Hello everybody and welcome to this webinar from the Mental Health Professional Network. I'd like to start by acknowledging 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 the Elders past, present and future and for the memories, the traditions, the culture and the hopes of Aboriginal and Torres Strait Islander Australia. So the acknowledgement of country is always important but certainly tonight with our topic being about whether we are ready as practitioners to make our services available to clients, patients who are Indigenous Australians. So I'd like to welcome everybody here tonight. We've currently got 638 people and rising logged into the webinar and also to people who watch the broadcast or the broadcast later on. So welcome everybody. Now I'm Steve Trumbull. My role here at the University of Melbourne where I am at the moment is as Head of Medical Education. I'm a GP by training. The only clinical work I do these days is to go out for a couple of months each year to remote communities in the Northern Territory as a GP but my main work here is the university. We've got a really good panel tonight to help us through the discussion. It's going to be a little bit of a typical webinar in that we're not going to follow the slides and to have a sort of slide driven presentation. We're going to learn by discussion and conversations tonight and also by responding to the questions that you ask through the question part on the webinar app. So we'll come to that in just a moment before we do that though and because we don't want to waste time going through everybody's bios in great detail because it's a fascinating group of people. I would like to introduce though our first panelist is Dr Lewis Peachy who many people will know. Lewis is a rural journalist from Atherton in Queensland. Welcome Lewis. You know. Good. We've got you there. That's great. Now we're going to jump straight in the deep end of this. There was some criticism of the webinar on Twitter during the week which you responded to. Some people felt that the title that we'd chosen was maybe inappropriate. Do you have what it takes to engage with indigenous people? What are your thoughts on that? I must admit I do find it interesting that people would get upset about a title without actually knowing what the content is but you know Lord Love them that's okay. I think part of the title was somewhere between ironic and facetious. But that was a little less based on the experience that a number of us have had working with non-indigenous health professionals who end up being very concerned about their ability to engage indigenous patients. And so we asked the question a little facetiously in a sense. And you know the short answer to it all is well if you're capable of some thought and empathy then you're probably qualified. But it was just it was basically calling out the elephant in the room as to how much people tend to be frightened about the topic matter. And certainly my experience in talking to non-indigenous health professionals is when it comes to mental health there tends to be just an extra layer of concern about dealing with indigenous patients. So I guess I think some people might cover people. Absolutely. So the Elephant's Frightened Centre which is the best way to deal with an elephant so we will examine it closely during the course of the webinar. Our next panelist is Dr Geoff Nelson who is also from Queensland a psychologist by training. So Geoff welcome from Cairns anything you'd like to add to what Lewis has said. Just quickly I mean I quite welcome the comments on Twitter even though I'm not a Twitter person. But also too there's that sort of whole conflict between or sort of difference in views about if it's about being culturally competent per se or being professionally efficient with indigenous mental health clients. I think those two things are worth talking about as you know is one is A necessary for B and can you have B without A. So look the more commentary the more people talk about it even though it may seem negative. Let's find out what I figure. Okay great well thanks for that. So we'll now meet the third member of our panel who's Dr Mary Emmaus. Now Mary you're also in Queensland you're on the Gold Coast. Lewis and Geoff are both Murray men you're a non-indigenous health practitioner. From your perspective what are your thoughts about what Lewis and Geoff have already said. Yeah look I don't really have much to add. I don't like upsetting people and you know I suppose I've found the title a bit odd as well to be honest but then I just and I felt a little bit nervous about the webinar which I don't usually do. Maybe because I'm on a panel tonight rather than facilitating. But then I thought you know I'm actually I feel really safe with Geoff and Lewis and so I don't really have anything to add on this one. I'll contribute more later. Absolutely and I think you've identified that the facilitator's got the easy job in this. It's the panelists that do all the heavy lifting but also the audience we definitely want to hear questions from people involved. Those of you who have been to MHPN webinars before notice that the platform's changed. The webcast platform and most of the navigation buttons you're going to need are located at the top right of your screen. So please have a look up there you'll see that you use the chat box and there are a few people using the chat box at the moment. There's the purple button there. If you've got questions use the blue hand button to enter your questions. I don't think we have any questions yet except Leslie can't hear anything so hopefully we'll get more questions as we go. And also the slides and resources and Mary's discovered some more resources that we'll put up towards the end of the webinar. You can get those through the light blue download button that's there. There's also a help button if you need assistance and red back of the conference providers. You can message them directly or ring the number that's there if you need to get in touch about any problems. So we'll get into the meat of the webinar now and you've had the case circulated again. We won't read through the case in detail. It's a little bit different again in that we are not looking so much at the needs of a client or a patient. We're looking at maybe the needs of the practitioner through this case study. So Sophie is a 27-year-old general practice registrar and you've seen that she's met with a patient, Jason, who she's seen a couple of times. She's now going to talk to her GP supervisor who is a very wise and slightly professionally advanced rural generalist GP. I don't know, Lewis, does that sound familiar to you and do you have you met Sophie's in your career? Yes, I have actually met a number of Sophie's in my career. What would you say to Sophie in this situation? I think I first said, well, I think you've done a good job here and the fact that this young chap you've managed to engage in and he's coming back to see you is already a very good start. I think typically my experience has been that these lovely young folk will wonder about whether or not there's particular cultural or social niceties. They'll be worried about making various pro-powers. They'll be worried as to whether or not there's something substantially different in dealing with mental health and indigenous patients or clients. And I suppose the end result in mental health is really the same across I think the entire species. I think the substantive difference that you're going to get in particular cultural groups, particularly indigenous groups is it might be the specific stressors that people are unfamiliar with. So how somebody responds to stress, how that might affect them spiritually, mentally, physiologically, I think that's all pretty much the same throughout the species. But the thing that might be the top 10 stressors on your list could be very different. On my days with Headspace it was one of the issues that we were having with a bit of software which was programmed beautifully for a lot of essentially urban-based non-indigenous kids. And they looked at the main stressors and the main stressors that a lot of the urban-based middle-class kids were having would probably not make the top 50, maybe not the top 100 of a lot of the Aboriginal young people that were coming on to Headspace. But how people respond to the stress, how it affects them, well that's pretty much the same. And in terms of having that therapeutic relationship, again it's all pretty much the same. There isn't a great deal of difference. Really once you've established that little rapport there may be some tiny little things you may not go out of your way sticking your eyeballs in front of the other person's eyeballs but I think that's to be true really of anybody who's feeling a bit sad or distressed as you try not to be able to come to the country. So I think the first thing is you've done a good job and don't be worried about this and this will unfold very naturally. And ultimately you're going to be culturally different from any patient who walks through your door. There's some patients that's going to be a small cultural step and others that's going to be a slightly larger count. Great, well thanks Liz. I think you've actually already hit on one of our first learning objectives which is that what we want to do is look at identity particularly through the webinar but through that discuss on how a focus on the commonalities and shared experiences we have can help in therapeutic work and how to go about achieving that. But we do want to look at what challenges, tips and strategies there may be for working with Indigenous clients including collaborative practice in the context of Australia's social, scientific and political environment so a very important one there. And finally we want to finish out the webinar by talking about how practice and discourse around boundaries can impact our work with Aboriginal and Torres Strait Islander clients across different professional disciplines. So plenty for us to cover tonight. Lewis has got us very well opened up with thinking about what we have in common and to basically reassure Sophie in this case that the fact that the patients come back to see her is a really good indication straight up that she must have done something right. So that's really important. So hopefully Sophie's feeling a little bit better about herself. I'm not sure though, Mary. You actually wrote this case. Tell us a little bit about Sophie and what she's going through at the moment. Yeah, look, it is pretty much based on my early career in North Queensland. So, you know, I guess I had a pretty good education at university about the gap between Indigenous health and non-Indigenous health and I guess I probably had some very idealistic views that I could go and make a difference. In actual fact, I did six months working in an Aboriginal medical service as a GP registrar and I actually found it really difficult. I found it really chaotic and I learned all these things about my own obsessional personality that it wasn't a really good environment for me. Interestingly, it's now my favourite environment and I love it much more than Gold Coast University Hospital. So, you know, I'm 20 years older, but I've also had the experience of actually getting to know lots of Indigenous people and people like Jess and Louis and Mark went and told me colleagues of mine. But I think as an early practitioner, I did kind of worry that I didn't really know what I was doing. That's true about everything. You feel like an imposter when you first start in any career, but especially working with Aboriginal people for the first time, I just felt like there was probably all this stuff I just didn't know. And to be honest, there are definitely still situations where I know there's lots of things I don't know. So maybe part of it is the fact that I'm more comfortable now with not knowing. So what do you do when you don't know? How do you resolve that discomfort? I'm more comfortable with saying to the person that I'm working with, look, I don't really know much about this or what, you know, even a kid that tells me about the video game they play, I'll ask them to explain it to me. Or I might say, you know, I've just recently come from a job working all over Cape York, and I very much don't know about the dynamics or the politics in the communities. I do think it's really important to try and learn as much as you can if you are going to a particular place. So I think what Sophie did really well was be respectful and patient and, you know, it's humanistic, rogerian, attunement, unconditional positive regard, empathy, and she communicated that effectively enough for the patient to feel comfortable. I do think it is important to have a knowledge of the history of Aboriginal and Torres Strait Islander people in Australia, and I think that's a lot easier to access now than it was when I was at uni. You can watch Blue Water Kingdom or lots of different stuff. And I think when you're going to a particular community, it's really helpful to find out about that local place. And the other thing I've found really helpful is understanding the value of having cultural mentors. So, you know, there's Indigenous health workers in most places that any of us will be working, and they're just invaluable because they're part of the community and they can help you figure out that stuff where, you know, the relationships between people and the history and it's very, very helpful. So obviously recruiting help from people like Aboriginal health workers is really important. What about other health professionals? I'm just wondering about psychologists, and this, I guess, brings us in with Jeff, who's a psychologist. It would be feasible, I guess, that Sophie, the doctor in this case, would refer to a psychologist. What would be your first up approach, Jeff, if you were to receive a patient or a client like Jason, how would you approach his care? In the context of Sophie or if I had Jason as a client? Well, I guess if we think that Sophie's made a diagnosis of depression and realising that, in fact, some counselling or some psychological intervention is going to be the best way to go, she might refer to you for that. How would you go about establishing your therapeutic relationship with Jason, and are you actually qualified to treat Jason? Look, I'd like to think that I am qualified to treat Jason. That was a provocative question, just to get things going, Jeff. Yeah, but look, if it was in the context of a small medical practice or we were in a small regional or remote area, I might suggest that Sophie does the handover to me with Jason, so there's a continuity of care. So, I mean, if Jason doesn't know me already, you know, Sophie actually introduces me, and there's a three-way conversation for us. So, Sophie's allowed to complete that part of her treatment. Yeah. And obviously, that's done in a very warm way, and that's sort of so Jason understands why it goes from person A to person B because there's so many times where there's interrupted service and by having that transfer that wouldn't be so interrupted. But generally, I was talking to Lewis and Mary the other night and sort of said, I know that Lewis and I are the best people to talk about how a non-indigenous person works with indigenous people because Mary said, you know, sometimes you don't know what you don't know, I think sometimes we don't know what we know. It doesn't make any sense. No, it does. Yeah. And things that I take for granted, I suppose, Lewis does as well. Other people look at us sort of a little bit strange. Well, it's interesting. Some of the questions that are coming through already are very much on the basics of creating rapport and engaging with the patient. There's a question there. Can a GP shake hands with an indigenous patient male or female? It seems like a fairly basic question to which I don't know the answer. What are your thoughts? My warning is yes. I mean, most, depending on where you are in Australia, I've found pretty regional differences. But most Aboriginal men will shake hands with a professional, but it's also a company by a looking away. And in non-indigenous society, you may see that as disrespect, but in indigenous society it's not. It's just I'm going to meet my obligation to you as a medical professional, and this is the way I do it. So don't read too much into the handshake. Sure. And then another fairly straightforward question, I think, or it's probably not straightforward, but anybody could answer this, I suppose, if the question's been asked about the terminology then, even the term we're using, indigenous. I know some people say it's better to use the word Aboriginal or First Nations people. There are different shades of meaning of all those things. Are we overthinking or is this really again about respect? I personally don't like indigenous, and I will always go to Aboriginal or Torres Strait Islander, or both, depending on what I know, and you can always ask that question. But that's my personal preference. Other people will be fine with something else. Like, I have clients who want to be called Murray and not Aboriginal. That's fine. What's certainly specific isn't acknowledging somebody's heritage rather than just a grab all term. What about you, La? What are your thoughts on that? Well, look, when I live with juniors of medical students and I'm teaching about the usage of the term, if they want to talk about a group of people, then I think you can have a group of indigenous people. But when it comes to individuals, I think you just want to be a little bit specific. And it'll take a little while to figure it out for your own area.  I mean, I think if somebody that asks my mother if she was an indigenous, that would have been an interesting and slightly unpleasant interaction to have had. She would have then explained to you the distinctions of the groups within that. But again, this is part of what Mary was saying also, you know, if you're going to go to an area, just find out a little bit of something about it, you know. And if there's indigenous health workers or liaison officers around, you can ask them that question. They'll be used to answering that question and say so. The local mob here, what do they usually refer to themselves? Do they call themselves Murray? Do they call themselves Aboriginal? What is it that they call themselves? And I'm sure that that person will be able to give you a fairly quick rundown. And if there's a very complicated local history, I'm sure they can give you a rundown on that as well. Great. So it really sounds like treating everybody as an individual again, not exactly a world-shattering insight for us tonight, but really important that we acknowledge that's what it's all about. There's something that's possibly more sensitive, which has come through in the questions again, which is the issue of transgenerational trauma and the trauma that people might bring into the room with them and how that would obviously contribute to the way they present. Somebody's asked the question about what's perceived as an aggressive stance, which is maybe driven by anger resulting from trauma and whether we need to acknowledge that as a part of the person's presentation. If anybody wants to answer that or comment on the issue, I'll call that. I would think of, I mean, if somebody comes in and they're upset, you're going to try and de-escalate that, but that doesn't change an awful lot between the particular person. And again, it's just going to be about sowing some decency and humanity and empathy and try and understand what's going on. And you can simply, you can say to any patient, look, I'm sorry, have I upset you? I'm not sure if I've missed something here. Honestly, I'm just trying to help, but if you could give me a bit of an idea as to what you're setting me from right now, then I'm happy to give it a go. I think when I was a young practitioner, there were lots of clever people around telling us the importance of maintaining a professional distance. And I'm not sure that the professional distance needed to be quite as profound as it was explained to me at the time. And I don't think it hurts to actually show a little bit of mutual vulnerability and let them know that you don't pretend that you're an expert and that you don't pretend that you know everything. And I look if I'm parking up the wrong tree, just give me a bit of an idea as to where we should go. And I think often you'll break through that. That issue of vulnerability is a really interesting one. Well, it's the mutual vulnerability. And Mary, you've shown some vulnerability, I guess, tonight by presenting us with a case which describes some of your own experiences. I'm also taken by the concept of mentoring. Now, it sounds like you were mentored in learning how best to make your services accessible to Aboriginal and Torres Strait Islander Australians. Yeah, look, I was just thinking before, actually a lot of the, you know, the most real local learning is actually from my patients. So, as Lewis said, just saying, look, what is it that you... how can I help you?  How do you guys refer to yourself? If I've been working somewhere for a while, I might know that.  And that's completely appropriate and comfortable for them. How do you negotiate that? That's a very sensitive approach. You must negotiate that relationship, I guess. Well, go... To be honest, I think some of us just having been working somewhere for a while and knowing individual people. So, just like you get to know any individual client if you see them over time, you come to understand how they talk and how they think. And I guess I do probably think it's valuable to reveal a bit more of myself. And maybe, look, I think working with Indigenous clients has actually taught me a lot about working with everybody. So, I'm quite likely... specifically at the moment, I've just moved down from North Queensland. And so, a lot of the patients I see, I'll say, hello. I'm Mary. I'm a psychiatry trainee. I used to be a GP, which means I'm a doctor. I work in mental health. And I just moved down from North Queensland. I don't know anything about the Gold Coast, so I might need you to help me. So, if you say you live in Mudbury Bar, where's that? What's that like? What was your high school like? I just have curiosity. I think curiosity is really valuable in any consultation, and particularly when you want it to be a therapeutic relationship. And I did have a thought when someone was talking about angry patients, and Lewis intuitively does what I've had to learn, I think. And one of the things I've learnt to think about is a sense of safety. So, if a person in front of me is, like, angry and shouting and freaked out, I don't think they're feeling very safe, and I often am not either. So, I'm then thinking about what do we need to do for us both to feel safe? And I sort of won incident in the inpatient mental health unit recently, where there was an Aboriginal man. He was really distressed, and I was called to come and help sort it out. And there was this poor man standing in the middle of a room with all this security standing around the outside, and no one was talking to him, and no one was meeting. And I basically went up to him and said, mate, you look really stressed out. Do you want to sit down and have a yarn? And he said, yes. And it wasn't complicated by itself. What do we need for us both to feel safe? That's really important. I mean, that whole concept about being curious and actually interpreting anger and what it means, being curious about what's behind it, not sort of thinking, how dare you be angry in my clinic? But I'm really wondering what this is communicating and responding more positively to it rather than just reacting to it would seem to be a way to go. It sort of leads to another question we've been asked in a rather vague way, but I'm not sure who wants to answer this one, but a few people have actually said that they're conscious of sometimes feeling a little bit helpless and overwhelmed in the face of the social determinants of health and the impact on health for communities. I must say as a GP, I feel a degree of envy about the cardiac surgeons who replace a mitral valve and people get better. I think working with mental health, you don't always get the great wins that you might get in the procedural specialties. What's the panel's thoughts about the reported high turnover rates in clinicians working with Aboriginal Torres Strait Islander patients? Is that an issue or is it to do with our or the practitioner's need for big wins all the time? I'm not sure. I think that's a bad right. But equally, I think we need to better appreciate what wins we do get. So even the little case study that we had at the beginning that the first thing for Sophie to realise is, none of the kids you've already had a win. We don't need to be sad about this. We don't need to be anxious about this. Celebrate the fact that you've already had a win and feel a bit positive. When you look at any big picture, any big picture can be massive and the problems can appear to be insurmountable. And you deal with that by... These half-dozen things are not fixable to me today. These other half-dozen things may not be fixable for the next year for me to be involved in. So let's just now go down on what things that I can make a difference about here now today between now and the next time that I see you. And just cut it down to the incremental steps. And I think that's with any part of healthcare. If you've got a patient who comes in who's hypertensive and you're going to start talking about some exercise and dietary changes, you don't get them to do everything today, everything at once.  Get this thing and win this. Then when we've won that battle, let's go on to battle number two, then battle number three and battle number four. If you try and battle everything all at the same time, you bounce loose and you'll be dispirited. So it is a thing of counting your blessings. There's a thing I went to recently and are talking to us about mindfulness. And one of the really interesting things that I thought with what this young psychologist was speaking about with mindfulness is that this is exactly what the ancient religious traditions have all taught. And Christianity, Islam, Judaism, Buddhism, Hinduism. And the thing about mindfulness, that thing about just being aware and being thankful and saying thanks for things. And I think it's very easy for us to be overcome by the storm around us and not forget to be thankful for this wonderful little thing that's in front of us. The fact that we've got a smile from the patient now, somebody who was clearly upset and very out of sorts when they came in and that we managed to get a smile. And that's good and that's a win and be happy about that. So that's a win. Yeah, there's also a question being asked about whether we should read communication into people turning up late or maybe not turning up and whether that is something we should be frustrated about or whether again we can be curious if this is somebody's way of checking us out before engaging. Are there any thoughts on that? Jeff, that must be difficult in your profession with long appointments. If somebody doesn't come, then you're twiddling your thumbs. Oh, look, I quite enjoy twiddling my thumbs. For me, my client group is 85%, 90% Aboriginal and Torres Strait Islander. And if you look as far as income bracket goes, probably at the lowest that we're going to see. So it's the nature of the beast that I expect on a liability. So I don't get frustrated when someone doesn't turn up. And I know that if I am working with someone and we approach something sensitive, I expect that we may see a no-show the next appointment because they've come close to something and they may have scared themselves. So I usually leave them a few days after the missed appointment and say, hey, I missed you the other day and I'll come back. So the unreliability of my client group, I expect, so I don't get upset. I suppose also I supervise other psychologists and I try to say to the other psychologists, this is not about you. This is about living in a world where sometimes things are really difficult and the unexpected usually comes up. And slowly they learn. Thanks. And so obviously also working in smaller communities and everybody's in a smaller community, I guess, in some ways, what about when we encounter clients in the street? Would you follow up with a client who didn't turn up if you bumped into them in the street or do you have a strategy that you use for trying to connect with somebody outside of the consulting room? I'm quite lucky because my clients will usually come to me in the street and those that don't, I don't acknowledge because they're not coming to me for a reason and I'll follow up maybe later that day. I'll never approach them if they don't come to me but Cairns is a small place. It's interesting. I did have that experience myself in the very small country town of Geelong where an elderly lady approached me in the supermarket and looked me in the eye and said, he died, you know, and walked away. I still, 20 years later, got no idea who she was talking about but it was a very awkward situation. What about you, Mary or Lewis? Are there any particular strategies that you use for connecting with clients who you might encounter in the street? Is that something that's an issue? An issue in Africa, it must be, even in the Gold Coast or in the Cape York? Sorry, go ahead. No, I just, I was sort of thinking about the question about people who don't come and it came up earlier for me as well. I actually have Maslow's hierarchy of needs on my wall which I know is 1950 sociology but it's really helpful and the question was about transgenerational trauma before. So when I think about what people are dealing with on a daily basis and what they've survived, then it helps me to realise they're doing their best. Now it's still okay for me to have boundaries to keep myself okay but when I can understand that they're doing their best in a really difficult circumstance that helps me to kind of cope with it and look, many of the people on our webinars are using Medicare and it's their income and so if the patient doesn't come they don't get paid so I think we also have to be pragmatic and maybe you can only do this work two days a week or something like that but I think for me it's just keeping that perspective of what are people's lives actually like and I never think people are not coming just to annoy me. There's usually some complex reason I might not know but I think it's a little worse. Fortunately you are. With regard to the folks downtown I think it's important to give a smile and they have not brought a lift point to acknowledge their presence. If they want to talk to you about something to do with the recent consultation which didn't happen or should have happened they'll bring it up. If they don't just acknowledge them as a fellow traveller in life and somebody else who shares the community with you and I think it's looking after them I don't think it's possible for me to walk down the street without seeing folks who are patients of mine and if somebody isn't a patient of mine then they're probably two degrees of separation I've looked after their brother, sister, mother, father and son and daughter so you just assume that everybody knows who you are anyway and if people want to talk just let them have that permission to talk I find people fairly respectful they won't invade my privacy very much some people get worried about that I haven't actually found that myself and I think at the end of the day I like the communities that I've driven like the people who come and see me so I don't know if they have a chat to me down the street but I don't find it particularly offensive Sure, well that sounds great Well questions come in which I'm finding really interesting here at the university we're trying very hard to move away from I guess a deficit model of Aboriginal and Torres Strait Islander health that we're teaching the students to look more at First Nations' knowledges or whatever we would call it the question's been asked about whether traditional belief systems can play a role in the care of people who are under stress and whether we're doing enough to actually engage with people's traditional belief systems in treating their mental health is that something we should be considering? Yes Yes, okay The numbers of services around the place who do already have established relationships with various traditional healers around the place and by all means if your patient, if your client looks like they're wanting to utilise those services then you can always encourage that Remember with a lot of Aboriginal people who would use those services they may well have already been to a traditional healer before they come to you in the first place and I suppose the importance is really in not dismissing what it is that somebody else who was ultimately a healthcare worker what it is that they do I might not understand all the workings of the nunnery in there in Central Australia but I'm not better than the disrespecter Equally with non-Indigenous clients if they come in and they're going to alternative therapies I try to be very careful to not be disparaging and to encourage them to know that if this works for you then that's fantastic because I think if they knew what most of us knew about medicine and how much of it is as much witchcraft as it is art and science then I suppose we might see that we all have a place and some things we'll understand better than others Another question has been asked which is also very important by somebody who worked for many years as a mental health nurse in remote Northern Territory and we had discussed as a group previously the issues of remote area nurses being called upon to provide mental health care in remote areas often with little support but Trevor's made the point that building trust is obviously so important how do we go about building trust with a client who may be an Aboriginal trust I know we've touched on some of this what about in small communities particularly maybe even where mental health can have a negative connotation or stigma I know in some communities that's very much the case I know it is in the medical community mental health is seen as something that we should be ashamed of having problems with it what are the panel's thoughts on how we go about building trust particularly in small communities with people who need our service I mean I would just throw in that you must be consistent, you must be respectful because if someone is vigilant to practitioners being inauthentic you need to be that same person every day and that goes back to what Lewis's comment is about when you're approached by someone in the street if you're warm with them in the clinic it doesn't make sense to be cold to them in the street and remember that in a smaller community when you deal with one person you deal with the whole family so you're all working across families and you're telling different family members different stories well then that's going to come back and buy you Grape any thoughts from you Mary on that? Yeah I think being authentic is really important look also on a practical level I did find it really helpful putting up the map of the indigenous country up on my wall at Headspace and then I could ask clients if they wanted to show me where their people were from and I have found it helpful if someone is from somewhere that I've actually been to talk about you know that I have some comprehension of what they're talking about where they're from that's perhaps about helping people's sense of safety as well but also finding things that we have in common rather than focusing on difference What was the most recent question you asked me Steve it's going so fast my thinking can't keep up There's certainly plenty going on but I guess it was about establishing rapport or trust with the client and maybe the youth mental health area is a good place to consider I mean young people are generally suspicious of healthcare providers I think most of it are Yeah that made me think The other thing is understanding that I've got you know if I'm working under Medicare I'm expected to work in the western medical paradigm but that isn't the only way of understanding the world so when I have respect for the way that the person who's coming to see me might understand things and then we're sharing knowledge I think that helps to build trust whereas if I come in with the view that I know what's wrong with you and how to fix it I don't think that's very helpful You've led us into the question then which I'm absolutely terrified to ask because it is such a massive it's such a fundamental question and brace yourselves people How do Aboriginal and Torres Strait Islander Australians conceptualise mental health or wellbeing Over to you I think it's well I suppose the almost the question itself I mean it's a very fine question but it's almost a little deficit in itself whereas I suppose it's about what is health and health is actually about feeling good and being good and being happy and being vital and I suppose I would just turn it around the other way that anything that makes you not feeling well, not feeling happy you know something is causing pain and whether that pain is physical, emotional, spiritual it's all pain and it's all going to make your life less happy than it could be I think for most Indigenous people there is just a whole of life view and in fairness I think that's not particularly different of a lot of other human beings I think most Australians are trying to seek an overall happiness but there is what I observe among non-Indigenous Australians as a cultural thing of this artificial separation of the different forms of health I find it really quite interesting that people artificially separate being emotionally happy from being physically well from being spiritually satiated that well I think they're all obviously exactly the same thing it's an interesting western paradigm and I think it's a recent western paradigm too by the way that's really an instance about the Second World War where we have this separation of these things into different compartments of our humanity and I'm not sure that that's an overly useful way to look at it I think it's more that looking at the whole person my experience among patients is they seem to appreciate the idea of you looking at them as a whole person and not just as a you're a heart that's got some trouble or you're a lung that's not working there's a whole human being attached to that as well and if we can make that person feel a bit better about a few other things it might be stress on the heart or the lung Can I add that I also think you're a major depressive disorder or you're a schizophrenic you know equally I don't think that's helpful Steve would it be okay if I put those slides in now because I think they really answer that question Yeah I think that's a great idea Mary we'll go to those now So I don't know whether the audience is aware but there is a manual for it's called Working Together Aboriginal and Torres Strait Islander Mental Health and Well-Being Principles Practise which I've found really helpful so Lewis and Jeff well in fact Jeff contributed to this manual but Lewis and Jeff kind of didn't need to know this stuff articulated in a theoretical way because they just know it but I did and I found this really helpful so I thought I would just quickly go over those so Lewis has already talked about that holistic view of everything and you know including land or self-determination is really really important in healthcare provision culturally valid understanding must shape the provision of service so we have to actually ask communities how they want care provided to them what it is we can bring that could be helpful understanding the history of trauma dispossession loss human rights has to be part of healthcare understanding that racism stigma, environmental degradation social disadvantage continue and continue to contribute to people's stress family and kinship is central something that has really helped me to also remember because I try not to but I'm sure I make assumptions all the time but realising like Lewis was saying with Headspace there isn't homogeneity there's lots and lots of different Aboriginal and Torres Strait Islander histories and current experiences and so that curiosity about the person with you and just thinking about what is the most what can I do for the person with me here right now rather than being overwhelmed by the big thing and then as everybody has said recognising that there's strength creativity, endurance deep understanding of the relationship between human beings and their environment and myself it might sound a bit weird but I have come to be really grateful that this kind of model of health and well-being rather than you know an illness based model is actually carried for everybody by Aboriginal and Torres Strait Islander people who have insisted that we keep that way of thinking and just think about their health and well-being in that way and I think it's good for all of us and I guess I also think we permit them to carry the sacred so we have a very secular culture and it's almost a bit awkward to talk about spirit or soul but I think certainly a lot of very soulful things I have learnt from Lewis and every time I have a conversation with Lewis I kind of feel he gave me permission to value the mentorship of the old white men who taught me medicine that was a bit awkward but Lewis like these have been really wired mentors for him and I thought they have been to me too and it's okay to say that and I just think being able to recognise the sacred and the soulful is okay well as the token old white men on the panel I'll advance to the next slide the question has been asked whether these night principles will be available and they will be you can see a link down the bottom there sorry Mary did you want to talk any further about the principles no no I think I was meant to advance the slides I was reading them on a different piece of paper so they're there now and there's a photograph of that manual it's available as a PDF online for free and I believe you can still ring up the telephone institute and order a copy great we have something to add on that because he has been involved with it so Jeff you were a contributor to it did anything further you wanted to add to what Mary's told us about that resource it looks very useful well I see it on lots of bookshelves which is positive I will honestly put my hand up so I haven't read every chapter in the book it's what you take out of it and how you apply it that's more important so you can read and read and read and read but being informed by your clients not by a book I think that's very important as well okay thanks for that there's still a chance to ask questions before we finish at half past the hour in eastern states there's a few more that have come in while we've been looking at that resource there's been a question about developing cultural literacy and the questions asked for non-AZE workers as a way to develop cultural literacy what's the best way to go about that I'm not sure whether any panel members have any thoughts on that topic and whether that also applies to health workers who are Aboriginal and Torres Strait Islanders themselves I think it comes from a conversation there if you're learning a new language you can learn all the important parts of that language but nothing builds it up so if I'm going to learn Italian then it's all very good I can do the online course and give all the video tapes and the audio tapes and that's all useful but nothing's quite as good as actually finding somebody around who is fluent in Italian and just sitting in and speaking with them and I think the same is true in this case the thing that's going to make the most amount of difference is in relationship finding that Indigenous person around who you can actually strike up a friendship with and have a conversation and it'll take time it'll take time to build that trust up but as you do you'll just learn more and you'll understand more and you become more fluent in the concepts and my very best friend in the world is an Africana and it's the and look this is my go-to guy if I was stressed about anything whatsoever my brother Chuck Gropler is the first guy I give on the phone to to help me deal with whatever stressors I'm facing and if you told the 21 year old me that when you used to be 50 years of age you're best made on the planet it's going to be a wife South African I have laughed at you I thought that that would have been just culturally impossible what quality is he got with us that you see in him that makes him such a good friend he is just one of the most decent wonderful loving human beings I've come across in my life he's just you know incredibly honest and incredibly incompetent and I know that if any time I ask my brother for help with anything that he possibly can it's a human relationship you know that I identify with this guy he's a fellow trucker in life and we have it was interesting one day we were talking about some things and he said I just have to admit I don't actually think the view is being black and I said that's okay but I don't really think the view is being white and so I think quickly you can move past those past those things and just and increase that cultural literacy that you have with somebody by just the actual practice of that relationship I think also just the other thing too with particularly with Aboriginal people we're an adoptive people and when we give them to know each other if we're in a large group of you know of Murray's and the first thing we'll start doing is genealogy and find out who belongs to you and who's related to you and once a relationship is established then that actually cuts through a lot of things and the other interesting thing with with you know Aboriginal people certainly Torres Strait Island people come across to the same thing that these interesting ways that non-Indigenous people have of describing family relationships and I've got things like stepbrothers and stepsisters and half-brothers and half-sisters and a doctor brother and a doctor sister which in Murray's family is such a thing that doesn't exist that either your family or they're not and how that person got to be in your family where are the physical children whether they're your family because they share your parents because your mother adopted them because you know their dad is your dad's best mate and all of that is just meaningless it only matters if they belong and I think that it's one of the things as people establish those relationships with the Indigenous Australians they'll find that you either belong or you don't and if you belong it doesn't matter how non-Indigenous you are doesn't matter how white you are doesn't matter how much you think that you come from the opposite if you once you're accepted you're accepted I don't think that's very complicated no absolutely and actually there's a very simple question being asked as well which again is quite complex and I know in the medical school we're very conscious of our Indigenous academics potentially being burnt out by being asked the same questions again and again the question has been asked how do Aboriginal and Torres Strait Islander health workers cope with do they get sick of being asked the same questions again and again about what terminology to use whether to shake hands whether to make eye contact questions we've asked of Lewis and Jeff tonight how do you approach that on a day-to-day basis when the new trainee asks exactly the same questions that's the last one he didn't want to answer that or anybody that wants to are you going to jump in and give your perspective Mary? well I was always going to say that if they do get sick of it they're probably going to laugh about me later and that's fine I think with humour this is something we've talked about like if you're intention if you're clearly authentic and you're clearly wanting to help and you're honestly asking a question people are gracious do you get ticked off Jeff? I mean you're both very gracious people but is this something that does get to you after a while? Jeff's phone's dropped out so well I'll take it then I suppose it's the sorry this is a slightly odd segue if you're humour me Michael Parkinson was talking about having interviewed a former England cricket captain and was asking about the stress of placing a fast bowler and this guy who was a veteran of the Battle of Britain so look having a precious one on nine up your arse that stress placing a fast bowler that's just the game I think in a sense of all the stressors we face when I went to school the stressors were trying to make sure that the teacher didn't notice me because if they did that was going to be bad for me trying to not give myself reason up in the school yard yet again for walking more black trying not to attract the attention the biggest stressor I've got to face today is having to explain to different people a few simple things about Murray's like this well that's not even stress you know it might get tedious but it's certainly not stressful okay well thanks for putting that in perspective that's absolutely brilliant we've had another couple of very practical questions about and I don't think Jeff's back with us yet to ask specifically about psychological interventions but can you continue to speak for are you there Jeff great fantastic somebody's asked the question about whether there are any particular approaches you might use in working with an Aboriginal and Torres Strait Islander client specifically like you know narrative therapy in preference for something else can you give us any thoughts on that well it might be a product of my age but I'm very much finding that you apply the existential principles and most Aboriginal men more generally will run with that the whole idea around responsibility freedom and choice and also sort of put it back so that you actually have your client doing the work outside of the therapy room and not inside the therapy room okay great what about you Mary what about in your work in psychiatry is there any I mean people have been asking questions about whether we overuse medications particularly in general practice are there any other approaches you think we should be using straight up obviously there are well we go back to that idea of people's understanding of health as being holistic so I'm always thinking you know what I ask people I mean I don't think people experience it is rude but you know who lives at your place what's your accommodation life do you feel safe there is it secure how are you financially okay do you have enough meaningful things to do how are your relationships what's your nutrition like how do you sleep do you get outside do you get in touch with nature yes we do overuse medications in Australia we are the third highest prescribers of antidepressants in the OECD not counting America so I think there's Norway then Canada then Australia but that's not just in Aboriginal and Torres Strait Islander people that's in everybody so I think again I said to already I have maslows on the wall so I probably do a lot of advocacy and sometimes filling out forms but a lot of education for people around you know we can call this a mental health symptom we can also call it an understandable response to all the things that have happened and we can help you feel safer in your world but first of all we have to make sure you actually have a safe world so that's kind of my approach great thanks for that we're getting to the time now where we need to be wrapping up but I just wonder if each of the panellists would be able to give us their closing thoughts on what's been discussed tonight maybe if we start with you Lewis oh I think for me the take on message is as simple as you're just sitting across the table from another human being that there's not really very much difference between you know one human being in the next when it comes to their needs as Mary keeps talking about the maslows hierarchy and just show a little with a thought, time, compassion bit of empathy and just point about that all things just to be how important it is to be able to be yourself and be reliably that same person over and over again so that you don't come across as being a fool and you don't do as people's trust but people are pretty forgiving and most of the time when they turn up to us they're actually after help, that's why they turn up in the first place and if you can just give them some sense that you're trying your best to offer it they'll probably stop being with you for a bit, they'll give you a go okay great thank you very much indeed what about you Mary I think you're next up, what are your closing thoughts and I must say the resource you've put up is getting a lot of love from the group it sounds like people are going to want to go into that so we'll make sure that's so clearly available the slides was that Steve yes I've actually also put some other resources in which I was a bit late so they'll be after the webinar but the Menzies School of Health Research has got a number of excellent resources for working with Aboriginal and Torres Strait Islander clients Black Dog Institute has got a list of all the online resources and there is also a six hour introduction to narrative practice for free from the Dulwich Centre in South Australia so those will all be in the resource box when it's posted online but I guess somebody asked about cultural literacy I do really love black comedy on ABC and if you watch the reruns I'm serious, like it's really really fun but it's actually really really accurate so I think I'm just going to leave that as my keep okay well there's a must watch for iView there from Mary thank you very much for that what about you Jeff, what are your closing thoughts from this evening I'm probably just a challenge to those who are working in the sort of psychology clinical space and that is sort of often that we see you walk into a psychologist room and you'll see chairs laid out nicely and you'll see a nice little coffee table with some probably very uninteresting books sort of scattered on the table take the table away and then try to look at who's actually uncomfortable because nine times out of ten it's the therapist and not the client if you're feeling uncomfortable maybe you're not doing something right so learn actually how to work with your client without the barrier when we move the table, leave the table outside the room you never bring it back it gets easier so table free consulting sounds excellent and actually you've hit the mark twice tonight with a couple of things that the chat's been picking up on one of them is that it's not about you, it's not about the therapist that comment you made earlier that the focus is on the client but the other thing is it is about you, it's about being authentic so it looks like that's been a real takeaway for people who are on the discussion tonight and the other thing that's come through quite strongly was this concept of being curious and being curious about the person who's sitting opposite you and what their background is or maybe even sitting beside you you never know maybe we've got time for one last question which is this come up which I have to resist which is about, can't resist it's about learning about the community you're in now Mary I gather you moved to Cape York how much time did you invest in finding out about the community that you'd arrived in? Look I didn't move there Steve I was fly and fly out but what I did was each of the communities on the Cape has a council so I went to the council website and I just read everything I could before I went and I also am just a curious person so if there's a plaque I'll go read the plaque if there's a display board somewhere I'll go and read it so I think just going in with an open mind and being observant and asking questions and people like being they like sharing their place with you and you having a genuine interest in it and I know we've already said our last thing but I did want to say like 20 years down the track I can honestly say that my work with Aboriginal and Torres Strait Islander clients has totally enriched my life and I feel like I've got much more out of it than I've probably contributed so just stick with it be yourself and it's really such a worthwhile thing to do and if you can't do it five days a week that's okay just do what you can Sure and the important thing you said then amongst other important things was being genuinely curious and having that sincerity that it really is tapping into ourselves as humans rather than just a professional quote that we put on when we're working so I think that's a really important point as well Okay so it's probably time to wrap up now and this is any final comments from the panel before we run through the shutdown script if not I'd like to thank you all very much all three of you I think you've given us an awful lot to think about and it's just been fabulous from my point of view I think I've learned an enormous amount there's also the opportunity for people who have watched us tonight to access the resources that Mary's referred to there's a light blue icon at the top right of the screen it might be a little moment before all the resources are uploaded but hopefully we'll be able to access the resources that are there there is an exit survey that we would encourage people to complete and that's the yellow icon at the top of the screen on your on your version so please fill it out it's really helpful for us to know whether tonight's webinar has helped us meet those learning objectives which you'll recall from the beginning of the session there are other mental health professional network webinars coming up there's better outcomes for people with schizophrenia taking a patient centered approach on the 7th of November there's also collaborating which is obviously the key for the mental health professional network to recognize and address conduct disorder on the 3rd of December there'll be email communications about some partner webinars coming up looking at emerging minds and working to support children and families living with fetal alcohol spectrum disorder that's the 26th of September not that far away as well as one with the GPMHC exploring collaborative care on suicide prevention and bereavement which is on Monday the 28th of October as well as the Department of Veterans Affairs on treating post traumatic stress disorder in veterans on Tuesday 29th of October so who's ever going to need free to air TV again a quick comment that the mental health professional network does support the engagement and ongoing maintenance of practitioner networks where clinicians from different disciplines meet regularly with other mental health practitioners and we share tips, resources build local referral pathways pathways in your area as well as engaging in CPD activities like this so to learn more about joining your local practitioner network and maybe watching a webinar in company please contact MHPN or go to the news section of the website and also you can register your interest in the exit survey that hopefully everybody's filling out so before I close this is a really important point I would like to acknowledge the lived experience of people and carers who have lived with mental illness in the past and those who continue to do so thank you to everyone tonight to Lewis and Jeff and Mary and all of you online for your participation this evening and I hope you enjoy the rest of the night thanks very much indeed


Thanks for Simone and FAO in wanting to take part in this important international open forest meeting. For our topic, our side meeting, the wild city. These are the big topics. When I think about the wild city, the most important thing I think was the relationship between the open forest and wild city. So the title of my presentation is open forest and live quality. I think the city in the beginning, they say that is a place where people live intensively, but along with the organization, modern city, we think in the future, maybe it's a harmonious home for not only women, but also the nature, including the animal, the birds. So the challenge of urbanization, we think about a minor way to solve the problem caused by the urbanization. Open forest and natural-based solution, this is our goals. The soil action plan proposes seven goals, green cities, cleaner cities, cooler cities, higher cities, more close cities, and more biodiversity. And the last one is the wild city cities. I think the last one is the most important one. What's the rule kind of open forest play in the wild city cities? From the soil action plan, we can see outcomes of wild city cities include the four parts. The first is the guidance framework and the eco model to assess ecosystem service, benefits, and the savings. That means the ecosystem service and the benefits is related to wild city cities. And the second is turning green, green to green. The third is the agreement and policies and regulations to promote green business, green jobs, open forest and tree products. The fourth is funding schemes and private public partnerships. For these four outcomes, the king action is, the first is action research on models to evaluate and accounting the ecosystem service. The second is agreements for promoting green business, green jobs, and marketing products. The third is create online marketplace of Asia city for green job opportunities and initiative. The fourth is join exciting public or private alignments and partnerships. So the first is create new alignments and partnerships and the last is the proposed regional context and awards for Asia particular green city. For this, from this, we can see what the relationship between urban forest and the wild city city. I think the contribution of urban forest to wild city cities, including at least three parts. The first is ecological contribution from the two days, in recent two days, many experts mentioned that the ecological benefits. That is to establish for a wild city, at least it's a template of functional forest ecological system, including urban forest courage, biological habitats, and forest recreation place for every person. So the second is economic contribution. And that means that they work with the benefits of forest economic system, urban forest have relation is related with the people's life quality, including the suburban farmers in economic incomes and the living environment. The third is the ecological contribution provide our variety of places for expressing ecological culture. In Chinese, recently we emphasize on the native tree and the home sickness culture and another is a natural education and is a promotion to ecological behavior. So I think what the rules can open forest playing in wild city cities, including at least four laws. The first is the ecological benefits from urban forest. In this field, Americans do a lot of work. They developed a city green model or actually model to evaluate the ecological benefits of the urban forest and urban trees. In United States alone, it is estimated that trees provide 18 billion in annual value due to the air pollution removal, reduced the building energy use, carbon sequestration and a wide pollutant emerges. This material from the David in New York. And the second I think is an economic income from urban forest in Asia, in recent years. This is very important. You only include two parts. The first is the yearly direct incomes. Urban forest ecosystem itself has a production function or production function, which provides rich forest products for suburban forest farmers and becomes their direct economic income source. In China, a city in Xinjiang province in 2020, the total output value of forest and the fruit in a city reached 15 billion and a per capita income for farmers reached 5,000 in accounting for about 30% of per capita incomes. And also in other cities, for example, in Beijing, every year, many people go to suburban area, take part in the chairing, picking activities. From these activities, many farmers can increase their economic incomes. Under another is indirect incomes. It is difficult to account, but it's very important. It provides fuel, if I need direct financial returns on investment, but it's standard, general, but difficult to assess. So the third is employment opportunities from urban forest, I take an example in Beijing. From 2012 to 2015, one million more forestation program in Beijing plan was implemented and more than 70,000 local farmers achieved greening employment from 2018 to 2020 a new round of one million more forestation program provided nearly 57,000 jobs and this including about 28,000 local farmers. This is a farmer who got jobs from the foresting program in Beijing into one million more forestation program in Beijing. The fourth is rural tourism driven by suburban forest environment and the beautiful landscape. In China, Zhejiang province, has grown into number one tourist destination in Yangtze River data in this year. It makes full use of natural resources and geographical advantages, tracks high income people in surrounding cities to consume and promotes rural development. The state is shown that in 2017, Zhejiang province hold one hundred and three villages will create a state state in farm or farm halls. Yeah, many people go to the suburban area to have a tourism and farmers can increase their economic income. The fourth is a reported resetting the ecological well-being from urban forests. Also material from Malaysia. In Malaysia, recreation areas that are developed and managed by government agencies have mainly satisfied the auto-recreation needs of urban low-income groups. Commercial auto-recreation areas are mainly catered for the middle and higher income groups. Another example in Beijing, in Shijinshan district of Beijing city, during the pursuing the national forest city, they built many parks to cover who those people can not go to the park within the five hundred meters. The sixth is a common prosperity of urban and suburban resetting from urban forest. Urban forest construction has brought about an improvement of rural environment and the economic development. And the third is the urban forest. And the fourth is the urban forest. And the sixth is the urban forest. And the seventh is the urban forest development and the promote the exchange between urban and rural residents including the rural landscape. Many villages become more beautiful than before. Improved rural environment and some people from the urban area the urban area can have an exchange with the farmer in the countryside. Increasing, another is the increasing rural economy. So Cyprus is a protection and in a heritage of local eco-culture from urban forest. In Singapore and also in India and Hong Kong, urban forest including forest park or wetland park, can provide a natural place for natural education and natural recreation by these activities can improve the human's ecological behaviors. And another activity is the forest swaths. And the urban forest can also provide many places to organize these kind of activities. So forest in the 80s is a habitat and a step stone for birds and animals for urban forest. Urban forest provides opportunities for urban nettings to connect with the natural world. In many urbanization cause the natural system destroyed in urban area. Urban forest can rebuild the natural system. This deal by this way, the habitat and the step stone for birds and animals can rebuild it. This picture shows that the birds in Sweden, in China the economy of forestry compress. This can see even in the urban area, if the urban forest developed very well, can also provide the habitat for the birds and some kind of animals. For the future for urban forest contribution to the wild cities, maybe the challenges that is the first stage, the ecological infrastructure construction. The most important is to put urban forest planning into the urban planning. Increase the wealth of urban forest. Urban forest is the living ecological infrastructure of the city. Our good urban forest environment is one of the symbols of our wild city. So from this important rules, so many cities should include the urban forest in their strategy for development in the future. And in recent years, land use conflict is very serious. Limited ecological land, balance of the different land use for economic food and the ecological environment, we should serve this kind of problem. And on even distribution, some cities, urban forest only in mountain area, and the in-city and rural city, the urban forest, especially natural forest patches is limited. And another is increasing the urban UTC tree canopy colorway in the urban area. The second challenge is urban biodiversity is also the wealth of the cities. Give our animal or friends a home. The city is not only for women, I think it also is the homes of some kind of animals and many birds. So the rest of the animals and plants in the urban area, by urban forest construction, we can provide many holidays for the animals and the birds. The high-risk urban forest ecosystem is very important. And during the urban forest construction, we should provide the natural space for a fragmentation. And we should we should turn the plantation into natural urban forest and also rebuild the ecological corridor. The third is balancing multiple demands. In the city, there is a gap between different department. In China, different departments have different goals. For forest department, they want more ecological space in the urban area. For the garden department, land culture. They want to have a more beautiful landscape. So for the agricultural department, we want more land to produce food. So during this, we should balance. And another gap is between different groups, urban and rural residents. In urban areas, urban people want a more beautiful environment, including the park, forest park, and have many places to do some recreation action. So this is very important for their health. But for the suburban people, the most important for them is they need to raise their economic incomes. The second is the environment. So in the future, we should balance their different demands. And the third is the forest and equality. Free open out of the city parks. Many city parks, even in China, they're not open. They should provide tickets to come into. So in the field, we have to free open in the future for these kind of city parks. And the last is urban forest have many benefits, but how to turn the urban forest benefits into cash is the most important. And the fourth is the method of elevation. Guidance framework and the indicator is very important. Continents of urban forest contribution to the city. The second is the evaluation model. Now, we usually use the ITRI and the EECOR model, but how to make this model suitable to Asia and Pacific city is the next work we should do. The spiral of economic benefits of urban forest, we should find a way to act later. The last is assessment report. Usually there are many reports every year, but the scientificity and the public acceptance is very important. So in the future, the guidance framework and the indicator is very important. The last is actions, turn our dreams into reality. Not only the green city, forest city, tree city, there are many names of the city. So mostly important is turn our dreams into reality. For example, in China, urban forest construction, according to the national forest city indicators in China, we transfer our dreams into many indicators, including fire part. For example, forest hardware for those cities who want to fill in the national forest city, the forest hardware at least 30%. And the urban canopy cover in the urban area at least 25%. And the diversity of trees and tree species, we're pursuing the local, native tree, most important. And the animal habitat, habitat, the cream to, we need more natural urban forest, not only the garden. And the service of urban green spaces, the city park and the national, including the forest and the wetland park should open free to the every person. And the Ecological Popular Science Education public attitude on these indicators should be, pay more attention during the national forest city construction. I stop here, that's all, yeah.


In this learning dialogue, we will talk about training and testing data. In our last video, we saw the three steps in machine learning. The first step is data collection and selecting the algorithms second step and training and testing is the third step. We talked about data collection last week and also we saw introduction to what is machine learning algorithms in previous video. We will talk about what is training and testing data in this video. In step one, let us assume you have collected 1000 students attendance, performance in a midterm and also the final exams course. Since I mentioned 1000 students, you may not have 1000 students in the current class. So, you have historical data say students across 10 departments or 5 departments their scores across multiple courses something like that. So, your 1000 students attendance, performance in midterm and also the final score. It can be that the same students data from different courses also possible to have 1000. And you check the data and you pre-process the data, there is no out layers, no errors, everything is checked. So, you have a data of 1000 students with all these two input variables that is attendance and performance midterm and also the Y is the final exams score. So, we want to create a model to predict the students final exams score. Step 2 is selecting the algorithm. Let us say for this sake of this example, you selected a simple linear regression algorithm or linear regression algorithm with the two variables not a simple multiple. Step 3 is training and testing. The question is which data pair will be used for training? You want to create a linear regression model that linear regression model if you remember is y equal to some mx plus c. Which data you will use to create that y equal to mx plus c to train the weights and m value and c value? So, what is the testing data set? Because testing data set means you need new students data without their final score. So, what is the testing data set you want to use it? You know all the why because I said that it is 1000 students data, you already have their final score also. What is the testing data set? Let us think about that last two points as a question. Think what is the data pair will be used for training data and what is the testing data set? List down your answers after listing it down, resume the video to continue. So, in ML, we usually split the data into two sets and use one for training set and one set for testing. For example, you have 1000 students data. So, let us consider you have used 700 students data for training and 300 for a test. So, even given a same data, we will use split the data into training and testing and use it. It is very general use split the data into two. But recently, not recently say five years before we started using a validation set also train set, validation set and test set. But let us not go into that. Let us see, keep it simple, we have only two sets of data that is training and testing. So, that is a train data 700 students historical data with X i and Y i information. So, 700 pairs of X i and Y i, X i can be X 1, X 2, Y i is only Y because we have only a performance only single variable. So, this pair is basically X 1, X 2 and Y 700 samples like this. In a simple linear regression the train model will look like this. I consider only the simple linear regression which means I have only one X no X 2, X 3. So, let us not keep X 2 only X 1. So, this looks like Y equal to M X plus C the slope equation we studied in class 8 or something. So, the values of this 0.76 or the 3.2 are computed based on the training data. Given a 700 training data, the algorithm computes the value of this suppose Y equal to C plus M X, the C and M can be computed from the training data or the 700 data. Now, we use this model to predict the performance of the test data. In test data we will give, so the test data will be Y predict, we will give sorry 3.2 plus 0.76 X. This X is the test data set which is having X i and Y i, but I will use only X i and apply here and I will get the Y predict value. So, what I am saying is we split the data into 2 training and testing, use the training data set to create the model then you apply the the test data set input variable to predict Y predict. Let us discuss in detail. Suppose this is a equation of the model we talked in the last class, so Y prediction is 0.56 X i into 31.96. This is not the same I just given some example here. Consider you have a training data, training data say 700 sorry, consider you have a training data or training data say 700 data here and you have a testing data that is 300 data value here. So, training data is X i, Y i, you are given into simple linear regression algorithm, it comes up with this particular equation. So, how it works we will discuss that in detail later, but consider it is a black box you are given this input to here and we got this particular equation that is what it gives you. C can be some value 0.76 is some value I am just given an example, it is not an actual any score to fit this values because I do not have 700 data, I just have 3 data here to show. Now, you want to predict the test this performance of this particular linear regression model on a test data set. Now, you have like a 300 test data that is 300 values of X i, apply this X i to this at each equation. So, you will have a Y predict, Y predict for each of this score like for each X i you will have a corresponding Y predict, something comes out. So, in general we use, so Y is 700, Y is 300. In general, we use 2 third of data for the training, 1 third of data for the testing that is 666 data, that is 666 data for training and 333 34 data for testing. So, the output will be thus testing at output will be X i, this X i, this X i and this Y prediction after applying the value here. Also, you know what is Y 1 because you already collected a supervised learning algorithm. So, you have a Y 1, Y i. So, this is a predicted value, this is the actual value in a test data set. Now, to compare these 2, you might able to validate the performance of this system. We will discuss that in detail in next lecture, but just want to tell you that you will get Y predict here. And comparing Y predict and Y i, you get the validation of a performance of this particular algorithm. So, you saw that we can split data into train and test. Do you think this is a drawback in splitting data into training and test just 2 third and 1 third? If you think what is a drawback, just don't your answers and resume the video to continue. So, there is a bias is the main problem in the particular data. I will tell you explain what is that. You classified the data into simple 666 and 333. How do you arrange the data? You might arrange the data based on the students in one class, first class 1, class 2, class 3 or based on the year they did the course in your subject or in the university or in the college. So, when you split the data, there is a high chance that the test data sets are not belong or may not be even related to the training data set. So, splitting a data as simply a 66 and 333 will lead to bias because the students bigger will be totally different. That is the one thing. Also, the data you selected of the same students in different class courses that is valid, but the data is from different batches. Say you are selected from one department or selected from other department and each department will have different teachers for different course. It is not just attendance only impacts the students performance. Attendance plus some other external factors like a teacher, teaching material or the course difficulty level or how many senior batches the students had all this information is needed. So, when you classify the data simply splitting into training and test set by random numbers say 66 or 333, it will not help, it will have bias. To avoid it, what we can do? We can select a two-third of data randomly from training instead of selecting the first 66, instead of selecting the first 66 data as the training and the last 3334 data as the testing, we can randomly pick 666 data for training and rest of data as a testing. That is the one way to do that. Still algorithm will be trained only for the trained data. The performance of the algorithm is tested only on the test data you have and it has trained only for the test data. So, how to avoid it? So, to avoid that error, we will use cross validation. In cross validation, we split the data set into n sets. Use the n minus 1 data set for training and left out set that is the set which you have not used for training for a testing. Repeat the same process n time with a different test set for each time. So, to do that in detail, let us see one example. Consider I want n equal to 4 which means 4-fold cross validation because it is a 4-fold cross validation because you have to do the testing for 4 times of a 4-fold. So, I have a data, complete data I created into 4 different sets. Set 1 has 25 percent of data, set 2 is 25 percent, set 4 is 25 percentage. Why this 25 percentage? Because I have 4-fold, if it is total data is 100, I will have 25 data. So, that is called 25 percentage in each set. I have a equal amount of data in the 4 sets. If you do not have equal amount, it will it is okay if you have one or more data is in one set it is just fine. So, what I will do in fold 1? In fold 1, I will use set 1, set 2, set 3 for the training. Test set will be the fold. So, this test set will be tested now. Initially, I test the algorithm or the model which I created using the test set fold. All the test set used as a training. In the second fold, second fold, I use 1, 2 and 4 as the training. This data as a test set. So, this data also will be tested now. Similarly, in the fold 3 and 4, we will use the other sets every all the data has been tested. So, this gives the performance of the algorithm. So, this gives the performance of the algorithm in a complete on all the test data available that is complete data, the n sample has been tested on the algorithm. Then this is more strong or more comparable compared to a simple split of 66% by 33%. So, it is always advisable to use the cross validation. So, how many fold to choose? Is it 4 or 5 or 10? It depends on the data set. It is always good to choose n equal to 10 or 10 fold castration is good. If you do not have that much data, you can select lesser number of fold. There is one more type of cross validation is called leave one out. So, in this particular leave one out approach, suppose you have a n number of data set, the n is total number of features. Here in this case, we have 1000 students data, right? If you have 1000 students data, the leave one out will be, this is the big n we consider the total number of students. The n fold will be 999 fold cross validation or it is 1000 fold cross validation. But n minus 1 data will be used for training. So, the leave one out, we will lose again the n is also a 1000 fold. So, we will use 999 data for training one for testing will repeat this for 1000 times. That is more strongly suggested now, but it is a lot of computational time and it is computationally costly also. So, if you have huge data, it is suggested go for 10 fold cross validation or depends upon your algorithm you can choose and number of folds in the cross validation. So, in this video, we saw what is training data and what is data split and also we discussed what is cross validation. In the next video, we will talk about some of the performance measures in a machine learning. Thank you.


Hi there, it's DJB and in this video I have a very special unboxing. This video was in fact sponsored by Mountain View Studios. They are a casting company located in Greenville, Tennessee. They have sent me one of their resin model horses to unbox on camera for you guys. So their website shows that they do a lot of different things, they have a lot of different casting services and it's pretty cool, it's a full team of staff. And so I'm very interested to see the quality of this resin because that plays a role in which casting company you should choose if you are going to be casting one of your original sculptures. And I have to film my reaction to how this is going to play out, so I'm very excited to do so. All right. Ooh, it comes with the letters. Here is Jamal, he is my new Arabian Colt resin. Thank you for collaborating with me and I can't wait to see how he turns out. Have a great day, Sherry Rhodes. Sherry Rhodes is the owner and artist of the studio and she wanted to send me one of her resins and see what I can do with it. There's the resin in the middle of the box. It's always funny because when you get blank resins, I find that they're never packaged well enough because I package my stuff crazy insane because I feel like everything's going to get destroyed so wrap them in million layers of overwrap into the picture and anything I can find in my house it's off. So I always find it funny when it's like just like one or two layers of wrapping here. Ta-da! Oh my goodness. Aw, he's like actually super cute. So I'm not going to lie, I didn't love the look of him in the photo. He really actually has quite a sweet face. He's very, very cute. I like him a lot. I'm actually pleased. This is, I don't have a traditional resin to show in the traditional resin category so this is really exciting for me. Casting wise, he is solid and I read that on the website on some of their other horses are solid cast which is really interesting because a lot of people go the hollow method so he has a bit of weight to him he's not super heavy though. Um, he stands good. You can see that he does have wire reinforced legs there's some wire peeking through that's normal in cast but in general like I don't see any weird pin holes I don't see any real flaws like he's pretty good. Some prepping but really not bad for resin. I've gotten resin in much worse condition before so that's pretty good, pretty good cast happening there. Super, super cute. I'm actually really excited. He has like a cute little pooky lip so I'm not sure which color I would like to paint him as I'm really not sure. So thank you so much Sherry. This is an amazing gift for me. I'm really, really excited. And you guys do really good work like this cast is really impressive. I'm, I'm very pleased. There's not a lot of prepping that I have to do to this guy before I can just go to paint. I can't say that that's the same for the other residents that I've received in the past. If you use the code JAM10 that's J-A-M-10 you will get $10 off the Jamal resin on the Mountain View Studios website. I know a lot of you guys are looking for resin horses where to buy resin horses so this could be a great place to start. But he's so cute. Thank you so much for watching and happy customizing.


We might just move on then to our final speaker for this session. So Lillian Capey is the senior technical advisor for health programs and lead for non-communicable disease interventions with the International Rescue Committee. She's been a public health practitioner for over 20 years and has extensive experience in different contexts. Thank you. So I'm going to give a brief presentation on IRC's SWAC on incidences, which is quite young, given that we've been focusing mostly on communicable diseases up to now. So the IRC, these are the contexts we work in. Our US program is really big because that's where IRC started several years ago with bringing refugees from Europe to America, a resettlement program during the Second World War. And now we've expanded into an international program and you can see how a lot of our work is in the conflict zones. And basically our work is health, education, protection, safety-related work, economic recovery and development, as well as governance and rights-related work. So in terms of NCDs, the contexts that we're working currently are really ranging from refugee settings in Kenya, Chad, and Thailand, to displaced population settings in Somalia and urban settings in the Sierra Response Region. And our teams in Europe also see migrants passing through with NCDs. A lot of the work we do is integrated within primary health care programs. Sorry. Yeah, so I wanted to show this just to show that very little is known about the burden of NCDs in the context we're working in, especially in the low-income countries like Chad, Kenya, and Thailand. And more is known in terms of the middle-income countries. And yet we're also aware that a lot of these are moving populations and we need to be conscious of the fact that we should prioritize varying models of care depending on the context. This graph actually raises more questions than answers. We analyzed data for 2015 from five countries. This is NCD data that we could get. And basically, we saw that hypertension is the most common NCD. We are not sure that this is OK. We are sure that this is not because of the high burden of hypertension, but because this is the illness that's most commonly diagnosed within the clinics, hypertension and diabetes, that is. And then in terms of Thailand, because they do screening every year, they have high cases of hypertension diagnosed during the screening sessions. In Jordan, we found that 33 percent of primary health care consultations are NCDs and over 60 percent of these are women. So in terms of the challenges we're finding in our young NCD program, insecurity is a big thing as we all know health care is being targeted. And we have examples of clinics and health care centers having been bombed and access to care affected as such, border closures. So we have cross-border programs in Turkey, Iraq and Jordan working to Syria and border closures as well as reduce access to the teams within those contexts. Means that patients have periods when access to drugs and supplies is limited. And so what we've been doing is trying to work with teams within Syria and working through partnerships to ensure continuity of care. A referral, especially for complications and terminal illness is also an issue. In terms of systems, so we realize that we need to be better at kind of estimating how much drugs and supplies we need for our programs. But how can we do this when we don't know the burden of disease? And in terms of human resources, capacity of staff to do the training is a big issue. We know that staff trainings ensure that programs are cohesive and our staff turnover in the areas we work in has meant that NCD management is not always done the way that it should be. And quality of care is reduced as a result of these and so we're looking at ways in which we can have a continuous training of staff. How do we make sure that we have TOTs in these places in Jordan? What we've done is train people from within Syria as TOT so that they can go back and continue with these trainings. Health information systems, as has been mentioned repeatedly this morning, is an issue, so we need to revise the health information systems with more focus to NCDs. Record systems, this affects adherence a lot, adherence and continuity of care, but also follow up of patients and follow up in terms of outcomes, but also in terms of individual patients. This is an example from DADAB where we have paper based systems. So in terms of individual level challenges, so there's limited knowledge about NCDs among communities we serve and generally this affects ability to affect positive lifestyle changes. But we're also seeing a situation where how do you talk about diet and exercise when there's no safe access? And also how do you talk about diet when people don't have access to other options? And so one of the things we're looking at is linking health and cash, where in our emergency programs we're looking at cash distribution, but also ensuring that our economic recovery programs are linked with our NCD programs. So there's also market to ensure that people have access to these healthy food options. Self-monitoring and self-care is not well established. So in some of our programs, for example, in DADAB, we have community health workers monitoring at community level, blood pressure and blood sugar, but this is not systematically done. And also it's not well-monitoring. Adherence to treatment, as I mentioned earlier, remains an issue, especially because we're not really able to follow up with people adhering to treatment at the moment. Secondly, we have patients moving from clinic to clinic and shopping for the survival of the providers they prefer. And so this remains an issue as well. Community level workers are not really integrating NCDs within our community health strategies. And there's limited resources for community engagement around NCDs. So one of the things we are talking about is how do we learn from examples of other chronic diseases like HIV and TB management at community level? So I'm happy to hear Helen's presentation on that. So what are we doing? We're bringing together these countries that have identified NCDs as a priority to review the state of prevention treatment and guidelines for NCD control and also linking with the efforts of the NCDs in the humanitarian crisis working group that's led by UNHCR so that this is done in a cohesive way. We've developed a theory of change that I will talk about briefly later to guide the program design and implementation and also working systematically to improve supply chains. On the prevention side, we realize that we need to harmonize routine and outcome data across countries to enable public health actions and also think about community prevalence and risk factors. And on the emergency side, including NCDs on rapid assessments and establishing systems for regular supply of medicines and diagnostics in this context. So this diagram is our theory of change. It's a bit difficult to read, but it's on the website and it's free for public use. It comes along with indicator lists and measurement guides as well. And basically it has two arms. So we have the prevention, health promotion arm and then the treatment diagnostic arm. And basically in terms of prevention and health promotion, we're looking at people having the resources to prevent and treat NCDs and people having the skills needed. So this is linking with education, whereas the resources links with our economic recovery programs. And then having an enabling community environment that enables people to adopt and practice preventive behaviors. And then people having the motivation as well. On the clinical management stabilization side, we're looking at people having demand. So creating demand for these services and also making sure services are equally accessible for vulnerable people as well as women and men and services being of good quality. So establishing quality control and monitoring of this on a regular basis. We realize that there's almost no evidence on NCDs, especially in humanitarian crisis. And one of the things we're doing is trying to define a research agenda. And these are the seven main areas we're looking at. We're working with people from various agencies and academic institutions to come up with a list of questions that can be answered. And this also is linked to the operational research we're trying to do. For example, in Jordan, we're trying to see if M Health could be an option and linking communities with community health workers and patients using ComCare, for example. Yeah, so in brief, that's what I had.