Good evening and welcome everybody to tonight's webinar. I'm Nicola Pulfrey and I'd like to welcome the panelists and all of you joining us tonight. Those of you that are watching us live, welcome and those of you that are watching the recording. First of all, MHPN would like to acknowledge the traditional custodians of the land, seas and waterways across Australia upon which our webinar presenters and participants are located. We wish to pay our respects to Elders past, present and future for the memories, the traditions, the cultures and hopes of Aboriginal and Torres Strait Islander Australians. So welcome everybody. We have almost 460 participants joining us already. So welcome and thank you for joining us at this time of the year. I'm Nicola Pulfrey. I'm a clinical psychologist located in Canberra and I'll be your facilitator for tonight. We're going to introduce you to the panelists to get into it straight away. So we've got a great panel for you tonight. The buyers have been distributed so in the interest of time I'm not going to read through them but let's get into it and get them chatting about themselves and why this area interests them and what they can add. So first of all I'd like to introduce Dr Andrew Leitch who's a general practitioner from WA. So welcome Andrew. And my first question in our resources that you've provided with us you talk about the Emerging Minds GP training that you've been working with. Could you tell us a little bit about that? Thanks Nicola and hello everybody. It's great to be back on the panel for tonight. The Emerging Minds is a really great resource that I've been working closely with throughout this year and I encourage anyone in the health profession really to have a look at their website. There's some great training there for engaging children in mental health and we've recently completed a module that is well worth doing. It takes probably a few hours to complete overall but there are some really great videos, interviews with children and particularly an area there on grief as well. So for a bit of upskilling and a bit of training and some CPID points I'd encourage you to have a look at that and that's been an area of interest of mine. Fantastic. Thank you. And there's resources for families and carers as well I know on children and grief so definitely worth checking out. So welcome Andrew. Thank you. Our next panellist is Dr Christy Felsi from WA. So they're joining us a little bit earlier in the day. Welcome Christy. And I've just got a question. What makes grief work different from other work that you may do? Hi. Hello to everyone that's watching. I guess one of the main things that makes it really different is in other types of counselling and psychotherapy people are often coming to work towards a change in their life whereas with grief I guess the change has already happened and it's often an unwanted change and an unexpected change in a lot of cases. And so the work that we do often goes quite deep quite quickly. You go into a lot of emotions and a lot of depth. And it's just very different I guess in how quickly you kind of start into some of that deeper work and it's such a rewarding area to work in. That's great. Thank you so much Christy. We're really excited to have you here tonight. And our third panellist is Julianne White who is an accredited mental health social worker amongst other things. Welcome Julianne. You've been working in this area of grief for a while now. It couldn't be a tricky area that people are sometimes reticent to work in. What do you find rewarding about this sort of work? Thank you for asking that question Nicola. It's a lovely question and welcome everyone here tonight. It's lovely to be on this panel. Look I love grief and lost work and trauma work because as like Christy said you get to a very deep place very quickly with people. It's very authentic. There's a holding space and I often feel that my job with sitting with people is to validate and just hold and be witness to intense emotions that perhaps other people, their family, their loved ones just might feel reticent to do or a little bit uncomfortable with. And what I love is that we can revisit grief over many, many years. It's not something that we're fixed with. Grief comes back many, many times and it's just a very lovely rewarding gentle space to work in. Thank you, Julie. And I think that's what we're going to get into tonight is actually how we do that because it is really important work and can be really lovely work but it's sometimes an area that people feel they're not sure if they're doing enough or should they be doing more. So it would be great to get into the detail. So welcome everybody. We've now got over 650 attendees. So that's great. Welcome. I'm just going to run through a couple of the ground rules for tonight. So of course in any space such as this, it's really important that we're respectful of each other of the participants and the panellists. Keeping comments in the chat box on topic and related to what we're chatting about tonight would be really appreciated. If there are technical problems then this year we've all become very aware of how technology can be our friend and foe. There is a number from MHPN which is 1-800-209-031 and you can email webinars at MHPN.org.au. All of these tech support information are in the original login details and emails that you would have received. So you can also click on the information icon which is in the lower right hand corner of your screen and click on webcast support and they'll be able to assist you there. If your webcast freezes or stops at any time, the good old refresh button is also a good place to start. If everything else fails, the webcast is being recorded so you can always catch up at another time if things don't get resolved. So to introduce you to the webinar platform, a lot of you will be familiar with the Zoom platform. However, let's run through it relatively quickly. So to interact with the platform and access resources, there are a number of options. So information is located with the I circle in the lower right hand corner and you can access presentation information, links for live chat resources and webcast support. To ask the speakers a question, click on the speech bubble icon in the lower right corner and that comes through as distinct from chat so that's where we'll be pulling the Q&A for the last part of the webinar. You can change your slide and video layout, excuse me, by clicking on the icon with two arrows inside a circle that's in the top right hand corner. This makes the video larger and the slide smaller and you can change your view to slide only or video only by clicking on a square icon with the upward and right direction arrow on the bottom right hand corner. So there will be a survey at the end of the webinar that we will encourage you to do and you can click on that at the end of the screen as well. Okay, so what are we going to be covering tonight? We will be looking through an exploration of the case study that we sent out to you earlier. We will be looking to identify the mental health indicators in the context of grief and loss and the range of reactions to grief that children may experience. We will discuss tips and strategies that can help a child feel safe and secure after experiencing a loss and we will discuss the importance of collaboration and appropriate referrals when supporting a child, their family and or their carers and their experience in grief including supports in areas such as the school setting. So this case study was a follow-on from when we used from a previous webinar which follows the story of Ben who we met two years ago when he lost his father to suicide. He continues to have some issues with sleep, emotions and tummy aches. So we will be able to explore Ben and his family and how our panel may work with him. So we are now ready to take over to Andrew for a GP's perspective. So over to you Andrew. Thanks Nicola. So at this point we are meeting Ben and his mother and they have come in in a real point of desperation especially his mum who is just not sure what to do next. Nicola if you go to the next slide we might start with this point that grief is a normal reaction but it can have a wide range of symptoms and feelings, emotions, behaviours and in children I think they can be quite different as well. The severity can change and I have certainly seen children where there is no reaction to that grief through to quite severe disruptive behaviours and symptoms. So there is a little bit of variation but with Ben we are seeing a lot of these symptoms here and feelings but recognising I guess at the first point that a lot of these are a normal response to a significant change in his life. It can be age dependent as well and at age eight we would probably expect Ben to have some understanding that this death is final, this is a very severe, serious complication and he may be worried now that he is also going to lose other loved ones and is experiencing a sense of anxiety and fear around that. Next slide please Nicola. So when and why does Ben need professional help? I would say if that experience of grief has been disrupting his home life and his school life or one or the other and have become prolonged then Ben needs professional help but the fact that his mother has brought him in to see us today is indicative that they are at a point where they do need help and remembering that Ben has not just experienced the loss of a loved one he has probably also experienced other significant changes in his life that are also probably impacting on how he is feeling and reacting to the world and his mum has certainly been stressed at home he is hearing things on the phone that his mum is talking to the police he has probably had friends talking to him he may be experiencing bullying at school so he is not immune to all the other eight year old issues that can arise and it would be interesting and useful to explore those with him about what is going on in his world so I guess any of these points here an extended period of time with any problem to do with the effects of this death Next slide Nicola So as a GP I would be keen to explore those with him and I have already talked about engaging children in general practice when we are talking about mental health but it really is about exploring his world and the next slide I will bring on in shortly we will talk a bit more about that also remembering that mum is part of this picture and his sister is also part of this picture so collectively gathering some of that information there have been physical symptoms and the GP does have a role to think about what might be causing the tummy pains and the insomnia and ensure that there is no medical force that is going on as well in the background whether there is any constipation checking his tummy giving him a physical examination before putting everything down to an emotional response the DSM criteria for grief is a bit tricky there is a DSM-5 criteria called persistent complex bereavement disorder and this diagnosis is assigned to individuals who experience an unusually disabling or prolonged episode of grief but it is still under review and there is still more research being completed and from what I was looking at in my reading I couldn't find much in terms of this being labelled with children but there are certainly secondary diagnosis that may come to light when dealing with Ben and that may be anxiety it might be depression oppositional defiance disorder grief is never a simple straightforward issue especially in this case here there is a very good chance that there are overlying and overlapping diagnosis to consider and the GP has a role there might be some screening tools that we could do such as the strengths and difficulties questionnaire or the DS21 with mum to help us to work those out safety netting is really important as well and asking Ben does he feel safe at home does he feel safe at school and ensuring that there are no risks to Ben in this setting and setting up your consultation so making sure you have long consultations with Ben making sure you're seeing him on a regular basis really holding that family as a whole and supporting them through the process and in itself that is therapeutic to this family next slide so as I mentioned we need Ben to really open up and that may not be easy and an eight year old boy he might be coming along really not wanting to see you and so that first couple of consults he's spent a lot of time building rapport and for me I often use that heads approach which we use in adolescence and teenagers which is just asking a bit about his home life his strengths, his interests what his friends are and working around in a bit of a circle before we actually find the key issues that are going on for him if I'm not getting anywhere I'm just drawing out a genogram and that can be a good ice breaker drawing out who is at home this isn't Ben's genogram but just an example of those first couple of generations of family members what is his relationship with other people other male figures in his family his uncle, his grandfather his teacher he's lost that male role model and for boys, young boys I can't imagine how significant that is I often normalise things as well another child I'm seeing who also is going through a tough time has X, Y and Z emotions going on is that something you've experienced and that can be a useful way to help Ben feel like well I'm not the only one in the world dealing with this and it's okay to have big feelings next slide please the presenting complaint today is sleep and sleep hygiene has become a bit of a concern in a lot of young people that I'm seeing at the moment and it revolves a lot around screen time so ensuring that there is no screen time he may have turned to enjoying other things like gaming and television and YouTube to wind down at night but just ensuring that he has that really relaxing calm, lower stimulation environment before bed and there might be some apps such as smiling minds that he can use to help with a mindfulness program before bed and mum could use it as well it could be a really good way to help with that bonding and that time together as they wind down for sleep mum may need to do some camp out in his room to help with that separation anxiety medications we don't use often but there are some available and that's something that he needs to discuss with his GP next slide so what are we going to do with Ben I think that the obvious thing is here this family needs support in more ways than one and as I said at the start holding this family is a really good way to support them but considering other referral options you know if we do feel like because of all the behavioural consequences of this grief that Ben does have an emerging anxiety then referral under a mental health care plan to an allied health professional OT psychologist or social worker would be really useful we know there's financial challenges here as well involving Centrelink if needed if mum needs a bit of time off work doing a Centrelink certificate for mum to give her some support with funding and looking at psychology services that may be government funded not easy I know at the moment but I know there has been an emergence of telephone support services telehealth psychology and I'll put some links but head to health is a really good way to look up those supports and find what might be available for this family and I know a lot of them are government funded so it might be a good starting point as well as the grief line which is a phone number they can use in sort of a more urgent situation so giving those contact numbers letting them know that you are here from them your door is open we want to see you regularly work on these issues and manage them and following up with a relevant allied health professional thanks very much okay so I guess some of the common things that we find for children around Ben's age between the 6 to 8 years of age is that children often become exaggerated versions of themselves when they're grieving some of their previous behaviour and coping methods are just really amplified and a lot bigger what they usually would be and so you might have a child that uses humour and they might be using that a lot more you might have a child that's quite loud and they're even more so loud or if they're quiet they might be even more withdrawn often their behaviour can regress if they're bit as well so they can lose a lot of skills that they've just previously mastered they can often revert back to younger behaviour which can also be I guess a bit confusing at the time for parents in particular and it can also be a bit frustrating too but when you can see it in the context of grief that makes a lot more sense children also express grief a little bit differently at different ages and you can touch on that a bit later if you have questions but as Andrew mentioned most children they have an understanding at that age around the finality of death and are quite curious they ask a lot of literal questions around the death and what happens to deceased body they often have beliefs around magic and thinking and they can often blame themselves for the death thinking that their behaviour or their thoughts may have caused the death and there can be a whole piece that needs to often get explored particularly around guilt if a child is struggling with that they can often personalise death as a person a monster or a deity and then impact with nightmares and fear of the dark and issues with sleeping so that could also be an important area to explore with Ben to see if there is anything like that behind someone who struggles around sleep next slide please so I guess some of the things that we would look at throughout the counselling is looking at how much Ben's world has changed like his whole trust in the world has been broken and the awareness that death can impact him and his family it really creates sometimes a lot of fear and anxiety around around day to day life and living so it would be really important to be able to create a safe space for Ben that he can share his memories of his dad and have open communication with his mum being able to do that helps him to feel connected to his dad I say like even though the person is no longer alive like that relationship is still so important and there's nothing that will replace that so it's really important for him to have a way of continuing that connection really important that he has a place to share his sadness and his pain and of anger with his mum and that she can reassure him that those big careless feelings that he's feeling are okay kids don't know how to grieve they often have never come across this before we really do look to the adults in their lives to know what's okay and what's not okay and to also get a bit of permission around how to grieve and how to share their emotions so really important that Melissa can have some of those conversations with him and also be able to show some of her grief to him as well also having honesty with kids in age appropriate information around the death and age appropriate information even just around grief and around emotions that helps to create trust it also just creates that security for the child and even if Ben has questions that his mum can't answer it's still really important that he feels that he can still ask them even if Melissa comes back and saying well I don't know I'll have to think about that or I'll have to get back to you it just creates again that connection and that closeness and that's helpful it's really important to continue to have boundaries and routines and schedules these help to provide predictability which turns into safety and security it just gives the child something to lean against especially when everything feels like like chaos then everything's changed it just helps them to feel like their home and their world is still still predictable grief lasts over the lifetime and I guess the intensity of it changes over time and so even though a few years on now it might not be as war as it was initially there's still going to be times where it spikes up all the intensity rises so just important to be aware of that knowing how to support Ben in those different moments important that he's included in rituals and traditions involved in age appropriate conversations and decisions this helps to empower him and just gives him a sense of control which also lessens that feeling of chaos permission to still be a child to still hope and look forward to things to know that he can still have fun and you can still go out with friends but also if he wants to spend time by himself then that's okay too but it's okay for him to still be sad it's okay for him to still cry but that his grief is able to be shown in different ways and that's okay also for adults around him to show him a lot of understanding and compassion around this and I've got a quote on the slide too that I'll read I've found that no matter how long it has been since someone has experienced grief they need to be heard whether the grief is only year old five years old or older people need to talk about their pain they need someone to listen yes there's been healing but the pain never quite goes away and so saying that not everyone needs to see a counselor or psychologist following a death however if there's a feeling of isolation or that they're lonely in their grief like other people don't understand it or they don't get it or they can't talk about it it can be really important that they have a safe space where they can explore that if they find it difficult to talk to friends and family it can be really important again for them to have a person that they can have those conversations with we often find that in the first few months all the family support networks are there helping and available but after a few months everyone just kind of disappears a little bit and families sometimes aren't as supportive about listening or hearing the story again and again and so it can be really important for them to be able to see a counselor to see someone where they can talk about the story again and as much as they need to and to share that person with someone if a child's behaviour has drastically changed so in Ben's case it would be advisable for him to see someone particularly that he went from being quite kind and gentle to being quite angry and withdrawn so that's quite a big shift and just again having that space where he can explore that if there's really heightened emotions that are frequently expressed such as that anger particularly at surviving family members whether that's his sister or his mum or other relatives or anything like that it would be really worthwhile for him to be able to see a professional to explore that and just to figure out what's underlying that and what's behind that for him if there's extreme behaviours like self-harm, suicidal ideation and substance use even though Ben's only 8 where you are finding that substance use still starts to enter quite early and just that will see it's a bit more vulnerable with everything he's gone through and also that he's just got that vulnerability around enhanced risk following his dad's suicide as well and so as Andrew's kind of touched on already like we're definitely wanting to follow up with his GP regularly around the sleeping and nightmares, the stomach aches the anger and the aggression as well and if there's any other physical symptoms or concerns that come up definitely to see the GP next slide please as we know healthy grief can impact on concentration, memory, energy levels which can greatly impact on school and learning and so it'd be really important for him in the school environment to be able to link him with the chaplain or the nurse, counsellor social worker, head of year level or teachers or just someone that he feels safe and connected to at school that he has a safe place that he can go when he's feeling overwhelmed, angry, tired or disconnected it'd be also important to explore some of the reasons for him not wanting to attend school and so whether that's the inability to concentrate priority, like whether he's finding school just isn't important in light of the death whether he's been bullied whether it's separation anxiety or that he can't talk to his friends but being able to find out what's behind that could make a really big difference and important to link mum and family into other supports as well whether that's support groups around grief or around parenting for mum or for the kids whether that's sporting clubs faith community, social clubs or other social areas particularly for Ben to have some of those male role models could be really really important for him that's probably a real need for him and a gap for him as well so it could be really important for him to be able to have that and I guess my last point I'll just make quickly is like a little picture on my slide says everyone kind of experience grief a little bit differently and it looks a little bit different for everyone and so it's just just yes seeing that and just being able to support them and be there for them wonderful, thank you just before we throw over to Julie Ann I just know a number of people are struggling with to find the chat it's in the i information icon at the bottom of your screen if you click on that chat will come up as an option and it will pop up as a separate tab so people a little second to maybe have a look for that because we know you guys like to chat to each other and we've got almost 880 people watching so there's a few people that might want to chat so the information icon click on that and look for chat okay hopefully you guys have got that thank you so much Christy and Andrew we'll hand over to Julie Ann when you're ready fantastic thanks so much Nicola and lovely to follow on from Christy and Andrew I just think watch wonderful presentations and a great wealth of knowledge what I want to go through too is not just look at some of the other grief perspectives but what a social worker might offer to this space but first of all grief from my experience is so misunderstood and often poorly responded to because we often see the symptom like Andrew was saying Ben's come in with stomach problems and might be some time from the grief so we don't always make the connection to grief and grief is really an impervious thing that sort of goes deep into the psyche of a person it's about our schemas our view of the world our sense of meaning it's a like I've got up there it's a psychological or biological and a physiological response to change where the person regardless of their age perceives that there's been a loss so it means we've got primary losses the grief the original big loss you know like his father Ben's father's death but then all the other secondary losses that both Christie and Andrew have talked about as well that actually can be just as powerful and overwhelming for young Ben or for anyone in this family and we need as health professionals to be very aware of both the primary and the secondary losses that can come about but what does social work bring to the table I often think what we can often contribute in a collaborative way is a bio sucker social approach looking at systems looking at collaborating with schools and helping with some of the other networking and some casework as well as well as that therapeutic support where we're looking at grief is not from a medical perspective and I know Ben was talking about the DSM-5 and it really does create a bit of a a quandary for us is where we try to fit grief if we're looking for a diagnosis and it is an adjustment issue is a lot of other symptoms that can come out like the anxiety and the depression and the concerns so it's really hard sometimes to find if we're going through a mental health treatment plan or looking for appropriate referrals just where do we fit that and what do we call it because often if we call it anxiety to depression we miss the grief because we're just going straight to perhaps professionals might go straight to an anxiety response rather than name it and looking deeper this is what Christy was saying earlier to get deeply into the meaning behind what might be causing this what we look at to is separating the problem from the person so looking at Ben in his age as a little so the older brother of a sister and a father who's suicide and I think there's that stigma little eight year olds regardless of the age they're very aware that this is not a normal death daddy didn't die of cancer daddy wasn't in hospital and people were hanging onto his hand as he was dying sorry Nicola thank you for doing that so we have to look at the macro the micro and the mitzo systems that are around this you know what else is going on here so at a macro level he'd be very aware of what society is saying what mum's saying like I think Christy you were mentioning that he would have heard the phone calls you know mum talking to police and then he overheard her saying something about dad hung himself you know there's huge stigma for little boys do you know what does that mean what does it look for this family we've got to look at the multiple perspectives that might be occurring here for young Ben but also for Madeline his sister and his mum Melissa and the extended family network we look at attachment theory was there a disordered or disorganised attachment prior to this was there arguing was there some other issues that might have been going on for this family not just look at yes he's grieving his father he's grieving his hopefully his role model or you know the dad the man in his life but there could be things around attachment issues that might be affecting these symptoms that he's getting around you know not sleeping in stomach aches we've got to use a trauma informed approach we can't cause more harm you can't actually go into questions or ways of working with Ben or his mother that are potentially going to bring up stories or feelings that are going to create more harm we've got to use a strengths approach to really working with young Ben around what does he do well you know what's in his toolbox how does he normally cope with you know things that are pretty not very nice we've got to look at values not only Ben's values but his families the schemers and in my grief work I look at all of these things I talk to people about schemers I talk about values I talk about what does this family what does death mean in this family how do the family grieve what are the cultural perspectives that might be impacting on this family and determining how Ben cries or grieves and how he reacts you know what are the other men do in his family and how do they grieve would be very much important to understanding so that good grief work can be done for not just Ben but his family and that's where we look at the family systems what else is going on here and the family narratives you know really finding out from mum and there's a chance you know from other teachers you know just what do they know about this family and how they make sense of their world the assessment like Andrew was saying you know using the strengths and difficulties questionnaire which uses multiple perspectives the teachers perspective the parents and the child is really excellent in the desk from the mother the other one I like to use too sometimes is ahead the hospital anxiety and depression because it takes stress out sometimes which can be a confusing compounder because it has the somatic symptoms so sometimes ahead is really useful but the strengths and difficulty questionnaire provides a lot of information next slide please Nicola so the grief and bereavement also has gone through significant change and I think all of you you know listening and watching and being part of this would know that we've moved a long way from the work that's been done originally by Warden and Kubler Ross around stages and phases and tasks and we now look at a dual processing model whereby we're not looking I think Christy you mentioned it you don't look at it just as a linear model we actually look at where that person is we're very very aware that we're looking at how are they coping with this trigger or this feeling or what is happening for them right now and it's about being present rather than actually labelling so and so you're in the angry phase or you're in this phase or even just sort of saying I will grief will change with time grief doesn't change with time grief changes with exposure and with maturity and with brain development and also then different life stages that we go through whereby the grief has different meanings and I think using models or interventions that give us a different perspective on meanings is real and I'll go through that shortly you know we need to just the next slide too please Nicola so you know the adults in little Ben's life are a big influence on him not just mum but also other role models that might be there teachers that are there people that how do I how do I navigate this and kids do it by osmosis you know we don't actually say to them well you know this is how you actually be a man young boys and young girls they pick up their influences from the people around them like young Ben his behaviours might look demanding or unreasonable I think Andrew you mentioned oppositional defined disorder sometimes they're really pushing back from everybody because it's almost like my world has been disrupted and I ain't gonna let anybody else in there and disrupt it again so maybe he's doing a bit of the push back to everybody to go you know what I just need to protect myself and he might be doing some of that which means as clinicians we need to really sit very carefully and allow him to express some of that one thing and I just had a young fellow in tonight who was nine and we did a lot of talk about what are the polarities you know what's you know if you're not sad what are you what's the opposite to sad and he said well happy and I said oh wow really you know are you happy are you happy now or are you sad and he really thought a lot about that you know wow you know I can I don't have to be the opposite to something I can just be not that and it was interesting to watch this little later nine-year-old just really grasp those really complex concepts I think kids we give them we can talk to them in really complex ways and I think most kids send to get it or they'll take in just what they need to hear next slide please Nicola so how Ben experiences grief will depend on how fully he understands the nature and finality of death and it's an eight or nine year old depending on what he's experienced if he's had animals or other things in his life have died he might have some perception of death and how they react depends on the disruption happens in their lives and how other people and I'm reading you know from the case study Melissa his mum really was struggling so obviously he feels that you know what do we do there's no role models that say this is how we integrate this into interactive the attachment Ben had to his father and a father image is really important we have to actually unpack some of that so we can help him make sense of what he's experiencing and feeling and I often think that's our job is to look at the child's behaviour and the family's behaviour and somehow unpack it a bit like a mind map you know how is this person making sense of their world based on their understandings in this new world which is so unfamiliar to him yes Nicola. Parental coping with their child's grief also involves understanding child's genuine concerns following the death and Nicola and Christy and Andrew both mentioned this as well you know and he's going through those polarities you know we're very concerned also about Melissa shielding Ben and including him informing him not scaring him and this is where it's really important I believe to actually use real words like dead dying death and not going to sleep or daddy's in the stars you know I just think that sometimes causes lots of problems with sleep because you know it's then what happens when I go to sleep well that happened to me too or if somebody else goes to sleep and then dies that can actually set up some really huge perspectives on what happens and what happens when we die and I think we can ask children about death so what do you think happens at death what happens to the body children are really fascinated by that and if we're comfortable with it we can actually sit there with them and go yeah it's really curious and we can externalize it and name it so we don't have to talk about dad but we can actually be talking about more broader concepts as you develop a relationship with young Ben and I see our benefit yeah our work is to actually work with Melissa the family to help establish a family life's narrative a cohesive narrative that includes my daddy died and that's really important I have the next slide please now this model I put up here the dual processing model both Schultz and strobe is one that I might write on back of envelopes back on any piece of paper that I have and I find this a wonderful just easy model you can say to people that over here we're dealing with loss the loss orientation dealing with the grief itself and on the other side we're actually dealing with what we call the restoration or living with the loss and how the life is impacted on our lives and often the secondary losses and what happens is that in life we oscillate between dealing with life coping having to go to school having to pack your lunches about who's going to drive me to footy practice and then oh my god this is really horrible my dad is not here and it's just revolting mum is really sad and everything's changed and children and all of us doesn't really matter what age you are just what I love about this model it's not age appropriate but it's often situational appropriate or grief appropriate and we oscillate I see my job is working with someone and finding triggers what might be the trigger that takes you from coping today and being able to go to school and do your stuff to actually not coping what will be those triggers is Christmas like it's just around the corner almost every person I'm seeing at the moment I'm saying you know what might be something that's happening for you right now how can I help you work out a way so that it's not traumatising and what I love about this model it's useful it's amazing it fits people go yeah I get it so someone 10 years on from a grief event or a major trauma can be oscillating because there was a major trigger and I can imagine with Ben there's going to be times in his life you know when he's 16 when he's 18 16 gets his licence hopefully 18 when he's allowed to drink you know 21 when he can vote or is it 18 we vote I don't remember but you know all of those key significant milestones that Ben's going to go through he's going to grieve his father again and as his brain develops and as he gets new understandings of my father died by hanging and suicide and now my am bereft of my father he's going to get new understandings of this at his life stages his brain develops and he gets new meanings so he might grieve you know as an 8 or 9 year old right now but at 35 he might just go into an absolute you know sort of deep longing and yearning for this man who's no longer in his life and how do I do a 35 year old man and how do I deal with issues in my life so he might re-experience the grief again in a way that like Christy was saying is very unique and individualised so we have to be very mindful and help people prepare for the oscillations between coping and grieving with this where there's a suicide a significant trauma trauma overlays this and I often think we've got to do the trauma work first it's like a cloud that sits over this model and we've first got to help people deal with their trauma and understand that this puts the mind into some place of just not coping it sort of throws all our schemers and understandings out so you've got to be careful before you can help people cope with coping with change thanks Nicola the next slide and how do we support the surviving parent you know we just don't work with Ben and you know his sister Melissa but we've got to look at what does mum do who else is around him and how can we actually put that support in place and this is where a collaborative multidisciplinary team is absolutely critical because not one clinician can do all of this good work for the whole family this you know we need to work with our GPs the psychologists you know find other allied health social workers and OTs who are qualified in this work and I think trauma and grief work is really unique work and you know we've really got to network well and find who can support us all in our work having a great relationship with the GPs absolutely critical and I work really closely with a lot of other psychologists because you know we all do something slightly different and you know we can't just be that person for something so complex as child's grief we also have to be brief with the child we have to be able to get to a point you can't go on for an hour and a half about issues the children's concentration is often quite short we have to be patient we have to be consistent we have to persist and we have to be there we have to validate this little person in his family and I think that's the biggest part of grief work thanks Nicola thank you thank you all that was wonderful sorry I was absorbed listening to everything that you were saying and so impressed with your timing so fantastic to hear all of your perspectives and the great thing is we now have time for some Q&A so I want to thank everybody that sent through their multiplicity of questions at registration and also those that are coming through from the Q&A so I'm going to open it up to the panel I'll direct the question to each of you but if others have wisdom that they would like to share I would love to invite you to do so I'm going to start with you Andrew if that's okay we've had a question on the Q&A from Wendy about GPs and continuity of care in the current circumstances with COVID and how can GPs I suppose prioritize or advocate for continuity of care either do you think it's important that has to be face to face the same GP what do you think are the most important priorities in working with a family like Ben's so COVID has really changed how we do work in general practice and I have found that the additional telehealth numbers that we are using are really helpful in the mental health space and the ability to touch base with patients through telehealth perhaps on a more regular basis than we would be able to see them face to face has been a good little bridge to check in on them and check that they're okay and have a quick phone chat or even a longer phone chat and having that available to us and having a nice number we can use is really beneficial and continuity has been harder in the sense that we are actually probably busier now it's harder to fit people in we're all time poor some of this work takes a lot longer and is a lot more time consuming but a lot heavier as well and can be exhausting so you have to look after yourself as well but I try to work a bit ahead and think a bit ahead and for a patient like Ben I would say booking two, three, four weeks in advance having that booking in place getting him to book every month or every fortnight making sure those bookings are long appointments with fill in gaps with the telehealth item numbers we will make it work and we'll get there eventually and navigating the schedule if they ring in a bit of a crisis and having a reception that's really good at working out when Ben might need to be squeezed in on the day and that's just part of our job and run a bit later and fit in these people even when we're fully booked but as I said there's usually a way to get there before you get to that point Fantastic thank you Andrew this year has taught us adaptability and it's not always bad to do things over the phone or some people actually prefer it so thank you we will crack through some of the questions we have over 900 people online which is fantastic so apologies if we don't get to everybody's individual questions we'll try and group them together in themes we had one that came through from the registrations which I might throw to you first Christy but Julie and you might also have something to add I'm sure and the question is what role do you see for expressive therapies in children dealing with grief I think they're so important particularly with children children really like relax I guess in that setting it's a bit more familiar to them we know with kids often when big stuff happens they reenact that in their play as a way of trying to process it so being able to use expressive therapies in the counselling room can be so helpful it's a language that children are really familiar with and so whether that's through drawing or art or music or writing or storytelling whether that's through play therapy yeah it's often a good way of connecting with a child and it's a good way of them taking ownership of their story and processing some of their questions around it and some of their feelings around it as well often as they reenact that in play or expression again the intensity shifts that drops down and they can take on that ownership I'll put that off. Fantastic. Julie Ann how do you work with expressive therapies a lot? Yeah I really agree with Christie too I think it's really important it's very much important to find out for the child also what their interests are their likes and dislikes but for the little boys particularly I find they don't do a lot of eye contact talking work very well and they really get very fidgety and bored very quickly so I think shifting it, changing it, being prepared having your box of little special things next to you and I use a lot of puppets I do I started introducing juggling into my little repertoire as a form of breathing technique and interspersing things into the therapy or getting up and moving trying to make it interactive as possible I personally don't do a lot of work around art or other forms of expressive work but just try to have props in the room that might shift from the intensity of one-on-one talking therapies which I think someone like Ben is a bit young for I think the side-by-side sometimes works well and I think in my experience they like it quite a lot if you're not very good at something like juggling so they can kind of enjoy that so that's fantastic thank you. I've got a quick question that anybody is welcome to answer from Katlyn, how soon after a person's death can a healthcare team begin to support a child and family? She's an OT and it had some information that they can't work with grief until after 12 months anyone want to care to say whether or not they think that that's I'd love to comment if I could please look isn't it just so interesting there's lots of schools of thought that say don't do anything until after the funeral don't start for 6 months you've got to wait for 12 months there's different diagnostic criteria as to when grief becomes a problem if it's not a problem if the patient is out if you've got a relationship with a family I live in a rural community things that happen like this are very well known I don't think there's a right time or a wrong time I think when people reach out to you is the right time regardless of it's the day of the death, the day after the death or whenever I think you just have to sit with a person and be appropriate if our work is trauma informed we're not going to do more harm if we're very conscious of not saying so I heard your father died for hanging or if we go in and say you must be grieving if we sit with a person and the child the family and really just hold the space then we're not going to do more harm and I think people's fear is they're going to create sadness we will make them sad they are sad leaning into the sadness is what we do as clinicians is show that we can hold this sad grief one thing I say to all my students I have here too never offer tissues take away, do not ever offer tissues to a person have them on the table have bucket loads in the room but never offer someone a tissue when they're crying just think about what it does it says wipe up your snot, clean your face up and get yourself into gear so it stops the conversation because they're wiping you know if they're snotting and doing all this stuff just put up with it let the tears flow and sit with the grief I love that, thank you it breaks it, go Christy I was just going to say I just wanted to add to that too the other thing as well is if a family member contacts even if the death has just happened it can be really important to be able to have some of those conversations with the adult whether that is around should the kids attend the funeral or how should I talk to them about that or how should I explain that this person has died so often parents can feel really out of their depth in knowing how to have those conversations with their kids and what to say and so it can be really important if they are reaching out in those early stages for support so I think that can be really really important time because that's often when they're so overwhelmed with everything and they're just trying to figure out how to even get through things but around like I guess counselling and support for kids I'm quite open to seeing them again similar to what Julianne was saying and how to kind of reach out I think it's important to work with that I think when I do see a family that's grieving depending on the situation but I'd probably put a little bit of space in between their appointments so life is kind of happening in between as well but then again if they're in higher distress it's easy to pull their appointments back to being a lot closer but yeah I think it's just important to go with the family timeline so I think that's a question people often have timelines when should we do this, how long does it go on when will people, and there's really no timelines for grief is there, it's an iterative process and all of us have had grief of some type in our life, whether it's a loss of a relationship or a loved one and we know that it can kind of creep up on us and ambush us at different times. There have been a number of questions and comments around other types of grief and we have stuck to the brief tonight around grief through bereavement and I do want to just recognise that people experience grief and loss through a whole lot of other experiences but in the interest of tonight and trying to kind of give you guys a detail Winnie, we are kind of sticking to this circumstance. One of the other questions that came through I'm going to throw to you Andrew if that's okay, is a bit about the balance and differentiation not necessarily in this case tell you, I'm going back on what I just said but distinguishing between adults how do you navigate the space of adult's grief and their children's grief and if their ability to see that, to see the behaviours or to see the things that are going on whether it's the aggressions or the aggression sensitively does that make sense? That's a very tricky question Sorry I'm trying to interpret the question as what's the difference between adults going through grief and children going through grief? How do you broach with an adult that their child is perhaps stopping them from seeing that? So that Melissa, the mum and in general terms I would definitely want to see the parent or caregiver on their own as well to have their time to talk through what's going on for them and to talk through what they're going through with their child and the impact it's having on the family as a whole So the caregiver, the mum, Melissa she needs her own appointment she needs her own support, she needs her own assessment and referrals as we said and in terms of educating her on this I think it's best just to be honest and upfront about what you're thinking and let her know Ben is experiencing or your child is experiencing a wide range of emotional reactions to a significant change in life and there may or may not be some kind of mental health problem that's coming from that we are trying to gather that information and work through it systematically but again like that first slide it's a very normal reaction to have and in children it can be very different to adults and it can be a behavioural change as Ben is experiencing it can be a physical symptom as Ben is experiencing as well but in general she needs her own time she needs her own consultation and it is hard work and if mum can't fit that in I'll ask her to go away and write things down and send them to me so that I can have a look at what she's thinking because it's not always easy to converse when you've got the child and the mother present it's not always easy to have some of those big discussions about those emotions and mum might want to talk about things privately but as being as open and honest as possible I think it's probably the best answer to that not shying away from what you're thinking and what you're wondering about and what they're wondering about I wonder also Andrew that you're talking about psychoeducation there in your talk about how children experience grief differently from children and there's been some questions about resources and there certainly will have those in the resources section and there are some really good resources around how children experience grief at different ages and stages across that social and emotional behaviour and they can be really helpful I think sometimes too perhaps to give to mum to take away and have a bit of a look at so it's kind of tangible so maybe providing some of that Yeah have a look at the resources and recognise that each age has its own sort of presentation and experience and we're dealing with an 8 year old today but it's completely different for a 4 year old and completely different for a zero a newborn every child I think will have some kind of emotional response to a significant life event such as this but it's finding those responses working with them and figuring out if they are responses that need to be managed in any way or whether we can just support them through the process and educate so have a look at those resources That's great thank you We also had lots of questions and I open this up again Julie Ann in particular might be able to assist with this from people working in educational settings so school councillors, guidance councillors and so forth. Any advice for them in terms of their role and how they might intersect with the kind of work you guys do and what role they might play in supporting someone like Ben in the school setting who wants to take it Alright Kristi do you want to Yeah I can Go Kristi first and then we'll throw to you Julie Ann to add something Okay so I guess one of the biggest roles that school psychologists can play is just being able to link in and create a space where that child can go to to be able to talk if they want or just even to have a time out if they need that, if they're feeling really overwhelmed or if they're feeling distressed or that they can't concentrate it's just important for them to just have that space where they can kind of regroup a little bit and just giving them permission that if they want to talk that they can and that you're there to hear and understand I think the other part that school councillors and guidance councillors play is being able to give teachers information around grief and around the child and how they're going sometimes teachers might not be as aware or they might see the child as presenting like they're doing quite well and just not I guess seeing the big picture of how the grief is impacting on them particularly like in Ben's case with it impacting on sleep and stuff like that it could just be really important to have some of those conversations with some of these teachers if he's really struggling with getting assignments on time or sitting in exams or even just keeping up with the school work and content and I guess I guess how they can liaise with us externally if they know that one of the students is seeing someone outside the school just being able to get in contact with us or getting contact through the family and then once we're able to liaise with consent and everything like that it would be a really good bridge that we can then provide you more information or if there's areas that you guys are concerned about or if there's any struggles or questions or anything like that then we can step into a bit of that gap and we can give you some information around how to support them and support the family as well as possible and just also for us to be able to support you in that role as well. I think that can help as well because then Ben can have one set of tools that he can draw on if they can learn we've been working with Ben on this about when he's feeling these ways or the strategies to calm down that if the educators are aware of that then he's not being told 10 different things by the different people and that's great. Thank you. Julianne, did you have anything to add? Look what Christy said was really fabulous and you backed up there Nicola as well it is really that link in the educative role is really critical and also just keeping the focus too on anniversaries because the child will go into another year next year ensuring that Melissa as we said we're talking about the case study but my experience is that when the child goes into the next class there might be a new teacher, a new environment and I think a really important thing is for whoever's in the school welfare team is to keep that front in the centre that that little boy or that little person will actually have a reaction at some point there will be a trigger, a community event or something that could create a situation for him or a reaction that's not quite expected the finger on the pulse and also for other children in the school that have actually had similar experiences or debts what I've seen too is sometimes there's a bit of a debt comparison, my debt's more important than your debt that my little brother died harder than yours or my daddy died by hanging but your daddy being aware of what's happening in the social media space, being aware of what's been and take it seriously I think is important but that continuity between classes is critical and that's a really excellent point, thank you Jolene go Christy, and then I'll go to you Andrew Jolene just totally triggers that like else for me as well so one of the things that we often talk to families about that would be really important for schools to be aware as well is if it's a parental death around Mother's Day and Father's Day often it's something that teachers kind of struggle with of going well do we include them, do we not do we get them to still do a card or to do this for that parent or not to do it for someone else and it can be really difficult especially when you know there's a little marketplace around Mother's or Father's Day or dads or parents come in for it and so often what we say to schools around that is kind of have a bit of that conversation one on one with the child if possible and just get their input and follow their lead so if they feel comfortable doing that you know that's great if they go no I just want to opt out that's completely fine too if you're feeling like the child is just kind of a bit poor on the spot let them know that they can talk to their caregiver about it some more and you can touch base with them to find out what their preference is and it's such an important conversation for parents to be having with their kids as well just to really get a sense of what the child wants to do around some of those big days whether that's the anniversary or whether it's Mother's Day and Father's Day or what not because they're kind of a bit of overwhelming days and just the other thought that jumped into my head as well as Julianne was talking is just also around some of the bullying we're finding that brave kids are often getting bullied just because they are quite different it can be that they're getting more attention or they're getting exceptions from doing stuff and so some kids start to target them or to start to pick on them because they're getting all this special attention and stuff like that and just because they're different the family looks different or their experience is quite different and so it's just also being aware of that side of things and just keeping an eye out and addressing that early on if possible Fantastic. Got a couple of minutes to go Andrew you want to add something? Oh really just reflecting exactly what Christy and Julianne have said about school I think GPs definitely have an important role to keep the school linked in with the process not always easy and I probably would say we don't do it very well but if we can somehow notify or talk to teachers or offer a correspondence to the staff, the teachers that are looking after the child can make a big difference and I wasn't aware of the impact that exemptions and things can have on a child but even just suggesting if there's some kind of extension or support in some way that can offer them more time to complete tasks now that they have this impact this concentration problem but time for one more quick question and this is doozy, I'm sorry there's lots of questions around cultural considerations and one of the things I thought maybe just to narrow it down a little bit is we've given advice Julianne you were speaking tonight about the frankness I suppose and use and language and so forth how do you navigate that with the family culturally or just in their own norms that they're very avoidant of that or they're very resistant to that what are your approaches you've got a way you like to work but perhaps the family aren't comfortable discussing death in that language or suicide for example really good question Nicola and a really important consideration all of us need to have and I think you've got to ask first and if you can't ask the family because the intensity of the grief you actually go to other trusted people that might know what are the culturally expected norms and this is where we link up things that we need to know about this particular family or this particular cultural group or issues that might be impacting on how regardless of the culture or regardless of the background of the family is find out and be respectful of it and it's just critical we can still challenge things gently as you build relationships because if some customs or practices aren't necessarily helpful in the children's best interests we can gently challenge them but not until you've built trust and relationship with that family by appreciating the cultural norms but getting to know them first and say how do you do grief what do you do when people die what words do you use getting to ask them first Kristi do you have anything to add to that if you have when you're working with different cultures and values around their view of death and grieving you know they would be finding this in different settings as well if they've got a different culture or if they've got a different religion or belief system or anything like that and so what we kind of find is they're normally quite happy to talk about that or educate us and so it's coming from that perspective like Julianne was saying of going I want to understand it from your perspective what's important for me to know about your beliefs or your culture what is their awareness around it and what does that look like and what language do they kind of use and so it's kind of following their lead a little bit and just being really observant and taking in how they speak about the person or what that looks like I know in some I think Aboriginal communities sometimes they don't even say the person's name once they die and so it can also be helpful for us to have a bit of an idea about some different cultures and some different belief systems around that but of course we're not going to know all of them and so it is just questioning and maybe putting that framework out early on of just saying I don't actually know a lot about how your culture grieves or what that looks like or what tradition do you have is it okay for us questions or I apologise if I make assumptions and so when you put that out early often they're quite generous in sharing or correcting or coming back to you with the actual information Fantastic. I think assumptions are what trip us up aren't they that we might know so asking I think with a genuine interest in listening at and adapting our work to be respectful this is a great place to start there's so many more questions we can't get to them but thank you guys so much we do have a couple of minutes for each of you to sum up so I wonder you Andrew just to sum up some of the key messages in working in this sort of circumstance with a family experiencing this grief what would you wrap up with I would say the GP is often one of the first points of call that a family such as this would present when they are dealing with struggles and difficulties and as a GP it's important just to listen to engage that family to talk to your patient of the child and to use age appropriate language and to help them sort out what those emotions are and where they're coming from and find out the key impacts on that family as a whole but also not forgetting that you also might need to involve mum and other members of that family the other part of our job is to then navigate a collaborative approach through involving other care professionals whether it is a psychologist or a social worker as we've heard from tonight or another professional such as another medical professional such as a psychiatrist or a pediatrician to really connect those dots together or whether we need to just hold this family and see them regularly so it's absolutely okay to do a mental health care plan if you're worried and you think they need more support it's fine to do a referral to not have all that on yourself and to have help from others and to be part of that process and support the family through. Wonderful thank you Andrew I think it's a really good point we haven't talked a lot about it but self-care is obviously important in this work so yeah making sure that we get the support that we need when we're sitting with and walking with people through these difficult circumstances Christy have you got a couple of key takeaways that you'd like to share with us? Okay so I guess Greeth you know it's chaotic it can often bring up a lot of feelings of feeling a bit out of our depth at times or that things are a little bit intense and I think one of the biggest gifts you can give someone is just being there in your presence to be able to listen and just to be able to hold that space and for someone to know they're not alone I think in particular with Ben's case open communication in the family is so important it makes such a big difference in just that feeling of safety and connection sharing memories is so important often when someone dies friends, families, even in schools and stuff people kind of go oh but if I bring up their name I'll get upset if I share a memory that's going to upset them but the reality is they're upset anyway whether they're showing it or not and talking about the person won't upset them because they're already upset but it will actually show them that you care and that you remember and that you feel sad that that person's not hearing you as well and so I think that can be such an important thing that if you knew the person to be able to talk about them yeah I think that makes such a huge difference they're probably my main takeaways that's wonderful I think it's a really good point I think another of the people that I know work with that have experienced grief actually one of the most hurtful things is people avoiding them for fear of upsetting them but actually by avoiding them they find that really hurtful and you don't have to have the right thing to say there's no right thing to say necessarily as you say versus kind of leaning in and yeah expressing a care for somebody but we can feel very frightened of doing that for saying the wrong thing and that can also be hurtful so thank you I think that's a really good point Julie Ann and Nicola that was such a good point you made then too is we just need to as clinicians letting people know that some of these things might happen and prepare them for situations that might take their breath away look something I've started doing a little bit more with young children and just to share with you now it's a little bit more about brain science and explaining to little people just what's going on in their brains when they can't work things out and I had one little boy the other night was saying I just was banging my head so that must feel so awful for you said no it makes it better it stops it hurting so we explored his thing and I said do you know what happens in your brain when you know when you can't think and you're stressed and it was when we took the focus away from his grief to something really tangible and understandable and you know he really got engaged in some understanding as some other stuff that I might not have actually introduced to somebody so young and I was really quite pleased and I've done it again this week to another young person and found that they really were fascinated by the fact that you know their brain tries to protect them from bad feelings bad thoughts so that's why your brain feels this and sometimes we act and hit and do things because behavior is communication and if we can't have words then we act and so sometimes putting it in these simple terms and then giving them some strategies so why do I feel so awful well you know this is what's happening in your brain and I think another thing we need to as modern day clinicians is think about the food and mood connection and maybe that's an exploration if you're not eating properly you're not going to get the right hormones if you're not going to get the right neurotransmitters and maybe that's an exploration like Andrew said you know work collaboratively maybe dieticians are needed as well or looking at his diet and maybe that's something that yeah can be added to our suite of things we offer but I think yeah just it's don't be an expert have all your knowledge be like that Zen warrior know where you come from and act from a point of knowing. Thank you I think that I mean we're going into other topics but I think that's that the brain science I mean it's taught in kindies you know these days around somebody was talking to me about it that their kindie child they talked about the wise owl as in the you know prefrontal cortex and the the barking dog as the amygdala and kind of that how that works and kids got it really well and it gave some sense of agency of understanding why in certain circumstances they respond and why these other skills that we're working with you on in terms of getting the wise owl to fly back to the nest can be helpful so we underestimate kids all the time I think in terms of how they how they feel and how they intuit and what they know what's going on but also that the agency they can have to understand what's going on point we're going to have to leave it there I could listen to this stuff all night but I do have to eat and so does everybody I really want to thank the panelists for a wonderful presentation on a really important topic tonight I think it was fantastic and I know from the feedback people have been messaging through that it was really helpful so thank you everybody Julianne Andrew and Christy it was a wonderful to hear from you and your expertise thank you everyone for joining us we cracked 900 viewers which is pretty impressive I think for Thursday night in December so thank you everyone that joined we would love you to complete the feedback again we have the exit survey the platforms a little bit different tonight so the exit survey if you click on the pie chart which is the lower right hand corner of your screen next to the speech bubble to fill out the survey that would be great or you will get a message to pop up on your screen after the webcast ends so just to let everybody know that after tonight you will get some follow-up communication from us you will get some detail and information with the recording of the activity and the resources and so forth we will get a statement of attendance as you see will be sent out within four weeks tonight's webinar was the last for 2020 so I think it was scheduled initially for maybe February feels like there's a few little things that have got in the way and so we're glad to have been able to do it it's been a very difficult year for everybody and MHPN are really pleased you'll be able to continue to provide professional development for you all we're working on the 2021 program and it promises to be great so the second MHPN conference if any of you participated in that that was fantastic will be in June 2021 so keep an eye out and save the date and we will continue to provide webinars on children there's partnership with emerging minds that will continue to do that and over the holidays you can catch up on MHPN presents podcast on Apple Spotify or on the website alright I think that brings us to pretty much the end tonight before I close one final acknowledgement I would like to acknowledge the lived experience of people and carers who have lived with mental illness in the past and for those who continue to live with mental illness in the present thank you everyone for participating this evening and I hope you get to have a restful and incident free holiday period thanks very much


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