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

10 October 2023

It is World Mental Health Day on October 10th. In the past we might have called this an ‘awareness raising’ day. However, we could hardly call it that now. In Australia there is constant discussion of mental health, mental illness, mental distress, anxiety in schools, suicide, depression, environmental anxiety, screen addiction, loneliness, overdose, isolation, disconnection.

So, what should we do differently on this day?

Dig a little deeper perhaps.

The World Health Organisation is emphasising human rights in relation to mental health, using the phrase ‘mental health is a universal human right’. If we spelled that out a little further, we might say that access to an environment that is not inherently harmful to mental wellbeing is a human right, as is professional mental health support when we need it.

So, 1) a good environment, and 2) good services.

What then does a rights-based approach urge us to consider?

Firstly, it’s worth noting the we have a Charter of Human Rights and Responsibilities Act (2006) in Victoria, as well as the new Mental Health and Wellbeing Act (2022). When the rubber hits the road, it’s the legal frameworks that provide a mechanism to formally object if we think that either a person’s or people’s 1) environment or 2) level of access to services violates either of these acts.

In First Step’s world we would focus on stigma in the health sector (for decades people who use drugs have been turned away from services despite their obvious severe need), access to addiction medicine and other health services in prisons (did you know prisons don’t use Medicare?), access in the community to evidence-based harm reduction treatments such as methadone via GPs (it’s been a crisis for decades), and access to a transdisciplinary team for people with multiple co-occurring needs (particularly common with our most vulnerable community members).

And then there’s poverty, the ‘cause of the causes’ of mental distress.

Did you know that 50% of Melbourne prisoners come from the poorest 6% of suburbs? 40%+ have a mental illness and 25% are on psychiatric medicines. Regardless of offending, most First Step clients grew up in conditions of poverty, many in out-of-home-care (there are 10,000 kids in out-of-home-care in Victoria tonight, 20-25% are ‘whereabouts unknown’), most suffered childhood abuse and neglect.

Generally, in our community do the people I have described above experience 1) a good environment and 2) good services? I’ll leave it to you to decide.

According to the National Study of Mental Health and Wellbeing 2020-22, 55% of people with symptoms of mental illness do not receive professional support. That’s a combination of lack of awareness, avoidance, lack of access to existing services, non-existence of appropriate services and combinations of the above. Regardless of the percentage breakdown, we clearly need to do a lot better.

Yes, it’s a matter of life and death, and it’s also a matter of human rights.

Patrick Lawrence Chief Executive Officer

27 September 2023

It is a beautiful autumn day in Melbourne, our best season, right? You just popped into your favourite café, and your favourite barista made your coffee just right. You’re walking calmly, towards the tram stop. Your travelling companion is an 11-year-old boy called Theo.

You see Theo once a month as part of a Big Brother Big Sister program, and it really is a highlight in your life. You know a bit about Theo, but you have been trained not to ask too many questions.  You know that Theo and his little brother are already with his third foster family, you know he is struggling academically and is being bullied at school. In your Big Brother Big Sister preparation, you were given extra training on trauma-informed care and appropriate behaviour around child abuse survivors . . . and you’ve quietly drawn your own conclusions. 

After the first couple of nervous meetings, the two of you are getting along beautifully. He’s bright-eyed, with a love of all ball sports, and today you’re taking him to the MCG, which, you can’t believe, he’s never been to before.

You’re on the tram, talking to Theo about your favourite trips to the 'G. He seems genuinely interested, and a bit excited, and you’re feeling that life just couldn’t get any better.

Your subconscious has registered that someone got on the back of the tram, when suddenly you hear a metallic bang then a loud male voice cursing “Ah ssshhhit! I dropped me bloody phone?!”

That’s it. Your bubble is burst, and your mood is instantly soured.

With trepidation you look up to see, as you knew you would, a very disheveled man in his mid-30s (maybe, it’s hard to tell) who is clearly intoxicated (which you assume is kind of normal for him) and looking pretty pissed off at the world . . . which you also assume is normal.  

“Why did he have to get on this tram!? Will he ask for money? Is he dangerous? Why can’t he look after himself!? What’s wrong with people these days!?”

Everything about this man annoys or even disgusts you. You know it shouldn’t, but it does. He's clearly vulnerable, probably had a shitty life, certainly needs help, but your heart is devoid of compassion at this moment.

Then something very strange happens. The motion of the tram and the movement of everyone in it slowly comes to a complete stop.  You realise that you are having a supernatural experience (remember, this is a thought experiment!). A ball of light appears between Theo and this man, and as you watch, the ball slowly elongates until it is a beam, connecting Theo and the man who are both bathed in its glow. They look up at each other and both smile gently, knowingly. 

You realise in that moment, that the man is Theo.  Not metaphorically, but literally, and somehow you have been given a glimpse across time, a sliding door moment. This man is Theo after 3 school expulsions, 17 foster homes including 2 group homes where he was sexually abused. After 5 years spent in prison for attempted murder of a man who wouldn’t stop dealing drugs to his little brother. After 10 more years in and out of the prison system, mostly on trafficking charges to pay for his addiction.  

Or not. 

Between ‘childhood’ and ‘adulthood’, will Theo get the support he needs? The answer to that question, to a great extent, rests with the not-for-profit sector and those philanthropists and governments who would support it. 

Will he receive integrated mental health, addiction, and legal support?  Will he be listened to?  Will a skilled professional look directly at him and ask “Theo, what do you need?  How can we help?” 

So . . . here’s another question.

If Theo the child deserves your compassion, energy, commitment and love, is there an age at which he would become unworthy of it?

The fact that so many of us struggle to empathise with or instinctively care about a man like the clumsy phone-breaker on the tram is hardly surprising.  He doesn’t seem to hold dear the things that are so important to you and me: self-care, caring for others, making a contribution, making the world a better place. 

But here’s the truth, he does hold those things dear.  He just needs help to achieve them, because he is in pain. 

That’s why First Step exists. 

We work with 1,800 people a year providing, free of charge, a uniquely skilled, one-of-a-kind integrated team of GPs, addiction specialists, psychologists and psychiatrists, case managers, therapists and lawyers. 

Just like you need a team for a complex physical health condition like cancer (GP, oncologist, surgeon, occupational therapist), you need a team for complex mental health, such as addiction. 

Makes sense, right?  

Patrick Lawrence Chief Executive Officer