Hello and welcome back to the Thought Broadcast, the trainee focused podcast from Australasian Psychiatry. On today's episode, we're going to explore a trainee's experience of working in a unique and complex field of intellectual disability psychiatry. My name is Dr. Ed Miller, and I'm the trainee editor for Australasian Psychiatry. And I'm joined today by our associate trainee editor, Yoon, who has previously worked as a psychiatry registrar with the Queensland Centre of Excellence in Intellectual Disability and Autism Health, or QCEDA for short. So welcome, Yoon. Thanks, Ted. And we're also joined by our guest speaker today, Dr. Belanie Jodson, a consultant psychiatrist from QCEDA and previous supervisor for Yoon. Welcome, Melanie, and thanks very much for joining us.

Thanks for having me.

So, Yoon, I think today we're going to have sort of two parts of the podcast. One is really going to be exploring the QCEDA service and letting our listeners hear a little bit about what that service is doing. And we're also going to get your perspective, Yoon, on what it's like to be a trainee kind of going through, you know, an intellectual disability sort of placement and what that's been like for you.

Yeah, no, no, thanks for that introduction. And yes, I suppose I might ask to Melanie a bit shortly as well to talk a little bit more about us, the service that I used to work in. But I suppose my part will be, you know, I'll be sharing it. I suppose a bit about my reflection as a, you know, as a trainee working in this complex field of IDD psychiatry. And a quote that I've taken really from is a novel that I'm quite passionate about myself, which is The Great Ghasty by Escort Fitzgerald. And the particular quote is I was within and without simultaneously enchanted and repelled by the indesorf variety of life. That line became kind of a length to understand the different layers of paradox that came with the work.

Thank you. That sounds really, really interesting. I wonder, Melanie, would you like to sort of start by just giving us a bit of an overview of your service and just some of the, yeah, just general information about how it works and what lots of things you do?

Yeah, so our service as a center of excellence means that we focus not just on clinical work, but on research, education, policy, and advocacy as well. So a bit of a background is that our service has existed in some shape or form at the MARDA Hospital in Brisbane over the last 20 years, but with a few different names and different models of care, which has been secondary to some changing funding models over the years. But we relaunched as a centre of excellence last year after we successfully secured a tender of funding from the Queensland government. And that came about following a parliamentary inquiry into the mental health of Queenslanders in 2023. And so the establishment of a centre of excellence is one of the key recommendations of the inquiry to help address that gap in equity of healthcare people with intellectual and developmental disability in Queensland, which of course is not isolated to Queensland and is an issue we see kind of over Australian across the world as well. But so as a Centre of Excellence, we aim to improve the health of people with intellectual disability through those different means we talked about. So education, research, and clinical work. What I think is really special about our service is that our clinical and research staff are all co-located together, working together on each of the projects while really making sure to center um co-design and co-production with people with intellectual and developmental disability throughout all aspects of that service. So that can look like people with intellectual disability and autism sitting on our advisory committee, but also we employ people with intellectual disability and autism in our research team. So I guess an overview of how we work is that we service all of Queensland and we run essentially as a consultation model. So we have a few psychiatrists, a GP, a rehab physician, and some nursing staff and Allied Health. And we work as a consultation model, meaning that we accept a referral, do an assessment, a sort of short bit of work, but have that shared care model with the person's primary care provider, whether that's a general practitioner or a specialist or a psychiatrist or other specialty area. And the reason for that is, I guess, the sheer numbers of the population that we serve. So there's more than 150,000 Queenslanders with intellectual disability or autism. So between sort of two FTE psychiatrists, we're just not able to service that population longer term. But the hope is as well, is that by working with the individuals' local providers, that we lead by example and we help them develop skills locally to better service their communities as well, no matter where they are in Queensland. So that's kind of an overview of our service and how we work.

That's amazing. Is that similar across other states in Australia?

Yeah, there are very different service models across Australia. It's probably most similar to the New South Wales model, where they have a sort of a statewide consultation service, but it's generally unique in the country of the amount of staff and resources we have. And we've also had a new initiative in Queensland where each hospital and health service is getting their own intellectual disability mental health team. And so part of our role will be to uh be a secondary consultation service for those teams as well to offer kind of second or third opinions on very complex public cases. And so the model that we have is quite unique, and I think Queensland is really sort of leading the way in terms of the number of dedicated health professionals working for people with intellectual disability and developmental disability.

That sounds amazing. So you guys would see patients, like they would come to your service as an outpatient, and you would also provide sort of second opinions and advice to other care providers, I guess, about complex patients that they might have.

Yes. So for our kind of public clinic where we see patients directly, um we see people in our clinic and via telehealth as well when they're remote. And in that service, we we do sort of reserve our referrals to be kind of quite complex cases, meaning that they're for individuals whose healthcare needs can't be met by the local general health services. And again, we just have to restrict that because of the limitations of our service and and how many people we can see in a day in a week. And then with the public mental health teams, which are still rolling out, but as they become established, we'll work with them with a liaison model as well. So we can see patients if that's what they're wanting from us, but also have that opportunity to have supervision, peer supervision, case discussion, and have that kind of adaptable and dynamic model to meet their needs as broadly as we can.

That sounds amazing. I have so many patients I would love to talk to you about. I'm just wondering, so Jun, what was your experience when when you first joined QCED? And I guess, firstly, had you worked in a disability service before, or what was your expectation like going into this sort of service?

Yeah, that's a very good question, Ed. Um, I suppose I actually applied for the role um when I was in my first year of training. And as I heard about service back in the days, it was called Minos Intellectual Disability and Autism Service, particularly because I was interested in predominantly at the time more autism. That was my main experience, especially as a junior trainee as an accredited registrar, where I worked in a service where we saw young people with more of a discual diagnosis of a mental health condition, but also simultaneously having a degree of neurodiversity, which then led me into that, you know, that complex area. And I suppose that led me into applying for the particular position. I think I'll be quite honest here, when I started the job versus what I was expecting was very different, but also not different at the same time. Different in a sense where the complexity that I thought that I was expecting was underrated when I joined the service, which taken me by quite a surprise. I think that complexity can be described in many different ways where you know the consumers or the young people that we might see they might have quite significant communication challenges, which makes a typical psychiatric assessment or review quite different or challenging at the time. There's also the variety, the inresourcible variety, should I say, of different systems involved, such as that could be families, carers, support coordinators, NDIS, NDIA, who's already involved for a number of years and trying to figure out what I might mean to them was also quite an eye-opening at the same time.

Was it that complexity and the multiple perspectives that made it sort of different from what you were expecting?

Yeah. I think there's a number of ways I think we can encapsulate that. I suppose I felt quite overwhelmed when I first joined the team. Um and at the time, you know, I had to take a really step back and figure out what I'm what I'm actually doing in the team here. And at the time, I've utilized more more of a more of the traditional bicicle-social model, which is I felt like had been engraved to us as medical school. When I try to apply this particular, you know, model of care, I came to this being feeling stuck, you know, essentially, where it was quite helpful in that initial assessment process, um, where we were able to have a question about the biological, the psychological, and the social elements. But it became quite challenging when the the different domains really intersected together. Like, for example, when we have a person who where there's a social disturbance creating the psychological distress, you know, leading to escalation in a behavior of concern. How do we differentiate different domains, the formulation and our recommendations that we make as well? Additionally, the bicycle social model didn't really encapsulate that level of emotive layer, which I felt was very strong in those consultation rooms. With that in mind, it kind of led me to take a step back to better understand the situation, which I think is where that more psychodynamic way of thinking came into my practice, which then led to this concept of to be more within and without. I suppose that concept can be seen in different ways. Felt like I was within that clinical route, but thinking on the emotional narratives that are being told by the family, the carers, I felt at times helpless and a bit stuck at the same time. Felt like I was physically present, but I felt like I was limited in the things I could do. And I suppose that's the time where, you know, the supervision became quite useful, in my opinion, um, where I didn't really realize what I was going through or all the emotional ailments that I was undergoing. Um, it'll be one of those, you know, after a consultation, I'll be on my driveway, you know, drive back home. And that a particular case would be in my mind for a while. And those are the particular cases I would often, you know, bring back to supervision and kind of vomit out this emotional narrative that I felt to Melanie. And I think Melanie that helped unpack some of those emotions. Um, and I think there was a degree of, for me at least, the psychological safety in that supervision space to actually discuss these concepts. Unpacking them doesn't necessarily give us a solution to that particular case or particular question that we might be asked for that individual, but it helped, at least for me, to be less reactive and provide a more of an authentic response, should I say.

Can you speak to that a little bit more in that complexity, like Ean said, about, you know, social factors influencing a psychological response, which might then cause someone to come to your service? And I can say, you know, living in Auckland and New Zealand, like I've alluded to, I've seen lots of young people that have ended up in acute mental health services who have intellectual disabilities because they've reacted to a particular sort of social situation or or lack of social supports, and they've ended up in mental health services. I'm just wondering, yeah, if you can speak to that sort of stuckness and complexity.

Yeah, I I think where it comes from, you're you're right, and that this is not isolated to our area of psychiatry. But I think I find with our people that we see, you know, we know the saying that there's there's three sides to every story: yours, mine, and the truth. And I think in our room there ends up being seven because there's the the patient, both of their parents, their behavior support practitioner, their GP, their support coordinator, the support worker. And so everyone's giving you their own version of events, but also interpretation of events. And so I think the amount of information that we're trying to compile and interpret becomes huge while also trying to figure out those dynamics within those relationships, which are often quite complicated as well. And so I think that's one part of where the complexity comes from. But I also think in the room can be quite chaotic. And I guess part of it is trying to, and it's very, very important to me to include the individual whose appointment it is, right? They're the center of what we're here for, and finding ways to include them in discussion, even when they may be quite minimally verbal, and have quite low tolerance for a clinical environment. So sometimes our in-person reviews, I think my record for the shortest one was about seven seconds that they came in, sat on the chair, got up and left because all they said was I had to see the doctor and I saw her, and now we're going. A common reason for referral is self-injury. And so for someone who expresses their distress via self-injury, we're commonly seeing that in our clinical environment as well. But then you get this kind of air of distress from caregivers, right? Because on the one hand, we do end up having quite a long wait list for our appointment. And so carers will really stress that they waited five months for this appointment and they've got to make it happen. And we can't cut it off early because you know we need an answer at the end of this session because we've waited so long for it. So it's balancing the expectations of what we're going to achieve today, what we might achieve long term, but also what can be achieved. And I think where this has really helped you and I kind of work together on this is that I have been in a youth's position. I was a registrar with the service as well. And I remember feeling quite overwhelmed with, I guess, what I perceive to be the expectations of the people coming to our clinic that we have, you know, especially now with the title of center of excellence. And what do you expect when you go to a center of excellence, right? You expect some answers. Again, not only in our area and um in most of psychiatry, there's not an answer to a problem. And so I think I struggled when I first joined as a registrar with that issue and sought supervision myself to say, what do I do when I don't have a good solution for what they've come in for? Which is most of the time, right? There's not a solution. There's a lot of small steps we can make. And I heard from my supervisor at the time that often what people are wanting is is reassurance and they want a listening ear to make sure that they feel that they're not alone with their problems. They want to make sure that they're not missing a big thing that would make a big change, that they're not doing anything wrong, that they're not missing out on an answer. And so sometimes, even though I feel like I haven't given them anything spectacular, people can get a lot of satisfaction from that appointment of feeling like, no, this is all to be kind of expected, and there's there's nothing missing from the plan. The plan is a good one, but we need time and patience and waiting for that to kind of come together to make change slowly.

It sounds like it's just as much about, you know, psychotherapy and dealing with complex systems with that psychotherapeutic sort of mindset as it is about the clinical now sort of intellectual disability psychiatry.

I think so. I think I'm thinking back to the sort of past experiences in in general services, and sometimes there can be, I guess, people who aren't familiar so much with intellectual and developmental disability psychiatry thinking of, well, what is the role of a psychiatrist with someone who doesn't talk? But I find that psychiatrists, you know, what is our special skill that we have that other people don't is the skill of formulation. And the formulations that we get are so rich because they encompass not only a person and their mind, but all of these different systems, the transference between individuals, between organizations, and between us and the individual and the people they're coming in with. So I think we're uniquely kind of skilled to pick apart those systems and formulate them.

And I'm wondering, Yoon, is that why this rotation was potentially so impactful for you? Was that the first time where you've really been exposed to a humane, rigorous formulation?

No, I'll definitely, I'll definitely echo that. I think re-aspect of psychiatry can be quite rich in formulation. Um, I definitely have Kim's term, which has been very rich in formulations as well. I will say that in this particular field of ideas, there is even more richness that we can bring out, especially, you know, I think from my view at least, is that by the time that these patients and the family sees us, they've already been involved with so many other doctors before, like pediatrician, geneticists, endocrinologists. And they've got this level of transference is for me, I felt like it was very much multiplied, where they're still engaged with other, you know, even the rehab physician, all these allied health and caregivers as well, where I think that level of projection might be even greater as well. And just being more mindful with myself as well, what that might mean and how that might play out in that consultation room, and how would that then determine my own formulation from there as well.

Were you expecting to learn so much about psychodynamic principles from an IG rotation?

Definitely not, definitely not. Yeah. And I suppose that's kind of where the within and without kind of came as well for me, where I felt I was invited into the system. I felt like every consultation was a meeting of different systems, the NDIA and support workers who's been there for 10 to 20 years, different medical professionals already involved as well. But I felt like sometimes I didn't truly belong, especially at a time of a consultation service where you know I might give recommendations, but it won't be myself to act on at the same time. I think with that, if I go back to my own special interest for the Great Gas V, when we think of Nick, and for those who might not know the novel, Nick was a character within the novel, not the main character, it would depend on who he asked, but not probably not the main character. But at the same time, he was a first-person narrator of the entire novel. And I think that's kind of the epitome of what it means to be within it, within and without. Where, you know, us as clinicians and doctors, we might not be the main character in someone's life. It should probably be that patient that's sitting in front of us, that should be the main character. But I think there's a role that we can play to guide what happens for where we go, uh, but not but not at the same time, you know, necessarily dictating everything that happens for the person, but helping, providing a framework or at least one lens or one reality or one formulation that can help guide us at the time.

I wonder if I can ask your question, Yun, because uh part of that is that yes, you know, we are a bit stuck of what we can influence. But I think also um the patients we see are subject to stigma and discrimination, and not necessarily by a person, but by the system, right? That's been demonstrated time and time again in the Royal Commission as well, that there is inequities in healthcare. And so I think often there's that feeling of stuckness, but also this kind of feeling of I should be able to do more, that there's unfairness kind of embedded in the system. And it is important for us to advocate for our patients, but finding the the best and the right time to do that as well, which I think can be quite, I find it quite exhausting because you think what I want to do is I want to sing in my patient and formulate and make up a management plan that then goes smoothly, and I can see how that works. But there's often then layers of calling someone to convince them to give something a go or even um for kind of straightforward medical care what you think should be straightforward, that someone doesn't want to offer surgery for a patient's breast cancer because they think they won't be able to tolerate the recovery, and you're dealing with that. And so I think there's this extra kind of strain of being an advocate in the system, that's a very important role and can be very fulfilling, but can be very frustrating and emotionally draining as well. I guess I wonder how you found that experience.

I think that's was quite a challenge. I think the way I way I thought about it at the time, and the way I still probably think about it now, is having different hats on the same time, as paradoxic that might sound. Like, for example, being part of the mental health, public mental health system that we want them to action more at times, um, but at the same time being an advocate to push more and having their medical experiencia to provide more of an advice and guidance and framework, at the same time feeling like I may having a bit of an imposter syndrome at times, perhaps, especially those moments where I'm literally on rare diseases.org before the patient walks into the room. So yeah, I think it's a way of balancing the different roles, which might seem paradoxical at times.

It sounds like you had you had to learn quite a lot of new skills. And um what do you think of your your overall experience or how do you think you changed, you know, as a result of doing the rotation and you know, looking back at your earlier self? How do you think you've you've grown or changed doing it?

Yeah. Well, I think if I talk about my emotions first, uh what and my passion first and what I walked into the clinic with excitement and a lot of passion, and then I started to question myself in the first couple of weeks do I really like autism and IDD? And then that passion then came back as well, the more I felt. Comfortable or at least more comfortable being distressed at times. And I think, you know, for me, I grew to understand about it might not always have a definitive one answer, like in most areas of psychiatry, but having a degree of comfort to be able to better mentalize and be less reactive. And I think one of the quotes, you know, it kind of goes back to my high school times where I was learning about different key concepts of English and poetry, where there was a there was a term um called negative capability, um tossed by John Keats from the 1800s as a poet, where it refers to essentially an individual's capability to embrace uncertainty. And I think for me that became a very key role and key skill that I've learnt during this term, and something that I'll definitely take away moving forward as well.

I was thinking, as I think Melanie was saying earlier, what is what's the unique skill of set of psychiatrists and you know formulation as well? And I'm thinking it's it's time we can sort of give people theoretically, not always, but we we have time to sort of listen to people and to engage in some of those kind of deeper psychotherapeutic kind of modalities and pools of which then make accessing you know formulation possible. It sounds like that's one of the real eye-openers from this rotation.

Yeah, definitely. Yeah, if I can add to that as well, is a concept of understanding that there are alternate realities that might exist at the same time, which is probably part of the psycho-therapeutic um approach as well. Um, understanding that multiple realities and multiple priorities can exist at the same time, especially when we have, you know, vulnerable consumers who have different systems involved and they often speak different language and different have different priorities of their own, and ultimately understanding that myself as a clinician, we are ultimately one part of the system, one part of the reality, and one part of the priority.

I wondered Nune, um, it it's interesting as you know, you talked about the the patient kind of dynamic system as well. And so I find a lot of intellectual disability psychiatrists end up doing a lot of that system work as well. So part of that is that Yoon has joined the binational committee for the section of psychiatry of intellectual and developmental disability. Um, and Yoon and I have been working on um the application for an advanced training certificate in ID psychiatry. So I think it's it's that you see you see those frustrations in the system and then realize that you can make change in a systemic way as well, which is a lot of work and a lot of time to see that come to fruition. But you see, I guess that there's a lot of ways to make change for patients.

Most definitely, yeah. I think it really highlights the importance of also, you know, can measures well, of not just being the medical expert, but to have a greater change or better doctor. And we do need that level of leadership, that advocacy, being a collaborator and being able to communicate well as well.

I think you have I think you've both written a paper together that's gonna possibly come out.

Yeah, that's right. Yeah, we have made the submission. Um and the goal is to publish full in preparation for the trainee uh editorial of the psychiatry.

Oh, awesome. Oh, that's great. Really, really look forward. Just for our readers, what what's the title of that paper called?

It's called Uh A Trainee's Perspective in Intellectual and Developmental Disability Psychiatry and with a quote of To Be Within and With Gow.

Awesome. Great. Any final thoughts from Yoon or from Melanie?

Umly that I really do need to get around to reading the Gate The Great Gatsby. I've seen the movie, but I need I need to read the book. I think one of my reflections was that Yoon was able to talk about um this concept recently at the consultation liaison congress. And it was really well received, and I and I think exposing people to that kind of richness of experience in this in this area of psychiatry that I think isn't one that people often kind of jump and and think of, but I think it's a really growing area and there'll be many, many more training opportunities. And so I think this is a great opportunity to think about the potential of the discipline as kind of a training area, but also as a supervisor to reflect on um when we're you know designing curriculums and we'll have more trainees coming through of how can we support them in um navigating that kind of increased exposure to kind of uh complexity and um I guess and a newer and emerging area of psychiatry.

That sounds like Ian was very lucky to have you as a supervisor. Sounds like you're a real champion for your particular sub-specialty and discipline. And yeah, it was a really valuable experience for him to have been able to learn about that from you.

It was definitely a great opportunity at the time. Um if I add to that as well, especially with our with the ID psychiatry services growing and developing across Australia and New Zealand, hopefully New Zealand and our terror. Um, I suppose that concept of the importance of supervision is something that I do would want to highlight. Um if I go back to some other lows, you know, hierarchy of need, I mean that level of safety and the sense of belonging into a team as well as in that supervision, I think will help that level of self-actualization, which is more at the top pinnacle of the hierarchy of need. And similarly to um my present my presentation at the Seal conference, I would like to end with a quote, um, a different quote actually from the Great Gas V, which reads, Whenever you feel like criticizing anyone, just remember that all the people in this world haven't had the advantages that we've had.

Thanks very much, Nene. And thanks so much, Melanie, to both of you for joining us today. And Melanie for telling us a bit about your service and and Yun for sharing your experiences as a registrar as well. And sounds like you you guys together are doing some really awesome work. So thanks for thanks for joining us today.

Thanks, Ed.

Thanks, Shad. We'd also like to acknowledge Nishtakuma from the college who gives us so much support in producing and editing the show. We're thankful to Australasian psychiatry for the opportunity to make these podcasts, as well as Sidoni Prentice for our artwork and Shady Dave for our music. We encourage our listeners to rate the podcast on whichever app you have accessed it, as well as promoting it to other registrals or supervisors. We always love your feedback or suggestions for further episodes, including volunteers interested in being a guest. Please get in touch via email at the thordbroadcast.podcast at ranzcp.org. That's all for now. My name is Ed. Thanks for listening, and we'll get to you next time.