Speakers: Ms Kristina Mossgraber, Dr Tony Pisani and Mr Stephen Scott
Stephen: Good afternoon everyone. My name is Stephen Scott. I'm from the New South Wales Ministry of Health, Mental Health branch, and welcome to this webinar on the Zero Suicides in Care initiative and particularly, the SafeSide suicide risk formulation training that is connected to the initiative. I'd like to start by acknowledging the traditional owners of the land that we're meeting on, the Gadigal people of the Eora nation, and paying my respects to the elders, past and present. I'll also acknowledge the lived experience of people with mental illness or with lived experience of suicide who are watching this webinar today, and thank you for your interest and contribution to suicide prevention and mental health. For all of the viewers of this webinar, you can ask questions throughout this webinar using the blue hand icon that's on your screen, so please send questions in and we will respond to them as best we can. And also, for any of your colleagues that are not able to view this webinar today, a copy will be made available on the New South Wales Health website in the near future. The Zero Suicides in Care initiative is one of the Toward Zero Suicides initiatives that is supporting the Premier's priority to reduce the suicide rate in New South Wales by 20 percent by 2023. And these initiatives address priorities under the strategic frameworks for suicide prevention in New South Wales and will be implemented in every local health district in New South Wales over the next three years. The Zero Suicides in Care initiative is a change management and quality improvement initiative to prioritise suicide prevention within the mental health system, both in acute and community care settings, and it responds to the greatly elevated risk for suicide among people with severe mental illnesses.
The Zero Suicides in Care initiative will have many different components but one of the key components will be, most essentially, an updating of our workforce's suicide prevention risk skills and response to people at risk of suicide within our system, which is what brings us to this webinar today and particularly to the SafeSide approach which has been advanced by Dr Tony Pisani and Ms Kristina Mossgraber from the United States. Both Tony and Kristina have worked with New South Wales Health over this year in two separate engagements, one in April and then another just in this last week - presenting workshops on the SafeSide approach in Queen Bee in Broken Hill, twice in Sydney, and also in Wollongong and Newcastle earlier this year as well. So, I'll now introduce Tony and Kristina, and we'll just proceed over the next hour with some quite informal discussion. As I've mentioned, you are very welcome to submit questions throughout the webinar, and we will respond to them, and you can use the blue hand icon for that purpose. So, Tony Pisani is an international leader in suicide prevention education. He is on the faculty of the University of Rochester Centre for the Study and Prevention of Suicide, and the founder of SafeSide prevention. Dr Pisani has published numerous academic papers and served on national workgroups including panels for joint commission and the workforce preparedness task force of the national action alliance for suicide prevention, which is also the current US National Suicide Prevention Strategy. And Ms Kristina Mossgraber is an advocate for recovery-oriented behavioural healthcare. A suicide attempt survivor, Kristina devotes herself to improving care for others who suffer as she did. She is director of education and community outreach for the Rochester chapter of the National Alliance for Mental Illness and provides lived experience expertise to all programs provided by SafeSide prevention. So welcome to Tony and Kristina.
Tony: Thank you. Kristina: Thank you so much.
Stephen: We might just start by asking a very broad question to request that you provide a summary of the SafeSide framework.
Tony: Yeah. Well, we're really glad to be here. Every problem becomes more manageable if you have a framework for understanding it. And what we've been developing over the last number of years is an approach to summarising what is now the set of best practices in suicide prevention that falls under the framework of Zero Suicide. And we can each share a little of how we came to this work. Do you wanna share Kristina?
Kristina: Yeah. So, five years ago, I almost lost my life to suicide. Like many people, I had struggled for a long time and wasn't really sure how to get help or what to do, and so, after I spent a month in the hospital at the of 2014, I embarked on a very difficult journey of recovery which is the hardest job I've ever had but the best job I've ever had. And in that process, I made a commitment to myself that I was gonna take this experience and do something positive with it for other people. I wasn't quite sure how that was gonna look or how that was gonna kind of tease out but I started volunteering and getting stronger, and working again and getting stronger, and joined a board at our medical centre and getting stronger, and that's where I had the great privilege of meeting Tony through a mutual friend and joining the SafeSide prevention team.
Tony: Yeah. Really my privilege actually because... So, I've... I came to suicide prevention also through some difficult circumstances. There was a service that I was part of and we lost two people to suicide in the course of three months, which was very traumatic, and the second of those suicides was also especially difficult for me personally and professionally because in my involvement, I had made a couple of errors and missed some things that weren't what led to the person's death but did lead to a lot of self-blame as well as... You know? At that time, it was a time in suicide prevention where there could be a lot of blame and scrutiny on people doing the work as well and I think that's something that's changing. And I know that just spending time here in New South Wales, I know that that's a very important commitment to create a culture where people feel supported, and that's extremely important to me too. So, out of the midst of that, I began learning what I could about suicide prevention, care settings, the real dilemmas that there are, cause it's always one thing to sort of say, Here's what would be good practice," but being really in it is another thing. So out of that, we developed this framework that has basically these four core tasks that we all engage in. The first is to form good connections, and then to have assessments that are gonna actually be actionable and engage a person at risk to respond and know what our responses need to be, and then to extend our care out beyond the individual, beyond the walls of any facility, and beyond any one episode of care. So, that's the framework that we work from, and have been privileged to continue this learning process by sharing what we learn and then learning more, sharing that. Because, really, nobody can call themselves an expert in suicide prevention. You know? As long as this is a problem, we're all learning.
Stephen: That's a really good point. One of the foundations, I guess, of SafeSide is this shift from the stratified risk or approach to risk that has characterised suicide prevention historically and really up until very recent times. And you instead use a language of risk formulation which represents quite a new and more innovative direction in the field. Could you talk a little more about what that shift means and why this new approach is so important?
Tony: Sure. Maybe we can share some of that. For a long time in our field, we've had trouble knowing how to synthesise the information that we gather. I think people are very good making connections and gathering information, but how do we bring it together? So we've often defaulted to this idea of saying somebody is at low risk or high risk or moderately low, high, moderate low, and I think all of us who have been working in the field sort of know that there's problems with that, but we haven't really necessarily had an alternative. And so, some colleagues of mine along with lots of input from people who work with youth, who work with adults, older adults, community settings developed this prevention-oriented risk formulation. And the idea is to really shift our mindsets from thinking about risk as something that we're engaging in to predict who is it that's going to be engaging in suicide behaviour. So rather the purpose is not prediction, it's planning. And once you sort of shift that mindset, it really kind of changes things a lot. One part of that, of this framework, involves not only summarising risk in a way that's more contextualised, cause when you think about it, risk compared to who? Risk compared to when? So, we try to contextualise risk in the person's setting and in the relation to their life but then also identify, as part of our formulation, what might change things quickly.
Kristina: So, the part of the risk formulation that Tony is just mentioning is something that actually happens to be my favourite part, which is something called 'foreseeable changes'. And that is identifying two things that if they happen in a person's life could send them into a really bad place really, really quickly. And when I first was learning about the model from Tony, that really resonated with me because I have fantastic safety plans, I have things in place, but I had never thought about it in that context. Like if something happened, what would something that would just really... like all those plans would go out the window, where if that happened in my life, it could just be just 'oh no!' moment immediately where I would need someone to step in and to help me get through that and navigate that. So...
Tony: And so, risk formulation is identifying if we have these sort of four concepts. First, risk status. That's risk compared to who. This person compared to others who are typically supported in our environment, where does the person's risk fall and then why. And the idea there is just exposing our thinking, making this transparent so that we can communicate across a team rather than just saying this person is at high risk, You know? This is how they match within their setting." Risk state which says risk compared to when. You know? This person, since they entered our service, maybe they're still at... their risk status might be still higher than other people because of all different things sort of happened in their life, but maybe their risk state has decreased. We wanna be able to account for that too. Identifying available resources and, as Kristina said, these foreseeable changes.
Stephen: One of the other quite appealing principles, I think, of the SafeSide approach is this concept of 'more than safety' which is... which I've seen on your slides and heard you talk about as well. Could you talk a little about how that's made meaningful in practice and how you address that through the framework?
Kristina: For me personally, that is such an important part of the framework and of our mission and our work because I was in the hospital for a month and I heard a lot about safety which is integral, right? We have to keep people safe and we have to manage environments and all those things that go into that, but there's more than safety in that we need to keep your safe so that. I think of it that way. It's the 'safe so that'. Safe so that. You know? In my case, I was 34 and I thought my life was over, that this was it, and I just needed to stay safe in the hospital, but safe so that you can go home. Safe so that I... so I could see my dog again, you know? Even just small things, you know? Safe so you can go home and rebuild your life. And again, safety is so integral but it helps shift the thinking to this safety as more than just that moment in time, keeping somebody in that episode safe.
Tony: And in terms of how that shows up, you know? That's why we call it a recovery-oriented approach to suicide prevention. I think this fits in very well with other movements that are already taking place here in Australia and even in New South Wales. I don't think it's really a new concept but I think it's something that we can all unite around. The idea that we're aiming higher than just safety or just stopping suicide. Well, we want, yes, of course, but we want people to flourish. And I think when you approach the work and think about, OK... You know? When we're working with people with suicide concerns, there's a automa... there's sort of a built-in opportunity for disconnect to happen because we're about preventing suicide, we don't stop suicide, prevent... You know? We want... To us, suicide is a problem, but often for the person who is struggling, suicide is a potential solution to a pain problem and almost... So, when we have these different perspectives, for us, suicide is a problem, the other person, potential solution, we have to figure out a way of bridging that. And that's, I think, where this shows up in the work is that, well, how do you bridge that? Well, one of the ways you bridge that is by having that common goal of feeling better, achieving what the person wants to achieve. In a sense, you could think of that the suicidal desire, we actually have a lot in common with the desire that it has, which is to just feel better, to escape the difficult feelings and be in a better place. And that's where we can both collaborate around.
Stephen: That's a fascinating insight, you're demonstrating there into some of the challenges, I think clinical interests or clinical objectives and suicidal thinking. And it's very interesting to hear you talk about a meeting point or a point at which you think these things can intersect. And I wanted to ask you, Christina, a little bit more about how you think this approach is of benefit to people with lived experiences consumers of mental health services, what kinds of changes can this type of approach bring about for people with mental illness who are at risk of suicide?
Kristina: I think that's such a great question. I think that this model is just so beneficial. And the first thing I'm going to say is just that, and it makes sense to me. I'm not a trained mental health clinician but even you know, the first time I read it, I could see myself in the model, and I could see how my care could have been different with a model such as the safe side prevention model, starting with the first concept in the assess where you're collecting the information, its strengths based. So the first piece of information that's being collected as strengths and protective factors, and it's all about what makes the person who they are. And I remember when I was in that place, I didn't think I had anything good to offer. I didn't think I had any strengths or anything like that. And so even just, even when we deliver the workshop and we practise, you know, the hearing it as a strength base, you know, beginning to the recovery journey is so powerful. And it creates an opportunity for transparency, it really creates an opportunity for patients and consumers and caregivers and clinicians to use a common language and talk to each other. I often felt that there was you know, they would all come in and talk to me and then there was some magic that happened in the conference room and then I wasn't going home or they were gonna change their medication or something was gonna happen, but I had no idea why. And using this really it, it creates, it changes the power balance. And to me, it creates a sense of respect, it creates respect and dignity for the person's experience and in the person's story and who they are versus you know, we talk to you and we go make some decisions in a conference room and that's that. So it's very powerful to me as a former patient Thinking about how my care would have been different I had amazing care, but it could have been a whole different trajectory just out of the gate, you know talking about it the way that the model talks about prevention, recovery.
Stephen: So Christina, you were picking up there on the first of I believe it's four steps in the framework. The first being assess, could you talk a little bit more, both of you about those steps, the first one as well as the subsequent steps as well, just so we start to flesh out a bit of detail about what this framework really yeah...
Tony: So we're at a little bit of a disadvantage in not being able to sort of show this framework that we're talking so much about. [Laughs] Especially since we're talking about, you know, something happening behind the curtain and then, So, in a sense, you know, we'll hope that we can have lots of opportunities to delve into it more but yeah, so Connect, assess, respond and extend. So we've talked a little bit about connecting around the common goal of recovery and committing to that goal with people and with our teams, having a prevention oriented assessment that is actionable and anchored in a context and then the other two are responding, respond and extend and respond. I can tell you, you know, working with people in a variety of different settings, one kind of anxiety point for me is, you know, especially when it when it seems like things are sort of deteriorating for somebody is like, what am I supposed to do? I mean, what is my job and so you start to kind of have a flurry of activity and, for me it's been so helpful to just Have a framework that tells me you know, there's really there's four things you got to cover. First, try to address the things that are driving the suicide concerns So that's one, second, make solid plans for the person's safety and sustenance. And then third, think about how to support the person in their least restrictive environment, how to think through when more support is needed or higher levels of care, but really aiming for that least restrictive environment. What are we doing to adjust our level of contact and observation? And then fourth is am I talking about it with other people on my team, address the drivers, make good plans support the person in the community, talk with the team and once I know OK, that's what my job is. Then I can kind of relax a little and then do the work that is really so critical if we're going to save lives, which is to really care and not be anxious or defensive, but just be there for a person. And so when you know that what your job is then it frees you up to then do the human work that is most essential.
Stephen: Mmhmm. Working in public health, I know you'll always be very familiar with the need for us to refer to an evidence base and to ensure that what we're doing is reflected in the literature in what we know to be best practice. Can you refer to the evidence base that has led to the development of safe side and also to the evaluation evidence for the model as well?
Tony: Sure. So the safe side framework is really a map of best practices. Each of those practices that are sort of on the map have their own literature base. And so in some ways, we're mapping territory that's been walked. And just bringing it together in a way that teams can share it in common with a common language and a common set of practices. So there's that literature. The training itself that we, that we tested in 2012 and published a paper about it, I think we were the first suicide prevention training that showed objectively rated changes in people's assessments. So we had trained coders looking at people's assessments and we're able to show objectively rated differences. And from that training, though, and from 2012 to now We've only kind of gone up, which was, first of all involving Christina. That was a training that didn't have persons with lived experience perspective in it. We also added a lot more video demonstration, we realised that you know, just hearing concepts or talking, you can only go so far. We need to really see these things in action, and then engage each other in discussing how does that apply in my setting. So there's that evaluation. We're also engaged in multiple other evaluations in different places. There's a large youth services organisation that has also conducted an evaluation and with respect to our training there was also evaluation done here in New South Wales. And we were really, very, you know, pleased to see that people found that very relevant to their work and setting. In fact, some of the measures that we've used in other studies The reaction was even stronger here in New South Wales. So we're pleased about that. And there's ongoing research at the University of Otago in New Zealand. And we've been very involved in Zero Suicide on the Gold Coast. And there's been a lot of evaluation around fidelity to the framework there, as well as some really encouraging you know, reductions in adverse events.
Stephen: You've touched on a whole number of points that I want to ask you which is great. Starting though I think with the lived experience component of the training that you've, been delivering, do you want Firstly, Tony, talked a little bit more about the way that came about in the first place, because obviously the involvement of people with lived experience really represents a sea change in the way that we do suicide prevention and mental health care over the last decade or so. And then additionally, Christina, if you could also talk about what your role is in the training, and what it is that you bring practically to the training.
Tony: Yeah. And beyond the training too. So a couple of years ago, I was speaking to a group of people I'd been, you know, sort of brought to an area to speak about suicide prevention. And I was strongly and passionately advocating for collaboration with people with lived experience that we, everything we do needs to be done together. And I realised I was standing up there by myself. So I had this sort of moment and try not to be too distracted by it for the rest of the time I was speaking like, I want you to start thinking about that... The whole rest of the time, I was thinking, I shouldn't really be doing this. Yeah, should I really be even here? You know, that's difficult to go on for the rest of the day like that. So I got to work on it after that. And so I was really, very actively seeking for a number of months, kind of somebody who would be, you know, really a very strong collaborator who could not only, you know, not only share in code training, but also provide, you know, active input into our programs and who would also be able to, you know, share honestly with me, places where maybe our approach didn't fit. And so I was very grateful to find, you know, Christina and, who has been just, you know, ideal collaborator and who's now you know, leading lived experience for us and you can share about your role in the training and as well as kind of our expansion of wanting to involve other people in each of the localities that we're working with. So really would be part of a team as well. So do you want to share your role in the team?
Kristina: Yeah. So, I mean, everything we do, you know we do together really, truly is a partnership with Tony and with the rest of our team. When we're creating new materials, I always, you know, review the scripts and offer input. That was actually I role when I first started, that was kind of the first thing we were developing all these things and I would read them and I was like, ooh, if somebody said that to me, I would walk right away. And so yeah, we've made changes and they, you know, as we started to work more together though, I felt heard and I was just so grateful to, you know, really because, you know, you start a new thing and you're like, OK, is this really where I need and want to be in? And as we got to do more and started doing more workshops I was like, Yes, this is definitely, This is definitely you know, walking the walk of it. And so I've, you know, provided an advisement on that and we teach everything together locally and globally. And our goal and our mission right now is to build a team, because there are so many more voices than just my voice that represents lived experience and, and lived experience from, you know, not only someone who's struggled with suicide concerns, but from family members and from loss survivors and that whole collective voice in different cultures and different areas and all those voices that make up the changes that are going to happen in suicide prevention and bereavement and all the other pieces that come with it because I think it's a great opportunity for a big culture change in suicide prevention and loss.
Stephen: Can I ask a few questions then about the delivery of the training if you can think of that in its broadest.
Tony: We call it a learning program.
Stephen: Learning Program Yes, because there is a number of different components or means that you are delivering this We've obviously had now six workshops in New South Wales this year, but physical in person workshops are not the only component of the learning program. So, can you help us explore a little bit of those other methods that you're using and how they kind of fit together as an integrated whole.
Tony: Yeah, as you said there, I mean, we've had really rich experiences and we love having those in person trainings, you know, spending a day with a group and we learned a lot that way as well. But yeah, there are there are limitations to that and, at one point, I sort of had a bit of a moment of truth about that, too I think, which was that, you know, there's a few existing models for training people and you know, you could do online learning. But you know, many times that's something that like happens on one corner of your screen while you do other things and we didn't want suicide prevention to be that way. And even us going to, you know, someplace it's, I think it's a very valuable thing but there isn't always follow up to that. And I started to really feel, you know, convinced that this has to be an ongoing thing. If we're really gonna have the kinds of goals like the Premier has said, it's not going to be a one and done thing. So we have developed something that we call in place learning, which starts with online learning you do as a group. So, rather than, you know, 60 people coming into a room and us at the front of the room, we really want to see teams and groups around a table, working through video based materials that are where Christina and I and others teach core concepts, demonstrate those in videos like I was describing before. And then having a chance to really talk about and practise those things and assess how does that fit with the population that we're working with and our location and our roles. Because there's so many different really important roles from people who are in, you know, very much clinician, clinical trained mental health, you know, mental health professionals. But also there's people who are in other supportive roles, you know, case management roles, peer specialists, who are all important parts of a team. And so if they can all, you know, take in some material that's online and available when it works in their schedule, but then have a chance to engage together with it, that's kind of the core part of our, and that launches the learning program. We follow that up with monthly opportunities to interact with us and other groups around the world who are kind of engaging with a similar framework through kind of, like a sort of a video based learning, collaborative type opportunity. We call it virtual office hours. And then in an ongoing way, having quick, you know, sort of five minute refreshers that keep us all thinking as we get frequently asked questions or as things change in the field, you know. This field is really changing rapidly in terms of what does it really mean to do the best kind of care we can. And so it's been really encouraging to see people's responses to that. You know, most people in mental health field really want to, you know, want to engage. And we have found certainly here incredible amounts of clinical wisdom and skill. And so it's been very fluid and engaging to, to then bring people together to go from there. So that's how we, that's how we're approaching it. And so we aim for the kind of workshops that we've done to really be a, you know, kind of a first step in, in engaging.
Stephen: It's a really different approach and a much more sustainable approach I think than just the fly in fly out approach. And, you know, as you say, with these ambitious goals that we have and because of the challenge and complexity that suicide represents for the whole community, these kinds of approaches that just skim across the surface are not going to suffice.
Tony: And you know, we know that change happens in groups.
Tony: And to me that's critical. I don't think people need to talk with us as much as they need to talk with each other, you know. That's, I think that's really where they change up. There's so much expertise in every team. And, you know, we're aiming to, you know, present some things that will hopefully stimulate and maybe, you know, advance the conversation. But really it's the expertise of the team sharing with each other, having a moment in our very busy schedules to step back and say, how are we doing this? How are we connecting, assessing, responding, extending the impact of what we do? How are we doing that with our, the people that we serve?
Stephen: It really addresses a whole number of issues I think that we have around responding to the risk of suicide in the care system. You know, whether that be the community or in inpatient settings where, you know, we need this consistency of approach. We do need teams to be engaged rather than just, you know, engaged collectively rather than just individual approaches taking place. And I feel as though this links back to some of the earlier remarks you made about addressing cultures of blame and taking more of a systems view rather than a, you know, an individual clinician's fault or flaws being, you know, the way that we should be analysing and responding to this issue.
Tony: Yeah. I think that that has for a long time sort of been the way we've sort of thought about it, but I think that is changing. You know, this kind of brings up one of the, I think sometimes the concerns people have with the words zero suicide. It's funny because, you know, people might think, oh, well does that mean we're going to be blamed if there is one? And it's actually the exact opposite. The idea behind zero suicide is that we create systems of support for us to do this work. And that it is the whole system's job. And so the, taking it out of, so it's not all up to me, is actually a tremendous relief. And I know that there's a great deal of work going on here too about supporting that kind of a culture where, where people can feel safe to do this really, really hard work.
Stephen: That's right. Now we are receiving quite a lot of questions here. So thank you to everyone...
Tony: Let's do it.
Stephen: Sending these in. Tony: Game on. But we definitely want to respond to as many of them as possible. So, first question here. We have downloaded the overview document, which is available on the webinar and that consists of some of the diagrams that are included in some of your presentations and promotional material. And, this has been looked at while we're presenting. So, could you explain where in the framework would you incorporate a mental health status assessment or a mental status assessment? Would this fit in the assess subjects?
Tony: Oh, yes. Yeah. So I think the materials that you have, the framework is pretty tiny, but if you have it on your computer, you can like zoom it in, you know, you can see that on the left side after connect, there are, maybe I won't put my hand right in front of your face. There's two circles, one that involves the sort of more enduring factors and then the other which is of more dynamic factors. Right here is symptoms suffering and recent changes. That's where we track mental status. So we kind of put it in the context of other factors that provide the, the sort of the setting in which your risk assessment occurs, but mental status happens under that sort of category in the collection of data that informs your formulation.
Stephen: OK. Thank you for clarifying that. There's a very interesting question here regarding the tailoring of the training to diverse contexts. So obviously you're working in a number of countries now with you know, some very diverse and different cultural settings. Even within New South Wales, I think you've probably seen a number of diverse and different settings. And so the question is about the tailoring to the Australian context, but perhaps you could also talk more generally about how you're responding to these different settings that you're providing a service to.
Tony: Yeah. So share our approach to kind of cultural responsiveness. So first of all the, the foundation is kind of what I described a few moments ago which is that the, you know, a key part of the learning is what the group is doing with the material. So throughout our video based training, it constantly reminds the group to discuss how does that apply and adapted with the cultures that you're serving. So that's, one part is the way it's sort of built in. But then we also have kind of a step wise approach to our kind of engagement and responsiveness with the specific cultures that we're serving. And this, our model for this kind of grew out of our work in New Zealand. We worked with, one of the sort of their equivalent of an LHD or DHB. And so the first step is getting feedback. And so in that example we have, we had some good feedback from Maori mental health groups that were engaging with the training and then, and then adapt and then actually updating the training based on that. So and, so as just as a small example, there was a clear bit of feedback that, in this approach there needed to be lots of time provided early on for points of connection. And so we adjusted the training based on that, and it turns out that actually helps everybody.
So that's the first step is gathering feedback where we have very active evaluation process, engaging with different groups, getting feedback and adjusting the training. The next level of that is, you know, Christina you mentioned it already which is that we want to engage people in each of the countries that we're working in to work with us. So the next step after that is, especially our first next step is working with persons with lived experience here in Australia. And the goal there would be to actually create new materials that will, as people are getting experience with the framework, create new materials both teaching and video demonstrations. And so actually that's the step that we're at now with our New Zealand colleagues, which is that we're in an engagement, of course, these things, especially around, you know, engaging with, you know, other cultures it needs to be a careful and, you know, thoughtful with lots of listening and back and forth. But we're in that big stage where the goal there is to, is to create some video demonstrations that with, you know, with New Zealanders and then have some modules that are teaching modules that are actually co-taught with people. So that's where the vision is and the steps that we're taking there and that will be our kind of approach here as well. Thankfully we have some good, some good initial feedback both from the evaluation here in New South Wales, but also from the implementation in, in Queensland. So we have now, you know, three years worth of feedback there about the relevance. And then we're also engaging in a nationwide effort here with the Department of Veteran Affairs. And so we'll be gathering, you know, that's another subculture really, or multiple probably subcultures. And so we'll be learning additionally from there. We have experience with veterans in the US and we're finding quite a lot of commonality actually. But where there are differences, we'll be making adjustments and creating new materials.
Stephen: OK. Thank you for that. Now we've got a couple of questions which are related I think. Firstly can non-clinicians working in mental health take the SafeSide training and quite specifically, do you also train mental health peer support workers with lived experience? So, I'm sure there's plenty to say about this.
[laughter]Kristina: Could you tell that I got excited?[laughter]So I mean, short answer being yes. And that's again part of the beauty of the model is that even, you know, non-clinicians if you will, I think, I don't like saying non-professionals because we're all professionals working in this. Peers are professionals. So anyone, you know, working in the field. There's parts where everyone can contribute, you know. I guess from my perspective, you know, when I, cause we've been thinking a lot about how to integrate into our training where peers can come in. And a big part of where I see that is when you're collecting the data in the beginning of the assess model, you know. Because a lot of times peers, people's lived experience will only tell a peer things. Now obviously there's boundaries and there's, there's things that have to be, you know, discussed and clarified and proper supervision in all the little things that we all need. But there's a very, very integral role for peer workers and for non-clinicians if you will, you know. Again I can tell you that my best connections were with the techs. The people that I worked with in the hospital, We didn't have peers on the inpatient unit that I was on, but there was technicians that came in and, you know, did all kinds of interviews and I talked with them the most. And so they would also fall kind of in that realm of, you know, non-clinician but frontline people. So...
Tony: Yeah, we aim for teams to be on the same page and with sharing a common framework and language, you know, and so every person is valuable in that. And so yes, it is des- I know. Our training does also include an additional sort of module for people who are in more clinical type roles. People who are the ones who sign their name at the bottom of the page. And so there might need to be some additional work for, for that subset of the team. But most of our training really is designed for the whole team.
Kristina: For everybody, yeah.
Stephen: OK. Thank you for addressing those points. There's also sort of a group of questions that relate to the in-place learning or the office hours, the various online aspects of SafeSide. So, people are just wanting a few more details, I think, about how that all works. So, I'll just read out these few questions.[crosstalk]Tony: We'll try to hit 'em. Kristina: We'll get them.
Stephen: Can you describe what kind of support is offered over online office hours? Can our team join you as a group to ask questions? I assume that's rather than individually. As a service, how do we select people to run our in-place learning. I think that's a really interesting and important question. And do those staff members require training to run the in-place learning sessions separately?
Tony: Those are really great questions. Shall we take them in order?[crosstalk]The first one is what's office hours like? Do you want to hit that one?
Kristina: Office hours are offered monthly and they're a half hour with Tony and I and other members of our team and we encourage people to bring their questions or their thoughts or their experiences to us. If there aren't any at the beginning, we do have an agenda that we've created with feedback we've received and things like that to kind of get the conversation going. It's a great opportunity to learn from people around the world. We had a great office hours. Our last one where someone asked about why risk was not called hope status and hope state which provoked an amazing conversation and got a lot of us thinking and experience sharing. We're there to answer questions and to offer support and feedback.
Tony: And also it holds us accountable. Because if we're teaching something and you're working on it as a team and you find things don't fit, we're always just a couple of weeks away from asking that question. It also helps us to improve too. That's office hours. I think the other question was about ...
Stephen: The in-place learning and particularly training of ...
Tony: Yes, right, so in-place is .. .I guess that there's a participant facilitator. Who's really - their job is to kind of organise the group to get together, make sure that there's a place to view the materials with good sound and good visuals to advance the videos and keep the group within the time limits that we've provided for discussion. And that's actually the hardest part of it. These topics tend to really get people going. Which is fine. There have been some groups that have decided, we're just going to take the full day so that we can have more discussion time than you leave. We've made it to be sensitive to all the time demands there are and the fact that there's people waiting to see it. We've kept it contained to a half of a day, three to four hours. Three hours for the full group, four hours for the additional clinician part. But, yeah, and so there's a five minute video orientation. You can find it on our You Tube channel. If you put into You Tube, SafeSide prevention facilitator orientation, you'll find it there. It's five minutes that says, here's your role as a facilitator. So it can really be anybody in the group. It doesn't require any special knowledge. It's more about somebody who has a willing spirit and who can be sort of, nudge people along and be like, hey the timer went off a while ago. Let's keep going.
Tony: Otherwise it would just take longer.
Stephen: Do those people have instructions available to them?
Stephen: Do they require separate
Tony: There's a one page facilitator guide that shows you what to do and this five minute video to watch to understand what your role is. But really that is the whole idea. It's that it doesn't require a big 'train the trainer' effort. We want teams to be able to, we can do this in two weeks. Let's just block a little time and do it and really try to have the lift be light so that the real effort can go into the conversation and the engagement with it.
Kristina: I just want to go back to office hours for one quick question. I did hear, can teams participate as a team?
Tony: Oh yeah.
Kristina: Or does it have to have the individual. And the answer is yes you can as a team but what I would recommend personally and yes people have, because it is just half an hour, it's such a short period of time, maybe have just a little pre-discussion of the question or questions you wanted to get across. Because we just have that short, precious half an hour. But we'd love to see as many of your team members as possible.
Tony: And people can attend, we offer, although it's only half an hour, because of the different time zones we offer it more than one time a month actually. And so, depending upon what time you're wanting to show up ...
Kristina: Time you want to get up!
Tony: You could attend more than one if you had an additional. question. We offer one during working hours in each of the major time zones we're working with.
Stephen: Thank you for clarifying those points. There's an interesting question here regarding the frameworks integration with technology. Would you recommend safety plans or other aspects of the framework on apps.
Tony: The short answer is yes. What the framework is really providing the content of what those practices are. And what are the principles in wanting to ... We're very much about not just what you do but how you do it. If you can again zoom in on your framework, when it comes to planning, there's creating safety and contingency plans, really key, and then it extends onto giving input and clear roles for other people. Now the question is how to do that in the best way. How are we going to extend the impact of our safety plans so they're not just a piece of paper. I think that's one of the big challenges we have with an important intervention like that. That it's not just a piece of paper. And not just an app either. Just because you put it on your phone, doesn't mean the person has really engaged either. With respect to that specific question, yeah we do think that it's probably the best place for a safety plan, is to be on your phone. That's the one thing that everybody usually has with them. And it's also how do you do that with the person, how to engage them. How do you make it as collaborative as possible knowing that sometimes it's very hard for people to come up with ideas and it's one of the things we talk about, it's let's get real about this. How do you really make it something that matters.
Stephen: There was an interesting question we received earlier regarding the applicability of SafeSide outside of the mental health context and I think that question's possibly open to some interpretation, but I was thinking that it may refer to, for example, settings which aren't necessarily the mental health system but might be youth services, the justice system, other settings which aren't so health focused.
Tony: We have not yet worked in corrections systems. I think the framework would be applicable and certainly we are applying risk formulation to violence risk assessment. There's actually a module of the training about that. We have specific versions of our training that are for primary health care and youth services. They are a little bit different from the core behavioural health training, mental health settings. The primary care one is a little bit briefer and has less about risk formulation and more about ... we wouldn't take out your beloved foreseeable changes but we don't get too much into risk status and risk state in a primary health setting. And in Youth Services it's really designed towards people who are in school support roles or those kinds of things. We do have particular versions for those.
Stephen: Thank you for that. A couple of final questions here. We are in our last few minutes so we will just try to get onto those. This is probably more a question for me to answer, which is whether New South Wales is adopting the SafeSide framework across all local health districts. As I mentioned earlier, we have had Christina and Tony here twice this year, presenting workshops in a number of our local health districts. We're currently working on a longer term engagement with SafeSide to make a range of the training available, as we've been discussing, not just through those face to face workshops but through the online support as well. As I mentioned at the beginning of the webinar, we do see this shift to a more contemporary risk formulation approach. It's been quite fundamental to the zero suicides in care initiative and to the effectiveness of a zero suicides health care approach in New South Wales. So we are working on bringing that piece of the zero suicides healthcare framework into the initiative in New South Wales. You can certainly stay tuned for more information about that. In the last few minutes that we have, there is a really great question here. After the travelling that you have done around our state and also in Queensland and now also in Canberra with your engagement with Veterans Affairs at the Commonwealth level, what do you think are the strengths of the system that we have here to prevent suicides? And really any other impressions that you have gained of our workforce, our system and the way that we are currently seeking to tackle suicide in New South Wales?
Kristina: I have to say quite honestly, my experiences have been nothing but positive. I feel very inspired. I think that people are really behind this movement. I see a lot of passion and I see a lot of drive and I see a lot of empathy. I see a lot of inclusion too. I've been really honoured to see so much inclusion of lived experience and of what everybody brings to the table to make this a reality. Everywhere I've gone there's been some poignant moment or some conversation that I've had that's really stuck with me. I go home from these trips so inspired again with the work that's been done here and I know the work that's to come and I really, truly believe that people are invested in this and that the change is going to happen here.
Tony: In my mind, Australia's leading the world actually in suicide prevention so we feel privileged to be part of this and we're learning at least as much as we're offering. In terms of strengths, I can speak at the system level as well as the clinician level. So there is more, I think, community outreach and focus happening here than almost anywhere. That's one clear strength. We have seen such clinical wisdom. The people that we have worked with here in New South Wales, there's depth here. Really, this is not about bringing brand new. It's really about bringing it together. Yeah. It's been a pleasure and there's tremendous strength that we're pleased to be joining up with.
Stephen: Thank you. We are almost out of time. Given that we have referred quite a bit in the webinar to a number of different slides or different resource materials that were illustrating some of the points, we may look at publishing those along with the webinar so that those that are viewing this in future and those that have viewed today can refer to those to help fill out some of the details that we were covering. But at this stage I would just like to thank everyone who has participated in the webinar. I've noticed that a few of you have sent through some more questions which unfortunately we're not going to quite have time for, but we will review those and provide a response to you either by email or over the New South Wales Health website. So thank you very much for participating today. And Tony and Christina, thank you both so much for both this webinar but also all of the work and commitment that you've been giving to us here in New South Wales over this year. We've greatly appreciated your insights and your enthusiasm and your passion for this work. It is quite infectious and so we look forward to seeing you again soon. Thank you again for everything you've done over these last few days as well.
Kristina: Thank you
Tony: Thank you.
Stephen: No problem. Have a great evening everyone who has been viewing this webinar. We will be presenting these types of webinars with some regularity, with different suicide prevention experts over the coming months. We very much appreciate your interest and your participation going forward. For further information on the Towards Zero Suicides initiatives, whether it's zero suicides in care or any of the other work that New South Wales Health is implementing, please go to the New South Wales Health website or feel free to contact any of us at the Ministry of Health to discuss those initiatives at any time. We very much welcome your approach to us. Have a great evening and thank you again.