After much planning, consultations and preparatory work, the Victorian Government released the “Victorian Alcohol and Drugs Strategy” two weeks ago. This was a long-awaited commitment that was generally well-received by the alcohol and other drug sector and the closely related mental health sector.

Believe it or not, this is Victoria’s first ever alcohol and other drugs (AOD) policy! The fact that AOD has been elevated to this level of consideration is in itself a positive. Given that the vast majority of Victorians use alcohol (over two-thirds of adults) or other drugs (47% of adult Victorians have used an illicit drug at some point in their life) this is clearly a worthy focus. When you also the yet to be determined number of people living with mental distress, substance use and other forms of stress in their lives, we start to get a picture of the potential significance of this strategy.

The core of the strategy are the 5 focus areas:

1) Information and access. This is about individuals and families having information about drugs and alcohol and the ability to access supports when they need help. Clearly SUPER important.
2) Harm reduction treatment and design. The focus on a reduction in harm rather than a focus on drugs used is contemporary and helpful. Treatment remains appropriately at the forefront.
3) Culturally safe, self-determined responses for Aboriginal Victorians. Given the wildly disproportionate (to the population) presence of Aboriginal Victorians, both a strong sub-sector and universal standards across the mainstream sector are crucial.
4) System innovation and continuous improvement. The AOD sector is only really 30 years old, having being born of the de-institutionalisation of mental health consumers in the 90s. It is a long way from perfect and needs this focus on innovation, particularly as our understanding of co-occurring needs develops.
5) Integration across intersecting systems. This is where First Step is particularly passionate and at the forefront of care. The focus area acknowledges both the need to provide integrated care at a single site with the need for organisations to have strong, collaborative relationships with each other to attempt to create the feeling of ‘one team’ as far as clients are concerned.

There is a laudable focus on the input of people with a lived and living experience of substance use, including lived and living experience workers, with which First Step closely identifies.

Furthermore, we applaud the focus on the coordination of government departments because human beings are not siloed and their care absolutely must be integrated:

All the help you want and need from one team in one place

That’s our definition, not the governments; they don’t have one.

And as our wonderful Dr John Sherman retires, the focus on strengthening the opioid pharmacotherapy system (methadone, buprenorphine, and the long acting injectables) is absolutely crucial. This involves bringing the primary care sector (GPs) closer to the AOD sector which we also applaud. There needs to be a series of significant improvements if we’re going to realise the potential of these extremely effective medications that save lives and reduce harm.

Obviously, a strategy is just that. Commitment and financial investment are a totally separate question, and if the government does not back this policy (walk the walk) there will be a very disappointed sector and a great deal of avoidable suffering. We applaud the strategy and await the further investment.

Patrick Lawrence Chief Executive Officer

Dear Tania,

I write to you as a colleague of 13 years who has worked alongside you in the very challenging intersection of primary care, mental health, substance use and legal need. Along with our many other fabulous colleagues, it has been quite the journey, one that has helped countless people and, I believe, shifted the landscape of what’s possible in community legal practice.

When you started at First Step, the term Health Justice Partnership barely existed in Australia. If it did, it certainly wasn’t in common usage, even in community legal settings. You and your colleagues at First Step Legal didn’t just adopt a model, you created it. You proved that when legal, clinical and social supports are brought together under one roof, the outcomes for people are profoundly different. You showed that it works, you showed that it matters, and you convinced governments and funders that this approach was not only viable but essential.

To grow a thriving, accredited community legal centre within a health service was a brave and unconventional decision. It changed the conversation, not just at First Step, but across the sector. What started as two lawyers working two days a week has become a full-time practice, recognised as a leader in its field. And that’s thanks to your vision, tenacity, and belief that a compassionate, integrated approach could break cycles that the traditional justice system could not.

I know that vision came from hard-earned experience. Earlier in your career you saw the same faces return to court time and again, their lives shaped by trauma, mental illness and substance use. You recognised that the court system was a blunt instrument, unable to respond to the complexity of human need, and you imagined something better. Building on the foundations laid by Melissa Hardham, you went ahead and built it. Just a few steps from where I write this, a whole team of lawyers now work hand-in-glove with mental health nurses, care coordinators, doctors, psychologists and psychiatrists, advocating, prioritising, and listening with a laser-like focus on what each client needs most. It’s a virtuosic thing to witness, and a legacy you should be immensely proud of.

Like all great achievements, this has not been without challenge. There have been moments of doubt, and no doubt some very hard days. But what has always sustained you, and what so many have remarked upon, is your compassion. Time and again, when we’ve heard our long-term clients share their stories, your name comes up. They talk about being seen, heard, and treated with dignity, about how First Step Legal, under your leadership, became a place where they mattered. Even for those we’ve sadly lost to substance use, I hope you take great comfort knowing that they had, in their final years, a place of safety and belonging, and people they trusted.

Your contribution to First Step, to our clients, and to the broader community legal sector cannot be overstated. You’ve built something that will outlast all of us - a model of practice that is compassionate, collaborative, and profoundly human. It’s been a privilege to work alongside you, to learn from your example, and to see the difference your leadership has made in so many lives.

So, I celebrate you, Tania - your achievements, your courage, and your generosity of spirit. Thank you for all you’ve given to First Step and to the people we serve. I know your next chapter will be just as impactful, and I can’t wait to see where your energy and brilliance take you next.

Look out world, here comes Tania Wolff!

Warm regards,

Patrick Lawrence Chief Executive Officer

Integrated care.  What is it?

Of course there is no single definition, but First Step is currently involved in five projects with integrated care in the title, and we have an opinion. In lay terms, it is all the help a person wants and needs from one team in one place. And if you can’t do that, then it’s all the help a person wants and needs from what feels like one team in as close as possible to one place.

Is this important for everyone? Yes it is. We all need the resulting convenience, communication between providers and enhanced, coordinated services that are the result. But the more elements (mental health, housing, substance use) that are included and the more entangled these are in a person’s life, then the more they need integrated care. And that entanglement, with multiple elements, is actually the norm.

At First Step we call ourselves a specialist centre for integrated care (medical, mental health and substance use) with an embedded community legal centre. We call these causal and perpetuating stressors n a person’s life ‘co-occurring needs.’ Co-occurring needs, especially substance use and chronic mental illness, can be directly linked to adverse childhood events. Regardless of the cause, it’s when a person can get all the help (one team, one place) that whole-of-life improvements are possible.

First Step is running an integrated care pilot for the state government, and is running a care coordination pilot for the South Eastern Melbourne Primary Health Network. We’ve also just provided (pro bono) integrated care advice to the City of Port Phillip to try to get the best results possible for long-term rough sleepers in the City. And we recently helped the Hamilton Centre adapt the Comprehensive Continuous Integrated System of Care from the US to a Victorian context. There is a lot of integrated talk going around.

But when you boil it down, it’s about values (welcome, empathy and hope), principles (trauma-informed, person centred, continuity of care), professions (medical, mental health, care coordination and housing (when needed) are close to essential) and ways of working. The team is to leave the egos at home, be curious about each others’ professions and their clients, be given the time to collaborate by management, and be damn good at their jobs.

That’s what we’re working on.

Patrick Lawrence Chief Executive Officer

As the election looms, we all know that cost-of-living polls as the number one issue. The stress is real, and it effects the majority of us, but I am less concerned about the middle class who have options, than I am about people already living in poverty who have none.

Last December I wrote about Michael Marmot’s conclusion that poverty is the cause of the causes of health inequality, and particularly mental health. And then there is the Adverse Childhood Events study that tells us:

• people in the lowest income quartile (the bottom 25%) are 500% more likely to have 4 or more adverse events in childhood, and
• people with 4 or more adverse childhood events are at a 1,220% increase risk of attempting suicide.

Then I look at campaign promises in the many billions, and calculate that increasing the JobSeeker, Austudy, single parent allowance by $40 a fortnight would cost under $1B per annum, but would have a huge impact on the poorest 1.4 million people in Australia.

On a more positive note, both major parties are promising to spend approximately $1B on mental health in the coming years. This is great, but let’s keep perspective and keep the pressure on.

According to the Australian Institute of Health and Welfare, mental health and alcohol and other drugs are responsible for 15% of the burden of disease in Australia - that is, the cost to the health system and a loss of productivity. However, expenditure on mental health including alcohol and other drugs as a percentage of total health spend is less than 2% (approx. $5B vs $250B).

The concern about the speed of role out of the costed plan by the federal government seems warranted also, with only 2% of the $1B to be spent in 2026. That's only $20m and it seems very slow indeed.

And finally, amidst the federal news, there is an announcement from the Victorian Minister for Health regarding access to the life-saving opiate blocker Naloxone. Naloxone in it’s most user-friendly form is a nasal spray that reverses (temporarily) the effect of an opiate overdose while you call the ambulance. Totally easy to administer with zero known side-effects or any substantial risk, free access to this drug is fantastic. It is now available for people to take home from any needle and syringe program and you can simply walk into any participating pharmacy and ask for Naloxone: no costs, no ID required, easy as that.

Patrick Lawrence Chief Executive Officer

It is important to know your limitations. At First Step, we do very little work with young people, so children and young people are not our area of expertise (as a rule it takes people about 20 years from first problematic drug use to seeking help, a curiously close number of years to the delay in reporting childhood sexual abuse).

What we are experts in, however, is what happens when children and young people have a difficult start in life, and don’t get the support they need. Because we see them 20 years later, after a lifetime of resilience, yes, but also a lifetime of unnecessary pain and loss.

This week’s changes to bail laws are a source of disappointment for many of us, and they should be for all of us.

You see, everyone agrees that community safety is paramount, but that is not what has actually been prioritised. Basically, making bail laws the same for children as they are for adults may indeed make the streets safer in the immediate term. But, surely, the long term impact is far more important, is what we should all be prioritising, and what should be the basis of governmental decision-making.

I’m a bleeding heart, lefty, progressive type. I care about social justice, about kids who grow up in poverty (or are exposed to family violence and worse) getting a decent chance in life. But let’s put all that to the side for the moment and totally forget about human rights or justice. Let’s just focus on ‘community safety.’

If a child commits a crime and is remanded (imprisoned) while awaiting trial, then of course they are less of a threat to the community, in the immediate sense. But this is the only question that matters in terms of community safety: Which approach (more or less childhood imprisonment) is more likely to lead to a lifetime of offending?

There is a wealth of research indicating a direct correlation between age of first imprisonment and continued criminal behaviour. There are all sorts of theories around ‘criminal identity’, ‘social learning theory’, ‘disrupted development’ etc etc. Why do we not discuss these? Why do we not look at the evidence and consult the experts. Yes, I know, the public pressure the bloody newspapers. Well, it’s not good enough. We simply label a kid with a crime (e.g. Car-jacking with a weapon, yes it’s horrible), be shocked and angry, and tighten bail laws with zero evidence that we are helping the community in any meaningful way. It’s very, very disappointing.

But there is decency in well-informed people. There is no movement in Australia to reintroduce the death penalty. And that’s because we think there is something sacred about human life, and because we know for a fact that mistakes are made. It’s socially unacceptable for the Commonwealth of Australia to murder people. If you tell the stories, explain the facts, interview the parents, enhance support services, document the success stories . . . then we can make incarcerating children socially unacceptable too.

Patrick Lawrence Chief Executive Officer

Dignity is a word you hear a lot. It is a given that dignity is a good thing; it’s a universal good. It’s impossible to have too much dignity (unless it’s feigned dignity), and not having dignity is a bad thing.

But generally, I think we see dignity as a choice that people make. To behave in a dignified manner is a choice. To prioritise dignity is a choice.

But what about injecting heroin in a laneway in Richmond. Is there any dignity in that? By any common standard, the answer would be no. But what about injecting heroin in a laneway in Richmond after being an adult survivor of childhood sexual abuse who has been staving off suicidal thoughts for two decades with heroin. Is there any dignity in that?

I think the answer is still no. Because if society thinks it’s undignified, then it’s undignified. There’s not much we can do about that. What we can affect though, is the facilitation of dignity by the combined response of justice, health and other systems in our society. Through decisions at a management and at a personal level, we can provide a space where dignity is possible. We can choose to prioritise dignity in all our interactions, and thereby make room for dignity in the life of another.
---
Now, most First Step clients have resilience in spades. First Step clients can teach First Step staff a thing or two about resilience, and it’s our job to be open to that learning. But dignity takes the active efforts of both parties. The request for assistance in a dignified manner, the provision of support in a dignified manner, and then the entering into a dignified relationship together.

A belated ‘definition’ of dignity here would include mutual respect, as well as empathy and hopefulness on all sides.

More than ever, First Step can provide that in our new home. Yes, of course, its mostly about the staff and clients, not buildings. But the built environment affects us all – unfortunately, because it’s expensive! Thanks to the amazing support of our community, we gathered the funds, the space and the determination to turn Mitford Street into a truly dignified environment.

One of the best reactions to our new premises is that staff feel that our clients deserve it, and clients feel that our staff deserve it. That’s dignity!

Patrick Lawrence Chief Executive Officer

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