Sometimes I sit in a conference or meeting about Alcohol and Other Drugs (AOD) and wonder to myself how long it will be before someone mentions poverty. Usually the answer is ‘never’. It’s kind of bizarre, because most of the people I hear speak about AOD are passionate people with a progressive perspective. These are people who probably do care about health inequality, but they don’t often (at least not publicly) link it with poverty. Why is that?

I really want you to have a look at the excellent article by a friend of First Step Sebastian Rosenberg, and his colleagues about the link between poverty and access to mental health support and treatment:

For richer, but not for poorer: how Australia’s mental health system fails those most in need

This is a truly insightful, easy to understand article about the disparity of access to mental health services based on wealth. If you’ve only got a minute, skip the rest of this blog and jump to the article.

What the research highlights, in the form of hard data, is that people living in poverty experience MUCH higher levels of mental distress yet receive MUCH less mental health support. With some kinds of care, poorer people are 7 times more likely to need support and 1/6th as likely to receive it. I think it’s a reasonable bit of maths to multiply that 7 by the 6 and say that this particular piece of analysis shows that wealthier people receive 42 times more care (need based) than poorer people.

I’m going to draw another bow, that I expect the authors of the article would agree with, even though it was not their main point. And that is that poor people are proportionally more like to suffer from mental distress or mental illness. There is a whole school of research behind this point, the essence of which is encapsulated well in the description of poverty as ‘the cause of the causes’ of mental illness.

By why should this be? Why should poor people suffer worse mental health. Well, because mental distress is always exacerbated by stress and trauma, and usually in fact it is caused by it. Mental illness does not strike with the role of a dice or at the whim a mean-spirited deity. It’s causal. I doubt anyone reading this would disagree that if a person is abandoned at birth, lives in 20 housing arrangements by the time they turn 18, does not finish school and is abused and neglected as a child . . . they are likely to suffer from mental illness.

Yes, mental illness can happen to anyone. BUT, wealth (at least being of average wealth in a wealthy country like Australia) is a massive protective factor against homelessness, hunger, being taken advantage of, early school leaving, lack of good role-models, low income-attainment, having no choices but bad choices, lack of mental health treatment etc etc.

Please be aware of the link between wealth inequality and mental illness. A poor person is not broken or hopeless or pathetic or cursed. In fact, they may well be amazingly resilient and resourceful. But they are at risk, and they at a terrible disadvantage. And our mental health system is, in the main, falling well short of making up the difference.

Patrick Lawrence Chief Executive Officer

Today is World Mental Health Day.

That’s a big thing. WORLD Mental Health Day. I’m going to think about the world, yes, but also the world of the person.

What can we say that is universal about mental health? I’m going to start with the obvious and move to the slightly contentious:

BEYOND DISPUTE:

• The concept of mental health is relevant to every human being. At any given time it can be good/high or bad/low, or anywhere in between.
• Good mental health is a public ‘good’. Governments and other societal organisations should both (a) act in a way that is proactively beneficial to mental health and (b) not act in a way that is detrimental to mental health.
• To the point above, the benefits of proactive efforts to improve mental health should be felt by those in need, regardless of social status, wealth, ethnicity/indigeneity, gender, sexual orientation or any other factor.

A BIT CONTENTIOUS:

• Access to mental health supports in the broadest sense and lack of exposure to significantly harmful experiences are a human right. If so, then obviously this human right must extend to all people, including children.

PERHAPS CONTROVERSIAL:

• Given that the diagnosis and treatment of mental illness is an inexact science, while clinical mental health services should be well funded, any mental health intervention should consider the stressors in a person’s life and attempt to address them. The way you do this is by being holistic - that is, engaging with, and supporting, the whole person.
• An individual or a group’s mental health can be adversely affected by anything that you might consider a significant stressor. This might include interpersonal relationship issues, money problems, concern about the environment or other large forces, vulnerability to harm/physical danger, insecure housing, harmful experiences in the past (that manifest as ongoing trauma). These factors are more important than genetics in determining mental health.
This, in essence, is what First Step advocates for in the provision of ‘mental health’ services anywhere: the provision of integrated clinical mental health, psycho-social, medical and legal supports and housing partnerships. It is the experience of our staff that our clients who are experiencing poor mental health (the vast majority) do so, because of the number and level of stressors in their life.
You can listen to more of my thoughts on this, in this short video:

So, as we consider World Mental Health Day, let us think about the ‘world’ of people with poor mental health, whether that is the stresses of a person more or less managing family, work, and other commitments or a person who has experienced neglect and abuse and has chronic mental health and substance use issues that put their lives at risk. And everyone in between.

Patrick Lawrence Chief Executive Officer

Another year older and deeper in debt. Well, that’s what the Victorian government is trying to avoid with a number of important spending commitments being postponed, and hopefully not cancelled. The roll out of the Local Mental Health and Wellbeing Centres has been postponed for 12 months; so far they’ve commissioned 15 of the post-royal-commission-promised 50. It’s important that this roll out is recommenced as soon as possible.

There will be no second supervised injecting room in Victoria. This is devastating news, particularly given earlier commitments that ‘we will listen to the experts’. Well, the expert who wrote the report the government commissioned, Ken Lay, said North Richmond Medically Supervised Injecting Room is clinically a runaway success and there is desperate need for one in the CBD.

My observation to media was that there are ‘hundreds of injecting rooms in the CBD, and injecting laneways, and injecting parks. We just want one with four walls, a roof, and medical staff inside.’ Is the goal that people keep injecting on the streets? Is that better for local business owners? Sigh. The campaign will dust itself off, lick its wounds and continue. One big fentanyl crisis (god forbid!!) and the need for this intervention will be in sharp relief.

The Victorian government has committed $7.4 million to getting 1,500 more people on opiate replacement therapies (methadone, buprenorphine and long-acting injectable buprenorphine) which First Step wants to be a part of. Big shake ups in the Department of Health so we’ll nag and see (just like ‘wait and see’, but less patient).

From the Feds we have a ‘new’ announcement about old funding: Medicare Mental Health Centres. In Victoria they’re call Head to Health and they will be rolled into the Local Mental Health and Wellbeing Centres (see above). No new funding. Some money for Hep C treatment which is important and saves lives.

Patrick Lawrence Chief Executive Officer

It is a very sad day today for the movement of individuals, families, and services advocating for a progressive approach to drug law reform in Australia.

The Allan government has announced that there will be no second injecting site in Melbourne’s CBD or anywhere else in Victoria, contrary to the advice of Ken Lay's report. Some of the report's recommendations have been followed by the government, but the key recommendation is being ignored: a second supervised injecting site in the CBD.

The CBD will still have hundreds of “injecting rooms”, injecting laneways, injecting streets, and injecting parks. But there won’t be one injecting room with four walls and a ceiling, staffed by doctors and nurses. The North Richmond Medically Supervised Injecting Room provides numerous health services to assist people with drug addiction and support them in breaking that cycle in a non-judgmental and welcoming environment. Unfortunately, that opportunity has been lost in the CBD.

The government is promoting the design of a wrap-around service for people who use drugs in the city, but this service will not be able to supervise the potentially fatal act of injecting itself. While they may offer needle and syringe programs and various harm minimisation advice, at the critical moment where a person is most likely to risk their life, they will have to leave the building and return to the streets of Melbourne’s CBD. Who is this good for? Is it beneficial for those individuals, the CBD residents, or the shop owners? Is it beneficial to the Government?

The government claims there was not sufficient community support for this initiative, but without considerable political will, life-saving reforms cannot be achieved. Have they pushed hard enough? Have they taken a moral stance? If the lack of community support is the key factor, will the government consider outer-urban and regional centres?

Ken Lay's report contains many great recommendations across its 100+ pages, many of which are in the government’s Action Plan. We fully endorse all of those inclusions: a hydromorphone trial, more support for pharmacotherapy etc. Financial support for services providing pharmacotherapy, a well-known life-saving treatment that minimises harm, is particularly essential. We support all the initiatives in the action plan, and will do our bit to assist successful implementation.

But we are devastated to see that critical key initiative is missing.

Patrick Lawrence Chief Executive Officer

7 April 2024

This year's World Health Day theme is ‘My health, my right.’ I like it.  The core message, at least the way I read it, is that we all have a human right to good quality health care. It’s an uncontroversial position in Australia where we do, even if it’s shrinking, have universal health care.

It brings to mind the distinction between equality (everyone gets the same resources) and equity (everyone gets the resources they need). Equity acknowledges a difference in needs, and in every country in the world there is an intimate link between poverty and health needs. This link is particularly clear (exponential) when we talk about intergenerational poverty and child homelessness (including out-of-home care) and most acutely in indigenous health and the health of people who use drugs.

As healthcare is mostly funded by the government in Australia, a commitment to equity, means a commitment to proactively providing integrated services for people living with multiple co-occurring needs, usually as a result of adverse childhood events. First Nations Australians might make the distinction between being ‘vulnerable’ and being ‘targetted’. So might people living with mental distress or intravenous drug users.

So, it’s lovely to talk about health equality, but what is our government doing to work towards health equity. That’s the whole business of First Step, and it’s important that we remember it. To quote American counsellor Vikki Reynolds “If what we are doing is ethical and helpful, we won’t be burnt out.” Even if they don’t use the language, there’s a bit of a social justice warrior in all of us at First Step. And its fair to say that we’re not entirely happy with the health equity of our clients. How about we take a few billion out of the ambulance at the bottom of the cliff (prisons) and put it into a fence at the top (primary health care)?

Patrick Lawrence Chief Executive Officer

20 March 2024

Addict. There’s not much hope in that word. No context, no nuance, no past or future. It’s better than ‘junkie,’ but not a lot. ‘Person living with addiction’. Well, that’s better because at least the word ‘person’ leaves open the possibility of some part of their life beyond drug or alcohol use. But it’s still one dimensional.

Let’s try this for 2-dimensional: “a person with co-occurring needs including drug use”. What we have now is a simple recognition of the truth, at least as far as every single First Step client is concerned. Our people have multiple, co-occurring needs, like mental health issues, housing issues, legal issues and more. If you only treat the substance use, it’s very unlikely that anything much will change (even ‘change’ is a judgy word, but it’s fair to say that people don’t come to First Step because they want things to stay the same).

So, time for 3 dimensions. “A community and family member with co-occurring needs including drug use.” This is true of everyone! The ripple effect, whether positive, negative or both, is a universal effect of each of our existences. Family members of people with co-occurring needs including drug use know that the chaos can spread far and wide, as can the recovery.

Now for the 4th dimension: Time. “A person currently experiencing co-occurring needs including drug use.” We know that ‘currently’ can seem like forever, but everybody has a past, present and a future. That’s where hope lives, and language can often shut us off from that hope.

The way we use words says everything about our unconscious assumptions. Yes, a diagnosis can sometimes be helpful. A person can feel liberated by the thought that they HAVE an ‘addiction’ as opposed to BEING an addict. But we don’t say an ‘MS’ or a ‘cancer’ or an ‘obese.’ When we use one word for a human being it tends to be overflowing with judgement: ‘fatty.’

At First Step we are working on a new way of saying ‘person living with addiction’ or ‘person with a substance use disorder.’ We have no problem with ‘person who uses drugs’ (in the Alcohol and Other Drug sector it is often abbreviated to PWUD). However, in the context of people seeking treatment and support, there is value in a widely accepted phrase to indicate when someone needs support, and that their use of drugs is one part of the picture.

Above, I used ‘person with co-occurring needs including drug use.’ If you have any ideas of your own, please drop us a line. Let’s move away from a diagnosis (a box) to an expression that allows for complexity and nuance. Because that reflects real life.

Patrick Lawrence Chief Executive Officer

20 February 2024

Today is World Social Justice Day.

What does social justice mean in the context of mental distress and substance use? Actually, it means quite a lot, and awareness is important.

I was lucky enough to attend last years’ International Harm Reduction Conference in Melbourne. One powerful presentation was by an African American woman who proclaimed “Our people are not ‘vulnerable’. They are ‘targeted’!”

It was powerful oratory that I will always remember, and it shifts the paradigm. Social injustice can be measured or described in so many ways, some of which might almost seem to contradict each other. ‘We live in such an unfair society where poverty brings a myriad of negative outcomes and is very hard to get out of’ is very different from ‘My people have been systematically targeted by law enforcement, discriminatory/racist policies and other deadly forms of discrimination since we/you set foot on this land.” Both describe true and terrible circumstances. One evokes empathy, the other invokes anger. Both can motivate.

On World Social Justice Day, I don’t suppose it matters if you lean towards the accidental or intentional theory of injustice. What matters is that you challenge your own preconceptions, and challenge existing injustice, because the world is a very unjust place. In the Alcohol and Other Drugs world, it’s almost impossible to argue why alcohol should be freely available to all adults, and cannabis should be illegal. Both can be beneficial in moderation (consensus view), both can cause harms. There is no doubt that alcohol causes in orders of magnitude more harms than cannabis (4.5% of total burden of disease and injury in Australia vs 0.3% for cannabis).

Where does the stigma come from? Who decides, and why do they decide, that the Age Pension ($1,096 per fortnight) should be far more generous than the Newstart allowance ($749 per fortnight)? Who decides it should be financially advantageous to buy a property as an investment (negatively geared) rather than a home?

At First Step, in the end, these are moot points; there’s nothing we can do about them at the coal face. But, when approximately 50% of our clients with complex mental health grew up in out-of-home care, and an estimated 95% were sexually abused as children, it’s pretty hard to ignore systemic poverty. Perhaps the role of social justice awareness for us at First Step, for our staff and supporters, and our whole community, is to get fired up and stay motived.

Yes, the injustice has been done, but are we up to the challenge of helping now, in every conceivable way, to give people every chance to overcome? Will we stand by people, celebrating their resilience while they develop agency. Will we stay connected to that burning desire for justice, or will we burn out?

Patrick Lawrence Chief Executive Officer

2 January 2024

In an extensive process through multiple staff meetings, groupwork, and a Board and Leadership Team workshop, First Step now has its official values.

It was a fascinating process to understand from our staff what they believe First Step is all about.

On the whole, there was extraordinary alignment about issues like compassion and respect, which expressed itself as empathy, listening, inquiry, dignity, communication, understanding, honesty, connectedness, validation, love, fairness and more.

In the end we needed a list that was truly representative, memorable and aspirational.

Innovation (with a bit of ‘evidence-based’ mixed in) is perhaps the most aspirational word, very much representative of First Step’s origins, but also of our desire, and need, to constantly improve our work as individuals, small teams and one big team. It also highlights what is needed for First Step to be an impactful organisation in the future that directly improves the lives of clients, but also helps our treatment sectors, governments and communities to do the same.

As a supporter of First Step, we hope that you can see yourself in these words, Compassion, Respect, Innovation, and that they inspire your continued devotion to our work and this community.

Patrick Lawrence Chief Executive Officer

13 December 2023

It’s been all over the news for the last several months that there is an Australia-wide GP shortage. It’s particularly acute in rural and regional areas, and the major stress in our cities is access to a bulk-billing GP.

Bulk-billing numbers are plummeting. Factors include GPs taking early retirement after the stresses of COVID-19 and Medicare payments (to doctors) not being linked to inflation and therefore effectively reducing over time.

However, the biggest factor is that young doctors don’t want to go down the General Medicine/General Practitioner pathway. That number has reduced from approximately 30% of young doctors to just 15%.

One important strategy to address this problem is the training/support/promotion of Nurse Practitioners. Nurse Practitioners are very similar to GPs - they can prescribe all manner of medications, conduct all manner of clinical investigations and implement all manner of treatment plans. The key difference is that Nurse Practitioners must show evidence (if they were ever audited or before the coroner) that they are practicing within their scope of practice.

It’s assumed, for example, given their extensive training, that GPs have studied diabetes and can treat and prescribe. Nurse Practitioners need to be able to prove it with documentation.

One area where Nurse Practitioners are of greatest value is in the Alcohol and Other Drugs sector, particularly supporting patients with Opiate Replacement Therapies like methadone, buprenorphine and injectable buprenorphine. These are treatments with a huge evidence-base improving health, increasing stability, reducing drug use and reducing injury and death.

And thousands of Victorians just can’t get access to a doctor to prescribe them.

Our Nurse Practitioner at First Step, Georgia Judd, has been an amazing addition to the team in recent months, bringing a wealth of experience, a collegial attitude (team spirit!), and a fabulous manner with clients. And we’re pretty sure she loves it here. Georgia can take all the time she needs with clients, work with the multi-disciplinary team and learn from over 100 years of GP experience in the building.

Our Nurse Practitioner program is funded by the South Eastern Melbourne Primary Health Network (SEMPHN) - the subsidy is essential because Nurse Practitioners cannot bill enough to cover their own wages. Long may SEMPHN continue to support this important work!

Patrick Lawrence Chief Executive Officer

1 November 2023

Most of us are occasionally asked the question “So, what do you do?” I usually jump at the opportunity to radically reframe illicit drug use. Why not? Sometimes I say “I work with adult survivors of childhood sexual abuse." This makes space to explain the trauma origins of most chronic illicit substance use. Other times I say “I’m in the stress reduction business.” This makes space to explain how it is that we help people at First Step.

November 1st is International Stress Awareness day. Stress is a factor in all our lives, bar none. Babies stress about contact and food. Elderly people stress about health and mortality . . . and maybe contact and food. In between, well there’s plenty else to stress about. And how does that stress manifest? In our clients, because of the adaptations they have developed to survive things like childhood sexual abuse, stress often leads to increased substance use (quantity and variety). Now, of course there are actual evidence-based ‘treatments’ for substance use disorders, but they are unlikely to succeed if you can’t help a person with their stressors. If however, you meet the many needs on Maslow’s hierarchy (an oldie but a goodie), then stress is inevitably reduced, and harmful substance use almost invariably reduces.

Who would not function better with secure housing (and no risk of incarceration), an income above the poverty line, your physical health (and substance use) being well supported, a safe place to seek help where you are welcomed and respected, a hope-filled perspective that draws on your strengths and the supported opportunity to take control of your life. However, achieving all those things, for many people, requires the dedication of a trans-disciplinary team of empathetic professionals. In our case: GPs and nurses focussed on addiction medicine, psychologists/psychiatrists/mental health nurses, care coordinators, lawyers, group therapists and family therapists. Now there’s a team that can reduce some stress.

Yes, there’s detox and rehab and methadone and cognitive behavioural therapy. But a smiling face, a listening ear, and a person-centred response to your specific needs. That’s priceless.

Patrick Lawrence Chief Executive Officer