Good evening everybody and welcome to another MHPN interdisciplinary panel discussion and this time it's the third in our series of complex trauma, which has been supported by some funding from the Royal Commission Into childhood sexual abuse and this is in partnership with ASCA the adult surviving childhood abuse Organization and I highly recommend their website if you haven't had a chance to look at it already now we've had a record number of Participants registered for this webinar currently we have 650 of you online and there have been 2,900 people have expressed an interest in this one and registered so That's very exciting for MHPN and I'm sure it indicates how important this topic is to everybody so I just Introduce myself. My name is Mary Emelius. I'm a general practitioner and psychotherapist I work at Headspace in Cairns It is Cold in Cairns it reached below 20 degrees last night and we had to turn off the fans and close the window And I know that we've got the distance from all around Australia and so I'd like to just let you know that the Panelists the panelists that we have on tonight the bite their biographies were distributed before the Webinar and you may have had a chance to look at that But I'll briefly just remind everybody of who we've got and we're really excited to have such experienced people tonight. I Think my Visuals are slightly slower than my conversation. So sorry if I'm a bit Stilted this evening. So at first we like to welcome Bradley Fox-Lewan who's the consumer advocate on our panel tonight now Bradley you're you're really here on the panel to represent the voice of the consumer And I wondered if you'd just like to just give us a very brief summary About about the kind of work that you do in this area as well as have a bat having a background yourself as a survivor Oh, hi, Mary. It's great to be here and thank you for that. Welcome Look my role yet is to be a consumer advocate in this situation I am also a practicing counsellor and Have had some experience in psychotherapy, but I'm really glad to be bringing the consumer perspective I currently work in a number of roles which have me identify first as a consumer and survivor And I bring that kind of experience to this situation from in training settings and also through the New South Wales Mental Health Commission in my role there as deputy commissioner and it's I really believe that we need to get across the space of Supporting the expertise of consumers and survivors to be central to the work that we do and and Without taking away the fantastic expertise. There are amongst people who are there to support Thanks very much Bradley and welcome and I'd like also to welcome Sarah Kokona So Sarah's a mental health nurse on our panel this evening and mental health nurses work across the discipline in mental health all sorts of Different settings. So I'm Sarah. I just wondered how you developed an interest in working with complex trauma Hi, Mary. Thanks. And yeah, great to be on the panel with everybody tonight I have most of my experience has been in the public adult sector mostly in the community but also inpatient and also working as a mental health nurse in the homeless health sector And I developed an interest in trauma-informed care because the vast majority of the people that I work with are survivors of complex trauma and I Instantly resonated with the principles of trauma-informed care and when I Was first exposed to the literature. I was so happy. It just made so much sense to me and recontextualized the way that I could think about working with consumers and Yeah, I just think really passionate about trauma and I'm involved in trying to introduce those kinds of changes in public mental health settings Thanks very much Sarah and welcome and I'd like to welcome Philip Hildon. I'm a Phillips The psychologist on our panel this evening and Philip I noticed in your biography that you You are a practitioner and something called Hakomi. Could you just give us a If it's possible ten-word introduction to what that is Hakomi is a synthesis of Western psychotherapy and Eastern philosophy really Buddhist and Daoist sort of philosophy A group of psychotherapists in the USA Came together in 1980 and to start an institute that was having principles of mindfulness in psychotherapy and Non-violence in psychotherapy Working holistically in psychotherapy and really trusting the client and trusting The implicit processes of the client and Hakomi sort of is a name as borrowed to fit that work and the meaning of Hakomi is, you know, how are you in relationship to To whatever, you know to these many realms to to yourself to your partner to your work To your history. It asks the question. How are you in relationship? So It's introspective But it's not solely You know interpretive as it's quite holistic and relational and very mindful Psychotherapy and and I fell in love with it when I first found it in early the early 90s And so I went and studied it as well as you know mainstream psychology and Have been blending the two ever since Thanks very much feel it and it's great to have Well, actually all of all of our panelists have a really broad experience and I guess that's one of the things I've been learning about trauma is that it has to be a holistic approach and and holistic in the term of the team That looks after someone as well Including the person themselves. So I think it's just it's a really really interesting panel tonight and Last but certainly not least I'd like to welcome Warwick Middleton who's a psychiatrist On our panel it's an adjunct professor and Warwick you've got a very long experience in the field of trauma and particularly in Interest and interest in dissociation and involvement with the Belmont Hospital in Brisbane and a number of our activities And I wonder if you could just briefly Say what it what it was that that made you interested in trauma I'm imagining that that may not have been an emphasis of your psychiatric training That's something's taken you down that path Yes, it wasn't emphasized when I trained I I take the view that complex trauma is mainstream psychiatry and it's actually It's actually been very interesting and quite heartening the way in which In the general health community in the mental health community in particular, you know over the last two decades in Australia has actually Progressively recognized that and the sort of audience that you're getting for this webinar reflects that sort of interest which we've seen across the board in conferences seminars publications and And when you look at some membership of international societies that that work in this area They've never been higher in Australia than they are now Thanks very much, and I guess that that's that's really heartening to hear that so and you've also Heard the case study before the webinar and some of you this might be the second or third in this series So you're familiar with our person Tanya just some technical matters Put your general questions into the chat box. So the panellists Will more or less keep in on top of that and I will try to as well You did submit some questions at registration and we will try to pick up those things throughout the webinar I apologize if your specific question doesn't get answered, but there are now 743 participants online. So it's going to be really hard to address everybody's questions at the same time So just remember that when you're in the chat box you may you certainly people are welcome to talk to each other Just remember it's a public space and 700 people can read what you're writing Your feedback is really important. So at the end of the webinar, please fill out the exit survey You will receive some CPD points in the weeks following that will be Email to you and MHPM certainly does take your feedback seriously so if you have any comments about other area topics of interest or Things that you'd like to be carried on further. Please feel welcome to put that into your exit survey Now there's some learning outcomes. So we're going to Hopefully through an interdisciplinary panel discussion about this case Understand the key principles along with the role and approach of the different disciplines in working Therapeutically with someone who has experienced or been exposed to childhood abuse to be able to identify Interventions approaches and strategies which promote positive outcomes for people who have experienced or been exposed to childhood abuse and To take home tips for interdisciplinary Collaboration to work Therapeutically with people who've been exposed to or experienced childhood abuse and I think that's one of the key messages I've been getting is it it's it's virtually impossible for one clinician to do this work alone and it needs to be a team And I think that's why the MHPN Format is just so important to build those networks So I think that that's probably enough just a reminder about Tanya who in our previous webinar she met she's a single mum of two young girls Teenagers she's been through a lot of things in her life and at this stage She's kind of engaged with a therapist that she's seeing on an ongoing basis So what was in the case study was about some of the things that have been happening in that therapy now? Some of those things might have been a bit confronting or a bit unusual, but for those people who work regularly in this field Most of it is kind of what what we use to But nevertheless these things are you know can often be surprising and difficult to handle So I'm sure we're going to cover lots of interesting material tonight. So I'd like to first of all welcome Our panel a panelist who is our consumer advocate Bradley. So Bradley when you read the case Study about Tanya's therapy and what's happening in there? I wonder how you would think about Tanya? So thanks very much and welcome Bradley Thank you Look when I read the scenario I really thought here's somebody who's seeking engagement and seeking relationship with another with a number of people and Wondering, you know, how could Tanya be supported to actually follow Follow up with that with that seeking in in kind of safe ways where she might not have actually had that opportunity in the past To be able to engage in a situation where she's held and feel safe and Some of the kind of approaches that she took to Engage and kind of get connection with people might not seem appropriate in the first part, but given the context that One could imagine that she's coming from it seems entirely understandable and kind of contextually correct really for her For her experience to be engaging in the ways that she's engaging. So it didn't hold a whole lot of surprises for me But it did lead me to kind of think Here's somebody doing the best with what they have and and how can we support her to the, you know, develop those skills further and Leads me to that the slide that's up on the up on the Slide show whatever you call it and it's something it's a little slide that I just really love It hangs on my on my curtain in my office and when I kind of get kind of maybe a little bit Possibly overwhelm myself by the process of identifying as a consumer and a survivor in this some in In the sector I go back to this and it says when somebody loves you the way they say your name is different You just know that it's safe in their mouth and it's a quote from a little boy named Billy I don't know where it comes from but it's just a Something that I hold is I hold as dear as you know When somebody approaches a professional or approaches any other human being if if their name is held as safe in that person's mouth Then we know we're in the right place to actually be together in a useful way So shall I continue with the slides and yes, sorry Now just one technical thing. I actually didn't explain I many of the petition events will be familiar with it, but each Present is going to present their their first response to the case before we commence the interdisciplinary discussion So Bradley if you could carry on with that and if you're happy to advance your own slides that'd be great. Thank you No problem. Yeah, I just want to if people can hold this idea of somebody's name being self safe in your mouth I think it's just a wonderful kind of concept and to come out of a four-year-old four-year-old's mouth just gives it even more of a poignant kind of You know lands with me in a particular way in For professionals and a lot of this is not me drawing on my own professional work It's in many ways drawing on what's actually helped me to recover from significant childhood trauma or at least be in recovery and What I'm in response to the scenario I would be asking people to be willing to really engage in diverse ways of knowing that create that You know people creatively adapt to their situation and And maybe don't always have the skills to do it in in a way that actually may seem like You know down in the middle ground sometimes it's quite edgy the way that people try and engage in relationships and and I see Tanya doing that and It doesn't mean that It's wrong It's just means that this is a way that a person has adapted to be able to try and kind of regulate their own experience and I've had those experiences of trying to regulate in unusual ways and That means that people Who are in the helping trades actually need to be able to kind of recognize that these some of these approaches will be Unusual and that that's not wrong. It's just a way that people learn how to cope And I just really like this quote by Steve on can on can He says that children that children make adaptations to survive that are brilliant and creative, but they're often personally costly and That you know, I've also done that myself engaged in some behaviors around drugs and alcohol that haven't actually Worked for me long term But while that was the thing that I could do that was that was the thing I did because it actually supported me to deal with the level of pain that I was experiencing and Allowed me, you know, they don't call I'm smoking pot getting out of it for no reason There's a reason for calling it getting out of it is because there's reason to get it to seek to get away from that Sort of internal pain and the experience of running up against possibly people who aren't going to understand you so in I just I really like this Contact is my Contact is the thing that I see as the first port of call It's people who have been able to contact me and hold me in a particular way That kind of supported me to come back into relationship in the very small sense in the first part That enabled me to go to a place of okay You know, I might feel safe enough to connect with this person and actually that content that contact over time actually has Supported me to make connections with a person that would then build into Relationship and over time that would lead me to has led me to a place of being able to manage and hold intimate relationships and and a sense of place of being in the world and and as a Result of getting a sense of place in the world being able to kind of like Reshape my own sense of self and that's what I see Tanya doing as well is She's kind of like seeking connections. She's seeking kind of contact on a number of different levels and if those smaller kind of Processes are held well then everything else becomes possible and that's why I kind of put that up there as a slide because I I don't and sometimes services actually go for Relationship, let's you know, we need to create relationship with people And that's all good and fine in how it's kind of put out there in language but the building blocks of relationship are around contact and Sometimes people are overwhelmed by that whole idea of here you could here's somebody trying to help me and be in relationship with me and that's just really too scary and so I'm going to exit out that door in order to create the isolation that actually allows me to manage my Disregulation my internal dysregulation and and escape that relationship. There's too fast too quick to overwhelming I've seen your slides and I know that they're fabulous And we've we have a limited time to get through each person So I was wondering if you had mine just going over them at a more superficial level and then we'll I promise I'll give you the opportunity to get more into depth in the panel discussion. No I mean really good stuff in there and I want to make sure we get through it all not rude at all I put my lion up here because People who are survivors often experience kind of like feeling like prey animals in in regard to service delivery and people trying to support them I Think it's absolutely imperative to support people to have an expert position in their own recovery and that Authority actually gets in the way whereas co-authoring actually is very supportive of people and Helping along the way and we'll talk about the got ski later and The person who's able to apologize is is a person who That evokes kind of trust somebody who's able to apologize and I've had this in my path Where people have said look, I'm really sorry something has disrupted our relationship And I'm sorry if I've had anything to do with that It may not be to do with me It may be to do with what's going on between us But I apologize for any part that I've had in it has been an amazing shift in In the relational quality and and how I've been able to support it be supported and I think Tanya would benefit from that too Yeah, let's talk about some of these other things later on so we can move on Only to say I think this is a lovely one Don't be afraid to open the can of worms the person's already living with them It's people don't have to be a fear of Opening the can of worms people are walking around with their can of worms and if we can engage that can of worms in a useful way We there's a future Yeah, and the and there's a last point around hope and despair Hope is for the relational kind of realm realm to spare is for supervision. It's what I'd like to say I particularly like that one Bradley. I knew it was coming up Thanks so much for that and now I'd like to welcome Sarah To respond from the mental health nurse perspective as to how you would be if you Saw Tanya, thanks very much. Just I'll go into your first slide. I think my Video is a little slower than the audio. So I'll let you do the slides now. Thank you. I've put it on to my first slide So thanks Mary So I'm aware that the participants in the webinar tonight have read the case study enough familiar with Tanya's history And I just want to highlight how important it is to hold Tanya's experiences in mind I think it's one of the most important trauma-informed approaches that we as clinicians can take is to respectfully Seriously ask what has happened to this person? This is just as essential to keep in mind with long-term clients as well as people with whom we work with short-term This inquiring humanistic stance helps to contextualize Tanya's presentation as one of resilience in the face of growth injustice a constant sense of danger a lack of security and support Overwhelming pain and stress and to my mind this framework is so much more useful and therapeutic than asking What's wrong with this person and then jumping straight into treating the problems and managing the risks? We know that the brain is plastic and is molded in particular by our early relationships with our primary caregivers and Tanya's neurobiological development has been seriously disturbed by her traumatic experiences which have been compounded again and again over the years and We can see that Tanya exhibits many of the vast array of symptoms of complex trauma So now that I have a curious dance of Tanya through a trauma-informed lens How can I actually begin to help Tanya? My assessment tells me that Tanya's in crisis at the moment her internal and external world or in chaos I'm very concerned about her safety emotionally physically and socially But apart from these outward behavioral manifestations of trauma and significant psychosocial Stressors, I also wonder about what she's experiencing internally and I imagine how overwhelmed that she must be feeling Wondering about some of the triggers about her daughter wanting to leave home might be touching on some of her own trauma from around the same time these awful nightmares and Intolerance for having food in her mouth which suggests that the sexual abuse experience has involved her mouth in some way which is leading to Massive interruption of her daily life in terms of not wanting to eat and losing a lot of weight malnutrition, which is a really serious problem It's interesting to know that she wants to reconnect with her mother at this time suggesting a really urgent need for love and attachment and security Sarah, can I just get you to pop your microphone a bit closer to your mouth? It's a little hard to hear you. Yeah, thank you Closer like I can get it without eating it. How's that? Fine, I'm just speak up. That's good. Thank you. I'm gonna speak up a little bit. Yes, please. Okay So it seems that Tanya is being overwhelmed by the stress and terror of her past unresolved traumas Which are seriously intruding into her life now as an adult As she hasn't yet developed the skills of self-care, which we acquire by relationships So it'd be really important to not rush Tanya into processing the details of her trauma with me until she's safe and Has the capacity for self-regulation and self-care It's possible that we might remain in that early phase of treatment which is focused on safety for a really long time Without moving on to Processing or anything just working in a safe and trusting manner will be a good start so there's obviously lots of issues to address and Tanya's story could Possibly be a little bit overwhelming. So it'll also be important to monitor my own reaction to Tanya and to attend clinical supervision So I'm really glad that that was in the case study But the first priority is to promote her sense of safety At this point I'd like to acknowledge the ASCA guidelines and the principles of trauma-informed care that are outlined in our family guidelines to be really helpful in terms of my own daily practice and Let me just move along the slide. So the trauma-informed principles are safety, trust, choice, collaboration and empowerment And to my mind these are things that are taken away from children to experience abuse and It's a primary therapeutic task to try and reinstate these features in my interactions, my therapeutic relationship with Tanya So safety is number one. Safety and not causing further harm and trauma are essential ideas for me to be holding in my mind Working with Tanya Beacons, unfortunately, I know that mental health professionals and mental health services can inadvertently re-traumatise survivors So if I do no harm, that's a good start Some more examples of promoting a sense of safety with Tanya in this case would be to help her feel calm and safe by being calm myself and having consistent boundaries So her earlier question inviting me to have sex with her is an opportunity to instill a sense of safety with Tanya I view this invitation of hers as a very disturbing reflection of just how deeply her boundaries have been violated and smashed by caregivers, so-called caregivers, and how sex is possibly a confusing and unsafe form of her seeking attachment with others I Would be very focused on taking all of Tanya's complaints very seriously and all of her concerns seriously being very careful not to dismiss her in any way I'd be on the lookout for dissociation and from the description in the case study of her change in tone and affect I think that's that's Probably what might be happening for her sometime So I'd be using grounding techniques making comments which reassure her that she's safe with me That what happened to her was not her fault And I'd be working on a knowledge of neurobiology in mind and being cautious not to overall Work within that our window of tolerance I'd be wanting to try to gain Tanya's trust slowly over time And Yeah, this is vital for her to begin to perhaps start to work with me to start to disclose some More details of her trauma and the related painful emotional states such as shame I would be wanting Tanya to trust me enough to Increase her frequency of visit. She's been coming monthly and Yeah, I don't think it's enough. I'd be wanting her to try to come more frequently weekly at least and really without being pushy letting her know that I am a thought of Consistency and support and nurturing that she can really rely upon I might even also offer phone contact and probably try to Yeah, involve other people in her care or other support I would think it's really important to let Tanya know that I don't judge her But I see her very worrying behaviors as her attempts to cope with overwhelming pain fear and stress And as her way of trying to put the pieces back together somehow I would be offering Tanya psycho education about trauma symptoms and Painting the landscape for her about what what she can expect and reassure her that her reactions are normal Responses toward warming stress and maybe give her a little bit of information about neuroplasticity the social brain and and healing It's essential to offer her hope that recovery is possible at any stage with the right kind of help And I would yeah explore with Tanya her personal meaning of the connections between her pain her Drinking of self-harm her suicidality try to get her meaning with those things I Would anticipate ongoing fluctuations with her affect and her attendance her engagement And this is will just be a normal part of the very slow healing process I would be focusing on on trying to foster her affect regulation and self soothing distress tolerance We're holding in mind that Healing relationships more than anything more than any particular Technique is is the healing factor and Trying to help Tanya integrate her emotional functioning cognitive functioning her physical health But again slowly over time Very holistically I'm probably running out of time But I just is that my last slide yesterday's I just wanted to quickly is that I can marry have I got another minute or so Yep, you've got Yeah, this is my last slide So Complex trauma as we know is often misdiagnosed and mistreated resulting in fragmented care over time That can inadvertently retraumatize someone like Tanya So it would be great if there was a stable person in her life who could coordinate her care But conform a stable base when more if more people become involved in her care Um There's some really practical terms apart from the psychotherapeutic needs that I'd like to quickly address and for me one of the red flags is child safety I'm pretty worried about the safety of her daughters at this point And the fact that she might need some help with parenting and she might we might need to have some very transparent and honest discussions about Particularly the risk of her younger daughter who's nine years old who by the sounds of it is being left alone at night sometimes or Tanya's bringing herself and intoxicated partner's home with her young nine-year-old in the house and I'd just be talking to Tanya about this that she's putting her children in and also her eldest daughter who's Probably undergoing some emotional. Yes, psychological harm from witnessing her deliberate self-harm. I'd be telling Tanya that I'm a mandatory reporter in my Professional role and letting her know about when I'll be obligated to report but framing that in a supportive way and trying to help her Take take care and take responsibility and accept some help with parenting The other red flag is suicide and I take Tanya's suicidality very seriously I'd be conducting a thorough suicide risk assessment and while I know that the ongoing safety and and Security of a long-term therapeutic relationship and other healing social relationships are going to be the long-term buffers against suicide that sometimes she might be an imminent risk and you know I need to put more supports in place daily contacts and put together a really good plan and really try to avoid calling a key care services and Admissions, but that might be a possibility at some point with Tanya Work with Tanya's strengths work with her goals. She's identified a couple of them. She's made a new friend She wants to keep parenting her daughters. She wants to keep her job The only other thing is sort of potential referrals to maybe her GP does you need a work certificate to Cut back to part-time work for a little while her job is at risk her finances are going to become a problem and Her physical health is there's a few other things. So but yeah, I'll leave it there for now Okay, thanks Sarah and I know that a number of the things that you've raised there around this Suicidality the child safety issues. There's been lots of themes coming up about boundaries and So we will revisit those in discussions altogether and thanks very much Sarah for your contribution and Philip I can see that your first slides up there and I'd welcome your response to Tanya. Thank you Thank you, Mary. Thanks for the invitation to talk about such an important topic as complex trauma from you know relational psychotherapeutic perspective psychology in the main Sort of tends towards the exposure therapy for trauma and When we enter the realm of complex trauma, we sort of have to go very easy on exposure so my first slide really talks about dissociation avoidance or flight and From my perspective with complex trauma, we need to make friends with avoidance behavior and actually probably even need to support it Let's be mindful of it and and not not fight with it in terms of needing to expose people but Actually support people more mindfully in their dissociative or avoidance behaviors in a therapeutic way, so Some of that is just a normalized fight or flight, you know our body our nervous system has these capabilities and Fight or moving away from stuff. It's overwhelming. It's good. It's healthy And by inference hey good on you for taking care of yourself in whatever way you're finding yourself needing to to cope currently so To normalize that is very very powerful and good in working with people Tanya shows a lot of flight impulses her eating her alcohol Potential dependency on Ramona Is another one her blackouts are self-harming or suicide behavior Her dreams of mummy taking all the pain away all of that I see as Indications of a flight response and so all of that I'm gonna make friends with not necessarily Delve into too deeply but just make friends with it I may do small Exercises with her in the room such as well.  I'm wondering if we can do an exercise for a moment and See if she's interested in that and say something like you know, we can do a small exercise where How about for a moment?  We'll call it the stress for each year And I just wonder if for a moment or two if you just have a little bit of time out in the stress for each year I mean, we can come back to all that stuff in in a second But you just look overwhelmed at the moment. So what I'm doing in therapy now is just doing a flight response Therapeutically, I'm not having her do any Anything else except move from stress to being stress-free and that's what she's doing with all her symptomatic behavior Her blackouts and parts of self Her blackouts are also needing to be Some psychoeducation as Sarah was saying some normalization some relational connection so blackouts I Would just normalize them and say hey anyone can have blackout if I drink too much. So And then to talk a little bit about parts of self parts of self the mind in someone who's a complex trauma survivor is Quite often quite fragmented and a person could be hearing voices and I Want to make friends with those parts of self and Indeed suggest that we take care of the different the many different parts of self and look after ourselves in that way I also want to talk about attachment and normalized attachment and And her secure attachment experiences that didn't get to happen and that she shows a lot of attachment needs and To help her Understand that it's normal again. It's physiologically normal for us human beings to want attachment and crave attachment And so that reference to you know, do you want to have sex with me in the vignette as Sarah was saying I would Tie that into her attachment needs and normalize that and at the same time is setting a clear boundary about the therapeutic relationship So I would say to something like Tanya your attachment needs are normal and healthy I know that you don't want to have them with some people because they're not to be had with some people but with yourself and the right people, you know attachments great and Then that leads me into hey, let's explore that a little bit So maybe just take a moment to connect with yourself or attach with yourself right now and just notice what that's like And so again take the the theme into the the present moment of doing some therapy with her The core relationship always has to be my I have a very strong bias here always with the client with themselves So I do hear what Sarah was saying about you know to develop good relationship with the therapist But my bias even more is to help the client really have a better relationship with themselves and then with me I want them to really hang out with themselves and start to make friends with themselves To be self understanding self regulating self-carrying self accepting So I really want the client to ultimately take over the parenting that they missed out on And now that takes some work, but that's the direction that I'd be heading with with Tanya and Finally clear boundaries and limits No matter what has happened to a client They still need to be appropriate as an adult and so I will be gently or not too gently sometimes Saying to people You know, I know you've been really Traumatised and so on but you know you can't treat your children you can't treat yourself you can't treat your parents You can't treat society in any anti-social sort of way So I'm glad you've come to talk to me because it's showing me that you want to change that and we can transform that into good relationships So clear therapeutic boundaries and limits are absolutely part of the picture as well Thanks, Mary Thanks very much Phillip and I know that what what you were saying before about the the person's relationship with themselves and their inner parenting and In it in the capacity to care for themselves is a little bit along what Bradley was going to talk about that we made him skim over. So Thank you for that. Now. I would like to welcome Warwick to just give his response also to Tanya before we start the discussion between the different disciplines Yeah, thanks Mary Tanya is a complex challenging individual and unfortunately because in our world all of the issues she has are actually quite common and That's the challenge is that You know this sort of trauma has largely been silenced by fear and shame and Well, I guess one of the things that I would emphasise in in in dealing with someone like Tanya is Just how important an acknowledgement of the of the shame and fear that that actually underlies the secrecy of abuse really is I Think one of the things that underlies all the therapeutic approaches is something we could call acceptance But then and that's part of the building of a sound therapeutic alliance and with a sound therapeutic alliance a Great deal is possible without it virtually nothing is possible. I I Part of my one of the things we're picking up about about Tanya is that she has had very Limited development of self-hood. So if you grow up in an environment where there are no boundaries It's very very hard to actually have sound boundaries because you learn boundaries by being brought up in environments that have them There's challenging things for the therapist in this that she she throws up issues about Self-harm which for some can be disturbing she throws up issues about sexual boundaries Which for some can be frightening and she throws up references to things that are difficult to for some people to Get there their head around in terms of the sort of traumas that that actually have happened to her someone made a question I noticed earlier about I Just think what it was it it was about You know the issue of whether you know it's possible to or it's desirable to sort of insist that people such as Tanya You know don't self-harm if they come into therapy or in the fact fact It's it's incredibly unhelpful because all you're doing is really setting up something that's unworkable because the vast majority of people That come from this spectrum self-harm has been a part of their life and a part of their coping style Since almost forever and what therapy is about is ultimately bit by bit replacing You know usable but fairly maladaptive forms of self soothing with more adaptive and that that means you know Utilizing skills Developing relationships, but somewhere I also say you know don't give up your day job You know there's the things that she's got that are strength She has been a mother she has worked in the workforce. She is capable of having friends So these are these are important things But also remember that that you know that the the average age at which you know Someone gets sexually abused a commonest age where it starts is something about the age of three So a three-year-old is very conditioned sexually and that brings with it the manipulation of the abuser About the mutilization of the of manipulation of a rival the Often at times the induction of altered ego states or dissociative states that actually are used by the abuser to enact their sexual abuse Processes look and I you know people people you know talk about You know processing trauma some some people you know, you know leaping a bit far too quickly really and and you know It all sort of goes pie-shaped. I mean what you're really trying to do is establish a safe avenue and In order to do that, you know one doesn't you know one looks at how much petrol you've got in the tank You don't set out on a journey where you haven't got enough petrol to make the journey It's been mentioned earlier tonight that you know is one one therapy session a month Adequate and almost certainly it's very very suboptimal and sometimes sometimes that can bring more problems than it solves if in some people that have been so traumatized and have you know so little ego strengths and so little support that they really They really have got food that they're they're a walking wounded casualty station sort of victim and You know you're not going to get them, you know charging out onto the battlefield again without a lot of time spent Initially getting to a point of basic safety and always remember that you know these people have been brought up in environments where where very few people were to be trusted and and Safety was something that they experienced Very infrequently and sometimes never experienced So at the other hand on the other side of the coin It doesn't help to Essentially say to the patient that you know because you've had such a terrible life You know it's excusable for you to do anything and and we'll excuse it on the basis that you've been so abused That you don't have to be responsible, you know You've ultimately you know life is very unfair and ultimately you've got to play the hand you've been dealt and and you know one of the one of the corollaries of that is that at the end of the day the majority of the work that has to Be done ultimately has to be done by the patient if you're in therapy and you're not being challenged And you're not feeling some discomfort about some of the things you're dealing with and you're probably Riding along pretty well, but but nothing much is changing and as I said earlier, you know, don't insist on pledges, you know that not to self-harm and don't anyway assume that in order to have therapy that you've got to have total trust from the patient I mean many of these patients transferences are based on What you might call Mistrust or indeed paranoia, but that doesn't mean that they won't turn up But they're checking you out and that they're checking out may go on for a long long time on the other hand Some people in this spectrum do develop trust and when they do it's a pretty solid Component of an ongoing positive therapeutic alliance, but don't insist on it and I always say, you know, I wouldn't I wouldn't if I was in your position I wouldn't trust anyone either So, you know and we dispense with the issue with that and it doesn't usually become an issue Could I just say that, you know therapy is not a manual, you know, there are a lot of Guidelines and principles a lot of which have been Enumerated by people here already tonight But it's very unhelpful to get a manual that says, you know by by week 10, you know, you should be processing this or you should be at this stage or that stage When people do that sort of thing it invariably ends up badly what you do is is Adhere to general principles that people are different enough that that that no, you know, regimented prescribed Process that seemingly works with one will generally can be applied Unchanged to another person people have different trajectory Some are a lot more social support some have got a lot of skills Some some some in fact are still in situations where they're being exposed to ongoing abuse and it stands to reason that you can't Do anything about processing past trauma when you're still actually having the same sort of trauma being re-enacted in your life And one of the one of the studies that I've been involved in is the issue of ongoing incestuous abuse during adulthood and when you deal with the people at the severe end of the complex trauma system system Those that have diagnosis of dissociative identity disorder one finds that a significant proportion I would say probably in the region of about one in eight of those have experienced or continued to experience ongoing incestuous abuse as adults and Some therapists are completely unaware that this is the reason that their patient is not getting well or is Periodically getting badly decompensated is before they're still being abused and in a dissociated state This is not being Enumerated or recognized and of course one of the things that comes up in this in this case is There are a lot of references to things that sound highly dissociative, you know changes in mood states Patchy or absent memory of you know sexual encounters with people and turning up in a very sexualized sort of seemingly State, you know offering sexual contact with a therapist Can I just leave you with just a couple of reference points for further reading one is one is With the ASCA guidelines are absolutely Very very helpful and and I guess a more specialized look at guidelines as they pertain to severe dissociation is the international society for the study of chromat and dissociation guidelines for the treatment of dissociative identity disorder and As indicative of the fact that this is very mainstream psychiatry in Australia Last month's edition of the Australian New Zealand Journal of psychiatry had an extensive review Which is available from the website or if anyone wants to contact me. I'll send them a copy. So thank you, Mary Thanks very much Warwick now. I'd like to what we're going to progress to now is the discussion between how we work together as Professionals to care for someone like Tanya now broadly something that came up in the participant chat box there was there's been a lot of conversation about Going slow and being respectful of people's you know Traumatized state and not pushing them into talking about things and this may seem in a way in contrast with your Encouragement to not be scared of opening the can of worms. So I wonder if you could just comment a little bit more about How we open can of work cans of worms in a slow and respectful way that doesn't harm people further Well, I think in Tanya's situation The can of worms is already open. It's not there's no kind of a risk in regard to kind of like Or fear to say well, I don't want to open a can of worms with people because I'm most trauma survivors in my experience are coming with that can of worms open Tanya is kind of operating in ways that kind of like show up that she's really struggling so it's not about kind of Going slowly for the sake of not trying to open the can of worms It's going slowly in order to be able to honor that it may take time for that for the trusting relationship to be built and that in the therapeutic relationship that trust is everything from my perspective around people being able to kind of like I'm Regulate themselves to the point of being able to make meaning around the good things that can come out of a therapeutic alliance That's where my approach to slowing down comes into it and the trust that's developed in the relational in the relational realm can support the articulation in a safe way of the ways in which Tanya is coping and Bradley I Understand that you also We didn't get time for the the got ski quite but but really what what it's talking about is that Every function in the child's development appears twice so on the social level level and then later on the individual level So in a way someone also spoke I think it was Philip about developing our own internal parent and the therapist can sometimes Form that function in loco parentis, which I know was an issue you wanted to raise So I wondered if you just wanted to kind of address that to Sarah and and we'll have how you would work together around that Sure sure my my perspective is that there are and I've had I have this discussion often and often around people working with people with mental illness as well is that what what elements of friendship actually exist in the in the worker-client relationship and what elements of in this situation what elements of being in loco parentis with a person is actually To the greater good and is supportive of the person feeling that they're well supported In an environment where they may never have had that actually occur in their life in the past or that's been undone through trauma So I would like to hear from others around what they think about that issue I might just open that up to you with as a therapist, you know, what's what's that experience like of becoming aware that you are in a way? Helping reparent someone and how do you how do you manage that in yourself as a therapist? Yeah Well, I'd just like to point out that I'm not a psychotherapist I think I'm probably the only person on the panel in the train in psychotherapy I but I work in long-term therapeutic relationships with highly complex poorly engaged and Bivalance people with multiple complex needs the vast majority of whom have Backgrounds of horrible abuse and have developed complex trauma So I work in a therapeutic way long term, but I'm not a therapist I'll just I'll just say that But yeah, I definitely know that feeling and recognize that dynamic of working with adults of all ages and I I'm being parentalized and I think it's absolutely fine because I will have my professional boundaries and I think it's very therapeutic to be attuning and using my skills to Soothe and calm listen validate attend to the needs of the consumers that I'm working with to promote a sense of safety and security and I'm very aware a lot of the time that I've worked with people that are very similar to Tanya who have been abused in their family times then moved on to institutions who then Been abused in those institutions who then wound up on the street had children early no time for self-healing Developing a sense of self or anything like that and then seeing this suite of Very creative but ultimately harmful ways of trying to cope with substances with self-harm with You know unsafe relationships and all of this kind of thing that we that we see with Tanya I Feel like without sounding patronizing It's part of my role to To soothe the inner child Even though I'm an adult and I'm working with an adult and we're not related. I'm not this person's parents I definitely see some of those elements of parenting as a A really important part of the way that I relate with my consumers and make this space between us a safe one a consistent one Yeah role modeling appropriate behavior Self-care and all of those things so I've probably I'm probably repeating myself now So yeah, and thanks for that Sarah and I think it follows on to what something Philip did raise about Building up the the the person's capacity to care for themselves in that way as well. So I wondered Philip if I could Take it over to you So you you had a comment about the importance of early intervention to attend to the presenting crisis issues and calming the nervous system and I wondered how How that goes about if you could just talk more about how that Is also about their capacity to care for themselves and how you practically build that up So start that sure. Thanks, Mary One of the bits and pieces that I'm looking for is Knowing that I'm progressing with someone I get a sense of that by just paying attention to How they are in the present moment and I hear the story, but I'm paying more attention if you like to the storyteller So that that orients me to the present moment and the person's present experience and Legacy of the complex trauma as Alexa As Reich said to us, you know is present in every breath and every gesture and every moment of the client's present experience So I want to do I want to get on to any presenting crisis matters and any Anything that's really threatening the person. I want to identify and Then say hey, there's a service that I know that can help you with that. Hey, hey, I can help you with that issue Hey, let's do that with that issue. That's let me get you this person's details and contacts to support you with that issue and so on And Philip, can I just interrupt you there just on a practical level how do you know? If you're you're you're aware how distressed this person is how vulnerable they are the complexity of what's going on How do you choose? Who to refer them to and how do you then communicate with that other person that they're seeing whether it's a support service or another? Therapist or you know, how do you build those relationships and how do you find people that you can trust to do a good job? Um, well, I have to trust a lot of professionals that they will do a general good job But those people that I know I'll refer to a straight a straight away So if I know a good legal person, I'll be straight on the phone to them If I know a good financial counselor for someone or someone who's got a welfare or social work I'll jump straight on the phone or straight on the internet or speak highly to the client of these resources and and Try and get that as the crisis matters Taking care of as quickly as possible. Now. I know we've talked about trust Trust is sometimes built resiera in that resiera in way. We just empathize with the clients feelings and so on and Trust I believe is also built through very pragmatic crisis and prevention if you Do something or offer something or suggest or Organize something that's very very helpful pragmatically. That's a mentor client to you very very strongly. So and What I'll be looking for then is This client sort of giving out a big sigh. Oh, you know, I can see a light at the end of the tunnel Oh, there is a hope here. There's there's something good about attending counseling. There's some way forward for me You know, I don't have to live in misery. There are better options a better possibility So Trying to look at the nervous system and I know I'm going well when my clients are relaxing when they're physically Melting if you like all those big size of relief or those big size of oh, I didn't know about that. Um, I wasn't aware of that and Oh, that's a possibility. I'll say that's a possibility for you and they go, oh, that's that feels so much better So when the weight's going off their shoulders, then I know I'm There's potential for more cortical or neocortical or self Awareness so I I get less of the child Acting out and more of the adult who can see your way forward And that's the parental in the inner parent or the inner self That I want this more grown-up self now to be more present And I ideally want to do more therapy with the grown-up self Then with the children the inner children I want the self to Talk to the inner children and and so there's an inner parenting that starts off here In this sort of elongated sort of fashion Thanks Philip and I I think that that would flow onto a question really for warwick Um, I'd like warwick to answer that's come from the general chat So warwick um, many of the practitioners in our um participant You know room tonight of him. They've been a steady 800 for the last hour um Are working in situations where they the the person only has access to them through medicare and they're limited to 10 sessions So I just wondered if you had any thoughts about Whether we should even embark on the on at a 10 session In treatment or you know What what to be careful about because I'm sure you have some thoughts about that. Yeah Yeah, I mean I inherit at times the refugees from this sort of scenario where someone's embarked on A once a month or something like that therapy with somebody who's Very dissociative and highly traumatized and you know can't hold it together from you know one week to the next that alone for four to five weeks and then You know it meanders along and then of course they run out of their sessions And then there's this what do I do now and that's probably at the entry point that you sort of hear about the problem Which gets back to what I was saying before about you know checking how much petrol you got in the tank before you set out on the journey if if You know generally speaking if you know and I mentioned the the international society guidelines on on the id which is that Applies to the sort of severe end of this spectrum and you know the general principles general principles there that if you If you're undertaking effective Therapy then you're probably looking you know reasonably long-term therapy that's happening about once to twice a week I might add it It generally doesn't help on a regular basis to do it more often than that because the message you're giving then is That you know you're telling the patient effectively that they're incapable of sort of managing their life day to day On the other hand if you set up A working with somebody who just is you know very unsafe and and You know seeing someone and saying well, you know, we'll see you in another five weeks time Is often less than helpful to the point of you know It it could in some cases actually be harmful I think to set up something that you've got no expectation of ever finishing and where you can never Logistically put together a workable therapy. So but having said that You know everyone as I said before is is different and and While some people get support by seeing someone relatively infrequently They know might be processing much, but it does provide some support and stability to their lives Others just become more fragmented by it and end up being referred on somewhere else And what about the idea of actually doing your 10 sessions weekly or or perhaps fortnightly but But starting to you know at the beginning of that knowing you've got 10 sessions Making sure that the person's got other supports in and then doing it in birth. You know, is that ever So what are you what I mean the the reality is then you get to the end of your 10 sessions in your burst and then You say well over to you now We'd I hope that you'd be cured now, but now you're just actually coming apart So So we're gonna lobby this If in doubt don't is generally the principle, you know If it's not it's not a good thing to be experimenting, you know, I've never done this before and I'll see what happens And whoops, you know, it turned out pie shape and now can I find somewhere to To kind of I'll float this terribly messed up patient that wasn't helped by therapy Which is often a hard sell as well Yeah, thank you for that Bradley. I wondered if you wanted to comment on that from the from the perspective of The consumer themselves, you know, whether a Short but supportive positive experience might be better than nothing Or whether it would be better to wait for them the more the option of the longer term support Okay, I really think it does come down to the individual. Um, I think um, I've often been heard to describe my recovery as accidental Moving from one kind of Supportive or situation to another and having short grabs at it and But I think it's the quality Because we don't live in an ideal world. We don't live in a situation where people are going to necessarily be able to active Engaging that long term counseling and I don't think our system set up for that either So, you know, my personal opinion from my own experience is that it can be done in the accidental recovery Kind of model But it's more ideally suited to have some significant opportunities to engage with somebody who Can hold that space or support the holding of that space while skills are developed that may not have been developed before But there is a thing called accidental recovery and I think there's many many people out there doing that And I think Bradley the research says that about 40 percent of the Change that happens during therapy is related to what we call extra therapeutic factors That things that actually happen in someone's life that are nothing to do with therapy So I'm sure you're right. Um, and I also just wanted your comment on, you know, if Phillip's been um Very you know strong about the fact that people also need to to to be responsible for behaving well and Not to behave in ways that are harming other people even Though they themselves have been traumatised and one of those things might be the child safety matter or sometimes Taking mandatory, you know action if someone's seriously suicidal, but I wonder how from the consumer point of view how How that can be experienced or or can a therapeutic relationship survive some of those mandatory responsibilities of the professional I think sometimes they can sometimes they can and sometimes they can't and My approach to it is is that um When a person is using coping strategies, um that they're that are harmful to themselves. That's one thing um and that um Those coping strategies are very creative ways of dealing with um dysregulation um And yet if there's imminent threat of harm to themselves or others I think a duty of care kind of um arrangement swings in there in support of the person staying on the planet and also in relation to children if there's imminent threat of um of harm um, and yet um Sometimes that gets over exaggerated in that a person is um not It's not an imminent threat to harm and the person is on the one hand They're in the rooms with the person seeking to make a difference in their lives And they haven't yet developed the skills and this is taking away homicide suicide as a as part of that equation But um in in tannin situation the self-harming Um uh scenario It's so easy to conflate self-harm with um with suicide And I think that's a mistake and they need to be kind of like um unpacked side by side Because for tanya the self-harming process may actually be a um a stress relieving activity Um that what that she's creatively adapted in order to be able to manage her internal pain So I think we can't kind of be very black and white about that But we do have to um stay close to what is our duty of care when it comes to that imminent Imminent serious harm to self or others So I think it's a it's a maturing conversation around what is the what's the agency in that You know we need to be able to consult people around their agency In regard to how they're managing their own self regulation And that without kind of going well, you can't do that anymore Even though that may be the only coping strategy you have without recognizing that it has had agency and it's costly And okay, how can once we've acknowledged that how can we develop some other strategies that might support you better? Thank you for that and I'm just we're just down to the last few minutes. So I'm going to invite everyone to um Offer their final comments But I guess what I'm really thinking about is if we have a team here where we've had this We've had a psychiatrist. We might have a mental health nurse in a in a general practice setting The patient may have been referred to a psychologist as well And then the person themselves So I wonder if you could be thinking about that that team Teamwork together for the recovery of this person In your final comments. So I think I will first um invite sarah to just um any final comments You want to leave for people with particularly about about collaboration with other professionals and the person themselves. Thank you Thanks, mary Yeah, look, I think um the thing to remember is that um the trauma-informed care revolutions have just sort of begun at the moment. We're working in imperfect systems and um different the services are kind of split up that um we should aim for integration and safety and Working together holistically and just holding those principles in our mind um And yeah, just that we you know, there is a national and an international movement that's happening um Resulting trauma-informed care. Um, but yeah at the moment, it's important for us to maintain um connections to our our networks our collegial networks um and um, yeah, keep increasing our knowledge base and um Working in a very person-centered um person-centered way. Um, yeah I I think uh multi-disciplinary collaboration is um essential and Yeah Thank you. And I think I'd like to invite warwick next and I I notice your comment warwick that you often end up seeing The refugees from the system where the system failed them So I wondered if you had any kind of final comments about how we can work well together to try to avoid the refugees happening um Look, I look, you know, so many of these people in this spectrum Have had us experiences where they were made to feel awful Or where effectively they they were trying to communicate in a system that spoke another language In fact, it was only like two hours ago that a patient said to me, you know, it's just I think the exact quote I just wrote it down because literally it was Two hours ago. She said the best feeling is having someone that speaks my language And you know, you get this discordance between people speaking in different tongues where where where somebody's Trauma and dissociation is interpreted as being bad behavior and manipulation or tension seeking Or that people think that that you know, people get some sort of joy out of, you know Inserting objects into themselves or cutting themselves or burning themselves, you know, to the point that they a recipient of disparaging remarks or Treated in such a way that they're clearly unwanted and and you know for somebody I I emphasize the issue of shame and You're talking about collaborative approaches You know, if the entire system did nothing else But actually treated people in such a way that didn't induce shame and showed a modicum of empathic connection You know, some of the things that escalate into crisis, you know, just just wouldn't happen I would just make a comment about there was one there was one part in the vignette that emphasizes this, you know, how an awareness of Detachment dynamics and and the processes of shame to make an awful big difference. We heard in the in the vignette that tanya made some sort of Sexual invitation to the therapist now for people who worked a long time in the field It's not that uncommon when that's that in some form or other you're going to encounter people who make Some sort of sexual invitation and yet there are multiple levels of meaning in that and to some it's Literally of a reality that that's the currency of relatedness in the all the environments they ever lived in so That's the only way they know to relate so it's going to come up in therapy It's come up in every single other relationship for others for others It's it's it's a way of actually paradoxically of testing safety Then that that and that sort of question arises at a time when they've actually deduced we talked about You know mistrust before when they actually Paradoxically have mistrust you less to the point that that they make that invitation so that they can be then satisfied that it's safe And and when that's that sort of awareness that makes a lot of difference, you know So other people could just say you know make some disparaging remark about their, you know sexual boundaries and and they just feel go away silently and and and Feel terrible yet again when you and I mentioned before those for which Abuse is ongoing that the amount of shame that that they carry is enormous So these are the people that have their bodies are racked with With self-harm and and their internal bodies often carry the scars of stuff that was done to them So thank you so much Warwick. I you know your wisdom is really invaluable And I know that was a theme that the participants were picking up as well So thank you very much for that now Bradley. I just wondered if you had any final comments about how we How we can work together Look, I think interdisciplinary practices the way forward And mental health nursing psychology psychiatry But what I would like to see embedded in that mix is peers peer peer workforce I know from previous experience of working in the acute test sector around Seclusion and restraint reduction that it was actually hearing the stories from peers That actually enabled In a kind of Hard struggle kind of a way For people to be able to come to a multi-voiced understanding And strategies that actually fell out the other end of that multi-voice understanding That worked for everybody by including The people who had the lived experience themselves In that mix Going when you say that this is how I experience it and psychiatry saying And I don't know quite how to do that differently for you, but let's have a ongoing conversation about that I think that's the interdisciplinary practice that has the best future is is one that involves all of the stakeholders and In particular a peer workforce or lived experience workforce that can support that Often unheard voice in that situation Thanks so much Raleigh and I should acknowledge we have the social workers occupational therapists Nationalist students in in the audience. So it's really really valuable to hear that. Thanks so much And Philip I'd just like to invite you to offer a final comment particularly about how we work together. Thank you Yeah, thanks Mary Um, I think sometimes some psycho education is needed about different professionals and different approaches um, I mean, I don't want to pick on anyone but the medical fraternity really Has a bit of a model of making symptoms go down And I think uh, psychologically and psychotherapeutic fraternity has more. Oh, no, let's let's have that. Let's notice that Let's see what that's saying. That's what's the message being conveyed there So we can appear to be working at odds with each other And I think to educate our clients, you know, that you know, this is just the way other Medical people may work with you. They may want things to go down and there's nothing wrong with that but You know, if you're going to come and work with me We we need to contain some things and make some things go away or go down But there's also a dialogical model or a relational model. Let's let's hear it. Let's let's see what it's about Let's engage with it. And so I I don't want to make other Allied professionals or other professionals wrong. I just say there's different ways of working and trying to educate my client around that And then generally be very, um, very forthright about referring clients. I'm very happy to refer Um, more over in the end, I'm hoping to really let my clients know that I I have a very positive outlook for them I I think they've got more strength more resilience more abilities more attributes more skill more beauty more Um potential than what maybe they're aware of and I'm going to try as early as I can to help them Get that I I see them as more than their limitations more than their Their pathology so to speak so there's more beauty in them than that so I I want my clients to get that as soon as they can that I see there's more to them than their pathologies as well. So and Keep supporting them in their growth into holism if you like be a full human being Thank you so much, Phillip. I think that's a really hopeful note to end on and It certainly is the message of understanding things in a trauma-informed way that recovery is possible And that these are understandable responses to things that have happened So thanks so much to the whole panel and to the participants aware that we have gone over time But I just decided that it was It was good to do that. Um, so I just encourage everybody to complete the exit survey Um, you will be sent a link to online resources within the next couple of days The next mhpn webinar is it is not in this series, but it will be equally interesting and valuable Which is around mental health parenting and recovery and it's an interdisciplinary discussion as well That will be on Thursday the 26th of June. Um, remember that this was part of a series of three The other two webinars are available to download and watch and the first one was particularly aimed at general practitioners So if any of you are dealing with gps that you think would benefit from learning this and might take the time to watch it Please send them the link And so once again, thank you very much to everybody and we'll see you all again at another mhpn Webinar and don't forget the main website to go and have a look for what's available in your area Thanks so much for participating and for staying the extra 10 minutes. Good night everybody Thank you, Mary. Good night. Good night. Good night