help us to manage that have we done enough have we put some things in place and this is a plan that we could be seen declined away with and then really look at again next time they come back and if they don't come back at least they've got something because that's the other thing that happens. People who have had suicide attempts and are coming and we know for Nathan because his parents kind of told him he should he may not want to come back and say you have another time to talk about this stuff if he doesn't want to. So we're giving him something at least to go away with and all the information we've been gathering this is a place for us to put it there and to work with him to develop up a reasonable plan around some of the triggers some of the means that he had talked about making sure that he's got some reduced access to those. It's difficult to get rid of all means but for someone who's impulsive it's really really important that there's distance between him and his thinking and him accessing means to harm himself so that's really important. Talking about alcohol be really important we know alcohol comes up in the data now the Australian Bureau of Statistics has data looking at psychosocial factors and some of the other information we haven't had before and alcohol comes up there. So there's lots of things that we can flag with Nathan there are lots of things that we can help him recognise and we can draw on some of the ways that he's coped help him to recognise some of the support that he might have the people that do care about him that he hasn't identified yet people that would want to know and be there for him if he's going through a difficult time and then of course the phone numbers that we've already talked about as well so that there's always someone there if it's not someone directly it's someone on the phone line so really important messages for him to go away with a plan and some hope that comes with that that's really important that can be built upon. Thanks Nifla. Thank you Lynn. Okay, now we've got a nice amount of time to have a Q&A with our panellists. I've got lots of questions coming through as I said I've got hundreds that came in before the webinar but one of the things I might throw to you first Kim if I can I think one of the things that came through very strongly in the questions before tonight and I think will be in people's minds tonight is can you help us make the distinction between risk assessment and safety planning and what that actually looks like when you're sitting across somebody such as Nathan? Yeah, kind of as Lynn alluded to we consider risk factors but the emphasis should be really on addressing individual needs assessing what people's needs are and being collaborative as Lynn said in terms of coming up with a plan of one of the next steps. So I think risk assessment is a little bit more mechanical whereas safety planning and needs assessment is more collaborative and is working with the person. Fantastic, thank you. And Graeme are you still on the line with us? Yeah, I'm still on the line. Hi Graeme. I was wondering if this is a question actually for all three of you but I thought we might start with you Graeme and talk a little bit about the process and the interactions that people like a multi-disciplinary team such as yourselves, how you might work together. So if you were the GP in this picture how would you see yourself liaising with someone like Kim in the emergency department and Lynn as a treating psychologist? What's the kind of relationship that you think works well in terms of working collaboratively for the best results? And that's the real fact in the real area you don't have access to a psychologist you might have access to a counsellor but that doesn't occur very often either. I probably would relate again to a psychiatrist but it's going to take you three to six months to get an appointment. Basically what I can't handle doesn't get done. I do have seen people off to psychologists but again I'll send them off with a referral letter and then three to six months later I'll get a letter back saying what they've done. Normally I send people off to psychologists to do some intensive ACT or CBT therapy and I guess that's going on. I'll come back with a report later on but from real areas it's very difficult to access anybody else. And that was just at the beginning so I've got to really establish a good relationship with people first off so they keep coming back and I can continue providing support. It's really difficult to access nobody in the regional hospitals want to know about them. It is difficult. And going to picking up on that how do you get somebody to come back? Are there particular things that you have found or success with in terms of engaging people that are often reluctant to come back? As I said in the beginning I really work very hard at establishing rapport at the beginning and really saying that I understand how bad they feel. I want to help them get better and I usually explain in terms of the model of how we're going to work to get things back together again and how we're going to switch the brain on. And I tell them that I'm the broken leg and their brain isn't working properly and we need to get that working properly and I use those nine things like poor self-esteem and not sleeping let the disease or all signs that the brain isn't working properly and we need to switch that back on by whatever means we can. I do psychotherapy as well and I use bits and pieces of CBT but in the time frame I've got I don't have any other spend with patients but I'll make sure they do that. Thank you Graeme. What about him? I was wondering if you might be able to weigh in there around that collaborating with other practitioners. How does that work for you? Given how busy you are in your clinical role? No, it's fine. I mean we often have people who are sent in by their private psychologist or GP into an ED for an assessment of someone's safety and that's okay. I tell patients all the time that the ED is not a necessarily comfortable place but it's a safe place and we never close. You're welcome back anytime if you don't feel safe. I also think there's a real emphasis on us being therapeutically positive with people in that collaborative way sending people the message that we will work with you to fix this and I think therapeutic optimism is very powerful and that's what people often looking for is some reassurance that with the right kind of support that this can be beaten. Graeme's right though outside of the metropolitan centres the resources for people in mental distress taper off quite drastically same with drug and alcohol services so I think that's our biggest challenge is how to meet the needs of people in more regional and rural areas. We've got a couple of questions about that as well but I might just throw to you Lynn if you don't mind about the interactions in your experience and the importance of interactions between general practitioners and other practitioners when working with somebody who may be experiencing suicideality. I think it's really crucial and it comes to that point of being you're only feeling like you're the only person that's there and that weight of responsibility and I guess the privilege that people come and talk to you about it but it also can feel like a huge responsibility so feeling like you're sharing that with the GP and I work in two practices in Melbourne's metropolitan areas and I'm still developing because I'm still quite new to the role but developing relationships with GPs and getting referrals and being able to have some conversations and reporting back to GPs so I'm looking to do that some more. I've also had some experiences in terms of people when they have used their safety plan and have gone to an emergency department and one of those suggestions on there and have had some contacts in the emergency department on discharge to let me know that they've been there so the client has said that I'm their treating practitioner and then I can follow up even if I'm not planning to see them for a while I can at least follow up with a phone call and have a conversation and check where things are at and what else we might need to do and if there's anything else we need to put in place would be one of the things that I'd be wanting to talk about. It's crucial that we do work as part of a team. I just feel like we don't always have enough even in the metropolitan areas. We don't have enough options so if somebody is critically in need and through our conversations, Nathan was saying that he did have some intent and wasn't going to be able to be safe and keep himself safe well then you would need to put something in place for me a CAT team or emergency department but if the other sort of extreme of that that there's no immediate need or if it's not something that you can feel like you can do that with apart from the safety plan there's not a lot of other support that's there at the moment and I know around the country there's various models and pilots and things happening in cafes and things like that for people to go to as an alternative to the emergency department but some emergency departments won't see people who if you turn up and need to have some support around their civil fidelity so they can get hunted off by the hospitals as well. So there's significant gaps in the system still despite what we've known and despite knowing this for a really, really long time and despite a lot of funding and a lot of talk and knowing we need to do something differently you can also feel a bit isolated in terms of doing this work so it is important that we connect and have good peer consultation, supervision people that we can talk to and good planning for ourselves to look after ourselves in this space and try to collaborate wherever we can I think is really important. Okay, thank you, Lynn. I'm going to pick up on a couple of those points. I'm not sure, Graeme, if you're happy to chat about this or either of the other panelists have experiences and a couple of questions from Leslie and also from Sarah around the role of telehealth and what role that might be able to play in supporting people who may be struggling with thoughts of suicide so have either of you had any experience? We use telehealth quite a bit. Basically, we use it for acute patients that are not so much suicidal but as I say, suicide is really the top of the iceberg of an underlying emotional disorder and sometimes we will use a psychiatrist or an adolescent children's psychiatrist or adult psychiatrist and they will spend an hour teleconferencing with a patient more often than not, I'll sit in on them but if I'm consulting a lot of things to do we get a nurse to sit on them and that is a very useful thing to do often they'll give me a different perspective of where I could be going or where I should be going the problem is that the next time you ring up it may be a different psychiatrist seeing the same patient so that becomes problematic as well It is a very good medium but it is not as good as face-to-face Yeah, no The difficulty is that face-to-face well, none of us can do face-to-face at the moment in the foreseeable future to a much lesser extent so we're going to have to keep being creative as people's pressures increase I wanted to touch on something Lynn brought up and I think maybe Tim I'll throw to you first and then over to Lynn around the impact of this work on clinicians themselves there is a lot of risk-holding that clinicians do a lot of anxiety around doing the right thing as Lynn mentioned Tim, have you got any advice or tips to share around self-care and what's really important for practitioners to have in place when they're working in this area? Yeah, it's a really important issue isn't it and I think Lynn and Graham have addressed that too being isolated practitioners in private practice or in GP clinics you can often feel like you're carrying a fairly heavy burden of risk on your shoulders and it's quite understandable you'd want to have another opinion and people share that risk with you so I think in terms of self-care well I always say that we're not mind readers and lie detectors or fortune tellers and there's only so much we can do to kind of keep people safe my work with people is on emphasizing the need for people to keep themselves safe and that's not taking away my responsibility but it's emphasizing that I can't follow people around all day to keep them safe and so I think in some ways we've got to realise that we can't control the uncontrollable but we also need to really take extra effort to care for ourselves and ensure that we have appropriate supervision or opportunities to discuss certain situations or scenarios with a colleague that we have supports in place through professional networks like this to discuss this heavy issue Thanks Lynn, do you have anything to add to that? Yeah, look I was just reminded of a day workshop that I did last year which was held by Living Works and it was called the Suicide to Hope program and a fair bit of that was about the practitioner thinking some of this stuff through so like I said earlier we don't tend to think about doing psychology or other mental health work as being life and death in a way that a nurse or a doctor might so this training actually got us to think about what are our perspectives around this and what are our own experiences as death and experiences that we might have had in terms of suicide and understanding where that might come from so I think there's a place for more of that kind of training and probably being built into actual coursework rather than having to do it later on but I think there's a real need for that that we actually sit with some of this and then can feel really a little bit more prepared for that and ready to hear the stories and to be able to sit with it so there's a lot of sitting with it there's a lot of trust that things are going to be okay and I agree about putting the responsibility with the client in terms of how are they going to keep themselves safe but of course we're in that space and if something doesn't go right then we'll be called upon to answer what we did so I think another important part of it is the documentation and that we can actually justify the decision that we made needing to be able to document well to show that we have asked questions and that means not shying away from a question around whether a person is feeling suicidal whether or not they have had suicide attempts or other times when they've thought about it we don't know what shifts people from a thought around suicide which we've said is very common into an act and then actually dying by suicide there's studies trying to understand that and of course there's no simple answer it's really complex and multi-dimensional so trying to understand it is difficult but as long as we can document that we've actually been through a process of asking the questions, documenting what we did and then the decision making process that we went through and the steps that we took and the safety planning and advising anybody else or keeping in contact with people if we need to then I guess we can take some confidence that we have done all that we can and that is a really important kind of feeling I guess to sleep at night or to feel that we have done the best that we can and to have supervision and talk to people about it and talk it through and that's some of the work that I've done with people has been just hearing that and for them to get to a point as a practitioner that they feel like well I did do those things and I have done it and I keep learning and these kind of feelings that we have can drive us to keep learning about it one of the drivers I guess for me to study suicideology is that because it is something we need to we need to keep learning and understanding and trying to continue to do better Thanks Lynn, I think it's a really good point I mean I think we all chips off the tongue very quickly that we need supervision and note takings important and those sorts of things but I think sometimes it's worth pausing as you have done now to say that the reason it's important to document it's obviously a requirement we also need to have containment in place sorry my dog won't go out we've had a number of questions about working with patients that have chronic suicidal thoughts it's funny if anybody wanted to take that up and see if there's a different approach to somebody who may be or does continue to struggle with thoughts of suicide on and off often years and years at a time Graham have you got any thoughts on is the approach any different or are there strategies that kick in there is that different from chronic depression what's the crossover of some of the questions coming through I think one of the things you'd be looking for is why are they getting these recurrent thoughts and some people just tend to be focused on recurrent thoughts and may not be suicide it might be something else it might be their mother or it could be anything I think you get to a stage where once people start using suicide often people use it as a tool as well you just try and deal with the underlying mental situation that's going on at the present time tend not to worry too much about the suicidal thoughts except to tell me that there's still a lot of problems underneath that top of that iceberg that we need to get to and deal with and sometimes a psychologist is very good at getting down to the bottom of that finding out what's going on on the ground that they've got more training I guess but they've also got they tend to spend an hour with a patient with a limit to 15 or 20 minutes someone's desperately unwell now thank you Lynn or Tim do you have any thoughts or anything different that you do with people that you may be working with over a long period of time or Tim that you see a lot returning to the ED? I've known people who have been suicidal for 20 years and again it's just evidence of just how difficult our role is in terms of circumventing suicide and these are people who have obviously had very challenging lives and we have to accept that people hold life with different value than we might and that's kind of understandable that people would contemplate ending their lives if they've had pretty difficult lives from the time it started and as with Lynn said with documentation I'd be documenting those kind of things that this person constitutes a long-term risk of suicide given the traumatic and adverse life they've had so I'm often documenting those sort of things I remind them that they're welcome to return at any stage I often will document things like the person has agreed that they'd rather live than die despite how challenging their situation is but yeah I think we have to accept there are a certain number of people who carry that question of whether they want to live or die with them for the long-term and I think we have to also society has accepted this that the only person who can prevent a suicide is the individual contemplating it Thank you Tim, Lynn I was wondering if you had anything to add in terms of working clinically with people who may be experiencing these sorts for a long period of time Yeah and I think it's probably more common than what we would know or would like to think about I think the other sort of consideration in addition to what others have said is that sometimes talking about suicide or sharing that can be a way of communicating the stress so it can also become a way that things are really bad and I'm not suicidal again or I had the suicidal thoughts again so I think it's trying to understand it, understand the meaning around it and trying to understand where that sort of language when it first started when does it come, when does it go so even some of the narrative therapy externalizing kind of stuff might be a long way of looking at it but I think there's a risk also that we can get a bit thinking that they're always like that or for some people around them perhaps to be thinking it's attention seeking which we sometimes hear they just say it, they just want attention you know the counter argument to that is pretty awful that people have to talk about that in terms of getting attention to get some news or get people to listen to them so we sort of have to be ready for that but I think we've still got to be ready for any changes in that so if somebody does often talk about suicidality we still need to be asking some questions whether this is different or the same as the other time because we've still got to look to see whether or not there's any change in that so it's quite different to a person with some kind of suicidal thoughts and what that might mean but if someone has had them forever we can't just assume that it stays the same and that they're not sort of at more risk than a person more or less risk than a person who's just sort of talking about it for the first time so I think it's complex again people trying to study it to look at it to try and understand it and I think we've still got to keep doing the same work around how do we build the protective factors in safety planning we want to give the message that their life is important and that we want to help them find some ways to be feeling better within that but they do have to be the ones working with us in that so I think it's complex and really demanding as well for practitioners doing that but to keep working out and look for any kind of changes that are happening I think it's important to validate the feelings are real and they're part of the person as well when they're coming and going or getting worse at different times I agree I think feeling suicidal thoughts as a symptom of distress and understandable symptoms of the stress is a really healthy way of working with people and it can be a bit habitual for suicidal thoughts to be a manifestation of people's distress but I think approaching that with some compassion and a non-judgmental perspective can really be really helpful Thank you. I think there's a lot of questions before the webinar around that have kind of broad how can you tell how can you tell if somebody is really suicidal so I think there's a lot of people there that struggle because it's such a difficult topic to almost try and make that distinction where what I think I'm hearing you guys saying is that we need to treat each time that somebody is committing their life or suicide or self-harm as a distinct episode and take the time as much as we can with all of our constraints to take it seriously and empathetically rather than the proverbial eye-rolling if we've heard it a few times before and wondering where it's coming from I mean, I've been up front with people and not blunt but I'll say to people, look I'm sorry mate but it puts me in an uncomfortable situation if you're starting to use suicide as a way of bargaining it's not really healthy for us to have a relationship when suicide becomes a bargaining tool you know, I want to hope you come here because you'd rather live than die and because I can be really helpful to you if that's what you want to do I guess I am sometimes quite avert in putting it out there with people who have habitual ways of expressing their suicidal thoughts and it's not being eye-rolling or cynical it's about being quite up front with people that you know, I'm really willing to help you but I want to talk to you about life not death That's great and I'm just wondering if that feeds in Graeme a bit about what you were speaking about earlier is if you're dealing with people whose brain has somewhat closed down as you said they can't think as flexibly as they can when they're not depressed sometimes we have to be a bit more concrete or up front in our questioning or our conversations with them that's not being cold or not being empathetic but being a bit more pragmatic with people probably by the second and third consultation with these people I'd actually go through this bottle with them and I'd explain to them that model I think it works very well to tell you how social and psychological factors will switch the brain down and how if you've got a biological problem it'll actually produce the social and psychological factors as well and patients actually appreciate that and can see that I'm quite up front about that but I just I actually don't use the word depression because I really see anybody with depression but I see people who are pissed off about absolutely everything particularly adolescent so I use that I will go straight in and say look and I did that just on Friday so to somebody you know your brain is shut down it is not working properly that's the reason you can't sleep it's the reason you have good energy it's the reason you can't get motivated and I go through those nine things and all of a sudden they say you do understand me and then we work through and it just depends on how switched down I think they are on counselling or whether I'm going to use some medication and often if they are really badly switched down I'll use some medication and then when their brain is working better I'll then take them further down that road of looking at themselves and looking at other strategies of dealing with their brain being switched down and dealing with the negative thoughts because people who are suicidal have no capacity at all to think positively that's great thank you we've got a couple more minutes and we've now got over 1300 participants online and I know it's been a bit tricky so thank you all for joining I hope you've still been able to get some of the great advice and expertise that the panel are offering. Lynn just before we wrap up I was wondering there's a lot of questions around inclusion of people within your patient or client's life so family members and so forth have you got any tips around engaging family members or when you do it not to do it when working with somebody who is expressing thoughts of suicide? I think it's really important but it's also really challenging so we're in this space of having to maintain confidentiality if there's no kind of obvious high need at that particular point in time. I mentioned before the resource beyond blue booklet that I think is useful for people to have but I think the idea of bringing people around the person so social support is really really important and it seems a bit strange at the moment talking about that when we're talking about physical distancing and what that's going to look like in the future but just as practitioners that can feel alone with the person I was going to say young person but any person who's suicidal can be feeling alone with that so the more support we can bring around them but equip them with it and there was some research that I saw about young people in America that did show that young people who could identify some adults in their lives and those adults who received training did a lot better than young people who couldn't identify any people or there weren't people around them who'd had the training so it wasn't just identifying people that can be there for you but it was also those people knowing how best to provide support so I think there's a lot of room to do some more work around that and to really try and help families know what to do because sometimes the best intentions can actually be unhelpful or seen as negative or not helpful to the person who's impacted but we have to work within our bounds of confidentiality we have to respect the person's decision in terms of who they tell but I think we have to keep sorting it in in terms of the safety planning and who are the people you would talk to who are the people that you would go to so they're quite different things who are the people you might chat to to feel better but who are the people you would go to when you're feeling down and needing some help and getting closer to that risk of suicide and then who are the health lines that you could call and how would you do that so I think there's various layers and I know from some of the work I do with psychologists working with people after suicide attempt that those people who don't have social support around them are the ones that the practitioner feels stuck with and the person gets stuck with so we know and we're hearing about it all the time now around social support and risks of people feeling alone so identifying family and friends who can be supportive but then identifying that we have to support them to know how to provide that support so I think there's more work we have to do but I think it's critical and I think we have to get to that somehow and manage the confidentiality constraints that are there and work with a person to help them see the benefit of it and help them to see how we could do it together perhaps Great. Let me hear. Yes. I've discussed particular with adolescents parents or other people that are supportive and keen I'll actually bring them in and discuss with the adolescent or with a patient what we'll discuss and what we won't discuss then we'll have a joint discussion with the patient and the carer there and often each knows what the other has been told and that's a very useful way of dealing with that it's really helpful to get there as on board I think I was going to throw to you Graeme actually I was just wondering that particular challenges in small communities, rural and remote communities around confidentiality, people knowing each other, do you find that that's a benefit or an extra challenge in these circumstances? I might have a challenge in my previous think where 40 years I was known as the mental health doctor so people coming to see me people are wondering so you've got a mental health problem and that wasn't always true I'm now the solo GP so people have no idea what they're coming to see me about so it's a bit different but I think hopefully in my towns I have made mental health understandable to the community so don't think it's as scary and I don't think that this takes for mental health as long as it is in some centers I think people are beginning to understand it and be comfortable that some people need help and I have people, even rural men coming in and saying doctor I'm stressed I need some help and that would never happen It's fantastic, it's hope it continues because there's a lot of people out there under a lot of stress at the moment and it doesn't seem to be going away anytime soon and it's going to get worse Yes, financial stress is on top of everything else that we've got going on while I've got you there Graeme I might just give you a couple of minutes and we'll sum up and reflect on what we've talked about tonight if there are a couple of key messages for the people out there watching and listening about working in this area what would it be I think the first thing is as I keep saying establish a rapport find out what the underlying problems are and find out exactly where the patient is in their Medley Hall status how functional are they and those questions they ask people tell me they're functional and state and then promise some solutions and keep following them up I really don't have people coming, really don't have people coming back when I say I want to see you in two days I want to see you in a week I want to see you in two weeks if you get that rapport established initially and you're going to help them through they'll keep coming back because they want to get better too. Thank you. A couple of key points for people to take home Yeah like Graeme said a rapport a human-to-human connection some empathy and understanding but also a focus on people's abilities their assets their positive intentions there's coping skills what's worked for them in the past and their future hopes Thank you very much We've got Lynn a few more minutes for you to wrap up as well Okay I think be ready that you're going to if you're working with people you're going to be coming across people who are at risk of suicide and don't be surprised by that and expected and be prepared to ask the questions about it and then trust your skills so just listening to rapport building and the problems that people bring that are leading them to suicidality are also the problems that you deal with with people all the time it's what you do if you're a mental health professional and you're doing that so trust your skills but keep learning as well so keep up-to-date follow people we've given you and the resources some suggestions and starting points for that so keep talking about learning keep keeping up-to-date with it but it's something that we do need to we need to be ready for and be prepared to sit with and hopefully tonight's given people some ideas of how to do that thank you Lynn. I'm just wondering as we wrap up we're moving into some uncharted territory around access and mobility and connection and so forth I was wondering just as we finish if either of you talked a little bit about it before about social distancing Lynn has anybody got any great ideas around how people can stay connected checking in with people or comments that they're worried about as we move further away from each other physically that's right last curly one into you I've been thinking about it a lot and I think we've got to be really valuing technology as much as it's really interesting how the tide is turning we've been critical of technology and some of the dangers and how it's impacting but now it's what we've got if we think about other times or other decades, centuries ago when people were in situations like this which was really a long time ago it was a very different life so we know the dangers that is isolation and people in quarantine we know the dangers of loneliness and we've been hearing a lot about that so we know there will be people at risk and people who are going to be extremely anxious I've been watching my interest in children I've been watching the stories and the discussions around closing schools and I really worry about kids at home and families and the pressure on families and what school gives people and that's all workplaces and a whole lot of places where people gather is where we get our our connections with each other and that's really important for our mental health so there's huge risks out there but we do have technology that we can probably be more creative with and really embrace and that's probably what will get us through as long as we are cautious as well and that will be interesting to see how that does play out but yeah it's very interesting times but pretty challenging that's for sure Tim or Graeme you've got any other last thoughts on that? Yeah I think social media can be helpful Twitter for example, lots of people I see on Twitter with a history of trauma and suicidality connect by Twitter I saw a guy last year, late last year who used to do a lot of blogging he was a guy with suicidal thoughts and he often found it really positive when people respond to blogs that he sent out on this blog site that he was on found that really reaffirming that people would actually take the time to respond to any of these blogs Great, all right we need to wrap it up now, that is fantastic thank you everybody who've dialed in and stuck with us through the technical difficulties to all the fantastic panellists that we've had there is a feedback exit survey that we would love you to complete obviously you can let us know anything that didn't work so well but also anything that was helpful or what else you might like in future webinars we do have a webinars coming up, MHPN Emerging Minds part of the National Workforce Centre that I'm a part of the 23rd of April on trans and gender diverse children and their families which will be fantastic I've seen a lot of their resources and they're great we have a webinar on Children by Grief coming up as well and Aboriginal children and the effects of intergenerational trauma so check out the MHPN schedule we hope you can join with those so finally MHPN supports the engagement and ongoing maintenance of practitioner networks where clinicians from different disciplines meet regularly with other mental health professionals and share tips and resources to build pathways and engage in CPD activities so the network meetings at the moment however due to the COVID-19 situation are mostly suspended or postponed so please check your local networks to see what's happening with that you can also indicate your interest in that in the exit survey and before I close I'd like to acknowledge people with a lived experience and carers of those with a lived experience with mental illness in the past and those who continue to live with mental illness in the present everyone for their participation this evening I hope you can all stay as well as you can and look out for each other thanks very much for coming on tonight