28 June 2021
Mental ill-health and addiction can happen to anyone. This is an important and immutable truth. Yet chronic mental illness combined with long-term substance use is very much concentrated among people with deprived, and often poor, childhoods (50% of Victoria’s prisoners come from 6% of Melbourne’s suburbs). Also immutable. At First Step we work with thousands of people whose start in life varied between inadequate and horrific.
When we come into this world, and in our early years, one could argue that the luckiest among us are provided with ‘gifts’. The gift of at least one loving and constant parent, the gift of not having to worry about where your next meal is coming from, the gift of physical safety, the gift of peace-time, the gift of a secure government and minimal corruption, the gift of a chance at education. Using this same language you could say that many First Step clients, due to no fault of their own, inherited not gifts but a great number of debts, deficits or absences of gifts. A deficit of capable parents, the deficits of 20-30 foster families by the age of 18, the deficit of poor education and limited opportunities, a deficit of love, belonging and self-esteem.
The law of karma says that no debt in the universe goes unpaid. I’m not religious, but I find this a seductive notion, and it applies very neatly to the gifts and deficits described above. Who pays the debt of a disastrous childhood? If we view ‘debt’ in financial terms, and apply for a moment the notion that no debt in the universe goes unpaid, then we would say that society pays that debt, sooner or later. We can intentionally pay it early and avoid ‘interest’, we can pay it in due course and pay tremendous interest, or we can entirely default on payment and suffer the disastrous financial consequences (prison, psychiatric wards etc). At First Step all we really care about is the person in front of us. But we’re also interested in the economics when they are linked to suffering or the alleviation of suffering. This is such a case.
As a society, how do we intentionally and proactively reduce the likelihood of a debt as described above in the first place? The answer in simplest terms is exceedingly simple: reduce inequality and therefore poverty. ‘Adverse childhood events’ are consistently linked to poverty which is often described as the ‘cause of the causes’ of suffering. A more equal society means less poverty and less relative poverty, both of which are linked to sickness and death generally, and mental ill-health and addiction specifically (greater stress, fewer social supports, fewer protective factors against abuse and neglect, financial precariousness, poor education, early school leaving, preteen illicit drug use etc.). In the common metaphor of a fence at the top of the cliff rather than an ambulance at the bottom, this step involves reducing the height of the hill. The cost? Hotly debated, possibly net zero.
A next step along the time continuum might be to look at parents struggling to provide a safe environment for their children who are at risk of being taken in to foster care. Intentionally spending on effective interventions/support at this early stage might be the best expenditure possible, though the long-term impacts are knowable only in the aggregate. Will this kid end up in prison? Don’t know, but we know how to minimise the risks.
Further down the path we can proactively go looking for vulnerable kids, or reactively intervene when they come to the attention of authorities. These kids might be in out-of-home care (foster care or group homes), unstable families or struggling regardless of a stable home environment. You might call this mid-stage intervention (neither early nor late), at which point we are paying hefty interest on the debt.
And then we can work with adults with complex mental health and substance use issues. This is almost entirely reactive, and should be considered late stage. In financial terms enormous ‘interest,’ linked to enormous suffering, would have been paid by this stage particularly in terms of unemployment benefits and interactions with the criminal justice and hospital systems. At this point, what is required are multi-disciplinary teams who simulatenously, and in a coordinated and long-term way, address the various areas of a person’s life that require assistance (mental health, addiction, legal, social inclusion, meaningful engagement such as work or volunteering and housing) seeking incremental, whole-of-life improvements. Despite the rarity of such multi-disciplinary teams, the good news is that both state and federal governments appear to have recognised the importance of such teams (see federally funded Adult Mental Health Hubs and the recommendations of the Royal Commission into Victoria’s Mental Health System). Also, compared to what now loom as enormous debts, significant out-patient clinical and non-clinical intervention is relatively inexpensive. First Step’s most support-intensive clients require only about $13,000 in services per annum, a tiny investment in comparison to a year in prison ($150K+) or just one week in acute hospital care ($10K). The debt in moral terms can at this point never be repaid, but fully defaulting at enormous expense is avoidable, essential and possible.
Sooner or later every society will pay its debts. Sooner is both cheaper and alleviates tremendous suffering. Later can cost millions of dollars for just one person, and the suffering is hard to fathom.
I am the CEO of First Step, a for-purpose organisation specialising in multi-disciplinary team care for addiction, mental health and legal supports. First Step is in the final days of its Winter Appeal. To donate visit www.firststep.org.au/donate
Chief Executive Officer